An improved technique for accessory papilla cannulation in pancreas divisum

Identification and management of pancreas divisum

Introduction: Pancreas divisum is the most common congenital malformation of the pancreas with the majority asymptomatic. The etiological role, pathogenesis, clinical significance and management of pancreas divisum in pancreatic disease has not been clearly defined and our understanding is yet to be fully elucidated.Areas covered: This review describes the role of pancreas divisum in the development of pancreatic disease and the ambiguity related to it. In our attempt to offer clarity, a comprehensive search on PubMed, Ovid, Embase and Cochrane Library from inception to May 2019 was undertaken using key words "pancreas divisum", "idiopathic recurrent acute pancreatitis" and "chronic pancreatitis".Expert opinion: Current research fails to define a clear association between pancreas divisum and pancreatic disease. Though debatable, several studies do suggest a pathological role of pancreas divisum in pancreatic disease and a benefit of minor papilla therapy in the setting of acute recurrent pancreatitis. Surgical and endoscopic therapeutic modalities have not been directly compared. With the current data available, it would be imprudent to advise a definitive line of management for pancreatic disease associated with pancreas divisum and should involve a comprehensive discussion with the individual patient to define expectations before embarking on any medical and/or interventional therapy.

Relationship between papillary fibrosis and patency of the accessory pancreatic duct

A study of structure and function of the minor duodenal papilla was carried out on 36 autopsy specimens of the human duodenopancreas. An original perfusion method with manometric control was developed for testing the minor papilla patency, i.e. resistency to intraductal pressure. According to this test, all the specimens were classified as: Type I: non-patent (45%); Type II: patent under normal, physiological pressure (36%); and Type III: patent under increased pressure (19%). After that, the whole minor papilla specimens underwent longitudinal sectioning with HE staining. Light microscopy showed various degrees of fibrosis (mild-45%, moderate-29%, and severe-26%). The correlation between the fibrosis and the patency was significant: papillae with lower degrees of fibrosis were more patent and vice versa. Further, the pancreatic tissue in the Santorini segment of the pancreatic head followed the same manner. No apparent sphincter of the minor papilla was found in any of the specimens analyzed.

A new synthetic porcine secretin for facilitation of cannulation of the dorsal pancreatic duct at ERCP in patients with pancreas divisum: a multicenter, randomized, double-blind comparative study

BACKGROUND

Secretin, a 27 amino acid polypeptide released in response to duodenal luminal acidification, stimulates secretion of water and bicarbonate from pancreatic ductal cells. To date the only secretin available for clinical use has been a biologically derived compound extracted from porcine duodenums. Although used to facilitate pancreatic duct cannulation, secretin has not been approved for this indication. In this study, a new synthetic porcine secretin with an identical amino acid composition was compared with saline solution for the facilitation of minor papilla cannulation in patients with pancreas divisum.

METHODS

A multicenter, prospective, randomized, placebo-controlled, double-blind, comparative trial was conducted at 4 centers with expertise in pancreaticobiliary endoscopy. Patients with pancreas divisum in whom minor papilla cannulation initially was unsuccessful were enrolled. Either saline solution (placebo) or synthetic porcine secretin was administered. If the minor papilla orifice and/or pancreatic juice flow was noted, cannulation was attempted and success or failure was documented (phase 1), as well as the time taken for successful cannulation. If cannulation was unsuccessful, no juice flow was noted, or the orifice was not seen, the alternate agent was administered (phase 2).

RESULTS

Twenty-nine patients (7 men, 22 women; mean age 51 years, range 21-76 years) were enrolled. In phase 1, cannulation was achieved in 1 of 13 patients (7.7%) after the placebo was given and in 13 of 16 patients (81.3%) after synthetic porcine secretin was given (p < 0.0001). In phase 2, cannulation was achieved in 12 of 12 patients (100%) after synthetic porcine secretin was given and in 0 of 3 patients (0%) after the placebo was given (p = 0.0022). Overall, cannulation was successful in 25 of 28 patients (89.3%) who received synthetic porcine secretin and in 1 of 16 (6.3%) who received the placebo (p < 0.0001). Mean time to cannulation was significantly greater for the placebo than for the synthetic porcine secretin (4.75 min vs. 2.63 min; p = 0.0001). No adverse events directly attributable to synthetic porcine secretin administration were documented.

CONCLUSIONS

This study confirmed the use and safety of synthetic porcine secretin in facilitating cannulation of the minor papilla in patients with pancreas divisum in whom cannulation was difficult. Use of this agent has the potential to further increase the cannulation success rate in this group of patients.

Facilitation of pancreatic duct cannulation using a new synthetic porcine secretin

OBJECTIVES

Cannulation of the pancreatic duct at ERCP can represent a technical challenge, even to experienced pancreaticobiliary endoscopists. Secretin is a polypeptide hormone that increases the volume and bicarbonate content of pancreatic secretions. We report our single center experience in the use of a new synthetic porcine secretin (sPS) for the facilitation of cannulation of either the major or minor pancreatic orifice during ERCP.

METHODS

Patients presenting for a variety of indications were enrolled. If identification or cannulation of the desired pancreatic duct was difficult, 0.2 microg/kg of sPS was administered i.v. Cannulation success or failure was recorded.

RESULTS

Between March, 1999, and May, 2000, a total of 25 patients (seven men and 18 women) were enrolled. The most frequent indication (15 of 25 cases) was facilitation of dorsal pancreatic duct cannulation in patients with pancreas divisum. The overall rate of successful cannulation secretin administration was 24 of 25 cases (96%). No adverse events directly attributable to secretin were observed.

CONCLUSIONS

The results of this study show that sPS is safe and efficacious in faciliting cannulation of either the major or minor pancreatic orifice at ERCP in the subset of patients who represent cannulation difficulties. Once commercially available, sPS can be added to the armamentarium of techniques to facilitate ERP.

A double-blind, randomized, dose response study testing the pharmacological efficacy of synthetic porcine secretin

BACKGROUND

Biologically derived porcine secretin has been used as a diagnostic agent in clinical gastrointestinal practice for many years. Pure synthetic porcine secretin is now available for investigational clinical use.

AIM

To compare the pharmacology of synthetic porcine secretin and biologically derived porcine secretin in healthy volunteers.

METHODS

Secretin stimulation tests were performed in 12 volunteer subjects in a double-blind, randomized, Latin square crossover design study comparing three doses of synthetic porcine secretin (0.05, 0.2, and 0.4 microgram/kg) with a standard dose of biologically derived porcine secretin (1 CU/kg). Duodenal aspirates were analysed for total volume and for bicarbonate concentration. Total bicarbonate output was calculated.

RESULTS

Twelve subjects completed four dosing regimens. A multiple comparison test was used to compare dosing regimens. The 0.2 and 0.4 microgram/kg doses of synthetic porcine secretin were not different from the 1 CU/kg dose of biologically derived porcine secretin for volume, bicarbonate concentration and total output from 0 to 60 min. Only one patient had an adverse event, which was mild, transient flushing after the 0.2 and 0.4 microgram/kg doses of synthetic porcine secretin and after the 1 CU/kg dose of biologically derived porcine secretin.

CONCLUSIONS

Synthetic porcine secretin has identical pharmacologic effects to biologically derived porcine secretin in normal subjects. Both drugs were safe and well-tolerated. This study validates synthetic porcine secretin as a substitute for biologically derived porcine secretin.

The role of ERCP in the diagnosis and treatment of idiopathic recurrent pancreatitis in children and adolescents

ERCP was performed in 51 patients, aged 1 to 18 years, as part of diagnostic evaluation for recurrent pancreatitis without obvious cause or as therapeutic intervention. ERCP was successful in 50 patients (98%). Thirty-four patients (68%) had anatomic findings indicating a possible cause of recurrent pancreatitis. Three patients (6%) had findings suggestive of sphincter of Oddi dysfunction. Eighteen of the 37 patients (49%) with ductal abnormalities underwent endoscopic therapy, with a favorable outcome in 15 (83%). Eleven patients were treated surgically, and 8 of these patients (73%) improved symptomatically. Eight patients received no treatment, and 6 of them (67%) had recurrent bouts of clinical pancreatitis. One mild case of pancreatitis (1.9%) occurred after ERCP, and 3 mild cases followed endoscopic therapy. In conclusion, ERCP is a relatively safe technique that produces opacification of the desired ductal system with a high degree of accuracy and provides useful information in the evaluation of children with idiopathic recurrent pancreatitis. These data suggest that endoscopic pancreatic therapy may result in symptomatic improvement, eliminating the need for surgery in selected children. Furthermore, the study demonstrates that manipulation of the pancreatic duct is comparatively safe and less hazardous than formerly believed.

Endoscopic management of pancreatic disease

Since its introduction in 1968, ERCP has developed from being a purely diagnostic method, mostly used in the investigation of unexplained upper abdominal pain, to an invaluable tool for the management of patients with pancreatic disorders. In cases with severe gallstone pancreatitis, the biliary obstruction is disclosed and relieved by ERCP and ES. In patients with severe acute pancreatitis of other aetiologies, as well as in post-traumatic pancreatitis, ERCP is indispensable for revealing complications (e.g. pancreatic duct rupture) and/or for planning the treatment strategy. Furthermore, in cases of pancreatitis not related to alcohol or gallstones, it often demonstrates causes which may be treatable, and it is also useful for evaluation of the gland after massive pancreatic necrosis. Moreover, ERCP is helpful in establishing the diagnosis of chronic pancreatitis and its complications as well as in demonstrating morphological grounds for therapeutic intervention. Although the indications, limitations, and practicability of the different techniques of therapeutic ERCP in various pancreatic diseases still remain to be defined, the method appears to offer an alternative to surgery, particularly in cases in which operative treatment is technically difficult and the results are less favourable. Frequency and severity of complications associated with both diagnostic and therapeutic ERCP seem to be, at least in the hands of experts, reasonably low.

Minor papilla cannulation and dorsal ductography in pancreas divisum

Until recently, pancreas divisum represented a major technical barrier to a complete evaluation of pancreatic ductal anatomy. Technical refinements have now made it possible to achieve minor papilla cannulation and dorsal ductography in more than 90% of attempts. In 120 consecutive dorsal ductograms, structural pathology was demonstrated in 36 subjects (30%): chronic pancreatitis in 23, pancreatic stones in 10, pseudocyst(s) in 4, ductal "cut-off" in 7, pancreatic cancer in 3, and partial agenesis in 1 (some patients had more than one finding). For patients in whom alcohol abuse was excluded, ductal pathology was present in 25%. Abnormal ventral ductograms were present in only 8% of cases, demonstrating that dorsal ductography has an appreciable additional diagnostic yield. When the clinical situation indicates the need for pancreatography, minor papilla cannulation should be performed if major papilla cannulation fails or reveals only the ventral pancreatogram of pancreas divisum.

Pancreas divisum: is it a normal anatomic variant?

One thousand five hundred twenty-nine pancreatograms were obtained between 1973 and 1985. Complete pancreas divisum was demonstrated in 41 patients, for an incidence of 2.7 percent, and incomplete pancreas divisum in 14 cases, for an incidence of 0.9 percent. No increased incidence of pancreas divisum was found in any of four groups: an incidental group, a group with alcoholic pancreatitis, a group with unexplained upper abdominal pain, and an idiopathic pancreatitis group. The majority of patients (80 percent) were found to have pancreas divisum as an incidental finding or in association with alcoholic pancreatitis. Of 82 patients with idiopathic pancreatitis, only 2 had pancreas divisum. The three patients with pancreas divisum who had sphincteroplasty of the minor papilla were not helped by the procedure. We conclude that pancreas divisum is a normal anatomic variant and is very seldom a cause of pancreatic pain.

Pancreas divisum: stenosis of the dorsally dominant pancreatic duct. A surgically correctable lesion

Pancreas divisum is a congenital variant of pancreatic duct drainage in which the dorsal duct dominates, most likely due to the failure of the two independent pancreatic ductal systems to fuse embryologically. Although 5 to 10 percent of the population have this congenital variation, few demonstrate symptoms related to their pancreaticobiliary ductal systems. However, patients may present with symptoms referable to this system, and the diagnosis is difficult. In this series, endoscopic retrograde cholangiopancreatography with cannulation and radiographic injection of the dorsal duct demonstrated this abnormality in 30 of 32 patients, and results of morphine-prostigmine testing were positive for symptoms, chemical enzyme elevation, or both in three fourths of the patients tested, but other maneuvers were not as helpful. The surgical approach has been to perform a sphincteroplasty of both the main and accessory ampullas and to excise the gallbladder when it is present. Pathologic study of the gallbladders showed nearly all of them to have been diseased, whereas histologic study of the ampullas was not as conclusive. In general, this condition should be suspected as part of the postcholecystectomy syndrome or in patients who present with idiopathic pancreatitis and whose conditions cannot be identified by all other diagnostic methods. Preoperative screening may be carried out with noninvasive techniques such as the morphine-prostigmine test, or by use of the secretin-stimulated ultrasonographic visualization of the ductal system. The primary tool for making the diagnosis is endoscopic retrograde cholangiopancreatography. The goal of surgical treatment should be the opening of the main and accessory ducts, since this offers the best chance for long-term relief of the patient's symptoms.