Nonprevention of post-endoscopic retrograde cholangiopancreatographic pancreatitis by pancreatic stent after aspiration of pure pancreatic juice in patients with intraductal papillary mucinous neoplasms of the pancreas

Risk Factors for Post-Endoscopic Retrograde Cholangio-Pancreatography Pancreatitis in Children With Chronic Pancreatitis and Its Prediction Using 4-Hour Postprocedure Serum Amylase and Lipase Levels

BACKGROUND

Post-endoscopic retrograde cholangio-pancreatography pancreatitis (PEP) is seen in 3% to 16% of children undergoing therapeutic endoscopic retrograde cholangio-pancreatography (ERCP). We evaluated the risk factors of PEP and utility of 4-hour post-ERCP amylase and lipase for early prediction of PEP in children with chronic pancreatitis (CP).

MATERIALS AND METHODS

Thirty children with CP (boys 20, 14.3 [interquartile range, 9.3-16] years) who underwent 62 ERCP procedures were studied. Clinical and procedural details with outcome were noted. Serum amylase and lipase were measured before, 4 hours, and 24 hours after ERCP. Multivariate analysis was done to identify risk factors for PEP. Cutoff scores of 4-hour amylase and lipase were identified.

RESULTS

PEP occurred in 14.5% (9/62) of ERCP procedures (mild, 8; moderate, 1) with no mortality. On univariate analysis, endoscopic sphincterotomy ( P = 0.04), difficult cannulation ( P = 0.004), and prior PEP ( P = 0.036) were risk factors, while prior ERCP ( P = 0.04) was protective. Difficult cannulation (odds ratio, 5.83; 95% confidence interval, 1.329-25.592) was the independent risk factor on multivariate analysis overall and for first ERCP session alone. Amylase >3.3 times upper limit of normal (ULN) and lipase of >5 times ULN at 4 hours had best sensitivity and specificity for diagnosis of PEP. All cases with PEP were symptomatic by 6 hours and none had amylase/lipase <3 ULN at 4 hours. Amylase/lipase of <3 ULN at 4 hours could exclude PEP with good sensitivity (100%) and specificity (76% and 81%, respectively).

CONCLUSIONS

PEP occurred in 14.5% of procedures in children with CP, with difficult cannulation being the independent risk factor. Asymptomatic patients with 4-hour amylase/lipase <3 times ULN can be safely discharged.

A comparison of 4-Fr with 5-Fr endoscopic nasopancreatic drainage catheters: A randomized, controlled trial

BACKGROUND AND AIM

Although endoscopic nasopancreatic drainage (ENPD) is useful for collecting samples for pancreatic juice cytology and for treating leakage of pancreatic juice and occlusive pancreatitis, placement of the ENPD catheter is associated with complications such as post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). We investigated whether an ENPD catheter with a smaller diameter could reduce the incidence of complications.

METHODS

Patients requiring placement of an ENPD catheter (n = 254) were enrolled and randomly assigned to one of two catheter-size groups: the 4-Fr group or the 5-Fr group. The incidence of PEP, cholangitis, and spontaneous catheter displacement and the suitability of pancreatic juice cytology samples were compared between groups. In addition, univariate and multivariate analyses were conducted on factors associated with PEP.

RESULTS

The incidence of PEP was significantly lower in the 4-Fr group compared with the 5-Fr group (4.1% vs 12.4%, respectively; P = 0.021). The rate of cholangitis and spontaneous catheter displacement and the suitability of pancreatic juice cytology samples did not differ between groups. Multivariate analysis revealed that the risk of PEP was 3.7 times higher when using a 5-Fr catheter than when using a 4-Fr catheter (P = 0.019). In addition, the risk of PEP was 4.1 times higher in patients with an intraductal papillary mucinous neoplasm than in those without (P = 0.0049) and 4.6 times higher in patients aged <65 than in those aged ≥65 (P = 0.0033).

CONCLUSIONS

A 4-Fr catheter is as useful as a 5-Fr catheter and is associated with a significantly lower incidence of PEP.

Role of the preoperative usefulness of the pathological diagnosis of pancreatic diseases

Pancreatic cancer is the fifth leading cause of cancer death and has the lowest survival rate of any solid cancer. Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) is currently capable of providing a cytopathological diagnosis of pancreatic malignancies with a higher diagnostic power, with a sensitivity and specificity of 85%-89% and 98%-99%, compared to pancreatic juice cytology (PJC), whose sensitivity and specificity are only 33.3%-93% and 83.3%-100%. However, EUS-FNA is not effective in the cases of carcinoma in situ and minimally invasive carcinoma because both are undetectable by endoscopic ultrasonography, although PJC is able to detect them. As for the frequency of complications such as post endoscopic retrograde cholangiopancreatography pancreatitis, EUS-FNA is safer than PJC. To diagnose pancreatic cancer appropriately, it is necessary for us to master both procedures so that we can select the best methods of sampling tissues while considering the patient’s safety and condition.

Factors associated with post-ERCP pancreatitis and the effect of pancreatic duct stenting in a pediatric population

BACKGROUND

Risk factors for the development of post-ERCP pancreatitis (PEP) have not been identified in the pediatric population. It remains unclear what constitutes appropriate prophylaxis in this patient population.

OBJECTIVES

To assess the prevalence and severity of PEP in the pediatric population and identify factors associated with developing PEP and to evaluate the effect of prophylactic pancreatic duct stenting in high-risk patients.

DESIGN

Retrospective analysis of an ERCP database at a single large pediatric center.

SETTING

Academic center.

PATIENTS

A total of 432 ERCPs performed on 313 patients younger than 19 years of age from January 2004 to October 2013.

INTERVENTION

ERCP for any indication.

MAIN OUTCOME MEASUREMENTS

Rates and severity of PEP, preprocedural and procedural risk factors for the development of PEP, and the effect of pancreatic stents on preventing PEP in high-risk patients.

RESULTS

PEP occurred after 47 procedures (prevalence, 10.9%). Thirty-four cases were mild, 9 were moderate, and 4 were severe. There was no mortality. On multiple logistic analysis, pancreatic duct injection (P<.0001; odds ratio 30.8; 95% confidence interval [CI], 9.1-103.9) and pancreatic sphincterotomy (P<.01; OR 3.8; 95% CI, 1.6-9.8) were positively associated with PEP. A history of chronic pancreatitis was negatively associated with PEP (P<.05; OR 0.37; 95% CI, 0.15-0.93). On subset analysis, placing a prophylactic pancreatic stent was associated with significantly increased rates of PEP in patients with pancreatic duct injection compared with those who had no attempt at stent placement (P<.01). Two patients with severe pancreatitis had prophylactic pancreatic stents in place.

LIMITATIONS

Retrospective investigation.

CONCLUSIONS

In the pediatric population, pancreatic duct injection and pancreatic sphincterotomy are associated with significantly increased rates of PEP, whereas a history of chronic pancreatitis is negatively associated. Prophylactic pancreatic stenting is associated with higher rates of PEP in high-risk patients and does not eliminate severe PEP.

Progress in research of intraductal papillary mucinous neoplasms

Intraductal papillary mucinous neoplasms (IPMNs) represent a spectrum of neoplasms arising from the main pancreatic duct or branch ducts and producing mucin and can be regarded as a type of precancerous lesions. Thanks to improvements in endoscopy and imaging techniques, IPMNs are being diagnosed with increasing frequency. However, there are currently no highly sensitive and specific preoperative criteria available to distinguish benign IPMNs from malignant ones. What's more, the necessity for EUS and ERCP in the diagnosis of IPMNs is still under debate. Here, we review recent advances in research of IPMNs and summarize potential differences between benign and malignant IPMNs.

Risk factors for post-ERCP pancreatitis in high risk patients who have undergone prophylactic pancreatic duct stenting: a multicenter retrospective study

BACKGROUND AND AIM

Pancreatitis remains a serious complication after endoscopic retrograde cholangiopancreatography (ERCP). The efficacy of prophylactic pancreatic duct stent placement to prevent post-ERCP pancreatitis in patients at high risk has been established in several randomized controlled trials. The aim of this study was to investigate the frequency and risk factors of post-ERCP pancreatitis in patients who had undergone prophylactic pancreatic duct stenting.

PATIENTS AND METHODS

Between July 2002 and January 2010, ERCP-related procedures were performed in 9192 cases of pancreatobiliary diseases at seven institutions. Among them, 414 patients (246 men, 168 women; mean age, 68 yr; age range, 22-91 yr) at high risk of post-ERCP pancreatitis who had undergone prophylactic pancreatic duct stenting were included in this study. The stent used in the present study was a 5-Fr stent with a single duodenal pigtail, which is made of soft polyethylene and has no flange (Pit-stent: Cathex, Co., Ltd., Tokyo, Japan). The pancreatic duct stent was placed via the channel of the duodenoscope over a guidewire with the assistance of fluoroscopy at the end of the procedure. The frequency and risk factors of post-ERCP pancreatitis were investigated. Post-ERCP pancreatitis was defined based on the consensus criteria.

RESULTS

Therapeutic ERCP was performed in 52% of the patients. Indications for prophylactic pancreatic duct stenting were as follows: difficult cannulation of the bile duct, 192; pancreatic duct cytology/biopsy, 95; precut sphincterotomy, 40; pancreatic sphincterotomy, 29; female gender, 28; papillectomy, 25; sphincter of Oddi dysfunction, 12; history of pancreatitis, 10. Hyperamylasemia at 18-24 h after ERCP was observed in 64% (267 patients) of the patients. Pancreatitis occurred in 9.9% (41 patients: mild, 37; moderate, 2; severe, 2). Univariate analysis revealed intraductal papillary mucinous neoplasm (IPMN) of the pancreas to be the only significant risk factor for pancreatitis (OR 2.9, 95% CI 1.2, 7.1). Multivariate analysis also showed IPMN to be the only risk factor for pancreatitis (OR 3.1, 95% CI 1.2, 7.8). The mean diameter of the pancreatic head duct in patients with IPMN who developed post-ERCP pancreatitis was significantly smaller than that in those who did not develop pancreatitis (3.0 ± 1 mm vs 4.7 ± 2.6 mm, p=0.0037).

CONCLUSION

Post-ERCP pancreatitis developed in 9.9% of the patients at high risk who had undergone prophylactic pancreatic duct stenting. Since the majority of cases of post-ERCP pancreatitis were mild, pancreatic duct stenting may contribute to lessening the severity of pancreatitis. The present results suggest that IPMN without a dilated pancreatic head duct is a possible risk factor for post-ERCP pancreatitis after prophylactic pancreatic duct stenting.