Endoscopic biliary drainage in chronic pancreatitis

Between April 1982 and March 1988, 25 patients with chronic pancreatitis presented with biliary stenosis and significant cholestasis. They were treated by endoprosthesis placement. Nineteen patients had jaundice, and, initially, seven had cholangitis (including three with hepatic abscesses). ERCP was successful in all 25 patients. Cholangitis, cholestasis, and jaundice resolved in all cases after stent placement. Two patients died in the 2 months after treatment. Complete follow-up (mean duration, 14 months, range 7 to 42 months) was available for 19 of the 23 remaining patients. Migration of the stent occurred in 10 patients and stent blockage in 8 patients, with relapsing cholestasis (N = 12), cholangitis (N = 4), or without symptoms (N = 2). Only three of these patients are now asymptomatic without a stent in place after 12 to 72 months. In all of the other cases, stents have been replaced or patients have been treated by surgery. We conclude that endoscopic biliary drainage is an effective treatment for resolving cholangitis or jaundice in patients with chronic pancreatitis and biliary stenosis, but that the results of definitive endoscopic drainage for these patients are less satisfactory because resolution of the stricture after removal of the stent is rarely obtained.     

Endoscopic pancreatic drainage in chronic pancreatitis associated with ductal stones: long-term results

Background: In severe chronic pancreatitis associated with intraductal stones, therapeutic endoscopy aims to reduce increased intraductal pressure by pancreatic sphincterotomy and stone clearance. Methods: Results of treatment were evaluated in 70 new patients who underwent pancreatic sphincterotomy and attempted stone removal. Technical results and frequency of pain relief and recurrence are compared. Results: Complete ductal clearance of calculi was obtained in 50% of cases. Immediate clinical improvement occurred in 95% of patients with painful attacks. No severe complications or mortality occurred. Fifty-four percent of all patients with painful chronic pancreatitis did not experience any pain recurrence within 2 years. Associations found to be statistically significant by multivariate analysis were ductal clearance and extracorporeal shock wave lithotripsy, pain disappearance and ductal clearance, pain recurrence and long evolution, and severe disease before treatment and presence of a ductal substenosis. Conclusions: In this subset of patients our results indicate that the pain of chronic pancreatitis is mainly related to increased intraductal pressure. Endoscopic management appears to be a safe, conservative, alternative to surgery. The best results are obtained when it is performed early in the course of calcifying chronic pancreatitis. (Gastrointest Endosc 1996;43:547-55.)     

Endoscopic treatment of pancreatic stones in patients with chronic pancreatitis

Background: The aim of our study was to evaluate the long-term results of endoscopic pancreatic stone removal in patients with chronic pancreatitis. Methods: We retrospectively included 53 patients with chronic pancreatitis, in whom an attempt was made at endoscopic stone removal between 1984 and 1993. Patients presented with pain (30) or an exacerbation of pancreatitis (23). A sphincterotomy was performed in 41 patients. A nasopancreatic drain was left in situ for saline flushing in 6 patients. A pancreatic stent was inserted beyond the stones in 28 patients. Fragmentation of stones was performed by mechanical lithotripsy in 4 patients or by extracorporeal shock wave lithotripsy in 8 patients. Results: All patients had pancreatic stones (multiple 33, single 20) with proximal dilatation of the pancreatic duct. Median follow-up was 33 months (range 4 to 131). Stone removal was successful in 42 patients (79%) (complete 39, partial 3) with relief of symptoms in 38 of 42 (90%). The remaining 4 patients had pancreatic surgery. Stone removal failed in 11 patients and 3 of 11 patients had symptomatic improvement. The remaining 8 patients needed either pancreatic surgery (4) or continued conservative treatment (4). Thirteen of the 53 patients (25%) had recurrent stones, which could be removed endoscopically in 10 of 13. Procedure-related complications occurred in 5 of 53 patients (9%). Mortality was 0%. Seven of the 28 stented patients (25%) had stent-related complications. Conclusions: Endoscopic treatment of pancreatic stones is a valid approach in patients with pancreatic lithiasis with an acceptable risk profile. (Gastrointest Endosc 1996;43:556-60.)     

Endoscopic pancreatic duct drainage and stenting for acute pancreatitis and pancreatic cyst and abscess

Background/Purpose

Endoscopic drainage of pancreatic pseudocysts using transpapillary and transmural approaches has been reported. In this study, endoscopic nasopancreatic drainage (ENPD) and pancreatic stenting were performed in patients with pseudocyst and abscess associated with acute pancreatitis, and the usefulness and problems of the procedures were investigated.

Methods

After endoscopic retrograde pancreatography was done, ENPD and/or pancreatic stenting were performed in 13 patients with pancreatitis and pseudocyst or abscess that communicated with the main pancreatic duct.

Results

ENPD was performed in seven patients, and was effective in all five patients with cysts: the cysts disappeared or shrank. However, the condition in the two patients with abscess was unchanged, and percutaneous drainage was performed. Stenting was carried out in six patients, and the cyst disappeared or pancreatitis was improved in all six. The stent was removed from two patients, but no recurrence has been noted so far.

Conclusions

ENPD and stenting are effective therapeutic choices for acute and chronic pancreatitis and pseudocysts, and they are superior to percutaneous drainage to avoid pancreatic fistula, but they may not be effective for pancreatic abscess. Selection of therapeutic methods corresponding to individual cases is important.     

Endoscopic drainage of pancreatic pseudocysts

Enlarging pancreatic pseudocysts, as well as those that develop complications such as bleeding, leak, infection, and intestinal or biliary obstruction, require treatment. This treatment is usually surgical and consists of internal or external drainage or, less commonly, excision. Transcutaneous aspiration with or without drain placement has also been reported. We describe four cases of endoscopic cystogastrostomy and cystoduodenostomy undertaken in high risk patients who had either failed previous surgery (two) or were initially refused surgery because of prohibitive operative risk (two). Technique, limitations, and potential use of this procedure are discussed.     

Endoscopic ultrasound in chronic pancreatitis

Endoscopic ultrasound has continuously gained importance and has proven to be of clinical value in patients with chronic pancreatitis. In addition, the much lower complication rate when compared to ERCP has to be recognised. Some authors have indicated that endoscopic ultrasound in the evaluation of chronic pancreatitis is the imaging method of choice, depending on both ductal and parenchymal criteria, but there are still some limitations. The two major limitations of EUS preventing it being the "gold standard" in patients with chronic pancreatitis are the lack of standard criteria to be used, and adequate education. Endoscopic ultrasound is difficult to learn and therefore teaching has to be standardised. A general acceptance of the staging of chronic pancreatitis using a catalogue based on criteria compatible to the Cambridge classification is required. Difficulties in evaluating parenchymal criteria with the exception of "indicative" calcifications, depend on the differentiation of the normal ageing process from sequelae of acute pancreatic, ethyl-toxic fibrosis and early stages of chronic pancreatitis. In addition, the differentiation of hypoechoic and cystic lesions as inflammatory changes or neoplastic tumours is still difficult; complementary imaging methods also have low sensitivity in this area. In conclusion, there is no doubt that endoscopic ultrasound has proven to be of value using an interdisciplinary approach in the evaluation and therapy of pseudocysts, peripancreatic necrosis, and pancreatic and bile duct obstruction.     

内镜下胰管支架置入内引流术17例临床观察

目的 探讨内镜下胰管支架置入术的适应证及疗效。方法 对中国人民解放军总医院2001-03～2003-03期间收治的9例慢性胰腺炎(3例伴胰管结石),1例急性复发性胰腺炎,4例胰腺癌,3例乳头腺瘤、癌患者,在内镜下行乳头括约肌切开13例,胰管取石2例,乳头腺瘤、癌切除3例,狭窄部扩张10例,置入胰管支架20例次,支架置留时间2周至8个月,平均3.43个月。结果 置入胰管支架后,有16例患者中上腹痛缓解,食欲增加,消化功能好转。胰腺炎患者取出支架后随访12～35个月,平均数26.17个月,7例上腹痛缓解无反复,有3例患者仍经常上腹痛。手术并发症:术后有3例发生血清淀粉酶、脂肪酸轻度升高,1例出现梗阻性黄疸。结论 胰管支架内引流术适应于慢性胰腺炎或肿瘤导致的胰管梗阻者,改善症状,疗效可靠,安全性较好。     

Endoscopic manometry of the sphincter of Oddi and pancreatic duct in chronic pancreatitis

Pancreatic duct pressure was studied by endoscopic manometry in 12 patients with chronic pancreatitis and in 9 patients with a normal pancreas (suspected biliary dyskinesia). To study the effect of increased intraduodenal concentration of pancreatic enzymes, the duct pressure was measured before and after intraduodenal enzyme infusion. The mean pancreatic duct pressure was 12 (range, 6-25) mm Hg and 18 (range, 6-38) mm Hg in the pancreatitis and 'control' groups, respectively. The occasional patient in each group who had a high duct pressure also had an elevated sphincter of Oddi pressure. A significant correlation between the two pressures was found in both groups of patients. During intraduodenal infusion of pancreatic enzymes a decrease of the pancreatic duct pressure occurred in only two patients. We conclude that an increased pancreatic duct pressure is not a frequent finding in chronic pancreatitis. An elevation of the duct pressure can also be found in patients without pancreatitis. The sphincter of Oddi pressure appears to be more important for the pancreatic duct pressure than the severity of the pancreatitis. Intraduodenal infusion of enzymes, as done in our study, had an inconsistent effect on the pancreatic duct pressure.     

慢性胰腺炎的内镜治疗

慢性胰腺炎治疗目的为解除胰管梗阻、缓解疼痛、防止复发，并争取改善胰腺外分泌功能。过去传统的治疗方法主要有内科长期药物维持治疗及外科减压手术等，但疗效均欠佳。目前内镜治疗在一定程度上可替代手术治疗，成为治疗慢性胰腺炎的首选方案。     

Endoscopic treatment of chronic pancreatitis

Treatment of chronic pancreatitis has been exclusively surgical for a long time. Recently, endoscopic therapy has become widely used as a primary therapeutic option. Initially performed for drainage of pancreatic cysts and pseudocysts, endoscopic treatments were adapted to biliary and pancreatic ducts stenosis. Pancreatic sphincterotomy which allows access to pancreatic ducts was firstly reported. Secondly, endoscopic methods of stenting, dilatation, and stones extraction of the bile ducts were applied to pancreatic ducts. Nevertheless, new improvements were necessary： failures of pancreatic stone extraction justified the development of extra-corporeal shock wave lithotripsy; dilatation of pancreatic stenosis was improved by forage with a new device; moreover endosonography allowed guidance for celiac block, gastro-cystostomy, duodeno-cystostomy and pancreatico-gastrostomy. Although endoscopic treatments are more and more frequently accepted, indications are still debated.     

Endoscopic management of chronic pancreatitis

Chronic pancreatitis (CP) is a common gastrointestinal illness, which affects the quality of life with substantial morbidity and mortality. The management includes medical, endoscopic and surgical approaches with the need for interaction between various specialties, calling for a concerted multidisciplinary approach. However, at the time of this publication, guidelines to establish care of these patients are lacking. This review provides the reader with a comprehensive overview of the studies summarizing the various treatment options available, including medical, surgical and endoscopic options. In addition, technological advances such as endoscopic retrograde cholangiopancreatogrophy, endoscopic shock wave lithotripsy and endoscopic ultrasound can now be offered with reasonable success for pancreatic decompression, stricture dilatation with stent placement, stone fragmentation, pseudocyst drainage, and other endoscopic interventions such as celiac plexus block for pain relief. We emphasize the endoscopic op-tions in this review, and attempt to extract the most up to date information from the current literature. The treatment of CP and its complications are discussed extensively. Complications such as biliary strictures. pancreatic pseudocysts, and chronic pain are common issues that arise as long-term complications of CP. These often require endoscopic or surgical management and possibly a combination of approaches, however choosing amongst the various therapeutic and palliative modalities while weighing the risks and benefits, makes the management of CP challenging. Treatment goals should be not just to control symptoms but also to prevent disease progression. Our aim in this paper is to advocate and emphasize an evidence based approach for the management of CP and associated long term complications.     

Endoscopic diagnosis of chronic pancreatitis

Endoscopy entered the diagnosis of pancreatic diseases in 1972 as the first endoscopic retrograde cholangiopancreaticography and during subsequent decades it markedly extended its field of action to comprise also endoscopic therapy of the pancreas. At present it represents together with abdominal sonography, computed tomography, endosonography, and nuclear magnetic resonance the basic spectrum of morphological examination methods of the pancreas. The disadvantage of endoscopic retrograde cholangiopancreaticography is the invasive character of this method associated with complications. In chronic pancreatitis this method can be used in particular to evaluate the extent of morphological changes--i.e. classification of chronic pancreatitis, whereby the most frequently used one is the Cambridge classification. The method, contrary to other morphological imaging methods can diagnose variants and malformations of the pancreatic efferent system, it cannot however, with the exception of chronic obstructive pancreatitis and chronic pancreatitis in pancreas divisum detect the cause of chronic pancreatitis and is also of very limited informative value in the differential diagnosis of chronic pancreatitis and carcinoma of the pancreas. Endoscopic retrograde pancreaticography cannot be implemented after some surgical operations of the pancreas.     

Endoscopic treatment of chronic pancreatitis

OBJECTIVES: Endoscopy offers an alternative to surgery for the treatment of ductal complications in patients with chronic pancreatitis. The aim of this study was to evaluate the efficacy of endoscopic treatment on pain, cholestasis and pseudocysts in these patients. PATIENTS AND METHODS: Thirty-nine patients (37 M, 2 F, mean age 44), were included in the study. All patients had at least one of the following criteria demonstrated by imaging tests: dilatation of the main pancreatic duct (MPD) with or without stricture (N = 13), bile duct stricture (N = 12), or pancreatic pseudocyst (N = 14) with pancreatic duct stricture (N = 11) or biliary stricture (N = 3). Pancreatic or biliary sphincterotomy, insertion of pancreatic or biliary stent, pseudocyst drainage with stent placement were performed according to ductal abnormalities. Patients were evaluated early and followed up during the stenting period, and after stent removal. RESULTS: Patients underwent a median of 3.5 endoscopic procedures with an interval of 2.2 months between 2 stenting sessions. A pancreatic or biliary stent was inserted in 25 patients with ductal abnormalities and in 11 patients with pseudocysts. Endoscopic pseudocyst drainage was performed in 6 cases. The mean stenting time was 6 months (range: 3-21). Mean follow-up after stent removal was 9.7 (2-48) months. Complications of endoscopic treatment were encountered in 7% of patients with no deaths. Pain relief was achieved after the first endoscopic procedure and during the overall stenting period in all patients. Recurrence of pain was observed after stent removal in 5/11 patients, requiring surgery in 4. Cholestasis decreased and biochemical values normalized within one month after biliary stenting. Recurrence of cholestasis was observed early after stent removal in 4/9 patients who required complementary surgical treatment. No recurrence of pancreatic pseudocyst was observed after endoscopic drainage and stent removal during the follow-up period. CONCLUSIONS: Endoscopic treatment of pain from pancreatic pseudocysts or ductal strictures is effective in the short-term and in the period of ductal stenting. However, the optimal duration of the latter remains to be determined.     

慢性胰腺炎的内镜治疗

慢性胰腺炎治疗目的为解除胰管梗阻、缓解疼痛、防止复发,并争取改善胰腺外分泌功能.过去传统的治疗方法主要有内科长期药物维持治疗及外科减压手术等,但疗效均欠佳.目前内镜治疗在一定程度上可替代手术治疗,成为治疗慢性胰腺炎的首选方案.     

内镜综合治疗慢性胰腺炎

目的探讨内镜在慢性胰腺炎治疗中的临床应用价值方法回顾性分析经内镜治疗的37例慢性胰腺炎患者的临床资料,总结治疗的体会。结果37例均经内镜下胰胆管造影明确诊断,患者均有不同程度的胰管扩张,其中胰管狭窄21例,伴有钙化9例,行乳头括约肌切开术37例,胰管括约肌切开术18例,网篮、球囊取胰石6例,胰管内支架引流17例,鼻胰管引流5例。37例中34例治疗后腹痛消失。结论内镜治疗慢性胰腺炎是较安全、有效的,而内镜下多种治疗方法的综合应用明显改善了传统慢性胰腺炎治疗的现状,提高了治疗水平。     

内镜治疗慢性胰腺炎的探讨

目的 探讨内镜治疗慢性阻塞性胰腺炎疗效及并发症。方法 经内镜治疗２９例慢性胰腺炎中胰管括约肌切开术２７例（１９例为７内镜治疗前处置）,副乳头切开８例,乳头括约肌切开术５例,网篮邓胰石９例,胰管内引流７例,鼻胰管引流３例,辅助探条或球囊扩张共１４例。１３例治疗前、后检测胰腺内分泌功能。结果 ２９例中２６例（８９．７％）治疗后腹痛消失或明显减轻,９例胰腺结石患者中６例取出胰石;７例胰管内引流管未阻塞。