Endoscopic Retrograde Pancreatography Research Articles

Detectability of pancreas divisum in patients with acute pancreatitis on multi-detector row computed tomography

The purpose of this study was to retrospectively assess the diagnostic performance of multi-detector row computed tomography (MDCT) in an evaluation of pancreas divisum using endoscopic retrograde pancreatography (ERP) as the reference standard. We analyzed 41 consecutive patients (14 cases of pancreas divisum and 27 cases of standard anatomy) who had undergone both MDCT and ERP for the evaluation of clinically diagnosed acute pancreatitis between November 2004 and June 2007. The CT reconstruction thickness and interval were both 3 mm. Two radiologists independently reviewed CT data, and the diagnostic confidence in determining the pancreatic ductal anatomy was scored using a five-point scale. CT detectability was correlated with the severity of pancreatitis and the degree of pancreatic necrosis based on the Balthazar index. With consensus, 16 of 41 cases (39.0%) were evaluated as indeterminate. Ductal anatomy was correctly diagnosed in 23 of 41 cases (56.1%). Eight of 14 cases (57.1%) were correctly diagnosed as pancreas divisum. Standard anatomy was identified in 15 of 27 cases (55.6%). The inter-observer agreement was substantial (κ = 0.71). Grade B or more pancreatitis and the presence of pancreatic necrosis significantly influenced the evaluation of ductal anatomy (p = 0.01 and p < 0.01, respectively). Pancreas divisum was correctly diagnosed in the case of grade A acute pancreatitis. The CT detectability of pancreas divisum in patients with grade B or more pancreatitis is still relatively low even in the MDCT era.

Hemosuccus Pancreaticus Diagnosed With Concurrent Endoscopic Retrograde Pancreatography and Selective Angiography

A 50-year-old man was admitted to our hospital with a principal complaint of massive hematemesis without abdominal pain. He had complained of recurrent episodes of melena with severe anemia about twice a month for the preceding 2 years. The source of bleeding was not identified despite repeated gastrointestinal examinations performed at another hospital. He had a medical history of alcohol-induced severe acute pancreatitis 11 years earlier. A physical examination revealed only that the patient appeared anemic.

Endoscopic Ultrasound in the Etiological Diagnosis of Idiopathic Pancreatitis

Aims: Recent new laboratory and technological advances have been able to shred the enigmatic veils of (Idiopathic Pancreatitis, IP) to a point wherein with extensive evaluation it is possible to reveal the etiology in 79%-80% of patients previously labeled as having idiopathic pancreatitis. More modern imaging investigations include, but are not limited to fine cut computerized tomography, endoscopic retrograde pancreatography, magnetic resonance pancreatography as well as endoscopic ultrasound.

A case of spindle cell type anaplastic carcinoma of the pancreas -review of Japanese case report-.

We present a case of cell type anaplastic carcinoma of the pancreas in a 63-year-old woman. A pancreatic mass was incidentally detected by routine abdominal ultrasonography examination for her hepatitis B infection, and she was admitted to our hospital for further examination. Computed tomography revealed a hypo-vascular mass measuring 25mm in maximal dimension at the pancreas body. Endoscopic ultrasonography showed a hypoechoic mass as the pancreas body and a swollen lymph node near the tumor. Endoscopic retrograde pancreatography revealed disruption of the main pancreatic duct, and carcinoma cells were detected in pancreatic juice obtained via an endoscopic nasopancreatic drainage tube. We diagnosed this case as an invasive ductal adenocarcinoma of the pancreas body, therefore the distal pancreatectomy with splenectomy (D1+α) was performed. The histopathological diagnosis for this case was a spindle cell type anaplastic carcinoma of the pancreas. The patient has remained well with no evidence of recurrence for 9 months since her operation.

Localized autoimmune pancreatitis, 9 mm in size, without strictures of the main pancreatic duct

A 74-year-old woman complaining of abdominal pain and fever was referred to our department. Her levels of liver enzymes and serum amylase were within normal ranges. CA19-9 and gastrin were elevated: 121.1 U/mL (normal 37.0 U/mL) and 1100 pg/mL (normal 201 pg/mL), respectively. MRCP demonstrated the pancreatic duct and bile tract to be normal. Magnetic resonance imaging revealed a small mass lesion in the pancreatic tail, showing an isointensity with T1-weighted imaging, a high intensity with T2-weighted imaging, and a remarkably high signal on diffusion-weighted imaging. CT showed a small mass lesion with a clear border and slight enhancement (Fig. 1). EUS revealed a low echoic mass 9 mm in diameter with a homogeneous internal structure in the pancreatic tail without abnormalities in the pancreatic and bile ducts (Fig. 2). Endoscopic retrograde pancreatography showed no stricture

Sirolimus may be associated with early recurrence of biliary obstruction in liver transplant patients undergoing endoscopic stenting of biliary strictures

Introduction. Recurrent biliary obstruction necessitating premature repeat endoscopic retrograde pancreatography (ERCP) remains a costly and morbid problem in patients undergoing treatment of post-or-thotopic liver transplantation (OLT) biliary strictures. We evaluated the relationship between prednisone or sirolimus use and early recurrence of biliary obstruction given their negative effects on collagen production and cholangiocyte regeneration.Methods. Medical records of adult patients who underwent OLT from 1998-2008 and developed anastomotic (ABS) and/or nonanastomotic (NABS) biliary strictures requiring endoscopic plastic stent therapy were reviewed. Outcome was early recurrence of biliary obstruction requiring repeat ERCP. Univariate and multivariable logistic regression analysis, adjusting for age, sex, and time from OLT to ERCP, were performed.Results. 35 patients with ABS and 9 patients with NABS underwent a total of 157 ERCPs. Median patient age was 56 years, 68% were male, and hepatitis C was the most common OLT indication (52%). Early recurrence of biliary obstruction ocurred following 17.1% of ERCPs. In univariate analysis, neither prednisone nor sirolimus was associated with early recurrence of biliary obstruction. In multivariate analysis, however, sirolimus use was associated with increased incidence of early recurrent biliary obstruction (OR = 2.53; 95% CI: 0.77-8.32; p = 0.12); this was more pronounced at doses > 3 (OR = 4.27; 95% CI: 0.62-29.3; p = 0.14) than at ≤ 3 mg/day (OR = 2.24; 95% CI: 0.62-8.13; p = 0.22) and statistically significant in patients with ABS only (OR = 1.44 per mg increase in sirolimus dose; 95% CI 1.02-2.03; p = 0.037).Conclusions. Sirolimus use, particularly at higher doses and patients with ABS, may be associated with an increased risk of early recurrence of biliary obstruction requiring repeat ERCP for post-OLT biliary strictures. Additional studies are needed to further investigate these findings and elucidate other risk factors.

Clinicopathologic Characteristics and Endoscopic Treatment of Post-Traumatic Pancreatic Pseudocysts

Surgery is the treatment of choice for traumatic pseudocyst. Minimally invasive management of these collections has been used. The aim was to analyze the outcome after endoscopic treatment and the integrity of the main pancreatic duct caused by abdominal trauma. A total of 51 patients with traumatic pseudocyst who underwent endoscopic therapy were studied. All were symptomatic with a persistent collection for more than 6 weeks. Endoscopic retrograde pancreatography allowed characterization according to Takishima classification (1, 2, and 3), in which guided therapy was divided into transpapillary drainage (Takishima 2 and 3 without bulging), transmural (type 1), or combined (type 2 or 3 with bulging). Endoscopic retrograde pancreatography was obtained in 47 (90%) of 51 patients. Drainage was transmural in 13, combined in 24, and transpapillary in 10. The success and recurrence rates of endoscopic treatment were 94% and 8%, respectively. There were 9 complications but no procedure-related deaths. Patients with penetrating trauma had more recurrences (P = 0.01) and risk for development of infection (P = 0.045) than those with blunt trauma. Endoscopic treatment of traumatic pancreatic collection is safe and effective and can be considered a first-choice alternative to surgical treatment. Endoscopic retrograde pancreatography and Takishima classification are useful in determining the best endoscopic approach.

Su1436 Combined Endoscopic Nasopancreatic and Percutaneous Drainage to Treat Pancreaticopleural Fistulae

Pancreaticopleural fistulae occur as a rare complication of acute or chronic pancreatitis and present as a high-amylase pleural effusion. Several reports demonstrated the efficacy of endotherapy with transpapillary stenting but the experience of endoscopic nasopancreatic drain (ENPD) placement is limited. The data with regard to the usefulness and safety of percutaneous drainage in combination with ENPD for treating pancreatic pleural effusion is also limited. The aim of the present study was to evaluate the efficacy and safety of combined ENPD placement and percutaneous approach to treat pancreaticopleural fistulae. From July 2008 to August 2010, six patients (age range: 23-68 years, 4 men and 2 women) with pancreatic pleural effusion with pancreatic duct disruption documented on pancreatogram were studied. All patients were treated by endoscopic pancreatic sphincterotomy, ENPD (5Fr) placement, and percutaneous drainage (8.5Fr). Main Outcome Measurements: Resolution of pancreaticopleural fistula and pancreatic pleural effusion, and development of chronic pancreaticocutaneous fistulae and ENPD-induced ductal strictures. Results: Of the six patients, four had alcoholic acute pancreatitis, one had alcoholic chronic pancreatitis, and one was associated with post-operative pancreatic trauma after splenectomy. The healing of pancreaticopleural fistulae was demonstrated by nasopancreatogram in 10-23 days (median 15 days) in all patients. The resolution of pancreatic pleural effusion was demonstrated as early as 10 days of combined modality. ENPD and percutaneous drain could be removed without another procedure. No patients had development of major complications including chronic pancreaticocutaneous fistulae and ENPD-induced ductal strictures. There was no recurrence of pancreatic pleural effusion at a mean follow up of 10 months. Pancreaticopleural fistulae can be treated by combined ENPD placement and percutaneous drainage effectively, avoiding repeated endoscopic retrograde pancreatography and development of pancreaticocutaneous fistulae and ENPD-induced ductal strictures.

Asymptomatic curable pancreatic ductal carcinoma detected during the follow-up of pancreatic cysts distinct from carcinoma.

Recent studies have reported that pancreatic ductal carcinomas are frequently found during the follow-up of pancreatic cysts distinct from carcinoma; however, the majority of them are detected in advanced stages. Therefore, the early detection of metachronous ductal carcinomas is one of the issues in the management of pancreatic cysts. A 25-mm pancreatic cyst in the pancreatic head was found during an annual check-up in a 70-year-old woman. She was followed up every 6months by abdominal ultrasound (US) and blood tests, and every 12months by an additional magnetic resonance imaging scan. Twelve months later, abdominal US revealed a suspicious low-echoic area of 17mm diameter in the pancreatic body. Eighteen months later, her serum carbohydrate antigen 19-9 level rose to 92U/ml. Endoscopic retrograde pancreatography demonstrated a strictured main pancreatic duct (MPD) of 15mm in length in the pancreatic body. A cytological examination of the brushed MPD revealed adenocarcinoma. The patient underwent distal pancreatectomy and splenectomy after chemoradiotherapy. An histological examination revealed a ductal carcinoma of 26mm diameter in the pancreatic body, which was successfully resected. This case might help to establish an optimal surveillance method to detect metachronous ductal carcinomas arising from the pancreas harboring cystic lesions.

A case of pancreatic solid-pseudopapillary neoplasm with marked ossification.

A cystic lesion of the pancreas was detected in a 25-year-old asymptomatic woman during a company medical checkup. Abdominal computed tomography (CT) revealed an ossified lesion in the pancreatic body, and the patient was referred to us for further management. Abdominal ultrasound and endoscopic ultrasound showed a hypoechoic mass with a large ossific focus, measuring 25mm in the pancreatic body. CT and magnetic resonance imaging (MRI) showed a nonenhancing tumor lesion with a large calcific focus, measuring 20mm in the pancreatic body. Endoscopic retrograde pancreatography revealed mild stenosis of the main pancreatic duct near the ossific focus in the pancreatic body. From the above, a pancreatic solid-pseudopapillary neoplasm (SPN) was suspected, and resection of the pancreatic body was performed. Intraoperatively, a whitish tumor measuring about 20mm was recognized. Histopathologically, moderately large-sized tumor cells containing eosinophilic cytoplasm were arranged in a pseudopapillary formation, and infiltrated the surrounding normal tissue with ossification. Immunostaining was positive for α1-antitrypsin, not inconsistent with the diagnosis of SPN. We report this case of pancreatic SPN with ossification and a review of the literature.

Endoscopic retrograde pancreatography criteria to diagnose autoimmune pancreatitis: an international multicentre study

BackgroundCharacteristic pancreatic duct changes on endoscopic retrograde pancreatography (ERP) have been described in autoimmune pancreatitis (AIP). The performance characteristics of ERP to diagnose AIP were determined.MethodsThe study was done in...

Pancreatic antegrade needle-knife (PANK) for treatment of symptomatic pancreatic duct obstruction in Whipple patients (with video)

Endoscopic decompression of symptomatic main pancreatic duct (MPD) dilation in Whipple patients is often difficult because of stenosis of the pancreaticojejunal (PJ) anastomosis. To evaluate the feasibility and procedural safety of the pancreatic antegrade needle-knife (PANK) technique, with the goal of restoring antegrade MPD flow, when endoscopic retrograde pancreatography (ERP) and EUS-guided rendezvous fail. Tertiary care center. Retrospective series. Three patients with symptomatic MPD dilation refractory to ERP and EUS-guided rendezvous. Under EUS guidance, a 19-gauge echo-needle was used to gain access to the dilated MPD and a Jagwire advanced. After failed attempts at antegrade guidewire passage across the PJ stenosis, deep transgastric MPD access was achieved via a Soehendra stent retriever and balloon dilation. Careful antegrade needle-knife of the stenotic site was performed. A long pancreatic stent spanning the jejunum, MPD, and gastric access site was placed. Four to 8 weeks later, this stent was upsized and converted to a PJ stent, which in turn was removed 4 weeks thereafter. Technical feasibility and complications. All 3 patients successfully underwent the PANK procedure. Pre- and post-MRCP studies showed the mean MPD diameter decreased 60% from 8.3 mm to 3.6 mm (mean follow-up 8 months). At 24-month follow-up, all 3 patients experienced decreased or resolved pain without further need for MPD intervention. Retrospective study with small numbers. When ERP and EUS rendezvous fail, the PANK procedure using a staged stent strategy seems to be an effective means of MPD decompression.

MUC1 Is a Useful Molecular Marker for Malignant Intraductal Papillary Mucinous Neoplasms in Pancreatic Juice Obtained From Endoscopic Retrograde Pancreatography

Some intraductal papillary mucinous neoplasms (IPMNs) have no proliferation to malignant IPMNs, and benign IPMNs can observe the natural course without a surgical intervention. Therefore, an accurate assessment is required to determine the appropriate decision on managing malignant IPMNs. Quantitative real-time reverse transcription-polymerase chain reaction was performed for pancreatic juice by a LightCycler instrument focused on carcinoembryonic antigen, MUC1, and human telomerase reverse transcriptase. MUC1/glyceraldehyde-3-phosphate dehydrogenase messenger RNA (mRNA) ratio in intraductal papillary mucinous carcinoma (IPMC; median, 4710.7) was significantly higher in intraductal papillary mucinous adenoma (IPMA; median, 727; P = 0.0229). Furthermore, the MUC1/glyceraldehyde-3-phosphate dehydrogenase mRNA ratio in carcinoma in situ and minimum invasive IPMC (median, 26,490) was significantly higher than that in IPMA (P = 0.0152). The cutoff level of MUC1 ratio was determined as 1600 for the division of IPMC from IPMA by the receiver-operating characteristic curve. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MUC1 mRNA were 88.9%, 71.4%, 80.0%, 83.3%, and 81.3%, respectively. Quantitative reverse transcription-polymerase chain reaction using MUC1 is useful for the detection of malignant IPMN in pure pancreatic juice.

DOES A PATENT ACCESSORY PANCREATIC DUCT PREVENT ACUTE PANCREATITIS?

The role of the accessory pancreatic duct (APD) in pancreatic pathophysiology has been unclear. We previously examined the patency of the APD in 291 control cases who had a normal pancreatogram in the head of the pancreas by dye-injection endoscopic retrograde pancreatography (ERP). APD patency was 43% and was closely related with the shape of the terminal portion of the APD. The present study aimed to clarify the clinical implications of a patent APD. Based on the underlying data, the patency rate of the APD was estimated from the terminal shape of the APD on ERP in 167 patients with acute pancreatitis. In patients with acute pancreatitis, stick-type APD, spindle-type APD, and cudgel-type APD, which showed a high patency, were rare, and branch-type APD and halfway-type or no APD, which showed quite low patency, were frequent in acute pancreatitis patients. Accordingly, the estimated patency of the APD in acute pancreatitis patients was only 21%. There was no significant relationship between the estimated APD patency and etiology or severity of acute pancreatitis. The terminal shapes of the APD with low patency were frequent in acute pancreatitis patients, and estimated APD patency was only 21% in acute pancreatitis. A patent APD may function as a second drainage system to reduce the pressure in the main pancreatic duct and prevent acute pancreatitis.

Successful management of a blunt pancreatic trauma by endoscopic stent placement.

The present study reports a case involving a 17-year-old man who was brought to the emergency department of our hospital with severe upper abdominal pain following a blow received in a rugby game. Emergency computed tomography (CT) revealed severe pancreatic neck injury, and the patient was subsequently given conservative treatment in the High Care Unit. Forty-eight hours later, follow-up enhanced CT revealed that the pancreas was clearly lacerated and the amount of peripancreatic fluid was increasing; furthermore, serum amylase and elastase levels were elevated. Endoscopic retrograde pancreatography revealed that contrast medium in the main pancreatic duct (MPD) had leaked to the parenchyma, indicating an MPD injury. To prevent traumatic pancreatitis from worsening, a stent was inserted endoscopically to a site distal to the injured portion of the MPD. Thereafter, the patient's condition dramatically improved, and his serum amylase levels returned to normal. CT revealed that the apparent pancreatic edema and peripheral fluid were also decreased. During a short-term follow-up period of 6months, removal of the stent was uneventfully carried out and the patient did not develop any exocrine or endocrine insufficiency. We suggest that, in some cases, endoscopic management of traumatic pancreatic duct disruption is feasible and effective.

A Malignant Pancreatic Neuro-Endocrine Tumor With Intraductal Growth within the Main Pancreaic Duct and Tumor Thrombus Within the Splenic Vein

A 71-year-old woman with ischemic colitis was admitted to our hospital for evaluation of a pancreatic tail tumor with splenic infiltration. Endoscopic ultrasonography revealed a heterogenous hypoechoic mass with an irregular, central echogenic area in the tail of the pancreas and a solitary hypoechoic mass within the lumen of the main pancreatic duct (MPD). Endoscopic retrograde pancreatography showed interruption of the MPD in the head of the pancreas. Biopsy of this lesion confirmed a pancreatic neuro-endocrine tumor (NET). A NET with intraductal growth into the MPD and splenic infiltration was diagnosed. The patient underwent curative surgery. Histopathological examination revealed the malignant NET with intraductal growth within the MPD and tumor thrombus within the splenic vein. The patient received no postoperative adjunctive chemotherapy and 11 months after surgery she is alive without recurrence.

A Case of Autoimmune Pancreatitis Whose FDG Accumulation Was Markedly Decreased After Steroid Therapy

A 41-year-old woman was admitted to our hospital with dull abdominal pain, brown urine and left palpebral swelling. Laboratory data revealed elevated levels of serum IgG4, abdominal CT demonstrated diffuse pancreatic swelling and a thickened intra-pancreatic bile duct wall, and endoscopic retrograde pancreatography revealed a diffuse narrow main pancreatic duct. Lymphoplasmacytic sclerosing pancreatitis on pancreatic biopsy indicated a diagnosis of autoimmune pancreatitis. FDG-PET before and after steroid therapy revealed remarkably decreased FDG accumulation. FDG-PET before and after steroid therapy appears to be a useful diagnostic examination to estimate the early steroid response and distinguish between autoimmune pancreatitis and pancreatic cancer.

Three cases of locally advanced pancreatic cancer successfully treated with chemoradiation and chemotherapy.

We report three cases with unresectable locally advanced pancreatic cancer (PC) treated with a combination of chemoradiotherapy (CRT) and systemic chemotherapy, using gemcitabine (GEM) and/or S-1. All three cases were diagnosed as having locally advanced unresectable PC without distant metastatic lesions based on computed tomography, endoscopic retrograde pancreatography and/or blushing cytology. In Cases 1 and 2, we applied a so-called sandwich therapy, which consisted of induction chemotherapy before CRT and maintenance chemotherapy after CRT. The induction and maintenance chemotherapy in Cases 1 and 2 used a combination of GEM and S-1, whereas maintenance therapy with GEM or S-1 was applied in Case 3. S-1-based CRT was performed in Cases 1 and 2, and GEM-based CRT in Case 3. Survivals were 27 and 65months, respectively, in two cases, and the disease remained stable in the other case 30months after diagnosis. We show three cases with unresectable locally advanced PC who achieved long-term survival (27-65months) after treatment with a combination of CRT and systemic chemotherapy, using GEM and/or S-1. Our findings indicate that sandwich therapy might be particularly effective for locally advanced PC.

A Patent Accessory Pancreatic Duct Prevents Pancreatitis following Endoscopic Retrograde Cholangiopancreatography

Background/Aim: Pancreatitis is the most common and feared complication of endoscopic retrograde cholangiopancreatography (ERCP). We previously examined patency of the accessory pancreatic duct (APD) by dye injection endoscopic retrograde pancreatography (ERP). APD patency was found in 43% of 291 control cases who had no particular changes in the head of the pancreas compared to only 6% in patients with acute pancreatitis. APD patency was closely related with the shape of the terminal portion of the APD. This study aimed to clarify whether patency of the APD prevents post-ERCP pancreatitis. Methods:We examined retrospectively the terminal shape of the APD by ERP in 34 patients with post-ERCP pancreatitis. Based on these data, patency of the APD was estimated from its terminal shape in patients with post-ERCP pancreatitis. Results: The stick-type APD (p < 0.01), which indicated high patency, was less frequent, and the branch-type APD (p < 0.01) and halfway-type APD, or no APD (p < 0.01), which showed quite low patency, were more frequent in patients with post-ERCP pancreatitis compared with controls. Accordingly, the estimated patency of the APD in post-ERCP pancreatitis patients was only 16%, which was significantly lower than the 43% in controls. There was no significant relationship between the estimated APD patency and the severity of post-ERCP pancreatitis. Conclusions: The estimated APD patency was significantly lower in patients with post-ERCP pancreatitis. A patent APD may function as a second drainage system to reduce the pressure in the main pancreatic duct and prevent post-ERCP pancreatitis.

Incidence of Synchronous and Metachronous Pancreatic Carcinoma in 168 Patients with Branch Duct Intraductal Papillary Mucinous Neoplasm

Background/Aims: Although branch duct intraductal papillary mucinous neoplasms of the pancreas (BD-IPMN) are being diagnosed with increasing frequency, the incidence of concomitant pancreatic carcinoma (PC) is not well known. We investigated the incidence and clinical features of synchronous and metachronous PC in patients with BD-IPMN. Methods: We studied 168 BD-IPMN patients diagnosed by various imaging modalities, including endoscopic retrograde pancreatography, between 1990 and 2008. We reviewed the medical records and clinical features in both patients developing and not developing PC. The diagnosis of PC was histologically verified in all patients. Results: PC was observed in 9 (5.4%) of 168 patients. Five were synchronously detected at the time of BD-IPMN diagnosis, whereas four were metachronously identified during the follow-up period. All PCs occurred in regions separate from the BD-IPMN lesion. All PCs represented histologically invasive ductal adenocarcinomas, whereas the BD-IPMN lesion was diagnosed as adenoma. Patients developing PC were significantly older than patients not developing PC (p = 0.017). The diameters of the BD-IPMN lesions and main pancreatic ducts were significantly smaller in patients developing PC than patients not developing PC (p = 0.013 and p<0.001, respectively). Conclusions: It was not infrequent for PC to occur in the pancreas with BD-IPMN. Particular attention should therefore be paid to the development of PC, even in low-risk BD-IPMN, as well as to changes in BD-IPMN.