1
|
Goda Y, Irie K, Anan H, Suzuki Y, Ikeda A, Ikeda R, Kaneko H, Sue S, Miwa H, Maeda S. The usefulness of texture and color enhancement imaging to identify the minor papilla orifice. DEN OPEN 2024; 4:e358. [PMID: 38586252 PMCID: PMC10995446 DOI: 10.1002/deo2.358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 03/10/2024] [Accepted: 03/19/2024] [Indexed: 04/09/2024]
Abstract
In clinical cases of pancreas divisum, endoscopic retrograde cholangiopancreatography often necessitates cannulation of the pancreatic duct through the minor papilla. Nevertheless, this procedure can be challenging because of the small size of the minor papilla and the difficulty in visualizing the ductal orifice. A new image-enhanced endoscopy technique called texture and color enhancement imaging (TXI) has been developed, which enhances texture, brightness, and color compared with white-light imaging, resulting in subtle differences in the surface mucosa. Herein, we describe the case of a 73-year-old man with pancreas divisum in whom TXI was useful in identifying the orifice of the minor papilla. He was referred to our hospital with repetitive acute exacerbation of chronic pancreatitis. Since contrast-enhanced computed tomography revealed a pancreatic stone in the main pancreatic duct, endoscopic retrograde cholangoepancreatography was performed as a therapeutic intervention. Despite the initial difficulty in identifying the orifice of the minor papilla on white-light imaging, TXI enhanced its visibility successfully, enabling dorsal pancreatic duct cannulation via the minor papilla. Subsequently, endoscopic pancreatic sphincterotomy was performed and a 6Fr plastic stent was placed. Post-endoscopic therapy, the patient's abdominal pain was relieved. TXI was useful in identifying the minor papilla orifice and led to successful cannulation.
Collapse
Affiliation(s)
- Yoshihiro Goda
- Division of GastroenterologyYokohama City University School of Medicine Graduate School of MedicineKanagawaJapan
| | - Kuniyasu Irie
- Division of GastroenterologyYokohama City University School of Medicine Graduate School of MedicineKanagawaJapan
| | - Hideyuki Anan
- Division of GastroenterologyYokohama City University School of Medicine Graduate School of MedicineKanagawaJapan
| | - Yuichi Suzuki
- Division of GastroenterologyYokohama City University School of Medicine Graduate School of MedicineKanagawaJapan
| | - Aya Ikeda
- Division of GastroenterologyYokohama City University School of Medicine Graduate School of MedicineKanagawaJapan
| | - Ryosuke Ikeda
- Division of GastroenterologyYokohama City University School of Medicine Graduate School of MedicineKanagawaJapan
| | - Hiroaki Kaneko
- Division of GastroenterologyYokohama City University School of Medicine Graduate School of MedicineKanagawaJapan
| | - Soichiro Sue
- Division of GastroenterologyYokohama City University School of Medicine Graduate School of MedicineKanagawaJapan
| | - Haruo Miwa
- Gastroenterological CenterYokohama City University Medical CenterKanagawaJapan
| | - Shin Maeda
- Division of GastroenterologyYokohama City University School of Medicine Graduate School of MedicineKanagawaJapan
| |
Collapse
|
2
|
Inamdar S, Cote GA, Yadav D. Endotherapy for Pancreas Divisum. Gastrointest Endosc Clin N Am 2023; 33:789-805. [PMID: 37709411 DOI: 10.1016/j.giec.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Pancreas divisum (PD) is a common anatomic variant of the pancreatic duct. Causal association between PD and pancreatitis has been debated for many years. Minor papilla sphincterotomy (miES) is offered in clinical practice to patients with idiopathic acute recurrent pancreatitis (iRAP) and PD. However, available data originate mainly from observational studies with many limitations. An ongoing international, multicenter, sham-controlled trial is evaluating the efficacy of miES in iRAP and PD. Endoscopic therapy for pain relief has limited to no benefit in patients with chronic abdominal pain or chronic pancreatitis who have PD and is not recommended.
Collapse
Affiliation(s)
- Sumant Inamdar
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Arkansas for Medical Sciences, Shorey Building, 8th Floor, 4301 West Markham Street, Little Rock, AR 72205, USA.
| | - Gregory A Cote
- Division of Gastroenterology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code L461, Portland, OR, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburg Medical Center, 200 Lothrop Street, M2, C-wing, Pittsburgh, PA 15213, USA
| |
Collapse
|
3
|
Dietrich CF, Bekkali NL, Burmeister S, Dong Y, Everett SM, Hocke M, Ignee A, On W, Hebbar S, Oppong K, Sun S, Jenssen C, Braden B. Controversies in ERCP: Technical aspects. Endosc Ultrasound 2021; 11:27-37. [PMID: 34677144 PMCID: PMC8887038 DOI: 10.4103/eus-d-21-00102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The aim of the series of papers on controversies of biliopancreatic drainage procedures is to discuss pros and cons of the varying clinical practices and techniques in ERCP and EUS for drainage of biliary and pancreatic ducts. While the first part focuses on indications, clinical and imaging prerequisites prior to ERCP, sedation options, post-ERCP pancreatitis prophylaxis, and other related technical topics, the second part discusses specific procedural ERCP techniques including precut techniques and their timing as well as management algorithms. In addition, reviews on controversies in EUS-guided bile duct and pancreatic drainage procedures are under preparation.
Collapse
Affiliation(s)
- Christoph F Dietrich
- Department of Ultrasound, The First Affiliated Hospital of Zhengzhou University, China; Johann Wolfgang Goethe University, Frankfurt/Main, Germany; Department of Allgemeine Innere Medizin, Kliniken Hirslanden Beau Site, Salem und Permanence, Bern, Switzerland
| | - Noor L Bekkali
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Sean Burmeister
- Surgical Gastroenterology Unit, Groote Schuur Hospital, Cape Town, South Africa
| | - Yi Dong
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | | | - Michael Hocke
- Medical Department, Helios Klinikum Meiningen, Germany
| | - Andre Ignee
- Medical Department 2, Caritas-Krankenhaus, Uhlandstr 7, D-97980 Bad Mergentheim, Germany
| | - Wei On
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Srisha Hebbar
- University Hospitals of North Midlands, United Kingdom
| | - Kofi Oppong
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Siyu Sun
- Endoscopy Center, ShengJing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Christian Jenssen
- Krankenhaus Märkisch-Oderland, Department of Internal Medicine, Strausberg; Brandenburg Institute for Clinical Ultrasound (BICUS) at Medical University Brandenburg, Neuruppin, Germany
| | - Barbara Braden
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom; Johann Wolfgang Goethe University, Frankfurt/Main, Germany
| |
Collapse
|
4
|
Conti Bellocchi MC, Crinò SF, Pin F, di Stefano S, Le Grazie M, Bernardoni L, Ruffini M, Frulloni L, Gabbrielli A. Reappraisal of factors impacting the cannulation rate and clinical efficacy of endoscopic minor papilla sphincterotomy. Pancreatology 2021; 21:805-811. [PMID: 33745788 DOI: 10.1016/j.pan.2021.01.019] [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: 10/30/2020] [Revised: 01/15/2021] [Accepted: 01/25/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND We aimed to assess factors impacting the endoscopic minor papilla sphincterotomy (EMPS) success rate, clinical efficacy, and safety in a large cohort of patients with symptomatic pancreas divisum (PD). METHODS Retrospective study including patients with PD referred to the Pancreas Institute of Verona from May 2009 to May 2020 to undergo EMPS. The whole population was analyzed to assess EMPS technical success, defined as the rate of deep cannulation of the dorsal duct. Patients treated for recurrent pancreatitis (RP) with a minimum follow-up of 1 year were included to evaluate the clinical efficacy, defined as resolution or significant reduction of acute pancreatitis (AP) episodes. Safety was defined as the rate of procedure-related adverse events (AEs) according to an international lexicon. The effects of the main determinants on study outcomes were evaluated. RESULTS Overall, 106 patients were evaluated. Technical success was obtained in 87 (82.1%). The presence of pancreatic calcifications was associated with failure (p < 0.0001). Clinical efficacy was evaluated in 59 patients. Resolution/reduction of AP episodes after EMPS was observed in 93% of patients over a median follow-up of 49 months (IQR 37-92). Smoking habit was associated with AP recurrence (p = 0.026). The overall AE rate was 14.9%, with post-ERCP pancreatitis as the most common complication (12.6%). CONCLUSIONS In our study, performed at a tertiary center, EMPS showed satisfactory technical success and an acceptable safety profile. If confirmed by prospective multicenter studies, EMPS could become the standard of care for the treatment of RP in PD.
Collapse
Affiliation(s)
- Maria Cristina Conti Bellocchi
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy.
| | - Stefano Francesco Crinò
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Federico Pin
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Serena di Stefano
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Marco Le Grazie
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Laura Bernardoni
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Martina Ruffini
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Luca Frulloni
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Armando Gabbrielli
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| |
Collapse
|
5
|
Abstract
Introduction: Pancreas divisum is the most common congenital malformation of the pancreas with the majority asymptomatic. The etiological role, pathogenesis, clinical significance and management of pancreas divisum in pancreatic disease has not been clearly defined and our understanding is yet to be fully elucidated.Areas covered: This review describes the role of pancreas divisum in the development of pancreatic disease and the ambiguity related to it. In our attempt to offer clarity, a comprehensive search on PubMed, Ovid, Embase and Cochrane Library from inception to May 2019 was undertaken using key words "pancreas divisum", "idiopathic recurrent acute pancreatitis" and "chronic pancreatitis".Expert opinion: Current research fails to define a clear association between pancreas divisum and pancreatic disease. Though debatable, several studies do suggest a pathological role of pancreas divisum in pancreatic disease and a benefit of minor papilla therapy in the setting of acute recurrent pancreatitis. Surgical and endoscopic therapeutic modalities have not been directly compared. With the current data available, it would be imprudent to advise a definitive line of management for pancreatic disease associated with pancreas divisum and should involve a comprehensive discussion with the individual patient to define expectations before embarking on any medical and/or interventional therapy.
Collapse
Affiliation(s)
- Aditya Gutta
- Advanced Endoscopy Gastroenterology Fellow, Indiana University School of Medicine, Division of Gastroenterology, 550 N. University Blvd, Indianapolis, IN 46202
| | - Evan Fogel
- Professor of Medicine, Indiana University School of Medicine, Division of Gastroenterology, 550 N. University Blvd, Suite 1602, Indianapolis, IN 46202
| | - Stuart Sherman
- Professor of Medicine, Glen Lehman Professor in Gastroenterology, Indiana University School of Medicine, Division of Gastroenterology, 550 N. University Blvd, Suite 1634, Indianapolis, IN 46202
| |
Collapse
|
6
|
Tavakkoli A, Bhalla S, Prabhu A. Use of combined methylene blue chromoendoscopy and intravenous secretin for endoscopic therapy in pancreas divisum. VideoGIE 2018; 3:397-398. [PMID: 30506007 PMCID: PMC6251701 DOI: 10.1016/j.vgie.2018.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Anna Tavakkoli
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Sean Bhalla
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Anoop Prabhu
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| |
Collapse
|
7
|
A systematic review and quantitative analysis of different therapies for pancreas divisum. Am J Surg 2017; 214:525-537. [PMID: 28110914 DOI: 10.1016/j.amjsurg.2016.12.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 12/26/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pancreas divisum is the most common anatomical variation of pancreatic ductal system affecting 5-10% of population. Therapy includes different endoscopic and surgical procedures. The aim of this article was to summarize actual evidence of different treatment. METHODS A Medline search was performed to identify all studies, investigating endoscopic or surgical therapy of Pancreas divisum. An individual data simulation model was applied to compare endoscopic and surgical studies. RESULT 56 observational studies (31 endoscopic and 25 surgical studies) were included in analyses. Surgery was significantly superior to endoscopic treatment in terms of success rate (72% vs. 62.3), complication rate (23.8% vs. 31.3%) and re-intervention rate (14.4% vs. 28.3%). CONCLUSION Surgery may be superior to endoscopy in terms of treatment success and complications. There is no study comparing these two therapies. Consequently, a randomized trial is needed to clarify if endoscopy or surgery is superior in the therapy of pancreas divisum.
Collapse
|
8
|
Somani P, Navaneethan U. Role of ERCP in Patients With Idiopathic Recurrent Acute Pancreatitis. ACTA ACUST UNITED AC 2016; 14:327-39. [PMID: 27371265 DOI: 10.1007/s11938-016-0096-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OPINION STATEMENT Recurrent acute pancreatitis (RAP) is defined based on the occurrence of two or more episodes of acute pancreatitis. RAP is differentiated from chronic pancreatitis based on the presence of a normal morphological appearance of the pancreas between episodes. RAP can be due to a variety of etiologies including common bile duct stones or sludge, sphincter of Oddi dysfunction (SOD), pancreas divisum (PD), anomalous pancreaticobiliary junction, genetic mutations, and alcohol related. In approximately 30 % of patients, the etiology of RAP is unclear and the term "idiopathic" is used. Endoscopic retrograde cholangiopancreatography (ERCP) can be utilized in both the diagnosis and the initial management of RAP, but it has known limitations and risks. Since gallbladder sludge and SOD account for most cases with RAP, cholecystectomy and, eventually, endoscopic biliary and/or pancreatic sphincterotomy are performed as a part of management. In patients with PD-associated RAP, data from uncontrolled and primarily retrospective studies point toward a benefit from minor papillary endoscopic intervention. However, given the lack of quality data from prospective randomized controlled trials (RCTs), endoscopic management in such patients remains an individualized decision, and RCTs are needed to ascertain its true long-term benefit. Future studies to investigate the role of endoscopic therapy in preventing progression to chronic pancreatitis are needed.
Collapse
Affiliation(s)
- Piyush Somani
- Center for Interventional Endoscopy, University of Central Florida College of Medicine, Florida Hospital, 601 E Rollins Street, Orlando, FL, 32803, USA
| | - Udayakumar Navaneethan
- Center for Interventional Endoscopy, University of Central Florida College of Medicine, Florida Hospital, 601 E Rollins Street, Orlando, FL, 32803, USA.
| |
Collapse
|
9
|
Consiglieri CF, Gornals JB, Albines G, De-la-Hera M, Secanella L, Pelaez N, Busquets J. EUS-guided methylene blue cholangiopancreatography for benign biliopancreatic diseases after failed ERCP. Gastrointest Endosc 2016; 84:152-7. [PMID: 26713876 DOI: 10.1016/j.gie.2015.12.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 12/05/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS When ERCP fails, EUS-guided interventional techniques may be an alternative. The aim of this study was to evaluate the general outcomes and safety of EUS-guided methylene blue cholangiopancreatography in patients with failed ERCP in benign biliopancreatic diseases. METHODS Patients with benign biliopancreatic diseases and failed ERCP were included. EUS-guided cholangiopancreatography plus injection of methylene blue was performed, and then ERCP using coloring agent flow as an indicator of papilla orifice was performed. Procedures were prospectively collected in this observational, single-center study. Technical success, clinical success, and adverse events were analyzed retrospectively. RESULTS Eleven patients were included (10 choledocholithiasis, 1 pancreatic stricture). The main reason for failed ERCP was an unidentifiable papilla. EUS-guided ductal access with cholangiopancreatography and papilla orifice identification was obtained in all cases. Technical success and clinical success rates of 91% were achieved, with successful biliopancreatic drainage in 10 patients. Adverse events included 1 peripancreatic abscess attributed to a precut, which was successfully treated. No adverse events were related to the first EUS-guided stage. CONCLUSION EUS-guided cholangiopancreatography with methylene blue injection seems to be a feasible and helpful technique for treatment in patients with benign biliopancreatic diseases with previous failed ERCP because of an undetectable papilla.
Collapse
Affiliation(s)
- Claudia F Consiglieri
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Catalonia, Spain
| | - Joan B Gornals
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Catalonia, Spain.
| | - Gino Albines
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Catalonia, Spain
| | - Meritxell De-la-Hera
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Catalonia, Spain
| | - Lluis Secanella
- General and Digestive Surgery Department, Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Catalonia, Spain
| | - Nuria Pelaez
- General and Digestive Surgery Department, Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Catalonia, Spain
| | - Juli Busquets
- General and Digestive Surgery Department, Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Catalonia, Spain
| |
Collapse
|
10
|
Wang W, Gong B, Jiang WS, Liu L, Bielike K, Xv B, Wu YL. Endoscopic treatment for pancreatic diseases: Needle-knife-guided cannulation via the minor papilla. World J Gastroenterol 2015; 21:5950-5960. [PMID: 26019460 PMCID: PMC4438030 DOI: 10.3748/wjg.v21.i19.5950] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 12/30/2014] [Accepted: 02/05/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the efficacy and safety of meticulous cannulation by needle-knife.
METHODS: Three needle-knife procedures were used to facilitate cannulation in cases when standard cannulation techniques failed. A total of 104 cannulations via the minor papilla attempted in 74 patients at our center between January 2008 and June 2014 were retrospectively reviewed.
RESULTS: Standard methods were successful in 79 cannulations. Of the 25 cannulations that could not be performed by standard methods, 19 were performed by needle-knife, while 17 (89.5%) were successful. Needle-knife use improved the success rate of cannulation [76.0%, 79/104 vs 92.3%, (79 + 17)/104; P = 0.001]. When the 6 cases not appropriate for needle-knife cannulation were excluded, the success rate was improved further (80.6%, 79/98 vs 98.0%, 96/98; P = 0.000). There were no significant differences in the rates of post-endoscopic retrograde cholangiopancreatography adverse events between the group using standard methods alone and the group using needle-knife after failure of standard methods (4.7% vs 10.5%, P = 0.301).
CONCLUSION: The needle-knife procedure may be an alternative method for improving the success rate of cannulation via the minor papilla, particularly when standard cannulation has failed.
Collapse
|
11
|
Abstract
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.
Collapse
|
12
|
Systematic pancreatic stenting after endoscopic snare papillectomy may reduce the risk of postinterventional pancreatitis. Surg Endosc 2013; 27:3377-87. [PMID: 23549765 DOI: 10.1007/s00464-013-2920-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Accepted: 02/22/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatitis is the most feared complication of endoscopic papillectomy (EP). Prevention by pancreatic duct stenting following EP has been advocated but not proven by a randomized trial. The purpose of the present retrospective review is to compare a period of systematic stenting with the period before in which stents were placed selectively. METHODS A total of 107 patients undergoing EP from February 1999 to December 2009 were retrospectively reviewed. After an initial period with selective stenting (dilated duct, previous pancreatitis) between 1999 and 2002 (n = 24, group 1), stents were placed routinely after EP unless pancreas divisum was diagnosed (2002-2009; n = 83, group 2) to reduce postpapillectomy acute pancreatitis (PAP). PAP rates defined by Consensus Criteria were compared in the two periods. RESULTS Five patients in group 1 were selected to receive a pancreatic stent (21%); in group 2 stenting was successful in 75 of 78 patients (success rate 96%) without pancreas divisum (n = 5). Overall, PAP occurred in 11% of patients. PAP rate was significantly reduced after introduction of systematic pancreatic stenting (5 vs 25%; p = 0.01) and occurred less often in stented than in nonstented patients: (5% (4/80) vs 27% (6/22), p = 0.0019). PAP also occurred in one of five patients with pancreas divisum. Selective stenting of patients also was an independent risk factor for PAP (OR 13, p = 0.001) in a multivariate analysis. CONCLUSIONS Attempts at systematic stenting after EP pancreatic stenting appears to prevent PAP. Results should be corroborated by a randomized trial.
Collapse
|
13
|
Buxbaum J. The role of endoscopic retrograde cholangiopancreatography in patients with pancreatic disease. Gastroenterol Clin North Am 2012; 41:23-45. [PMID: 22341248 DOI: 10.1016/j.gtc.2011.12.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Given the significant risk of pancreatitis and the advent of high-fidelity diagnostic techniques, ERCP is now reserved as a therapeutic procedure for those with pancreatic disease. Early ERCP benefits those with gallstone pancreatitis who present with or develop cholangitis or biliary obstruction. Among those with idiopathic pancreatitis, ERCP may be used to confirm and treat SOD, microlithiasis, and structural anomalies, including pancreas divisum. Pancreatic endotherapy is a consideration to decrease pain in those with pancreatic duct obstruction, although surgical decompression may be more durable, particularly in those with severe disease. Pancreatic duct leaks may respond to endoscopic drainage, but optimal therapy is achieved if a bridging stent can be placed. Finally, using a wire-guided technique and pancreatic duct stents in high-risk patients, particularly in cases of suspected SOD, may minimize the risk of post-ERCP pancreatitis.
Collapse
Affiliation(s)
- James Buxbaum
- Los Angeles County Hospital, Division of Gastroenterology and Liver Diseases, The University of Southern California, Keck School of Medicine, Los Angeles, CA 90033, USA.
| |
Collapse
|
14
|
Abstract
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.
Collapse
Affiliation(s)
- Damien Meng Yew Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.
| | | |
Collapse
|
15
|
Abstract
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.
Collapse
Affiliation(s)
- Haritha Avula
- Division of Gastroenterology/ Hepatology, Indiana University Medical Center, Indianapolis, IN, USA
| | - Stuart Sherman
- Division of Gastroenterology/ Hepatology, Indiana University Medical Center - Internal Medicine, UH 4100, IN 46202, USA
| |
Collapse
|
16
|
Barkay O, Sherman S, McHenry L, Yoo BM, Fogel EL, Watkins JL, DeWitt J, Al-Haddad MA, Lehman GA. Therapeutic EUS-assisted endoscopic retrograde pancreatography after failed pancreatic duct cannulation at ERCP. Gastrointest Endosc 2010; 71:1166-73. [PMID: 20303489 DOI: 10.1016/j.gie.2009.10.048] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Accepted: 10/14/2009] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cannulation of the pancreatic duct (PD) during endoscopic retrograde pancreatography (ERP) can fail even in experienced hands. A technique for therapeutic EUS-assisted rendezvous ERP has been described in a few case reports. OBJECTIVE To investigate the efficacy and safety of therapeutic EUS-assisted ERP. DESIGN Retrospective study. SETTING Tertiary-care medical center. PATIENTS This study involved 21 patients after failed ERP. INTERVENTION EUS-guided transgastric pancreatography by using a mixture of contrast media and methylene blue was attempted. If that was successful, ERP was attempted by using methylene blue flow as an indicator of the PD orifice or by a rendezvous technique using a wire passed into the PD and the small bowel through the EUS needle. MAIN OUTCOME MEASUREMENTS Technical success rate and complications. RESULTS The PD was of a normal diameter in 7 patients and was dilated in 14 patients. EUS-guided pancreatography was successfully done in all patients with a dilated PD but only in 4 of 7 patients (57%) with normal-diameter PDs. In 6 patients, ERP was successfully performed by using methylene blue flow as an indicator of the PD orifice. The rendezvous technique was successful in 4 of 12 cases (33%), and reasons for failure were either a tight stricture (n = 5) or a suboptimal angle of EUS needle insertion (n = 3). Overall, EUS-assisted ERP was successful in 10 of 21 patients (48%). Complications included peripancreatic abscess in 1 patient and mild pancreatitis in 1 patient. LIMITATIONS Retrospective study, small sample size. CONCLUSION EUS-assisted ERP is a complex procedure that can provide access to the PD in selected cases after failed standard ERP.
Collapse
Affiliation(s)
- Olga Barkay
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Qayed E, Reid AL, Willingham FF, Keilin S, Cai Q. Advances in endoscopic retrograde cholangiopancreatography cannulation. World J Gastrointest Endosc 2010; 2:130-7. [PMID: 21160728 PMCID: PMC2998904 DOI: 10.4253/wjge.v2.i4.130] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2009] [Revised: 04/01/2010] [Accepted: 04/08/2010] [Indexed: 02/05/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography is an important tool in the diagnosis and treatment of pancreatobiliary diseases. A critical step in this procedure is deep cannulation of the bile duct as failure of cannulation generally results in an aborted procedure and failed intervention. Expert endoscopists usually achieve a high rate of successful cannulation while those less experienced typically have a much lower rate and a greater incidence of complications. Prolonged attempts at cannulation can result in significant morbidity to patients, anxiety for endoscopists, unnecessary radiation exposure and inefficient patient care. Here we review the most common endoscopic techniques used to achieve selective biliary cannulation. Pharmacologic aids to cannulation are also discussed briefly in this review.
Collapse
Affiliation(s)
- Emad Qayed
- Emad Qayed, Ashley L Reid, Field F Willingham, Steve Keilin, Qiang Cai, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA 30322, United States
| | | | | | | | | |
Collapse
|
18
|
Barkay O, Fogel EL, Watkins JL, McHenry L, Lehman GA, Sherman S. Endoscopic retrograde pancreatography. Clin Gastroenterol Hepatol 2009; 7:931-43. [PMID: 19523537 DOI: 10.1016/j.cgh.2009.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2009] [Revised: 05/29/2009] [Accepted: 06/02/2009] [Indexed: 02/07/2023]
Affiliation(s)
- Olga Barkay
- Division of Gastroenterology and Hepatology, Indiana University Hospital, Indianapolis, Indiana 46202, USA.
| | | | | | | | | | | |
Collapse
|
19
|
Testoni PA. Endoscopic pancreatic duct stent placement for inflammatory pancreatic diseases. World J Gastroenterol 2008. [PMID: 18023085 DOI: 10.3748/wjg.13.5971] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The role of endoscopic therapy in the management of pancreatic diseases is continuously evolving; at present most pathological conditions of the pancreas are successfully treated by endoscopic retrograde cholangio-pancreatography (ERCP) or endoscopic ultrasound (EUS), or both. Endoscopic placement of stents has played and still plays a major role in the treatment of chronic pancreatitis, pseudocysts, pancreas divisum, main pancreatic duct injuries, pancreatic fistulae, complications of acute pancreatitis, recurrent idiopathic pancreatitis, and in the prevention of post-ERCP pancreatitis. These stents are currently routinely placed to reduce intraductal hypertension, bypass obstructing stones, restore lumen patency in cases with dominant, symptomatic strictures, seal main pancreatic duct disruption, drain pseudocysts or fluid collections, treat symptomatic major or minor papilla sphincter stenosis, and prevent procedure-induced acute pancreatitis. The present review aims at updating and discussing techniques, indications, and results of endoscopic pancreatic duct stent placement in acute and chronic inflammatory diseases of the pancreas.
Collapse
|
20
|
Testoni PA. Endoscopic pancreatic duct stent placement for inflammatory pancreatic diseases. World J Gastroenterol 2008; 13:5971-8. [PMID: 18023085 PMCID: PMC4250876 DOI: 10.3748/wjg.v13.45.5971] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The role of endoscopic therapy in the management of pancreatic diseases is continuously evolving; at present most pathological conditions of the pancreas are successfully treated by endoscopic retrograde cholangio-pancreatography (ERCP) or endoscopic ultrasound (EUS), or both. Endoscopic placement of stents has played and still plays a major role in the treatment of chronic pancreatitis, pseudocysts, pancreas divisum, main pancreatic duct injuries, pancreatic fistulae, complications of acute pancreatitis, recurrent idiopathic pancreatitis, and in the prevention of post-ERCP pancreatitis. These stents are currently routinely placed to reduce intraductal hypertension, bypass obstructing stones, restore lumen patency in cases with dominant, symptomatic strictures, seal main pancreatic duct disruption, drain pseudocysts or fluid collections, treat symptomatic major or minor papilla sphincter stenosis, and prevent procedure-induced acute pancreatitis. The present review aims at updating and discussing techniques, indications, and results of endoscopic pancreatic duct stent placement in acute and chronic inflammatory diseases of the pancreas.
Collapse
|
21
|
Abstract
Recent advances in understanding of pancreatitis and advances in technology have uncovered the veils of idiopathic pancreatitis to a point where a thorough history and judicious use of diagnostic techniques elucidate the cause in over 80% of cases. This review examines the multitude of etiologies of what were once labeled idiopathic pancreatitis and provides the current evidence on each. This review begins with a background review of the current epidemiology of idiopathic pancreatitis prior to discussion of various etiologies. Etiologies of medications, infections, toxins, autoimmune disorders, vascular causes, and anatomic and functional causes are explored in detail. We conclude with management of true idiopathic pancreatitis and a summary of the various etiologic agents. Throughout this review, areas of controversies are highlighted.
Collapse
|
22
|
Keenan J, Mallery S, Freeman ML. EUS rendezvous for pancreatic stent placement during endoscopic snare ampullectomy. Gastrointest Endosc 2007; 66:850-3. [PMID: 17719045 DOI: 10.1016/j.gie.2007.01.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2006] [Accepted: 01/04/2007] [Indexed: 12/17/2022]
Affiliation(s)
- Joseph Keenan
- Division of Gastroenterology, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN 55415, USA
| | | | | |
Collapse
|
23
|
Abstract
Pancreas divisum is the most common congenital anomaly of the pancreas. Abnormal hedgehog protein signaling appears related to the formation of several pancreatic malformations, including annular pancreas, pancreatic-biliary malunion, pancreatic rests, and pancreas divisum. Pancreas divisum by itself should not necessarily require intervention. A careful evaluation should be performed to exclude other causes of symptoms. If the patient is asymptomatic, no further evaluation is necessary. However, a significant percentage of patients with pancreas divisum and acute recurrent pancreatitis benefit from intervention. Surgical sphincteroplasty and endoscopic interventions appear similar in outcome. Thus, endoscopic intervention with prophylactic temporary stenting is advised as initial therapy. Surgery should be reserved for patients with chronic pancreatitis.
Collapse
Affiliation(s)
- J Steven Burdick
- Baylor University Medical Center, 3500 Gaston Avenue, 3rd Floor Truett, Dallas, TX 75246, USA.
| | | |
Collapse
|
24
|
Affiliation(s)
- Martin L Freeman
- Division of Gastroenterology, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN 55415, USA
| | | |
Collapse
|
25
|
Dewitt J, McHenry L, Fogel E, Leblanc J, McGreevy K, Sherman S. EUS-guided methylene blue pancreatography for minor papilla localization after unsuccessful ERCP. Gastrointest Endosc 2004; 59:133-6. [PMID: 14722569 DOI: 10.1016/s0016-5107(03)02278-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- John Dewitt
- Department of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana 46202-5121, USA
| | | | | | | | | | | |
Collapse
|