What are the long-term results of endoscopic pancreatic sphincterotomy?

Adverse Events and Reinterventions Following Pancreatic Endoscopic Sphincterotomy

OBJECTIVES

Pancreatic endoscopic sphincterotomy (PES) is an independent risk factor for short- and long-term adverse events (AEs) of endoscopic retrograde cholangiopancreatography. We sought to measure PES-specific AEs and trends in the use of PES.

METHODS

This was a retrospective cohort of consecutive patients who underwent first-time PES between June 2008 and June 2015. Indications for PES were dichotomized: (1) structural pathology (chronic pancreatitis and local complications of acute pancreatitis) and (2) suspected sphincter pathology (idiopathic recurrent acute pancreatitis and sphincter of Oddi dysfunction). Rates of AEs and pancreatic orifice reinterventions were measured, with reintervention rates limited to those having a minimum of 12-month follow-up.

RESULTS

Of 567 patients, 198 (34.9%) underwent PES for structural and 369 (65.1%) for suspected sphincter pathology. Rates of post-endoscopic retrograde cholangiopancreatography pancreatitis and unplanned hospitalization were high when PES was originally performed for suspected sphincter pathology (12.6% and 14.6%, respectively). The overall reintervention rate was 28.9% and significantly greater for sphincter (41.7%) compared with structural pathology (13.5%, P = 0.005).

CONCLUSIONS

The likelihood of reintervention after PES is high, particularly when the primary indication is suspected sphincter pathology such as idiopathic recurrent acute pancreatitis. Further prospective studies are needed to clarify if and when this maneuver confers significant benefit to patients.

Hereditary pancreatitis: current perspectives

Hereditary pancreatitis (HP) is a rare cause of acute, recurrent acute, and chronic pancreatitis. It may present similarly to other causes of acute and chronic pancreatitis, and often there has been a protracted evaluation prior to the diagnosis of HP. Since it was first described in 1952, multiple genetic defects that affect the action of digestive enzymes in the pancreas have been implicated. The most common mutations involve the PRSS1, CFTR, SPINK1, and CTRC genes. New mutations in these genes and previously unrecognized mutations in other genes are being discovered due to the increasing use of next-generation genomic sequencing. While the inheritance pathways of these genetic mutations may be variable and complex, sometimes involving coinheritance of other mutations, the clinical presentation of patients tends to be similar. Interactions with environmental triggers often play a role. Patients tend to present at an early age (prior to the second decade of life) and have a significantly increased risk for the development of pancreatic adenocarcinoma. Patients with HP may develop sequelae of chronic pancreatitis such as strictures and fluid collections as well as exocrine and endocrine insufficiency. Management of patients with HP involves avoidance of environmental triggers, surveillance for pancreatic adenocarcinoma, medical therapy for endocrine and exocrine insufficiency, pain management, and endoscopic or surgical treatment for complications. Care for affected patients should be individualized, with an emphasis on early diagnosis and multidisciplinary involvement to develop a comprehensive treatment strategy.

The Role of Endoscopic Retrograde Cholangiopancreatography in Management of Pancreatic Diseases

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.

Current status of endotherapy for chronic pancreatitis

Chronic pancreatitis is associated with varied morphological complications, including intraductal stones, main pancreatic ductal strictures, distal biliary strictures and pseudocysts. Endoscopic therapy provides a less invasive alternative to surgery. In addition, extracorporeal shockwave lithotripsy improves the success rate of endoscopic clearance of intraductal stones. However, recent data from randomised trials have shown better long-term outcomes with surgical drainage for obstructive pancreatic ductal disease. In patients with distal biliary strictures, stent insertion leads to good immediate drainage, but after stent removal, recurrent narrowing is common. Endoscopic drainage of pancreatic pseudocysts has excellent outcome and should be accompanied by pancreatic ductal stenting when a ductal communication is evident. In those who remain symptomatic, endoscopic ultrasonography-guided coeliac plexus block may provide effective but short-term pain relief. In this review, we present the current evidence for the role of endotherapy in the management of patients with chronic pancreatitis.

Sphincter of Oddi Dysfunction

This article reviews the diagnosis and management of sphincter of Oddi dysfunction (SOD), including the various factors to consider before embarking on endoscopic therapy for SOD. Selection starts with patient education to include possible patient misconceptions related to symptoms caused by the pancreaticobiliary sphincter as well as reinforcing the risks associated with the diagnosis and therapy. The likelihood of relief of recurrent abdominal pain attributed to SOD is related to the classification of SOD type and a crucial consideration before considering endoscopic therapy in light of recent evidence.

Sphincter of Oddi dysfunction: an evidence-based review

Sphincter of Oddi dysfunction is a painful syndrome that presents as recurrent episodes of right upper quadrant biliary pain, or recurrent idiopathic pancreatitis. It is a disease process that has been a subject of controversy, in part because its natural history, disease course and treatment outcomes have not been clearly defined in large controlled studies with long-term follow-up. This review is aimed at clarifying the state-of-the-art with an evidence-based summary of the current diagnostic and therapeutic approaches and modalities for sphincter of Oddi dysfunction.

Endoscopic therapy for acute recurrent pancreatitis

Endoscopy plays an important role in both the diagnosis and the initial management of recurrent acute pancreatitis, as well as the investigation of refractory disease, but it has known limitations and risks. Sound selective use of these therapies, complemented with other lines of investigation such as genetic testing, can dramatically improve frequency of attacks and associated quality of life. Whether endoscopic therapy can reduce progression to chronic pancreatitis, or reduce the risk of malignancy, is debatable, and remains to be proven.

Endoscopic approach to the patient with motility disorders of the bile duct and sphincter of Oddi

Since its original description by Oddi in 1887, the sphincter of Oddi has been the subject of much study. Furthermore, the clinical syndrome of sphincter of Oddi dysfunction (SOD) and its therapy are controversial areas. Nevertheless, SOD is commonly diagnosed and treated by physicians. This article reviews the epidemiology, clinical manifestations, and current diagnostic and therapeutic modalities of SOD.

Hereditary pancreatitis for the endoscopist

Hereditary pancreatitis shares a majority of clinical and morphologic features with chronic alcoholic pancreatitis, but may present at an earlier age. The term hereditary pancreatitis has primarily been associated with mutations in the serine protease 1 gene (PRSS1) which encodes for cationic trypsinogen. PRSS1 mutations account for approximately 68-81% of hereditary pancreatitis. Mutations in other genes, primarily serine protease inhibitor Kazal type 1 (SPINK1) and the cystic fibrosis transmembrane conductance regulator (CFTR) are also associated with hereditary pancreatitis. While chronic alcoholic pancreatitis may develop in the fourth or fifth decades, patients with hereditary pancreatitis may develop symptoms in the first or second decades of life. Hereditary pancreatitis is diagnosed either by detecting a causative gene mutation or by the presence of chronic pancreatitis in two first-degree or three second-degree relatives, in two or more generations, without precipitating factors and with a negative workup for known causes. Patients with hereditary pancreatitis may have recurrent acute pancreatitis and may develop pancreatic exocrine and endocrine insufficiency. Hereditary pancreatitis may involve premature trypsinogen activation or decreased control of trypsin. Recurrent inflammation can lead to acute pancreatitis and subsequently to chronic pancreatitis with parenchymal calcification. There is a markedly increased risk of pancreatic carcinoma compared with the general population. Patients are often referred for evaluation of pancreatitis, biliary or pancreatic ductal dilatation, jaundice, biliary obstruction, pancreatic duct stone or stricture, pancreatic pseudocysts, and for evaluation for malignancy. Medical treatment includes pancreatic enzyme supplementation, nutritional supplementation, diabetes management, and palliation of pain. Patients should avoid tobacco use and alcohol exposure. Hereditary pancreatitis is reviewed and recommendations for genetic testing are discussed.

Dynamic changes of echogenicity and the size of the papilla of Vater before and after cholecystectomy

This study investigated the changes in echogenicity, as measured by endoscopic ultrasound, and the surface area of the papilla of Vater (PV) and their relationship with postoperative symptoms in a group of 80 patients with symptomatic gallstones before and at 3 and 6 months after cholecystectomy. After cholecystectomy, 50 patients experienced early atypical symptoms characteristic of postcholecystectomy syndrome (PCS) and 30 patients were asymptomatic. The surface area of the PV was larger than normal prior to surgery and increased after surgery. The healthy PV is isoechogenic, but 48% of all patients were anisoechogenic preoperatively, increasing to 61% at 3 months after surgery, and decreasing to 25% at 6 months postsurgery. There was no significant difference between the two patient groups, suggesting that the changes observed in the PV do not explain the presence of the atypical symptoms of PCS.

Endoscopic therapy in chronic pancreatitis

Chronic pancreatitis (CP) is a debilitating disease that can result in chronic abdominal pain, malnutrition, and other related complications. The main aims of treatment are to control symptoms, prevent disease progression, and correct any complications. A multidisciplinary approach involving medical, endoscopic, and surgical therapy is important. Endoscopic therapy plays a specific role in carefully selected patients as primary interventional therapy when medical measures fail or in patients who are not suitable for surgery. Endoscopic therapy is also used as a bridge to surgery or as a means to assess the potential response to pancreatic surgery. This review addresses the role of endoscopic therapy in relief of obstruction of the pancreatic duct (PD) and bile du ct, closure of PD leaks, and drainage of pseudocysts in CP. The role of endoscopic ultrasound-guided celiac plexus block for pain in chronic pancreatitis is also discussed.

Extracorporeal shock wave lithotripsy with a transportable mini-lithotripter and subsequent endoscopic treatment improves clinical outcome in obstructive calcific chronic pancreatitis

BACKGROUND

Extracorporeal shock wave lithotripsy (ESWL) of pancreatic duct stones followed by ERCP with mechanical clearance of the pancreatic duct and subsequent stenting is an established treatment option for chronic calcific pancreatitis.

OBJECTIVE

To test the efficacy of a modified transportable mini-lithotripter for ESWL of pancreatic duct stones.

DESIGN

Prospective single-center study.

SETTING

University hospital.

PATIENTS

This study involved 32 patients with obstructive chronic calcific pancreatitis and pain in whom previous endoscopic stone removal and pancreatic duct decompression had failed.

INTERVENTIONS

ESWL followed by ERCP for stone clearance of the pancreatic duct and mechanical removal of stones or stenting.

MAIN OUTCOME MEASUREMENTS

Endoscopic duct clearance and/or stent insertion, pain and quality-of-life scores.

RESULTS

A median of 4 ESWL sessions (interquartile range 2.75-8.5) with a median of 6800 shock waves (4225-15,425) were required. Pain relief after ESWL only was noted in 24 patients (75.0%), whereas no change in the intensity of pain was reported by 7 patients (21.9%), and pain was worse in 1 patient. All patients underwent ERCP and stent placement, resulting in complete resolution of pain in 17 patients (53.1%) and pain improvement in 28 patients (87.5%). The quality-of-life score was significantly improved after ESWL and endoscopic clearance or stenting in all patients.

LIMITATIONS

Uncontrolled study.

CONCLUSIONS

ESWL with the mini-lithotripter results in fragmentation of pancreatic duct calculi. ESWL in conjunction with endoscopic clearance of the pancreatic duct and stenting is associated with significant improvement in clinical outcome and quality of life in patients with obstructive calcific chronic pancreatitis.

Therapeutic pancreatic endoscopy

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.

What is the role of endotherapy in chronic pancreatitis?

Chronic pancreatitis (CP) can have debilitating clinical course due to chronic abdominal pain, malnutrition and related complications. Medical, endoscopic and surgical treatment of CP should aim at control of symptoms, prevention of progression of the disease and correction of complications. Endoscopic management plays a specific role in carefully selected patients as primary interventional therapy when medical measures fail or in high-risk surgical candidates. Endotherapy for CP is utilized also as a bridge to surgery or to assess potential response to pancreatic surgery. In this review we address the role of endotherapy for the relief of obstruction of the pancreatic duct (PD) and bile duct, closure of PD leaks and drainage of pseudocysts in the setting of CP. In addition, endotherapy for relief of pancreatic pain by endoscopic ultrasound-guided celiac plexus block for CP is discussed.

Pain and chronic pancreatitis: is it the plumbing or the wiring?

Our progress in understanding the biology of chronic pancreatitis has been slow, particularly with respect to the pathogenesis of pain, the cardinal symptom. Although traditional theories have focused on anatomic changes, with interstitial and ductal hypertension as the main inciting factors for pain generation, subsequent studies have not confirmed a correlation between ductal pressure and the severity of pain or its relief after ductal decompression. Empirical approaches directed at anatomic causes are at best of marginal value. Although these phenomena are clearly associated with the disease, they are not likely the root cause of the pain. Instead, they probably are inciting factors on a background of neuronal sensitization induced by damage to the perineurium and subsequent exposure of the nerves to mediators and products of inflammation. In this review, we discuss the inherent limitations in our current therapies and try to identify new targets and approaches for the future, such as TRPV1, nerve growth factor-TrkA signaling, and perhaps protease activator receptor-2.

Transduodenal sphincteroplasty in the management of sphincter of Oddi dysfunction and pancreas divisum in the modern era

BACKGROUND

Surgical management of sphincter of Oddi dysfunction and pancreas divisum is controversial. In the modern era of therapeutic endoscopy, pain persisting despite endoscopic sphincterotomy and anatomy that makes the ampulla endoscopically inaccessible prompt referral for surgical transduodenal sphincteroplasty (TS). A retrospective review of sphincter of Oddi dysfunction and pancreas divisum patients who underwent TS for refractory pain in a recent time period was undertaken.

STUDY DESIGN

The medical records of all patients who underwent TS for sphincter of Oddi dysfunction and pancreas divisum at the Medical University of South Carolina between January 2001 and December 2005 were reviewed. Longterm outcomes were assessed by a standardized written questionnaire and the SF-36 version 2 Quality of Life Survey.

RESULTS

Sixty-eight patients underwent TS (median age 43 years, 54 women). Fifty-one had earlier endoscopic sphincterotomy; 17, with previous gastric surgery, did not. Operative morbidity was 10.3%, with no mortality. Forty-five patients (66%) completed the questionnaire; 62% had improvement in pain, without reintervention, over a median followup of 42.5 months (range 16 to 75 months). There was a trend toward more favorable outcomes in patients with earlier gastric surgery (no previous endoscopic sphincterotomy) compared with others (90% versus 54%, p=0.06). Multivariate analysis showed chronic pancreatitis (odds ratio 0.11 [95% CI 0.02 to 0.68; p=0.02]) and younger age (odds ratio 3.9 [95% CI 1.32 to 11.53; p=0.01] per decade) were independent predictors of poorer outcomes.

CONCLUSIONS

Good longterm outcomes with low operative morbidity can be obtained with TS in selected patients, including those with postgastric bypass, but younger age and chronic pancreatitis appear to predict poorer outcomes.

The role of endoscopy in the therapy of chronic pancreatitis

Almost all the therapeutic efforts in the treatment of chronic pancreatitis are directed towards pain control. Endoscopic techniques available for this purpose are endoscopic retrograde cholangiopancreatography (combined or not with extracorporeal shock wave lithotripsy) and endoscopic ultrasound. Pancreatic stones and strictures, pancreatic pseudocysts, and common bile duct strictures complicating chronic pancreatitis can be treated by endoscopy. The development of endoscopic ultrasound extended the possibilities in the treatment of pancreatic pseudocysts and main pancreatic duct drainage. Endoscopy is considered the first-line treatment in chronic pancreatitis and can be useful also as a 'bridge to surgery'. In fact the endoscopic approach to chronic pancreatitis can predict the response to surgical therapy as a definitive treatment. Medical, endoscopic and surgical methods for the management of chronic pancreatitis should all be considered in decision-making, and the best treatment should be chosen case by case and according to the local expertise.

Pancreatic sphincterotomy: Technique, indications, and complications

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.

Endoscopic pancreatic-stent placement and sphincterotomy for relief of pain in tropical pancreatitis: results of a 1-year follow-up

BACKGROUND

Tropical chronic pancreatitis frequently presents with intractable abdominal pain. Surgical treatment has its own morbidity and mortality, and long-term results may not be satisfactory.

OBJECTIVE

To analyze the results of endoscopic pancreatic-stent placement and sphincterotomy for the pain of tropical pancreatitis.

DESIGN

Retrospective review.

SETTING

Tertiary-referral hospital.

PATIENTS

Twenty-four patients with tropical pancreatitis with severe, persistent pain not responding to standard medical therapy over a period of 30 months beginning January 1998.

INTERVENTIONS

Stent placement of the pancreatic duct, along with sphincterotomy.

MAIN OUTCOME MEASUREMENTS

At least 80% global improvement in pain as reported by the patient during follow-up after the procedure.

RESULTS

In the 19 evaluable patients, the intended procedure, pancreatic stent placement along with sphincterotomy, was successful in 14 (73.7%); 3 others had sphincterotomy alone. Over a follow-up period of 6 to 38 months, 12 of the 14 patients (85.7%) who underwent stent placement plus sphincterotomy and 2 of the 3 patients who had sphincterotomy alone responded. Twelve of these were completely free of pain, and the remaining 2 patients had mild infrequent pain that occurred once in 2 to 4 months, lasting a few hours at a time and never needing hospitalization. The only major complication was the development of pancreatic sepsis, which required stent removal in 1 patient. Eight patients were stent free at the end of 6 months, and, over a further follow-up of 6 to 20 months, the pattern of pain relief persisted in them.

LIMITATIONS

The retrospective nature of the study, the limited numbers studied, and the lack of assessment of pain on a standard visual analog scale.

CONCLUSIONS

Stent placement of the pancreatic duct with pancreatic sphincterotomy constitutes an important nonsurgical therapeutic option for the intractable pain of tropical pancreatitis.

Endoscopic stent therapy for patients with chronic pancreatitis: results from a prospective follow-up study

OBJECTIVES

Obstruction of the pancreatic duct is a common feature of chronic pancreatitis and often requires interventional therapy. The current prospective study investigated clinical success in 19 patients after initial endoscopic retrograde pancreaticography and relapse rates during a 2-year follow-up period.

METHODS

Seventeen of 19 patients with chronic pancreatitis (stage III according to the Cambridge classification) were treated by sphincterotomy and stent insertion. Endoscopic retrograde pancreaticography failed in 2 patients.

RESULTS

Strictures were cannulated, dilated, and stones were removed with a dormia basket in 13 of 17 patients. Extracorporeal shock wave lithotripsy was necessary in 5 patients. Polyethylene stents (7F-11.5F) were placed into the dilated pancreatic duct. Mean duration of internal pancreatic stenting was 5.6 months. Three of 17 patients had recurrence of pain during the first follow-up year after stent extraction; in the second follow-up year, another 2 patients had a relapse. Overall, patients' assessment of the stent therapy revealed complete satisfaction in 17 of 19 patients.

CONCLUSIONS

Endoscopic stent therapy is a safe, minimally invasive, and effective procedure in patients experiencing pain attacks during chronic pancreatitis associated with dilated pancreatic duct. According to our results, a relapse rate of approximately 30% can be expected within 2 years after stent extraction. These patients may be treated by repeated stent therapy.

Predictors of outcomes after biliary and pancreatic sphincterotomy for sphincter of oddi dysfunction

BACKGROUND

There are few data on combined pancreatic and biliary sphincterotomy for sphincter of Oddi dysfunction (SOD), especially regarding clinical features that might predict outcomes. We sought to examine the relative importance of various clinical features and the presence or absence of objective biliary abnormalities in determining responses to endoscopic therapy.

METHODS

A cohort of consecutive patients with suspected SOD was treated with biliary sphincterotomy, with additional pancreatic sphincterotomy at initial or subsequent endoscopic retrograde cholangiopancreatography if there was abnormal pancreatic manometry in conjunction with pain refractory to biliary sphincterotomy, continuous pain, or a history of amylase elevation. Repeat intervention was offered until response was achieved or complete ablation of all treated sphincters was achieved. Response was assessed by patients using a 5-point Likert scale, and multivariate logistic regression analysis used to identify predictors of response.

RESULTS

Of 121 patients, 112 (92%) were female, 105 (87%) postcholecystectomy, and by modified Milwaukee biliary classification 18 (15%) were type I, 53 (44%) type II, and 50 (41%) type III. All patients underwent biliary sphincterotomy and 49 (40%) pancreatic sphincterotomy. Good or excellent response at final follow-up was reported by 83 (69%) of 121 patients, including 37 (61%) of 61 patients requiring repeated intervention. Response was not significantly different between biliary types I, II, and III. Patient characteristics (with adjusted odds ratios) that were significant predictors of poor response were normal pancreatic manometry (4.6), delayed gastric emptying (6.0), daily opioid use (4.0), and age <40 (2.7). Abnormal liver function tests or dilated bile duct were not significant.

CONCLUSIONS

For the treatment of SOD incorporating pancreatic and biliary sphincterotomy, patient characteristics and pancreatic sphincter manometry may be more important predictors of outcome than the traditional classification based on liver chemistries and bile duct dilation.

Systematic review: sphincter of Oddi dysfunction--non-invasive diagnostic methods and long-term outcome after endoscopic sphincterotomy

BACKGROUND

Sphincter of Oddi dysfunction is a benign, functional gastrointestinal disorder for which invasive endoscopic therapy with potential complications is often recommended.

AIMS

To review the available evidence regarding the diagnostic accuracy of non-invasive methods that have been used to establish the diagnosis and to estimate the long-term outcome after endoscopic sphincterotomy.

METHODS

A systematic review of English language articles and abstracts containing relevant terms was performed.

RESULTS

Non-invasive diagnostic methods are limited by their low sensitivity and specificity, especially in patients with Type III sphincter of Oddi dysfunction. Secretin-stimulated magnetic resonance cholangiopancreatography appears to be useful in excluding other potential causes of symptoms, and morphine-provocated hepatobiliary scintigraphy also warrants further study. Approximately 85%, 69% and 37%, of patients with biliary Types I, II and III sphincter of Oddi dysfunction, respectively, experience sustained benefit after endoscopic sphincterotomy. In pancreatic sphincter of Oddi dysfunction, approximately 75% of patients report symptomatic improvement after pancreatic sphincterotomy, but the studies have been non-controlled and heterogeneous.

CONCLUSIONS

Patients with suspected sphincter of Oddi dysfunction, particularly those with biliary Type III, should be carefully evaluated before considering sphincter of Oddi manometry and endoscopic sphincterotomy. Further controlled trials are needed to justify the invasive management of patients with biliary Type III and pancreatic sphincter of Oddi dysfunction.

Endoscopic management of sphincter of Oddi dysfunction in children

BACKGROUND

Data on sphincter of Oddi dysfunction (SOD) in children are scant. Most children diagnosed with SOD are treated by biliary sphincterotomy with suboptimal results. The efficacy and safety of pancreatic and dual sphincterotomy in children with SOD has not been previously reported.

OBJECTIVE

To evaluate the efficacy and safety of pancreatic and dual sphincterotomy in children with SOD.

MATERIALS AND METHODS

Prospective evaluation of all children who underwent endoscopic retrograde cholangiopancreatogram (ERCP) with sphincter of Oddi manometry for evaluation of suspected SOD over a 3-year period. Children diagnosed with SOD underwent pancreatic or dual sphincterotomy with prophylactic pancreatic stenting.

RESULTS

SOD was diagnosed by sphincter of Oddi manometry in 6 of 11 children who underwent ERCP for suspected SOD. Of the 6 children (mean age, 11 years; range, 5-16; 4 girls) with SOD, 3 presented with recurrent pancreatitis and 3 with postcholecystectomy pain. Pancreatic sphincter hypertension was noted in all 6 patients; concomitant biliary sphincter hypertension was noted in 3 patients with postcholecystectomy pain. Patients with recurrent pancreatitis underwent pancreatic sphincterotomy and those with postcholecystectomy pain underwent dual sphincterotomy. Prophylactic pancreatic stents were placed in all patients. One girl experienced mild post-ERCP pancreatitis. At a mean follow-up of 583 days (range, 325-1445), 4 patients were asymptomatic, 1 experienced partial symptom relief and 1 had recurrent symptoms.

CONCLUSIONS

As in adults, pancreatic and dual sphincterotomy, in expert hands, is effective and safe in a subgroup of children with SOD. Prospective, randomized trials with larger number of patients are required to validate the efficacy of endotherapy in children with SOD.

Diagnosis and management of chronic pancreatitis

Chronic pancreatitis represents a condition that is challenging for clinicians secondary to the difficulty in making an accurate diagnosis and the less than satisfactory means of managing chronic pain. This review emphasises the various manifestations that patients with chronic pancreatitis may have and describes recent advances in medical and surgical therapy. It is probable that many patients with chronic abdominal pain are suffering from chronic pancreatitis that is not appreciated. As the pathophysiology of this disorder is better understood it is probable that the treatment will be more successful.

Endoscopic minor papilla interventions in patients without pancreas divisum

BACKGROUND

Endoscopic treatment through the minor papilla is well known in patients with pancreas divisum. However, there are few data concerning endoscopic minor papilla interventions in patients without pancreas divisum when access to the main pancreatic duct via the major papilla is technically difficult.

METHODS

Records for 213 patients without pancreas divisum who, from April 2001 to June 2003, underwent ERCP for various pancreatic diseases were retrospectively reviewed. Patients were included if they had endoscopic interventions via the minor papilla because access through the major papilla was not possible.

OBSERVATIONS

Minor papilla papillotomy or fistulotomy with endoscopic interventions was successful in 10 (91%) of 11 patients. Of these 10 patients, 9 had chronic pancreatitis and one had pancreatic ductal leak from previous pancreatic surgery. The reasons for the inability to access the main pancreatic duct to the tail of the gland via the major papilla included a distorted course of the main pancreatic duct (n=5), impacted stone (n=5), and stricture (n=8). In 8 patients, there were two causes. No complication related to the minor papilla interventions was observed in any patient.

CONCLUSIONS

Endoscopic minor papilla interventions are technically feasible in patients with pancreatic diseases but not pancreas divisum when access to the main pancreatic duct via the major papilla is not possible.

Endoscopic therapy of chronic pancreatitis

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.

Endoscopic management of chronic pancreatitis

Endoscopic management of CP is generally safe, minimally invasive, and often effective for years, does not hinder further surgery, and can be repeated. It should be applied as a first-line approach to improving the clinical condition of patients with this chronic disease. The best results are obtained when endoscopic treatment is performed early in the course of CP. Proper patient selection, adequate expertise, and a supporting multidisciplinary infrastructure are essential. New technologies will continue to be developed and to extend the scope of therapeutic pancreatic endoscopy.

Key issues in sphincter of Oddi dysfunction

SOD is a challenging condition that is difficult to diagnose and treat. The high failure rate of endoscopic and surgical treatment reflects the difficulties in establishing accurate diagnosis and the lack of specific objective criteria by which appropriate therapy could be determined. In general, sphincter ablation should be offered for type I patients. An initial trial of medical therapy is appropriate for type II patients with mild-to-moderate symptoms and for all type III patients. SOM is highly recommended for type II patients and is mandatory for all type III patients if sphincter ablation is contemplated. Other causes of abdominal pain such as chronic pancreatitis or functional disorders should be considered in patients not benefiting from sphincter ablation. All procedures on the sphincter should be undertaken with caution after meticulous investigation, and patient selection should be based on strict objective criteria.

Long-term outcome of endoscopic dual pancreatobiliary sphincterotomy in patients with manometry-documented sphincter of Oddi dysfunction and normal pancreatogram

BACKGROUND

For patients with sphincter of Oddi dysfunction and abnormal pancreatic basal sphincter pressure, additional pancreatic sphincterotomy has been recommended. The outcome of endoscopic dual pancreatobiliary sphincterotomy in patients with manometry-documented sphincter of Oddi dysfunction was evaluated.

METHODS

An ERCP database was searched for data entered from January 1995 to November 2000 on patients with sphincter of Oddi dysfunction who met the following parameters: sphincter of Oddi manometry of both ducts, abnormal pressure for at least 1 sphincter (> or =40 mm Hg), no evidence of chronic pancreatitis, and endoscopic dual pancreatobiliary sphincterotomy. Patients were offered reintervention by repeat ERCP if clinical symptoms were not improved. The frequency of reintervention was analyzed according to ducts with abnormal basal sphincter pressure, previous cholecystectomy, sphincter of Oddi dysfunction type, and endoscopic dual pancreatobiliary sphincterotomy method.

RESULTS

A total of 313 patients were followed for a mean of 43.1 months (median, 41.0 months; interquartile range: 29.8-60.0 months). Immediate postendoscopic dual pancreatobiliary sphincterotomy complications occurred in 15% of patients. Reintervention was required in 24.6% of patients at a median follow-up (interquartile range) of 8.0 (5.5-22.5) months. The frequency of reintervention was similar irrespective of ducts with abnormal basal sphincter pressure, previous cholecystectomy, or endoscopic dual pancreatobiliary sphincterotomy method. Of patients with type III sphincter of Oddi dysfunction, 28.3% underwent reintervention compared with 20.4% with combined types I and II sphincter of Oddi dysfunction (p = 0.105). When compared with endoscopic biliary sphincterotomy alone in historical control patients from our unit, endoscopic dual pancreatobiliary sphincterotomy had a lower reintervention rate in patients with pancreatic sphincter of Oddi dysfuntion alone and a comparable outcome in those with sphincter of Oddi dysfunction of both ducts.

CONCLUSION

Endoscopic dual pancreatobiliary sphincterotomy is useful in patients with pancreatic sphincter of Oddi dysfunction. Prospective randomized trials of endoscopic biliary sphincterotomy alone versus endoscopic dual pancreatobiliary sphincterotomy based on sphincter of Oddi manometry findings are in progress.

Pancreatitis: etiology, diagnosis, and management

Inflammation of the pancreas (pancreatitis) has many presentations in children and adolescents, ranging from intrauterine congenital onset with sequelae of early exocrine pancreatic insufficiency as in the diseases of cystic fibrosis and Shwachman-Diamond syndrome to postnatal onset as a consequence of embryologic anomalies affecting pancreatic drainage postulated to exist in pancreas divisum, or of traumatic, obstructive, hemodynamic, metabolic or biochemical insults. The etiology is often elusive with up to 30% of cases being idiopathic. Modern imaging modalities of endoscopic ultrasonography and magnetic resonance cholangiopancreatography extend the diagnostic power of conventional abdominal ultrasonography and computed tomography. In addition, there is increasing pediatric experience with endoscopic retrograde cholangiopancreatography. Medical management remains supportive, with optimal timing and indications for surgery in cases of pancreatic necrosis and pseudocyst assessed. Three temporal patterns of pancreatitis appear in children: acute pancreatitis, recurrent acute pancreatitis, and chronic pancreatitis. Acute pancreatitis is of abrupt onset, often attributable to a specific cause, and of variable severity and duration but self-limited with eventual resolution. Acute attacks of pancreatitis recurring after periods of remission characterize acute recurrent pancreatitis and indicate an intrinsic problem or susceptibility. Chronic pancreatitis is present in most of these cases in which pancreatic inflammation and destruction never completely remits.