Endoscopic ultrasound-guided diagnosis and therapy in pancreatic disease.
Soetikno RM. Chang K.
Gastroenterology Division, Brigham and Women's Hospital, Boston, Massachusetts, USA.
The role of endoscopic ultrasound (EUS) in the detection and staging of pancreatic cancer is well established in medical literature. The development of EUS-guided fine needle aspiration (FNA) and subsequently EUS-guided fine needle injection (FNI) has expanded the clinical utility of EUS. These newer techniques made "interventional" EUS possible. Several recent applications of EUS-guided FNI include celiac nerve block, pseudocyst drainage, and drug delivery into pancreatic tumors. EUS is also gaining acceptance as an alternative diagnostic modality in the management of choledocholithiasis. The value of EUS in the diagnosis of early chronic pancreatitis is still being actively studied. This article reviews a number of recent developments in EUS-guided diagnosis and therapy with an emphasis on EUS-guided FNA and EUS-guided FNI.
Endoscopic measurement of pancreatic blood flow.
Lo SK. Sherman S. Reber HA.
University of California at Los Angeles, Los Angeles, CA, USA.
A reduction of pancreatic blood flow has been observed in acute and chronic pancreatitis in animal models. Most available blood flow techniques are either too invasive or impractical to carry out in humans. Since the arrival of endoscopic retrograde cholangiopancreatography (ERCP), our understanding and management of pancreatic disorders has gradually improved. It may now be utilized to investigate what is believed to be a very important factor in the pathogenesis of pancreatic disease and symptoms: pancreatic tissue perfusion.
Tissue sampling at ERCP in suspected pancreatic cancer.
Lee JG. Leung J.
Division of Gastroenterology, University of California Davis Medical Center, Sacramento, California 95817, USA.
Endoscopic retrograde cholangiopancreatography (ERCP) is highly sensitive at detecting abnormalities of the pancreas and the biliary tract. Radiographic findings may be highly suggestive of malignancy, but a definitive diagnosis requires examination of cellular material obtained by bile or pure pancreatic juice collection, brushing, fine needle aspiration, or biopsy.This article reviews the general concepts of diagnostic testing and its interpretation, as well as specific results of the various methods used during ERCP to obtain tissue samples.
Endoscopic therapy of pancreatic disease in children.
Gastroenterology Department, Hospital General del Oeste, MSAS, Los Magallanes de Catia, Caracas, Venezuela.
The advent of endoscopic retrograde cholangiopancreatography (ERCP) has revolutionized the approach to the diagnosis and management of pancreatic disorders in adults. In the past 5 years, endoscopic pancreatic therapy in children has moved from an investigational concept to a practical service provided by specialized centers. When performed by experienced endoscopists, therapeutic pancreatography can be successfully performed in a selected group of children with a low rate of complications.
The role of endoscopic therapy in chronic pancreatitis-induced common bile duct strictures.
Ng C. Huibregtse K.
Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
During endoscopic retrograde cholangiography, common bile duct strictures are encountered in up to 30% of patients with chronic pancreatitis. The indications for treatment of these strictures are discussed. A surgical biliodigestive anastomosis has always been the traditional treatment modality. Not all patients need treatment, however, and endoscopic biliary drainage is the treatment of choice for certain subgroups of patients.
Endoscopic management of pseudocysts of the pancreas.
Howell DA. Elton E. Parsons WG.
Division of Gastroenterology, Maine Medical Center, Portland, ME 04102, USA.
Endoscopic pseudocyst management should not be regarded as an exercise in applied technology. Rather, it is of vital importance for the clinician to be thoroughly aware of the many considerations in patient selection and to understand the available treatment alternatives prior to undertaking such a venture. Despite these considerations, it is our opinion that endoscopic pseudocyst management at present is the method of choice in the majority of patients requiring drainage of symptomatic pseudocysts.
Endoscopic pancreatic sphincterotomy: techniques and complications.
Sherman S. Lehman GA.
Division of Gastroenterology/Hepatology, Indiana University Medical Center, Indianapolis, Indiana 46202-5000, USA.
Endoscopic pancreatic sphincterotomy of the major and minor papilla has expanded our approach to the management of a variety of pancreatic disorders. Analysis of the complication rates of this therapy is difficult, however, because a variety of techniques are often used in conjunction with the pancreatic sphincterotomy. This article reviews the techniques and complications of endoscopic pancreatic sphincterotomy. Based on the currently available data, it appears that the complication rates of pancreatic sphincterotomy are probably higher than those of biliary sphincterotomy. Should application of this technique become more widespread, methods to reduce the incidence of post-procedure pancreatitis will demand further investigation.
The role of sphincter of Oddi manometry in the diagnosis and therapy of pancreatic disease.
Kuo WH. Pasricha PJ. Kalloo AN.
Division of Gastroenterology, The Johns Hopkins Hospital, Baltimore, Maryland 21287, USA.
Endoscopic manometry of the sphincter of Oddi (SO) is now an accepted technique in the diagnosis and therapy of biliary disease. Its role in the evaluation of pancreatic sphincter function for pancreatic diseases, however, is evolving.There are now preliminary data to suggest that pancreatic SO manometry may identify a subgroup of patients with pancreatic sphincter dysfunction that may benefit from endoscopic therapy. Further prospective clinical trials are sorely needed to evaluate the response of endoscopic therapy based on pancreatic SO basal pressure or pancreatic ductal pressure.
ERCP and biliary endoscopic sphincterotomy-induced pancreatitis.
Gottlieb K. Sherman S.
Division of Gastroenterology/Hepatology, Indiana University Medical Center, Indianapolis, Indiana 46202-5000, USA.
The magnitude of post-ERCP pancreatitis as a clinical and economic problem has increased, and with it the need to find ways of decreasing its incidence and severity. Furthermore, the study of post-ERCP pancreatitis is interesting as a unique model for acute pancreatitis in general. Current thinking and results of recent promising studies are reviewed.
Diagnosis and therapy of pancreas divisum.
Lehman GA. Sherman S.
Division of Gastroenterology/Hepatology, Indiana University Medical Center, Indianapolis, Indiana 46202, USA.
Pancreas divisum patients make up a small but problematic portion of ERCP cases. Minor papilla cannulation techniques have been improved. Recurrent pancreatitis patients generally benefit from minor papilla therapy. Methods to select patients who are likely to respond to invasive therapy need refinement. Clinicians and endoscopists are strongly encouraged to be cautious and conservative with this patient group until stronger data indicate optimal management schemes.
Endoscopic diagnosis and therapy of unexplained (idiopathic) acute pancreatitis.
Tarnasky PR. Hawes RH.
Digestive Health Associates of Texas, Dallas, Texas 75208-2359, USA.
A significant minority of patients with acute pancreatitis show no obvious cause for the attack during a routine evaluation.There is no consensus regarding the appropriate diagnostic and therapeutic approach in this setting. This article reviews the available data, outlines directions for further investigation, and provides recommendations for management of patients who have recovered from a prior episode of unexplained acute pancreatitis.
Endoscopic therapy of complete and partial pancreatic duct disruptions.
Section of Gastroenterology, Virginia Mason Medical Center, Seattle, Washington 98111, USA.
Although ductal disruptions are common in persistent, smoldering pancreatitis, pancreatic necrosis, or acute pancreatic fluid collections, chronic pancreatic fistulas have traditionally been defined as internal or external. Closure of these fistulas depends upon site and size of duct disruption, superinfection, downstream obstruction as a consequence of stricture or stone, or the presence of the "disconnected duct syndrome." Medical treatment is aimed at minimizing pancreatic secretion (low fat diet, pancreatic enzymes vs. NPO/hyperalimentation, octreotide, repeated/chronic drainage procedures). Resective or decompressive pancreatic surgery requires preoperative ERCP to define the anatomy. More recently, transpapillary endoprostheses have been used in a patient subset and deserve additional consideration in patients who fail to respond to conservative measures.
Endoscopic management of acute gallstone pancreatitis.
Soetikno RM. Carr-Locke DL.
Department of Endoscopic Surgery, University Hospital Eppendorf, Hamburg, Germany.
Urgent management of acute biliary pancreatitis has increasingly included early endoscopic intervention. Endoscopic intervention allows effective removal of the offending stone(s) and reestablishment of biliary drainage. Four randomized controlled trials involving more than 800 patients in Western and Asian countries have been completed. This article summarizes the findings of these studies and proposes a preferred approach to the management of acute biliary pancreatitis.
Pancreatic duct stones management.
Deviere J. Delhaye M. Cremer M.
Department of Gastroenterology, ULB Hopital Erasme, Free University of Brussels, Belgium.
Pancreatic stone formation is characteristic of chronic pancreatitis. Ductal obstruction is a major cause of pain and the principal disabling symptom of the disease. This article briefly reviews the pathophysiology of pancreatic stone formation and describes the current nonsurgical range of therapeutic modalities.
Reflux strictures of the esophagus.
Kuo WH. Kalloo AN.
Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA.
Gastroesophageal reflux disease (GERD) is the most common cause of esophageal strictures, accounting for approximately 70% of all cases. Reflux strictures of the esophagus are serious complications of GERD and are associated with a high relapse rate. Goals of long-term management include the relief of dysphagia, prevention of stricture recurrence, and avoidance of complications with safe, cost-effective therapy. Despite recent advances in knowledge about GERD, reflux stricture still remains a relatively common and challenging clinical problem.
Esophageal strictures. A radiologic approach to diagnosis and management.
Lautner D. Gray R. Reid D.
Department of Medicine, University of Calgary, Alberta, Canada.
Strictures of the esophagus represent persistent luminal narrowing following an inflammatory insult to mural tissues or a manifestation of malignant disease. Barium studies remain the cornerstone of evaluation of patients with a suspected stricture. The diagnostic features of the various causes of strictures are discussed. Balloon dilatation and stent placement, as well as other radiologic interventions, often have an important role in the treatment of patients with advanced disease. This article discusses the indications and general application of these procedures as well as the nature and evaluation of the associated complications.
Endosonography in the assessment of esophageal stenosis.
Woolfolk GM. Wiersema MJ.
St. Vincent Hospitals and Health Care Center, Indianapolis, Indiana, USA.
EUS is an invaluable tool to delineate the cause of esophageal strictures. In primary esophageal carcinoma, EUS is the most accurate means for locoregional tumor staging. The addition of EUS FNA improves lymph node staging accuracy over EUS alone. EUS FNA can also play a role in diagnosing the cause of strictures associated with lymphadenopathy or metastatic tumor. In all settings, aggressive dilation to allow passage of the echoendoscope is associated with a substantial risk of perforation and should be avoided. To overcome this problem, catheter-based and over-the-wire probes are being developed to permit EUS imaging of severe stenoses.
Benign nonpeptic esophageal strictures. Diagnosis and treatment.
Miller LS. Jackson W. McCray W. Chung CY.
Gastroenterology Section, Temple University Hospital, Philadelphia, Pennsylvania, USA.
This article studies the causes and treatment of benign nonpeptic esophageal strictures. The authors also discuss various therapeutic techniques for esophageal strictures, including esophageal dilatation with various dilators and balloons. Although the goals of stricture therapy are to relieve dysphagia and prevent stricture reoccurrence, only the first of these goals (effective dilatation with bougienage or balloon dilatation) has been achieved. The prevention of stricture reoccurrence remains to be achieved.
Extramucosal stenosis of the esophagus.
Memon MA. Jones WF.
Department of Medicine, University of Louisville School of Medicine, Kentucky, USA.
Extramucosal lesions of the esophagus compose a small but clinically important group of diagnoses presenting as stenosis. Because of their infrequency, they can present a diagnostic dilemma in patients with dysphagia, odynophagia, or radiologic abnormalities on imaging studies. Definitive management is frequently conservative, consisting of reassurance; definitive surgical management, however, may be necessary.
Esophageal stenosis in children.
Dohil R. Hassall E.
Royal London School of Medicine, England.
This article focuses on the special features of esophageal stenosis which pertain to children. In order to focus on stenoses intrinsic to the esophagus, esophageal stenosis due to extrinsic compression is excluded. While the causes of esophageal stenosis may be grouped as either congenital or acquired, congenital causes account for less than 5% of cases.
Nutritional aspects of strictures.
Division of Gastrointestinal Diseases and Gastrointestinal Oncology, MD Anderson Cancer Center, Houston, Texas, USA.
Malnutrition is common and often undiagnosed in affected patients, especially those in the hospital, and is associated with impaired organ function, increased morbidity, and prolongation of hospital stay. It should be recognized and treated appropriately, because artificial nutritional support in malnourished patients leads to improvement in nutritional status and clinical outcome. There are multiple methods to provide nutrition, some by simply keeping the esophageal lumen patent, others by providing additional or all nutrients, including enteral and parenteral routes. The enteral route is preferred due to patient acceptance, lesser expense, and lower risk of complications. The addition of specific nutrients over standard diets may add benefit. Preoperative nutrition may reduce the risk of postoperative complications. Lastly, in the terminally ill patient, minimal intervention may be all that is needed to achieve the patient's comfort, perhaps the most important goal.
Surgery for peptic strictures.
Mamazza J. Schlachta CM. Poulin EC.
Department of Surgery, University of Toronto, Ontario, Canada.
Benign peptic stricture of the esophagus is a complex disorder which results from persistent gastroesophageal reflux. Its successful management depends on an accurate preoperative evaluation of the stricture and the patient. Surgical management of peptic strictures can be quite effective in relieving the symptoms and halting the pathologic gastroesophageal reflux that accompanies this disorder. This article reviews the general principles of evaluation and surgical treatment of benign peptic esophageal strictures.
An overview of the management of cancer of the esophagus.
University of Lyon, France.
The surgical treatment of esophageal cancer concerns a small percentage of patients with small Stage I or II tumors and a good performance status. Nonsurgical management with concurrent radiation and chemotherapy concerns a larger group of patients, and complete tumor responses have been observed at a significant rate. This applies to inoperable patients and to operable patients when there is a relative contraindication or when large malignant lymph nodes are detected at the preoperative stage. Endoscopic palliation in monotherapy should be restricted to the smallest possible number of patients.
Operative treatment of malignancy.
Poulin EC. Schlachta CM. Mamazza J.
Department of Surgery, University of Toronto, Ontario, Canada.
The overall prognosis of patients afflicted with cancer of the esophagus is dismal and has not changed greatly over the last few decades. Improvements have largely been due to better perioperative care rather than new surgical techniques. There remain, about the optimal treatment of these patients, and these differences are summarized in this article. The principal elements required to make an appropriate surgical decision also are outlined. Until new markers for early detection and effective systematic therapy emerge, improvement is likely to occur only in subsets of patients referred early and treated in an environment that guarantees low operative mortality.
Radiation and chemotherapy in the management of malignant esophageal strictures.
Brierley JD. Oza AM.
University of Toronto, Ontario, Canada.
The management of malignant and esophageal strictures with radiation and chemotherapy is reviewed. There is no evidence to support the use of adjuvant radiation. Studies demonstrate that concurrent chemotherapy and radiation are superior to radiation alone. The trials of preoperative combined chemotherapy and radiation are discussed, and it is suggested that further studies are needed before such treatment could be accepted as standard therapy. The roles of radiation and chemotherapy in palliative management are briefly discussed, and some potential areas for further study are proposed.
Nonthermal ablation of malignant esophageal strictures. Photodynamic therapy, endoscopic intratumoral injections, and novel modalities.
Saidi RF. Marcon NE.
Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.
Several novel nonthermal ablative modalities for the palliation of malignant esophageal stenoses have been developed over the past decade. In this article, the authors review techniques and clinical experience with photodynamic therapy as well as the intratumoral injection of alcohol, cytotoxins, and immunomodulators.
Malignant strictures. Thermal treatment.
Gossner L. Ell C.
Medizinische Klinik II, Klinikum Wiesbaden, Germany.
Malignant stenoses can occur in any part of the gastrointestinal tract. Endoscopic treatment options are available, however, only for the rectosigmoid area, the esophagus, and the esophagocardial transition. Strictures in the esophageal region represent the quantitatively predominant type of stenoses encountered in everyday endoscopy.
The use of stents in the management of malignant esophageal strictures.
Medizinische Klinik, Evangelisches Krankenhaus, Dusseldorf, Germany.
The majority of patients with intrinsic or extrinsic obstructing esophageal malignancies are not treatable for cure because of an advanced tumor stage at the time of diagnosis or a recurrence after primary curative therapy. Palliative treatment is mainly directed at relieving dysphagia, which is a frequent cause of patient distress and malnutrition. The approach should be rapidly effective, safe, and well tolerated; the period of hospitalization should be limited in view of a life expectancy of only a few months.