Management of pancreas divisum

Role of Endoscopic Ultrasound in Diagnosis and Management of Pancreas Divisum: A Case Study and Literature Review

The long-term efficacy of endoscopic treatment of pancreas divisum is controversial. This review focuses on recent literature on the role of endoscopic ultrasonography (EUS) as effective clinical support in the diagnosis and management of pancreas divisum. A challenging case study in a patient with pancreas divisum affected by recurrent acute pancreatitis and chronic pain is also reported. Our methodology was developed from a search strategy based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. A comprehensive electronic search across multiple databases, including Medline/PubMed, EMBASE, Medline/Metacrawler and the Cochrane Library, to identify relevant publications for this systematic review was conducted. A total of 308 articles were found. According to EMBASE grouping criteria, 31 articles were considered major clinical studies and were analysed, reporting for each study the relevant clinical features. In the majority of studies examined, EUS proved useful in diagnosing a pancreatic divisum. The EUS diagnostic yield was reported to have a sensitivity ranging from 51% to 95% and high diagnostic accuracy up to 97%. EUS has shown high sensitivity and specificity in diagnosing pancreas divisum. Studies indicate that EUS can achieve sensitivity rates ranging from 80% to 100% and specificity rates around 97% to 100% for detecting pancreas divisum. Based on these figures, EUS is the most reliable imaging system in terms of diagnostic capability compared with other imaging systems.

Cost minimization analysis comparing diagnostic strategies in unexplained pancreatitis

OBJECTIVES

Both endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography (EUS) are commonly performed in the evaluation of idiopathic pancreatitis. However, comparative trials of these modalities are lacking, and thus the ideal endoscopic diagnostic strategy to evaluate idiopathic pancreatitis remains unknown.

METHODS

A decision analysis model of patients with 2 attacks of idiopathic pancreatitis with gallbladder in situ was constructed using TreeAge software. We analyzed cost and overall diagnostic ability of 3 strategies, namely, EUS, ERCP with manometry and bile aspiration, and laparoscopic cholecystectomy.

RESULTS

Using the base case analysis, initial EUS was the preferred initial modality for the diagnosis. The expected cost for initial EUS was $4469 compared with $4615 for ERCP and $6268 for laparoscopic cholecystectomy. For cholecystectomy to be the preferred strategy, the total cost would need to be less than $1314, well below any realistic cost estimate. If the prevalence of microlithiasis/sludge was greater than 80%, then cholecystectomy would be preferred, whereas ERCP would be preferred with a prevalence of less than 41%.

CONCLUSIONS

This cost minimization study identifies EUS as the least costly initial test for the diagnostic evaluation of patients with idiopathic pancreatitis with gallbladder in situ.