Systematic Reviews
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Feb 16, 2019; 11(2): 155-167
Published online Feb 16, 2019. doi: 10.4253/wjge.v11.i2.155
Role of pancreatoscopy in management of pancreatic disease: A systematic review
Tarun Kaura, Field F Willingham, Saurabh Chawla
Tarun Kaura, Division of Gastroenterology and Hepatology, Aurora St Luke’s Medical center, University of Wisconsin School of Medicine and Public Health, Milwaukee, WI 53215, United States
Field F Willingham, Saurabh Chawla, Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, United States
Author contributions: All authors equally contributed to this paper with conception and design, literature review and analysis, drafting and critical revision and editing, and approval of the final version.
Conflict-of-interest statement: All authors declare no potential conflicts of interest. No financial support.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Saurabh Chawla, FACG, MD, Associate Professor, Division of Digestive Diseases, Department of Internal Medicine, Emory University School of Medicine, Faculty Office Building, 49 Jesse Hill Jr. Drive, Suite 431, Atlanta, GA 30303, United States.
Telephone: +1-404-7781684 Fax: +1-404-2780277
Received: November 3, 2018
Peer-review started: November 5, 2018
First decision: November 28, 2018
Revised: December 30, 2018
Accepted: January 23, 2019
Article in press: January 23, 2019
Published online: February 16, 2019
Research background

Pancreatoscopy has been used for over 30 years in the diagnosis and management of pancreatic diseases; however, its use remains limited to large volume referral centers. Data regarding its efficacy and safety are limited and have been available mainly from single or multicenter retrospective case series. Well-designed large randomized controlled trials are lacking and may be difficult to conduct due to a heterogeneous patient population. With this study, we have compiled a systematic review of available data, thus highlighting the valuable role of per oral pancreatoscopy in managing pancreatic diseases.

Research motivation

The main aim of our study was to systematically analyze available data regarding the therapeutic potential of pancreatoscopy in managing difficult pancreatic stone disease and pancreatic ductal neoplasia. It appears to be safe, with rare serious side effects, and serves a crucial complementary role to other pancreatic endoscopic modalities.

Research objectives

The main objective of the study was to gather data related to the safety and efficacy of pancreatoscopy. We wanted to identify the success rates and factors associated with treatment failure for pancreatoscopic management of stone disease. We also aimed to analyze the pancreatoscopic visual findings associated with pancreatic ductal neoplasia, and how it can be differentiated from benign pancreatic duct strictures. The diagnostic potential of adjunctive techniques like POP guided/assisted biopsy, pancreatic juice cytology and intraductal ultrasound (IDUS) was evaluated separately.

Research methods

This is a systematic review of available studies published in English. We performed an extensive medical database search to identify relevant publications. Case reports and stand-alone abstract publications were excluded from the final analysis. Data regarding safety and efficacy were extracted and presented. Studies addressing the role of POP in management of pancreatic ductal neoplasia with adjunctive modalities were examined separately.

Research results

Pancreatoscopy is overall safe, with rare reported serious side effects. The success rate ranges between 37.5%-100% for treating pancreatic stone disease. Factors associated with failure include the presence of multiple stones, stones in side branches causing failure of visualization, and the presence of stricture. Visual impression during pancreatoscopy provides important information in patients with indeterminate pancreatic ductal strictures. The key finding in our study was the association between villous projections with red color markings, which is associated with high-risk advanced neoplastic lesions across multiple studies. Smooth narrowing with the presence of coarse mucosa, protein plugs or stones, and blurred mucosal vessels are seen in patients with strictures caused by chronic pancreatitis. POP-assisted tissue acquisition, as well as adjunctive techniques such as cytology, narrow band imaging and IDUS, greatly enhance the diagnostic potential and help in treatment planning.

Research conclusions

Pancreatoscopy is an overall safe and effective diagnostic and therapeutic modality. It serves as an important bridge for patients with pancreatolithiasis who fail conventional Endoscopic retrograde cholangiopancreatography or ESWL. Patients with multiple stones in body/tail, or those with pancreatic strictures, may have risk of decreased success with POP-guided therapy; the recognition of these factors may help in treatment planning. POP visual impression provides a plethora of information regarding etiology in patients with indeterminate pancreatic ductal strictures, although there is an overlap between benign and malignant conditions. POP-guided tissue acquisition has been shown to greatly enhance the diagnostic yield, but limitations persist due to technical challenges. The addition of newer imaging technology may further augment the potential of POP in managing such scenarios.

Research perspectives

Appropriate future action may involve multicenter prospective studies to identify patient characteristics, which may make them amenable to POP-guided endotherapy for pancreatic diseases. Continued improvement in imaging technology, such as narrow band imaging and probe-based confocal laser endomicroscopy, need to be evaluated extensively before mainstream use is implemented.