Endoscopic Retrograde Pancreaticography Research Articles

Pancreatoscopy-guided electrohydraulic lithotripsy for the treatment of obstructive pancreatic duct stones: a prospective consecutive case series

Pancreatoscopy-guided electrohydraulic lithotripsy (EHL) has shown potential in the treatment of patients with obstructive chronic calcifying pancreatitis (CCP). We aimed to prospectively investigate the efficacy and safety of EHL as first-line therapy in patients with CCP of the pancreatic duct (PD). A prospective single-center consecutive case series was performed including symptomatic CCP patients with obstructing stones >5mm in the head or neck of the pancreas. Stone fragmentation was performed using EHL. Primary study outcome was technical success. Secondary outcomes were clinical success, adverse events, and number of interventions. Thirty-four consecutive patients were included. Complete or partial stone clearance after EHL was achieved in 24 patients (70.6%). Pancreatoscopy was not performed because of failure to cannulate the PD (n= 5) or resolution of stones after stent placement at the index endoscopic retrograde pancreaticography (ERP) procedure (n= 3). After successful PD cannulation, pancreatoscopy was technically successful in 24 of 26 patients (92.3%). In 1 patient, the stone could not be visualized because of a resilient stricture. Complete stone clearance was achieved in 20 patients (80%) and partial clearance in 5 patients (20%), after a median of 2 ERP procedures (interquartile range, 2) and 1 EHL procedure (interquartile range, 1). In patients who underwent pancreatoscopy with EHL, mean Izbicki pain score at baseline was 62.3 ± 23.1 (25/25) and dropped significantly to 27.5 ± 35.0 (22/25) at the 6-month follow-up (P< .001). The most common adverse event was acute pancreatitis, all mild and treated conservatively (n= 7). Pancreatoscopy-guided EHL is a promising treatment for symptomatic CCP patients with obstructive PD stones. (Clinical trial registration number: NTR6853.).

Cholangiocyte organoids from human bile retain a local phenotype and can repopulate bile ducts in vitro.

The well‐established 3D organoid culture method enabled efficient expansion of cholangiocyte‐like cells from intrahepatic (IHBD) and extrahepatic bile duct (EHBD) tissue biopsies. The extensive expansion capacity of these organoids enables various applications, from cholangiocyte disease modelling to bile duct tissue engineering. Recent research demonstrated the feasibility of culturing cholangiocyte organoids from bile, which was minimal‐invasive collected via endoscopic retrograde pancreaticography (ERCP). However, a detailed analysis of these bile cholangiocyte organoids (BCOs) and the cellular region of origin was not yet demonstrated. In this study, we characterize BCOs and mirror them to the already established organoids initiated from IHBD‐ and EHBD‐tissue. We demonstrate successful organoid‐initiation from extrahepatic bile collected from gallbladder after resection and by ERCP or percutaneous transhepatic cholangiopathy from a variety of patients. BCOs initiated from these three sources of bile all show features similar to in vivo cholangiocytes. The regional‐specific characteristics of the BCOs are reflected by the exclusive expression of regional common bile duct genes (HOXB2 and HOXB3) by ERCP‐derived BCOs and gallbladder‐derived BCOs expressing gallbladder‐specific genes. Moreover, BCOs have limited hepatocyte‐fate differentiation potential compared to intrahepatic cholangiocyte organoids. These results indicate that organoid‐initiating cells in bile are likely of local (extrahepatic) origin and are not of intrahepatic origin. Regarding the functionality of organoid initiating cells in bile, we demonstrate that BCOs efficiently repopulate decellularized EHBD scaffolds and restore the monolayer of cholangiocyte‐like cells in vitro. Bile samples obtained through minimally invasive procedures provide a safe and effective alternative source of cholangiocyte organoids. The shedding of (organoid‐initiating) cholangiocytes in bile provides a convenient source of organoids for regenerative medicine.

Endoscopic Ultrasound-Guided Pancreaticogastrostomy

In patients with symptomatic dilatation of the pancreatic duct in whom the conventional approach for the placement of an endoscopic transpapillary drainage catheter has been unsuccessful, endoscopic ultrasound (EUS)-guided pancreatic duct drainage (EUPD) has been introduced as an alternative to surgery or a rescue therapy after surgery. Here is demonstrated an EUS-guided pancreaticogastrostomy (EUS-PG) in a patient after acute necrotizing pancreatitis and endoscopic retrograde pancreaticography (ERP) showing a complete rupture of the pancreatic duct behind the head without filling of the duct in the corpus and tail of the pancreas. The dilated pancreatic duct in the corpus and tail of the pancreas looks for a disconnected pancreatic tail syndrome. This article is part of an expert video encyclopedia.

Pancreatic Injury

Injury to the pancreas, because of its retroperitoneal location, is a rare occurrence, most commonly seen with penetrating injuries (gun shot or stab wounds). Blunt trauma to the pancreas accounts for only 25% of the cases. Pancreatic injuries are associated with high morbidity and mortality due to accompanying vascular and duodenal injuries. Pancreatic injuries are not always easy to diagnose resulting in life threatening complications. Physical examination as well as serum amylase is not diagnostic following blunt trauma. Computed tomography (CT) scan can delineate the injury or transaction of the pancreas. Endoscopic retrograde pancreaticography (ERCP) is the main diagnostic modality for evaluation of the main pancreatic duct. Unrecognized ductal injury leads to pancreatic pseudocyst, fistula, abscess, and other complications. Management depends upon the severity of the pancreatic injury as well as associated injuries. Damage control surgery in hemodynamic unstable patients reduces morbidity and mortality.

Endoscopic Stent Therapy For Patients With Chronic Pancreatitis

Obstruction of the pancreatic duct is a common feature of chronic pancreatitis and often requires interventional therapy. The current prospective study investigated clinical success in 19 patients after initial endoscopic retrograde pancreaticography and relapse rates during a 2-year follow-up period. Seventeen of 19 patients with chronic pancreatitis (stage III according to the Cambridge classification) were treated by sphincterotomy and stent insertion. Endoscopic retrograde pancreaticography failed in 2 patients. Strictures were cannulated, dilated, and stones were removed with a dormia basket in 13 of 17 patients. Extracorporeal shock wave lithotripsy was necessary in 5 patients. Polyethylene stents (7F-11.5F) were placed into the dilated pancreatic duct. Mean duration of internal pancreatic stenting was 5.6 months. Three of 17 patients had recurrence of pain during the first follow-up year after stent extraction; in the second follow-up year, another 2 patients had a relapse. Overall, patients' assessment of the stent therapy revealed complete satisfaction in 17 of 19 patients. Endoscopic stent therapy is a safe, minimally invasive, and effective procedure in patients experiencing pain attacks during chronic pancreatitis associated with dilated pancreatic duct. According to our results, a relapse rate of approximately 30% can be expected within 2 years after stent extraction. These patients may be treated by repeated stent therapy.

Endoscopic stent therapy of obstructive chronic pancreatitis: Results from a prospective follow up study

Obstruction of the pancreatic duct is a common feature of chronic pancreatitis and often requires interventional therapy. Multicenter trials have revealed that stent therapy is effective in pain relief and improvement of obstruction. The current prospective study investigated relapse rates and outcome after successful stenting one year after stent therapy was completed. 19 patients with chronic pancreatitis had strictures and/or stones in the pancreatic duct, associated with chronic pain. 17 patients received successful endoscopic retrograde pancreaticography (ERP), stricture dilatation, followed by stone removal (basket) and internal stenting (7–11.5 French); ERP failed in 2 patients in which cannulation or permanent stent therapy could not be achieved. Mean duration of internal pancreatic stenting was 5.6 months; stents were extracted after improvement of clinical symptoms. Stent therapy resulted in complete pain relief in 10/19 patients; 7/19 patients reported significant improvement of symptoms. 3/17 patients had a recurrence of pain during the following 1 year after stent extraction and were re-treated by stent implantation. 13/17 patients had a gain of weight of more than 5% compared to their weight before stent therapy. Overall patients' assessment of the stent therapy revealed complete satisfaction in 17/19 patients. In conclusion, endoscopic stent therapy is a safe, minimally invasive and very effective procedure in patients with obstructive chronic pancreatitis. Our prospective study reveals that one year after completion of the therapy, clinical improvement is achieved and maintained in more than 82% of the patients.

The value of endoscopic diagnosis and the treatment of pancreas injuries following blunt abdominal trauma

Injuries to the pancreas following blunt abdominal trauma are rare due to its protected retroperitoneal position. Many pancreatic lesions remain unnoticed at first and only become apparent when complications arise or during treatment of other injuries. The mortality rate is between 12 and 30%, and if treatment is delayed it is as high as 60%. Using medical records over the past 5 years, we investigated when and in what circumstances endoscopic retrograde cholangiopancreaticography (ERCP) was used in the diagnosis and treatment of pancreas injuries after blunt abdominal trauma. Penetrating injuries were not taken into consideration. An ERCP was performed on a total of five patients with suspected injuries to the pancreas after blunt abdominal trauma. No duct participation could be determined in three of the patients with a first degree pancreatic lesion. A 44-year-old woman sustained severe internal and external injuries after a traffic accident. Because of the nature of her injuries, pancreatic left resection with splenectomy was necessary. After the operation, a pancreatic fistula diagnosed. The ductus pancreaticus (DP) was successfully treated by stenting with the use of endoscopic retrograde pancreaticography. A 24-year old woman was kicked in the epigastrium by a horse. On the day after the incident, she complained of increasing pain in the upper abdomen, and she had elevated amylase and lipase levels. Computed tomography scan showed free fluid. Less than 48 h after the accident, ERCP was performed and a leakage in the DP in the head-body region (fourth degree) was identified. We placed a stent, and during the subsequent laparoscopy the omental bursa was flushed out and a drainage laid. After 14 days, the patient was sent home. We removed the drainage 4 weeks after the accident, and the stent after 12 weeks. The major advantage of the prompt retrograde discription of the pancreatobiliary system after an accident in which pancreas involvement is suspected is the more precise assessment of the extent of the injuries. If a stent is placed in the same session, it is possible to carry out definitive and interventional treatment.

Value of combinations of pancreatic function tests to predict mild or moderate chronic pancreatitis.

Pancreatic function tests share an insufficient accuracy concerning the detection of mild or moderate forms of chronic pancreatitis. It was evaluated here whether by combination of different assays the prediction or exclusion of chronic pancreatitis could be improved. 62 patients with chronic abdominal pain and suspected chronic pancreatitis underwent an endoscopic retrograde pancreaticography. The duct alterations were classified according to the Cambridge criteria. In all individuals the pancreolauryl test in serum (PLT-S) and urine (PLT-U) was performed and elastase 1-immunoreactivity (E) as well as chymotrypsin (Chy) activity in stool were measured. Sensitivities, specificities, receiver-operator-curves as well as cut-off points at optimal accuracies were calculated for each single assay and all test combinations. Cut offs were optimized by a mathematical model to achieve highest accuracies. In 30 patients the pancreatic duct was normal and in 32 patients alterations of the duct system were found. These were classified as mild in 10 patients, as moderate in 8 patients and as severe in 14 patients. In those with mild and moderate disease all pancreatic function tests showed sensitivities/specificities of 60-65% and 65-70%, respectively. Only in severe chronic pancreatitis elastase was superior to the other tests. Combinations of function tests did not lead to improved accuracy. After mathematical optimization the accuracy (sensitivity 80%, specificity 80%) was best for the combination of PLT-S (cut off 4.7 micrograms/ml) and E (cut off 500 micrograms/g). Both parameters had to be below these newly defined cut offs to diagnose chronic pancreatitis. The accuracy of pancreatic function tests may be improved by use of altered cut offs and a combination of serum pancreolauryl test and elastase. These newly defined cut offs will have to be evaluated in a much larger study.

A RESECTED CASE OF DUCTECTATIC TYPE CYSTADENOMA OF THE PANCREAS

It is not always easy to make a differential diagnosis of cystic lesion of the pancreas whether it is a cyst, cystadenoma, or cystadenocarcinoma. Particularly cystic lesions with the size of less than several centimeter which can be detected by ERP, ultrasonography, and CT scan often have atypical papillary hyperplasia, which poses a problem whether it is reactive or tumorous. This paper describes our experience with a case of ductectatic type cystadenoma of the pancreas which was difficult to differentiate from mucous-producing cancer of the pancreas preoperatively. A 53-year-old was admitted to the hospital because of right hypochondraligia. Computed tomographic examination showed a low density area in the head of the pancreas. Pancreaticoduodenectomy was performed when endoscopic retrograde pancreaticography (ERP) showed dilatation of the main pancreatic duct and cystic dilatation of the lesser ducts with a filling defect. Pathological findings revealed atypical papillary hyperplasia with staining by anti-CEA monoclonal antibody and goblet cell metaplasia. Further investigations to diagnose the pancreatic cystic lesions whether cancerous or not are necessary measuring oncogene expression such as K-ras point mutation.

A CASE OF EPIDERMOID CYST OCCURRING IN AN INTRAPANCREATIC ACCESSORY SPLEEN

A very rare case of cyst formation of an intrapancreatic accessory spleen is reported. A 28-year-old male was admitted to the hospital because of epigastralgia and back pain. Tenderness at the right upper quadrant was present, but no mass was palpable on physical examination of the abdomen. Abdominal computed tomography and ultrasonography revealed a smooth-surfaced cyst with calcification at the tail of the pancreas. On endoscopic retrograde pancreaticography, there was no stenosis nor dilatation in the pancreatic duct, nor communication between the duct and the cyst.Operation was performed under a diagnosis of pancreatic cyst. There was a cyst of 25 mm in diameter in the tail of the pancreas, and caudal pancreatectomy was performed. The content was grayish-brown fluid with low amylase value, and parasite, hair and bacteria were not recognized at all.Histologically, an epidermoid cyst surrounded by thin layer of splenic tissue was in the pancrease, and the diagnosis of cyst formation in an intrapancreatic accessory spleen was made.Accessory spleen was not rare. It is found in 10 percent of autopsies, and its 20 percent was in the pancreas tail. However, reports on its cyst formation has been only three in the world literature.

A CASE REPORT OF MUCIN PRODUCING PANCREATIC CARCINOMA

The case involves a 71-year-old male under strict observation for chronic pancreatitis. Computed tomography and ultrasonography indicated a cyst in the pancreas head and dilatation of the main pancreatic duct. endoscopic retrograde pancreaticography showed the same main duct dilatation and a partial filling defect image in the cyst. The duodenal papilla was swelling, widely opened, and emission of viscous mucus was noted. Pancreatic-oduodenectomy was performed based on a preoperative diagnosis of a mucin producing pancreatic carcinoma. Perioperative use of pancreatic duct scope was proved effective in determing the lesions, and curative operation had done. Histopathological examination revealed a well differentiated papillary adenocarcinoma. A review of 91 cases reported in Japan was also described.

Endoscopic retrograde pancreatography and exocrine pancreatic function.

The incidence of pancreatitis has been increasing during the last decennium paralleling a rapid enhancement in alcohol consumption. For many years, diagnostic criteria of chronic pancreatitis were exclusively based on the estimation of the exocrine pancreatic function. New valuable information is provided from endoscopic retrograde pancreaticography (ERP) and pancreatic ultrasonography. In a consecutive series of patients with chronic alcoholism changes in the pancreatogram were demonstrated in approximately 44% of the patients. A comparative study of ERP and exocrine pancreatic function showed that only patients with advanced pancreatic lesions had a significant reduction in pancreatic function. It is suggested that 'subclinical pancreatitis' is frequent among alcoholics. Complementary use of pancreatic ultrasonography and ERP gives a differentiated picture of pancreatic disease and is recommended among the first steps in the diagnostic chain for pancreatic disease.

Pancreatic tissue pressure and pain in chronic pancreatitis.

Pancreatic tissue pressure (PTP) was measured peroperatively by the needle technique in 14 patients with chronic pancreatitis undergoing drainage operations for pseudocysts (six patients) or dilated ducts (eight patients). All patients suffered from severe abdominal pain before the operation, and a pain evaluation was made at discharge and after 8-18 months of observation. PTP was increased in all patients and was not different in the two groups. PTP decreased significantly in both groups after drainage. Pain relief at discharge was good or fair in 12 patients and poor in one (one patient died postoperatively). During observation, pain returned in four patients. Long-term pain relief was not related to PTP decrease, PTP after operation, type of operation, or patency of anastomosis as seen by endoscopic retrograde pancreaticography.

Duodenal Output and Concentration of Lactoferrin in Chronic Pancreatitis: Correlation to Amylase Secretion and Duct Morphology

To evaluate the clinical value of lactoferrin determination in duodenal contents in patients with chronic pancreatitis, three different studies were performed. No significant difference in meal stimulated output or secretion pattern was found between seven patients with chronic pancreatitis and six controls. After a meal test in 88 patients suspected for pancreatitis no correlation between concentration of lactoferrin and amylase was found. No correlation was found between degree of obstruction at endoscopic retrograde pancreaticography and duodenal concentration of lactoferrin. We conclude that the diagnostic value of lactoferrin determinations in chronic pancreatitis is doubtful.

Computed tomography of the dilated main pancreatic duct.

The ducts of the pancreas undergo changes secondary to pancreatic disease. This report is based on computed tomographic studies of 13 cases with enlarged main pancreatic ducts. All patients showed severe pancreatic disease of tumoral or inflammatory etiology. The dilatation of the main pancreatic duct was confirmed by endoscopic retrograde cholangiography and pancreaticography, surgical intervention, biopsy, and/or autopsy in all but two cases.

A Case of Zollinger-Ellison Syndrome

A case of Zollinger-Ellison syndrome was reported. The patient was a 46-year-old male with the chief complaint of nocturnal severe hunger pain. He had been undergone hemigastrectomy for hemorrhagic gastric ulcer five years ago.Many clinical and laboratory examinations were made including of gastric acid secretion, X-ray check of upper G. I. series, sella trucica, endoscopic retrograde pancreaticography, selective celiac angiography, measurement of serum electrolyte, serum gastrin level and hepato-pancreatic scintigraphy.No familial involvement was recognized in his three children at present time.Laparotomy disclosed a giant duodenal ulcer (3×3 cm) penetrating to the liver and total gastrectomy was performed. Non-β Islet cell tumor of the pancreas and its metastasis in the liver and lymphnode could not be disclosed because of massive adhesion by the previous operation and the ulcer penetration. The serum gastrin level measured preoperatively marked maximal 1, 400 pg/ml, and gradually decreased to minimal 33.6 pg/ml three months postoperatively, but again increased to 653.2 pg/ml 22 months postoperatively.The authors' experience was discussed with a review of the literature.

EXPERIENCE WITH ENDOSCOPIC RETROGRADE PANCREATICOGRAPHY

Review of our experience with the endoscopic retrograde pancreaticography is based on 650 examinations.An anatomic nomenclature of the pancreatic duct system is proposed. In the course of the normal evacuation of the pancreatic duct 3 different phases are distinguished. In papillary stenosis and in papillary spasm these phases are changed pathologically and the total evacuation time is prolonged. In chronic pancreatitis there are irregularities of the outline of the course of the duct with progress of the disease; there are ectasias, solitary or multiple stenoses, and deformities of the side ducts.Stones in the pancreatic main duct appear as defects in the contrast medium filling.The special value of the diagnostic proof of pancreatic abscesses and pseudocysts shown by contrast medium extraductation is discussed as regards surgical intervention.The duct changes seen in pancreatic carcinoma are often similar to those of chronic pancreatitis.The normal appearance of the pancreatic main duct and side ducts b...