Pancreatic Duct Strictures Research Articles

A case of pancreatic adenocarcinoma initially detected as a pancreatic duct stricture that rapidly grew and formed a mass over 3 months

A case of pancreatic adenocarcinoma initially detected as a pancreatic duct stricture that rapidly grew and formed a mass over 3 months

Role of per-oral pancreatoscopy in the evaluation of suspected pancreatic duct neoplasia: a 13-year U.S. single-center experience

The role of per-oral pancreatoscopy (POP) in the evaluation of occult pancreatic duct (PD) lesions remains limited to case series. The aim of this study was to evaluate the ability of POP to differentiate malignant from benign diseases of the PD. Patients who underwent POP between 2000 and 2013 for the evaluation of indeterminate PD strictures, dilatations, or with suspected or known main duct intraductal papillary mucinous neoplasm were identified. Main outcome measurements were visual impression accuracy, POP tissue sampling, efficacy, and safety of POP. During the study period, 79 patients who underwent POP for the evaluation of pancreatic stricture or dilatation were identified. Technical success was achieved in 78 (97%). In the PD neoplasia group (n= 33), the final diagnosis was based on index confirmatory POP-guided tissue sampling in 29 (88%). For the detection of PD neoplasia, POP visual impression had a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 87%, 86%, 83%, 91%, and 87%, respectively. When combined with POP-guided tissue sampling, the values were 91%, 95%, 94%, 93%, and 94%, respectively. Of 102 POPs performed, adverse events were noted in 12 (12%) cases. This study demonstrates a high technical success rate, visual impression accuracy, and tissue sampling capability of POP. Examinations were performed by endoscopists with expertise in pancreatoscopy interpretation, and the results may not be generalizable.

Placement of a 6 mm, fully covered metal stent for main pancreatic head duct stricture due to chronic pancreatitis: a pilot study (with video).

Background:Temporary stent placement is widely performed for pancreatic duct stenosis due to chronic pancreatitis. A fully covered self-expandable metal stent (FCSEMS) has a larger diameter, and therefore longer stent patency, and the effect of expansion of the main pancreatic duct stricture may be obtained. However, if stent migration upstream occurs, stent removal is extremely difficult. In addition, because of the diameter gap between the FCSEMS and the main pancreatic duct, stent-induced ductal change may occur. To prevent these adverse events, the technical feasibility, safety and efficacy of the placement of a novel 6 mm diameter FCSEMS with a long suture, to facilitate its removal in cases of stent migration upstream, were evaluated in a pilot study.Methods:Between December 2014 and August 2015, symptomatic chronic pancreatitis patients with abdominal pain and a main pancreatic head duct stricture were enrolled. Stent placement for main pancreatic duct stricture was performed under endoscopic retrograde cholangiopancreatography (ERCP) guidance and stent removal was performed within 6 months.Results:A total of 13 patients were retrospectively enrolled in this study. Metal stent insertion was successfully performed in all patients and clinical success was high (12/13, 92%). As adverse events, stent migration upstream was seen in two patients. Another 11 patients successfully underwent stent removal without any adverse events. During follow up (median 258 days), 2 patients still underwent pancreatic duct stenting because of continuing main pancreatic duct stricture.Conclusion:In conclusion, this novel FCSEMS is acceptable for stent placement in cases of chronic pancreatitis with a main pancreatic duct stricture.

Diagnosis and treatment of autoimmune pancreatitis

Diagnosis and treatment of autoimmune pancreatitis

ERCP tissue sampling

ERCP tissue sampling

Sa1198 Fully Covered Self-Expandable Metal Stents to Dilate Pancreatic Duct Strictures Due to Chronic Pancreatitis: A Pilot Study

Symptomatic main pancreatic duct (MPD) strictures secondary to chronic pancreatitis (CP) may be treated endoscopically by insertion of single or multiple plastic stents. MPD stricture resolution after plastic stents removal occurs in near 60% of the cases. We evaluate the use of removable fully covered, self expandable metal stents (FC-SEMS) to dilate MPD strictures secondary to CP.

Diagnostic yield of secretin-enhanced magnetic resonance cholangiopancreatography in the investigation of patients with acalculous biliary pain

BackgroundSecretin-enhanced magnetic resonance cholangiopancreatography (S-MRCP) facilitates better visualization of the pancreaticobiliary ductal system but its role in patients with acalculous biliary pain (ABP) is yet to be established. The aim of this study was to assess the diagnostic yield and the role of S-MRCP in the investigation of ABP patients.MethodsThis is a retrospective analysis of patients who had S-MRCP to investigate ABP over a 5-year period from June 2008 to May 2013. The findings and diagnosis as reported in the S-MRCP were compared with the findings on MRCP. The primary endpoint was the diagnostic yield of S-MRCP in ABP patients.ResultsA total of 117 patients with ABP [28 (24%) male] had S-MRCP during the study period. The most common abnormality identified was obstruction at the level of ampulla or in the proximal pancreatic duct. S-MRCP was able to identify significant pathological findings in 8 of 34 (22%) patients in whom MRCP did not detect any abnormality. Endoscopic ultrasound (EUS) was performed in 67% of patients. S-MRCP identified abnormalities in 21 of 41 (54%) patients who had a normal EUS.ConclusionsWe conclude that the diagnostic yield of S-MRCP for recognizing anatomical variants of the pancreatic ductal system, in particular ampullary or proximal pancreatic duct stricture, is better than MRCP and EUS. These findings reflect the dynamic nature of S-MRCP and its complementary role alongside MRCP, EUS and endoscopic retrograde cholangiopancreatography in ABP patients.

Integrated analysis of autoimmune pancreatitis by CT, MRCP and DWI

PurposeCT, MRCP and diffusion weighted imaging characteristics were discussed to improve the diagnostic accuracy of autoimmune pancreatitis. Materials and methods23 cases of confirmed autoimmune pancreatitis were retrospectively analyzed before treatments. 23 cases underwent CT unenhanced and enhanced scans, 21 cases underwent MRCP examination, and 11 cases underwent DWI examination. Pancreatic lesion, involvement of the pancreatic duct and bile duct, changes of adjacent artery and vein, and other organs lesions. CT values and ADC values of pancreas and lesion were measured. ResultsFocal type lesions were shown in 6 cases, diffuse type in14 cases, and both types in 3 cases. Diffuse pancreatic swelling was shown in 20 cases, and peripancreatic halo in 13 cases. Mean CT values of lesions: unenhanced scan 35.81 ± 6.23 HU, late arterial phase 75.80 ± 17.47 HU, venous phase 93.19 ± 14.06 HU, and equilibrium phase 90.00 ± 14.67HU. Delayed homogenous enhancement was shown in 17 cases. Tapered narrowing (12 cases) or multiple segmental pancreatic duct stenosis (8 cases) was detected, the absence of main pancreatic duct dilatation or less than 3.5 mm in 20 cases, and duct penetrating sign in 20 cases. Bile duct lesions were found in 20 cases. ADC values of lesions (0.99 ± 0.03 × 103 mm2/s) were significantly lower that of pancreas (1.47 ± 0.16 × 103 mm2/s). ConclusionCT and MRI integrated diagnosis was helpful for accurate diagnosis based on the distinctive imaging characteristics of autoimmune pancreatitis.

A Case of IgG4-Related Disease: A Unique Presentation of a Rare Entity

IgG4-related disease is a rare, systemic fibroinflammatory condition characterized by lymphoplasmacytic infiltrates and often times elevated serum IgG4 levels. Multiple organs are implicated in the disease and although the pathogenesis is not entirely understood, genetic risk factors and autoimmune dysregulation have been associated. Pathology from biopsied lesions is varied and can range from a dense lymphoplasmacytic infiltrate to fibrosis. Currently, there are limited reports of IgG4-related disease in the literature. A 69 year-old female with a past medical history significant for salivary gland tumor (s/p resection and radiation), rheumatoid arthritis (on Methotrexate), alcohol use (2-3 glasses of wine for several years) presented to hepatology clinic for evaluation of elevated liver function tests noted on routine blood work. ALP was 367 IU/L, ALT 162 IU/L and AST 67 IU/L. CA 19-9 was also elevated to 45 U/mL, however MRI and EUS were unremarkable. Liver biopsy showed portal fibrosis, lymphocytic, neutrophilic and eosinophilic portal and lobular hepatitis with bile ductular proliferation. After an unrevealing extensive workup for other causes of abnormal liver tests, it was thought the abnormal tests and biopsy finding may be secondary to ethanol abuse and methotrexate. Over the subsequent year, the patient continued to have elevated liver function tests, a thirty-five pound weight loss, jaundice and pruritus. MRI of the abdomen revealed an infiltrating peri-choledochal, peripancreatic, porta hepatic and retroperitoneal soft tissue mass, narrowing the common bile duct and multiple enlarged retroperitoneal and pericardial lymph nodes. EUS showed an irregular, 2.3 x 2.3 cm, poorly defined area within the region of the head of the pancreas, dilation of the pancreatic duct and distal common bile duct stricture. Biopsies were not performed, and cytology from FNA revealed only benign pancreatic acini. IgG4 levels were ordered to evaluate for IgG4 related autoimmune pancreatitis/sclerosing cholangitis and were elevated to 125 mg/dL. Given the elevated IgG4, and multiple organ dysfunction, a presumed diagnosis of IgG4-related disease was made. Although glucocorticosteroids are the mainstay of therapy, the patient has not since returned to clinic. IgG4-related disease is a rare yet potentially treatable entity that can mimic primary organ disease or malignancy, yet should always remain in the differential diagnosis. Close follow up and cognizance of this disease entity is critical as a lag in treatment can have significant implications.

Pancreatic Ductal Stent Placement for the Palliation of Pain in Patients With Pancreatic Adenocarcinoma, With and Without Pancreatic Ductal Dilatation

Background: Endoscopic pancreatic duct stenting is commonly performed for pancreatic duct strictures and ductal dilatation. Though much less common than celiac plexus block, there are reports of the use of pancreatic duct stenting for the management of pain in patients with pancreatic cancer and pancreatic ductal dilatation. There are no published reports of pain relief with stenting in patients with pancreatic cancer without pancreatic ductal dilatation. Methods: A retrospective review was performed in two patients who underwent pancreatic duct stenting prior to a diagnosis of pancreatic carcinoma. Results: Two patients were evaluated for chronic abdominal pain. The first patient, was a 76 year-old male, with no significant past medical history who presented with greater than 6 months of worsening epigastric abdominal pain and a 22 pound weight loss. At the time of presentation, 2 computed tomography scans and magnetic resonance imaging had revealed pancreas divisum and pancreatic ductal dilatation without a pancreatic mass lesion. The second patient was a 41-year-old male with no significant past medical history who presented with chronic upper abdominal pain. His imaging had revealed an ill-defined retroperitoneal mass surrounding the proximal superior mesenteric artery (SMA). An EUS and biopsy had been negative for malignancy. The main pancreatic duct was not dilatated, and there was no intrahepatic biliary ductal dilatation. Both patients underwent ERCP with pancreatic duct stent placement (via the minor papilla and major papilla, respectively). Both patients experienced complete relief of their pain and their stents were subsequently removed. A diagnosis of adenocarcinoma was subsequently established in both patients by EUS and CT guided biopsy respectively. Conclusion: Relative to celiac plexus block, pancreatic duct stenting is much less commonly used in the palliation of pain in pancreatic adenocarcinoma. In two patients initially with chronic pain but without a diagnosis of malignancy, pancreatic ductal stenting provided complete relief, both in the presence and in the absence of pancreatic ductal dilatation. Further investigation may help determine the role of stent placement as compared to other interventions in patients with and without dilatation of the main pancreatic duct.

Intraductal biliopancreatic imaging: European Society of Gastrointestinal Endoscopy (ESGE) technology review.

This technology review expresses the current view of the European Society of Gastrointestinal Endoscopy (ESGE) on the available techniques for intraductal biliopancreatic imaging. The three cholangioscopy techniques are described: the "dual-operator" and " single-operator" mother-baby approaches using dedicated instruments, and the "direct" technique using currently available ultrathin gastroscopes. The mother-baby method is standardized and reproducible, while direct cholangioscopy is technically demanding and its safety requires further evaluation. As well as direct visualization of the bile ducts, cholangioscopy has the further advantage of allowing targeted biopsy. Image quality is still suboptimal for single-operator cholangioscopy, while the other techniques have achieved adequately detailed imaging. The costs of mother-baby cholangioscopy are high and its application in clinical practice should be restricted to selected cases (i.e. indeterminate biliary strictures/intraluminal lesions, difficult biliary stones) and to the setting of tertiary care centers. Peroral pancreatoscopy may find an indication in situations where other imaging modalities (mainly EUS) are inconclusive (i.e. delineation of main duct intraductal papillary mucinous neoplasia extension, sampling of indeterminate main pancreatic duct strictures). Intraductal ultrasonography (IDUS) has a poorer performance than EUS in the staging of pancreatic malignancies and can increase the risk of pancreatitis. A promising indication for IDUS could be the evaluation of indeterminate biliary strictures and ampullary tumors. Probe-based confocal laser endomicroscopy (pCLE) of the bile ducts is a difficult and expensive technique. Appropriate training needs to be established, since interpretation of images is challenging. pCLE can be an important diagnostic tool in the setting of indeterminate biliary strictures.

Placement of a novel fully covered metallic stent for refractory pancreatic duct stricture

Plastic stent placement under endoscopic retrograde cholangiopancreatography is performed widely for the treatment of benign pancreatic stricture [1]. However, this techniquemay have several disadvantages such as short stent patency and persistent stricture compared with fully covered metallic stents (FCMS) [2,3]. Therefore, although FCMS placement for benign pancreatic stricture is still controversial as a result of a relatively high rate of stent migration (especially distal migration), the FCMS has a potential clinical impact in patients with symptomatic chronic pancreatitis. This report describes the placement of a novel FCMS (6mm×6cm, Niti-S Biliary S-Type Stent Long Suture; TaeWoong Medical, Seoul, Korea; Century Medical Inc., Tokyo, Japan) in patients with chronic pancreatitiswho have refractory pancreatic duct stricture (● Fig.1). This novel FCMShas a long removal suture, and therefore, if distal stent migration doesoccur, the stent can be removedeasily by grasping the suture thread. A 66-year-old man was admitted to the Osaka Medical College Hospital with abdominal pain caused by pancreatic stent occlusion. He had undergone placement of a 10-Fr plastic stent 1 month earlier for pancreatic duct stricture caused by chronic pancreatitis. Despite several stent exchanges, the pancreatic duct stricture persisted. Therefore, it was decided to place a novel FCMS. First, the plastic stent was removed, and contrast medium was injected into the main pancreatic duct. A pancreatic duct stricture of the pancreatic head was seen (● Fig.2). Next, the novel metallic stent delivery system (8Fr) was inserted through the stenosis site (● Fig.3), and the stent was successfully placed (● Fig.4, ● Video 1). No adverse events occurred and the patient was discharged. After 6 months, no late adverse events, including stent migration, were observed. This stent may be a safer device because if the stent migrates it can be retrieved easily by grasping the long suture thread. However, results from a prospective study with long term follow-up are needed to confirm this.

OC-110 Covered metal stent placement using santorini’s duct (Minor Papilla) for pain management in chronic calcific pancreatitis – feasibility and safety: Abstract OC-110 Table 1

Introduction Pain control in chronic calcific pancreatitis is often unsatisfactory. Both endoscopic and surgical drainage procedures have been described for management of intractable or recurrent severe pain. Pancreatojejunostomy has been shown to be more effective than endoscopic management (using plastic stents) of main pancreatic duct stricture (PDS).1,2Fully Covered-Self expanding metal stent (FC-SEMS) placement across PDS has been assessed as a new endoscopic approach with the aim of achieving enhanced PD drainage.3,4As a part of a larger series, we have identified 8 cases in which access for PD drainage has been achieved via Santorini’s Duct. Method 8 patients (M:F 3:5 mean age 58 years) had FC-SEMS placed using Santorini’s Duct. 5 patients had pancreatic divisum confirmed on imaging and ERCP. 5 patients had prior placement of plastic stents and 3 had no prior endoprostheses. Planned outpatient follow up was at 3, 6 and 12 months. Mean duration of stent insertion was 3 months and response (i.e. pain control) was assessed at 3 months by using a 1–10 visual analogue scale to compare pre- and post-intervention symptoms. A score of 2 or less was classified as complete response, whereas a score of 3 or above was classified as partial response or if there was an improvement by 4 or more points in the scale. Results FC-SEMS insertion using Santorini’s Duct was feasible in all patients. The SEMS was removed at a median of 3 months (range 1.2 to 4 months). Mean follow up duration was 8.7 months. 5 patients (62.5%) reported complete response to pain while 2 (25%) had a partial response. One (12.5%) patient reported no response post endotherapy and was considered for surgical drainage. In one patient (partial response), the stricture had not resolved on FC SEMS withdrawal. A short stricture at the upstream stent margin was seen in one patient and responded to balloon dilatation. There were no instances of stent migration. View this table: Abstract OC-110 Table 1 Conclusion We describe the first series reporting the use of Santorini’s Duct to deliver FC-SEMS in PDS due to chronic pancreatitis. This approach is feasible, safe with early evidence of efficacy. The duration of duct patency and as a consequence success of pain management requires longer term follow up. Disclosure of interest None Declared.

OC-111 Diagnostic yield of endoscopic ultrasound (EUS) in the evaluation of idiopathic pancreatitis. a single tertiary referral centre experience

<h3>Introduction</h3> Idiopathic acute pancreatitis (IAP) represents a diagnostic and therapeutic challenge. IAP is prone to high recurrence and understanding its aetiology may assist in preventing recurrent episodes and its related morbidity and mortality. Appropriate investigations help to determine the underlying aetiology and can guide further effective management. We describe our experience to evaluate the role of endoscopic ultrasound (EUS) in patients with unexplained acute pancreatitis in whom cross sectional imaging and conventional laboratory testing had failed to identify the aetiology in a tertiary pancreatico-biliary referral centre. <h3>Method</h3> We retrospectively identified all patients who underwent EUS for assessment of idiopathic acute or recurrent pancreatitis during the period Jan 2007–Dec 2013. All patients had appropriate radiological investigations and no underlying cause identified on transabdominal ultrasound, computed tomography (CT) and on magnetic resonance cholangiopancreatography (MRCP). Patients with risk factors known to precipitate pancreatitis including alcohol excess, medications, metabolic or autoimmune conditions, were excluded. <h3>Results</h3> 44 patients (male 32, female 12) were identified with a mean age of 50 years (range 21–79 years). 33 (75%) patients had recurrent attacks of acute pancreatitis whereas 11 (25%) patients were referred for EUS after a single attack of acute pancreatitis. EUS revealed a cause of pancreatitis in 21/44 (47.7%) patients. Pancreatic duct stones were detected in 10 (22.7%); biliary duct microlithiasis in 4 (9%); pancreatic divisum in 3 (6.8%) and peri-ampullary lesions in 2 (4.5%) patients. One each had a pancreatic duct stricture, biliary duct stricture and one patient was diagnosed with IPMN (intra-papillary mucinous neoplasm). No underlying cause could be found in 23 (52.3%) patients. <h3>Conclusion</h3> EUS demonstrated aetiology in almost half of patients with unexplained acute or recurrent pancreatitis. Our findings support the emerging evidence that EUS is a valuable diagnostic tool in the evaluation of patients with idiopathic pancreatitis and should be considered where initial diagnostic workup including cross sectional imaging remains inconclusive. <h3>Disclosure of interest</h3> None Declared.

EUS-guided wirsung-gastrostomy: Outcomes and long-term management

Introduction: Technical success for endoscopic wirsung-gastrostomy (EWG) is about 40% with a complication rate >20%. Long-term results are scarce. Case: A 46 year old patient with alcoholic liver and pancreatic chronic disease with active consumption referred recurrent pancreatic like type pain requiring intensive analgesic therapy. CT scan showed pancreatic duct dilation proximal to the head of the pancreas with distal pancreatic duct stenosis and severe perigastric collateral vessels related to portal hypertension. The patient was considered as high surgical risk so in October 2011 pancreatic stent placement was attempted but failed because of impossibility of pancreatic duct cannulation. EUS-guided transgastric pancreatic duct access was performed. Wirsungraphy was accomplished through the transgastric EUS guided needle showing a severe pancreatic duct stenosis in the pancreatic isthmus hindering guidewirenavigation and the EWGwas completed by insertion of a 5F pancreatic stent connecting the pancreatic duct and the gastric lumen. The patient had a favourable outcome and could stop taking analgesics. In may 2012 a second transgastric 7F stent placement was scheduled uneventfully to ensure pancreatic drainage. The patient remained asymptomatic thereafter despite keeping toxic habits, until august 2013 when he was admitted for a septic clinical picture with abdominal pain. A CT scan showed two abdominal collections with transgastric pancreatic stents correctly placed. The patient was diagnosed of acute relapse over chronic pancreatitis and percutaneous drainage of both collections was performed. In order to rule out origin of those collections from the EWG, the transgastric fistula was cannulated showing no leakage and improvement of the pancreatic head stenosis. Three plastic pancreatic stents were placed through the gastric wall into the pancreatic duct. The patient remains asymptomatic 40 months after initial EWG. Conclusion: In our experience, the EWG offers good clinical long-term outcomes in patients with high surgical risk.

Intervencional endoscopy for the treatment of walled off necrosis: A single center experience

Introduction: Technical success for endoscopic wirsung-gastrostomy (EWG) is about 40% with a complication rate >20%. Long-term results are scarce. Case: A 46 year old patient with alcoholic liver and pancreatic chronic disease with active consumption referred recurrent pancreatic like type pain requiring intensive analgesic therapy. CT scan showed pancreatic duct dilation proximal to the head of the pancreas with distal pancreatic duct stenosis and severe perigastric collateral vessels related to portal hypertension. The patient was considered as high surgical risk so in October 2011 pancreatic stent placement was attempted but failed because of impossibility of pancreatic duct cannulation. EUS-guided transgastric pancreatic duct access was performed. Wirsungraphy was accomplished through the transgastric EUS guided needle showing a severe pancreatic duct stenosis in the pancreatic isthmus hindering guidewirenavigation and the EWGwas completed by insertion of a 5F pancreatic stent connecting the pancreatic duct and the gastric lumen. The patient had a favourable outcome and could stop taking analgesics. In may 2012 a second transgastric 7F stent placement was scheduled uneventfully to ensure pancreatic drainage. The patient remained asymptomatic thereafter despite keeping toxic habits, until august 2013 when he was admitted for a septic clinical picture with abdominal pain. A CT scan showed two abdominal collections with transgastric pancreatic stents correctly placed. The patient was diagnosed of acute relapse over chronic pancreatitis and percutaneous drainage of both collections was performed. In order to rule out origin of those collections from the EWG, the transgastric fistula was cannulated showing no leakage and improvement of the pancreatic head stenosis. Three plastic pancreatic stents were placed through the gastric wall into the pancreatic duct. The patient remains asymptomatic 40 months after initial EWG. Conclusion: In our experience, the EWG offers good clinical long-term outcomes in patients with high surgical risk.

PTH-015 Safety and utility of endoscopic retrograde cholangio-pancreatography (ercp) in children and adolescents performed by adult gastroenterologists– a tertiary care hospital experience

Introduction Endoscopic retrograde cholangio-pancreatography (ERCP) is a technically demanding endoscopic procedure and is not widely performed in children. Limited data is available on safety and usefulness of this procedure in children. At many institutions, paediatric ERCP is performed by adult gastroenterologists not formally trained in paediatric gastroenterology. The aim of this study was to evaluate the safety and efficacy of ERCP in children and adolescents with pancreaticobiliary diseases performed by adult gastroenterologists in a single tertiary care centre. Method We conducted a retrospective review on the data of all paediatric patients aged Results One hundred and eighty procedures were performed on 112 patients. 58 (52%) were girls, and mean age was 10.2 years (range, 1 week–18 years). Most frequent indications for ERCP were: cholestatic jaundice with abnormal imaging (n = 55), choledocholithiasis (n = 29), pancreatitis (n = 19), biliary/pancreatic duct stricture (n = 18), bile leak (n = 14) and pancreatic duct trauma (n = 9). Successful biliary cannulation was achieved in 94% (170) cases. ERCP findings were: bile duct strictures 40 (23%), bile duct stone (s) 26 (15%), choledochal anomaly 15 (8.8%), pancreatic duct strictures 10 (6%), biliary atresia 10 (6%), pancreatic divisum 8 (4.7%) and pancreatic duct stone (s) in 5 (3%) patients. Therapeutic interventions performed included biliary sphinterotomy (n = 21), precut sphinterotomy (n = 4), pancreatic sphincterotomy (n = 3), biliary stenting (n = 47), pancreatic duct stent placement (n = 25) and balloon dilation of stricture (n = 18). 30 (16.6%) cases were complicated with post-ERCP pancreatitis (PEP). Mild bleeding occurred in 5(2.7%) cases and none of them required blood transfusion. There was only one case of duodenal perforation following pre-cut sphincterotomy which was managed conservatively. There were no deaths reported within 30 days of the procedure Conclusion Overall ERCP in children and adolescents is a safe and reliable procedure and should be safely performed by adult gastroenterologists well-trained in advanced endoscopy. Disclosure of interest None Declared.

Long term cancer surveillance of patients with hereditary pancreatitis and ERCP-proven pancreatic duct strictures

In view of paucity of literature we analyzed our experience of acute recurrent pancreatitis (ARP) to study clinical profile and long-term outcome.Over 13 years, 93 consecutive children (≤18 years) diagnosed to have ARP were included in this study. Magnetic resonance cholangiopancreatography was done at baseline and on follow-up. Common mutations for serine-protease-inhibitor (SPINK1 N34S), protease inhibitor (PRSS1 R122S) and cystic fibrosis transmembrane conductance regulator (CFTR deltaF508, 5T) were studied in 22 idiopathic cases.The median age of the children with ARP was 13 (10–14.5) years, 53 were males. Etiology included biliary in 14 (15%), pancreas divisum in 6 (7%), others in 3 (3.5%) and idiopathic in the remaining 70 (75%). SPINK1 mutation was found in 10/22 (45%) cases. Over a median follow-up of 25.5 (8.25–48) months, 37 (42%) of 88 (5 lost to follow-up) developed chronic pancreatitis (CP). On multivariate analysis idiopathic etiology (p < 0.03), presence of SPINK1 mutation (p = 0.01), longer follow-up (p < 0.001) were associated with progression to CP.Biliopancreatic structural/obstructive causes should always be looked for. It seems ARP is a precursor of CP and progression is associated with idiopathic etiology and presence of genetic mutations. Hence, patients with ARP should be kept on regular follow-up to detect CP.

Who needs to be operated? Prognostic evaluation of the necessity of surgery in chronic pancreatitis according to the M-ANNHEIM classification

s / Pancreatology 15 (2015) S1eS141 S71 patients underwent resective surgery for complications of pancreatitis; none had developed pancreatic cancer. 3 patients died, one from metastatic oral cavity cancer, one frommetastatic malignantmelanoma and one from oesophagus cancer. Conclusion: In clinical follow up of patients with hereditary pancreatitis pancreatic cancer development is rare. Neither is the presence of pancreatic duct stenosis on ERCP a reliable positive predictor for pancreatic cancer development, nor its absence a negative predictor (Choudari et al. Gastrointest Endosc.2002;561:66-71).

Mo1392 Covered Metal Stent Placement Using Santorini's Duct (Minor Papilla) for Pain Management in Chronic Calcific Pancreatitis - Feasibility and Safety

Mo1391 The Usefulness of Concurrent Use of Fully Covered Self-Expandable Metal Stentsand Plastic Stentsin Benign Pancreatic Ductal Stricture Dongwook Oh*, Sang Soo Lee, Tae Jun Song, Do Hyun Park, Dong Wan Seo, Sung Koo Lee, Myung-Hwan Kim Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea (the Republic of) Background and Aims: Recently, fully covered self-expandable metal stents (FCSEMSs) has been used for pancreatic ductal strictures in chronic pancreatitis. However, distal stent migration and stent-induced ductal stricture are not uncommon. The purpose of this study was to investigate the feasibility, efficacy, safety of concurrent use ofFCSEMSsand plastic stentsin patients with benign pancreatic ductal stricture. Patients and Methods: We retrospectively reviewed the data of 18 patients who received endoscopic treatment with concurrent FCSEMSsand plastic stents for the benign pancreatic ductal stricture between August 2011 and November 2013. Additional plastic stents, which were longer than FCSEMSs, were inserted through FCSEMSs lumen. Results: Stents placement was successful through the major (nZ11) or minor papilla (nZ7). All patients could achieve pain relief after stents placement. In all patients,stents could be easily removed median 181 days (range from 68 to 181days) after stents insertion. There was no distal or proximal stent migration. Ductal stricture was resolved in 16 (88.9%) patients. During follow-up periods (median 527 days, range from 127 to 963 days), stent-induced ductal stricture did not developed after stent removal. Conclusions: The concurrent use of FCSEMSs and plastic stentsmay be safeand effective in the treatment of benign pancreatic ductal stricture. Baseline characteristics