Role of endoscopic retrograde cholangiopancreatography in pancreatic diseases

Feasibility of Magnetic Resonance Cholangiopancreatography in Dogs-A Post-Mortem Study

Magnetic resonance cholangiopancreatography (MRCP) is commonly used in humans and is also feasible in cats. The aim of this post-mortem study was to investigate the feasibility of MRCP in eight adult dogs by comparing the visibility and measured diameters of the biliary tract and pancreatic ducts in MRCP with those of fluoroscopic retrograde cholangiopancreatography (FRCP) and corrosion casting. In autopsy, six dogs had no evidence of hepatobiliary disorders, one had pancreatic pathology, and one had biliary pathology. The gallbladder (GB), cystic duct, and common bile duct (CBD) were visible in the MRCP images of all eight dogs. However, the extrahepatic ducts and pancreatic ducts were only variably visible. There was statistical agreement between MRCP and FRCP in measuring the diameters of the GB (fundus and body) and CBD (at papilla and extrahepatic ducts' junction). The diameter measurements correlated between MRCP and corrosion casting. Our study showed that MRCP is feasible in dogs and allowed for proper visualization of the biliary tract. However, ducts with diameters of <1 mm were difficult to visualize using a 1.5 Tesla MRI machine. Further studies are warranted to apply MRCP in the diagnostic imaging of live dogs.

Imaging of Fibrosis in Chronic Pancreatitis

Chronic pancreatitis (CP) describes long-standing inflammation of the pancreas, which leads to irreversible and progressive inflammation of the pancreas with fibrosis. CP also leads to abdominal pain, malnutrition, and permanent impairment of exocrine/endocrine functions. However, it is difficult to assess CP pathologically, and imaging modalities therefore play an important role in the diagnosis and assessment of CP. There are four modalities typically used to assess CP. Pancreatic duct features are assessed with magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP). However, ERCP is a rather invasive diagnostic modality for CP, and can result in adverse events such as post-ERCP pancreatitis. Computed tomography (CT) is often the most appropriate initial imaging modality for patients with suspected CP, and has high diagnostic specificity. However, CT findings typically only appear in advanced stages of CP, and it is difficult to detect early CP. Endoscopic ultrasonography (EUS) provides superior spatial resolution compared with other imaging modalities such as CT and magnetic resonance imaging (MRI), and is considered the most reliable and efficient diagnostic modality for pancreatic diseases. The EUS-based Rosemont classification plays an important role in diagnosing CP in clinical practice. Evaluation of tissue stiffness can be another option to assess the diagnosis and progression of CP, and MRI and EUS can be used to assess CP not only with imaging, but also with elasticity measurement. MR and EUS elastography are expected to provide new alternative diagnostic tools for assessment of fibrosis in CP, which is difficult to evaluate pathologically.

Six-year retrospective analysis of endoscopic ultrasonography-guided pancreatic ductal interventions at a tertiary referral center

BACKGROUND AND AIM

Endoscopic ultrasonography-guided pancreatic ductal intervention (EUS-PDI) serves as a rescue therapy in patients with failure of retrograde access to the pancreatic duct (PD) at the time of endoscopic retrograde pancreatography (ERP). We review our experience of this procedure.

METHODS

This is a retrospective study of patients who underwent EUS-PDI for an unsuccessful ERP and altered anatomy.

RESULTS

A total of 44 (65.9% male) patients underwent EUS-PDI with a mean age of 43.5 years, (range: 23-67). Transgastric rendezvous technique was carried out in 23/44 (52.3%), transgastric pancreaticogastrostomy in 18/44 (40.9%) and transduodenal pancreaticobulbostomy in 3/44 (6.8%). Overall technical and clinical success was seen in 88.6% (39/44) and 81.8% (36/44), respectively. Technical success of transgastric rendezvous was 95.6% and that of transgastric pancreaticogastrostomy was 77.8%. Two of seven patients with failure to access the PD had successfully undergone EUS-PD stenting at subsequent attempt. Ten immediate adverse events (AE) were noted which included abdominal pain (n = 4), pancreatitis (n = 2), fever (n = 2), minor bleeding (n = 1), and stripping of wire (n = 1). Delayed AE included stent blockage in 12/39 (30.8%) and spontaneous stent migration in 5/39 (12.8%) which were managed with stent exchange at follow up. The rendezvous technique was associated with fewer AE than transgastric pancreaticogastrostomy.

CONCLUSIONS

Endoscopic ultrasonography-PDI is an effective treatment modality and salvage therapy in patients with unsuccessful ERP. Technical and clinical success seen with this study is comparable to studies conducted across the world. EUS-PDI needs to show cost-effectiveness in future studies.

Endoscopic ultrasound and endoscopic retrograde cholangiopancreatography: Can they be successfully combined?

Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) have much in common, including their main indications (biliopancreatic disorders), powerful therapeutic capacities and a steep learning curve. Over the years they have evolved from novel diagnostic procedures to interventional therapeutic techniques, but along different paths (different scopes or devices and endoscopists specializing exclusively in one or the other technique). However, EUS has gradually developed into a therapeutic technique that requires skills in the use of ERCP devices and stents, leading some ERCP specialists to explore the therapeutic potential of EUS. The corresponding literature, which has grown exponentially, includes recent experiments on combining the two techniques, which have gradually come to be used in routine care in a number of centers, with positive technical, clinical and financial outcomes. We review EUS and ERCP as individual or combined procedures for managing biliopancreatic disorders.