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Miyamoto R, Takahashi A, Ogura T, Kitamura K, Ishida H, Matsudaira S, Suzuki Y, Shimizu S, Kawashima Y. Impact of endoscopic ultrasound-guided transmural drainage for postoperative pancreatic fistula after pancreatic surgery. DEN OPEN 2024; 4:e270. [PMID: 37404728 PMCID: PMC10315642 DOI: 10.1002/deo2.270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 06/20/2023] [Accepted: 06/22/2023] [Indexed: 07/06/2023]
Abstract
Objectives Postoperative pancreatic fistula (POPF) is a major cause of morbidity after pancreatic surgery. Recently, endoscopic ultrasound-guided transmural drainage (EUS-TD) has been widely used to manage pancreatic pseudocysts after acute pancreatitis. Several studies have reported the effectiveness of EUS-TD for POPF, although there is insufficient evidence regarding the performance of EUS-TD for POPF. We herein report on the safety, efficacy, and appropriate timing of EUS-TD for POPF compared with conventional percutaneous intervention. Methods Eight patients who underwent EUS-TD of POPF and 36 patients who underwent percutaneous intervention were retrospectively enrolled. Clinical outcomes, including technical success, clinical success, and complications, were analyzed among the two groups. Results In terms of clinical outcomes between the EUS-TD and percutaneous intervention groups, significant differences were observed in the number of interventions (1 vs. 4, p = 0.011), period of clinical success (6 days vs. 11 days, p = 0.001), incidence of complications (0 vs. 3, p = 0.021), postoperative hospital stays (27 days vs. 34 days, p = 0.027), and recurrence of POPF (0 vs. 5, p = 0.001). Conclusions EUS-TD for POPF appears to be safe and technically feasible. This approach should be considered a therapeutic option in patients with POPF after pancreatic surgery.
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Affiliation(s)
- Ryoichi Miyamoto
- Department of Gastroenterological SurgerySaitama Cancer CenterSaitamaJapan
- Department of Gastroenterological SurgeryTokyo Medical University Ibaraki Medical CenterIbarakiJapan
| | - Amane Takahashi
- Department of Gastroenterological SurgerySaitama Cancer CenterSaitamaJapan
| | - Toshiro Ogura
- Department of Gastroenterological SurgerySaitama Cancer CenterSaitamaJapan
| | - Kei Kitamura
- Department of Gastroenterological SurgerySaitama Cancer CenterSaitamaJapan
| | - Hiroyuki Ishida
- Department of Gastroenterological SurgerySaitama Cancer CenterSaitamaJapan
| | | | - Yuko Suzuki
- Department of GastroenterologySaitama Cancer CenterSaitamaJapan
| | - Satoshi Shimizu
- Department of GastroenterologySaitama Cancer CenterSaitamaJapan
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Dirweesh A, Trikudanathan G, Freeman ML. Endoscopic Management of Complications in Chronic Pancreatitis. Dig Dis Sci 2022; 67:1624-1634. [PMID: 35226223 DOI: 10.1007/s10620-022-07391-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Management of complications in patients with chronic pancreatitis is often suboptimal. This review discusses detailed endoscopic approaches for managing complications in CP. LITERATURE FINDINGS CP is characterized by progressive and irreversible destruction of pancreatic parenchyma and ductal system resulting in fibrosis, scarring, and loss of glandular function. Abdominal pain remains is the most common symptom of the disease and the main aim of medical, endoscopic, and surgical therapy is to help relieve symptoms, prevent disease progression, and manage complications related to CP. In fact, advances in our understanding of CP have improved medical care and quality of life in these patients. With significant sequela, morbidity and a progressive nature, a thorough understanding of the pathophysiology, natural course, diagnostic approaches, and optimal management strategies for this disease is warranted. The existing modalities and new innovations in this field are safe, effective, and likely to have a positive impact on management of complication in CP whenever used in the right context.
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Affiliation(s)
- Ahmed Dirweesh
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, MMC 36, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, MMC 36, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Martin L Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, MMC 36, 420 Delaware St SE, Minneapolis, MN, 55455, USA.
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Beyer G, Hoffmeister A, Michl P, Gress TM, Huber W, Algül H, Neesse A, Meining A, Seufferlein TW, Rosendahl J, Kahl S, Keller J, Werner J, Friess H, Bufler P, Löhr MJ, Schneider A, Lynen Jansen P, Esposito I, Grenacher L, Mössner J, Lerch MM, Mayerle J. S3-Leitlinie Pankreatitis – Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – September 2021 – AWMF Registernummer 021-003. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:419-521. [PMID: 35263785 DOI: 10.1055/a-1735-3864] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Georg Beyer
- Medizinische Klinik und Poliklinik II, LMU Klinikum, Ludwig-Maximilians-Universität München, Deutschland
| | - Albrecht Hoffmeister
- Bereich Gastroenterologie, Klinik und Poliklinik für Onkologie, Gastroenterologie, Hepatologie Pneumologie und Infektiologie, Universitätsklinikum Leipzig, Deutschland
| | - Patrick Michl
- Universitätsklinik u. Poliklinik Innere Medizin I mit Schwerpunkt Gastroenterologie, Universitätsklinikum Halle, Deutschland
| | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Deutschland
| | - Wolfgang Huber
- Comprehensive Cancer Center München TUM, II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Hana Algül
- Comprehensive Cancer Center München TUM, II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Albrecht Neesse
- Klinik für Gastroenterologie, gastrointestinale Onkologie und Endokrinologie, Universitätsmedizin Göttingen, Deutschland
| | - Alexander Meining
- Medizinische Klinik und Poliklinik II Gastroenterologie und Hepatologie, Universitätsklinikum Würzburg, Deutschland
| | | | - Jonas Rosendahl
- Universitätsklinik u. Poliklinik Innere Medizin I mit Schwerpunkt Gastroenterologie, Universitätsklinikum Halle, Deutschland
| | - Stefan Kahl
- Klinik für Innere Medizin m. Schwerpkt. Gastro./Hämat./Onko./Nephro., DRK Kliniken Berlin Köpenick, Deutschland
| | - Jutta Keller
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - Jens Werner
- Klinik für Allgemeine, Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Universitätsklinikum München, Deutschland
| | - Helmut Friess
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar, München, Deutschland
| | - Philip Bufler
- Klinik für Pädiatrie m. S. Gastroenterologie, Nephrologie und Stoffwechselmedizin, Charité Campus Virchow-Klinikum - Universitätsmedizin Berlin, Deutschland
| | - Matthias J Löhr
- Department of Gastroenterology, Karolinska, Universitetssjukhuset, Stockholm, Schweden
| | - Alexander Schneider
- Klinik für Gastroenterologie und Hepatologie, Klinikum Bad Hersfeld, Deutschland
| | - Petra Lynen Jansen
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin, Deutschland
| | - Irene Esposito
- Pathologisches Institut, Heinrich-Heine-Universität und Universitätsklinikum Duesseldorf, Duesseldorf, Deutschland
| | - Lars Grenacher
- Conradia Radiologie München Schwabing, München, Deutschland
| | - Joachim Mössner
- Bereich Gastroenterologie, Klinik und Poliklinik für Onkologie, Gastroenterologie, Hepatologie Pneumologie und Infektiologie, Universitätsklinikum Leipzig, Deutschland
| | - Markus M Lerch
- Klinik für Innere Medizin A, Universitätsmedizin Greifswald, Deutschland.,Klinikum der Ludwig-Maximilians-Universität (LMU) München, Deutschland
| | - Julia Mayerle
- Medizinische Klinik und Poliklinik II, LMU Klinikum, Ludwig-Maximilians-Universität München, Deutschland
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Approach to management of pancreatic strictures: the gastroenterologist's perspective. Clin J Gastroenterol 2021; 14:1587-1597. [PMID: 34405382 DOI: 10.1007/s12328-021-01503-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 08/13/2021] [Indexed: 12/15/2022]
Abstract
Pancreatic strictures represent a complex clinical problem which often requires multidisciplinary management with a team of gastroenterologists, surgeons and radiologists. Dominant strictures are largely due to inflammatory processes of the pancreas like chronic pancreatitis. However, differentiating benign from malignant processes of the pancreas, leading to strictures is imperative and remains a challenge. With advances in endoscopic management, options for therapy include endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasound-guided pancreatic drainage (EUS-PD) in situations where ERCP is not feasible or fails. However, endoscopic therapy is suited for a select group of patients and surgery remains key to management in many patients. In this narrative review, we look at the gastroenterologist's perspective and approach to pancreatic ductal strictures, including endoscopic and surgical management.
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Sundaram S, Choksi D, Kale A, Giri S, Patra B, Bhatia S, Shukla A. Outcomes of Dilation of Recalcitrant Pancreatic Strictures Using a Wire-Guided Cystotome. Clin Endosc 2021; 54:903-908. [PMID: 33657781 PMCID: PMC8652154 DOI: 10.5946/ce.2020.297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/05/2021] [Indexed: 11/29/2022] Open
Abstract
Background/Aims Pancreatic strictures in chronic pancreatitis are treated using endoscopic retrograde cholangiopancreatography (ERCP) with plastic stent placement. The management of recalcitrant strictures remains a challenge, with the use of a Soehendra stent retriever or a needle knife described in case reports. Here, we discuss our experience with dilation of dominant pancreatic strictures with a 6-Fr cystotome.
Methods A retrospective review of an endoscopy database was performed to search for patients with pancreatic strictures recalcitrant to conventional methods of dilation in which a cystotome was used. Technical success was defined as the successful dilation of the stricture with plastic stent placement. Functional success was defined as substantial pain relief or resolution of pancreatic fistulae.
Results Ten patients (mean age, 30.8 years) underwent dilation of a dominant pancreatic stricture secondary to chronic pancreatitis, with a 6-Fr cystotome. Seven patients presented with pain. Three patients had pancreatic fistulae (two had pancreatic ascites and one had a pancreaticopleural fistula). The median stricture length was 10 mm (range, 5–25 mm). The head of the pancreas was the most common location of the stricture (60%). Technical and functional success was achieved in all patients. One patient had self-limiting bleeding, whereas another patient developed mild post-ERCP pancreatitis.
Conclusions The use of a 6-Fr cystotome (diathermy catheter) can be an alternative method for dilation of recalcitrant pancreatic strictures after the failure of conventional modalities.
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Affiliation(s)
- Sridhar Sundaram
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Dhaval Choksi
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Aditya Kale
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Suprabhat Giri
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Biswaranjan Patra
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Shobna Bhatia
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Akash Shukla
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
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Papalavrentios L, Musala C, Gkolfakis P, Devière J, Delhaye M, Arvanitakis M. Multiple stents are not superior to single stent insertion for pain relief in patients with chronic pancreatitis: a retrospective comparative study. Endosc Int Open 2019; 7:E1595-E1604. [PMID: 31788540 PMCID: PMC6877416 DOI: 10.1055/a-1006-2658] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 07/22/2019] [Indexed: 12/19/2022] Open
Abstract
Background and study aims Patients with painful chronic pancreatitis (CP) and distal main pancreatic duct (MPD) stricture are considered candidates for treatment using a single plastic stent insertion. Multiple side-by-side stents have been proposed as an alternative treatment but comparative studies are lacking. The aim of this retrospective study is to assess differences in characteristics and treatment outcomes in patients with CP and MPD strictures treated with a different number of stents during the stenting period. Patients and methods Patients with painful CP and distal MPD obstruction requiring endoscopic treatment (01.2004 - 12.2012) were considered. The study population was divided in three groups: Patients treated with (A) exclusively one stent; (B) one or two stents; and (C) exclusively two stents during the stenting period. Patient characteristics and treatment outcomes were retrospectively assessed. Results Among 284 patients, 85 were selected according to inclusion criteria (Group A: 18, Group B: 35, Group C: 32). Median follow-up duration was 84 months. The median number of endoscopic procedures needed was higher for group B [3 (A) vs. 3 (C) vs. 4 (B), P = 0.001]. Regarding outcome, successful endoscopic treatment was lower in Group C (50 % vs. 88.2 % and 74.2 % for groups A and B, respectively; P = 0.02). This difference was attributed to better clinical outcome in Group A compared to Group C patients [OR(95%CI): 7.50 (1.46 - 38.70); P = 0.04]. Moreover, group C patients experienced higher levels of pain at the end of follow-up period [median Izbicki Score 0 (group A) vs. 0 (group B) vs. 6 (group C), P = 0.03]. Conclusions In patients with painful CP and distal MPD obstruction, treatment with a single stent is associated with better clinical outcome compared to treatment with exclusively two stents during the stenting period.
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Affiliation(s)
- Lavrentios Papalavrentios
- Erasme University Hospital, Université Libre de Bruxelles, Division of Gastroenterology, Hepatopancreatology and Digestive Oncology, Brussels, Belgium
| | - Carmen Musala
- Erasme University Hospital, Université Libre de Bruxelles, Division of Gastroenterology, Hepatopancreatology and Digestive Oncology, Brussels, Belgium
| | - Paraskevas Gkolfakis
- Erasme University Hospital, Université Libre de Bruxelles, Division of Gastroenterology, Hepatopancreatology and Digestive Oncology, Brussels, Belgium
| | - Jacques Devière
- Erasme University Hospital, Université Libre de Bruxelles, Division of Gastroenterology, Hepatopancreatology and Digestive Oncology, Brussels, Belgium
| | - Myriam Delhaye
- Erasme University Hospital, Université Libre de Bruxelles, Division of Gastroenterology, Hepatopancreatology and Digestive Oncology, Brussels, Belgium
| | - Marianna Arvanitakis
- Erasme University Hospital, Université Libre de Bruxelles, Division of Gastroenterology, Hepatopancreatology and Digestive Oncology, Brussels, Belgium
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7
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The Effectiveness and Feasibility of Endoscopic Ultrasound-guided Transgastric Drainage of Postoperative Fluid Collections Early After Pancreatic Surgery. Surg Laparosc Endosc Percutan Tech 2018; 27:267-272. [PMID: 28520649 DOI: 10.1097/sle.0000000000000413] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSES To assess the feasibility and usefulness of endoscopic ultrasound-guided transgastric drainage (EUS-GD) in patients who required early postoperative drainage of peripancreatic fluid collection or postoperative pancreatic fistulas after pancreatic surgery. PATIENTS AND METHODS Between May 2012 and January 2016, 33 patients who developed peripancreatic fluid collection or postoperative pancreatic fistulas after pancreatic resection underwent EUS-GD or percutaneous drainage (PTD). Outcomes were compared retrospectively. RESULTS The drainage procedures were performed on postoperative day 4 to 71 (median, 12) in the EUS-GD group, and 7 to 35 (median, 14) in the PTD group. Technical and clinical success rates reached 92% (11/12) in the EUS-GD group, and 100% (21/21) in the PTD group with no complications or mortality. The duration of hospital stay after drainage was 10 to 44 (median, 15) days for EUS-GD, compared with 10 to 39 (median, 21) days for PTD. CONCLUSIONS EUS-GD is a safe and useful method for early drainage, which could be a good alternative to PTD.
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8
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Jagielski M, Smoczyński M, Jabłońska A, Adrych K. Endoscopic treatment of intraductal pancreatic stent fragmentation. Dig Endosc 2017; 29:798-805. [PMID: 28419588 DOI: 10.1111/den.12887] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 04/05/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Complications of endoscopic treatment are reported more and more often as a result of popularization of pancreatic endotherapy. Our study presents the results of treatment in patients with intraductal pancreatic stent fragmentation diagnosed during endotherapy of chronic pancreatitis. METHODS Retrospective analysis of 2496 endoscopic retrograde cholangiopancreatography procedures which were carried out in 607 patients at the Gastrointestinal Endoscopy Unit of the University Clinical Center in Gdansk. RESULTS In the course of pancreatic endotherapy, intraductal pancreatic stent fragmentation was stated during 33 of 2496 (0.013%) procedures in 33 of 607 (5.44%) patients with chronic pancreatitis. In 33 patients, there were 46 intraductal fragments of broken stents. Most patients were asymptomatic. In 31/33 patients, fragments of broken stents were removed from the pancreatic duct endoscopically. In the case of two patients, endoscopic management was ineffective and they were treated surgically. Altogether, 44/46 stent fragments were removed endoscopically. Most fragments of pancreatic stents were removed during the first endoscopic procedure. One fragment of a broken stent was retrieved with polypectomy snare and four with Dormia basket. The remaining fragments of broken pancreatic stents were removed with rat-tooth forceps. CONCLUSIONS Intraductal fragmentation of pancreatic stent is a rare complication of pancreatic endotherapy and it often has an asymptomatic course. Most fragments of broken pancreatic stents can be removed endoscopically from the pancreatic duct with an acceptable complication rate.
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Affiliation(s)
- Mateusz Jagielski
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Gdansk, Poland
| | - Marian Smoczyński
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Gdansk, Poland
| | - Anna Jabłońska
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Gdansk, Poland
| | - Krystian Adrych
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Gdansk, Poland
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9
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Coronel E, DaVee T, Lee JH. Advances in endotherapy in chronic pancreatitis. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii170001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Emmanuel Coronel
- Department of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, IL, USA
| | - Tomas DaVee
- Department of Gastroenterology, Hepatology and Nutrition, MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey H. Lee
- Department of Gastroenterology, Hepatology and Nutrition, MD Anderson Cancer Center, Houston, TX, USA
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10
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Ohyama H, Mikata R, Ishihara T, Sakai Y, Sugiyama H, Yasui S, Tsuyuguchi T. Efficacy of multiple biliary stenting for refractory benign biliary strictures due to chronic calcifying pancreatitis. World J Gastrointest Endosc 2017; 9:12-18. [PMID: 28101303 PMCID: PMC5215114 DOI: 10.4253/wjge.v9.i1.12] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 08/25/2016] [Accepted: 11/02/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate endoscopic therapy efficacy for refractory benign biliary strictures (BBS) with multiple biliary stenting and clarify predictors.
METHODS Ten consecutive patients with stones in the pancreatic head and BBS due to chronic pancreatitis who underwent endoscopic therapy were evaluated. Endoscopic insertion of a single stent failed in all patients. We used plastic stents (7F, 8.5F, and 10F) and increased stents at intervals of 2 or 3 mo. Stents were removed approximately 1 year after initial stenting. BBS and common bile duct (CBD) diameter were evaluated using cholangiography. Patients were followed for ≥ 6 mo after therapy, interviewed for cholestasis symptoms, and underwent liver function testing every visit. Patients with complete and incomplete stricture dilations were compared.
RESULTS Endoscopic therapy was completed in 8 (80%) patients, whereas 2 (20%) patients could not continue therapy because of severe acute cholangitis and abdominal abscess, respectively. The mean number of stents was 4.1 ± 1.2. In two (20%) patients, BBS did not improve; thus, a biliary stent was inserted. BBS improved in six (60%) patients. CBD diameter improved more significantly in the complete group than in the incomplete group (6.1 ± 1.8 mm vs 13.7 ± 2.2 mm, respectively, P = 0.010). Stricture length was significantly associated with complete stricture dilation (complete group; 20.5 ± 3.0 mm, incomplete group; 29.0 ± 5.1 mm, P = 0.011). Acute cholangitis did not recur during the mean follow-up period of 20.6 ± 7.3 mo.
CONCLUSION Sequential endoscopic insertion of multiple stents is effective for refractory BBS caused by chronic calcifying pancreatitis. BBS length calculation can improve patient selection procedure for therapy.
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Riff BP, Chandrasekhara V. The Role of Endoscopic Retrograde Cholangiopancreatography in Management of Pancreatic Diseases. Gastroenterol Clin North Am 2016; 45:45-65. [PMID: 26895680 DOI: 10.1016/j.gtc.2015.10.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endoscopic retrograde cholangiopancreatography is an effective platform for a variety of therapies in the management of benign and malignant disease of the pancreas. Over the last 50 years, endotherapy has evolved into the first-line therapy in the majority of acute and chronic inflammatory diseases of the pancreas. As this field advances, it is important that gastroenterologists maintain an adequate knowledge of procedure indication, maintain sufficient procedure volume to handle complex pancreatic endotherapy, and understand alternate approaches to pancreatic diseases including medical management, therapy guided by endoscopic ultrasonography, and surgical options.
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Affiliation(s)
- Brian P Riff
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1069, New York, NY 10029, USA
| | - Vinay Chandrasekhara
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, Perelman Center for Advanced Medicine South Pavilion, 7th Floor, Philadelphia, PA 19104, USA.
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12
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Raijman I, Tarnasky PR, Patel S, Fishman DS, Surapaneni SN, Rosenkranz L, Talreja JP, Nguyen D, Gaidhane M, Kahaleh M. Endoscopic drainage of pancreatic fluid collections using a fully covered expandable metal stent with antimigratory fins. Endosc Ultrasound 2015; 4:213-8. [PMID: 26374579 PMCID: PMC4568633 DOI: 10.4103/2303-9027.163000] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Endoscopic drainage is the first consideration in treating pancreatic fluid collections (PFCs). Recent data suggests it may be useful in complicated PFCs as well. Most of the available data assess the use of plastic stents, but scarce data exists on metal stent management of PFCs. The aim of our study to evaluate the efficacy and safety of a metal stent in the management of PFCs. PATIENTS AND METHODS Data were collected prospectively on 47 patients diagnosed with PFCs from March 2007 to August 2011 at 3 tertiary care centers. These patients underwent endoscopic transmural placement of a fully covered self-expanding metal stent (FCSEMS) with antimigratory fins of 10 mm diameter. RESULTS The stent was successfully placed in all patients, and left in place an average of 13 weeks (range 0.4-36 weeks). Etiology of the PFC was biliary pancreatitis (23), pancreas divisum (2), trauma (4), hyperlipidemia (3), alcoholic (8), smoking (2), idiopathic (4), and medication-induced (1). PFCs resolved in 36 patients, for an overall success rate of 77%. Complications included fever (3), stent migration (2) and abdominal pain (1). CONCLUSIONS The use of FCSEMS is successful in the majority of patients with low complication rates. A large sample-sized RCT is needed to confirm if the resolution of PFCs is long-standing.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Michel Kahaleh
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, USA
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13
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Rotman SR, Kahaleh M. Pancreatic fluid collection drainage by endoscopic ultrasound: new perspectives. Endosc Ultrasound 2014; 1:61-8. [PMID: 24949339 PMCID: PMC4062209 DOI: 10.7178/eus.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Accepted: 04/26/2012] [Indexed: 12/13/2022] Open
Abstract
Since the introduction of endoscopic ultrasonography (EUS), many centers have utilized this imaging modality for transmural pancreatic fluid collection (PFC) drainage. The expanded use of EUS has resulted in increased safety and efficacy of endoscopic PFC drainage. The major procedural steps include EUS-guided transgastric or transduodenal fistula creation into the PFC, and stent placement or nasocystic drain deployment to decompress the collection. In this and other applications, EUS has become a major therapeutic advancement in the field of endoscopy and has figured in myriad diagnostic applications. Recent research indicates a number of situations in which EUS-guided PFC drainage is appropriate. These include unusual location of the collection, small window of entry, non-bulging collections, coagulopathy, intervening varices, or failed conventional transmural drainage. In this study, we discuss the EUS-guided technique and review current literatures.
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Affiliation(s)
- Stephen R Rotman
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, Presbyterian Hospital, New York, NY 10021, USA
| | - Michel Kahaleh
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, Presbyterian Hospital, New York, NY 10021, USA
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Singhal S, Rotman SR, Gaidhane M, Kahaleh M. Pancreatic fluid collection drainage by endoscopic ultrasound: an update. Clin Endosc 2013; 46:506-14. [PMID: 24143313 PMCID: PMC3797936 DOI: 10.5946/ce.2013.46.5.506] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2013] [Revised: 07/25/2013] [Accepted: 08/01/2013] [Indexed: 12/14/2022] Open
Abstract
Endoscopic management of symptomatic pancreatic fluid collections (PFCs) is now considered to be first line therapy. Expanded use of endoscopic ultrasound (EUS) techniques has resulted in increased applicability, safety, and efficacy of endoscopic transluminal PFC drainage. Steps include EUS-guided trangastric or transduodenal fistula creation into the PFC followed by stent placement or nasocystic drain deployment in order to decompress the collection. With the remarkable improvement in the available accessories and stents and development of exchange free access device; EUS drainage techniques have become simpler and less time consuming. The use of self-expandable metal stents with modifications to drain PFC has helped in overcoming some previously encountered challenges. PFCs considered suitable for endoscopic drainage include collection present for greater than 4 weeks, possessing a well-formed wall, position accessible endoscopically and located within 1 cm of the duodenal or gastric walls. Indications for EUS-guided drainage have been increasing which include unusual location of the collection, small window of entry, nonbulging collections, coagulopathy, intervening varices, failed conventional transmural drainage, indeterminate adherence of PFC to the luminal wall or suspicion of malignancy. In this article, we present a review of literature to date and discuss the recent developments in EUS-guided PFC drainage.
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Affiliation(s)
- Shashideep Singhal
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY, USA
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15
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Gao DJ, Hu B, Pan YM, Wang TT, Wu J, Lu R, Wang SP, Shi ZM, Huang H, Wang SZ. Feasibility of using wire-guided needle-knife electrocautery for refractory biliary and pancreatic strictures. Gastrointest Endosc 2013; 77:752-8. [PMID: 23357494 DOI: 10.1016/j.gie.2012.11.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Accepted: 11/19/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic management of biliary or pancreatic strictures by stent insertion is well established. However, some high-grade strictures are refractory to dilation and stent placement with conventional methods. OBJECTIVE To evaluate the safety and efficacy of the wire-guided electrotomy technique in dilating stiff biliary and/or pancreatic stenoses when ordinary methods failed. DESIGN Retrospective analysis of a prospective database. SETTING Tertiary referral university hospital. PATIENTS This study involved 279 patients with biliary or pancreatic strictures who underwent ERCP for stenting. INTERVENTION After conventional dilation failed, wire-guided needle-knife electrocautery was attempted to facilitate insertion of the dilating devices and eventually endoprosthesis. MAIN OUTCOME MEASUREMENTS The successful treatment and drainage of biliary or pancreatic strictures. RESULTS With wire-guided needle-knife cauterization, the success rate of stricture dilatation increased from 95.7% (267 of 279 patients) to 98.9% (276 of 279 patients). Dilation of stenoses was successful in 9 of 10 patients (90%) by using electrocautery with the wire-guided needle-knife technique. Postprocedure adverse events included self-limited bleeding, mild acute pancreatitis, hyperamylasemia, cholangitis, and biliary perforation. No procedure-related death occurred. LIMITATIONS Retrospective, single-center study and small sample size. CONCLUSIONS Wire-guided needle-knife electroincision appears to be effective for traversing refractory biliary or pancreatic strictures and can be considered as an alternative approach to conventional methods. However, the safety of such a technique needs to be further evaluated.
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Affiliation(s)
- Dao-jian Gao
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai 200438, China
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Bikhchandani J, Suraweera DB, Upchurch BR. Multiple pancreatic pseudocysts treated with endoscopic transpapillary drainage. Clin Pract 2013; 3:e10. [PMID: 24765490 PMCID: PMC3981223 DOI: 10.4081/cp.2013.e10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 01/24/2013] [Indexed: 11/25/2022] Open
Abstract
Management of a solitary pancreatic pseudocyst with endoscopic transpapillary stent drainage is a well recognized treatment modality. Endoscopic options are however limited in the presence of multiple pancreatic pseudocysts. Conventionally surgery has been the mainstay of treatment in this situation. In this case report, we present a patient with multiple pancreatic pseudocysts who was successfully treated via transpapillary placement of pancreatic duct stent.
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Affiliation(s)
- Jai Bikhchandani
- Department of Gastrointestinal Endoscopy, Creighton University Medical Center , Omaha, NE, USA
| | - Duminda B Suraweera
- Department of Gastrointestinal Endoscopy, Creighton University Medical Center , Omaha, NE, USA
| | - Bennie R Upchurch
- Department of Gastrointestinal Endoscopy, Creighton University Medical Center , Omaha, NE, USA
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Clarke B, Slivka A, Tomizawa Y, Sanders M, Papachristou G, Whitcomb DC, Yadav D. Endoscopic therapy is effective for patients with chronic pancreatitis. Clin Gastroenterol Hepatol 2012; 10:795-802. [PMID: 22245964 PMCID: PMC3381994 DOI: 10.1016/j.cgh.2011.12.040] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Revised: 12/21/2011] [Accepted: 12/28/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endoscopic therapy (ET) frequently is used to treat patients with painful chronic pancreatitis (CP), but little is known about outcomes of patients for whom ET was not successful who then underwent surgery, or outcomes after ET compared with only medical treatment. We evaluated use and long-term effectiveness of ET in a well-defined cohort of patients with CP. METHODS We analyzed data from 146 patients with CP who participated in the North American Pancreatitis Study 2 at the University of Pittsburgh Medical Center from 2000 to 2006; 71 (49%) patients received ET at the University of Pittsburgh Medical Center. Success of ET and surgery were defined by cessation of narcotic therapy and resolution of episodes of acute pancreatitis. Disease progression was followed up from its onset until January 1, 2011 (mean, 8.2 ± 4.7 y). RESULTS Patients who underwent ET had more symptoms (pain, recurrent pancreatitis) and had more complex pancreatic morphology (based on imaging) than patients who received medical therapy. ET had a high rate of technical success (60 of 71 cases; 85%); its rates of clinical success were 51% for 28 of 55 patients for whom follow-up data were available (mean time, 4.8 ± 3.0 y) and 50% for 12 of 24 patients who underwent surgery after receiving ET. Patients who responded to ET were significantly older, had a shorter duration of disease before ET, had less constant pain, and required fewer daily narcotics than patients who did not respond to ET. Among the 36 symptomatic patients who received medical therapy and were followed up for a mean period of 5.7 ± 4.1 years, 31% improved and 53% had no change in symptoms; of these, 21% underwent surgery. CONCLUSIONS ET is clinically successful for 50% of patients with symptomatic CP. When ET is not successful, surgery has successful outcomes in 50% of patients. Symptoms resolve in 31% of symptomatic patients who receive only medical therapy.
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Affiliation(s)
- Bridger Clarke
- Department of Medicine, University of Pittsburgh, Pittsburgh PA
| | - Adam Slivka
- Department of Medicine, University of Pittsburgh, Pittsburgh PA
| | - Yutaka Tomizawa
- Department of Medicine, University of Pittsburgh, Pittsburgh PA
| | - Michael Sanders
- Department of Medicine, University of Pittsburgh, Pittsburgh PA
| | | | - David C. Whitcomb
- Department of Medicine, University of Pittsburgh, Pittsburgh PA
- Department of Human Genetics, University of Pittsburgh, Pittsburgh PA
| | - Dhiraj Yadav
- Department of Medicine, University of Pittsburgh, Pittsburgh PA
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Endoscopic ultrasound-guided transmural drainage for pancreatic fistula or pancreatic duct dilation after pancreatic surgery. Surg Endosc 2011; 26:1710-7. [PMID: 22179480 DOI: 10.1007/s00464-011-2097-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Accepted: 11/26/2011] [Indexed: 01/11/2023]
Abstract
BACKGROUND Endoscopic ultrasound (EUS)-guided drainage is widely used to manage pancreatic pseudocysts. Several studies have reported the use of EUS-guided drainage for pancreatic fistula and stasis of pancreatic juice caused by stricture of the pancreatic duct after pancreatic resection. METHODS At the authors' hospital, 262 patients underwent surgery involving pancreatic resection from April 2005 to March 2010. In 90 of these patients (34%), a grade B or C postoperative pancreatic fistula developed that required additional treatment. The authors performed EUS-guided transmural drainage (EUS-TD) for six patients (2.1%) with a pancreatic fistula or dilation of the main pancreatic duct visible by EUS. Percutaneous drainage was provided for 18 patients (6.8%). The success rates for EUS-TD and percutaneous drainage were compared in a retrospective analysis. RESULTS In all six cases, EUS-TD was performed successfully without complications. Five of the six patients were successfully treated with only one trial of EUS-TD. The final technical success rate was 100% for both EUS-TD and percutaneous drainage. Both the short- and long-term clinical success rates for EUS-TD were 100% and those for percutaneous drainage were 61.1 and 83%, respectively. The differences in these rates were not significant (short-term success, P = 0.091 vs. long-term success, P = 0.403). However, the time to clinical success was significantly shorter with EUS-TD (5.8 days) than with percutaneous drainage (30.4 days; P = 0.0013) in the current series. CONCLUSIONS The EUS-TD approach appears to be a safe and technically feasible alternative to percutaneous drainage and may be considered as first-line therapy for pancreatic fistulas visible by EUS.
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Comparative evaluation of transpapillary drainage with nasopancreatic drain and stent in patients with large pseudocysts located near tail of pancreas. J Gastrointest Surg 2011; 15:772-6. [PMID: 21359595 DOI: 10.1007/s11605-011-1466-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Accepted: 02/08/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Endoscopic transpapillary drainage is usually not advocated for large pseudocysts for fear of infection. We compared efficacy of transpapillary drainage with nasopancreatic drain (NPD) or stent alone in large pseudocysts (>6 cm) located near tail of pancreas. METHODS In a prospective study, a 5-Fr stent/NPD was placed across/near pancreatic duct disruption in 11 patients (nine chronic and two acute pancreatitis) with large pseudocysts located near tail of pancreas. The patients were followed up for resolution of pseudocyst, need for surgery, and complications. RESULTS Pseudocysts diameter ranged from 7 to 15 cm. An attempt to place NPD was made in five patients and a stent in six patients. In NPD group, deep cannulation could not be achieved in one patient; it was treated successfully with percutaneous drainage. In four patients with partial duct disruption, NPD was successfully placed bridging disruption and all had resolution within 6 weeks. In stent group, five had partial and one had complete duct disruption, who later recovered by placement of a stent. Of five patients with partial disruption, one recovered uneventfully at 6 weeks with stent bridging disruption. Other four patients (bridging stent in three) developed febrile illness and infection of pseudocyst. They required additional percutaneous drainage and antibiotics. There was no recurrence of pseudocysts over follow-up of 16.4 months. CONCLUSION Endoscopic transpapillary drainage with NPD bridging disruption is associated with good outcome in patients with large pseudocysts at tail end of pancreas. However, there was increased frequency of infection when stent was used for drainage.
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Abstract
Although the common indications for therapeutic pancreatic endoscopy - management of ductal strictures and calculi - have remained constants, the last decade has witnessed the emergence of several new endoscopic techniques for managing pancreatic disorders. While many of the advances in therapeutic pancreatic endoscopy have paralleled the shift of endoscopic ultrasound from a purely diagnostic to therapeutic modality, other new techniques are simply modifications on existing procedures. Despite these exciting times in therapeutic endoscopy, it is important to recognize that the endoscopist is one part of an interdisciplinary team of experts - a model which is essential in the successful management of patients with pancreatic disorders.
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Affiliation(s)
- Andrew S Ross
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98111, United States.
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21
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Rana SS, Bhasin DK, Nanda M, Siyad I, Gupta R, Kang M, Nagi B, Singh K. Endoscopic transpapillary drainage for external fistulas developing after surgical or radiological pancreatic interventions. J Gastroenterol Hepatol 2010; 25:1087-92. [PMID: 20594223 DOI: 10.1111/j.1440-1746.2009.06172.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND AIMS External pancreatic fistulas (EPFs) are a therapeutic challenge. The present study was conducted to evaluate the efficacy of endoscopic transpapillary nasopancreatic drainage (NPD) in patients with EPF. METHODS Over 12 years, 23 patients (19 males) with EPF underwent attempted endoscopic transpapillary NPD. The end points were fistula closure with healing of pancreatic duct disruption on nasopancreatogram, or need for surgery. RESULTS All 23 patients had persistent drain output (>50 mL/day) for >6 weeks. The mean output volume of the fistula was 223 mL (range: 60 mL to 750 mL). Sixteen patients had partial and seven patients had complete pancreatic duct disruption. The NPD could be successfully placed in 21/23 (91.3%) patients. Disruption was bridged in 15 of 16 patients with partial duct disruption. EPF healed in 2-8 weeks of placement of NPD in all of the patients with partial duct disruption that was bridged and there was no recurrence at a mean follow-up of 38 months. The EPF resolved in only 2/6 (33%) patients with complete duct disruption. CONCLUSIONS External pancreatic fistulas developing following percutaneous drainage of pancreatic fluid collections or surgical necrosectomy can be effectively treated by transpapillary nasopancreatic drain placement especially when there is partial ductal disruption and the disruption can be bridged.
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Affiliation(s)
- Surinder Singh Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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22
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Bhasin DK, Rana SS, Nanda M, Chandail VS, Masoodi I, Kang M, Kalra N, Sinha SK, Nagi B, Singh K. Endoscopic management of pancreatic pseudocysts at atypical locations. Surg Endosc 2009; 24:1085-91. [PMID: 19915913 DOI: 10.1007/s00464-009-0732-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2009] [Accepted: 10/12/2009] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND AIMS There is paucity of data on endoscopic management of pseudocysts at atypical locations. We evaluated the efficacy of endoscopic transpapillary nasopancreatic drain (NPD) placement in the management of pseudocysts of pancreas at atypical locations. PATIENTS AND METHODS Eleven patients with pseudocysts at atypical locations were treated with attempted endoscopic transpapillary nasopancreatic drainage. On endoscopic retrograde pancreatography (ERP), a 5-F NPD was placed across/near the site of duct disruption. RESULTS Three patients each had mediastinal, intrahepatic, and intra/perisplenic pseudocysts and one patient each had renal and pelvic pseudocyst. Nine patients had chronic pancreatitis whereas two patients had acute pancreatitis. The size of the pseudocysts ranged from 2 to 15 cm. On ERP, the site of ductal disruption was in the body of pancreas in five patients (45.4%), and tail of pancreas in six patients (54.6%). All the patients had partial disruption of pancreatic duct. The NPD was successfully placed across the disruption in 10 of the 11 patients (90.9%) and pseudocysts resolved in 4-8 weeks. One of the patients developed fever, 5 days after the procedure, which was successfully treated by intravenous antibiotics. In another patient, NPD became blocked 12 days after the procedure and was successfully opened by aspiration. The NPD slipped out in one of the patient with splenic pseudocyst and was replaced with a stent. There was no recurrence of symptoms or pseudocysts during follow-up of 3-70 months. CONCLUSION Pancreatic pseudocysts at atypical locations with ductal communication and partial ductal disruption that is bridged by NPD can also be effectively treated with endoscopic transpapillary NPD placement.
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Affiliation(s)
- Deepak Kumar Bhasin
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India.
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23
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Prevalence and clinical features of chronic pancreatitis in China: a retrospective multicenter analysis over 10 years. Pancreas 2009; 38:248-54. [PMID: 19034057 DOI: 10.1097/mpa.0b013e31818f6ac1] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES A multicenter study was initiated by the Chinese Chronic Pancreatitis Study Group to determine the nature and magnitude of chronic pancreatitis (CP) in China. METHODS Twenty-two hospitals representing all 6 urban health care regions in China participated in the study. The survey covered a 10-year period from May 1, 1994, to April 30, 2004. Multiple logistic regression was used for analyses. RESULTS The analysis included 2008 patients (64.99% were men, and 35.01% were female; mean age, 48.9 years [SD, 15.0 years]). Chronic pancreatitis prevalence increased yearly from 1996 to 2003: 3.08, 3.91, 5.28, 7.61, 10.43, 11.92, 12.84, and 13.52 per 100,000 inhabitants. Chronic pancreatitis etiologies were alcohol (35.11%), biliary stones (34.36%), hereditary (7.22%), and idiopathic CP (12.90%). Clinical feature were pain (76.25%), maldigestion (36.11%), jaundice (13.40%), and steatorrhea (6.92%). Complications were pseudocyst (26.25%), diabetes (21.61%), bile duct strictures (13.40%), and ascites (1.74%). With regard to the diagnosis, the sensitivity and specificity of endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography were 88% and 93%, and 87% and 93%, respectively. Three hundred ninety-one patients (19.47%) received endoscopic therapy. Surgery was performed in 239 patients (11.90%). CONCLUSION In China, the incidence of CP is rising rapidly; alcohol and biliary stones are the main causes. Endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography are highly sensitive and specific diagnostic methods.
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Talreja JP, Shami VM, Ku J, Morris TD, Ellen K, Kahaleh M. Transenteric drainage of pancreatic-fluid collections with fully covered self-expanding metallic stents (with video). Gastrointest Endosc 2008; 68:1199-203. [PMID: 19028232 DOI: 10.1016/j.gie.2008.06.015] [Citation(s) in RCA: 140] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2008] [Accepted: 06/15/2008] [Indexed: 12/13/2022]
Abstract
BACKGROUND Drainage of pancreatic-fluid collections (PFCs) by using fully covered self-expanding metallic stents (CSEMSs) offers the option of providing a larger-diameter access fistula for drainage when compared with plastic stents. OBJECTIVE To evaluate the efficacy and safety of transenteric drainage of PFCs by using CSEMSs. DESIGN A prospective case series. SETTING A tertiary-referral center. PATIENTS Between January 2007 and September 2007, 18 patients underwent drainage of PFCs by using CSEMSs. Follow-up and final results were prospectively recorded until May 2008. INTERVENTIONS Placement of CSEMSs with a double-pigtail stent placed alongside (4 cases) or into the CSEMS (14 cases) to prevent migration. MAIN OUTCOME MEASUREMENTS The number of sessions and time to resolution of the PFCs. RESULTS A median of 1 session was required to achieve drainage (range 1-4) when using CSEMSs. Complications included superinfection (5), bleeding (2), and inner migration (1). A total of 17 of 18 patients (95%) responded successfully, with 14 patients (78%) achieving complete resolution of their PFC. The mean (+/- SD) time of follow-up until final resolution was 77 +/- 80 days (range 15-310 days). CONCLUSIONS Placement of CSEMSs seems to offer an effective and safe alternative for the drainage of PFCs. A randomized controlled trial should be performed to compare this technique with plastic-stent drainage.
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Affiliation(s)
- Jayant P Talreja
- Digestive Health Center of Excellence, University of Virginia Health System, Charlottesville, Virginia 22908-0708, USA
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Wang LW, Li ZS. Status quo of endoscopic management in chronic pancreatitis. Shijie Huaren Xiaohua Zazhi 2008; 16:236-239. [DOI: 10.11569/wcjd.v16.i3.236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The incidence of chronic pancreatitis (CP) is increasing all over the world. However, it is rather difficult to treat it because its etiological factor and pathogenesis are still unclear. In recent years, the rapid advances in endoscopy techniques have provided new treatment modalities for CP. We, in this paper, describe the present status and advances in endoscopy for CP as well as the problems and difficulties, thus contributing to the treatment for CP.
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Familiari P, Spada C, Costamagna G. Dilation of a severe pancreatic stricture by using a guidewire left in place for 24 hours. Gastrointest Endosc 2007; 66:618-20. [PMID: 17521643 DOI: 10.1016/j.gie.2006.12.050] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2006] [Accepted: 12/26/2006] [Indexed: 02/08/2023]
Affiliation(s)
- Pietro Familiari
- Digestive Endoscopy Unit, Catholic University, A. Gemelli University Hospital, Rome, Italy
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Abstract
Pancreatic sphincterotomy serves as the cornerstone of endoscopic therapy of the pancreas. Historically, its indications have been less well-defined than those of endoscopic biliary sphincterotomy, yet it plays a definite and useful role in diseases such as chronic pancreatitis and pancreatic-type sphincter of Oddi dysfunction. In the appropriate setting, it may be used as a single therapeutic maneuver, or in conjunction with other endoscopic techniques such as pancreatic stone extraction or stent placement. The current standard of practice utilizes two different methods of performing pancreatic sphincterotomy: a pull-type sphincterotome technique without prior stent placement, and a needle-knife sphincterotome technique over an existing stent. The complications associated with pancreatic sphincterotomy are many, although acute pancreatitis appears to be the most common and the most serious of the early complications. As such, it continues to be reserved for those endoscopists who perform a relatively high-volume of therapeutic pancreaticobiliary endoscopic retrograde cholangio-pancreatography.
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Affiliation(s)
- Jonathan M Buscaglia
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, 1830 E. Monument Street, Room 7100-A, Baltimore, MD 21205, USA.
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28
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Arvanitakis M, Delhaye M, Bali MA, Matos C, De Maertelaer V, Le Moine O, Devière J. Pancreatic-fluid collections: a randomized controlled trial regarding stent removal after endoscopic transmural drainage. Gastrointest Endosc 2007; 65:609-19. [PMID: 17324413 DOI: 10.1016/j.gie.2006.06.083] [Citation(s) in RCA: 179] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2006] [Accepted: 06/20/2006] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic transmural drainage is obtained by creating a communication between the intestinal tract and the pancreatic-fluid collection, and then inserting 1 or more stents. Collection recurrence after therapy is noted in 10% to 30% of cases. It is not known whether leaving the stents in position reduces recurrence rates. OBJECTIVE To test the hypothesis that patients who have undergone previous successful pancreatic-collection drainage and whose stents are retrieved have higher recurrence rates. DESIGN Randomized controlled trial. SETTING Tertiary referral center. PATIENTS During a period of 27 months, 46 of 77 patients who had undergone endoscopic transmural drainage for pancreatic collections met inclusion or exclusion criteria, and 28 of these patients were randomized. INTERVENTIONS Fifteen patients were assigned to group A, whose stents were left in place, and 13 were assigned to group B, whose stents were removed after collection resolution. The remaining 18 patients, who were not randomized, also had their stents left in place. All 46 patients were similarly followed. MAIN OUTCOME MEASUREMENT Recurrence of the same pancreatic collection that required therapy. RESULTS All patients were followed for a median period of 14 months (interquartile range, 8.2-22 months) after treatment. The primary end point was reached in 5 patients in group B (stent retrieval), as opposed to none in group A (P = .013). Moreover, no recurrence was observed in the remaining 18 nonrandomized patients. LIMITATIONS Small sample size. CONCLUSIONS In patients who underwent successful transmural drainage of pancreatic collections, stent retrieval was associated with higher recurrence rates.
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Arvanitakis M, Delhaye M, Bali MA, Matos C, Le Moine O, Devière J. Endoscopic treatment of external pancreatic fistulas: when draining the main pancreatic duct is not enough. Am J Gastroenterol 2007; 102:516-24. [PMID: 17335445 DOI: 10.1111/j.1572-0241.2006.01014.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Transpapillary drainage of the main pancreatic duct (MPD) has been proposed for the treatment of external pancreatic fistulas (EPF) but may not suffice to treat complex cases. The aim of the present study was to explore the efficacy of various endoscopic or combined percutaneous and endoscopic techniques in the treatment of EPFs. METHODS Sixteen patients presenting with EPFs were treated in our department. The techniques applied and patients' clinical outcome are described. RESULTS All but three patients underwent transpapillary MPD drainage by pancreatic sphincterotomy (N = 13). Additional endoscopic procedures performed were: (a) pancreatic fluid collection (PFC) drainage (N = 5), (b) transmural drainage between the fistula path and the gastrointestinal (GI) tract (N = 5), and (c) endoscopic ultrasound (EUS)-guided pancreaticoduodenostomy because of complete pancreatic duct rupture (N = 1). Fistula closure was achieved in all patients except one, who required surgery. During a median follow-up period of 18 months (range 6-52) three patients had fistula recurrence, and two, PFC recurrence. Both conditions were cured successfully by repeated endoscopic therapy. All recurrences occurred within 3 months of initial successful treatment. CONCLUSIONS Combined endoscopic and percutaneous treatment appears to be safe and effective for the management of complex cases of EPFs.
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Cahen DL, Gouma DJ, Nio Y, Rauws EAJ, Boermeester MA, Busch OR, Stoker J, Laméris JS, Dijkgraaf MGW, Huibregtse K, Bruno MJ. Endoscopic versus surgical drainage of the pancreatic duct in chronic pancreatitis. N Engl J Med 2007; 356:676-84. [PMID: 17301298 DOI: 10.1056/nejmoa060610] [Citation(s) in RCA: 459] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND For patients with chronic pancreatitis and a dilated pancreatic duct, ductal decompression is recommended. We conducted a randomized trial to compare endoscopic and surgical drainage of the pancreatic duct. METHODS All symptomatic patients with chronic pancreatitis and a distal obstruction of the pancreatic duct but without an inflammatory mass were eligible for the study. We randomly assigned patients to undergo endoscopic transampullary drainage of the pancreatic duct or operative pancreaticojejunostomy. The primary end point was the average Izbicki pain score during 2 years of follow-up. The secondary end points were pain relief at the end of follow-up, physical and mental health, morbidity, mortality, length of hospital stay, number of procedures undergone, and changes in pancreatic function. RESULTS Thirty-nine patients underwent randomization: 19 to endoscopic treatment (16 of whom underwent lithotripsy) and 20 to operative pancreaticojejunostomy. During the 24 months of follow-up, patients who underwent surgery, as compared with those who were treated endoscopically, had lower Izbicki pain scores (25 vs. 51, P<0.001) and better physical health summary scores on the Medical Outcomes Study 36-Item Short-Form General Health Survey questionnaire (P=0.003). At the end of follow-up, complete or partial pain relief was achieved in 32% of patients assigned to endoscopic drainage as compared with 75% of patients assigned to surgical drainage (P=0.007). Rates of complications, length of hospital stay, and changes in pancreatic function were similar in the two treatment groups, but patients receiving endoscopic treatment required more procedures than did patients in the surgery group (a median of eight vs. three, P<0.001). CONCLUSIONS Surgical drainage of the pancreatic duct was more effective than endoscopic treatment in patients with obstruction of the pancreatic duct due to chronic pancreatitis. (Current Controlled Trials number, ISRCTN04572410 [controlled-trials.com].).
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Affiliation(s)
- Djuna L Cahen
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands.
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Bhasin DK, Rana SS, Udawat HP, Thapa BR, Sinha SK, Nagi B. Management of multiple and large pancreatic pseudocysts by endoscopic transpapillary nasopancreatic drainage alone. Am J Gastroenterol 2006; 101:1780-6. [PMID: 16780558 DOI: 10.1111/j.1572-0241.2006.00644.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Endoscopic drainage of a single pseudocyst is a well-known treatment modality. Its role in the management of multiple pseudocysts is not well established. We evaluated the role of endoscopic transpapillary nasopancreatic drain (NPD) placement in the management of multiple and large pseudocysts. METHODS Over 3 yr (2001-2004), endoscopic transpapillary NPD placement was attempted in 11 patients (age range 12-50 yr, 10 men) with symptomatic communicating multiple pseudocysts of pancreas (three in two and two in nine cases). A 5Fr/7Fr NPD was placed across the most distal duct disruption or into one of the pseudocysts. RESULTS Eight patients had an underlying chronic pancreatitis and three patients had pseudocysts as sequelae of acute pancreatitis. The size of pseudocysts ranged from 2 to 14 cm (mean 7.5 cm). Eight patients (72.7%) had at least one pseudocyst more than 6 cm in size. Nine patients had a partial disruption and two patients had complete disruption of the pancreatic duct. The NPD was successfully placed in 10 of 11 (90.9%) patients. Postprocedure acute febrile illness in one patient was the only complication noted, which responded to intravenous antibiotics. All pseudocysts resolved in 4-8 wk in 7 of 7 patients with successful bridging of the most distal ductal disruption. There was no recurrence of the pseudocysts in a mean follow-up of 19.4 months. Two patients, in whom there was a complete disruption and the NPD could not bridge the disruption, required surgery for the nonresolution of pseudocysts. In one patient with partial ductal disruption that could not be bridged, there was complete resolution of one pseudocyst and a decrease in the size of the other pseudocyst from 12 to 4 cm. The NPD was replaced by a stent and both the pseudocysts resolved in 20 wk. CONCLUSION Endoscopic transpapillary NPD placement is a safe and effective modality for the treatment of multiple and large pseudocysts, especially when there is partial ductal disruption, and the disruption can be bridged.
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Affiliation(s)
- Deepak K Bhasin
- Department of Gastroenterology, Post-Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Ahmed SA, Wray C, Rilo HLR, Choe KA, Gelrud A, Howington JA, Lowy AM, Matthews JB. Chronic pancreatitis: recent advances and ongoing challenges. Curr Probl Surg 2006; 43:127-238. [PMID: 16530053 DOI: 10.1067/j.cpsurg.2005.12.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Syed A Ahmed
- University of Cincinnati Medical Center, Ohio, USA
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Abstract
When endoscopic therapy is used for the treatment of patients with painful chronic pancreatitis, extracorporeal shock wave lithotripsy (ESWL) can be proposed as a first-line approach when obstructive ductal stone(s) induce upstream dilation of the main pancreatic duct. Stone fragmentation by ESWL is followed by endoscopic ductal drainage using pancreatic sphincterotomy, fragmented stone(s) extraction, and pancreatic stenting in case of ductal stricture. After completion of endoscopic pancreatic ductal drainage, long-term clinical benefit can be expected for two thirds of the patients. Best clinical results are associated with absence or cessation of smoking and with early treatment in the course of chronic pancreatitis, while alcohol abuse increases the risks of diabetes, steatorrhea and mortality. The complications of chronic pancreatitis are mainly the development of pseudocyst secondary to the downstream ductal obstruction, and biliary obstruction caused by fibrotic changes in the head of the pancreas. Successful endoscopic pseudocyst drainage is currently obtained in most patients, and carries a low complication rate. Biliary stenting is a safe and effective technique for the short-term treatment of symptomatic bile duct stricture due to chronic pancreatitis, but permanent resolution is obtained in only 25% of cases. In conclusion, endoscopic management is now considered to be the preferred interventional treatment of chronic pancreatitis, for patients selected on the basis of the anatomical changes caused by the disease. This treatment is generally safe, minimally invasive, often effective for years, does not prevent further surgery, and can be repeated.
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Affiliation(s)
- M Delhaye
- Medicosurgical Department of Gastroenterology, Erasme University Hospital, Brussels, Belgium.
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Bali MA, Sztantics A, Metens T, Arvanitakis M, Delhaye M, Devière J, Matos C. Quantification of pancreatic exocrine function with secretin-enhanced magnetic resonance cholangiopancreatography: normal values and short-term effects of pancreatic duct drainage procedures in chronic pancreatitis. Initial results. Eur Radiol 2005; 15:2110-21. [PMID: 15991016 DOI: 10.1007/s00330-005-2819-5] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2005] [Revised: 04/28/2005] [Accepted: 05/10/2005] [Indexed: 01/30/2023]
Abstract
The aim of this study was to quantify pancreatic exocrine function in normal subjects and in patients with chronic pancreatitis (CP) before and after pancreatic duct drainage procedures (PDDP) with dynamic secretin-enhanced magnetic resonance (MR) cholangiopancreatography (S-MRCP). Pancreatic exocrine secretions [quantified by pancreatic flow output (PFO) and total excreted volume (TEV)] were quantified twice in ten healthy volunteers and before and after treatment in 20 CP patients (18 classified as severe, one as moderate, and one as mild according to the Cambridge classification). PFO and TEV were derived from a linear regression between MR-calculated volumes and time. In all subjects, pancreatic exocrine fluid volume initially increased linearly with time during secretin stimulation. In controls, the mean PFO and TEV were 6.8 ml/min and 97 ml; intra-individual deviations were 0.8 ml/min and 16 ml. In 10/20 patients with impaired exocrine secretions before treatment, a significant increase of PFO and TEV was observed after treatment (P<0.05); 3/20 patients presented post-procedural acute pancreatitis and a reduced PFO. The S-MRCP quantification method used in the present study is reproducible and provides normal values for PFO and TEV in the range of those obtained from previous published intubation studies. The initial results in CP patients have demonstrated non-invasively a significant short-term improvement of PFO and TEV after PDDP.
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Affiliation(s)
- M A Bali
- Department of Radiology, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium.
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Chen F, Li ZS, Li SD, Wang LW, Xu GM. Etiology, diagnosis and treatment of chronic pancreatitis: an analysis of 294 cases. Shijie Huaren Xiaohua Zazhi 2004; 12:2829-2832. [DOI: 10.11569/wcjd.v12.i12.2829] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the associated factors, diagnosis and treatment of chronic pancreatitis in Shanghai, China.
METHODS: Two hundred and ninety four patients with confirmed chronic pancreatitis in Changhai Hospital were retrospectively studied, including investigation of their associated etiological factors, diagnostic and therapeutic methods.
RESULTS: Of all the 294 patients, there were 89 with biliary chronic pancreatitis (30.3%) and 84 with alcoholic pancreatitis (28.6%). The rest included idiopathic chronic pancreatitis, abnormity of pancreatic duct, hereditary pancreatitis and autoimmune pancreatitis. The most common symptom of chronic pancreatitis was abdominal pain. A few patients were accompanied by steatorrhoea and decrease body weight. Forty-nine patients were diagnosed by histopathology. Others were diagnosed by imaging procedures. The positive rate for imaging diagnosis was 88.0% on average. Most patients suffered less after non-operation therapies.
CONCLUSION: Biliary diseases are still the most common etiological factors of chronic pancreatitis, but its rate has significantly decreased in Shanghai. Meanwhile, the rate of alcoholic chronic pancreatitis is increasing gradually. Imaging procedures play the most important role in diagnosis, and non-operation therapies are the main methods to treat chronic pancreatitis.
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Affiliation(s)
- Fu Chen
- Department of Gastroenterology, Changhai Hospital, Second Millitary Medical University, Shanghai 200433, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Changhai Hospital, Second Millitary Medical University, Shanghai 200433, China
| | - Shu-De Li
- Department of Gastroenterology, Changhai Hospital, Second Millitary Medical University, Shanghai 200433, China
| | - Luo-Wei Wang
- Department of Gastroenterology, Changhai Hospital, Second Millitary Medical University, Shanghai 200433, China
| | - Guo-Ming Xu
- Department of Gastroenterology, Changhai Hospital, Second Millitary Medical University, Shanghai 200433, China
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Delhaye M, Arvanitakis M, Verset G, Cremer M, Devière J. Long-term clinical outcome after endoscopic pancreatic ductal drainage for patients with painful chronic pancreatitis. Clin Gastroenterol Hepatol 2004; 2:1096-106. [PMID: 15625655 DOI: 10.1016/s1542-3565(04)00544-0] [Citation(s) in RCA: 142] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endotherapy for patients with painful chronic pancreatitis (CP) gives early and midterm clinical results comparable with those of conventional surgery. The authors evaluated long-term clinical outcome after endoscopic pancreatic ductal drainage, focusing on pain and pancreatic endocrine/exocrine functions. METHODS Of 110 patients with painful CP endoscopically treated between October 1987 and December 1989, 56 long-surviving patients were followed-up for 14.4 years (SD, .6 y); 40 patients died and 14 patients were lost to follow-up evaluation. Technical results included decreased ductal dilation and stone clearance. Clinical results included the rate of hospitalizations for pain before and after endotherapy, the need for surgery, the course of endocrine/exocrine insufficiencies, and late mortality. RESULTS Complete or partial technical success initially was obtained in 48 of 56 long-surviving patients. Long-term clinical success (< or =5 hospitalizations for pain during follow-up evaluation, without surgery) was obtained for 37 of 56 patients. At a mean follow-up time of 14.4 years, 44 patients had avoided surgery and the annual rate of hospitalizations for pain decreased significantly (before endotherapy: 0.98 [+/-1.36] vs 0.40 [+/-0.51] for the 3 years thereafter vs 0.14 [+/-0.22] for the last 11 years of follow-up evaluation; P < .001). Short duration of disease before initial therapy and absence of smoking at the last follow-up evaluation were associated with long-term clinical success. CONCLUSIONS Endotherapy provides long-term benefits for about two thirds of patients with painful CP. Good clinical outcome was associated with cessation or absence of smoking, whereas alcohol abuse increased the risks for diabetes mellitus, steatorrhea, and mortality.
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Affiliation(s)
- Myriam Delhaye
- Medicosurgical Department of Gastroenterology, Erasme University Hospital, 1070 Brussels, Belgium.
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Abstract
We present an overview of endoscopic therapies for chronic pancreatitis (CP) and its associated conditions. It is evident that endoscopy can be a definite therapy for pancreatic pseudocysts, pancreatic ascites and pancreatic duct (PD) disruption. Endoscopic therapy has also been useful in the short-term and medium therapy of common bile duct strictures due to CP, the best results being obtained if there are no calcifications in the head of the pancreas. Although most experts agree that obstruction to the outflow of pancreatic juice and the resulting increased pressure within the main PD is one of the major factors contributing to pain and that endoscopic therapy has been proven effective to remove stones as well as to dilate PD strictures and place stents across the PD, there is no convincing evidence from randomized trials that the patient's dominant symptom of CP, i.e. pain, is resolved in an appropriate and long-term fashion. We believe that there are other factors which are important in the etiology of chronic pain such as pancreatic inflammation and peripancreatic fibrosis with resulting nerve entrapment around the gland. The reader is reminded that endoscopic therapy is associated with significant and important complications, therefore appropriate patient selection and patient information are of paramount importance. Nevertheless, it is important to consider that one advantage of endoscopic management of CP is that it is less invasive as compared with surgery, often effective for years, does not hinder further surgery, and can be repeated. Finally we want to emphasize that there are many valid surgical, radiological and endoscopic techniques to treat the complications of CP. Therefore, the approach to CP and its complications should be by a multidisciplinary team of gastroenterologists, surgeons, radiologists, endoscopists and pain specialists.
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Affiliation(s)
- Klaus E Monkemuller
- Otto-von-Guericke Universitat, Universitatsklinikum Magdeburg, Magdeburg, Deutschland
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