Drainage Of Main Pancreatic Duct Research Articles

EUS-guided pancreatic ductal intervention: A comprehensive literature review

EUS has opened a new frontier in endoscopic techniques for accessing pancreatic ducts in patients with failed ERCP. The major indications of EUS-guided pancreatic duct intervention (EUS-PDI) are main pancreatic duct (MPD) strictures due to chronic pancreatitis or strictures of pancreaticojejunal or pancreaticogastric anastomosis after Whipple resection, which lead to recurrent acute pancreatitis. EUS-guided pancreaticogastro or duodenostomy offers an alternative to surgery when transpapillary drainage fails or is not possible. We provide an expert commentary and a brief overview on this relatively novel technique utilizing EUS-PDI creation in patients with impaired drainage of the MPD who have failed other conventional endoscopic techniques for MPD drainage and either are poor surgical candidates or are reluctant to undergo surgery.

Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Updated August 2018.

ESGE suggests endoscopic therapy and/or extracorporeal shockwave lithotripsy (ESWL) as the first-line therapy for painful uncomplicated chronic pancreatitis (CP) with an obstructed main pancreatic duct (MPD) in the head/body of the pancreas. The clinical response should be evaluated at 6 - 8 weeks; if it appears unsatisfactory, the patient's case should be discussed again in a multidisciplinary team and surgical options should be considered.Weak recommendation, low quality evidence.ESGE suggests, for the selection of patients for initial or continued endoscopic therapy and/or ESWL, taking into consideration predictive factors associated with a good long-term outcome. These include, at initial work-up, absence of MPD stricture, a short disease duration, non-severe pain, absence or cessation of cigarette smoking and of alcohol intake, and, after initial treatment, complete removal of obstructive pancreatic stones and resolution of pancreatic duct stricture with stenting.Weak recommendation, low quality evidence.ESGE recommends ESWL for the clearance of radiopaque obstructive MPD stones larger than 5 mm located in the head/body of the pancreas and endoscopic retrograde cholangiopancreatography (ERCP) for MPD stones that are radiolucent or smaller than 5 mm. Strong recommendation, moderate quality evidence.ESGE suggests restricting the use of endoscopic therapy after ESWL to patients with no spontaneous clearance of pancreatic stones after adequate fragmentation by ESWL.Weak recommendation, moderate quality evidence.ESGE suggests treating painful dominant MPD strictures with a single 10-Fr plastic stent for one uninterrupted year if symptoms improve after initial successful MPD drainage. The stent should be exchanged if necessary, based on symptoms or signs of stent dysfunction at regular pancreas imaging at least every 6 months. ESGE suggests consideration of surgery or multiple side-by-side plastic stents for symptomatic MPD strictures persisting beyond 1 year after the initial single plastic stenting, following multidisciplinary discussion. Weak recommendation, low quality evidence.ESGE recommends endoscopic drainage over percutaneous or surgical treatment for uncomplicated chronic pancreatitis (CP)-related pseudocysts that are within endoscopic reach.Strong recommendation, moderate quality evidence.ESGE recommends retrieval of transmural plastic stents at least 6 weeks after pancreatic pseudocyst regression if MPD disruption has been excluded, and long-term indwelling of transmural double-pigtail plastic stents in patients with disconnected pancreatic duct syndrome.Strong recommendation, low quality evidence.ESGE suggests the temporary insertion of multiple side-by-side plastic stents or of a fully covered self-expandable metal stent (FCSEMS) for treating CP-related benign biliary strictures.Weak recommendation, moderate quality evidence.ESGE recommends maintaining a registry of patients with biliary stents and recalling them for stent removal or exchange.Strong recommendation, low quality evidence.

337 ENDOSCOPIC ULTRASOUND (OLYMPUS MINIPROBE) ASSISTED RETROGRADE PANCREATIC DUCT ACCESS IN PATIENTS WITH COMPLETE STENOSIS OF PANCREATICOJEJUNOSTOMY AFTER WHIPPLE SURGERY

337 ENDOSCOPIC ULTRASOUND (OLYMPUS MINIPROBE) ASSISTED RETROGRADE PANCREATIC DUCT ACCESS IN PATIENTS WITH COMPLETE STENOSIS OF PANCREATICOJEJUNOSTOMY AFTER WHIPPLE SURGERY

Outcome of Pancreatic Head Coring in as Key Surgical Treatment in Head Dominant Chronic Pancreatitis in Tertiary Referral Centers of Bangladesh

Background: Pancreatic head coring procedure, an organ preserving surgery in which diseased head of pancreas is cored with drainage of main pancreatic duct by lateral pancreatico-jejunostomy. Chronic pancreatitis is a persistently occurring inflammatory disease that causes pancreatic duct stones or calcification, stricture, dilatation of pancreatic duct and irreversible morphological changes resulting intractable pain and losses of exocrine and endocrine function. Appropriate management protocol recognizing underlying pathology, can prevent complications and improves the quality of life. Apart from ductal decompression, in Frey’s’ procedure resection of the “pacemaker of pain” (Head of the pancreas) gives excellent outcome.Methods: In this prospective observational study, we have intended to further validate the Frey’s procedure an effective surgical method in head dominant severe chronic pancreatitis. The study was carried out on 106 Bangladeshi patients who underwent Frey’s Procedure with Lateral Pancreaticojejunostomy from January 2000 to December 2017.Result: The study revealed 51 patients (48.11%) were in 3rd decade of life with 45 male and 61 female. We found 77 patients presented with diabetes mellitus, mostly on insulin. Steatorrhoea was noted in 39 patients and Malnutrition in 79 patients. Visual Analog Scale (VAS) was used for scoring pain. Postoperative morbidity was noted in 29 patients 27.35 % cases, but there was no anastomotic leakage or mortality in the immediate postoperative period in our series.Conclusion: Quality of life has always been the most important decisive factor for patients with severe chronic Pancreatitis. Pain is the predominant clinical feature and very difficult to control. Correction of diabetes and malnutrition are major challenges too. This study revealed, Frey’s procedure with adequate ductal clearance with wide pancreato-jejunal anastomosis in head dominant severe chronic pancreatitis is key to better pain control, improves quality of life and prevents recurrence.Birdem Med J 2018; 8(2): 151-158

Extracorporeal shock wave lithotripsy is a safe and effective treatment for pancreatic stones coexisting with pancreatic pseudocysts

We aimed to investigate outcomes of pancreatic extracorporeal shock wave lithotripsy (P-ESWL) for the removal of large pancreatic stones coexisting with pancreatic pseudocysts (PPCs) in chronic pancreatitis (CP). This is a prospective study performed in CP patients with at least 1 stone (≥5mm). Patients were divided into the PPC group (stones coexisting with PPCs) or the control group (stones alone). Patients were initially subjected to successive P-ESWL treatments, followed by ERCP. Primary outcomes were P-ESWL adverse events, and secondary outcomes were stone clearance, long-term pain relief, improved quality-of-life scores, and PPC regression. A total of 849 patients (59 in the PPC group and 790 in the control group) was subjected to P-ESWL between March 2011 and October 2013. Occurrences of P-ESWL adverse events were similar between the PPCgroup and the control group (11.86% vs 12.41%, P= .940). After the treatment of initial P-ESWL combined with ERCP, the complete, partial, and nonclearance of stones occurred in 67.24%, 20.69%, and 12.07%, respectively, of patients in PPC group, with no significant difference from the control group (complete, partial, and nonclearance: 83.17%, 10.40%, and 11.39%, respectively; P= .106). Fifty-five of 59 patients (93.22%) with PPCs were followed for a median period of 21.9 months (range, 12.0-45.1). PPCs disappeared in 56.36% (31/55) and 76.36% (42/55) of patients after 3 months and 1 year of follow-up visits, respectively. Moreover, complete and partial pain relief were achieved in 63.64% (35/55) and 25.45% (14/55) of patients, respectively. The scores for quality of life (P< .001), physical health (P< .001), and weight loss (P< .001) improved. In our multispecialty tertiary center, initial P-ESWL followed by ERCP was safe in patients with coexisting pancreatic stones and PPCs and effective for stone clearance, main pancreatic duct drainage, and pain relief.

The role of endoscopy in the therapy of chronic pancreatitis

Almost all the therapeutic efforts in the treatment of chronic pancreatitis are directed towards pain control. Endoscopic techniques available for this purpose are endoscopic retrograde cholangiopancreatography (combined or not with extracorporeal shock wave lithotripsy) and endoscopic ultrasound. Pancreatic stones and strictures, pancreatic pseudocysts, and common bile duct strictures complicating chronic pancreatitis can be treated by endoscopy. The development of endoscopic ultrasound extended the possibilities in the treatment of pancreatic pseudocysts and main pancreatic duct drainage. Endoscopy is considered the first-line treatment in chronic pancreatitis and can be useful also as a 'bridge to surgery'. In fact the endoscopic approach to chronic pancreatitis can predict the response to surgical therapy as a definitive treatment. Medical, endoscopic and surgical methods for the management of chronic pancreatitis should all be considered in decision-making, and the best treatment should be chosen case by case and according to the local expertise.

Endoscopic Treatment of External Pancreatic Fistulas: When Draining the Main Pancreatic Duct Is Not Enough

Transpapillary drainage of the main pancreatic duct (MPD) has been proposed for the treatment of external pancreatic fistulas (EPF) but may not suffice to treat complex cases. The aim of the present study was to explore the efficacy of various endoscopic or combined percutaneous and endoscopic techniques in the treatment of EPFs. Sixteen patients presenting with EPFs were treated in our department. The techniques applied and patients' clinical outcome are described. All but three patients underwent transpapillary MPD drainage by pancreatic sphincterotomy (N = 13). Additional endoscopic procedures performed were: (a) pancreatic fluid collection (PFC) drainage (N = 5), (b) transmural drainage between the fistula path and the gastrointestinal (GI) tract (N = 5), and (c) endoscopic ultrasound (EUS)-guided pancreaticoduodenostomy because of complete pancreatic duct rupture (N = 1). Fistula closure was achieved in all patients except one, who required surgery. During a median follow-up period of 18 months (range 6-52) three patients had fistula recurrence, and two, PFC recurrence. Both conditions were cured successfully by repeated endoscopic therapy. All recurrences occurred within 3 months of initial successful treatment. Combined endoscopic and percutaneous treatment appears to be safe and effective for the management of complex cases of EPFs.

EUS-Guided Pancreaticoduodenostomy: A New Technique for Main Pancreatic Duct Drainage in Acute and Chronic Pancreatitis

Background: Endoscopic drainage of the main pancreatic duct (MPD) in chronic pancreatitis (CP) can lead to a decrease in ductal hypertension, resulting in pain relief. Moreover, MPD drainage can be helpful in acute pancreatitis (AP) complicated with pancreatic duct disruption (PDD), in order to decrease the leakage of pancreatic juice from the disconnected pancreatic segment. However, in case of complete MPD obstruction (CP) or complete PDD (AP), transpapillary access to the proximal MPD segment cannot be obtained and conventional endoscopic ductal drainage is not possible. In these cases, a new technique, EUS-guided pancreaticoduodenostomy (PD), can be useful. Patients and Methods: We report five patients with CP (n = 4) or AP (n = 1) who underwent EUS-guided PD in order to achieve MPD drainage. In all patients, cannulation of the proximal segment of the MPD was not possible by means of a transpapillary approach. Results: Four patients with painful CP presented severe ductal dilation above a tight distal stricture. The remaining patient had presented severe AP, complicated with complete PDD and a pancreaticocutaneous fistula secondary to a previous percutaneous collection drainage. The proximal segment of the MPD was dilated in all patients. PD was performed as follows: Under EUS-guidance, a 19 gauge needle was inserted transduodenally into the proximal, dilated MPD, after its visualization with the tip of the echo-endoscope positioned in the duodenal bulb. Contrast medium was injected, confirming correct location of the needle in the duct. The needle was then exchanged over a guidewire for a 6.5 F diathermic sheath, introduced in the pancreaticoduodenal channel using cutting current. This channel was further enlarged by balloon dilation in two patients. Finally, a pancreaticoduodenal plastic straight stent was placed. In both patients who had previous balloon dilation of the PD, a 10 F stent was placed, whereas smaller diameter stents (6 F or 7 F) were initially used in the remaining patients. These stents were replaced by 10F stents during a second procedure. No complications were recorded. All patients had initial symptom resolution (pain relief and fistula closure) and remained well during a mean follow-up of 10 months (range: 3-30) with the stent in place. Conclusions: EUS guided PD is a new method of ductal decompression in patients with CP or AP, in cases when conventional ERCP fails to obtain access to the proximal MPD. Background: Endoscopic drainage of the main pancreatic duct (MPD) in chronic pancreatitis (CP) can lead to a decrease in ductal hypertension, resulting in pain relief. Moreover, MPD drainage can be helpful in acute pancreatitis (AP) complicated with pancreatic duct disruption (PDD), in order to decrease the leakage of pancreatic juice from the disconnected pancreatic segment. However, in case of complete MPD obstruction (CP) or complete PDD (AP), transpapillary access to the proximal MPD segment cannot be obtained and conventional endoscopic ductal drainage is not possible. In these cases, a new technique, EUS-guided pancreaticoduodenostomy (PD), can be useful. Patients and Methods: We report five patients with CP (n = 4) or AP (n = 1) who underwent EUS-guided PD in order to achieve MPD drainage. In all patients, cannulation of the proximal segment of the MPD was not possible by means of a transpapillary approach. Results: Four patients with painful CP presented severe ductal dilation above a tight distal stricture. The remaining patient had presented severe AP, complicated with complete PDD and a pancreaticocutaneous fistula secondary to a previous percutaneous collection drainage. The proximal segment of the MPD was dilated in all patients. PD was performed as follows: Under EUS-guidance, a 19 gauge needle was inserted transduodenally into the proximal, dilated MPD, after its visualization with the tip of the echo-endoscope positioned in the duodenal bulb. Contrast medium was injected, confirming correct location of the needle in the duct. The needle was then exchanged over a guidewire for a 6.5 F diathermic sheath, introduced in the pancreaticoduodenal channel using cutting current. This channel was further enlarged by balloon dilation in two patients. Finally, a pancreaticoduodenal plastic straight stent was placed. In both patients who had previous balloon dilation of the PD, a 10 F stent was placed, whereas smaller diameter stents (6 F or 7 F) were initially used in the remaining patients. These stents were replaced by 10F stents during a second procedure. No complications were recorded. All patients had initial symptom resolution (pain relief and fistula closure) and remained well during a mean follow-up of 10 months (range: 3-30) with the stent in place. Conclusions: EUS guided PD is a new method of ductal decompression in patients with CP or AP, in cases when conventional ERCP fails to obtain access to the proximal MPD.

A new application for therapeutic EUS: Main pancreatic duct drainage with a “pancreatic rendezvous technique”

A new application for therapeutic EUS: Main pancreatic duct drainage with a “pancreatic rendezvous technique”

7241 Endoscopic therapy in chronic pancreatitis through the minor papilla in non-divisum patients.

INTRODUCTION: A subset of patients with chronic pancreatitis (CP) have symptoms related to obstruction of the main pancreatic duct (MPD). Endoscopic decompression via stricture dilation or stone removal may alleviate symptoms. In patients with distal MPD obstruction and proximal dilation (Cremer IV), access to the MPD via the major papilla may be impossible. We describe 5 such cases in which endoscopic therapy was accomplished following access to the MPD through the minor papilla. METHODS:We reviewed 5 patients with CP undergoing ERCP for evaluation of recurrent pancreatitis (3) or chronic unremitting pain (2). There were 4 males, mean age 54yrs (range 34-81yrs). The etiology was ETOH in 4/5. On CT all had parenchymal calcifications, 4 had CBD dilation, 2 had PD dilation and 1 had PD calculi. RESULTS: After failed access to the MPD via the major papilla due to obstructing distal stricture (4) or stone (1), successful access to the Santorini's duct through the minor papilla revealed dilation of the MPD (5-20mm). Additionally 2 patients had free floating MPD stones. Endoscopic therapy included minor papilla sphincterotomy in 4, minor papilla push dilation (10fr) in 1, MPD stone extraction in 1 and minor papilla stent in 4. In addition 3 required biliary sphincterotomy and biliary stents. Excellent MPD drainage was observed in all patients. 4 had immediate complete symptom relief while 1 had partial relief. Repeat ERCP with minor papilla dilation and temporary stenting was performed in 2. In long term follow-up, surgery was performed in 2 (pylorus-preserving Whipple-1, Beger procedure-1) and recommended to a 3rd. The 2 remaining patients had durable symptom relief (1yr and 1.5yrs). CONCLUSIONS: In patients with CP and distal MPD obstruction, endoscopic therapy can be applied accessing the MPD through the minor papilla. As with endoscopic therapy for CP via the major papilla, short term pain relief can be expected and durable relief is seen in a subset.