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Journal of Clinical and Experimental... 2023Endoscopic retrograde cholangiopancreatography (ERCP) has been a significant development in gastrointestinal endoscopy. I did my first ERCP at SKIMS on December 5, 1982,... (Review)
Review
Endoscopic retrograde cholangiopancreatography (ERCP) has been a significant development in gastrointestinal endoscopy. I did my first ERCP at SKIMS on December 5, 1982, and over the last 40 years, I have performed 10,100 ERCP procedures, including 600 Sphincter of Oddi manometries (SOM), and 3200 therapeutic ERCPs. We were confronted with many clinical challenges that needed answers by applying ERCP as a primary diagnostic tool. These studies gave birth to and/or recognition of several clinical syndromes. The hepatobiliary and pancreatic ascariasis (HBPA) as a clinical disease was recognized in 1985. The nematode, , was the most common cause of hepatobiliary and pancreatic diseases in Kashmir, and its impact on healthcare, clinical profile, management policies, and control measures was identified. Kashmir was recognized as an endemic zone for recurrent pyogenic cholangitis (RPC), which constituted 12.5% of all biliary diseases. RPC in this population was found essentially to be an aftermath of HBPA. A subset of patients with hepatic hydatidosis with rupture into the biliary tract was recognized at ERCP and primarily treated by endotherapy. Cholangiographic abnormalities in children with portal cavernoma evolved into the recognition of portal biliopathy. Extensive studies of the sphincter of Oddi manometry in patients with unexplained biliary and/or pancreatic pain following cholecystectomy identified the entity of the sphincter of Oddi dyskinesia (SOD). In a cross-over trial, Nifedipine, compared with a placebo, showed a significant clinical response in 20 of 28 such patients. ERCP studies done in patients with tropical calcific pancreatitis showed an anomalous union of bile and pancreatic ducts. Forty of the 220 patients with liver transplantation had biliary complications namely biliary leaks, bile duct strictures, SOD, and recurrence of underlying primary biliary cholangitis. Biliary complications caused considerable morbidity and mortality in patients with liver transplantation.
PubMed: 37975034
DOI: 10.1016/j.jceh.2023.05.010 -
Pancreatology : Official Journal of the... Feb 2024Factors that influence the pancreas microbiome are not well understood. Regular proton pump inhibitor (PPI) use induces significant alterations in the gut microbiome,...
Factors that influence the pancreas microbiome are not well understood. Regular proton pump inhibitor (PPI) use induces significant alterations in the gut microbiome, including an increase in the abundance of Streptococcus, and may be associated with pancreatic cancer risk. The aim of this study was to examine whether PPI use is associated with pancreatic and duodenal tissue microbiomes. We compared 16S rRNA microbiome profiles of normal pancreatic and duodenal tissue from 103 patients undergoing pancreatic surgery for non-malignant indications, including 34 patients on PPIs, accounting for factors including age, smoking, body mass index and the presence of main pancreatic duct dilation. Histologically normal tissue from the pancreatic head had higher alpha diversity and enrichment of Firmicutes by phylum-level analysis and Streptococcus species compared to normal pancreas body/tail tissues (16.8 % vs 8.8 %, P = .02, and 5.9 % vs 1.4 %, P = .03, respectively). Measures of beta diversity differed significantly between the pancreas and the duodenum, but in subjects with main pancreatic duct dilation, beta diversity of pancreatic head tissue was more similar to normal duodenal tissue than those without pancreatic duct dilation. Duodenal tissue of PPI users had significant enrichment of Firmicute phyla (34.7 % vs. 14.1 %, P = .01) and Streptococcus genera (19.5 % vs. 5.2 %, P = .01) compared to non-users; these differences were not evident in pancreas tissues. By multivariate analysis, PPI use was associated with alpha diversity in the duodenum, but not in the pancreas. However, some differences in pancreas tissue beta diversity were observed between PPI users and non-users. In summary, we find differences in the microbiome profiles of the pancreas head versus the pancreatic body/tail and we find PPI use is associated with alterations in duodenal and pancreatic tissue microbiome profiles.
Topics: Humans; Proton Pump Inhibitors; RNA, Ribosomal, 16S; Duodenum; Pancreas; Microbiota; Pancreatic Hormones
PubMed: 38161092
DOI: 10.1016/j.pan.2023.12.010 -
Digestive Diseases and Sciences Aug 2023In this commentary, the recent study "Safety and Efficacy of Long-Term Transmural Plastic Stent Placement After Removal of Lumen Apposing Metal Stent In Resolved...
In this commentary, the recent study "Safety and Efficacy of Long-Term Transmural Plastic Stent Placement After Removal of Lumen Apposing Metal Stent In Resolved Pancreatic Fluid Collections With Duct Disconnection at Head/Neck of Pancreas" is addressed. Some background information regarding endoscopic management of walled off necrosis is mentioned, then the study is summarized, followed by a critique about the strengths and limitations of the study. Further areas of research are also mentioned.
Topics: Humans; Drainage; Pancreatic Diseases; Pancreas; Stents; Necrosis; Syndrome; Pancreatic Ducts
PubMed: 37269370
DOI: 10.1007/s10620-023-07974-6 -
Current Opinion in Gastroenterology Mar 2024This review discusses evidence regarding progenitor populations of the biliary tree in the tissue regeneration and homeostasis, and the pathobiology of cholangiopathies... (Review)
Review
PURPOSE OF REVIEW
This review discusses evidence regarding progenitor populations of the biliary tree in the tissue regeneration and homeostasis, and the pathobiology of cholangiopathies and malignancies.
RECENT FINDINGS
In embryogenesis biliary multipotent progenitor subpopulation contributes cells not only to the pancreas and gall bladder but also to the liver. Cells equipped with a constellation of markers suggestive of the primitive endodermal phenotype exist in the peribiliary glands, the bile duct glands, of the intra- and extrahepatic bile ducts. These cells are able to be isolated and cultured easily, which demonstrates the persistence of a stable phenotype during in vitro expansion, the ability to self-renew in vitro, and the ability to differentiate between hepatocyte and biliary and pancreatic islet fates.
SUMMARY
In normal human livers, stem/progenitors cells are mostly restricted in two distinct niches, which are the bile ductules/canals of Hering and the peribiliary glands (PBGs) present inside the wall of large intrahepatic bile ducts. The existence of a network of stem/progenitor cell niches within the liver and along the entire biliary tree inform a patho-biological-based translational approach to biliary diseases and cholangiocarcinoma since it poses the basis to understand biliary regeneration after extensive or chronic injuries and progression to fibrosis and cancer.
Topics: Humans; Biliary Tract; Stem Cells; Cholangiocarcinoma; Bile Ducts, Intrahepatic; Bile Duct Neoplasms
PubMed: 38320197
DOI: 10.1097/MOG.0000000000001005 -
Gastrointestinal Endoscopy Clinics of... Jul 2024Pancreatic duct (PD) leaks are a common complication of acute and chronic pancreatitis, trauma to the pancreas, and pancreatic surgery. Diagnosis of PD leaks and... (Review)
Review
Pancreatic duct (PD) leaks are a common complication of acute and chronic pancreatitis, trauma to the pancreas, and pancreatic surgery. Diagnosis of PD leaks and fistulas is often made with contrast-enhanced pancreatic protocol computed tomography or magnetic resonance imaging with MRCP. Endoscopic retrograde pancreatography with pancreatic duct stenting in appropriately selected patients is often an effective treatment, helps to avoid surgery, and is considered first-line therapy in cases that fail conservative management.
Topics: Humans; Cholangiopancreatography, Endoscopic Retrograde; Pancreatic Fistula; Pancreatic Ducts; Stents; Pancreatitis; Tomography, X-Ray Computed; Postoperative Complications
PubMed: 38796289
DOI: 10.1016/j.giec.2024.02.001 -
ANZ Journal of Surgery May 2024Pancreatic cancer recurrence following surgery is a significant challenge, and personalized surgical care is crucial. Topographical variations in pancreatic duct anatomy...
INTRODUCTION
Pancreatic cancer recurrence following surgery is a significant challenge, and personalized surgical care is crucial. Topographical variations in pancreatic duct anatomy are frequent but often underestimated. This study aimed to investigate the potential importance of these variations in outcomes and patient survival after Whipple's procedures.
METHODS
Data were collected from 105 patients with confirmed pancreatic head neoplasms who underwent surgery between 2008 and 2020. Radiological measurements of pancreatic duct location were performed, and statistical analysis was carried out using IBM SPSS.
RESULTS
Inferior pancreatic duct topography was associated with an increased rate of metastatic spread and tumour recurrence. Additionally, inferior duct topography was associated with reduced overall and recurrence-free survival. Posterior pancreatic duct topography was associated with decreased incidence of perineural sheet infiltration and improved overall survival.
DISCUSSION
These findings suggest that topographical diversity of pancreatic duct location can impact outcomes in Whipple's procedures. Intraoperative review of pancreatic duct location could help surgeons define areas of risk or safety and deliver a personalized surgical approach for patients with beneficial or deleterious anatomical profiles. This study provides valuable information to improve surgical management by identifying high-risk patients and delivering a personalized surgical approach with prognosis stratification.
Topics: Humans; Pancreatic Neoplasms; Male; Female; Pancreatic Ducts; Aged; Middle Aged; Pancreaticoduodenectomy; Retrospective Studies; Neoplasm Recurrence, Local; Treatment Outcome; Prognosis
PubMed: 38426386
DOI: 10.1111/ans.18903 -
Heliyon Nov 2023Tumors involving the main pancreatic duct (MPD) used to be a contraindication for enucleation.
BACKGROUND
Tumors involving the main pancreatic duct (MPD) used to be a contraindication for enucleation.
METHODS
Clinical data of consecutive patients with pancreatic tumors who received laparoscopic or robotic enucleation (LEN or REN) between January 2019 and December 2021 at Fudan University Shanghai Cancer Center were analyzed.
RESULTS
Ninety-six patients were included in the analysis, with 55 in the LEN group and 41 in the REN group, and no conversion to laparotomy. Most tumors were located in the head of pancreas (71.9 %). The tumor diameter (3.1 vs. 1.9 cm) was larger, and more cystic tumors (92.7 % vs. 56.4 %) and more tumors involving the MPD (34.1 % vs. 3.6 %) were observed in the REN group. MPD support tube insertion was performed in 15 cases, with 11 in the REN group and 4 in the LEN group. The incidence of biochemical and grade B postoperative pancreatic fistula (POPF) was both 46.9 %, and no grade C POPF occurred. Among the 45 patients with grade B POPF, 28 cases (62.2 %) were due to carrying drainage tube >3 weeks without additional treatment, and only 4 cases required invasive treatment. For patients with MPD support tube implantation (n = 15), support tube fall-offs were observed in 12 cases, 2 patients had MPD dilatation, and no MPD stricture, stone formation or pancreatic atrophy was observed during follow-up.
CONCLUSIONS
The incidence of POPF was high but still controllable without serious complications after minimally invasive enucleation. The MPD is no longer a restricted area, and the robotic system has advantages in handling complex enucleations.
PubMed: 38027678
DOI: 10.1016/j.heliyon.2023.e21917 -
Gastrointestinal Endoscopy Clinics of... Jul 2024Pain secondary to chronic pancreatitis is a poorly understood and complex phenomenon. Current endoscopic treatments target pancreatic duct decompression secondary to... (Review)
Review
Pain secondary to chronic pancreatitis is a poorly understood and complex phenomenon. Current endoscopic treatments target pancreatic duct decompression secondary to strictures, stones, or inflammatory and neoplastic masses. When there is refractory pain and other treatments have been unsuccessful, one can consider an endoscopic ultrasound-guided celiac plexus block. Data on the latter are underwhelming.
Topics: Humans; Pancreatitis, Chronic; Endosonography; Pain Management; Celiac Plexus; Pancreatic Ducts; Nerve Block; Abdominal Pain; Cholangiopancreatography, Endoscopic Retrograde
PubMed: 38796291
DOI: 10.1016/j.giec.2024.02.003 -
Journal of Gastrointestinal Surgery :... Nov 2023Sphincter of Oddi dysfunction is a challenging and rare clinical entity resulting in pancreatobiliary pain and stasis of bile and pancreatic juice. This problem was...
BACKGROUND
Sphincter of Oddi dysfunction is a challenging and rare clinical entity resulting in pancreatobiliary pain and stasis of bile and pancreatic juice. This problem was classically treated with surgical therapy, but as classification of the disease has changed and newer methods of endoscopic evaluation and therapy have evolved, operative transduodenal sphincteroplasty is now generally reserved as a final therapeutic option for these patients. In this video and manuscript, we describe our approach to operative transduodenal sphincteroplasty in a patient with type I Sphincter of Oddi dysfunction.
METHODS
A 50-year-old female with history of Roux-en-Y gastric bypass presented with episodic right-upper-quadrant and epigastric abdominal pain with associated documented elevations in liver chemistries. Preoperative cross-sectional imaging demonstrated dilation of her common bile duct. After multidisciplinary discussion, the decision was made to pursue operative transduodenal sphincteroplasty.
RESULTS
All key operative steps of the transduodenal sphincteroplasty are demonstrated in the embedded video. Key operative steps include laparotomy, generous Kocher maneuver, and duodenotomy over the ampulla, allowing access for sequential biliary and pancreatic sphincterotomies and sphincteroplasties with absorbable suture. The duodenotomy and abdominal fascia are then closed. Our patient underwent sequential diet advancement and was discharged to home on postoperative day five. At clinic follow-up, pancreatobiliary-type pain had resolved.
CONCLUSION
The embedded video demonstrates a case of operative transduodenal sphincteroplasty, which can provide durable results in appropriate patient populations.
Topics: Humans; Female; Middle Aged; Sphincterotomy, Transduodenal; Sphincter of Oddi; Sphincter of Oddi Dysfunction; Common Bile Duct; Pain; Ampulla of Vater
PubMed: 37787871
DOI: 10.1007/s11605-023-05842-2 -
Annals of Surgical Oncology Sep 2023Portal Annular Pancreas (PAP) is a relatively uncommon entity with 4% reported incidence. Pancreaticoduodenectomy is challenging in cases with PAP and is associated with...
BACKGROUND
Portal Annular Pancreas (PAP) is a relatively uncommon entity with 4% reported incidence. Pancreaticoduodenectomy is challenging in cases with PAP and is associated with higher postoperative pancreatic fistula rate and overall morbidity. PAP is classified according to the pattern and location of fusion around the portal vein as-supra-splenic, infra-splenic & mixed fusion type. Also, the ductal anatomy can vary as pancreatic duct present only in the ante-portal portion or only in the retro-portal portion or ducts in both ante and retro-portal portion. At present, ideal surgical strategy is not defined as per the PAP types.
METHODS
The case demonstrated in the video presented with a localized, large duodenal mass with type IIA PAP (supra-splenic fusion with both ante and retro-portal ducts) detected on the preoperative triphasic CT scan. To achieve a single pancreatic cut surface with a single pancreatic duct for anastomosis, an extended pancreatic resection was performed using meso-pancreas triangle approach.
RESULTS
Patient had a smooth intraoperative course & the postoperative recovery was also uneventful. Pathology reported pT3 duodenal cancer with negative margins and uninvolved lymph nodes.
CONCLUSION
A preoperative knowledge of PAP and its various types is extremely important in order to tailor intraoperative management, specially of the retro-portal portion. In patients with retro-portal duct or both ante and retro-portal ducts (as the case presented in the video), an extended resection is recommended to mitigate postoperative pancreatic fistula.
Topics: Humans; Pancreaticoduodenectomy; Pancreatic Fistula; Pancreas; Anastomosis, Surgical; Postoperative Complications; Pancreatic Hormones; Pancreatic Neoplasms; Portal Vein
PubMed: 37402974
DOI: 10.1245/s10434-023-13782-z