Pancreatic Duct Stent Research Articles

1329 Choledochocele: An Unlikely Culprit of Acute Relapsing Pancreatitis

INTRODUCTION: Choledochocele, a type III biliary cyst representing 1-5% of all biliary cysts, is a congenital or acquired cystic dilatation of the intraduodenal bile duct more commonly seen in patients of Asian descent. Patients are usually asymptomatic, but can occasionally present with abdominal pain, jaundice, and a palpable abdominal mass; with malignancy less frequently seen than in other types of biliary cysts. Acute, relapsing pancreatitis is an uncommon presentation. We present a case of recurrent pancreatitis secondary to a choledochocele. CASE DESCRIPTION/METHODS: An 84-year-old woman with a history of DM, HTN, and recurrent gallstone pancreatitis s/p cholecystectomy 2 weeks prior presented with generalized abdominal pain for 1 day. She was febrile to 100.2, with tenderness to palpation of the epigastrium. Lipase was elevated to 1388. CT Abdomen/Pelvis was remarkable for mild common bile duct (CBD) dilation with bulging into the ampulla, a cystic structure in the uncinate process measuring 2.1 cm, and edematous changes in the peripancreatic space around the head and uncinate; consistent with pancreatitis. An MRCP was obtained, and showed no evidence of choledocholithiasis, dynamic bulbous dilatation of the distal CBD at the ampulla of unclear etiology, and interval enlargement of a 2.1 cm simple-appearing pancreatic uncinate cyst. She underwent EUS, which was significant for a choledochocele; followed by ERCP with sphincterotomy and unroofing of the choledochocele with a needle knife, as well as pancreatic duct (PD) stent placement. She was then discharged with follow-up but returned 6 days later, with progressively worsening RUQ pain with nausea and vomiting. Imaging revealed a 2.8 cm peripancreatic fluid collection associated with pancreatic stranding and PD stent dislodgement. She had EUS and FNA of the pancreatic cyst, which showed infected pancreatic necrosis. She improved with Vancomycin and was soon discharged home with outpatient follow-up. DISCUSSION: Choledochocele is an uncommon cause of acute, relapsing pancreatitis, which can cause significant pancreatic pathology over time. If the cyst becomes symptomatic, treatment is required. Since first described by J Siegel in 1981, first-line management has involved sphincterotomy with unroofing. In cases of large >3 cm cysts, or cysts that did not respond to endoscopic management, surgery must be considered.

3012 Pancreatic Ascites in a Patient With Thromboembolic Disease

INTRODUCTION: Pancreatic ascites is a rare condition characterized by abdominal pain, weight loss and progressive ascites. It is a complication of pancreatic duct disruption leading to leakage into the peritoneal cavity. The epidemiology is not well studied, which makes diagnosis challenging for clinicians. CASE DESCRIPTION/METHODS: A 54-year old female with a history of alcohol abuse, alcoholic cirrhosis, and chronic pancreatitis with pseudocyst presented to the Emergency Department with pleuritic chest pain, right calf pain and swelling for several days. She also had chronic abdominal pain, nausea, vomiting and poor appetite with 10-pound weight loss in 3 months. Her pseudocyst was routinely followed up with no significant change. The patient's significant vitals included BMI of 14.45 kg/m2, tachypnea and tachycardia. Physical examination revealed epigastric tenderness, abdominal distension and right calf swelling. Significant labs included hypoalbuminemia 1.3 g/dL, D-dimer 13.68 mcg/mL and Pro-calcitonin 19.92 mcg/L. CTA of chest revealed bilateral pulmonary emboli with right heart strain. Lower extremity duplex was positive for right femoral DVT. Patient was subsequently started on heparin infusion. A CT scan of abdomen and pelvis revealed an unchanged 2.2 × 1.1 cm pseudocyst in head of pancreas. Diagnostic paracentesis showed fluid analysis of albumin 0.5 g/dl, protein 1.4 g/dl and elevated amylase 836 U/L. The SAAG score was 0.8, which was clinical congruent with pancreatic ascites. MRCP identified the pseudocyst having a thin tubular extension along anterior pancreatic body. ERCP with pancreatic duct sphincterotomy and stent placement did not provide clinical improvement. EUS visualized a 6.6 cm fluid collection between stomach and spleen, with the pseudocyst was 1 cm adjacent to the gastric wall. It was aspirated and metal stent was placed to dilate entry into pseudocyst via endoscopic cystogastrostomy. The fluid content was finally suctioned out. The patient clinically improved and was discharged on warfarin. The stent was removed a month later. DISCUSSION: This case illustrates the importance of immediate paracentesis in diagnosing pancreatic ascites, a rare and potentially fatal condition if left untreated. Diagnosis is made with elevated fluid amylase, low SAAG score and clinical picture congruent with chronic pancreatitis with accompanied pseudocyst or severe acute pancreatitis. Early endoscopic intervention has shown highly successful at reducing mortality, hospital length of stay and recurrence.

1264 Mediastinal Pancreatic Pseudocyst With Expansion Into Bilateral Pleural Spaces

INTRODUCTION: Pseudocysts are a common complication of both acute and particularly chronic pancreatitis. Uncommonly, pseudocysts may communicate with thoracic cavities, including the mediastinum. We describe a case of acute pancreatitis complicated by a mediastinal pseudocyst with bilateral pleural space involvement. CASE DESCRIPTION/METHODS: A 51-year-old male with a history of alcohol abuse presented shortly after discharge from a prolonged hospitalization for his first lifetime episode of acute alcohol-induced pancreatitis. A CT of the chest ordered on admission for new onset respiratory distress demonstrated bilateral pleural effusions. Fluid analysis showed a right sided empyema and left sided aseptic exudative effusion. The right empyema resolved after chest tube placement but there was rapid recrudescence of a right pleural effusion after chest tube removal. Repeat fluid analysis was significant for a pancreatic specific amylase level of 2620. Repeat CT imaging demonstrated a posterior mediastinal fluid collection that arose from the pancreas, extended through the esophageal hiatus and was contiguous with new fluid collections in both pleural spaces and this was confirmed with MRCP. The mediastinal pseudocyst was deemed not amenable to endoscopic drainage so ERCP was performed with stent placement to the ventral pancreatic duct along with chest tube placement for the larger right sided fluid collection and subcutaneous octreotide administration, with eventual reduction of pseudocyst size. DISCUSSION: Mediastinal pseudocysts are a rare complication of acute pancreatitis more commonly seen in chronic pancreatitis, though exceedingly rare in general. It is theorized that mediastinal pseudocysts occur based on ease of pancreatic fluid movement. The pararenal and pelvic extraperitoneal spaces are typically the easiest spaces for this fluid to penetrate but conditions that create inflammatory fibrosis of these areas may make ascending flow into the mediastinum the path of least resistance. On CT scan and on MRCP, our patient had a mediastinal pseudocyst that communicated directly and inseparably with both the right and left pleural space. To our knowledge, this has not been previously seen in the limited case reports of mediastinal pseudocysts. Despite not being amenable to endoscopic drainage based on location, the use of octreotide coupled with pancreatic duct stenting proved effective in reducing the caliber of this mediastinal pseudocyst on interval imaging.

2141 “Knock Out” Pancreas: An Unusual Case of Isolated Pancreatic Duct Laceration in a Mixed Martial Arts Fighter

INTRODUCTION: Isolated Pancreatic duct laceration due to blunt trauma to the abdomen is very rare. Diagnosis requires a high level of suspicion as delay in diagnosis can lead to complications such as pseudocyst, abscess and duct stricture. We present an unusual case of pancreatic duct laceration complicated with pseudocyst formation due to blunt trauma to the abdomen during a Mixed Martial Arts fight. CASE DESCRIPTION/METHODS: 33-year-old MMA fighter with no past medical history sustained a blunt trauma to the abdomen during a fight resulting in a knockout. Patient was emergently transferred to the hospital for evaluation. Lab work revealed elevated lipase >2000 IU consistent with acute traumatic pancreatitis. CT of the abdomen revealed diffuse edema of the pancreas with suspicion for possible laceration of the pancreatic duct. Patient was conservatively managed and later discharged once pain improved. Patient continued to have abdominal pain and returned to the emergency room 3 months later with abdominal distention associated with nausea and vomiting. Repeat CT of the abdomen revealed a 13 cm × 12.5 cm cystic lesion around the body of the pancreas with communication with the pancreatic duct (Image 1,2). MRI revealed a large cystic lesion with potential communication with the pancreatic duct seen on T2 images (Image 3).An ERCP was attempted but due to the mechanical compression caused by the cyst, the ampulla could not be accessed. An Endoscopic Ultrasound guided placement of a 10 × 10 mm cyst gastrostomy stent resulted in successful drainage of the pancreatic pseudocyst. Patient was later discharged and followed up in 1 month with repeat imaging showing complete resolution of the cyst. Endoscopy was repeated 4 weeks later with removal of the cystgastrostomy stent. Patient has since been doing well and awaits ERCP to evaluate the anatomy of the pancreatic duct. DISCUSSION: Isolated laceration of the pancreatic duct due to blunt trauma to the abdomen is very rare. Sudden severe impact to the abdomen, such as a punch, compresses the pancreas against the vertebral column resulting in pancreatic laceration. Diagnosis requires a high degree of suspicion and imaging confirmation. Management can be challenging as most pancreatic duct lacerations are often missed resulting in complications such as in our patient. There have been case reports of successful management with early endoscopic pancreatic duct stent placement. Refractory cases often require complex abdominal surgeries such as pancreatico - jejunostomy.

1318 Pancreaticopleural Fistula in a Patient With Recurrent Alcoholic Pancreatitis: Combined Endoscopic and Medical Management

INTRODUCTION: Pancreaticopleural fistula (PPF) is a rare complication of pancreatitis, resulting from disruption of the pancreatic duct. This injury may be secondary to acute/chronic pancreatitis, trauma, or surgery. Here we describe a patient with a PPF, and our workup and treatment for this rare condition. CASE DESCRIPTION/METHODS: A 61-year-old male with COPD, alcohol misuse, and history of recurrent acute alcoholic pancreatitis complicated by pseudocysts was admitted with one month of worsening shortness of breath from a large left pleural effusion, which reaccumulated within four days after a 1.6 L thoracentesis. On examination he had mild abdominal tenderness in the RUQ and epigastrium. Labs were notable for serum amylase 1105 U/L, lipase >1000 U/L, and WBC 10.8. He underwent another thoracentesis, removing 1.5 L of fluid which was an exudate with amylase greater than 2000 U/L. CT of the chest and abdomen showed a subdiaphragmatic LUQ fluid collection with communication to the pancreatic body and duct. A chest tube was then placed to prevent fluid re-accumulation. MRCP confirmed a PPF from the proximal pancreatic body duct to the left pleura. He was started on octreotide. ERCP confirmed a fistula originating from the distal pancreatic duct but attempts to pass a wire into the dorsal pancreatic duct were unsuccessful, and a ventral pancreatic sphincterotomy was performed. His chest tube was removed after one day, and he was discharged to continue octreotide at home. Unfortunately, he returned the following day with complaints of dyspnea. Pancrelipase was then added in an attempt to minimize pancreatic exocrine secretions. On follow-up 1 and 2 months later, the pleural fluid is much smaller, and the patient's dyspnea has resolved. DISCUSSION: Here we present a novel management of PPF without pancreatic duct stent placement and instead with pancreatic sphincterotomy to divert pancreatic secretions away from the fistula tract and medical therapy (octreotide and pancrelipase) to reduce the pancreatic secretion. The diagnosis was reached through a combination of clinical history, lab studies (particularly, the elevated amylase in the pleural fluid), and CT and MR imaging. This was further confirmed with ERCP, which is useful especially if a stent can be placed to divert secretions away from fistula tract. Ultimately, this diagnosis requires a high index of suspicion, particularly in patients who present with recurrent effusions in the setting of pancreatitis.

1441 Beyond Pseudocysts: When Acute Pancreatitis Involves the Colon

INTRODUCTION: While common complications of acute pancreatitis can include pseudocysts, necrosis and infection, colonic involvement, leading to stenosis and necrosis, is a rare sequela of severe acute pancreatitis. We present the case of an unfortunate gentleman with severe pancreatitis complicated by sigmoid stricture and large bowel obstruction requiring hemicolectomy. CASE DESCRIPTION/METHODS: The patient is a 46-year-old man with history of necrotizing pancreatitis secondary to familial hypertriglyceridemia, complicated by pseudocyst formation, requiring cyst gastrostomy and stent placement, who presented with subacute nausea, vomiting and diffuse abdominal pain. Laboratory findings, including complete metabolic panel, complete blood cell count and lipase were unremarkable. Computed tomography, however, revealed interval development of large bowel obstruction, with transition point within the proximal descending colon. The patient was managed conservatively initially but required colonic decompression with colonic stent placement of the descending colon. Colonoscopy did not reveal any mucosal lesion and biopsy confirmed the absence of malignant cells. Due to persistent large bowel obstruction, the patient underwent an exploratory laparotomy and removal of fibrosis bowel with left hemicolectomy. His course was complicated by post-operative hypotension and an increase in peripancreatic fluid collection requiring endoscopic retrograde cholangiopancreatography with sphincterotomy and pancreatic duct stent placement. A drain was subsequently placed for infected intrabdominal fluid collection and the patient was discharged on a 10-day course of antibiotics. DISCUSSION: Cited only a few times in the literature, colonic involvement as a complication of acute pancreatitis is a rare and interesting finding. Inflammatory pancreatic enzymes precipitate necrosis, leading to fibrosis with stricture formation, perforation or peritonitis. The colon is affected due to its anatomic proximity with the pancreas. The splenic flexure, which abuts the pancreatic tail, is most commonly involved. While aggressive debridement of necrotic pancreatic tissue and drainage of retroperitoneal collections can help prevent colonic pathology, once involved, large bowel necrosis carries a mortality rate as high as 50% and 95%. Management is with early colon resection. Interestingly, compression by a pancreatic pseudocyst can cause colon involvement and may have been the etiology for our patient's sigmoid stricture.

1383 Making It Work With the Tools at Hand: Use of a Biliary Stent to Repair a Pancreatic Leak

INTRODUCTION: Pancreatic duct leaks (PDL) are primarily managed by advanced endoscopist, interventional radiologists, and sometimes by pancreatic surgeons. The mainstay of endotherapy for PDL is trans-papillary pancreatic duct stent placement bridging the PDL. Fully covered biliary metal stents are widely accepted in biliary leaks due to its radial force but there is no conventional fully covered metal stent (FCMS) in US for pancreatic duct for refractory PDL. We describe a patient with refractory PDL where biliary SEMS was used to successfully treat PDL. CASE DESCRIPTION/METHODS: Case Presentation A 43-year-old African American male presented to our hospital one month after admission for hemorrhagic pancreatitis attributed to dyslipidemia. Course was complicated by loculated retroperitoneal abscess tracking from pancreas to scrotum. Patient underwent exploratory laparotomy with pancreatic necrosectomy along with broad-spectrum antibiotics resulting in mild improvement in condition. Magnetic resonance cholangiopancreatography revealed PD injury confirmed on abdominal CT with contrast. ERCP confirmed PDL. A 5 F × 8 cm single pigtail plastic pancreatic stent (PPS) was placed. Unfortunately, PPS failed to maintain drainage and prevent leak as observed on contrasted abdominal CT 6 days later. PDL was confirmed again on repeat ERCP and an 8 mm × 6 cm biliary fully covered SEMS was placed in PD. Post stent placement, occlusion pancreatogram (OP) showed no leak. Four days later, repeat CT showed improving fluid collections without leak. After 4 weeks, third ERCP was performed, SEMS was removed with rat tooth forceps without complications, ERCP showed no PDL and a 7 F × 7 cm PPS was placed. Six weeks later, PPS was removed, ERCP showed no PDL and a 7 F × 4 cm PPS was placed. At this time, patient has continued to follow on outpatient basis without further incident. DISCUSSION: Discussion Endoscopic treatments for PDL have replaced surgical interventions in number of situations. Biflanged fully covered metal stents for PDL are only available outside US. In the meantime, cases like this emphasize the importance of considering alternative approaches in the treatment of PDL.

2160 Transpapillary Drainage of Persistent Pseudocyst Causing Dysphagia

INTRODUCTION: Pseudocysts (PC) are well-known complications of acute and chronic pancreatitis. Symptoms can include abdominal pain, early satiety and weight loss. We present a unique case of a PC presenting with dysphagia. CASE DESCRIPTION/METHODS: A 47-year-old female with history of acute on chronic pancreatitis due to alcoholism complicated by a persistent PC presented with weight loss and progressively worsening dysphagia for one year. Prior attempted surgical cystgastrostomy and percutaneous aspiration of her PC were unsuccessful. Esophagram showed a stricture of the distal esophagus, without passage of a barium tablet, and computed tomography and magnetic resonance imaging demonstrated a 6 × 5.3 cm PC compressing the distal esophagus (Figure 1). Esophagogastroduodenoscopy with balloon dilation was not efficacious. Endoscopic ultrasound cystgastrostomy was attempted but not feasible due to the proximal location of the PC. Endoscopic retrograde cholangiopancreatography (ERCP) was consistent with severe chronic pancreatitis by Cambridge classification; there was a high-grade stricture at the genu with upstream pancreatic duct (PD) dilation and communication with the PC. The stricture would only allow dilation initially with a 5-4-3 cannula, which allowed placement of a 5-French PD stent to bridge the stricture, and a 10-French double pigtail stent for transpapillary drainage of the pseudocyst (Figure 2). Stricture brushings were negative for malignancy. Her dysphagia resolved with resulting weight gain, and subsequent ERCPs (with serial PD stenting to 10-French) demonstrated resolution of her PC and PD stricture. DISCUSSION: Dysphagia due to PC has been rarely reported. It is usually due to mediastinal extension of a PC, which has been treated by endoscopic (e.g. transpapillary and transmural drainage), radiologic, and surgical means with good technical success1,2. In our case, due to the proximal position of the PC which prohibited transmural drainage, along with failure of prior surgery and percutaneous aspiration, transpapillary drainage was necessary and effective. Resolution of the inciting PD stricture by stenting was of paramount importance for the prevention of PC recurrence.

Хирургическое лечения осложненных форм хронического панкреатита открытым стентированием панкреатического протока

Хирургическое лечение хронического панкреатита (ХП) – одна из наиболее сложных и не решенных до настоящего времени проблем хирургической панкреатологии. Целью научной работы являлось исследование эффективности открытого стентирования панкреатического протока с целью восстановление дренажной функции протоковой системы поджелудочной железы путем создания искусственного хода в паренхиме головки поджелудочной железы, соединяющего просвет главного панкреатического протока с просветом 12-перстной кишки. В ходе исследования был теоретически обоснован, разработан и внедрен в клиническую практику новый способ хирургического лечения ХП, позволяющий восстановить поступление панкреатического сока в двенадцатиперстную кишку и эффективно купирующий острый процесс в ПЖ, поддерживаемый панкреатической протоковой гипертензией – открытое стентирование панкреатического протока. Данная технология позволяет быстро купировать болевой синдром и воспалительный процесс в поджелудочной железе, восстановить пассаж панкреатического сока в двенадцатиперстную кишку, устранить трофологические нарушения, уменьшить количество и тяжесть послеоперационных осложнений, улучшить качество жизни пациентов, исключить развитие сахарного диабета непосредственно после операции.

Video Comment on Rasoul Sotoudehmanesh et al.

Rasoul Sotoudehmanesh et al. Pharmacological prophylaxis versus pancreatic duct stenting plus pharmacological prophylaxis for prevention of post-ERCP pancreatitis in high risk patients: a randomized trial

Endoscopic ultrasound-guided pancreatic duct stent placement for symptomatic pancreaticojejunostomy stricture.

Endoscopic ultrasound-guided pancreatic duct stent placement for symptomatic pancreaticojejunostomy stricture.

Pancreatic calcifications associate with diverse aetiological risk factors in patients with chronic pancreatitis: A multicentre study of 1500 cases

BackgroundPancreatic calcifications is a common finding in patients with chronic pancreatitis (CP), but the underlying pathophysiology is incompletely understood. Past studies for risk factors of calcifications have generally been focused on single parameters or limited by small sample sizes. The aim of this study was to explore several patient and disease characteristics and their associations with pancreatic calcifications in a large cohort of CP patients with diverse aetiological risk factors. MethodsThis was a multicentre, cross-sectional study including 1509 patients with CP. Patient and disease characteristics were compared for patients with calcifications (n = 912) vs. without calcifications (n = 597). Multivariable logistic regression was performed to assess the parameters independently associated with calcifications. ResultsThe mean age of patients was 53.9 ± 14.5 years and 1006 (67%) were men. The prevalence of calcifications was 60.4% in the overall patient cohort, but highly variable between patients with different aetiological risk factors (range: 2–69%). On multivariate analysis, alcoholic aetiology (OR 1.76 [95% CI, 1.39–2.24]; p < 0.001) and smoking aetiology (OR 1.77 [95% CI, 1.39–2.26], p < 0.001) were positively associated with the presence of calcifications, while an autoimmune aetiology was negatively associated with calcifications (OR 0.15 [95% CI, 0.08–0.27], p < 0.001). Patients with pancreatic calcifications were more likely to have undergone pancreatic duct stenting (OR 1.59 [95%CI, 1.16–2.19], p = 0.004). ConclusionThe presence of pancreatic calcifications is associated with diverse aetiological risk factors in patients with CP. This observation attest to the understanding of CP as a complex disease and may have implications for disease classification.

Flower Basket Retrieval: Utilization of a Device with a Unique Design for Endoscopic Rescue in Cases Involving Proximal Migration of Pancreatic Duct Stents

Flower Basket Retrieval: Utilization of a Device with a Unique Design for Endoscopic Rescue in Cases Involving Proximal Migration of Pancreatic Duct Stents

Stent-induced symptomatic pancreatic duct stricture after endoscopic prophylactic pancreatic duct stent placement for the normal pancreas

Background/ObjectivesStent-induced pancreatic duct stricture (SI-PDS) is a complication associated with pancreatic stent placement. However, symptomatic SI-PDS associated with prophylactic pancreatic duct stents has not been sufficiently investigated. MethodsWe examined the incidence and characteristics of symptomatic SI-PDS in patients who underwent pancreatic duct stent placement to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) between April 2007 and March 2017. ResultsWe examined 124 patients with normal pancreases consisting of 75 men and 49 women with a median age of 67.5 years [interquartile range (IQR): 61–74 years]. The median main pancreatic duct (MPD) diameter was 3.3 mm (IQR: 2.6–4.1 mm). The median duration of stent placement was 7 days (IQR: 3–14 days). Spontaneous dislodgment stents were placed in 43.5% of cases (54/124). The diameter of the stent was 5 Fr in 93.5% of cases (116/124) and 7 Fr in 6.5% of cases (8/124). Symptomatic SI-PDS was observed in 2.4% (3/124) of patients overall: 6.5% of patients with an MPD diameter of <3 mm and 0% of patients with an MPD diameter of ≥3 mm. Univariate analysis revealed that an MPD diameter <3 mm was a significant factor for symptomatic SI-PDS (p = 0.048). All cases of symptomatic SI-PDS improved with endoscopic treatment. ConclusionsSymptomatic SI-PDS occurred in 2.4% of patients who underwent prophylactic pancreatic duct stent placement for normal pancreases. Patients with an MPD diameter of <3 mm may be susceptible to symptomatic SI-PDS.

Etiology, clinical presentation and management of pancreatic pseudocyst

Background: The clinical presentation of pseudocyst is varied among individuals and so does the spectrum of management ranging from resolution to open or minimal access/ endoscopic drainage procedures. This study aims to review the various etiological factors, mode of clinical presentation of pseudocyst in relation to age and sex, and to study various modalities of investigation &amp; management of pseudocysts.Methods: In this prospective study, 31 diagnosed patients of pseudocyst of pancreas were included who underwent different biochemical and radiological investigations. The study duration was 2 years from November 2016 to October 2018 carried out at a tertiary care hospital and the management and outcome of these patients were studied.Results: Males (93.54%) were the predominating gender suffering from pseudocyst and alcohol consumption (70.96%) was the most common etiological factor. 67.74% of patients had pseudocyst formation after recurrent attacks of pancreatitis. 20 patients (64.51%) patients were managed conservatively with complete resolution of pseudocyst in 10 patients. In rest of the 11 patients, 7 patients underwent open internal drainage, 2 patients underwent endoscopic internal drainage and pancreatic duct stenting; in one patient, external drainage was performed and another patient distal pancreatic resection was done.Conclusions: Pseudocyst of pancreas is predominantly seen in males with alcohol consumption being the commonest etiological factor. Spontaneous resolution of pseudocyst occurs in most of the patients and symptomatic patients can be managed by intervention by open/endoscopic internal drainage with or without pancreatic stenting and external drainage should be reserved for infected pseudocysts.

Current approaches to the treatment of complications of endoscopic transpapillary interventions

Objective. Retrospective analysis of the treatment of complications after endoscopic retrograde transpapillary interventions. Material and methods. There were 5701 endoscopic retrograde interventions for the period from 01.01.2008 to 01.01.2019. Overall incidence of complications was 1.5%, mortality rate – 0.24%. Bleeding after endoscopic papillosphincterotomy developed in 13 (0.22%) cases, acute postoperative pancreatitis in 49 (10.85%) cases, ERCPassociated perforation in 24 (0.42%) patients. Results. Endoscopic approach (epinephrine injection into the edges of major duodenal papilla and cautery) was usually effective for bleeding after endoscopic retrograde cholangiopancreatography. Massive intraoperative bleeding required surgical treatment in one case with favorable outcome. There were no cases of recurrent bleeding. One patient died due to severe bleeding in 3 days after surgery. ERСP-associated (“retroduodenal”) perforation occurred in 24 (0.42%) patients. Endoscopic treatment was undertaken in 16 cases and was effective in 15 (93.75%) cases. Overall mortality among patients with ERCP-induced perforation was 20.8%. An attempt of pancreatic duct stenting for postoperative pancreatitis was made in 30 cases; successful procedure was in 28 (93.3%) cases. Surgery resulted recovery in 26 (86.7%) patients. Progression of acute postoperative pancreatitis followed by death occurred in 2 cases despite successful pancreatic duct stenting. Mortality rate was 25%. Conclusion. Treatment of ERCP-associated complication is lengthy, time-consuming and expensive. Timely diagnosis and assessment of severity of complications is essential. It is necessary to determine an adequate surgical approach. Everyone should keep in mind all possible risk factors, clearly define the indications for ERCP and follow the technique of the procedure strictly in order to reduce complication rate. In our opinion, endoscopic approach is advisable for post-ERCP complications, because conventional surgery results higher postoperative mortality, increased duration and cost of treatment.

Radiopaque Short Pancreatic Stents Reliably Migrate in Nearly All Patients When Inserted for Prevention of Pancreatitis

Placement of a pancreatic duct (PD) stent for prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP)1-3 often necessitates a second procedure for stent removal, generally within 2-4 weeks to avoid stent occlusion or injury to the duct.4 These procedures are associated with increased costs and may result in procedure-related complications. Stents without internal anchoring flaps were developed to allow spontaneous migration into the duodenum,5 thus obviating the need for a repeat procedure. However, radiographic confirmation of a migrated stent can be challenging.6.

Clinical value of endoscopic retrograde pancreatic drainage for pancreatic fistula

Objective To evaluate the clinical value of endoscopic retrograde pancreatic drainage (ERPD) in patients with pancreatic fistula. Methods Data of 42 patients with pancreatic fistula, who were treated with ERPD at Changhai Hospital and Henan Provincial People's Hospital from June 2013 to September 2018, were collected. The pancreatic fistula curative rate, healing duration of pancreatic fistula, and the incidence of complications were analyzed. Results Among 42 patients with pancreatic fistula, there were 30 males (71.4%) and 12 females (28.6%) with mean age of 41.5±12.8 years old. Pancreatic duct stents of 37 cases (88.1%) went across the fistula. The overall curative rate was 90.5% (38/42) . The median healing duration of pancreatic fistula was 32.0 d (8-183 d) . The healing time of pancreatic fistula after injury (19.0±9.9 d, t=3.50, P=0.002) and of pancreatic fistula after surgery (20.3±10.7 d, t=3.35, P=0.003) were shorter than that of pancreatic fistula after acute severe pancreatitis (60.0±48.6 d) . The healing time of pancreatic fistula with pancreatic pseudocysts was longer than that of pancreatic fistula without pancreatic pseudocysts (65.3±55.4 d VS 32.6±23.6 d, t=2.21, P=0.040) . There were no significant differences in pancreatic fistula curative rate, pancreatic healing duration and times of ERCP in pancreatic fistula at different position.Postoperative stent-related complications occurred in 2 patients (4.8%) , and 1 patient (2.4%) developed mild pancreatitis. Conclusion ERPD is an important treating method with good therapeutic effect and low complications for pancreatic fistula. Key words: Stent; Pancreatic fistula; Endoscopic retrograde pancreatic drainage

Lessons learned from isolated blunt major pancreatic injury: Surgical experience in one trauma centre

IntroductionThe aim of this study was to present our surgical experience of isolated blunt major pancreatic injury (IBMPI), and to compare its characteristic outcomes with that of multi-organ injury. Materials and methodsFrom 1994–2015, 31 patients with IBMPI and 54 patients with multi-organ injury, who underwent surgery, were retrospectively studied. ResultsOf the 31 patients with IBMPI, 22 were male and 9 were female. The median age was 30 years (interquartile range, 20–38). Twenty-one patients were classified as the American Association for the Surgery of Trauma–Organ Injury Scale Grade III, and 10 patients as Grade IV. Patients with IBMPI had significantly lower shock-at-triage rates, lower injury severity scores, longer injury-to-surgery time, and shorter length of hospital stay than those with multi-organ injury. There were no statistically significant differences in sex, age, trauma mechanism, laboratory data, surgical procedures, and complications between the two groups. Eight patients with IBMPI underwent endoscopic retrograde pancreatography, and 5 patients with complete major pancreatic duct (MPD) disruption underwent pancreatectomy eventually. The remaining 3 patients had partial MPD injury and two of them received a pancreatic duct stent for the treatment of existing postoperative pancreatic fistula. Spleen-sacrificing distal pancreatectomy (SSDP) was performed in 13 patient with IBMPI, followed by spleen-preserving distal pancreatectomy (n = 12), peripancreatic drainage (n = 4), and central pancreatectomy with Roux-en-Y reconstruction (n = 2). The overall complication rates, related to the SSDP, SPDP, peripancreatic drainage, and central pancreatectomy, were 10/13 (77%), 4/12 (33%), 3/4 (75%), and 2/2 (100%), respectively. Three patients died resulting in a 10% mortality rate, and the other 16 patients developed intra-abdominal complications resulting in a 52% morbidity rate. In the subgroup analysis of the 25 patients who underwent distal pancreatectomy, SPDP was associated with a shorter injury-to-surgery time than SSDP. ConclusionsPatients with IBMPI have longer injury-to-surgery times, compared to those with multi-organ injury. Of the distal pancreatectomy patients, the time interval from injury to surgery was a significant associated factor in preserving or sacrificing the spleen.

Controversies on the endoscopic and surgical management of pain in patients with chronic pancreatitis: pros and cons!

Pain is the dominating symptom of chronic pancreatitis (CP) causing impairment of quality of life, decreased activity, unemployment and major healthcare costs.1 Opinions differ on the best strategy to treat...