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Nabi Z, Nageshwar Reddy D. Role of endoscopic retrograde cholangiopancreatography in pancreatitis. J Can Assoc Gastroenterol 2025; 8:S74-S80. [PMID: 39990510 PMCID: PMC11842904 DOI: 10.1093/jcag/gwae043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2025] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from mainly a diagnostic tool to a treatment method, thanks to newer noninvasive techniques like magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS). This paper looks at how ERCP is used to treat conditions such as acute gallstone pancreatitis, pancreas divisum (PD), sphincter of Oddi dysfunction (SOD), and chronic pancreatitis (CP). For acute gallstone pancreatitis, early ERCP to reduce severity or mortality is now questioned, except when there is cholangitis or ongoing bile duct blockage. For patients with recurring acute pancreatitis due to PD, endoscopic treatment aims to lower duct pressure, but there is not enough strong evidence to support its long-term success. In SOD cases, recent research suggests being more careful with endoscopic sphincterotomy. ERCP plays a clearer role in CP by helping to manage duct stones and strictures in suitable patients. The rising use of pancreatoscopy-assisted lithotripsy as an alternative to ESWL is also discussed.
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Affiliation(s)
- Zaheer Nabi
- Asian Institute of Gastroenterology, Hyderabad 500082, India
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Yadlapati S, Gutta A, Fogel EL. Determining the value of endoscopic retrograde cholangiopancreatography in the management of patients with acute pancreatitis and related complications. Expert Rev Gastroenterol Hepatol 2025:1-19. [PMID: 39921919 DOI: 10.1080/17474124.2025.2464057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2024] [Revised: 02/02/2025] [Accepted: 02/04/2025] [Indexed: 02/10/2025]
Abstract
INTRODUCTION Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a diagnostic to a therapeutic tool in acute pancreatitis management, largely due to the availability of less invasive diagnostic modalities such as endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP). AREAS COVERED This review explores the therapeutic applications of ERCP across various acute pancreatitis etiologies and its role in managing complications such as bile duct obstructions, pancreatic duct disruptions, and infected necrosis. The discussion highlights the procedure's expanding indications and its critical role in addressing complex cases. EXPERT OPINION ERCP remains central to the management of acute pancreatitis complications. As endoscopic techniques and devices continue to advance, its therapeutic scope is likely to grow. Performing ERCP for appropriate indications and optimizing its use is essential for minimizing risks and improving outcomes.
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Affiliation(s)
- Sujani Yadlapati
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indiana University Hospital, Indianapolis, IN, USA
| | - Aditya Gutta
- Division of Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Evan L Fogel
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indiana University Hospital, Indianapolis, IN, USA
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Malik S, Ullah H, Loganathan P, Singh Dahiya D, Chandan S, Mohan BP, Adler DG. Efficacy of Endoscopic Therapy in Symptomatic Pancreatic Divisum: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2025; 59:183-189. [PMID: 38457418 DOI: 10.1097/mcg.0000000000001986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 01/31/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND AND AIMS Pancreas divisum (PD) is a congenital malformation of the pancreas and is implicated as a cause of pancreatitis. The role of endotherapy has been variable in symptomatic PD indicated by recurrent acute pancreatitis (RAP), chronic pancreatitis (CP), or chronic pancreatic-type abdominal pain (PP). The aim of this study was to analyze the pooled data to determine the success of endoscopic intervention for pancreas divisum. METHODS We conducted a comprehensive search of several databases (inception to July 2023) to identify studies reporting on the use of endoscopic therapy in symptomatic pancreatic divisum. The random-effects model was used to calculate the pooled rates and I2 % values were used to assess the heterogeneity. RESULTS A total of 27 studies were retrieved that reported endoscopic intervention in pancreatic divisum. The calculated pooled rate of technical success was 92% (95% CI: 87-95; I2 =63%). The calculated pooled rate of clinical success was 65% (95% CI: 60-70; I2 =60%). The rate of clinical success by PD subtypes was highest in RAP at 71% (95% CI: 65-76; I2 =24%). Available studies had significant heterogeneity in defining clinical success. The rate of adverse events was 71% (95% CI: 65-76; I2 =24%). CONCLUSIONS The role of endoscopic therapy in pancreatic divisum is variable with the highest success rate in recurrent acute pancreatitis. Endoscopic intervention is associated with a higher-than-usual rate of adverse events, including post-ERCP pancreatitis.
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Affiliation(s)
- Sheza Malik
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY
| | - Hamid Ullah
- Department of Internal Medicine, Hamid Ullah, West Virginia University Priyadarshini Loganathan, UT Health, San Antonio, TX
| | - Priyadarshini Loganathan
- Department of Internal Medicine, Hamid Ullah, West Virginia University Priyadarshini Loganathan, UT Health, San Antonio, TX
| | | | - Saurabh Chandan
- Department of Gastroenterology, CHI Creighton Medical Center, Omaha, NE
| | - Babu P Mohan
- Department of Gastroenterology, Orlando Gastroenterology PA, Orlando, FL
| | - Douglas G Adler
- Gastroenterology & Hepatology,Center for Advanced Therapeutic Endoscopy at Porter Adventist Hospital in Denver, CO
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Kuraishi Y, Nakamura A, Kondo S, Yanagisawa T, Horiuchi I, Minamisawa M, Sasaki N, Iwaya Y, Nagaya T, Umemura T. Endoscopic assessment of minor papilla morphology: Predictors of successful cannulation and procedural pancreatitis risk in minor papilla endotherapy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2024; 31:926-934. [PMID: 39252430 PMCID: PMC11660995 DOI: 10.1002/jhbp.12068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
BACKGROUND We evaluated for predictors of successful cannulation and post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in minor papilla endotherapy (MPE), emphasizing endoscopic minor papilla morphology. METHODS We retrospectively analyzed 232 MPEs in 65 patients, assessing minor papilla morphology based on three features: bulge as "prominent" or "subtle," mucosal appearance as "papilla-like" resembling the main papilla or "SMT-like" akin to a gastrointestinal submucosal tumor, and orifice visibility as "clear" or "unclear." Cannulation success was evaluated in 65 enrolled patients, with PEP risk assessed in all 232 MPEs. RESULTS Minor papilla morphology was categorized as prominent/subtle bulge in 42/23 patients, papilla-like/SMT-like mucosal appearance in 42/23, and clear/unclear orifice visibility in 24/41. Cannulation succeeded in 54/65 patients (83%). A papilla-like appearance and clear orifice visibility was significantly associated with cannulation success. PEP incidence was 5.2% and predominantly mild. A papilla-like appearance significantly decreased PEP incidence, while precutting technique and orifice dilation significantly increased PEP risk. CONCLUSION Evaluating minor papilla morphology may help predict cannulation success and PEP risk in MPE. A papilla-like mucosal appearance prognosticates cannulation success and reduced PEP risk, with clear orifice visibility serving as a success predictor. These findings provide practical guidance for preprocedural planning by emphasizing the importance of minor papilla morphology evaluation.
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Affiliation(s)
- Yasuhiro Kuraishi
- Department of GastroenterologyShinshu University HospitalNaganoJapan
| | - Akira Nakamura
- Department of GastroenterologyShinshu University HospitalNaganoJapan
| | - Shohei Kondo
- Department of GastroenterologyShinshu University HospitalNaganoJapan
| | - Takumi Yanagisawa
- Department of GastroenterologyShinshu University HospitalNaganoJapan
| | - Ichitaro Horiuchi
- Department of GastroenterologyShinshu University HospitalNaganoJapan
| | | | - Nobukazu Sasaki
- Department of GastroenterologyShinshu University HospitalNaganoJapan
| | - Yugo Iwaya
- Department of GastroenterologyShinshu University HospitalNaganoJapan
| | - Tadanobu Nagaya
- Department of GastroenterologyShinshu University HospitalNaganoJapan
| | - Takeji Umemura
- Department of GastroenterologyShinshu University HospitalNaganoJapan
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Kimura K, Koizumi K, Masuda S, Makazu M, Kubota J, Teshima S. A suspected case of serum IgG4-negative type 1 autoimmune pancreatitis detected due to localized pancreatic duct narrowing: a case report. Clin J Gastroenterol 2024; 17:976-981. [PMID: 38834827 DOI: 10.1007/s12328-024-01993-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 05/29/2024] [Indexed: 06/06/2024]
Abstract
A 50-year-old woman was referred to our hospital with elevated serum amylase levels. Physical examination revealed no jaundice or abdominal tenderness. Serum IgG4 was negative. Computed tomography revealed a localized pancreatic duct narrowing in the pancreatic head, with caudal pancreatic duct dilation and an intraductal papillary mucinous neoplasm. Pancreatic enlargement was not observed. Endoscopic ultrasonography (EUS) showed a small hypoechoic mass. Although EUS-guided, fine-needle aspiration was performed, no diagnosis was established. Endoscopic retrograde pancreatography showed a localized narrowing in the main pancreatic duct of the pancreatic head. A biopsy of the narrowing was performed through the minor papilla because of difficult access from the major papilla. The specimen showed the infiltration of numerous IgG4-positive plasma cells, suggesting type 1 autoimmune pancreatitis (AIP). Six months later, magnetic resonance cholangiopancreatography revealed improvement in the narrowing without specific treatment. The patient presented with localized narrowing of the pancreatic duct and caudal duct dilation, which was distinct from pancreatic cancer. Diagnostic difficulties arose from negative serum IgG4 results, the lack of typical imaging characteristics of AIP, and failure to meet the AIP criteria according to the relevant Japanese and international guidelines. However, AIP was suspected and surgery was successfully avoided through a biopsy.
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Affiliation(s)
- Karen Kimura
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan.
| | - Kazuya Koizumi
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Sakue Masuda
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Makomo Makazu
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Jun Kubota
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Shinichi Teshima
- Department of Diagnostic Pathology, Shonan Kamakura General Hospital, Kanagawa, Japan
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Inamdar S, Cote GA, Yadav D. Endotherapy for Pancreas Divisum. Gastrointest Endosc Clin N Am 2023; 33:789-805. [PMID: 37709411 DOI: 10.1016/j.giec.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Pancreas divisum (PD) is a common anatomic variant of the pancreatic duct. Causal association between PD and pancreatitis has been debated for many years. Minor papilla sphincterotomy (miES) is offered in clinical practice to patients with idiopathic acute recurrent pancreatitis (iRAP) and PD. However, available data originate mainly from observational studies with many limitations. An ongoing international, multicenter, sham-controlled trial is evaluating the efficacy of miES in iRAP and PD. Endoscopic therapy for pain relief has limited to no benefit in patients with chronic abdominal pain or chronic pancreatitis who have PD and is not recommended.
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Affiliation(s)
- Sumant Inamdar
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Arkansas for Medical Sciences, Shorey Building, 8th Floor, 4301 West Markham Street, Little Rock, AR 72205, USA.
| | - Gregory A Cote
- Division of Gastroenterology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code L461, Portland, OR, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburg Medical Center, 200 Lothrop Street, M2, C-wing, Pittsburgh, PA 15213, USA
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Medas R, Ferreira-Silva J, Girotra M, Barakat M, Tabibian JH, Rodrigues-Pinto E. Best Practices in Pancreatico-biliary Stenting and EUS-guided Drainage. J Clin Gastroenterol 2023; 57:553-568. [PMID: 36040964 DOI: 10.1097/mcg.0000000000001760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Indications for endoscopic placement of endoluminal and transluminal stents have greatly expanded over time. Endoscopic stent placement is now a well-established approach for the treatment of benign and malignant biliary and pancreatic diseases (ie, obstructive jaundice, intra-abdominal fluid collections, chronic pancreatitis etc.). Ongoing refinement of technical approaches and development of novel stents is increasing the applicability and success of pancreatico-biliary stenting. In this review, we discuss the important developments in the field of pancreatico-biliary stenting, with a specific focus on endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-associated developments.
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Affiliation(s)
- Renato Medas
- Gastroenterology Department, Centro Hospitalar São João
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Joel Ferreira-Silva
- Gastroenterology Department, Centro Hospitalar São João
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Mohit Girotra
- Digestive Health Institute, Swedish Medical Center, Seattle, WA
| | | | - James H Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar
- UCLA Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA CA
| | - Eduardo Rodrigues-Pinto
- Gastroenterology Department, Centro Hospitalar São João
- Faculty of Medicine of the University of Porto, Porto, Portugal
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Han S, Obando JV, Bhatt A, Bucobo JC, Chen D, Copland AP, Das KK, Girotra M, Kahn A, Krishnan K, Sakaria SS, Saumoy M, Trikudanathan G, Trindade AJ, Yang J, Law RJ, Lichtenstein DR. Biliary and pancreatic stents. IGIE 2023; 2:240-253. [DOI: 10.1016/j.igie.2023.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2025]
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Kawaguchi S, Satoh T, Terada S, Endo S, Shirane N. Diagnostic ability of pancreatic juice cytology via the minor papilla in patients with pancreas divisum. DEN OPEN 2022; 2:e62. [PMID: 35310692 PMCID: PMC8828241 DOI: 10.1002/deo2.62] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/06/2021] [Accepted: 09/08/2021] [Indexed: 11/06/2022]
Abstract
Background and study aim Endoscopic retrograde cholangiopancreatography (ERCP) is generally performed via the major papilla when evaluating patients with pancreatic disease. However, in patients with pancreas divisum (PD) or distortion of the main pancreatic duct, endoscopic retrograde pancreatography (ERP) should be performed via the minor papilla (MP). Our aim was to evaluate the efficacy and safety of endoscopic pancreatic juice cytology (PJC), performed via the MP, in patients with PD. Patients and methods Patients with PD who underwent diagnostic ERP via the MP, between January 2010 and February 2021, were identified retrospectively from our hospital's ERCP database. Twenty‐two patients contributing to 24 ERCPs were included in the analysis. Results MP cannulation was successful in 23 of 24 ERCPs (96%). In one patient, successful cannulation was achieved on the second attempt and the procedure was performed twice in another. Serial pancreatic juice aspiration cytologic examination (SPACE) was performed in 17 patients, with a single aspiration of pancreatic juice performed in the other five. The sensitivity, specificity, and accuracy rates of ERCP diagnosis, overall, were 56%, 100%, and 80%, respectively. When diagnosis only based on SPACE was considered, the accuracy rate was even higher at 87%. Three patients (13%) developed mild pancreatitis as an adverse event. Conclusions The diagnostic ability of endoscopic PJC, via the MP in patients with PD was technically feasible and relatively effective under experienced pancreatobiliary endoscopists, however, requiring careful attention to post‐ERCP pancreatitis when performed.
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Affiliation(s)
- Shinya Kawaguchi
- Department of Gastroenterology Shizuoka General Hospital Shizuoka Japan
| | - Tatsunori Satoh
- Department of Gastroenterology Shizuoka General Hospital Shizuoka Japan
| | - Shuzo Terada
- Department of Gastroenterology Shizuoka General Hospital Shizuoka Japan
| | - Shinya Endo
- Department of Gastroenterology Shizuoka General Hospital Shizuoka Japan
| | - Naofumi Shirane
- Department of Gastroenterology Shizuoka General Hospital Shizuoka Japan
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Lusman SS, Ovchinsky N, Rosh JR. Cystic Fibrosis and Congenital Anomalies of the Exocrine Pancreas. PEDIATRIC GASTROINTESTINAL AND LIVER DISEASE 2021:905-921.e6. [DOI: 10.1016/b978-0-323-67293-1.00081-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Identifying Factors Predicting Response to Endoscopic Management of Chronic Pancreatitis Secondary to Pancreas Divisum. J Gastrointest Surg 2020; 24:585-589. [PMID: 30887289 DOI: 10.1007/s11605-019-04122-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 01/13/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Appropriately selecting patients with chronic pancreatitis associated with pancreas divisum (PD) for endoscopic retrograde cholangiopancreatography (ERCP)-based therapy versus surgery remains difficult. The objective of this study was to identify factors that predict success or failure of ERCP for treatment of chronic pancreatitis in PD. METHODS Patients undergoing ERCP for a diagnosis of PD and pancreatitis between 2008 and 2016 were identified and grouped according to whether they required one or two ERCPs or three or more ERCPs. Groups were compared along demographic, diagnostic, laboratory, ERCP-related, and outcome variables. RESULTS Patients requiring 1-2 ERCPs were less likely to have back pain on initial presentation (4 vs. 24%, p = 0.02) and less likely to have a dilated bile duct on imaging prior to their first ERCP (8 vs. 30%, p = 0.04) than those requiring 3+ ERCPs. Patients requiring 1-2 ERCPs were also less likely to eventually require operative intervention for treatment of their chronic pancreatitis than those requiring 3+ ERCPs (24 vs. 44%, p = 0.047). On multivariable analysis, a dilated bile duct (odds ratio (OR) = 6.0, 95% confidence interval (CI) = 1.01-36.0, p = 0.048) was independently associated with requiring 3+ ERCPs. Back pain (OR = 6.3, 95% CI = 0.73-54.2, p = 0.09) trended toward but did not reach statistical significance for being independently associated with requiring 3+ ERCPs. CONCLUSIONS The success of endoscopic treatment of chronic pancreatitis in patients with PD is dependent on proper patient selection. Patients with a dilated bile duct and back pain upon presentation may not respond well to endoscopic treatment alone and are more likely to eventually require operative intervention. Consideration should be given to early operative intervention in these patients.
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Abstract
Introduction: Pancreas divisum is the most common congenital malformation of the pancreas with the majority asymptomatic. The etiological role, pathogenesis, clinical significance and management of pancreas divisum in pancreatic disease has not been clearly defined and our understanding is yet to be fully elucidated.Areas covered: This review describes the role of pancreas divisum in the development of pancreatic disease and the ambiguity related to it. In our attempt to offer clarity, a comprehensive search on PubMed, Ovid, Embase and Cochrane Library from inception to May 2019 was undertaken using key words "pancreas divisum", "idiopathic recurrent acute pancreatitis" and "chronic pancreatitis".Expert opinion: Current research fails to define a clear association between pancreas divisum and pancreatic disease. Though debatable, several studies do suggest a pathological role of pancreas divisum in pancreatic disease and a benefit of minor papilla therapy in the setting of acute recurrent pancreatitis. Surgical and endoscopic therapeutic modalities have not been directly compared. With the current data available, it would be imprudent to advise a definitive line of management for pancreatic disease associated with pancreas divisum and should involve a comprehensive discussion with the individual patient to define expectations before embarking on any medical and/or interventional therapy.
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Affiliation(s)
- Aditya Gutta
- Advanced Endoscopy Gastroenterology Fellow, Indiana University School of Medicine, Division of Gastroenterology, 550 N. University Blvd, Indianapolis, IN 46202
| | - Evan Fogel
- Professor of Medicine, Indiana University School of Medicine, Division of Gastroenterology, 550 N. University Blvd, Suite 1602, Indianapolis, IN 46202
| | - Stuart Sherman
- Professor of Medicine, Glen Lehman Professor in Gastroenterology, Indiana University School of Medicine, Division of Gastroenterology, 550 N. University Blvd, Suite 1634, Indianapolis, IN 46202
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Wen J, Li T, Liu L, Bie LK, Gong B. Long-term outcomes of therapeutic ERCP in pediatric patients with pancreas divisum presenting with acute recurrent or chronic pancreatitis. Pancreatology 2019; 19:834-841. [PMID: 31421974 DOI: 10.1016/j.pan.2019.08.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 08/02/2019] [Accepted: 08/07/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the long-term outcomes of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for pediatric patients with pancreas divisum (PD) presenting with acute recurrent pancreatitis (ARP) or chronic pancreatitis (CP). METHODS Between May 2008 and August 2017, pediatric patients with PD who received endotherapy at Ruijin Hospital were identified and grouped according to clinical presentation, namely ARP and CP. Primary success was defined as patients' improvement in symptoms after index ERCPs, without further intervention or any analgesic. RESULTS A total of 74 ERCPs were performed in 38 pediatric patients. The frequency of at least 1 genetic mutation identified in patients with ARP and CP was 44.4% and 68.4%, respectively. Patients with CP required more ERCPs than those with ARP (2.4 ± 1.7 vs. 1.1 ± 0.4, P = 0.005). The incidence of post-ERCP complications was 14.9%, including pancreatitis of 13.5% and hemorrhage of 1.4%. During a median follow-up duration of 41 months (range, 12-123 months), the frequency of pancreatitis episodes decreased significantly from 2.31 to 0.45 (P < 0.0001). The 25% recurrence and reintervention rates were estimated at 25 and 48 months, respectively, without significant difference between patients with ARP or CP. There was a nonsignificant trend towards a higher rate of primary success in patients with ARP than those with CP (92.9% vs. 69.6%, P = 0.123). After further endotherapy, 91.3% patients with CP improved clinically. CONCLUSIONS Therapeutic ERCP is an effective and safe intervention for pediatric patients with symptomatic PD. Patients presenting with CP seem to achieve improvement after additional ERCPs.
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Affiliation(s)
- Jun Wen
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Tao Li
- Department of Gastroenterology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Lei Liu
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Li-Ke Bie
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Biao Gong
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
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Sánchez Rodríguez E, García García de Paredes A, Albillos A. Current management of acute idiopathic pancreatitis and acute recurrent pancreatitis. Rev Clin Esp 2019. [DOI: 10.1016/j.rceng.2019.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Sánchez Rodríguez E, García García de Paredes A, Albillos A. Manejo actual de la pancreatitis aguda idiopática y la pancreatitis aguda recurrente. Rev Clin Esp 2019; 219:266-274. [DOI: 10.1016/j.rce.2018.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 12/28/2018] [Indexed: 02/07/2023]
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Chapman CG, Lodhia NA, Manzano M, Waxman I. Endoscopic Evaluation and Management of Pancreaticobiliary Disease. SHACKELFORD'S SURGERY OF THE ALIMENTARY TRACT, 2 VOLUME SET 2019:1300-1322. [DOI: 10.1016/b978-0-323-40232-3.00111-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Abstract
Recurrent acute pancreatitis (RAP) is a clinically significant problem globally. The etiology remains unclear in approximately 10% to 15% of patients despite a thorough workup. Data on natural history and efficacy of treatments are limited. We aimed to establish criteria for diagnosis, evaluate the causative factors, and arrive at a consensus on the appropriate workup and management of patients with RAP. The organizing committee was formed, and a set of questions was developed based on the current evidence, controversies, and topics that needed further research. After a vetting process, these topics were assigned to a group of experts from around the world with special interest in RAP. Data were presented as part of a workshop on RAP organized as a part of the annual meeting of the America Pancreatic Association. Pretest and Posttest questions were administered, and the responses were tabulated by the current Grades of Recommendation Assessment, Development and Evaluation system. The consensus guidelines were established in the format of a diagnostic algorithm. Several deficiencies were identified with respect to data on etiology, treatment efficacies, and areas that need immediate research.
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Balloon Dilatation of the Minor Duodenal Papilla Up to 4 mm is Safe in a Porcine Model. Surg Laparosc Endosc Percutan Tech 2017; 27:e44-e47. [PMID: 28520650 DOI: 10.1097/sle.0000000000000414] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Balloon dilatation of the minor duodenal papilla is a treatment option for symptomatic pancreas divisum. The histologic effects of balloon dilatation have not yet been evaluated. The aim of this study is to investigate the tolerated extent of dilatation of the minor papilla. MATERIALS AND METHODS A dilatation of the minor papilla was performed in freshly explanted pancreas of pigs using biliary balloon dilatators. Three organs were not dilated (control group), in each 8 organs a dilatation of 4, 6, and 8 mm, respectively, was performed. Tissue damage was assessed by microscopic evaluation. Ductal wall disruption and perforation as well as a semiquantitative inflammation score was described and compared. RESULTS Ductal wall disruption was increased by dilatation of 6 (5/8; P=0.019) and 8 mm (6/8; P=0.006) compared with 4 mm (1/8). Median inflammation score was 0 (0 to 0), 1 (0 to 2), and 1 (0 to 2) for dilatation of 4, 6, and 8 mm, respectively (4 vs. 6 mm, P=0.007; 4 vs. 8 mm, P=0.026). No perforation occurred in the 4 (0/8) and 6 mm (0/8) group, 1 perforation occurred in the 8 mm group (1/8). CONCLUSIONS A dilatation of up to 4 mm seems to be safe. However, dilatation of the minor papilla from 4 mm onwards is increasingly associated with tissue damage. These findings should be considered in endoscopic procedures dilating the minor duodenal papilla.
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Michailidis L, Aslam B, Grigorian A, Mardini H. The efficacy of endoscopic therapy for pancreas divisum: a meta-analysis. Ann Gastroenterol 2017; 30:550-558. [PMID: 28845111 PMCID: PMC5566776 DOI: 10.20524/aog.2017.0159] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 04/24/2017] [Indexed: 12/16/2022] Open
Abstract
Background The purpose of this study was to perform a meta-analysis assessing the efficacy and predictors of success of endoscopic therapy in the management of patients with pancreas divisum. Methods An electronic database search (PubMed and ScienceDirect) was performed for relevant studies. Studies were selected based on predefined criteria and data were extracted on patient population, follow up, endotherapy methods, success rates and complication rates. A random-effect model was used to pool the effect size across studies. Heterogeneity testing and publication bias assessment were performed. Multivariate regression analysis was performed to identify predictors of successful endoscopic therapy. Results Of 381 articles reviewed, 23 studies with 874 patients met the inclusion criteria. All were case series with suboptimal quality. Endoscopic therapy included minor papilla sphincterotomy, minor papilla sphincteroplasty and dorsal duct stenting. Mean follow-up duration was 37 months. The rate of “improvement” as defined by authors after endoscopic therapy varied significantly across studies, ranging from 31-96%: 589/874 patients were reported to have improved, corresponding to a pooled efficacy rate of 67.5% (95% confidence interval [CI] 0.610-0.734; P=0.0001). The pooled rate of pancreatitis after endoscopic retrograde cholangiopancreatography was 10.1% (95%CI 0.084-0.124; 2-sided P=0.0001). On subgroup analysis, patients with recurrent acute pancreatitis had better endoscopic outcomes (pooled efficacy rate 76%, 95%CI 0.712-0.803, P=0.0001). Dorsal duct stenting and longer follow up were the only parameters predictive of successful endotherapy. Significant heterogeneity was observed within and across studies. Conclusions Endoscopic efficacy in pancreas divisum is estimated at 67.5%. Available studies are of poor quality with significant heterogeneity. Comparative studies with rigorous methodology are needed.
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Affiliation(s)
- Lamprinos Michailidis
- Department of Medicine, Division of Digestive Diseases and Nutrition, University of Kentucky College of Medicine, USA
| | - Bilal Aslam
- Department of Medicine, Division of Digestive Diseases and Nutrition, University of Kentucky College of Medicine, USA
| | - Alla Grigorian
- Department of Medicine, Division of Digestive Diseases and Nutrition, University of Kentucky College of Medicine, USA
| | - Houssam Mardini
- Department of Medicine, Division of Digestive Diseases and Nutrition, University of Kentucky College of Medicine, USA
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A systematic review and quantitative analysis of different therapies for pancreas divisum. Am J Surg 2017; 214:525-537. [PMID: 28110914 DOI: 10.1016/j.amjsurg.2016.12.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 12/26/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pancreas divisum is the most common anatomical variation of pancreatic ductal system affecting 5-10% of population. Therapy includes different endoscopic and surgical procedures. The aim of this article was to summarize actual evidence of different treatment. METHODS A Medline search was performed to identify all studies, investigating endoscopic or surgical therapy of Pancreas divisum. An individual data simulation model was applied to compare endoscopic and surgical studies. RESULT 56 observational studies (31 endoscopic and 25 surgical studies) were included in analyses. Surgery was significantly superior to endoscopic treatment in terms of success rate (72% vs. 62.3), complication rate (23.8% vs. 31.3%) and re-intervention rate (14.4% vs. 28.3%). CONCLUSION Surgery may be superior to endoscopy in terms of treatment success and complications. There is no study comparing these two therapies. Consequently, a randomized trial is needed to clarify if endoscopy or surgery is superior in the therapy of pancreas divisum.
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Somani P, Navaneethan U. Role of ERCP in Patients With Idiopathic Recurrent Acute Pancreatitis. ACTA ACUST UNITED AC 2016; 14:327-39. [PMID: 27371265 DOI: 10.1007/s11938-016-0096-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OPINION STATEMENT Recurrent acute pancreatitis (RAP) is defined based on the occurrence of two or more episodes of acute pancreatitis. RAP is differentiated from chronic pancreatitis based on the presence of a normal morphological appearance of the pancreas between episodes. RAP can be due to a variety of etiologies including common bile duct stones or sludge, sphincter of Oddi dysfunction (SOD), pancreas divisum (PD), anomalous pancreaticobiliary junction, genetic mutations, and alcohol related. In approximately 30 % of patients, the etiology of RAP is unclear and the term "idiopathic" is used. Endoscopic retrograde cholangiopancreatography (ERCP) can be utilized in both the diagnosis and the initial management of RAP, but it has known limitations and risks. Since gallbladder sludge and SOD account for most cases with RAP, cholecystectomy and, eventually, endoscopic biliary and/or pancreatic sphincterotomy are performed as a part of management. In patients with PD-associated RAP, data from uncontrolled and primarily retrospective studies point toward a benefit from minor papillary endoscopic intervention. However, given the lack of quality data from prospective randomized controlled trials (RCTs), endoscopic management in such patients remains an individualized decision, and RCTs are needed to ascertain its true long-term benefit. Future studies to investigate the role of endoscopic therapy in preventing progression to chronic pancreatitis are needed.
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Affiliation(s)
- Piyush Somani
- Center for Interventional Endoscopy, University of Central Florida College of Medicine, Florida Hospital, 601 E Rollins Street, Orlando, FL, 32803, USA
| | - Udayakumar Navaneethan
- Center for Interventional Endoscopy, University of Central Florida College of Medicine, Florida Hospital, 601 E Rollins Street, Orlando, FL, 32803, USA.
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Schneider L, Contin P, Fritz S, Strobel O, Büchler MW, Hackert T. Surgical ampullectomy: an underestimated operation in the era of endoscopy. HPB (Oxford) 2016; 18:65-71. [PMID: 26776853 PMCID: PMC4750227 DOI: 10.1016/j.hpb.2015.07.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 05/28/2015] [Accepted: 07/10/2015] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Benign neoplastic, inflammatory or functional pathologies of the ampulla of Vater are mainly treated by primary endoscopic interventions. Consequently, transduodenal surgical ampullectomy (TSA) has been abandoned in many centres, although it represents an important tool not only after unsuccessful endoscopic treatment. The aim of the study was to analyse TSA for benign lesions of the ampulla of Vater. PATIENTS AND METHODS All patients who underwent TSA between 2001 and 2014 were included. Patients were analysed in terms of indications, postoperative morbidity and mortality as well as long-term success. RESULTS Eighty-three patients underwent TSA. Indications included adenomas in 44 and inflammatory stenosis in 39 patients. 96% of the patients had undergone endoscopic therapeutic approaches prior to TSA (median no. of interventions n = 3). Postoperative morbidity occurred in 20 patients (24%). There was one procedure-associated death (mortality 1.2%). The mean follow-up was 54 months. Long-term overall success rate for TSA was 83.6%. After TSA for ampullary adenoma, the recurrence rate was 4.5%. CONCLUSION TSA is an underestimated surgical procedure, which can be performed safely with high long-term efficacy. It can be implemented in clinical algorithms for patients with benign pathologies of the ampulla of Vater, particularly after unsuccessful endoscopic treatment.
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Affiliation(s)
- Lutz Schneider
- Correspondence Markus Büchler, Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany. Tel.: +49 6221 566110. Fax: +49 6221 56 5450.
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Das R, Yadav D, Papachristou GI. Endoscopic Treatment of Recurrent Acute Pancreatitis and Smoldering Acute Pancreatitis. Gastrointest Endosc Clin N Am 2015; 25:737-48. [PMID: 26431601 DOI: 10.1016/j.giec.2015.06.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Recurrent acute pancreatitis (RAP) is a challenging condition that can lead to chronic pancreatitis and long-term morbidity. Etiology-based treatment can potentially have an impact on the natural history of RAP and its progression to chronic pancreatitis. In cases of divisum-associated RAP and idiopathic RAP, several studies have been performed to evaluate the efficacy of endoscopic therapy in alleviation of symptoms and frequency of AP events. This review discusses the literature available on these topic as well as touching on the role of endoscopic therapy in smoldering acute pancreatitis.
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Affiliation(s)
- Rohit Das
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PUH, M2, C Wing, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PUH, M2, C Wing, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Georgios I Papachristou
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PUH, M2, C Wing, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
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Chandrasekhara V, Chathadi KV, Acosta RD, Decker GA, Early DS, Eloubeidi MA, Evans JA, Faulx AL, Fanelli RD, Fisher DA, Foley K, Fonkalsrud L, Hwang JH, Jue TL, Khashab MA, Lightdale JR, Muthusamy VR, Pasha SF, Saltzman JR, Sharaf R, Shaukat A, Shergill AK, Wang A, Cash BD, DeWitt JM. The role of endoscopy in benign pancreatic disease. Gastrointest Endosc 2015; 82:203-14. [PMID: 26077456 DOI: 10.1016/j.gie.2015.04.022] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 04/14/2015] [Indexed: 02/06/2023]
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Wang W, Gong B, Jiang WS, Liu L, Bielike K, Xv B, Wu YL. Endoscopic treatment for pancreatic diseases: Needle-knife-guided cannulation via the minor papilla. World J Gastroenterol 2015; 21:5950-5960. [PMID: 26019460 PMCID: PMC4438030 DOI: 10.3748/wjg.v21.i19.5950] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 02/01/2015] [Accepted: 02/05/2015] [Indexed: 02/06/2023] Open
Abstract
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 cannulations via the minor papilla attempted in 74 patients at our center between January 2008 and June 2014 were retrospectively reviewed. RESULTS Standard methods were successful in 79 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 vs 98.0%, 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.
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Mariani A, Di Leo M, Petrone MC, Arcidiacono PG, Giussani A, Zuppardo RA, Cavestro GM, Testoni PA. Outcome of endotherapy for pancreas divisum in patients with acute recurrent pancreatitis. World J Gastroenterol 2014; 20:17468-17475. [PMID: 25516660 PMCID: PMC4265607 DOI: 10.3748/wjg.v20.i46.17468] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 05/09/2014] [Accepted: 07/24/2014] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the rate of relapses of acute pancreatitis (AP), recurrent AP (RAP) and the evolution of endosonographic signs of chronic pancreatitis (CP) in patients with pancreas divisum (PDiv) and RAP. METHODS Over a five-year period, patients with PDiv and RAP prospectively enrolled were divided into two groups: (1) those with relapses of AP in the year before enrollment were assigned to have endoscopic therapy (recent RAP group); and (2) those free of recurrences were conservatively managed, unless they relapsed during follow-up (previous RAP group). All patients in both groups entered a follow-up protocol that included clinical and biochemical evaluation, pancreatic endoscopic ultrasonography (EUS) every year and after every recurrence of AP, at the same time as endoscopic retrograde cholangiopancreatography (ERCP). RESULTS Twenty-two were treated by ERCP and 14 were conservatively managed during a mean follow-up of 4.5 ± 1.2 years. In the recent RAP group in whom dorsal duct drainage was achieved, AP still recurred in 11 (57.9%) after the first ERCP, in 6 after the second ERCP (31.6%) and in 5 after the third ERCP (26.3%). Overall, endotherapy was successful 73.7%. There were no cases of recurrences in the previous RAP group. EUS signs of CP developed in 57.9% of treated and 64.3% of untreated patients. EUS signs of CP occurred in 42.8% of patients whose ERCPs were successful and in all those in whom it was unsuccessful (P = 0.04). There were no significant differences in the rate of AP recurrences after endotherapy and in the prevalence of EUS signs suggesting CP when comparing patients with dilated and non-dilated dorsal pancreatic ducts within each group. CONCLUSION Patients with PDiv and recent episodes of AP can benefit from endoscopic therapy. Effective endotherapy may reduce the risk of developing EUS signs of CP at a rate similar to that seen in patients of previous RAP group, managed conservatively. However, in a subset of patients, endotherapy, although successful, did not prevent the evolution of endosonographic signs of CP.
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Abstract
OBJECTIVE A subpopulation of patients with pancreas divisum experience symptomatic events such as recurrent acute pancreatitis and chronic pancreatitis. Minor papilla sphincterotomy has been reported as being an effective treatment. The aim of this study was to evaluate the safety and efficacy of endoscopic balloon dilation for the minor papilla. METHODS Between 2000 and 2012, 16 patients were retrospectively included in this study. After endoscopic balloon dilation for the minor papilla was received, a pancreatic stent or a nasal pancreatic drainage catheter was placed for 1 week. If a stricture or obstruction was evident, it was treated with balloon dilation followed by long-term stent placement (1 year). When an outflow of pancreatic juice was disturbed by a pancreatic stone, endoscopic stone extraction was performed. RESULTS Balloon dilation and stent placement were achieved and were successful in all the cases (16/16; 100%). Clinical improvement was achieved in 7 (84.7%) of the 9 patients with recurrent acute pancreatitis and in 6 (85.7%) of the 7 patients with chronic pancreatitis. Early complications were observed in 1 (6.3%) patient. Pancreatitis or bleeding related to balloon dilation was not observed. CONCLUSIONS Endoscopic balloon dilation for the minor papilla is feasible for the management of symptomatic pancreas divisum.
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Kanth R, Samji NS, Inaganti A, Komanapalli SD, Rivera R, Antillon MR, Roy PK. Endotherapy in symptomatic pancreas divisum: a systematic review. Pancreatology 2014; 14:244-50. [PMID: 25062871 DOI: 10.1016/j.pan.2014.05.796] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 05/27/2014] [Accepted: 05/31/2014] [Indexed: 12/11/2022]
Abstract
Pancreas divisum (PD) is the most common congenital variant of the pancreas and has been implicated as a cause of pancreatitis; however, endoscopic treatment is controversial. Our objective was to examine patient response to endotherapy for treatment of symptomatic PD in adult patients in a systematic review of the literature. A systematic review of all case series and case-control studies with ten or more patients undergoing endotherapy for treatment of symptomatic PD indicated by acute recurrent pancreatitis (ARP), chronic pancreatitis (CP), or chronic abdominal pain (CAP) was performed. PubMed, Embase, and Web of Science databases were searched from inception through February 2013 using [pancreas divisum] AND [endoscopic retrograde cholangiopancreatography (ERCP)] OR [endotherapy] OR [endoscopy] as search terms. Importantly, the majority of studies were retrospective in nature, significantly limiting analysis capacity. Main outcomes measures included endotherapy response rate in patients with PD and ARP, CP, or CAP. Twenty-two studies were included in the review, with a total of 838 patients. Response to endoscopy was seen in 528 patients, but response rate varied by clinical presentation. Patients with ARP had a response rate ranging from 43% to 100% (median 76%). Reported response rates were lower in the other two groups, ranging from 21% to 80% (median 42%) for patients with CP and 11%-55% (median 33%) for patients with CAP. Complications reported included perforation, post-endoscopic retrograde cholangiopancreatography pancreatitis, bleeding, and clogged stents. Endotherapy appears to offer an effective treatment option for patients with symptomatic PD, with the best results in patients presenting with ARP.
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Affiliation(s)
- Rajan Kanth
- Department of Internal Medicine, Marshfield Clinic, Marshfield, WI, USA
| | - N Swetha Samji
- Department of Internal Medicine, Marshfield Clinic, Marshfield, WI, USA
| | - Anupama Inaganti
- Department of Internal Medicine, Marshfield Clinic, Marshfield, WI, USA
| | | | - Ramon Rivera
- Department of Gastroenterology and Hepatology, Ochsner Medical Center, New Orleans, LA, USA
| | - Mainor R Antillon
- Department of Gastroenterology and Hepatology, Ochsner Medical Center, New Orleans, LA, USA
| | - Praveen K Roy
- Department of Gastroenterology and Hepatology, Ochsner Medical Center, New Orleans, LA, USA; Department of Gastroenterology, Marshfield Clinic, Marshfield, WI, USA.
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Abstract
Endoscopy plays an important role in both the diagnosis and the initial management of recurrent acute pancreatitis, as well as the investigation of refractory disease, but it has known limitations and risks. Sound selective use of these therapies, complemented with other lines of investigation such as genetic testing, can dramatically improve frequency of attacks and associated quality of life. Whether endoscopic therapy can reduce progression to chronic pancreatitis, or reduce the risk of malignancy, is debatable, and remains to be proven.
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Fujimori N, Igarashi H, Asou A, Kawabe K, Lee L, Oono T, Nakamura T, Niina Y, Hijioka M, Uchida M, Kotoh K, Nakamura K, Ito T, Takayanagi R. Endoscopic approach through the minor papilla for the management of pancreatic diseases. World J Gastrointest Endosc 2013; 5:81-8. [PMID: 23515847 PMCID: PMC3600553 DOI: 10.4253/wjge.v5.i3.81] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Revised: 11/08/2012] [Accepted: 01/23/2013] [Indexed: 02/05/2023] Open
Abstract
AIM: To clarify the efficacy and safety of an endoscopic approach through the minor papilla for the management of pancreatic diseases.
METHODS: This study included 44 endoscopic retrograde cholangiopancreatography (ERCP) procedures performed in 34 patients using a minor papilla approach between April 2007 and March 2012. We retrospectively evaluated the clinical profiles of the patients, the endoscopic interventions, short-term outcomes, and complications.
RESULTS: Of 44 ERCPs, 26 were diagnostic ERCP, and 18 were therapeutic ERCP. The most common cause of difficult access to the main pancreatic duct through the major papilla was pancreas divisum followed by distortion of Wirsung’s duct. The overall success rate of minor papilla cannulation was 80% (35/44), which was significantly improved by wire-guided cannulation (P = 0.04). Endoscopic minor papillotomy (EMP) was performed in 17 of 34 patients (50%) using a needle-knife (13/17) or a pull-type papillotome (4/17). EMP with pancreatic stent placement, which was the main therapeutic option for patients with chronic pancreatitis, recurrent acute pancreatitis, and pancreatic pseudocyst, resulted in short-term clinical improvement in 83% of patients. Mild post-ERCP pancreatitis occurred as an early complication in 2 cases (4.5%).
CONCLUSION: The endoscopic minor papilla approach is technically feasible, safe, and effective when the procedure is performed in a high-volume referral center by experienced endoscopists.
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Affiliation(s)
- Nao Fujimori
- Nao Fujimori, Hisato Igarashi, Akira Asou, Lingaku Lee, Takamasa Oono, Taichi Nakamura, Yusuke Niina, Masayuki Hijioka, Masahiko Uchida, Kazuhiro Kotoh, Kazuhiko Nakamura, Tetsuhide Ito, Ryoichi Takayanagi, Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka 812-8582, Japan
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Pfau PR, Pleskow DK, Banerjee S, Barth BA, Bhat YM, Desilets DJ, Gottlieb KT, Maple JT, Siddiqui UD, Tokar JL, Wang A, Song LMWK, Rodriguez SA. Pancreatic and biliary stents. Gastrointest Endosc 2013; 77:319-27. [PMID: 23410693 DOI: 10.1016/j.gie.2012.09.026] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 09/20/2012] [Indexed: 02/08/2023]
Abstract
Biliary and pancreatic stents are used in a variety of benign and malignant conditions including strictures and leaks and in the prevention of post-ERCP pancreatitis.Both plastic and metal stents are safe, effective, and easy to use. SEMSs have traditionally been used for inoperable malignant disease. Covered SEMSs are now being evaluated for use in benign disease. Increasing the duration of patency of both plastic and metal stents remains an important area for future research.
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Abstract
OBJECTIVE The aim of this study was to determine the diagnosis and endoscopic management of pancreas divisum with results from long-term experience at our institution. METHODS A prospectively collected database of all patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) with the diagnosis of pancreas divisum at our institution from January 2001 to April 2010 was retrospectively analyzed. RESULTS A total of 45 patients were identified with pancreas divisum with 62 ERCP procedures. The major indication for ERCP included pancreatitis in 33 patients (73.3%), of whom 18 had idiopathic recurrent acute pancreatitis, 8 had recurrent pancreatic-type pain and 7 had chronic pancreatitis. The median size of the incision of sphincterotomy was 5 mm (range 3-8 mm). In all 37 patients (82.2%) underwent placement of stent into the dorsal pancreatic duct, with a median stent size of 5 Fr by 7 cm (range 3-10 Fr by 3-12 cm). The overall response rate was 75.8%. CONCLUSIONS The frequency of finding pancreas divisum during ERCP varies among institutions and is low compared with the autopsy series, given that many patients may remain asymptomatic or might not undergo ERCP even if the symptoms develop. Our study is the first to describe specific procedure-related details during therapeutic endoscopy for pancreas divisum.
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Affiliation(s)
- Tarun Rustagi
- Department of Internal Medicine, University of Connecticut, Farmington, CT 06032, USA.
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Nakazawa T, Hayashi K, Naitoh I, Okumura F, Joh T. Endoscopic Approach via the Minor Papilla for the Treatment of Pancreatic Stones. Clin Endosc 2012; 45:189-93. [PMID: 22977799 PMCID: PMC3429733 DOI: 10.5946/ce.2012.45.3.189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Revised: 07/26/2012] [Accepted: 07/30/2012] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND/AIMS We aimed to evaluate whether the advanced techniques have influenced the minor papilla approach. METHODS We studied the success rate of guide wire insertion by using ordinary techniques and advanced techniques (rendezvous method and precut method) in 30 patients via the minor papilla. We compared the selection of the access routes between before (52 patients) and after (28 patients) the introduction of the Soehendra stent retriever. RESULTS In 19 out of 30 patients (63%), guide wire insertion via the minor papilla could be achieved by using ordinary techniques. In total, the guide wire could be inserted in 27 patients (90%) by using the advanced techniques. Before introduction of the Soehendra stent retriever, the major papilla approach was chosen in 38 cases (73%), and the minor papilla approach in 14 cases (27%). After introduction of the Soehendra stent retriever, the major papilla approach was used in 26 cases (93%) and the minor papilla in 2 cases (7%). The frequency of selecting the minor papilla approach has significantly decreased (p<0.05). CONCLUSIONS The advanced techniques have contributed to the improvement of endoscopic approaches via the minor papilla, and decreased the frequency of selecting the minor papilla approach.
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Affiliation(s)
- Takahiro Nakazawa
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Buxbaum J. The role of endoscopic retrograde cholangiopancreatography in patients with pancreatic disease. Gastroenterol Clin North Am 2012; 41:23-45. [PMID: 22341248 DOI: 10.1016/j.gtc.2011.12.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Given the significant risk of pancreatitis and the advent of high-fidelity diagnostic techniques, ERCP is now reserved as a therapeutic procedure for those with pancreatic disease. Early ERCP benefits those with gallstone pancreatitis who present with or develop cholangitis or biliary obstruction. Among those with idiopathic pancreatitis, ERCP may be used to confirm and treat SOD, microlithiasis, and structural anomalies, including pancreas divisum. Pancreatic endotherapy is a consideration to decrease pain in those with pancreatic duct obstruction, although surgical decompression may be more durable, particularly in those with severe disease. Pancreatic duct leaks may respond to endoscopic drainage, but optimal therapy is achieved if a bridging stent can be placed. Finally, using a wire-guided technique and pancreatic duct stents in high-risk patients, particularly in cases of suspected SOD, may minimize the risk of post-ERCP pancreatitis.
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Affiliation(s)
- James Buxbaum
- Los Angeles County Hospital, Division of Gastroenterology and Liver Diseases, The University of Southern California, Keck School of Medicine, Los Angeles, CA 90033, USA.
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Herszényi L, Szmola R, Tulassay Z. [Clinical importance of pancreas divisum]. Orv Hetil 2011; 152:1764-1771. [PMID: 21997581 DOI: 10.1556/oh.2011.29231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Pancreas divisum, the most common congenital pancreatic anomaly, is associated with three main duct abnormalities: type I, with total failure of fusion; type II, with dorsal duct dominant drainage; and type III, incomplete divisum where a small communication branch is present. Three clinical conditions are associated with pancreas divisum: (1) acute recurrent pancreatitis; (2) chronic pancreatitis with the chronic inflammation in the dorsal bed; (3) abdominal "pancreatic-type" obstructive pain. Endoscopic retrograde cholangiopancreatography is the primary method for diagnosing pancreas divisum, but magnetic resonance cholangiopancreatography is becoming a first choice for non-invasive evaluation. Pancreas divisum per se does not require medical intervention. Patients who experience mild episodic acute pancreatitis should be managed medically. Surgical or endoscopic interventions relieve the obstruction by improving dorsal duct drainage via the minor papilla.
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Affiliation(s)
- László Herszényi
- Semmelweis Egyetem, Általános Orvostudományi Kar II. Belgyógyászati Klinika, Budapest.
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Pancreas divisum: a differentiated surgical approach in symptomatic patients. World J Surg 2011; 35:1360-6. [PMID: 21472371 DOI: 10.1007/s00268-011-1076-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Some patients with pancreas divisum (PD) develop symptoms of recurrent pancreatitis. This is probably caused by insufficient drainage of the pancreatic duct. We report the results of our follow-up of patients who underwent surgery for symptomatic pancreas divisum according to an individualized surgical approach. METHODS Between October 2001 and April 2009, 28 patients with symptomatic pancreas divisum were operated at the University Hospital of Heidelberg. According to the localization and type of morphological changes of the pancreas, patients received a reinsertion of the papilla (SP; n=11), duodenum-preserving pancreatic head resection (DPPHR; n=10), pylorus-preserving Whipple (ppWhipple; n=4), or other pancreatic resections (n=3). Hospitalization, morbidity, mortality, pain course, and patient satisfaction were analyzed. RESULTS Before surgery, patients received a median of three endoscopic interventions and were hospitalized for 77 days. The median postoperative follow-up was 4.1 years. Surgical morbidity was 11% and mortality 0%. We performed an SP when the pancreas was soft (n=10). When the pancreas was inflammatory altered, a DPPHR was performed in ten, ppW in four, segmental resection in two, and SP and pancreatic left resection in one case. A redo operation for persisting symptoms was needed in six patients (3 soft and 3 altered pancreas). Compared with the preoperative situation, pain was significantly reduced in the follow-up (median Visual Analogue Scale 0 vs. 10). Ninety-six percent of patients were without symptoms during the follow-up. CONCLUSIONS The individualized surgical approach for patients with symptomatic PD achieves significant reduction of pain in all patients. Reinsertions of the papilla should be performed as a first surgical intervention in patients with a soft pancreas when symptoms persist despite adequate endoscopic treatment. DPPHR should be performed when fibrotic alterations of the pancreas are present.
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Atlas AB, Rosh JR. Cystic Fibrosis and Congenital Anomalies of the Exocrine Pancreas. PEDIATRIC GASTROINTESTINAL AND LIVER DISEASE 2011:890-904.e5. [DOI: 10.1016/b978-1-4377-0774-8.10081-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Recurrent acute pancreatitis: clinical profile and an approach to diagnosis. Dig Dis Sci 2010; 55:3610-6. [PMID: 20232145 DOI: 10.1007/s10620-010-1175-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2009] [Accepted: 02/19/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Though recurrent acute pancreatitis is often seen in clinical practice, there are few comprehensive articles on this entity. The aim of this study therefore was to assess the etiological and clinical profile as well as diagnostic yield of non-invasive and invasive tests in this group of patients. METHODS All patients with recurrent acute pancreatitis seen from 2002 to 2007 were included in the study, retrospectively. Clinical information, investigation, and treatment data were collected for all patients by a standardized review of medical charts. Diagnostic tests were grouped into level one (non-invasive) and level two (invasive) tests and their yield was assessed. Comparison was made between the group with known etiology and idiopathic group to look for significant differences. RESULTS A total of 188 patients with recurrent acute pancreatitis were seen during the study period. Common etiological factors were biliary disease (37%), pancreas divisum (8.5%) and alcohol (6.4%). Multiple etiologies were seen in 7% of cases, and no cause was found in 32.4%. The diagnostic yield of level-one investigation (non-invasive) was 29.3%. Level-two tests (invasive) identified presumptive etiologies in 38.3% of cases. Complications developed in 12.2% and there was no mortality. Clinical features and complications were similar in the idiopathic group and those with known etiology. CONCLUSIONS Etiological diagnosis was obtained in 67.6% of patients after comprehensive diagnostic work up. Diagnosis in the majority of patients could only be reached after invasive tests (bile crystal analysis, EUS, ERCP). Early diagnosis and etiology-based therapy is the key to optimum patient outcome.
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Long-term clinical outcomes after endoscopic minor papilla therapy in symptomatic patients with pancreas divisum. Pancreas 2009; 38:903-6. [PMID: 19672208 DOI: 10.1097/mpa.0b013e3181b2bc03] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To assess the long-term outcomes of endoscopic minor papilla therapy in a spectrum of symptomatic patients with pancreas divisum. METHODS Patients with pancreas divisum coded in a prospective database as having had minor papilla endotherapy (July 1997-May 2003, n = 145) were grouped into 3 categories: (1) acute recurrent pancreatitis, (2) chronic pancreatitis, and (3) chronic/recurrent epigastric pain. Telephone follow-up was conducted (78% of patients), including questions regarding interval co-interventions and narcotic use. Primary success was defined as clinical improvement (better or cured on a Likert scale), without needing narcotics, after 1 therapeutic endoscopic retrograde cholangiopancreatography. Fisher exact and Mann-Whitney U tests and multivariate logistic regression were used to identify predictors of success. RESULTS Primary success rates in acute recurrent pancreatitis, chronic pancreatitis, and chronic/recurrent epigastric pain were achieved in 53.2%, 18.2%, and 41.4%, respectively; and secondary success rates (<or=2 additional endoscopic retrograde cholangiopancreatographies), 71.0%, 45.5%, and 55.2%, respectively (median follow-up, 43.0 months; range, 14-116 months). Younger age (median age, 46.5 years [no success] vs 58.0 years [success]; P < 0.0001) and chronic pancreatitis (odds ratio, 0.10; 95% confidence interval, 0.03-0.39; P = 0.001) independently predicted a lower chance of success. CONCLUSIONS Significant long-term improvement can be achieved with endoscopic therapy in selected patients with pancreas divisum, although many require multiple procedures. Older patients, without chronic pancreatitis, were most likely to respond.
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Abstract
OBJECTIVES Both endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography (EUS) are commonly performed in the evaluation of idiopathic pancreatitis. However, comparative trials of these modalities are lacking, and thus the ideal endoscopic diagnostic strategy to evaluate idiopathic pancreatitis remains unknown. METHODS A decision analysis model of patients with 2 attacks of idiopathic pancreatitis with gallbladder in situ was constructed using TreeAge software. We analyzed cost and overall diagnostic ability of 3 strategies, namely, EUS, ERCP with manometry and bile aspiration, and laparoscopic cholecystectomy. RESULTS Using the base case analysis, initial EUS was the preferred initial modality for the diagnosis. The expected cost for initial EUS was $4469 compared with $4615 for ERCP and $6268 for laparoscopic cholecystectomy. For cholecystectomy to be the preferred strategy, the total cost would need to be less than $1314, well below any realistic cost estimate. If the prevalence of microlithiasis/sludge was greater than 80%, then cholecystectomy would be preferred, whereas ERCP would be preferred with a prevalence of less than 41%. CONCLUSIONS This cost minimization study identifies EUS as the least costly initial test for the diagnostic evaluation of patients with idiopathic pancreatitis with gallbladder in situ.
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Affiliation(s)
- Charles Mel Wilcox
- Department of Medicine, Division of Gastroenterology and Hepatology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL 35294-0007, USA.
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Maple JT, Keswani RN, Edmundowicz SA, Jonnalagadda S, Azar RR. Wire-assisted access sphincterotomy of the minor papilla. Gastrointest Endosc 2009; 69:47-54. [PMID: 18656861 DOI: 10.1016/j.gie.2008.04.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2007] [Accepted: 04/07/2008] [Indexed: 12/17/2022]
Abstract
BACKGROUND Recommended techniques for minor papilla sphincterotomy include performing a standard pull-type sphincterotomy (PTS) or using a needle-knife over a stent. A wire-assisted access sphincterotomy (WAAS) technique may hold some technical advantages over these accepted methods, but has not been robustly described. OBJECTIVE To describe the safety and efficacy of WAAS compared with PTS in a series of patients from our institution. DESIGN Retrospective audit of initial minor papilla sphincterotomies over a 6-year period. Demographic and procedural data were abstracted, and the medical record was reviewed for clinical follow-up. SETTING A large tertiary referral center. PATIENTS One hundred twenty-eight consecutive patients with pancreas divisum who underwent ERCPs between April 2001 and April 2007, 64 of whom underwent an initial minor papilla sphincterotomy. INTERVENTIONS WAAS was performed by deeply cannulating the dorsal duct with a guidewire and then passing a needle-knife sphincterotome alongside the wire and cutting the minor papilla by inserting the needle-knife beside the wire and cutting away from the wire. MAIN OUTCOME MEASUREMENTS Clinical procedural success and reported adverse events. RESULTS Thirty-two patients had recurrent acute pancreatitis, 15 had pain only, and 13 had chronic pancreatitis. Thirty-two underwent WAAS, 24 had PTS, and 8 had other types of sphincterotomies. Patients undergoing WAAS (32) versus PTS (24) were similar in age, sex, and procedural indication. Mild post-ERCP pancreatitis and mild intraprocedural bleeding occurred more commonly in the WAAS group, although the differences were not statistically significant. LIMITATIONS Retrospective, nonrandomized study. CONCLUSIONS WAAS is an effective technique that may be used either to begin a minor papilla sphincterotomy or to perform the entire sphincterotomy. Complications appear similar to those seen with conventional methods but require a larger patient sample to fully evaluate.
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Affiliation(s)
- John T Maple
- Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma 73117, USA.
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Romagnuolo J, Guda N, Freeman M, Durkalski V. Preferred designs, outcomes, and analysis strategies for treatment trials in idiopathic recurrent acute pancreatitis. Gastrointest Endosc 2008; 68:966-74. [PMID: 18725158 DOI: 10.1016/j.gie.2008.05.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2007] [Accepted: 05/05/2008] [Indexed: 12/13/2022]
Affiliation(s)
- Joseph Romagnuolo
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina 29425-2900, USA
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Chacko LN, Chen YK, Shah RJ. Clinical outcomes and nonendoscopic interventions after minor papilla endotherapy in patients with symptomatic pancreas divisum. Gastrointest Endosc 2008; 68:667-73. [PMID: 18436218 DOI: 10.1016/j.gie.2008.01.025] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2007] [Accepted: 01/14/2008] [Indexed: 12/18/2022]
Abstract
BACKGROUND Long-term outcomes of minor papilla endotherapy (MPE) in pancreas divisum are limited. OBJECTIVE To determine the efficacy of MPE in symptomatic pancreas divisum subgroups. DESIGN This was a retrospective study of patients from an endoscopy database. The data collection instrument included preprocedure and postprocedure pain score, narcotic use, acute pancreatitis episodes, emergency department visits, and hospitalizations. A follow-up was obtained by chart review and telephone contact with a questionnaire. SETTING A tertiary-referral center. MAIN OUTCOME MEASUREMENTS (1) Clinical improvement defined as a > or = 50% reduction in the evaluated data points and (2) non-MPE interventions for pain. RESULTS Between January 2000 and April 2006, 57 patients were identified. Indications were recurrent acute pancreatitis (RAP) (n = 27 [47%]), abdominal pain and chronic pancreatitis (CP) (n = 20 [35%]), abdominal pain alone (n = 8 [14%]), other (n = 2 [4%]). Successful MPE occurred in 49 of 57 patients (86%). Initial MPE entailed minor papilla sphincterotomy (n = 46), stenting without sphincterotomy (n = 2), and tamponade of bleeding (n = 1). Follow-up was obtained in 56 of 57 patients (98%) for a median of 20 months (interquartile range 12-39 months); 28 of 48 patients (58%) with successful MPE had clinical improvement: 16 of 21 (76%) with RAP, 8 of 19 (42%) with CP, and 2 of 6 (33%) with pain alone (RAP vs non-RAP; P = .019). Two patients had resolution of a dorsal-duct leak and bleeding, respectively. Twelve of 57 patients (21%) underwent 16 additional interventions for incomplete response: celiac plexus block (4), intrathecal narcotic pump (2), sphincteroplasty (7), bilateral thoracic splanchnicectomy (2), and Puestow procedure (1); 7 of 12 patients (58%) clinically improved. LIMITATION This was a retrospective study. CONCLUSIONS (1) MPE is most effective in patients with pancreas divisum and with RAP with or without pancreatic ductal changes, (2) although patients with chronic pain and pancreas divisum respond poorly to MPE, the majority will have clinical improvement after additional nonendoscopic interventions for pain management.
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Affiliation(s)
- Lyssa N Chacko
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Colorado at Denver and Health Sciences Center, Aurora, Colorado 80045, USA
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MRCP-secretin test-guided management of idiopathic recurrent pancreatitis: long-term outcomes. Gastrointest Endosc 2008; 67:1028-34. [PMID: 18179795 DOI: 10.1016/j.gie.2007.09.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2006] [Accepted: 09/04/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND In patients with recurrent pancreatitis of unknown etiology and nondilated ducts, accurate morphofunctional evaluation of the pancreaticobiliary ductal system and sphincter of Oddi function is important in the diagnostic workup. However, ERCP and sphincter of Oddi manometry may be nondiagnostic and postprocedure complications may be frequent. OBJECTIVE Our purpose was to assess the diagnostic accuracy of the magnetic resonance cholangiopancreatography with secretin test (MRCP-S) in patients with recurrent acute pancreatitis of unknown etiology. Accuracy was established on the basis of ERCP findings and a minimum of 24 months' clinical follow-up. DESIGN Thirty-seven consecutive patients with intact gallbladder and a nondilated pancreaticobiliary ductal system with nonpathologic EUS findings entered a prospective MRCP-S-guided and ERCP-guided diagnostic and therapeutic study protocol. RESULTS Patients were followed up for a mean of 31.3 months (range 26-38 months). MRCP-S identified some pancreatic outflow impairment, suggesting morphofunctional dysfunction of either the major or minor papilla, in 12 of 37 patients (32.4%). The addition of ERCP to MRCP-S did not substantially improve the diagnostic yield for the etiology of recurrent pancreatitis, and 13.6% of cases had mild postprocedure pancreatitis. The S-test was abnormal in 12 of 20 cases (60%) in whom some dysfunction of the sphincter of Oddi or minor papilla was assumed on the basis of follow-up findings. The outcome was successful after biliary or pancreatic sphincterotomy in all patients with an abnormal S-test result. Sensitivity, specificity, and positive and negative predictive values of the S-test for the diagnosis of pancreatic outflow impairment at the major or minor papilla were, respectively, 57.1%, 100%, 100%, and 64%. When the test showed an abnormal result, we were unable to distinguish between biliary and pancreatic segment dysfunction of the sphincter of Oddi. CONCLUSIONS In idiopathic recurrent pancreatitis with nondilated ducts, the MRCP-S-guided approach gave diagnostic accuracy comparable to ERCP with regard to morphologic lesions, and it can be used as an alternative, avoiding ERCP-related complications in the diagnostic phase. An abnormal S-test result showed an excellent positive predictive value and somewhat disappointing negative predictive value for sphincter of Oddi or minor papilla dysfunction and for clinical success of therapeutic endoscopic approach.
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Testoni PA. Endoscopic pancreatic duct stent placement for inflammatory pancreatic diseases. World J Gastroenterol 2008. [PMID: 18023085 DOI: 10.3748/wjg.13.5971] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The role of endoscopic therapy in the management of pancreatic diseases is continuously evolving; at present most pathological conditions of the pancreas are successfully treated by endoscopic retrograde cholangio-pancreatography (ERCP) or endoscopic ultrasound (EUS), or both. Endoscopic placement of stents has played and still plays a major role in the treatment of chronic pancreatitis, pseudocysts, pancreas divisum, main pancreatic duct injuries, pancreatic fistulae, complications of acute pancreatitis, recurrent idiopathic pancreatitis, and in the prevention of post-ERCP pancreatitis. These stents are currently routinely placed to reduce intraductal hypertension, bypass obstructing stones, restore lumen patency in cases with dominant, symptomatic strictures, seal main pancreatic duct disruption, drain pseudocysts or fluid collections, treat symptomatic major or minor papilla sphincter stenosis, and prevent procedure-induced acute pancreatitis. The present review aims at updating and discussing techniques, indications, and results of endoscopic pancreatic duct stent placement in acute and chronic inflammatory diseases of the pancreas.
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Testoni PA. Endoscopic pancreatic duct stent placement for inflammatory pancreatic diseases. World J Gastroenterol 2008; 13:5971-8. [PMID: 18023085 PMCID: PMC4250876 DOI: 10.3748/wjg.v13.45.5971] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The role of endoscopic therapy in the management of pancreatic diseases is continuously evolving; at present most pathological conditions of the pancreas are successfully treated by endoscopic retrograde cholangio-pancreatography (ERCP) or endoscopic ultrasound (EUS), or both. Endoscopic placement of stents has played and still plays a major role in the treatment of chronic pancreatitis, pseudocysts, pancreas divisum, main pancreatic duct injuries, pancreatic fistulae, complications of acute pancreatitis, recurrent idiopathic pancreatitis, and in the prevention of post-ERCP pancreatitis. These stents are currently routinely placed to reduce intraductal hypertension, bypass obstructing stones, restore lumen patency in cases with dominant, symptomatic strictures, seal main pancreatic duct disruption, drain pseudocysts or fluid collections, treat symptomatic major or minor papilla sphincter stenosis, and prevent procedure-induced acute pancreatitis. The present review aims at updating and discussing techniques, indications, and results of endoscopic pancreatic duct stent placement in acute and chronic inflammatory diseases of the pancreas.
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Canlas KR, Branch MS. Role of endoscopic retrograde cholangiopancreatography in acute pancreatitis. World J Gastroenterol 2008. [PMID: 18081218 DOI: 10.3748/wjg.13.6314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is a useful tool in the evaluation and management of acute pancreatitis. This review will focus on the role of ERCP in specific causes of acute pancreatitis, including microlithiasis and gallstone disease, pancreas divisum, Sphincter of Oddi dysfunction, tumors of the pancreaticobiliary tract, pancreatic pseudocysts, and pancreatic duct injury. Indications for endoscopic techniques such as biliary and pancreatic sphincterotomy, stenting, stricture dilation, treatment of duct leaks, drainage of fluid collections and stone extraction will also be discussed in this review. With the advent of less invasive and safer diagnostic modalities including endoscopic ultrasound (EUS) and magnetic retrograde cholangiopancreatography (MRCP), ERCP is appropriately becoming a therapeutic rather than diagnostic tool in the management of acute pancreatitis and its complications.
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Affiliation(s)
- Karen R Canlas
- Division of Gastroenterology and Hepatology, Duke University Medical Center, DUMC Box 3662, Durham, NC 27710, United States
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Abstract
Recent advances in understanding of pancreatitis and advances in technology have uncovered the veils of idiopathic pancreatitis to a point where a thorough history and judicious use of diagnostic techniques elucidate the cause in over 80% of cases. This review examines the multitude of etiologies of what were once labeled idiopathic pancreatitis and provides the current evidence on each. This review begins with a background review of the current epidemiology of idiopathic pancreatitis prior to discussion of various etiologies. Etiologies of medications, infections, toxins, autoimmune disorders, vascular causes, and anatomic and functional causes are explored in detail. We conclude with management of true idiopathic pancreatitis and a summary of the various etiologic agents. Throughout this review, areas of controversies are highlighted.
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Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is a useful tool in the evaluation and management of acute pancreatitis. This review will focus on the role of ERCP in specific causes of acute pancreatitis, including microlithiasis and gallstone disease, pancreas divisum, Sphincter of Oddi dysfunction, tumors of the pancreaticobiliary tract, pancreatic pseudocysts, and pancreatic duct injury. Indications for endoscopic techniques such as biliary and pancreatic sphincterotomy, stenting, stricture dilation, treatment of duct leaks, drainage of fluid collections and stone extraction will also be discussed in this review. With the advent of less invasive and safer diagnostic modalities including endoscopic ultrasound (EUS) and magnetic retrograde cholangiopancreatography (MRCP), ERCP is appropriately becoming a therapeutic rather than diagnostic tool in the management of acute pancreatitis and its complications.
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Vitale GC, Vitale M, Vitale DS, Binford JC, Hill B. Long-term follow-up of endoscopic stenting in patients with chronic pancreatitis secondary to pancreas divisum. Surg Endosc 2007; 21:2199-202. [PMID: 17514389 DOI: 10.1007/s00464-007-9347-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2006] [Revised: 12/29/2006] [Accepted: 01/22/2007] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pancreas divisum is the most common anatomic variant of pancreatic development and may lead to pancreatitis. This study evaluated the efficacy of endoscopic stenting in patients with chronic pancreatitis due to pancreas divisum. METHODS Between 1993 and 2005, 32 patients with chronic pancreatitis due to pancreas divisum were treated with endoscopic stenting. Each patient underwent an endoscopic retrograde cholangiopancreatography to confirm the diagnosis of pancreas divisum prior to endoscopic stenting. A survey was conducted by telephone conversation to evaluate pain intensity, symptom relief, hospital admissions, quality of life and pain medication usage, which was verified by a statewide narcotic electronic database. Eight of the 32 patients were unavailable for the interview and were not included in the analysis of the study. Results are expressed as mean +/- standard error of the mean (SEM). RESULTS Twenty-four patients were followed up for a period of 59.6 months. The overall pain level average in the 24 patients decreased significantly from 8.9 +/- 0.4 pre-stenting to 3.9 +/- 0.7 post-stenting (P < 0.05) on a scale of 1 to 10. The number of hospital admissions per year in these patients decreased significantly from 7.3 +/- 2.1 pre-stenting to 2.1 +/- 0.4 post-stenting (P < 0.05). Pain medication usage reported by the patients found a decrease in 58% of patients, 21% remained the same, and 13% increased their usage. There was improvement in nausea (67%), vomiting (63%), and chronic pain (75%). Thirteen patients (55%) were treated endoscopically without requiring surgery and 11 (45%) patients required surgery after stenting. These 11 patients had surgery an average of 25 months post-stenting. The complication rate of post-procedural pancreatitis was 3.4%. No mortality was reported in this study. CONCLUSION Endoscopic stenting of the pancreatic duct is a safe and effective first treatment for patients with pancreatitis secondary to pancreas divisum. Surgery, when performed for endoscopic stenting failure, is effective as an adjunctive treatment.
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Affiliation(s)
- Gary C Vitale
- Department of Surgery, University of Louisville School of Medicine, Louisville, KY 40292, USA.
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