Pancreatic endoscopic retrograde cholangiopancreatography (ERCP)

We review developments in five areas of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) and management of pancreatic tumors during the period September 2005 - August 2006. First, in the management of painful chronic pancreatitis, the use of multiple plastic stents for aggressive dilation of strictures located in the head of the pancreas has been put forward to resolve two significant issues associated with current techniques, i. e., the requirement for numerous ERCPs for stent exchange and the high relapse rate after stent removal. We then discuss the identification of protective factors against post-ERCP pancreatitis following pancreatic sphincterotomy. Next, bearing in mind the prospect of increasing use of neoadjuvant chemotherapy for resectable pancreatic ductal adenocarcinoma, new evidence supporting the systematic use of self-expandable metal biliary stents before cancer staging is presented and critically considered. A French study on the natural history of intraductal papillary mucinous neoplasms, which reinforces the current recommendation not to operate on all of these patients, is also discussed. Finally two centers with a high volume of cases have reported their experience with the drainage of pancreatic fluid collections with or without endosonography (EUS) guidance. It appears that EUS has extended the applicability of endoscopic drainage but, for collections amenable to conventional endoscopic techniques, it remains uncertain whether safety and effectiveness are improved when EUS guidance is used. Technical requisites for long-term success of drainage have been confirmed: multiple, double-pigtail stents should be inserted for a minimum of 6 weeks. It has also become evident that training in this technique is insufficient at many centers.

References

• 1 Farnbacher M J, Muhldorfer S, Wehler M. et al . Interventional endoscopic therapy in chronic pancreatitis including temporary stenting: a definitive treatment?.  Scand J Gastroenterol. 2006;  41 111-117
• 2 Costamagna G, Bulajic M, Tringali A. et al . Multiple stenting of refractory pancreatic duct strictures in severe chronic pancreatitis: long-term results.  Endoscopy. 2006;  38 254-259
• 3 Eleftheriadis F, Dinu F, Delhaye M. et al . Long-term outcome after pancreatic stenting in severe chronic pancreatitis.  Endoscopy. 2005;  37 223-230
• 4 Morgan D E, Smith J K, Hawkins K. et al . Endoscopic stent therapy in advanced chronic pancreatitis: relationships between ductal changes, clinical response, and stent patency.  Am J Gastroenterol. 2003;  98 821-826
• 5 Freeman M L, DiSario J A, Nelson D B. et al . Risk factors for post-ERCP pancreatitis: a prospective, multicenter study.  Gastrointest Endosc. 2001;  54 425-434
• 6 Hookey L C, RioTinto R, Delhaye M. et al . Risk factors for pancreatitis after pancreatic sphincterotomy: a review of 572 cases.  Endoscopy. 2006;  38 670-676
• 7 Brackbill S, Young S, Schoenfeld P. et al . A survey of physician practices on prophylactic pancreatic stents.  Gastrointest Endosc. 2006;  64 45-52
• 8 Guda N, Partington S, Freeman M. Does the type of current (pure vs blended) matter for post ERCP complications: a meta analysis.  Gastrointest Endosc. 2005;  61 AB191
• 9 Fisher L, Fisher A, Thomson A. Cardiopulmonary complications of ERCP in older patients.  Gastrointest Endosc. 2006;  63 948-955
• 10 Wasan S M, Ross W A, Staerkel G A. et al . Use of expandable metallic biliary stents in resectable pancreatic cancer.  Am J Gastroenterol. 2005;  100 2056-2061
• 11 Chen V K, Arguedas M R, Baron T H. Expandable metal biliary stents before pancreaticoduodenectomy for pancreatic cancer: a Monte Carlo decision analysis.  Clin Gastroenterol Hepatol. 2005;  3 1229-1237
• 12 Maire F, Hammel P, Ponsot P. et al . Long-term outcome of biliary and duodenal stents in palliative treatment of patients with unresectable adenocarcinoma of the head of pancreas.  Am J Gastroenterol. 2006;  101 735-742
• 13 Lawrence C, Howell D A, Conklin D E. et al . Delayed pancreaticoduodenectomy for cancer patients with prior ERCP-placed, nonforeshortening, self-expanding metal stents: a positive outcome.  Gastrointest Endosc. 2006;  63 804-807
• 14 Levy P, Jouannaud V, O’Toole D. et al . Natural history of intraductal papillary mucinous tumors of the pancreas: actuarial risk of malignancy.  Clin Gastroenterol Hepatol. 2006;  4 460-468
• 15 Irie H, Yoshimitsu K, Aibe H. et al . Natural history of pancreatic intraductal papillary mucinous tumor of branch duct type: follow-up study by magnetic resonance cholangiopancreatography.  J Comput Assist Tomogr. 2004;  28 117-122
• 16 Eguchi H, Ishikawa O, Ohigashi H. et al . Patients with pancreatic intraductal papillary mucinous neoplasms are at high risk of colorectal cancer development.  Surgery. 2006;  139 749-754
• 17 Tanaka M, Chari S, Adsay V. et al . International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas.  Pancreatology. 2006;  6 17-32
• 18 Hookey L C, Debroux S, Delhaye M. et al . Endoscopic drainage of pancreatic-fluid collections in 116 patients: a comparison of etiologies, drainage techniques, and outcomes.  Gastrointest Endosc. 2006;  63 635-643
• 19 Kahaleh M, Shami V M, Conaway M R. et al . Endoscopic ultrasound drainage of pancreatic pseudocyst: a prospective comparison with conventional endoscopic drainage.  Endoscopy. 2006;  38 355-359
• 20 Seewald S, Groth S, Omar S. et al . Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm (videos).  Gastrointest Endosc. 2005;  62 92-100
• 21 Cahen D, Rauws E, Fockens P. et al . Endoscopic drainage of pancreatic pseudocysts: long-term outcome and procedural factors associated with safe and successful treatment.  Endoscopy. 2005;  37 977-983
• 22 Yusuf T E, Baron T H. Endoscopic transmural drainage of pancreatic pseudocysts: results of a national and an international survey of ASGE members.  Gastrointest Endosc. 2006;  63 223-227
• 23 Harewood G C, Wright C A, Baron T H. Impact on patient outcomes of eperience in the performance of endoscopic pancreatic fluid collection drainage.  Gastrointest Endosc. 2003;  58 230-235