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Wang S, Bai B, Liu S, Fang Y, Zhang C, Chen X, Huang Q, Wang J, Hong J, Li Y, Xu Z, Liu X, Bao J, Mei Q, Hong R. Transpancreatic Sphincterotomy After Double Guidewire Technique Was Noninferior to Primary Transpancreatic Sphincterotomy in Difficult Biliary Cannulation. Dig Dis Sci 2024; 69:2215-2222. [PMID: 38594433 DOI: 10.1007/s10620-024-08319-7] [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: 10/18/2023] [Accepted: 01/25/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND When unintentional pancreatic duct access occurs during difficult biliary cannulation, the double guidewire (DGW) or transpancreatic sphincterotomy (TPS) may be utilized. DGW can be easily switched to TPS due to the existing guidewire in the pancreatic duct. However, the efficacy of TPS after DGW, named sequential DGW-TPS technique, versus primary TPS has not been assessed. AIMS Our aim was to compare the benefits and adverse events of sequential DGW-TPS technique and primary TPS. METHODS We performed a comparative retrospective cohort study that enrolled a total of 117 patients with native papillae. The patients were divided into one of 2 groups according to the primary bile duct access technique (sequential DGW-TPS or primary TPS), both with pancreatic stenting. RESULTS Between November 2017 and May 2023, a total of 84 patients were grouped into sequential DGW-TPS and 33 into primary TPS. The overall post-ERCP pancreatitis (PEP) rate was 4.3% in the entire cohort, with no statistical differences were observed between the groups in terms of PEP rates (P = 0.927), PEP severity (P = 1.000), first biliary cannulation success (P = 0.621), overall cannulation success (P = 1.000), hyperamylasemia incidence (P = 0.241), elevated amylase levels (P = 0.881), and postoperative hospital stay (P = 0.185). Furthermore, these results remained consistent in multivariable regression analysis. CONCLUSIONS The sequential DGW-TPS technique showed a comparable safety and biliary cannulation success rate to primary TPS in difficult biliary cannulation. Given the potential long-term complications associated with TPS, DGW should be first if inadvertent pancreatic access occurs, with TPS serving as second only if DGW fails.
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Affiliation(s)
- Shaofei Wang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
- Department of Gastroenterology, Suzhou First People's Hospital, Suzhou, 234000, Anhui Province, China
| | - Bingqing Bai
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Sisi Liu
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Yuanyuan Fang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Chenyu Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Xinwen Chen
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Qiming Huang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Jiren Wang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Jianglong Hong
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Yang Li
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Zhangwei Xu
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Xiaochang Liu
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Junjun Bao
- Department of Endoscopy, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Qiao Mei
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China
| | - Rutao Hong
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, China.
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Cui Y, Kozarek RA. Evolution of Pancreatic Endotherapy. Gastrointest Endosc Clin N Am 2023; 33:679-700. [PMID: 37709404 DOI: 10.1016/j.giec.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
In the last half century, endotherapy for pancreatic diseases has changed considerably. Although endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) were introduced initially as diagnostic tools, they quickly evolved into therapeutic tools for preventing and managing complications of pancreatitis. More recently, therapeutic endoscopy has shown potential in palliation and cure of pancreatic neoplasms. This article discusses the changing landscape of pancreatic endotherapy as therapeutic ERCP and EUS were introduced and because they have evolved to treat different diseases.
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Affiliation(s)
- YongYan Cui
- Department of Gastroenterology, Virginia Mason Medical Center
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Sundaram S, Jagtap N. Transpancreatic biliary sphincterotomy: justified or overkill? Endoscopy 2021; 53:985. [PMID: 34438459 DOI: 10.1055/a-1408-3258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Sridhar Sundaram
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
| | - Nitin Jagtap
- Asian Institute of Gastroenterology, Hyderabad, India
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Koskensalo V, Udd M, Rainio M, Halttunen J, Sipilä M, Lindström O, Kylänpää L. Transpancreatic biliary sphincterotomy for biliary access is safe also on a long-term scale. Surg Endosc 2020; 35:104-112. [PMID: 31993817 PMCID: PMC7746558 DOI: 10.1007/s00464-019-07364-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 12/24/2019] [Indexed: 02/07/2023]
Abstract
Background Transpancreatic biliary sphincterotomy (TPBS) is an advanced cannulation method for accessing common bile duct (CBD) in endoscopic retrograde cholangiopancreatography (ERCP). If CBD cannulation is difficult, an endoscopist can open the septum between the pancreatic and biliary duct with a sphincterotome to gain access. Long-term results of this procedure are unclear. We wanted to evaluate the short- and long-term complications of TPBS on patients with native papilla and benign indication for ERCP. Patients and Methods ERCPs performed in Helsinki University Hospital between 2007 and 2013 were reviewed. The study group comprised 143 consecutive patients with TPBS and 140 controls (CG). Data were collected from patient records and a phone survey was performed as a follow-up ≥ 4 years after the index ERCP. Results Post-ERCP pancreatitis (PEP) developed in seven patients (4.9%) in TPBS and one patient (0.7%) in CG (p = 0.067). The rates of other acute complications were similar between the groups. ERCP ended with no access to CBD in four cases (2.8%) in TPBS. The median length of follow-up was 6 years in TPBS and 7 years in CG. During this period, three patients (2.1%) in TPBS and six patients (4.3%) in CG suffered from acute pancreatitis (AP) (p = 0.238). One (0.7%) patient in CG and none in TPBS developed chronic pancreatitis (CP). Abdominal pain was suffered by ten patients (6.9%) in TPBS and twelve patients (8.6%) in CG daily, whereas by six patients (4.2%) in TPBS and twelve patients (8.6%) in CG weekly. Conclusion TPBS is a useful procedure, with acceptable complication rates. No significant difference occurred between the groups when evaluating the short-term or long-term complications with a follow-up period of four to 10 years. Additionally, no significant differences occurred in upper abdominal pain, episodes of AP, or development of CP.
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Affiliation(s)
- Vilja Koskensalo
- Abdominal Center, Helsinki University Hospital, Haartmaninkatu 4, 00029 HUS, Helsinki, Finland.
- University of Helsinki, Helsinki, Finland.
| | - Marianne Udd
- Abdominal Center, Helsinki University Hospital, Haartmaninkatu 4, 00029 HUS, Helsinki, Finland
- University of Helsinki, Helsinki, Finland
| | - Mia Rainio
- Abdominal Center, Helsinki University Hospital, Haartmaninkatu 4, 00029 HUS, Helsinki, Finland
- University of Helsinki, Helsinki, Finland
| | - Jorma Halttunen
- Abdominal Center, Helsinki University Hospital, Haartmaninkatu 4, 00029 HUS, Helsinki, Finland
- University of Helsinki, Helsinki, Finland
| | | | - Outi Lindström
- Abdominal Center, Helsinki University Hospital, Haartmaninkatu 4, 00029 HUS, Helsinki, Finland
- University of Helsinki, Helsinki, Finland
| | - Leena Kylänpää
- Abdominal Center, Helsinki University Hospital, Haartmaninkatu 4, 00029 HUS, Helsinki, Finland
- University of Helsinki, Helsinki, Finland
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Pérez Roldán F, González Carro P. Pancreatic stents in ERCP. Where are we? REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 110:413-415. [PMID: 29893580 DOI: 10.17235/reed.2018.5670/2018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Post-ERCP pancreatitis (PEP) is a common complication most feared by endoscopists. Incidence ranges widelly from 2.1% to 24.4%, which results from patient heterogeneity and differences in endoscopist expertise, method, PEP definition, and severity. Pathophysiology is multifactorial, and involves a combination of chemical, thermal, mechanical, hydrostatic, enzymatic, allergic, and microbiological factors resulting from papillary instrumentation and/or contrast administration within the pancreatic duct (volume and osmolarity). Even genetic abnormalities may represent a risk factor, as is the case with homozygous alpha-1-antitrypsin deficiency, which leads to an increase in hemorrhagic PEP rates.
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Abstract
Painless jaundice is a harbinger of malignant biliary obstruction, with the majority of cases due to pancreatic adenocarcinoma. Despite advances in treatment, including improved surgical techniques and neoadjuvant (preoperative) chemotherapy, long-term survival from pancreatic cancer is rare. This lack of significant improvement in outcomes is believed to be due to multiple reasons, including the advanced stage at diagnosis and lack of an adequate biomarker for screening and early detection, prior to the onset of jaundice or epigastric pain. Close attention is required to select appropriate patients for preoperative biliary decompression, and to prevent morbid complications from biliary drainage procedures, such as pancreatitis and cholangitis. Use of small caliber plastic biliary stents during endoscopic retrograde cholangiopancreatography should be minimized, as metal stents have increased area for improved bile flow and a reduced risk of adverse events during neoadjuvant therapy. Efforts are underway by translational scientists, radiologists, oncologists, surgeons, and gastroenterologists to augment lifespan for our patients and to more readily treat this deadly disease. In this review, the authors discuss the rationale and techniques of endoscopic biliary intervention, mainly focusing on malignant biliary obstruction by pancreatic cancer.
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Affiliation(s)
- Jeffrey H Lee
- Division of Medicine, Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Tomas DaVee
- Division of Medicine, Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Riff BP, Chandrasekhara V. The Role of Endoscopic Retrograde Cholangiopancreatography in Management of Pancreatic Diseases. Gastroenterol Clin North Am 2016; 45:45-65. [PMID: 26895680 DOI: 10.1016/j.gtc.2015.10.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endoscopic retrograde cholangiopancreatography is an effective platform for a variety of therapies in the management of benign and malignant disease of the pancreas. Over the last 50 years, endotherapy has evolved into the first-line therapy in the majority of acute and chronic inflammatory diseases of the pancreas. As this field advances, it is important that gastroenterologists maintain an adequate knowledge of procedure indication, maintain sufficient procedure volume to handle complex pancreatic endotherapy, and understand alternate approaches to pancreatic diseases including medical management, therapy guided by endoscopic ultrasonography, and surgical options.
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Affiliation(s)
- Brian P Riff
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1069, New York, NY 10029, USA
| | - Vinay Chandrasekhara
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, Perelman Center for Advanced Medicine South Pavilion, 7th Floor, Philadelphia, PA 19104, USA.
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Bachmann K, Tomkoetter L, Erbes J, Hofmann B, Reeh M, Perez D, Vashist Y, Bockhorn M, Izbicki JR, Mann O. Beger and Frey procedures for treatment of chronic pancreatitis: comparison of outcomes at 16-year follow-up. J Am Coll Surg 2014; 219:208-16. [PMID: 24880955 DOI: 10.1016/j.jamcollsurg.2014.03.040] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 12/10/2013] [Accepted: 12/17/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND Chronic pancreatitis is a chronic inflammatory disorder characterized by progressive fibrosis of pancreatic tissue. The principal symptom is chronic pain resulting in reduced quality of life and inability to work. Short-term follow-up has shown that duodenum-preserving pancreatic head resections (DPPHRs) are superior in outcomes to pancreaticoduodenectomy. Therefore, these organ-sparing procedures have gained wide acceptance. This trial was conducted to compare patient outcomes 16 years after treatment for chronic pancreatitis by means of the Beger or the Frey procedure. STUDY DESIGN Seventy-four patients suffering from chronic pancreatitis were randomly assigned to 2 treatment groups (Beger n = 38) and Frey (n = 36). The perioperative courses in the randomized controlled trial and the 8-year follow-up have been reported previously. All participating patients were contacted with a standardized, validated questionnaire to evaluate long-term survival, quality of life, pain, and exocrine and endocrine function. RESULTS No significant differences between the 2 groups in terms of quality of life, pain control, or other somatic parameters were detected after a median of 16 years postoperatively. Mortality was comparable after Beger and Frey procedures at 39% vs 34%, respectively, with postoperative survivals of 13.0 ± 1.1 years and 13.3 ± 0.9 years, respectively (p = 0.660). No statistically significant differences were found in rates of endocrine insufficiency (Beger 87% vs Frey 86%; p = 0.953) or exocrine insufficiency (Beger 77% vs Frey 83%; p = 0.655). CONCLUSIONS Duodenum-preserving resections of the pancreatic head offered good and permanent pain relief and substantially increased quality of life in chronic pancreatitis. Overall, a 16-year long-term follow-up found comparable outcomes for the Beger and Frey procedures.
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Affiliation(s)
- Kai Bachmann
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Lena Tomkoetter
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes Erbes
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bianca Hofmann
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Reeh
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel Perez
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Yogesh Vashist
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian Bockhorn
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Oliver Mann
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Argo JL, Contreras JL, Wesley MM, Christein JD. Pancreatic Resection with Islet Cell Autotransplant for the Treatment of Severe Chronic Pancreatitis. Am Surg 2008. [DOI: 10.1177/000313480807400612] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Pancreatic resection can alleviate pain in properly selected patients with severe chronic pancreatitis (CP), although the apancreatic state causes “brittle” diabetes. Islet auto-transplantation (IAT) after resection can decrease diabetes-related morbidity. Twenty-six consecutive patients with CP who underwent 27 pancreatic resections with IAT from April 2005 to December 2007 were evaluated in this retrospective case control study. Data were collected by chart and operative note reviews and query of hospital databases. Subgroup analysis was performed on 21 cases of total pancreatectomy and six cases of pancreaticoduodenectomy (PD). Mean age was 43.8 years and 46.2 per cent of patients were female. The most common etiology of CP was alcoholism (34.6%), followed by idiopathic causes (30.8%) and pancreatic divisum (23.1%). There was no mortality and the complication rate was 56 per cent. Islet equivalents infused and islet equivalents/gram of pancreas were 82,094 and 2,739 respectively. Mean discharge insulin dose was 10.7 units/day. Mean follow-up was 6.5 months. At 6 months, 80 per cent of patients reporting had decreased or eliminated their use of narcotic medication and all total pancreatectomy patients required insulin (mean 23 units/day). In appropriately selected patients, pancreatic resection with IAT is safe and effective for the treatment of intractable pain associated with CP.
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Affiliation(s)
- Joshua L. Argo
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Health Services and Outcomes Research Training Program, University of Alabama at Birmingham, Birmingham, Alabama
| | - Juan L. Contreras
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mary M. Wesley
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - John D. Christein
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
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