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Molero X, Ayuso JR, Balsells J, Boadas J, Busquets J, Casteràs A, Concepción M, Cuatrecasas M, Fernàndez Esparrach G, Fort E, Garcia Borobia F, Ginès À, Ilzarbe L, Loras C, Masachs M, Merino X, Olsina JJ, Puig-Diví V, Salord S, Serrano T, Vaquero EC. Chronic pancreatitis for the clinician: complications and special forms of the disease. Interdisciplinary position paper of the Catalan Society of Digestology (SCD) and the Catalan Pancreatic Society (SCPanc). Minerva Gastroenterol (Torino) 2024; 70:208-224. [PMID: 35262306 DOI: 10.23736/s2724-5985.22.03127-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Chronic pancreatitis tends to develop a number of complications that may constitute the form of presentation of the disease. Some societies have issued guidelines for diagnosis and treatment of chronic pancreatitis complications, but the level of evidence for any topic is usually low and recommendations tend to be weak. We aimed to provide defined position statements for the clinician based on updated review of published literature and on multidisciplinary expert agreement. The goal was to propose defined terminology and rational diagnostic/therapeutic circuits based on current knowledge. To this end 14 sections related to complications and special forms of chronic pancreatitis (early chronic, groove and autoimmune pancreatitis) were reviewed by 21 specialists from 6 different fields to generate 32 statements. Featured statements assert common bile duct stenosis does not require invasive treatment (endoscopic or surgical) unless cholestasis, cholangitis, lithiasis or other symptoms develop. Pancreatic duct strictures and calculi should be approached (after ruling out malignancy) if causing pain, pancreatitis, pseudocysts or other complications. Treatment of symptomatic pseudocysts must be individualized, considering associated main duct stenosis, vascular and pericystic complications. Higher risk conditions for pancreatic cancer are advance age, smoking, genetic background, recent diagnosis of chronic pancreatitis or diabetes, and appearance of new symptoms. Groove pancreatitis can initially be treated with conservative measures. Both prednisolone or rituximab can induce remission and maintenance of autoimmune pancreatitis. Internal fistula, vascular complications, bacterial overgrowth, osteoporosis and renal lithiasis require specific therapeutic approaches.
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Affiliation(s)
- Xavier Molero
- Unit of Exocrine Pancreas Research, Department of Gastroenterology, VHIR, CIBERehd, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain -
| | - Juan R Ayuso
- Department of Radiology, CDI, IDIBAPS, Hospital Clínic Barcelona, Barcelona, Spain
| | - Joaquim Balsells
- Department of Hepato-Pancreato-Biliary and Transplantation Surgery, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Jaume Boadas
- Department of Gastroenterology, Consorci Sanitari de Terrassa, Terrassa, Spain
| | - Juli Busquets
- Department of Hepatobiliary and Pancreatic Surgery, IDIBELL, Bellvitge University Hospital, University of Barcelona, L'Hospitalet de Llobregat, Spain
| | - Anna Casteràs
- Unit of Diabetes and Metabolism Research, VHIR, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Mar Concepción
- Department of Gastroenterology, Santa Creu i Sant Pau Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Míriam Cuatrecasas
- Department of Pathology, CIBEREHD, IDIBAPS, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain
| | - Gloria Fernàndez Esparrach
- Unit of Endoscopy, Department of Gastroenterology, CIBEREHD IDIBAPS, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain
| | - Esther Fort
- Department of Gastroenterology, Doctor Josep Trueta University Hospital, Girona, Spain
| | | | - Àngels Ginès
- Unit of Endoscopy, Department of Gastroenterology, CIBEREHD IDIBAPS, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain
| | - Lucas Ilzarbe
- Department of Gastroenterology, Hospital del Mar Parc Salut Mar, Barcelona, Spain
| | - Carme Loras
- Department of Gastroenterology, CIBERehd, University of Barcelona, Terrassa, Spain
| | - Miquel Masachs
- Department of Endocopy, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Terrassa, Spain
| | - Xavier Merino
- Department of Radiodiagnostic, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Jorge J Olsina
- Department of General Surgery, Institute for Research in Biomedicine of Lleida (IRBLleida), University Hospital Arnau de Vilanova, Lleida, Spain
| | - Valentí Puig-Diví
- Department of Gastroenterology, Parc Taulí Research and Innovation Institute I3PT, Parc Taulí University Hospital, Sabadell, Spain
| | - Sílvia Salord
- Unit of Hepato-Bilio-Pancreatic, Department of Digestive Diseases, IDIBELL, Bellvitge University Hospital, University of Barcelona, L'Hospitalet de Llobregat, Spain
| | - Teresa Serrano
- Department of Pathology, IDIBELL, CIBERehd, Bellvitge University Hospital, L'Hospitalet de Llobregat, Spain
| | - Eva C Vaquero
- Department of Gastroenterology, CIBEREHD IDIBAPS, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain
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Funamizu N, Uraoka M, Numata Y, Koizumi M, Ogawa K, Ikeda Y, Takada Y. Refractory postoperative pancreatic fistula following laparoscopic distal pancreatectomy for pancreatic cancer caused by incomplete pancreas divisum: a case report. Clin J Gastroenterol 2024; 17:587-591. [PMID: 38460085 DOI: 10.1007/s12328-024-01942-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 02/19/2024] [Indexed: 03/11/2024]
Abstract
Pancreas divisum (PD) represents a prevalent congenital pancreatic variant, typically arising from the failure of fusion between the ventral and dorsal pancreatic ducts. This condition is frequently associated with recurrent pancreatitis. We herein present a case involving an incomplete PD diagnosis following the identification of a refractory postoperative pancreatic fistula (POPF) after laparoscopic distal pancreatectomy (DP) for pancreatic cancer. A 74-year-old female patient, who had undergone laparoscopic DP for pancreatic cancer, developed a POPF accompanied by intraabdominal bleeding, necessitating urgent intervention radiology to avert life-threatening complications. Following this, intraabdominal drainage was performed through an intraoperative drainage root. Subsequent fistulography and endoscopic retrograde pancreatography unveiled the presence of an incomplete PD for the first time. Consequently, a stent was placed in the Santorini duct. However, the volume of pancreatic juice from the intraabdominal drainage tube exhibited no reduction. Despite repeated attempts to access the pancreatic duct via a guidewire through the drainage tube, these endeavors proved futile. Paradoxically, the removal of the external drainage tube led to a recurrence of intraabdominal abscess formation. Consequently, reinsertion of the drainage tube became imperative. Consideration was given to draining the abscess under endoscopic ultrasonography and performing pancreatic duct drainage. However, due to the diminution of the abscess cavity through the external fistula drainage procedure, coupled with the absence of pancreatic duct dilation and its tortuous course, it was deemed a formidable challenge. the patient necessitated a lifestyle adaptation with a permanently placed percutaneous drainage tube.
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Affiliation(s)
- Naotake Funamizu
- Department of Hepatobiliary Pancreatic Surgery, Ehime University Graduate School of Medicine, 454 Shitsugawa, Toon, Ehime, 791-0295, Japan.
| | - Mio Uraoka
- Department of Hepatobiliary Pancreatic Surgery, Ehime University Graduate School of Medicine, 454 Shitsugawa, Toon, Ehime, 791-0295, Japan
| | - Yuki Numata
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Mitsuhito Koizumi
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Kohei Ogawa
- Department of Hepatobiliary Pancreatic Surgery, Ehime University Graduate School of Medicine, 454 Shitsugawa, Toon, Ehime, 791-0295, Japan
| | - Yoshio Ikeda
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Yasutsugu Takada
- Department of Hepatobiliary Pancreatic Surgery, Ehime University Graduate School of Medicine, 454 Shitsugawa, Toon, Ehime, 791-0295, Japan
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Wang YH. Advances in minimally invasive endoscopic treatment of pancreatic divisum. WORLD CHINESE JOURNAL OF DIGESTOLOGY 2024; 32:199-202. [DOI: 10.11569/wcjd.v32.i3.199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/29/2024]
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Volkan B, Şahin Akkelle B, Bayrak NA, Tutar E, Kalaycık Şengül Ö, Polat E, Kutluk G, Ertem D. Long-Term Follow-Up and Outcome of Pediatric Acute Pancreatitis: A Multicenter Study. Turk Arch Pediatr 2023; 58:388-394. [PMID: 37357452 PMCID: PMC10441128 DOI: 10.5152/turkarchpediatr.2023.22261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 04/03/2023] [Indexed: 06/27/2023]
Abstract
OBJECTIVE Over the past decades, the incidence of acute pancreatitis is increasing, but the progression of acute recurrent pancreatitis and chronic pancreatitis is still not well documented in children. The aim of this multicenter study is to delineate the changes that occur in a certain time period in the course of childhood pancreatitis. MATERIALS AND METHODS The data of consecutive patients hospitalized with acute pancreatitis between 2010 and 2017 in 4 different pediatric gastroenterology units were reviewed. The clini- cal characteristics of the disease were defined. RESULTS A total of 165 patients (55.2% female) were included. Over the years, the rate of acute pancreatitis admissions increased while the duration of hospitalization decreased (P < .05). Nearly two-thirds of the patients with acute pancreatitis resolved spontaneously, 30.9% and 4.3% of the cases developed acute recurrent pancreatitis and chronic pancreatitis, respectively. Furthermore, 27.4% patients with acute recurrent pancreatitis progressed to chronic pancre- atitis, and eventually, 12.7% of cases developed chronic pancreatitis within 3-4 years. Local complications developed in 13.3% of the patients with pancreatitis in this cohort. CONCLUSION The result of this study confirmed the increased incidence of acute pancreatitis in recent years. Conversely, the length of hospital stay decreased over the years. Patients with pancreaticobiliary abnormalities or genetic risk factors had a higher rate of progression to acute recurrent pancreatitis or chronic pancreatitis. Therefore, genetic testing and radiological imaging should be considered early in the follow-up of patients with acute pancreatitis having risk factors for progression to acute recurrent pancreatitis/chronic pancreatitis.
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Affiliation(s)
- Burcu Volkan
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Marmara University Faculty of Medicine, İstanbul, Turkey
| | - Bilge Şahin Akkelle
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Marmara University Faculty of Medicine, İstanbul, Turkey
| | - Nevzat Aykut Bayrak
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Marmara University Faculty of Medicine, İstanbul, Turkey
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Health Sciences, Zeynep Kamil Children’s Hospital, İstanbul, Turkey
| | - Engin Tutar
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Marmara University Faculty of Medicine, İstanbul, Turkey
| | - Özlem Kalaycık Şengül
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Marmara University Faculty of Medicine, İstanbul, Turkey
| | - Esra Polat
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Marmara University Faculty of Medicine, İstanbul, Turkey
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Health Sciences, Sancaktepe City Hospital, İstanbul, Turkey
| | - Günsel Kutluk
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Marmara University Faculty of Medicine, İstanbul, Turkey
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Health Sciences, Çam and Sakura City Hospital, İstanbul, Turkey
| | - Deniz Ertem
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Marmara University Faculty of Medicine, İstanbul, Turkey
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Liu K, Liu X, Shi C, Liu S, Du H, Li Y, Wang N, Feng Z, Jiang H. Double plastic stent implantation for recurrent acute pancreatitis with incomplete pancreas divisum: a case report and literature review. J Int Med Res 2021; 49:3000605211060142. [PMID: 34842463 PMCID: PMC8647234 DOI: 10.1177/03000605211060142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Pancreas divisum (PD) is a common pancreatic malformation caused by the failure of fusion between ventral and dorsal pancreatic ducts. There is a small branch of communication between the two systems in incomplete PD, and this variation has an incidence of 15%. A 43-year-old female patient presented to our department with recurrent abdominal pain. Magnetic resonance cholangiopancreatography (MRCP) showed that the ventral pancreatic duct was curved, with a local pouchlike dilatation. Endoscopic ultrasonography supported the diagnosis of incomplete PD and showed a thin branch of communication between ventral and dorsal pancreatic ducts. Endoscopic retrograde cholangiopancreatography (ERCP) and papillotomy of the minor papilla with double plastic stent implantation were performed. One pancreatic plastic stent was inserted across the minor and major papilla over the guide wire, creating a U-shape. The other wire-guided plastic stent was inserted through the minor papilla into the dorsal pancreatic duct. The pancreatic fluid drained smoothly after stent placement. During the 6-month follow-up, the patient remained well, without recurrence of pancreatitis.
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Affiliation(s)
- Kunyi Liu
- Department of Gastroenterology, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, 71213Second Hospital of Hebei Medical University, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Xuechen Liu
- Department of Gastroenterology, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, 71213Second Hospital of Hebei Medical University, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Chengyi Shi
- Department of Gastroenterology, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, 71213Second Hospital of Hebei Medical University, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Siqi Liu
- Department of Gastroenterology, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, 71213Second Hospital of Hebei Medical University, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Hongwei Du
- Department of Gastroenterology, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, 71213Second Hospital of Hebei Medical University, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Yan Li
- Department of Gastroenterology, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, 71213Second Hospital of Hebei Medical University, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Na Wang
- Department of Gastroenterology, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, 71213Second Hospital of Hebei Medical University, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Zhijie Feng
- Department of Gastroenterology, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, 71213Second Hospital of Hebei Medical University, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Huiqing Jiang
- Department of Gastroenterology, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, 71213Second Hospital of Hebei Medical University, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
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Ding T, Hu YL. Comparison of etomidate and propofol-mediated anesthesia induction followed by intubation and sevoflurane maintenance during ERCP in obese patients. Am J Transl Res 2021; 13:9853-9859. [PMID: 34540121 PMCID: PMC8430081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 04/08/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE In this study, we focused on obese patients (Body Mass Index (BMI) ≥30 kg/m2) and compared the efficacy and safety of etomidate or propofol-mediated anesthesia induction followed by intubation and sevoflurane maintenance during endoscopic retrograde cholangiopancreatography (ERCP). METHODS A total of 180 patients were computer-randomized into a propofol group or an etomidate group, with 90 cases in each group. Patients received anesthesia induction by etomidate or propofol followed by intubation and sevoflurane maintenance during ERCP. Baseline characteristics, information about procedure-related time and satisfaction, and adverse events were collected and compared between the etomidate group and propofol group. RESULTS Baseline characteristics of both groups were similar. The propofol group had a longer time of intraoperative SpO2 <95% (etomidate group vs propofol group, 0.07±0.47 min vs 0.24±0.87 min, P-value = 0.019), higher frequency of SpO2 <95% for any period of time (etomidate group vs propofol group, 2.22% vs 11.11%, P-value = 0.032), and higher frequency of transient hypotension (etomidate group vs propofol group, 1.11% vs 8.89%, P-value = 0.034). The etomidate group had longer induction time and recovery time than the propofol group with P-values of 0.019 and 0.004, respectively. CONCLUSION In obese patients who underwent ERCP and needed intubation, etomidate appears better than propofol for anesthesia induction followed by anesthesia maintenance of sevoflurane.
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Affiliation(s)
- Tao Ding
- Hanchuan People's Hospital Hanchuan 431600, Hubei Province, China
| | - Yan-Lan Hu
- Hanchuan People's Hospital Hanchuan 431600, Hubei Province, China
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de Jong DM, Stassen PM, Poley JW, Fockens P, Timmer R, Voermans RP, Verdonk RC, Bruno MJ, de Jonge PJ. Clinical outcome of endoscopic therapy in patients with symptomatic pancreas divisum: a Dutch cohort study. Endosc Int Open 2021; 9:E1164-E1170. [PMID: 34222643 PMCID: PMC8216775 DOI: 10.1055/a-1460-7899] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/15/2021] [Indexed: 10/28/2022] Open
Abstract
Background and study aims Although the majority of patients with pancreas divisum (PDiv) are asymptomatic, a subgroup present with recurrent pancreatitis or pain for which endoscopic therapy may be indicated. The aim of this study was to evaluate success rates and long-term outcomes of endoscopic treatment in patients with symptomatic PDiv. Patients and methods A multicenter, retrospective cohort study was performed. Patients with symptomatic PDiv presenting with recurrent acute pancreatitis (RAP), chronic pancreatitis (CP), or chronic abdominal pancreatic-type pain (CAP) who underwent endoscopic retrograde cholangiopancreatography (ERCP) between January 2000 and December 2019 were included. The primary outcome was clinical success, defined as either no recurrent episode of acute pancreatitis (AP) for RAP patients, no flares for CP patients, or absence of abdominal pain for patients with CAP after technically successful ERCP. Results In 60 of 81 patients (74.1 %) a technically successful papilla minor intervention was performed. Adverse events were reported in 30 patients (37 %), with post-ERCP pancreatitis in 18 patients. The clinical success rate for patients with at least 3 months of follow-up was 42.6 %, with higher rates of success among patients presenting with RAP (44.4 %) as compared to those with CP (33.3 %) or CAP (33.3 %). Long-term sustained response was present in 40.9 % of patients with a technically successful intervention. In patients with RAP who did not completely respond to treatment, the mean number of AP episodes after treatment decreased significantly from 3.5 to 1.1 per year, and subsequently the interval between AP episodes increased from 278 to 690 days ( P = 0.0006). A potential predictive factor of failure of clinical success after technically successful ERCP, at univariate analysis, was male sex (OR = 0.25, P = 0.02). Conclusions Endoscopic therapy in patients with symptomatic PDiv is moderately effective, with its highest yield in patients presenting with RAP. Future studies are needed to assess factors predictive for success of endoscopic therapy and potential risk factors for relapse after ERCP.
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Affiliation(s)
- David M. de Jong
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Pauline M. Stassen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jan Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, the Netherlands
| | - Robin Timmer
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Rogier P. Voermans
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, the Netherlands
| | - Robert C. Verdonk
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Pieter J.F. de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Pan G, Yang K, Gong B, Deng Z. Analysis of the Efficacy and Safety of Endoscopic Retrograde Cholangiopancreatography in Children With Symptomatic Pancreas Divisum. Front Pediatr 2021; 9:761331. [PMID: 34796156 PMCID: PMC8592933 DOI: 10.3389/fped.2021.761331] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 10/12/2021] [Indexed: 12/11/2022] Open
Abstract
Background: Endoscopic retrograde cholangiopancreatography (ERCP) has been increasingly performed in children with symptomatic pancreas divisum (PD). Aim: To investigate the safety and efficacy of ERCP in the treatment of children with symptomatic PD. Methods: We performed a retrospective analysis on children with PD who were treated with ERCP at Shanghai Children's Medical Center between June 2015 and May 2020. Pertinent patient, clinical and procedural data were collected to assess the therapeutic effects and identify the risk factors for post-ERCP pancreatitis (PEP). Results: Overall, 114 ERCPs were performed in 46 children with PD. With a median follow-up of 28.5 months (12-71 months), 40 (87.0%) children achieved clinical remission, the median number of acute pancreatitis episodes decreased from four times per year pre-operatively to once per year post-operatively (P < 0.001), and the nutritional score improved post-operatively (P = 0.004). The incidence of PEP was 7.9%, and female sex, stone extraction, and gene mutations were identified as possible risk factors for PEP on univariate analysis. However, there was no statistical significance on multivariate analysis (P > 0.05). Conclusion: Therapeutic ERCP is an effective and safe intervention for children with symptomatic PD.
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Affiliation(s)
- Guixian Pan
- Department of Gastroenterology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kaihua Yang
- Department of Gastroenterology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Biao Gong
- Department of Gastroenterology, Shanghai Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zhaohui Deng
- Department of Gastroenterology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Wood CG, Lopes Vendrami C, Craig E, Mittal PK, Miller FH. Pancreatitis in the developmentally anomalous pancreas. Abdom Radiol (NY) 2020; 45:1316-1323. [PMID: 31468154 DOI: 10.1007/s00261-019-02197-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Developmental anomalies of the pancreas include more common entities such as pancreas divisum and annular pancreas, and unusual entities such as heterotopic pancreas. While these anomalies can present a diagnostic challenge to the radiologist, when the pancreatic tissue involved in these processes develops pancreatitis, the radiographic appearance can present a diagnostic dilemma. Awareness of these pancreatic anomalies and familiarity with their appearance when inflamed is necessary to distinguish pancreatitis in the developmentally anomalous pancreas from other inflammatory or neoplastic processes.
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Affiliation(s)
- Cecil G Wood
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Camila Lopes Vendrami
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Elizabeth Craig
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Pardeep K Mittal
- Department of Radiology and Imaging, Medical College of Georgia, 1120 15th Street BA-1411, Augusta, GA, 30912, USA
| | - Frank H Miller
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA.
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N. St. Clair St. Suite 800, Chicago, IL, 60611, USA.
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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.
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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
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Coté GA, Durkalski-Mauldin VL, Serrano J, Klintworth E, Williams AW, Cruz-Monserrate Z, Arain M, Buxbaum JL, Conwell DL, Fogel EL, Freeman ML, Gardner TB, van Geenen E, Groce JR, Jonnalagadda SS, Keswani RN, Menon S, Moffatt DC, Papachristou GI, Ross A, Tarnasky PR, Wang AY, Wilcox CM, Hamilton F, Yadav D. SpHincterotomy for Acute Recurrent Pancreatitis Randomized Trial: Rationale, Methodology, and Potential Implications. Pancreas 2019; 48:1061-1067. [PMID: 31404020 PMCID: PMC6699897 DOI: 10.1097/mpa.0000000000001370] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES In patients with acute recurrent pancreatitis (ARP), pancreas divisum, and no other etiologic factors, endoscopic retrograde cholangiopancreatography (ERCP) with minor papilla endoscopic sphincterotomy (miES) is often performed to enlarge the minor papillary orifice, based on limited data. The aims of this study are to describe the rationale and methodology of a sham-controlled clinical trial designed to test the hypothesis that miES reduces the risk of acute pancreatitis. METHODS The SpHincterotomy for Acute Recurrent Pancreatitis (SHARP) trial is a multicenter, international, sham-controlled, randomized trial comparing endoscopic ultrasound + ERCP with miES versus endoscopic ultrasound + sham for the management of ARP. A total of 234 consented patients having 2 or more discrete episodes of acute pancreatitis, pancreas divisum confirmed by magnetic resonance cholangiopancreatography, and no other clear etiology for acute pancreatitis will be randomized. Both cohorts will be followed for a minimum of 6 months and a maximum of 48 months. RESULTS The trial is powered to detect a 33% risk reduction of acute pancreatitis frequency. CONCLUSIONS The SHARP trial will determine whether ERCP with miES benefits patients with idiopathic ARP and pancreas divisum. Trial planning has informed the importance of blinded outcome assessors and long-term follow-up.
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Affiliation(s)
| | | | - Jose Serrano
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | - Erin Klintworth
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - April W Williams
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Zobeida Cruz-Monserrate
- Division of Gastroenterology, Hepatology, and Nutrition
- Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Mustafa Arain
- Department of Medicine, University of California, San Francisco, San Francisco
| | - James L Buxbaum
- Department of Medicine, Keck School of Medicine of USC, Los Angeles, CA
| | | | - Evan L Fogel
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Martin L Freeman
- Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Timothy B Gardner
- Department of Medicine, Dartmouth Geisel School of Medicine, Lebanon, NH
| | - Erwin van Geenen
- Division of Gastroenterology and Hepatology, University Medical Center St Radboud, Nijmegen, Netherlands
| | - J Royce Groce
- Division of Gastroenterology, Hepatology, and Nutrition
| | | | - Rajesh N Keswani
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Shyam Menon
- Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Dana C Moffatt
- Department of Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | | | - Andrew Ross
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA
| | | | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA
| | - C Mel Wilcox
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Frank Hamilton
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | - Dhiraj Yadav
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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12
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Pancreas divisum: a reemerging risk factor for pancreatic diseases. ROMANIAN JOURNAL OF INTERNAL MEDICINE 2018; 56:233-242. [DOI: 10.2478/rjim-2018-0022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Indexed: 12/30/2022] Open
Abstract
Abstract
Pancreas divisum (PD) is the most common developmental anatomic variant of pancreatic duct. The attention towards the PD has grown significantly since there are reports that this condition may cause acute relapsing pancreatitis, chronic pancreatitis and chronic abdominal pain syndrome. Furthermore, over the years, there have been multiple reports of PD associated with different types of tumors. There is evidence that PD can be associated with pancreatic tumors (up to 12.5% of cases). The golden standard for diagnosing PD is endoscopic retrograde cholangiopancreatography, but since it is an invasive procedure magnetic resonance cholangiopancreatography with secretin is a good alternative. In case the patient is symptomatic, endoscopic or surgical treatment should be performed. This review describes the key points of the pathophysiology, diagnostic modalities, risks of pancreatitis and tumors, as well as treatment options of PD.
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13
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Abstract
Patients with recurrent acute pancreatitis (RAP) have few treatment options available to them to manage their symptoms or prevent progression to chronic pancreatitis. At present, endotherapy is typically pursued as a means to achieve symptom remission and reduce rates of recurrence, hospitalization, abdominal pain, narcotic use, and surgical intervention. However, evidence that endotherapy effectively alters the natural history of disease remains limited. This article reviews the recent literature on the efficacy of endoscopic intervention in the treatment RAP with a focus on high-quality prospective randomized controlled studies. Additional studies are needed to corroborate these findings.
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Affiliation(s)
- Averill Guo
- Columbia University Medical Center, 161 Fort Washington Avenue, Suite 852, New York, NY 10032, USA
| | - John M Poneros
- Columbia University Medical Center, 161 Fort Washington Avenue, Suite 852, New York, NY 10032, USA.
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14
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Jagannath S, Garg PK. Recurrent Acute Pancreatitis: Current Concepts in the Diagnosis and Management. ACTA ACUST UNITED AC 2018; 16:449-465. [PMID: 30232693 DOI: 10.1007/s11938-018-0196-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW There have been significant developments in the diagnosis, clinical approach, and management of patients with recurrent acute pancreatitis (RAP) in the last decade. This review systematically summarizes our current understanding of RAP. NEW FINDINGS Gallstones and alcohol are common causes of RAP. Non-alcohol non-biliary RAP (nAnB RAP) is a difficult group of patients after excluding these two causes because extensive workup is required to elucidate the etiology. Idiopathic RAP is diagnosed after excluding all the known causes and recurrence is noted to be higher in such patients. Patients with non-biliary RAP are prone to develop chronic pancreatitis (CP) suggesting a continuum from acute to recurrent to chronic pancreatitis. Often, patients destined to develop CP present at an earlier stage with RAP. Endoscopic ultrasound and magnetic resonance cholangiopancreatography (MRCP) are the investigations of choice to detect microlithiasis, choledocholithiasis, ductal abnormalities, peri-ampullary malignancies, and early changes of chronic pancreatitis. The role of pancreas divisum, sphincter of Oddi dysfunction, and anomalous pancreatobiliary union in causing RAP is controversial. Genetic testing may be advisable in younger patients. CONCLUSION With a focused approach and appropriate investigations, the etiology of RAP can be identified in a significant proportion of patients. Therapeutic options are limited and future research is needed to improve understanding of the disease.
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Affiliation(s)
- Soumya Jagannath
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Pramod Kumar Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
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