ERCP for biliary strictures associated with chronic pancreatitis

Endoscopic Retrograde Cholangiopancreatography for Management of Chronic Pancreatitis

Management of symptomatic chronic pancreatitis (CP) has shifted its approach from surgical procedures to minimally invasive endoscopic procedures. Increased experience and advanced technology have led to the use of endoscopic retrograde cholangiopancreatography (ERCP) as a therapeutic tool to provide pain relief and treat CP complications including pancreatic stones, strictures, and distal biliary strictures, pseudocysts, and pancreatic duct fistulas. In this article the authors will discuss the use of ERCP for the management of CP, its complications, recent advancements, and techniques from the most up to date literature available.

Novel therapeutics to treat chronic pancreatitis: targeting pancreatic stellate cells and macrophages

INTRODUCTION

Chronic pancreatitis (CP) is a persistent, recurrent, and progressive disorder that is characterized by chronic inflammation and irreversible fibrosis of the pancreas. It is associated with severe morbidity, resulting in intense abdominal pain, diabetes, exocrine and endocrine dysfunction, and an increased risk of pancreatic cancer. The etiological factors are diverse and the major risk factors include smoking, chronic alcoholism, as well as other environmental and genetic factors. The treatment and management of CP is challenging, and no definitive curative therapy is currently available.

AREAS COVERED

This review paper aims to provide an overview of the different cell types in the pancreas that is known to mediate disease progression and outline potential novel therapeutic approaches and drug targets that may be effective in treating and managing CP. The information presented in this review was obtained by conducting a NCBI PubMed database search, using relevant keywords.

EXPERT OPINION

In recent years, there has been an increased interest in the development of novel therapeutics for CP. A collaborative multi-disciplinary approach coupled with a consistent funding for research can expedite progress of translating the findings from bench to bedside.

Management of Benign Biliary Stricture in Chronic Pancreatitis

Endoscopic therapy is the first line of management for chronic pancreatitis (CP)-related benign biliary strictures. Multiple plastic stents (MPS) exchanged at regular intervals and temporary placement of fully covered self-expanding metal stents (FCSEMS) are preferred modalities of endotherapy. FCSEMS placement is non-inferior to MPS and requires fewer sessions of endoscopic retrograde cholangiopancreatography than MPS placement. The presence of head calcifications, severe CP, and length of stricture are predictors of failure or recurrence after endotherapy. Failure of endotherapy should be considered after 1 year when surgery should be considered.

Benign biliary strictures associated with acute biliary pancreatitis

BACKGROUND AND AIMS

There are limited data about the benign biliary strictures (BBS) which can develop during the clinical course of acute biliary pancreatitis (ABP) due to compression of the common bile duct (CBD) by edematous and inflamed pancreatic tissue. We aimed to determine the incidence of BBS due to ABP and its clinical course after endoscopic management.

METHODS

The study was retrospectively conducted among patients with ABP who were admitted to a single tertiary reference center during 3 years. BBS-ABP was defined as distal narrowing of the CBD with proximal dilatation and delayed drainage of the contrast into the duodenum. Endoscopic treatment was performed by inserting a single 7F or 10F plastic stent which was exchanged every 3 months until stricture resolution. Patients were followed for 1 year after stricture resolution.

RESULTS

Seven hundred and twenty-one patients had ABP during the study period. Among them, 257 (35.6%) patients underwent ERCP and 26 patients (3.6%) had CBD stricture due to ABP. A 7 Fr plastic stent was inserted in 18 patients and 10 Fr in 8 patients. The stricture was completely resolved at 3 months in 66.7%, at 6 months 23.8% and at 9 months (9.5%) of the patients. There was no procedure-related complications other than asymptomatic stent migration in 4 (19%) patients. None of the patients had recurrent biliary stricture during the 1 year stent-free follow-up period.

CONCLUSION

BBS-ABP is a frequently seen clinical entity. In most patients, the stricture improves within 3 months and temporary endoscopic stenting prevents the patients from the consequences of the obstruction during this period.

Endotherapy in Pancreatic Diseases

Interventional endoscopy is now considered an effective minimally invasive treatment modality for the management of pancreatic diseases. It is important for the clinician to know the indications and contraindications as well as the timing of various endoscopic interventions. This will help in its safe and effective use and consequently decrease morbidity and mortality from various pancreatic diseases. This review will provide a broad overview of the indications, techniques, and outcomes of pancreatic endotherapy.

Fully Covered Self-Expanding Metal Stent vs Multiple Plastic Stents to Treat Benign Biliary Strictures Secondary to Chronic Pancreatitis: A Multicenter Randomized Trial

BACKGROUND & AIMS

Benign biliary strictures (BBS) are complications of chronic pancreatitis (CP). Endotherapy using multiple plastic stents (MPS) or a fully covered self-expanding metal stent (FCSEMS) are acceptable treatment options for biliary obstructive symptoms in these patients.

METHODS

Patients with symptomatic CP-associated BBS enrolled in a multicenter randomized noninferiority trial comparing 12-month treatment with MPS vs FCSEMS. Primary outcome was stricture resolution status at 24 months, defined as absence of restenting and 24-month serum alkaline phosphatase not exceeding twice the level at stenting completion. Secondary outcomes included crossover rate, numbers of endoscopic retrograde cholangiopancreatography (ERCPs) and stents, and stent- or procedure-related serious adverse events.

RESULTS

Eighty-four patients were randomized to MPS and 80 to FCSEMS. Baseline technical success was 97.6% for MPS and 98.6% for FCSEMS. Eleven patients crossed over from MPS to FCSEMS, and 10 from FCSEMS to MPS. For MPS vs FCSEMS, respectively, stricture resolution status at 24 months was 77.1% (54/70) vs 75.8% (47/62) (P = .008 for noninferiority intention-to-treat analysis), mean number of ERCPs was 3.9 ± 1.3 vs 2.6 ± 1.3 (P < .001, intention-to-treat), and mean number of stents placed was 7.0 ± 4.4 vs 1.3 ± .6 (P < .001, as-treated). Serious adverse events occurred in 16 (19.0%) MPS and 19 (23.8%) FCSEMS patients (P = .568), including cholangitis/fever/jaundice (9 vs 7 patients respectively), abdominal pain (5 vs 5), cholecystitis (1 vs 3) and post-ERCP pancreatitis (0 vs 2). No stent- or procedure-related deaths occurred.

CONCLUSIONS

Endotherapy of CP-associated BBS has similar efficacy and safety for 12-month treatment using MPS compared with a single FCSEMS, with FCSEMS requiring fewer ERCPs over 2 years. (ClinicalTrials.gov, Number: NCT01543256.).

Evaluation of the Feasibility and Effectiveness of Placement of Fully Covered Self-Expandable Metallic Stents via Various Insertion Routes for Benign Biliary Strictures

Background and aims: The goals of the management of benign biliary stricture (BBS) are to relieve symptoms and resolve short-/long-term stricture. We performed fully covered self-expandable metallic stent (hereafter, FCSEMS) placement for BBS using various methods and investigated the treatment outcomes and adverse events (AEs). Methods: We retrospectively studied patients who underwent FCSEMS placement for refractory BBS through various approaches between January 2017 and February 2020. FCSEMS were placed for 6 months, and an additional FCSEMS was placed if the stricture had not improved. Technical success rate, stricture resolution rate, and AE were measured. Results: A total of 26 patients with BBSs that were difficult to manage with plastic stents were included. The mean overall follow-up period was 43.3 ± 30.7 months. The cause of stricture was postoperative (46%), inflammatory (31%), and chronic pancreatitis (23%). There were four insertion methods: endoscopic with duodenoscopy, with enteroscopy, EUS-guided transmural, and percutaneous transhepatic. The technical success rate was 100%, without any AE. Stricture resolution was obtained in 19 (83%) of 23 cases, except for three cases of death due to other causes. Stent migration and cholangitis occurred in 23% and 6.3%, respectively. Stent fracture occurred in two cases in which FCSEMSs were placed for more than 6 months (7.2 and 10.3 months). Conclusion: FCSEMS placement for refractory BBS via various insertion routes was feasible and effective. FCSEMSs should be exchanged every 6 months until stricture resolution because of stent durability. Further prospective study for confirmation is required, particularly regarding EUS-guided FCSEMS placement.

Conservative Treatment of Chronic Pancreatitis: A Practical Approach

BACKGROUND

Chronic pancreatitis is a long-standing, inflammatory condition of the pancreas that leads to the progressive damage and loss of function of pancreatic parenchyma and to the development of possible locoregional and systemic medical complications.

MATERIALS AND METHODS

In this review, we tried to summarize the current evidence on non-surgical treatment trying to suggest a practical approach to the management of chronic pancreatitis.

RESULTS

Besides the unclear pathophysiological mechanism and a poorly unknown epidemiology, chronic pancreatitis is a complex syndrome that displays different possible challenges for physicians. Despite being traditionally considered as a benign disease, chronic pancreatitis encompasses 10-year mortality rates which are superior to the ones reported for some of the most common cancers.

CONCLUSIONS

Chronic pancreatitis encompasses the management of multiple and complex medical co-morbidities that needs to be understood and addressed in a multidisciplinary specialist context.

Incidence and Significance of Biliary Stricture in Chronic Pancreatitis Patients Undergoing Extracorporeal Shock Wave Lithotripsy for Obstructing Pancreatic Duct Stones

Background/Aims

This study assessed the significance of biliary stricture in symptomatic chronic pancreatitis patients requiring extracorporeal shock wave lithotripsy (ESWL) and endoscopic retrograde cholangiopancreatography (ERCP) to remove obstructing pancreatic calculi.

Methods

A total of 97 patients underwent ESWL followed by ERCP to remove pancreatic calculi between October 2014 and October 2017 at Virginia Mason Medical Center. Significant biliary stricture (SBS) was defined as a stricture with upstream dilation on computed tomography scan or magnetic resonance cholangiopancreatography scans accompanied by cholestasis and/or cholangitis. SBS was initially managed by either a plastic stent or fully covered self-expandable metallic stent (fcSEMS). If the stricture did not resolve, the stent was replaced with either multiple plastic stents or another fcSEMS. Data were collected by retrospectively reviewing the medical records.

Results

Biliary strictures were noted in approximately one-third of patients (34/97, 35%) undergoing ESWL for pancreatic calculi. Approximately one-third of the biliary strictures (11/34, 32%) were SBS. Pseudocysts were more frequently found in those with SBS (36% vs 8%, p=0.02), and all pseudocysts in the SBS group were located in the pancreatic head. The initial stricture resolution rates with fcSEMSs and plastic prostheses were 75% and 29%, respectively. The overall success rate for stricture resolution was 73% (8/11), and the recurrence rate after initial stricture resolution was 25% (2/8).

Conclusions

Although periductal fibrosis is the main mechanism underlying biliary stricture development in chronic pancreatitis, inflammation induced by obstructing pancreatic calculi, including pseudocysts, is an important contributing factor to SBS formation during the acute phase.

Endoscopic Retrograde Cholangiopancreatography: Deciphering the Black and White

Endoscopic Retrograde Cholangiopancreatography (ERCP) remains the conventional method of imaging the pancreatic and biliary tree and is performed by direct injection of iodinated contrast material via the major papilla. This diagnostic procedure gained popularity in the 1970s and subsequently paved way for ERCP guided interventions such as sphincterotomy, stone retrieval and stent placement. Currently, therapeutic ERCP is more widespread than diagnostic ERCP primarily due to the availability of noninvasive imaging. Nevertheless, more than half a million ERCPs are performed annually in the United States and radiologists need to be comfortable interpreting them. The following review will familiarize the reader with the imaging appearances of biliary and pancreatic disorders on conventional ERCP, and elaborate on therapeutic ERCP with illustrative examples.

Stenting for Benign and Malignant Biliary Strictures

Benign and malignant biliary strictures are common indications for endoscopic retrograde cholangiopancreatography. Diagnosis involves high-quality cross-sectional imaging and cholangiography with various endoscopic sampling techniques. Treatment options include placement of plastic biliary stents and self-expanding metal stents, which differ in patency duration and cost effectiveness. Whether the etiology is benign or malignant, a multidisciplinary strategy should be implemented. This article will discuss general principles of biliary stenting in both benign and malignant conditions.

Risk Factors and Nomogram for Common Bile Duct Stricture in Chronic Pancreatitis: A Cohort of 2153 Patients

GOALS

To identify the risk factors and develop nomograms for common bile duct (CBD) stricture in chronic pancreatitis (CP) patients.

BACKGROUND

CBD stricture is a common complication in CP and has a variable clinical presentation ranging from asymptomatic to overt jaundice and cholangitis.

STUDY

Patients with CP admitted to Changhai Hospital (Shanghai, China) from January 2000 to December 2013 were enrolled. Cumulative rates of CBD stricture after onset and diagnosis of CP were calculated. Patients were randomly assigned, in a 2:1 ratio, to the training and validation cohort. On the basis of the training cohort, risk factors for CBD stricture and symptomatic CBD stricture were identified through Cox proportional hazards regression model, and nomograms was developed, respectively. Internal and external validations were performed based on the training and validation cohort, respectively.

RESULTS

With a total of 2153 patients, the median duration of follow-up was 7.0 years. CBD strictures were detected in 340 (15.8%) patients, whereas 159 of them were symptomatic. Male gender, age at onset of CP, smoking, body mass index, and morphology of main pancreatic duct were identified risk factors for CBD stricture development. Age at onset of CP, body mass index, and type of pain were identified risk factors for symptomatic CBD stricture development. Both nomograms achieved good concordance indexes with well-fitted calibration curves.

CONCLUSIONS

The nomogram achieved an individualized prediction of symptomatic CBD stricture development in CP patients. It may help the early diagnosis and intervention of symptomatic CBD stricture and reduce the rates of severe adverse events.

Benign biliary strictures: prevalence, impact, and management strategies

Benign biliary strictures (BBSs) may form from chronic inflammatory pancreaticobiliary pathologies, postoperative bile-duct injury, or at biliary anastomoses following liver transplantation. Treatment aims to relieve symptoms of biliary obstruction, maintain long-term drainage, and preserve liver function. Endoscopic therapy, including stricture dilatation and stenting, is effective in most cases and the first-line treatment of BBS. Radiological and surgical therapies are reserved for patients whose strictures are refractory to endoscopic interventions. Response to treatment is dependent upon the technique and accessories used, as well as stricture etiology. In this review, we discuss the various BBS etiologies and their management strategies.

The diagnostic challenge of the sequelae of acute pancreatitis on CT imaging: a pictorial essay

PURPOSE

The purpose of the study was to present a pictorial review of the long-term sequelae of acute pancreatitis on CT imaging as these findings can cause diagnostic confusion in the absence of a proper clinical history and/or prior CT imaging.

METHODS

We retrospectively identified 81 patients who had an episode of acute pancreatitis with diagnostic findings on CT and also underwent one or more follow-up CT scans at least 1 month beyond the acute episode. The residual findings on all follow-up CT scans were tabulated, including the time interval since the initial bout of acute pancreatitis.

RESULT

Residual inflammatory changes were present in 19.8% of cases, with a median time period lasting 86 days since the initial episode of acute pancreatitis. Residual fluid collections were seen in 27.2% and persisted for a median of 132 days. Three patients had residual solid-appearing inflammatory masses, which could be mistaken for neoplasms. Other long-term sequelae were also tabulated, including pancreatic ductal dilatation, pancreatic atrophy, new or increased pancreatic calcifications, biliary tract dilatation, central portal venous occlusion, and pseudoaneurysm formation. These residual findings and long-term complications are presented as a pictorial essay.

CONCLUSION

Recognizing the spectrum of residual findings of acute pancreatitis, some of which can be long term, is important in the correct interpretation of a pancreatic CT. These findings can mimic acute pancreatitis or a pancreatic/peripancreatic neoplasm and often cause diagnostic confusion, especially in the absence of prior CT imaging.

Endoscopic management of benign biliary strictures

Endoscopic management of biliary obstruction has evolved tremendously since the introduction of flexible fiberoptic endoscopes over 50 years ago. For the last several decades, endoscopic retrograde cholangiopancreatography (ERCP) has become established as the mainstay for definitively diagnosing and relieving biliary obstruction. In addition, and more recently, endoscopic ultrasonography (EUS) has gained increasing favor as an auxiliary diagnostic and therapeutic modality in facilitating decompression of the biliary tree. Here, we provide a review of the current and continually evolving role of gastrointestinal endoscopy, including both ERCP and EUS, in the management of biliary obstruction with a focus on benign biliary strictures.

Endoscopic management of benign biliary strictures

Benign biliary strictures are a common indication for endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic management has evolved over the last 2 decades as the current standard of care. The most common etiologies of strictures encountered are following surgery and those related to chronic pancreatitis. High-quality cross-sectional imaging provides a road map for endoscopic management. Currently, sequential placement of multiple plastic biliary stents represents the preferred approach. There is an increasing role for the treatment of these strictures using covered metal stents, but due to conflicting reports of efficacies as well as cost and complications, this approach should only be entertained following careful consideration. Optimal management of strictures is best achieved using a team approach with the surgeon and interventional radiologist playing an important role.

Chronic pancreatitis

PURPOSE OF REVIEW

We review selected important clinical observations in chronic pancreatitis reported in 2013.

RECENT FINDINGS

Early diagnosis of chronic pancreatitis remains difficult, although newer techniques utilizing endoscopic ultrasonography-elastography and MRI hold promise. Patients with chronic pancreatitis are at risk of nutritional deficiencies. Osteoporosis, osteopenia, and bone fracture are particularly common in these patients, and require active intervention and treatment. Diabetes caused by chronic pancreatitis, type 3c diabetes, has specific characteristics and requires careful management. Antioxidants and neuromodulators may decrease pain in some patients with chronic pancreatitis. Endoscopic treatment is effective and can be utilized in patients with painful chronic pancreatitis, although randomized trials demonstrate that surgical therapy is somewhat more durable and effective. Although surgery has typically been a last resort, some advocate early surgical intervention but the optimal time remains unknown.

SUMMARY

Early diagnosis of pancreatitis may be improved by newer techniques associated with endoscopic ultrasonography imaging. Treatment of nutritional deficiencies and diabetes is an important aspect of treating chronic pancreatitis. Pain relief with adjunct means of pain modulation should be tried before starting narcotics for pain control. Endoscopic therapy is appropriate for treating chronic pancreatitis and its local complications and surgical intervention can be considered early in carefully selected individuals.

Endoscopic approach to the diagnosis and treatment of pancreatic disease

PURPOSE OF REVIEW

The purpose of this review is to provide an update on the diagnosis and treatment of pancreatic disorders using endoscopy.

RECENT FINDINGS

The role of endoscopy in the diagnosis and management of pancreatic disorders continues to increase in importance. The use of post-endoscopic retrograde cholangio-pancreatography (ERCP) provides therapy for many pancreatic disorders, including in the treatment of pancreatitis, its complications and pancreatic neoplasia. In recent years, there has been a focus on improving its safety in the prevention of post-ERCP pancreatitis. Pancreatic endotherapy by ERCP for the treatment of biliary strictures and chronic pain in chronic pancreatitis will also be reviewed. Endoscopic ultrasound (EUS) has a vital diagnostic role in pancreatic disorders; however, much of the recent focus has been on its therapeutic role for simple and complex pancreatic fluid collections. As for the role of EUS in pancreatic cancer, recent technical advances in conjunction with on-site cytopathology service continue to improve pancreatic cancer diagnosis. EUS has an increasing role in treatment with fiducial placement for stereotactic body radiation therapy.

SUMMARY

In this review, I will examine the literature over the last year in ERCP and EUS as they apply to specific pancreatic disorders.