Pancreatic endotherapy for pseudocysts and fluid collections

Safety and efficacy of endoscopic retrograde cholangiopancreatography in pediatric pancreatic and biliary disorders

INTRODUCTION

There is sparse data from India on indications, technical success, safety and outcomes of endoscopic retrograde cholangiopancreatography (ERCP) using standard adult duodenoscope in the pediatric population.

METHODS

Retrospective analysis of prospectively maintained electronic endoscopy and clinical database was performed to identify pediatric patients (age ≤ 18 years) who underwent ERCP between January 2017 and December 2022. Demographics and procedural details including indications, cholangio-pancreatogram findings, endotherapy type performed, technical and clinical success and complications were noted.

RESULTS

As many as 150 pediatric patients were included of whom 88 had pancreatic (mean age-13.7 years) and 62 had biliary disease (mean age- 14.9 years). Common pancreatic ERCP indications were chronic pancreatitis (n = 45 [51.1%]), pancreatic duct disruption fistula (n = 21 [23.9%]) and recurrent acute pancreatitis (n = 16 [18.2%]). Among biliary indications were choledocholithiasis (n = 29 [46.8%]), benign bile duct strictures (n = 13 [21%]), bile duct injury/leak and biliary stent removal (n = 7 [11.3%]) , choledochal cyst (n = 5  [8.1%]) and pancreatic mass causing biliary compression (n = 1 [1.6%]). Technical success in pancreatic and biliary ERCP was 94.3% and 95.2%, respectively, and clinical success was 84.1% and 93.5%, respectively. Most common complications following pancreatic ERCPs were acute pancreatitis (n = 9 [10.2%]) (mild = 5, moderate = 4) patients and post sphincterotomy bleed in one (1.1%). Among biliary ERCPs, post ERCP pancreatitis was seen in (n = 3 [4.8%]) (mild = 2, moderate = 1).

CONCLUSION

ERCP can be safely and effectively performed in children using standard duodenoscope. Chronic pancreatitis, choledocholithiasis and pancreatic divisum are common pediatric ERCP indications.

Endoscopic management of pancreatic fluid collections with disconnected pancreatic duct syndrome

Disconnected pancreatic duct syndrome (DPDS) is an important and common complication of acute necrotizing pancreatitis. Endoscopic approach has been established as the first-line treatment for pancreatic fluid collections (PFCs) with less invasion and satisfactory outcome. However, the presence of DPDS significantly complicates the management of PFC; besides, there is no standardized treatment for DPDS. The diagnosis of DPDS presents the first step of management, which can be preliminarily established by imaging methods including contrast-enhanced computed tomography, ERCP, magnetic resonance cholangiopancreatography (MRCP), and EUS. Historically, ERCP is considered as the gold standard for the diagnosis of DPDS, and secretin-enhanced MRCP is recommended as an appropriate diagnostic method in existing guidelines. With the development of endoscopic techniques and accessories, the endoscopic approach, mainly including transpapillary and transmural drainage, has been developed as the preferred treatment over percutaneous drainage and surgery for the management of PFC with DPDS. Many studies concerning various endoscopic treatment strategies have been published, especially in the recent 5 years. Nonetheless, existing current literature has reported inconsistent and confusing results. In this article, the latest evidence is summarized to explore the optimal endoscopic management of PFC with DPDS.

Successful treatment of a pancreatic pseudocyst accompanied by massive hemothorax: a case report

BACKGROUND

It is rare to encounter massive hemothorax as a complication of pancreatic pseudocyst. In addition, as no obvious hypotension and abdominal discomfort were noted, it was difficult to consider gastrointestinal lesion a possibility.

CASE PRESENTATION

A 54-year-old Taiwanese man had tightness on the left side of his chest and shortness of breath for 3 days. He had a history of acute pancreatitis 3 months ago. After history taking and a series of examinations including thoracocentesis and computed tomography of his abdomen and chest, the diagnosis was finally confirmed based on the high amylase levels in his pleural fluid.

CONCLUSIONS

Treatment with distal pancreatectomy and splenectomy was subsequently successfully performed. Based on our experience, we briefly discuss the currently available treatment options for pancreatic pseudocyst.

ERCP in the management of pancreatic diseases in children

BACKGROUND

ERCP experience in pancreatic disorders in children is limited.

OBJECTIVE

This study evaluated the utility and efficacy of ERCP in children with pancreatic diseases at a tertiary care referral center.

PATIENTS AND SETTINGS

Consecutive patients 18 years of age and younger who underwent ERCP for pancreatic diseases from January 2010 to June 2011 were identified. Indications, findings, interventions, adverse events, and outcomes were recorded.

RESULTS

A total of 221 ERCPs were performed in 172 children (102 boys, mean ± standard deviation age 13.8 ± 3.2 years, 157 therapeutic). A total of 143 children (83.1%) had chronic pancreatitis (CP), 19 (11%) had recurrent acute pancreatitis (RAP), and 10 (5.8%) had acute pancreatitis (AP). Indications included pain (153, 89.4%), pancreatic fistula (11, 6.3%), symptomatic pseudocyst (4, 2.3%), and jaundice (3, 1.7%). In chronic pancreatitis patients, findings included a dilated and irregular main pancreatic duct (92, 64.3%), pancreatic duct (PD) calculi (76, 53%), dominant PD stricture (23, 16%), PD leak (7, 4.9%), pancreas divisum (35, 24.5%), and common bile duct (CBD) stricture (3, 2%). Therapeutic procedures included major papilla sphincterotomy (93, 65%), minor papilla sphincterotomy (32, 22.3%), PD stenting (77, 53.8%), and CBD stenting (3, 2.2%). PD stones larger than 5 mm were retrieved endoscopically after 57 extracorporeal shock wave lithotripsy sessions in 50 patients (34.9%). In patients with RAP, 6 (31.5%) had complete and 1 partial pancreas divisum. All underwent minor papillotomy. In patients with AP, 4 (40%) had stenting for PD leak, 2 (20%) underwent CBD clearance for biliary pancreatitis, and 4 (40%) had transpapillary pseudocyst drainage. During 13 ± 4.7 months (range 6-22 months) of follow-up, improvement of symptoms was seen in 143 of 172 (83%) patients. Procedure-related adverse events were seen in 8 (4.7%) patients.

LIMITATIONS

Retrospective study.

CONCLUSION

ERCP is a safe therapeutic option for pancreatic disorders in children.

Outcome of pancreatic ascites in patients with tropical calcific pancreatitis managed using a uniform treatment protocol

Pancreatic ascites or internal pancreatic fistula is a known complication of chronic pancreatitis. This condition is associated with considerable morbidity and mortality. The management approach of pancreatic ascites in tropical calcific pancreatitis is infrequently reported owing to the low incidence of this condition. Between December 2005 and June 2007, 11 patients with pancreatic ascites with tropical calcific pancreatitis (male:female 7:4, mean age 29.5 [14.2] years) were treated. A retrospective analysis of patients who underwent endotherapy and surgery for this condition based on an institutional protocol was performed. The end point was resolution of pancreatic ascites and relief of symptoms. All patients had pancreatic ascites, and one patient also had pancreatic pleural effusion. Endoscopic transpapillary stenting was possible in nine patients (81%). Identification of site of leak and placement of an endoscopic stent across the PD disruption was possible in five (45%) patients. All these patients had relief of ascites. Mean number of endotherapy sessions required before control of ascites was 1.8. Among the remaining four (36.6%) patients who had ERCP, placement of stent across the leak was unsuccessful; however stenting helped stabilize the general condition and nutritional status. These four patients and two patients who failed ERP underwent lateral pancreatojejunostomy surgery. Morbidity was observed in three patients who underwent surgery and one patient died due to sepsis and hemorrhage. All patients who had surgical drainage had complete relief of ascites and symptoms. In patients with pancreatic ascites in tropical calcific pancreatitis endotherapy and transpapillary stenting helps in resolution of ascites in nearly half of the patients. In the remaining patients preliminary conservative management followed by surgical pancreatic ductal drainage provides good relief of symptoms.

Debridement and drainage of walled-off pancreatic necrosis by a novel laparoendoscopic rendezvous maneuver: experience with 6 cases

BACKGROUND

Walled-off pancreatic necrosis (WOPN) is a known complication of acute and chronic pancreatitis. Indications for treatment of WOPN are infection, a rapid increase in size, pain, or biliary or duodenal obstruction. Endoscopic transgastric treatment of pseudocysts with liquid content is successful in approximately 90% of patients; however, the treatment of WOPN is less satisfactory.

OBJECTIVE

A demonstration of a novel minimally invasive approach to adequately remove and drain pancreatic necrosis.

DESIGN

Between June 2004 and June 2006, a nonrandomized observational study was conducted with 6 consecutive patients. WOPN was treated by a minimally invasive laparoendoscopic rendezvous technique.

SETTING

All patients were examined at the university hospital in Freiburg, Germany.

PATIENTS

Six patients were treated for WOPN of an average diameter of 13 cm (range 9-20 cm). In 5 cases, the WOPN was a consequence of acute pancreatitis; there was 1 case of chronic pancreatitis. The average interval between diagnosis and initial treatment was 14 weeks (range 6-20 weeks).

RESULTS

Conventional surgery was avoided in 5 patients (83%) over a median follow-up of 14 months (range 1.5-27 months). Six endoscopic sessions (range 4-11) were performed during the entire treatment period. One patient needed emergency surgery on day 4 after the intervention for a perforation because of gastric-wall separation from the necrotic cavity. There was 1 lethal gastric variceal bleeding, which occurred when a gastrostomy tube was removed 46 days after the initial treatment.

LIMITATION

The small number of patients.

CONCLUSIONS

In selected cases, minimally invasive laparoendoscopic treatment of WOPN is possible without the need of laparotomy or laparoscopy.

Drenagem endoscópica transmural de pseudocisto pancreático: resultados a longo prazo

RACIONAL: Os pseudocistos pancreáticos são complicações relativamente comuns em pacientes adultos com pancreatite. OBJETIVO: Avaliar os resultados a longo prazo da drenagem endoscópica transmural, estabelecendo seu papel no manejo do pseudocisto pancreático. MÉTODOS: Foram estudados 14 pacientes com pseudocisto de pâncreas, cuja principal queixa à apresentação foi dor no andar superior do abdome e massa abdominal palpável, submetidos a cistogastrostomia (n = 12) e cistoduodenostomia (n = 2), acompanhados clinicamente e com tomografia computadorizada de abdome por até 51 meses. A colangiopancreatografia endoscópica retrógrada era tentada em todos os casos para estudo do ducto pancreático e classificação dos cistos. RESULTADOS: A pancreatite crônica alcoólica agudizada foi responsável por 10 casos (71,5%) e a biliar por 4 (28,5%). As duas formas de drenagens (cistogastrostomia e cistoduodenostomia) endoscópicas foram efetivas. Não houve mudança na conduta terapêutica proposta; em dois pacientes a migração da órtese para o interior do pseudocisto, no momento da inserção, foi a principal complicação, sendo possível sua retirada no mesmo ato, com o uso da cesta de Dormia, sob o auxílio de fluoroscopia. Não houve mortalidade, nem recidiva até o momento. O tempo médio de permanência hospitalar foi de 3 dias. CONCLUSÃO: A drenagem endoscópica transmural se apresentou como terapêutica eficaz, com baixo índice de complicações, mortalidade nula e pequeno tempo de internação hospitalar.

Treatment of pancreatic pseudocysts

According to the Atlanta classification an acute pseudocyst is a collection of pancreatic juice enclosed by a wall of fibrous or granulation tissue, which arises as a consequence of acute pancreatitis or pancreatic trauma, whereas a chronic pseudocyst is a collection of pancreatic juice enclosed by a wall of fibrous or granulation tissue, which arises as a consequence of chronic pancreatitis and lack an antecedent episode of acute pancreatitis. It is generally agreed that acute and chronic pseudocysts have a different natural history, though many reports do not differentiate between pseudocysts that complicate acute pancreatitis and those that complicate chronic disease. Observation--"conservative treatment"--of a patient with a pseudocyst is preponderantly based on the knowledge that spontaneous resolution can occur. It must, however, be admitted that there is substantial risk of complications or even death; first of all due to bleeding. There are no randomized studies for the management protocols for pancreatic pseudocysts. Therefore, today we have to rely on best clinical practice, but still certain advice may be given. First of all it is important to differentiate acute from chronic pseudocysts for management, but at the same time not miss cystic neoplasias. Conservative treatment should always be considered the first option (pseudocysts should not be treated just because they are there). However, if intervention is needed, a procedure that is well known should always be considered first. The results of percutaneous or endoscopic drainage are probably more dependent on the experience of the interventionist than the choice of procedure and if surgery is needed, an intern anastomosis can hold sutures not until several weeks (if possible 6 weeks).

Appropriate timing of cholecystectomy in patients who present with moderate to severe gallstone-associated acute pancreatitis with peripancreatic fluid collections

SUMMARY BACKGROUND DATA

Standard management of gallstone-associated acute pancreatitis calls for cholecystectomy to be performed during the same hospitalization after acute symptoms have subsided. However, infectious complications are common when cholecystectomy is performed sooner than 3 weeks after severe acute pancreatitis. Fluid collections, common in patients with moderate to severe acute pancreatitis, are additionally problematic. No previous study has examined the role of peripancreatic fluid collections and subsequent pseudocyst in outcomes after cholecystectomy in these patients.

OBJECTIVES

We compare results of delaying cholecystectomy after moderate to severe acute pancreatitis with early cholecystectomy.

METHODS

Since 1987, all patients with moderate to severe gallstone-associated acute pancreatitis and associated fluid collections were addressed. Moderate to severe acute pancreatitis was defined as > 5 Ranson prognostic indicators. Fluid collection was established by computed tomography (CT) scan. Patients were evaluated for duration of hospitalization, complications of cholecystectomy, resolution or persistence of pseudocysts, nonoperative interventions performed on pseudocysts, intercurrent episodes of acute pancreatitis during the monitoring period, episodes of sepsis, and mortality.

RESULTS

A total of 187 patients with moderate to severe gallstone-associated acute pancreatitis survived their acute stage; 151 had peripancreatic fluid collections. Seventy-eight of the 187 had early cholecystectomy, 62 of whom had fluid collections; 109 were monitored before cholecystectomy, 89 of whom had fluid collections. Fluid collections resolved without intervention in 36 (40%) of 89 in the monitored group and in 13 (21%) of 62 in the early cholecystectomy group. Percutaneous drainage was performed in 16 (18%) of 89 in the monitored group and in 31 (50%) of 62 in the early cholecystectomy group. Sepsis occurred in 6 (7%) of 89 in the monitored group and 29 (47%) of 62 in the early cholecystectomy group. Complications of cholecystectomy occurred in 6 (5.5%) of 109 of the monitored patients and in 34 (44%) of 78 in the early cholecystectomy group. Fifty-three patients in the monitored group and 49 patients in the early cholecystectomy group required operative pseudocyst-enterostomy. This procedure was combined with cholecystectomy in the monitored patients. Mean hospitalization was longer in the early operation group.

CONCLUSION

Cholecystectomy should be delayed in patients who survive an episode of moderate to severe acute biliary pancreatitis and demonstrate peripancreatic fluid collections or pseudocysts until the pseudocysts either resolve or persist beyond 6 weeks, at which time pseudocyst drainage can safely be combined with cholecystectomy.