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 EUS-TS, ductal structures should be excluded to prevent pancreatic ductal leakage.

Quality of life after endoscopic procedures for chronic pancreatitis: A multicentre study.

BACKGROUND: Chronic Pancreatitis (CP) causes morphological changes in the pancreatic tissue, leading to complications and pain, which may require endoscopic interventions. OBJECTIVE: Our aim was to determine the frequency of endoscopic procedures (EP) in CP patients and to analyse pain and quality of life (QoL) in these patients after their EP. METHODS: This study included 1327 CP patients from the Scandinavian Baltic Pancreatic Club (SBPC) database including four countries and eight centres. We analysed patients undergoing EPs and gathered information on the EP, pancreatic function, pain, disease and duration. The EORTC C-30 QoL questionnaire was gathered prospectively and multivariable analysis was conducted on independent parameters between the groups. The reference population had no interventions (n = 870). RESULTS: 260 CP patients (22%) underwent EPs, median one year (range 0-39 years) after CP diagnosis. 68% were males. The median age was 59 (20-90) years. Most common aetiological factors were alcohol in 65% and smoking in 71%. Extracorporeal shock wave lithotripsy (ESWL) was used in 6% of the CP population and in 21% of the EP group. Biliary duct stenting was performed on 37% and pancreatic stenting was performed on 56% of the patients. There was no difference in pain patterns between patients who had pancreatic stenting and the reference population. The EP group had slightly better QoL (p = 0.047), functioning and fewer symptoms than the reference population, in the multivariable analysis there was no interaction effect analysis between the groups. The pancreatic stent group had better QoL and the same amount of pain than the reference group. The patients who needed later surgery (23%) had more pain (p = 0.043) and fatigue (p = 0.021). CONCLUSIONS: One in five of the CP patients underwent EP. These patients scored higher on QoL responses and had better symptom scores. CP patients who had pancreatic stenting performed had the same pain patterns as the reference population. Randomised prospective trials are needed to determine the effect of endoscopy procedures on CP patients.

Case report: Endoscopic retrieval of a proximally migrated pancreatic stent using the basket-through- the-sphincterotome technique.

Background: The retrieval of a proximally migrated pancreatic duct (PD) stent via endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging, often requiring surgical intervention. We report a case with proximal migration of a pancreatic stent that was successfully removed by a basket-through-the-sphincterotome technique. Case presentation: A 46-year-old man with prior history of chronic pancreatitis was admitted to our hospital with 1 month history of epigastric discomfort. 9 months prior he had undergone ERCP with Endoscopic sphincterotomy (EST) and a 5 Fr × 9 cm plastic pancreatic stent placement to relieve pancreatic duct stricture and abdominal pain. Magnetic retrograde cholangiopancreatography (MRCP) done this time revealed PD dilation and a stent-shaped signal inside the PD. The subsequent endoscopic ultrasonography (EUS) verified total pancreatic stent proximal migration with no visible distal end of the stent in the papilla. ERCP was performed again with an attempt to retrieve the stent. General techniques of PD cannulation with a 0.035-in guidewire over the migrated stent and balloon extraction failed. We used a mini-basket (Endoflex Germany) to replace the guidewire, which was inserted into the PD and advanced over the proximal end of the stent through the channel of the sphincterotome. The distal end of the stent was easily caught by manipulating the tip of the sphincterotome, and the stent was then pulled out. A naso-pancreatic drainage tube was placed in the main PD, and the patient was discharged 2 days after tube withdrawal. Conclusion: This was a successful case of proximally migrated pancreatic stent retrieval using the unique idea of basket-through-the-sphincterotome technique, which has rarely been reported. The basket-through-the-sphincterotome technique provides the endoscopist another way to catch the distal end without difficulty. It can improve the success rate of proximally migrated pancreatic stent retrieval, especially the pig-tail pancreatic stent, of which the sticking of the proximal end into pancreatic duct branches often makes the distal end the only choice to retrieve.

How i do it: microscope augmented pancreaticojejunostomy.

PURPOSE: Post-operative pancreatic fistula (POPF) is perhaps one of most dreaded pancreatoduodenectomy-related complications. Various approaches to mitigate this risk have been explored, with conflicting results and no clear consensus on the comparative superiority of any one technique. We postulate that regardless of technique, the key to reducing POPF is a robust pancreatic anastomosis with careful apposition of tissues, in particular the duct-to-mucosa anastomosis. METHOD: We describe the fashioning of a pancreatojejunostomy with an external pancreatic stent in the setting of a high-risk anastomosis with help of a 10 × magnification surgical microscope. A technical description with a short, edited video is presented.

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.

The success rate of cannulation of needle-knife precut is superior to continuing wire-guided after difficult biliary cannulation with pancreatic stent placement.

BACKGROUND: Difficult biliary cannulation and unintended pancreatic cannulation exist in biliary interventions during endoscopic retrograde cholangiopancreatography. Wire-guided cannulation over a pancreatic stent (PS-WGC) and needle-knife precut over a pancreatic stent (PS-NKP) may facilitate biliary cannulation. This study aimed to compare the outcomes of PS-NKP and PS-WGC following guidewire passage into the pancreatic duct. METHODS: A total of 304 patients who inserted a pancreatic stent and continued cannulation using wire-guided (PS-WGC) or needle-knife precut (PS-NKP) from October 2018 to November 2021 in three centers were ultimately enrolled in this study. The success rate of cannulation and incidence of complications were compared between the two groups. RESULTS: Results of the success rate of cannulation in the PS-NKP (n = 98) group were significantly higher compared with the PS-WGC (n = 206) group (96.9% vs. 89.8%; P < 0.05). The overall adverse events were 10.2% (31/304), and PS-NKP had lower (PEP) rates compared with the PS-WGC (3.1% vs. 10.7%, P < 0.05). CONCLUSION: The PS-NKP group is superior to the PS-WGC group in terms of the effectiveness and safety of continued cannulation. Using needle-knife precut, especially early use, over the pancreatic stent to continue cannulation reduced PEP compared with PS-WGC.

Successful endoscopic retrieval of a proximally migrated pancreatic stent in a patient with pancreaticojejunal anastomotic stenosis.

Objective: We report a case of successful endoscopic retrieval of a proximal (upstream) migrated pancreatic stent through a pancreaticojejunal anastomosis. Patient: A 71-year-old man with a history of pancreatoduodenectomy with modified Child's reconstruction and concomitant internal pancreatic ductal stenting for cholangiocarcinoma 41 months before presentation, was referred to our department for the treatment of acute pancreatitis. Endoscopic stent retrieval was performed using a short-type single-balloon enteroscope with a transparent hood. A pancreaticojejunal anastomosis was identified as a pinhole-like opening buried within the intestinal folds and dilated using a balloon catheter. Finally, the migrated pancreatic stent was successfully retrieved using a wire-guided basket catheter, without complications. Conclusion: Endoscopic retrieval of a proximally migrated pancreatic stent after pancreatoduodenectomy should be attempted, even in cases of stenotic pancreaticojejunal anastomosis, to avoid highly invasive procedures, including surgery.

Endoscopic retrieval of a migrated pancreatic stent stuck at both ends: A case report.

Background: Endoscopic pancreatic stenting is an effective way to relieve the stricture of the pancreatic duct. However, proximal stent migration presents a threat to the patient and a challenge to the doctor. The limited space in the pancreatic duct often prevents the operation of suitable devices for stent removal. Case presentation: A 34-year-old man with painful chronic pancreatitis received endoscopic retrograde cholangiopancreatography (ERCP) and insertion of a pancreatic plastic stent, with 8.5 Fr in diameter and 12 cm in length. A year later, radiography revealed that the proximal end of the stent rested in the pancreatic tail while the distal end rested in the branch duct. Both balloon and rat-tooth forceps were used but failed to retrieve the stent. A week later, a second ERCP was performed. After dilation with a 10-mm balloon, a small amount of bleeding was noticed and a crack appeared in the wall of the branch duct. Consequently, the distal end of the stent was released. Then, rat-tooth forceps was used to grasp the distal end, and the stent was pulled out successfully. Conclusions: For a proximally migrated pancreatic stent stuck at both ends, a strategy of maximum dilation can be used cautiously to retrieve the stent.

Successful endoscopic retrieval of a migrated pancreatic stent using a basket catheter for peroral cholangioscopy through a biliary plastic stent pusher tube: a case report.

Objective: Retrieval is challenging once prophylactic pancreatic stents migrate deep into the pancreatic duct. Herein, we describe a case of successful endoscopic retrieval of a migrated prophylactic pancreatic stent using a basket catheter through a biliary plastic stent pusher tube. Patient: A 71 year-old man was referred to our hospital for removal of a straight-shaped migrated 5-Fr 3-cm prophylactic pancreatic stent with a flap on the duodenal side. There were no subjective symptoms at the time of the hospital visit. Results: During endoscopic retrograde cholangiopancreatography, we inserted an 8.5-Fr plastic biliary stent pusher tube in front of the migrated pancreatic stent. The stent was then grasped using a basket catheter for peroral cholangioscopy through the biliary stent pusher tube. The stent was pulled into the pusher tube and was successfully retrieved from the pancreatic duct. No complications were associated with endoscopic retrograde cholangiopancreatography. Conclusion: Although rare, prophylactic pancreatic duct stent migration after pancreatic duct guidewire placement should be noted. In our case, endoscopic retrieval of a migrated prophylactic pancreatic stent using a basket catheter for peroral cholangioscopy through the biliary plastic stent pusher tube was successful.

Basic and Advanced Biliary Cannulation: How Do I Do It?

Successful biliary cannulation of a native papilla is usually the rate-limiting step toward a successful ERCP. Standard cannulation techniques usually succeed, particularly when utilizing the wire-guided technique. There are, however, a myriad of confirmations of the major papilla as well as anatomic variants and certain pathologies which can make cannulation exceedingly difficult. For these cases, advanced cannulation techniques and techniques termed "access sphincterotomy" have been developed which should allow successful cannulation in >90% of cases. This article should help all those performing ERCP to improve their cannulation rate.

Laparoscopic clamp-crushing enucleation with a pancreatic duct stent for tumors located close to the main pancreatic duct.

The perioperative management and technical details of laparoscopic clamp-crushing enucleation for low-malignant-potential pancreatic neuroendocrine neoplasms (PNENs) located close to the main pancreatic duct (MPD) in the body/tail of the pancreas using a perioperative MPD stent are reported. The procedure was performed in two patients with PNEN (13 and 10 mm in diameter) in the body/tail of the pancreas. A naso-pancreatic stent (NPS) was placed preoperatively in both patients. Resection was performed using Maryland-type bipolar forceps. The surgical duration was 139 and 55 min, and the estimated blood loss was 5 and 0 mL, respectively. One patient was discharged uneventfully on postoperative day (POD) 12. The other patient developed a grade B pancreatic fistula, but was discharged on POD 22. Laparoscopic clamp-crushing enucleation with an NPS might be a viable treatment option for tumors located close to the MPD.

Successful endoscopic retrieval of a migrated pancreatic stent using a basket catheter for peroral cholangioscopy through a biliary plastic stent pusher tube: a case report / Journal of Rural Medicine

Objective: Retrieval is challenging once prophylactic pancreatic stents migrate deep into the pancreatic duct. Herein, we describe a case of successful endoscopic retrieval of a migrated prophylactic pancreatic stent using a basket catheter through a biliary plastic stent pusher tube.Patient: A 71 year-old man was referred to our hospital for removal of a straight-shaped migrated 5-Fr 3-cm prophylactic pancreatic stent with a flap on the duodenal side. There were no subjective symptoms at the time of the hospital visit.Results: During endoscopic retrograde cholangiopancreatography, we inserted an 8.5-Fr plastic biliary stent pusher tube in front of the migrated pancreatic stent. The stent was then grasped using a basket catheter for peroral cholangioscopy through the biliary stent pusher tube. The stent was pulled into the pusher tube and was successfully retrieved from the pancreatic duct. No complications were associated with endoscopic retrograde cholangiopancreatography.Conclusion: Although rare, prophylactic pancreatic duct stent migration after pancreatic duct guidewire placement should be noted. In our case, endoscopic retrieval of a migrated prophylactic pancreatic stent using a basket catheter for peroral cholangioscopy through the biliary plastic stent pusher tube was successful.

Efficacy of early endoscopic intervention in pediatric pancreatic duct injury management.

BACKGROUND: The optimal management method for pediatric pancreatic trauma is controversial. Moreover, the efficacy of stent placement via endoscopic retrograde pancreatography (ERP) remains poorly documented. METHODS: The present, retrospective review of pediatric patients with pancreatic trauma was conducted from 2010 to 2020 at a single institution. RESULTS: Ten, male children with the median age of 9.5 years (range 4-14 years) with a grade I (n = 2), II (n = 4) or III (n = 4) pancreatic injury were identified. Of six of these patients in whom ERP was performed, four had a pancreatic duct injury (PDI). Pancreatic stent placement was performed in all the patients with ERP at a site proximal to the injury in four patients and across the injury in two patients. A pseudocyst or pancreatic fluid collection was detected in five patients, of these, two with a grade II injury were managed successfully with conservative therapy while three with PDI required surgery. In the four patients with PDI, only one in whom the stent was placed across the PDI was able to avoid surgery. CONCLUSION: Therapeutic ERP might be effective even if a patient has a PDI, therefore, early ERP should be considered as a treatment option.

Colocación intraoperatoria anterógrada de stent pancreático y plastia de ligamento redondo para prevenir la fístula pancreática tras la pancreatectomía distal / Anterograde intraoperative pancreatic stent placement and round ligament patch to prevent pancreatic fistula after distal pancreatectomy

La fístula pancreática tras la pancreatectomía distal supone una de las complicaciones más frecuentes y con mayor morbilidad asociada en este tipo de cirugía. Hasta el momento ningún método empleado se ha mostrado eficaz en reducir la fístula pancreática de forma contrastada. Presentamos el desarrollo de una nueva técnica quirúrgica que combina la colocación del stent pancreático junto con la colocación de parche autólogo de ligamento redondo sobre el borde pancreático. Tras la realización de la transección pancreática, se introduce de forma anterógrada la prótesis pancreática previo paso de una guía. Se comprueba la colocación de la prótesis y se cierra el conducto de Wirsung. Por último, se realiza una plastia autóloga de ligamento falciforme. A las 6-8 semanas se retira la prótesis vía endoscópica. La técnica ha sido empleada en 2 pacientes sin presentar fístula pancreática postoperatoria. Esta técnica combinada pretende introducir un nuevo elemento en la prevención de la fístula pancreática mediante una técnica reproducible sin una dificultad técnica añadida. (AU)

Postoperative pancreatic fistula in distal pancreatectomy is one of the most important complications in this surgery and it is associated with high morbidity and mortality. Pancreatic fistula after distal pancreatectomy remains an unsolved problem and none preventive procedure has been shown effectively. We present a new technique that combine pancreatic stent placement with round ligament autologous patch over pancreatic edge. A guide is introduced through Wirsung duct prior to stent placement. After stent assessment, Wirsung duct is closed. Finally, falciform ligament autologous patch is placed over pancreatic edge. After 6-8 weeks, the stent is removed by oral endoscopy. This technique introduces a new issue on the pancreatic fistula prevention. (AU)

Transabdominal ultrasonography to reduce the burden of X-ray imaging in prophylactic pancreatic stent localization after ERCP-A prospective trial.

BACKGROUND: Before performing endoscopy to remove prophylactic pancreatic stents placed in patients with high risk of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP), X-ray imaging is recommended to confirm the stents position in the pancreatic duct. OBJECTIVES: The aim of the present study was to investigate the feasibility of prophylactic pancreatic stent detection by transabdominal ultrasonography, to reduce the burden of X-ray imaging, which is currently the golden standard. METHODS: All patients who received a pancreatic stent for PEP prophylaxis were included in the present prospective trial. First, stent position was determined by transabdominal ultrasonography. Afterwards, it was verified by X-ray imaging. Retained stents were removed by esophagogastroduodenoscopy. Dislocated stents needed no further intervention. RESULTS: Fourty-one patients were enrolled in this study. All prophylactic pancreatic stents were straight 6 cm long 5 Fr stents with external flap. All stents were removed between day 1 and 10 (median: 3 days) in all cases. In 34 of 41 cases (83.0%), the pancreatic stent was still in place on the day of examination. Twenty-nine of 34 (85.3%) stents were detected correctly by transabdominal ultrasonography. Overlying gas prevented visualization of the pancreas in 3/41 (7.3%) cases. Sensitivity of sonographic detection of the stent was 93.5% (29/31). Six of seven stents were determined correctly as dislocated by ultrasonography. Here, specificity was 85.7%. A positive predictive value of 96.7% (29/30) was examined. The negative predictive value was 75.0% (6/8). CONCLUSION: Transabdominal ultrasonography detects the majority of prophylactic pancreatic stents. Thereby, it helps to identify patients with an indication for endoscopy sufficiently. X-ray imaging could subsequently be omitted in about 70% of examinations, reducing the radiation exposure for the patient and the endoscopy staff.

Network meta-analysis of prophylactic pancreatic stents and non-steroidal anti-inflammatory drugs in the prevention of moderate-to-severe post-ERCP pancreatitis.

BACKGROUND: There is an ongoing debate that non-steroidal anti-inflammatory drugs (NSAID) or prophylactic pancreatic stents (PPS) are more beneficial in preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). In our present network meta-analysis, we aimed to compare PPSs to rectal NSAIDs in the prevention of moderate and severe PEP in average- and high-risk patients. METHODS: We performed a systematic search for randomized controlled trials (RCT) from MEDLINE (via PubMed), Embase and Cochrane Central databases. RCTs using prophylactic rectal NSAIDs or PPSs in patients subjected to ERCP at average- and high-risk population were included. The main outcome was moderate and severe PEP defined by the Cotton criteria. Pairwise Bayesian network meta-analysis was performed, and interventions were ranked based on surface under cumulative ranking (SUCRA) values. RESULTS: Seven NSAID RCTs (2593 patients), and 2 PPS RCTs (265 patients) in the average-risk, while 5 NSAID RCTs (1703 patients), and 8 PPS RCTs (974 patients) in the high-risk group were included in the final analysis. Compared to placebo, only PPS placement reduced the risk of moderate and severe PEP in both patient groups (average-risk: RR = 0.07, 95% CI [0.002-0.58], high-risk: RR = 0.20, 95% CI [0.051-0.56]) significantly. Rectal NSAID also reduced the risk, but this effect was not significant (average-risk: RR = 0.58, 95% CI [0.22-1.3], high-risk: RR = 0.58, 95% CI [0.18-2.3]). Based on SUCRA, PPS placement was ranked as the best preventive method. CONCLUSION: Prophylactic pancreatic stent placement but not rectal NSAID seems to prevent moderate-to-severe PEP better both, in average- and high-risk patients.

Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: An Updated Review of Current Preventive Strategies.

Pancreatitis is a serious complication of endoscopic retrograde cholangiopancreatography, with incidence rates as high as 16% in some centers. Recent studies have also shown an upward trend in hospitalization due to endoscopic retrograde cholangiopancreatography-related pancreatitis. Early interventions taken before, during, and after the procedure can significantly reduce the risk of pancreatitis and decrease morbidity and mortality of the patients. To select appropriate patients for endoscopic retrograde cholangiopancreatography, in-depth knowledge of the patient-related and procedure-related risk factors is required. This updated clinical review outlines various pharmacological agents and surgical methods used for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis. Current evidence supports the use of rectal non-steroidal anti-inflammatory drugs and pancreatic stent placement as an effective preventive strategy. Further research is needed to compare these preventive modalities to improve patient outcomes after endoscopic retrograde cholangiopancreatography.