Endoscopic Management of Recurrent Acute Pancreatitis

Superiority of linear-array EUS over MRCP in diagnosing pancreas divisum: evidence from a multicenter retrospective study in Oriental cohorts (with video)

BACKGROUND AND AIMS

Pancreas divisum (PD) is the most common developmental anatomic variant of pancreatic duct. The published data on the accuracy of the detection of PD by means of linear-array endoscopic ultrasound (L-EUS) is limited. This study aimed to assess the diagnostic accuracy of L-EUS compared with magnetic resonance cholangiopancreatography (MRCP) for identifying PD.

METHODS

Patients who underwent L-EUS for pancreaticobiliary indications and subsequently received endoscopic retrograde pancreatograghy (ERP) treatment were retrospectively evaluated from January 2019 to July 2023.

RESULTS

A total of 1378 patients from 3 tertiary centers were included, of which 120 were diagnosed with PD, as confirmed with the use of ERP, yielding an endoscopic detection rate of 8.7%. L-EUS exhibited a high sensitivity of 90.8% (95% confidence interval [CI], 85.7%-96.0%) and an overall accuracy of 99% (95% CI, 98.5%-99.5%) for the diagnosis of PD. These figures were significantly superior to those of MRCP, which showed a sensitivity of 48.4% (95% CI, 38.1%-58.6%) and an accuracy of 95.4% (95% CI, 93.5%-96.3%) (P < .001). Furthermore, the area under the receiver operating characteristic curve (AUC) for PD diagnosis was notably higher for L-EUS (95.7%) compared with MRCP (74.1%) (P < .001). Consistency testing revealed that L-EUS had an excellent kappa value of 0.934, compared with the reference standard of 0.621. Univariate logistic regression analysis identified the presence of pancreatic duct stones, chronic pancreatitis, and severe pancreatitis as potential factors leading to diagnostic failure in detecting PD with the use of L-EUS. Subsequent multivariate logistic regression analysis confirmed that the presence of pancreatic duct stones (odds ratio [OR], 5.627; 95% CI, 1.391-22.765) and severe pancreatitis (OR, 12.818; 95% CI, 2.280-72.061) were significantly associated with increased odds of L-EUS diagnostic failure for PD.

CONCLUSIONS

Our study conclusively demonstrates that L-EUS significantly outperforms MRCP in diagnosing PD. L-EUS exhibits markedly higher sensitivity and AUC values. However, its diagnostic reliability decreases in the presence of pancreatic duct stones or severe pancreatitis.

Symptomatic gallstone disease: Recurrence patterns and risk factors for relapse after first admission, the RELAPSTONE study

BACKGROUND

Delayed cholecystectomy in patients with symptomatic gallstone disease is associated with recurrence. Limited data on the recurrence patterns and the factors that determine them are available.

OBJECTIVE

We aimed to determine the pattern of relapse in each symptomatic gallstone disease (acute pancreatitis, cholecystitis, cholangitis, symptomatic choledocholithiasis, and biliary colic) and determine the associated factors.

METHODS

RELAPSTONE was an international multicenter retrospective cohort study. Patients (n = 3016) from 18 tertiary centers who suffered a first episode of symptomatic gallstone disease from 2018 to 2020 and had not undergone cholecystectomy during admission were included. The main outcome was relapse-free survival. Kaplan-Meier curves were used in the bivariate analysis. Multivariable Cox regression models were used to identify prognostic factors associated with relapses.

RESULTS

Mean age was 76.6 [IQR: 59.7-84.1], and 51% were male. The median follow-up was 5.3 months [IQR 2.1-12.4]. Relapse-free survival was 0.79 (95% CI: 0.77-0.80) at 3 months, 0.71 (95% CI: 0.69-0.73) at 6 months, and 0.63 (95% CI: 0.61-0.65) at 12 months. In multivariable analysis, older age (HR = 0.57; 95% CI: 0.49-0.66), sphincterotomy (HR = 0.58, 95% CI: 0.49-0.68) and higher leukocyte count (HR = 0.79; 95% CI: 0.70-0.90) were independently associated with lower risk of relapse, whereas higher levels of alanine aminotransferase (HR = 1.22; 95% CI: 1.02-1.46) and multiple cholelithiasis (HR = 1.19, 95% CI: 1.05-1.34) were associated with higher relapse rates.

CONCLUSION

The relapse rate is high and different in each symptomatic gallstone disease. Our independent predictors could be useful for prioritizing patients on the waiting list for cholecystectomies.

Interventional endoscopy for abdominal transplant patients

Interventional endoscopy can play a significant role in the care and management of children pre-and post- abdominal solid organ transplantation. Such procedures primarily include endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS), and balloon-assisted enteroscopy (BAE), though additional interventions are available using standard endoscopes (gastroscopes, colonoscopes) for therapeutics purposes such as endoscopic hemostasis. The availability of pediatric practitioners with the advanced training to effectively and safely perform these procedures are most often limited to large tertiary care pediatric centers. These centers possess the necessary resources and ancillary staff to provide the comprehensive multi-disciplinary care needed for these complex patients. In this review, we discuss the importance of interventional endoscopy in caring for transplant patients, during their clinical course preceding the potential need for solid organ transplantation and inclusion of a discussion related to endoscopic post-surgical complication management. Given the highly important role of interventional endoscopy in patients with recurrent and chronic pancreatitis, we also include a discussion related to this complex disease process leading up to those patients that may need pancreas surgery including total pancreatectomy with islet autotransplantation (TPIAT).

Endotherapy in Pancreatic Diseases

Interventional endoscopy is now considered an effective minimally invasive treatment modality for the management of pancreatic diseases. It is important for the clinician to know the indications and contraindications as well as the timing of various endoscopic interventions. This will help in its safe and effective use and consequently decrease morbidity and mortality from various pancreatic diseases. This review will provide a broad overview of the indications, techniques, and outcomes of pancreatic endotherapy.