Endoscopic Management of Acute Biliopancreatic Disorders

Usefulness of Intraductal Placement of a Dumbbell-Shaped Fully Covered Self-Expandable Metal Stent for Post-Cholecystectomy Bile Leaks

Background and aims: In the treatment of post-cholecystectomy bile leaks, endoscopic naso-biliary drainage (ENBD) or biliary stenting using plastic stents is the standard of care. Fully covered self-expandable metal stent (FCSEMS) placement across the sphincter of Oddi is considered a salvage therapy for refractory cases, but pancreatitis and migration are the major concerns. Intraductal placement of a dumbbell-shaped FCSEMS (D-SEMS) could avoid these drawbacks of FCMSESs. In this retrospective study, we investigated the usefulness of intraductal placement of the D-SEMS for post-cholecystectomy bile leaks. Methods: Six patients who underwent intraductal placement of the D-SEMS for post-cholecystectomy bile leaks were enrolled. This method was performed as initial treatment in three patients and as salvage treatment in three ENBD refractory cases. Results: Technical and clinical successes were obtained in 6 (100%) patients and 5 (83%) patients, respectively. One clinically unsuccessful patient required laparoscopic peritoneal lavage. The early adverse event was one case of mild pancreatitis (17%). The median duration of the D-SEMS indwelling was 61 days (42-606 days) with no migration cases, all of which were successfully removed. The median follow-up after index ERCP was 761 (range: 161-1392) days with no cases of recurrent bile leaks. Conclusions: Intraductal placement of the D-SEMS for post-cholecystectomy bile leaks might be safe and effective even in refractory cases.

Traumatic pancreatitis

Post-traumatic pancreatitis can develop secondary to blunt or penetrating abdominal trauma, post-endoscopic retrograde cholangiopancreatography, or following pancreatic surgery. Clinical findings are often nonspecific, and imaging findings can be subtle on presentation. Early diagnosis of pancreatic duct injury is critical and informs management strategy; imaging plays important role in diagnosis of ductal injury and identification of delayed complications such as retroperitoneal fluid collections, pancreatic fistula, ductal strictures, and recurrent pancreatitis. Delayed diagnosis of pancreatic injury is associated with high mortality and morbidity, and therefore, heightened clinical suspicion is important in order for the radiologist to effectively impact patient care. There are accepted scoring systems for classification of post-traumatic pancreatic injuries and these should be included in radiology reports. Pancreatitis following ERCP appears similar on imaging to other causes of acute pancreatitis unless concomitant perforation occurs. Postoperative pancreatitis may be difficult to diagnose given associated or overlapping expected postoperative findings. Postoperative pancreatic fistulas typically arise from either a leaking pancreatic resection surface or the pancreatoenteric anastomosis and are more common in patients with a "soft" pancreas. Preoperative imaging biomarkers like duct diameter, pancreatic glandular steatosis and parenchymal fibrosis can help predict risk of development of postoperative pancreatic fistula. This review will illustrate the imaging features and the most important imaging findings in patients with post-traumatic pancreatitis.