Endoscopic Management of Complications in Chronic Pancreatitis

Technical success, clinical efficacy, and safety of endoscopic minor papilla interventions for symptomatic pancreatic diseases

BACKGROUND

Endoscopic minor papilla intervention (EMPI) is an option for diagnosing or treating symptomatic pancreatic diseases in cases with failed pancreatic duct deep cannulation via the major papilla, pancreas divisum with obstruction of the minor papilla, or an abnormal patulous orifice of the minor papilla during endoscopic retrograde cholangiopancreatography (ERCP). However, the relatively low patency and small opening of the minor papillae pose technical challenges.

AIM

To evaluate the technical success, clinical success, stone clearance, and safety profile of EMPI for diagnosis and treatment of symptomatic pancreatic diseases.

METHODS

Patients diagnosed with symptomatic pancreatic diseases and EMPI between February 1996 and February 2023 were included. The primary outcomes were the initial technical success, defined as successful deep cannulation via the minor papilla (DCMP; access of the guidewire to the upstream pancreatic duct via the minor papilla) alone, overall technical success, defined as successful DCMP alone and successful DCMP with additional needle-knife precut minor papillotomy (NKPMP), and immediate clinical success, defined as > 50% improvement in abdominal pain after therapeutic EMPI. Secondary outcomes included long-term clinical success at 1, 3, and 7 years, pancreatic stone clearance, and procedure-related early and late adverse events (AEs).

RESULTS

Overall, 43 patients, 32 with obstructive chronic pancreatitis, 8 with pancreatic divisum, and 3 with intraductal papillary mucinous neoplasm were included. The initial and overall technical success rates were 74.4% (32/43) and 88.4% (38/43), respectively. The immediate clinical success rate was 79.1% (34/43), and the long-term clinical success rates at 1, 3, and 7 years were 74.7%, 55.3%, and 41.5%, respectively, among the 22 patients with a follow-up period of 57.5 (7-266) months. Complete and partial success of pancreatic stone clearance was achieved in 53.9% (7/13) and 15.4% (2/13), respectively. Early AEs included post-ERCP pancreatitis (PEP, n = 5) and self-limiting bleeding (n = 1); surgery therapy was required for 1 case with severe PEP and conservative management for the other 4 with mild PEP. Late AEs included minor papilla stricture (n = 1) after endoscopic minor papillotomy and pancreatic duct stricture (n = 1) after double pancreatic stent placement; no specific treatment was implemented for these events.

CONCLUSION

EMPI is feasible, effective, and safe for symptomatic pancreatic diseases, in terms of the technical and clinical success, stone clearance, and incidence and severity of AEs. NKPMP appears to enhance technical success. However, potential risks of developing PEP and late AEs should be kept in mind.

Endoscopic Retrograde Cholangiopancreatography for Management of Chronic Pancreatitis

Management of symptomatic chronic pancreatitis (CP) has shifted its approach from surgical procedures to minimally invasive endoscopic procedures. Increased experience and advanced technology have led to the use of endoscopic retrograde cholangiopancreatography (ERCP) as a therapeutic tool to provide pain relief and treat CP complications including pancreatic stones, strictures, and distal biliary strictures, pseudocysts, and pancreatic duct fistulas. In this article the authors will discuss the use of ERCP for the management of CP, its complications, recent advancements, and techniques from the most up to date literature available.

Evaluating the role of endoscopic ultrasound in pancreatitis

INTRODUCTION

Endoscopic ultrasound (EUS) provides high-resolution images of both pancreatic parenchyma and duct and therefore is an integral component of evaluating and treating patients with pancreatitis and its complications. The development of enhanced EUS imaging techniques and newer EUS-specific accessories has expanded the diagnostic and therapeutic role of EUS in patients with acute and chronic pancreatitis (CP).

AREAS COVERED

This review discusses the current diagnostic and therapeutic role of EUS in acute pancreatitis (AP), CP, and autoimmune pancreatitis (AIP).

EXPERT OPINION

EUS plays a vital role in patients with AP by confirming the presence of common bile duct (CBD) stones in patients with acute biliary pancreatitis and intermediate probability of CBD stones. It plays an important role in the etiological evaluation of patients with idiopathic acute and recurrent pancreatitis. EUS is also an essential modality for diagnosing and managing pancreatico-biliary as well as gastroduodenal complications associated with CP. EUS-guided FNB using newer generation core biopsy needles has made possible accurate diagnosis of AIP by providing tissue samples with preserved architecture.