Search

Η χρόνια παγκρεατίτιδα αποτελεί φλεγμονώδη διεργασία της εξωκρινούς μοίρας του παγκρέατος, η οποία χαρακτηρίζεται από προοδευτική και μη αναστρέψιμη καταστροφή του παγκρεατικού παρεγχύματος. Η βαριά κατανάλωση αλκοόλης έχει θεωρηθεί ο κύριος αιτιολογικός παράγοντας εμφάνισης χρόνιας παγκρεατίτιδας στις αναπτυγμένες χώρες της δύσης. Η χρόνια παγκρεατίτιδα αποτελεί την κύρια αιτία δημιουργίας παγκρεατικών λίθων. Οι παγκρεατικοί λίθοι εντοπίζονται είτε εντός του παγκρεατικού πόρου είτε στο παγκρεατικό παρέγχυμα. Οι λίθοι που εντοπίζονται εντός του πόρου χαρακτηρίζονται αληθείς. Η κατανάλωση αλκοόλης, η οποία σχετίζεται άμεσα με τη χρόνια παγκρεατίτιδα, λειτουργεί τοξικά στα λοβιακά κύτταρα του παγκρέατος προκαλώντας διαταραχή στον κυτταρικό μεταβολισμό. Τα απεικονιστικά χαρακτηριστικά της χρόνιας παγκρεατίτιδας αντικατοπτρίζουν την ανομοιογενή, τμηματική ή συνολική καταστροφή του παρεγχύματος και την κομβολογιοειδή διάταση του παγκρεατικού πόρου λόγω των ινώσεων που υφίσταται το τοίχωμα του, και των διατάσεων καθώς και λόγω της ανώμαλης διαμόρφωσης των μικρών εκφορητικών πόρων. Οι απεικονιστικές μέθοδοι που η επιστημονική κοινότητα διαθέτει στη φαρέτρα της είναι ικανές και αλληλοσυμπληρώνουν η μια την άλλη στην ανάδειξη των ευρημάτων και στην παρακολούθηση των ασθενών με χρόνια παγκρεατίτιδα., Chronic pancreatitis is an inflammatory process of the exocrine portion of the pancreas, which is characterized by progressive and irreversible destruction of the pancreatic parenchyma. Heavy alcohol consumption has been considered the main cause of chronic pancreatitis in developed western countries. Chronic pancreatitis is the main cause of pancreatic stones. Pancreatic stones are located either within the pancreatic duct or in the pancreatic parenchyma. Stones found within the pore are classified as true. Alcohol consumption, which is directly related to chronic pancreatitis, works toxically on the lobular cells of the pancreas causing a disturbance in cellular metabolism. The imaging features of chronic pancreatitis reflect the inhomogeneous, partial or total destruction of the parenchyma and the convoluted dilatation of the pancreatic duct due to the fibrosis that its wall undergoes, and the stretching as well as due to the abnormal configuration of the small excretory ducts. The imaging methods that we have in our disposal are capable and complement each other in highlighting the findings and monitoring patients with chronic pancreatitis., Σε συνεργασία με: Ιατρικής (Δημοκρίτειο Πανεπιστήμιο Θράκης), Μηχανικών Περιβάλλοντος (Διεθνές Πανεπιστήμιο Ελλάδας)

BACKGROUND Chronic pancreatitis occasionally requires surgical treatment that can be performed with various techniques. Often, this type of surgery presents with postoperative complications. We report a case of a successful retrograde pancreatojejunostomy for chronic pancreatitis and infected pancreatic cysts. CASE SUMMARY A 62-year-old male with a 10-year history of chronic pancreatitis presented with epigastric pain for one week and a 20 kg weight loss over one year. Computed tomography showed stones in the pancreas (mainly the head), expansion of the main pancreatic duct, and thinning of the pancreatic parenchyma. Magnetic resonance imaging showed infected pancreatic cysts connected to the stomach with a fistula from the splenic hilum to the caudal portion of the liver’s lateral segment. An endoscopic retrograde pancreatography was performed; the guide wires could not pass through the stones in the pancreas and therefore, drainage of the main pancreatic duct was not achieved. Next, a distal pancreatomy and splenectomy were performed; however, the pancreatic juice in the remaining parenchyma was blocked by the stones. Hence, we performed a retrograde pancreatojejunostomy and Roux-en-Y anastomosis. The patient had no postoperative complications and was discharged from the hospital on postoperative day 14. CONCLUSION A distal pancreatomy, retrograde pancreatojejunostomy, and Roux-en-Y anastomosis could be an effective surgical procedure for intractable chronic pancreatitis.

Background Despite pancreatic extracorporeal shock wave lithotripsy (P-ESWL) is a minimally invasive treatment for pancreatic stones, complications exist. Case presentation A 37-year-old male was diagnosed with chronic pancreatitis and admitted to our hospital for recurrent acute pancreatitis. After the first P-ESWL session, the patient complained of a new type of pain different from the previous pain pattern. Computerized tomography and colonoscopy were arranged and colonic hematoma was found. Since the patient had stable vital signs, no special treatment was given focusing on the colonic hematoma. Five days later, P-ESWL treatment was repeatedly performed for four consecutive days. Two days after the last P-ESWL session, the patient underwent endoscopic retrograde cholangiopancreatography. At the three-month follow up visit, the colonic hematoma disappeared and pancreatic stones decreased significantly. Conclusions To the best of our knowledge, colonic hematoma after P-ESWL for pancreatic stones has never been reported. Here, we present the only case of colonic hematoma after P-ESWL, which was coincidentally found in more than 6000 P-ESWL sessions in our hospital. As the symptoms of colonic hematoma are mild, we believe the incidence of colonic hematoma has been underestimated. Many people with colonic hematoma after P-ESWL may be undiagnosed or misdiagnosed. Treatment for colonic hematoma depends on whether there is severe clinical state. Exploration of more precise location method for pancreatic stones may reduce the probability of P-ESWL complication.

Video Video 1 Pancreatic stones treated via an EUS-guided pancreaticogastrostomy with a fully covered self-expandable metal stent. A 42-year-old man who had undergone a distal pancreatectomy 2 years earlier for chronic pancreatitis due to alcohol use, with pancreatic stones, presented because of severe abdominal pain. Blood tests revealed elevated inflammatory markers and pancreatic enzymes. CT depicted pancreatic stones up to 1 cm in size in the entire pancreatic parenchyma and main pancreatic duct. Obstructive pancreatitis caused by pancreatic stones was diagnosed. Transpapillary removal of the stones was attempted, but the main pancreatic duct could not be approached because of the pancreatic stones near the duodenal papilla. We attempted to approach the main pancreatic duct via the transgastric route with endoscopic ultrasound guidance. CT showed pancreatic stones in the main pancreatic duct.

Peroral pancreatoscopy (POPS) is a demanding endoscopic procedure that can be used to perform intracanal lithotripsy in obstructing pancreatic stones but the experience is limited. Most stones can be removed successfully by endoscopic retrograde cholangio-pancreatography but patients with large stones require advanced therapeutic approaches, such as extracorporeal shock wave lithotripsy (alone or followed by endoscopic retrograde cholangio-pancreatography), currently the mainstay of treatment. Unfortunately, in about 10% of cases, extracorporeal shock wave lithotripsy can fail; moreover, it is not be available in many institutions. For this subgroup of patients, POPS guided-lithotripsy can play a role and have benefits. The most consistent study concerns a retrospective multicenter analysis that enrolled few patients per center. Considering the epidemiological scenario and the scant volume of skilled endoscopists, POPS must be developed in very few high-volume referral centers with standardized pathways and capable of performing multi-modality treatment. In addition, we could reasonably assume that POPS-guided-lithotripsy should be used as rescue therapy in special situations, identifying the ideal candidate who can achieve the maximum clinical result, and carefully balancing risk/benefits ratio.

Background: Idiopathic chronic calcific pancreatitis is a rare entity. Early surgical intervention and a parenchyma sparing procedure should be advocated to prevent further decay of the pancreas and the occurrence of cancer. Case Presentations: Case 1: A 14-year-old boy presented with a 3-year history of right upper abdominal pain that has been aggravated in the last 2 months. Imaging revealed a dilated pancreatic duct of 6 mm with pancreatic duct stones in the head of pancreas. He underwent a Frey's procedure. Unfortunately, he was discharged with grade B pancreatic fistula. Case 2: A 12-year-old boy presented with a 1-year history of dull and recurring epigastric pain. Imaging studies showed multiple stones in a 12 mm dilated pancreatic duct. The patient underwent a modified Puestow procedure. Up to the 42th month follow-up, the patient had no pain complaints. Case 3: A 12-year-old boy with a 1-week history of a dull epigastric pain presented with with multiple stones in a 10 mm duct. He underwent a modified Puestow procedure and was discharged with alleviated pain. Conclusions: “Conservative” surgery allows satisfactory pancreatic duct drainage, reduced rehospitalizations, and longer pain relief than alternative endoscopic procedures.

Although surgical or endoscopic treatment is effective for pain control in symptomatic calcified chronic pancreatitis, it is still unknown whether early intervention in mild symptomatic pancreatic stones would reduce the frequency of acute exacerbation and improve long-term outcomes. The aim of this randomized-controlled trial was to explore the efficacy of early endotherapy for mild symptomatic pancreatic stones in comparison with the wait-and-see policy.Patients with mild symptoms because of pancreatic stones were assigned randomly to the endotherapy or the wait-and-see group. The wait-and-see group received endotherapy only when they developed refractory exacerbation or intractable pain. The primary outcome was the cumulative incidence of intolerable pain attacks and acute exacerbation. The secondary outcomes were the development of pancreatic insufficiency and the progression of pancreatic atrophy.A total of 20 patients were enrolled between March 2008 and March 2011. The study was terminated prematurely because of the poor patient enrollment. Early endotherapy tended to reduce the cumulative incidence of pain attacks and exacerbation, (P=0.17) with the composite incidence of pain attacks and exacerbation of 30% in the endotherapy group and 60% in the wait-and-see group. There were no significant differences in terms of diabetic status and the presence of steatorrhea. The thickness of the pancreas decreased significantly in the wait-and-see group (9.2-6.8 mm, P=0.041), but not in the endotherapy group (8.7-9.0 mm, P=0.60).In a small group of patients, early endotherapy in mild symptomatic chronic pancreatitis was associated with a trend toward a minor number of acute attacks and atrophy progression of the pancreas.

Background and study aims The role of the digital single-operator pancreatoscopy (D-SOP) with electrohydraulic (EHL) or laser lithotripsy (LL) in treating pancreatic ductal stones is unclear. We investigated the safety and efficacy of D-SOP with EHL or LL in patients with obstructing pancreatic duct stones. Patients and methods Retrospective analysis of 109 patients who underwent D-SOP for pancreatic stones at 17 tertiary centers in the United States and Europe from February 2015 to September 2017. Logistic regression was performed to identify factors associated with the need for more than one D-SOP with EHL/LL. Results Most patients were males (70.6 %),mean age 54.7 years. Fifty-nine (54.1 %) underwent EHL and 50 (45.9 %) underwent LL. Mean procedure time was longer in the EHL group (74.4 min vs 53.8 min; P Conclusion D-SOP with EHL or LL is effective and safe in patients with pancreatic ductal stones.

Direct endoscopic visualization of the biliary and pancreatic ducts by single-operator cholangioscopy (SOC) and pancreatoscopy (SOP) is an expanding technique with an increasing number of indications. This review provides technical tips and tricks and a literature update on the usefulness of SOC and SOP in clinical practice. SOC has shown a 91.3% and 87.3% diagnostic procedural success in indeterminate strictures and difficult stones respectively, with a 9.4%–16.4% complication rate. Although the interpretation of the images suspected for malignancy can be challenging, new classifications based in mucosal and vascular patterns as well as better devices are in development. A higher sensitivity has been associated to targeted biopsies, compared to brushing and blinded biopsies. Indeed, SOC has recently demonstrated a decrease in the number of procedures and costs when compared with endoscopic retrograde cholangiopancreatography. This technique has also been reported for many other diagnostic and therapeutic indications, such as cholangiocarcinoma staging and foreign body extraction. Similarly, diagnostic and therapeutic SOP in indeterminate strictures or pancreatic stones, and intraductal papillary mucinous neoplasms, has been successfully reported. Research to date supports the use of cholangioscopy as a complementary examination in patients with indeterminate strictures, difficult stones and specific situations. In a near future, there will probably be new established indications, a better understanding of the imaging findings and a place of SOC/SOP as first line in selected scenarios.

Background/Aims: Our study aimed to evaluate the effect of oral litholysis in patients with chronic calcific pancreatitis (CCP) unresponsive to or ineligible for extracorporeal shock wave lithotripsy (ESWL) and endoscopic therapy. Methods: Trimethadione, an antiepileptic agent, was administered orally at a dose of 0.6–0.9 g/day to 15 patients with this condition. Treatment outcome was evaluated by assessment of dissolution of the pancreatic stones on plain X-ray films and computed tomography scans of the upper abdomen. Plasma glucose, hemoglobin A1c, and body mass index (BMI) were also monitored throughout the therapy. Results: Litholysis was observed in 13 out of 15 patients (86.7%) and was definite in 10 and partial in 3. Six patients had pancreatitis attacks during the therapy; 5 of whom showed definite litholysis and had only 1 mild attack. Of the 11 patients with normal or impaired glucose tolerance at baseline, none developed diabetes mellitus and all showed litholysis. BMI significantly increased in patients whose pancreatic stones dissolved. There was no vital organ impairment by trimethadione. Conclusion: Oral litholysis using trimethadione may represent a noninvasive and effective complementary treatment in patients with CCP unresponsive to or ineligible for ESWL and endoscopic therapy.

Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) play a critical role in the diagnosis and management of benign and malignant pancreatobiliary diseases. In the last several years, role of ERCP has evolved from just a diagnostic procedure to mostly a therapeutic procedure. It plays a key role in the diagnosis of indeterminate biliary strictures and evaluation of bile leaks. Therapeutic ERCP utilizes various techniques for the extraction of biliary and pancreatic stones, management of bile leaks, and the treatment of malignant and benign strictures. EUS plays a central role in tissue acquisition for diagnostic purposes. Therapeutic applications of EUS have significantly increased in the recent years and include management of pancreatic fluid collections, pancreatic necrosis, drainage of the biliary obstruction, gall bladder drainage, and EUS-assisted ERCP. These procedures have good efficacy and acceptable side effect profile when performed by expert endoscopists at tertiary care medical centers.

BACKGROUND AND AIM Although endotherapy for pancreatic stones is less invasive compared with surgical interventions, its recurrence rate is high and residual pancreatic stones can be a cause of recurrence. We previously reported usefulness of a novel basket catheter with nitinol fine reticular structure for pancreatic stone retraction. In this retrospective study, we aimed to evaluate the long-term outcomes of endotherapy for pancreatic stones with and without the use of this dedicated basket catheter. METHODS We retrospectively compared patients with symptomatic pancreatic stones who underwent the initial endotherapy between 2008 and 2019. The primary outcome was the symptomatic recurrence after complete stone clearance. Secondary outcomes were the rate of complete stone clearance, complications, risk factors for recurrences, and the treatment cost. RESULTS A total of 101 patients who underwent endotherapy for pancreatic stones were analyzed: 41 patients by using the dedicated basket catheter and 60 patients by only the conventional devices. The complete stone clearance was achieved in 87.8% in the dedicated basket group and 88.3% in the conventional device group. Symptomatic recurrence was observed in 16.7% of the dedicated basket group and 47.2% of the conventional device group (P

Pancreatic calculi are typically a sequela of chronic pancreatitis. Here, we present a patient who was found to have an obstructing one-centimeter pancreatic calculus secondary to recurrent gallstone pancreatitis. Recent retrospective studies have focused on the optimal treatment of large pancreatic calculi that were defined as greater than five millimeters. But most studies fail to comment on much larger stone as in this case report. Further guidelines and investigation need to be done aiming toward the optimal treatment of relatively large pancreatic stones.

Objectives The aim of this study was to establish a standard to describe the spatial distribution of pancreatic stones in chronic pancreatitis (CP). Methods Two hundred forty-seven CP patients with pancreatic stones from June to December 2012 were enrolled. Two-dimensional images from coronal projection of 3-dimensional computed tomography images of pancreatic stones were gained. The number (n) of all stones and the geometric standard deviation (σ) of distances between the centroid of all stones and the centroids of every stone that represented the spatial distribution nonuniformity were calculated by Stone Reconstruction and Identification Programming System. Results The mean value of n and σ were 13.6 and 22.5; n > 13.6 and σ > 22.5 were determined as "multistones" and "nonuniform," respectively. Compared with alcoholic CP, idiopathic CP was less prone to multistones (odds ratio [OR], 0.310) and more prone to nonuniform (OR, 3.247). Pancreatic pseudocyst (OR, 2.211) in CP course was a risk factor of multistones, whereas diabetes mellitus in first-/second-/third-degree relatives (OR, 0.382) was a protective factor. Age at diagnosis of pancreatic stones (OR, 1.022) was a risk factor of nonuniformity. Conclusions Compared with idiopathic CP, alcoholic CP patients were prone to more pancreatic stones that distribute more uniformly.

Pancreatic duct stones are sequela of chronic pancreatitis. They can cause pancreatic duct obstruction which is the most important cause of pain in chronic pancreatitis. Stone resolution has shown to improve pain. The goal of this review is to highlight recent endoscopic and surgical advancements in treatment of pancreatic duct stones. Stone fragmentation by extracorporeal shock wave lithotripsy has become first line and the mainstay of treatment for majority of patients with pancreatic duct stones. Introduction of digital video pancreatoscopy in the last few years with the capability of guided lithotripsy has provided a robust therapeutic option where extracorporeal shock wave lithotripsy is unsuccessful or unavailable. Historically, surgery has been considered a more reliable and durable option when feasible. However, it had not been compared with more effective endoscopic therapy. Lithotripsy (extracorporeal and pancreatoscopy guided) is evolving as a strong treatment modality for pancreatic stones.

Pancreatic extracorporeal shock wave lithotripsy (P-ESWL) has been recommended for the management of large pancreatic stones. It is considered to be a noninvasive and low morbidity procedure. However, despite its minimal invasiveness, it does have complications.

Aim. To determine surgical tactics and principles of preferential surgical intervention for chronic calculous pancreatitis based on assessment of results of various approaches and methods of surgical correction. Material and Methods. Since January 1989 till March 2016 475 patients were treated. There were 234 draining, 15 resection-draining operations and 14 resections. In 174 patients (36.6%) 2 or more operations were executed due to ineffective primary intervention. Results. Two patients died after draining operations. After draining operations the incidence of early and long-term postoperative complications was 10.3% and 23.9% respectively, after resection-draining operations – 6.7% and 13.3%; after resections – 21.4% and 78.6%. Obstructive jaundice was not observed after resection-draining operations. One patient had pancreatic diabetes and recurrent abdominal pain. Topographic and anatomical features of calculous pancreatic changes were established. Ductal hypertension is accompanied by its enlargement in 75.9% of patients. Pancreatic stones are predominantly localized in glandular head along anterior surface. Virsungolithiasis was noted in 20–25% of patients. Conclusion. Parenchyma-sparing interventions are more effective compared with resections. In our opinion, the most advisable surgery for chronic calculous pancreatitis are resection-draining operations including longitudinal pancreaticocystojejunostomy by Frey’s procedure type supplemented by contact ultrasound lithotripsy. It is suggested clinical classification of chronic calculous pancreatitis that should be kept in mind to determine surgical tactics.

AIM To evaluate the endoscopic treatment efficacy and prognostic factors of long-term response to treatment for painful chronic pancreatitis. METHODS This retrospective analysis identified 168 patients with painful chronic pancreatitis hospitalized during January 2010-January 2015 in a Romanian tertiary referral center. Data on demographics, medical history, alcohol consumption, smoking habit, clinical parameters, type and number of endoscopic procedures and hospital admissions number were collected from the medical charts and analyzed. The absence or substantial reduction of pain (mild pain) at the end of the follow-up associated with the technical success of endotherapy was considered as clinical success. RESULTS Among the 168 patients with painful chronic pancreatitis admitted to our department during the study period, 39 (23.21%) had optimal response to the medical therapy. One hundred and twenty-nine patients required endoscopic treatment. The median follow-up period was 15 mo (range, 0-60 mo). Overall, technical success of endotherapy was achieved in 105 patients (81.39%). More than two-thirds of patients (82.78%) had substantial improvement of pain after the endoscopic treatment, including frequency and severity of the pain attacks. Patients younger than 40 years had significantly more successful endoscopic procedures (P = 0.041). Clinical success was higher in non-smoking patients (P = 0.003). The hospital admission rate was higher in patients with recognized alcohol consumption (P = 0.03) and in smokers (P = 0.027). The number and location of pancreatic stones and locations of strictures did not significantly influence the technical success (P > 0.05) or the clinical success (P > 0.05). CONCLUSION Younger age than 40 years can be considered an important factor positively influencing endoscopic treatment outcome in patients with painful chronic pancreatitis.

Background and aims Pancreatic extracorporeal shock wave lithotripsy (P-ESWL) is recommended as the first-line treatment for pancreatic stones. However, how well P-ESWL performs in pediatric patients remains unclear. We aimed to evaluate the safety and efficacy of P-ESWL for pediatric patients with chronic pancreatitis. Methods This prospective observational study was conducted in patients with painful chronic pancreatitis who underwent P-ESWL. Patients aged under 18 years were included in the pediatric group; patients aged over 18 years who underwent P-ESWL in the same period were assigned to the control group. For investigation of long-term follow-up, the pediatric group were matched with patients from the control group in a 1:1 ratio. The primary outcomes were P-ESWL complications and pain relief. The secondary outcomes included: stone clearance, physical and mental health, quality of life score, and growth and developmental state. Results From March 2011 to March 2015, P-ESWL was performed in 1135 patients (72 in the pediatric group, 1063 in the control group). No significant differences were observed in the occurrence of P-ESWL complications between the two groups (11.1 % vs. 12.8 %; P = 0.68). Among the 67 pediatric patients (93.1 %) who underwent follow-up for 3.0 years (range 1.3 – 5.2), complete pain relief was achieved in 52 patients (52 /67; 77.6 %); this value was not significantly different from that of the matched controls (55 /69; 79.7 %; P = 0.94). Conclusions P-ESWL is safe and effective for pediatric patients with chronic pancreatitis. It can promote significant pain relief and stone clearance, and can benefit growth and development.

A 43-year-old female with hereditary chronic pancreatitis presented with increasing pancreatic pain and multiple pancreatic stones, despite extracorporeal shockwave lithotripsy and pancreatic stenting 12 months previously. Direct lithotripsy was performed via endoscopic retrograde cholangio-pancreatography and the stones were further evaluated.