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BACKGROUND: Precut over a pancreatic duct stent (PPDS) and transpancreatic precut sphincterotomy (TPS) with immediate pancreatic duct stent placement are techniques employed to promote biliary access during endoscopic retrograde cholangiopancreatography (ERCP) in cases of challenging biliary cannulation. However, limited data are available to compare the efficacy of these two pancreatic stent-assisted precut sphincterotomy techniques. AIMS: The aim of this study was to compare the efficacy of PPDS versus TPS. METHODS: A retrospective analysis was performed on the clinical data of consecutive patients who underwent ERCP between April 1, 2019 and May 31, 2023. According to the selected cannulation approaches, patients were assigned to two groups. In the PPDS group, a pancreatic duct stent was initially placed, followed by needle-knife precut over the stent. In the TPS group, transpancreatic precut sphincterotomy was initially performed, followed by immediate pancreatic stent placement. The success rate of biliary cannulation and the incidence of post-ERCP pancreatitis (PEP) between the two groups were analysed. RESULTS: Among 864 patients who underwent ERCP, 46 patients were equally enrolled in the two groups. Selective bile duct cannulation was successfully achieved in 42 out of 46 (91.3%) cases using the PPDS and in 32 out of 46 (69.6%) cases using TPS technique alone, indicating significantly higher success rate of bile duct cannulation with PPDS compared to TPS (91.3% vs. 69.6%, P = 0.009). The overall success rates for bile duct cannulation were 93.5% and 97.8% in the PPDS and TPS groups, respectively, with no significant difference identified (P = 0.307). PEP occurred in 0 and 4 (8.7%) cases in the PPDS and TPS groups, respectively, with no significant difference between the two groups (8.7% vs. 0%, P = 0.117). There were no cases of bleeding or perforation in either group. CONCLUSIONS: Both PPDS and TPS followed by immediate pancreatic duct stent placement are viable options. TPS stands out for its simplicity and cost-effectiveness, while PPDS is more appropriate for patients who are at a high-risk of developing PEP.

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Background: Early-stage ampullary adenomas have only been reported in a small case series on endoscopic management. Hence, this study aimed to evaluate the long-term outcomes of early ampullary adenoma with endoscopic management and identify the risk factors for acute pancreatitis after endoscopic papillectomy (EP). Methods: In this study, 115 patients who underwent EP at Changhai Hospital (Shanghai, China) between January 2012 and December 2018 were retrospectively analysed. Endoscopy was performed at 1, 3, 6, and 12 months after EP. Data were statistically analysed using the t-test or the Mann-Whitney U test. Results: A total of 107 patients were included in this study and the follow-up period was 75 ± 43 months. The average age of the 107 patients was 54.6 years and the average tumor size was 17 mm. The average age of the patients (53.7 ± 10.7 years vs 55.2 ± 10.5 years, P = 0.482), minimum tumor size (13 vs 19 mm, P = 0.063), and complete resection rate (84.78% vs 85.25%, P = 0.947) did not differ significantly between the stent placement and non-stent placement groups. Post-EP acute pancreatitis rates in the non-stent placement and stent placement groups were 11.48% and 4.35%, respectively. The risk of post-EP acute pancreatitis was significantly associated with the preoperative carcinoembryonic antigen level in univariate analysis, but not in multivariate analysis. The risk of post-EP acute pancreatitis was not significantly associated with the placement of the pancreatic stent in either univariate or multivariate analysis. Moreover, delayed proximal pancreatic duct stenosis was not noted in either group during long-term follow-up. Conclusions: EP is a satisfactory option for treating adenomas of the ampulla of the duodenum.

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BACKGROUND AND AIMS: Standard endotherapy for pancreatic duct (PD) disruption is pancreatic stenting and sphincterotomy. In patients refractory to standard treatment, treatment algorithm is currently not standardized. This study aims to report the 10-year experience with the endoscopic treatment of postoperative or traumatic PD disruption and to share our algorithmic approach. METHODS: This retrospective study was conducted on 30 consecutive patients who underwent endoscopic treatment for postoperative (n = 26) or traumatic (n = 4) PD disruption between 2011 and 2021. Standard treatment was initially applied to all patients. Endoscopic modalities used with a step-up approach in patients unresponsive to standard treatment were stent upsizing and N-butyl-2-cyanoacrilate (NBCA) injection for partial disruption, and the bridging of the disruption with a stent and cystogastrostomy for complete disruption. RESULTS: PD disruption was partial in 26 and complete in 4 patients. Cannulation and stenting of PD was successful in all patients and sphincterotomy was performed in 22 patients. Standard treatment was successful in 20 patients (66.6%). The resolution of PD disruption in 9 of 10 patients refractory to standard treatment was achieved with stent upsizing in 4, NBCA injection in 2, the bridging of the complete disruption in one, and cystogastrostomy after spontaneously and intentionally developed pseudocyst in one patient each. Overall, therapeutic success rate was 96.6% (100% for partial, 75% for complete disruption). Procedural complications occurred in 7 patients. CONCLUSIONS: Standart treatment for PD disruption is usually effective. In patients refractory to standard treatment, the outcome may be improved by step-up approach using alternative endoscopic modalities.

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PURPOSE: This study aimed to reveal the role of preoperative main pancreatic duct (MPD) stent placement in reducing the intraoperative main pancreatic duct injury rate and the incidence of postoperative pancreatic leakage following pancreatic tumor enucleation. METHODS: A retrospective cohort analysis was performed for all patients with benign/borderline pancreatic head tumors who were treated with enucleation. The patients were divided into two groups (standard vs. stent) depending on whether they underwent main pancreatic duct stent placement prior to surgery. RESULTS: Thirty-three patients were finally included in the analytical cohort. Compared with the standard group, patients in the stent group had a shorter distance between tumors and main pancreatic duct (p=0.01) and presented with larger tumors (p<0.01). The rates of POPF (grade B&C) were 39.1% (9/23) and 20% (2/10) in the standard and stent groups, respectively (p<0.01). Major postoperative complications occurred more frequently in the standard group than in the stent group (14 versus 2; p<0.01). No significant differences in mortality, in-hospital stay or medical cost were observed between the two groups (p>0.05). CONCLUSIONS: MPD stent placement prior to surgery may facilitate pancreatic tumor enucleation, minimize MPD injury and decrease the occurrence of postoperative fistula.

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Several pancreatitis-related genetic variants have been identified. Recently, the association of loss-of-function variants in the transient receptor potential cation channel subfamily V member 6 (TRPV6) gene and early-onset non-alcoholic chronic pancreatitis (CP) has been reported. However, detailed clinical presentation of the cases carrying TRPV6 variants remains largely unknown. We report a case of early CP carrying a TRPV6 variant in which recurrent attacks of pancreatitis were successfully managed by pancreatic duct stenting. A 12-year-old boy with CP was referred to our hospital for further investigation. He had experienced recurrent pancreatitis attacks since he was 11 years old. Pancreatic ductal anomalies were not identified on magnetic resonance cholangiopancreatography. Genetic analysis revealed that the patient had a loss-of-function TRPV6 c.1448G > A (p.R483Q) variant in a heterozygous form. Conservative treatments were not effective; thus, we placed pancreatic duct stent by endoscopic intervention, and the frequency of relapses have dramatically decreased. We present the first pediatric report of early CP associated with the TRPV6 variant that was successfully treated with pancreatic duct stenting. This case suggests that pancreatic duct stenting is effective in preventing the relapse of pancreatitis related to the TRPV6 variant.

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Objective:To explore the preventive effects of pancreatic duct stent combined with rectal administration of indomethacin suppository for post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) after difficult bile duct intubation during endoscopic retrograde cholangiopancreatography (ERCP).Methods:From January 2019 to December 2021, patients with biliary and pancreatic diseases undergoing ERCP in Hangzhou Hospital Affiliated to Nanjing Medical University were given 100 mg indomethacin suppository to anal canal 30 minutes before the operation. And those with difficult bile duct intubation during the operation ( n=204) were included in this study. According to the random number table, they were divided into the combination group (implanted with pancreatic duct stent during the operation, n=104) and the indomethacin group (not implanted with stent, n=100). The incidences of hyperamylasemia and PEP were compared between the two groups. Results:The incidences of postoperative hyperamylasemia [21.2% (22/104) VS 34.0% (34/100), χ2=4.22, P=0.040] and PEP [14.4% (15/104) VS 32.0% (32/100), χ2=8.88, P=0.003] in the combination group were significantly lower than those in the indomethacin group. There was no significant difference in the incidence of severe PEP between the two groups [1.0% (1/104) VS 1.0% (1/100), χ2=0.001, P=0.978]. Conclusion:Compared with rectal administration of indomethacin suppository alone, the incidences of hyperamylasemia and PEP after difficult bile duct intubation during ERCP can be further reduced when it is combined with pancreatic duct stent placement.

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Endoscopic ultrasonography guided pancreatic duct drainage (EUS-PD) is a novel therapeutic strategy for pancreatic duct obstruction-induced high-pressure pancreatic duct. The success rate of EUS-PD has been steadily going up due to the continual improvement of technique, while the adverse events have been steadily decreasing. As a consequence of this, EUS-PD has developed into a reliable alternative to endoscopic retrograde cholangiopancreatography in cases where the latter has been unsuccessful. The authors review the research progress on EUS-PD by reviewing relevant literature and combining clinical practices.

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Pancreatic duct (PD) stent migration is among the recognized complications of endoscopic retrograde cholangiopancreatography (ERCP) with PD stent placement. Proximal stent migration poses a challenge for removal due to risks of PD damage, smaller caliber, and possible stricture. Here, we present a case of SpyGlass DS system-assisted PD stent repositioning after failure with traditional tools.

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Background: Pancreatitis is one of the most crucial complications following endoscopic retrograde cholangiopancreatography (ERCP). The purpose of the current study was to investigate patient-related post-ERCP pancreatitis (PEP) risk factors in two groups of patients: prophylactic pancreatic stent and rectal indomethacin. Methods: Two different prophylactic modalities were planned and complications were assessed based on the defined inclusion criteria. In this study, the patients were evaluated for the procedure and patient-related risk factors in post-ERCP pancreatitis in the recipient groups of the prophylactic pancreatic stent and rectal indomethacin. Results: Pancreatitis was confirmed in 27 of all 170 selected patients after ERCP. By univariate analysis, two variables were significant with the development of PEP. Regarding the patient-related risk factors, unique subjects with common bile duct (CBD) dilated 10mm were more exposed to an increased chance of PEP (P=0. 015); meanwhile, other factors did not correlate with the increased possibility of PEP in both groups. The only procedure-related risk factor for PEP was the deep cannulation of the pancreatic duct in both groups during the procedure with an incremental significant incidence of pancreatitis (P=0.005). Comparison of prophylactic pancreatic stent and rectal indomethacin showed no effects in term of post ERCP pancreatitis reduction. Additionally, there was no significant difference between these two strategies in the rate of PEP. Conclusion: Prophylactic pancreatic duct stents and administration of rectal indomethacin cannot have particular approaches for reducing the possible occurrence of PEP. The increase in time of deep cannulation and the presence of CBD dilation <10mm could be considered as important risk factors.

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PURPOSE: To evaluate the effectiveness of pancreatic duct stent placement for preventing postoperative pancreatic fistula after pancreaticoduodenectomy. METHODS: PubMed, the Cochrane Central Register of Controlled Trials, Embase and ClinicalTrials.gov databases were searched up to February 26, 2022. Studies comparing outcomes following pancreaticoduodenectomy with or without pancreatic duct stents were included. The primary outcome measured was postoperative pancreatic fistula rate, and secondary outcomes were in-hospital mortality rate, reoperation rate, delayed gastric emptying rate and wound infection rate. RESULTS: Seven RCTs involving 847 patients met the inclusion criteria. No statistically significant difference between the stent group and non-stent group was detected in the incidence of postoperative pancreatic fistula (RR = 0.85, 95%CI: 0.57-1.26, P = 0.41), in-hospital mortality, reoperation, delayed gastric emptying rate and wound infection. Subgroup analyses revealed that use of an external stent significantly reduced the incidence of pancreatic fistula (RR = 0.61, 95%CI: 0.43-0.86, P = 0.005). CONCLUSIONS: Our preliminary results from this systematic review and meta-analysis revealed that pancreatic duct stents did not reduce the risk of POPF and other complications after pancreaticoduodenectomy compared with no stents. External stents were associated with a reduced POPF rate compared with no stents. Large-scale RCTs are required to assess the effectiveness and assist in clarifying the real role of pancreatic duct stents with respect to the POPF rates after pancreaticoduodenectomy.

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BACKGROUND: Outcomes of pancreaticojejunostomy without pancreatic duct during open pancreaticoduodenectomy (OPD) are unknown and controversial, and corresponding reports in laparoscopic surgery are lacking. METHODS: Patients were evaluated at West China Hospital, and standard laparoscopic pancreaticoduodenectomy (LPD) was planned. A prospective randomized trial was conducted, in which the patients were randomly assigned to the no-stent and internal-stent groups in a single-center trial. The primary outcomes were the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) and 90-day mortality. Preliminary results were reported. RESULTS: From November 2019 to March 2021, we enrolled 90 patients (41 in the no-stent group and 49 in the internal-stent group) in the study. All baseline parameters of both groups, including age, sex ratio, pancreatic duct diameter, and intraoperative blood loss, were comparable between the two groups except for pathological diagnosis and the texture of remnants. Twenty-seven (65.9%) and 19 (38.8%) patients in the no-stent and internal-stent groups, respectively, had soft pancreatic remnants (P = 0.010). The total incidence of CR-POPF was 5.6% and included two patients (4.9%) in the no-stent group and three patients (6.1%) in the internal-stent group (P = 1.000). Only one patient in the internal-stent group died of heart failure within 90 days after the operation. No significant difference in other postoperative complications was observed between the groups except for biochemical fistula [no-stent group vs. internal-stent group = 31.7% vs. 12.2%, (P = 0.024)]. CONCLUSIONS: In a high-volume LPD center, duct-to-mucosa pancreaticojejunostomy without pancreatic duct stent is safe and reliable. In addition, duct-to-mucosa pancreaticojejunostomy without pancreatic duct stent was more challenge. We recommend using the stent during anastomosis and pulling it out after the procedure.

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BACKGROUND: Postoperative Pancreatic Fistula (POPF) development remains a challenge after pancreaticoduodenectomy, occurring in 3-45% of cases [1]. The placement of a trans-anastomotic Wirsung stent is usually done in high-risk patients to decrease incidence and severity of POPF. METHODS: Herein, we present a fully robotic pancreaticoduodenectomy with a biodegradable ductal stent interposition in a 47 y.o. female with a main duct IPMN of the pancreatic head and a fistula risk score of 6 (Moderate-risk). VIDEO: After gastrocolic ligament division and hepatic flexure and duodenum mobilization, the loco-regional lymphadenectomy was performed. Following gastric transection with endo-GIA, the bile duct and gastroduodenal artery have been divided, and the cholecystectomy performed. The neck of the pancreas has been transected, the jejunum divided with endo-GIA and mobilized from the Treitz ligament, and the uncinate process dissected from the mesenteric vessels. A Blumgart anastomosis has been performed between the soft-texture pancreatic stump and the jejunal loop with the interposition of a 6 Fr/60 mm long, medium degrading stent (20 days) in the 2 mm duct (Archimedes BPS®, AMG Int., Winsen-Germany). The hepatico-jejunostomy and gastro-jejunostomy have been performed distally on the same loop. Three abdominal drains have been positioned. RESULTS: Surgery lasted 480 min, with 175 mls blood loss. The patient postoperatively developed a biochemical leak and was discharged home by day 12. She was readmitted a month later for an amylase-negative intra-abdominal abscess that was successfully treated with percutaneous drainage. CONCLUSION: Biodegradable pancreatic stent positioning could be an effective strategy in reducing POPF occurrence in high-risk patients.

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INTRODUCTION: Pancreatic duct stents are widely used to reduce the incidence of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD); however, small stents may cause adverse effects, such as occlusion. Recently, we have tried placing a 7.5-Fr pancreatic duct stent to achieve more effective exocrine output from the pancreas; however, the association between pancreatic duct stent size and POPF remains unknown. METHODS: Sixty-five patients with soft pancreatic texture who underwent PD were retrospectively analyzed. After dividing the pancreas, a pancreatic duct stent (stent size 4.0 in 29 patients, 5.0 in 18, and 7.5 Fr in 18) was placed in the main pancreatic duct. RESULTS: Twenty-five of 65 patients with soft pancreatic texture (38.5%) developed POPF. POPF became less frequent as the pancreatic duct stent size increased (p = 0.003). The factors associated with POPF development were a 7.5-Fr pancreatic duct stent (p = 0.005), 5.0-Fr pancreatic duct stent (p = 0.031), and male sex (p = 0.008). Pancreatic duct stent size and pancreatic duct diameter did not differ between the POPF and non-POPF groups. DISCUSSION/CONCLUSIONS: In patients with a soft pancreas, the placement of a 7.5-Fr pancreatic duct stent may reduce the incidence of POPF.

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Long-term placement of non-degradable silicone rubber pancreatic duct stents in the body is likely to cause inflammation and injury. Therefore, it is necessary to develop degradable and biocompatible stents to replace silicone rubber tubes as pancreatic duct stents. The purpose of our research was to verify the feasibility and biological safety of extrusion-based 3D printed radiopaque chitosan (CS) ducts for pancreaticojejunostomy. Chitosan-barium sulfate (CS-Ba) ducts with different molecular weights (low-, medium-, and high-molecular weight CS-Ba: LCS-Ba, MCS-Ba, and HCS-Ba, respectively) were soaked in vitro in simulated pancreatic juice (SPJ) (pH 8.0) with or without pancreatin for 16 weeks. Changes in their weight, water absorption rate and mechanical properties were tested regularly. The biocompatibility, degradation and radiopaque performance were verified by in vivo and in vitro experiments. The results showed that CS-Ba ducts prepared by this method had regular compact structures and good molding effects. In addition, the lower the molecular weight of the CS-Ba ducts was, the faster the degradation rate was. Extrusion-based 3D-printed CS-Ba ducts have mechanical properties that match those of soft tissue, good biocompatibility and radioopacity. In vitro studies have also shown that CS-Ba ducts can promote the growth of fibroblasts. These stents have great potential for use in pancreatic duct stent applications in the future.

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BACKGROUND: The prognostic value of external vs internal pancreatic duct stents after pancreaticoduodenectomy remains controversial. This study aimed to evaluate the benefits of external and internal stents using the Fistula Risk Score system with regard to the incidence of clinically relevant postoperative pancreatic fistula. METHODS: A total of 382 patients who underwent pancreaticoduodenectomy with duct to mucosa pancreaticojejunostomy were retrospectively enrolled from January 2015 to October 2019. The receiver operating characteristic curve was performed for subgroup analysis of the patients at different levels of risk for pancreatic fistula. RESULTS: There were no significant differences in terms of pancreatic fistula or other postoperative complications. According to the receiver operating characteristic curve threshold of 3.5, 172 patients with a Fistula Risk Score ≥ 4 and 210 patients with a Fistula Risk Score < 4 were divided into separate groups. The number of valid cases was insufficient to support the subsequent research in patients with a Fistula Risk Score < 4. In patients with a Fistula Risk Score ≥ 4, the use of an external pancreatic duct stent was significantly more effective than the use of an internal stent, especially with regard to the risk for pancreatic fistula (Grade C) (P = 0.039), at ameliorating the incidence of clinically relevant postoperative pancreatic fistula (P = 0.019). Additionally, the incidence of lymphatic leakage was significantly higher in the external stent group compared with the internal stent group (P = 0.040). CONCLUSIONS: Compared with internal stents, the use of an external stent could reduce the incidence of clinically relevant postoperative pancreatic fistula in patients with a Fistula Risk Score ≥ 4. More large-scale prospective clinical trials are warranted to further clarify our results.

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BACKGROUND: There is no specific evidence regarding the benefits of external and internal pancreatic duct stents after pancreaticoduodenectomy since pancreatic fistula (grade A) have been redefined with no clinical treatment effect. We aimed to reevaluate the prognostic value of external and internal stents in clinically relevant postoperative pancreatic fistula over pancreaticoduodenectomy. METHODS: PubMed, Web of Science, EMBASE and the Cochrane Database were specifically searched for pertinent and original articles published before May 2019. The project has been registered in PROSPERO (Registration number: CRD42019137579). RESULTS: Four randomized controlled trials and six nonrandomized controlled trials with a total of 2101 patients were enrolled in this meta-analysis. The use of an external stent resulted in better performance than the use of an internal stent in terms of pancreatic fistula (grade C) (OR 0.58, P = 0.03) but did not reduce the rate of pancreatic fistula (grade B) (OR 0.99, P = 0.94) in all studies. The meta-analysis of randomized controlled trials found that the use of an external stent approached a level of significance for an increased rate of clinically relevant postoperative pancreatic fistula compared to the use of an internal stent (OR 1.40, P = 0.10) but had no significant effect on pancreatic fistula (grade B) (OR 1.34, P = 0.26) or pancreatic fistula (grade C) (OR 1.68, P = 0.62). CONCLUSION: Compared with internal stents, the use of external stent might be associated with a lower rate of pancreatic fistula (grade C). More randomized clinical trials are warranted to further explore safety and efficacy of pancreatic duct external stents.

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Objective:To investigate the clinical efficacy of early pancreatic duct stenting in the treatment of acute pancreatitis.Methods:The retrospective and descriptive study was conducted. The clinical data of 201 patients with acute pancreatitis who were admitted to General Hospital of Ningxia Medical University from October 2011 to December 2017 were collected. There were 106 males and 95 females, aged from 18 to 90 years, with a median age of 62 years. Of 201 patients, there were 178 cases with moderate severe acute pancreatitis and 23 cases with serious severe acute pancreatitis. Patients were treated with pancreatic duct stenting within 48 hours after admission. Observation indicators: (1) treatment; (2) follow-up. Follow-up was conducted using outpatient examination and telephone interview to detect recurrence of acute pancreatitis after surgery up to June 2019. Measurement data with normal distribution were represented by Mean± SD, and the independent sample t test was used for comparison between groups, and the matched samples t test was used for comparison between before and after. Measurement data with skewed distribution were represented by M( P25 ,P75) or M(range), and the Mann-Whitney U test was used for comparison between groups, and the Wilcoxon signed rank sum test was used for comparison between before and after. Count data were expressed as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test . Results:(1) Treatment: 201 patients received pancreatic duct stenting successfully, 63 of which were detected pancreatic obstruction with white-floc. The interval time from admission to surgery , operation time, time for initial oral intake, duration of hospital stay and hospital expenses of 201 patients were 10 hours(4 hours,22 hours), (35±15)minutes, 3 days(2 days,5 days), 6 days(5 days,10 days) and 3.8×10 4 yuan (3.0×10 4 yuan,4.9×10 4 yuan). Of 201 patients, 22 patients were transferred to intensive care unit, including 1 case with serious severe underwent inhospital death and 1 case with moderate severe and 7 cases with serious severe underwent auto-discharge from hospital. There were 25 cases with local complications, including 17 cases with pancreatic infectious necrosis, 7 cases with pancreatic walled-off necrosis and 1 case with spleen infarction. All 25 patients were cured after surgical inter-vention or conservative treatment. Further analysis showed that cases being transferred to intensive care unit, cases undergoing surgical treatment, the time for initial oral intake, duration of hospital stay and cases undergoing auto-discharge from hospital were 6, 11, 3 days(2 days,5 days), 6 days(5 days,10 days) and 1 for the 178 moderate severe cases, versus 16, 5, 7 days(4 days,9 days), 9 days (7 days,17 days) and 7 for the 23 serious severe cases, showing significant differences ( χ2=91.561, 6.730, Z=6.485, 5.463, χ2=47.561, P<0.05). The white blood cell count, serum amylase indexes and chronic health evaluation Ⅱ score of 201 patients were (14±6)×10 9/L, 928 U/L(411 U/L,1 588 U/L), 9±5 before admission, versus (10±4)×10 9/L, 132 U/L(72 U/L,275 U/L), 6±4 at 48 hours after admission, respectively, showing significant differences ( t=12.219, Z=11.639, t=16.016, P<0.05). (2) Follow-up: of 201 patients, 153 cases were followed up for 40 months (27 months,55 months). During the follow-up, 32 of the 153 cases had recurrence of acute pancreatitis. Conclusion:Early pancreatic duct stenting is safe and feasible in the treatment of acute pancreatitis.