Pancreatic Duct Obstruction Research Articles

AYURVEDIC MANAGEMENT OF PANCREATIC CALCULI, THE SEQUELAE OF CHRONIC PANCREATITIS: A CASE REPORT

Background: Pancreatitis is the inflammation of the pancreas, which may be acute or chronic. Chronic pancreatitis is characterised by epigastric pain, which is persistent and severe. Pancreatic calculi are sequelae of chronic pancreatitis, which causes pancreatic duct obstruction. In the present case, a 29-year-old female suffering from epigastric pain and burning sensation was diagnosed with pancreatic calculi and was treated with Ayurvedic treatment protocol. Results and discussion: At the end of the treatment, she had relief from symptoms. The prescribed medicines prevented further inflammation and had litholytic properties, as no evident calculi were noted in the reports.

Progress in minimally invasive treatment of biliary pancreatic duct obstruction after digestive tract reconstruction by endoscopic retrograde cholangiopancreatography

Progress in minimally invasive treatment of biliary pancreatic duct obstruction after digestive tract reconstruction by endoscopic retrograde cholangiopancreatography

Pancreatic extracorporeal shock wave lithotripsy: a key technology truly improves treatment model for pancreatic stones

Abstract Chronic pancreatitis (CP) is characterized by irreversible destruction of pancreatic parenchyma, inflammatory cell infiltration and progressive fibrosis of pancreatic tissue. Obstruction of pancreatic duct by pancreatic stone is the common pathological change in the course of CP with the incidence of over 50 % at the diagnosis of CP. These ductal stones would cause pancreatic parenchymal hypertension and local ischemia, which was eventually followed by recurrent episodes of painful pancreatitis or other manifestations of pancreatic exocrine and endocrine insufficiency. Removing pancreatic stones has been confirmed as the core to reduce pressure, improve drainage and lessen pain. Surgical therapy achieves satisfying pain relief with more complications, higher cost and less repeatability compared with endoscopic therapy. Endoscopic retrograde cholangiopancreatography, which used to be the standard endoscopic therapy for pancreatic stones, would fail if these stones are large or complex, while pancreatic extracorporeal shock wave lithotripsy (P-ESWL), which has been applied since 1987, could overcome this problem. Up to now, a large number of guidelines have recommended the P-ESWL as the first-line treatment strategy for radiopaque obstructive main pancreatic duct stones larger than 5 mm located in the head/body of the pancreas, and P-ESWL had completely changed the traditional treatment model for CP patients with pancreatic stones. In this article, we will focus on the technical progress, efficacy, safety and potential research areas of P-ESWL, we also give us suggestions for lithotripters improvement.

Feasibility and safety of a novel plastic stent designed specifically for endoscopic ultrasound-guided pancreatic duct drainage.

Background and study aims Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD) is emerging as an effective alternative treatment for obstructive pancreatitis after unsuccessful endoscopic retrograde pancreatography (ERP). However, the high incidence of adverse events associated with EUS-PD (approximately 20%) remains an issue. Recently, we developed a novel plastic stent for EUS-PD, with a radiopaque marker positioned at approximately one-third of the length from the distal end of the stent and side holes positioned exclusively distal to the marker. This study aimed to evaluate the feasibility and safety of using this stent in EUS-PD. Patients and methods We retrospectively reviewed data from 10 patients who underwent EUS-PD with the novel plastic stent at the National Cancer Center Hospital between March 2021 and October 2023. Technical and clinical success, procedure times, adverse events (AEs), recurrent pancreatic duct obstruction (RPO), and time to RPO were assessed. Results Of the 10 patients, five had postoperative benign pancreaticojejunal anastomotic strictures and five had malignant pancreatic duct obstruction. The technical and clinical success rates were both 100% (10/10). An AE (self-limited abdominal pain) occurred in one patient (10.0%). Two patients (20.0%) died of their primary disease during the follow-up period (median, 44 days; range, 25-272 days). The incidence of RPO was 10.0% (1/10), and the 3-month non-RPO rate was 83.3%. Conclusions The novel plastic stent shows potential as a useful and safe tool in EUS-PD.

Long-term outcomes of endoscopic ultrasound-guided pancreatic duct interventions: A single tertiary center experience

Background and aimsEndoscopic ultrasound-guided pancreatic duct intervention (EUS-PDI) is one of the most technically challenging procedures. There remains a knowledge gap due to its rarity. The aim is to report the accumulated EUS-PDI experience in a tertiary center. MethodsSingle tertiary center, retrospective cohort study of prospectively collected data during the study period, from January 2013 to June 2021. ResultsIn total, 14 patients (85% male; mean age, 61 years, range 37–81) and 25 EUS-PDI procedures for unsuccessful endoscopic retrograde pancreatography (ERP) were included. Principal etiology was chronic pancreatitis with pancreatic duct obstruction (78%). EUS-guided assisted (colorant and/or guidewire, rendezvous) ERP was performed in 14/25 (56%); and transmural drainage in 11 procedures, including pancreaticogastrosmy in 9/25 (36%) and pancreaticoduodenostomy in 2/25 (8%). Overall technical and clinical success was 78.5% (11/14). Three (21%) patients required a second procedure with success in all cases. Two failed cases required surgery. Three (21%) adverse events (AEs) were noted (fever, n=1; perforation, n=1; pancreatitis, n=1). Patients underwent a median of 58 months (range 24–108) follow-up procedures for re-stenting. Spontaneous stent migration was detected in 50% of cases. ConclusionsEUS-PDI is an effective salvage therapy for unsuccessful ERP, although 21% of patients may still experience AEs. In case of EUS-guided rendezvous failure, it can cross over to a transmural drainage.

An NCDB analysis of the predictive factors associated with the receival of tumor resection in mucinous cystadenoma of the pancreas.

e16356 Background: Mucinous cystadenoma (MCN) of the pancreas is characterized by mucin-producing cystic tumors that may lead to pancreatic ductal obstruction. While many of these cystic lesions are benign, there exists a notable risk for malignancy. Presently, the standard approach to managing MCN involves surveillance. Surgical resection is considered after evaluating histological features, the patient's age, surgical risk, and tumor size. Previous studies have linked surgical resection to favorable overall outcomes. However, no studies have investigated the predictive factors correlated to receiving surgery in MCN patients. This study aims to utilize the National Cancer Database (NCDB) to analyze factors that determine receival of tumor resection in patients with MCN of the pancreas. Methods: The NCDB was used to identify patients diagnosed with MCN of the pancreas from 2004 to 2019 using the histology codes 8470 as assigned by the Commission on Cancer Accreditation program. Kaplan-Meier, ANOVA Chi-Square, and Multilevel Logistic Regression were performed, and data were analyzed using SPSS version 27. Statistical significance was set at α = 0.05. Results: 827 patients with MCN of the pancreas formed the initial sample. 552 patients received a tumor resection whereas 274 patients did not receive surgery ( 66.7% vs 33.1%, respectively). Surgical patients experienced significantly longer overall survival than nonsurgical patients ( 111.2 months vs. 20.1 months, p < 0.001). Complete tumor resection with no residual tumor cells was associated with improved outcomes in MCN( p < 0.001). Metastasis to distant sites was associated with decreased likelihood of receiving surgery ( p < 0.001). Well and moderately differentiated disease, stage I, II, and II disease, treatment at an academic facility, and private insurance status were associated with increased likelihood of receiving tumor resection ( p < 0.001). Income status and race did not appear to impact overall survival of these patients. Adjuvant therapies did not appear to impact overall survival of these patients. Conclusions: The results of this research align with other studies, affirming that surgical resection yields superior outcomes in patients with MCN of the pancreas. Factors such as well or moderately differentiated disease, early-stage diagnosis, treatment at academic facilities, and private insurance status increased the likelihood of tumor resection. Distant metastasis reduced the likelihood of receiving surgery. Complete tumor removal without presence of residual tumor cells post-surgery is correlated with improved survival. Income status and race did not appear to impact overall survival, and adjuvant therapies showed no discernible effect. To improve current treatment protocols for patients with MCN of the pancreas, more research needs to be conducted on the predictive factors of receiving surgery.

Pancreatic quantitative sensory testing to predict treatment response of endoscopic therapy or surgery for painful chronic pancreatitis with pancreatic duct obstruction: study protocol for an observational clinical trial

IntroductionTreatment for abdominal pain in patients with chronic pancreatitis (CP) remains challenging in the setting of central nervous system sensitisation, a phenomenon of remodelling and neuronal hyperexcitability resulting from persistent...

Hypercalcemia in Primary Hyperparathyroidism with Manifestations of Acute Pancreatitis

Background: Primary hyperparathyroidism can result in hypercalcemia and hypophosphatemia which can cause gastrointestinal symptoms, electrolyte disturbances, renal dysfunction, and acute pancreatitis. The association between pancreatitis and primary hyperparathyroidism is rarely discussed. Case Illustration: We report a 32-year-old man who presented with a history of abdominal pain, nephrolithiasis, and increasing calcium serum. Primary hyperparathyroidism was overlooked until the patient was referred due to pancreatitis. The patient had additional risk factors for pancreatitis such as a history of alcohol consumption and hypertriglyceridemia. The patient had a worsening condition and died because of a septic condition and multiple organ failure. Conclusion: Hyperparathyroidism can cause acute pancreatitis through hypercalcemia with the mechanisms of trypsinogen activation, pancreatic duct obstruction, and genetics. In patients with acute pancreatitis with hypercalcemia, further hyperparathyroidism evaluation is necessary.

Effectiveness of Ultrasound-guided Percutaneous Catheter Drainage for Pancreatic Fluid Collections: An Interventional Study

Introduction: Pancreatic Fluid Collections (PFCs) are accumulations of pancreatic fluid or debris contained within a granulation tissue wall. Unlike true cysts, they arise as complications of various conditions like acute pancreatitis, abdominal trauma, pancreatic surgery, or chronic pancreatic duct obstruction. While smaller PFCs (under 4 cm) often resolve on their own without intervention, larger collections exceeding 6 cm or those causing symptoms like infection or bile duct obstruction have significantly lower rates of spontaneous resolution. In such cases, drainage intervention is typically recommended. Aim: To assess the treatment effectiveness of Percutaneous Catheter Drainage (PCD) for PFCs using ultrasound guidance. Materials and Methods: A prospective interventional study was conducted in the Department of Radiodiagnosis, Government Stanley Medical College and Hospital, Chennai, Tamil Nadu, India, from September 2021 to August 2022. The study focused on patients (N=73) with PFC as a complication of acute pancreatitis necessitating ultrasound-guided PCD. The study outcomes were clinical effectiveness, reinterventions, and mortality rates. Additionally, authors investigated the impact of various drainage factors, such as indication, PFC type, location relative to the pancreas, PFC size, Modified Computed Tomography (CT) Severity Index (CTSI), duration between symptom onset and PCD initiation, total catheter dwell time, and duration between symptom onset and reintervention. Statistical analyses employed International Business Machine (IBM) Statistical Packages for Social Sciences (SPSS) Statistics. Descriptive statistics and independent samples t-test for continuous variables; Chi-square test for categorical data (p<0.05). Results: In present study, the mean age of the subjects was 47 years. PCD in terms of clinical success was 63% (n=46) and clinical failure was 37% (n=27). Open necrosectomy was performed on 15 patients (20.5%) and open cystogastrostomy was performed on 11 patients (15.1%). Conclusion: The utilisation of ultrasound-guided PCD for PFCs represents a technique associated with relatively low morbidity and mortality rates. This approach can serve as either definitive treatment or a transitional measure before resorting to open surgery.

SAT243 A Rare Triad

Abstract Disclosure: H. Liaqat: None. F. Pasha: None. L. Chavez: None. Introduction: Hypercalcemia contributing to and directly causing pancreatitis is a well-known etiology in literature. Possible mechanisms identified include increased intrapancreatic conversion from trypsinogen to trypsin leading to damage of the pancreas and deposition of calcium in the pancreatic duct followed by pancreatic duct obstruction. The etiology of hypercalcemia-induced acute pancreatitis is usually hypercalcemia of malignancy. Less than ten cases of sarcoid-induced hypercalcemia leading to acute pancreatitis have been reported in the literature. Case Report: We present a case of a 39-year-old male who presented with complaints of generalized fatigue 60, pound weight loss, severe abdominal pain and sensation of lumps in his groin and neck. Examination revealed cervical and inguinal lymphadenopathy and a palpable spleen. Blood work revealed elevated lipase, creatinine, and hypercalcemia up to 14.8 mg/dl. Initial imaging revealed massive hepatosplenomegaly, hilar adenopathy and bilaterally miliary nodules in the lungs. Further workup of hypercalcemia revealed suppressed PTH, normal levels of PTHrP, and 25 hydroxyvitamin but elevated ACE levels and 1,25 dihydroxy vitamin D. Presentation and workup was concerning for sarcoidosis, and diagnosis was confirmed with a liver biopsy. The patient was treated initially with IV fluids, calcitonin, and steroids with resolution of his hypercalcemia and eventually pancreatitis symptoms. Case Discussion: Less than ten cases of sarcoid-induced hypercalcemia leading to acute pancreatitis have been reported in the literature, making this an extremely rare triad. The mechanism remains similar to other causes of hypercalcemia that lead to pancreatitis. Despite steroids not being recommended during an acute pancreatitis episode, this is one of the uncommon instances where steroids would be the preferred approach to tackle sarcoid-induced hypercalcemia. Other calcium-lowering therapies can be used short term like calcitonin and zoledronic acid. Presentation: Saturday, June 17, 2023

Extracorporeal shock wave lithotripsy for pancreatic duct stones in patients with chronic pancreatitis: Are we underutilizing a new technology?

The progressive inflammatory nature of chronic pancreatitis and its sparse therapeutic toolbox remain obstacles in offering patients durable solutions for their symptoms. Obstruction of the main pancreatic duct by either strictures or stones represents a scenario worthy of therapeutic focus, as nearly all patients with pancreatitis eventually have intraductal stones. A more recent option for removal of main duct stones is extracorporeal shock wave lithotripsy (ESWL). In an effort to explore the role of ESWL in a Canadian setting, we evaluated our initial experience over an 8-year period (2011-2019).

Pancreatitis as a Consequence of Endoscopic Retrograde Cholangiopancreatography: A Comprehensive Review of the Literature from a Case Report

Post ERCP pancreatitis, also known as post-endoscopic retrograde cholangiopancreatography pancreatitis, is a potentially serious complication that can occur after this endoscopic procedure. It is characterized by acute inflammation of the pancreas, triggered by the manipulation and trauma induced during ERCP. This clinical condition manifests with severe abdominal pain, nausea, vomiting, bloating and fever. It varies in severity and may be associated with significant complications, such as pancreatic pseudocysts, abscesses, systemic infections, gastrointestinal bleeding, bile duct and pancreatic duct obstruction, as well as the possibility of pancreatic necrosis. Management involves a multidisciplinary approach, including supportive measures, analgesic therapy and, in severe cases, hospitalization and additional procedures such as percutaneous drainage or surgery. To prevent this complication, precautions are recommended during ERCP, such as the use of aseptic techniques, careful handling of endoscopic instruments and prophylactic use of medications. In conclusion, post-ERCP pancreatitis requires early diagnosis, an appropriate therapeutic approach and close surveillance to avoid adverse consequences and promote patient recovery.

Distal Pancreatectomy with Splenectomy in Pancreatic Tail Cyst: Case Report

Pancreatic cyst is a pathological condition characterized by the presence of a fluid-filled cavity or sac within the pancreatic tissue. It can arise from various etiologies, including chronic pancreatitis, acute pancreatitis, pancreatic duct obstruction, and benign or malignant pancreatic lesions. Histopathological classification of pancreatic cysts reveals distinct subtypes such as pseudopapillary cysts, serous cysts, mucinous cysts, solid cysts, and intraductal papillary mucinous neoplasms, each exhibiting unique characteristics that influence clinical management. Diagnosis of pancreatic cysts relies on a combination of imaging modalities including ultrasound, computed tomography, magnetic resonance imaging, as well as blood tests and, in selected cases, biopsy. Treatment of pancreatic cysts depends on several factors, including size, location, and associated symptoms. Small asymptomatic cysts are often managed with regular surveillance, while symptomatic, large, or worrisome cysts may necessitate more aggressive interventions such as percutaneous drainage or surgical intervention. Targeted pharmacological therapy may be considered in specific cases.

Risk factors for post-endoscopic retrograde pancreatography pancreatitis in malignant extrahepatic biliary obstruction: a retrospective single-center study

Background. Decompression interventions under the endoscopic retrograde cholangiopancreatography (ERCP) is the method of choice in malignant extrahepatic biliary obstruction (MEHBO). Acute pancreatitis is the most common complication of ERCP. Many studies have been performed to identify the risk factors for post-ERCP pancreatitis (PEP). However, these works in general include the analysis of ERCP in patients with various causes of biliary obstruction without subdividing patients with malignant obstruction.
 Purpose.The aim of this study was to determine the risk factors for PEP in patients with MEHBO.
 Materials and Methods. A retrospective analysis of 100 cases of ERCP in MEHBO was done. PEP was in 2 patients, and 14 patients had hyperamylasemia (HA). The following factors were analyzed: gender, age, level of MEHBO, obstruction of the main pancreatic duct (MPD), total bilirubin level, history of endoscopic papillosphincterotomy (EPST), periampullary diverticulum, successful ERCP, primary selective biliary cannulation, catheterization and/or contrast injection into MPD, Precut EPST, successful decompression.
 Results and discussion. Univariate analysis showed that PEP is associated with an obstruction at the level of the proximal and middle third of the hepaticocholedochus (p = 0.004) and with absence of MPD obstruction (p = 0.022); female gender (p = 0.012), obstruction at the level of the proximal and middle third of the hepaticocholedochus (p < 0.001), absence of MPD obstruction (p < 0.001), catheterization and/or contrast injection into MPD (p = 0.040) are associated with PEP or hyperamylasemia (HA); female gender (p = 0.024), obstruction at the level of the proximal and middle third of the hepaticocholedochus (p < 0.001), absence of MPD obstruction (p=0.006), catheterization and/or contrast injection into MPD (p = 0.035), successful decompression (p = 0.004) are associated with HA. Multivariate regression analysis showed that, for PEP and for PEP or HA as well as for HA, the risk factors are obstruction at the level of the proximal and middle third of the hepaticocholedochus (p = 0.005; p < 0.001; p < 0.001, respectively) and absence of MPD obstruction (p = 0.022; p < 0.001; p = 0.008, respectively). Female gender is a risk factor for PEP or HA and HA (p = 0.011; p = 0.028, respectively), and catheterization and/or contrast injection into MPD are risk factors for PEP or HA (p = 0.04). Conclusion. Development of PEP in MEHBO depends on the localization of a tumor and involvement of the pancreas. The risk factors for PEP in MEHBO are tumor localization at the level of the middle and proximal third of the hepaticocholedochus and absence of MPD obstruction.

Management of Pancreatic Calculi in Chronic Pancreatitis: A Review Article.

Chronic pancreatitis is a slow, irreversible, and progressive inflammatory condition with abdominal pain, loss of parenchyma, fibrosis, and calculus formation. It also causes loss of exocrine and endocrine function. Gallstones and alcohol is the most frequent cause of chronic pancreatitis. It is also caused by other factors, including oxidative stress, fibrosis, and repeated incidence of acute pancreatitis. Chronic pancreatitis is followed by several sequelae, one of them being formation of calculi in the pancreas. The formation of calculi can occur in the main pancreatic duct, branches of the duct, and parenchyma. The cardinal sign of chronic pancreatitis is pain caused by obstruction of pancreatic ducts and its branches leading to ductal hypertension resulting in pain. The main aim of endotherapy includes pancreatic duct decompression. The management options vary based on the type and size of the calculus. The treatment of choice for small-sized pancreatic calculi is endoscopic retrograde cholangiopancreatography (ERCP) followed by sphincterotomy and extraction. The large-sized calculi need fragmentation before extraction, which is done by extracorporeal shock wave lithotripsy (ESWL). Surgery can be an option for patients having severe pancreatic calculi if endoscopic therapy fails. For diagnostic purposes, imaging plays a very important role. The treatment options remain complex if the radiological and laboratory findings overlap. Due to advancements in diagnostic imaging, treatment options have become precise and helpful. It can significantly lower the quality of life along with immediate and long-term problems that pose a serious risk to life. This review comprises the various management options available for removing calculi following chronic pancreatitis, including surgical, endoscopic, and medical therapy.

Long-term outcomes of pancreatoscopy-guided electrohydraulic lithotripsy for the treatment of obstructive pancreatic duct stones.

Background and study aims Pancreatoscopy-guided electrohydraulic lithotripsy (EHL) has proven to be an effective first-line therapy in symptomatic chronic pancreatitis (CP) patients with obstructing pancreatic duct (PD) stones 1 . However, long-term outcomes of endoscopic EHL remain unknown. The aim of the present study was to evaluate the long-term treatment effects of EHL as first-line therapy and to compare with those obtained in a historical cohort of patients who underwent extracorporeal shockwave lithotripsy (ESWL) as primary treatment. Patients and methods An observational retrospective single-center long-term follow-up study was performed including 19 consecutive patients who previously underwent endoscopic EHL compared to 18 patients who underwent ESWL followed by endoscopic retrograde pancreatography (ERP). The primary endpoint was long-term treatment success after EHL or ESWL defined as no recurrence of symptomatic intraductal stones confirmed on imaging. Secondary endpoints for the EHL-population included long-term clinical success (i. e., a similar or lower Izbicki Pain Score or reduction in opiate usage as compared to 6-month follow-up), quality of life (QoL), pancreatic function and hospital re-admission rate. Results In the EHL group, 37 % of the patients developed recurrent symptomatic PD stones versus 61 % in the ESWL group after a median follow-up of 35.0 and 76.5 months. Of the patients with recurrence, 71 % versus 100 % underwent a reintervention. Median time to recurrence was 12.0 versus 13.0 months. Clinical success sustained in 58 % of the EHL patients. QoL was not significantly different compared with 6-month follow-up and baseline. Conclusions Also at long-term follow-up, endoscopic EHL as first-line treatment is moderately effective for symptomatic CP patients with treatment success rates that seems at least equally effective as ESWL.

Techniques and Outcomes of Endoscopic Ultrasound Guided—Pancreatic Duct Drainage (EUS- PDD)

Endoscopic ultrasound guided-pancreatic duct drainage (EUS- PDD) is one of the most technically challenging procedures for the interventional endoscopist. The most common indications for EUS- PDD are patients with main pancreatic duct obstruction who have failed conventional endoscopic retrograde pancreatography (ERP) drainage or those with surgically altered anatomy. EUS- PDD can be performed via two approaches: the EUS-rendezvous (EUS- RV) or the EUS-transmural drainage (TMD) techniques. The purpose of this review is to provide an updated review of the techniques and equipment available for EUS- PDD and the outcomes of EUS- PDD reported in the literature. Recent developments and future directions surrounding the procedure will also be discussed.

CLINICAL COURSE OF MEDICALLY MANAGED PATIENTS WITH LARGE AND SMALL DUCT CHRONIC PANCREATITIS.

Pancreatic duct obstruction is the primary indication for endoscopic and/or surgical therapy in patients with chronic pancreatitis (CP). However, the clinical course of medically managed patients in relation to pancreatic duct obstruction is largely unknown. This was a retrospective cohort study of medically managed CP patients. We classified patients based on pancreatic duct obstruction from a stricture or stone using cross-sectional imaging (i.e., large vs small duct CP). We compared prevalence of diabetes and exocrine insufficiency (EPI) between subgroups at inclusion and investigated risk of new onset diabetes, EPI, and all-cause mortality over a follow-up period of 5 years. Changes in pancreatic morphology were studied in patients who underwent follow-up imaging. A total of 198 patients (mean age 58 ± 12 years, 70% male, 60% alcoholic aetiology, 38% large duct CP) were evaluated. At inclusion, patients with large vs small duct CP had a higher prevalence of both diabetes (43% vs 24%, P=0.004) and EPI (47% vs 28%, P=0.007). There was an increased risk of new onset EPI in patients with large duct CP (hazard ratio 1.72; 95% CI [1.05-2.80], P=0.031) and higher rates of pancreatic atrophy (P<0.001). No differences between groups were observed for new onset diabetes and all-cause mortality. Conversion from small to large duct CP or vice versa during follow-up was observed in 14% of patients. In a medically managed cohort of patients, large duct CP was associated with increased risk of EPI and pancreatic atrophy compared to small duct CP.

OGBN P06 Expectant Management Following Endoscopic Sphincterotomy for Choledocholithiasis: Is It Safe?

Abstract Background Gallstone disease is one of the most common gastrointestinal conditions in the UK. It is estimated that 10–15% of adults in the UK have gallstones. Most gallstones are found in the gallbladder but sometimes they can pass through the cystic duct into the common bile duct (CBD) causing choledocholithiasis. CBD stones may present with symptoms of jaundice, cholangitis, pancreatitis or be asymptomatic. Endoscopic sphincterotomy (ES), first reported in 1974, is considered a safe and effective method for managing choledocholithiasis. A significant proportion of patients who undergo ES for symptomatic CBD stones are subsequently referred for cholecystectomy. However, it is unclear whether cholecystectomy itself is necessary after endoscopic CBD stone removal. Some studies recently have indicated that cholecystectomy may not always be needed following endoscopic duct clearance (expectant management), especially for patients that remain asymptomatic or decline surgery (due to frailty, significant comorbidities or patient choice). The primary aim of this study was to assess the outcomes of patients who had expectant management (EM) after endoscopic CBD stone removal. Methods We retrospectively analysed the records of patients who underwent Endoscopic Retrograde Cholangiopancreatography (ERCP) in a UK District General Hospital between 01 January 2019 and 31 December 2019. Inclusion criteria were a) presence of CBD stones, and b) patients who underwent ERCP without prior cholecystectomy. The following patients were excluded: a) previous cholecystectomy, b) patients who underwent ERCP for other biliary pathologies, including malignancy. The original data set was obtained from the clinical coding department. ERCP reports, clinic letters, discharge summaries and the hospital results reporting systems were reviewed to extract patient data including demographics, comorbidities, management decision following ERCP, need for repeat ERCP and readmission rate. Results A total of 220 patients underwent ERCP in 2019. After excluding patients who did not fit the inclusion criteria,106 patients were included in this study. The median age was 75 years (22–97). 60 patients were women and 46 were men. Median follow up period was 36 months (30–42), excluding patients who died within the follow up period. 63 (59%) patients had a course of expectant management following ERCP for choledocholithiasis while 43 (41%) had a planned cholecystectomy (CS). Of the sixty-three patients who had EM, 40 were considered unfit for surgery, 18 were asymptomatic following ERCP, 3 did not wish to have surgery and the reason is unknown in 2. The median age for EM patients was 80 years (22–91), whereas the CS group had a median age of 62 years (25–82). In the EM group, 11 patients passed away within the follow-up period, none related to biliary pathology. Of the remaining 52 patients, only 1 proceeded to have cholecystectomy during the 3 year follow-up period due to multiple episodes of cholangitis. 2 out of 52 (4%) were readmitted with biliary complications but they continued to be managed conservatively due to frailty. Conclusions Endoscopic sphincterotomy and clearance of ductal stones followed by cholecystectomy is the most common treatment for choledocholithiasis. Recent NICE guidelines recommend CS for all patients with symptomatic or asymptomatic CBD stones. However, there is minimal evidence regarding the safety of leaving the gallbladder in situ after ES and thus the issue remains debatable. The majority of studies that have evaluated the complication rates of EM have focused only on elderly patients (age&amp;gt;80years), whereas our study has evaluated all patients after ERCP regardless of age and comorbidities. Pancreatitis did not occur during follow-up in any patients without cholecystectomy. This is in keeping with previous evidence as ES may in itself be definitive in prophylaxis against pancreatitis as it decreases the risk of pancreatic duct obstruction. The majority of patients (95%) with choledocholithiasis who did not undergo cholecystectomy after ERCP remained asymptomatic, indicating that expectant management is safe. However, we recognise this was a single centre study with limited patient numbers and medium-term follow-up. We suggest that future randomized controlled trials be multicentre and should include an assessment of patients’ quality of life and non-hospital managed symptoms.

Recurrent acute pancreatitis: a diagnostic and a therapeutic dilemma

Although uncommon, surgeons and physicians are sometimes confronted with patients who presents with recurrent episodes of acute pancreatitis. When two or more episodes of acute pancreatitis occur without an identifiable cause, it is referred to as Recurrent Acute Pancreatitis (RAP). In such patients, selecting the most appropriate management strategy continue to pose a challenge due to multiple aetiological factors, associated conditions, microanatomical and pathological processes and complex immunological mechanisms of this condition. The identifiable causes of RAP such as bile duct stones, biliary sludge or crystals, Sphincter of Oddi Dysfunction (SOD), pancreatic duct obstructions due to benign and malignant neoplasms, genetic mutations, Pancreatic Divisum (PD), metabolic disorders, alcohol consumption and smoking may be identified in some patients. There are several other rare conditions which may be associated with RAP. However, in about 30%, no cause/s can be identified. Diagnosis is further complicated by the fact that, although the gland may appear morphologically normal following the initial episode of Acute Pancreatitis (AP), in some patients, evidence of Chronic Pancreatitis (CP) may manifest later. Furthermore, there is an ongoing debate as to whether, recurrent bouts of pancreatitis following the first; the Sentinel Acute Pancreatitis episode in patients who are 'immunologically' predisposed may lead to Chronic Pancreatitis. In such patients who subsequently develop acute episodes, i.e., Acute on Chronic Pancreatitis will further complicate recognition of aetiological factors of RAP. The recognition of possible causes, associated factors, and understanding of pathological progressions are therefore important in the management of such patients. Detailed clinical assessment and clinical reasoning, standard haematological and biochemical workup and basic and advanced imaging studies will help identify patients who can be selected for specific invasive and medical therapy to prevent acute episodes. This brief review is a clinical update to guide clinicians, the best way forward in the management of RAP.