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Background: This study aims to evaluate the clinical efficacy of pancreatic duct stenting in the treatment of SAP, providing reference for clinical diagnosis and treatment. Methods: A retrospective analysis was conducted on clinical data from patients with SAP admitted to the General Hospital of Ningxia Medical University from June 1, 2019 to December 31, 2022. A total of 51 patients were included (33 males, 18 females). Patients were divided into two groups based on treatment: the control group (n = 28) receiving conventional treatment and the stent group (n = 23) undergoing pancreatic duct stenting in addition to conventional treatment. Data collected and analyzed include demographic information, rates of late local complications, late surgical interventions, new-onset OF, infected pancreatic necrosis and new-onset systemic complications. Specific outcomes measured were incidences of new-onset respiratory, renal and circulatory failure, single and multiple OF, sepsis, ACS, abdominal hypertension, and pancreatogenic encephalopathy, as well as use of ≥ 3 types of antibiotics, time of antibiotic use, time of analgesic administration, oral refeeding, length of hospital stay, ICU care, and length of ICU stay. These indicators were used to assess the therapeutic efficacy of pancreatic duct stenting. Results: All 23 patients in the stent group successfully underwent stenting. The incidence of new-onset OF and new-onset systemic complications was significantly lower in the stent group compared to the control group (χ2 = 4.96, 6.65, P < 0.05). However, no significant differences were observed between the groups regarding late local complications, infected pancreatic necrosis, and late surgical intervention (χ2 = 0.22, 0.002, 0.024, P > 0.05). Notably, two patients in the control group required additional procedures due to inadequate drainage, with one undergoing endoscopic debridement and the other, laparotomy. Mortality rates were 3 (10.7%) in the control group and 4 (17.4%) in the stent group, with no statistically significant difference (P > 0.05). Furthermore, significant differences were noted in new-onset respiratory failure, single OF, sepsis, abdominal hypertension, time of analgesic administration, oral refeeding, length of enzyme inhibitor use, and hospitalization expenses (χ2 = 3.94, 4.37, 5.79, 4.79; Z = − 2.008, − 4.176, − 4.165, − 2.309; P < 0.05). No significant differences were found in new-onset renal, circulatory, multiple OF, ACS, pancreatogenic encephalopathy, use of ≥ 3 types of antibiotics, time of antibiotic use, length of hospital stay, ICU care, and length of ICU stay (P > 0.05). Conclusions: Pancreatic duct stenting effectively reduces the incidence of new-onset systemic complications and OF in SAP, preventing further deterioration. Pancreatic duct stenting can alleviate symptoms, shorten oral refeeding, and promote patient recovery. Trial registration: This study was recorded as a single-center, retrospective case–control study (ChiCTR1900025833). [ABSTRACT FROM AUTHOR]

Pancreatic trauma is often associated with high mortality and morbidity. Current management protocol advises conservative management when the duct is not involved but if there are higher-grade injuries with duct disruption it requires major pancreatic surgeries. These surgeries are technically challenging and carry a significant risk of morbidity and mortality. In this article, we propose open pancreatic duct stenting as the open counterpart of endoscopic retrograde cholangiopancreatography (ERCP) in open surgeries for pancreatic preservation. A 20-year-old male presented to emergency 3 days after blunt trauma abdomen with the chief complaint of upper abdominal pain and vomiting. Lab parameters were normal except S. amylase was − 1563 IU/L. Contrast-enhanced computerised tomography (CECT) abdomen shows almost complete transection at the level of the neck of the pancreas with complete disruption of the main pancreatic duct (MPD). Exploratory laparotomy with stenting of the pancreatic duct with pancreatic tissue repair with feeding jejunostomy was done instead of major pancreatic resection and anastomosis. The recovery period was uneventful, and the patient was discharged on the 8th postoperative day. In the literature, there are very few reports available where intraoperative pancreatic duct stenting was done without ductal repair in the trauma setting. Until now, ten cases have been reported in which a pancreatic duct could be approximated and was repaired over a stent. In recent years, there has been a paradigm shift in trauma management that advocates organ preservation. Existing pancreatic trauma guidelines still recommend morbid surgeries such as distal pancreatectomy or pancreaticoduodenectomy for severe-grade pancreatic trauma. However, there is an obvious need to consider organ preservation because pancreatic resection procedures have inherent complications as well as high morbidity and mortality. [ABSTRACT FROM AUTHOR]

Introduction: Chronic calcific pancreatitis (CCP) is a debilitating inflammatory condition characterized by the accumulation of calcific deposits in the pancreatic tissue, leading to chronic abdominal pain and functional insufficiencies. This study aims to systematically review and meta-analyse comparative studies assessing the efficacy of endotherapy versus surgery in managing CCP-related pain. Methods: MEDLINE, EMBASE, and Cochrane library (CENTRAL and CDSR), from inception to October 2023, were searched. The inclusion criteria encompassed randomized controlled trials (RCTs) and non-randomized controlled trials (NRS), and cohort studies comparing endoscopic interventions to surgery for pain management in patients with CCP. Pain relief, procedural technical success, and procedural-related complications were the outcomes of interest. Two review authors (CN, KK) independently assessed study eligibility criteria and performed data extraction. Using a random-effects model, pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated. The level of certainty of the evidence was assessed using the GRADE approach. Results: Five studies were included. For the outcome of pain relief, a meta-analysis of five studies (3 RCTs and 2 cohort studies) demonstrated a significant therapeutic effect in favour of surgery with an OR of 2.36 (95% CI: 1.12 to 5.00, I2 = 41.70), with moderate level of certainty of evidence. In the analysis of five studies (3 RCTs, 1 NRS and 2 cohort studies), procedural technical success was comparable between the two groups (OR of 3.02, 95% CI: 0.47 to 19.59, I2 = 79.27%) as were adverse events (OR 1.31, 95% CI: 0.47 to 3.70, I2 = 50.93%). Conclusion: In conclusion, this systematic review and meta-analysis suggest that surgery may be more effective in relieving pain in patients with CCP compared to endoscopic interventions. Disease stage may be important to determine the appropriateness of each procedure. PROSPERO (CRD42023476153) [ABSTRACT FROM AUTHOR]

Highlights: What are the main findings? CP and ARP are common in paediatric populations with varied aetiologies. ERCP is more commonly used compared to EUS in paediatrics and is limited to specialist centres. What is the implication of the main finding? ERCP and EUS are safe and efficacious, with minimal complications in the management of CP and ARP in a paediatric cohort. Indications for both diagnostic and therapeutic EUS are increasing. ERCP and EUS offer a more 'patient-friendly', minimally invasive approach to CP and ARP. Objectives: To evaluate the role of ERCP (endoscopic retrograde cholangio-pancreatography) and EUS (endoscopic ultrasound) and to describe the efficacy and safety of these procedures in a paediatric cohort with chronic pancreatitis (CP) and acute recurrent pancreatitis (ARP). Methods: All patients (<18 years) undergoing an ERCP or EUS for ARP and CP between January 2008 and December 2022 were included. Data collection included indications for the procedure, technical success, adverse events and outcome data. Results: A total of 222 ERCPs were performed in 98 patients with CP and ARP (60% female, median age 10 years). The commonest indications were a main pancreatic duct stricture (PD) with or without a stone within the main PD. Successful cannulation was achieved in 98% of cases. Improved stricture resolution was demonstrated in 63% of patients. The overall adverse event rate for ERCP was low (n = 8/222, 3.6%). An improvement in abdominal pain was demonstrated in (75/98) 76% of patients. Their Body Mass Index also significantly improved post ERCP (15.5 ± 1.41 vs. 12.9 ± 1.16 kg/m2, p = 0.001). A total of 54 EUS procedures were undertaken in 48 individuals. Moreover, 35 individuals underwent a therapeutic EUS procedure, for which the commonest indication was the drainage of a pancreatic fluid collection. The overall complication rate was low (n = 2.4%) in all EUS cases. Conclusions: ERCP and EUS can be safely and effectively used in a paediatric population with indications analogous to an adult cohort. [ABSTRACT FROM AUTHOR]

Background: The effectiveness of prophylactic pancreatic duct stenting (PPDS) in preventing post-ampullectomy pancreatitis (PAP) at the time of endoscopic ampullectomy (EA) has been reported, however, results are conflicting. We conducted a systematic review and meta-analysis looking at the use of PPDS in reducing PAP as well as overall post-ampullectomy complications. Methods: Multiple databases were searched through May 2023 for studies reporting on EA. Meta-analysis was performed to determine pooled proportions and relative risk (RR) with 95% confidence intervals (CI) of PAP, with and without PPDS. Pooled rates of adverse events including perforation, delayed bleeding, cholangitis, and procedure related mortality were assessed. Random effects model was used for our meta-analysis and heterogeneity was assessed using the I2 statistics. Results: Thirty-four studies (14 case series, 18 cohort studies and 2 randomized controlled trials) with 1868 patients were included. The overall pooled rate of PAP was 12.3% (CI 10.3–14.5). We found no statistically significant difference in rates of PAP among patients with PPDS, 11.9% (CI 8.9–15.7) and without PPDS, 16.6% (CI 13.4–20.4), RR 0.8 (CI 0.51–1.28), p = 0.4. In terms of severe PAP, we found no difference between the two groups. The overall pooled rates of successful en-bloc and piecemeal resection were 74.8% (CI 67.3–81.1) and 25.1% (CI 19–32.4). Additionally, pooled rates of ampullary stenosis, post procedural bleeding, perforation, cholangitis, and procedure related mortality were 3.6%, 11.1%, 4.2%, 3.5%, and 1.3%, respectively. Conclusions: Our analysis shows that PPDS at the time of EA does not offer a significant protective effect against PAP. While the incidence of PAP was higher among the no PPDS group, it is plausible that this is more likely due to variation among studies in terms of lesion size, length/size of pancreatic stent used and etiology of ampullary lesions. Future well-designed randomized controlled trials are needed to validate our findings. [ABSTRACT FROM AUTHOR]

Background: This study aimed to investigate the feasibility, effectiveness, and safety of pancreatic duct stenting in managing acute biliary pancreatitis (ABP) necessitating endoscopic retrograde cholangiopancreatography (ERCP). It further aimed to provide valuable insights for subsequent clinical diagnosis and treatment. Methods: This research employs an observational retrospective case–control study design, encompassing patients with ABP who underwent ERCP at the hepatobiliary surgery department of the General Hospital of Ningxia Medical University between August 1, 2018, and December 31, 2020. A total of 229 cases were screened based on inclusion and exclusion criteria. Regardless of ABP severity, patients were categorized into the stent group (141) and the non-stent group (88). Changes in blood amylase (Amy), lipase (LIP), leukocyte count (WBC), total bilirubin (TBIL), alanine aminotransferase (ALT), hematocrit (HCT), and creatinine (CR) were compared between the two groups. Moreover, variables such as recovery time for oral feeding, hospitalization duration, hospitalization costs, local complications, systemic complications, and new organ failure were recorded to assess the therapeutic effect of pancreatic duct stenting. Results: No significant differences were observed in gender, age, Acute Physiology and Chronic Health Evaluation (APACHE) II score, ABP severity grade, organ failure (OF), cholangitis, or biliary obstruction between the pancreatic stent and non-stent groups (P > 0.05). There was no significant difference in the incidence of complications related to acute pancreatitis between the two groups (P > 0.05). The median fasting and hospitalization times of patients in the stent group were significantly shorter than those in the non-stent group (P < 0.05). No significant differences between the groups were observed in hospitalization costs and in-hospital mortality (P > 0.05). There were no significant variations in white blood cell (WBC) count, TBIL, ALT, and creatinine (Cr) at admission, 72 h, and in the differences between the two groups (P > 0.05). The levels of Amy at admission and 72 h in the stent group were significantly higher than those in the non-stent group (P < 0.05). The differences in LIP and HCT in the stent group were considerably higher than in the non-stent group (P < 0.05). Although no significant differences were observed in mean Amy and LIP between the two groups (P > 0.05), the mean 72-h HCT in the stent group was 38.39% (95% confidence interval [CI] 37.82%–38.96%) was lower than that in the non-stent group (39.44%, 95% CI 38.70–40.17%) (P < 0.05). Conclusion: In the stent group, feeding time and hospital stay were significantly shorter than those in the non-stent group. No significant differences were observed between the two groups in the incidence of complications and mortality. The HCT value decreased more rapidly in the stent group. Early pancreatic stent implantation demonstrated the potential to shorten the eating and hospitalization duration of patients with ABP, facilitating their prompt recovery. Trial Registration: This study was registered as a single-center, retrospective case series (ChiCTR1800019734) at chictr.org.cn. [ABSTRACT FROM AUTHOR]

Objectives: Although covered self‐expandable metal stents (CSEMSs) are associated with the risk of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis due to pancreatic duct (PD) orifice obstruction, they are often used for biliary drainage treatment in malignant biliary obstruction (MBO). This study aimed to investigate the efficacy of PD stenting in preventing post‐ERCP pancreatitis after CSEMS implantation. Methods: This retrospective cohort study analyzed 554 patients with transpapillary CSEMS for MBO. Patients with noninitial deployment, benign disease, CSEMS deployment above the papilla, surgically altered anatomy, uncovered self‐expandable metal stents, multiple thin self‐expandable metal stents, and unavailable procedure videos were excluded. Logistic regression analysis estimated the association between PD stenting and post‐ERCP pancreatitis incidence. We adjusted for age, sex, pancreatitis history, prophylactic rectal nonsteroidal anti‐inflammatory drug use, naïve papilla, MBO etiology, and prolonged biliary cannulation time. Results: Among 554 patients, 67 (12.1%) experienced post‐ERCP pancreatitis. Post‐ERCP pancreatitis was recorded in 13.7% of patients in the non‐PD stenting and 4.3% in the PD stenting groups. Pancreatic duct stenting was associated with lower risks of post‐ERCP pancreatitis (odds ratio [OR] 0.28; 95% confidence interval [CI] 0.099–0.79; P = 0.028). In multivariable analysis, the association between PD stenting and lower post‐ERCP pancreatitis incidence was consistent (OR 0.19; 95% CI 0.062–0.58; P = 0.0034). Conclusions: Pancreatic duct stenting could reduce the risk of post‐ERCP pancreatitis after CSEMSs. [ABSTRACT FROM AUTHOR]

Background: The effectiveness of pancreatic duct (PD) stenting in the early stages of acute pancreatitis (AP) remains controversial. This study aimed to investigate the efficacy and safety of PD stenting in the early stages of AP.Methods: This is a retrospective cohort study. The clinical data of 131 patients with AP from 2018 to 2019 were analysed and divided into two groups: the study group (n = 46, PD stenting) and the control group (n = 85, standard treatment).Results: There was a statistically significant reduction in pain relief, oral refeeding, hospitalization, and intensive care unit (ICU) stay in the study group compared with that of the control group (P < 0.05). There were no significant differences in the incidence of complications between the two groups. Further multivariate analysis of risk factors for new-onset organ failure showed that the control group (odds ratio [OR] (95% confidence interval [CI]): 6.533 (1.104-70.181)) and a higher level of haematocrit (HCT) at admission (HCT > 46.1%, OR (95%CI): 8.728 (1.264-116.767)) were independent risk factors.Conclusions: In the early phase of AP, PD stenting has the potential to reduce pain relief time, oral refeeding time, ICU stay time, and overall hospital stay time. This finding highlights a new route for the treatment of AP. [ABSTRACT FROM AUTHOR]

Introduction: Pancreatic Ductal Disruption (PDD) may remain a localised collection to form pseudocyst or dissect into adjacent organs or rupture freely into the peritoneal cavity or pleural cavity resulting in massive or high-volume ascites or pleural effusions. The management of pseudocyst is well known among general and gastrosurgeons, but ascites and plural effusion remain difficult decisions. Depending on the availability of resources total parenteral nutrition, octreotide, pancreatic duct stenting are used with varying success. There are no guidelines as to which intervention is preferable in different clinical scenarios. Aim: To audit the clinical characters and management of patients with pancreatic ascites and pleural effusion. Materials and Methods: This study was done at the Department of Surgical Gastroenterology, Karnataka Institute of Medical Sciences, Hubballi, Karnataka, India. Fifty two patients with pancreatic ascites or pancreatico pleural fistula in the background of chronic pancreatitis satisfying both inclusion and exclusion criteria were identified and studied from the prospectively maintained database of patients with chronic pancreatitis in the period from September 2010 to September 2020. The patients were classified as conservatively managed, endoscopic main pancreatic duct stenting or surgery. Statistical analysis was done using windows excel. The results were expressed as percentage, mean and Standard Deviation (SD). Results: Five patients with ascites and two patients with pleural effusion responded completely to conservative measures (13.4%). In one of them ascites recurred at two months and one had left pleural effusion recurrence at one month. Fifteen patients died while on conservative management (68.2% mortality). Among eight patients undergoing endoscopic pancreatic duct stenting, ascites/pleural effusion resolved in six (75% success rate) and remained asymptomatic during mean follow-up of 12 months. Two patients who were not improving after stenting were lost to follow-up. Twenty-two patients underwent surgery namely lateral pancreatojejunostomy with resolution of symptoms. Two patients undergoing surgery died in postoperative period due to sepsis and chest infection (9% mortality). At a mean follow-up of 14 months they remained symptom free. Conclusion: Conservative management alone has high mortality. Early aggressive management can aim to stop leak either by pancreatic duct stenting or surgical lateral pancreatojejunostomy will help reduce mortality and morbidity. [ABSTRACT FROM AUTHOR]

Enucleation is an effective surgical method to treat pancreatic insulinoma, however, the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) is high. We aim to investigate the risk factors for CR-POPF which have not been well characterized and develop effective methods to prevent CR-POPF after enucleation. This retrospective cohort study included 161 patients diagnosed with insulinoma from June 2016 to July 2020 in Peking Union Medical College Hospital. The risk factors for CR-POPF were evaluated and the role of prophylactic pre-operative pancreatic stent to prevent the occurrence of CR-POPF after enucleation of pancreatic insulinoma were explored. A cohort of 161 insulinoma cases were reviewed. The CT or MRI imaging reports could be tracked in 108 cases. A total of 96 patients underwent surgery, while 81 experienced pancreatic enucleation. Univariate and multivariate analyses showed that the distance from insulinoma to the main pancreatic duct (MPD) ≤2 mm was an independent risk factor for CR-POPF (p = 0.003, OR = 6.011, 95% Cl 1.852–19.512). The pre-operative pancreatic stent substantially reduced the incidence of CR-POPF in patients with tumor located in proximity to (distance ≤2 mm) the MPD (CR-POPF of the stented group vs the non-stented group: 37.5% vs 71.4%, p = 0.028). The distance from insulinoma to MPD ≤2 mm is a predictive factor for CR-POPF after enucleation. Pancreatic duct stenting may benefit patients with insulinoma in proximity to the MPD by enabling a lower CR-POPF rate, so it should be considered before the enucleation of the insulinoma in proximity to the MPD (distance ≤2 mm). [ABSTRACT FROM AUTHOR]

Background Endoscopic retrograde cholangiopancreatography (ERCP) was first described as a diagnostic technique. ERCP is used for management of various biliary and pancreatic diseases. Post-ERCP pancreatitis is defined as new-onset abdominal pain following ERCP, which is associated with amylase levels that are elevated three times the normal range, Pancreatic stenting is widely employed after pancreatic sphincterotomy with goals of reducing both early restenosis and post-ERCP pancreatitis. The risk of pancreatitis is significantly decreased when a pancreatic stent is placed and then left in following a precut sphincterotomy. Aim To evaluate the efficacy of pancreatic stent to decrease the risk of post-ERCP pancreatitis in patients with calcular obstructive jaundice. Patients and methods A prospective randomized study was conducted that included 40 patients with obstructive jaundice with a difficult biliary cannulation who are at risk to develop post-ERCP pancreatitis in patients with calcular obstructive jaundice. Group A included 20 patients with manipulation of pancreatic duct guidewire without pancreatic stent insertion. Group B included 20 patients with manipulation of pancreatic duct guidewire with pancreatic stent insertion. Results There was a highly statistically significant. Pancreatic stent placement decreases the risk of post-ERCP pancreatitis. Conclusion Prophylactic pancreatic duct stenting after difficult cannulation of the pancreatic duct is a safe and feasible procedure and significantly reduces the rate of post- ERCP pancreatitis. [ABSTRACT FROM AUTHOR]

A presumed benign cystic tumor in the pancreatic head had been pointed out to a 78-year-old man 4 years ago. In addition to no communication between the tumor and the main pancreatic duct, magnetic resonance imaging showed that the cystic fluid was serous. Gradual tumor enlargement from 2.1 to 4.0 cm urged us to resect the tumor. In order to safely enucleate the tumor, we preoperatively placed a pancreatic duct stent and covered the pancreatic parenchyma with a polyglycolic acid sheet, fibrin glue, and thrombin after tumor enucleation. The patient postoperatively developed grade B pancreatic fistula but recovered with antibiotics therapy. Postoperative computed tomography showed successful preservation of the main pancreatic duct. Pathological study showed a well-defined tumor mainly composed of loosely textured and S-100-positive spindle cells with abundant and hyalinized blood vessels in the cystic walls with palisading spindle cells, leading to the diagnosis of Antoni B schwannoma. The patient was discharged on the 11th day after operation. Both pancreatic duct stunting and covering the exposed pancreatic parenchyma with a polyglycolic acid sheet, fibrin glue, and thrombin are feasible measures to enucleate large benign tumors in the pancreatic head. [ABSTRACT FROM AUTHOR]

Pancreatic-pleural fistula (PPF) is a rare sequela of pancreatitis. High degree of clinical suspicion is required to diagnose a PPF. Confirmation is done by high amylase content in pleural fluid analysis. Here, we present two cases with varied presentation of PPF. A 43-year-old man presented with acute on chronic pancreatitis with bilateral (predominantly right) pleural effusion. Another 57-year-old man, previously diagnosed with chronic calcific pancreatitis, presented with left pleural effusion. Both cases were effectively managed with endoscopic pancreatic duct stenting. [ABSTRACT FROM AUTHOR]

Background and Aim Complications of endoscopic treatment are reported more and more often as a result of popularization of pancreatic endotherapy. Our study presents the results of treatment in patients with intraductal pancreatic stent fragmentation diagnosed during endotherapy of chronic pancreatitis. Methods Retrospective analysis of 2496 endoscopic retrograde cholangiopancreatography procedures which were carried out in 607 patients at the Gastrointestinal Endoscopy Unit of the University Clinical Center in Gdansk. Results In the course of pancreatic endotherapy, intraductal pancreatic stent fragmentation was stated during 33 of 2496 (0.013%) procedures in 33 of 607 (5.44%) patients with chronic pancreatitis. In 33 patients, there were 46 intraductal fragments of broken stents. Most patients were asymptomatic. In 31/33 patients, fragments of broken stents were removed from the pancreatic duct endoscopically. In the case of two patients, endoscopic management was ineffective and they were treated surgically. Altogether, 44/46 stent fragments were removed endoscopically. Most fragments of pancreatic stents were removed during the first endoscopic procedure. One fragment of a broken stent was retrieved with polypectomy snare and four with Dormia basket. The remaining fragments of broken pancreatic stents were removed with rat-tooth forceps. Conclusions Intraductal fragmentation of pancreatic stent is a rare complication of pancreatic endotherapy and it often has an asymptomatic course. Most fragments of broken pancreatic stents can be removed endoscopically from the pancreatic duct with an acceptable complication rate. [ABSTRACT FROM AUTHOR]

Background: To evaluate the management and outcomes of blunt pancreatic injuries based on the integrity of the major pancreatic duct (MPD).Methods: Between August 1996 and August 2015, 35 patients with blunt pancreatic injuries underwent endoscopic retrograde pancreatography (ERP). Medical charts were retrospectively reviewed for demography, ERP timing, imaging findings, management, and outcome.Results: Of the 35 patients, 21 were men and 14 were women, with ages ranging from 11 to 70 years. On the basis of the ERP findings, we propose a MPD injury classification as follows: class 1 indicates normal MPD; class 2, partial injury with intact MPD continuity; and class 3, complete injury with disrupted MPD continuity. Both classes 2 and 3 are subdivided into classes a, b, and c, which represent the pancreatic tail, body, and head, respectively. In this report, 14 cases belonged to class 1, 10 belonged to class 2, and 11 belonged to class 3. Of the 14 patients with class 1 injuries, 10 underwent nonsurgical treatment and 4 underwent pancreatic duct stenting. Of the 10 patients with class 2 injuries, 4 underwent nonsurgical treatment and 6 underwent pancreatic duct stenting. Two of the 11 patients with class 3 injuries underwent pancreatic duct stenting; one in the acute stage developed sepsis that led to death even after converting to distal pancreatectomy plus splenectomy. Of the 11 patients with class 3 injuries, spleen-preserving distal pancreatectomy was performed in 6, distal pancreatectomy plus splenectomy in 2, and Roux-en-Y pancreaticojejunostomy after central pancreatectomy in 2. The overall pancreatic-related morbidity rate was 60% and the mortality rate was 2.8%.Conclusion: Based on our experience, class 1 and 2 injuries could be treated by nonsurgical means and pancreatic duct stenting could be an adjunctive therapy in class 2b and 2c injuries. Operation is warranted in class 3 injuries. [ABSTRACT FROM AUTHOR]

Pain affects approximately 80% of patients with pancreatic cancer, with half requiring strong opioid analgesia, namely: morphine-based drugs on step three of the WHO analgesic ladder (as opposed to the weak opioids: codeine and tramadol). The presence of pain is associated with reduced survival. This article reviews the literature regarding pain: prevalence, mechanisms, pharmacological, and endoscopic treatments and identifies areas for research to develop individualized patient pain management pathways. The online literature review was conducted through: PubMed, Clinical Key, Uptodate, and NICE Evidence. There are two principal mechanisms for pain: pancreatic duct obstruction and pancreatic neuropathy which, respectively, activate mechanical and chemical nociceptors. In pancreatic neuropathy, several histological, molecular, and immunological changes occur which correlate with pain including: transient receptor potential cation channel activation and mast cell infiltration. Current pain management is empirical rather etiology-based and is informed by the WHO analgesic ladder for first-line therapies, and then endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) in patients with resistant pain. For EUS-CPN, there is only one clinical trial reporting a benefit, which has limited generalizability. Case series report pancreatic duct stenting gives effective analgesia, but there are no clinical trials. Progress in understanding the mechanisms for pain and when this occurs in the natural history, together with assessing new therapies both pharmacological and endoscopic, will enable individualized care and may improve patients' quality of life and survival. [ABSTRACT FROM AUTHOR]

We report a case of massive left sided hemorrhagic effusion secondary to pancreaticopleural fistula (PPF) in a young, previously healthy female of 17 years. High pleural fluid amylase levels prompted us for evaluation of this uncommon cause. Computed tomography (CT) of thorax and abdomen and magnetic resonance cholangio-pancreatography (MRCP) confirmed the diagnosis of PPF. Patient was managed with intercostal drainage of pleural effusion and therapeutic endoscopic retrograde cholangio-pancreatography (ERCP) with stenting of the pancreatic duct. Patient recovered completely and is doing well after one year of follow up without any recurrence of pleual effusion. Thus, high index of suspicion, and measurement of pleural fluid amylase, especially in large and or recurrent (left sided) pleural effusions, will help in early and definitive diagnosis of PPF. Above approach with therapeutic ERCP would cure this condition with less morbidity. Advances in the latter techniques dramatically reduced the need for surgical interventions and prolonged hospital stay with conservative treatment approach. [ABSTRACT FROM AUTHOR]

Background and Aim Although biliary cannulation with pancreatic guidewire placement ( P- GW) is useful for difficult cases in endoscopic retrograde cholangiopancreatography ( ERCP), the clinical significance of wire-guided cannulation with P- GW (double-guidewire technique: DGT) has not been clarified. The aim of the present study was to evaluate the usefulness of DGT for difficult biliary cannulation after unsuccessful biliary cannulation using a cannula/sphincterotome under guidance of injected contrast with P- GW (single-guidewire technique: SGT). Methods One-hundred and forty-six patients with difficult biliary cannulation who underwent SGT were included in this retrospective study. DGT was carried out if SGT was unsuccessful. Pancreatic duct ( PD) stenting was attempted to prevent post- ERCP pancreatitis ( PEP) in all patients. The success rate of cannulation and the risk factors for PEP were investigated. Results Biliary cannulation with SGT was achieved in 70%. DGT was carried out in 25 patients with unsuccessful SGT, biliarycannulation being successful in 72%. Of the 13 patients who underwent precut sphincterotomy, biliary cannulation was achieved in 46%. The incidence of PEP in patients who had undergone SGT, DGT, and precut sphincterotomy was 8% (12: mild, 8; moderate, 3; severe, 1), 4% (mild, 1), and 0%, respectively. PD stenting was successfully carried out in 86%. Multivariate analysis revealed unsuccessful PD stenting to be the only risk factor for PEP ( OR 8.3, 95% CI 2.3-30). Conclusions DGT may replace SGT or become the salvage procedure in cases of unsuccessful SGT as a result of its high success rate with an acceptable incidence of PEP. Failed pancreatic duct stenting in these techniques was frequently associated with PEP. [ABSTRACT FROM AUTHOR]

For ampullary cancer, pancreaticoduodenectomy is considered to be the standard treatment. Endoscopic papillectomy (EP) has been utilized in cases of ampullary adenoma since the early 1980s. We aimed to provide a review concerning EP. We conducted a review of studies regarding EP for ampullary neoplasms. Since neither lymphatic permeation, vascular invasion, nor lymph node metastasis is observed in patients with ampullary cancer limited to the mucosa, EP of such tumors without ductal infiltration into the pancreatic/bile duct can be justified as radical treatment. For its application in patients with ampullary neoplasms, accurate pretreatment staging is indispensable. EUS, which can be carried out on an outpatient basis with a low risk of complications, is useful for differential diagnosis as well as detection of periampullary tumors. Although intraductal US of the bile duct tends to result in overestimation of tumor staging in cases of ampullary neoplasm, it can provide useful information for making therapeutic decisions, especially in cases appropriate for EP. While the technical success rate of EP is high, the complication rate and recurrence rate are not as low as a satisfactory level. Pancreatic duct stenting after EP is expected to contribute to prevention of post-EP pancreatitis. There is no consensus regarding the mode of resection current nor the need for addition of biliary/pancreatic sphincterotomy and biliary stenting. EP has been reported to be useful in selected patients with ampullary neoplasms. Data on further long-term follow up after EP are awaited. [ABSTRACT FROM AUTHOR]

A diagnosis of pancreatic cancer carries a very dismal prognosis, with the 5-year survival rate being the lowest of all types of cancer. Surgical resection offers the only hope for cure in these patients. Pancreatic resectional surgery is technically demanding, and while mortality has decreased in centers of excellence, the morbidity remains significant. Numerous controversies exist regarding various aspects of complex pancreatic resections. This review attempts to address these controversies with an evidence-based perspective. We performed a literature search in MEDLINE (www.pubmed.org) with relevant key words and the corresponding MeSH terms. The search was limited to English language publications on human subjects. A manual cross-reference search of the bibliographies of relevant papers was carried out to identify publications for possible inclusion. [ABSTRACT FROM AUTHOR]

Although endoscopic transpapillary treatment of chronic pancreatitis (CP) is gaining acceptance, it is not always possible, especially in patients with inflammatory stenosis of the duodenum due to CP or with a history of a Whipple's procedure. Linear array echoendoscopes (ES) provide high-quality images of the pancreas along with adjacent organs and allow therapeutic applications. echoendoscope-related procedures, such as ES-guided pancreatic duct drainage (ESPD) are feasible and useful in selected patients with CP suffering from PD stricture in whom conventional endoscopic retrograde cholangiopancreatography (ERCP) is impossible. [ABSTRACT FROM AUTHOR]