Peroral Pancreatoscopy Research Articles

Identification of the course of plastic stent-induced pancreatic duct mucosal change in chronic pancreatitis using peroral pancreatoscopy (with video).

Stent-induced ductal change is a complication of endoscopic treatment of the main pancreatic duct in chronic pancreatitis. Most previous reports have been based on morphological duct changes observed via pancreatography. Here, we describe a case of stent-induced ductal change in which the course of the mucosal changes was observed through peroral pancreatoscopy with a videoscopy. The patient presented with chronic alcoholic pancreatitis. Main pancreatic duct stenosis in the pancreatic head was identified and a 10-Fr plastic stent was inserted. Follow-up pancreatography revealed a focally elevated duct change of approximately 4.5mm at the distal tip of the stent, and peroral pancreatoscopy was performed. The elevated ductal change was identified as a clear villiform-like nodular mucosal change with the spread of pale papillary and granular mucosa. Reassessment after stent removal showed an improvement in the elevated mucosal lesion, with residual discoloration and mucosal retraction suggestive of scarring. The stent may cause irreversible changes, undetectable morphologically by pancreatography, likely underestimating stent-induced ductal change in chronic pancreatitis.

Digital peroral pancreatoscopy to determine surgery for patients who have intraductal papillary mucinous neoplasms of the pancreas with mural nodules.

Background and study aims Because more than a few patients have intraductal papillary mucinous neoplasms of the pancreas (IPMNs) with mural nodules (MNs) that are benign, clinical plans should be determined by using histocytological specimens especially, for patients with high risk for surgery or with a small MN. Patients and methods This study included 27 patients to evaluate the efficacy of peroral pancreatoscopy using a SpyGlass DS system (POPS-DS) for patients with MN-positive IPMN, mainly focusing on the ability of POPS-DS to detect malignancy. Results Biopsy specimens obtained under POPS-DS guidance could be used for histological evaluation of all patients with MNs in the main pancreatic duct and 67% of the patients with MNs in the branch ducts, whereas fluid specimens collected during POPS-DS could be used for histocytological evaluation for all patients. For the 13 patients who underwent surgery just after POPS-DS, the sensitivity, specificity, and accuracy of POPS-DS to detect malignancy were 89%, 100%, and 92%, respectively. For the 12 patients who underwent surveillance without surgery, the cumulative 3-year progression rates for nine benign IPMNs and three malignant ones determined using POPS-DS were 0% and 100%, respectively. However, the sensitivity of POPS to detect IPMN epithelium in the resection margin was 20%. Only one patient developed procedure-related pancreatitis (mild). Conclusions POPS-DS could be used to accurately detect malignancy in patients with MN-positive IPMN. Therefore, histocytological evaluation using POPS-DS can contribute to selection of patients for whom surgery would be appropriate.

Into the pancreas: an underwater world filled with an intraductal papillary mucinous neoplasm seen via peroral pancreatoscopy.

Into the pancreas: an underwater world filled with an intraductal papillary mucinous neoplasm seen via peroral pancreatoscopy.

Successful observation of intraductal papillary mucinous neoplasm in the accessory pancreatic duct using a novel peroral pancreatoscopy.

Successful observation of intraductal papillary mucinous neoplasm in the accessory pancreatic duct using a novel peroral pancreatoscopy.

Successful retrieval of a migrated stent in the pancreatic duct after endoscopic ultrasound-guided pancreaticogastrostomy with peroral pancreatoscopy.

Successful retrieval of a migrated stent in the pancreatic duct after endoscopic ultrasound-guided pancreaticogastrostomy with peroral pancreatoscopy.

Basket-assisted method for removal of floating pancreatic stones by electronic hydraulic lithotripsy through peroral pancreatoscopy.

Basket-assisted method for removal of floating pancreatic stones by electronic hydraulic lithotripsy through peroral pancreatoscopy.

Antegrade stenting for pancreaticojejunostomy stricture following successful guidewire placement through the pancreaticogastrostomy facilitated by peroral pancreatoscopy.

Watch a video of this article.

Peroral pancreatoscopy with videoscopy and narrow-band imaging in intraductal papillary mucinous neoplasms with dilatation of the main pancreatic duct.

This corrects the article "Peroral Pancreatoscopy with Videoscopy and Narrow-Band Imaging in Intraductal Papillary Mucinous Neoplasms with Dilatation of the Main Pancreatic Duct" in Volume 55 on page 270.

A novel peroral pancreatoscopy combined endoscopic ultrasonography-assisted rendezvous procedure: a new strategy for bridging disconnected pancreatic duct syndrome.

A novel peroral pancreatoscopy combined endoscopic ultrasonography-assisted rendezvous procedure: a new strategy for bridging disconnected pancreatic duct syndrome.

Single-balloon-assisted endoscopy with peroral pancreatoscopy and electrohydraulic lithotripsy.

Single-balloon-assisted endoscopy with peroral pancreatoscopy and electrohydraulic lithotripsy.

Per-oral pancreatoscopy-guided lithotripsy vs. extracorporeal shock wave lithotripsy for treating refractory main pancreatic duct stones in chronic pancreatitis: Protocol for an open-label multi-center randomized clinical trial

Backgrounds/ObjectivesPatients with chronic pancreatitis may develop pancreatic duct stones that can obstruct outflow leading to ductal hypertension and pain. Both endoscopic retrograde pancreatography (ERP) with per-oral pancreatoscopy (POP) and intraductal lithotripsy and extracorporeal shock wave lithotripsy (ESWL) are feasible options to attempt ductal stone clearance. This study aims to compare POP-guided lithotripsy with ESWL in the management of refractory symptomatic main pancreatic duct stones. MethodsThis is an open-label, multi-center, parallel, randomized clinical trial. Patients with chronic pancreatitis and main pancreatic duct stones ≥5 mm who fail standard ERP methods for stone removal will be eligible for this study. In total, 150 subjects will be randomized 1:1 to either ESWL or POP. A maximum of 4 sessions of either ESWL or POP will be allowed in each arm, with crossover permitted thereafter. The primary outcome is complete stone clearance and secondary outcomes include quality of life, pain scores, number of interventions, and daily opiate requirements. ConclusionsThis study aims to answer the question of which lithotripsy method is superior in removing refractory pancreatic duct stones while addressing the effects of lithotripsy on quality of life and pain in patients with chronic calcific pancreatitis (ClinicalTrials.gov NCT04115826).

S1732 ERCP With Per-Oral Pancreatoscopy-Guided Laser Lithotripsy for Difficult Pancreatic Duct Stones

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and balloon/basket extraction is the first line management for symptomatic pancreatic duct (PD) stones. The risk of stone extraction failure via ERCP increases with PD stones that are >10mm, impacted, multiple stones or in a complicated location [1]. With difficult PD stones, fragmentation prior to extraction may be required. Stone fragmentation can be accomplished through extracorporeal shock wave lithotripsy (ESWL), per-oral pancreatoscopy (POP) laser lithotripsy (LL) and POP- electrohydraulic lithotripsy (EHL). We report a case of difficult PD stones successfully managed by POP-LL holmium laser. Case Description/Methods: A 48-year-old man with advanced primary sclerosing cholangitis with percutaneous biliary drainage and chronic pancreatitis presented for recurrent jaundice, right upper quadrant and midepigastric abdominal pain and pruritus. ERCP revealed the ventral PD filled with numerous stones and was swept with a balloon and 1 stone was removed. Repeat ERCP was performed 2 weeks later with balloon extraction of a few small stones and debris from the PD. The ventral duct was then explored under pancreatoscopy using Spyglass, revealing multiple stones in the head and neck of the pancreas. Lithotripsy was then accomplished using a holmium laser. No immediate nor distant post-ERCP complications were encountered. A 1-week follow up revealed resolution of abdominal pain. Discussion: The patient in our case had recurrent abdominal pain caused by pancreatic duct stones resulting in pancreatic outflow obstruction. Both attempts using ERCP with balloon sweeping were unsuccessful in complete stone extraction leading to the use of POP Spyglass with laser lithotripsy for the management of the multiple remaining stones. Direct visualization of the PD with technology like Spyglass, has shown to reduce the risk of duct injury, allows the visualization of stones that may have been missed previously, and permits confirmation of clearance of the PD (Figure). As seen in this case, POP allowed for visualization of PD stones that could not be accessed through ERCP management and used in conjunction with laser lithotripsy, the PD stones were successfully and safely fragmented. POP-LL has been shown to successfully fragment difficult to manage PD stones, as evidenced in this case and other studies, and should be considered as a useful alternative in the management of numerous PD stones and/or multiple unsuccessful ERCP attempts.Figure 1.: Laser lithotripsy with holmium laser being applied through the catheter (red arrow) to the PD stone (White arrow).

The role of pancreatoscopy in the diagnostic work-up of intraductal papillary mucinous neoplasms: a systematic review and meta-analysis.

Confirming the diagnosis, invasiveness, and disease extent of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas is challenging. The aim of this study was to summarize the literature on the efficacy and safety of peroral pancreatoscopy (POP) in the diagnosis of IPMN, including the impact of pre- and intraoperative POP on the management of IPMN. The EMBASE, Medline Ovid, Web of Science, Cochrane CENTRAL, and Google Scholar databases were systematically searched for articles. Eligible articles investigated cohorts of patients who underwent POP for (suspected) IPMN. 25 articles were identified and included in this review; with 22 of these reporting on the diagnostic yield of POP in IPMN and 11 reporting on the effect of pre- or intraoperative POP on clinical decision-making. Cannulation and observation rates, and overall diagnostic accuracy were high across all studies. Frequently reported visual characteristics of IPMN were intraductal fish-egg-like lesions, hypervascularity, and granular mucosa. Overall, the adverse event rate was 12 %, primarily consisting of post-endoscopic retrograde cholangiopancreatography pancreatitis, with a pooled rate of 10 %, mostly of mild severity. Regarding the impact of POP on clinical decision-making, POP findings altered the surgical approach in 13 %-62 % of patients. POP is technically successful in the vast majority of patients with (suspected) IPMN, has a consistently high diagnostic accuracy, but an adverse event rate of 12 %. Data on intraoperative pancreatoscopy are scarce, but small studies suggest its use can alter surgical management. Future studies are needed to better define the role of POP in the diagnostic work-up of IPMN.

Single-operator peroral pancreatoscopy in the preoperative diagnostics of suspected main duct intraductal papillary mucinous neoplasms: efficacy and novel insights on complications

BackgroundDistinguishing intraductal papillary mucinous neoplasms (IPMNs) from other pancreatic cystic lesions is essential since IPMNs carry the risk of becoming malignant. Differentiating the main pancreatic duct involving IPMNs (MD-IPMNs) through conventional imaging is deficient. Single-operator peroral pancreatoscopy (SOPP) represents a promising method offering additional information on suspected lesions in the pancreatic main duct (MD). We aimed to determine the role of SOPP in the preoperative diagnostics of suspected MD-IPMNs and identify factors contributing to SOPP-related complications.Materials and MethodsIn this primarily retrospective study, SOPPs were performed at three high-volume centers on suspected MD-IPMNs. Primary outcome was the clinical impact of SOPP to subsequent patient care. Additionally, we documented post-SOPP complications and analyzed several assumed patient- and procedure-related risk factors.ResultsOne hundred and one (101) SOPPs were performed. Subsequent clinical management was affected due to the findings in 86 (85%) cases. Surgery was planned for 29 (29%) patients. A condition other than IPMN explaining MD dilatation was found in 28 (28%) cases. In 35 (35%) cases, follow-up with MRI was continued. Post-SOPP pancreatitis occurred in 20 (20%) patients and one of them was fatal. A decrease in odds of post-SOPP pancreatitis was seen as the MD diameter increases (OR 0.714 for 1.0 mm increase in MD diameter, CI 95% 0.514–0.993, p = 0.045). Furthermore, a correlation between lower MD diameter values and higher severity post-SOPP pancreatitis was seen (TJT = 599, SE = 116.6, z = − 2.31; p = 0.020). History of pancreatitis after endoscopic retrograde cholangiopancreatography was a confirmed risk factor for post-SOPP pancreatitis. Conclusions between complications and other risk factors could not be drawn.ConclusionSOPP aids clinical decision-making in suspected MD-IPMNs. Risk for post-SOPP pancreatitis is not negligible compared to non-invasive imaging methods. The risk for pancreatitis decreases as the diameter of the MD increases.

Pancreatoscopy-guided laser dissection of obstructing pancreatic duct stricture: pancreas-preserving endotherapy.

Video 1The case report is presented in the video, with a description of the patient's clinical course along with a set of endoscopic interventions including the use of per-oral pancreatoscopy with holmium laser therapy for stricturoplasty and stone fragmentation.

Efficacy and Safety of Peroral Pancreatoscopy Through the Fistula Created by Endoscopic Ultrasound-Guided Pancreaticogastrostomy.

Endoscopic ultrasound/endosonography-guided pancreaticogastrostomy (EUS-PGS) is a useful alternative when endoscopic retrograde pancreatography is difficult. Recently, many procedures, including peroral pancreatoscopy (POPS), have been performed through the mature fistula (MF) created by EUS-PGS. We evaluate the efficacy and safety of POPS to diagnose and treat pancreatic ductal stricture/pancreato-jejunal anastomotic stricture (PDS/PJAS) through the MF. Twenty patients underwent EUS-PGS; 13 of these underwent POPS through the MF at Juntendo University Hospital. All patients were studied retrospectively in terms of technical and clinical success rates and adverse events (AEs). The technical and clinical success rates of EUS-PGS were 95% and 100%. The early and late AEs rates were 20% and 15%. The technical success rate of POPS was 100%, with one AE. Biopsy of PDS/PJAS under POPS guidance revealed recurrent/residual intrapapillary mucinous adenoma (3 patients) and benign fibrotic stricture (10 patients). In the latter patients, multiple plastic stents were placed to dilate PDS/PJAS. Four patients with improvement of PDS/PJAS were stent free, but the remaining patients were not yet. Endoscopic ultrasound/endosonography-guided pancreaticogastrostomy and various procedures (including POPS) performed through the MF are feasible and effective and can diagnose and treat PDS/PJAS with acceptable AEs rates.

Predicting Malignancy by Peroral Pancreatoscopy of an Intraductal Papillary Mucinous Neoplasm with a Dilated Main Pancreatic Duct: Is Seeing Enough?

Predicting Malignancy by Peroral Pancreatoscopy of an Intraductal Papillary Mucinous Neoplasm with a Dilated Main Pancreatic Duct: Is Seeing Enough?

Single-Operator Peroral Pancreatoscopy in the Preoperative Diagnostics of Suspected Main Duct Intraductal Papillary Mucinous Neoplasms: Efficacy and Novel Insights on Complications

Introduction: Differentiating the main pancreatic duct involving IPMNs (MD-IPMNs) through conventional imaging is deficient. Single-operator peroral pancreatoscopy (SOPP) represents a promising method offering additional information on suspected lesions in the pancreatic main duct (MD).

Peroral Pancreatoscopy with Videoscopy and Narrow-Band Imaging in Intraductal Papillary Mucinous Neoplasms with Dilatation of the Main Pancreatic Duct.

Background/AimsEndoscopic evaluation of intraductal papillary mucinous neoplasms (IPMNs) is useful in determining whether the lesions are benign or malignant. This study aimed to examine the usefulness of peroral pancreatoscopy (POPS) in determining the prognosis of IPMNs. MethodsPOPS with videoscopy was performed using the mother–baby scope technique. After surgery, computed tomography/magnetic resonance cholangiopancreatography or ultrasonography and blood tests were performed every 6 months during the follow-up. ResultsA total of 39 patients with main pancreatic duct (MPD)–type IPMNs underwent POPS using a videoscope, and the protrusions in the MPD were observed in 36 patients. The sensitivity and specificity of cytology/biopsy performed at the time of POPS were 85% and 87.5%, respectively. Of 19 patients who underwent surgery, 18 (95%) patients had negative surgical margins and 1 (5%) patient had a positive margin. ConclusionsIn IPMNs with dilatation of the MPD, POPS is considered effective if the lesions can be directly observed. The diagnosis of benign and malignant lesions is possible depending on the degree of lesion elevation. However, in some cases, slightly elevated lesions may increase in size during the follow-up or multiple lesions may be simultaneously present; therefore, careful follow-up is necessary.

Per-oral pancreatoscopy-guided lithotripsy for the endoscopic management of pancreatolithiasis: A systematic review and meta-analysis.

Pancreatic stones result from chronic pancreatitis and can occur in the main pancreatic duct, pancreatic branches or parenchyma. Although extracorporeal shock wave lithotripsy (ESWL) is considered the first-line treatment, per-oral pancreatoscopy (POP) has emerged as a useful method for treating pancreatic stones. The aim of this systematic review and meta-analysis was to determine the efficacy and safety of POP-guided lithotripsy, electrohydraulic lithotripsy (EHL) and laser lithotripsy (LL), in patients with pancreatolithiasis. Literature review was conducted in PubMed, OVID, MEDLINE and Cochrane Library databases for studies published up to August 2020. Altogether 15 studies were analyzed, of which 11 were retrospective and four were prospective. The studies comprised 370 patients, of whom 66.4% were male. The patients underwent 218 EHL and 155 LL. The pooled technical and clinical success rate of the overall POP was 88.1% and 87.1%. For EHL-POP, the pooled technical success rate was 90.9% (95% CI 87.2%-95.2%) and the pooled clinical success rate was 89.8% (95% CI 87.2%-95.2%). While for LL-POP, the pooled technical and clinical success rate was 88.4% (95% CI 85.9%-95.1%) and 85.8% (95% CI 80.6%-91.6%). In total 43 adverse events occurred (12.1%; 95% CI 8.7%-15.5%). POP-guided lithotripsy has a high rate of technical and clinical success for managing pancreatolithiasis with a low complication rate. Both EHL-POP and LL-POP achieve similar efficacy in the endoscopic therapy of pancreatolithiasis. Further large randomized controlled trials are needed to compare EHL-POP and LL-POP with ESWL and evaluate whether POP may replace ESWL as the first-line management of pancreatolithiasis.