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

Role of endoscopic retrograde cholangiopancreatography in pancreatitis

Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from mainly a diagnostic tool to a treatment method, thanks to newer noninvasive techniques like magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS). This paper looks at how ERCP is used to treat conditions such as acute gallstone pancreatitis, pancreas divisum (PD), sphincter of Oddi dysfunction (SOD), and chronic pancreatitis (CP). For acute gallstone pancreatitis, early ERCP to reduce severity or mortality is now questioned, except when there is cholangitis or ongoing bile duct blockage. For patients with recurring acute pancreatitis due to PD, endoscopic treatment aims to lower duct pressure, but there is not enough strong evidence to support its long-term success. In SOD cases, recent research suggests being more careful with endoscopic sphincterotomy. ERCP plays a clearer role in CP by helping to manage duct stones and strictures in suitable patients. The rising use of pancreatoscopy-assisted lithotripsy as an alternative to ESWL is also discussed.

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.

Evaluating approaches to diagnosis and management of idiopathic acute pancreatitis

INTRODUCTION

Idiopathic acute pancreatitis (IAP) is a diagnosis of exclusion; systematic work-up is challenging but essential. Recent advances suggest IAP results from micro-choledocholithiasis, and that laparoscopic cholecystectomy (LC) or endoscopic sphincterotomy (ES) may prevent recurrence.

METHODS

Patients diagnosed with IAP from 2015-21 were identified from discharge billing records. Acute pancreatitis was defined by the 2012 Atlanta classification. Complete workup was defined per Dutch and Japanese guidelines.

RESULTS

A total of 1499 patients were diagnosed with IAP; 455 screened positive for pancreatitis. Most (N = 256, 56.2%) were screened for hypertriglyceridemia, 182 (40.0%) for IgG-4, and 18 (4.0%) MRCP or EUS, leaving 434 (29.0%) patients with potentially idiopathic pancreatitis. Only 61 (14.0%) received LC and 16 (3.7%) ES. Overall, 40% (N = 172) had recurrent pancreatitis versus 46% (N = 28/61) following LC and 19% (N = 3/16) following ES. Forty-three percent had stones on pathology after LC; none developed recurrence.

CONCLUSION

Complete workup for IAP is necessary but was performed in <5% of cases. Patients who potentially had IAP and received LC were definitively treated 60% of the time. The high rate of stones on pathology further supports empiric LC in this population. A systematic approach to IAP is lacking. Interventions aimed at biliary-lithiasis to prevent recurrent IAP have merit.

Endoscopy and Pediatric Pancreatitis

Children and adolescents are increasingly impacted by pancreatic disease. Interventional endoscopic procedures, including endoscopic retrograde cholangiopancreatography) and endoscopic ultrasonography, are integral to the diagnosis and management of many pancreatic diseases in the adult population. In the past decade, pediatric interventional endoscopic procedures have become more widely available, with invasive surgical procedures now being replaced by safer and less disruptive endoscopic interventions.

Safety and efficacy of minor papillotomy in children and adolescents with pancreas divisum

INTRODUCTION

Pancreas Divisum (PD) is a common pancreatic ductal variant which is twice as common in pediatric patients with acute recurrent pancreatitis (ARP) relative to the general population (14% vs. 7%). Endoscopic retrograde cholangiopancreatography (ERCP) with minor papillotomy has been performed to facilitate drainage of pancreatic juice from the diminutive minor papilla to prevent pancreatitis and pancreatic damage.

METHODS

We searched our prospectively-maintained endoscopy databases for patients 18 and younger who underwent ERCP with minor papillotomy between 2009 and 2019. Demographic data, indications, procedural interventions and findings, as well as available clinical outcomes data were analyzed.

RESULTS

54 ARP/PD patients underwent ERCP with minor papillotomy. Median age was 14 (range 7-18) years, and 26 (48.1%) patients were female. Post-ERCP pancreatitis developed in 10/54 patients (18.5%). 12-month post-ERCP clinical trajectory was available in 47/54 (87%) patients and most patients (38/47, 80.8%) improved clinically after minor papillotomy, with 9/47 (19.1%) experiencing resolution of pancreatitis episodes and none indicated worsening severity or frequency of pancreatitis episodes following ERCP.

CONCLUSION

The majority of children and adolescents with PD and ARP who underwent ERCP with minor papillotomy experienced subjective improvement in their symptoms following the intervention. These data suggest that ERCP with minor papillotomy for pediatric patients with PD and ARP is beneficial and may be curative in a subset of patients-higher rates of improvement than have been previously reported in adults.

Magnetic Resonance Cholangiopancreatography vs Endoscopy Retrograde Cholangiopancreatography for Detection of Anatomic Variants of the Pancreatic Duct in Children

OBJECTIVE

To compare the efficacy of magnetic resonance cholangiopancreatography (MRCP) with endoscopy retrograde cholangiopancreatography (ERCP) in children for the identification of pancreatic duct variants.

STUDY DESIGN

We identified children with a pancreatic duct variant by ERCP and separately queried our MRCP database for similar variants. Patients with a paired ERCP-MRCP were reviewed. Three radiologists blinded to the ERCP and MRCP findings were asked to independently review the MRCP studies and define the pancreatic duct anatomy. These blinded reviewers also graded the magnetic resonance imaging examination quality.

RESULTS

Seventy-four pairs of ERCP-MRCP examinations were identified. Pancreas divisum was the most frequent ductal variant encountered (73%). There was fair agreement between the radiology reviewers as to the quality of the magnetic resonance imaging studies (Fleiss Kappa agreement). Concordance of the reviewers with that of the ERCP was moderate for the exact diagnosis, moderate for the presence of pancreas divisum, and fair for agreement on the presence of any duct variant. Concordance among reviewers was moderate for the exact diagnosis, moderate for normal vs abnormal, and substantial for the presence of pancreas divisum.

CONCLUSIONS

Diagnostic limitations exist when comparing MRCP with the gold reference standard of ERCP, specifically when assessing for pancreatic duct variants in children.

Long-Term Outcomes of Endoscopic Intervention in the Treatment of Symptomatic Pancreas Divisum

To evaluate the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of patients with symptomatic pancreas divisum (PD) and to discuss the possible risk factors of endoscopic reintervention for symptomatic PD. A total of 50 patients with symptomatic PD who underwent ERCP from January 2010 to December 2019 were finally brought into study. All patients were divided into the nonage and the adult group according to their ages. Meanwhile, all patients were also divided into the intervention and the reintervention group according to times of ERCP. The long-term outcome of each patient was collected during the follow-up by phone call. The total success rate of ERCP was 94.7% (89/93), and the effective rate of first ERCP was 58% (29/50). There were no statistical differences on the outcomes of ERCP treatment between the adult and nonage group. There were 17 patients with complete pancreas divisum and 19 patients with chronic pancreatitis in the reintervention group, which were more than 6 patients and 8 patients in the intervention group (P < 0.05). In bivariate regression analysis, chronic pancreatitis and complete pancreas divisum might be significant risk factors for endoscopic reintervention for patients with symptomatic PD (OR, 8.010, 95% CI, 1.483–43.276, P=0.016; OR, 8.869, 95% CI, 1.450–54.254, P=0.018, respectively). ERCP in treating adult and nonage patients with symptomatic PD are effective and safe. But, many patients may need endoscopic reintervention. Complete pancreas divisum and chronic pancreatitis may be risk factors of ERCP reintervention for patients with symptomatic PD.

Clinical outcome of endoscopic therapy in patients with symptomatic pancreas divisum: a Dutch cohort study

Background and study aims  Although the majority of patients with pancreas divisum (PDiv) are asymptomatic, a subgroup present with recurrent pancreatitis or pain for which endoscopic therapy may be indicated. The aim of this study was to evaluate success rates and long-term outcomes of endoscopic treatment in patients with symptomatic PDiv. Patients and methods  A multicenter, retrospective cohort study was performed. Patients with symptomatic PDiv presenting with recurrent acute pancreatitis (RAP), chronic pancreatitis (CP), or chronic abdominal pancreatic-type pain (CAP) who underwent endoscopic retrograde cholangiopancreatography (ERCP) between January 2000 and December 2019 were included. The primary outcome was clinical success, defined as either no recurrent episode of acute pancreatitis (AP) for RAP patients, no flares for CP patients, or absence of abdominal pain for patients with CAP after technically successful ERCP. Results  In 60 of 81 patients (74.1 %) a technically successful papilla minor intervention was performed. Adverse events were reported in 30 patients (37 %), with post-ERCP pancreatitis in 18 patients. The clinical success rate for patients with at least 3 months of follow-up was 42.6 %, with higher rates of success among patients presenting with RAP (44.4 %) as compared to those with CP (33.3 %) or CAP (33.3 %). Long-term sustained response was present in 40.9 % of patients with a technically successful intervention. In patients with RAP who did not completely respond to treatment, the mean number of AP episodes after treatment decreased significantly from 3.5 to 1.1 per year, and subsequently the interval between AP episodes increased from 278 to 690 days ( P  = 0.0006). A potential predictive factor of failure of clinical success after technically successful ERCP, at univariate analysis, was male sex (OR = 0.25, P  = 0.02). Conclusions  Endoscopic therapy in patients with symptomatic PDiv is moderately effective, with its highest yield in patients presenting with RAP. Future studies are needed to assess factors predictive for success of endoscopic therapy and potential risk factors for relapse after ERCP.

Clinical Outcomes Following Therapeutic Endoscopic Retrograde Cholangiopancreatography in Children With Pancreas Divisum

OBJECTIVES

Pancreas divisum (PD) is a risk factor in children for the development of acute pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP) with minor papilla endoscopic sphincterotomy (mPES) may be of clinical benefit, however, the clinical outcomes from endotherapy remain unclear. We sought to review the outcomes and safety of therapeutic ERCP in children with PD.

METHODS

We performed a retrospective chart of children with PD who underwent an ERCP between February 2012 and December 2018. Pertinent patient, clinical and procedure information was collected including procedure-related adverse events. A follow-up questionnaire of the parent was conducted to determine the clinical impact from endotherapy.

RESULTS

Fifty-eight ERCPs were performed in 27 patients (14 boys; mean age: 9.7 years, range 2-19) with PD. All patients underwent a successful mPES. A genetic variant was identified in 19/26 (73%) tested patients. Post-ERCP pancreatitis (PEP) was the only observed adverse event; 21% (12/58). Median follow-up interval from first ERCP intervention to questionnaire completion was 31.5 months (range: 4--72 months). Of the 20 questionnaire responders, 13 reported clinical improvement from endotherapy.

CONCLUSIONS

The majority of children from our PD cohort possessed at least 1 genetic variant. Most questionnaire responders had a favorable response to endotherapy. PEP rate was comparable with that of prior reports in adult patients.

Incidence and risk factors for post-ERCP pancreatitis in pancreas divisum patients without chronic pancreatitis

Aims: The studies on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in pancreas divisum (PD) patients without chronic pancreatitis (CP) are rare. In this study, we aimed to evaluate the incidence of PEP in PD patients without CP and the risk and protective factors for PEP.Methods: Consecutive patients with symptomatic PD that underwent ERCP from January 2005 to December 2017 were retrospectively analyzed. The patients were divided into PD without CP group and CP group. The basic information and medical records of patients were collected. The risk and protective factors for PEP in PD patients without CP were analyzed by univariate logistic analysis.Results: A total of 89 ERCP procedures were performed in 51 PD patients without CP, and 249 procedures in 136 patients with CP. The incidence of PEP was significantly higher in PD patients without CP than those with CP (15.7% vs. 5.6%, p = .005). Female gender were independent risk factors for PEP, while dorsal duct stent placement was a protective factor.Conclusion: CP may be a protective factor against PEP in PD patients. Female was a risk factor for PEP in PD patients and dorsal duct stent placement was a preventive factor that reduced the incidence of PEP in PD patients without CP.

Pancreatitis in the developmentally anomalous pancreas

Developmental anomalies of the pancreas include more common entities such as pancreas divisum and annular pancreas, and unusual entities such as heterotopic pancreas. While these anomalies can present a diagnostic challenge to the radiologist, when the pancreatic tissue involved in these processes develops pancreatitis, the radiographic appearance can present a diagnostic dilemma. Awareness of these pancreatic anomalies and familiarity with their appearance when inflamed is necessary to distinguish pancreatitis in the developmentally anomalous pancreas from other inflammatory or neoplastic processes.

Identifying Factors Predicting Response to Endoscopic Management of Chronic Pancreatitis Secondary to Pancreas Divisum

INTRODUCTION

Appropriately selecting patients with chronic pancreatitis associated with pancreas divisum (PD) for endoscopic retrograde cholangiopancreatography (ERCP)-based therapy versus surgery remains difficult. The objective of this study was to identify factors that predict success or failure of ERCP for treatment of chronic pancreatitis in PD.

METHODS

Patients undergoing ERCP for a diagnosis of PD and pancreatitis between 2008 and 2016 were identified and grouped according to whether they required one or two ERCPs or three or more ERCPs. Groups were compared along demographic, diagnostic, laboratory, ERCP-related, and outcome variables.

RESULTS

Patients requiring 1-2 ERCPs were less likely to have back pain on initial presentation (4 vs. 24%, p = 0.02) and less likely to have a dilated bile duct on imaging prior to their first ERCP (8 vs. 30%, p = 0.04) than those requiring 3+ ERCPs. Patients requiring 1-2 ERCPs were also less likely to eventually require operative intervention for treatment of their chronic pancreatitis than those requiring 3+ ERCPs (24 vs. 44%, p = 0.047). On multivariable analysis, a dilated bile duct (odds ratio (OR) = 6.0, 95% confidence interval (CI) = 1.01-36.0, p = 0.048) was independently associated with requiring 3+ ERCPs. Back pain (OR = 6.3, 95% CI = 0.73-54.2, p = 0.09) trended toward but did not reach statistical significance for being independently associated with requiring 3+ ERCPs.

CONCLUSIONS

The success of endoscopic treatment of chronic pancreatitis in patients with PD is dependent on proper patient selection. Patients with a dilated bile duct and back pain upon presentation may not respond well to endoscopic treatment alone and are more likely to eventually require operative intervention. Consideration should be given to early operative intervention in these patients.

Identification and management of pancreas divisum

Introduction: Pancreas divisum is the most common congenital malformation of the pancreas with the majority asymptomatic. The etiological role, pathogenesis, clinical significance and management of pancreas divisum in pancreatic disease has not been clearly defined and our understanding is yet to be fully elucidated.Areas covered: This review describes the role of pancreas divisum in the development of pancreatic disease and the ambiguity related to it. In our attempt to offer clarity, a comprehensive search on PubMed, Ovid, Embase and Cochrane Library from inception to May 2019 was undertaken using key words "pancreas divisum", "idiopathic recurrent acute pancreatitis" and "chronic pancreatitis".Expert opinion: Current research fails to define a clear association between pancreas divisum and pancreatic disease. Though debatable, several studies do suggest a pathological role of pancreas divisum in pancreatic disease and a benefit of minor papilla therapy in the setting of acute recurrent pancreatitis. Surgical and endoscopic therapeutic modalities have not been directly compared. With the current data available, it would be imprudent to advise a definitive line of management for pancreatic disease associated with pancreas divisum and should involve a comprehensive discussion with the individual patient to define expectations before embarking on any medical and/or interventional therapy.

Long-term outcomes of therapeutic ERCP in pediatric patients with pancreas divisum presenting with acute recurrent or chronic pancreatitis

OBJECTIVES

The aim of this study was to evaluate the long-term outcomes of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for pediatric patients with pancreas divisum (PD) presenting with acute recurrent pancreatitis (ARP) or chronic pancreatitis (CP).

METHODS

Between May 2008 and August 2017, pediatric patients with PD who received endotherapy at Ruijin Hospital were identified and grouped according to clinical presentation, namely ARP and CP. Primary success was defined as patients' improvement in symptoms after index ERCPs, without further intervention or any analgesic.

RESULTS

A total of 74 ERCPs were performed in 38 pediatric patients. The frequency of at least 1 genetic mutation identified in patients with ARP and CP was 44.4% and 68.4%, respectively. Patients with CP required more ERCPs than those with ARP (2.4 ± 1.7 vs. 1.1 ± 0.4, P = 0.005). The incidence of post-ERCP complications was 14.9%, including pancreatitis of 13.5% and hemorrhage of 1.4%. During a median follow-up duration of 41 months (range, 12-123 months), the frequency of pancreatitis episodes decreased significantly from 2.31 to 0.45 (P < 0.0001). The 25% recurrence and reintervention rates were estimated at 25 and 48 months, respectively, without significant difference between patients with ARP or CP. There was a nonsignificant trend towards a higher rate of primary success in patients with ARP than those with CP (92.9% vs. 69.6%, P = 0.123). After further endotherapy, 91.3% patients with CP improved clinically.

CONCLUSIONS

Therapeutic ERCP is an effective and safe intervention for pediatric patients with symptomatic PD. Patients presenting with CP seem to achieve improvement after additional ERCPs.

SpHincterotomy for Acute Recurrent Pancreatitis Randomized Trial: Rationale, Methodology, and Potential Implications

OBJECTIVES

In patients with acute recurrent pancreatitis (ARP), pancreas divisum, and no other etiologic factors, endoscopic retrograde cholangiopancreatography (ERCP) with minor papilla endoscopic sphincterotomy (miES) is often performed to enlarge the minor papillary orifice, based on limited data. The aims of this study are to describe the rationale and methodology of a sham-controlled clinical trial designed to test the hypothesis that miES reduces the risk of acute pancreatitis.

METHODS

The SpHincterotomy for Acute Recurrent Pancreatitis (SHARP) trial is a multicenter, international, sham-controlled, randomized trial comparing endoscopic ultrasound + ERCP with miES versus endoscopic ultrasound + sham for the management of ARP. A total of 234 consented patients having 2 or more discrete episodes of acute pancreatitis, pancreas divisum confirmed by magnetic resonance cholangiopancreatography, and no other clear etiology for acute pancreatitis will be randomized. Both cohorts will be followed for a minimum of 6 months and a maximum of 48 months.

RESULTS

The trial is powered to detect a 33% risk reduction of acute pancreatitis frequency.

CONCLUSIONS

The SHARP trial will determine whether ERCP with miES benefits patients with idiopathic ARP and pancreas divisum. Trial planning has informed the importance of blinded outcome assessors and long-term follow-up.

Pancreas Divisum in Pediatric Acute Recurrent and Chronic Pancreatitis: Report From INSPPIRE

INTRODUCTION

The significance of pancreas divisum (PD) as a risk factor for pancreatitis is controversial. We analyzed the characteristics of children with PD associated with acute recurrent or chronic pancreatitis to better understand its impact.

PATIENTS AND METHODS

We compared children with or without PD in the well-phenotyped INSPPIRE (INternational Study group of Pediatric Pancreatitis: In search for a cuRE) cohort. Differences were analyzed using 2-sample t test or Wilcoxon rank sum test for continuous variables, Pearson χ or Fisher exact test for categorical variables.

RESULTS

PD was found in 52 of 359 (14.5%) subjects, a higher prevalence than the general population (∼7%). Females more commonly had PD (71% vs. 55%; P=0.02). Children with PD did not have a higher incidence of mutations in SPINK1, CFTR, CTRC compared with children with no PD. Children with PD were less likely to have PRSS1 mutations (10% vs. 34%; P<0.01) or a family history of pancreatitis (P<0.05), and more likely to have hypertriglyceridemia (11% vs. 3%; P=0.03). Children with PD underwent significantly more endoscopic procedures and pancreatic sphincterotomy. Patients with PD had fewer attacks of acute pancreatitis (P=0.03) and were less likely to develop exocrine pancreatic insufficiency (P=0.01). Therapeutic endoscopic retrograde cholangiopancreatography was considered most helpful if pancreatic duct was impacted with stones (83% helpful).

CONCLUSIONS

PD is likely a risk factor for acute recurrent pancreatitis and chronic pancreatitis in children that appears to act independently of genetic risk factors. Patients with PD and stones obstructing the pancreatic duct benefit most from therapeutic endoscopic retrograde cholangiopancreatography.

Pancreas divisum and recurrent pancreatitis: long-term results of minor papilla sphincterotomy

Background and aims: Pancreas divisum (PD) is the most common congenital variant of the pancreatic ductal system and a potential cause of acute recurrent pancreatitis (ARP). Endoscopic therapy is a therapeutic option for symptomatic PD, but there is limited data on long-term results. We aimed to assess the effect of minor papilla endoscopic sphincterotomy (MiES) in the setting of ARP in patients with PD. Methods: Consecutive patients treated by MiES were included. Clinical data, including gender, age, smoking and drinking habits, number of episodes of acute pancreatitis (AP) as well as technical data pertaining to the endoscopic therapy were reviewed. Patients available for follow-up were contacted to assess the long-term impact of MiES using the Patient's Global Impression of Change (PGIC) questionnaire. Results: A total of 138 patients with PD including 77 patients with ARP underwent MiES; 48 patients were available for long-term follow-up using the PGIC score, with a mean follow-up period of 9.7 years. Procedure-related adverse events developed in 10 cases (12.9%): 5 post-MiES delayed bleeding and 5 mild pancreatitis. MiES was clinically successful in 35 patients (72.9%) who did not experience any more episodes of AP. Improvement in quality of life (PGIC ≥6) occurred in 41/48 patients (85.4%). On multivariate analysis, stenosis of the MiES was the only predictive factor for increased risk of recurrent pancreatitis after initial therapy. Conclusion: MiES resulted an efficient treatment for ARP in patients with PD with clinical benefit, patient satisfaction and improved quality of life even at long-term follow-up.

Difficult biliary cannulation: Historical perspective, practical updates, and guide for the endoscopist

Despite improvements in endoscopic technologies and accessories, development of advanced endoscopy fellowship programs, and advances in ancillary imaging techniques, biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP) can still be unsuccessful in up to 20% of patients, even in referral centers. Once cannulation has been deemed to be difficult, the risk of post-ERCP pancreatitis and technical failure inherently increases. A number of factors, including endoscopist experience and patient anatomy, have been associated with difficult biliary cannulation, but predicting a case of difficult cannulation a priori is often not possible. Numerous techniques such as pancreatic guidewire and stenting, early pre-cut, and rendezvous may be employed when standard approaches fail. Data regarding the rate of success and adverse events of these techniques have been variable, though most studies suggest that pancreatic duct stenting generally reduces the rate of post-ERCP pancreatitis in instances of difficult biliary cannulation. Here we provide a review on difficult biliary cannulation and discuss how the choice of which techniques to employ and how to best employ them should be individualized and take into account the skill of the endoscopist, the disorder being treated, the anatomy of the patient, and the available biomedical literature.

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.

Endoscopic Intervention through Endoscopic Retrograde Cholangiopancreatography in the Management of Symptomatic Pancreas Divisum: A Long-Term Follow-Up Study

Background/Aims

To evaluate the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) for the treatment of symptomatic pancreas divisum (PD) and to discuss whether ERCP procedures and outcomes in younger patients differ from those of adults.

Methods

Symptomatic patients with PD were included in the study and divided into underaged (age ≤17 years) and adult (age ≥18 years) group. The clinical information of each patient was reviewed, and then the patients were contacted by telephone or their medical records were reviewed to determine their long-term follow-up outcomes.

Results

A total of 141 procedures were performed in 82 patients (17 underaged and 65 adult patients). The ERCP indications included abdominal pain (39.02%), pancreatitis (12.20%), recurrent pancreatitis (36.59%), and other discomfort (12.20%). The endoscopic interventions included endoscopic pancreatic sphincterotomy in 44.68% of the patients, bouginage in 26.95%, pancreatic ductal stone extraction in 19.15%, endoscopic nasopancreatic drainage in 21.99%, and endoscopic retrograde pancreatic drainage in 56.74%. After a median follow-up of 41 months, the overall response rate was 62.32%. Between the underaged group and the adult group, significant differences were not observed in the ERCP procedures, complications and long-term follow-up results.

Conclusions

ERCP is a safe and effective treatment for symptomatic PD. Based on the details, complications, and follow-up results, the ERCP procedure did not present differences between the underaged and adult groups.

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.

Pancreas divisum: correlation between anatomical abnormalities and bile precipitation in the gallbladder in seven patients

Pancreas divisum is a genetic defect associated with recurrent acute pancreatitis due to insufficient drainage of the accessory pancreatic duct. Seven young patients diagnosed with pancreatic divisum and thickening of the gallbladder bile as shown on magnetic resonance cholangio-pancreatography without pancreatic ductal changes underwent laparoscopic cholecystectomy. During the mean follow-up of 32 months no episode of pancreatitis was reported. There is an association between PD and higher concentration of bile in the gallbladder. Cholecystectomy can be considered curative in patients with PD in the absence of indications for major surgery.

Role of ERCP in Patients With Idiopathic Recurrent Acute Pancreatitis

OPINION STATEMENT

Recurrent acute pancreatitis (RAP) is defined based on the occurrence of two or more episodes of acute pancreatitis. RAP is differentiated from chronic pancreatitis based on the presence of a normal morphological appearance of the pancreas between episodes. RAP can be due to a variety of etiologies including common bile duct stones or sludge, sphincter of Oddi dysfunction (SOD), pancreas divisum (PD), anomalous pancreaticobiliary junction, genetic mutations, and alcohol related. In approximately 30 % of patients, the etiology of RAP is unclear and the term "idiopathic" is used. Endoscopic retrograde cholangiopancreatography (ERCP) can be utilized in both the diagnosis and the initial management of RAP, but it has known limitations and risks. Since gallbladder sludge and SOD account for most cases with RAP, cholecystectomy and, eventually, endoscopic biliary and/or pancreatic sphincterotomy are performed as a part of management. In patients with PD-associated RAP, data from uncontrolled and primarily retrospective studies point toward a benefit from minor papillary endoscopic intervention. However, given the lack of quality data from prospective randomized controlled trials (RCTs), endoscopic management in such patients remains an individualized decision, and RCTs are needed to ascertain its true long-term benefit. Future studies to investigate the role of endoscopic therapy in preventing progression to chronic pancreatitis are needed.

Endoscopic sphincterotomy (ES) may not alter the natural history of idiopathic recurrent acute pancreatitis (IRAP)

BACKGROUND

The role of endoscopic sphincterotomy (ES) in idiopathic recurrent acute pancreatitis (IRAP) is unclear. We hypothesized that ES will alter the natural history of IRAP.

METHODS

We retrospectively studied the course of 50 IRAP patients from the NAPS2 study from UPMC based on whether they underwent ES or were managed medically. Data included age at first AP, rate of attacks, and history of severe AP. Primary outcomes were any subsequent AP and rate of attacks; secondary outcome was chronic pancreatitis (CP) diagnosis during follow-up. Similar data was abstracted for alcoholic RAP.

RESULTS

When compared with medically managed IRAP patients (n = 24, 48%), those who underwent ES (n = 26, 52%) had similar rate of attacks/year (median 1.54 vs. 1.41, p = 0.63), but significantly more attacks (median 3 vs. 2, p = 0.04) at baseline. During follow-up (median 7 years), rate of attacks/year decreased significantly, and were similar in both groups (median 0.16 vs. 0, p = ns). Predictors for rate of attacks during follow-up were sex (ratio 0.54 in females, p = 0.045) and rate of attacks at baseline (ratio for doubling 1.2, p = 0.025), but not ES. Alcoholic RAP patients had lower rate of attacks at baseline, but higher risk of subsequent AP (80 vs. 46%, p = 0.021) and rate of attacks/year (median 0.25 vs. 0, p = 0.016) during follow-up. Progression to CP occurred in IRAP and ES, medically managed IRAP, and alcoholic RAP in 27%, 8% and 27% respectively (p = ns).

CONCLUSIONS

ES, chosen in patients with higher burden of attacks, does not seem to impact the natural history of IRAP.

The Role of Endoscopic Retrograde Cholangiopancreatography in Management of Pancreatic Diseases

Endoscopic retrograde cholangiopancreatography is an effective platform for a variety of therapies in the management of benign and malignant disease of the pancreas. Over the last 50 years, endotherapy has evolved into the first-line therapy in the majority of acute and chronic inflammatory diseases of the pancreas. As this field advances, it is important that gastroenterologists maintain an adequate knowledge of procedure indication, maintain sufficient procedure volume to handle complex pancreatic endotherapy, and understand alternate approaches to pancreatic diseases including medical management, therapy guided by endoscopic ultrasonography, and surgical options.

Surgical ampullectomy: an underestimated operation in the era of endoscopy

INTRODUCTION

Benign neoplastic, inflammatory or functional pathologies of the ampulla of Vater are mainly treated by primary endoscopic interventions. Consequently, transduodenal surgical ampullectomy (TSA) has been abandoned in many centres, although it represents an important tool not only after unsuccessful endoscopic treatment. The aim of the study was to analyse TSA for benign lesions of the ampulla of Vater.

PATIENTS AND METHODS

All patients who underwent TSA between 2001 and 2014 were included. Patients were analysed in terms of indications, postoperative morbidity and mortality as well as long-term success.

RESULTS

Eighty-three patients underwent TSA. Indications included adenomas in 44 and inflammatory stenosis in 39 patients. 96% of the patients had undergone endoscopic therapeutic approaches prior to TSA (median no. of interventions n = 3). Postoperative morbidity occurred in 20 patients (24%). There was one procedure-associated death (mortality 1.2%). The mean follow-up was 54 months. Long-term overall success rate for TSA was 83.6%. After TSA for ampullary adenoma, the recurrence rate was 4.5%.

CONCLUSION

TSA is an underestimated surgical procedure, which can be performed safely with high long-term efficacy. It can be implemented in clinical algorithms for patients with benign pathologies of the ampulla of Vater, particularly after unsuccessful endoscopic treatment.

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.

Endoscopic treatment for pancreatic diseases: Needle-knife-guided cannulation via the minor papilla

AIM

To determine the efficacy and safety of meticulous cannulation by needle-knife.

METHODS

Three needle-knife procedures were used to facilitate cannulation in cases when standard cannulation techniques failed. A total of 104 cannulations via the minor papilla attempted in 74 patients at our center between January 2008 and June 2014 were retrospectively reviewed.

RESULTS

Standard methods were successful in 79 cannulations. Of the 25 cannulations that could not be performed by standard methods, 19 were performed by needle-knife, while 17 (89.5%) were successful. Needle-knife use improved the success rate of cannulation [76.0%, 79/104 vs 92.3%, (79 + 17)/104; P = 0.001]. When the 6 cases not appropriate for needle-knife cannulation were excluded, the success rate was improved further (80.6%, 79/98 vs 98.0%, 96/98; P = 0.000). There were no significant differences in the rates of post-endoscopic retrograde cholangiopancreatography adverse events between the group using standard methods alone and the group using needle-knife after failure of standard methods (4.7% vs 10.5%, P = 0.301).

CONCLUSION

The needle-knife procedure may be an alternative method for improving the success rate of cannulation via the minor papilla, particularly when standard cannulation has failed.

Outcome of endotherapy for pancreas divisum in patients with acute recurrent pancreatitis

AIM

To assess the rate of relapses of acute pancreatitis (AP), recurrent AP (RAP) and the evolution of endosonographic signs of chronic pancreatitis (CP) in patients with pancreas divisum (PDiv) and RAP.

METHODS

Over a five-year period, patients with PDiv and RAP prospectively enrolled were divided into two groups: (1) those with relapses of AP in the year before enrollment were assigned to have endoscopic therapy (recent RAP group); and (2) those free of recurrences were conservatively managed, unless they relapsed during follow-up (previous RAP group). All patients in both groups entered a follow-up protocol that included clinical and biochemical evaluation, pancreatic endoscopic ultrasonography (EUS) every year and after every recurrence of AP, at the same time as endoscopic retrograde cholangiopancreatography (ERCP).

RESULTS

Twenty-two were treated by ERCP and 14 were conservatively managed during a mean follow-up of 4.5 ± 1.2 years. In the recent RAP group in whom dorsal duct drainage was achieved, AP still recurred in 11 (57.9%) after the first ERCP, in 6 after the second ERCP (31.6%) and in 5 after the third ERCP (26.3%). Overall, endotherapy was successful 73.7%. There were no cases of recurrences in the previous RAP group. EUS signs of CP developed in 57.9% of treated and 64.3% of untreated patients. EUS signs of CP occurred in 42.8% of patients whose ERCPs were successful and in all those in whom it was unsuccessful (P = 0.04). There were no significant differences in the rate of AP recurrences after endotherapy and in the prevalence of EUS signs suggesting CP when comparing patients with dilated and non-dilated dorsal pancreatic ducts within each group.

CONCLUSION

Patients with PDiv and recent episodes of AP can benefit from endoscopic therapy. Effective endotherapy may reduce the risk of developing EUS signs of CP at a rate similar to that seen in patients of previous RAP group, managed conservatively. However, in a subset of patients, endotherapy, although successful, did not prevent the evolution of endosonographic signs of CP.

Endoscopic minor papilla balloon dilation for the treatment of symptomatic pancreas divisum

OBJECTIVE

A subpopulation of patients with pancreas divisum experience symptomatic events such as recurrent acute pancreatitis and chronic pancreatitis. Minor papilla sphincterotomy has been reported as being an effective treatment. The aim of this study was to evaluate the safety and efficacy of endoscopic balloon dilation for the minor papilla.

METHODS

Between 2000 and 2012, 16 patients were retrospectively included in this study. After endoscopic balloon dilation for the minor papilla was received, a pancreatic stent or a nasal pancreatic drainage catheter was placed for 1 week. If a stricture or obstruction was evident, it was treated with balloon dilation followed by long-term stent placement (1 year). When an outflow of pancreatic juice was disturbed by a pancreatic stone, endoscopic stone extraction was performed.

RESULTS

Balloon dilation and stent placement were achieved and were successful in all the cases (16/16; 100%). Clinical improvement was achieved in 7 (84.7%) of the 9 patients with recurrent acute pancreatitis and in 6 (85.7%) of the 7 patients with chronic pancreatitis. Early complications were observed in 1 (6.3%) patient. Pancreatitis or bleeding related to balloon dilation was not observed.

CONCLUSIONS

Endoscopic balloon dilation for the minor papilla is feasible for the management of symptomatic pancreas divisum.

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 minor papilla sphincterotomy in patients with santoriniceles reduces pain and improves quality of life

BACKGROUND

Pancreas divisum patients with focal obstruction of the minor papilla and resulting dilation of the dorsal pancreatic duct [a santorinicele (SC)] have been reported to improve with endoscopic sphincterotomy of the minor papilla (ESMP). In this study, we assess the long-term efficacy of ESMP in SC patients.

METHODS

A retrospective review of the endoscopic database was performed. Fifteen patients with SCs were identified. A follow-up questionnaire was mailed to patients to assess for changes in quality of life (QOL), narcotic use, hospital admissions, and pain after ESMP.

RESULTS

Fifteen patients were mailed questionnaires and 11 responses were obtained. The average pain score prior to ESMP was 8.6/10 (SD ± 1.7) and significantly decreased to 2.7/10 (SD ± 2.0) (p < 0.05) after treatment. Six patients required narcotics before ESMP and none used narcotics for recurrent pancreatic type pain after. Nine patients had recurring admissions for pancreatitis prior to ESMP while only two were admitted after treatment. Mean QOL score prior to ESMP was 4.5/10 (SD ± 2.7) and increased significantly to 8.4/10 (SD ± 1.3) (p < 0.05) with two patients rating their QOL at 10/10.

CONCLUSIONS

QOL, narcotic use, hospital admissions, and pain scores all improved with ESMP. Endoscopic therapy for this uncommon condition appears both justified and potentially curative.

Endoscopic approach through the minor papilla for the management of pancreatic diseases

AIM: To clarify the efficacy and safety of an endoscopic approach through the minor papilla for the management of pancreatic diseases.

METHODS: This study included 44 endoscopic retrograde cholangiopancreatography (ERCP) procedures performed in 34 patients using a minor papilla approach between April 2007 and March 2012. We retrospectively evaluated the clinical profiles of the patients, the endoscopic interventions, short-term outcomes, and complications.

RESULTS: Of 44 ERCPs, 26 were diagnostic ERCP, and 18 were therapeutic ERCP. The most common cause of difficult access to the main pancreatic duct through the major papilla was pancreas divisum followed by distortion of Wirsung’s duct. The overall success rate of minor papilla cannulation was 80% (35/44), which was significantly improved by wire-guided cannulation (P = 0.04). Endoscopic minor papillotomy (EMP) was performed in 17 of 34 patients (50%) using a needle-knife (13/17) or a pull-type papillotome (4/17). EMP with pancreatic stent placement, which was the main therapeutic option for patients with chronic pancreatitis, recurrent acute pancreatitis, and pancreatic pseudocyst, resulted in short-term clinical improvement in 83% of patients. Mild post-ERCP pancreatitis occurred as an early complication in 2 cases (4.5%).

CONCLUSION: The endoscopic minor papilla approach is technically feasible, safe, and effective when the procedure is performed in a high-volume referral center by experienced endoscopists.

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 is not a cause of pancreatitis by itself but acts as a partner of genetic mutations

OBJECTIVES

The role of pancreas divisum (PD) as a cause of acute recurrent or chronic pancreatitis (AR/CP) is still a matter of debate.

METHODS

The aims of this study were to evaluate the frequency of PD diagnosed using magnetic resonance cholangiopancreatography (MRCP) in patients with AR/CP of unknown origin (n=40) after careful exclusion of all known causes and to test the hypothesis of an interaction between anatomical (PD) and functional genetic anomalies (SPINK1, PRSS1, or CFTR gene mutations or polymorphisms (n=19, 25, and 30, respectively)) that could result in AR/CP. Patients with alcohol-induced pancreatitis (n=29) and subjects who had MRCP for a nonpancreatic disease (n=45) served as controls.

RESULTS

PD frequency was 7% in subjects without pancreatic disease, 7% in patients with alcohol-induced pancreatitis, and 5, 16, 16, and 47% in those with idiopathic, and PRSS1-, SPINK1-, and CFTR-associated pancreatitis, respectively (P<0.0001). There was no significant difference between idiopathic pancreatitis and the two control groups. The frequency of PD was higher in patients with CFTR gene-associated pancreatitis as compared with those with idiopathic and alcoholic pancreatitis (P<0.0001) and with those with SPINK1 and PRSS1 gene-associated pancreatitis (P<0.02).

CONCLUSIONS

The frequency of PD was not different in patients with idiopathic pancreatitis as compared with controls, demonstrating that PD by itself is not a cause of pancreatitis. PD frequency was higher in patients with genetic pancreatitis, especially in those with CFTR mutations or polymorphisms, suggesting a cumulative effect of these two cofactors.

Endoscopic therapy in chronic pancreatitis

Chronic pancreatitis (CP) is a debilitating disease that can result in chronic abdominal pain, malnutrition, and other related complications. The main aims of treatment are to control symptoms, prevent disease progression, and correct any complications. A multidisciplinary approach involving medical, endoscopic, and surgical therapy is important. Endoscopic therapy plays a specific role in carefully selected patients as primary interventional therapy when medical measures fail or in patients who are not suitable for surgery. Endoscopic therapy is also used as a bridge to surgery or as a means to assess the potential response to pancreatic surgery. This review addresses the role of endoscopic therapy in relief of obstruction of the pancreatic duct (PD) and bile du ct, closure of PD leaks, and drainage of pseudocysts in CP. The role of endoscopic ultrasound-guided celiac plexus block for pain in chronic pancreatitis is also discussed.

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.

Risk factors for ERCP-related complications in patients with pancreas divisum: a retrospective study

BACKGROUND

Limited data are available on complication rates of ERCP in patients with pancreas divisum (PD), and it is unclear whether traditional risk factors for post-ERCP pancreatitis (PEP) apply.

OBJECTIVES

To describe the rates of ERCP complications in patients with PD and assess patient and procedure-related risk factors for PEP.

DESIGN

Retrospective cohort study.

SETTING

Tertiary care referral center.

PATIENTS

A total of 2753 ERCPs performed in 1476 patients with PD from 1997 to 2010.

MAIN OUTCOME MEASUREMENTS

Rates of PEP, hemorrhage, perforation, cholecystitis, and hospitalization directly attributable to ERCP.

RESULTS

Early complications occurred after 7.8% of procedures, with PEP, hemorrhage, perforation, cholecystitis, and cardiorespiratory complications in 6.8%, 0.7%, 0.2%, 0.1%, and 0.1% of procedures, respectively. PEP was uncommon in patients who did not undergo attempted dorsal duct cannulation, occurring in 1.2% of procedures. With dorsal duct cannulation and cannulation with minor papilla sphincterotomy (MiS), the rates of PEP increased significantly to 8.2% and 10.6%, respectively (P<.01 for each comparison). Significant predictors of PEP after multivariate logistic regression included age younger than 40 (odds ratio [OR] 1.8; 95% CI, 1.27-2.59), female sex (OR 1.94; 95% CI, 1.25-3.01), previous PEP (OR 2.02; 95% CI, 1.32-3.1), attempted dorsal duct cannulation (OR 7.45; 95% CI, 3.25-17.07), and MiS (OR 1.62; 95% CI, 1.05-2.48). Presence of severe chronic pancreatitis was a protective factor (OR 0.46; 95% CI, 0.22-0.98).

LIMITATIONS

Retrospective analysis of prospectively collected data.

CONCLUSIONS

Among patients with PD, the rate of PEP is low (1.2%) if dorsal duct cannulation is not attempted. However, patients with PD undergoing dorsal duct cannulation with or without MiS are at high risk of PEP (8.2% without and 10.6% with). Traditional PEP risk factors apply to patients with PD.

What is the role of endotherapy in chronic pancreatitis?

Chronic pancreatitis (CP) can have debilitating clinical course due to chronic abdominal pain, malnutrition and related complications. Medical, endoscopic and surgical treatment of CP should aim at control of symptoms, prevention of progression of the disease and correction of complications. Endoscopic management plays a specific role in carefully selected patients as primary interventional therapy when medical measures fail or in high-risk surgical candidates. Endotherapy for CP is utilized also as a bridge to surgery or to assess potential response to pancreatic surgery. In this review we address the role of endotherapy for the relief of obstruction of the pancreatic duct (PD) and bile duct, closure of PD leaks and drainage of pseudocysts in the setting of CP. In addition, endotherapy for relief of pancreatic pain by endoscopic ultrasound-guided celiac plexus block for CP is discussed.

A long-term follow-up study on endoscopic management of children and adolescents with chronic pancreatitis

OBJECTIVES

Data on therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for chronic pancreatitis (CP) in children and adolescents, especially with long-term follow-up of consequences, are rarely reported. The aim of this study was to determine the long-term follow-up results of therapeutic ERCP for CP in children and adolescents.

METHODS

All patients with CP who received therapeutic ERCP at Changhai Hospital from January 1997 to May 2009, with the age at first onset of pain being less than 18.0 years, were included. Attempts were made to contact all adolescents and follow-up data were recorded. Clinical data were assessed before and after every ERCP.

RESULTS

Follow-up information was available in 42 (91.3%) of the 46 patients who received therapeutic ERCP. There were 20 boys and 22 girls, with the age at first onset being 11.8+/-4.5 years. A total of 110 therapeutic ERCP sessions were performed in the 42 patients. The post-ERCP complication rate was 17.3%, including mild and moderate pancreatitis (n=17) and mild cholangitis (n=2). The mean follow-up period of time was 61.4 (range: 24-132) months. Five patients underwent subsequent surgery because of refractory abdominal pain after endotherapy. Of the remaining 37 patients who received therapeutic ERCP alone, abdominal pain improved in 30 (81.1%) patients, and was completely relieved in 24 (64.9%) patients during the period of follow-up.

CONCLUSIONS

Therapeutic ERCP may offer long-term improvement in pain in children and adolescents with CP.