Endoscopic ultrasound-guided tissue sampling induced pancreatic duct leak resolved by the placement of a pancreatic stent:A case report

BACKGROUND Pancreatic ductal leaks complicated by endoscopic ultrasonography-guided tissue sampling(EUS-TS)can manifest as acute pancreatitis.CASE SUMMARY A 63-year-old man presented with persistent abdominal pain and weight loss.Diagnosis:Laboratory findings revealed elevated carbohydrate antigen 19-9(5920 U/mL)and carcinoembryonic antigen(23.7 ng/mL)levels.Magnetic resonance imaging of the pancreas revealed an approximately 3 cm ill-defined space-occupying lesion in the inferior aspect of the head,with severe encasement of the superior mesenteric artery.Pancreatic ductal adenocarcinoma was confirmed after pathological examination of specimens obtained by EUS-TS using the fanning method.Interventions and outcomes:The following day,the patient experienced severe abdominal pain with high amylase(265 U/L)and lipase(1173 U/L)levels.Computed tomography of the abdomen revealed edematous wall thickening of the second portion of the duodenum with adjacent fluid collections and a suspicious leak from either the distal common bile duct or the main pancreatic duct in the head.Endoscopic retrograde cholangiopancreatography revealed dye leakage in the head of the main pancreatic duct.Therefore,a 5F 7 cm linear plastic stent was deployed into the pancreatic duct to divert the pancreatic juice.The patient’s abdominal pain improved immediately after pancreatic stent insertion,and amylase and lipase levels normalized within a week.Neoadjuvant chemotherapy was then initiated.CONCLUSION Using the fanning method in EUS-TS can inadvertently cause damage to the pancreatic duct and may lead to clinically significant pancreatitis.Placing a pancreatic stent may immediately resolve acute pancreatitis and shorten the waiting time for curative therapy.When using the fanning method during EUSTS,ductal structures should be excluded to prevent pancreatic ductal leakage.

Placement of prophylactic pancreatic stents to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients: A meta-analysis

AIM: To assess the effectiveness of pancreatic stents for preventing pancreatitis in high-risk patients after endoscopic retrograde cholangiopancreatography (ERCP).

Need for pancreatic stenting after sphincterotomy in patients with difficult cannulation

AIM: To investigate the need for pancreatic stenting after endoscopic sphincterotomy (EST) in patients with difficult biliary cannulation.

Comment on “Updated meta-analysis of pancreatic stent placement in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis”

I read with interest an article "Updated meta-analysis of pancreatic stent placement in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis" by Fan and colleagues in World J Gastroenterol 2015;21(24): 7577-7583. Although I appreciate their work, I have found problems with the data extracted and analyzed by the authors, and will give my comment in this letter. It would be valuable if the authors could provide an accurate estimation of their extracted data.

Endoscopic ultrasound-guided pancreaticogastrostomy for symptomatic pancreatic duct obstruction caused by migrated pancreatic stent

Endoscopic pancreatic stenting has been widely used in various pancreatic conditions. With the increasing use of pancreatic stents, many complications have been recognized. Especially, proximal stent migration presents a serious condition because of subsequent pancreatic duct obstruction, impaired drainage, ductal dilation, and pancreatic pain. Although endoscopic retrieval is the preferred treatment for proximally migrated pancreatic stents, it is not always successful, resulting in conversion to surgery. To date, endoscopic ultrasound-guided pancreatic duct drainage(EUS-PD) has never been reported for treatment of pancreatic duct obstruction caused by proximally migrated pancreatic stent. We herein describe a case of pancreatic duct rupture and obstruction caused by proximally migrated pancreatic stent that was successfully treated by EUS-guided pancreaticogastrostomy while keeping the former stent in situ after failed endoscopic retrograde cholangiopancreatography. We believe that this report adds to the increasing evidence of symptomatic pancreatic duct obstruction being successfully treated by EUS-PD.

Usefulness of an algorithm for endoscopic retrieval of proximally migrated 5Fr and 7Fr pancreatic stents

BACKGROUND:Proximal migration of pancreatic stent (PMPS)is an infrequent event but its management can be technically challenging and there are no standard retrieval methods.This study aimed to determine the results of an endoscopic stent retrieval algorithm in terms of feasibility and efficacy of the endoscopic procedure. METHODS:During the period from January 2008 to December 2009,15 patients(8 women and 7 men with a mean age of 51.9 years)with PMPS were included in this study.Stent retrieval was approached initially with balloon extraction followed by rat-tooth forceps and basket.A rescue approach such as using a stent retriever was attempted when other approaches failed. RESULTS:All the PMPSs(six 5Fr,nine 7Fr)were retrieved successfully within one ERCP session.Balloon extraction was successful in 9(60%)patients.In the 6 failed cases of balloon extraction,wire-guided rat-tooth forceps grasp was successful in 4,and stone extraction basket grasp was successful in 1 in whom forceps grasp failed.One stent was finally rescued with a stent retriever when balloon extraction,forceps and basket grasp all failed.In patients with successful balloon extraction,44.4% (4/9)developed post-ERCP hyperamylasemia but none of them developed post-procedure pancreatitis. CONCLUSIONS:With this algorithm,5Fr and 7Fr PMPS were successfully retrieved in all of the patients.Most PMPSs can be safely retrieved with the commonly-used approaches in this study.Those less used approaches can be used as a rescue method.

Stent A pancreaticojejunostomy after pancreatoduodenectomy:Is it always necessary?

The establishment of a postoperative pancreatic fistula(POPF)is considered the most common and,concomitantly,the most serious complication associated with pancreaticoduodenectomy(PD).The search for either technical modifications of the operative technique or pharmaceutical interventions that could possibly aid in decreasing the incidence of this often-devastating complication appears justified.The stenting of the pancreatic duct,with the use of either internal or external stents,has been evaluated in this direction.In theory,it is an approach that could eliminate many pathophysiological factors responsible for the occurrence of a POPF.The purpose of the present study was to review the current data regarding the role of pancreatic duct stenting on the incidence of POPF,after PD,by using PubMed and Reference Citation Analysis.In general,previous studies seem to highlight the superiority of external stents over their internal counterparts in regard to the incidence of POPF;this is at the cost,however,of increased morbidity associated mainly with the stent removal.Certainly,the use of an internal stent is a less invasive approach with acceptable results and is definitely deprived of the drawbacks arising through the complete diversion of pancreatic juice from the gastrointestinal tract.Bearing in mind the scarcity of high-quality data on the subject,an approach of reserving stent placement for the high-risk for POPF patients and individualizing the selection between the use of an internal or an external stent according to the distinct characteristics of each individual case scenario appears appropriate.

Traumatic pancreatic ductal injury treated by endoscopic stenting in a 9-year-old boy:A case report

BACKGROUND Traumatic pancreatic injury is relatively rare in children,accounting for approximately 3%-12%of blunt abdominal trauma cases.Most traumatic pancreatic injuries in boys are related to bicycle handlebars.Traumatic pancreatic injuries often result in delayed presentation and treatment,leading to high morbidity and mortality.The management of children with traumatic main pancreatic duct injuries is still under debate.CASE SUMMARY We report the case of a 9-year-old boy who was presented at our institution with epigastric pain after being stuck with his bicycle handlebar at the upper abdomen and then treated with endoscopic stenting because of a pancreatic ductal injury.CONCLUSION We believe that endoscopic stenting of pancreatic ductal injuries may be a feasible technique in certain cases of children with traumatic pancreatic duct injuries to avoid unnecessary operations.

Long-term follow-up of endoscopic papillectomy and the value of preventive pancreatic stent placement(with videos)

Background:Early-stage ampullary adenomas have only been reported in a small case series on endoscopic management.Hence,this study aimed to evaluate the long-term outcomes of early ampullary adenoma with endoscopic management and identify the risk factors for acute pancreatitis after endoscopic papillectomy(EP).Methods:In this study,115 patients who underwent EP at Changhai Hospital(Shanghai,China)between January 2012 and December 2018 were retrospectively analysed.Endoscopy was performed at 1,3,6,and 12months after EP.Data were statistically analysed using the t-test or the Mann–Whitney U test.Results:A total of 107 patients were included in this study and the follow-up period was 75643 months.The average age of the 107 patients was 54.6 years and the average tumor size was 17mm.The average age of the patients(53.7610.7 years vs 55.2610.5 years,P=0.482),minimum tumor size(13 vs 19mm,P=0.063),and complete resection rate(84.78%vs 85.25%,P=0.947)did not differ significantly between the stent placement and non-stent placement groups.Post-EP acute pancreatitis rates in the non-stent placement and stent placement groups were 11.48%and 4.35%,respectively.The risk of post-EP acute pancreatitis was significantly associated with the preoperative carcinoembryonic antigen level in univariate analysis,but not in multivariate analysis.The risk of post-EP acute pancreatitis was not significantly associated with the placement of the pancreatic stent in either univariate or multivariate analysis.Moreover,delayed proximal pancreatic duct stenosis was not noted in either group during long-term follow-up.Conclusions:EP is a satisfactory option for treating adenomas of the ampulla of the duodenum.

Endoscopic pancreatic duct stent placement for inflammatory pancreatic diseases

The role of endoscopic therapy in the management of pancreatic diseases is continuously evolving; at present most pathological conditions of the pancreas are successfully treated by endoscopic retrograde cholangio- pancreatography （ERCP） or endoscopic ultrasound （EUS）, or both. Endoscopic placement of stents has played and still plays a major role in the treatment of chronic pancreatitis, pseudocysts, pancreas divisum, main pancreatic duct injuries, pancreatic fistulae, complications of acute pancreatitis, recurrent idiopathic pancreatitis, and in the prevention of post-ERCP pancreatitis. These stents are currently routinely placed to reduce intraductal hypertension, bypass obstructing stones, restore lumen patency in cases with dominant, symptomatic strictures, seal main pancreatic duct disruption, drain pseudocysts or fluid collections, treat symptomatic major or minor papilla sphincter stenosis, and prevent procedure-induced acute pancreatitis. The present review aims at updating and discussing techniques, indications, and results of endoscopic pancreatic duct stent placement in acute and chronic inflammatory diseases of the pancreas.

Comparison of postoperative complications between internal and external pancreatic duct stenting during pancreaticoduodenectomy: a meta-analysis

Background：Two types of pancreatic duct stents are used to improve postoperative outcomes of pancreatic anastomosis.The aim of this meta-analysis was to evaluate and compare the postoperative outcomes of patients with internal or external stenting during pancreaticoduodenectomy（PD）.Methods：We searched Pub Med,EMBASE,the Cochrane Library and Web of Science databases until the end of December,2014.Studies comparing outcomes of external vs.internal stent placement in PD were eligible for inclusion.Included literature was extracted and assessed by two independent reviewers.Results：Seven articles were identified for inclusion：three randomized controlled trials（RCTs）and four observational clinical studies（OCS）.The meta-analyses revealed that use of external stents had advantage on reducing the incidences of pancreatic fistula（PF）in total[odds ratio（OR）=0.69;95%confidence interval（CI）,0.48-0.99;P=0.04],PF in soft pancreas（OR=0.30;95%CI,0.16-0.56;P=0.0002）and delayed gastric emptying（DGE）（OR=0.58;95%CI,0.38-0.89;P=0.01）compared with internal stents.There were no significant differences in other postoperative outcomes between two stenting methods,including postoperative morbidity（OR=0.93;95%CI,0.39-2.23;P=0.88）,overall mortality（OR=0.70;95%CI,0.22-2.25;P=0.55）,and intra-abdominal collections（OR=0.67;95%CI,0.26-1.71;P=0.40）.Conclusions：Based upon this meta-analysis,the use of external pancreatic stents might have potential benefit in reducing the incidence of PF and DGE.Due to the limited number of original studies,more RCTs are needed to further support our result and clarify the issue.

Pancreatic guidewire placement for achieving selective biliary cannulation during endoscopic retrograde cholangio-pancreatography

AIM: To investigate the frequency and risk factors for acute pancreatitis after pancreatic guidewire placement (P-GW) in achieving cannulation of the bile duct during endoscopic retrograde cholangio-pancreatography (ERCP). METHODS: P-GW was performed in 113 patients in whom cannulation of the bile duct was difficult. The success rate of biliary cannulation, the frequency and risk factors of post-ERCP pancreatitis, and the frequency of spontaneous migration of the pancreatic duct stent were investigated. RESULTS: Selective biliary cannulation with P-GW was achieved in 73% of the patients. Post-ERCP pancreatitis occurred in 12% (14 patients: mild, 13; moderate, 1). Prophylactic pancreatic stenting was attempted in 59% of the patients. Of the 64 patients who successfully underwent stent placement, three developed mild pancreatitis (4.7%). Of the 49 patients without stent placement, 11 developed pancreatitis (22%: mild, 10; moderate, 1). Of the five patients in whom stent placement was unsuccessful, two developed mild pancreatitis. Univariate and multivariate analyses revealed no pancreatic stenting to be the only significant risk factor for pancreatitis. Spontaneous migration of the stent was observed within two weeks in 92% of the patients who had undergone pancreatic duct stenting.CONCLUSION: P-GW is useful for achieving selective biliary cannulation. Pancreatic duct stenting after P-GW can reduce the incidence of post-ERCP pancreatitis, which requires evaluation by means of prospective randomized controlled trials.

Potential risk factors for nonalcoholic steatohepatitis related to pancreatic secretions following pancreaticoduodenectomy

AIM: To identify risk factors for nonalcoholic steatohepatitis following pancreaticoduodenectomy, with a focus on factors related to pancreatic secretions. METHODS: The medical records of 228 patients who had a pancreaticoduodenectomy over a 16-mo period were reviewed retrospectively. The 193 patients who did not have fatty liver disease preoperatively were included in the final analysis. Hepatic steatosis was diagnosed using the differences between splenic and hepatic attenuation and liver-to-spleen attenuation as measured by non-enhanced computed tomography. RESULTS: Fifteen patients (7.8%) who showed postoperative hepatic fatty changes were assigned to Group A, and the remaining patients were assigned to Group B. Patient demographics, preoperative laboratory findings (including levels of C-peptide, glucagon, insulin and glucose tolerance test results), operation types, and final pathological findings did not differ significantly between the two groups; however, the frequency of pancreatic fistula (P = 0.020) and the method of pancreatic duct stenting (P = 0.005) showed significant differences between the groups. A multivari- ate analysis identified pancreatic fistula (HR = 3.332, P = 0.037) and external pancreatic duct stenting (HR = 4.530, P = 0.017) as independent risk factors for the development of postoperative steatohepatitis. CONCLUSION: Pancreatic fistula and external pancreatic duct stenting were identified as independent risk factors for the development of steatohepatitis following pancreaticoduodenectomy.

Continuing episodes of pain in recurrent acute pancreatitis: Prospective follow up on a standardised protocol with drugs and pancreatic endotherapy

AIM To assess the outcomes of drug therapy(DT)followed by pancreatic endotherapy for continuing painful episodes in recurrent acute pancreatitis.METHODS DT comprised of pancreatic enzymes and antioxidants failing which,endotherapy(ET;pancreatic sphincterotomy and stent placement)was done.The frequency of pain,its visual analogue score(VAS),quality of life(Qo L),serum C peptide and faecal elastase were compared between baseline and after 1 year of follow up in all patients and in the two subgroups on DT and ET.Response was defined as at least 50%reduction in the severity of pain to below a score of 5.RESULTS Of the thirty nine patients analysed,21(53.9%)responded to DT and 18(46.1%)underwent ET.The VAS for pain(7.0±2.0 vs 1.3±2.5,P<0.001)and the number of days with pain per month decreased[1.0(1.0,2.0)vs 1.0(0.0,1.0),P<0.001],and the Qo L scores[55.0(44.0,66.0)vs 38.0(32.00,51.00),P<0.01]improved significantly during follow up.Similar significant improvements were seen in patients in the subgroups of DT and ET except for Qo L in ET.The serum C-peptide(P=0.001)and FE(P<0.001)levels improved significantly in the entire group and in the two subgroups of patients except for the C peptide levels in patients on DT.CONCLUSION A standardised protocol of DT,followed by ET decreased the intensity and frequency of pain in recurrent acute pancreatitis,enhanced Qo L and improved pancreatic function.

Early successes and late failures in the prevention of post endoscopic retrograde cholangiopancreatography

Acute pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). The only way to prevent this complication is to avoid an ERCP all together. Because of the risks involved, a careful consideration should be given to the indication for ERCP and the potential risk/benefit ratio of the test. Once a decision to perform an ERCP is made, the procedure should be carried out with meticulous care by an experienced endoscopist, and with a minimum of pancreatic duct opacification. Several pharmacologic agents have been tested, but to date the most important method of reducing post ERCP pancreatitis is the placement of pancreatic stent. Pancreatic stents should be placed in all patients at high risk of this complication such as those undergoing pancreatic sphincterotomy, pancreatic duct manipulation and intervention, and patients with suspected sphincter of Oddi dysfunction. Pancreatic stents should be also considered in patients requiring precut sphincterotomy to gain biliary access.

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.

NSAIDs for prevention of pancreatitis after endoscopic retrograde cholangiopancreatography:Ready for prime time?

Acute pancreatitis is the most common and the most fearful complication of endoscopic retrograde cholangiopancreatography (ERCP).Prevention of post-ERCP pancreatitis has therefore been of great interest to endoscopists performing ERCP procedures.So far,only pancreatic duct stenting during ERCP and rectal administration of a non-steroidal anti-inflammatory drug (NSAID) prior to or immediately after ERCP have been consistently shown to be effective for prevention of post-ERCP pancreatitis.This commentary focuses on a short discussion about the rates,mechanisms,and risk factors for post-ERCP pancreatitis,and effective means for its prevention with emphasis on the use of NSAIDs including a recent clinical trial published in The New England Journal of Medicine by Elmunzer et al.

Endoscopic papillectomy of minor papillar adenoma associated with pancreas divisum

Tumors of the minor papilla of the duodenum are quite rare.We successfully and safely treated an 18-mm adenoma of the minor papilla associated with pancreas divisum using endoscopic papillectomy.A 64-year-old man was admitted to our hospital for treatment of an asymptomatic mass in the minor papilla detected by upper gastrointestinal endoscopy.Endscopic analysis showed an 18-mm,whitish,sessile mass,located in the duodenum proximal to a normal-appearing major papilla.Endoscopic retrograde pancreatography did not reveal the pancreatic duct.Magnetic resonance cholangiopancreatography showed a lack of the ventral pancreatic duct.We suspected this case was associated with pancreatic divisum;therefore,we performed endoscopic papillectomy of the minor papilla tumor.Subsequently,endoscopic pancreatic stent placement in the minor papilla was done to prevent drainage disturbance.The patient has been asymptomatic without recurrence of tumor or stenosis of the Santorini orifice upon endoscopic examination for the past 2 years.

Analysis of the risk factors for severity in post endoscopic retrograde cholangiopancreatography pancreatitis: The indication of prophylactic treatments

To determine the risk factors of severe post endoscopic retrograde cholangiopancreatography pancreatitis (sPEP) and clarify the indication of prophylactic treatments. METHODSAt our hospital, endoscopic retrograde cholangiopancreatography (ERCP) was performed on 1507 patients from May 2012 to December 2015. Of these patients, we enrolled all 121 patients that were diagnosed with post endoscopic retrograde PEP. Fourteen of 121 patients diagnosed as sPEP were analyzed. RESULTSForty-one patients had contrast media remaining in the pancreatic duct after completion of ERCP. Seventy-one patients had abdominal pain within three hours after ERCP. These were significant differences for sPEP (P < 0.05). The median of Body mass index, the median time for ERCP, the median serum amylase level of the next day, past histories including drinking and smoking, past history of pancreatitis, sphincter of Oddi dysfunction, whether emergency or not, expertise of ERCP procedure, diverticulum nearby Vater papilla, whether there was sphincterotomy or papillary balloon dilation, pancreatic duct cannulation, use of intra-ductal ultrasonography enforcement, and transpapillary biopsies had no significant differences with sPEP. CONCLUSIONContrast media remaining in the pancreatic duct and the appearance of abdominal pain within three hours after ERCP were risk factors of sPEP.