Pancreatic sphincterotomy and pancreatic endoprosthesis

Recently, endoscopic sphincterotomy (EST), developed as a treatment of bile duct stone or papillary stenosis, has been used for transpapillary biliary drainage in cases of extrahepatic biliary stenosis. For the nonoperative treatment of chronic pancreatitis, we have developed this procedure into a technique for opening the pancreatic duct orifice. Pancreatic sphincterotomy was performed successfully in 10 out of 13 cases with chronic pancreatitis and improved the clinical symptoms in 9 cases. Moreover, in 3 cases we succeeded in inspecting the intrapancreatic duct by peroral pancreatoscopy, and in removing stones from the main pancreatic duct in 2 cases in this series, using the basket. Also through the opened pancreatic orifice, a pancreatic endoprosthesis was placed endoscopically into the main pancreatic duct in 3 cases to improve pancreatic drainage. This report discusses method, evaluation, and complications of pancreatic sphincterotomy in the endoscopic treatment of chronic pancreatitis, and describes successful cases of the basket removal of pancreatic stones and the placement of pancreatic endoprosthesis through the opening of the pancreatic orifice.     

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.     

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.     

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。     

Treatment of pancreatic pseudocysts, pancreatic necrosis, and pancreatic duct leaks

Pancreatic pseudocysts arise as a complication of acute and chronic pancreatitis or pancreatic trauma (including postsurgical). Pancreatic necrosis occurs following severe pancreatitis and may evolve into an entity termed organized pancreatic necrosis that is endoscopically treatable. Pancreatic duct leaks are frequently seen in relation to pseudocysts and necrosis. Alternatively, pancreatic duct leaks may present with pleural effusions, ascites, or after pancreatic surgery or percutaneous drainage. Endoscopic treatment of pancreatic fluid collections and pancreatic duct leaks can be achieved using transpapillary and/or transmural stent placement.     

Endoscopic management of pancreatic pseudocysts.

Pancreatic pseudocysts occur as a consequence of acute pancreatitis, chronic pancreatitis, or pancreatic trauma. Pseudocysts that are symptomatic, complicated, or enlarging with time can be treated surgically, via percutaneous drainage, or by endoscopic methods. Currently, there are two endoscopic approaches for managing pancreatic pseudocysts: transpapillary and transmural. Endoscopy nurses play an important role in the care of patients before, during, and after an endoscopic drainage procedure. This article reviews the indications, techniques, potential complications, limitations, and nursing care involved in endoscopic management of pancreatic pseudocysts.     

Endoscopic management of pancreatic pseudocyst: a long-term follow-up

BACKGROUND AND STUDY AIMS: No studies with real long-term follow-up after endoscopic drainage of pancreatic pseudocysts are available. The present study was undertaken to investigate the long-term outcome of endoscopic management of pancreatic pseudocyst with a minimum follow-up of 2 years. PATIENTS AND METHODS: A total of 38 consecutive patients with pancreatic pseudocyst underwent endoscopic cystogastrostomy (n = 27), endoscopic cystoduodenostomy (n = 6) and transpapillary drainage (n = 5). Patients were monitored at 1 and 3 months after drainage, and finally between 24 and 80 months. Upper gastrointestinal endoscopy was done at 1 and 3 months after drainage while ultrasound was done at 3 months and at the end of follow-up. Endoscopic retrograde cholangiopancreatography (ERCP) was only done before cyst drainage if no cyst bulge was visible in the stomach or duodenum or if obstructive jaundice was present. RESULTS: Biliary pancreatitis was responsible for the pseudocyst in 19 cases while the remaining occurrences were caused by alcohol (n = 12) and trauma (n = 7). All forms of endoscopic drainage were effective in treating pancreatic pseudocyst and there was complete disappearance of the cyst within 3 months of drainage, irrespective of cause. Over a mean follow-up of 44.23 months (24 - 80 months). Three patients had symptomatic recurrences while three had asymptomatic recurrences; all had alcohol-induced pancreatitis. No recurrences were seen in the biliary pancreatitis and trauma group. All symptomatic recurrences were successfully managed with endoscopic cystogastrostomy and stenting. A massive bleed in one patient required surgery while stent block and cyst infection in three patients and perforation in one patient were managed conservatively. ERCP was done before cyst drainage in eight patients because there was no visible bulge into the stomach or duodenum (n = 5), or because obstructive jaundice was present (n = 3). In five patients ERCP revealed cyst duct communication. All these patients were managed by transpapillary drainage and there was only one asymptomatic recurrence in this group. CONCLUSION: Endoscopic management of pancreatic pseudocyst is quite an effective and safe mode of treatment in experienced hands. ERCP before the procedure is only required when the cyst does not bulge into gut lumen, for a decision about the feasibility of transpancreatic drainage. On long-term follow-up, recurrences were seen only in the alcoholic pancreatitis group. In the biliary pancreatitis group, no recurrences were seen after cholecystectomy and removal of common bile duct (CBD) stones if present. No recurrences were seen in the trauma group.     

Management of the late effects of disconnected pancreatic duct syndrome: A case report

BACKGROUND There have been few reports about the late effects of disconnected pancreatic duct syndrome(DPDS). Although few reports have described the recurrence interval of pancreatitis, it might be rare for recurrence to occur more than 5 years later.Herein, we describe a case of recurrence in an 81-year-old man after the treatment of walled-off necrosis(WON) with pancreatic transection 7 years ago.CASE SUMMARY An 81-year-old man visited our hospital with chief complaints of fever and abdominal pain 7 years after the onset of WON due to severe necrotic pancreatitis. His medical history included an abdominal aortic aneurysm(AAA),hypertension, dyslipidemia, and chronic kidney disease. Computed tomography(CT) scan showed that the pancreatic fluid collection(PFC) had spread to the aorta with inflammation surrounding it, and CT findings suggested that bleeding occurred from the vasodilation due to splenic vein occlusion. First, we attempted to perform transpapillary drainage because of venous dilation around the residual stomach and the PFC. However, pancreatic duct drainage failed because of complete main pancreatic duct disruption. Second, we performed endoscopic ultrasound-guided drainage. After transmural drainage, the inflammation improved and stenting for the AAA was performed successfully. The inflammation was resolved, and he has been free from infection for more than 2 years after the procedure.CONCLUSION This case highlights the importance of continued follow-up of patients for recurrence after the treatment of WON with pancreatic transection.     

Pancreatic endoscopic sphincterotomy in patients with chronic pancreatitis: a single-center experience in 171 consecutive patients

BACKGROUND AND STUDY AIMS: In recent years, interest in endoscopic therapy techniques for pancreatic diseases has been constantly increasing. The aim of the present study was to assess the technical success, technique, and complications of endoscopic pancreatic sphincterotomy (EPS) in patients with chronic pancreatitis. PATIENTS AND METHODS: A total of 171 patients with chronic pancreatitis and abdominal complaints were identified in whom at least one attempt at EPS was carried out. During the procedure, sphincterotomy was carried out using a guide-wire sphincterotome or a needle-knife papillotome. Patients were followed up after EPS for at least 24 h, including clinical symptoms and laboratory data (pancreatic enzymes and hemoglobin/hematocrit). RESULTS: EPS was performed in 167 of the 171 patients (technical success rate: 97.7 %). In 24 patients (14 %), a precut technique was necessary using a needle-knife sphincterotome. Sphincterotomy-related complications were observed in seven of the 171 patients (4.1 %), including three cases of bleeding, three patients with mild pancreatitis, and one with retroduodenal perforation. All complications were managed medically. There was no treatment-related mortality. CONCLUSIONS: Endoscopic sphincterotomy of the pancreatic duct in patients with chronic pancreatitis is a fairly safe procedure with a high technical success rate.     

Usefulness of Intraductal Ultrasonography in the Diagnosis of Cholangiocarcinoma and IgG4-Related Sclerosing Cholangitis

The technique of intraductal ultrasonography (IDUS) of the bile duct with a thin-caliber probe and a ropeway system has provided excellent images of the bile duct and periductal structures and is an easy transpapillary approach. In addition, once the guide wire is inserted into the bile duct, IDUS and transpapillary biopsy after endoscopic retrograde cholangiopancreatography can be performed in a single session. Here, we review the usefulness of IDUS in the diagnosis of cholangiocarcinoma and IgG4-related sclerosing cholangitis.     

Endoscopic management of pancreatic pseudocysts

Recently, endoscopic interventional procedures were introduced for nonsurgical therapy of symptomatic pancreas pseudocysts. We reported 25 patients treated by endoscopic retrograde pancreas drainage (ERPD), endoscopic cystogastrostomy (ECG), or endosopic cystoduodenostomy (ECD).ERPD was performed in 9 patients by placement of a 5 Fr. or 7 Fr. endoprosthesis transpapillary into the cyst or the main pancreatic duct. ECG was carried out in 10 cases, in 7 of these, a double pigtail catheter was additionally inserted. Three patients suffering from pseudocysts of the pancreas head were treated by ECD. In a further 3 cases, ERPD and ECG were combined.All patients reported a dramatic reduction of pain with a simultaneous increase of appetite and body weight. The drainage tubes were removed after disappearance of symptoms, and abnormal clinical and endoscopic findings within 2 to 12 months. In 4 cases, a recurrence of the cyst was found 10 and 22 months later, in 3 cases the endoprostheses had to be renewed because of catheter occlusion or dislocation. 2 patient underwent surgical treatment after insufficient endoscopic drainage due to haemorrhage or recurrence.Endoscopic treatment of pancreatic pseudocysts yielded good results with low rates of recurrence and complications. According to our experiences we think endoscopic interventional techniques will oust surgery from its present dominant position in the next years.     

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.     

EUS-guided biliary drainage with placement of a new partially covered biliary stent for palliation of malignant biliary obstruction: a case series

Endoscopic ultrasonography-guided biliary drainage (EUS-BD) has been developed as an alternative drainage technique in patients with obstructive jaundice where endoscopic retrograde cholangiopancreatography (ERCP) has failed. Between July 2008 and December 2009, 16 patients (9 men; median age 79 years) with biliopancreatic malignancy, who were candidates for alternative techniques of biliary decompression because ERCP had been unsuccessful, underwent EUS-BD with placement of a transmural or transpapillary partially covered nitinol self-expandable metal stent (SEMS). EUS-assisted cholangiography was successful in all patients, with definition of the relevant anatomy, but biliary drainage was successfully performed in only 12 (75?%) of the 16 patients (9 choledochoduodenostomies with SEMS placement and 3 biliary rendezvous procedures with papillary SEMS placement), with regression of the cholestasis. No major complications and no procedure-related deaths occurred. There was one case of pneumoperitoneum which was managed conservatively. The median follow-up was 170 days. During the follow-up, eight patients of the 12 patients in whom biliary draining was successful died; four are currently alive. None of the patients required endoscopic reintervention. This series demonstrated that EUS-BD with a partially covered SEMS has a high rate of clinical success and low complication rates, and could represent an alternative choice for biliary decompression.     

Combined endoscopy/laparoscopy/percutaneous transhepatic biliary drainage,hybrid techniques in gastrointestinal and biliary diseases

In recent years, a wide range of gastrointestinal endoscopy techniques have been developed, such as endoscopic submucosal dissection (ESD) and endoscopic retrograde cholangiopancreatography (ERCP). Although ESD and ERCP have an important role in gastrointestinal and biliary diseases, each technique has its limitations. Hybrid techniques that combine endoscopic and surgical procedures have emerged that have the advantages of different procedures and negate their limitations at the same time. Laparoscopic endoscopic cooperative surgery and modified laparoscopic endoscopic cooperative surgery combine ESD and laparoscopic techniques to resect submucosal tumors with minimum resection area. Air leak test by intraoperative endoscopy can effectively identify a mechanically insufficient anastomosis and decrease the complication rate. The rendezvous technique that combines percutaneous transhepatic biliary drainage and endoscopy can be performed as a rescue approach for the treatment of biliary obstruction, stenosis and bile duct injuries. For patients with simultaneous presence of stones in the gallbladder and the common bile duct, the laparo-endoscopic rendezvous technique can perform ERCP and laparoscopic cholecystectomy at the same time and reduces the risk of pancreatic injury caused by ERCP. Biliobiliary and bilioenteric anastomosis using magnetic compression anastomosis is another choice for biliary obstruction. The most common used approach to deliver the magnets is by percutaneous-peroral tract. Laparoscopic-assisted ERCP is a safe and highly effective therapy for patients who develop biliary diseases after Roux-en-Y gastric bypass surgery.     

Indications et choix de technique de drainage en cas de pancréatite aiguë grave ?

Definition of severe acute pancreatitis includes organ failure or/and pancreatic or peripancreatic fluid collections. Three types of emergency drainage can be discussed in such a situation: Biliary drainage by early endoscopic sphincterotomy, transpapillary endoscopic drainage in case of early pancreatic fistula, and peripancreatic fluid collections drainage using four different approaches (percutaneous radiologic drainage, retroperitoneal drainage by surgical laparoscopy, transgastric or transduodenal endoscopic drainage and open surgical necrosectomy). The purpose of this mini-review is to focus on the current indications and choices of these different types of drainage approach.     

Therapeutic pancreatic endoscopy

A number of endoscopic interventions have expanded the range of treatment options in symptomatic pancreatic diseases. Early endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) appear to be beneficial in patients with severe acute biliary pancreatitis. Endoscopic pancreatic sphincterotomy can be safely performed with high technical success rates in patients with chronic pancreatitis. Routine additional biliary ES or drainage procedures are not apparently necessary. Stenting can be limited to the treatment of dominant pancreatic duct strictures. In patients with sphincter of Oddi dysfunction, temporary placement of pancreatic stents reduces the morbidity associated with ES. Transpapillary or transmural endoscopic drainage achieves resolution of pancreatic pseudocysts in the majority of selected patients. Drainage procedures with endoscopic ultrasound guidance can potentially expand the indications and reduce the procedure-related morbidity. Therapeutic endoscopy should be considered in symptomatic patients with pancreas divisum, as well as in selected children with pancreatic diseases. Most of the published studies on therapeutic pancreatic endoscopy have been conducted retrospectively. Additional prospective controlled trials are warranted to allow further evaluation of the impact of these methods on the clinical outcome in comparison with alternative treatment strategies.     

Transpapillary miniscopy and mini-biopsy of the pancreatic duct

This paper reports on the new combined examination of peroral transpapillary fine-caliber endoscopy (miniscope 0.5 mm in diameter) with mini-biopsy of the pancreatic duct in 10 patients and 19 surgical pancreas resection preparations. With this technique, endoscopic-retrograde inspection of the whole length of the pancreatic duct is possible without the need for papillotomy. In the case of pancreatic duct changes due to carcinoma of the pancreas, and chronic pancreatitis, the ductal lesions can be inspected. Furthermore, with the aid of a new mini-biopsy forceps (1.5 mm in diameter), material for histological evaluation can be much more efficiently obtained than was normally possible with conventional biopsy forceps (2.2 mm). This new endoscopic-bioptic technique promises to improve the diagnostic reliability in pancreatic duct lesions requiring clarification.     

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.     

Endoscopic transpapillary gallbladder drainage for management of acute cholecystitis with coagulopathy

Acute cholecystitis is a common and frequently occurring disease, and laparoscopic cholecystectomy is the preferred treatment method. Percutaneous transhepatic gallbladder drainage is regarded as the first-line palliative procedure for elderly patients with poor cardiopulmonary function who cannot tolerate general anesthesia. However, for patients with acute cholecystitis who are undergoing treatment with oral antithrombotics or who have abnormal coagulation mechanisms, endoscopic transpapillary gallbladder drainage may be a good choice. Endoscopic transpapillary gallbladder drainage is an endoscopic retrograde cholangiopancreatography-based technique that drains the gallbladder by placing a tube into the cavity of the gallbladder though the cystic gall duct. It is the application of the concept of natural orifice transluminal endoscopic surgery in the biliary system. This technique can not only achieve gallbladder drainage but can also minimize the risk of procedure-induced bleeding. In this paper, we describe a representative case to introduce the key points of this procedure and the associated clinical care, hoping to provide useful information for clinicians and nurses.     

Magnetic resonance pancreatography (MRP)

Magnetic resonance pancreatography (MRP) is a technique that permits accurate evaluation of the pancreatic duct without instrumentation, contrast material administration, or ionizing radiation. Because MRP is entirely noninvasive, MRP avoids complications associated with endoscopic retrograde pancreatography (ERP) such as pancreatitis and perforation. MRP allows for the noninvasive evaluation of patients with acute and chronic pancreatitis, variant anatomy of the pancreatic duct, pancreatic duct trauma, and pancreatic neoplasia. MRP yields diagnostic information in the setting of a failed or incomplete ERP. When MRP is performed in conjunction with conventional abdominal MR, the result is a comprehensive examination of the pancreatic duct as well as the pancreas and other solid organs of the abdomen.