Endoscopic ultrasound-assisted rendezvous maneuver to achieve pancreatic duct drainage in obstructive chronic pancreatitis

Patients with mechanical obstruction of the pancreatic duct, which can be caused by chronic pancreatitis, suffer from recurrent attacks of pain and inflammation of the pancreas. We report a novel approach using an endoscopic ultrasound- (EUS-) assisted rendezvous technique, which allows drainage of the pancreatic duct in patients in whom primary management by transpapillary drainage during an endoscopic retrograde cholangiopancreatography (ERCP) procedure has failed. Transgastric puncture of the pancreatic duct was performed using a 19-gauge needle under EUS guidance, and a 0.035-inch guide wire was introduced into the duct and advanced through the papilla. This wire was pulled into the duodenum using a side-viewing duodenoscope. A papillotomy was performed using the standard technique and a plastic prosthesis was introduced. The patient tolerated the intervention well and was discharged with no further complaints. EUS-assisted drainage of the pancreatic duct using a rendezvous technique is an elegant and feasible minimally invasive endoscopic treatment for symptomatic patients with chronic pancreatitis, in whom transpapillary introduction of a catheter is not possible.     

Floating pancreatic duct concrements in chronic pancreatitis. Pain relief by endoscopic removal

This report describes 3 patients with chronic relapsing pancreatitis, floating pancreatic duct concrements between 4 and 6 mm in diameter, moderate to advanced ductal changes, and repeated severe attacks of pain during acute relapses over a period of several months. Immediate relief of pain was achieved in all 3 patients by endoscopic papillotomy aimed at widening the main pancreatic duct and subsequent extraction or spontaneous passage of pancreatic duct concrements. On the basis of our experience with the patients presented here, endoscopic papillotomy widening the main pancreatic duct may be useful in some patients with chronic pancreatitis and floating pancreatic duct concrements.     

内镜下诊断与治疗慢性胰腺炎17例

目的 探讨内镜下诊断和治疗慢性胰腺炎的价值。方法 对17例慢性胰腺炎均行内镜下逆行胰胆管造影术(ERCP)，并对部分胰管狭窄患者施行塑料支架放置引流术(ERPD)或鼻胰管引流术(ENPD)，对部分胰管内结石行内镜下胰管括约肌切开术(EPS)并行网篮取石。结果 有8例胰管狭窄者放置塑料支架，平均引流时间为276d。5例胰管结石中2例行EPS后网篮取出结石，3例行鼻胰管引流术后手术取出。结论 ERCP可作为有条件医院检查慢性胰腺炎的常规手段，是治疗部分慢性胰腺炎安全有效的方法。     

Chronic pancreatic pain successfully treated by endoscopic ultrasound-guided pancreaticogastrostomy using fully covered self-expandable metallic stent

One of the most common symptoms presenting in patients with chronic pancreatitis is pancreatic-type pain. Obstruction of the main pancreatic duct in chronic pancreatitis can be treated by a multitude of therapeutic approaches, ranging from pharmacologic, endoscopic and radiologic treatments to surgical interventions. When the conservative treatment approaches fail to resolve symptomatic cases, however, endoscopic retrograde pancreatography with pancreatic duct drainage is the preferred second approach, despite its well-recognized drawbacks. When the conventional transpapillary approach fails to achieve the necessary drainage, the patients may benefit from application of the less invasive endoscopic ultrasound (EUS)-guided pancreatic duct interventions. Here, we describe the case of a 42-year-old man who presented with severe abdominal pain that had lasted for 3 mo. Computed tomography scanning showed evidence of chronic obstructive pancreatitis with pancreatic duct stricture at genu. After conventional endoscopic retrograde pancreaticography failed to eliminate the symptoms, EUS-guided pancreaticogastrostomy (PGS) was applied using a fully covered, self-expandable, 10-mm diameter metallic stent. The treatment resolved the case and the patient experienced no adverse events. EUS-guided PGS with a regular biliary fully covered, self-expandable metallic stent effectively and safely treated pancreatic-type pain in chronic pancreatitis.     

Chronic pancreatitis

Chronic pancreatitis is the progressive and permanent destruction of the pancreas resulting in exocrine and endocrine insufficiency and, often, chronic disabling pain. The etiology is multifactorial. Alcoholism plays a significant role in adults, whereas genetic and structural defects predominate in children. The average age at diagnosis is 35 to 55 years. Morbidity and mortality are secondary to chronic pain and complications (e.g., diabetes, pancreatic cancer). Contrast-enhanced computed tomography is the radiographic test of choice for diagnosis, with ductal calcifications being pathognomonic. Newer modalities, such as endoscopic ultrasonography and magnetic resonance cholangiopancreatography, provide diagnostic results similar to those of endoscopic retrograde cholangiopancreatography. Management begins with lifestyle modifications (e.g., cessation of alcohol and tobacco use) and dietary changes followed by analgesics and pancreatic enzyme supplementation. Before proceeding with endoscopic or surgical interventions, physicians and patients should weigh the risks and benefits of each procedure. Therapeutic endoscopy is indicated for symptomatic or complicated pseudocyst, biliary obstruction, and decompression of pancreatic duct. Surgical procedures include decompression for large duct disease (pancreatic duct dilatation of 7 mm or more) and resection for small duct disease. Lateral pancreaticojejunostomy is the most commonly performed surgery in patients with large duct disease. Pancreatoduodenectomy is indicated for the treatment of chronic pancreatitis with pancreatic head enlargement. Patients with chronic pancreatitis are at increased risk of pancreatic neoplasm; regular surveillance is sometimes advocated, but formal guidelines and evidence of clinical benefit are lacking.     

胰管支架安置在胰管狭窄中的治疗作用

目的 采用胰管支架安置治疗胰管狭窄病例,以缓解胰管梗阻症状,同时对胰管支架的适应证及操作技术进行探讨.方法 对诊断明确的胰腺癌及慢性胰腺炎伴胰管狭窄的病例,先行内镜下逆行胰胆管造影及胰管腔内超声检查,确定狭窄长度及距乳头的距离,选择合适的胰管支架,在导丝的引导下,用推送器将支架送到目的部位,然后摄片定位.结果 该组18例安置顺利,支架都超过狭窄的远端,吸引后胰液外流,患者症状很快缓解.结论 胰管支架是治疗各种原因引起的胰管狭窄的有效的姑息治疗措施,对于胰管阻塞的病例能起到缓解症状、提高生活质量的目的,尤其是塑料胰管支架安置及取出较方便,并发症少.     

High complication rate of bile duct stents in patients with chronic alcoholic pancreatitis due to noncompliance

BACKGROUND AND STUDY AIMS: Biliary obstruction in chronic pancreatitis is frequently treated by endoscopic insertion of a plastic stent into the common bile duct, a therapy regarded as having a low complication rate. The aim of this study is to analyze the frequency and severity of complications caused by biliary stents in patients with chronic alcoholic pancreatitis. PATIENTS AND METHODS: We retrospectively analyzed all our patients with chronic pancreatitis (n = 14) who were provided with a plastic stent for biliary stenosis between June 1993 and December 1997. Stent exchanges were followed until December 1998. RESULTS: Stent insertion was performed without early complications and was successful in each patient. Only two patients were admitted after 3-4 months at the scheduled dates for stent exchange, both without complications. In one of these patients, the bile duct stenosis was reopened after two stent exchanges over a total period of 8 months. Most of our patients (n=12) did not come at the arranged dates for stent exchange. They were repeatedly admitted (mean 2.9 times/patient, range 1-5) as emergency cases with severe complications of biliary obstruction, such as cholangitis or biliary sepsis. Reopening of the bile duct stenosis was not achieved in these patients. CONCLUSIONS: We associate the high rate of complications with the noncompliance of our patients, who were all alcoholics. The high incidence of late complications in noncompliant patients is a limitation of biliary stenting, and appears to be potentially harmful.     

Current advances in the management of chronic pancreatitis

Chronic pancreatitis is characterized by irreversible destruction of pancreatic parenchyma and its ductal system resulting from longstanding inflammation, leading to fibrosis and scarring due to genetic, environmental, and other risk factors. The diagnosis of chronic pancreatitis is made based on a combination of clinical features and characteristic findings on computed tomography or magnetic resonance imaging. Abdominal pain is the most common symptom of chronic pancreatitis. The main aim of treatment is to relieve symptoms, prevent disease progression, and manage complications related to chronic pancreatitis. Patients who do not respond to medical treatment or not a candidate for surgical treatment are usually managed with endoscopic therapies. Endoscopic therapies help with symptoms such as abdominal pain and jaundice by decompression of pancreatic and biliary ducts. This review summarizes the risk factors, pathophysiology, diagnostic evaluation, endoscopic treatment of chronic pancreatitis, and complications. We have also reviewed recent advances in endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-guided therapies for pancreatic duct obstruction due to stones, strictures, pancreatic divisum, and biliary strictures.     

Lithotritie extracorporelle d’une lithiase wirsungienne

Lithiasis of Wirsung duct is rare. It usually causes chronic pancreatitis due to obstruction. Because of its morphological and chemical features, its removal by endoscopic retrograde cholangiopancreatography (ERCP) is difficult. Extracorporeal lithotripsy is therefore well indicated.     

Features of ultrasound imaging of chronic pancreatitis in combination with duodenal ulcer

Analysis of ultrasonic scanning images demonstrated that each form of chronic pancreatitis (CP) has its characteristic US features. For example, if CP runs in the presence of duodenal ulcer, the pancreas presents with blurred outline, high parenchymal echogenicity, diffuse structural heterogeneity, short-term visualization of the Wirsung's duct. There were also gastric hypersecretion and signs of fibrosing ductulitis. Biliary and alcoholic CP is characterized by the absence of dynamic changes of the Wirsung's duct diameter.     

GP2, the homologue to the renal cast protein uromodulin, is a major component of intraductal plugs in chronic pancreatitis.

Protein plug obstruction of the pancreatic duct is one of the early events in chronic pancreatitis yet little is known about its pathogenesis. GP2, a protein in the exocrine pancreas, is a glycosyl phosphatidylinositol-anchored protein that is cleaved from the zymogen granule membrane and secreted into pancreatic juice. Since its homologue, uromodulin, is involved in renal cast formation, we asked the question whether GP2 might play a similar role in plug formation in chronic pancreatitis. The protein composition of intraductal plugs from patients with noncalcific chronic pancreatitis was examined. Plugs purified from pancreatic juice obtained by endoscopic cannulation were analyzed by SDS-PAGE. A 97-kD protein was found not only to be a reproducible constituent but also enriched within intraductal plugs. This protein was confirmed as GP2 by its localization to zymogen granule membranes, its isoelectric point, and by Western blotting. Although the pancreatic stone protein was identified in plugs, it was not a major reproducible component. These results demonstrate that GP2 is an integral component of plugs in pancreatic juice and suggest that GP2 may play a role in pancreatic plug formation that is analogous to the role played by uromodulin in the pathogenesis of renal casts.     

Disintegration of a pancreatic duct stone with extracorporeal shock waves in a patient with chronic pancreatitis

We report the case of a 33-year-old woman with chronic calcifying pancreatitis in whom an intraductal pancreatic stone with a diameter of 8 mm was successfully disintegrated with extracorporeal shock waves, permitting subsequent endoscopic extraction of the fragments. The patient had a mild attack of pancreatitis after the treatment. We conclude that shockwave lithotripsy of a pancreatic duct stone in patients with chronic pancreatitis is possible. It should, however, be viewed with reservation until further experience has been gained.     

Risk factors for pancreatitis after pancreatic sphincterotomy: a review of 572 cases

BACKGROUND AND STUDY AIMS: Endoscopic pancreatic sphincterotomy is indispensable for many therapeutic endoscopic maneuvers, but is also associated with a higher risk of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). In this study, this subgroup of patients was investigated in order to identify risk factors and protective factors. PATIENTS AND METHODS: A retrospective chart review identified 572 endoscopic pancreatic sphincterotomies that met the inclusion criteria. Charts were examined for indications, endoscopic technique, and outcomes, including pancreatitis. RESULTS: A total of 477 patients underwent 572 endoscopic pancreatic sphincterotomies during a 5-year period. Indications for sphincterotomy included chronic pancreatitis (n = 398), access for tissue sampling (n = 52), acute recurrent pancreatitis (n = 45), transpapillary drainage of a pancreatic pseudocyst (n = 32), precut access to the common bile duct (n = 29), and others (n = 16). Pancreatic duct drainage was performed in 69.1 % of the procedures (nasopancreatic catheter, n = 290, or pancreatic stent placement, n = 105). Post-ERCP pancreatitis occurred in 69 cases (12.1 %) and was severe in 10. The multivariate analysis identified female sex as being associated with a higher risk of pancreatitis, while an elevated C-reactive protein level, pancreatic ductal stones, sphincterotomy at only the major papilla, and pancreatic duct drainage with a nasopancreatic catheter or stent were associated with a lower risk. CONCLUSIONS: This large series of patients undergoing endoscopic pancreatic sphincterotomy provides further evidence that both patient characteristics and technical factors modify the risk profile for post-ERCP pancreatitis. In addition to providing further definition of which patients are at risk, it also suggests that pancreatic duct drainage is an independently significant protective maneuver.     

Calcifications within the duct of Wirsung in calcific pancreatitis

A review of abdominal radiographs of 50 patients with the clinical diagnosis of chronic pancreatitis showed calcific pancreatitis in 27 patients. Ten patients had severe pain associated with weight loss. Five had obstruction of the duct of Wirsung: one by a pseudocyst and four by large stones near the ampulla of Vater. The radiologic workup presented emphasizes the need to study the duct of Wirsung in patients with chronic pancreatitis to guide the surgical approach for relief of intractable pain. Theories regarding the pathophysiology of calcium deposition and stone formation and migration are reviewed.     

Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline

BACKGROUND AND AIMS: Clarification of the position of the European Society of Gastrointestinal Endoscopy (ESGE) regarding the interventional options available for treating patients with chronic pancreatitis. METHODS: Systematic literature search to answer explicit key questions with levels of evidence serving to determine recommendation grades. The ESGE funded development of the Guideline. SUMMARY OF SELECTED RECOMMENDATIONS: For treating painful uncomplicated chronic pancreatitis, the ESGE recommends extracorporeal shockwave lithotripsy/endoscopic retrograde cholangiopancreatography as the first-line interventional option. The clinical response should be evaluated at 6 - 8 weeks; if it appears unsatisfactory, the patient's case should be discussed again in a multidisciplinary team. Surgical options should be considered, in particular in patients with a predicted poor outcome following endoscopic therapy (Recommendation grade B). For treating chronic pancreatitis associated with radiopaque stones ≥ 5 mm that obstruct the main pancreatic duct, the ESGE recommends extracorporeal shockwave lithotripsy as a first step, combined or not with endoscopic extraction of stone fragments depending on the expertise of the center (Recommendation grade B). For treating chronic pancreatitis associated with a dominant stricture of the main pancreatic duct, the ESGE recommends inserting a single 10-Fr plastic stent, with stent exchange planned within 1 year (Recommendation grade C). In patients with ductal strictures persisting after 12 months of single plastic stenting, the ESGE recommends that available options (e. g., endoscopic placement of multiple pancreatic stents, surgery) be discussed in a multidisciplinary team (Recommendation grade D).For treating uncomplicated chronic pancreatic pseudocysts that are within endoscopic reach, the ESGE recommends endoscopic drainage as a first-line therapy (Recommendation grade A).For treating chronic pancreatitis-related biliary strictures, the choice between endoscopic and surgical therapy should rely on local expertise, patient co-morbidities and expected patient compliance with repeat endoscopic procedures (Recommendation grade D). If endoscopy is elected, the ESGE recommends temporary placement of multiple, side-by-side, plastic biliary stents (Recommendation grade A).     

Successful endoscopic decompression for intramural duodenal hematoma with gastric outlet obstruction complicating acute pancreatitis

Non-traumatic intramural duodenal hematoma (IDH) with duodenal obstruction caused by acute pancreatitis is rare. Most patients with non-extensive hematoma show improvement with non-operative treatments. Percutaneous drainage or surgery may be necessary in cases with suspected malignancy, perforation, or intestinal tract obstruction. We present a case of IDH caused by acute pancreatitis that led to obstruction of the duodenum and an experience of successful endoscopic decompression of the hematoma.     

Pancreatic pseudocyst,pancreatitis, and incomplete pancreas divisum in a child treated with endotherapy: a case report

Pancreatic divisum (PD) is caused by the lack of fusion of the pancreatic duct during the embryonic period. Considering the incidence rate of PD, clinicians lack an understanding of the disease, which is usually asymptomatic. Some patients with PD may experience recurrent pancreatitis and progress to chronic pancreatitis. Recently, a 13-year-old boy presented with pancreatic pseudocyst, recurrent pancreatitis, and incomplete PD, and we report this patient’s clinical data regarding the diagnosis, medical imagining, and treatment. The patient had a history of recurrent pancreatitis and abdominal pain. Magnetic resonance cholangiopancreatography was chosen for diagnosis of PD, pancreatitis, and pancreatic pseudocyst, followed by endoscopic retrograde cholangiopancreatography, minor papillotomy, pancreatic pseudocyst drainage, and stent implantation. In the follow-up, the pseudocyst lesions were completely resolved, and no recurrent pancreatitis has been observed.     

A prospective,randomized trial comparing endoscopic and surgical therapy for chronic pancreatitis

BACKGROUND AND STUDY AIMS: Invasive treatment for abdominal pain due to chronic pancreatitis may be either surgical or endoscopic, particularly in cases of ductal obstruction. To date, the data published on the effectiveness of these two forms of therapy have been mostly retrospective, and there have been no randomized studies. A prospective, randomized study comparing surgery with endoscopy in patients with painful obstructive chronic pancreatitis was therefore conducted. PATIENTS AND METHODS: Consecutive patients with pancreatic duct obstruction and pain were invited to participate in a randomized trial comparing endotherapy and surgery, the latter consisting of resection and drainage procedures, depending on the patient's individual situation. Patients who did not agree to participation and randomization were also further assessed using the same follow-up protocol. RESULTS: Of 140 eligible patients, only 72 agreed to be randomized. Surgery consisted of resection (80 %) and drainage (20 %) procedures, while endotherapy included sphincterotomy and stenting (52 %) and/or stone removal (23 %). In the entire group, the initial success rates were similar for both groups, but at the 5-year follow-up, complete absence of pain was more frequent after surgery (37 % vs. 14 %), with the rate of partial relief being similar (49 % vs. 51 %). In the randomized subgroup, results were similar (pain absence 34 % after surgery vs. 15 % after endotherapy, relief 52 % after surgery vs. 46 % after endotherapy). The increase in body weight was also greater by 20 - 25 % in the surgical group, while new-onset diabetes developed with similar frequency in both groups (34 - 43 %), again with no differences between the results for the whole group and the randomized subgroup. CONCLUSIONS: Surgery is superior to endotherapy for long-term pain reduction in patients with painful obstructive chronic pancreatitis. Better selection of patients for endotherapy may be helpful in order to maximize results. Due to its low degree of invasiveness, however, endotherapy can be offered as a first-line treatment, with surgery being performed in case of failure and/or recurrence.     

Pancreatic and biliary tract disorders in inflammatory bowel disease

Hepatobiliary disorders occur frequently in patients with IBD, with PSC and cholangiocarcinoma being the most clinically significant for endoscopists. Endoscopic therapy for PSC is effective in improving symptoms, biochemical parameters, and radiographic abnormalities. Endoscopic therapy may also confer survival benefit, but this has yet to be confirmed in randomized, controlled trials. Treatment should be restricted to those individuals with a rapid decline in liver function testing or those with recurrent cholangitis. Cholangiocarcinoma is a serious complication of PSC and carries an extremely poor prognosis. ERCP with brush cytology has a relatively low sensitivity and the diagnosis is usually made after the disease has become metastatic. Malignant biliary obstruction can be palliated by endoscopic stenting. Photodynamic therapy is a promising experimental technique that may confer symptomatic and survival benefit in patients with nonresectable, advanced cholangiocarcinoma. IBD patients also have an elevated risk for developing acute and chronic pancreatitis as well as pancreatic insufficiency. The majority of cases of acute pancreatitis are likely due to medication side effects and local structural complications of IBD. The remainder may possibly represent true extraintestinal manifestations of IBD. Chronic pancreatitis is frequently subclinical, but may be accompanied by clinically relevant exocrine insufficiency. ERCP is the test of choice for the diagnosis of chronic pancreatitis, but the role of endoscopy in the therapeutic management of IBD-associated chronic pancreatitis remains to be defined.     

早期内镜胆总管Oddi括约肌切开术治疗急性胆源性胰腺炎

目的：探讨早期内镜胆总管Oddi括约肌切开术(EWT)治疗急性胆源性胰腺炎的临床疗效。方法：对42例经内镜胆总管Oddi括约肌切开术和经内镜鼻胆管引流术(ENBD)等内镜技术治疗的急性胆源性胰腺炎的临床资料进行分析。结果：42例急性胆源性胰腺炎患者，经内镜Oddi括约肌切开后4l例得到治愈，l例先天性胆总管囊肿、胆胰管合流异常的病例在EST和ENBD后病情缓解，但3月后再次发生急性胰腺炎．经胆总管囊肿切除后才治愈。22例急性胆管炎经ENBD后也迅速缓解，26例胆总管结石在EST后结石自行排出或用网蓝取出；20例胆囊结石在胰腺炎治愈后择期行腹腔镜胆囊切除术，消除胰腺炎的诱发因素。结论：内镜治疗直接针对胆源性胰腺炎的发病原因，解除胆胰管开口的梗阻，排除梗阻因素，通畅胆胰液的引流，降低胆胰管内压，起到了良好的治疗作用，有助于防止轻症胰腺炎向重症转化，是临床上治疗胆源性胰腺炎的一种有价值的治疗方法。