Retroperitoneal perforation of a pancreatic cyst during endoscopic retrograde pancreatography

A 70‐year‐old man was admitted to Ueno Municipal Hospital, Ueno, Japan, for evaluation of abdominal distension. Computed tomography showed a 1 × 1 cm cyst at the pancreas tail. Endoscopic retrograde pancreatography (ERP) showed a normal pancreatic duct after the first gentle injection and an enhanced cyst at the pancreas tail. Extravasation of the contrast medium occurred from the pancreatic duct to the superior‐dorsal extrapancreas at the same time of the next low‐pressure manual injection. Computed tomography showed extravasation of the contrast medium from the pancreas cyst to the retroperitoneal space after ERP. It was considered that the cyst wall weakness, in addition to slight elevated pancreatic duct pressure, caused the disruption of the cyst wall.     

Patency of the accessory pancreatic duct evaluated by dye‐injection endoscopic retrograde pancreatography: Methods and clinical implication

The accessory pancreatic duct (APD) is sometimes developmentally obliterated near the duodenum. We evaluated patency of the APD by dye‐injection endoscopic retrograde pancreatography (ERP). We injected 2–3 mL contrast medium containing indigocarmine into the main pancreatic duct (MPD) via a selectively cannulated endoscopic catheter. Patency of the APD was evaluated by observing the excretion of dye from the minor duodenal papilla. Of the 291 control cases studied, 43% demonstrated a patent APD. Patency of the APD in patients with acute pancreatitis was only 17%, signi?cantly lower than that of controls (P < 0.01). Mean caliber of patent APD was 1.6 ± 0.5 mm, signi?cantly greater than the 1.1 ± 0.5 mm of non‐patent APD (P < 0.01). Regarding the terminal shape of the APD, spindle‐ and cudgel‐type APD were frequently patent (93% and 88%, respectively, (P < 0.01). With respect to APD course, long‐type APD showed most frequent patency (75%, P < 0.01). Dye‐injection ERP represents a simple and de?nitive method for examining APD function. A patent APD may prevent acute pancreatitis by reducing pressure in the MPD. Patency of the APD might be dependent on duct caliber, course, and terminal shape.     

Comparative study of diagnostic value of cytologic sampling by endoscopic ultrasonography-guided fine-needle aspiration and that by endoscopic retrograde pancreatography for the management of pancreatic mass without biliary stricture

BACKGROUND: Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) can now provide a cytopathological diagnosis of underlying pancreatic malignancy with higher success rates than endoscopic retrograde pancreatography (ERP). To determine the significance of EUS-FNA for the diagnosis of pancreatic mass without biliary stricture, the value of cytopathological diagnosis obtained by EUS-FNA was retrospectively compared with that by ERP, and the complications associated with these procedures evaluated. METHODS: Eighty-three patients who were suspected to have a pancreatic mass (excluding a cystic mass), without biliary stricture on conventional ultrasound and/or computed tomography were enrolled. The EUS-FNA biopsy was performed in 53 patients and cytology utilizing ERP was performed in 30 patients. RESULTS: The sampling rate of adequate specimen was 100% in both groups. In the EUS-FNA group, the overall results for the available samples were sensitivity 92.9% and accuracy 94.3%. In contrast, in the ERCP group, the overall results were sensitivity 33.3% and accuracy 46.7%. There was a significant difference between the two groups (P < 0.01). With regard to complications, there was a significant difference (P < 0.01) in the frequency of post-procedure pancreatitis between the EUS-FNA group and ERP group (0%, 0/53 vs 33.3%, 10/30, respectively). CONCLUSION: Endoscopic ultrasonography-guided fine-needle aspiration is safer and more accurate for the cytopathological diagnosis of suspected pancreatic masses without a biliary stricture as compared with cytology during ERP. Endoscopic ultrasonography with FNA should be considered a preferred test (prior to attempting endoscopic retrograde cholangiopancreatography) when a cytological diagnosis of a pancreatic mass is required, especially when there is no biliary obstruction, or when emergent decompression of an obstructed biliary tree is not considered clinically necessary due to lack of signs and symptoms of cholangitis.     

内镜下逆行胰胆管造影加取石术诊治胆总管结石

[目的]评价内镜下逆行胰胆管造影(ERCP)同时行乳头括约肌切开术(EST)对胆总管结石的诊断与治疗价值.[方法]回顾性分析98例经B超检查诊断为胆总管结石的患者,先行ERCP检查,再行内镜下EST治疗胆总管结石.[结果]98例中ERCP准确诊断胆总管结石96例,怀疑胆总管结石1例,未发现异常1例,其确诊率为97.9%.96例EST后采取网篮取石、球囊取石和机械碎石网篮取石成功,1例失败.[结论]ERcP对胆总管结石诊断价值较高.EST是一种治疗胆总管结石安全、有效、简便的方法.     

Endoscopic retrograde pancreatography in pancreatic trauma: Need to break the mental barrier

Pancreatic injury has a high morbidity and mortality. The integrity of the main pancreatic duct is the most important determinant of prognosis. Serum amylase, peritoneal lavage and computed tomography of the abdomen can assist with diagnosis but endoscopic retrograde pancreatography (ERP) is the most accurate investigation for diagnosing the site and extent of ductal disruption. However, it is invasive and can be associated with significant complications. Magnetic resonance cholangiopancreatography (MRCP) and secretin-enhanced MRCP probably parallel ERP in delineating pancreatic ductal injuries. They can also delineate the duct upstream to complete disruption, an area not visualized on ERP. In relation to therapy, endoscopic transpapillary drainage has been successfully used to heal duct disruptions in the early phase of pancreatic trauma and, in the delayed phase, to treat the complications of pancreatic duct injuries such as pseudocysts and pancreatic fistulae. Transpapillary drainage is especially effective in patients who have partial pancreatic duct disruption that can be bridged. Endoscopic transmural drainage has also been successfully used to treat post-traumatic pancreatic pseudocysts. Further large, prospective and randomized studies are required to adjudge the efficacy and long-term safety of pancreatic duct drainage in the treatment of post-traumatic pancreatic duct injuries.     

Size,location and patency of the minor duodenal papilla as determined by dye‐injection endoscopic retrograde pancreatography

Background: The accessory pancreatic duct (APD) sometimes is developmentally obliterated near the duodenum. We evaluated patency of the minor duodenal papilla by dye‐injection endoscopic retrograde pancreatography to determine whether patency was related to papillary size and location. Methods: We injected 2–3 mL of contrast material containing indigocarmine into the main pancreatic duct via an endoscopic catheter in 104 patients. It was endoscopically observed whether dye was extruded from the minor papilla. Size of the minor papilla and distance from the orifice of the major duodenal papilla to the apex of the minor papilla were measured endoscopically with measuring forceps. Results: The APD was patent in 56 of 104 cases (54%). Size of the minor papilla varied considerably from 3 to 6 mm, but showed no correlation with patency. Half of the patients with chronic pancreatitis (6/13) had the minor papilla larger than 6 mm. In cases where the terminal APD had a cudgel or tapering‐off configuration, the minor papilla was larger than in cases where the duct had a stick shape. The minor papilla was patent in 9 out of 10 cases (90%) when it was near the major papilla (≤ 1.5 cm). Frequency of a patent minor papilla was 16 out of 33 (48%) when it existed 1.5 to 2.0 cm from the major papilla, and 31 out of 61 (51%) when the distance was more than 2.0 cm. Conclusions: The minor papilla was more frequently patent when it was close to the major papilla (P < 0.05).     

Resolution of refractory pancreatic ascites after continuous infusion of octreotide acetate

Summary The treatment of pancreatic ascites remains a clinical challenge. Both medical and surgical management have high rates of mortality and recurrence. New methods in the treatment of pancreatic ascites are actively sought. We describe the successful use of a continuous infusion of octreotide acetate in the treatment of refractory alcoholic pancreatic ascites.     

Serum α2-macroglobulin–trypsin complex and early recognition of severe acute pancreatitis after endoscopic retrograde pancreatography

Serum α₂-macroglobulin-trypsin complex (α₂M-T) was measured to differentiate the elevation of serum pancreatic enzymes caused by severe acute pancreatitis from simple elevation after endoscopic retrograde pancreatography (ERP). A patient with severe acute pancreatitis demonstrated marked elevation of serum α₂M-T. In patients without severe acute pancreatitis, serum αM-T did not rise in spite of elevated serum pancreatic enzymes. In conclusion, abdominal pain with elevated serum α₂M-T can be an early diagnostic clue to severe acute pancreatitis after ERP.     

Endoscopic treatment as first-line therapy for pancreatic ascites and pleural effusion

Background:  Ascites and pleural effusion are well recognized complications of pancreatic diseases. Drug therapy of these is limited by high cost, prolonged hospitalization and failure rates; surgery is invasive and is associated with considerable morbidity and mortality.
Objective:  To analyze the data on patients with pancreatic ascites and/or pleural effusion treated endoscopically over a ten-year period.
Methods:  Patients with symptomatic ascites/pleural effusion for at least 3 weeks with a fluid amylase level of > 1000 S units/dl and underlying pancreatic disease were included. The interventions were a 5 mm sized pancreatic sphincterotomy and placement of a 7 Fr pancreatic stent. Somatostatin/octreotide and parenteral nutrition were not used after endoscopic therapy.
Results:  Of the 28 patients included (22 men), 17 (60.7%) had chronic pancreatitis. The causes were tropical pancreatitis (13, 46.4%), alcohol abuse (10, 35.7%), idiopathic acute pancreatitis (4, 14.3%) and resective surgery for gastric cancer (1, 3.6%). Ascites alone was seen in 15, pleural effusion alone in 6 and both in 7 patients. Ten patients (35.7%) had 14 pseudocysts. Endotherapy was successful in 27 (96.4%). Twenty-six (92.8%) patients had complete resolution of ascites/effusion over a median 5 weeks. The stents were removed 3–6 weeks later without any recurrence over the next 6–36 (median = 17) months. Complications (7, 25%) included severe pain in 2 (7.1%) and fever in 5 (17.8%) of which 3 (10.7%) had infection of residual fluid collections. No patient died.
Conclusion:  Endoscopic therapy offers an excellent therapeutic alternative in patients with pancreatic ascites and pleural effusion.     

Mathematical model for predicting biliary therapeutic endoscopic retrograde pancreatography (ERCP)

INTRODUCTION: Magnetic resonance cholangiopancreatography is as sensitive as endoscopic retrograde pancreatography in the evaluation of biliary tract diseases but does not offer therapeutic options. The aim of the present study was to develop a mathematical model to predict 'therapeutic endoscopic retrograde pancreatography' using clinical variables so that patients with low probability could be more appropriately investigated by magnetic resonance cholangiopancreatography in future. METHODS: Endoscopic retrograde pancreatography cases between January 1996 to December 1997 were retrospectively reviewed (before introduction of magnetic resonance cholangiopancreatography). Clinical, biochemical and radiological variables were analysed and a model was developed using multiple logistic regression. RESULTS: Case notes for 573 patients were successfully reviewed. A total of 330 patients underwent therapeutic endoscopic retrograde pancreatography (sphincterotomy or stent insertion). Clinical indications of obstructive jaundice and cholangitis, ultrasonographic findings of dilated common bile duct, and raised liver function tests (two or more elevated parameters) were each found to be predictive for 'therapeutic' endoscopic retrograde pancreatography. Using these variables, the mathematical model in the present study has specificity of 77% and sensitivity of 75% at the probability level of 50% or higher. This model has been tested in a separate group of endoscopic retrograde pancreatography cases carried out in 1998 and was found to have sensitivity 77.6%, specificity 80.3%, positive predictive value 68.5% and negative predictive value 86.6%. CONCLUSIONS: The model reported in the present study can help clinicians to identify cases for therapeutic endoscopic retrograde pancreatography and diagnostic magnetic resonance cholangiopancreatography.     

Original research: Attitudes to radiation safety and cholangiogram interpretation in endoscopic retrograde cholangiopancreatography (ERCP): a UK survey

BackgroundFluoroscopy during endoscopic retrograde cholangiopancreatography (ERCP) exposes staff and patients to potentially harmful ionizing radiation. We performed a UK survey to explore trainee and trainer attitudes to radiation protection and cholangiogram interpretation in ERCP.MethodsAn electronic 10-point survey was prospectively distributed to endoscopy unit leads, training programme directors between October and November 2019. Only UK-based ERCP trainees and trainers with hands-on procedural exposure were eligible for the survey.ResultsThe survey was completed by 107 respondents (58 trainees and 49 trainers), with an estimated overall response rate of 46%. Overall, 49% of respondents were up to date with their radiation protection course, 38% were aware of European Basic safety standards directive (BSSD), 38% wore radiation protection goggles, and 40% were aware of the average radiation screening dose per ERCP procedure. Compared with trainers, trainees were less likely to routinely wear thyroid protection shields (76% vs 92%; p=0.028), have awareness of the BSSD (20% vs 49%; p=0.037) or know their average procedural radiation dosages (21% vs 63%; p<0.001). With regard to cholangiogram interpretation, only 26% had received formal training, with 97% of trainees expressing a desire for further training.ConclusionThis survey highlights a relative complacency in safety attitudes to radiation protection during ERCP. These data provide impetus to improve training and quality assurance in radiation protection, which should be regarded as a mandatory safety aspect prior to commencing hands-on ERCP training.     

治疗性经内镜逆行胰胆管造影在胆胰疾病治疗中的应用

目的分析治疗性经内镜逆行胰胆管造影(ERCP)对胆胰疾病患者肝功能和治疗效果的影响。方法筛选2005年1月-2015年7月北京市垂杨柳医院应用电子十二指肠镜行ERCP治疗的397例胆胰疾病患者。根据不同病种分为8组:良性梗阻组(109例)、恶性梗阻组(47例)、胰腺炎组(27例)、异物梗阻组(127例)、单纯性胆管炎组(19例)、胆瘘组(15例)、十二指肠乳头憩室组(29例)、肝移植术后组(24例)。实施ERCP前1天和实施ERCP 4周后检测受试者的肝功能:ALT、AST、ALP、GGT和TBil。ERCP治疗完成后1个月对疗效进行全面评估。计量资料同组治疗前后比较采用配对t检验,多组间比较采用方差分析;计数资料组间比较采用χ~2检验。结果各组受试者实施ERCP后,其ALT、AST、ALP、GGT以及TBil均有显著改善,即ERCP可以明显改善受试者肝功能(P值均0.05)。疗效评估发现,ERCP治疗后,各组的症状均有明显缓解,单纯性胆管炎组全部治愈,而肝移植术后组和恶性梗阻组只能达到好转的效果。结论治疗性ERCP可显著改善患者的肝功能;但对肝移植术后患者和胆胰肿瘤患者,需要在进行ERCP治疗的同时实施腹腔镜手术联合治疗。     

Risk of pancreatitis after endoscopic retrograde cholangiopancreatography and endoscopic biliary drainage

Background:

Pancreatitis is the most common and serious complication to occur after endoscopic retrograde cholangiopancreatography (ERCP). It is often associated with additional diagnostic modalities and/or treatment of obstructive jaundice. The aim of this study was to determine the risk of post-ERCP pancreatitis associated with pancreaticobiliary examination and endoscopic biliary drainage (EBD).

Methods:

A total of 740 consecutive ERCP procedures performed in 477 patients were analysed for the occurrence of pancreatitis. These included 470 EBD procedures and 167 procedures to further evaluate the pancreaticobiliary tract using brush cytology and/or biopsy, intraductal ultrasound and/or peroral cholangioscopy or peroral pancreatoscopy. The occurrence of post-ERCP pancreatitis was analysed retrospectively.

Results:

The overall incidence of post-ERCP pancreatitis was 3.9% (29 of 740 procedures). The risk factors for post-ERCP pancreatitis were: being female (6.5%; odds ratio [OR] 2.5, P= 0.02); first EBD procedure without endoscopic sphincterotomy (ES) (6.9%; OR 3.0, P= 0.003), and performing additional diagnostic procedures on the pancreatobiliary duct (9.6%; OR 4.6, P < 0.0001). Pancreatitis after subsequent draining procedures was rare (0.4%; OR for first-time drainage 16.6, P= 0.0003). Furthermore, pancreatitis was not recognized in 59 patients who underwent ES. Seven patients with post-EBD pancreatitis were treated with additional ES.

Conclusions:

Invasive diagnostic examinations of the pancreaticobiliary duct and first-time perampullary biliary drainage without ES were high-risk factors for post-ERCP pancreatitis. Endoscopic sphincterotomy may be of use to prevent post-EBD pancreatitis.     

Yield of endoscopic ultrasound-guided fine needle aspiration and endoscopic retrograde cholangiopancreatography for solid pancreatic neoplasms

Objective: Both endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and endoscopic retrograde cholangiopancreatography (ERCP) cytology may provide tissue diagnoses in solid pancreatic neoplasms. However, there are scant data comparing these two methods. This study aims at retrospectively comparing EUS-FNA and ERCP tissue sampling and ability of cytopathological diagnosis in solid pancreatic neoplasms and to determine usefulness and adverse events of combining both procedures. Material and methods: Two hundred and thirty four patients suspected to have solid pancreatic mass on abdominal ultrasound and/or computed tomography (CT) were enrolled. EUS-FNA (group A), ERCP cytology (group B) and combined procedures (Group C) performed in 105, 91 and 38 cases, respectively. Results: Sensitivity, specificity and accuracy were 98.9%, 93.3% and 98.1% for group A, and 72.1%, 60% and 71.4% for group B. Those for group C were all 100%. Sensitivity for malignancy in the pancreas head was 100% for group A and 82.4% for group B, and in the pancreas body and tail, 97.6% for group A and 57.1% for group B. EUS-FNA was more sensitive than ERCP cytology in diagnosing malignant pancreatic neoplasms 21–30?mm in size (p?=?0.0068), 31–40?mm (p?=?0.028) and?≥41?mm (p?Conclusions: EUS-FNA is superior to ERCP cytology for diagnosis of solid pancreatic neoplasms. Although combination of both procedures provide efficient tissue diagnosis and with a minimal adverse events rate, a prospective study including larger number of patients is required.     

Endoscopic ultrasonography and endoscopic retrograde pancreatography in the diagnosis of chronic pancreatitis

Background : The diagnosis of chronic pancreatitis (CP) in the early stages is often problematic. Endoscopic retrograde pancreatography (ERP), secretin test and computed tomography are not sensitive enough to detect the early stages of CP. The aim of this study was to investigate the features of CP in endoscopic ultrasonography (EUS) in patients with unexplained abdominal pain and/or suspected CP. Methods : Thirty‐four consecutive patients in whom CP was suspected after reviewing their history, abdominal ultrasonography and upper gastrointestinal endoscopy findings underwent EUS. Endoscopic ultrasonography was performed by an author who was aware of the history but blinded to the ERP results. Nineteen patients underwent ERP. Endoscopic ultrasonography was used to evaluate parenchymal changes (echogenic foci, echo pattern, prominent interlobular septa, lobularity, cyst and cavities) and ductal changes (dilatation, echogenicity of duct wall, irregularity, side branch ectasia, tortuousity). Results : Nine patients were found to be normal with regard to EUS examination. Abnormal studies for EUS were 25, while for ERP they were 17. The agreement between ERP and EUS was 100% in the 14 patients with moderate and severe disease. The diagnosis of early or mild CP was established with EUS in 11 patients. Endoscopic retrograde pancreatography, which was performed in five of the patient groups with mild disease, was normal in two patients and showed mild changes in three patients. Conclusions : Endoscopic ultrasonography may contribute to establishing the diagnosis and severity of CP found by ERP. Prospective randomized studies and long‐term follow up of patients are needed in order to determine the role of EUS in the diagnosis of early CP.     

Concurrent pancreatic ductal changes in alcoholic liver disease

BACKGROUND: Alcohol is a common etiological factor in both liver disease and chronic pancreatitis, but in a single individual it does not usually produce clinically significant disease in both organs. We assessed the prevalence of pancreatic ductal changes in patients presenting with alcoholic liver disease of different stages. METHODS: Forty-six patients with alcoholic liver disease were included in the present study. Liver biopsy was performed in patients with normal coagulogram. Endoscopic retrograde pancreatogram was performed in all patients and changes in chronic pancreatitis were noted. RESULTS: Of the 46 patients with alcoholic liver disease, 31 had cirrhosis of the liver, nine had fatty liver and two patients had alcoholic hepatitis. Twenty (43.47%) patients had features of chronic pancreatitis on endoscopic retrograde pancreatogram and these consisted of minimal pancreatitis changes in 10 patients, moderate changes in nine patients and advanced changes in one patient. There was no difference in the prevalence of pancreatitis changes in cirrhotics in comparison to non-cirrhotics. There was no correlation between the amount and length of alcohol intake and changes in pancreatitis. CONCLUSION: Pancreatic ductal changes on endoscopic retrograde pancreatogram are common in patients with alcoholic liver disease.     

Therapeutic endoscopic retrograde cholangiopancreatography and related modalities have many roles in hepatobiliary hydatid disease

The authors report their experience about 8 cases of intrabiliary rupture of hepatobiliary hydatid disease, and add an algorithm for treatment. To our opinion, the use of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in the management of hepatobiliary hydatid disease was not stated properly in their proposed algorithm. According to the algorithm, the use of ERCP and related modalities was only stated in the case of postoperative biliary fistulae. We think that postoperative persistant fistula is not a sole indication, there are many indications for ERCP and related techniques namely sphincterotomy, extraction, nasobiliary drainage and stenting, in the treatment algorithm before or after surgery.