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Yadlapati S, Gutta A, Fogel EL. Determining the value of endoscopic retrograde cholangiopancreatography in the management of patients with acute pancreatitis and related complications. Expert Rev Gastroenterol Hepatol 2025:1-19. [PMID: 39921919 DOI: 10.1080/17474124.2025.2464057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2024] [Revised: 02/02/2025] [Accepted: 02/04/2025] [Indexed: 02/10/2025]
Abstract
INTRODUCTION Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a diagnostic to a therapeutic tool in acute pancreatitis management, largely due to the availability of less invasive diagnostic modalities such as endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP). AREAS COVERED This review explores the therapeutic applications of ERCP across various acute pancreatitis etiologies and its role in managing complications such as bile duct obstructions, pancreatic duct disruptions, and infected necrosis. The discussion highlights the procedure's expanding indications and its critical role in addressing complex cases. EXPERT OPINION ERCP remains central to the management of acute pancreatitis complications. As endoscopic techniques and devices continue to advance, its therapeutic scope is likely to grow. Performing ERCP for appropriate indications and optimizing its use is essential for minimizing risks and improving outcomes.
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Affiliation(s)
- Sujani Yadlapati
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indiana University Hospital, Indianapolis, IN, USA
| | - Aditya Gutta
- Division of Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Evan L Fogel
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indiana University Hospital, Indianapolis, IN, USA
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Malik S, Ullah H, Loganathan P, Singh Dahiya D, Chandan S, Mohan BP, Adler DG. Efficacy of Endoscopic Therapy in Symptomatic Pancreatic Divisum: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2025; 59:183-189. [PMID: 38457418 DOI: 10.1097/mcg.0000000000001986] [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] [Received: 08/30/2023] [Accepted: 01/31/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND AND AIMS Pancreas divisum (PD) is a congenital malformation of the pancreas and is implicated as a cause of pancreatitis. The role of endotherapy has been variable in symptomatic PD indicated by recurrent acute pancreatitis (RAP), chronic pancreatitis (CP), or chronic pancreatic-type abdominal pain (PP). The aim of this study was to analyze the pooled data to determine the success of endoscopic intervention for pancreas divisum. METHODS We conducted a comprehensive search of several databases (inception to July 2023) to identify studies reporting on the use of endoscopic therapy in symptomatic pancreatic divisum. The random-effects model was used to calculate the pooled rates and I2 % values were used to assess the heterogeneity. RESULTS A total of 27 studies were retrieved that reported endoscopic intervention in pancreatic divisum. The calculated pooled rate of technical success was 92% (95% CI: 87-95; I2 =63%). The calculated pooled rate of clinical success was 65% (95% CI: 60-70; I2 =60%). The rate of clinical success by PD subtypes was highest in RAP at 71% (95% CI: 65-76; I2 =24%). Available studies had significant heterogeneity in defining clinical success. The rate of adverse events was 71% (95% CI: 65-76; I2 =24%). CONCLUSIONS The role of endoscopic therapy in pancreatic divisum is variable with the highest success rate in recurrent acute pancreatitis. Endoscopic intervention is associated with a higher-than-usual rate of adverse events, including post-ERCP pancreatitis.
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Affiliation(s)
- Sheza Malik
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY
| | - Hamid Ullah
- Department of Internal Medicine, Hamid Ullah, West Virginia University Priyadarshini Loganathan, UT Health, San Antonio, TX
| | - Priyadarshini Loganathan
- Department of Internal Medicine, Hamid Ullah, West Virginia University Priyadarshini Loganathan, UT Health, San Antonio, TX
| | | | - Saurabh Chandan
- Department of Gastroenterology, CHI Creighton Medical Center, Omaha, NE
| | - Babu P Mohan
- Department of Gastroenterology, Orlando Gastroenterology PA, Orlando, FL
| | - Douglas G Adler
- Gastroenterology & Hepatology,Center for Advanced Therapeutic Endoscopy at Porter Adventist Hospital in Denver, CO
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Kuraishi Y, Nakamura A, Kondo S, Yanagisawa T, Horiuchi I, Minamisawa M, Sasaki N, Iwaya Y, Nagaya T, Umemura T. Endoscopic assessment of minor papilla morphology: Predictors of successful cannulation and procedural pancreatitis risk in minor papilla endotherapy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2024; 31:926-934. [PMID: 39252430 PMCID: PMC11660995 DOI: 10.1002/jhbp.12068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
BACKGROUND We evaluated for predictors of successful cannulation and post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in minor papilla endotherapy (MPE), emphasizing endoscopic minor papilla morphology. METHODS We retrospectively analyzed 232 MPEs in 65 patients, assessing minor papilla morphology based on three features: bulge as "prominent" or "subtle," mucosal appearance as "papilla-like" resembling the main papilla or "SMT-like" akin to a gastrointestinal submucosal tumor, and orifice visibility as "clear" or "unclear." Cannulation success was evaluated in 65 enrolled patients, with PEP risk assessed in all 232 MPEs. RESULTS Minor papilla morphology was categorized as prominent/subtle bulge in 42/23 patients, papilla-like/SMT-like mucosal appearance in 42/23, and clear/unclear orifice visibility in 24/41. Cannulation succeeded in 54/65 patients (83%). A papilla-like appearance and clear orifice visibility was significantly associated with cannulation success. PEP incidence was 5.2% and predominantly mild. A papilla-like appearance significantly decreased PEP incidence, while precutting technique and orifice dilation significantly increased PEP risk. CONCLUSION Evaluating minor papilla morphology may help predict cannulation success and PEP risk in MPE. A papilla-like mucosal appearance prognosticates cannulation success and reduced PEP risk, with clear orifice visibility serving as a success predictor. These findings provide practical guidance for preprocedural planning by emphasizing the importance of minor papilla morphology evaluation.
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Affiliation(s)
- Yasuhiro Kuraishi
- Department of GastroenterologyShinshu University HospitalNaganoJapan
| | - Akira Nakamura
- Department of GastroenterologyShinshu University HospitalNaganoJapan
| | - Shohei Kondo
- Department of GastroenterologyShinshu University HospitalNaganoJapan
| | - Takumi Yanagisawa
- Department of GastroenterologyShinshu University HospitalNaganoJapan
| | - Ichitaro Horiuchi
- Department of GastroenterologyShinshu University HospitalNaganoJapan
| | | | - Nobukazu Sasaki
- Department of GastroenterologyShinshu University HospitalNaganoJapan
| | - Yugo Iwaya
- Department of GastroenterologyShinshu University HospitalNaganoJapan
| | - Tadanobu Nagaya
- Department of GastroenterologyShinshu University HospitalNaganoJapan
| | - Takeji Umemura
- Department of GastroenterologyShinshu University HospitalNaganoJapan
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Schepis T, Pafundi PC, Tringali A, Carcagnì A, Familiari P, Landi R, Boskoski I, Perri V, Spada C, Costamagna G. Endoscopic minor papilla sphincterotomy in patients with complete pancreas divisum and acute recurrent pancreatitis: a metanalysis. Scand J Gastroenterol 2024; 59:225-231. [PMID: 37795553 DOI: 10.1080/00365521.2023.2266079] [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: 06/19/2023] [Revised: 09/22/2023] [Accepted: 09/28/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND AND AIMS Pancreas divisum (PD) is a congenital variant of the pancreatic ductal system and a potential cause of acute recurrent pancreatitis (ARP). Endoscopic minor papilla sphincterotomy (MiES) is the most common procedure performed in the management of PD-related ARP. The aim of this study is to perform a meta-analysis estimating the efficacy and the safety of MiES in the management of patients with PD-related ARP. METHODS A research was performed in Pubmed, EMBASE and Web of science, the studies were reviewed and selected according to inclusion and exclusion criteria. Evaluation of Heterogeneity and publication bias was performed, and a random effect model was used to estimate the effect size of each study. RESULTS One hundred and thirteen articles were selected and reviewed, 13 met the inclusion criteria. All the studies were retrospective with a mean follow-up duration of 45.9 months. A total of 323 patients with PD-related ARP treated with MiES were included in the meta-analysis. The overall clinical success rate of MiES (defined as no further episodes of ARP, reduction of episodes of ARP, or improvement in quality of life) was of 77% (95%CI: 72%-81%; p = 0.30). Evaluating only the studies with clinical success rate defined as "no further AP in the follow-up" the clinical success rate was of 69.8% (95%CI: 61.3%-77.2%; p = 0.57), while evaluating the studies with other definitions (reduction of episodes of ARP or improvement in quality of life) the clinical success rate was of 81.2% (95%CI: 75.2%-86.1%; p = 0.45). The common fixed effects model disclosed a 25.5% overall adverse events rate (95%CI: 19.3%-32.8%; p = 0.42): acute pancreatitis in 14.3% (95%CI: 9.7%-20.6%; p = 0.36), bleeding in 5.6% (95%CI: 2.9%-10.4%; p = 0.98), and other adverse events in 5.6% (95%CI: 2.9%-10.4%; p = 0.67). CONCLUSION MiES is an effective and relatively safe treatment in the management of PD-related ARP. The retrospective nature of the studies selected is the main limitations of this metanalysis. Prospective trials are needed to confirm these data.
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Affiliation(s)
- T Schepis
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - P C Pafundi
- Facility of Epidemiology and Biostatistics, Gemelli Generator, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - A Tringali
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - A Carcagnì
- Facility of Epidemiology and Biostatistics, Gemelli Generator, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - P Familiari
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - R Landi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - I Boskoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - V Perri
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - C Spada
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - G Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
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Walia S, Zaidi MY, McGuire S, Milam C, Fogel EL, Sherman S, Lehman G, Pitt HA, Nakeeb A, Schmidt CM, House MG, Ceppa EP, Timsina L, Zyromski NJ. Contemporary Outcomes of Transduodenal Sphincteroplasty: the Importance of Surgical Quality. J Gastrointest Surg 2023; 27:2885-2892. [PMID: 38062321 DOI: 10.1007/s11605-022-05539-y] [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: 02/24/2022] [Accepted: 06/04/2022] [Indexed: 02/04/2024]
Abstract
BACKGROUND Sphincter of Oddi dysfunction (SOD) is managed primarily by endoscopic sphincterotomy (ES); however, surgical transduodenal sphincteroplasty (TDS) is a treatment option for select patients. In our high-volume pancreatico-biliary practice, we have observed variable outcomes among TDS patients; therefore, we sought to determine preoperative predictors of durable improvement in quality of life. METHODS SOD patients treated by TDS between January 2006 and December 2015 were studied. The primary outcome measure was long-term changes in quality of life after sphincteroplasty. The secondary outcome measure examined postoperative outcomes, including postoperative complications, need for repeat procedures, and readmission rates. Perioperative data were abstracted, and the SF-36 quality-of-life (QoL) survey was administered. Standard statistical analysis included non-parametric methods to examine bivariate associations. RESULTS Eighty-eight patients had an average follow-up duration of 6.7 (± 2.9) years. Thirty (34%) patients were naïve to endoscopic therapy. Patients with prior endoscopy averaged 2.1 procedures (range 1 to 13) prior to surgery. Perioperative morbidity was 27%; one postoperative death was caused by severe acute pancreatitis. Twenty-nine (33%) patients required subsequent biliary-pancreatic procedures. QoL analysis from available patients showed that 66% were improved or much improved. With multivariable analysis including SOD type and prior endoscopic instrumentation, freedom from surgical complication was the only variable that correlated significantly with a good outcome (p < 0.02). CONCLUSION Surgical transduodenal sphincteroplasty provides durable symptom management for select patients with sphincter of Oddi dysfunction. Minimizing surgical complications optimizes long-term outcomes.
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Affiliation(s)
- Sonal Walia
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, Emerson Hall 519, Indianapolis, IN, 46202, USA
| | - Mohammad Y Zaidi
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, Emerson Hall 519, Indianapolis, IN, 46202, USA
| | - Sean McGuire
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, Emerson Hall 519, Indianapolis, IN, 46202, USA
| | - Claire Milam
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, Emerson Hall 519, Indianapolis, IN, 46202, USA
| | - Evan L Fogel
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University Medical Center, 550 N. University Boulevard, UH 4100, Indianapolis, IN, 46202, USA
| | - Stuart Sherman
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University Medical Center, 550 N. University Boulevard, UH 4100, Indianapolis, IN, 46202, USA
| | - Glen Lehman
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University Medical Center, 550 N. University Boulevard, UH 4100, Indianapolis, IN, 46202, USA
| | - Henry A Pitt
- Department of Surgery, Robert Wood Johnson Medical School and Rutgers Cancer Institute of New Jersey, 195 Little Albany Street, New Brunswick, NJ, 08903, USA
| | - Attila Nakeeb
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, Emerson Hall 519, Indianapolis, IN, 46202, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, Emerson Hall 519, Indianapolis, IN, 46202, USA
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, Emerson Hall 519, Indianapolis, IN, 46202, USA
| | - Eugene P Ceppa
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, Emerson Hall 519, Indianapolis, IN, 46202, USA
| | - Lava Timsina
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, Emerson Hall 519, Indianapolis, IN, 46202, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, Emerson Hall 519, Indianapolis, IN, 46202, USA.
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Inamdar S, Cote GA, Yadav D. Endotherapy for Pancreas Divisum. Gastrointest Endosc Clin N Am 2023; 33:789-805. [PMID: 37709411 DOI: 10.1016/j.giec.2023.04.012] [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
Pancreas divisum (PD) is a common anatomic variant of the pancreatic duct. Causal association between PD and pancreatitis has been debated for many years. Minor papilla sphincterotomy (miES) is offered in clinical practice to patients with idiopathic acute recurrent pancreatitis (iRAP) and PD. However, available data originate mainly from observational studies with many limitations. An ongoing international, multicenter, sham-controlled trial is evaluating the efficacy of miES in iRAP and PD. Endoscopic therapy for pain relief has limited to no benefit in patients with chronic abdominal pain or chronic pancreatitis who have PD and is not recommended.
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Affiliation(s)
- Sumant Inamdar
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Arkansas for Medical Sciences, Shorey Building, 8th Floor, 4301 West Markham Street, Little Rock, AR 72205, USA.
| | - Gregory A Cote
- Division of Gastroenterology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code L461, Portland, OR, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburg Medical Center, 200 Lothrop Street, M2, C-wing, Pittsburgh, PA 15213, USA
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Grover AS, Gugig R, Barakat MT. Endoscopy and Pediatric Pancreatitis. Gastrointest Endosc Clin N Am 2023; 33:363-378. [PMID: 36948751 DOI: 10.1016/j.giec.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Children and adolescents are increasingly impacted by pancreatic disease. Interventional endoscopic procedures, including endoscopic retrograde cholangiopancreatography) and endoscopic ultrasonography, are integral to the diagnosis and management of many pancreatic diseases in the adult population. In the past decade, pediatric interventional endoscopic procedures have become more widely available, with invasive surgical procedures now being replaced by safer and less disruptive endoscopic interventions.
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Affiliation(s)
- Amit S Grover
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA 02115, USA
| | - Roberto Gugig
- Division of Pediatric Gastroenterology, Lucille Packard Children's Hospital at Stanford University Medical Center, Stanford, CA 94305, USA
| | - Monique T Barakat
- Division of Pediatric Gastroenterology, Lucille Packard Children's Hospital at Stanford University Medical Center, Stanford, CA 94305, USA; Division of Gastroenterology, Stanford University Medical Center, Stanford, CA 94305, USA.
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Barakat MT, Husain SZ, Gugig R. Safety and efficacy of minor papillotomy in children and adolescents with pancreas divisum. Pancreatology 2023; 23:171-175. [PMID: 36641286 DOI: 10.1016/j.pan.2022.12.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 12/06/2022] [Accepted: 12/13/2022] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Pancreas Divisum (PD) is a common pancreatic ductal variant which is twice as common in pediatric patients with acute recurrent pancreatitis (ARP) relative to the general population (14% vs. 7%). Endoscopic retrograde cholangiopancreatography (ERCP) with minor papillotomy has been performed to facilitate drainage of pancreatic juice from the diminutive minor papilla to prevent pancreatitis and pancreatic damage. METHODS We searched our prospectively-maintained endoscopy databases for patients 18 and younger who underwent ERCP with minor papillotomy between 2009 and 2019. Demographic data, indications, procedural interventions and findings, as well as available clinical outcomes data were analyzed. RESULTS 54 ARP/PD patients underwent ERCP with minor papillotomy. Median age was 14 (range 7-18) years, and 26 (48.1%) patients were female. Post-ERCP pancreatitis developed in 10/54 patients (18.5%). 12-month post-ERCP clinical trajectory was available in 47/54 (87%) patients and most patients (38/47, 80.8%) improved clinically after minor papillotomy, with 9/47 (19.1%) experiencing resolution of pancreatitis episodes and none indicated worsening severity or frequency of pancreatitis episodes following ERCP. CONCLUSION The majority of children and adolescents with PD and ARP who underwent ERCP with minor papillotomy experienced subjective improvement in their symptoms following the intervention. These data suggest that ERCP with minor papillotomy for pediatric patients with PD and ARP is beneficial and may be curative in a subset of patients-higher rates of improvement than have been previously reported in adults.
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Affiliation(s)
- Monique T Barakat
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Stanford University School of Medicine, Stanford, CA 94305, United States; Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Lucile Packard Children's Hospital at Stanford, Stanford, CA 94305, United States
| | - Sohail Z Husain
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Lucile Packard Children's Hospital at Stanford, Stanford, CA 94305, United States
| | - Roberto Gugig
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Lucile Packard Children's Hospital at Stanford, Stanford, CA 94305, United States.
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Long-Term Outcomes of Endoscopic Intervention in the Treatment of Symptomatic Pancreas Divisum. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:8508943. [PMID: 35469227 PMCID: PMC9034906 DOI: 10.1155/2022/8508943] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 04/05/2022] [Indexed: 11/17/2022]
Abstract
To evaluate the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of patients with symptomatic pancreas divisum (PD) and to discuss the possible risk factors of endoscopic reintervention for symptomatic PD. A total of 50 patients with symptomatic PD who underwent ERCP from January 2010 to December 2019 were finally brought into study. All patients were divided into the nonage and the adult group according to their ages. Meanwhile, all patients were also divided into the intervention and the reintervention group according to times of ERCP. The long-term outcome of each patient was collected during the follow-up by phone call. The total success rate of ERCP was 94.7% (89/93), and the effective rate of first ERCP was 58% (29/50). There were no statistical differences on the outcomes of ERCP treatment between the adult and nonage group. There were 17 patients with complete pancreas divisum and 19 patients with chronic pancreatitis in the reintervention group, which were more than 6 patients and 8 patients in the intervention group (P < 0.05). In bivariate regression analysis, chronic pancreatitis and complete pancreas divisum might be significant risk factors for endoscopic reintervention for patients with symptomatic PD (OR, 8.010, 95% CI, 1.483–43.276, P=0.016; OR, 8.869, 95% CI, 1.450–54.254, P=0.018, respectively). ERCP in treating adult and nonage patients with symptomatic PD are effective and safe. But, many patients may need endoscopic reintervention. Complete pancreas divisum and chronic pancreatitis may be risk factors of ERCP reintervention for patients with symptomatic PD.
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Kawaguchi S, Satoh T, Terada S, Endo S, Shirane N. Diagnostic ability of pancreatic juice cytology via the minor papilla in patients with pancreas divisum. DEN OPEN 2022; 2:e62. [PMID: 35310692 PMCID: PMC8828241 DOI: 10.1002/deo2.62] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/06/2021] [Accepted: 09/08/2021] [Indexed: 11/06/2022]
Abstract
Background and study aim Endoscopic retrograde cholangiopancreatography (ERCP) is generally performed via the major papilla when evaluating patients with pancreatic disease. However, in patients with pancreas divisum (PD) or distortion of the main pancreatic duct, endoscopic retrograde pancreatography (ERP) should be performed via the minor papilla (MP). Our aim was to evaluate the efficacy and safety of endoscopic pancreatic juice cytology (PJC), performed via the MP, in patients with PD. Patients and methods Patients with PD who underwent diagnostic ERP via the MP, between January 2010 and February 2021, were identified retrospectively from our hospital's ERCP database. Twenty‐two patients contributing to 24 ERCPs were included in the analysis. Results MP cannulation was successful in 23 of 24 ERCPs (96%). In one patient, successful cannulation was achieved on the second attempt and the procedure was performed twice in another. Serial pancreatic juice aspiration cytologic examination (SPACE) was performed in 17 patients, with a single aspiration of pancreatic juice performed in the other five. The sensitivity, specificity, and accuracy rates of ERCP diagnosis, overall, were 56%, 100%, and 80%, respectively. When diagnosis only based on SPACE was considered, the accuracy rate was even higher at 87%. Three patients (13%) developed mild pancreatitis as an adverse event. Conclusions The diagnostic ability of endoscopic PJC, via the MP in patients with PD was technically feasible and relatively effective under experienced pancreatobiliary endoscopists, however, requiring careful attention to post‐ERCP pancreatitis when performed.
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Affiliation(s)
- Shinya Kawaguchi
- Department of Gastroenterology Shizuoka General Hospital Shizuoka Japan
| | - Tatsunori Satoh
- Department of Gastroenterology Shizuoka General Hospital Shizuoka Japan
| | - Shuzo Terada
- Department of Gastroenterology Shizuoka General Hospital Shizuoka Japan
| | - Shinya Endo
- Department of Gastroenterology Shizuoka General Hospital Shizuoka Japan
| | - Naofumi Shirane
- Department of Gastroenterology Shizuoka General Hospital Shizuoka Japan
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Dietrich CF, Bekkali NL, Burmeister S, Dong Y, Everett SM, Hocke M, Ignee A, On W, Hebbar S, Oppong K, Sun S, Jenssen C, Braden B. Controversies in ERCP: Technical aspects. Endosc Ultrasound 2021; 11:27-37. [PMID: 34677144 PMCID: PMC8887038 DOI: 10.4103/eus-d-21-00102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The aim of the series of papers on controversies of biliopancreatic drainage procedures is to discuss pros and cons of the varying clinical practices and techniques in ERCP and EUS for drainage of biliary and pancreatic ducts. While the first part focuses on indications, clinical and imaging prerequisites prior to ERCP, sedation options, post-ERCP pancreatitis prophylaxis, and other related technical topics, the second part discusses specific procedural ERCP techniques including precut techniques and their timing as well as management algorithms. In addition, reviews on controversies in EUS-guided bile duct and pancreatic drainage procedures are under preparation.
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Affiliation(s)
- Christoph F Dietrich
- Department of Ultrasound, The First Affiliated Hospital of Zhengzhou University, China; Johann Wolfgang Goethe University, Frankfurt/Main, Germany; Department of Allgemeine Innere Medizin, Kliniken Hirslanden Beau Site, Salem und Permanence, Bern, Switzerland
| | - Noor L Bekkali
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Sean Burmeister
- Surgical Gastroenterology Unit, Groote Schuur Hospital, Cape Town, South Africa
| | - Yi Dong
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | | | - Michael Hocke
- Medical Department, Helios Klinikum Meiningen, Germany
| | - Andre Ignee
- Medical Department 2, Caritas-Krankenhaus, Uhlandstr 7, D-97980 Bad Mergentheim, Germany
| | - Wei On
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Srisha Hebbar
- University Hospitals of North Midlands, United Kingdom
| | - Kofi Oppong
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Siyu Sun
- Endoscopy Center, ShengJing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Christian Jenssen
- Krankenhaus Märkisch-Oderland, Department of Internal Medicine, Strausberg; Brandenburg Institute for Clinical Ultrasound (BICUS) at Medical University Brandenburg, Neuruppin, Germany
| | - Barbara Braden
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom; Johann Wolfgang Goethe University, Frankfurt/Main, Germany
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12
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Conti Bellocchi MC, Crinò SF, Pin F, di Stefano S, Le Grazie M, Bernardoni L, Ruffini M, Frulloni L, Gabbrielli A. Reappraisal of factors impacting the cannulation rate and clinical efficacy of endoscopic minor papilla sphincterotomy. Pancreatology 2021; 21:805-811. [PMID: 33745788 DOI: 10.1016/j.pan.2021.01.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/15/2021] [Accepted: 01/25/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND We aimed to assess factors impacting the endoscopic minor papilla sphincterotomy (EMPS) success rate, clinical efficacy, and safety in a large cohort of patients with symptomatic pancreas divisum (PD). METHODS Retrospective study including patients with PD referred to the Pancreas Institute of Verona from May 2009 to May 2020 to undergo EMPS. The whole population was analyzed to assess EMPS technical success, defined as the rate of deep cannulation of the dorsal duct. Patients treated for recurrent pancreatitis (RP) with a minimum follow-up of 1 year were included to evaluate the clinical efficacy, defined as resolution or significant reduction of acute pancreatitis (AP) episodes. Safety was defined as the rate of procedure-related adverse events (AEs) according to an international lexicon. The effects of the main determinants on study outcomes were evaluated. RESULTS Overall, 106 patients were evaluated. Technical success was obtained in 87 (82.1%). The presence of pancreatic calcifications was associated with failure (p < 0.0001). Clinical efficacy was evaluated in 59 patients. Resolution/reduction of AP episodes after EMPS was observed in 93% of patients over a median follow-up of 49 months (IQR 37-92). Smoking habit was associated with AP recurrence (p = 0.026). The overall AE rate was 14.9%, with post-ERCP pancreatitis as the most common complication (12.6%). CONCLUSIONS In our study, performed at a tertiary center, EMPS showed satisfactory technical success and an acceptable safety profile. If confirmed by prospective multicenter studies, EMPS could become the standard of care for the treatment of RP in PD.
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Affiliation(s)
- Maria Cristina Conti Bellocchi
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy.
| | - Stefano Francesco Crinò
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Federico Pin
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Serena di Stefano
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Marco Le Grazie
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Laura Bernardoni
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Martina Ruffini
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Luca Frulloni
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Armando Gabbrielli
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
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13
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Meng QQ, Zhao SB, Wang ZJ, Shen Z, Xia T, Wang SL, Gu L, Pan P, Li ZS, Yao J, Shi YH, Bai Y. Incidence and risk factors for post-ERCP pancreatitis in pancreas divisum patients without chronic pancreatitis. Scand J Gastroenterol 2020; 55:732-736. [PMID: 32567400 DOI: 10.1080/00365521.2020.1774922] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Aims: The studies on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in pancreas divisum (PD) patients without chronic pancreatitis (CP) are rare. In this study, we aimed to evaluate the incidence of PEP in PD patients without CP and the risk and protective factors for PEP.Methods: Consecutive patients with symptomatic PD that underwent ERCP from January 2005 to December 2017 were retrospectively analyzed. The patients were divided into PD without CP group and CP group. The basic information and medical records of patients were collected. The risk and protective factors for PEP in PD patients without CP were analyzed by univariate logistic analysis.Results: A total of 89 ERCP procedures were performed in 51 PD patients without CP, and 249 procedures in 136 patients with CP. The incidence of PEP was significantly higher in PD patients without CP than those with CP (15.7% vs. 5.6%, p = .005). Female gender were independent risk factors for PEP, while dorsal duct stent placement was a protective factor.Conclusion: CP may be a protective factor against PEP in PD patients. Female was a risk factor for PEP in PD patients and dorsal duct stent placement was a preventive factor that reduced the incidence of PEP in PD patients without CP.
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Affiliation(s)
- Qian-Qian Meng
- Digestive Endoscopy Center, Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Sheng-Bing Zhao
- Digestive Endoscopy Center, Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Zhi-Jie Wang
- Digestive Endoscopy Center, Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Zhen Shen
- Digestive Endoscopy Center, Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Tian Xia
- Digestive Endoscopy Center, Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Shu-Ling Wang
- Digestive Endoscopy Center, Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Lun Gu
- Digestive Endoscopy Center, Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Peng Pan
- Digestive Endoscopy Center, Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Zhao-Shen Li
- Digestive Endoscopy Center, Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Jun Yao
- Department of Gastroenterology, The Second Clinical Medical College, Jinan University, Shenzhen, China
| | - Yi-Hai Shi
- Department of Gastroenterology, Gongli Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Yu Bai
- Digestive Endoscopy Center, Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
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14
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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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Wen J, Li T, Liu L, Bie LK, Gong B. Long-term outcomes of therapeutic ERCP in pediatric patients with pancreas divisum presenting with acute recurrent or chronic pancreatitis. Pancreatology 2019; 19:834-841. [PMID: 31421974 DOI: 10.1016/j.pan.2019.08.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 08/02/2019] [Accepted: 08/07/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the long-term outcomes of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for pediatric patients with pancreas divisum (PD) presenting with acute recurrent pancreatitis (ARP) or chronic pancreatitis (CP). METHODS Between May 2008 and August 2017, pediatric patients with PD who received endotherapy at Ruijin Hospital were identified and grouped according to clinical presentation, namely ARP and CP. Primary success was defined as patients' improvement in symptoms after index ERCPs, without further intervention or any analgesic. RESULTS A total of 74 ERCPs were performed in 38 pediatric patients. The frequency of at least 1 genetic mutation identified in patients with ARP and CP was 44.4% and 68.4%, respectively. Patients with CP required more ERCPs than those with ARP (2.4 ± 1.7 vs. 1.1 ± 0.4, P = 0.005). The incidence of post-ERCP complications was 14.9%, including pancreatitis of 13.5% and hemorrhage of 1.4%. During a median follow-up duration of 41 months (range, 12-123 months), the frequency of pancreatitis episodes decreased significantly from 2.31 to 0.45 (P < 0.0001). The 25% recurrence and reintervention rates were estimated at 25 and 48 months, respectively, without significant difference between patients with ARP or CP. There was a nonsignificant trend towards a higher rate of primary success in patients with ARP than those with CP (92.9% vs. 69.6%, P = 0.123). After further endotherapy, 91.3% patients with CP improved clinically. CONCLUSIONS Therapeutic ERCP is an effective and safe intervention for pediatric patients with symptomatic PD. Patients presenting with CP seem to achieve improvement after additional ERCPs.
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Affiliation(s)
- Jun Wen
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Tao Li
- Department of Gastroenterology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Lei Liu
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Li-Ke Bie
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Biao Gong
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
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16
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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: 3.5] [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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17
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Tringali A, Voiosu T, Schepis T, Landi R, Perri V, Bove V, Voiosu AM, Costamagna G. Pancreas divisum and recurrent pancreatitis: long-term results of minor papilla sphincterotomy. Scand J Gastroenterol 2019; 54:359-364. [PMID: 30880501 DOI: 10.1080/00365521.2019.1584640] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background and aims: Pancreas divisum (PD) is the most common congenital variant of the pancreatic ductal system and a potential cause of acute recurrent pancreatitis (ARP). Endoscopic therapy is a therapeutic option for symptomatic PD, but there is limited data on long-term results. We aimed to assess the effect of minor papilla endoscopic sphincterotomy (MiES) in the setting of ARP in patients with PD. Methods: Consecutive patients treated by MiES were included. Clinical data, including gender, age, smoking and drinking habits, number of episodes of acute pancreatitis (AP) as well as technical data pertaining to the endoscopic therapy were reviewed. Patients available for follow-up were contacted to assess the long-term impact of MiES using the Patient's Global Impression of Change (PGIC) questionnaire. Results: A total of 138 patients with PD including 77 patients with ARP underwent MiES; 48 patients were available for long-term follow-up using the PGIC score, with a mean follow-up period of 9.7 years. Procedure-related adverse events developed in 10 cases (12.9%): 5 post-MiES delayed bleeding and 5 mild pancreatitis. MiES was clinically successful in 35 patients (72.9%) who did not experience any more episodes of AP. Improvement in quality of life (PGIC ≥6) occurred in 41/48 patients (85.4%). On multivariate analysis, stenosis of the MiES was the only predictive factor for increased risk of recurrent pancreatitis after initial therapy. Conclusion: MiES resulted an efficient treatment for ARP in patients with PD with clinical benefit, patient satisfaction and improved quality of life even at long-term follow-up.
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Affiliation(s)
- Andrea Tringali
- a Digestive Endoscopy Unit, Policlinico Agostino Gemelli Foundation IRCCS , Rome , Italy.,b Centre for Endoscopic Research Therapeutics and Training - CERTT, Catholic University of the Sacred Heart , Rome , Italy
| | - Theodor Voiosu
- a Digestive Endoscopy Unit, Policlinico Agostino Gemelli Foundation IRCCS , Rome , Italy.,c Gastroenterology Department , Colentina Clinical Hospital , Bucharest , Romania.,d Carol Davila School of Medicine, Internal medicine , Bucharest , Romania
| | - Tommaso Schepis
- a Digestive Endoscopy Unit, Policlinico Agostino Gemelli Foundation IRCCS , Rome , Italy
| | - Rosario Landi
- a Digestive Endoscopy Unit, Policlinico Agostino Gemelli Foundation IRCCS , Rome , Italy.,b Centre for Endoscopic Research Therapeutics and Training - CERTT, Catholic University of the Sacred Heart , Rome , Italy
| | - Vincenzo Perri
- a Digestive Endoscopy Unit, Policlinico Agostino Gemelli Foundation IRCCS , Rome , Italy.,b Centre for Endoscopic Research Therapeutics and Training - CERTT, Catholic University of the Sacred Heart , Rome , Italy
| | - Vincenzo Bove
- a Digestive Endoscopy Unit, Policlinico Agostino Gemelli Foundation IRCCS , Rome , Italy.,b Centre for Endoscopic Research Therapeutics and Training - CERTT, Catholic University of the Sacred Heart , Rome , Italy
| | - Andrei Mihai Voiosu
- c Gastroenterology Department , Colentina Clinical Hospital , Bucharest , Romania
| | - Guido Costamagna
- a Digestive Endoscopy Unit, Policlinico Agostino Gemelli Foundation IRCCS , Rome , Italy.,b Centre for Endoscopic Research Therapeutics and Training - CERTT, Catholic University of the Sacred Heart , Rome , Italy.,e Chair of Digestive Endoscopy, IHU-USIAS , University of Strasbourg , Strasbourg , France
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18
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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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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: 20] [Impact Index Per Article: 2.9] [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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20
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Abstract
Recurrent acute pancreatitis (RAP) is a clinically significant problem globally. The etiology remains unclear in approximately 10% to 15% of patients despite a thorough workup. Data on natural history and efficacy of treatments are limited. We aimed to establish criteria for diagnosis, evaluate the causative factors, and arrive at a consensus on the appropriate workup and management of patients with RAP. The organizing committee was formed, and a set of questions was developed based on the current evidence, controversies, and topics that needed further research. After a vetting process, these topics were assigned to a group of experts from around the world with special interest in RAP. Data were presented as part of a workshop on RAP organized as a part of the annual meeting of the America Pancreatic Association. Pretest and Posttest questions were administered, and the responses were tabulated by the current Grades of Recommendation Assessment, Development and Evaluation system. The consensus guidelines were established in the format of a diagnostic algorithm. Several deficiencies were identified with respect to data on etiology, treatment efficacies, and areas that need immediate research.
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Balloon Dilatation of the Minor Duodenal Papilla Up to 4 mm is Safe in a Porcine Model. Surg Laparosc Endosc Percutan Tech 2017; 27:e44-e47. [PMID: 28520650 DOI: 10.1097/sle.0000000000000414] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Balloon dilatation of the minor duodenal papilla is a treatment option for symptomatic pancreas divisum. The histologic effects of balloon dilatation have not yet been evaluated. The aim of this study is to investigate the tolerated extent of dilatation of the minor papilla. MATERIALS AND METHODS A dilatation of the minor papilla was performed in freshly explanted pancreas of pigs using biliary balloon dilatators. Three organs were not dilated (control group), in each 8 organs a dilatation of 4, 6, and 8 mm, respectively, was performed. Tissue damage was assessed by microscopic evaluation. Ductal wall disruption and perforation as well as a semiquantitative inflammation score was described and compared. RESULTS Ductal wall disruption was increased by dilatation of 6 (5/8; P=0.019) and 8 mm (6/8; P=0.006) compared with 4 mm (1/8). Median inflammation score was 0 (0 to 0), 1 (0 to 2), and 1 (0 to 2) for dilatation of 4, 6, and 8 mm, respectively (4 vs. 6 mm, P=0.007; 4 vs. 8 mm, P=0.026). No perforation occurred in the 4 (0/8) and 6 mm (0/8) group, 1 perforation occurred in the 8 mm group (1/8). CONCLUSIONS A dilatation of up to 4 mm seems to be safe. However, dilatation of the minor papilla from 4 mm onwards is increasingly associated with tissue damage. These findings should be considered in endoscopic procedures dilating the minor duodenal papilla.
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22
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Michailidis L, Aslam B, Grigorian A, Mardini H. The efficacy of endoscopic therapy for pancreas divisum: a meta-analysis. Ann Gastroenterol 2017; 30:550-558. [PMID: 28845111 PMCID: PMC5566776 DOI: 10.20524/aog.2017.0159] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 04/24/2017] [Indexed: 12/16/2022] Open
Abstract
Background The purpose of this study was to perform a meta-analysis assessing the efficacy and predictors of success of endoscopic therapy in the management of patients with pancreas divisum. Methods An electronic database search (PubMed and ScienceDirect) was performed for relevant studies. Studies were selected based on predefined criteria and data were extracted on patient population, follow up, endotherapy methods, success rates and complication rates. A random-effect model was used to pool the effect size across studies. Heterogeneity testing and publication bias assessment were performed. Multivariate regression analysis was performed to identify predictors of successful endoscopic therapy. Results Of 381 articles reviewed, 23 studies with 874 patients met the inclusion criteria. All were case series with suboptimal quality. Endoscopic therapy included minor papilla sphincterotomy, minor papilla sphincteroplasty and dorsal duct stenting. Mean follow-up duration was 37 months. The rate of “improvement” as defined by authors after endoscopic therapy varied significantly across studies, ranging from 31-96%: 589/874 patients were reported to have improved, corresponding to a pooled efficacy rate of 67.5% (95% confidence interval [CI] 0.610-0.734; P=0.0001). The pooled rate of pancreatitis after endoscopic retrograde cholangiopancreatography was 10.1% (95%CI 0.084-0.124; 2-sided P=0.0001). On subgroup analysis, patients with recurrent acute pancreatitis had better endoscopic outcomes (pooled efficacy rate 76%, 95%CI 0.712-0.803, P=0.0001). Dorsal duct stenting and longer follow up were the only parameters predictive of successful endotherapy. Significant heterogeneity was observed within and across studies. Conclusions Endoscopic efficacy in pancreas divisum is estimated at 67.5%. Available studies are of poor quality with significant heterogeneity. Comparative studies with rigorous methodology are needed.
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Affiliation(s)
- Lamprinos Michailidis
- Department of Medicine, Division of Digestive Diseases and Nutrition, University of Kentucky College of Medicine, USA
| | - Bilal Aslam
- Department of Medicine, Division of Digestive Diseases and Nutrition, University of Kentucky College of Medicine, USA
| | - Alla Grigorian
- Department of Medicine, Division of Digestive Diseases and Nutrition, University of Kentucky College of Medicine, USA
| | - Houssam Mardini
- Department of Medicine, Division of Digestive Diseases and Nutrition, University of Kentucky College of Medicine, USA
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23
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A systematic review and quantitative analysis of different therapies for pancreas divisum. Am J Surg 2017; 214:525-537. [PMID: 28110914 DOI: 10.1016/j.amjsurg.2016.12.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 12/26/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pancreas divisum is the most common anatomical variation of pancreatic ductal system affecting 5-10% of population. Therapy includes different endoscopic and surgical procedures. The aim of this article was to summarize actual evidence of different treatment. METHODS A Medline search was performed to identify all studies, investigating endoscopic or surgical therapy of Pancreas divisum. An individual data simulation model was applied to compare endoscopic and surgical studies. RESULT 56 observational studies (31 endoscopic and 25 surgical studies) were included in analyses. Surgery was significantly superior to endoscopic treatment in terms of success rate (72% vs. 62.3), complication rate (23.8% vs. 31.3%) and re-intervention rate (14.4% vs. 28.3%). CONCLUSION Surgery may be superior to endoscopy in terms of treatment success and complications. There is no study comparing these two therapies. Consequently, a randomized trial is needed to clarify if endoscopy or surgery is superior in the therapy of pancreas divisum.
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Somani P, Navaneethan U. Role of ERCP in Patients With Idiopathic Recurrent Acute Pancreatitis. ACTA ACUST UNITED AC 2016; 14:327-39. [PMID: 27371265 DOI: 10.1007/s11938-016-0096-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OPINION STATEMENT Recurrent acute pancreatitis (RAP) is defined based on the occurrence of two or more episodes of acute pancreatitis. RAP is differentiated from chronic pancreatitis based on the presence of a normal morphological appearance of the pancreas between episodes. RAP can be due to a variety of etiologies including common bile duct stones or sludge, sphincter of Oddi dysfunction (SOD), pancreas divisum (PD), anomalous pancreaticobiliary junction, genetic mutations, and alcohol related. In approximately 30 % of patients, the etiology of RAP is unclear and the term "idiopathic" is used. Endoscopic retrograde cholangiopancreatography (ERCP) can be utilized in both the diagnosis and the initial management of RAP, but it has known limitations and risks. Since gallbladder sludge and SOD account for most cases with RAP, cholecystectomy and, eventually, endoscopic biliary and/or pancreatic sphincterotomy are performed as a part of management. In patients with PD-associated RAP, data from uncontrolled and primarily retrospective studies point toward a benefit from minor papillary endoscopic intervention. However, given the lack of quality data from prospective randomized controlled trials (RCTs), endoscopic management in such patients remains an individualized decision, and RCTs are needed to ascertain its true long-term benefit. Future studies to investigate the role of endoscopic therapy in preventing progression to chronic pancreatitis are needed.
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Affiliation(s)
- Piyush Somani
- Center for Interventional Endoscopy, University of Central Florida College of Medicine, Florida Hospital, 601 E Rollins Street, Orlando, FL, 32803, USA
| | - Udayakumar Navaneethan
- Center for Interventional Endoscopy, University of Central Florida College of Medicine, Florida Hospital, 601 E Rollins Street, Orlando, FL, 32803, USA.
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Das R, Yadav D, Papachristou GI. Endoscopic Treatment of Recurrent Acute Pancreatitis and Smoldering Acute Pancreatitis. Gastrointest Endosc Clin N Am 2015; 25:737-48. [PMID: 26431601 DOI: 10.1016/j.giec.2015.06.008] [Citation(s) in RCA: 14] [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
Recurrent acute pancreatitis (RAP) is a challenging condition that can lead to chronic pancreatitis and long-term morbidity. Etiology-based treatment can potentially have an impact on the natural history of RAP and its progression to chronic pancreatitis. In cases of divisum-associated RAP and idiopathic RAP, several studies have been performed to evaluate the efficacy of endoscopic therapy in alleviation of symptoms and frequency of AP events. This review discusses the literature available on these topic as well as touching on the role of endoscopic therapy in smoldering acute pancreatitis.
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Affiliation(s)
- Rohit Das
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PUH, M2, C Wing, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PUH, M2, C Wing, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Georgios I Papachristou
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PUH, M2, C Wing, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
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Wang W, Gong B, Jiang WS, Liu L, Bielike K, Xv B, Wu YL. Endoscopic treatment for pancreatic diseases: Needle-knife-guided cannulation via the minor papilla. World J Gastroenterol 2015; 21:5950-5960. [PMID: 26019460 PMCID: PMC4438030 DOI: 10.3748/wjg.v21.i19.5950] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 12/30/2014] [Accepted: 02/05/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the efficacy and safety of meticulous cannulation by needle-knife.
METHODS: Three needle-knife procedures were used to facilitate cannulation in cases when standard cannulation techniques failed. A total of 104 cannulations via the minor papilla attempted in 74 patients at our center between January 2008 and June 2014 were retrospectively reviewed.
RESULTS: Standard methods were successful in 79 cannulations. Of the 25 cannulations that could not be performed by standard methods, 19 were performed by needle-knife, while 17 (89.5%) were successful. Needle-knife use improved the success rate of cannulation [76.0%, 79/104 vs 92.3%, (79 + 17)/104; P = 0.001]. When the 6 cases not appropriate for needle-knife cannulation were excluded, the success rate was improved further (80.6%, 79/98 vs 98.0%, 96/98; P = 0.000). There were no significant differences in the rates of post-endoscopic retrograde cholangiopancreatography adverse events between the group using standard methods alone and the group using needle-knife after failure of standard methods (4.7% vs 10.5%, P = 0.301).
CONCLUSION: The needle-knife procedure may be an alternative method for improving the success rate of cannulation via the minor papilla, particularly when standard cannulation has failed.
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Lee TH, Park DH. Endoscopic prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis. World J Gastroenterol 2014; 20:16582-16595. [PMID: 25469026 PMCID: PMC4248201 DOI: 10.3748/wjg.v20.i44.16582] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 03/11/2014] [Accepted: 04/29/2014] [Indexed: 02/06/2023] Open
Abstract
Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is not an uncommon adverse event but may be an avoidable complication. Although pancreatitis of severe grade is reported in 0.1%-0.5% of ERCP patients, a serious clinical course may be lethal. For prevention of severe PEP, patient risk stratification, appropriate selection of patients using noninvasive diagnostic imaging methods such as magnetic resonance cholangiopancreatography or endoscopic ultrasonography (EUS), and avoidance of unnecessary invasive procedures, are important measures to be taken before any procedure. Pharmacological prevention is also commonly attempted but is usually ineffective. No ideal agent has not yet been found and the available data conflict. Currently, rectal non-steroidal anti-inflammatory drugs are used to prevent PEP in high-risk patients, but additional studies using larger numbers of subjects are necessary to confirm any prophylactic effect. In this review, we focus on endoscopic procedures seeking to prevent or decrease the severity of PEP. Among various cannulation methods, wire-guided cannulation, precut fistulotomy, and transpancreatic septostomy are reviewed. Prophylactic pancreatic stent placement, which is the best-known prophylactic method, is reviewed with reference to the ideal stent type, adequate duration of stent placement, and stent-related complications. Finally, we comment on other treatment alternatives, and make the point that further advances in EUS-guided techniques may afford useful PEP prophylaxis.
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Abstract
OBJECTIVE A subpopulation of patients with pancreas divisum experience symptomatic events such as recurrent acute pancreatitis and chronic pancreatitis. Minor papilla sphincterotomy has been reported as being an effective treatment. The aim of this study was to evaluate the safety and efficacy of endoscopic balloon dilation for the minor papilla. METHODS Between 2000 and 2012, 16 patients were retrospectively included in this study. After endoscopic balloon dilation for the minor papilla was received, a pancreatic stent or a nasal pancreatic drainage catheter was placed for 1 week. If a stricture or obstruction was evident, it was treated with balloon dilation followed by long-term stent placement (1 year). When an outflow of pancreatic juice was disturbed by a pancreatic stone, endoscopic stone extraction was performed. RESULTS Balloon dilation and stent placement were achieved and were successful in all the cases (16/16; 100%). Clinical improvement was achieved in 7 (84.7%) of the 9 patients with recurrent acute pancreatitis and in 6 (85.7%) of the 7 patients with chronic pancreatitis. Early complications were observed in 1 (6.3%) patient. Pancreatitis or bleeding related to balloon dilation was not observed. CONCLUSIONS Endoscopic balloon dilation for the minor papilla is feasible for the management of symptomatic pancreas divisum.
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Kanth R, Samji NS, Inaganti A, Komanapalli SD, Rivera R, Antillon MR, Roy PK. Endotherapy in symptomatic pancreas divisum: a systematic review. Pancreatology 2014; 14:244-50. [PMID: 25062871 DOI: 10.1016/j.pan.2014.05.796] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 05/27/2014] [Accepted: 05/31/2014] [Indexed: 12/11/2022]
Abstract
Pancreas divisum (PD) is the most common congenital variant of the pancreas and has been implicated as a cause of pancreatitis; however, endoscopic treatment is controversial. Our objective was to examine patient response to endotherapy for treatment of symptomatic PD in adult patients in a systematic review of the literature. A systematic review of all case series and case-control studies with ten or more patients undergoing endotherapy for treatment of symptomatic PD indicated by acute recurrent pancreatitis (ARP), chronic pancreatitis (CP), or chronic abdominal pain (CAP) was performed. PubMed, Embase, and Web of Science databases were searched from inception through February 2013 using [pancreas divisum] AND [endoscopic retrograde cholangiopancreatography (ERCP)] OR [endotherapy] OR [endoscopy] as search terms. Importantly, the majority of studies were retrospective in nature, significantly limiting analysis capacity. Main outcomes measures included endotherapy response rate in patients with PD and ARP, CP, or CAP. Twenty-two studies were included in the review, with a total of 838 patients. Response to endoscopy was seen in 528 patients, but response rate varied by clinical presentation. Patients with ARP had a response rate ranging from 43% to 100% (median 76%). Reported response rates were lower in the other two groups, ranging from 21% to 80% (median 42%) for patients with CP and 11%-55% (median 33%) for patients with CAP. Complications reported included perforation, post-endoscopic retrograde cholangiopancreatography pancreatitis, bleeding, and clogged stents. Endotherapy appears to offer an effective treatment option for patients with symptomatic PD, with the best results in patients presenting with ARP.
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Affiliation(s)
- Rajan Kanth
- Department of Internal Medicine, Marshfield Clinic, Marshfield, WI, USA
| | - N Swetha Samji
- Department of Internal Medicine, Marshfield Clinic, Marshfield, WI, USA
| | - Anupama Inaganti
- Department of Internal Medicine, Marshfield Clinic, Marshfield, WI, USA
| | | | - Ramon Rivera
- Department of Gastroenterology and Hepatology, Ochsner Medical Center, New Orleans, LA, USA
| | - Mainor R Antillon
- Department of Gastroenterology and Hepatology, Ochsner Medical Center, New Orleans, LA, USA
| | - Praveen K Roy
- Department of Gastroenterology and Hepatology, Ochsner Medical Center, New Orleans, LA, USA; Department of Gastroenterology, Marshfield Clinic, Marshfield, WI, USA.
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Abstract
Chronic pancreatitis (CP) is a progressive disease with irreversible changes in the pancreas. Patients commonly present with pain and with exocrine or endocrine insufficiency. All therapeutic efforts in CP are directed towards relief of pain as well as the management of associated complications. Endoscopic therapy offers many advantages in patients with CP who present with ductal calculi, strictures, ductal leaks, pseudocyst or associated biliary strictures. Endotherapy offers a high rate of success with low morbidity in properly selected patients. The procedure can be repeated and failed endotherapy is not a hindrance to subsequent surgery. Endoscopic pancreatic sphincterotomy is helpful in patients with CP with minimal ductal changes while minor papilla sphincterotomy provides relief in patients with pancreas divisum and chronic pancreatitis. Extracorporeal shock wave lithotripsy is the standard of care in patients with large pancreatic ductal calculi. Long term follow up has shown pain relief in over 60% of patients. A transpapillary stent placed across the disruption provides relief in over 90% of patients with ductal leaks. Pancreatic ductal strictures are managed by single large bore stents. Multiple stents are placed for refractory strictures. CP associated benign biliary strictures (BBS) are best treated with multiple plastic stents, as the response to a single plastic stent is poor. Covered self expanding metal stents are increasingly being used in the management of BBS though further long term studies are needed. Pseudocysts are best drained endoscopically with a success rate of 80%-95% at most centers. Endosonography (EUS) has added to the therapeutic armamentarium in the management of patients with CP. Drainage of pseudcysts, cannulation of inaccessible pancreatic ducts and celiac ganglion block in patients with intractable pain are all performed using EUS. Endotherapy should be offered as the first line of therapy in properly selected patients with CP who have failed to respond to medical therapy and require intervention.
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Abstract
Endoscopy plays an important role in both the diagnosis and the initial management of recurrent acute pancreatitis, as well as the investigation of refractory disease, but it has known limitations and risks. Sound selective use of these therapies, complemented with other lines of investigation such as genetic testing, can dramatically improve frequency of attacks and associated quality of life. Whether endoscopic therapy can reduce progression to chronic pancreatitis, or reduce the risk of malignancy, is debatable, and remains to be proven.
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Fujimori N, Igarashi H, Asou A, Kawabe K, Lee L, Oono T, Nakamura T, Niina Y, Hijioka M, Uchida M, Kotoh K, Nakamura K, Ito T, Takayanagi R. Endoscopic approach through the minor papilla for the management of pancreatic diseases. World J Gastrointest Endosc 2013; 5:81-8. [PMID: 23515847 PMCID: PMC3600553 DOI: 10.4253/wjge.v5.i3.81] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Revised: 11/08/2012] [Accepted: 01/23/2013] [Indexed: 02/05/2023] Open
Abstract
AIM: To clarify the efficacy and safety of an endoscopic approach through the minor papilla for the management of pancreatic diseases.
METHODS: This study included 44 endoscopic retrograde cholangiopancreatography (ERCP) procedures performed in 34 patients using a minor papilla approach between April 2007 and March 2012. We retrospectively evaluated the clinical profiles of the patients, the endoscopic interventions, short-term outcomes, and complications.
RESULTS: Of 44 ERCPs, 26 were diagnostic ERCP, and 18 were therapeutic ERCP. The most common cause of difficult access to the main pancreatic duct through the major papilla was pancreas divisum followed by distortion of Wirsung’s duct. The overall success rate of minor papilla cannulation was 80% (35/44), which was significantly improved by wire-guided cannulation (P = 0.04). Endoscopic minor papillotomy (EMP) was performed in 17 of 34 patients (50%) using a needle-knife (13/17) or a pull-type papillotome (4/17). EMP with pancreatic stent placement, which was the main therapeutic option for patients with chronic pancreatitis, recurrent acute pancreatitis, and pancreatic pseudocyst, resulted in short-term clinical improvement in 83% of patients. Mild post-ERCP pancreatitis occurred as an early complication in 2 cases (4.5%).
CONCLUSION: The endoscopic minor papilla approach is technically feasible, safe, and effective when the procedure is performed in a high-volume referral center by experienced endoscopists.
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Affiliation(s)
- Nao Fujimori
- Nao Fujimori, Hisato Igarashi, Akira Asou, Lingaku Lee, Takamasa Oono, Taichi Nakamura, Yusuke Niina, Masayuki Hijioka, Masahiko Uchida, Kazuhiro Kotoh, Kazuhiko Nakamura, Tetsuhide Ito, Ryoichi Takayanagi, Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka 812-8582, Japan
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Buxbaum J. The role of endoscopic retrograde cholangiopancreatography in patients with pancreatic disease. Gastroenterol Clin North Am 2012; 41:23-45. [PMID: 22341248 DOI: 10.1016/j.gtc.2011.12.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Given the significant risk of pancreatitis and the advent of high-fidelity diagnostic techniques, ERCP is now reserved as a therapeutic procedure for those with pancreatic disease. Early ERCP benefits those with gallstone pancreatitis who present with or develop cholangitis or biliary obstruction. Among those with idiopathic pancreatitis, ERCP may be used to confirm and treat SOD, microlithiasis, and structural anomalies, including pancreas divisum. Pancreatic endotherapy is a consideration to decrease pain in those with pancreatic duct obstruction, although surgical decompression may be more durable, particularly in those with severe disease. Pancreatic duct leaks may respond to endoscopic drainage, but optimal therapy is achieved if a bridging stent can be placed. Finally, using a wire-guided technique and pancreatic duct stents in high-risk patients, particularly in cases of suspected SOD, may minimize the risk of post-ERCP pancreatitis.
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Affiliation(s)
- James Buxbaum
- Los Angeles County Hospital, Division of Gastroenterology and Liver Diseases, The University of Southern California, Keck School of Medicine, Los Angeles, CA 90033, USA.
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Herszényi L, Szmola R, Tulassay Z. [Clinical importance of pancreas divisum]. Orv Hetil 2011; 152:1764-71. [PMID: 21997581 DOI: 10.1556/oh.2011.29231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Pancreas divisum, the most common congenital pancreatic anomaly, is associated with three main duct abnormalities: type I, with total failure of fusion; type II, with dorsal duct dominant drainage; and type III, incomplete divisum where a small communication branch is present. Three clinical conditions are associated with pancreas divisum: (1) acute recurrent pancreatitis; (2) chronic pancreatitis with the chronic inflammation in the dorsal bed; (3) abdominal "pancreatic-type" obstructive pain. Endoscopic retrograde cholangiopancreatography is the primary method for diagnosing pancreas divisum, but magnetic resonance cholangiopancreatography is becoming a first choice for non-invasive evaluation. Pancreas divisum per se does not require medical intervention. Patients who experience mild episodic acute pancreatitis should be managed medically. Surgical or endoscopic interventions relieve the obstruction by improving dorsal duct drainage via the minor papilla.
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Affiliation(s)
- László Herszényi
- Semmelweis Egyetem, Általános Orvostudományi Kar II. Belgyógyászati Klinika, Budapest.
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Abstract
Recurrent acute pancreatitis is a common clinical problem. Most cases of pancreatitis are identified by a careful history and physical examination. Despite advanced evaluation, the cause is not apparent in about 10% of cases. The etiology of recurrent acute pancreatitis appears to be multifactorial, with genetic and environmental influences playing a significant role. The strength of evidence for certain etiologies is highly variable, and natural history data are limited. Controversy exists regarding the most appropriate diagnostic and therapeutic approach. Recurrent acute pancreatitis often represents a continuum with chronic pancreatitis.
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Moffatt DC, Coté GA, Avula H, Watkins JL, McHenry L, Sherman S, Lehman GA, Fogel EL. Risk factors for ERCP-related complications in patients with pancreas divisum: a retrospective study. Gastrointest Endosc 2011; 73:963-70. [PMID: 21392753 DOI: 10.1016/j.gie.2010.12.035] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Accepted: 12/28/2010] [Indexed: 12/29/2022]
Abstract
BACKGROUND Limited data are available on complication rates of ERCP in patients with pancreas divisum (PD), and it is unclear whether traditional risk factors for post-ERCP pancreatitis (PEP) apply. OBJECTIVES To describe the rates of ERCP complications in patients with PD and assess patient and procedure-related risk factors for PEP. DESIGN Retrospective cohort study. SETTING Tertiary care referral center. PATIENTS A total of 2753 ERCPs performed in 1476 patients with PD from 1997 to 2010. MAIN OUTCOME MEASUREMENTS Rates of PEP, hemorrhage, perforation, cholecystitis, and hospitalization directly attributable to ERCP. RESULTS Early complications occurred after 7.8% of procedures, with PEP, hemorrhage, perforation, cholecystitis, and cardiorespiratory complications in 6.8%, 0.7%, 0.2%, 0.1%, and 0.1% of procedures, respectively. PEP was uncommon in patients who did not undergo attempted dorsal duct cannulation, occurring in 1.2% of procedures. With dorsal duct cannulation and cannulation with minor papilla sphincterotomy (MiS), the rates of PEP increased significantly to 8.2% and 10.6%, respectively (P<.01 for each comparison). Significant predictors of PEP after multivariate logistic regression included age younger than 40 (odds ratio [OR] 1.8; 95% CI, 1.27-2.59), female sex (OR 1.94; 95% CI, 1.25-3.01), previous PEP (OR 2.02; 95% CI, 1.32-3.1), attempted dorsal duct cannulation (OR 7.45; 95% CI, 3.25-17.07), and MiS (OR 1.62; 95% CI, 1.05-2.48). Presence of severe chronic pancreatitis was a protective factor (OR 0.46; 95% CI, 0.22-0.98). LIMITATIONS Retrospective analysis of prospectively collected data. CONCLUSIONS Among patients with PD, the rate of PEP is low (1.2%) if dorsal duct cannulation is not attempted. However, patients with PD undergoing dorsal duct cannulation with or without MiS are at high risk of PEP (8.2% without and 10.6% with). Traditional PEP risk factors apply to patients with PD.
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Maple JT, Mansour L, Ammar T, Ansstas M, Coté GA, Azar RR. Physician-controlled wire-guided cannulation of the minor papilla. DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2010; 2010:629308. [PMID: 20827381 PMCID: PMC2935163 DOI: 10.1155/2010/629308] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2010] [Accepted: 07/09/2010] [Indexed: 12/29/2022]
Abstract
Background. Minor papilla (MiP) cannulation is frequently performed using specialized small-caliber accessories. Outcomes data for MiP cannulation with standard-sized accessories are lacking. Methods. This is a case series describing MiP cannulation outcomes in consecutive patients treated by two endoscopists between July 2005 and November 2008 at two tertiary referral centers. MiP cannulation was attempted using a 4.4 Fr tip sphincterotome loaded with a 0.035(″), 260 cm hydrophilic-tip guidewire, using a wire-guided technique under physician control. Results. 25 patients were identified (14 women, mean age 45). Procedure indications included recurrent acute pancreatitis in 16 patients (64%) and chronic pancreatitis in 2 (8%), among other indications. MiP cannulation was successful in 24 patients (96%). Sphincterotomy followed by pancreatic stent placement was performed in 21 patients (84%). Mild post-ERCP pancreatitis occurred in 3 patients (12%). Conclusion. Physician-controlled wire-guided MiP cannulation using a 4.4 Fr sphincterotome and 0.035(″) guidewire is an effective and safe technique.
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Affiliation(s)
- John T. Maple
- Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, 920 Stanton L. Young Boulevard, WP 1345, Oklahoma City, Oklahoma 73117, USA
| | - Lilah Mansour
- Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, 920 Stanton L. Young Boulevard, WP 1345, Oklahoma City, Oklahoma 73117, USA
| | - Tarek Ammar
- Division of Gastroenterology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8124, St. Louis, MO 63110, USA
| | - Michael Ansstas
- Division of Gastroenterology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8124, St. Louis, MO 63110, USA
| | - Gregory A. Coté
- Division of Gastroenterology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8124, St. Louis, MO 63110, USA
| | - Riad R. Azar
- Division of Gastroenterology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8124, St. Louis, MO 63110, USA
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Kethu SR, Adler DG, Conway JD, Diehl DL, Farraye FA, Kantsevoy SV, Kaul V, Kwon RS, Mamula P, Pedrosa MC, Rodriguez SA, Tierney WM. ERCP cannulation and sphincterotomy devices. Gastrointest Endosc 2010; 71:435-45. [PMID: 20189502 DOI: 10.1016/j.gie.2009.07.038] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2009] [Accepted: 07/28/2009] [Indexed: 12/12/2022]
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Long-term clinical outcomes after endoscopic minor papilla therapy in symptomatic patients with pancreas divisum. Pancreas 2009; 38:903-6. [PMID: 19672208 DOI: 10.1097/mpa.0b013e3181b2bc03] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To assess the long-term outcomes of endoscopic minor papilla therapy in a spectrum of symptomatic patients with pancreas divisum. METHODS Patients with pancreas divisum coded in a prospective database as having had minor papilla endotherapy (July 1997-May 2003, n = 145) were grouped into 3 categories: (1) acute recurrent pancreatitis, (2) chronic pancreatitis, and (3) chronic/recurrent epigastric pain. Telephone follow-up was conducted (78% of patients), including questions regarding interval co-interventions and narcotic use. Primary success was defined as clinical improvement (better or cured on a Likert scale), without needing narcotics, after 1 therapeutic endoscopic retrograde cholangiopancreatography. Fisher exact and Mann-Whitney U tests and multivariate logistic regression were used to identify predictors of success. RESULTS Primary success rates in acute recurrent pancreatitis, chronic pancreatitis, and chronic/recurrent epigastric pain were achieved in 53.2%, 18.2%, and 41.4%, respectively; and secondary success rates (<or=2 additional endoscopic retrograde cholangiopancreatographies), 71.0%, 45.5%, and 55.2%, respectively (median follow-up, 43.0 months; range, 14-116 months). Younger age (median age, 46.5 years [no success] vs 58.0 years [success]; P < 0.0001) and chronic pancreatitis (odds ratio, 0.10; 95% confidence interval, 0.03-0.39; P = 0.001) independently predicted a lower chance of success. CONCLUSIONS Significant long-term improvement can be achieved with endoscopic therapy in selected patients with pancreas divisum, although many require multiple procedures. Older patients, without chronic pancreatitis, were most likely to respond.
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Lawrence C, Romagnuolo J, Cotton PB, Payne KM, Hawes RH. Post-ERCP pancreatitis rates do not differ between needle-knife and pull-type pancreatic sphincterotomy techniques: a multiendoscopist 13-year experience. Gastrointest Endosc 2009; 69:1271-5. [PMID: 19246037 DOI: 10.1016/j.gie.2008.10.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2008] [Accepted: 10/11/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pancreatic sphincterotomy is one of several factors associated with an increased risk of post-ERCP pancreatitis (PEP). The needle-knife pancreatic sphincterotomy technique (NKS) is purported to result in less-frequent post-ERCP pancreatitis compared with a standard pull-type sphincterotomy (PTS). OBJECTIVE Our purpose was to analyze the experience with both endoscopic pancreatic sphincterotomy (EPS) techniques with respect to post-ERCP pancreatitis at a single tertiary-level referral center. DESIGN Retrospective analysis. SETTING Tertiary-care medical center (Charleston, South Carolina). PATIENTS Patients without chronic pancreatitis and with normal retrograde pancreatogram who underwent EPS between 1994 and 2007 were identified. Patients were excluded for the following reasons: pancreatic stent not placed, both sphincterotomy techniques used, any balloon dilation of the ampullary orifice, precut or access papillotomy, pancreas divisum. RESULTS A total of 481 patients were identified and underwent 510 ERCPs. Indications for ERCP were recurrent pancreatic-type pain (n = 353) or pancreatitis (n = 157). NKS was used for 395 of 510 (77.5%) cases versus 115 of 510 (22.5%) in which PTS was used. The incidence of post-ERCP pancreatitis was no different between NKS (25/395, 6.4%) and PTS (9/115, 7.8%). Most cases were mild pancreatitis; a single episode of severe PEP occurred in each group. CONCLUSIONS The risk of post-ERCP pancreatitis does not differ between EPS techniques when performed at a high-volume pancreaticobiliary referral center when using routine prophylactic pancreatic duct stent placement.
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Mao Z, Zhu Q, Wu W, Wang M, Li J, Lu A, Sun Y, Zheng M. Duodenal perforations after endoscopic retrograde cholangiopancreatography: experience and management. J Laparoendosc Adv Surg Tech A 2009; 18:691-5. [PMID: 18803511 DOI: 10.1089/lap.2008.0020] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE The aim of this study was to summary the experiences and lessons from periduodenal perforations related to endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST). METHODS A retrospective review from 2004 to 2007 identified 9 patients (0.37%) of periduodenal perforation related to ERCP/EST. Charts were reviewed for the following parameters: clinical presentation of patients, ERCP findings, diagnostic methods, treatment (surgical or conservative procedures), complications, and outcome. RESULTS Nine patients who had periampullary perforations received ERCP/EST for common bile duct stones. Cannulation was considered difficult in 7 of 9 patients, and the precut technique was used. The diagnosis was made due to subcutaneous emphysema or peritonitis, and 3 patients received emergent operations (e.g., external biliary or retroperitoneal drainage), and 1 patient had a reoperation for a retroperitoneal sealed abscess. Their median length of hospital stay was 50 days. The other 6 were treated conservatively with nasal-duodenal and nasal-biliary drainage. Their median length of hospital stay was 13 days. There was no mortality. CONCLUSIONS The precut technical may be a risk factor of duodenal perforation. Early diagnosis of duodenal perforation is essential for an optimum outcome, and subcutaneous emphysema may be a sensitive sign. Although the management of perforation after ERCP/EST is still controversial, a selective management is proposed, based on the features of classification type. Nevertheless, duodenal and biliary drainage is essential in both surgical and conservative therapy.
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Affiliation(s)
- Zhihai Mao
- Department of General Surgery, Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiaotong University, Shanghai, China
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Maple JT, Keswani RN, Edmundowicz SA, Jonnalagadda S, Azar RR. Wire-assisted access sphincterotomy of the minor papilla. Gastrointest Endosc 2009; 69:47-54. [PMID: 18656861 DOI: 10.1016/j.gie.2008.04.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2007] [Accepted: 04/07/2008] [Indexed: 12/17/2022]
Abstract
BACKGROUND Recommended techniques for minor papilla sphincterotomy include performing a standard pull-type sphincterotomy (PTS) or using a needle-knife over a stent. A wire-assisted access sphincterotomy (WAAS) technique may hold some technical advantages over these accepted methods, but has not been robustly described. OBJECTIVE To describe the safety and efficacy of WAAS compared with PTS in a series of patients from our institution. DESIGN Retrospective audit of initial minor papilla sphincterotomies over a 6-year period. Demographic and procedural data were abstracted, and the medical record was reviewed for clinical follow-up. SETTING A large tertiary referral center. PATIENTS One hundred twenty-eight consecutive patients with pancreas divisum who underwent ERCPs between April 2001 and April 2007, 64 of whom underwent an initial minor papilla sphincterotomy. INTERVENTIONS WAAS was performed by deeply cannulating the dorsal duct with a guidewire and then passing a needle-knife sphincterotome alongside the wire and cutting the minor papilla by inserting the needle-knife beside the wire and cutting away from the wire. MAIN OUTCOME MEASUREMENTS Clinical procedural success and reported adverse events. RESULTS Thirty-two patients had recurrent acute pancreatitis, 15 had pain only, and 13 had chronic pancreatitis. Thirty-two underwent WAAS, 24 had PTS, and 8 had other types of sphincterotomies. Patients undergoing WAAS (32) versus PTS (24) were similar in age, sex, and procedural indication. Mild post-ERCP pancreatitis and mild intraprocedural bleeding occurred more commonly in the WAAS group, although the differences were not statistically significant. LIMITATIONS Retrospective, nonrandomized study. CONCLUSIONS WAAS is an effective technique that may be used either to begin a minor papilla sphincterotomy or to perform the entire sphincterotomy. Complications appear similar to those seen with conventional methods but require a larger patient sample to fully evaluate.
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Affiliation(s)
- John T Maple
- Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma 73117, USA.
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Ahmed F, Sherman S. Minor papilla endotherapy in patients with symptomatic pancreas divisum. Gastrointest Endosc 2008; 68:674-5. [PMID: 18926177 DOI: 10.1016/j.gie.2008.04.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2008] [Accepted: 04/28/2008] [Indexed: 02/08/2023]
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Conklin L, Zeitlin PL, Cuffari C. Cystic fibrosis presenting as recurrent pancreatitis in a young child with a normal sweat test and pancreas divisum: a case report. J Med Case Rep 2008; 2:176. [PMID: 18501000 PMCID: PMC2435544 DOI: 10.1186/1752-1947-2-176] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2007] [Accepted: 05/23/2008] [Indexed: 12/02/2022] Open
Abstract
Introduction Pancreatitis is a rare manifestation of cystic fibrosis (CF) and may rarely be the presenting symptom in adolescent or adult patients with CF. We report a case of a 4 year-old female who initially presented with recurrent pancreatitis, a normal sweat test, and a diagnosis of pancreas divisum. She was subsequently diagnosed with cystic fibrosis at the age of 6 years, despite normal growth and no pulmonary symptoms, after nasal potential difference measurements suggested possible CF and two known CF-causing mutations (ΔF508 and L997F) were detected. Case Presentation An otherwise healthy 4 year-old female developed chronic pancreatitis and was diagnosed with pancreas divisum. Sphincterotomy was performed without resolution of her pancreatitis. Sweat test was negative for cystic fibrosis, but measurement of nasal potential differences suggested possible cystic fibrosis. These results prompted extended Cystic Fibrosis Transmembrane Regulator Conductance (CFTR) mutational analysis that revealed a compound heterozygous mutation: ΔF508 and L997F. Conclusion CFTR mutations should be considered in cases of chronic or recurrent pancreatitis despite a negative sweat test and the presence of pancreas divisum. Children with CFTR mutations may present with recurrent pancreatitis, lacking any other signs or symptoms of cystic fibrosis. It is possible that the combination of pancreas divisum and abnormal CFTR function may contribute to the severity and frequency of recurrent pancreatitis.
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Affiliation(s)
- Laurie Conklin
- Division of Pediatric Gastroenterology and Nutrition, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Morgan KA, Romagnuolo J, Adams DB. Transduodenal sphincteroplasty in the management of sphincter of Oddi dysfunction and pancreas divisum in the modern era. J Am Coll Surg 2008; 206:908-14; discussion 914-7. [PMID: 18471721 DOI: 10.1016/j.jamcollsurg.2007.12.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2007] [Accepted: 12/01/2007] [Indexed: 12/17/2022]
Abstract
BACKGROUND Surgical management of sphincter of Oddi dysfunction and pancreas divisum is controversial. In the modern era of therapeutic endoscopy, pain persisting despite endoscopic sphincterotomy and anatomy that makes the ampulla endoscopically inaccessible prompt referral for surgical transduodenal sphincteroplasty (TS). A retrospective review of sphincter of Oddi dysfunction and pancreas divisum patients who underwent TS for refractory pain in a recent time period was undertaken. STUDY DESIGN The medical records of all patients who underwent TS for sphincter of Oddi dysfunction and pancreas divisum at the Medical University of South Carolina between January 2001 and December 2005 were reviewed. Longterm outcomes were assessed by a standardized written questionnaire and the SF-36 version 2 Quality of Life Survey. RESULTS Sixty-eight patients underwent TS (median age 43 years, 54 women). Fifty-one had earlier endoscopic sphincterotomy; 17, with previous gastric surgery, did not. Operative morbidity was 10.3%, with no mortality. Forty-five patients (66%) completed the questionnaire; 62% had improvement in pain, without reintervention, over a median followup of 42.5 months (range 16 to 75 months). There was a trend toward more favorable outcomes in patients with earlier gastric surgery (no previous endoscopic sphincterotomy) compared with others (90% versus 54%, p=0.06). Multivariate analysis showed chronic pancreatitis (odds ratio 0.11 [95% CI 0.02 to 0.68; p=0.02]) and younger age (odds ratio 3.9 [95% CI 1.32 to 11.53; p=0.01] per decade) were independent predictors of poorer outcomes. CONCLUSIONS Good longterm outcomes with low operative morbidity can be obtained with TS in selected patients, including those with postgastric bypass, but younger age and chronic pancreatitis appear to predict poorer outcomes.
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Affiliation(s)
- Katherine A Morgan
- Department of Surgery, Digestive Diseases Center, Medical University of South Carolina, Charleston, SC 29425, USA
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Delhaye M, Matos C, Arvanitakis M, Devière J. Pancreatic ductal system obstruction and acute recurrent pancreatitis. World J Gastroenterol 2008; 14:1027-33. [PMID: 18286683 PMCID: PMC2689404 DOI: 10.3748/wjg.14.1027] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [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
Acute recurrent pancreatitis is a clinical entity largely associated with pancreatic ductal obstruction. This latter includes congenital variants, of which pancreas divisum is the most frequent but also controversial, chronic pancreatitis, tumors of the pancreaticobiliary junction and sphincter of Oddi dysfunction. This review summarizes current knowledge about diagnostic work-up and therapy of these conditions.
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Attasaranya S, Abdel Aziz AM, Lehman GA. Endoscopic management of acute and chronic pancreatitis. Surg Clin North Am 2008; 87:1379-402, viii. [PMID: 18053837 DOI: 10.1016/j.suc.2007.08.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Endoscopic therapy has been increasingly recognized as the effective therapy in selected patients with acute pancreatitis and chronic pancreatitis (CP). Utility of endotherapy in various conditions occurring in acute pancreatitis and CP is discussed. Its efficacy, limitations, and alternatives are addressed. For the best management of these complex entities, a multidisciplinary approach involving expertise in all pancreatic specialties is essential to achieve the goal.
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Affiliation(s)
- Siriboon Attasaranya
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University Medical Center, 550 North University Boulevard, UH 4100, Indianapolis, IN 46202, USA
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Abstract
Almost all the therapeutic efforts in the treatment of chronic pancreatitis are directed towards pain control. Endoscopic techniques available for this purpose are endoscopic retrograde cholangiopancreatography (combined or not with extracorporeal shock wave lithotripsy) and endoscopic ultrasound. Pancreatic stones and strictures, pancreatic pseudocysts, and common bile duct strictures complicating chronic pancreatitis can be treated by endoscopy. The development of endoscopic ultrasound extended the possibilities in the treatment of pancreatic pseudocysts and main pancreatic duct drainage. Endoscopy is considered the first-line treatment in chronic pancreatitis and can be useful also as a 'bridge to surgery'. In fact the endoscopic approach to chronic pancreatitis can predict the response to surgical therapy as a definitive treatment. Medical, endoscopic and surgical methods for the management of chronic pancreatitis should all be considered in decision-making, and the best treatment should be chosen case by case and according to the local expertise.
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Freeman ML. Pancreatic stents for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis. Clin Gastroenterol Hepatol 2007; 5:1354-65. [PMID: 17981248 DOI: 10.1016/j.cgh.2007.09.007] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Placement of pancreatic stents is a relatively new and increasingly adopted approach to reduce the risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Evidence for the efficacy of pancreatic stents in reducing post-ERCP pancreatitis continues to accumulate. Routine use of pancreatic stents in high-risk cases at advanced centers has changed the complexion of ERCP, reducing the incidence and severity of post-ERCP pancreatitis to a more acceptable level, and eliminating some of the fear factor surrounding previously prohibitively risky settings, such as treatment of sphincter of Oddi dysfunction (SOD). On the other hand, the adoption of prophylactic pancreatic stenting into some practices has been sporadic. Problems with pancreatic stent placement include technical difficulty with placement, need for follow-up evaluation to ensure passage or removal, and potential for inducing pancreatic ductal injury. There remain many challenges and unanswered questions which will be addressed in this review, including which patients are at risk for post-ERCP pancreatitis, how might pancreatic stents reduce risk, what is the evidence supporting efficacy of pancreatic stenting in reducing risk; and based on those data, which ERCPs are at sufficiently high risk to warrant a stent; at what point in an ERCP should a pancreatic stent be placed; how long pancreatic stents need to remain in place to be effective, the risk of inducing pancreatic duct injury by placement of a stent; the frequency and consequences of failure at attempted stent placement, and effectiveness of pancreatic stent placement in the hands of those with limited experience. Current recommendations for use of pancreatic stents and areas requiring further investigation are discussed.
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Affiliation(s)
- Martin L Freeman
- Minnesota Pancreas and Liver Center, Division of Gastroenterology, University of Minnesota, Hennepin County Medical Center, Minneapolis, Minnesota 55415, USA.
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