Benign Pancreatic Duct Strictures Research Articles

An Atypical Complication of Chronic Pancreatitis

An Atypical Complication of Chronic Pancreatitis

A prospective study of fully covered self-expandable metal stents for refractory benign pancreatic duct strictures.

Fully covered self-expanding metal stents (FCSEMSs) are a relatively novel option for treating painful main pancreatic duct refractory strictures in patients with chronic pancreatitis. Herein, we aimed to assess the efficacy, feasibility, and safety of FCSEMSs in this patient group. This prospective single-center study included patients who underwent endoscopic retrograde pancreatography with FCSEMS placement. The primary endpoints were the technical and clinical success rates. A reduction in visual analog scale pain score of >50% compared with that before stent placement was defined as clinical success. Secondary endpoints were resolution of pancreatic strictures on fluoroscopy during endoscopic retrograde pancreatography and the development of stent-related adverse events. Thirty-six patients were included in the analysis. The technical success rate was 100% (n=36) and the clinical success rate was 86.1% (n=31). There was a significant increase in stricture diameter from 1.7 mm to 3.5 mm (p<0.001) after stent removal. The mean visual analog scale pain score showed statistically significant improvement. At 19 months of follow-up, 55.6% of the patients were asymptomatic. Stent migration (16.7%), intolerable abdominal pain (8.3%), development of de novo strictures (8.3%), and mild pancreatitis (2.8%) were the most common adverse events. FCSEMS placement showed good technical and clinical success rates for achieving pain relief in patients with refractory main pancreatic duct strictures.

Preliminary study of a modified, nonflared, short, fully covered metal stent for refractory benign pancreatic duct strictures (with videos)

Fully covered self-expanding metal stents (FCSEMSs) are considered to be more effective than plastic stents for the treatment of main pancreatic duct (MPD) strictures associated with chronic pancreatitis (CP) because of their larger diameter and exertion of a radial expansion force. However, the current FCSEMSs have several limitations. To overcome these, a novel modified nonflared FCSEMS was developed. In this study we conducted a prospective long-term follow-up evaluation of the efficacy of the novel FCSEMS for the treatment of refractory benign PD strictures in patients with CP. Consecutive patients with symptomatic CP associated with refractory MPD strictures were enrolled prospectively in this single-arm study. The nonflared FCSEMS was placed intraductally or transpapillary according to the location and length of the stricture. Stent removal was performed at 3 months after placement. The primary outcome was the resolution of the pancreatic ductal stricture. Endoscopic placement of modified nonflared FCSEMSs was technically successful in all 25 patients. Intraductal FCSEMS placement was performed in 14 patients (56.0%). Stents of diameter 8mm were used in 17 patients (68.0%). Stents of lengths 3 and 5 cm were inserted in 22 (88.0%) and 3 (12.0%) patients, respectively. In 1 patient (4.0%), stent migration developed. All other stents were removed successfully. After stent removal, resolution of the MPD stricture was confirmed in all patients, and no FCSEMS-related de novo stricture was observed. During the follow-up period (median, 34 months; interquartile range, 25-56) after the stents had been removed from the 25 patients, reintervention for recurrence of MPD stricture with abdominal pain was performed in 2 patients (8.0%). Endoscopic placement of a novel modified nonflared FCSEMS resulted in long-term stricture resolution with pain relief and reduced the rate of stent-related adverse events, particularly stent migration and stent-induced de novo MPD stricture. (Clinical trial registration number: UMIN000035681.).

10 Fr S-Type Plastic Pancreatic Stents in Chronic Pancreatitis Are Effective for the Treatment of Pancreatic Duct Strictures and Pancreatic Stones.

Aim Endoscopic pancreatic stenting for refractory pancreatic duct strictures associated with impacted pancreatic stones in chronic pancreatitis cases has yielded conflicting results. We retrospectively evaluated the efficacy of endoscopic treatment in chronic pancreatitis patients with pancreatic duct strictures. Methods Pancreatic sphincterotomy, dilatation procedures, pancreatic brush cytology, and pancreatic juice cytology were routinely performed, and malignant diseases were excluded. After gradual dilatation, a 10 Fr plastic pancreatic stent was inserted. The stents were replaced every 3 months and removed after the strictures were dilated. Statistical analyses were performed to determine the risk of main pancreatic duct restenosis. Results Endoscopic pancreatic stents were successfully placed in 41 of a total of 59 patients (69.5%). The median duration of pancreatic stenting was 276 days. Pain relief was obtained in 37 of 41 patients (90.2%). Seventeen patients (41.5%) had recurrence of main pancreatic duct stricture, and restenting was performed in 16 patients (average placement period 260 days). During the follow-up period, pancreatic cancer developed in three patients (5.1%). Multivariate analysis revealed that the presence of remnant stones after stenting treatment was significantly associated with a higher rate of main pancreatic duct restenosis (p = 0.03). Conclusion The use of 10 Fr S-type plastic pancreatic stents with routine exchange was effective for both short-term and long-term outcomes in chronic pancreatitis patients with benign pancreatic duct strictures and impacted pancreatic stones.

Pilot Study of Dumbbell-Type Covered Self-Expandable Metal Stent Deployment for Benign Pancreatic Duct Stricture (with Videos)

BackgroundFully-covered, self-expandable metal stents (FCSEMS) have been deployed to treat symptomatic chronic pancreatitis (CP) complicated with main pancreatic duct (MPD) stricture. Although this strategy can be effective, it has the disadvantages of stent migration or stent-induced ductal change. Removal of an FCSEMS can also be challenging in the face of distal migration because of MPD stricture. Dumbbell-type FCSEMS have been developed to prevent stent-induced ductal changes and improve removability when treating benign biliary stricture. This stent might also confer clinical benefits upon patients with MPD stricture. AimsThe present pilot study aimed to determine the feasibility and safety of deploying dumbbell-type FCSEMS in patients with CP complicated by MPD stricture. MethodStents were deployed in 22 patients with MPD stricture caused by CP and complicated by abdominal pain. ResultsStrictures were located at the head (n = 19), body (n = 2), and head and tail (n = 1) of the MPD. Stents were deployed above the papilla in three patients. All stents were deployed for a median duration of 142 (range, 49–190) days and removed. The resolution of MPD strictures was confirmed by pancreatography in 19 (86.3%) patients. Two metal stents that spontaneously tore during removal from two patients had otherwise functioned normally. Only three patients developed recurrent MPD stricture during a median follow-up of 419 (range, 261–484) days.. ConclusionsDeployment of a dumbbell-type FCSEMS seems feasible for MPD stricture, and the rate of adverse events is acceptable.

Prospective pilot study of fully covered self-expandable metal stents for refractory benign pancreatic duct strictures: long-term outcomes.

Background and study aims: Background and study aims: Temporary placement of a fully covered self-expandable metal stent (FCSEMS) has recently emerged as a treatment option for pancreatic duct strictures due to chronic pancreatitis refractory to conventional plastic stenting. However, there are no data about long-term outcomes with this therapeutic option. The aims of the current study were to estimate the feasibility, safety, efficacy, and long-term outcomes of temporary FCSEMS placement for refractory pancreatic duct strictures. Patients and methods: This was a prospective, single-center feasibility study. Ten patients with refractory pancreatic duct strictures due to chronic pancreatitis underwent FCSEMS placement for 3 months. We evaluated the rate of recurrent symptoms after stent removal during long-term follow-up, as well as adverse events (AEs). Results: Two patients required early (within 1 week) stent removal because of intolerable pain or pancreatitis. In the remaining 8 patients, the recurrence rate of any symptoms after FCSEMS removal was 63% during 35 months of follow up. The causes of recurrent symptoms were as follows: recurrence of stricture in 2; stent-induced stricture in 1; impaction of pancreatic stones in 1; and development of a pseudocyst in 1. When limited to stricture, the recurrence rate was 38%. Additional endoscopic treatments were required in 4 patients: a second FCSEMS placement in 1; plastic stent (PS) placement in 1; stone extraction in 1; and endoscopic ultrasound–guided pseudocyst drainage in 1. Asymptomatic stent migration occurred in 2 patients. Suppurative pancreatic ductitis due to food impaction in the FCSEMS occurred in 2 patients, and endoscopic pancreatic duct drainage was performed. Stent-induced ductal changes developed in 2 patients and PS treatment was required in 1 patient for pain relief. Conclusion: The FCSEMS appears to be a feasible and potentially effective option for the management of refractory pancreatic duct strictures due to chronic pancreatitis during long-term follow-up. AEs including post-procedure pain, stent-induced ductal changes, migration, and ductitis are issues that need to be resolved.

Su1712 Treatment of Benign Pancreatic Duct Strictures With Fully Covered Self Expandable Metal Stents (FC-SEMS) Is Feasible, Safe and Effective in Patients With Symptomatic Chronic Pancreatitis (CP)

Su1712 Treatment of Benign Pancreatic Duct Strictures With Fully Covered Self Expandable Metal Stents (FC-SEMS) Is Feasible, Safe and Effective in Patients With Symptomatic Chronic Pancreatitis (CP)

Su1711 Management of Pancreatic Ductal Leaks in Patients With Chronic Pancreatitis

Su1711 Management of Pancreatic Ductal Leaks in Patients With Chronic Pancreatitis

Usefulness of Brush Cytology Combined With Pancreatic Juice Cytology in the Diagnosis of Pancreatic Cancer

Pancreatic juice cytology (PJC) and brush cytology (BC) performed during endoscopic retrograde cholangiopancreatography could make a definite diagnosis of pancreatic cancer. The aim of this study was to improve the diagnostic value of cytology performed during endoscopic retrograde cholangiopancreatography in the diagnosis of pancreatic cancer. The subjects comprised 127 patients with pancreatic ductal adenocarcinoma (PDAC) and 74 with benign pancreatic duct stricture mimicking PDAC. Final diagnosis was confirmed based on histopathology by resection or on more than 1 year of follow up. Pancreatic juice cytology was examined before and after BC. And the sensitivity of PJC combined with BC was examined. No malignancy was detected by PJC or by BC in patients with benign pancreatic duct strictures (specificity, 100%). In those with PDAC, the sensitivity of PJC before and after brushing was 21.3% and 40.9%, respectively; that of BC was 48.8%. Of 65 patients with PDAC, in whom neither PJC before brushing nor BC indicated malignancy, 16 were diagnosed with pancreatic cancer using PJC after brushing. Brush cytology combined with PJC after brushing significantly raised the diagnostic sensitivity for PDAC to 61.4%. Diagnosis of pancreatic cancer based on BC combined with PJC after brushing was more reliable than PJC before brushing or BC.

The Role of Anesthesiology During the Performance of Endoscopic Retrograde Cholangiopancreatography: Indications and Outcomes at a Tertiary Care Center

Background: Adequate sedation and amnesia are important in the performance of ERCP's. In the ill or uncooperative patient the decision to involve anesthesiology for administrating monitored anesthesia care (MAC) or general anesthesia (GA) is often important for patient safety and procedural success. We evaluated characteristics, indications, and complications in patients undergoing ERCP with anesthesiology assistance at our tertiary referral center. Results: From 7/1/02 to 6/30/04 2077 ERCP's were performed. A total of 192 procedures were performed in 111 patients with anesthesiology assistance. One hundred eighty-nine patients received GA and 3 received MAC. Sixty patients were female. The average procedural age was 43.9 years. Indications for GA or MAC included age of 18 or less (34%), ASA class IV (10.4 %), inability to sedate during an earlier procedure (11.4 %), chronic narcotic use (14.1 %), age 85 or greater (6 %), and sepsis (4.6 %). Thirty-four percent were ASA II and 40.6 % were ASA class III. Eight had PSC, 11 had choledochoceles, and 2 were pregnant. Ninety-one percent of procedures were therapeutic. Findings: 6 normal exams, pancreatic duct dilation in 75, common bile duct (CBD) dilation in 57, CDB stone in 30, benign CBD stricture in 35, benign pancreatic duct stricture 39, malignant biliary stricture in 11, pseudocyst 16, anastomotic stricture after liver transplantation in 9, pancreatic divisum in 5, and pancreatic mass in 5 patients. Procedural success was 98%. Anesthesia complications occurred in 2 patients (1%) (prolonged paralysis and uncomplicated ventricular tachycardia). Thirty- four patients were discharged the same day. Seventy-two were discharged within 24 hours of the procedure. Thirty-six of the 72 had sphincterotomies necessitating a 24 hour observational stay at our institution. Fifteen patients were discharged within 48 hours. Eight patients were admitted for an average of 6.9 days. The remaining 57 procedures were performed on hospitalized patients. Conclusion: Anesthesia support is employed in a variety of conditions and not limited to those with multiple comorbidities. The involvement of anesthesiology increases the procedural success and can be accomplished with low morbidity.

Past, Present, and Future of Endoscopic Retrograde Cholangiopancreatography: Perspectives on the National Institutes of Health Consensus Conference

Past, Present, and Future of Endoscopic Retrograde Cholangiopancreatography: Perspectives on the National Institutes of Health Consensus Conference

Pancreatic Duct Strictures.

The treatment of pancreatic duct strictures is based on an accurate assessment of the etiology of the disease, and then the degree of symptomatology. Our outline for therapy is as follows: Exclude a diagnosis of malignancy by using radiologic, endoscopic, histologic, and molecular biologic modalities. Once a benign stricture has been demonstrated, we favor a trial of endoscopic dilation and stent placement For the unresectable pancreatic neoplasm, in which an obstructive etiology for pain is suspected, a trial of endoscopic dilation and stent placement also should be considered. In benign pancreatic duct strictures complicated by biliary obstruction, and where the most durable treatment modality is sought, surgical intervention merits earlier consideration. Pancreatic duct stent placement should seldom be considered definitive therapy, and the risk of stent-induced duct injury must be weighed against potential therapeutic benefit.

Benign pancreatic duct strictures: medical and endoscopic therapy.

Pancreatic duct strictures usually reflect underlying pancreatic disease and are likely caused by one or more of the following: acute or chronic pancreatitis, benign or malignant pancreatic neoplasm, pseudocyst and trauma. The characteristics of pancreatic strictures are identified, and medical and endoscopic therapy options are reviewed.

Endoscopic treatment of pancreatic duct strictures

Pancreatic duct strictures present one of the most challenging diagnostic and therapeutic pancreatic disorders. Patients present with a variety of symptoms, including recurrent or persistent abdominal pain, particularly in the setting of chronic pancreatitis. Other presenting symptoms may be those generally present in other patients with chronic pancreatitis and include weight loss, steatorrhea, nausea, and vomiting. The finding of pancreatic duct strictures often possess a diagnostic dilemna regarding a cause. Differential diagnosis includes acute and chronic pancreatitis, pseudocysts, and neoplasm. An accurate diagnosis requires one or more radiographic studies. Appropriate use of endoscopic retrograde cholangiopancreatography (ERCP) allows for the conformation of pancreatic duct strictures, diagnostic tissue sampling, and therapeutic treatment options. Endoscopic techniques in the treatment of strictures have included dilation and pancreatic duct stenting at variable intervals. Several studies have demonstrated the success of placement, safety, and efficacy of transpapillary stenting in benign disease, although follow-up data have been short. Complications of stenting have been reported to include stent migration, stent occlusion, episode of acute pancreatitis, and anatomic changes of the main pancreatic duct similar to chronic pancreatitis. Randomized, controlled clinical trials comparing the efficacy of endoscopic versus surgical treatment options are needed to establish the optimal, long-term therapy of benign pancreatic duct strictures.

Dilation of a difficult benign pancreatic duct stricture using the Soehendra stent extractor

Endoscopic therapy for pancreatic disease continues to evolve. Treatment of benign pancreatic strictures with dilation and stent placement can lead to improvement in abdominal pain in selected patients with chronic pancreatitis.1,2 Recently, difficult malignant biliary strictures that allowed passage of only a guidewire have been traversed and dilated using a Soehendra stent extractor.3-5 This report describes its use for dilating a difficult benign pancreatic stricture.