Safety and efficacy of minor papillotomy in children and adolescents with pancreas divisum

IntroductionPancreas Divisum (PD) is a common pancreatic ductal variant which is twice as common in pediatric patients with acute recurrent pancreatitis (ARP) relative to the general population (14% vs. 7%). Endoscopic retrograde cholangiopancreatography (ERCP) with minor papillotomy has been performed to facilitate drainage of pancreatic juice from the diminutive minor papilla to prevent pancreatitis and pancreatic damage.MethodsWe searched our prospectively-maintained endoscopy databases for patients 18 and younger who underwent ERCP with minor papillotomy between 2009 and 2019. Demographic data, indications, procedural interventions and findings, as well as available clinical outcomes data were analyzed.Results54 ARP/PD patients underwent ERCP with minor papillotomy. Median age was 14 (range 7–18) years, and 26 (48.1%) patients were female. Post-ERCP pancreatitis developed in 10/54 patients (18.5%). 12-month post-ERCP clinical trajectory was available in 47/54 (87%) patients and most patients (38/47, 80.8%) improved clinically after minor papillotomy, with 9/47 (19.1%) experiencing resolution of pancreatitis episodes and none indicated worsening severity or frequency of pancreatitis episodes following ERCP.ConclusionThe majority of children and adolescents with PD and ARP who underwent ERCP with minor papillotomy experienced subjective improvement in their symptoms following the intervention. These data suggest that ERCP with minor papillotomy for pediatric patients with PD and ARP is beneficial and may be curative in a subset of patients—higher rates of improvement than have been previously reported in adults.     

Endoscopic treatment for pancreatic diseases:Needle-knife-guided cannulation via the minor papilla

AIM: To determine the efficacy and safety of meticulous cannulation by needle-knife.METHODS: Three needle-knife procedures were used to facilitate cannulation in cases when standard cannulation techniques failed. A total of 104 cannulationsvia the minor papilla attempted in 74 patients at our center between January 2008 and June 2014 were retrospectively reviewed.RESULTS: Standard methods were successful in79 cannulations. Of the 25 cannulations that could not be performed by standard methods, 19 were performed by needle-knife, while 17(89.5%) were successful. Needle-knife use improved the success rate of cannulation [76.0%, 79/104 vs 92.3%,(79 +17)/104; P = 0.001]. When the 6 cases not appropriate for needle-knife cannulation were excluded, the success rate was improved further(80.6%, 79/98 vs98.0%, 96/98; P = 0.000). There were no significant differences in the rates of post-endoscopic retrograde cholangiopancreatography adverse events between the group using standard methods alone and the group using needle-knife after failure of standard methods(4.7% vs 10.5%, P = 0.301).CONCLUSION: The needle-knife procedure may be an alternative method for improving the success rate of cannulation via the minor papilla, particularly when standard cannulation has failed.     

Reappraisal of factors impacting the cannulation rate and clinical efficacy of endoscopic minor papilla sphincterotomy

BackgroundWe aimed to assess factors impacting the endoscopic minor papilla sphincterotomy (EMPS) success rate, clinical efficacy, and safety in a large cohort of patients with symptomatic pancreas divisum (PD).MethodsRetrospective study including patients with PD referred to the Pancreas Institute of Verona from May 2009 to May 2020 to undergo EMPS. The whole population was analyzed to assess EMPS technical success, defined as the rate of deep cannulation of the dorsal duct. Patients treated for recurrent pancreatitis (RP) with a minimum follow-up of 1 year were included to evaluate the clinical efficacy, defined as resolution or significant reduction of acute pancreatitis (AP) episodes. Safety was defined as the rate of procedure-related adverse events (AEs) according to an international lexicon. The effects of the main determinants on study outcomes were evaluated.ResultsOverall, 106 patients were evaluated. Technical success was obtained in 87 (82.1%). The presence of pancreatic calcifications was associated with failure (p < 0.0001). Clinical efficacy was evaluated in 59 patients. Resolution/reduction of AP episodes after EMPS was observed in 93% of patients over a median follow-up of 49 months (IQR 37–92). Smoking habit was associated with AP recurrence (p = 0.026). The overall AE rate was 14.9%, with post-ERCP pancreatitis as the most common complication (12.6%).ConclusionsIn our study, performed at a tertiary center, EMPS showed satisfactory technical success and an acceptable safety profile. If confirmed by prospective multicenter studies, EMPS could become the standard of care for the treatment of RP in PD.     

Endoscopic papillectomy of minor papillar adenoma associated with pancreas divisum

Tumors of the minor papilla of the duodenum are quite rare. We successfully and safely treated an 18-mm adenoma of the minor papilla associated with pancreas divisum using endoscopic papillectomy. A 64-year-old man was admitted to our hospital for treatment of an asymptomatic mass in the minor papilla detected by upper gastrointestinal endoscopy. Endscopic analysis showed an 18-mm, whitish, sessile mass, located in the duodenum proximal to a normal-appearing major papilla. Endoscopic retrograde pancreatography did not reveal the pancreatic duct. Magnetic resonance cholangiopancreatography showed a lack of the ventral pancreatic duct. We suspected this case was associated with pancreatic divisum; therefore, we performed endoscopic papillectomy of the minor papilla tumor. Subsequently, endoscopic pancreatic stent placement in the minor papilla was done to prevent drainage disturbance. The patient has been asymptomatic without recurrence of tumor or stenosis of the Santorini orifice upon endoscopic examination for the past 2 years.     

Endoscopic resection of carcinoid of the minor duodenal papilla

We encountered a 65-year-old man with a carcinoid tumor of the minor duodenal papilla. Since he had liver cirrhosis and completely refused surgery, we performed an endoscopic snare papillectomy. The papillectomy was performed successfully without procedure-related complication. The specimens revealed a carcinoid tumor showing that the margin of the tumor was positive. One week later, upper GI endoscopy was performed and the biopsy specimens obtained from base of ulcer showed no neoplastic cells. We performed a duodenoscopy and CT 3, 6 and 18 mo later, and there was no macroscopic or microscopic evidence of tumor recurrence after more than 4 years.     

胰腺分裂的内镜诊断

为了认识胰腺分裂及其临床意义，对２５００例经内镜逆行胰胆管造影（ＥＲＣＰ）检查中检出的３７例胰腺分裂患者资料进行回顾分析。３７例均经主、副乳头插管显示出腹胰管及背胰管，胆管显影１４例，显影率３７．８％。体会到胰腺分裂者ＥＲＣＰ时插胆管困难，并对胰腺分裂的ＥＲＣＰ诊断及临床意义进行了讨论     

Entering the duodenal diverticulum: A method for cannulation of the intradiverticular papilla

Successful cannulation of the common bile duct may be difficult in patients in whom the papilla is located entirely within a diverticulum.In this study,we report successful biliary cannulation in three patients following intubation of the distal tip of the duodenoscope into the duodenal diverticulum and locating the major papilla.No complications occurred during the operation or during the postoperative period.This method didn't need second incubation an endoscope and might lower the burden of patients.So this skill is useful to deal with the papilla hidden inside the large diverticulum because of its safety and convenience.     

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。     

Endoscopic findings of the duodenal papilla in patients with pancreaticobiliary maljunction

Background: To our knowledge this is the first report describing the relation between the form of the duodenal papilla and the pancreaticobiliary maljunction (PBM). Methods: The duodenal papilla was studied endoscopically in 46 patients with PBM and in 80 patients without PBM. Results: The duodenal papilla was classified into three types by three independent endoscopists. Conclusion: The oral protrusion of the duodenal papilla in patients with PBM was shorter or absent compared with the duodenal papilla in patients without PBM.     

Endoscopic prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis

Post-endoscopic retrograde cholangiopancreatography(ERCP) pancreatitis(PEP) is not an uncommon adverse event but may be an avoidable complication. Although pancreatitis of severe grade is reported in 0.1%-0.5% of ERCP patients, a serious clinical course may be lethal. For prevention of severe PEP, patient risk stratification, appropriate selection of patients using noninvasive diagnostic imaging methods such as magnetic resonance cholangiopancreatography or endoscopic ultrasonography(EUS), and avoidance of unnecessary invasive procedures, are important measures to be taken before any procedure. Pharmacological prevention is also commonly attempted but is usually ineffective. No ideal agent has not yet been found and the available data conflict. Currently, rectal non-steroidal anti-inflammatory drugs are used to prevent PEP in high-risk patients, but additional studies using larger numbers of subjects are necessary to confirm any prophylactic effect. In this review, we focus on endoscopic procedures seeking to prevent or decrease the severity of PEP. Among various cannulation methods, wire-guided cannulation,precut fistulotomy,and transpancreatic septostomy are reviewed.Prophylactic pancreatic stent placement,which is the best-known prophylactic method,is reviewed with reference to the ideal stent type,adequate duration of stent placement,and stentrelated complications.Finally,we comment on other treatment alternatives,and make the point that further advances in EUS-guided techniques may afford useful PEP prophylaxis.     

Clinical significance of the minor duodenal papilla and accessory pancreatic duct

The accessory pancreatic duct (APD) is the main drainage duct of the dorsal pancreatic bud in the embryo, entering the duodenum at the minor duodenal papilla (MIP). As development progresses, the duct of the dorsal bud undergoes varying degrees of atrophy at the duodenal end. In cases of patent APD, smooth-muscle fiber bundles derived from the duodenal proper muscular tunics surround the APD. The APD shows long and short patterns on pancreatography, and ductal fusion in the two types appears to differ embryologically. Patency of the APD in control cases, as determined by dye-injection endoscopic retrograde pancreatography, was 43%. Patency of the APD may depend on duct caliber, course, and terminal shape of the APD. A patent APD may prevent acute pancreatitis by reducing the pressure in the main pancreatic duct. Pancreas divisum is a common anatomical anomaly in which the ventral and dorsal pancreatic ducts do not unite embryologically. As the majority of exocrine flow is routed through the MIP in individuals with pancreas divisum, interrelationships between poor function of the MIP and increased flow of pancreatic juice caused by alcohol or diet may increase dorsal pancreatic duct pressure and lead to the development of pancreatitis. Wire-guided minor sphincterotomy, followed by dorsal duct stenting, is recommended for acute recurrent pancreatitis associated with pancreas divisum.     

Role of endoscopic retrograde cholangiopancreatography in pancreatic diseases

Over the last 15 years,endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a diagnostic tool to one that is primarily used to provide therapy. This development occurred f irst for biliary disorders and subsequently to a lesser extent for pancreatic diseases. Computed tomography, magnetic resonance imaging,magnetic resonance cholangiopancreatography and endoscopic ultrasonography suggest a diagnosis in the majority of patients with pancreatic diseases today and can help physicians and pati...     

胰管良恶性狭窄的内镜治疗

目的 探讨内镜治疗胰管狭窄的临床疗效。方法 36例影像学检查确诊的胰管狭窄患者,病因包括慢性胰腺炎、胰腺分裂症、胰头癌、胰腺假性囊肿等,分别在内镜逆行胰胆管造影基础上行内镜治疗,包括胰管支架置入、气囊扩张、探条扩张以及经内镜胰管括约肌切开术（EPS）、经内镜乳头括约肌切开术（EST）,同时观察术后症状缓解情况（如腹痛缓解率）、并发症发生率以及近期与远期疗效。结果36例分别进行了胰管支架引流术、气囊扩张、探条扩张、EPS和EST,术后腹痛症状有不同程度的改善,并发症发生率较低。随访1个月～36个月,平均15个月。术后近期（≤3个月）腹痛缓解率为72.2％（26/36）,长期（>3个月）随访显示47.2％（17/36）的患者腹痛缓解无复发,63.9％（23/36）的患者体重增加,生活质量改善。高淀粉酶血症、出血的发生率分别为13.9％（5/36）和5.6％（2/36）,均经一般内科治疗于3日内缓解。支架阻塞、支架脱落的发生率分别为12.5％（3/24）和4.2％（1/24）。结论 经内镜治疗胰管狭窄是安全而有效的方法。     

Endoscopic retrograde cholangiopancreatography-related perforations: Diagnosis and management

Endoscopic retrograde cholangiopancreatography (ERCP) has become an important therapeutic modality for biliary and pancreatic disorders. Perforation is one of the most feared complications of ERCP and endoscopic sphincterotomy. A MEDLINE search was performed from 2000-2014 using the keywords “perforation”, “ERCP” and “endoscopic sphincterotomy”. All articles including more than nine cases were reviewed. The incidence of ERCP-related perforations was low (0.39%, 95%CI: 0.34-0.69) with an associated mortality of 7.8% (95%CI: 3.80-13.07). Endoscopic sphincterotomy was responsible for 41% of perforations, insertion and manipulations of the endoscope for 26%, guidewires for 15%, dilation of strictures for 3%, other instruments for 4%, stent insertion or migration for 2% and in 7% of cases the etiology was unknown. The diagnosis was made during ERCP in 73% of cases. The mechanism, site and extent of injury, suggested by clinical and radiographic findings, should guide towards operative or non-operative management. In type I perforations early surgical repair is indicated, unless endoscopic closure can be achieved. Patients with type II perforations should be treated initially non-operatively. Non-operative treatment includes biliary stenting, fasting, intravenous fluid resuscitation, nasogastric drainage, broad spectrum antibiotics, percutaneous drainage of fluid collections. Non-operative treatment was successful in 79% of patients with type II injuries, with an overall mortality of 9.4%. Non-operative treatment was sufficient in all patients with type III injuries. Surgical technique depends on timing, site and size of defect and clinical condition of the patient. In conclusion, diagnosis is based on clinical suspicion and clinical and radiographic findings. Whilst surgery is usually indicated in patients with type I injuries, patients with type II or III injuries should be treated initially non-operatively. A minority of them will finally require surgical intervention.     

Endoscopic approach to malignant strictures at the hepatic hilum

Hilar tumors have proven to be a challenge to treat and manage because of their poor sensitivity to conventional therapies and our inability to prevent or to detect early tumor formation. Endoscopic stent drainage has been proposed as an alternative to biliary-enteric bypass surgery and percutaneous drainage to palliate malignant biliary obstruction. Prosthetic palliation of patients with malignant hilar stenoses poses particular difficulties, especially in advanced lesions （type Ⅱ lesions or higher）. The risk of cholangitis after contrast injection into the biliary tree in cases where incomplete drainage is achieved is well known. The success rate of plastic stent insertion is around 80% in patients with proximal tumors. Relief of symptoms can be achieved in nearly all patients successfully stented.     

Updated meta-analysis of pancreatic stent placement in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis

AIM: To investigate the efficacy and safety profile of pancreatic duct (PD) stent placement for prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).METHODS: We performed a search of MEDLINE, EMBASE, and Cochrane Library to identify randomized controlled clinical trials of prophylactic PD stent placement after ERCP. RevMan 5 software provided by Cochrane was used for the heterogeneity and efficacy analyses, and a meta-analysis was performed for the data that showed homogeneity. Categorical data are presented as relative risks and 95% confidence intervals (CIs), and measurement data are presented as weighted mean differences and 95%CIs.RESULTS: The incidence rates of severe pancreatitis, operation failure, complications and patient pain severity were analyzed. Data on pancreatitis incidence were reported in 14 of 15 trials. There was no significant heterogeneity between the trials (I² = 0%, P = 0.93). In the stent group, 49 of the 1233 patients suffered from PEP, compared to 133 of the 1277 patients in the no-stent group. The results of this meta-analysis indicate that it may be possible to prevent PEP by placing a PD stent.CONCLUSION: PD stent placement can reduce postoperative hyperamylasemia and might be an effective and safe option to prevent PEP if the operation indications are well controlled.     

Endoscopic retrograde pancreatography: When should we do it?

Endoscopic retrograde pancreatography (ERP) is an accurate imaging modality in the diagnosis of pancreatobiliary diseases. However, its use has been substantially reduced due to the invasiveness of procedure, the risk of complications and the widespread availability of non-invasive cross-section imaging techniques (computed tomography, magnetic resonance imaging, and endoscopic ultrasound). Since the introduction of endoscopic sphincterotomy, ERP has transformed from diagnostic method to an almost exclusively therapeutic procedure. Pancreatic duct injection substantially increased the risk of post-ERP pancreatitis (1.6%-15.7%); therefore, according to international guidelines ERP is recommended only in cases where biliary intervention is required. However, the role of ERP in the management of pancreatic diseases is currently not clearly defined, but in some cases the filling of pancreatic duct may provide essential information complementing the results of non-invasive imaging techniques. The aim of this publication is to systematically summarize the literature dealing with the diagnostic yield of ERP. We would like to define the precise indications of ERP and overview a diagnostic protocol of pancreatic diseases depending on international guidelines and the opinion of Hungarian experts, because it may improve the diagnostic accuracy, minimize of burden of patients and reduce the risk of procedure related complications.     

Pancreas divisum and recurrent pancreatitis: long-term results of minor papilla sphincterotomy

Background and aims: Pancreas divisum (PD) is the most common congenital variant of the pancreatic ductal system and a potential cause of acute recurrent pancreatitis (ARP). Endoscopic therapy is a therapeutic option for symptomatic PD, but there is limited data on long-term results. We aimed to assess the effect of minor papilla endoscopic sphincterotomy (MiES) in the setting of ARP in patients with PD.

Methods: Consecutive patients treated by MiES were included. Clinical data, including gender, age, smoking and drinking habits, number of episodes of acute pancreatitis (AP) as well as technical data pertaining to the endoscopic therapy were reviewed. Patients available for follow-up were contacted to assess the long-term impact of MiES using the Patient’s Global Impression of Change (PGIC) questionnaire.

Results: A total of 138 patients with PD including 77 patients with ARP underwent MiES; 48 patients were available for long-term follow-up using the PGIC score, with a mean follow-up period of 9.7 years. Procedure-related adverse events developed in 10 cases (12.9%): 5 post-MiES delayed bleeding and 5 mild pancreatitis. MiES was clinically successful in 35 patients (72.9%) who did not experience any more episodes of AP. Improvement in quality of life (PGIC ≥6) occurred in 41/48 patients (85.4%). On multivariate analysis, stenosis of the MiES was the only predictive factor for increased risk of recurrent pancreatitis after initial therapy.

Conclusion: MiES resulted an efficient treatment for ARP in patients with PD with clinical benefit, patient satisfaction and improved quality of life even at long-term follow-up.     

Endoscopic transpapillary nasopancreatic drainage alone to treat pancreatic ascites and pleural effusion

BACKGROUND: Pancreatic ascites and pleural effusion are uncommon sequelae of pancreatitis and are associated with significant morbidity and mortality. Endoscopic decompression of the pancreatic duct through transpapillary stent or nasopancreatic drain (NPD) has shown encouraging results but the experience is limited. The aim of the present study was to evaluate the efficacy of endoscopic transpapillary nasopancreatic drainage in patients with pancreatic ascites and pleural effusion. METHODS: Over a period of 9 years, 10 patients (eight male) with pancreatic ascites and/or pleural effusion with pancreatic duct disruption documented on pancreatogram were studied. After informed consent, endoscopic transpapillary NPD was placed. The end-points were resolution of ascites and/or pleural effusion or need for surgery. RESULTS: Of 10 patients (age range: 13 months-46 years), four patients had only ascites, four had only pleural effusion and two had both ascites and pleural effusion. Ascites and/or pleural effusion resolved in all the patients within 4 weeks of placement of NPD. The healing of ductal disruption was demonstrated by nasopancreatogram as early as 2 weeks and NPD could be removed without necessitating another endoscopy. No major complications related to NPD placement were noted. There was no recurrence of pancreatic ascites and/or pleural effusion at a mean follow up of 39 months. CONCLUSIONS: Pancreatic ascites and pleural effusion can be effectively treated by endoscopic retrograde pancreatography and transpapillary NPD placement.