review of literature on clinical pancreatology - The Pancreapedia

Precut at sphincterotomyPrecut is performed when biliary access at endoscopic retrograde cholangiopancreatography(ERCP) fails. Precut may have adjunctive risks, but some authors have suggested that theattempts to cannulate the papilla that precede precutting cause complications. It wastherefore evaluated the role <strong>of</strong> the timing <strong>of</strong> precut in determining the development <strong>of</strong>complications and with respect to the other factors involved. During ERCP, after 10 min <strong>of</strong>attempts to cannulate, patients were randomized to an early-precut group (n=77) undergoingprecut immediately or a late-access group (n=74) in which cannulation was attempted for 10further minutes before the endoscopist was free to perform precut or to persist incannulation. Occurrence <strong>of</strong> complications and the associated risk factors were recorded. Thetwo groups were similar for general characteristics. The number <strong>of</strong> attempts to cannulate, thenumber <strong>of</strong> pancreas injections, and the incidence <strong>of</strong> acinarization were higher in the lateaccessgroup. The cannulation rate was 94 percent. The incidence <strong>of</strong> overall complicationswas similar, but the pancreatitis rate was higher in the late-access group (14.9 vs 2.6 %).Amylase levels increased by 399 + 879 in the early-precut group and 834 + 1478 in the lateaccessgroup, which was a significant difference. Nondilated bile duct and pancreaticinjection were related to the development <strong>of</strong> pancreatitis, whereas the performance <strong>of</strong> precutwas related to other complications. The authors concluded that early precut is associatedwith lower pancreatitis rate, suggesting that pancreatitis develops as a consequence <strong>of</strong> theattempts to cannulate the papilla and pancreatic injection, and not pre-cutting [200].ERCP in severe biliary pancreatitisPrevious studies have included only a relatively small number <strong>of</strong> patients with predictedsevere acute biliary pancreatitis in most studies. It was now again investigated the clinicaleffects <strong>of</strong> early ERCP in these patients in a prospective, observational multicenter study in 8university medical centers and 7 major teaching hospitals. One hundred fifty-three patientswith predicted severe acute biliary pancreatitis without cholangitis were enrolled in arandomized multicenter trial on probiotic prophylaxis in acute pancreatitis and wereprospectively followed. Conservative treatment or ERCP within 72 hours after symptomonset (at discretion <strong>of</strong> the treating physician) were compared for complications and mortality.Patients without and with cholestasis (bilirubin: >2.3 mg/dL and/or dilated common bile duct)were analyzed separately. Of the 153 patients, 81 (53 %) underwent ERCP and 72 (47 %)conservative treatment. Groups were highly comparable at baseline. Seventy-eight patients(51 %) had cholestasis. In patients with cholestasis, ERCP (52/78 patients: 67 %), ascompared with conservative treatment, was associated with significantly fewer complications(25 % vs 54 %). This included significantly fewer patients with >30 percent pancreaticnecrosis (8 % vs 31 %). Mortality was nonsignificantly lower after ERCP (6 % vs 15 %). Inpatients without cholestasis, ERCP (29/75 patients: 39 %) was not associated with reducedcomplications (45 % vs 41 %) or mortality (14 % vs 17 %). It was concluded that early ERCPis associated with fewer complications in predicted severe acute biliary pancreatitis ifcholestasis is present [201].Value <strong>of</strong> EUSWhen conventional ERCP methods fail because <strong>of</strong> periampullary or ductal obstruction, EUSguidedcholangiopancreatography (EUS-CP) may aid in pancreaticobiliary access.Consecutive patients undergoing EUS-CP were prospectively identified. These patients hadundergone failed attempt(s) at therapeutic ERCP. Technical success was decompression <strong>of</strong>the duct <strong>of</strong> interest. Clinical success was resolution <strong>of</strong> jaundice or at least a 50 percentreduction in pain or narcotics, as applicable. Between 2003 and 2007, EUS-CP wasattempted in 20 patients (11 men, 9 women age 58 years). Indications included jaundice(n=8), biliary stones (n=3), chronic pancreatitis (n=6), acute pancreatitis (n=2), and papillarystenosis (n=1). Reasons for failed ERCP included periampullary mass (n=8), intradiverticularpapillae (n=4), and pancreatic duct stricture (n=7) or stone (n=1). Technical success wasachieved in 18 <strong>of</strong> 20 patients (90 %). Biliary decompression was obtained in 11 <strong>of</strong> 12 patients(92 %) (7 transpapillary and 4 transenteric-transcholedochal). Pancreatic decompression