Endoscopic Minor Papilla Sphincterotomy Research Articles

Endoscopic minor papilla sphincterotomy in patients with complete pancreas divisum and acute recurrent pancreatitis: a metanalysis

Background and Aims Pancreas divisum (PD) is a congenital variant of the pancreatic ductal system and a potential cause of acute recurrent pancreatitis (ARP). Endoscopic minor papilla sphincterotomy (MiES) is the most common procedure performed in the management of PD-related ARP. The aim of this study is to perform a meta-analysis estimating the efficacy and the safety of MiES in the management of patients with PD-related ARP. Methods A research was performed in Pubmed, EMBASE and Web of science, the studies were reviewed and selected according to inclusion and exclusion criteria. Evaluation of Heterogeneity and publication bias was performed, and a random effect model was used to estimate the effect size of each study. Results One hundred and thirteen articles were selected and reviewed, 13 met the inclusion criteria. All the studies were retrospective with a mean follow-up duration of 45.9 months. A total of 323 patients with PD-related ARP treated with MiES were included in the meta-analysis. The overall clinical success rate of MiES (defined as no further episodes of ARP, reduction of episodes of ARP, or improvement in quality of life) was of 77% (95%CI: 72%–81%; p = 0.30). Evaluating only the studies with clinical success rate defined as “no further AP in the follow-up” the clinical success rate was of 69.8% (95%CI: 61.3%–77.2%; p = 0.57), while evaluating the studies with other definitions (reduction of episodes of ARP or improvement in quality of life) the clinical success rate was of 81.2% (95%CI: 75.2%–86.1%; p = 0.45). The common fixed effects model disclosed a 25.5% overall adverse events rate (95%CI: 19.3%–32.8%; p = 0.42): acute pancreatitis in 14.3% (95%CI: 9.7%–20.6%; p = 0.36), bleeding in 5.6% (95%CI: 2.9%–10.4%; p = 0.98), and other adverse events in 5.6% (95%CI: 2.9%–10.4%; p = 0.67). Conclusion MiES is an effective and relatively safe treatment in the management of PD-related ARP. The retrospective nature of the studies selected is the main limitations of this metanalysis. Prospective trials are needed to confirm these data.

ASO Visual Abstract: Preoperative Endoscopic Minor Papilla Sphincterotomy for Pancreas Divisum in a Patient with Pancreatic Cancer Who Underwent Laparoscopic Distal Pancreatectomy.

ASO Visual Abstract: Preoperative Endoscopic Minor Papilla Sphincterotomy for Pancreas Divisum in a Patient with Pancreatic Cancer Who Underwent Laparoscopic Distal Pancreatectomy.

ASO Author Reflections: Preoperative Endoscopic Minor Papilla Sphincterotomy May Effectively Prevent Pancreatic Fistula After Distal Pancreatectomy in Patients with Pancreas Divisum.

ASO Author Reflections: Preoperative Endoscopic Minor Papilla Sphincterotomy May Effectively Prevent Pancreatic Fistula After Distal Pancreatectomy in Patients with Pancreas Divisum.

Preoperative Endoscopic Minor Papilla Sphincterotomy for Pancreas Divisum in a Patient with Pancreatic Cancer Who Underwent Laparoscopic Distal Pancreatectomy.

Pancreas divisum (PD) is a congenital anomaly that occurs due to failure of fusion of the dorsal and ventral pancreatic ductal systems.1-3 In PD, pancreatic juice drains mainly through the minor papilla via the dorsal duct, leading to high intraductal pressure, which can cause pancreatitis.1-3 We report a case of PD that underwent preoperative decompression using endoscopic minor papilla sphincterotomy (EMPS) before laparoscopic distal pancreatectomy (LDP) for pancreatic cancer.3 METHODS: The patient was a 74-year-old woman with pancreatic tail cancer, measuring 35 mm in size, in PD with an entirely dilated dorsal duct, implying high, intraductal pressure caused by minor papillary dysfunction. We performed EMPS to prevent postoperative pancreatitis and pancreatic fistula before LDP using a left-posterior approach, as previously described.4 As the pancreatic transection margin was positive for high-grade pancreatic intraepithelial neoplasia on intraoperative pathology, an additional resection of the pancreatic head to the right side of the portal vein was performed after the liberation of the gastroduodenal artery with both the dorsal and ventral pancreatic ducts ligated and divided. The operative time was 421 min, and blood loss was 70 mL. The postoperative course was uneventful, with no evidence of pancreatitis or pancreatic fistula. The patient was discharged on postoperative Day 10. Postoperative computed tomography revealed reduced dilatation of the dorsal duct. Preoperative EMPS may be effective in preventing pancreatic fistula after LDP in patients with PD.

Reappraisal of factors impacting the cannulation rate and clinical efficacy of endoscopic minor papilla sphincterotomy

BackgroundWe aimed to assess factors impacting the endoscopic minor papilla sphincterotomy (EMPS) success rate, clinical efficacy, and safety in a large cohort of patients with symptomatic pancreas divisum (PD). MethodsRetrospective study including patients with PD referred to the Pancreas Institute of Verona from May 2009 to May 2020 to undergo EMPS. The whole population was analyzed to assess EMPS technical success, defined as the rate of deep cannulation of the dorsal duct. Patients treated for recurrent pancreatitis (RP) with a minimum follow-up of 1 year were included to evaluate the clinical efficacy, defined as resolution or significant reduction of acute pancreatitis (AP) episodes. Safety was defined as the rate of procedure-related adverse events (AEs) according to an international lexicon. The effects of the main determinants on study outcomes were evaluated. ResultsOverall, 106 patients were evaluated. Technical success was obtained in 87 (82.1%). The presence of pancreatic calcifications was associated with failure (p < 0.0001). Clinical efficacy was evaluated in 59 patients. Resolution/reduction of AP episodes after EMPS was observed in 93% of patients over a median follow-up of 49 months (IQR 37–92). Smoking habit was associated with AP recurrence (p = 0.026). The overall AE rate was 14.9%, with post-ERCP pancreatitis as the most common complication (12.6%). ConclusionsIn our study, performed at a tertiary center, EMPS showed satisfactory technical success and an acceptable safety profile. If confirmed by prospective multicenter studies, EMPS could become the standard of care for the treatment of RP in PD.

Clinical Outcomes Following Therapeutic Endoscopic Retrograde Cholangiopancreatography in Children With Pancreas Divisum.

Pancreas divisum (PD) is a risk factor in children for the development of acute pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP) with minor papilla endoscopic sphincterotomy (mPES) may be of clinical benefit, however, the clinical outcomes from endotherapy remain unclear. We sought to review the outcomes and safety of therapeutic ERCP in children with PD. We performed a retrospective chart of children with PD who underwent an ERCP between February 2012 and December 2018. Pertinent patient, clinical and procedure information was collected including procedure-related adverse events. A follow-up questionnaire of the parent was conducted to determine the clinical impact from endotherapy. Fifty-eight ERCPs were performed in 27 patients (14 boys; mean age: 9.7 years, range 2-19) with PD. All patients underwent a successful mPES. A genetic variant was identified in 19/26 (73%) tested patients. Post-ERCP pancreatitis (PEP) was the only observed adverse event; 21% (12/58). Median follow-up interval from first ERCP intervention to questionnaire completion was 31.5 months (range: 4--72 months). Of the 20 questionnaire responders, 13 reported clinical improvement from endotherapy. The majority of children from our PD cohort possessed at least 1 genetic variant. Most questionnaire responders had a favorable response to endotherapy. PEP rate was comparable with that of prior reports in adult patients.

SpHincterotomy for Acute Recurrent Pancreatitis Randomized Trial: Rationale, Methodology, and Potential Implications.

In patients with acute recurrent pancreatitis (ARP), pancreas divisum, and no other etiologic factors, endoscopic retrograde cholangiopancreatography (ERCP) with minor papilla endoscopic sphincterotomy (miES) is often performed to enlarge the minor papillary orifice, based on limited data. The aims of this study are to describe the rationale and methodology of a sham-controlled clinical trial designed to test the hypothesis that miES reduces the risk of acute pancreatitis. The SpHincterotomy for Acute Recurrent Pancreatitis (SHARP) trial is a multicenter, international, sham-controlled, randomized trial comparing endoscopic ultrasound + ERCP with miES versus endoscopic ultrasound + sham for the management of ARP. A total of 234 consented patients having 2 or more discrete episodes of acute pancreatitis, pancreas divisum confirmed by magnetic resonance cholangiopancreatography, and no other clear etiology for acute pancreatitis will be randomized. Both cohorts will be followed for a minimum of 6 months and a maximum of 48 months. The trial is powered to detect a 33% risk reduction of acute pancreatitis frequency. The SHARP trial will determine whether ERCP with miES benefits patients with idiopathic ARP and pancreas divisum. Trial planning has informed the importance of blinded outcome assessors and long-term follow-up.

Pancreas Divisum and Pancreatitis: Is Sphincterotomy Worth It?

For decades, the performance of minor papilla endoscopic sphincterotomy (MiES) in patients with pancreas divisum has been debated, and opponents cite

Pancreas divisum and recurrent pancreatitis: long-term results of minor papilla sphincterotomy

Background and aims: Pancreas divisum (PD) is the most common congenital variant of the pancreatic ductal system and a potential cause of acute recurrent pancreatitis (ARP). Endoscopic therapy is a therapeutic option for symptomatic PD, but there is limited data on long-term results. We aimed to assess the effect of minor papilla endoscopic sphincterotomy (MiES) in the setting of ARP in patients with PD.Methods: Consecutive patients treated by MiES were included. Clinical data, including gender, age, smoking and drinking habits, number of episodes of acute pancreatitis (AP) as well as technical data pertaining to the endoscopic therapy were reviewed. Patients available for follow-up were contacted to assess the long-term impact of MiES using the Patient’s Global Impression of Change (PGIC) questionnaire.Results: A total of 138 patients with PD including 77 patients with ARP underwent MiES; 48 patients were available for long-term follow-up using the PGIC score, with a mean follow-up period of 9.7 years. Procedure-related adverse events developed in 10 cases (12.9%): 5 post-MiES delayed bleeding and 5 mild pancreatitis. MiES was clinically successful in 35 patients (72.9%) who did not experience any more episodes of AP. Improvement in quality of life (PGIC ≥6) occurred in 41/48 patients (85.4%). On multivariate analysis, stenosis of the MiES was the only predictive factor for increased risk of recurrent pancreatitis after initial therapy.Conclusion: MiES resulted an efficient treatment for ARP in patients with PD with clinical benefit, patient satisfaction and improved quality of life even at long-term follow-up.

Efficacy of Endoscopic Minor Papilla Sphincterotomy for Symptomatic Santorinicele.

Santorinicele, a rare focal cystic dilation of the distal portion of the dorsal pancreatic duct at the minor papilla, can be a cause of recurrent acute pancreatitis (RAP). Endoscopic minor papilla sphincterotomy (EMPS) has been evaluated as a treatment in case reports but never systematically investigated. We performed a retrospective analysis of the efficacy of EMPS in reducing episodes of pancreatitis. We collected data on 30 patients with santorinicele and RAP who underwent EMPS from June 2009 through April 2015 at University Hospital of Verona in Italy. The mean follow-up period was 43.8 months. The average number of pancreatitis episodes per year before EMPS was 1.59 vs 0.18 episodes after EMPS; the average number of pancreatitis cases that occurred during a comparable timeperiod before EMPS was 2.63 vs 0.67 cases after EMPS (P < .0001). Complete responses toEMPS (no recurrence of pancreatitis) were reported for 80% of patients. Six patients relapsed after amean time of 16 months. Five patients were found to have a potential cause of RAP beyond santorinicele (2 patients had post-sphincterotomy stenosis, 1 patient was a chronic consumer of alcohol, 1 patient had a mutation in the CFTR gene, and 1 patient had a side-branch intraductal papillary mucinous neoplasm). EMPS is effective in reducing the incidence of pancreatitis in patients with santorinicele.

Mo1331 When, Why and How Do Patients With Acute Pancreatitis Die? A Large Experience of 910 Direct (Not Transfer), Consecutive Admissions in Recent Years

G A A b st ra ct s Pancreatitis after Minor Papilla Endoscopic Sphincterotomy ( FRAMES )study. Results: RAP patients had at least 2 or more episodes of pancreatitis and were aged 45.82; m/f 18/31. There were 31 subjects in the FRAMES study. Mean age:56.8 y, 52% were males. From the QLQ-C30 and QLQ-PAN26 the professionals identified 22 issues relevant to RAP, including pain, fatigue, eating/food/GI symptoms, bowel function, social and family function, and financial worries. RAP patients reported significant impairment (similar to CP) in quality of life in Role/Emotional/Cognitive/Social and Sexual domains and increased symptoms: Pain/ altered bowel/N+V, Fatigue/insomnia. Overall QOL was reduced less than in CP patients (mean scores as %: normal 71; RAP 57; CP 39). Conclusions: RAP significantly impairs quality of life compared to normal individuals. Impairment in most domains is similar to CP. A subset of questions form the EORTC QLQ-C30 and QLQ-PAN26 can be used as a new RAP QOLI for future studies of RAP Functional scales in Normal, Recurrent Acute Pancreatitis, Chronic Pancreatitis and Patients with Pancreas divisum undergoing minor papillotomy

Mo1427 Outcomes After Minor Papilla Endoscopic Sphincterotomy (MPES) for Unexplained Acute Pancreatitis and Pancreas Divisum: Final Results of the Multicenter Prospective FRAMES (Frequency of Recurrent Acute Pancreatitis After Minor Papilla Endoscopic Sphincterotomy) Study

The role of pancreas divisum in unexplained acute pancreatitis (AP) is controversial. Most data on minor papilla endoscopic sphincterotomy (MPES) come from retrospective series without validated pain outcomes. The FRAMES NIH study aims to examine outcomes after MPES in the largest prospective series to date.

Mo1428 Prospective Study of Imaging Predictive Value and Agreement in Diagnosing Pancreas Divisum: the FRAMES (Frequency of Recurrent Acute Pancreatitis After Minor Papilla Endoscopic Sphincterotomy) Study

Mo1428 Prospective Study of Imaging Predictive Value and Agreement in Diagnosing Pancreas Divisum: the FRAMES (Frequency of Recurrent Acute Pancreatitis After Minor Papilla Endoscopic Sphincterotomy) Study

Endoscopic Minor Papilla Sphincterotomy in Patients with Santoriniceles Reduces Pain and Improves Quality of Life

Pancreas divisum patients with focal obstruction of the minor papilla and resulting dilation of the dorsal pancreatic duct [a santorinicele (SC)] have been reported to improve with endoscopic sphincterotomy of the minor papilla (ESMP). In this study, we assess the long-term efficacy of ESMP in SC patients. A retrospective review of the endoscopic database was performed. Fifteen patients with SCs were identified. A follow-up questionnaire was mailed to patients to assess for changes in quality of life (QOL), narcotic use, hospital admissions, and pain after ESMP. Fifteen patients were mailed questionnaires and 11 responses were obtained. The average pain score prior to ESMP was 8.6/10 (SD ± 1.7) and significantly decreased to 2.7/10 (SD ± 2.0) (p < 0.05) after treatment. Six patients required narcotics before ESMP and none used narcotics for recurrent pancreatic type pain after. Nine patients had recurring admissions for pancreatitis prior to ESMP while only two were admitted after treatment. Mean QOL score prior to ESMP was 4.5/10 (SD ± 2.7) and increased significantly to 8.4/10 (SD ± 1.3) (p < 0.05) with two patients rating their QOL at 10/10. QOL, narcotic use, hospital admissions, and pain scores all improved with ESMP. Endoscopic therapy for this uncommon condition appears both justified and potentially curative.

Etiology of recurrent acute pancreatitis, with special emphasis on pancreaticobiliary malformation

This study was aimed to investigate etiology and clinical profiles of recurrent acute pancreatitis (RAP), particularly from the morphology of the pancreaticobiliary duct system. Pancreaticobiliary morphology was examined in 230 of 381 patients with acute pancreatitis (AP) using endoscopic retrograde cholangiopancreatography. We analyzed factors associated with RAP including the pancreaticobiliary duct system. RAP was diagnosed in 74 patients (19%). Major etiologies of RAP were alcoholic (38%), idiopathic (26%) and pancreaticobiliary malformation (22%). Patients with alcoholic RAP were significantly younger (47.2±11.6 years) than those with gallstone RAP (67.3±16.8; p<0.05). RAP with pancreaticobiliary malformation (male-to-female ratio: 1:4.3; p<0.01) and gallstone RAP (1:1.7; p<0.05) occurred predominantly in females in comparison with alcoholic RAP (1:0.2). Recurrence rate was 80% for AP with pancreaticobiliary malformation, significantly higher than for the others (p<0.01). Pancreas divisum was suspected as the etiology of mild RAP in 7 patients. Four RAP patients with pancreas divisum underwent endoscopic minor papilla sphincterotomy and improved. Pancreaticobiliary maljunction with biliary dilatation (choledochal cyst) was suspected as the etiology of mild RAP in 3 patients. The 3 RAP patients with choledochal cyst underwent prophylactic flow diversion surgery with complete resection of the dilated common bile duct, and achieved improvement. High confluence of pancreaticobiliary ducts was suspected as the etiology of mild RAP in 6 patients. Pancreaticobiliary malformation is one of the major causes of RAP. As some of them benefit from endoscopic or surgical treatment, morphology of the pancreaticobiliary duct system should be examined where possible in RAP patients.

Su1370 Endoscopic Minor Papilla Sphincterotomy in Patients With Santoriniceles Provides a Durable Reduction in Pain and Improves Quality of Life

Endoscopic treatment of pancreas divisum (PD) in patients with relapsing pancreatitis remains controversial; however, a subset of PD patients with focal obstruction of the minor papilla and resulting dilation of the dorsal pancreatic duct (a Santorinicele) have been reported to improve with endoscopic sphincterotomy of the minor papilla (ESMP). The durability of ESMP in reducing pain and improving quality of life (QOL) is unclear. This study assesses the long term efficacy of ESMP in patients with a Santorinicele.Design: Sixteen patients with Santoriniceles were identified by searching the endoscopic database over a 12 year period (1999-2011).

ENDOSCOPIC APPROACH TO THE MINOR DUODENAL PAPILLA: SPECIAL EMPHASIS ON ENDOSCOPIC MANAGEMENT ON PANCREAS DIVISUM

Diagnostic and therapeutic approach to the minor duodenal papilla including standardized technique was reviewed. In cases in which a pancreatogram is not achieved or those in which only a small portion of the ductal anatomy is visualized via the major duodenal papilla, cannulation of the minor papilla provides a second route of access to the ductal system. Successful minor papilla cannulation requires meticulous attention to technique. As the orifice of the minor papilla is usually of pinpoint size, needle-tipped catheters are useful. As minor papilla cannulation in pancreas divisum carries the risk of severe pancreatitis, the procedure should be performed with more caution. In some patients with pancreas divisum, an increased resistance to flow across the small orifice results in dorsal pancreatic duct hypertension and clinical symptoms including acute recurrent pancreatitis, chronic pancreatitis, and pancreatic-type pain. Pancreas divisum patients with acute recurrent pancreatitis are the best candidates for endoscopic management for dorsal-duct decompression including endoscopic minor papilla sphincterotomy and stenting.

Endoscopic Approach via the Minor Duodenal Papilla

Background/Aims: We describe procedures for endoscopic approach via the minor papilla in symptomatic patients with pancreas divisum, pancreatic stones, and stricture of the Santorini’s duct, and neoplasms of the minor papilla: endoscopic minor papilla sphincterotomy, endoscopic pancreatic stone removal, endoscopic stent placement in Santorini’s duct, and resection of minor papilla neoplasms. Methods: The most important procedural detail was insertion of a guide wire into Santorini’s duct via the minor papilla, requiring gentle manipulation of both the cannula and guide wire to avoid subsequent complications such as pancreatitis. Results: Minor papilla sphincterotomy was most effective in the treatment of patients with pancreas divisum and associated with acute recurrent pancreatitis; these patients are the best candidates for endoscopic dorsal duct decompression including minor papilla sphincterotomy and stenting. Endoscopic treatment via the minor duodenal papilla was the only useful method for patients whose lesions could not be approached via the major papilla. It is a safe procedure to relieve pain. Long-term results of dorsal ductal stenting were satisfactory in 76 and 90% of patients (19/25 and 9/10, respectively). Conclusion: The high level of endoscopic skills necessary and the small number of patients who need these procedures should limit this approach to select institutions with appropriate endoscopic expertise.

ENDOSCOPIC APPROACH TO THE MINOR DUODENAL PAPILLA: SPECIAL EMPHASIS ON ENDOSCOPIC MANAGEMENT ON PANCREAS DIVISUM

Diagnostic and therapeutic approach to the minor duodenal papilla including standardized technique was reviewed. In cases in which a pancreatogram is not achieved or those in which only a small portion of the ductal anatomy is visualized via the major duodenal papilla, cannulation of the minor papilla provides a second route of access to the ductal system. Successful minor papilla cannulation requires meticulous attention to technique. As the orifice of the minor papilla is usually of pinpoint size, needle‐tipped catheters are useful. As minor papilla cannulation in pancreas divisum carries the risk of severe pancreatitis, the procedure should be performed with more caution. In some patients with pancreas divisum, an increased resistance to flow across the small orifice results in dorsal pancreatic duct hypertension and clinical symptoms including acute recurrent pancreatitis, chronic pancreatitis, and pancreatic‐type pain. Pancreas divisum patients with acute recurrent pancreatitis are the best candidates for endoscopic management for dorsal‐duct decompression including endoscopic minor papilla sphincterotomy and stenting.

A Case of Chronic Pancreatitis with Pancreatic Stones Successfully Treated with Endoscopic Minor Papilla Sphincterotomy for Pancreas Divisum

A 65-year-old male was admitted to our hospital because of repeated abdominal pain. The patient had been previously diagnosed as having chronic pancreatitis with pancreatic stones on the basis of finding of abdominal computed tomography (CT) . Endoscopic retrograde pancreatography revealed pancreas divisum and chronic pancreatitis with pancreatic stones. We judged that chronic dorsal pancreatitis was caused by insufficiency of pancreatic juice drainage from minor papilla, so we performed endoscopic minor papilla sphincterotomy for the improvement of pancreatic juice drainage. After the treatment, the patient has been free of episode of abdominal pain. Our experience suggests that endoscopic minor papilla sphincterotomy is one of the effective and noninvasive treatments of chronic dorsal pancreatitis with pancreas divisum.