Pancreatic Strictures Research Articles

Endoscopic interventions in pancreatic strictures and stones-A structured approach.

Chronic pancreatitis (CP) is an irreversible disease of varied etiology characterized by destruction of pancreatic tissue and loss of both exocrine and endocrine function. Pain is the dominant and most common presenting symptom. The common cause for pain in CP is ductal hypertension due to obstruction of the flow of pancreatic juice in the main pancreatic duct either due to stones or stricture or a combination of both. With advances in technology and techniques, endoscopic retrograde cholangiography (ERCP) and stenting should be the first line of therapy for strictures of the main pancreatic duct (MPD). Small calculi in the MPD can be extracted by ERCP and balloon trawl. Extracorporeal shockwave lithotripsy (ESWL) remains the standard of care for large pancreatic calculi and aims to fragment the stones 3mm or less that can easily be extracted by a subsequent ERCP. Single operator pancreatoscopy with intraductal lithotripsy is a technique in evolution and can be tried when ESWL is not available or is unsuccessful in producing stone fragmentation.

Technical review of endoscopic ultrasound‐guided drainage/anastomosis and trans‐endosonographically created route procedures for the treatment of pancreatic diseases

AbstractEndoscopic ultrasound (EUS)‐guided pancreatic duct drainage includes two procedures: EUS‐guided drainage/anastomosis (EUS‐D/A) and trans‐papillary drainage with EUS‐assisted pancreatic rendezvous. EUS‐guided pancreatogastrostomy is the most common EUS‐D/A procedure and is recommended as a salvage procedure in cases in which endoscopic retrograde cholangiopancreatography fails or is difficult. However, initial EUS‐D/A is performed in patients with surgically altered anatomy at our institution. It is one of the most difficult interventional EUS procedures and has a high incidence of adverse events. The technical difficulties differ according to etiology, and the incidence of adverse events varies between initial EUS‐D/A and subsequent trans‐endosonographically/EUS‐guided created route procedures. Hence, it is important to meticulously prepare a procedure based on the patient's condition and the available devices. The technical difficulties in EUS‐D/A include: (1) determination of the puncture point, (2) selection of a puncture needle and guidewire, (3) guidewire manipulation, and (4) dilation of the puncture route and stenting. Proper technical procedures are important to increase the success rate and reduce the incidence and severity of adverse events. The complexity of EUS‐D/A is also contingent on the severity of pancreatic fibrosis and stricture. In post‐pancreatectomy cases, determination of the puncture site is important for success because of the remnant pancreas. Trans‐endosonographically/EUS‐guided created route procedures following initial EUS‐D/A are also important for achieving the treatment goal. This article focuses on effective strategies for initial EUS‐D/A, based on the etiology and condition of the pancreas. We mainly discuss EUS‐D/A, including its indications, techniques, and success‐enhancing strategies.

Endoscopic luminal stenting: Current applications and future perspectives.

Endoscopic luminal stenting (ELS) represents a minimally invasive option for the management of malignant obstruction along the gastrointestinal tract. Previous studies have shown that ELS can provide rapid relief of symptoms related to esophageal, gastric, small intestinal, colorectal, biliary, and pancreatic neoplastic strictures without compromising cancer patients' overall safety. As a result, in both palliative and neoadjuvant settings, ELS has largely surpassed radiotherapy and surgery as a first-line treatment modality. Following the abovementioned success, the indications for ELS have gradually expanded. To date, ELS is widely used in clinical practice by well-trained endoscopists in managing a wide variety of diseases and complications, such as relieving non-neoplastic obstructions, sealing iatrogenic and non-iatrogenic perforations, closing fistulae and treating post-sphincterotomy bleeding. The abovementioned development would not have been achieved without corresponding advances and innovations in stent technology. However, the technological landscape changes rapidly, making clinicians' adaptation to new technologies a real challenge. In our mini-review article, by systematically reviewing the relevant literature, we discuss current developments in ELS with regard to stent design, accessories, techniques, and applications, expanding the research basis that was set by previous studies and highlighting areas that need to be further investigated.

Long-term clinical outcomes of a fully covered self-expandable metal stent for refractory pancreatic strictures in symptomatic chronic pancreatitis: An 11-year follow-up study.

A fully covered self-expandable metal stent (FCSEMS) has recently been applied in the management of chronic pancreatitis patients with pancreatic strictures. However, related long-term effects remain unclear. This study aimed to evaluate the long-term outcomes of FCSEMS placement in chronic pancreatitis patients with refractory strictures. We retrospectively reviewed our database for patients undergoing FCSEMS placement for refractory pancreatic strictures between September 2008 and December 2010. The main outcomes were technical, radiological, and clinical success, as well as recurrence and adverse events. A total of 35 patients were included. Technical success was achieved in all patients. The median FCSEMS indwelling time was 3.2months (interquartile range [IQR], 3.0-4.9months). Radiological success was achieved in all patients (complete, n=2; partial, n=33). Clinical success was achieved in 29 patients (82.9%; complete analgesic cessation, n=19; analgesic reduction >50%, n=11). During the median follow-up of 136months, (IQR, 85.8-145.5months), eight patients (22.9%) experienced recurrence. The median interval from stent removal to recurrence was 24.9months (IQR, 11.3-30.3months). Biliary obstruction, an early adverse event, occurred in two patients (5.7%); the late adverse event stent-induced de novo stricture was observed in 17 patients (48.6%). Our findings suggest that an FCSEMS is effective for relieving refractory strictures in chronic pancreatitis. However, FCSEMSs were associated with stent-induced de novo strictures in nearly half of the patients. Prospective studies are required to further evaluate the long-term efficacy and safety of FCSEMSs in chronic pancreatitis.

Pancreatic stenosis and pancreatolithiasis in chronic pancreatitis: Endoscopic management.

Pancreatic stenosis and pancreatolithiasis in chronic pancreatitis: Endoscopic management.

S1860 Diffuse Large B Cell Lymphoma Presenting as Acute Recurrent Pancreatitis

Introduction: Extra-nodal Non-Hodgkin’s lymphomas are mostly made of gastrointestinal sites1. Primary pancreatic lymphomas account for < 1% of all extra-nodal lymphomas and are extremely rare. Diagnosis is often missed or delayed due to the prevalence of chronic pancreatitis or pancreatic adenocarcinoma as thought to be the main causes of any pancreatic stricture or mass seen when diagnosing a patient. We present a case of pancreatic lymphoma presenting as acute recurrent pancreatitis. Case Description/Methods: A 51-year-old male with past medical history of rheumatoid arthritis and nicotine use presented with jaundice, abdominal pain, and fatigue and 30-pound weight loss. MRCP showed intra- and extra-hepatic biliary dilation, showing double duct sign. CT suggested acute pancreatitis. ERCP was done showing a single localized biliary malignant appearing stricture in the lower third of the main bile duct with upstream dilation. EUS showed a 19 mm by 19 mm mass in the head of pancreas and 8 mm dilation of the common bile duct. EUS fine needle biopsy showed chronic pancreatitis with dense fibrosis and benign peri-pancreatic lymph nodes. PET CT showed activity in the pancreas and retroperitoneal lymph nodes. Tumor markers (AFP, CEA, CA 19-9) were within normal limits. (Figure) Patient had no known risk factors for chronic pancreatitis therefore, the acute presentation and biopsy results in congruent with the clinical history led us to repeat EUS one month later. This showed a 20 mm by 15 mm irregular mass in the head of the pancreas with upstream pancreatic duct dilation. This time, pathology was sent for flow cytometry and came back positive for lymphoid infiltrate with a preponderance of B-cells surrounded by dense fibrosis and was positive for CD 19, 20, 22 and 10. By this point, malignancy other than adenocarcinoma was suspected and IR guided biopsy of retroperitoneal lymph nodes confirmed a diagnosis of diffuse large B cell lymphoma. Patient started chemotherapy with a 70% chance of being cured. ERCP one month later showed the stricture had resolved and the stent was removed. Discussion: Keeping a broad differential in mind for pancreatic masses is essential to prevent delayed diagnoses. With that in mind, although rare, pancreatic lymphoma should always be in the differential and physicians should consider sending for flow cytometry to avoid missing this diagnosis. When patients present with recurrent pancreatitis and no risk factors, lymphoma should be kept in the differential.Figure 1.: a) CT showing inflammatory reaction of the pancreas with bile duct dilation; b) Bile duct stricture on ERCP; c) EUS image showing common bile duct stent.

Endoscopic electroincision of challenging benign biliopancreatic strictures

Background and study aims Endoscopic drainage of benign biliary and pancreatic strictures can be challenging, especially when tightness of the stenosis does not allow passage of mechanical and pneumatic dilation catheters. Electroincision of benign biliopancreatic can be considered in selected cases. Patients and methods Three male patients (mean age 33 years, range 9–60) underwent endoscopic retrograde cholangiopancreatography to drain anastomotic biliary stricture (ABS) following orthotopic liver transplantation (n = 2) and pancreatic duct stenosis due to abdominal trauma (n = 1). The biliopancreatic strictures could be passed only with a thin 0.020-inch hydrophilic guidewire. Conventional mechanical and pneumatic dilators failed to pass the strictures due to weakness of the guidewire. Therefore, electrosurgical incision by over-the-wire 6Fr cystotome or needle-knife was attempted using pure cut current. Results The two cases of ABS were approached also by cholangioscopy and the 6Fr cystotome easily passed the strictures, allowing subsequent pneumatic dilatation and insertion of multiple plastic stents. The patient with a pancreatic duct stricture underwent electrosurgical incision using a thin needle knife over-the-wire, resulting in insertion of a 7Fr pancreatic stent. No adverse events occurred; all the patients were discharged within 24 to 48 hours. Conclusions Electrosurgical incision of benign biliopancreatic strictures could be considered in selected patients whom conventional dilation techniques fail.

Outcomes and predictors of response to endotherapy in pancreatic ductal disruptions with refractory internal and high-output external fistulae.

Endoscopic retrograde cholangiopancreatography (ERCP) remains the primary treatment for a subset of patients with pancreatic fistulae. The objective of this study was reporting outcomes of ERCP and predictors of resolution in patients with pancreatic fistulae refractory to conservative therapy. Retrospective review of patients who underwent ERCP and pancreatic stent placement for pancreatic fistula not responding to medical therapy was performed. Clinical features, laboratory parameters, radiological features and pancreatogram findings were noted. Clinical resolution of fistula was the primary outcome measure. Sixty-eight patients underwent ERCP for high-output pancreatic fistula (Mean age 34.1 years, 91.1% males, 35/68 chronic pancreatitis, 52.9% alcohol etiology). Internal fistulae (pancreatic ascites, pleural effusion, or pericardial effusion) were seen in 55 (80.9%) patients and external fistula in 13 (19.1%) patients. Technical success for ERCP was 92.6% (63/68). Leak was seen in 98.4% (62/63). The most common leak site was body (69.8%). Multiple leak sites were seen in 23.1%. Pancreatic stricture was found in 36.5%. In 44 (69.4%) patients, stent was placed beyond the site of the leak. Resolution at six weeks was achieved in 76.4% (52/68). On univariate and multivariate analyses, placement of stent beyond site of leak was significantly associated with resolution of high-output fistulae (3/41 [7.3%] vs. 5/19 [26.3%], p = 0.03; odds ratio: 6.5, 95% confidence interval: 1.211-34.94). In our experience, ERCP was successful in 76% of patients with pancreatic fistulae refractory to conservative therapy. Stent placement beyond the site of leak was associated with higher resolution of fistulae.

Endoscopy versus early surgery for the management of chronic pancreatitis: a systematic review and meta-analysis.

Endoscopic stone removal and stenting of pancreatic strictures are the initial treatment for treating chronic pancreatitis-related pain. Surgery is considered when endoscopic interventions fail to improve symptoms. In this meta-analysis, we have compared early surgery versus endoscopic interventions. The study was performed as per the PRISMA statement. The literature search was conducted on online databases to identify studies that compared endoscopy and surgery for the management of chronic pancreatitis symptoms. Primary outcomes of interest were pain relief, complications, and exocrine/endocrine insufficiency. Secondary outcomes were mean length of stay and mean number of procedures. Pooled odds ratio (OR) was calculated using random-effects model with 95% confidence interval (CI). Of a total of 9880 articles that were screened, three randomized controlled trials and two retrospective studies with 602 patients (71.4% males) were found to be eligible. Endoscopic interventions were performed in 317 patients and 285 patients underwent early surgery. Early surgery provided significantly better pain relief compared to endoscopy (OR 0.46; 95%CI 0.27-0.80; p = 0.01; I2 = 17.65%) and required less number of procedures (Mean difference 1.66; 95%CI 0.9-2.43; p = 0.00; I2 = 96.46%). There was no significant difference in procedure-related complication (OR 0.91; 95%CI 0.51-1.61; p = 0.74; I2 = 38.8%), endocrine (OR 1.18; 95%CI 0.63-2.20; p = 0.61; I2 = 28.24%), or exocrine insufficiency (OR 1.78; 95%CI 0.66-4.79; p = 0.25; I2 = 30.97%) or the length of stay (Mean difference 1.21; 95%CI -7.12 to 4.70; p = 0.69). Compared to endoscopy, early surgery appears to be better in controlling chronic pancreatitis-related pain, with no significant difference in procedure-related complications. However, larger randomized controlled trials are needed to ascertain their efficacy.

An international experience with single-operator cholangiopancreatoscopy in patients with altered anatomy

Background and study aims The utility of digital single- operator cholangiopancreatoscopy (D-SOCP) in surgically altered anatomy (SAA) is limited. We aimed to evaluate the technical success and safety of D-SOCP in patients SAA. Patients and methods Patients with SAA who underwent D-SOCP between February 2015 and June 2020 were retrospectively evaluated. Technical success was defined as completing the intended procedure with the use of D-SOCP. Results Thirty-five patients underwent D-SOCP (34 D-SOC, 1 D-SOP). Bilroth II was the most common type of SAA (45.7 %), followed by Whipple reconstruction (31.4 %). Twenty-three patients (65.7 %) patients had prior failed ERCP due to the presence of complex biliary stone (52.2 %). A therapeutic duodenoscope was utilized in the majority of the cases (68.6 %), while a therapeutic gastroscope (22.7 %) or adult colonoscope (8.5 %) were used in the remaining procedures. Choledocholithiasis (61.2 %) and pancreatic duct calculi (3.2 %) were the most common indications for D-SOCP. Technical success was achieved in all 35 patients (100 %) and majority (91.4 %) requiring a single session. Complex interventions included electrohydraulic or laser lithotripsy, biliary or pancreatic stent placement, stricture dilation, and target tissue biopsies. Two mild adverse events occurred (pancreatitis and transient bacteremia). Conclusions In SAA, D-SOCP is a safe and effective modality to diagnose and treat complex pancreatobiliary disorders, especially in cases where standard ERCP attempts may fail.

A prospective study of fully covered self-expandable metal stents for refractory benign pancreatic duct strictures.

Fully covered self-expanding metal stents (FCSEMSs) are a relatively novel option for treating painful main pancreatic duct refractory strictures in patients with chronic pancreatitis. Herein, we aimed to assess the efficacy, feasibility, and safety of FCSEMSs in this patient group. This prospective single-center study included patients who underwent endoscopic retrograde pancreatography with FCSEMS placement. The primary endpoints were the technical and clinical success rates. A reduction in visual analog scale pain score of >50% compared with that before stent placement was defined as clinical success. Secondary endpoints were resolution of pancreatic strictures on fluoroscopy during endoscopic retrograde pancreatography and the development of stent-related adverse events. Thirty-six patients were included in the analysis. The technical success rate was 100% (n=36) and the clinical success rate was 86.1% (n=31). There was a significant increase in stricture diameter from 1.7 mm to 3.5 mm (p<0.001) after stent removal. The mean visual analog scale pain score showed statistically significant improvement. At 19 months of follow-up, 55.6% of the patients were asymptomatic. Stent migration (16.7%), intolerable abdominal pain (8.3%), development of de novo strictures (8.3%), and mild pancreatitis (2.8%) were the most common adverse events. FCSEMS placement showed good technical and clinical success rates for achieving pain relief in patients with refractory main pancreatic duct strictures.

Cholangioscopy: Has It Changed Management?

AbstractThe single operator per oral cholangioscope is a catheter-based system that allows for direct visualization of the bile duct and pancreatic duct. The instrument with its improved imaging technique and larger accessory channel allows for high-quality image acquisition and performance of therapeutic and diagnostic procedures within the bile duct and pancreatic duct. There has been an increase in the range of indications for the use of the cholangioscope. The current indications include management of difficult biliary stones, pancreatic calculi, assessment of indeterminate biliary stricture, pancreatic stricture, intra-ductal papillary mucinous neoplasms, and extractions of proximally migrated stents. The use of laser lithotripsy and electro-hydraulic lithotripsy has improved the management of difficult bile duct stones. Direct visualization of biliary and pancreatic duct strictures is helpful in the diagnosis of indeterminate strictures. In this review, we explore how cholangioscopy has changed management.

Pancreatic duct stones and laser treatment: A case report

A 62 years-old Caucasian male, who had a consumptive condition associated with recurrent episodes of abdominal pain, was evaluated in a Gastroenterology consultation. Physical examination was quite innocent and the following imaging exams were performed. A Computed Tomography (CT) showed a thin gallbladder and chronic pancreatitis signs with pancreatic intraductal stones, dominant at tail and body, associated with pancreatic tail atrophy. An abdominal-Magnetic Resonance Imaging (MRI) showed an abnormal pancreatic parenchyma, a mild Wirsung dilatation and an unknown pancreatic head stenosis etiology. Therefore, to clarify the pancreatic stenosis, an echo-endoscopy (EUS) was performed. This exam showed a 10-mmstone associated with a focal narrowing in the head/tail transition. A pancreatoscopy-guided holmium laser using a mini-endoscope inserted into the pancreatic duct successfully broke the impacted stone and cleared the obstruction, without complications. After that, endotherapy with plastic stents was repeatedly done, during the following 6 months. After endoscopic treatment, the patient recovered quite well, without any symptoms, without pancreatic stenosis and higher quality of life.

S1513 Pancreaticoduodenal Fistula Cannulation as an Approach to Stent Pancreatic Stricture

S1513 Pancreaticoduodenal Fistula Cannulation as an Approach to Stent Pancreatic Stricture

Approach to management of pancreatic strictures: the gastroenterologist's perspective.

Pancreatic strictures represent a complex clinical problem which often requires multidisciplinary management with a team of gastroenterologists, surgeons and radiologists. Dominant strictures are largely due to inflammatory processes of the pancreas like chronic pancreatitis. However, differentiating benign from malignant processes of the pancreas, leading to strictures is imperative and remains a challenge. With advances in endoscopic management, options for therapy include endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasound-guided pancreatic drainage (EUS-PD) in situations where ERCP is not feasible or fails. However, endoscopic therapy is suited for a select group of patients and surgery remains key to management in many patients. In this narrative review, we look at the gastroenterologist's perspective and approach to pancreatic ductal strictures, including endoscopic and surgical management.

Endoscopic retrograde cholangiopancreatography: Current practice and future research.

Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a primarily diagnostic to therapeutic procedure in hepatobiliary and pancreatic disease. Most commonly, ERCPs are performed for choledocholithiasis with or without cholangitis, but improvements in technology and technique have allowed for management of pancreatic duct stones, benign and malignant strictures, and bile and pancreatic leaks. As an example of necessity driving innovation, the new disposable duodenoscopes have been introduced into practice. With the advantage of eliminating transmissible infections, they represent a paradigm shift in quality improvement within ERCP. With procedures becoming more complicated, the necessity for anesthesia involvement and safety of propofol use and general anesthesia has become better defined. The improvements in endoscopic ultrasound (EUS) have allowed for direct bile duct access and EUS facilitated bile duct access for ERCP. In patients with surgically altered anatomy, selective cannulation can be performed with overtube-assisted enteroscopy, laparoscopic surgery assistance, or the EUS-directed transgastric ERCP. Cholangioscopy and pancreatoscopy use has become ubiquitous with defined indications for large bile duct stones, indeterminate strictures, and hepatobiliary and pancreatic neoplasia. This review summarizes the recent advances in infection prevention, quality improvement, pancreaticobiliary access, and management of hepatobiliary and pancreatic diseases. Where appropriate, future research directions are included in each section.

First Use of Superpulsed Fibre Thulium Laser-Based Contact Stone Ablation in Common Bile and Main Pancreatic Ducts

Aim. A clinical demonstration of the feasibility of novel superpulsed thulium fibre laser in contact intraductal lithotripsy in patients with choledocholithiasis and pancreatic lithiasis.Key points. We describe two clinically successful ablations of large biliary and pancreatic calculi using a FiberLase U2 superpulse fibre thulium laser appliance (IRE-Polus, Russia) during oral transpapillary cholangiopancreaticoscopy in patients with technically unfeasible conventional minimally invasive treatment for choledocho- and pancreatic lithiasis. A 72-yo patient was urgently admitted with acute mechanical jaundice, cholangitis and a history of endoscopic papillosphincterotomy (EPST) and bilioduodenal stenting with a plastic implant for technically impractical lithotripsy and lithoextraction. An ineffective extracorporeal lithotripsy attempt was followed on day 3 by a second retrograde intervention and endoscopic contact laser lithotripsy controlled in oral transpapillary cholangioscopy with FiberLase U2. A 50-yo patient was admitted with clinical signs of chronic calculous pancreatitis and a history of EPST, pancreatic ductotomy and plastic pancreatic stenting. The first endoscopy stage comprised the encrusted pancreatic stent removal, retrograde pancreaticography, pancreatic ductotomy, narrowed terminal Wirsung’s duct bougienage with mechanical dilators and additional balloon-assisted dilation of the excision area and pancreatic stricture. Mechanical intraductal lithotripsy was unsuccessful. Contact lithotripsy with a novel superpulsed fibre thulium laser has been rendered. The technique presented ensures a complete sanation of the duct at no mucosal damage.Conclusion. We present the fully successful first national and world experience of the superpulsed fibre thulium laser application in contact lithotripsy of large calculi in common bile and main pancreatic ducts.

ID: 3525682 IN A PINCH: USE OF SMALL CALIBER DILATING BALLOONS DURING ERCP FOR SALVAGE TREATMENT OF HIGH-GRADE BILIARY AND PANCREATIC DUCT STRICTURES

Biliary and pancreatic strictures can often be challenging to manage with endoscopic retrograde cholangiopancreatography (ERCP). Very tight strictures can be difficult to traverse with standard ERCP accessories. The aim of this study is to describe the use and outcomes of SCDBs for management of biliary and pancreatic duct strictures.

Successful Surgical Removal of Firmly Impacted Pancreatic Duct Stent: Two Case Report

Successful surgical removal of firmly impacted pancreatic duct stent: Two case report Recently, the self-expandable metallic and plastic stents are increasingly being used for management of different pancreatic disorders. The major indications for pancreatic stent placement are: pancreatic duct stones, chronic pancreatitis, pancreatic strictures, unresectable pancreatic cancer, preventing POPF and post-ERCP pancreatitis, papillary adenoma. Stent placement or retrieval and exchange is difficult process and sometimes it could be the serious clinical challenge. We report two cases of successful removal of firmly impacted pancreatic duct stent by open surgical intervention and transduodenal approach with lateral “side-to-side” pancreaticojejunostomy to prevent the risk of main pancreatic duct restenosis in the first case and with the sphincteroplasty in the second. Therefore, in these challenging cases of firmly impacted pancreatic duct stents, our choice seems to be the most optimal and effective surgical procedure, which could be considered like “parachute” option after failed attempts of stents removal by endoscopic and radiological procedures.

Successful Surgical Removal of Firmly Impacted Pancreatic Duct Stent: Two Case Report

Successful surgical removal of firmly impacted pancreatic duct stent: Two case report Recently, the self-expandable metallic and plastic stents are increasingly being used for management of different pancreatic disorders. The major indications for pancreatic stent placement are: pancreatic duct stones, chronic pancreatitis, pancreatic strictures, unresectable pancreatic cancer, preventing POPF and post-ERCP pancreatitis, papillary adenoma. Stent placement or retrieval and exchange is difficult process and sometimes it could be the serious clinical challenge. We report two cases of successful removal of firmly impacted pancreatic duct stent by open surgical intervention and transduodenal approach with lateral “side-to-side” pancreaticojejunostomy to prevent the risk of main pancreatic duct restenosis in the first case and with the sphincteroplasty in the second. Therefore, in these challenging cases of firmly impacted pancreatic duct stents, our choice seems to be the most optimal and effective surgical procedure, which could be considered like “parachute” option after failed attempts of stents removal by endoscopic and radiological procedures.