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JAMA Jan 2020For patients with painful chronic pancreatitis, surgical treatment is postponed until medical and endoscopic treatment have failed. Observational studies have suggested... (Comparative Study)
Comparative Study Randomized Controlled Trial
IMPORTANCE
For patients with painful chronic pancreatitis, surgical treatment is postponed until medical and endoscopic treatment have failed. Observational studies have suggested that earlier surgery could mitigate disease progression, providing better pain control and preserving pancreatic function.
OBJECTIVE
To determine whether early surgery is more effective than the endoscopy-first approach in terms of clinical outcomes.
DESIGN, SETTING, AND PARTICIPANTS
The ESCAPE trial was an unblinded, multicenter, randomized clinical superiority trial involving 30 Dutch hospitals participating in the Dutch Pancreatitis Study Group. From April 2011 until September 2016, a total of 88 patients with chronic pancreatitis, a dilated main pancreatic duct, and who only recently started using prescribed opioids for severe pain (strong opioids for ≤2 months or weak opioids for ≤6 months) were included. The 18-month follow-up period ended in March 2018.
INTERVENTIONS
There were 44 patients randomized to the early surgery group who underwent pancreatic drainage surgery within 6 weeks after randomization and 44 patients randomized to the endoscopy-first approach group who underwent medical treatment, endoscopy including lithotripsy if needed, and surgery if needed.
MAIN OUTCOMES AND MEASURES
The primary outcome was pain, measured on the Izbicki pain score and integrated over 18 months (range, 0-100 [increasing score indicates more pain severity]). Secondary outcomes were pain relief at the end of follow-up; number of interventions, complications, hospital admissions; pancreatic function; quality of life (measured on the 36-Item Short Form Health Survey [SF-36]); and mortality.
RESULTS
Among 88 patients who were randomized (mean age, 52 years; 21 (24%) women), 85 (97%) completed the trial. During 18 months of follow-up, patients in the early surgery group had a lower Izbicki pain score than patients in the group randomized to receive the endoscopy-first approach group (37 vs 49; between-group difference, -12 points [95% CI, -22 to -2]; P = .02). Complete or partial pain relief at end of follow-up was achieved in 23 of 40 patients (58%) in the early surgery vs 16 of 41 (39%)in the endoscopy-first approach group (P = .10). The total number of interventions was lower in the early surgery group (median, 1 vs 3; P < .001). Treatment complications (27% vs 25%), mortality (0% vs 0%), hospital admissions, pancreatic function, and quality of life were not significantly different between early surgery and the endoscopy-first approach.
CONCLUSIONS AND RELEVANCE
Among patients with chronic pancreatitis, early surgery compared with an endoscopy-first approach resulted in lower pain scores when integrated over 18 months. However, further research is needed to assess persistence of differences over time and to replicate the study findings.
TRIAL REGISTRATION
ISRCTN Identifier: ISRCTN45877994.
Topics: Adult; Analgesics, Opioid; Area Under Curve; Calculi; Drainage; Endoscopy; Female; Humans; Lithotripsy; Male; Middle Aged; Pain; Pain Management; Pain Measurement; Pancreatic Ducts; Pancreatitis, Chronic
PubMed: 31961419
DOI: 10.1001/jama.2019.20967 -
Endoscopy Apr 20211: ESGE recommends against diagnostic/therapeutic papillectomy when adenoma is not proven.Strong recommendation, low quality evidence. 2: ESGE recommends endoscopic...
1: ESGE recommends against diagnostic/therapeutic papillectomy when adenoma is not proven.Strong recommendation, low quality evidence. 2: ESGE recommends endoscopic ultrasound and abdominal magnetic resonance cholangiopancreatography (MRCP) for staging of ampullary tumors.Strong recommendation, low quality evidence. 3: ESGE recommends endoscopic papillectomy in patients with ampullary adenoma without intraductal extension, because of good results regarding outcome (technical and clinical success, morbidity, and recurrence).Strong recommendation, moderate quality evidence. 4: ESGE recommends en bloc resection of ampullary adenomas up to 20-30 mm in diameter to achieve R0 resection, for optimizing the complete resection rate, providing optimal histopathology, and reduction of the recurrence rate after endoscopic papillectomy.Strong recommendation, low quality evidence. 5: ESGE suggests considering surgical treatment of ampullary adenomas when endoscopic resection is not feasible for technical reasons (e. g. diverticulum, size > 4 cm), and in the case of intraductal involvement (of > 20 mm). Surveillance thereafter is still mandatory.Weak recommendation, low quality evidence. 6: ESGE recommends direct snare resection without submucosal injection for endoscopic papillectomy.Strong recommendation, moderate quality evidence. 7: ESGE recommends prophylactic pancreatic duct stenting to reduce the risk of pancreatitis after endoscopic papillectomy.Strong recommendation, moderate quality evidence. 8: ESGE recommends long-term monitoring of patients after endoscopic papillectomy or surgical ampullectomy, based on duodenoscopy with biopsies of the scar and of any abnormal area, within the first 3 months, at 6 and 12 months, and thereafter yearly for at least 5 years.Strong recommendation, low quality evidence.
Topics: Ampulla of Vater; Common Bile Duct Neoplasms; Duodenal Neoplasms; Endoscopy, Gastrointestinal; Humans; Neoplasm Recurrence, Local; Pancreatic Ducts
PubMed: 33728632
DOI: 10.1055/a-1397-3198 -
Theranostics 2021Recent studies have proven that the overall pathophysiology of pancreatitis involves not only the pancreatic acinar cells but also duct cells, however, pancreatic duct...
Recent studies have proven that the overall pathophysiology of pancreatitis involves not only the pancreatic acinar cells but also duct cells, however, pancreatic duct contribution in acinar cells homeostasis is poorly known and the molecular mechanisms leading to acinar insult and acute pancreatitis (AP) are unclear. Our previous work also showed that S100A9 protein level was notably increased in AP rat pancreas through iTRAQ-based quantitative proteomic analysis. Therefore, we investigated the actions of injured duct cells on acinar cells and the S100A9-related effects and mechanisms underlying AP pathology in the present paper. In this study, we constructed S100A9 knockout (s100a9) mice and an coculture system for pancreatic duct cells and acinar cells. Moreover, a variety of small molecular inhibitors of S100A9 were screened from ChemDiv through molecular docking and virtual screening methods. We found that the upregulation of S100A9 induces cell injury and inflammatory response via NLRP3 activation by targeting VNN1-mediated ROS release; and loss of S100A9 decreases AP injury and . Moreover, molecular docking and mutant plasmid experiments proved that S100A9 has a direct interaction with VNN1 through the salt bridges formation of Lys57 and Glu92 residues in S100A9 protein. We further found that compounds CHNO and CHFNOS can significantly improve AP injury and through inhibiting S100A9-VNN1 interaction. Our study showed the important regulatory effect of S100A9 on pancreatic duct injury during AP and revealed that inhibition of the S100A9-VNN1 interaction may be a key therapeutic target for this disease.
Topics: Acinar Cells; Amidohydrolases; Animals; Calgranulin B; Cell Line; GPI-Linked Proteins; Humans; Inflammation; Male; Mice; Mice, Inbred C57BL; Mice, Knockout; Molecular Docking Simulation; NLR Family, Pyrin Domain-Containing 3 Protein; Pancreatic Ducts; Pancreatitis; Reactive Oxygen Species; Small Molecule Libraries
PubMed: 33754072
DOI: 10.7150/thno.54245 -
Annals of Surgery Mar 2023The aim of this study was to develop a classification system for pancreas-associated risk factors in pancreatoduodenectomy (PD). (Meta-Analysis)
Meta-Analysis
A Simple Classification of Pancreatic Duct Size and Texture Predicts Postoperative Pancreatic Fistula: A classification of the International Study Group of Pancreatic Surgery.
OBJECTIVE
The aim of this study was to develop a classification system for pancreas-associated risk factors in pancreatoduodenectomy (PD).
SUMMARY BACKGROUND DATA
Postoperative pancreatic fistula (POPF) is the most relevant PD-associated complication. A simple standardized surgical reporting system based on pancreas-associated risk factors is lacking.
METHODS
A systematic literature search was conducted to identify studies investigating clinically relevant (CR) POPF (CR-POPF) and pancreas-associated risk factors after PD. A meta-analysis of CR-POPF rate for texture of the pancreas (soft vs not-soft) and main pancreatic duct (MPD) diameter was performed using the Mantel-Haenszel method. Based on the results, the International Study Group of Pancreatic Surgery (ISGPS) proposes the following classification: A, not-soft (hard) texture and MPD >3 mm; B, not-soft (hard) texture and MPD ≤3 mm; C, soft texture and MPD >3 mm; D, soft texture and MPD ≤3 mm. The classification was evaluated in a multi-institutional, international cohort.
RESULTS
Of the 2917 articles identified, 108 studies were included in the analyses. Soft pancreatic texture was significantly associated with the development of CR-POPF [odds ratio (OR) 4.24, 95% confidence interval (CI) 3.67-4.89, P < 0.01) following PD. Similarly, MPD diameter ≤3 mm significantly increased CR-POPF risk compared with >3 mm diameter MPDs (OR 3.66, 95% CI 2.62-5.12, P < 0.01). The proposed 4-stage system was confirmed in an independent cohort of 5533 patients with CR-POPF rates of 3.5%, 6.2%, 16.6%, and 23.2% for type A-D, respectively ( P < 0.001).
CONCLUSION
For future pancreatic surgical outcomes studies, the ISGPS recommends reporting these risk factors according to the proposed classification system for better comparability of results.
Topics: Humans; Pancreatic Fistula; Pancreas; Pancreatic Ducts; Pancreaticoduodenectomy; Risk Factors; Postoperative Complications
PubMed: 33914473
DOI: 10.1097/SLA.0000000000004855 -
Endoscopy Jul 2016This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It provides practical advice on how to achieve successful...
This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It provides practical advice on how to achieve successful cannulation and sphincterotomy at minimum risk to the patient. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. Main recommendations 1 ESGE suggests that difficult biliary cannulation is defined by the presence of one or more of the following: more than 5 contacts with the papilla whilst attempting to cannulate; more than 5 minutes spent attempting to cannulate following visualization of the papilla; more than one unintended pancreatic duct cannulation or opacification (low quality evidence, weak recommendation). 2 ESGE recommends the guidewire-assisted technique for primary biliary cannulation, since it reduces the risk of post-ERCP pancreatitis (moderate quality evidence, strong recommendation). 3 ESGE recommends using pancreatic guidewire (PGW)-assisted biliary cannulation in patients where biliary cannulation is difficult and repeated unintentional access to the main pancreatic duct occurs (moderate quality evidence, strong recommendation). ESGE recommends attempting prophylactic pancreatic stenting in all patients with PGW-assisted attempts at biliary cannulation (moderate quality evidence, strong recommendation). 4 ESGE recommends needle-knife fistulotomy as the preferred technique for precutting (moderate quality evidence, strong recommendation). ESGE suggests that precutting should be used only by endoscopists who achieve selective biliary cannulation in more than 80 % of cases using standard cannulation techniques (low quality evidence, weak recommendation). When access to the pancreatic duct is easy to obtain, ESGE suggests placement of a pancreatic stent prior to precutting (moderate quality evidence, weak recommendation). 5 ESGE recommends that in patients with a small papilla that is difficult to cannulate, transpancreatic biliary sphincterotomy should be considered if unintentional insertion of a guidewire into the pancreatic duct occurs (moderate quality evidence, strong recommendation).In patients who have had transpancreatic sphincterotomy, ESGE suggests prophylactic pancreatic stenting (moderate quality evidence, strong recommendation). 6 ESGE recommends that mixed current is used for sphincterotomy rather than pure cut current alone, as there is a decreased risk of mild bleeding with the former (moderate quality evidence, strong recommendation). 7 ESGE suggests endoscopic papillary balloon dilation (EPBD) as an alternative to endoscopic sphincterotomy (EST) for extracting CBD stones < 8 mm in patients without anatomical or clinical contraindications, especially in the presence of coagulopathy or altered anatomy (moderate quality evidence, strong recommendation). 8 ESGE does not recommend routine biliary sphincterotomy for patients undergoing pancreatic sphincterotomy, and suggests that it is reserved for patients in whom there is evidence of coexisting bile duct obstruction or biliary sphincter of Oddi dysfunction (moderate quality evidence, weak recommendation). 9 In patients with periampullary diverticulum (PAD) and difficult cannulation, ESGE suggests that pancreatic duct stent placement followed by precut sphincterotomy or needle-knife fistulotomy are suitable options to achieve cannulation (low quality evidence, weak recommendation).ESGE suggests that EST is safe in patients with PAD. In cases where EST is technically difficult to complete as a result of a PAD, large stone removal can be facilitated by a small EST combined with EPBD or use of EPBD alone (low quality evidence, weak recommendation). 10 For cannulation of the minor papilla, ESGE suggests using wire-guided cannulation, with or without contrast, and sphincterotomy with a pull-type sphincterotome or a needle-knife over a plastic stent (low quality evidence, weak recommendation).When cannulation of the minor papilla is difficult, ESGE suggests secretin injection, which can be preceded by methylene blue spray in the duodenum (low quality evidence, weak recommendation). 11 In patients with choledocholithiasis who are scheduled for elective cholecystectomy, ESGE suggests intraoperative ERCP with laparoendoscopic rendezvous (moderate quality evidence, weak recommendation). ESGE suggests that when biliary cannulation is unsuccessful with a standard retrograde approach, anterograde guidewire insertion either by a percutaneous or endoscopic ultrasound (EUS)-guided approach can be used to achieve biliary access (low quality evidence, weak recommendation). 12 ESGE suggests that in patients with Billroth II gastrectomy ERCP should be performed in referral centers, with the side-viewing endoscope as a first option; forward-viewing endoscopes are the second choice in cases of failure (low quality evidence, weak recommendation). A straight standard ERCP catheter or an inverted sphincterotome, with or without the guidewire, is recommended by ESGE for biliopancreatic cannulation in patients who have undergone Billroth II gastrectomy (low quality evidence, strong recommendation). Endoscopic papillary ballon dilation (EPBD) is suggested as an alternative to sphincterotomy for stone extraction in the setting of patients with Billroth II gastrectomy (low quality evidence, weak recommendation).In patients with complex post-surgical anatomy ESGE suggests referral to a center where device-assisted enteroscopy techniques are available (very low quality evidence, weak recommendation).
Topics: Ampulla of Vater; Catheterization; Cholangiopancreatography, Endoscopic Retrograde; Dilatation; Humans; Pancreatic Ducts; Sphincterotomy, Endoscopic
PubMed: 27299638
DOI: 10.1055/s-0042-108641 -
Journal of Ayub Medical College,... 2019Hemosuccus pancreaticus (HP) defined as bleeding into the pancreatic duct was first described in 1931 by Lower and Farell. HP also popularly known as wirsungorrhaghia... (Review)
Review
Hemosuccus pancreaticus (HP) defined as bleeding into the pancreatic duct was first described in 1931 by Lower and Farell. HP also popularly known as wirsungorrhaghia and pseudohemobilia is a rare cause of gastrointestinal bleed. The unfamiliarity of this condition makes HP a diagnostic challenge. HP should be considered in patients with chronic pancreatitis presenting with acute gastrointestinal bleeding. The diagnosis is usually confirmed with a computerized tomography (CT) scan of the abdomen. A mesenteric angiogram with coil embolization can be performed to arrest the bleeding. The literature on this condition is restricted to case reports, case series and retrospective studies. We describe a case of HP in a patient with gastrointestinal bleeding and take this opportunity to review the literature outlining the diagnosis and management of HP.
Topics: Angiography; Gastrointestinal Hemorrhage; Humans; Male; Middle Aged; Pancreatic Diseases; Pancreatic Ducts; Retrospective Studies; Tomography, X-Ray Computed
PubMed: 31933323
DOI: No ID Found -
Saudi Journal of Gastroenterology :... 2019Endoscopic transpapillary or transanastomotic pancreatic duct drainage (PD) is the mainstay of drainage in symptomatic pancreatic duct obstruction or leakage. However,... (Review)
Review
Endoscopic transpapillary or transanastomotic pancreatic duct drainage (PD) is the mainstay of drainage in symptomatic pancreatic duct obstruction or leakage. However, transpapillary or transanastomotic PD can be technically difficult due to the tight stricture or surgically altered anatomy (SAA), and endoscopic ultrasound (EUS)-guided PD (EUS-PD) is now increasingly used as an alternative technique. There are two approaches in EUS-PD: EUS-guided rendezvous (EUS-RV) and EUS-guided transmural drainage (EUS-TMD). In cases with normal anatomy, EUS-RV should be the first approach, whereas EUS-TMD can be selected in cases with SAA or duodenal obstruction. In our literature review, technical success and adverse event rates were 78.7% and 21.8%, respectively. The technical success rate of EUS-RV appeared lower than EUS-TMD due to the difficulty in guidewire passage. In future, development of dedicated devices and standardization of EUS-PD procedure are necessary.
Topics: Drainage; Endosonography; Humans; Pancreatic Diseases; Pancreatic Ducts; Surgery, Computer-Assisted
PubMed: 30632484
DOI: 10.4103/sjg.SJG_474_18 -
Abdominal Radiology (New York) Aug 2022Percutaneous pancreatic interventions performed by abdominal radiologists play important diagnostic and therapeutic roles in the management of a wide range of pancreatic... (Review)
Review
Percutaneous pancreatic interventions performed by abdominal radiologists play important diagnostic and therapeutic roles in the management of a wide range of pancreatic pathology. While often performed with endoscopy, pancreatic mass biopsy obtained via a percutaneous approach may serve as the only feasible option for diagnosis in patients with post-surgical anatomy, severe cardiopulmonary conditions, or prior non-diagnostic endoscopic attempts. Biopsy of pancreatic transplants are commonly performed percutaneously due to inaccessible location of the allograft by endoscopy, usually in the right lower quadrant or pelvis. Percutaneous drainage of collections in acute pancreatitis is primarily indicated for infection with clinical deterioration and may be performed alone or in combination with endoscopic drainage. Post-surgical pancreatic collections related to pancreatic duct fistula or leak also often warrant therapeutic percutaneous drainage. Knowledge of appropriate indications, strategies of approach, technique, and complications associated with these procedures is critical for a successful clinical practice.
Topics: Acute Disease; Biopsy; Drainage; Endoscopy, Gastrointestinal; Humans; Pancreas; Pancreatic Ducts; Pancreatitis; Treatment Outcome
PubMed: 34410433
DOI: 10.1007/s00261-021-03244-z -
Journal of Ayub Medical College,... 2017pancreatitis appears to exist in the presence of such calculi upon radiology. Having said that, pancreatic ductal stone due to biliary causes (origin), in face of acute...
pancreatitis appears to exist in the presence of such calculi upon radiology. Having said that, pancreatic ductal stone due to biliary causes (origin), in face of acute pancreatitis, is rare. To the best of our knowledge this was the first case of its kind presented to our hospital in recent past. A 25-year-old female presented to the emergency department of our hospital with an acute episode of pancreatitis. Computerized tomography (CT) scan, endoscopic retrograde cholangiopancreatography (ERCP) & magnetic resonance cholangiopancreatography (MRCP) concluded acute pancreatitis (AP) with dilated main pancreatic duct left side branches and intra ductal calculi. The findings were not suggestive of any chronic pancreatitis. Conservative treatment was given for the episodic attack of AP. After the episode resolved, an exploration and extraction of the pancreatic ductal calculus was performed successfully. The pancreatic duct stones were removed by lateral pancreaticojejunostomy (partington-rochelle procedure). The patient made a remarkable recovery after the procedure and was perfectly healthy and well-oriented in time and space at 4-months follow up. Acute pancreatitis is an inflammatory condition of pancreas, when, associated with pancreatic duct stones a lateral pancreaticojejunostomy is done, which, results in better outcomes decreasing the mortality and morbidity. Acute pancreatitis due to ductal calculi is rare for which extraction is safe after resolution of the episode of AP. Studies need to be carried out to look for the outcome and the effectiveness of the procedure, when, specifically and specially done for this condition.
Topics: Acute Disease; Adult; Calculi; Cholangiopancreatography, Endoscopic Retrograde; Female; Humans; Pancreatic Ducts; Pancreaticojejunostomy; Pancreatitis; Tomography, X-Ray Computed
PubMed: 28712198
DOI: No ID Found -
Gut Sep 2022
Topics: Cholangiopancreatography, Endoscopic Retrograde; Humans; Pancreatic Ducts; Pancreatic Neoplasms
PubMed: 33963040
DOI: 10.1136/gutjnl-2021-324335