Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline.

BACKGROUND AND AIMS: Clarification of the position of the European Society of Gastrointestinal Endoscopy (ESGE) regarding the interventional options available for treating patients with chronic pancreatitis. METHODS: Systematic literature search to answer explicit key questions with levels of evidence serving to determine recommendation grades. The ESGE funded development of the Guideline. SUMMARY OF SELECTED RECOMMENDATIONS: For treating painful uncomplicated chronic pancreatitis, the ESGE recommends extracorporeal shockwave lithotripsy/endoscopic retrograde cholangiopancreatography as the first-line interventional option. The clinical response should be evaluated at 6 - 8 weeks; if it appears unsatisfactory, the patient's case should be discussed again in a multidisciplinary team. Surgical options should be considered, in particular in patients with a predicted poor outcome following endoscopic therapy (Recommendation grade B). For treating chronic pancreatitis associated with radiopaque stones ≥ 5 mm that obstruct the main pancreatic duct, the ESGE recommends extracorporeal shockwave lithotripsy as a first step, combined or not with endoscopic extraction of stone fragments depending on the expertise of the center (Recommendation grade B). For treating chronic pancreatitis associated with a dominant stricture of the main pancreatic duct, the ESGE recommends inserting a single 10-Fr plastic stent, with stent exchange planned within 1 year (Recommendation grade C). In patients with ductal strictures persisting after 12 months of single plastic stenting, the ESGE recommends that available options (e. g., endoscopic placement of multiple pancreatic stents, surgery) be discussed in a multidisciplinary team (Recommendation grade D).For treating uncomplicated chronic pancreatic pseudocysts that are within endoscopic reach, the ESGE recommends endoscopic drainage as a first-line therapy (Recommendation grade A).For treating chronic pancreatitis-related biliary strictures, the choice between endoscopic and surgical therapy should rely on local expertise, patient co-morbidities and expected patient compliance with repeat endoscopic procedures (Recommendation grade D). If endoscopy is elected, the ESGE recommends temporary placement of multiple, side-by-side, plastic biliary stents (Recommendation grade A).

Successful videocapsule endoscopy in patients with an abdominal cardiac pacemaker.

Pacemaker location in the abdominal wall is considered a contraindication to videocapsule endoscopy (VCE). The aim of this study was to review our experience on the use of VCE in patients with a pacemaker located in the abdominal wall. VCE was carried out with monitoring of cardiac rhythm. This was a retrospective review of VCE case studies performed at two tertiary care university medical centers (pediatric and adult). The main outcome measures were adverse events and quality of VCE images. No adverse events were experienced in any of the five patients with implanted cardiac pacemakers, including the two with abdominal pacemaker. No interference with the VCE recording was observed during the studies, although the capsule was observed to be briefly inactivated by the pacemaker in one case. The present study, though small, suggests that VCE is safe in adult and pediatric patients who are fitted with cardiac pacemakers, even when implanted in the abdominal wall. The VCE exam can be carried out successfully under close supervision. Dysfunction of the capsule appears to be more likely than problems with cardiac pacing.

Renal transplantation from a living related donor with a retrocaval ureter--a note of caution.

In our study we describe a renal transplant from a living related donor who was found to have a retrocaval ureter. The retrocaval ureter is a rare congenital anomaly resulting from a defect in the embryological development of the ureter and the inferior vena cava (IVC). The compression of the ureter between the IVC and the vertebrae can result in progressive hydronephrosis. The non-dilated segment of the ureter was used for the uretero-neocystostomy. The patient presented with ureteric obstruction in the immediate post-transplant period, and at surgical exploration the ureteroneocystostomy was revised using the dilated portion of the ureter. We recommend that when transplanting a kidney with a retrocaval ureter, caution should be exercised in using the non-dilated portion of the ureter, since either the blood supply may be compromised or the peristalsis may be interrupted.