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Ito K, Takuma K, Okano N, Yamada Y, Saito M, Watanabe M, Igarashi Y, Matsuda T. Current status and future perspectives for endoscopic treatment of local complications in chronic pancreatitis. Dig Endosc 2024. [PMID: 39364545 DOI: 10.1111/den.14926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 08/25/2024] [Indexed: 10/05/2024]
Abstract
Chronic pancreatitis is a progressive disease characterized by irregular fibrosis, cellular infiltration, and parenchymal loss within the pancreas. Chronic pancreatitis treatment includes lifestyle modifications based on disease etiology, dietary adjustments appropriate for each stage and condition, drug therapy, endoscopic treatments, and surgical treatments. Although surgical treatments of symptomatic chronic pancreatitis provide good pain relief, endoscopic therapies are recommended as the first-line treatment because they are minimally invasive. In recent years, endoscopic therapy has emerged as an alternative treatment method to surgery for managing local complications in patients with chronic pancreatitis. For pancreatic stone removal, a combination of extracorporeal shock wave lithotripsy and endoscopic extraction is used. For refractory pancreatic duct stones, intracorporeal fragmentation techniques, such as pancreatoscopy-guided electrohydraulic lithotripsy and laser lithotripsy, offer additional options. Interventional endoscopic ultrasound has become the primary treatment modality for pancreatic pseudocysts, except in the absence of disconnected pancreatic duct syndrome. This review focuses on the current status of endoscopic therapies for common local complications of chronic pancreatitis, including updated information in the past few years.
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Affiliation(s)
- Ken Ito
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Kensuke Takuma
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Naoki Okano
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Yuto Yamada
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Michihiro Saito
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Manabu Watanabe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Yoshinori Igarashi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Takahisa Matsuda
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
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Rodge G, Giri S, Kolhe K, Afzalpurkar S, Harindranath S, Sundaram S, Kale A. Fully Covered Self-expandable Metallic Stents for Refractory Benign Pancreatic Duct Strictures: A Systematic Review and Meta-analysis. Surg Laparosc Endosc Percutan Tech 2024; 34:529-540. [PMID: 39225126 DOI: 10.1097/sle.0000000000001315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 07/18/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Endoscopic treatment of refractory pancreatic duct (PD) strictures includes the placement of multiple plastic stents. Recent studies have shown the benefit of fully covered self-expandable metal stents (FCSEMS). This systematic review analyzes the efficacy and safety of FCSEMS in PD strictures. METHODS A comprehensive search of all suitable studies was conducted using the databases of MEDLINE, EMBASE, and Scopus from inception to November 2022. The outcomes assessed were efficacy and safety of FCSEMS in PD strictures. Using a random-effects inverse-variance model, the pooled proportions were calculated. RESULTS A total of 22 studies with 439 patients were included in the analysis. The pooled stricture resolution rate was 91.6% (95% CI: 87.4-95.7), while the pooled pain resolution rate was 84.9% (95% CI: 77.7-92.1). The pooled incidences of stent-related adverse events, including acute pancreatitis, pain requiring stent removal, and de novo stricture, were 3.9% (95% CI: 1.2-6.7), 0.8% (95% CI: 0.0-2.1), and 3.3% (95% CI: 0.7-5.8). The pooled incidence of stent migration, stricture recurrence, and the need for restenting were 12.9% (95% CI: 6.7-19.1), 9.3% (95% CI: 4.7-13.8), and 12.3% (95% CI: 6.9-17.8), respectively. CONCLUSIONS FCSEMSs can be considered in carefully selected patients with benign PD strictures with high resolution rate and acceptable adverse event rate. De-novo structure formation appears to be a significant problem. Further studies may help to decide the role of FCSEMS in the algorithm.
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Affiliation(s)
- Gajanan Rodge
- Department of Gastroenterology, Bombay Hospital & Medical Research Centre
| | - Suprabhat Giri
- Department of Gastroenterology, Kalinga Institute of Medical Sciences, Bhubaneswar
| | - Kailash Kolhe
- Department of Gastroenterology, Narayana Hospital, Nanded
| | - Shivaraj Afzalpurkar
- Department of Gastroenterology, Nanjappa Multispecialty Hospital, Davangere, India
| | | | - Sridhar Sundaram
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital
| | - Aditya Kale
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital
- Department of Digestive Diseases and Clinical Nutrition, Advanced Centre for Treatment, Research and Education in Cancer, Kharghar, Mumbai
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Joshi D, Shafi T, Al-Farsi U, Keane MG, Grammatikopoulos T, Kronfli R, Makin E, Davenport M, Hayward E, Pool A, Reffitt D, Devlin J, Harrison P. Endoscopic Retrograde Cholangio-Pancreatography and Endoscopic Ultrasound in the Management of Paediatric Acute Recurrent Pancreatitis and Chronic Pancreatitis. J Clin Med 2024; 13:5523. [PMID: 39337011 PMCID: PMC11432529 DOI: 10.3390/jcm13185523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2024] [Revised: 08/11/2024] [Accepted: 08/13/2024] [Indexed: 09/30/2024] Open
Abstract
Objectives: To evaluate the role of ERCP (endoscopic retrograde cholangio-pancreatography) and EUS (endoscopic ultrasound) and to describe the efficacy and safety of these procedures in a paediatric cohort with chronic pancreatitis (CP) and acute recurrent pancreatitis (ARP). Methods: All patients (<18 years) undergoing an ERCP or EUS for ARP and CP between January 2008 and December 2022 were included. Data collection included indications for the procedure, technical success, adverse events and outcome data. Results: A total of 222 ERCPs were performed in 98 patients with CP and ARP (60% female, median age 10 years). The commonest indications were a main pancreatic duct stricture (PD) with or without a stone within the main PD. Successful cannulation was achieved in 98% of cases. Improved stricture resolution was demonstrated in 63% of patients. The overall adverse event rate for ERCP was low (n = 8/222, 3.6%). An improvement in abdominal pain was demonstrated in (75/98) 76% of patients. Their Body Mass Index also significantly improved post ERCP (15.5 ± 1.41 vs. 12.9 ± 1.16 kg/m2, p = 0.001). A total of 54 EUS procedures were undertaken in 48 individuals. Moreover, 35 individuals underwent a therapeutic EUS procedure, for which the commonest indication was the drainage of a pancreatic fluid collection. The overall complication rate was low (n = 2.4%) in all EUS cases. Conclusions: ERCP and EUS can be safely and effectively used in a paediatric population with indications analogous to an adult cohort.
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Affiliation(s)
- Deepak Joshi
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London SE5 9RS, UK
| | - Taimur Shafi
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London SE5 9RS, UK
| | - Usama Al-Farsi
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London SE5 9RS, UK
- Department of Gastroenterology, Nizwa Hospital, Oman
| | - Margaret G Keane
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Tassos Grammatikopoulos
- Paediatric Liver, GI & Nutrition Centre and Mowat Labs, King's College Hospital NHS Foundation Trust, London SE5 9RS, UK
| | - Rania Kronfli
- Department of Paediatric Surgery, King's College Hospital NHS Foundation Trust, London SE5 9SR, UK
| | - Erica Makin
- Department of Paediatric Surgery, King's College Hospital NHS Foundation Trust, London SE5 9SR, UK
| | - Mark Davenport
- Department of Paediatric Surgery, King's College Hospital NHS Foundation Trust, London SE5 9SR, UK
| | - Elizabeth Hayward
- Department of Anaesthetics, King's College Hospital NHS Foundation Trust, London SE5 9SR, UK
| | - Andrew Pool
- Department of Anaesthetics, King's College Hospital NHS Foundation Trust, London SE5 9SR, UK
| | - David Reffitt
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London SE5 9RS, UK
| | - John Devlin
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London SE5 9RS, UK
| | - Philip Harrison
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London SE5 9RS, UK
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Tandan M, Pal P, Jagtap N, Reddy DN. Endoscopic interventions in pancreatic strictures and stones-A structured approach. Indian J Gastroenterol 2024:10.1007/s12664-024-01644-9. [PMID: 39145851 DOI: 10.1007/s12664-024-01644-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 06/25/2024] [Indexed: 08/16/2024]
Abstract
Chronic pancreatitis (CP) is an irreversible disease of varied etiology characterized by destruction of pancreatic tissue and loss of both exocrine and endocrine function. Pain is the dominant and most common presenting symptom. The common cause for pain in CP is ductal hypertension due to obstruction of the flow of pancreatic juice in the main pancreatic duct either due to stones or stricture or a combination of both. With advances in technology and techniques, endoscopic retrograde cholangiography (ERCP) and stenting should be the first line of therapy for strictures of the main pancreatic duct (MPD). Small calculi in the MPD can be extracted by ERCP and balloon trawl. Extracorporeal shockwave lithotripsy (ESWL) remains the standard of care for large pancreatic calculi and aims to fragment the stones 3 mm or less that can easily be extracted by a subsequent ERCP. Single operator pancreatoscopy with intraductal lithotripsy is a technique in evolution and can be tried when ESWL is not available or is unsuccessful in producing stone fragmentation.
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Affiliation(s)
- Manu Tandan
- Medical Gastroenterology, Asian Institute of Gastroenterology, Somajiguda, 6-3-661, Hyderabad, 500 082, India.
| | - Partha Pal
- Medical Gastroenterology, Asian Institute of Gastroenterology, Somajiguda, 6-3-661, Hyderabad, 500 082, India
| | - Nitin Jagtap
- Medical Gastroenterology, Asian Institute of Gastroenterology, Somajiguda, 6-3-661, Hyderabad, 500 082, India
| | - D Nageshwar Reddy
- Medical Gastroenterology, Asian Institute of Gastroenterology, Somajiguda, 6-3-661, Hyderabad, 500 082, India
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Bofill-Garcia A, Lupianez-Merly C. Endoscopic Retrograde Cholangiopancreatography for Management of Chronic Pancreatitis. Gastrointest Endosc Clin N Am 2024; 34:449-473. [PMID: 38796292 DOI: 10.1016/j.giec.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
Management of symptomatic chronic pancreatitis (CP) has shifted its approach from surgical procedures to minimally invasive endoscopic procedures. Increased experience and advanced technology have led to the use of endoscopic retrograde cholangiopancreatography (ERCP) as a therapeutic tool to provide pain relief and treat CP complications including pancreatic stones, strictures, and distal biliary strictures, pseudocysts, and pancreatic duct fistulas. In this article the authors will discuss the use of ERCP for the management of CP, its complications, recent advancements, and techniques from the most up to date literature available.
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Affiliation(s)
- Aliana Bofill-Garcia
- Department of Gastroenterology and Hepatology, Mayo Clinic Rochester, 200 First Street Southwest, Rochester, MN 55905, USA.
| | - Camille Lupianez-Merly
- Department of Gastroenterology and Hepatology, Mayo Clinic Rochester, 200 First Street Southwest, Rochester, MN 55905, USA
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Jeropoulos RM, Joshi D, Aldeiri B, Davenport M. Surgical and Endoscopic Intervention for Chronic Pancreatitis in Children: The Kings College Hospital Experience. CHILDREN (BASEL, SWITZERLAND) 2024; 11:74. [PMID: 38255387 PMCID: PMC10813922 DOI: 10.3390/children11010074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/02/2024] [Accepted: 01/05/2024] [Indexed: 01/24/2024]
Abstract
Paediatric chronic pancreatitis (CP) is a rare and debilitating pathology that often requires invasive diagnostics and therapeutic interventions either to address a primary cause such as a pancreaticobiliary malunion or to deal with secondary complications such as chronic pain. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) are two endoscopic modalities that have an established diagnostic role in paediatric CP, and their therapeutic utilisation is increasing in popularity. Surgical decompression of the obstructed and dilated pancreatic duct plays a role in alleviating pancreatic duct hypertension, a common association in CP. Surgery equally has a role in certain anatomical abnormalities of the pancreaticobiliary draining system, or occasionally in some CP complications such as drainage of a symptomatic pancreatic pseudocyst.
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Affiliation(s)
- Renos M. Jeropoulos
- Department of Paediatric Surgery, Chelsea and Westminster Hospital, London SW10 9NH, UK; (R.M.J.); (B.A.)
| | - Deepak Joshi
- Institute of Liver Studies, King’s College Hospital, London SE5 9RS, UK;
| | - Bashar Aldeiri
- Department of Paediatric Surgery, Chelsea and Westminster Hospital, London SW10 9NH, UK; (R.M.J.); (B.A.)
| | - Mark Davenport
- Department of Paediatric Surgery, Kings College Hospital, London SE5 9RS, UK
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Rai P, Kumar P, Kumar A, Asari S, Agarwal K, Mayank, Krishna Kishore RV, Mishra P. Self-expanding metallic stent for refractory pancreatic duct stricture in chronic pancreatitis: A prospective follow-up study. Indian J Gastroenterol 2023:10.1007/s12664-023-01445-6. [PMID: 37768445 DOI: 10.1007/s12664-023-01445-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 08/08/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND AND AIMS In chronic pancreatitis, fully covered self-expanding metal stents (FCSEMS) are used to treat refractory pancreatic duct strictures. However, the FCSEMS design, effectiveness, safety, optimal stent indwelling time and patient selection remain unclear. This study aimed at evaluating technical success, clinical success and adverse events with FCSEMS in patients with symptomatic pancreatic duct stricture. METHODS The prospective study was conducted between May 2017 and May 2021 at a tertiary care center for chronic pancreatitis with refractory pancreatic duct stricture using controlled radial expansion (CRE) endoscopic retrograde cholangiopancreatography (ERCP) with FCSEMS (Niti-S, Bumpy stent, Taewoong Medical, Gimpo-Si, South Korea). RESULTS During the study period, a total of 11 patients underwent ERCP with FCSEMS for refractory pancreatic duct stricture. The mean age (± standard deviation, [SD]) was 32.36 ± 10.98 years and nine patients (81%) were male. Technical and clinical success rates were 100% and 90.9%, respectively. All patients had a history of prior pancreatic endotherapy. The median (inter quartile range, [IQR]) stent indwell time was seven (6-10) months. The median visual analogue scale (VAS) pain score pre and post-FCSEMS was 8 (5-8) and 1 (0-2), respectively (p-value 0.003). Median (IQR) follow-up after stent removal was 48 (40-60) months. One patient (9%) developed de novo main pancreatic duct (MPD) stricture, which was asymptomatic. None of the patients had cholangitis, pancreatitis, perforation, proximal migration or stent fracture. CONCLUSION The FCSEMS treatment appears to be safe, feasible and possibly an effective option for patients who have not responded to endoscopic plastic stenting.
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Affiliation(s)
- Praveer Rai
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India.
| | - Pankaj Kumar
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Ashok Kumar
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Sana Asari
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Kartik Agarwal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Mayank
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Ravi V Krishna Kishore
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Prabhaker Mishra
- Department of Biostatistics and Health Informatics, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, 226 014, India
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Ko SW, So H, Oh D, Song TJ, Park DH, Lee SS, Seo DW, Lee SK. Long-term clinical outcomes of a fully covered self-expandable metal stent for refractory pancreatic strictures in symptomatic chronic pancreatitis: An 11-year follow-up study. J Gastroenterol Hepatol 2023; 38:460-467. [PMID: 36626274 DOI: 10.1111/jgh.16105] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 11/29/2022] [Accepted: 01/08/2023] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND AIMS A fully covered self-expandable metal stent (FCSEMS) has recently been applied in the management of chronic pancreatitis patients with pancreatic strictures. However, related long-term effects remain unclear. This study aimed to evaluate the long-term outcomes of FCSEMS placement in chronic pancreatitis patients with refractory strictures. METHOD We retrospectively reviewed our database for patients undergoing FCSEMS placement for refractory pancreatic strictures between September 2008 and December 2010. The main outcomes were technical, radiological, and clinical success, as well as recurrence and adverse events. RESULTS A total of 35 patients were included. Technical success was achieved in all patients. The median FCSEMS indwelling time was 3.2 months (interquartile range [IQR], 3.0-4.9 months). Radiological success was achieved in all patients (complete, n = 2; partial, n = 33). Clinical success was achieved in 29 patients (82.9%; complete analgesic cessation, n = 19; analgesic reduction >50%, n = 11). During the median follow-up of 136 months, (IQR, 85.8-145.5 months), eight patients (22.9%) experienced recurrence. The median interval from stent removal to recurrence was 24.9 months (IQR, 11.3-30.3 months). Biliary obstruction, an early adverse event, occurred in two patients (5.7%); the late adverse event stent-induced de novo stricture was observed in 17 patients (48.6%). CONCLUSIONS Our findings suggest that an FCSEMS is effective for relieving refractory strictures in chronic pancreatitis. However, FCSEMSs were associated with stent-induced de novo strictures in nearly half of the patients. Prospective studies are required to further evaluate the long-term efficacy and safety of FCSEMSs in chronic pancreatitis.
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Affiliation(s)
- Sung Woo Ko
- Department of Internal Medicine, The Catholic University of Korea, Eunpyeong St. Mary's Hospital, Seoul, South Korea
| | - Hoonsub So
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Dongwook Oh
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Tae Jun Song
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Do Hyun Park
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Sang Soo Lee
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Dong-Wan Seo
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Sung Koo Lee
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
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Yi JH, Li ZS, Hu LH. Pancreatic duct stents. J Dig Dis 2022; 23:675-686. [PMID: 36776138 DOI: 10.1111/1751-2980.13158] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 02/03/2023] [Accepted: 02/08/2023] [Indexed: 02/14/2023]
Abstract
Pancreatic duct stenting using endoscopy or surgery is widely used for the management of benign and malignant pancreatic diseases. Endoscopic pancreatic stents are mainly used to relieve pain caused by chronic pancreatitis and pancreas divisum, and to treat pancreatic duct disruption and stenotic pancreaticointestinal anastomosis after surgery. They are also used to prevent postendoscopic retrograde cholangiopancreatography pancreatitis and postoperative pancreatic fistula, treat pancreatic cancer, and locate radiolucent stones. Recent advances in endoscopic techniques, such as endoscopic ultrasonography and balloon enteroscopy, and newly designed stents have broadened the indications for pancreatic duct stenting. In this review we outlined the types, insertion procedures, efficacy, and complications of endoscopic pancreatic duct stent placement, and summarized the applications of pancreatic duct stents in surgery.
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Affiliation(s)
- Jin Hui Yi
- Department of Gastroenterology, First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Zhao Shen Li
- Department of Gastroenterology, First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Liang Hao Hu
- Department of Gastroenterology, First Affiliated Hospital of Naval Medical University, Shanghai, China
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Tringali A, Costa D, Rota M, Adler DG, Costamagna G. Covered self-expandable metal stents for pancreatic duct stricture: a systematic review and meta-analysis. Endosc Int Open 2022; 10:E1311-E1321. [PMID: 36118636 PMCID: PMC9473849 DOI: 10.1055/a-1880-7430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 06/14/2022] [Indexed: 11/09/2022] Open
Abstract
Background and study aims Placement of a covered (C)-self-expandable metal stent (SEMS) has been recently investigated as an alternative endoscopic treatment for main pancreatic duct stricture (MPDS) in chronic pancreatitis. Our aim was to carry out a systematic review and meta-analysis of studies quantifying efficacy and safety of C-SEMSs in the management of MPDS. Methods A multiple database search was performed, including MEDLINE, Embase and Cochrane Library, from January 2000 to September 2020, to identify studies reporting the efficacy and safety of C-SEMSs in patients with MPDS. Stricture and pain resolution were investigated. Other outcomes included technical success, stent migration, stricture recurrence and need for repeated stent placement. Pancreatitis, severe abdominal pain requiring stent removal and de-novo stricture were recorded as complications. Results Nineteen studies were identified, which included a total of 300 patients. C-SEMSs showed a pooled stricture resolution rate of 91 % [95 % confidence interval (CI), 85 %-96 %] and a pooled pain resolution rate of 92 % (95 % CI, 85 %-98 %). The pooled proportion for stricture recurrence was equal to 6 % (95 % CI, 1 %-14 %), while stent migration occurred in 33 of 300 patients, the pooled proportion being 7 % (95 % CI 1 %-15 %). The pooled mean stent duration was 133 days (95 % CI, 100-166 days). The most common complication was pancreatitis (3 %, 95 % CI 0 %-8 %), while de-novo stricture pooled proportion was 2 % (95 % CI, 0 %-5 %). Conclusions C-SEMSs are effective and safe in the treatment of MPDS. However, there is a significant need for further high-quality, well-designed studies to produce evidence-based data on short and long-term efficacy, safety, costs of C-SEMSs, and also optimal stent duration.
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Affiliation(s)
- Alberto Tringali
- Endoscopy Unit, Department of Medicine, ULSS 2 Marca Trevigiana, Conegliano Hospital, Italy
| | - Deborah Costa
- Endoscopy Unit, Department of Medicine, ULSS 2 Marca Trevigiana, Conegliano Hospital, Italy
| | - Matteo Rota
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Douglas G. Adler
- Center for Advanced Therapeutic Endoscopy (CATE), Centura Health, Denver, Colorado, United States
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
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11
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Nabi Z, Lakhtakia S. Endoscopic management of chronic pancreatitis. Dig Endosc 2021; 33:1059-1072. [PMID: 33687105 DOI: 10.1111/den.13968] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/02/2021] [Accepted: 03/05/2021] [Indexed: 02/05/2023]
Abstract
Chronic pancreatitis (CP) is an inflammatory process characterized by irreversible morphological changes in the pancreas. Pain is the predominant symptom observed during the course of CP. The etiopathogenesis of pain in CP is multifactorial and includes ductal hypertension due to obstruction of the pancreatic duct (PD), neuropathic causes, and extrapancreatic complications of CP like pseudocyst and distal biliary obstruction. A sizeable proportion of patients with CP are amenable to endoscopic treatment. The mainstay of endotherapy includes decompression of PD with one or more plastic stents in those with stricture, and fragmentation of PD calculi using extracorporeal shock wave lithotripsy. Nearly two-thirds of the patients achieve pain relief in the long term with endotherapy. Upfront assessment for the suitability of endotherapy is paramount to achieve the best outcomes. The predictors of poor response to endotherapy include multifocal disease, like those with multifocal strictures or multiple calculi throughout the pancreas, or a combination of both PD strictures and stones. With the emerging use of covered metal stents, the outcomes are likely to improve in cases with refractory PD strictures as well as CP-related distal biliary obstruction. The optimum stent design and indwell time of metal stents in cases with refractory PD strictures need further evaluation. Endoscopic ultrasonography has emerged as a complementary endoscopic modality in the management of CP as well as associated complications like pseudocysts, refractory pain, and vascular complications.
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Affiliation(s)
- Zaheer Nabi
- Asian Institute of Gastroenterology, Hyderabad, India
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12
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Lam R, Muniraj T. Fully covered metal biliary stents: A review of the literature. World J Gastroenterol 2021; 27:6357-6373. [PMID: 34720527 PMCID: PMC8517778 DOI: 10.3748/wjg.v27.i38.6357] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 07/09/2021] [Accepted: 08/27/2021] [Indexed: 02/06/2023] Open
Abstract
Fully covered self-expandable metal stents (FCSEMS) represent the latest advancement of metal biliary stents used to endoscopically treat a variety of obstructive biliary pathology. A large stent diameter and synthetic covering over the tubular mesh prolong stent patency and reduce risk for tissue hyperplasia and tumor ingrowth. Additionally, FCSEMS can be easily removed. All these features address issues faced by plastic and uncovered metal stents. The purpose of this paper is to comprehensively review the application of FCSEMS in benign and malignant biliary strictures, biliary leak, and post-sphincterotomy bleeding.
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Affiliation(s)
- Robert Lam
- Department of Medicine, Yale University School of Medicine, New Haven, CT 06520, United States
| | - Thiruvengadam Muniraj
- Department of Medicine, Yale University School of Medicine, New Haven, CT 06520, United States
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Han SY, Papachristou GI, Shah RJ, Conwell DL. Effect of pancreatic endotherapy on quality of life in chronic pancreatitis patients: A systematic review. World J Gastrointest Endosc 2021; 13:336-355. [PMID: 34512881 PMCID: PMC8394180 DOI: 10.4253/wjge.v13.i8.336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 06/11/2021] [Accepted: 07/13/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreatic endotherapy provides treatment options for the management of chronic pancreatitis-related structural complications such as pancreatic duct stones, strictures, and pancreatic fluid collections. Most studies detailing endotherapy, however, have focused on technical success outcomes such as stone clearance or stricture resolution. AIM To review the effect of pancreatic endotherapy on patient-centered outcomes. METHODS Systematic review of studies examining pancreatic endotherapy. RESULTS A total of 13 studies including 3 randomized clinical trials were included. The majority of studies found an improvement in quality of life with pancreatic endotherapy. CONCLUSION While pancreatic endotherapy does appear to improve quality of life, there are clear gaps in knowledge regarding many pancreatic endotherapy modalities. Furthermore, qualitative analysis is lacking in these studies and further work is needed to elucidate the patient experience with pancreatic endotherapy.
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Affiliation(s)
- Samuel Y Han
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Georgios I Papachristou
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Raj J Shah
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, United States
| | - Darwin L Conwell
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
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14
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Sanders DJ, Bomman S, Krishnamoorthi R, Kozarek RA. Endoscopic retrograde cholangiopancreatography: Current practice and future research. World J Gastrointest Endosc 2021; 13:260-274. [PMID: 34512875 PMCID: PMC8394185 DOI: 10.4253/wjge.v13.i8.260] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/18/2021] [Accepted: 07/09/2021] [Indexed: 02/06/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a primarily diagnostic to therapeutic procedure in hepatobiliary and pancreatic disease. Most commonly, ERCPs are performed for choledocholithiasis with or without cholangitis, but improvements in technology and technique have allowed for management of pancreatic duct stones, benign and malignant strictures, and bile and pancreatic leaks. As an example of necessity driving innovation, the new disposable duodenoscopes have been introduced into practice. With the advantage of eliminating transmissible infections, they represent a paradigm shift in quality improvement within ERCP. With procedures becoming more complicated, the necessity for anesthesia involvement and safety of propofol use and general anesthesia has become better defined. The improvements in endoscopic ultrasound (EUS) have allowed for direct bile duct access and EUS facilitated bile duct access for ERCP. In patients with surgically altered anatomy, selective cannulation can be performed with overtube-assisted enteroscopy, laparoscopic surgery assistance, or the EUS-directed transgastric ERCP. Cholangioscopy and pancreatoscopy use has become ubiquitous with defined indications for large bile duct stones, indeterminate strictures, and hepatobiliary and pancreatic neoplasia. This review summarizes the recent advances in infection prevention, quality improvement, pancreaticobiliary access, and management of hepatobiliary and pancreatic diseases. Where appropriate, future research directions are included in each section.
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Affiliation(s)
- David J Sanders
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
| | - Shivanand Bomman
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
| | - Rajesh Krishnamoorthi
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
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15
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Sofi AA, Khan MA, Ahmad S, Khan Z, Peerzada MM, Sunguk J, Vargo J. Comparison of clinical outcomes of multiple plastic stents and covered metal stent in refractory pancreatic ductal strictures in chronic pancreatitis- a systematic review and meta-analysis. Pancreatology 2021; 21:854-861. [PMID: 33941467 DOI: 10.1016/j.pan.2021.03.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 02/24/2021] [Accepted: 03/26/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Symptomatic pancreatic duct (PD) strictures in chronic pancreatitis refractory to single plastic stenting are usually managed by placement of multiple plastic stents (MPS). Fully covered self-expanding metallic stents (FCSEMS) have also been used in the management of these patients. However, the overall efficacy and safety of different types of stents is unclear from the currently available studies. We performed this meta-analysis to assess the efficacy and complications from MPS and FCSEMS in patients with PD strictures refractory to treatment with single plastic stents. METHODS Several electronic databases were searched for all the studies evaluating the outcome of placement of multiple plastic stents and fully covered metal stents in patients with PD strictures refractory to single plastic stenting. We calculated the Weighted Pooled Ratio (WPR) with Confidence Interval (CI) between the MPS and FCSEMS. RESULTS A total of 13 studies (including 2 abstracts) were included in the analysis. MPS were placed in 106 patients and FCSEMS in 192 patients. Improvement in pain after stenting (P = 0.794), risk of recurrence of pain after removal of stent (P = 0.48) and stricture recurrence after stent removal (P = 0.52) were comparable between MPS and FCSEMS. Risk of endoscopic re-intervention was also comparable between metal stents and MPS. However, FCSEMS was associated with overall higher risk of adverse events (P < 0.0001). CONCLUSION FCSEMS are comparable to multiple plastic stents in the treatment of symptomatic refractory PD strictures. However, use of FCSEMS is associated with increased risk of adverse events.
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Affiliation(s)
- Aijaz Ahmed Sofi
- Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Muhammad Ali Khan
- Division of Gastroenterology, University of Alabama, Birmingham, AL, USA
| | | | - Zubair Khan
- Division of Gastroenterology, University of Texas-Houston, Houston, TX, USA
| | | | - Jang Sunguk
- Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John Vargo
- Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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16
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Kong YL, Zhang HY, Liu CL, He XJ, Zhao G, Wang C, Kong LH, Zhao J. Improving biliary stent patency for malignant obstructive jaundice using endobiliary radiofrequency ablation: experience in 150 patients. Surg Endosc 2021; 36:1789-1798. [PMID: 33788032 DOI: 10.1007/s00464-021-08457-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 03/17/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although self-expandable mental stents (SEMS) placement is the standard care for relieving obstructive jaundice caused by unresectable malignant biliary stricture, how to maintain stent potency remains an intractable problem. This study was to evaluate the efficacy and safety of endobiliary radiofrequency ablation (RFA) through percutaneous transhepatic cholangiography (PTC) pathway in treating such patients. METHODS Consecutive patients who were performed endobiliary RFA as well as SEMS placement because of unresectable malignant obstructive jaundice in single institution in recent 8 years were retrospectively reviewed. As comparison, patients who underwent only percutaneous SEMS placement for unresectable malignant biliary stricture during the contemporary period were reviewed. Stent patency, complications, complications, and overall survival (OS) were investigated and analyzed. RESULTS One hundred and fifty patients who underwent endobiliary RFA and 127 patients who underwent only stent placement were included in this study. In the study group of endobiliary RFA, 87 patients (58.0%) underwent ablation for 1 time, 49 (32.7%) for 2 times, and 14 (9.3%) for 3 times. Complications related to RFA as well as SEMS placement happened in 113 patients (75.3%), without severe complications that needed emergent surgery or interventional therapy. The median duration of stent patency after ablation was 11.2 month, and the median survival time was 12.3 month. As comparison, difference was found in the number of interventional procedures and stents placed, duration of initial stent patency, and the incidence of moderate bleeding and pain. In the study group, only the type of tumor that caused biliary obstruction (intrahepatic carcinoma vs. extrahepatic carcinoma) was a poor independent factor (P = 0.035) for recurrent biliary obstruction. Repeated interventional therapy and adoption of subsequent therapy were only independent factors for OS. CONCLUSIONS Endobiliary RFA and SEMS placement is technically safe and feasible for unresectable malignant obstructive jaundice to improve the quality of life and prolong survival.
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Affiliation(s)
- Ya-Lin Kong
- Department of Hepatobiliary Surgery, Chinese PLA Air Force Medical Center Affiliated To Air Force Military Medical University, 30 Fucheng Rd, Beijing, 100142, China.
| | - Hong-Yi Zhang
- General Surgery Department, Tiantan Hospital Affiliated To Capital Medical University, Beijing, 100070, China
| | - Cheng-Li Liu
- Department of Hepatobiliary Surgery, Chinese PLA Air Force Medical Center Affiliated To Air Force Military Medical University, 30 Fucheng Rd, Beijing, 100142, China
| | - Xiao-Jun He
- Department of Hepatobiliary Surgery, Chinese PLA Air Force Medical Center Affiliated To Air Force Military Medical University, 30 Fucheng Rd, Beijing, 100142, China
| | - Gang Zhao
- Department of Hepatobiliary Surgery, Chinese PLA Air Force Medical Center Affiliated To Air Force Military Medical University, 30 Fucheng Rd, Beijing, 100142, China
| | - Cheng Wang
- Department of Hepatobiliary Surgery, Chinese PLA Air Force Medical Center Affiliated To Air Force Military Medical University, 30 Fucheng Rd, Beijing, 100142, China
| | - Ling-Hong Kong
- Department of Hepatobiliary Surgery, Chinese PLA Air Force Medical Center Affiliated To Air Force Military Medical University, 30 Fucheng Rd, Beijing, 100142, China
| | - Jing Zhao
- Department of Hepatobiliary Surgery, Chinese PLA Air Force Medical Center Affiliated To Air Force Military Medical University, 30 Fucheng Rd, Beijing, 100142, China
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17
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Vila JJ, Bolado F. Endoscopic management of local complications of chronic pancreatitis. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 113:602-609. [PMID: 33267598 DOI: 10.17235/reed.2020.7372/2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Endoscopic treatment of local complications in patients with chronic pancreatitis has gained ground over the surgical alternative in the last few years. The lower aggressiveness of endoscopic treatment, as well as the possibility to use it repeatedly in high-risk patients, has favored this development. In addition, the incorporation of new, highly accurate endoscopic therapeutic options such as pancreatoscopy-guided lithotripsy and endoscopic ultrasound-guided treatments make endoscopic treatment the first choice in many cases, despite discordant data in the literature. This article reviews the endoscopic treatment of the most common local complications of chronic pancreatitis, such as pancreatolithiasis, pseudocysts, and pancreatic, biliary, and duodenal ductal stenosis.
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Affiliation(s)
- Juan J Vila
- Aparato Digestivo, Complejo Hospitalario de Navarra, España
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18
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Han S, Shah RJ. Cholangiopancreatoscopy-guided laser dissection and ablation for pancreas and biliary strictures and neoplasia. Endosc Int Open 2020; 8:E1091-E1096. [PMID: 32743063 PMCID: PMC7373658 DOI: 10.1055/a-1192-4082] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 05/08/2020] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Cholangiopancreatoscopy-guided laser dissection or ablation (CPL) is a novel therapeutic modality for refractory benign strictures. Our aim was to describe the safety and efficacy of CPL for pancreaticobiliary disorders. Patients and methods Patients who underwent CPL using holmium or thulium laser between February 2017 and September 2019 were included. For stricture dissection, gentle strokes of the laser fiber from a distal to proximal approach were applied until luminal patency permitted advancement of the cholangiopancreatoscope. Immediate technical success was defined as ability to traverse the stricture with the cholangiopancreatoscope after CPL. Short-term technical success was defined as > 90 % resolution of the stricture on follow-up pancreatogram. Results Eleven patients underwent a mean of 3.6 ERCPs (mean total diameter of 14.2 Fr of stenting) prior to CPL. Indications included pancreatic duct stricture (n = 8), pancreaticojejunostomy anastomotic stricture (n = 1), bile duct stricture (n = 1) and pancreatic intraductal papillary mucinous neoplasm ablation (n = 1). Immediate technical success was 94.1 % and short-term technical success rates was 88.2 %. At a mean follow-up of 12.1 months, there have been no stricture recurrences. Conclusions CPL may be an effective therapy for strictures refractory to conventional dilation and multiple stenting.
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Affiliation(s)
- Samuel Han
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Raj J. Shah
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
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19
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Han S, Shah RJ. No flare(s), no problem: treating recalcitrant pancreatic duct strictures with short fully covered metal stents. Gastrointest Endosc 2020; 91:834-836. [PMID: 32204816 DOI: 10.1016/j.gie.2019.12.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 12/27/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Samuel Han
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Raj J Shah
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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