Endoscopic sphincterotomy is a useful preoperative management for refractory pancreatitis associated with pancreaticobiliary maljunction

Recurrent Acute Pancreatitis in the Setting of Abnormal Pancreaticobiliary Junction

Anomalous or abnormal pancreaticobiliary junction (APBJ) is an important structural cause of recurrent acute pancreatitis. Outside of the common causes of recurrent acute pancreatitis, such as alcohol, gallstones, or hypertriglyceridemia, this anatomical variant can often be overlooked and lead to delays in patient care and even mismanagement. It can be defined as the abnormal junction of the pancreatic duct and common bile duct that occurs outside the duodenal wall to form a long common channel (>8 mm). We describe a case of a 51-year-old female with multiple episodes of acute pancreatitis. Further investigation led to the diagnosis of an aberrant pancreatic duct anatomy with the common bile duct measuring around 20 mm. This report will include a discussion about the pancreaticobiliary junction, how it can be diagnosed, and what complications it can precipitate.

Clinical comparison between the presence and absence of protein plugs in pediatric choledochal cysts: experience in 390 patients over 30 years in a single center

Purpose

The incidence of choledochal cyst (CC) with protein plugs is between 15.5%-40.4%. However, studies on CCs with protein plugs in children are limited. We aimed to analyze the clinical features, surgical findings, and complications of pediatric CCs with and without protein plugs.

Methods

We retrospectively analyzed 390 patients who underwent surgery for CCs between January 1987 and September 2017. The patients were divided into 2 groups: groups A (CC with protein plugs) and B (CC without protein plugs). The presence of protein plugs was evaluated using preoperative images or identified during surgery.

Results

One hundred forty-two (36.4%) patients had protein plugs in the pancreaticobiliary duct. The most common initial clinical presentation was abdominal pain, and its incidence was significantly higher in group A (66.2%) than in group B (54.8%) (P = 0.032). The incidence of accompanying pancreatitis was also significantly higher in group A (37.3% vs. 27.0%) (P = 0.040). Anomalous pancreaticobiliary ductal union (APBDU) was found in 261 patients (66.9%) and its incidence was significantly higher in group A (74.6% vs. 62.5%) (P = 0.014). Most protein plugs were found in the cyst (88.0%) and common channel (31.7%). The incidence of early complications was higher in group A; conversely, that of late complications did not differ.

Conclusion

Approximately 36.4% of the pediatric CC patients were accompanied by protein plugs. Abdominal pain, pancreatitis, and APBDU were more commonly observed among those with protein plugs than among those without; long-term complications did not differ between them.

Double common bile duct associated with pancreaticobiliary maljunction

A 45-year-old female was admitted to the hospital with a diagnosis of acute pancreatitis. A computed tomography scan showed two extrahepatic bile ducts. Magnetic resonance cholangiopancreatography suggested a stone in one of the bile ducts. Endoscopic retrograde cholangiopancreatography revealed two extrahepatic bile ducts joining at the hilum of the liver accompanied with pancreaticobiliary maljunction. Sphincterotomy was performed and a protein plug was drained from the bile duct. Several treatment options were discussed, and the patient was treated with laparoscopic cholecystectomy without extrahepatic bile duct resection and planned to be followed up considering the risk of carcinogenesis in the bile ducts.

Dilatation of the common channel in pediatric congenital biliary dilatation remaining after radical operation

BACKGROUND

In congenital biliary dilatation, the protein plug is likely impacted, especially in a dilated common channel. However, nobody has discussed whether this dilatation of common channel remains after radical operation. The aim of this study was to investigate the situation of the dilated common channel after radical operation.

METHODS

The status of the common channel was investigated at radical operation and follow-up. We then evaluated whether dilation of the common channel remained postoperatively. Moreover, the association between status of the common channel and postoperative pancreatic complication was evaluated.

RESULTS

Postoperative condition of the common channel was able to be evaluated ultrasonographically in 42 patients. The common channel was dilated at the time of operation in 18 patients and remained dilated postoperatively in 11 of these 18 patients. Dilatation of the common channel was not identified in any patients without dilatation at the time of operation. No patients in this series showed any postoperative pancreatic complications, even if a dilated common channel remained.

CONCLUSIONS

Dilatation of the common channel can remain postoperatively in congenital biliary dilatation, but does not appear to be associated with postoperative pancreatic complications.

Endoscopic biliary drainage management for children with serious cholangitis caused by congenital biliary dilatation

Congenital biliary dilatation (CBD) is usually associated with complications such as recurrent cholangitis, manifested as abdominal pain, vomiting, and jaundice. If cholangitis cannot be controlled by conservative treatment, a good therapeutic effect can be obtained through percutaneous biliary drainage or open T-tube drainage. We aimed to evaluate our experiences in biliary drainage through endoscopic retrograde cholangiopancreatography in children with cholangitis caused by CBD. From January 2014 to December 2017, 167 children with CBD were treated in our hospital. 17 patients (10.18%) with serious cholangitis caused by CBD underwent ERCP. There were 4 males and 13 females with an age range of 10-120 months (average 56.4 months). Placement of a biliary stent was attempted for biliary drainage through endoscopic retrograde cholangiopancreatography. Of the 17 patients studied, 13 children had jaundice and 15 had elevated aminotransferases. ERCP showed CBD in all patients and a common biliopancreatic duct in 12 of 17 patients (70.6%). Five patients underwent nasobiliary drainage and 12 patients underwent biliary drainage through double pigtail tubes. All patients achieved successful biliary drainage. Postoperative pancreatitis occurred in one patient. Biochemical indicators decreased significantly in 12 patients (70.6%) on the second postoperative day. The average length of hospital stay after surgery was 4.5 (range 3-7) days. No major complications related to ERCP were observed and all children had a good prognosis so far. Endoscopic biliary drainage is a safe, simple, and reliable technique. It can be used to resolve CBD-associated cholangitis, evaluate the biliary tract and pancreatobiliary duct junction, and guide pediatric surgeons to choose the right time and the correct procedure for CBD.

Endoscopic therapy for patients with pancreaticobiliary maljunction: a follow-up study

Background

Data on the experience of endoscopic retrograde cholangiopancreatography (ERCP) in the management of pancreaticobiliary maljunction (PBM) is limited.

Methods

A retrospective review of patients with PBM who underwent therapeutic ERCP at our endoscopy center between January 2008 and January 2016 was performed. Demographic, clinical, radiological and endoscopic data was documented. Patients who underwent sphincterotomy were divided into dilated group and undilated group based on their common channel diameter.

Results

Sixty-three PBM patients underwent 74 ERCP procedures. The technical success rate was 97.3%. ERCP therapy significantly decreased the levels of elevated liver enzymes and bilirubin. After an average of 27 months follow-up, 7 patients (11.1%) were lost. The overall effective rate of ERCP therapy was 60.7% (34/56). Decline in severity and frequency of abdominal pain was significant. Procedure-related complications were observed in 5 (6.8%) cases. Between the dilated group and undilated group, no significant difference was observed in effective rate, adverse events and follow-up results.

Conclusions

ERCP can serve as a transitional step to stabilize PBM patients before definitive surgery. PBM patients with undilated common channel could benefit from sphincterotomy as well as those with dilated common channel.

Endoscopic Sphincterotomy for Gallbladder Muddy Stones or Sludge in Patients With Papillary Disease: A Retrospective Study

BACKGROUND

The formation of gallbladder stones is associated with dysfunctional contraction and duodenal papilla diseases. However, endoscopic sphincterotomy can improve the contraction of the gallbladder and resolve duodenal papilla disease.

AIM

The aim of the study was to assess the feasibility and effectiveness of endoscopic sphincterotomy in the treatment of muddy stones or sludge in the gallbladder during papillary disease.

METHODS

The clinical data of 53 patients with gallbladder muddy stones or sludge undergoing endoscopic sphincterotomy were retrospectively analyzed.

RESULTS

A total of 53 patients received successful endoscopic sphincterotomy with no serious complications. Sphincterotomy did not significantly lower resting gallbladder volume from 63.2±10.8 to 50.1±5.9 mL (P>0.05), but significantly increased gallbladder ejection fraction from 0.41±0.13 to 0.63±0.16 (P<0.01), as measured by the lipoid food test. The static liver and gallbladder imaging examination also showed an increase in gallbladder ejection fraction from 0.45±0.08 to 0.68±0.11 (P<0.01). In addition, the choledochus pressure reduced from 21.9±4.0 to 15.6±2.5 mm Hg, and the gallbladder muddy stones or sludge disappeared after endoscopic sphincterotomy. At the end of the follow-up period, there was no relapse of sludge or muddy stones in the gallbladder.

CONCLUSIONS

The formation of gallbladder muddy stones or sludge is associated with papilla disease. Endoscopic sphincterotomy can resolve papilla disease, decrease gallbladder bile stasis, improve gallbladder evacuation, and prevent the formation of gallbladder stones.

Japanese clinical practice guidelines for congenital biliary dilatation

Until now, there have been no practical clinical guidelines for congenital biliary dilatation (CBD). In this review article, the Japanese Study Group on Congenital Biliary Dilatation (JSCBD) propose to establish clinical practice guidelines for CBD. Because the evidence-based literature is relatively small, we decided to create guidelines based on the consensus of experts, using the medical literature for reference. A total of 20 clinical questions (CQs) were considered by the members of the editorial committee responsible for the guidelines. The CQs included the distinct aspects of CBD: (1) Concepts and Pathology (three CQs); (2) Diagnosis (six CQs); (3) Pancreaticobiliary Complications (three CQs); Treatments and Prognosis (eight CQs). Each statements and comments for CQs were made by the guidelines committee members. CQs were finally approved after review by members of the editorial committee and the guidelines evaluation board of CBD. These guidelines were created to provide assistance in the clinical practice of CBD management; their contents focus on clinical utility, and they include general information on CBD to make this disease more widely recognized.

Role of pediatric endoscopic retrograde cholangiopancreatography in an era stressing less-invasive imaging modalities

BACKGROUND

The significance of pediatric endoscopic retrograde cholangiopancreatography (ERCP) according to age or disease variation is inconclusive. This study aimed to evaluate the usefulness of pediatric ERCP in diagnosing or treating small children with pancreaticobiliary disorders, including choledochal cyst (CC) and biliary atresia (BA).

METHODS

From 1980 to 2011, 235 ERCPs were performed in 220 pediatric patients (median age, 2 years) at our institution. Underlying pathology was CC in 92 patients (3 years), BA in 62 patients (55 days), and others in 66 patients. Success and complication rates, and ERCP findings were retrospectively analyzed.

RESULTS

The overall success rate was 96%. Rates for individual pathologies were 99% for CC, 92% for BA, and 96% for others. The success rate was 100% among children >3 years, but 92% when limited to infants. Post-ERCP hyperamylasemia and duodenal perforation occurred in 9% and 0.4% of cases, respectively. Regarding preoperative evaluation of the pancreaticobiliary system in CC, ERCP clearly delineated pancreaticobiliary maljunction (79%) and the pancreatic duct (94%), whereas it visualized the common bile duct and intrahepatic bile duct at relatively low rates (77% and 33%, respectively). ERCP successfully identified 16 cases (18%) with non-BA of 90 patients with suspected BA. Moreover, ERCP demonstrated only pancreatic duct in 70% of all BA.

CONCLUSIONS

ERCP among children including infants with CC and BA can be performed with fairly satisfactory results. Although pediatric ERCP can also help describe the pancreaticobiliary system in detail, its indication should be deliberately considered when anatomical information from less-invasive imaging modalities is insufficient.

Urinary amylase/urinary creatinine ratio (uAm/uCr)--a less-invasive parameter for management of hyperamylasemia

Background

The serum level of amylase (sAm) is commonly used as a biochemical marker for diagnosis and management of pancreatic disorders. However, the use of the urine level of amylase (uAm) is limited in practice, because the diagnostic ability of uAm is inferior to that of sAm. In the present study, the possible concordance of uAm-rerated parameters with sAm was investigated, and evaluate the usefulness of uAm for management of hyperamylasemia.

Methods

From June 1995 to October 2009, 804 samples of both urine and blood were collected from 128 patients in order to measure the serum level of amylase (sAm) and the urine level of amylase (uAm) and creatinine (uCr). Concordance of parameters using uAm compared to sAm was assessed. Parameters used were uAm, amylase creatinine clearance ratio (ACCR), and the ratio of uAm to uCr (uAm/uCr).

Results

uAm/uCr had the best correlation with sAm (r = 0.779, p < 0.001) compared to uAm (r = 0.620, p < 0.001) and to ACCR (r = 0.374, p < 0.001), when sAm was over the standard level. The area under the receiver operating characteristic curve of uAm/uCr (0.884) was significantly higher than that of uAm (0.766) and of ACCR (0.666) (p < 0.001 for each). The cutoff value of uAm/uCr was 569.8, with a sensitivity of 81.0% and a specificity of 83.1%.

Conclusions

The uAm/uCr ratio correlated with sAm, and may be an alternative to sAm for prediction of hyperamylasemia. Use of urine samples results in a decreased need for blood sampling, which is especially beneficial in pediatric patients.

Endoscopic biliary drainage for children with persistent or exacerbated symptoms of choledochal cysts

BACKGROUND

Symptoms of choledochal cysts sometimes persist or become exacerbated. As preoperative management for patients with these cysts, we prospectively employed endoscopic drainage, based on the theory that protein plugs cause symptoms by obstructing the pancreatobiliary ducts.

METHODS

Children with choledochal cysts underwent endoscopic retrograde cholangiopancreatography (ERCP). When ERCP showed compaction with filling defects in patients with persistent or worsening symptoms (study patients), the placement of a short biliary stent tube was attempted for drainage. The clinical and ERCP findings of the study patients were compared with those of patients who were asymptomatic at ERCP (asymptomatic patients).

RESULTS

There were 13 study patients (median age 2.9 years) and 41 asymptomatic patients (4.7 years) enrolled in the study between August 2005 and February 2011. Study patients more frequently had jaundice and elevated transaminase levels. ERCP showed that all study patients had obstruction or compacted filling defects in the common channel or the narrow segment distal to the cyst. Insertion of a stent tube was successful in 11 patients. Symptoms were relieved soon after biliary drainage. Surgery revealed that the obstructing materials were protein plugs, except in one case, which involved fatty acid calcium stones.

CONCLUSIONS

These results support the protein plug theory. Endoscopic short-tube stenting is adequate and effective as preoperative management.

Japanese clinical practice guidelines for pancreaticobiliary maljunction

There have been no clinical guidelines for the management of pancreaticobiliary maljunction (PBM). The Japanese Study Group on Pancreaticobiliary Maljunction (JSPBM) has proposed to establish clinical practice guidelines on how to deal with PBM, with the support of the Japan Biliary Association (JBA). Because the body of evidence-based literature is relatively small, we decided to create guidelines based on the consensus of experts, using the medical literature for reference. A total of 46 clinical questions (CQs) were considered by the members of the editorial committee responsible for the guidelines. The CQs covered distinct aspects of PBM: (1) Concepts and Pathophysiology (10 CQs); (2) Diagnosis (10 CQs); (3) Pancreatobiliary complications (9 CQs); and (4) Treatments and prognosis (17 CQs). Statements and comments for each CQ were prepared by the guidelines committee members and collaborating partners. The CQs were completed after review by members of the editorial committee, meetings of this committee, public comments on the homepages of the JSPBM and the JBA, public hearings, and assessment and approval by the guidelines evaluation board. PBM includes cases where the bile duct is dilated (PBM with biliary dilatation) and those in which it is not (PBM without biliary dilatation). In these guidelines, PBM with biliary dilatation is defined as being identical to congenital biliary dilatation of Todani type I (except for type Ib) and type IV-A, both of which are accompanied by PBM in almost all cases. These guidelines are created to provide assistance in the clinical practice of PBM management; their contents focus on clinical utility, and they include general information on PBM to make this disease more widely recognized.

Laparoscopic-assisted clearance of protein plugs in the common channel in children with choledochal cysts

BACKGROUND

The purpose of the study was to assess the efficacy of laparoscopic-assisted removal of protein plugs from the common channel in choledochal cysts.

METHODS

Between 2001 and 2009, 34 patients with choledochal cysts (mean age, 4.98 years) with protein plugs in the common channel successfully underwent laparoscopic cyst excision and Roux-en-Y hepatojejunostomy. Under direct vision during laparoscopy, urethroscopes or catheters were inserted into the common channel to irrigate and remove the protein plugs. Complete clearance was confirmed by either direct urethroscopic visualization or cholangiogram that demonstrated (1) no filling defects in the common channel, (2) significant reduction of common channel diameter, (3) free passage of contrast agent into the duodenum, and (4) no pancreatic duct reflux. Operative time and blood loss, postoperative hospital stay, duration of drainage, postoperative complications, perioperative ultrasonographic findings, and laboratory results were reviewed.

RESULTS

Protein plugs were completely removed in all the patients. The mean operative time, postoperative hospital stay, and drainage duration were 3.51 hours, 7.08 days, and 3.41 days, respectively. The median follow-up period was 32 months. Neither mortality nor complications of pancreatic juice leak, pancreatitis, or stone formation were observed. Liver function parameters and serum amylase levels returned to normal postoperatively.

CONCLUSIONS

Laparoscopic-assisted clearance of the protein plugs in the common channel in choledochal cyst is effective, with good medium-term results observed.

Endoscopic retrograde cholangiopancreatography in pancreatic and biliary tract disease in Korean children

AIM: To assess the indications, findings, therapeutic procedures, safety, and complications of endoscopic retrograde cholangiopancreatography (ERCP) performed in Korean children.

METHODS: The demographic characteristics, indications for ERCP, findings, therapeutic procedures, and complications of 122 pediatric patients who underwent 245 ERCPs in the Asan Medical Center between June 1994 and March 2008 were investigated.

RESULTS: The mean age of the 122 patients was 8.0 ± 4.2 years. Indications were biliary pathology in 78 (64.0%), pancreatic pathology in 43 (35.2%), and chronic abdominal pain in one. Biliary indications included choledochal cysts in 40, choledocholithiasis in 24, suspected sclerosing cholangitis in 8, trauma in 2, and other conditions in 4. Pancreatic indications included acute pancreatitis in 7, acute recurrent pancreatitis in 11, chronic pancreatitis in 20, trauma in 3, and pancreatic mass in 2. Of the 245 ERCPs, success rate was 98.4% and 190 (77.6%) were for therapeutic purposes, including endoscopic nasal drainage (51.8%), biliary sphincterotomy (38.0%), pancreatic sphincterotomy (23.3%), stent insertion (15.1%), stone extraction (18.8%), and balloon dilatation (11.0%). Complications were post-ERCP pancreatitis in 16 (6.5%), ileus in 23 (9.4%), hemorrhage in 2 (0.8%), perforation in 2 (0.8%), sepsis in 1 (0.4%), and impacted basket in 1 (0.4%). There were no procedure-related deaths, and most complications improved under supportive care.

CONCLUSION: This study showed that there is a high incidence of choledochal cyst and diagnostic and therapeutic ERCP for the management of various biliary and pancreatic diseases was safe and effective in Korean children.

Acidic and basic solutions dissolve protein plugs made of lithostathine complicating choledochal cyst/pancreaticobiliary maljunction

BACKGROUND

Symptoms of choledochal cysts are caused by protein plugs made of lithostathine, which block the long common channel and increase pancreaticobiliary ductal pressure. Agents that dissolve protein plugs can provide relief from or prevent symptoms. In the present study, drugs reportedly effective for pancreatic and biliary stones were used in dissolution tests.

METHODS

Protein plugs were obtained from choledochal cysts during surgery in two children (5- and 6-year-old girls). Plugs approximately 2 mm in diameter were immersed in citric acid, tartaric acid, dimethadione, bromhexine, dehydrocholic acid, sodium citrate, hydrochloric acid, and sodium hydroxide solutions under observation with a digital microscope. The pH of each solution was measured using a pH meter.

RESULTS

Plugs dissolved in citric acid (5.2 mM; pH 2.64), tartaric acid (6.7 mM; pH 2.51), dimethadione (75 mM; pH 3.70), hydrochloric acid (0.5 mM; pH 3.13), and sodium hydroxide (75 mM; pH 12.75) solutions. Plugs did not dissolve in dimethadione (7.5 mM; pH 4.31), bromhexine (0.1%; pH 4.68), dehydrocholic acid (5%; pH 7.45), and sodium citrate (75 mM; pH 7.23) solutions.

CONCLUSION

Protein plugs in choledochal cysts are dissolved in acidic and basic solutions, which may eliminate longitudinal electrostatic interactions of the lithostathine protofibrils.