Pancreatic Duct Stent Placement Research Articles

Clinical Vignettes/Case Reports - Biliary/Pancreas.

54-year-old African-American male with alcohol abuse and chronic pancreatitis presented to the emergency room with 3 weeks of dyspnea. Chest X-ray revealed a left sided pleural effusion. Computerized Tomography (CT) of the chest demonstrated a large left sided pleural effusion along with a pancreatic pseudocyst with free fluid in the abdominal cavity communicating with the left pleural cavity. A pigtail catheter in the left pleural cavity drained 2 liters of serosanguinous fluid. Fluid analysis revealed increased amylase. Considering high pleural amylase levels and imaging, diagnosis of pancreatopleural fistula (PPF) was considered. Patient's pleural effusion improved with pigtail catheter but recurred after removal of the catheter. MRCP demonstrated peri-diaphragmatic inflammation with concern for fistulization from the abdominal cavity to the left pleural cavity. Considering the diagnosis of pancreatopleural fistula, ERCP was performed. On ERCP, pancreatogram demonstrated active extravasation from the mid pancreatic duct into the left pleural cavity (Figure 1). A 7Fr x 13CM pancreatic stent was placed in the pancreatic duct (Figure 2). Three days later the pigtail catheter was removed and the patient was monitored for 2 days. The patient clinically improved and repeat chest X-ray demonstrated complete resolution of left-sided pleural effusion. Repeat ERCP was performed 8 weeks after the initial stent placement and pancreatogram demonstrated no active extravasation demonstrating successful closure of PPF with the use of a pancreatic stent (Figure 3).Figure 1Figure 2Figure 3Patients with pleural effusions as a result of pancreatopleural fistula are managed conservatively with NPO, total parenteral nutrition, and placement of a chest tube. Octreotide can be administered to decrease the pancreatic duct secretions and help close the fistula. If symptoms persist after 2-4 weeks of conservative management, more invasive treatments such as pancreatic duct stent placement, placement of nasopancreatic drain or surgery should be considered. The goal of pancreatic duct stent placement is to decrease the pressure gradient in the pancreatic duct and to divert the secretions into the duodenum. ERCP is both diagnostic and therapeutic by performing a pancreatogram and stent placement. Repeat ERCP is performed in 8 weeks to assess the closure of the fistula. Patients with persistent and recurrent pleural effusions even after stent placement require surgical intervention.

Acute Pancreatitis After Removal of Retained Pancreatic Duct Stent Placed for Post-ERCP Pancreatitis Prophylaxis: A Rare Complication

Prophylactic pancreatic duct (PD) stent placement is now performed often in patients at high risk of developing post-ERCP pancreatitis (PEP). Removal of retained PD stents 5 to 7 days after initial ERCP is considered low risk for endoscopic complications. We herein describe a case of acute pancreatitis (AP) occurring after EGD with PD stent removal. A 67 year old female presented with history of right-sided abdominal discomfort and pruritus. Physical exam showed jaundice and RUQ tenderness without rebound. Laboratory data revealed ALT 104 U/L, AST 81 U/L, Alkp 267 U/L, Tbil 9.1 mg/dL, Dbil 6.2 mg/dL, albumin 3.2 g/dL, INR 1.5, normal CBC. Ultrasound showed cholelithiasis and dilated CBD of 7 mm. A soft tissue mass in the gallbladder and a 6.8 cm vascular right hepatic lobe lesion were detected. CT revealed a heterogeneous mass around the gallbladder fossa with extensive porta hepatis confluent lymphadenopathy, resulting in moderate intrahepatic biliary ductal dilatation and mass effect upon the main portal vein. A percutaneous biopsy of the gallbladder mass was performed and IHC stains were consistent with a neuroendocrine tumor. Initial ERCP for biliary drainage resulted in failed CBD cannulation. Repeat ERCP demonstrated technical difficulty in accessing CBD. Placement of a straight 5 Fr x 3 cm plastic PD stent with internal flange prior to precut sphincterotomy was employed. As CBD cannulation was again unsuccessful, EUS-guided rendezvous ERCP with hepatogastric biliary access was performed. A single SEMS was placed across two focal CBD strictures. Biliary decompression was successful. EGD with PD stent removal was performed at day 7 after ERCP for retained PD stent. Within 24 hours of EGD, the patient developed moderate epigastric abdominal pain, nausea, and vomiting. Serum lipase was 308 U/L and a CT abdomen demonstrated peri-pancreatic inflammatory stranding involving the body, neck, and head of pancreas. The patient was admitted to the hospital for 2 days. Conclusions: 1) Acute pancreatitis after endoscopic removal of retained PD stent placed during ERCP for PEP prophylaxis is uncommon; 2) AP in this setting may be related to plastic stents with internal flange; 3) Endoscopists should be aware of this complication as part of the informed consent process.

Black Ascites: An interesting presentation of pancreatic duct leak

Introduction: Common causes of ascites include liver cirrhosis, heart failure, and malignancy. Pancreatic etiology is lesscommon for ascites, but is most often a result of chronic pancreatitis secondary to alcoholic liver damage or pancreatic duct leak.Case description: The following case describes a patient with black-colored ascites secondary to pancreatic duct leak after totalcolectomy with ileorectal anastomosis. The colectomy was indicated by MYH-positive polyposis, and the there was no knownprior liver or pancreas disease. Management included pancreatic duct stent placement, and drains from the pancreatic tail.Discussion: Pancreatic etiology is rare among ascites diagnoses; this case is even rarer due to gross appearance of the asciticfluid and its iatrogenic cause.

The safety and efficacy of pancreatic duct stent placement in the emergency ERCP of acute biliary pancreatitis

The safety and efficacy of pancreatic duct stent placement in the emergency ERCP of acute biliary pancreatitis

Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline.

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It provides practical advice on how to achieve successful cannulation and sphincterotomy at minimum risk to the patient. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. Main recommendations 1 ESGE suggests that difficult biliary cannulation is defined by the presence of one or more of the following: more than 5 contacts with the papilla whilst attempting to cannulate; more than 5 minutes spent attempting to cannulate following visualization of the papilla; more than one unintended pancreatic duct cannulation or opacification (low quality evidence, weak recommendation). 2 ESGE recommends the guidewire-assisted technique for primary biliary cannulation, since it reduces the risk of post-ERCP pancreatitis (moderate quality evidence, strong recommendation). 3 ESGE recommends using pancreatic guidewire (PGW)-assisted biliary cannulation in patients where biliary cannulation is difficult and repeated unintentional access to the main pancreatic duct occurs (moderate quality evidence, strong recommendation). ESGE recommends attempting prophylactic pancreatic stenting in all patients with PGW-assisted attempts at biliary cannulation (moderate quality evidence, strong recommendation). 4 ESGE recommends needle-knife fistulotomy as the preferred technique for precutting (moderate quality evidence, strong recommendation). ESGE suggests that precutting should be used only by endoscopists who achieve selective biliary cannulation in more than 80 % of cases using standard cannulation techniques (low quality evidence, weak recommendation). When access to the pancreatic duct is easy to obtain, ESGE suggests placement of a pancreatic stent prior to precutting (moderate quality evidence, weak recommendation). 5 ESGE recommends that in patients with a small papilla that is difficult to cannulate, transpancreatic biliary sphincterotomy should be considered if unintentional insertion of a guidewire into the pancreatic duct occurs (moderate quality evidence, strong recommendation).In patients who have had transpancreatic sphincterotomy, ESGE suggests prophylactic pancreatic stenting (moderate quality evidence, strong recommendation). 6 ESGE recommends that mixed current is used for sphincterotomy rather than pure cut current alone, as there is a decreased risk of mild bleeding with the former (moderate quality evidence, strong recommendation). 7 ESGE suggests endoscopic papillary balloon dilation (EPBD) as an alternative to endoscopic sphincterotomy (EST) for extracting CBD stones < 8 mm in patients without anatomical or clinical contraindications, especially in the presence of coagulopathy or altered anatomy (moderate quality evidence, strong recommendation). 8 ESGE does not recommend routine biliary sphincterotomy for patients undergoing pancreatic sphincterotomy, and suggests that it is reserved for patients in whom there is evidence of coexisting bile duct obstruction or biliary sphincter of Oddi dysfunction (moderate quality evidence, weak recommendation). 9 In patients with periampullary diverticulum (PAD) and difficult cannulation, ESGE suggests that pancreatic duct stent placement followed by precut sphincterotomy or needle-knife fistulotomy are suitable options to achieve cannulation (low quality evidence, weak recommendation).ESGE suggests that EST is safe in patients with PAD. In cases where EST is technically difficult to complete as a result of a PAD, large stone removal can be facilitated by a small EST combined with EPBD or use of EPBD alone (low quality evidence, weak recommendation). 10 For cannulation of the minor papilla, ESGE suggests using wire-guided cannulation, with or without contrast, and sphincterotomy with a pull-type sphincterotome or a needle-knife over a plastic stent (low quality evidence, weak recommendation).When cannulation of the minor papilla is difficult, ESGE suggests secretin injection, which can be preceded by methylene blue spray in the duodenum (low quality evidence, weak recommendation). 11 In patients with choledocholithiasis who are scheduled for elective cholecystectomy, ESGE suggests intraoperative ERCP with laparoendoscopic rendezvous (moderate quality evidence, weak recommendation). ESGE suggests that when biliary cannulation is unsuccessful with a standard retrograde approach, anterograde guidewire insertion either by a percutaneous or endoscopic ultrasound (EUS)-guided approach can be used to achieve biliary access (low quality evidence, weak recommendation). 12 ESGE suggests that in patients with Billroth II gastrectomy ERCP should be performed in referral centers, with the side-viewing endoscope as a first option; forward-viewing endoscopes are the second choice in cases of failure (low quality evidence, weak recommendation). A straight standard ERCP catheter or an inverted sphincterotome, with or without the guidewire, is recommended by ESGE for biliopancreatic cannulation in patients who have undergone Billroth II gastrectomy (low quality evidence, strong recommendation). Endoscopic papillary ballon dilation (EPBD) is suggested as an alternative to sphincterotomy for stone extraction in the setting of patients with Billroth II gastrectomy (low quality evidence, weak recommendation).In patients with complex post-surgical anatomy ESGE suggests referral to a center where device-assisted enteroscopy techniques are available (very low quality evidence, weak recommendation).

Pancreatic duct guidewire placement for biliary cannulation for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis.

Difficult cannulation is a risk factor for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). It has been postulated that the pancreatic duct guidewire (PGW) technique may improve biliary cannulation success and reduce the risk of PEP in people with difficult cannulation. To systematically review evidence from randomised controlled trials (RCTs) assessing the effectiveness and safety of the PGW technique compared to persistent conventional cannulation (CC) (contrast- or guidewire-assisted cannulation) or other advanced techniques in people with difficult biliary cannulation for the prevention of PEP. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and CINAHL databases, major conference proceedings, and for ongoing trials on the ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) up to March 2016, using the Cochrane Upper Gastrointestinal and Pancreatic Diseases model with no language restrictions. RCTs comparing the PGW technique versus persistent CC or other advanced techniques in people undergoing ERCP with difficult biliary cannulation. Two review authors independently conducted study selection, data extraction, and methodological quality assessment. Using intention-to-treat analysis with random-effects models, we combined dichotomous data to obtain risk ratios (RR) with 95% confidence intervals (CI). We assessed heterogeneity using the Chi(2) test (P < 0.15) and I(2) test (> 25%). To explore sources of heterogeneity, we conducted a priori subgroup analyses according to trial design, use of pancreatic duct (PD) stent, involvement of trainees in cannulation, publication type, and risk of bias. To assess the robustness of our results, we carried out sensitivity analyses using different summary statistics (RR versus odds ratio (OR)) and meta-analytic models (fixed-effect versus random-effects). We included seven RCTs comprising 577 participants. There was no significant heterogeneity among trials for the outcome of PEP (P = 0.32; I(2) = 15%). The PGW technique significantly increased PEP compared to other endoscopic techniques (RR 1.98, 95% CI 1.14 to 3.42; low-quality evidence). The number needed to treat for an additional harmful outcome was 13 (95% CI 5 to 89). Among the three studies that compared the PGW technique with persistent CC, the incidence of PEP was 13.5% for the PGW technique and 8.7% for persistent CC (RR 1.58, 95% CI 0.83 to 3.01; low-quality evidence). Among the two studies that compared the PGW technique with precut sphincterotomy, the incidence of PEP was 29.8% in the PGW group versus 10.3% in the precut group (RR 2.92, 95% CI 1.24 to 6.88; low-quality evidence). Among the two studies that compared the PGW technique with PD stent placement, the incidence of PEP was 11.7% for the PGW technique and 5.0% for PD stent placement (RR 1.75, 95% CI 0.08 to 37.50; very low-quality evidence). There was no significant difference in common bile duct (CBD) cannulation success with the randomised technique (RR 1.04, 95% CI 0.87 to 1.24; low-quality evidence) or overall CBD cannulation success (RR 1.04, 95% CI 0.91 to 1.18; low-quality evidence) between the PGW technique and other endoscopic techniques. There was also no statistically significant difference in the risk of other ERCP-related complications (bleeding, perforation, cholangitis, and mortality). The results were robust in sensitivity analyses. The overall quality of evidence for the outcome of PEP was low or very low because of study limitations and imprecision. In people with difficult CBD cannulation, sole use of the PGW technique appears to be associated with an increased risk of PEP. Prophylactic PD stenting after use of the PGW technique may reduce the risk of PEP. However, the PGW technique is not superior to persistent attempts with CC, precut sphincterotomy, or PD stent in achieving CBD cannulation. The influence of co-intervention in the form of rectal peri-procedural nonsteroidal anti-inflammatory drug administration is unclear.

Endoscopic Therapy With Lumen-apposing Metal Stents Is Safe and Effective for Patients With Pancreatic Walled-off Necrosis.

Endoscopic ultrasound-guided transmural drainage and necrosectomy have become the standard treatment for patients with pancreatic walled-off necrosis (WON). Lumen-apposing metal stents (LAMS) have shown success in the management of pancreatic fluid collections. However, there are few data on their specific roles in management of WON. We investigated the efficacy and safety of LAMS in treatment of WON. We performed a retrospective multicenter case series of 124 patients with WON who underwent endoscopic transmural drainage by using LAMS at 17 tertiary care centers from January 2014 through May 2015. Patients underwent endoscopic ultrasound-guided cystogastrostomy or cystoenterostomy with placement of an LAMS into the WON collection. At the discretion of the endoscopist, we performed direct endoscopic necrosectomy, irrigation with hydrogen peroxide, and/or nasocystic drain placement. We performed endoscopic retrograde cholangiopancreatography with pancreatic duct stent placement when indicated. Concomitant therapies included direct endoscopic debridement (n= 78), pancreatic duct stent placement for leak (n= 19), hydrogen peroxide-assisted necrosectomy (n= 38), and nasocystic irrigation (n= 22). We collected data for a median time of 4 months (range, 1-34 months) after the LAMS placement. The primary outcomes were rates of technical success (successful placement of the LAMS), clinical success (resolution of WON, on the basis of image analysis, without need for further intervention via surgery or interventional radiology), and adverse events. The median size of the WON was 9.5 cm (range, 4-30 cm). Eight patients had 2 LAMS placed for multiport access, all with technical success (100%). Clinical success was achieved in 107 patients (86.3%) after 3 months of follow-up. Thirteen patients required a percutaneous drain, and 3 required a surgical intervention to manage their WON. The stents remained patent in 94% of patients (117 of 124) and migrated in 5.6% of patients (7 of 124). The median number of endoscopic interventions was 2 (range, 1-9 interventions). On the basis of a retrospective analysis of 124 patients, endoscopic therapy of WON by using LAMS is safe and effective. Creation of a large and sustained cystogastrostomy or cystoenterostomy tract is effective in the drainage and treatment of WON.

Sa1490 The Safety and Efficacy of Pancreatic Duct Stent Placement in the Emergency ERCP of Acute Biliary Pancreatitis

Several prospective, randomized trials have demonstrated that early ERCP and biliary endoscopic sphincterotomy (ES) with/without stone extraction was superior in reducing the mortality and morbidity rates in acute biliary pancreatitis (ABP) compared with conservative treatment. Prophylactic pancreatic duct (PD) stent placement has been shown to reduce the risk of post-ERCP pancreatitis. However, there are few reports about PD stent placement in the emergency ERCP of ABP. The aim of current study was to evaluate the safety and effectiveness of emergency ERCP and PD stent placement in patients with ABP.

Sa1188 No Added Benefit of Indomethacin in the Prevention of Post-ERCP Pancreatitis After Protective Pancreatic Duct Stent Placement in Low Risk Patients

Sa1188 No Added Benefit of Indomethacin in the Prevention of Post-ERCP Pancreatitis After Protective Pancreatic Duct Stent Placement in Low Risk Patients

Ways to prevent complications in endoscopic transpapillary interventions

Aim. To assess the effectiveness of preventive measures in endoscopic interventions on the major duodenal papilla.Methods. 1028 transpapillary interventions related to benign and malignant diseases were performed on 575 patients from 2007 to 2015. The analysis of complications rate and structure in different time intervals, taking into account the changing of patients management tactics and the use of different preventive technologies, was performed.Results. During 2007-2015, 30 cases of post-manipulational complications were registered (2.9% of patients) with a mortality rate of 0.09%. In the period from 2007 to 2008 post-manipulational complications rate was 8.5%. The main causes of complications were surgery long duration (up to 2 hours) and the lack of endoscopist experience. During this period, there was only one death, which was caused by acute cardiovascular insufficiency. From 2009 to 2011, the complications number decreased to 3.4% due to the careful patients selection for elective surgery, including the endosonography in diagnostic algorithm, octreotide, and hyoscine butylbromide use, the expansion of indications for the bile ducts stenting, exclusion the main pancreatic duct contrast, nasobiliary drainage in obstructive jaundice and suppurative cholangitis. In the period from 2012 to 2015, in the presence of a high risk of post-manipulational pancreatitis, every fifth intervention was completed by the main pancreatic duct stent placement with reducing of manipulations duration to 25-35 minutes, and increasing the surgery phases number. During this period, post-manipulational complications rate was 1.2%.Conclusion. Analysis of post-manipulational complications allowed to identify the most important measures to enhance the transpapillary interventions safety, thereby reducing the number of complications from 8.5% in the period of 2007-2008, to 1.2% in the period of 2014-2015.

Early precut is as efficient as pancreatic stent in preventing post-ERCP pancreatitis in high-risk subjects - A randomized study.

The most common adverse event of endoscopic retrograde cholangiopancreatography is pancreatitis. Precut sphincterotomy has been regarded as a risk factor. Some authors have stated that early precut may actually reduce post-ERCP pancreatitis risk. However, early precut as a preventive measure has not been compared to other preventive measures, such as pancreatic duct stent placement. To compare the efficacy of early precut sphincterotomy versus pancreatic duct stent placement in high-risk subjects undergoing endoscopic retrograde cholangiopancreatography for the prevention of post-endoscopic cholangiopancreatography. This was a single-blinded, randomized trial that took place in two tertiary referral centers in Buenos Aires, from November 2011 to December 2013. ERCP subjects presented at least one of the following risk factors: female sex, age less than 40 years, clinical suspicion of sphincter of Oddi dysfunction, previous pancreatitis, and/or common bile duct diameter of less than 8 mm. Only those who presented a difficult biliary cannulation were randomized into two groups: those who received early precut sphincterotomy and those in whom persistency of biliary cannulation was intended, with subsequent pancreatic duct stent placement after cholangiography was achieved. The incidence of post-ERCP pancreatitis, as well as other adverse events incidence, was compared. Overall, 101 patients were enrolled, 51 in the pancreatic duct stent group and 50 in the early precut group. Pancreatitis rate was similar in both groups (3.92% vs 4%, p NS). In all cases, pancreatitis was classified as mild. There were no deaths registered. Early precut was associated with an incidence of adverse events similar to pancreatic duct stent placement.

Pancreatic Fistula Presenting as Gastric Outlet Obstruction Concerning for Gastric Malignancy: Piecing the Puzzle

Background: Gastric outlet obstruction (GOO) is a clinical syndrome comprising epigastric pain and post-prandial vomiting, often due to mechanical obstruction. Compression by intramural pancreatic pseudocysts (PP) resulting in GOO is a well-defined phenomenon. We present the first reported case of GOO secondary to pancreatic fistula leading to an intramural fluid collection of the pylorus. Case: 54 year-old man with recent cholecystectomy presented with non-bilious emesis of 4 days. Patient endorsed outside hospital admission for similar complaints 4 months ago, but spontaneous symptom resolution. He had hypoactive bowel sounds but otherwise non-tender, non-distended abdomen. Rou[ tine lab work was unremarkable. Computed tomography (CT) without contrast described pyloric heterogeneity and gastric distension, and a possibility of gastric malignancy causing GOO. EGD revealed ballooning around the pyloric opening, giving appearance of circumferential pyloric channel tumor. The scope could not be advanced further. Endoscopic ultrasound (EUS) demonstrated a hypoechoic pyloric lesion confined to the deep mucosa. FNA aspirated dark fluid. Fluid analysis: amylase (>75,000 U/L). Enlarged Peri-gastric lymph node FNA was negative for malignancy. Repeat CT with contrast disclosed a 2.4x4.5x5.7cm fluid collection around the pylorus with communication to the pancreatic duct (PD). Fluid collection was drained endoscopically with subsequent placement of PD stent. Patient later disclosed having a remote episode of pancreatitis and prior surgical pseudo cyst drainage, which confirmed our clinical suspicion of pancreatic fistula. Discussion: Most PPs resolve spontaneously and uneventfully. Rarely, PP may have communication with PD, in which case may arise, a rare complication of fistula formation to other viscera. Pathogenesis of PP is believed to be due to disruption of the main PD or peripheral ductules causing leakage and activation of pancreatic enzymes, which further explains the formation of the fistula. Symptomatic fistulae present as pain, fever, septicemia, and compression of neighboring structures. Endoscopic drainage via cystgastrostomy or cystoduodenostomy is the preferred approach followed by placement of PD stent to allow further drainage and fistula healing. Performed independently, both drainages are effective, safe and well-coded and the expertise on these procedures is widespread. Surgical drainage is reserved for recurrence or for endoscopic failures.Figure 1Figure 2Figure 3

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.

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.

Mo1407 Post ERCP Complications: Comparing Standard Biliary Cannulation With Needle Knife Fistulotomy

Mo1406 Pancreatic Duct Stenting for the Prevention of Post-ERCP Pancreatitis: National Trends Mohammad H. Shakhatreh*, Somashekar G. Krishna, Jeffery R. Groce, Sheetal Sharma, Jon P. Walker, Alice Hinton, Samer El-Dika Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH; Division of Biostatistics, School of Public Health, The Ohio State University, Columbus, OH Introduction: Studies have emerged to support the use of prophylactic pancreatic duct (PD) stent placement for the prevention of post-ERCP pancreatitis. Patients with choledocholithiasis do not usually have a PD stent placed during ERCP unless it is for the sole purpose of preventing post-ERCP pancreatitis. The aim of the present study was to evaluate the effect these studies have had on national trends in prophylactic PD stent placement. Methods: Using the Nationwide Inpatient Sample from 2003 to 2011, we retrospectively collected data on inpatients undergoing ERCP for choledocholithiasis. We analyzed the overall number of ERCPs and the number done when a PD stent was placed and evaluated the trend of utilization during the study period. We also evaluated the demographics and hospital characteristics for these patients. Results: During the study period, the number of admissions for choledocholithiasis increased from 112,675 (0.29% of all admissions) in 2003 to 149,271 (0.39% of all admissions) in 2011 (p!0.0001) (Figure 1). There was a decrease in the proportion of inpatient ERCPs among patients admitted with choledocholithiasis from 67.0% in 2003 to 62.8% in 2007, but then this gradually increased to 65.6% in 2011 (Figure 1). During the same study period, an increase in the use of pancreatic duct stenting was noted, starting in 2005 and peaking at 3.6% in 2010 (Figure 1). The mean age of patients who underwent ERCP with PD stent placement was 56.8 years (95%CI 55.9-57.7). Most PD stents were placed in women (64.8%) and in Whites (68.8%). The use of PD stents was more common in urban teaching hospitals (51.8%) and large size hospitals (67.5%). Most patients who underwent placement of a PD stent had an Elixhauser comorbidity index of less than 3 (64.2%). Conclusion: Despite the decline in the proportion of inpatient ERCPs among patients admitted with choledocholithiasis between 2003 and 2011, the use of PD stenting has significantly increased, especially since 2005, after multiple studies were published reporting decreased rates of post-ERCP pancreatitis with the use of prophylactic PD stents.

Prophylactic Pancreatic Stents in High-Risk Population and Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

Background: Acute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography (ERCP). Several medical and surgical procedures have been analyzed in prevention of post-ERCP pancreatitis as a major post-ERCP complication, so we conducted a study to assess the role of prophylactic pancreatic stents on prevention and severity of post-ERCP pancreatitis. Materials and Methods: This case control studied adult patients undergoing ERCP at the ERCP unit of a referral educational hospital. Data of the case (stent, N=90) and control (non-stent) (N=105) groups were retrieved from medical records. In our center, sphinctrerotomy was performed for 103 patients of non-stent group and successful pancreatic stent placement was done in 86 patients of stent group in a standard fashion. In stent group, a 5F, 4 centimeter pancreatic stent was emplaced over a guide wire under fluoroscopic guidance. All post–ERCP pancreatitis and major complications of all patients were retrieved too. Results: Of 255 enrolled patients, 195 were at high risk of post-ERCP pancreatitis allocated in two groups of this study. Successful pancreatic stent placement was done in 86 patients (95.6%) of stent group. There was no major complication during procedures. The migration of pancreatic duct stent was diagnostic in 3 (3.5%) patients. The overall post ERCP pancreatitis was 4.0% and 16.6% in stent and non-stent groups, respectively. Conclusion: Based on our findings in this study, we strongly recommended pancreatic duct stent placement in high-risk patients; although the experience of endoscopist plays a crucial role. [GMJ.2015;4(2):67-71]

Endoscopic management of pain in pancreatic cancer.

Pancreatic cancer is the fourth leading cause of cancer-related death in the United States and one of the leading causes of cancer mortality in the United States. Due to its aggressive behavior and lack of effective therapies, palliation plays a critical role in the management of the disease. Most patients with pancreatic cancer suffer from severe pain, which adversely predicts prognosis and significantly impacts the quality of life. Therefore pain management plays a central role in palliation. Non-steroidal anti-inflammatory drugs and opioid agents are often first line medications in pain management, but they do not target the underlying pathophysiology of pain and their use is limited by adverse effects and dependence. The proposed mechanisms of pain development in pancreatic cancer include neurogenic inflammation and ductal hypertension which may be targeted by endoscopic therapies. Endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) and pancreatic duct stent placement are the two primary endoscopic modalities for palliative management in pancreatic cancer patients with refractory pain. Other endoscopic treatments such as biliary stent placement and enteral stent placement for biliary and duodenal obstruction may also help palliate pain in addition to their role in decompression. This article reviews the existing evidence for these endoscopic interventions for pain management in pancreatic cancer.

Updated meta-analysis of pancreatic stent placement in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis.

To investigate the efficacy and safety profile of pancreatic duct (PD) stent placement for prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). We performed a search of MEDLINE, EMBASE, and Cochrane Library to identify randomized controlled clinical trials of prophylactic PD stent placement after ERCP. RevMan 5 software provided by Cochrane was used for the heterogeneity and efficacy analyses, and a meta-analysis was performed for the data that showed homogeneity. Categorical data are presented as relative risks and 95% confidence intervals (CIs), and measurement data are presented as weighted mean differences and 95%CIs. The incidence rates of severe pancreatitis, operation failure, complications and patient pain severity were analyzed. Data on pancreatitis incidence were reported in 14 of 15 trials. There was no significant heterogeneity between the trials (I(2) = 0%, P = 0.93). In the stent group, 49 of the 1233 patients suffered from PEP, compared to 133 of the 1277 patients in the no-stent group. The results of this meta-analysis indicate that it may be possible to prevent PEP by placing a PD stent. PD stent placement can reduce postoperative hyperamylasemia and might be an effective and safe option to prevent PEP if the operation indications are well controlled.

Post-endoscopic retrograde cholangiopancreatography pancreatitis.

Acute pancreatitis remains the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). It is reported to occur in 2–10% of unselected patient samples and up to 40% of high-risk patients. The purpose of this article is to review the evidence behind the known risk factors for post-ERCP pancreatitis, as well as the technical and medical approaches developed to prevent it. There have been many advances in identifying the causes of this condition. Based on this knowledge, a variety of preventive strategies have been developed and studied. The approach to prevention begins with careful patient selection and performing ERCP for specific indications, while considering alternative diagnostic modalities when appropriate. Patients should also be classified by high-risk factors such as young age, female sex, suspected sphincter of Oddi dysfunction, a history of post-ERCP pancreatitis, and normal serum bilirubin, all of which have been identified in numerous research studies. The pathways of injury that are believed to cause post-ERCP pancreatitis eventually lead to the common endpoint of inflammation, and these individual steps can be targeted for preventive therapies through procedural techniques and medical management. This includes the use of a guide wire for cannulation, minimizing the number of cannulation attempts, avoiding contrast injections or trauma to the pancreatic duct, and placement of a temporary pancreatic duct stent in high-risk patients. Administration of rectal non-steroidal anti-inflammatory agents (NSAIDs) in high-risk patients is the proven pharmacological measure for prevention of post-ERCP pancreatitis. The evidence for or against numerous other attempted therapies is still unclear, and ongoing investigation is required.

Pancreaticoureteral Fistula: A Rare Complication of Pancreatitis

Introduction: Pancreatitis is an inflammatory condition that can cause progressive and permanent destruction of the pancreas, which can lead to exocrine and endocrine insufficiency. There are many other complications associated with pancreatitis including formation of pseudocysts, pancreatic ascites, pleural effusions, splenic or portal vein thrombosis, pseudoaneurysm of splenic artery, and pancreatic fistulas. This case report describes an uncommon formation of a pancreaticoureteral fistula as a result of pancreatitis. Case Report: A 69-year-old Hispanic female with past medical history significant for recurrent episodes of pancreatitis with pseudocyst formation presented to emergency department with a chief complaint of sharp, severe, constant abdominal pain associated with nausea and a few episodes of non-bloody, non-bilious vomiting. Her last episode of acute pancreatitis was 2 months ago. Vital signs were normal. Physical examination revealed mild tenderness in the left upper and left lower quadrant without any guarding or rigidity. A computed topography (CT) scan of abdomen was performed which showed an abnormal pancreatic duct in the body and tail of the pancreas with complex multiloculated pseudocyst within the body and tail of the pancreas, extending anteriorly into the lesser sac to the stomach, posteriorly and medially extending into the level of the left kidney with possible fistula formation with mild left-sided hydronephrosis. To evaluate the presence of the fistula, the patient underwent cystoscopy with a left retrograde pyelogram which confirmed the presence of a fistula connecting the left renal pelvis to the pancreatic duct. A ureteral stent was placed at that time to facilitate closure of the fistula. Despite ureteral stent placement, the patient’s symptom did not improve so she underwent an endoscopic retrograde cholangiopancreatography (ERCP) with pancreatic duct stent placement. The patient remained symptomatic and ultimately underwent pancreatic cyst gastrostomy. Post-procedure, the patient improved and a repeat left retrograde pyelogram showed resolution of the pancreaticoureteral fistula. Conclusion: Pancreatic fistulas are rare complications of pancreatitis. Diagnosis can be made by imaging modalities such a CT, MRCP, ERCP, fistulography, etc. Treatment is conservative medical management; however, patients may need endoscopic or surgical intervention. Keep this rare complication in mind when evaluating a patient presenting with pancreatitis and urinary complaints.