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Kadkhodayan K, Viana A, Singh S, Kegan J, Amawi Y, Jain D, Yang D, Arain M, Cosgrove N, Shayan I, Hasan MK. Chromo-pancreatoscopy for preoperative evaluation of main duct intraductal pancreatic mucinous neoplasm. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2024; 9:194-196. [PMID: 38618613 PMCID: PMC11009480 DOI: 10.1016/j.vgie.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Affiliation(s)
| | - Artur Viana
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida
| | - Sanmeet Singh
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida
| | | | - Yusuf Amawi
- Florida State University College of Medicine, Tallahassee, Florida
| | | | - Dennis Yang
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida
| | - Mustafa Arain
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida
| | - Natalie Cosgrove
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida
| | | | - Muhammad K Hasan
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida
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de Jong DM, Stassen PMC, Groot Koerkamp B, Ellrichmann M, Karagyozov PI, Anderloni A, Kylänpää L, Webster GJM, van Driel LMJW, Bruno MJ, de Jonge PJF. The role of pancreatoscopy in the diagnostic work-up of intraductal papillary mucinous neoplasms: a systematic review and meta-analysis. Endoscopy 2022; 55:25-35. [PMID: 35668651 PMCID: PMC9767751 DOI: 10.1055/a-1869-0180] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Confirming the diagnosis, invasiveness, and disease extent of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas is challenging. The aim of this study was to summarize the literature on the efficacy and safety of peroral pancreatoscopy (POP) in the diagnosis of IPMN, including the impact of pre- and intraoperative POP on the management of IPMN. METHODS The EMBASE, Medline Ovid, Web of Science, Cochrane CENTRAL, and Google Scholar databases were systematically searched for articles. Eligible articles investigated cohorts of patients who underwent POP for (suspected) IPMN. RESULTS 25 articles were identified and included in this review; with 22 of these reporting on the diagnostic yield of POP in IPMN and 11 reporting on the effect of pre- or intraoperative POP on clinical decision-making. Cannulation and observation rates, and overall diagnostic accuracy were high across all studies. Frequently reported visual characteristics of IPMN were intraductal fish-egg-like lesions, hypervascularity, and granular mucosa. Overall, the adverse event rate was 12 %, primarily consisting of post-endoscopic retrograde cholangiopancreatography pancreatitis, with a pooled rate of 10 %, mostly of mild severity. Regarding the impact of POP on clinical decision-making, POP findings altered the surgical approach in 13 %-62 % of patients. CONCLUSION POP is technically successful in the vast majority of patients with (suspected) IPMN, has a consistently high diagnostic accuracy, but an adverse event rate of 12 %. Data on intraoperative pancreatoscopy are scarce, but small studies suggest its use can alter surgical management. Future studies are needed to better define the role of POP in the diagnostic work-up of IPMN.
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Affiliation(s)
- David M. de Jong
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Pauline M. C. Stassen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mark Ellrichmann
- Department of Interdisciplinary Endoscopy, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Petko I. Karagyozov
- Department of Interventional Gastroenterology, Acibadem City Clinic Tokuda University Hospital, Sofia, Bulgaria
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Clinical and Research Center, IRCCS, Milan, Italy
| | - Leena Kylänpää
- Abdominal Center, Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - George J. M. Webster
- Department of Gastroenterology, University College London Hospitals, London, UK,Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK
| | - Lydi M. J. W. van Driel
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Pieter J. F. de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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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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Yousaf MN, Ehsan H, Wahab A, Muneeb A, Chaudhary FS, Williams R, Haas CJ. Endoscopic retrograde cholangiopancreatography guided interventions in the management of pancreatic cancer. World J Gastrointest Endosc 2020; 12:323-340. [PMID: 33133370 PMCID: PMC7579529 DOI: 10.4253/wjge.v12.i10.323] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/23/2020] [Accepted: 09/22/2020] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer is the leading cause of cancer-related morbidity and mortality with an overall five-year survival of less than 9% in the United States. At presentation, the majority of patients have painless jaundice, pruritis, and malaise, a triad that develops secondary to obstruction, which often occurs late in the course of the disease process. The technical advancements in radiological imaging and endoscopic interventions have played a crucial role in the diagnosis, staging, and management of patients with pancreatic cancer. Endoscopic retrograde cholangiopancreatography (ERCP)-guided diagnosis (with brush cytology, serial pancreatic juice aspiration cytologic examination technique, or biliary biopsy) and therapeutic interventions such as pancreatobiliary decompression, intraductal and relief of gastric outlet obstruction play a pivotal role in the management of advanced pancreatic cancer and are increasingly used due to improved morbidity and complication rates compared to surgical management. In this review, we highlight various ERCP-guided diagnostic and therapeutic interventions for the management of pancreatic cancer.
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Affiliation(s)
- Muhammad Nadeem Yousaf
- Department of Medicine, Medstar Union Memorial Hospital, Baltimore, MD 21218, United States
- Department of Medicine, MedStar Good Samaritan Hospital, Baltimore, MD 21239, United States
- Department of Medicine, Medstar Franklin Square Medical Center, Baltimore, MD 21237, United States
- Department of Medicine, MedStar Harbor Hospital, Baltimore, MD 21225, United States
| | - Hamid Ehsan
- Department of Medicine, Medstar Union Memorial Hospital, Baltimore, MD 21218, United States
| | - Ahsan Wahab
- Department of Hospital Medicine, Baptist Medical Center South, Montgomery, AL 36116, United States
| | - Ahmad Muneeb
- Department of Medicine, Faisalabad Medical University, Faisalabald 38000, Punjab, Pakistan
| | - Fizah S Chaudhary
- Department of Medicine, Medstar Union Memorial Hospital, Baltimore, MD 21218, United States
- Department of Medicine, MedStar Good Samaritan Hospital, Baltimore, MD 21239, United States
- Department of Medicine, Medstar Franklin Square Medical Center, Baltimore, MD 21237, United States
- Department of Medicine, MedStar Harbor Hospital, Baltimore, MD 21225, United States
| | - Richard Williams
- Department of Medicine, Medstar Union Memorial Hospital, Baltimore, MD 21218, United States
- Department of Medicine, MedStar Good Samaritan Hospital, Baltimore, MD 21239, United States
- Department of Medicine, Medstar Franklin Square Medical Center, Baltimore, MD 21237, United States
- Department of Medicine, MedStar Harbor Hospital, Baltimore, MD 21225, United States
| | - Christopher J Haas
- Department of Medicine, Medstar Union Memorial Hospital, Baltimore, MD 21218, United States
- Department of Medicine, MedStar Good Samaritan Hospital, Baltimore, MD 21239, United States
- Department of Medicine, Medstar Franklin Square Medical Center, Baltimore, MD 21237, United States
- Department of Medicine, MedStar Harbor Hospital, Baltimore, MD 21225, United States
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Asif S, Kalpala R, Reddy DN. Peroral pancreatoscopy-assisted removal of internally migrated fractured pancreatic stent. Endoscopy 2020; 52:E359. [PMID: 32219784 DOI: 10.1055/a-1122-8051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Shujaath Asif
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Rakesh Kalpala
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - D Nageshwar Reddy
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
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Per Oral Pancreatoscopy Identification of Main-duct Intraductal Papillary Mucinous Neoplasms and Concomitant Pancreatic Duct Stones: Not Mutually Exclusive. Pancreas 2019; 48:792-794. [PMID: 31210658 PMCID: PMC6582996 DOI: 10.1097/mpa.0000000000001333] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Per oral pancreatoscopy (POP) assists in the evaluation and treatment of select benign and neoplastic pancreatic disorders including main-duct intraductal papillary mucinous neoplasm (MD-IPMN). Although pancreatic duct stones are classically thought of as pathognomonic for chronic pancreatitis, its co-occurrence with MD-IPMN as identified via POP may help identify an alternative etiology for presumed idiopathic chronic pancreatitis. METHODS This was a multicenter retrospective case series of patients found to have pancreatic duct stones with concomitant MD-IPMN by POP. RESULTS Thirteen patients with presumed idiopathic chronic calcific pancreatitis were found on POP to have both pancreatic duct stones and MD-IPMN. All patients had a dilated pancreatic duct, and most (92.3%) were symptomatic. CONCLUSIONS Per-oral pancreatoscopy may identify MD-IPMN as an etiology for patients with presumed idiopathic chronic calcific pancreatitis and associated dilated pancreatic duct. Larger prospective studies are needed to validate these findings.
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Kaura T, Willingham FF, Chawla S. Role of pancreatoscopy in management of pancreatic disease: A systematic review. World J Gastrointest Endosc 2019; 11:155-167. [PMID: 30788034 PMCID: PMC6379742 DOI: 10.4253/wjge.v11.i2.155] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 12/30/2018] [Accepted: 01/23/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Per-oral pancreatoscopy (POP) plays a role in the diagnosis and therapy of pancreatic diseases. With recent technological advances, there has been renewed interest in this modality.
AIM To evaluate the efficacy and safety of POP in management of pancreatic stone disease and pancreatic ductal neoplasia.
METHODS To determine the safety and efficacy of POP in the management of pancreatic diseases, a systematic search was conducted in MEDLINE, EMBASE and Ovid. Articles in languages other than English and case reports were excluded. All published case series were eligible. Data specific to POP were extracted from studies, which combined cholangiopancreatoscopy. Ten studies were included in the analysis of POP therapy for pancreatic stone disease, and 15 case series satisfied the criteria for inclusion for the role of POP in the management of pancreatic ductal neoplasia. The examined data were subcategorized according to adjunctive modalities, such as direct tissue sampling, cytology, the role of intraoperative POP, intraductal ultrasound (IDUS) and POP combined with image-enhancing technology.
RESULTS The success rate for complete ductal stone clearance ranged from 37.5%-100%. Factors associated with failure included the presence of strictures, multiple stones and the inability to visualize the target area. Although direct visualization can identify malignant and premalignant conditions, there is significant overlap with benign diseases. Visually-directed biopsies provide a high degree of accuracy, and represent a unique approach for tissue acquisition in patients with ductal abnormalities. Addition of pancreatic fluid cytology increases diagnostic yield for indeterminate lesions. Protrusions larger than 3 mm noted on IDUS are significantly more likely to be associated with malignancy. The rate of adverse events associated with POP ranged from 0%-35%.
CONCLUSION Current evidence supports wider adoption of pancreatoscopy, as it is safe and effective. Improved patient selection and utilization of novel technologies may further enhance its role in managing pancreatic disease.
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Affiliation(s)
- Tarun Kaura
- Division of Gastroenterology and Hepatology, Aurora St Luke’s Medical center, University of Wisconsin School of Medicine and Public Health, Milwaukee, WI 53215, United States
| | - Field F Willingham
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, United States
| | - Saurabh Chawla
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, United States
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De Luca L, Repici A, Koçollari A, Auriemma F, Bianchetti M, Mangiavillano B. Pancreatoscopy: An update. World J Gastrointest Endosc 2019; 11:22-30. [PMID: 30705729 PMCID: PMC6354109 DOI: 10.4253/wjge.v11.i1.22] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 12/21/2018] [Accepted: 12/30/2018] [Indexed: 02/06/2023] Open
Abstract
Per-oral pancreatoscopy (POPS) is an endoscopic procedure to visualize the main pancreatic duct. POPS specifically has the advantage of direct visualization of the pancreatic duct, allowing tissue acquisition and directed therapies such as stones lithotripsy. The aim of this review is to analyze and summarize the literature around pancreatoscopy. Pancreatoscopy consists of the classic technique of the mother-baby method in which a mini-endoscope is passed through the accessory channel of the therapeutic duodenoscope. Pancreatoscopy has two primary indications for diagnostic purpose. First, it is used for visualization and histological diagnosis of intraductal papillary mucinous neoplasms. In these cases, POPS is very useful to assess the extent of malignancy and for the study of the intraductal papillary mucinous neoplasm in order to guide the surgery resection margins. Second, it is used to determine pancreatic duct strictures, particularly important in cases of chronic pancreatitis, which is associated with both benign and malignant strictures. Therefore POPS allows differentiation between benign and malignant disease and allows mapping the extent of the tumor prior to surgical resection. Also tissue sampling is possible, but it can be technically difficult because of the limited maneuverability of the biopsy forceps in the pancreatic ducts. Pancreatoscopy can also be used for therapeutic purposes, such as pancreatoscopy-guided lithotripsy in chronic painful pancreatitis with pancreatic duct stones. The available data for the moment suggests that, in selected patients, pancreatoscopy has an important and promising role to play in the diagnosis of indeterminate pancreatic duct strictures and the mapping of main pancreatic duct intraductal papillary mucinous neoplasms. However, further studies are necessary to elucidate and validate the pancreatoscopy role in the therapeutic algorithm of chronic pancreatitis.
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Affiliation(s)
- Luca De Luca
- Gastroenterology and Digestive Endoscopy Unit, Ospedali Riuniti Marche Nord, Piazzale Cinelli, Pesaro 61121, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Italy
- Humanitas University, Pieve Emanuele 20090, Italy
| | - Adea Koçollari
- Gastroenterology Unit, University Medical Center “Mother Theresa” Hospital, Tirana 1000, Albania
| | - Francesco Auriemma
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza 21053, Italy
| | - Mario Bianchetti
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza 21053, Italy
| | - Benedetto Mangiavillano
- Humanitas University, Pieve Emanuele 20090, Italy
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza 21053, Italy
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Abstract
PURPOSE OF REVIEW To provide an overview of the field of pancreatoscopy and to summarize the data informing its clinical utility. RECENT FINDINGS Regarding the technological advance of pancreatoscopy, recent studies are the first to report the use of digital, single-operator pancreatoscopy (SpyGlass DS; Boston Scientific, Natick, MA). New data on the use of preoperative pancreatoscopy offer promising results for the potential to optimize treatment of intraductal papillary mucinous neoplasms and to differentiate between benign and malignant pancreatic strictures. Finally, there has been accumulating evidence for the use of pancreatoscopy-guided lithotripsy for the management of painful chronic calcific pancreatitis. SUMMARY Endoscopic pancreatoscopy offers the advantage of direct visualization of the pancreatic duct, allowing for optimal macroscopic assessment, targeted tissue acquisition and guided therapies such as lithotripsy of pancreatic duct stones. The data informing some aspects remain limited, but the accumulating literature forms our understanding of the current and future role of pancreatoscopy in the management of pancreatic disease.
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Hoshi H, Zaheer A, El Abiad RG, Maxwell JE, Chu LC, Gerke H, Chan CH. Management of pancreatic intraductal papillary mucinous neoplasm. Curr Probl Surg 2018; 55:126-152. [DOI: 10.1067/j.cpsurg.2018.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 03/11/2018] [Indexed: 12/16/2022]
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Efficacy, Safety, and Outcomes of Endoscopic Retrograde Cholangiopancreatography With Per-Oral Pancreatoscopy: A Multicenter Experience. J Clin Gastroenterol 2017; 51:e101-e105. [PMID: 28059943 DOI: 10.1097/mcg.0000000000000796] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Per-oral pancreatoscopy can be used for both evaluation and treatment of pancreatic duct stones during endoscopic retrograde cholangiopancreatography, evaluating and treating pancreatic duct strictures of indeterminate etiology, and visual inspection and direct biopsy of pancreatic duct mucosa for diagnosis of intraductal papillary mucinous neoplasm (IPMN). We aim to describe the efficacy, safety, and outcomes of pancreatoscopy in a large, multicenter series of patients. MATERIALS AND METHODS A multicenter retrospective review was conducted of all patients who underwent per-oral pancreatoscopy at 2 large tertiary-care medical centers. Review of relevant medical records, laboratory data, imaging studies, endoscopic procedure notes, telephone follow-up notes, and progress notes was performed. RESULTS Thirty-three patients underwent 41 pancreatoscopy procedures. Indications included: 20 (48.8%) for diagnosis and treatment of pancreatic duct stones, 16 (39%) for investigation of IPMN, and 5 (12.2%) for evaluation of pancreatic duct strictures.In 20 procedures performed for stone disease, complete pancreatic duct clearance was achieved in 17 of 20 (85%) cases. Strictures were successfully dilated in 5 of 5 (100%) procedures. Direct visualization and biopsy demonstrated IPMN in 11 of 11 (100%) cases. Adverse events occurred in 3 of 41 (7.3%) of procedures, all of which were mild. CONCLUSIONS In this large series, we demonstrate that in patients with difficult to manage stone disease, strictures and possible malignant ductal pathology, pancreatoscopy is an effective and safe tool that can facilitate both diagnosis and effective therapy. Adverse events in our study were mild and within acceptable limits, further demonstrating that this is a safe procedure that should be offered to appropriate patients.
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Role of per-oral pancreatoscopy in the evaluation of suspected pancreatic duct neoplasia: a 13-year U.S. single-center experience. Gastrointest Endosc 2017; 85:737-745. [PMID: 27473181 DOI: 10.1016/j.gie.2016.07.040] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 07/10/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The role of per-oral pancreatoscopy (POP) in the evaluation of occult pancreatic duct (PD) lesions remains limited to case series. The aim of this study was to evaluate the ability of POP to differentiate malignant from benign diseases of the PD. METHODS Patients who underwent POP between 2000 and 2013 for the evaluation of indeterminate PD strictures, dilatations, or with suspected or known main duct intraductal papillary mucinous neoplasm were identified. Main outcome measurements were visual impression accuracy, POP tissue sampling, efficacy, and safety of POP. RESULTS During the study period, 79 patients who underwent POP for the evaluation of pancreatic stricture or dilatation were identified. Technical success was achieved in 78 (97%). In the PD neoplasia group (n = 33), the final diagnosis was based on index confirmatory POP-guided tissue sampling in 29 (88%). For the detection of PD neoplasia, POP visual impression had a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 87%, 86%, 83%, 91%, and 87%, respectively. When combined with POP-guided tissue sampling, the values were 91%, 95%, 94%, 93%, and 94%, respectively. Of 102 POPs performed, adverse events were noted in 12 (12%) cases. CONCLUSIONS This study demonstrates a high technical success rate, visual impression accuracy, and tissue sampling capability of POP. Examinations were performed by endoscopists with expertise in pancreatoscopy interpretation, and the results may not be generalizable.
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Komanduri S, Thosani N, Abu Dayyeh BK, Aslanian HR, Enestvedt BK, Manfredi M, Maple JT, Navaneethan U, Pannala R, Parsi MA, Smith ZL, Sullivan SA, Banerjee S. Cholangiopancreatoscopy. Gastrointest Endosc 2016; 84:209-21. [PMID: 27236413 DOI: 10.1016/j.gie.2016.03.013] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 03/03/2016] [Indexed: 02/08/2023]
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Nagayoshi Y, Aso T, Ohtsuka T, Kono H, Ideno N, Igarashi H, Takahata S, Oda Y, Ito T, Tanaka M. Peroral pancreatoscopy using the SpyGlass system for the assessment of intraductal papillary mucinous neoplasm of the pancreas. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 21:410-7. [PMID: 24123930 DOI: 10.1002/jhbp.44] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Peroral pancreatoscopy (POPS) using a mother-baby endoscope system is often useful for assessment of intraductal papillary mucinous neoplasm (IPMN) of the pancreas with main pancreatic duct (MPD) involvement, but is not widely used for several reasons. The aim of this study was to evaluate the usefulness of the SpyGlass Direct Visualization System for assessment of IPMN. METHODS Seventeen patients diagnosed with possible IPMN with MPD dilation underwent peroral pancreatoscopy using the SpyGlass system at our institution. The quality of visualization and the sensitivities of cytological and pathological investigations for diagnosing malignant lesions were evaluated. RESULTS Peroral pancreatoscopy was performed using the SpyScope in 12 patients and an endoscopic retrograde cholangiopancreatography (ERCP) catheter in five patients. Sufficient visualization was achieved in 92% of cases using the SpyScope and 40% of cases using the ERCP catheter. Biopsy under direct visualization was successful in seven patients. Biopsy specimens showed adenocarcinoma in one patient, benign neoplastic epithelium in five patients, and regenerative changes in one patient; and had 25% sensitivity and 100% specificity for detecting malignancy. SpyGlass pancreatoscopy with irrigation cytology had 100% sensitivity and 100% specificity for detecting malignancy. SpyGlass pancreatoscopy was useful for determining the operative excision line in three patients. There were no severe procedure-related adverse events. CONCLUSIONS Peroral pancreatoscopy using the SpyGlass system seems to be feasible and useful for assessment of IPMN with a dilated MPD.
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Affiliation(s)
- Yosuke Nagayoshi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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Predictors of malignancy in intraductal papillary mucinous neoplasm of the pancreas: analysis of 310 pancreatic resection patients at multiple high-volume centers. Pancreas 2013; 42:883-8. [PMID: 23508017 DOI: 10.1097/mpa.0b013e31827a7b84] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The present study was a retrospective investigation of predictors of malignancy in intraductal papillary mucinous neoplasm (IPMN) of the pancreas. METHODS The subjects were 310 patients who underwent pancreatic resection at 3 high-volume centers. Preoperative laboratory and imaging findings were analyzed in logistic regression analyses. Endoscopic ultrasonography measurements were essential for the size of mural nodules, and a central review was conducted for pathological diagnosis. RESULTS Pathological diagnosis was benign IPMN in 150 cases and malignant in 160 (noninvasive carcinoma, n = 100; invasive, n = 60). In multivariate analysis, size of mural nodules, diameter of main pancreatic duct, and cyst size of branch pancreatic duct were independent predictors of malignancy, and areas under the receiver operating characteristic curve for these 3 factors were 0.798, 0.643, and 0.601, respectively. With 7 mm taken as the cutoff value for the size of mural nodules, the diagnosis of malignant IPMN had sensitivity of 74.3% and specificity of 72.7%. Carcinoma without nodules was present in 15 patients (15/160 [9.4%]). CONCLUSIONS The size of mural nodules measured with endoscopic ultrasonography showed high predictive ability. However, about 10% of carcinoma patients did not have nodules, and the handling of the diagnosis in such cases is a problem for the future.
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Gallucci F, Avolio D, de Ritis R, Ferrara L, Valentino U, Uomo G. Intraductal papillary mucinous neoplasm of the pancreas. Personal series and synthetic review. ITALIAN JOURNAL OF MEDICINE 2012. [DOI: 10.1016/j.itjm.2012.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Shimizu Y, Kanemitsu Y, Sano T, Senda Y, Mizuno N, Yamao K. A nomogram for predicting the probability of carcinoma in patients with intraductal papillary-mucinous neoplasm. World J Surg 2011; 34:2932-8. [PMID: 20845037 DOI: 10.1007/s00268-010-0785-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The objective of the present study was to use clinical and laboratory data to develop a model for predicting the presence of carcinoma in patients with intraductal papillary mucinous neoplasm (IPMN). METHODS Data were collected on 81 patients with IPMN who underwent a pancreatic resection between 1989 and 2008 at Aichi Cancer Center Hospital. Variables analyzed included age, gender, laboratory findings (serum amylase, carcinoembryonic antigen, and carbohydrate antigen 19-9 level), pancreatic juice cytology grade, and imaging studies. Factors associated with the presence of carcinoma were evaluated by univariate and multivariate logistic regression analysis. RESULTS Among the 81 patients with IPMN, 34 (42%) had malignant tumors (noninvasive carcinoma in 22 and invasive carcinoma in 12), and 47 (58%) had adenoma. On multivariate analysis, existing carcinoma was associated with female gender, main pancreatic duct IPMN, nodule size, and pancreatic juice cytology grade. Based on these variables, a predictive nomogram was developed. The area under the receiver operating characteristic curve (AUC) for the model was 0.903. The sensitivity and specificity of the model were 97.1 and 68.1%, respectively, in the validation study, for which the predictive probability of >10% was used to indicate the presence of carcinoma. CONCLUSIONS The nomogram has high diagnostic predictability for carcinoma in patients with IPMN and for individual cancer probability. This instrument may help to identify patients who need a surgical procedure.
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Affiliation(s)
- Yasuhiro Shimizu
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Kanokoden 1-1, Chikusa-ku, Nagoya, 464-8681, Japan.
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Nallamothu G, Hilden K, Adler DG. Endoscopic retrograde cholangiopancreatography for non-gastroenterologists: what you need to know. Hosp Pract (1995) 2011; 39:70-80. [PMID: 21576899 DOI: 10.3810/hp.2011.04.396] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) represents the most powerful and widely employed platform for pancreaticobiliary interventions. Endoscopic retrograde cholangiopancreatography allows diagnosis and treatment of a broad spectrum of diseases of the pancreaticobiliary tree that are both benign and malignant in nature. Endoscopic retrograde cholangiopancreatography continues to evolve rapidly, and non-gastroenterologists need to understand the indications, contraindications, limitations, and role of ERCP to effectively manage and coordinate the care of patients with known or suspected pancreaticobiliary disease. This article will review the role of ERCP in detail to further an understanding of the procedure as a whole and to assess when referral of a patient for an ERCP or other related test is indicated.
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Affiliation(s)
- Geetha Nallamothu
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Huntsman Cancer Center, Salt Lake City, UT 84312, USA
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19
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Augustin T, Vandermeer TJ. Intraductal papillary mucinous neoplasm: a clinicopathologic review. Surg Clin North Am 2010; 90:377-98. [PMID: 20362793 DOI: 10.1016/j.suc.2009.12.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Intraductal papillary mucinous neoplasm (IPMN) is an intraductal mucin-producing epithelial neoplasm that arises from the main pancreatic duct (MD-IPMN), secondary branch ducts (BD-IPMN), or both (mixed type; Mix-IPMN). Neoplastic progression from benign adenoma to invasive adenocarcinoma has not been proven but is generally thought to occur. With increasing recognition of IPMN, our understanding of the diagnosis and management of the tumors is evolving. At present, treatment options for patients with IPMN range from observation to pancreatic resection depending on the natural history of the lesion. This review focuses on currently available data that guide management decisions for patients with IPMN.
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MESH Headings
- Adenocarcinoma, Mucinous/diagnosis
- Adenocarcinoma, Mucinous/genetics
- Adenocarcinoma, Mucinous/metabolism
- Adenocarcinoma, Mucinous/pathology
- Adenocarcinoma, Mucinous/surgery
- Algorithms
- Biopsy, Fine-Needle/methods
- Carcinoma, Pancreatic Ductal/diagnosis
- Carcinoma, Pancreatic Ductal/genetics
- Carcinoma, Pancreatic Ductal/metabolism
- Carcinoma, Pancreatic Ductal/pathology
- Carcinoma, Pancreatic Ductal/surgery
- Carcinoma, Papillary/diagnosis
- Carcinoma, Papillary/genetics
- Carcinoma, Papillary/metabolism
- Carcinoma, Papillary/mortality
- Carcinoma, Papillary/pathology
- Carcinoma, Papillary/surgery
- Cholangiopancreatography, Endoscopic Retrograde
- Diagnostic Imaging
- Dilatation, Pathologic
- Disease Progression
- Endosonography
- Epithelium/pathology
- Humans
- Mucins/metabolism
- Neoplasm Invasiveness
- Pancreatic Ducts/pathology
- Survival Analysis
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Affiliation(s)
- Toms Augustin
- Department of Surgery, Guthrie-Robert Packer Hospital, One Guthrie Square, Sayre, PA 18840, USA
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20
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Nguyen NQ, Binmoeller KF, Shah JN. Cholangioscopy and pancreatoscopy (with videos). Gastrointest Endosc 2009; 70:1200-10. [PMID: 19863954 DOI: 10.1016/j.gie.2009.07.010] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2009] [Accepted: 07/05/2009] [Indexed: 02/08/2023]
Affiliation(s)
- Nam Q Nguyen
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California 94115, USA
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21
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Itoi T, Neuhaus H, Chen YK. Diagnostic value of image-enhanced video cholangiopancreatoscopy. Gastrointest Endosc Clin N Am 2009; 19:557-66. [PMID: 19917461 DOI: 10.1016/j.giec.2009.06.002] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We summarized past and present results concerning the observation capability of cholangiopancratoscopy using chromoendoscopy, autofluorescence imaging (AFI), and narrow-band imaging (NBI). New generation peroral and percutaneous transhepatic video cholangiopancreatoscopes provide superior quality images. Pilot studies suggest that chromoendocholangioscopy using methylene blue or cholangioscopy using AFI can distinguish benign from malignant bile duct lesions. On the other hand, the NBI system enhances the imaging of certain features such as mucosal structures and microvessels in pancreatobiliary lesions. In patients with main-duct-type intraductal papillary mucinous neoplasm, peroral pancreatoscopy can be used to determine extent of tumor involvement. Although many technical hurdles still need to be overcome, image-enhanced cholangiopancratoscopy appears to be a promising modality to improve diagnostic accuracy of pancreatobiliary diseases, particularly in distinguishing benign from malignant lesions.
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Affiliation(s)
- Takao Itoi
- Department of Gastroenterology, Tokyo Medical University, Nishishinjuku 6-7-1, Shinjuku-ku, Tokyo 160-0023, Japan.
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22
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Abstract
Cholangiopancreatoscopy (CP) is a well-established modality for the direct visualization of intrahepatic biliary, extrahepatic biliary, and pancreatic ductal systems. The use of CP in the treatment of difficult biliary stones has become paramount when standard endoscopic retrograde cholangiopancreatography is ineffective. This article describes the available cholangioscopic devices and technical and clinical applications of cholangiopancreatoscopy. The efficacy and limitations of CP, as well as published comparative studies, are briefly reviewed.
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23
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Iqbal S, Stevens PD. Cholangiopancreatoscopy for targeted biopsies of the bile and pancreatic ducts. Gastrointest Endosc Clin N Am 2009; 19:567-77. [PMID: 19917462 DOI: 10.1016/j.giec.2009.06.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Establishing a tissue diagnosis in patients with suspected pancreaticobiliary malignancies remains challenging. Endoscopic retrograde cholangiopancreatography (ERCP)-based sampling methods have been reviewed in a previous issue of this journal but, unfortunately, the diagnostic yield continues to be inadequate in a significant minority of patients. The availability and image quality of cholangioscopy and pancreatoscopy have advanced in the last few years and our ability to make a diagnosis on imaging alone is improving. However, a definitive diagnosis requires tissue; cholangiopancreatoscopy allows targeted biopsies of the epithelium of the biliary and pancreatic ducts. This article reviews the evidence that cholangioscopy- and pancreatoscopy-guided biopsies improves diagnostic yield over ERCP-based tissue sampling techniques.
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Affiliation(s)
- Shahzad Iqbal
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University College of Physicians and Surgeons, P&S 10-508, 630 West 168th Street, NY 10032, USA
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Ringold DA, Shah RJ. Peroral pancreatoscopy in the diagnosis and management of intraductal papillary mucinous neoplasia and indeterminate pancreatic duct pathology. Gastrointest Endosc Clin N Am 2009; 19:601-13. [PMID: 19917466 DOI: 10.1016/j.giec.2009.07.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Peroral pancreatoscopy (POP) is an exciting modality for the evaluation of pancreatic diseases. It has proved efficacy in the evaluation of suspected intraductal papillary mucinous neoplasia and allows for a determination of the presence and extent of pancreatic duct involvement. When other imaging modalities are inconclusive, POP seems a useful adjunct in the evaluation of indeterminate pancreatic duct strictures and permits tissue sampling under direct vision. Despite recent advances, refinements in endoscope caliber, tip deflection, and optics are still required for more routine application in pancreatic diseases.
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Affiliation(s)
- Daniel A Ringold
- Division of Gastroenterology and Hepatology, University of Colorado Denver, MS F735, 1635 Aurora Court, Room AIP 2.031, Aurora, CO 80045, USA
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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.
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26
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Abstract
Pancreaticobiliary ductal diseases are largely investigated by indirect imaging techniques. Therefore, the pathology of up to 30% of cases remains undetermined. Cholangiopancreatoscopy allows direct visualization of ductal abnormalities with the ability to sample tissue and deliver a number of endotherapies. The technique can be broadly categorized into either two-operator or single-operator systems. Both systems provide important diagnostic information in the investigation of undetermined biliary or pancreatic strictures, intraductal papillary mucinous neoplasia, occult ductal malignant changes in patients with primary sclerosing cholangitis and occult intraductal stones in patients with complex biliary stone diseases. Therapeutically, cholangiopancreatoscopy-guided endotherapies provide a highly effective and safe alternative to surgery for patients with difficult extrahepatic and intrahepatic ductal stones that are not amenable to conventional endoscopic extraction by endoscopic retrograde cholangiopancreatography. The clinical application of cholangiopancreatoscopy, however, will be limited unless the technology is further refined to improve its durability, image quality, therapeutic capability and technical feasibility.
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Affiliation(s)
- Nam Q Nguyen
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
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27
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Intraductal papillary mucinous neoplasms of the pancreas: differentiation of malignant and benign tumors by endoscopic ultrasound findings of mural nodules. Ann Surg 2009; 249:628-34. [PMID: 19300203 DOI: 10.1097/sla.0b013e3181a189a8] [Citation(s) in RCA: 139] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND AIM Intraductal papillary mucinous neoplasms (IPMNs)have a wide pathologic spectrum and it is difficult to differentiate malignant from benign tumors. The aim of this study was to identify predictors of malignancy using contrast-enhanced endoscopic ultrasound (CE-EUS). SUBJECTS AND METHODS In our institute, main duct type and mixed type IPMNs, branch duct type IPMNs with mural nodules, and IPMNs with coexistent invasive ductal cancer were indications for surgery. Eighty-seven IPMNs (14 main duct, 25 mixed, and 48 branch duct type) were resected and CE-EUS findings were compared with pathologic findings. Twelve clinicopathological variables and CE-EUS morphologic findings were assessed.Mural nodules defined as blood flow supplied protrusions were classified into 4 types: type I: low papillary nodule, type II: polypoid nodule, type III:papillary nodule, and type IV: invasive nodule. RESULTS Forty-two, 26, 16, and 3 were pathologically diagnosed as adenoma,noninvasive carcinoma, invasive IPMNs, and coexistent invasive ductal cancer, respectively. Multivariable logistic regression analysis showed that types III/IV mural nodule (odds ratio = 10.8; 95% confidential intervals = 2.75-56.1) and symptomatic IPMNs (odds ratio = 4.31; 95% confidential intervals = 1.37-14.7) were significant for malignancy. For mural nodule diameter, invasive IPMNs were significantly larger, but types III and IV mural nodules were more frequently associated with malignancy, particularly invasive cancer, at 88.9% and 91.7%, respectively. The diagnosis of IPMNs with types III or IV mural nodule as malignant resulted in a sensitivity of 60%, specificity of 92.9%, and accuracy of 75.9%. CONCLUSIONS In conclusion, new morphologic criteria were useful to identify the malignant potentials of IPMNs.
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28
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Matsubayashi H, Fukutomi A, Kanemoto H, Maeda A, Matsunaga K, Uesaka K, Otake Y, Hasuike N, Yamaguchi Y, Ikehara H, Takizawa K, Yamazaki K, Ono H. Risk of pancreatitis after endoscopic retrograde cholangiopancreatography and endoscopic biliary drainage. HPB (Oxford) 2009; 11:222-8. [PMID: 19590651 PMCID: PMC2697892 DOI: 10.1111/j.1477-2574.2008.00020.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2008] [Accepted: 10/25/2008] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreatitis is the most common and serious complication to occur after endoscopic retrograde cholangiopancreatography (ERCP). It is often associated with additional diagnostic modalities and/or treatment of obstructive jaundice. The aim of this study was to determine the risk of post-ERCP pancreatitis associated with pancreaticobiliary examination and endoscopic biliary drainage (EBD). METHODS A total of 740 consecutive ERCP procedures performed in 477 patients were analysed for the occurrence of pancreatitis. These included 470 EBD procedures and 167 procedures to further evaluate the pancreaticobiliary tract using brush cytology and/or biopsy, intraductal ultrasound and/or peroral cholangioscopy or peroral pancreatoscopy. The occurrence of post-ERCP pancreatitis was analysed retrospectively. RESULTS The overall incidence of post-ERCP pancreatitis was 3.9% (29 of 740 procedures). The risk factors for post-ERCP pancreatitis were: being female (6.5%; odds ratio [OR] 2.5, P= 0.02); first EBD procedure without endoscopic sphincterotomy (ES) (6.9%; OR 3.0, P= 0.003), and performing additional diagnostic procedures on the pancreatobiliary duct (9.6%; OR 4.6, P < 0.0001). Pancreatitis after subsequent draining procedures was rare (0.4%; OR for first-time drainage 16.6, P= 0.0003). Furthermore, pancreatitis was not recognized in 59 patients who underwent ES. Seven patients with post-EBD pancreatitis were treated with additional ES. CONCLUSIONS Invasive diagnostic examinations of the pancreaticobiliary duct and first-time perampullary biliary drainage without ES were high-risk factors for post-ERCP pancreatitis. Endoscopic sphincterotomy may be of use to prevent post-EBD pancreatitis.
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Affiliation(s)
| | - Akira Fukutomi
- Divisions of Gastrointestinal Oncology, Shizuoka Cancer CentreNagaizumi, Suntogun, Shizuoka, Japan
| | - Hideyuki Kanemoto
- Divisions of Hepatopancreatobiliary Surgery, Shizuoka Cancer CentreNagaizumi, Suntogun, Shizuoka, Japan
| | - Atsuyuki Maeda
- Divisions of Hepatopancreatobiliary Surgery, Shizuoka Cancer CentreNagaizumi, Suntogun, Shizuoka, Japan
| | - Kazuya Matsunaga
- Divisions of Hepatopancreatobiliary Surgery, Shizuoka Cancer CentreNagaizumi, Suntogun, Shizuoka, Japan
| | - Katsuhiko Uesaka
- Divisions of Hepatopancreatobiliary Surgery, Shizuoka Cancer CentreNagaizumi, Suntogun, Shizuoka, Japan
| | - Yosuke Otake
- Divisions of Endoscopy, Shizuoka Cancer CentreNagaizumi, Suntogun, Shizuoka, Japan
| | - Noriaki Hasuike
- Divisions of Endoscopy, Shizuoka Cancer CentreNagaizumi, Suntogun, Shizuoka, Japan
| | - Yuichiro Yamaguchi
- Divisions of Endoscopy, Shizuoka Cancer CentreNagaizumi, Suntogun, Shizuoka, Japan
| | - Hisatomo Ikehara
- Divisions of Endoscopy, Shizuoka Cancer CentreNagaizumi, Suntogun, Shizuoka, Japan
| | - Kohei Takizawa
- Divisions of Endoscopy, Shizuoka Cancer CentreNagaizumi, Suntogun, Shizuoka, Japan
| | - Kentaroh Yamazaki
- Divisions of Gastrointestinal Oncology, Shizuoka Cancer CentreNagaizumi, Suntogun, Shizuoka, Japan
| | - Hiroyuki Ono
- Divisions of Endoscopy, Shizuoka Cancer CentreNagaizumi, Suntogun, Shizuoka, Japan
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Fishman DS, Tarnasky PR, Patel SN, Raijman I. Management of pancreaticobiliary disease using a new intra-ductal endoscope: The Texas experience. World J Gastroenterol 2009; 15:1353-8. [PMID: 19294765 PMCID: PMC2658829 DOI: 10.3748/wjg.15.1353] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate a new single-operator mini-endoscope, Spyglass®, for its performance, feasibility and safety in the management of pancreaticobiliary disease.
METHODS: In a multicenter retrospective analysis of patients undergoing intraductal endoscopy, we evaluated 128 patients (71 men, mean age 57.6 years). Indications were therapeutic (TX) in 72 (56%) and diagnostic (DX) in 56 (44%).
RESULTS: Peroral endoscopy was performed in 121 and percutaneous in seven. TX indications included CBD stones in 41, PD stones in six, and biliary strictures in 25. DX indications included abnormal LFT’s in 15, abnormal imaging in 38 and cholangiocarcinoma staging in three. Visualization of the stone(s) was considered good in 31, fair in six, and poor in four. Advancement of the electrohydraulic lithotripsy probe was not possible in three patients and proper targeting of the lesion was partial in four patients. A holmium laser was used successfully in three patients. Ductal clearance was achieved in 37 patients after one procedure and in four patients after two procedures. Diagnosis of biliary strictures was modified in 20/29 and confirmed to be malignant in 10/23. Of the modified patients, no diagnosis was available in 17. Spyglass® demonstrated malignancy in 8/17 and non-malignancy in nine. Suspected pathology by imaging studies and abnormal LFT’s was modified in 43/63 (66%). Staging of cholangiocarcinoma demonstrated multicentric cholangiocarcinoma in 2/3. There was no morbidity associated with the use of Spyglass®.
CONCLUSION: Spyglass Spyscope® is a first generation, single operator miniature endoscope that can evaluate and treat various biliary and pancreatic tract diseases.
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Fritz S, Warshaw AL, Thayer SP. Management of mucin-producing cystic neoplasms of the pancreas. Oncologist 2009; 14:125-36. [PMID: 19211618 DOI: 10.1634/theoncologist.2008-0200] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
During the last decade small lesions of the pancreas have been increasingly recognized in clinical practice. Among these lesions, mucin-producing cystic neoplasms represent a recently described and unique entity among pancreatic tumors. In 1996, the World Health Organization distinguished two different types of mucinous cystic tumors: intraductal papillary mucinous neoplasms (IPMNs) of the pancreas, which are characterized by mucin production, cystic dilation of the pancreatic ducts, and intrapapillary growth, and mucinous cystic neoplasms (MCNs), which are defined by ovarian-like stroma and in most cases do not communicate with pancreatic ducts. Further, IPMNs can be subdivided into main-duct type, mixed-type, and branch-duct type tumors. Older data did not distinguish among different subsets of cystic neoplasms of the pancreas, and consequently many databases were inconsistent. Histopathologically, both IPMNs and MCNs demonstrate a wide spectrum of cellular atypia ranging from mild mucinous hyperplasia to invasive adenocarcinoma. Because mucinous cystic neoplasms of the pancreas show significant differences in clinical behavior from patient to patient, knowledge of the clinicopathologic characteristics and natural history of specific subtypes of IPMNs and MCNs has become crucial for physicians working in the field of gastroenterology. The present work offers an overview of current and generally accepted clinical guidelines for the diagnosis and treatment of IPMNs and MCNs.
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Affiliation(s)
- Stefan Fritz
- Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
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31
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Kobayashi G, Fujita N, Noda Y, Obana T, Takasawa O. Ultrasonographic findings and natural history of intraductal papillary-mucinous neoplasms of the pancreas. J Med Ultrason (2001) 2008; 35:85-96. [PMID: 27278830 DOI: 10.1007/s10396-008-0188-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2008] [Accepted: 06/05/2008] [Indexed: 02/07/2023]
Abstract
It is clear that the prevalence of malignancy is high in the main-duct type of intraductal papillary-mucinous neoplasm (IPMN). Branch-duct IPMNs include several histologic conditions such as carcinoma, adenoma, and hyperplasia. Intraductal papillary adenocarcinoma and papillary adenoma are characterized by papillary protrusions and thick septum-like structures in dilated ducts as delineated by ultrasonography. A solid mass showing a mixedecho pattern in the pancreatic parenchyma is a characteristic finding of invasive types of IPMN. The international guidelines for the management of branch-duct IPMNs suggest that the appearance of symptoms attributable to the cyst, the presence of intramural nodules, a cyst size greater than 30 mm, and dilation of the main pancreatic duct (>6 mm) are indications for resection. Based on the relationship between the height of a papillary protrusion and the diameter of a cystic dilated branch as well as on histological findings, branch-duct IPMNs with papillary protrusions more than 10 mm in height as shown by imaging should be resected, and it is not adequate to differentiate carcinoma from other lesions based on the diameter of cystic branches alone. A follow-up study on branch-duct IPMNs revealed that most papillary protrusions showed a slow increase in size or development of lateral spread, and that there was no development of cancer with stromal invasion during an average follow-up of 46 months. Therefore, the presence of intramural nodules alone should not be an indication for surgery. Also, patients without papillary protrusions or thick septum-like structures are not immediate candidates for surgery. Invasive adenocarcinoma can develop at a pancreatic site different from the area of interest showing cystic changes, with such invasion possibly being multicentric. Therefore, in patients with branch-duct IPMNs, attention should be paid to the entire pancreas when performing follow-up examinations.
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Affiliation(s)
- Go Kobayashi
- Department of Gastroenterology, Sendai City Medical Center, 5-22-1 Tsurugaya, Miyagino-ku, Sendai, 983-0824, Japan.
| | - Naotaka Fujita
- Department of Gastroenterology, Sendai City Medical Center, 5-22-1 Tsurugaya, Miyagino-ku, Sendai, 983-0824, Japan
| | - Yutaka Noda
- Department of Gastroenterology, Sendai City Medical Center, 5-22-1 Tsurugaya, Miyagino-ku, Sendai, 983-0824, Japan
| | - Takashi Obana
- Department of Gastroenterology, Sendai City Medical Center, 5-22-1 Tsurugaya, Miyagino-ku, Sendai, 983-0824, Japan
| | - Osamu Takasawa
- Department of Gastroenterology, Sendai City Medical Center, 5-22-1 Tsurugaya, Miyagino-ku, Sendai, 983-0824, Japan
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Shah RJ, Adler DG, Conway JD, Diehl DL, Farraye FA, Kantsevoy SV, Kwon R, Mamula P, Rodriguez S, Wong Kee Song LM, Tierney WM. Cholangiopancreatoscopy. Gastrointest Endosc 2008; 68:411-21. [PMID: 18538326 DOI: 10.1016/j.gie.2008.02.033] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2008] [Accepted: 02/11/2008] [Indexed: 02/08/2023]
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33
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Judah JR, Draganov PV. Intraductal biliary and pancreatic endoscopy: An expanding scope of possibility. World J Gastroenterol 2008; 14:3129-36. [PMID: 18506916 PMCID: PMC2712843 DOI: 10.3748/wjg.14.3129] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Intraductal endoscopy describes the use of an endoscope to directly visualize the biliary and pancreatic ducts. For many years, technological challenges have made performing these procedures difficult. The “mother-baby” system and other various miniscopes have been developed, but routine use has been hampered due to complex setup, scope fragility and the time consuming, technically demanding nature of the procedure. Recently, the SpyGlass peroral cholangiopancreatoscopy system has shown early success at providing diagnostic information and therapeutic options. The clinical utility of intraductal endoscopy is broad. It allows better differentiation between benign and malignant processes by allowing direct visualization and targeted sampling of tissue. Therapeutic interventions, such as electrohydraulic lithotripsy (EHL), laser lithotripsy, photodynamic therapy, and argon plasma coagulation (APC), may also be performed as part of intraductal endoscopy. Intraductal endoscopy significantly increases the diagnostic and therapeutic yield of standard endoscopic retrograde cholangiography (ERCP), and as technology progresses, it is likely that its utilization will only increase. In this review of intraductal endoscopy, we describe in detail the various endoscopic platforms and their diagnostic and clinical applications.
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34
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Itoi T, Sofuni A, Itokawa F, Kurihara T, Tsuchiya T, Ishii K, Tsuji S, Ikeuchi N, Arisaka Y, Moriyasu F. Initial experience of peroral pancreatoscopy combined with narrow-band imaging in the diagnosis of intraductal papillary mucinous neoplasms of the pancreas (with videos). Gastrointest Endosc 2007; 66:793-7. [PMID: 17905024 DOI: 10.1016/j.gie.2007.03.1096] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2006] [Accepted: 03/26/2007] [Indexed: 12/12/2022]
Abstract
BACKGROUND It is very important to determine the extent of intraductal mucinous neoplasms (IPMNs), because this can greatly affect the determination of the indications of surgery. Peroral pancreatovideoscopy (POPS) has been recognized as a new diagnostic tool for clear imaging of IPMN. Recently, narrow-band imaging (NBI) has made it possible to emphasize certain image features, such as mucosal structures and capillary vessels. OBJECTIVE To evaluate the clinical usefulness of POPS by using NBI for the diagnosis of IPMN. DESIGN Case reports. SETTING This procedure was performed at Tokyo Medical University Hospital. PATIENTS Three patients with IPMN. INTERVENTION All patients underwent POPS with NBI. MAIN OUTCOME MEASUREMENT Efficacy and safety of this technique. RESULTS POPS with NBI was performed in 3 patients, without procedure-related complications. Identification of the surface structure and the capillary vessels by NBI observation was better than by conventional observation. Furthermore, NBI identified skip tumor lesions in the tail of pancreas, which were not detected by conventional POPS. LIMITATIONS Because none of the patients in the 3 cases underwent surgical resection, a comparison to clarify total agreement between the preoperative POPS findings and the resected specimen was not possible. CONCLUSIONS POPS with NBI may facilitate the observation of both fine mucosal structures and capillary vessels in patients with IPMN, although further study is necessary to fully establish the clinical benefit.
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Affiliation(s)
- Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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Tanaka M, Chari S, Adsay V, Fernandez-del Castillo C, Falconi M, Shimizu M, Yamaguchi K, Yamao K, Matsuno S. International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas. Pancreatology 2006; 6:17-32. [PMID: 16327281 DOI: 10.1159/000090023] [Citation(s) in RCA: 1401] [Impact Index Per Article: 77.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Non-inflammatory cystic lesions of the pancreas are increasingly recognized. Two distinct entities have been defined, i.e., intraductal papillary mucinous neoplasm (IPMN) and mucinous cystic neoplasm (MCN). Ovarian-type stroma has been proposed as a requisite to distinguish MCN from IPMN. Some other distinct features to characterize IPMN and MCN have been identified, but there remain ambiguities between the two diseases. In view of the increasing frequency with which these neoplasms are being diagnosed worldwide, it would be helpful for physicians managing patients with cystic neoplasms of the pancreas to have guidelines for the diagnosis and treatment of IPMN and MCN. The proposed guidelines represent a consensus of the working group of the International Association of Pancreatology.
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MESH Headings
- Endocrine Surgical Procedures
- Humans
- Neoplasms, Cystic, Mucinous, and Serous/classification
- Neoplasms, Cystic, Mucinous, and Serous/diagnosis
- Neoplasms, Cystic, Mucinous, and Serous/surgery
- Neoplasms, Cystic, Mucinous, and Serous/therapy
- Pancreatic Neoplasms/classification
- Pancreatic Neoplasms/diagnosis
- Pancreatic Neoplasms/surgery
- Pancreatic Neoplasms/therapy
- Papilloma, Intraductal/classification
- Papilloma, Intraductal/diagnosis
- Papilloma, Intraductal/surgery
- Papilloma, Intraductal/therapy
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Affiliation(s)
- Masao Tanaka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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Tanaka M, Kobayashi K, Mizumoto K, Yamaguchi K. Clinical aspects of intraductal papillary mucinous neoplasm of the pancreas. J Gastroenterol 2005; 40:669-75. [PMID: 16082582 DOI: 10.1007/s00535-005-1646-4] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2005] [Accepted: 06/03/2005] [Indexed: 02/04/2023]
Abstract
Intraductal papillary mucinous neoplasm (IPMN) is a spectrum of neoplasia in the pancreatic duct epithelium characterized by cystic dilation of the main and/or branch pancreatic duct. According to the site of involvement IPMNs are classified into three categories, i.e., main duct type, branch duct type, and combined type. Most branch duct IPMNs are benign, whereas the other two types are often malignant. A large size of branch duct IPMN and marked dilation of the main pancreatic duct indicate the presence of adenoma at least. The additional existence of large mural nodules increases the possibility of malignancy in all types. Of recent interest is the relatively high prevalence of synchronous and/or metachronous malignancy in various organs, including the pancreas. The prognosis is favorable after complete resection of benign and noninvasive malignant IPMNs. Malignant IPMNs acquiring aggressiveness after parenchymal invasion necessitate adequate lymph node dissection. On the other hand, asymptomatic branch duct IPMNs without mural nodules can be observed without resection for a considerably long time. This review addresses available data, current understanding, controversy, and future directions.
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Affiliation(s)
- Masao Tanaka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Fukuoka, 812-8582, Japan
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Adler DG, Baron TH, Davila RE, Egan J, Hirota WK, Leighton JA, Qureshi W, Rajan E, Zuckerman MJ, Fanelli R, Wheeler-Harbaugh J, Faigel DO. ASGE guideline: the role of ERCP in diseases of the biliary tract and the pancreas. Gastrointest Endosc 2005; 62:1-8. [PMID: 15990812 DOI: 10.1016/j.gie.2005.04.015] [Citation(s) in RCA: 271] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Thompson CC, Kelsey PB. Duodenoscope assisted cholangiopancreatoscopy: a review of clinical applications. Curr Opin Gastroenterol 2003; 19:487-91. [PMID: 15703595 DOI: 10.1097/00001574-200309000-00010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Duodenoscope assisted cholangiopancreatoscopy allows direct visualization of the pancreatic duct and bile duct. There are several circumstances where direct ductal visualization might be helpful in clarifying a diagnosis or providing targeted treatment. Duodenoscope assisted cholangiopancreatoscopy is currently employed for a variety of indications including: indeterminate ductal strictures and filling defects, marginal chronic pancreatitis, treatment of large intraductal stones, localization of intraductal papillary mucinous tumors, and localization and treatment of hemobilia. There have however been no randomized controlled trials evaluating the diagnostic or therapeutic functions of duodenoscope assisted cholangiopancreatoscopy. This article reviews recent descriptive studies that attempt to clarify the clinical role of this technology.
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