Endoscopic pancreatic sphincter balloon dilation for effective retrieval of pancreatic duct stone

To facilitate pancreatic stone retrieval, four patients with chronic pancreatitis and pancreatic stones underwent endoscopic pancreatic sphincter balloon dilation (EPSBD) rather than pancreatic sphincterotomy. Extracorporeal shock wave lithotripsy combined with endoscopic removal was carried out in three patients. Stone removal following EPSBD was completely successful in all four patients. Patients showed no severe complications during the dilation procedure. In one patient, to prevent pancreatitis, an endoscopic nasopancreatic drain was placed for 1 week after EPSBD. Compared with pancreatic sphincterotomy, EPSBD can be performed safely in patients with chronic pancreatitis to assist in the extraction of pancreatic duct stones. Use of the EPSBD procedure in cases of chronic pancreatitis provides a useful approach to improve endoscopic clearance of pancreatic duct stones.     

Pancreatic intubation by endoscopy in chronic calcifying pancreatitis]

BACKGROUND: The aim of our study was to assess the efficacy of endoscopic pancreatic stenting on pain and frequency of acute pancreatitis in patients with calcifying chronic pancreatitis. PATIENTS: Between 1987 and 1996, 70 patients underwent endoscopic management for calcifying chronic pancreatitis. RESULTS: Endoscopic stent placement was successful in 59 patients (85%). 46 patients were followed for a mean duration of 29 +/- 26.4 months after stent removal. The presence of pancreatic pseudocysts in 26 patients appeared to modify pain improvement rate but did not influence the decrease in the frequency of acute pancreatitis. An improvement of pancreatic pain occurred at the end of stenting and after removal of the stent in respectively 44% and 38% of the patients without pseudocysts and in 85% (P < 0.02) and 65% of the patients presenting with pancreatic pseudocysts. Before stenting, 43/70 (61%) patients had at least two episodes of acute pancreatitis. After removal of the stent, only 5/46 (11%) had one episode of acute pancreatitis. Improvement of weight loss and diabetes was observed in respectively 28 cases (52%), 7 cases (39%) at the end of pancreatic stenting and was still persisting in 21 (51%) and 5 cases (26%) after removal of the stent. CONCLUSION: After pancreatic stenting, the improvement of pain appears to be moderate in the absence of pancreatic pseudocyst. Nevertheless, the improvement of pain is maintained after stent removal. Moreover, the frequency of acute pancreatitis is significantly decreased after pancreatic stenting.     

ENDOSCOPIC PANCREATIC SPHINCTEROTOMY PLUS LARGE‐BALLOON DILATION FOR REMOVAL OF A LARGE IMPACTED PANCREATIC DUCT STONE (WITH VIDEO)

Pancreatic duct stones are a common complication of chronic pancreatitis. We describe successful endoscopic removal of a large pancreatic duct stone using large‐balloon dilation in combination with pancreatic sphincterotomy. A 63‐year‐old woman was admitted for endoscopic treatment of acute on chronic pancreatitis with diabetes and epigastric pain with liver dysfunction due to a large impacted stone within the distal main pancreatic duct. Endoscopic pancreatic sphincterotomy was carried out using a wire‐guided pull‐type sphincterotome. Although we could carry out a relatively large incision, the stone could not be extracted. We therefore carried out papillary dilation using a large balloon (diameter 12 to 15 mm) to make room alongside the stone. A 10 × 20‐mm white pancreatic duct stone was extracted during the process of pulling a dilating balloon into the working channel of the endoscope. Eventually, the second stone was removed without any procedure‐related complication.     

Evaluation of Cancer-Associated Carbohydrate Antigen (NCC-ST-439) Measurement in Pure Pancreatic Juice Collected by Endoscopic Aspiration

Abstract: This study was undertaken to elucidate the diagnostic significance of the measurement of a cancer-associated carbohydrate antigen, NCC-ST-439 (ST-439), in pure pancreatic juice collected by endoscopic cannulation, chiefly from patients with pancreatic diseases. The mean concentrations of ST-439 in each of the 4 fractions collected were significantly higher in patients with pancreatic cancer than in controls, but patients with chronic pancreatitis or cholecystolithiasis did not have higher levels. Similarly, a significant increase in the mean output of ST-439 was observed only in patients with pancreatic cancer. When the cut-of value was set at the mean concentration+ 2 X the standard deviations of the controls, significant concentrations of ST-439 were found, in the first fraction (washout phase) in 56% of the pancreatic cancer cases, 31% of the chronic pancreatitis cases and 0% of the cholecystolithiasis cases; in the third fraction (secretory phase) results were 50%, 7% and 0%, respectively. Furthermore, when the cut-of value was set at the highest concentration found among patients with chronic pancreatitis (to enhance the specificity for pancreatic cancer), the prevalence of significant ST-339 levels among Pancreatic cancer patients was 50% in the first fraction and 44% in the third fraction. These results indicate that the measurement of ST-439 in pancreatic juice is useful as a specific marker for pancreatic cancer, although its sensitivity is less than was initially hoped,     

Long-term results of endoscopic management of pancreas divisum with recurrent acute pancreatitis

BACKGROUND: The long-term efficacy of endoscopic treatment in pancreas divisum is controversial. This study evaluated the long-term results of dorsal duct stent insertion and endoscopic sphincterotomy of the minor papilla in patients presenting with recurrent acute pancreatitis or chronic pain. METHODS: Pancreas divisum was diagnosed in 175 patients between 1980 and 1998. Twenty-four patients seen with recurrent acute pancreatitis without underlying chronic calcifying pancreatitis or significant alcohol consumption were included in this study with a follow-up of at least 24 months. Eight were treated by sphincterotomy of the minor papilla alone, and 16 underwent dorsal duct stent insertion for a median duration of 8 months. RESULTS: The median duration of follow-up after endoscopic management was 39 months (range 24-105; interquartile range 40.5). All patients had recurrent acute pancreatitis before endoscopic treatment during a median period of 5 years. At the end of the follow-up there were only 2 recurrences of acute pancreatitis (p < 0.01). The number of patients with chronic pain before endoscopic treatment and at the end of follow-up decreased from 20 of 24 (83%) to 7 of 24 (29%) without reaching statistical significance. The 25% recurrence rate was estimated at 50 months by Kaplan-Meier analysis. Nine patients presented with a dilated dorsal duct before endoscopic treatment. After stent insertion, dorsal duct dilatation appeared in all 16 patients who underwent stent placement, and pancreatic duct stenosis developed in 3. Four patients (19%) required further treatment for pain recurrence or acute pancreatitis, with surgical procedures being performed in 2 cases. Complications occurred in 9 of 24 patients (38%), mainly acute pancreatitis or stenosis of the minor papilla. All complications except one were managed conservatively. Complications seemed to be less frequent after minor papilla sphincterotomy than after pancreatic stent insertion (25% vs. 44%). CONCLUSION: In patients with pancreas divisum, both dorsal duct stent insertion and minor papilla sphincterotomy decrease the rate of recurrent acute pancreatitis, whereas relief of chronic pain was less obvious.     

Measurement of sialylated stage-specific embryonic antigen-1 in pure pancreatic juice for the diagnosis of pancreatic cancer

The diagnostic significance of measuring sialylated stage-specific embryonic antigen-1 (SLX) in pure pancreatic juice was evaluated in 20 patients with pancreatic cancer, 43 with chronic pancreatitis, 13 with cholecystolithiasis, and 15 control individuals. Four fractions of pure pancreatic juice were collected sequentially from the pancreatic duct by endoscopic cannulation. The SLX levels in all four fractions of pure pancreatic juice were significantly higher in patients with pancreatic cancer than in controls. On the other hand, patients with chronic pancreatitis or cholecystolithiasis did not have SLX levels that significantly differed from those of controls in any fraction. When the cut-off value was set as the mean concentration + 2 times the standard deviation of the control values, the positive rates of SLX in the first fraction (washout phase) and the third fraction (secretory phase) of pure pancreatic juice from pancreatic cancer were 55% (11/20) and 40% (8/20), respectively. Although the false positive rates in the first fraction were high in chronic pancreatitis (30%) and cholecystolithiasis (31%), such high SLX levels in the third fraction were found only in one (2%) patient with chronic pancreatitis and in one (8%) with cholecystolithiasis. The specificities of the test for pancreatic cancer in the first fraction and the third fraction were 70% (39/56) and 96% (54/56), respectively. These results indicate that the measurement of SLX in the third fraction of pure pancreatic juice is useful as a specific marker for pancreatic cancer.     

What are the long-term results of endoscopic pancreatic sphincterotomy?

BACKGROUND: Endoscopic pancreatic sphincterotomy has been touted as effective therapy for chronic pancreatitis and unexplained abdominal pain resulting from pancreatic sphincter dysfunction. Although short-term data are encouraging, there are no reports on how these patients fare beyond the first few months. METHODS: We performed a retrospective review of records on all patients who had pancreatic sphincterotomy during a 4-year period between August 1992 and November 1996. Chronic pancreatitis was diagnosed by pancreatography. Patients were evaluated for symptomatic response to pancreatic sphincterotomy and clinical improvement was defined as greater than 50% reduction in the magnitude of pain. RESULTS: Fifty-five patients had pancreatic sphincterotomy including patients with (n = 40) and without (n = 15) chronic pancreatitis. After a median follow-up of 16 months, 60% of all patients reported improvement of pain scores (3.6 +/- 3.4 vs. 8.8 +/- 1.8; p < 0.01) with the best response in patients without evidence of chronic pancreatitis. Complications of pancreatic sphincterotomy included pancreatitis in 5 patients (9%), bleeding in 2 (3.6%) and early stent occlusion in 5 patients (9%). There were no deaths. CONCLUSIONS: In a subgroup of patients with pancreatic sphincter dysfunction, endoscopic pancreatic sphincterotomy results in significant sustained clinical improvement.     

Pancreatic cysts and pseudocysts associated with acute and chronic pancreatitis

We reviewed 106 consecutive patients with cysts or pseudocysts of the pancreas associated with pancreatitis. A pancreatic fluid collection (PFC) was defined as a limited collection containing pancreatic juice either pure or with pus or blood. Seventy-seven patients presented with chronic pancreatitis (CP) and 29 patients presented with acute pancreatitis (AP). CP-associated PFC was observed in young alcoholic men (mean age 40.8 years) on a high fat, protein, and carbohydrate diet. None of this group had gallstones. In this population, PFC was located in the head of the pancreas in 68% of the cases, was partly extrapancreatic in 22% of the cases, and resolved spontaneously in 9%. AP- associated PFC was as frequent in nonalcoholic men as in nonalcoholic women and presented with gallstones in 48%. They developed later (mean age 53.0 years), resolved spontaneously in 20%, and were located in the body or tail of the gland in 69%. CP-PFC may be designated retention cysts or retention pseudocysts (extrapancreatic); AP-PFC may be designated necrotic pseudocysts.     

Endotherapy for pain in chronic pancreatitis

Pain is the most distressing symptom of chronic pancreatitis. Although the pathogenesis of pain is still poorly understood, an increase in intraductal pressure may be the dominant factor. The management of pain can involve medical, endoscopic, neurolytic, and surgical therapies. Endotherapy includes pancreatic sphincterotomy, extraction of stones, placement of stent, and dilatation of strictures, sometimes preceded or followed by extracorporeal shock‐wave lithotripsy. Several studies have now shown that endotherapy provides partial or complete relief of pancreatic pain in a majority of patients with an acceptable frequency of early and late complications. Endotherapy should now graduate from an experimental form of treatment to a realistic treatment option in patients with chronic or relapsing pain, particularly in the setting of calcific chronic pancreatitis.     

内窥镜逆行胰胆管造影术对胰腺分裂症的诊断、治疗价值研究

目的:探讨内窥镜逆行胰胆管造影术(ERCP)对胰腺分裂症(PD)的诊断、治疗方法及其效果的价值。方法:回顾性分析本院2008年6月至2012年9月明确诊断的20例PD患者的临床表现、诊断及治疗方法,比较治疗前后患者的体重变化,用直观模拟标度尺(VAS)评分来评估腹痛症状改善的情况。结果:患者症状以腹痛为主,急性胰腺炎或慢性胰腺炎急性发作的发生率为75%。经ERCP确诊的患者中,磁共振胆胰管成像(MRCP)的检出率为24%。内镜下治疗包括行内镜下十二指肠主和(或)副乳头切开引流(95%)、胰管支架置入(65%)及鼻胰管引流(55%)。治疗后患者体重增加(P<0.05),疼痛VAS评分下降(P<0.05)。结论:PD患者主要症状为腹痛,急性胰腺炎或慢性胰腺炎急性发作的发生率较高,内镜下治疗可有效减少PD患者腹痛的程度并增加患者体重。     

Comparison of the Secretin Stimulated Endoscopic Pancreatic Function Test to Retrograde Pancreatogram

Duodenal intubation techniques with hormonal stimulation are the most accurate at diagnosing early chronic pancreatitis. Pancreatography (ERCP), the radiologic gold standard, can accurately diagnose chronic pancreatitis, but is expensive, may expose the patient to radiation, and/or induce acute pancreatitis. We have developed an endoscopic pancreatic function test (ePFT) that can assess pancreatic secretory function during upper endoscopy. We sought to determine the accuracy of the endoscopic secretin pancreatic function test using retrograde pancreatogram as the gold standard. Patients referred to The Pancreas Clinic for the evaluation and management of chronic abdominal pain and suspected chronic pancreatitis who had both endoscopic function testing and pancreatic duct imaging (ERCP) were studied. Pancreatograms were scored for duct morphologic characteristics (Cambridge classification) and compared to peak bicarbonate concentration in secretin stimulated duodenal juice. The ePFT consisted of a test dose of intravenous synthetic porcine secretin (0.2 microg), full-dose intravenous secretin (0.2 microg/kg) over 1 min, (3) upper endoscopy with moderate sedation, (4) gastric fluid aspirated and discarded, (5) duodenal fluid aspirations at 0, 15, 45, and 60 min after secretin injection, and (6) fluid analysis with lab autoanalyzer for bicarbonate concentration (historical normal cutpoint >80 mEq/L). Thirty-six patients had both the endoscopic function test and ERCP. Seventeen had chronic abdominal pain with normal pancreatograms, and nineteen had chronic abdominal pain with abnormal pancreatograms, consistent with chronic pancreatitis. The sensitivity and specificity of the endoscopic function test were 94% and 79%, respectively. The positive and negative predictive values were 80% and 94%, respectively. Overall agreement with ERCP was 86%. The ePFT with synthetic porcine secretin has excellent correlation with abnormal pancreatogram (chronic pancreatitis). Furthermore, a normal bicarbonate (negative function test, HCO(3) >80 mEq/L) essentially rules out chronic pancreatitis as a diagnostic cause of abdominal pain. Endoscopic pancreatic function testing may decrease the need for ERCP in patients with chronic abdominal pain.     

Pancreatic sphincterotomy： Technique, indications, and complications

Pancreatic sphincterotomy serves as the cornerstone of endoscopic therapy of the pancreas. Historically, its indications have been less well-defined than those of endoscopic biliary sphincterotomy, yet it plays a definite and useful role in diseases such as chronic pancreatitis and pancreatic-type sphincter of Oddi dysfunction. In the appropriate setting, it may be used as a single therapeutic maneuver, or in conjunction with other endoscopic techniques such as pancreatic stone extraction or stent placement. The current standard of practice utilizes two different methods of performing pancreatic sphincterotomy： a pull-type sphincterotome technique without prior stent placement, and a needleknife sphincterotome technique over an existing stent. The complications associated with pancreatic sphincterotomy are many, although acute pancreatitis appears to be the most common and the most serious of the early complications. As such, it continues to be reserved for those endoscopists who perform a relatively high-volume of therapeutic pancreaticobiliary endoscopic retrograde chola ngio-pancreatography.     

Morphological advantages of endoscopic treatment in obstructive chronic pancreatitis

Backgroundand study aims: Chronic pancreatitis is associated with recurrent or persistent abdominal pain over the course of the disease. Ductal hypertension showing obstructed and dilated pancreatic duct has been suggested as a major factor in the mechanism of pain in chronic pancreatitis. Many studies investigating pain relief after endoscopic treatment of pancreatic duct (PD) are available, but the number of studies regarding the morphological changes to pancreas such as changes in PD caliber, pancreatic parenchyma, and especially pancreatic volume is far fewer. As such, we analyzed the changes of ductal caliber and parenchymal volume after endoscopic treatment of PD in patients with obstructive chronic pancreatitis.Patients and methodsIn this retrospective study, we compared two groups of patients with obstructive chronic pancreatitis that either received endoscopic management of PD or conservative treatment without such endoscopic management. After we obtained age, sex, etiology of chronic pancreatitis, diabetic status, smoking and alcohol abuse status from the database, we compared the incidence for changes in pancreatic parenchymal volume and PD caliber between two groups.ResultIn our study population, total of 480 patients was diagnosed with chronic pancreatitis between January 2006 and December 2016, and 166 (34.5%) of these patients were diagnosed with obstructive chronic pancreatitis with obstructed and dilated PD. After reviewing the population with the exclusion criteria, 71 patients were available for the final analysis. 28 of those patient received endoscopic treatment of pancreatic duct and 43 received conservative treatment without any endoscopic treatment of PD. Statistical analysis with Cox proportional hazards models showed that diabetes and endoscopic PD management were significant predictors for progression of PD caliber and in pancreatic parenchyma, and that only PD management influenced the pancreatic volume loss.ConclusionEndoscopic management of PD in obstructive chronic pancreatitis have advantages on morphologic change such as pancreatic volume loss and progression of PD caliber in long follow-up period.     

Pharmacological treatment of non-alcoholic steatohepatitis: The current evidence

¹²⁵I-protein-radioiodinated pure pancreatic juice samples from patients with adenocarcinoma of the pancreas, chronic pancreatitis, or intact pancreas were analysed by high-resolution SDS-polyacrylamide gel electrophoresis and subsequent autoradiography. Experiments resulted in the detection of a 180K protein, probably a glycoprotein, in the pure pancreatic juice from pancreatic carcinoma (93%) and chronic pancreatitis (73%) patients, which was completely absent from pancreatic juice from intact pancreas. Sephadex G-200-isolated 18UK protein was found to be different from carcinoembryonic antigen (CEA) when traced by a commercial CEA radioimmunoassay, but it seemed identical in pancreatic juice samples from patients with pancreatic carcinoma and chronic pancreatitis, at least with regard to isoelectric point. In brief, the present results suggest that 180K protein identification in pancreatic juice permits adenocarcinoma of the pancreas and chronic pancreatitis to be differentiated from normal conditions but that distinction between pancreatic carcinoma and chronic pancreatitis is unlikely.     

Pancreatic duct drainage in chronic pancreatitis.

Pancreatic duct drainage is an effective method of dealing with many of the surgical complications of chronic pancreatitis without sacrificing pancreatic endocrine or exocrine function. Between 65 and 90% of patients with intractable pain of chronic pancreatitis and a dilated pancreatic duct will have substantial pain relief with complete ductal drainage by a lateral pancreaticojejunostomy. The mortality of this procedure ranges from 0 to 5%. In spite of operation, late mortality of this disease remains high with 1/3 to 1/2 of patients dying within 10 years. Fixed biliary tract obstruction and upper gastrointestinal obstruction can also complicate chronic pancreatitis. We have combined drainage of the common bile duct and stomach with pancreaticojejunostomy to deal with these problems and have found no increase in morbidity or mortality. Pseudocysts occur more frequently in patients with chronic pancreatitis. We have also combined pseudocyst drainage with lateral pancreaticojejunostomy in 26 patients having both pseudocysts and chronic pancreatitis. These patients achieve the same degree of pain relief noted in patients undergoing lateral pancreaticojejunostomy alone without any increase in morbidity or mortality. Drainage procedures are safe and effective and are our preferred method of dealing with obstructive complications of chronic pancreatitis.     

Peroral Micro-Pancreatoscopy (PMPS) for the Diagnosis of Pancreatic Diseases

In order to observe the inside of the main pancreatic duct endoscopically, we have performed pancreatoscopy using a microfiberscope with an external diameter of 0.75 mm which was inserted even into the undilated duct via a canula for ERCP without papillotomy. The peroral micro-pancreatoscopy (PMPS) was carried out on 38 patients (16 cases of tumor, 21 of chronic pancreatitis and 1 of a cyst) and was successful in 33 patients (87%). In patients with cancer, rough elevation, redness, bleeding, or ulceration were recognized on the mucosa of the stenotic and the obstructed duct. In chronic pancreatitis, protein plugs were most frequently observed floating in the juice or attached to the ductal wall; some stones were also found in two patients. PMPS is one of the most useful techniques for the diagnosis of the earlier stages of pancreatic diseases.     

Dilation of refractory pancreatic duct strictures: the turn of the screw

BACKGROUND: Endoscopic pancreatic ductal drainage may improve pain from chronic pancreatitis but stricture dilation may be technically difficult. METHODS: Eight patients with refractory pancreatic strictures had dilation with a Soehendra stent retriever. Each had sphincterotomy, guidewire placement, stent retriever dilation to 7F to 10F, and stenting for 6 to 12 months. RESULTS: All procedures were successful and 1 (13%) was complicated by mild pancreatitis. The mean follow-up was 21 months. Each patient had substantial pain relief with patent stents in place, but 7 (88%) relapsed with stent occlusion or removal. Four (50%) patients underwent surgery with excellent results. However, endoscopic therapy alone resulted in just modest benefits or pain recurrence in 3 (38%) and persistent relief in only 1 (13%). CONCLUSIONS: The Soehendra stent retriever is effective as a dilating device for pancreatic strictures resistant to conventional dilation. However, substantial symptom relief may persist only while patent stents are in place.     

Management of Pancreatic Calculi: An Update

Pancreatolithiasis, or pancreatic calculi (PC), is a sequel of chronic pancreatitis (CP) and may occur in the main ducts, side branches or parenchyma. Calculi are the end result, irrespective of the etiology of CP. PC contains an inner nidus surrounded by successive layers of calcium carbonate. These calculi obstruct the pancreatic ducts and produce ductal hypertension, which leads to pain, the cardinal feature of CP. Both endoscopic therapy and surgery aim to clear these calculi and decrease ductal hypertension. In small PC, endoscopic retrograde cholangiopancreatography (ERCP) followed by sphincterotomy and extraction is the treatment of choice. Large calculi require fragmentation by extracorporeal shock wave lithotripsy (ESWL) prior to their extraction or spontaneous expulsion. In properly selected cases, ESWL followed by ERCP is the standard of care for the management of large PC. Long-term outcomes following ESWL have demonstrated good pain relief in approximately 60% of patients. However, ESWL has limitations. Per oral pancreatoscopy and intraductal lithotripsy represent techniques in evolution, and in current practice their use is limited to centers with considerable expertise. Surgery should be offered to all patients with extensive PC, associated multiple ductal strictures or following failed endotherapy.     

PROPHYLACTIC PANCREAS STENTING FOLLOWED BY NEEDLE‐KNIFE FISTULOTOMY IN PATIENTS WITH SPHINCTER OF ODDI DYSFUNCTION AND DIFFICULT CANNULATION: NEW METHOD TO PREVENT POST‐ERCP PANCREATITIS

Introduction: The aim of the present study was to reduce post‐endoscopic retrograde cholangiopancreatography (ERCP) complications with a combination of early needle‐knife access fistulotomy and prophylactic pancreatic stenting in selected high‐risk sphincter of Oddi dysfunction (SOD) patients with difficult cannulation. Methods: Prophylactic pancreatic stent insertion was attempted in 22 consecutive patients with definite SOD and difficult cannulation. After 10 min of failed selective common bile duct cannulation, but repeated (>5×) pancreatic duct contrast filling, a prophylactic small calibre (3–5 Fr) pancreatic stent was inserted, followed by fistulotomy with a standard needle‐knife, then a standard complete biliary sphincterotomy followed. The success and complication rates were compared retrospectively with a cohort of 35 patients, in which we persisted with the application of standard methods of cannulation without pre‐cutting methods. Results: Prophylactic pancreatic stenting followed by needle‐knife fistulotomy was successfully carried out in all 22 consecutive patients, and selective biliary cannulation and complete endoscopic sphincterotomy were achieved in all but two cases. In this group, not a single case of post‐ERCP pancreatitis was observed, in contrast with a control group of three mild, 10 moderate and two severe post‐ERCP pancreatitis cases. The frequency of post‐ERCP pancreatitis was significantly different: 0% versus 43%, as were the post‐procedure (24 h mean) amylase levels: 206 U/L versus 1959 U/L, respectively. Conclusions: In selected, high‐risk, SOD patients, early, prophylactic pancreas stent insertion followed by needle‐knife fistulotomy seems a safe and effective procedure with no or only minimal risk of post‐ERCP pancreatitis. However, prospective, randomized studies are awaited to lend to support to our approach.