Endoscopic approach to pancreas divisum

Determining the value of endoscopic retrograde cholangiopancreatography in the management of patients with acute pancreatitis and related complications

INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a diagnostic to a therapeutic tool in acute pancreatitis management, largely due to the availability of less invasive diagnostic modalities such as endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP).

AREAS COVERED

This review explores the therapeutic applications of ERCP across various acute pancreatitis etiologies and its role in managing complications such as bile duct obstructions, pancreatic duct disruptions, and infected necrosis. The discussion highlights the procedure's expanding indications and its critical role in addressing complex cases.

EXPERT OPINION

ERCP remains central to the management of acute pancreatitis complications. As endoscopic techniques and devices continue to advance, its therapeutic scope is likely to grow. Performing ERCP for appropriate indications and optimizing its use is essential for minimizing risks and improving outcomes.

Efficacy of Endoscopic Therapy in Symptomatic Pancreatic Divisum: A Systematic Review and Meta-analysis

BACKGROUND AND AIMS

Pancreas divisum (PD) is a congenital malformation of the pancreas and is implicated as a cause of pancreatitis. The role of endotherapy has been variable in symptomatic PD indicated by recurrent acute pancreatitis (RAP), chronic pancreatitis (CP), or chronic pancreatic-type abdominal pain (PP). The aim of this study was to analyze the pooled data to determine the success of endoscopic intervention for pancreas divisum.

METHODS

We conducted a comprehensive search of several databases (inception to July 2023) to identify studies reporting on the use of endoscopic therapy in symptomatic pancreatic divisum. The random-effects model was used to calculate the pooled rates and I2 % values were used to assess the heterogeneity.

RESULTS

A total of 27 studies were retrieved that reported endoscopic intervention in pancreatic divisum. The calculated pooled rate of technical success was 92% (95% CI: 87-95; I2 =63%). The calculated pooled rate of clinical success was 65% (95% CI: 60-70; I2 =60%). The rate of clinical success by PD subtypes was highest in RAP at 71% (95% CI: 65-76; I2 =24%). Available studies had significant heterogeneity in defining clinical success. The rate of adverse events was 71% (95% CI: 65-76; I2 =24%).

CONCLUSIONS

The role of endoscopic therapy in pancreatic divisum is variable with the highest success rate in recurrent acute pancreatitis. Endoscopic intervention is associated with a higher-than-usual rate of adverse events, including post-ERCP pancreatitis.

Evolution of Pancreatic Endotherapy

In the last half century, endotherapy for pancreatic diseases has changed considerably. Although endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) were introduced initially as diagnostic tools, they quickly evolved into therapeutic tools for preventing and managing complications of pancreatitis. More recently, therapeutic endoscopy has shown potential in palliation and cure of pancreatic neoplasms. This article discusses the changing landscape of pancreatic endotherapy as therapeutic ERCP and EUS were introduced and because they have evolved to treat different diseases.

Pancreas divisum: a reemerging risk factor for pancreatic diseases

Pancreas divisum (PD) is the most common developmental anatomic variant of pancreatic duct. The attention towards the PD has grown significantly since there are reports that this condition may cause acute relapsing pancreatitis, chronic pancreatitis and chronic abdominal pain syndrome. Furthermore, over the years, there have been multiple reports of PD associated with different types of tumors. There is evidence that PD can be associated with pancreatic tumors (up to 12.5% of cases). The golden standard for diagnosing PD is endoscopic retrograde cholangiopancreatography, but since it is an invasive procedure magnetic resonance cholangiopancreatography with secretin is a good alternative. In case the patient is symptomatic, endoscopic or surgical treatment should be performed. This review describes the key points of the pathophysiology, diagnostic modalities, risks of pancreatitis and tumors, as well as treatment options of PD.

Recurrent Acute Pancreatitis: International State-of-the-Science Conference With Recommendations

Recurrent acute pancreatitis (RAP) is a clinically significant problem globally. The etiology remains unclear in approximately 10% to 15% of patients despite a thorough workup. Data on natural history and efficacy of treatments are limited. We aimed to establish criteria for diagnosis, evaluate the causative factors, and arrive at a consensus on the appropriate workup and management of patients with RAP. The organizing committee was formed, and a set of questions was developed based on the current evidence, controversies, and topics that needed further research. After a vetting process, these topics were assigned to a group of experts from around the world with special interest in RAP. Data were presented as part of a workshop on RAP organized as a part of the annual meeting of the America Pancreatic Association. Pretest and Posttest questions were administered, and the responses were tabulated by the current Grades of Recommendation Assessment, Development and Evaluation system. The consensus guidelines were established in the format of a diagnostic algorithm. Several deficiencies were identified with respect to data on etiology, treatment efficacies, and areas that need immediate research.

Balloon Dilatation of the Minor Duodenal Papilla Up to 4 mm is Safe in a Porcine Model

OBJECTIVES

Balloon dilatation of the minor duodenal papilla is a treatment option for symptomatic pancreas divisum. The histologic effects of balloon dilatation have not yet been evaluated. The aim of this study is to investigate the tolerated extent of dilatation of the minor papilla.

MATERIALS AND METHODS

A dilatation of the minor papilla was performed in freshly explanted pancreas of pigs using biliary balloon dilatators. Three organs were not dilated (control group), in each 8 organs a dilatation of 4, 6, and 8 mm, respectively, was performed. Tissue damage was assessed by microscopic evaluation. Ductal wall disruption and perforation as well as a semiquantitative inflammation score was described and compared.

RESULTS

Ductal wall disruption was increased by dilatation of 6 (5/8; P=0.019) and 8 mm (6/8; P=0.006) compared with 4 mm (1/8). Median inflammation score was 0 (0 to 0), 1 (0 to 2), and 1 (0 to 2) for dilatation of 4, 6, and 8 mm, respectively (4 vs. 6 mm, P=0.007; 4 vs. 8 mm, P=0.026). No perforation occurred in the 4 (0/8) and 6 mm (0/8) group, 1 perforation occurred in the 8 mm group (1/8).

CONCLUSIONS

A dilatation of up to 4 mm seems to be safe. However, dilatation of the minor papilla from 4 mm onwards is increasingly associated with tissue damage. These findings should be considered in endoscopic procedures dilating the minor duodenal papilla.

The efficacy of endoscopic therapy for pancreas divisum: a meta-analysis

Background

The purpose of this study was to perform a meta-analysis assessing the efficacy and predictors of success of endoscopic therapy in the management of patients with pancreas divisum.

Methods

An electronic database search (PubMed and ScienceDirect) was performed for relevant studies. Studies were selected based on predefined criteria and data were extracted on patient population, follow up, endotherapy methods, success rates and complication rates. A random-effect model was used to pool the effect size across studies. Heterogeneity testing and publication bias assessment were performed. Multivariate regression analysis was performed to identify predictors of successful endoscopic therapy.

Results

Of 381 articles reviewed, 23 studies with 874 patients met the inclusion criteria. All were case series with suboptimal quality. Endoscopic therapy included minor papilla sphincterotomy, minor papilla sphincteroplasty and dorsal duct stenting. Mean follow-up duration was 37 months. The rate of “improvement” as defined by authors after endoscopic therapy varied significantly across studies, ranging from 31-96%: 589/874 patients were reported to have improved, corresponding to a pooled efficacy rate of 67.5% (95% confidence interval [CI] 0.610-0.734; P=0.0001). The pooled rate of pancreatitis after endoscopic retrograde cholangiopancreatography was 10.1% (95%CI 0.084-0.124; 2-sided P=0.0001). On subgroup analysis, patients with recurrent acute pancreatitis had better endoscopic outcomes (pooled efficacy rate 76%, 95%CI 0.712-0.803, P=0.0001). Dorsal duct stenting and longer follow up were the only parameters predictive of successful endotherapy. Significant heterogeneity was observed within and across studies.

Conclusions

Endoscopic efficacy in pancreas divisum is estimated at 67.5%. Available studies are of poor quality with significant heterogeneity. Comparative studies with rigorous methodology are needed.

A systematic review and quantitative analysis of different therapies for pancreas divisum

BACKGROUND

Pancreas divisum is the most common anatomical variation of pancreatic ductal system affecting 5-10% of population. Therapy includes different endoscopic and surgical procedures. The aim of this article was to summarize actual evidence of different treatment.

METHODS

A Medline search was performed to identify all studies, investigating endoscopic or surgical therapy of Pancreas divisum. An individual data simulation model was applied to compare endoscopic and surgical studies.

RESULT

56 observational studies (31 endoscopic and 25 surgical studies) were included in analyses. Surgery was significantly superior to endoscopic treatment in terms of success rate (72% vs. 62.3), complication rate (23.8% vs. 31.3%) and re-intervention rate (14.4% vs. 28.3%).

CONCLUSION

Surgery may be superior to endoscopy in terms of treatment success and complications. There is no study comparing these two therapies. Consequently, a randomized trial is needed to clarify if endoscopy or surgery is superior in the therapy of pancreas divisum.

Endoscopic Treatment of Recurrent Acute Pancreatitis and Smoldering Acute Pancreatitis

Recurrent acute pancreatitis (RAP) is a challenging condition that can lead to chronic pancreatitis and long-term morbidity. Etiology-based treatment can potentially have an impact on the natural history of RAP and its progression to chronic pancreatitis. In cases of divisum-associated RAP and idiopathic RAP, several studies have been performed to evaluate the efficacy of endoscopic therapy in alleviation of symptoms and frequency of AP events. This review discusses the literature available on these topic as well as touching on the role of endoscopic therapy in smoldering acute pancreatitis.

Endotherapy in symptomatic pancreas divisum: a systematic review

Pancreas divisum (PD) is the most common congenital variant of the pancreas and has been implicated as a cause of pancreatitis; however, endoscopic treatment is controversial. Our objective was to examine patient response to endotherapy for treatment of symptomatic PD in adult patients in a systematic review of the literature. A systematic review of all case series and case-control studies with ten or more patients undergoing endotherapy for treatment of symptomatic PD indicated by acute recurrent pancreatitis (ARP), chronic pancreatitis (CP), or chronic abdominal pain (CAP) was performed. PubMed, Embase, and Web of Science databases were searched from inception through February 2013 using [pancreas divisum] AND [endoscopic retrograde cholangiopancreatography (ERCP)] OR [endotherapy] OR [endoscopy] as search terms. Importantly, the majority of studies were retrospective in nature, significantly limiting analysis capacity. Main outcomes measures included endotherapy response rate in patients with PD and ARP, CP, or CAP. Twenty-two studies were included in the review, with a total of 838 patients. Response to endoscopy was seen in 528 patients, but response rate varied by clinical presentation. Patients with ARP had a response rate ranging from 43% to 100% (median 76%). Reported response rates were lower in the other two groups, ranging from 21% to 80% (median 42%) for patients with CP and 11%-55% (median 33%) for patients with CAP. Complications reported included perforation, post-endoscopic retrograde cholangiopancreatography pancreatitis, bleeding, and clogged stents. Endotherapy appears to offer an effective treatment option for patients with symptomatic PD, with the best results in patients presenting with ARP.

Endoscopic therapy for acute recurrent pancreatitis

Endoscopy plays an important role in both the diagnosis and the initial management of recurrent acute pancreatitis, as well as the investigation of refractory disease, but it has known limitations and risks. Sound selective use of these therapies, complemented with other lines of investigation such as genetic testing, can dramatically improve frequency of attacks and associated quality of life. Whether endoscopic therapy can reduce progression to chronic pancreatitis, or reduce the risk of malignancy, is debatable, and remains to be proven.

Endoscopic management of acute pancreatitis

Patients presenting with acute pancreatitis can be complex on different levels. Having a multifaceted approach to these patients is often necessary with radiographic, endoscopic, and surgical modalities all working to benefit the patient. Major surgical intervention can often be avoided or augmented by therapeutic and diagnostic endoscopic maneuvers. The diagnostic role of endoscopy in patients presenting with acute idiopathic pancreatitis can help define specific causative factors and ameliorate symptoms by endoscopic maneuvers. Etiologies of an acute pancreatitis episode, such as choledocholithiasis with or without concomitant cholangitis, microlithiasis or biliary sludge, and anatomic anomalies, such as pancreas divisum and pancreatobiliary ductal anomalies, often improve after endoscopic therapy.

Diagnosis and therapy of pancreas divisum by ERCP: a single center experience

OBJECTIVE

The aim of this study was to determine the diagnosis and endoscopic management of pancreas divisum with results from long-term experience at our institution.

METHODS

A prospectively collected database of all patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) with the diagnosis of pancreas divisum at our institution from January 2001 to April 2010 was retrospectively analyzed.

RESULTS

A total of 45 patients were identified with pancreas divisum with 62 ERCP procedures. The major indication for ERCP included pancreatitis in 33 patients (73.3%), of whom 18 had idiopathic recurrent acute pancreatitis, 8 had recurrent pancreatic-type pain and 7 had chronic pancreatitis. The median size of the incision of sphincterotomy was 5 mm (range 3-8 mm). In all 37 patients (82.2%) underwent placement of stent into the dorsal pancreatic duct, with a median stent size of 5 Fr by 7 cm (range 3-10 Fr by 3-12 cm). The overall response rate was 75.8%.

CONCLUSIONS

The frequency of finding pancreas divisum during ERCP varies among institutions and is low compared with the autopsy series, given that many patients may remain asymptomatic or might not undergo ERCP even if the symptoms develop. Our study is the first to describe specific procedure-related details during therapeutic endoscopy for pancreas divisum.

Pancreas divisum: a differentiated surgical approach in symptomatic patients

BACKGROUND

Some patients with pancreas divisum (PD) develop symptoms of recurrent pancreatitis. This is probably caused by insufficient drainage of the pancreatic duct. We report the results of our follow-up of patients who underwent surgery for symptomatic pancreas divisum according to an individualized surgical approach.

METHODS

Between October 2001 and April 2009, 28 patients with symptomatic pancreas divisum were operated at the University Hospital of Heidelberg. According to the localization and type of morphological changes of the pancreas, patients received a reinsertion of the papilla (SP; n=11), duodenum-preserving pancreatic head resection (DPPHR; n=10), pylorus-preserving Whipple (ppWhipple; n=4), or other pancreatic resections (n=3). Hospitalization, morbidity, mortality, pain course, and patient satisfaction were analyzed.

RESULTS

Before surgery, patients received a median of three endoscopic interventions and were hospitalized for 77 days. The median postoperative follow-up was 4.1 years. Surgical morbidity was 11% and mortality 0%. We performed an SP when the pancreas was soft (n=10). When the pancreas was inflammatory altered, a DPPHR was performed in ten, ppW in four, segmental resection in two, and SP and pancreatic left resection in one case. A redo operation for persisting symptoms was needed in six patients (3 soft and 3 altered pancreas). Compared with the preoperative situation, pain was significantly reduced in the follow-up (median Visual Analogue Scale 0 vs. 10). Ninety-six percent of patients were without symptoms during the follow-up.

CONCLUSIONS

The individualized surgical approach for patients with symptomatic PD achieves significant reduction of pain in all patients. Reinsertions of the papilla should be performed as a first surgical intervention in patients with a soft pancreas when symptoms persist despite adequate endoscopic treatment. DPPHR should be performed when fibrotic alterations of the pancreas are present.

Physician-controlled wire-guided cannulation of the minor papilla

Background. Minor papilla (MiP) cannulation is frequently performed using specialized small-caliber accessories. Outcomes data for MiP cannulation with standard-sized accessories are lacking. Methods. This is a case series describing MiP cannulation outcomes in consecutive patients treated by two endoscopists between July 2005 and November 2008 at two tertiary referral centers. MiP cannulation was attempted using a 4.4 Fr tip sphincterotome loaded with a 0.035(″), 260 cm hydrophilic-tip guidewire, using a wire-guided technique under physician control. Results. 25 patients were identified (14 women, mean age 45). Procedure indications included recurrent acute pancreatitis in 16 patients (64%) and chronic pancreatitis in 2 (8%), among other indications. MiP cannulation was successful in 24 patients (96%). Sphincterotomy followed by pancreatic stent placement was performed in 21 patients (84%). Mild post-ERCP pancreatitis occurred in 3 patients (12%). Conclusion. Physician-controlled wire-guided MiP cannulation using a 4.4 Fr sphincterotome and 0.035(″) guidewire is an effective and safe technique.

Long-term clinical outcomes after endoscopic minor papilla therapy in symptomatic patients with pancreas divisum

OBJECTIVES

To assess the long-term outcomes of endoscopic minor papilla therapy in a spectrum of symptomatic patients with pancreas divisum.

METHODS

Patients with pancreas divisum coded in a prospective database as having had minor papilla endotherapy (July 1997-May 2003, n = 145) were grouped into 3 categories: (1) acute recurrent pancreatitis, (2) chronic pancreatitis, and (3) chronic/recurrent epigastric pain. Telephone follow-up was conducted (78% of patients), including questions regarding interval co-interventions and narcotic use. Primary success was defined as clinical improvement (better or cured on a Likert scale), without needing narcotics, after 1 therapeutic endoscopic retrograde cholangiopancreatography. Fisher exact and Mann-Whitney U tests and multivariate logistic regression were used to identify predictors of success.

RESULTS

Primary success rates in acute recurrent pancreatitis, chronic pancreatitis, and chronic/recurrent epigastric pain were achieved in 53.2%, 18.2%, and 41.4%, respectively; and secondary success rates (<or=2 additional endoscopic retrograde cholangiopancreatographies), 71.0%, 45.5%, and 55.2%, respectively (median follow-up, 43.0 months; range, 14-116 months). Younger age (median age, 46.5 years [no success] vs 58.0 years [success]; P < 0.0001) and chronic pancreatitis (odds ratio, 0.10; 95% confidence interval, 0.03-0.39; P = 0.001) independently predicted a lower chance of success.

CONCLUSIONS

Significant long-term improvement can be achieved with endoscopic therapy in selected patients with pancreas divisum, although many require multiple procedures. Older patients, without chronic pancreatitis, were most likely to respond.

Wire-assisted access sphincterotomy of the minor papilla

BACKGROUND

Recommended techniques for minor papilla sphincterotomy include performing a standard pull-type sphincterotomy (PTS) or using a needle-knife over a stent. A wire-assisted access sphincterotomy (WAAS) technique may hold some technical advantages over these accepted methods, but has not been robustly described.

OBJECTIVE

To describe the safety and efficacy of WAAS compared with PTS in a series of patients from our institution.

DESIGN

Retrospective audit of initial minor papilla sphincterotomies over a 6-year period. Demographic and procedural data were abstracted, and the medical record was reviewed for clinical follow-up.

SETTING

A large tertiary referral center.

PATIENTS

One hundred twenty-eight consecutive patients with pancreas divisum who underwent ERCPs between April 2001 and April 2007, 64 of whom underwent an initial minor papilla sphincterotomy.

INTERVENTIONS

WAAS was performed by deeply cannulating the dorsal duct with a guidewire and then passing a needle-knife sphincterotome alongside the wire and cutting the minor papilla by inserting the needle-knife beside the wire and cutting away from the wire.

MAIN OUTCOME MEASUREMENTS

Clinical procedural success and reported adverse events.

RESULTS

Thirty-two patients had recurrent acute pancreatitis, 15 had pain only, and 13 had chronic pancreatitis. Thirty-two underwent WAAS, 24 had PTS, and 8 had other types of sphincterotomies. Patients undergoing WAAS (32) versus PTS (24) were similar in age, sex, and procedural indication. Mild post-ERCP pancreatitis and mild intraprocedural bleeding occurred more commonly in the WAAS group, although the differences were not statistically significant.

LIMITATIONS

Retrospective, nonrandomized study.

CONCLUSIONS

WAAS is an effective technique that may be used either to begin a minor papilla sphincterotomy or to perform the entire sphincterotomy. Complications appear similar to those seen with conventional methods but require a larger patient sample to fully evaluate.

Clinical outcomes and nonendoscopic interventions after minor papilla endotherapy in patients with symptomatic pancreas divisum

BACKGROUND

Long-term outcomes of minor papilla endotherapy (MPE) in pancreas divisum are limited.

OBJECTIVE

To determine the efficacy of MPE in symptomatic pancreas divisum subgroups.

DESIGN

This was a retrospective study of patients from an endoscopy database. The data collection instrument included preprocedure and postprocedure pain score, narcotic use, acute pancreatitis episodes, emergency department visits, and hospitalizations. A follow-up was obtained by chart review and telephone contact with a questionnaire.

SETTING

A tertiary-referral center.

MAIN OUTCOME MEASUREMENTS

(1) Clinical improvement defined as a > or = 50% reduction in the evaluated data points and (2) non-MPE interventions for pain.

RESULTS

Between January 2000 and April 2006, 57 patients were identified. Indications were recurrent acute pancreatitis (RAP) (n = 27 [47%]), abdominal pain and chronic pancreatitis (CP) (n = 20 [35%]), abdominal pain alone (n = 8 [14%]), other (n = 2 [4%]). Successful MPE occurred in 49 of 57 patients (86%). Initial MPE entailed minor papilla sphincterotomy (n = 46), stenting without sphincterotomy (n = 2), and tamponade of bleeding (n = 1). Follow-up was obtained in 56 of 57 patients (98%) for a median of 20 months (interquartile range 12-39 months); 28 of 48 patients (58%) with successful MPE had clinical improvement: 16 of 21 (76%) with RAP, 8 of 19 (42%) with CP, and 2 of 6 (33%) with pain alone (RAP vs non-RAP; P = .019). Two patients had resolution of a dorsal-duct leak and bleeding, respectively. Twelve of 57 patients (21%) underwent 16 additional interventions for incomplete response: celiac plexus block (4), intrathecal narcotic pump (2), sphincteroplasty (7), bilateral thoracic splanchnicectomy (2), and Puestow procedure (1); 7 of 12 patients (58%) clinically improved.

LIMITATION

This was a retrospective study.

CONCLUSIONS

(1) MPE is most effective in patients with pancreas divisum and with RAP with or without pancreatic ductal changes, (2) although patients with chronic pain and pancreas divisum respond poorly to MPE, the majority will have clinical improvement after additional nonendoscopic interventions for pain management.

MRCP-secretin test-guided management of idiopathic recurrent pancreatitis: long-term outcomes

BACKGROUND

In patients with recurrent pancreatitis of unknown etiology and nondilated ducts, accurate morphofunctional evaluation of the pancreaticobiliary ductal system and sphincter of Oddi function is important in the diagnostic workup. However, ERCP and sphincter of Oddi manometry may be nondiagnostic and postprocedure complications may be frequent.

OBJECTIVE

Our purpose was to assess the diagnostic accuracy of the magnetic resonance cholangiopancreatography with secretin test (MRCP-S) in patients with recurrent acute pancreatitis of unknown etiology. Accuracy was established on the basis of ERCP findings and a minimum of 24 months' clinical follow-up.

DESIGN

Thirty-seven consecutive patients with intact gallbladder and a nondilated pancreaticobiliary ductal system with nonpathologic EUS findings entered a prospective MRCP-S-guided and ERCP-guided diagnostic and therapeutic study protocol.

RESULTS

Patients were followed up for a mean of 31.3 months (range 26-38 months). MRCP-S identified some pancreatic outflow impairment, suggesting morphofunctional dysfunction of either the major or minor papilla, in 12 of 37 patients (32.4%). The addition of ERCP to MRCP-S did not substantially improve the diagnostic yield for the etiology of recurrent pancreatitis, and 13.6% of cases had mild postprocedure pancreatitis. The S-test was abnormal in 12 of 20 cases (60%) in whom some dysfunction of the sphincter of Oddi or minor papilla was assumed on the basis of follow-up findings. The outcome was successful after biliary or pancreatic sphincterotomy in all patients with an abnormal S-test result. Sensitivity, specificity, and positive and negative predictive values of the S-test for the diagnosis of pancreatic outflow impairment at the major or minor papilla were, respectively, 57.1%, 100%, 100%, and 64%. When the test showed an abnormal result, we were unable to distinguish between biliary and pancreatic segment dysfunction of the sphincter of Oddi.

CONCLUSIONS

In idiopathic recurrent pancreatitis with nondilated ducts, the MRCP-S-guided approach gave diagnostic accuracy comparable to ERCP with regard to morphologic lesions, and it can be used as an alternative, avoiding ERCP-related complications in the diagnostic phase. An abnormal S-test result showed an excellent positive predictive value and somewhat disappointing negative predictive value for sphincter of Oddi or minor papilla dysfunction and for clinical success of therapeutic endoscopic approach.

The role of endoscopy in the therapy of chronic pancreatitis

Almost all the therapeutic efforts in the treatment of chronic pancreatitis are directed towards pain control. Endoscopic techniques available for this purpose are endoscopic retrograde cholangiopancreatography (combined or not with extracorporeal shock wave lithotripsy) and endoscopic ultrasound. Pancreatic stones and strictures, pancreatic pseudocysts, and common bile duct strictures complicating chronic pancreatitis can be treated by endoscopy. The development of endoscopic ultrasound extended the possibilities in the treatment of pancreatic pseudocysts and main pancreatic duct drainage. Endoscopy is considered the first-line treatment in chronic pancreatitis and can be useful also as a 'bridge to surgery'. In fact the endoscopic approach to chronic pancreatitis can predict the response to surgical therapy as a definitive treatment. Medical, endoscopic and surgical methods for the management of chronic pancreatitis should all be considered in decision-making, and the best treatment should be chosen case by case and according to the local expertise.

Long-term follow-up of endoscopic stenting in patients with chronic pancreatitis secondary to pancreas divisum

BACKGROUND

Pancreas divisum is the most common anatomic variant of pancreatic development and may lead to pancreatitis. This study evaluated the efficacy of endoscopic stenting in patients with chronic pancreatitis due to pancreas divisum.

METHODS

Between 1993 and 2005, 32 patients with chronic pancreatitis due to pancreas divisum were treated with endoscopic stenting. Each patient underwent an endoscopic retrograde cholangiopancreatography to confirm the diagnosis of pancreas divisum prior to endoscopic stenting. A survey was conducted by telephone conversation to evaluate pain intensity, symptom relief, hospital admissions, quality of life and pain medication usage, which was verified by a statewide narcotic electronic database. Eight of the 32 patients were unavailable for the interview and were not included in the analysis of the study. Results are expressed as mean +/- standard error of the mean (SEM).

RESULTS

Twenty-four patients were followed up for a period of 59.6 months. The overall pain level average in the 24 patients decreased significantly from 8.9 +/- 0.4 pre-stenting to 3.9 +/- 0.7 post-stenting (P < 0.05) on a scale of 1 to 10. The number of hospital admissions per year in these patients decreased significantly from 7.3 +/- 2.1 pre-stenting to 2.1 +/- 0.4 post-stenting (P < 0.05). Pain medication usage reported by the patients found a decrease in 58% of patients, 21% remained the same, and 13% increased their usage. There was improvement in nausea (67%), vomiting (63%), and chronic pain (75%). Thirteen patients (55%) were treated endoscopically without requiring surgery and 11 (45%) patients required surgery after stenting. These 11 patients had surgery an average of 25 months post-stenting. The complication rate of post-procedural pancreatitis was 3.4%. No mortality was reported in this study.

CONCLUSION

Endoscopic stenting of the pancreatic duct is a safe and effective first treatment for patients with pancreatitis secondary to pancreas divisum. Surgery, when performed for endoscopic stenting failure, is effective as an adjunctive treatment.

[Endoscopic pancreatic sphincterotomy: when and how]

Endoscopic pancreatic sphincterotomy (EPS) has fallen into disuse for some time because of the risk of severe complications. More recently, EPS has been advocated as an effective treatment modality for several pancreatic disorders, including severe chronic pancreatitis, pancreatic pseudocyst, ampulloma, pancreas divisum, and pancreatic sphincter dysfunction. Favorable outcomes in patients undergoing EPS to facilitate further interventions, in whom long-term follow-up was available, was 70%; complications occurred in 14% and reintervention was required in 23%. The results were as good as those of surgery after long-term follow-up. Patients who underwent some form of pancreatic drainage after sphincterotomy had fewer complications (p = 0.03). Approximately 75% of patients with pancreas divisum who presented with idiopathic acute recurrent pancreatitis improved after endoscopic therapy, but only 25% of patients experienced pain reduction of at least 50%. The National Institutes of Health Consensus recommends EPS in patients with type I sphincter of Oddi dysfunction (SOD). In patients with type II SOD, prior manometry should be performed. In our series of 17 patients, we obtained results similar to those of other studies, although the number of patients was small. EPS appears to be a safe and effective technique, but further, well-designed, multicenter, prospective and long-term studies are required to evaluate these results and settle current controversies.

Endoscopic pancreatic sphincterotomy for pancreas divisum by using a needle-knife or standard pull-type technique: safety and reintervention rates

BACKGROUND

Technical options for pancreatic sphincterotomy of the minor papilla for pancreas divisum include a needle-knife cut over a plastic stent and a standard pull-type cut with a sphincterotome.

OBJECTIVE

Our objective was to compare the frequency, safety, and intermediate-term efficacy of these 2 techniques at our institution.

PATIENTS AND METHODS

Retrospective review of the GI-Trac database from July 1994 to July 2004 for patients with pancreas divisum undergoing an initial minor papilla sphincterotomy.

INTERVENTIONS

Patients were separated into 2 groups on the basis of the endoscopic pancreatic sphincterotomy technique used, either a needle-knife sphincterotomy (NKS) or standard pull-type sphincterotomy (PTS). The groups were compared on the basis of need for any reintervention, restenosis rates, and complication rates with use of Cox proportional hazards models.

RESULTS

There were 133 patients (72%) in the NKS group and 51 (28%) in the PTS group. Clinical presentations were similar in the 2 groups. At a median follow-up of 5 years, additional endoscopic therapy including repeat endoscopic pancreatic sphincterotomy, endoscopic balloon dilation, stone extraction, or stenting was necessary in 29% of patients after NKS and in 26% after PTS. Papillary restenosis rates were 24% over a median follow-up of 6 years after NKS and 20% over a median follow-up of 5 years after PTS. Overall complication rates were similar in those undergoing NKS and PTS (8.3% vs 7.8%). Age less than 40 years independently predicted reintervention (hazard ratio 2.21) and restenosis (hazard ratio 2.41) (both P < .01).

CONCLUSIONS

NKS is used more than PTS for minor papilla sphincterotomy at our institution, but the 2 techniques appear equally safe and effective. Younger age may be associated with higher reintervention rates.

Surgical treatment of pancreas divisum causing chronic pancreatitis: the outcome benefits of duodenum-preserving pancreatic head resection

Pancreas divisum (PD) represents a duct anomaly in the pancreatic head ducts, leading frequently leading to recurrent acute pancreatitis (rAP) or chronic pancreatitis (CP). Based on endoscopic retrograde cholangiopancreatography, pancreas divisum can be found in 1% to 6% of patients with pancreatitis. The correlation of this abnormality with pancreatic disease is an issue of continuing controversy. Because of the underlying duct anomalies and major pathomorphological changes in the pancreatic head, duodenum-preserving pancreatic head resection (DPPHR) offers an option for causal treatment. Thirty-six patients with pancreatitis caused by PD were treated surgically. Thirty patients suffered from CP, 6 from rAP. The mean duration of the disease was 47.5 and 49.8 months, respectively. The age at the time of surgery was 39.2 years in the CP group, and 27.6 years in the rAP group. Median hospitalization since diagnosis was 18.8 weeks for CP patients and 24.6 weeks for rAP patients. Previous procedures performed in these patients included endoscopic papillotomy (30%), duct stenting (14%), and surgical treatment (17%). The median preoperative pain score was 8 on a visual analog scale. According to the classification of pancreas divisum, 10 patients demonstrated a complete PD, 25 had a functionally incomplete PD, and 1 had a dorsal duct type. The pain status as well as the endocrine (oral glucose tolerance test) and exocrine (pancreolauryl test) function were evaluated preoperatively and early and late postoperatively with a median follow-up time of 39.3 months. There was no operative-related mortality. The follow-up was 100%; 4 patients died (1 from suicide, 1 from cardiac arrest, and 2 from cancer of the esophagus). Fifty percent of the patients were completely pain-free, 31% had a significant reduction of pain with a median pain score of 2 (P < 0.001). Six patients (5 CP, 1 rAP) had further attacks of acute pancreatitis with a need for hospitalization. DPPHR reduced pain and preserved the endocrine function in the majority of patients with pancreas divisum. Therefore, DPPHR is an alternative to other resective or drainage procedures after failure of interventional treatment.

Relationship between papillary fibrosis and patency of the accessory pancreatic duct

A study of structure and function of the minor duodenal papilla was carried out on 36 autopsy specimens of the human duodenopancreas. An original perfusion method with manometric control was developed for testing the minor papilla patency, i.e. resistency to intraductal pressure. According to this test, all the specimens were classified as: Type I: non-patent (45%); Type II: patent under normal, physiological pressure (36%); and Type III: patent under increased pressure (19%). After that, the whole minor papilla specimens underwent longitudinal sectioning with HE staining. Light microscopy showed various degrees of fibrosis (mild-45%, moderate-29%, and severe-26%). The correlation between the fibrosis and the patency was significant: papillae with lower degrees of fibrosis were more patent and vice versa. Further, the pancreatic tissue in the Santorini segment of the pancreatic head followed the same manner. No apparent sphincter of the minor papilla was found in any of the specimens analyzed.

[Pancreas divisum and the dominant dorsal duct syndrome]

Pancreas divisum, the most frequent congenital malformation of the pancreas, results from the absence of embryologic fusion of the dorsal and ventral pancreatic ducts which keep an autonomy of drainage. The dorsal pancreatic duct is dominant and drains the major part of the pancreatic fluid through a non adapted accessory papilla. The high prevalence of pancreas divisum in patients presenting recurrent acute pancreatitis, the presence of obstructive pancreatitis electively located on the dorsal pancreatic duct and the results of the treatments targeted on the accessory papilla are the arguments pleading for the pathogenic character of the pancreas divisum. Currently, the diagnosis of pancreas divisum is based on magnetic resonance imaging. For symptomatic patients (after exclusion of patients with intestinal functional disorders), results of endoscopic sphincterotomy or surgical sphincteroplasty are favourable in 75% of patients with recurrent acute pancreatitis. They are worse in patients with chronic pain. Surgical sphincteroplasty must be discussed in the same manner as the endoscopic treatment for sometimes avoiding multiplication of the procedures.

Approach to idiopathic recurrent pancreatitis

Acute pancreatitis is caused by acute or chronic alcohol intake or choledocholithiasis in approximately 80% of cases. In the absence of alcohol abuse or gallstones, a variety of established and putative factors must be considered, any of which can cause a single or recurrent attacks of acute pancreatitis. When the underlying cause eludes detection following an initial thorough search and leads to a second attack, the term idiopathic acute recurrent pancreatitis (IARP) is applied. This article discusses IARP and its work-up.

Complications of endoscopic sphincterotomy: can heparin prevent acute pancreatitis after ERCP?

BACKGROUND

An exploratory analysis of a prospective study of risk factors for acute pancreatitis after ERCP combined with endoscopic sphincterotomy showed that the frequency of acute pancreatitis was lower in patients who received heparin compared with patients not treated with heparin. The study was continued to further analyze the effect of heparin on the frequency of acute pancreatitis.

METHODS

Potential risk factors for acute pancreatitis and outcomes were evaluated prospectively for all ERCP procedures with endoscopic sphincterotomy performed between September 1994 and December 1998. The results were analyzed by univariate and multivariate methods to determine risk factors for complications. Heparin was administered to 32.9% of the patients (heparin group [HEP group], n = 268) for various clinical reasons (low-molecular-weight heparin, n = 208, unfractionated heparin n = 60). A group of 547 patients who did not receive heparin served as control patients (CON group).

RESULTS

Eight hundred fifteen patients underwent ERCP with endoscopic sphincterotomy; acute pancreatitis occurred in 6.4% (n = 52). The frequency of acute pancreatitis was significantly lower in the HEP group versus the CON group in the final multivariate model, which included significant risk factors for acute pancreatitis (HEP group: 3.4%, 9/268 vs. CON group: 7.9%, 43/547; p = 0.005). HEP did not increase the risk of hemorrhage (HEP group: 1.1%, 3/268, 2 severe, none fatal vs. CON group: 2.0%, 11/547, 3 severe, 2 fatal). HEP (p = 0.005; OR 0.3: 95% CI [0.16, 0.73]) and the number of risk factors present (p = 0.0001; OR 2.5: 95% CI [1.80, 3.50]) influenced the frequency of acute pancreatitis independently.

CONCLUSIONS

Heparin was significantly associated with an extremely low frequency of post-ERCP pancreatitis without increasing the risk of hemorrhage after endoscopic sphincterotomy. Because this effect could not be attributed to other known or suspected confounders, our conclusion was that heparin administration before ERCP reduces the risk of pancreatitis.

Idiopathic acute recurrent pancreatitis

Acute recurrent pancreatitis (ARP) results most commonly from alcohol abuse or gallstone disease. Initial evaluation fails to detect the cause of ARP in 10-30% of patients, and as a result the diagnosis of "idiopathic" ARP is given. In these patients, a more extensive evaluation including specialized labs, ERCP, endoscopic ultrasound, or magnetic resonance cholangiopancreatography typically leads to a diagnosis of microlithiasis, sphincter of Oddi dysfunction, or pancreas divisum. Less commonly, hereditary pancreatitis, cystic fibrosis, a choledochocele, annular pancreas, an anomalous pancreatobiliary junction, pancreatobiliary tumors, or chronic pancreatitis are diagnosed. Determining the etiology is important, as it helps to direct therapy, limits further unnecessary evaluation, and may improve a patient's long term prognosis.

Endoscopic retrograde cholangiopancreatography in the management of pancreaticobiliary disorders in children

BACKGROUND AND AIM

The role of endoscopic retrograde cholangiopancreatography (ERCP) is not yet fully established in children. The purpose of this study was to assess the use of ERCP in the diagnosis and management of various pancreaticobiliary disorders in children.

METHODS

Eighty-four ERCPs were performed over 5.5 years in 72 children with suspected pancreaticobiliary tract disorders with an adult-type duodenoscope. In all cases, indications, procedure time, ERCP findings, complications, patients course and therapeutic intervention (if any) were recorded.

RESULTS

The mean (+/- SD) age of these children was 8.8 +/- 3.3 years. Successful cannulation was possible in 70 (97%) cases. Of the 44 cases with suspected biliary tract disease, 14 had a choledochal cyst, 13 had portal biliopathy, two each had CBD stones, primary sclerosing cholangitis and a bile leak, one had biliary ascariasis, eight had a normal cholangiogram, and CBD cannulation failed in two. Eight of the 28 children with suspected pancreatic disorders had chronic pancreatitis, five had pancreatic duct disruption, three had pancreas divisum and the rest had a normal pancreatogram (including all eight children with unexplained abdominal pain). Therapeutic ERCP was performed in 22 children, endoscopic nasobiliary or a nasocystic drain was placed in 16, biliary stenting was conducted in two, pancreatic duct stenting was conducted in three, and minor papilla dilation was conducted in one child. Six children had mild procedure-related complications.

CONCLUSION

Endoscopic retrograde cholangiopancreatography is very useful in the treatment of cholangitis, bile leak, pseudocyst and pancreatic fistulae in children. However, its role in unexplained abdominal pain is doubtful.

Pancreas divisum: endoscopic therapy

Pancreas divisum is a common congenital variation that can be associated with pancreatic disease. Symptomatic patients with divisum must be classified according to clinical presentation and morphologic findings. Response to endoscopic therapy is best in patients with ARP, of whom 75% benefit. Results in patients with chronic pancreatitis and pain but without objective pancreatitis are mixed, and patients should be carefully selected.

Idiopathic recurrent pancreatitis: long-term results after ERCP, endoscopic sphincterotomy, or ursodeoxycholic acid treatment

OBJECTIVE

In about 30% of cases, the etiology of acute recurrent pancreatitis remains unexplained, and the term "idiopathic" is currently used to define such disease. We aimed to evaluate the long-term outcome of patients with idiopathic recurrent pancreatitis who underwent endoscopic cholangiopancreatography (ERCP) followed by either endoscopic biliary (and seldom pancreatic) sphincterotomy or ursodeoxycholic acid (UDCA) treatment, in a prospective follow-up study.

METHODS

A total of 40 consecutive patients with intact gallbladder entered the study protocol after a 24-month observation period during which at least two episodes of pancreatitis occurred. All patients underwent diagnostic ERCP, followed by biliary or minor papilla sphincterotomy in cases of documented or suspected bile duct microlithiasis and sludge, type 2 sphincter of Oddi dysfunction, or pancreas divisum with dilated dorsal duct. Patients with no definite anatomical or functional abnormalities received long-term treatment with UDCA. After biliary sphincterotomy, patients with further episodes of pancreatitis underwent main pancreatic duct stenting followed by pancreatic sphincterotomy if the stent had proved to be effective.

RESULTS

ERCP found an underlying cause of pancreatitis in 70% of cases. Patients were followed-up for a period ranging from 27 to 73 months. Effective therapeutic ERCP or UDCA oral treatment proved that occult bile stone disease and type 2 or 3 sphincter of Oddi dysfunction (biliary or pancreatic segment) had been etiological factors in 35 of the 40 cases (87.5%) After therapeutic ERCP or UDCA, only three patients still continued to have episodes of pancreatitis.

CONCLUSIONS

Diagnostic and therapeutic ERCP and UDCA were effective in 92.5% of our cases, over a long follow-up, indicating that the term "idiopathic" was justified only in a few patients with acute recurrent pancreatitis.

Long-term results after endoscopic pancreatic stent placement without pancreatic papillotomy in acute recurrent pancreatitis due to pancreas divisum

BACKGROUND

There is no consensus regarding the appropriate endoscopic treatment for acute recurrent pancreatitis associated with pancreas divisum. Endoscopic papillotomy of the minor papilla appears to yield improvement in most cases, but optimal depth and height have not been defined.

METHODS

Endoscopic pancreatic stent placement after minor papilla dilation was performed in 25 patients with pancreas divisum and acute recurrent pancreatitis. Five patients drank alcohol daily; no other cause of pancreatitis was detected. After adequate dilation, a transpapillary pancreatic stent (5F to 7F, 5 to 7 cm) was inserted over a guidewire into the dorsal duct. The stent was replaced twice, after 2- to 3-month intervals.

RESULTS

While stents were in place, no further episodes of pancreatitis occurred in 23 patients. However, dorsal duct changes of unknown clinical significance were seen in 21 cases. At mean follow-up of 24 months (range 3 to 70 months) after stent removal, 19 (76%) remained symptom free. Pancreatitis recurred in 6 patients during the follow-up after final stent removal; no further pancreatitis occurred in 2 of 3 who underwent repeat stent insertion. Complications in the series were minimal.

CONCLUSION

Endoscopic pancreatic stent placement after minor papilla and dorsal duct dilation, without endoscopic papillotomy, provided safe and effective endoscopic treatment in patients with pancreas divisum and acute recurrent pancreatitis.

Endoscopic botulinum toxin injection into the minor papilla for treatment of idiopathic recurrent pancreatitis in patients with pancreas divisum

BACKGROUND

In some patients with pancreas divisum, obstruction to the flow of pancreatic juice into the duodenum is the presumptive cause of acute recurrent pancreatitis. However, identification of those patients who may benefit from minor papilla sphincterotomy or stent placement is difficult.

METHODS

Five patients with acute recurrent pancreatitis and pancreas divisum were therefore treated by endoscopic injection of 50 units of botulinum toxin into the minor papilla in an outpatient setting.

RESULTS

Botulinum toxin injection was successfully performed on six occasions in 5 patients and no adverse effects were noted. Two patients relapsed after 9 and 10 months, respectively, but had definite relief of symptoms after needle-knife sphincterotomy. One patient relapsed 7 months after botulinum toxin injection but became symptom free again after a second botulinum toxin injection. Another patient is still in clinical remission 4 months after botulinum toxin administration, and 1 patient did not respond to either botulinum toxin administration or to sphincterotomy and stent placement.

CONCLUSIONS

Endoscopic injection of botulinum toxin into the minor papilla in patients with pancreas divisum and acute recurrent pancreatitis is a safe procedure that is easy to perform and provides short-term relief in some patients. Response to botulinum toxin injection may predict whether patients with pancreas divisum and acute recurrent pancreatitis will benefit from other forms of endoscopic therapy.

The role of endoscopy in acute recurrent and chronic pancreatitis and pancreatic cancer

Endoscopy plays an important role in the diagnosis and treatment of acute and chronic pancreatitis as well as pancreatic cancer. Sphincterotomy and stone removal in biliary pancreatitis, stone extraction and drainage in chronic pancreatitis, and stent implantation in pancreatic cancer are the predominant procedures. With endoscopy, minimal invasive techniques are at hand to solve urgent and long term problems.

Endoscopic pancreatic sphincterotomy: indications, outcome, and a safe stentless technique

BACKGROUND

Endoscopic pancreatic sphincterotomy is less widely practiced than biliary sphincterotomy, in part because of the lack of firm data regarding its indications and safety. In addition, recent reports of ductal and parenchymal changes occurring after pancreatic stenting raise concerns about the standard practice of stent placement at the time of pancreatic sphincterotomy. We report our experience with pancreatic sphincterotomy and describe the use of a technique involving overnight nasopancreatic drainage rather than stenting.

METHODS

We reviewed the records of the 164 pancreatic sphincterotomies performed on 160 patients at our institution between January 1, 1991, and October 1, 1996, comparing procedures done with overnight nasopancreatic catheter placement with those done with stenting or no drainage. We also examined the long-term clinical outcome of patients after pancreatic sphincterotomy.

RESULTS

Of the 164 sphincterotomies, 98 were done with overnight nasopancreatic drainage, 50 with stent placement, and 16 with no drainage. Complications (all pancreatitis) were significantly more frequent in the group with no drainage (12.5%) as compared with those with drainage (0.7%); p < 0.003. Nasopancreatic drainage was as safe as stent placement, with no complications after 98 procedures. Pancreatic sphincterotomy was effective when used as primary therapy, with 64% of patients so treated experiencing complete and long-lasting resolution of symptoms after the procedure.

CONCLUSIONS

Pancreatic sphincterotomy is safe and effective, although pancreatic drainage is required to reduce the incidence of pancreatitis. Overnight nasopancreatic drainage is the method of choice, as it carries as low a complication rate as stent placement, but without the need for a repeat procedure, and presumably without the risk of ductal and parenchymal damage.