Advanced endoscopic interventions on the pancreas and pancreatic ductal system: a primer for radiologists

Abstract

In recent years, technological advancements including endoscopic ultrasound (EUS) guidance and availability of specifically designed stents further expanded the indications and possibilities of interventional endoscopy. Although technically demanding and associated with non-negligible morbidity, advanced pancreatic endoscopic techniques now provide an effective minimally invasive treatment for complications of acute and chronic pancreatitis. Aiming to provide radiologists with an adequate familiarity, this pictorial essay reviews the indications, techniques, results and pre- and post-procedural cross-sectional imaging appearances of advanced endoscopic interventions on the pancreas and pancreatic ductal system. Most of the emphasis is placed on multidetector CT and MRI findings before and after internal drainage of pseudocysts and walled-off necrosis via EUS-guided endoscopic cystostomy, and on stent placement to relieve strictures or disruption of the main pancreatic duct, respectively in patients with chronic pancreatitis and disconnected pancreatic duct syndrome.

Mind the Gap—Disconnected Duct Syndrome

“…Bang et al 27 demonstrated a 100% correlation between CT localization and EUS localization of DDS. Endoscopic ultrasound also provides an opportunity for therapeutic intervention 29 …”

Pediatric Pancreaticobiliary Intervention

“…3 Indications for percutaneous or endoscopic intervention include management of pancreatic duct leaks or obstruction, symptomatic fluid collections, need for diagnostic tissue biopsy, and bleeding or other vascular complications. [4][5][6] Pancreatic Duct Leak or Obstruction Pediatric pancreatitis can be divided into acute pancreatitis, acute recurrent pancreatitis, and chronic pancreatitis. 7 Etiologies of acute pancreatitis include duct obstruction, drug toxicity, and systemic illness.…”

Role of pancreatography in the endoscopic management of encapsulated pancreatic collections – review and new proposed classification

“…Although some terms are often used by various authors and clinicians, terminology and descriptor language has not been standardized[ 35 ]. The most commonly utilized terms to describe abnormalities in literature are: Disruption (some authors dived into partial/incomplete and total/complete disruptions), disconnection, DPDS, transected, leak, fistula, rupture, stricture, stenosis, cut-off, obstruction and communication/non-communication with collection[ 9 , 13 , 14 , 18 , 19 , 22 , 36 - 40 ]. This heterogeneity may lead to confusion when reporting and interpreting data[ 8 ].…”

“…The complete disruption of the MPD is one of two necessary conditions to diagnose DPDS. An image study showing a functional pancreatic tissue upstream to the complete disruption is necessary to define DPDS[ 11 , 40 ]. Therefore, ERCP alone cannot appropriately describe this phenomena; however, when pancreatography is performed by MRCP it is possible to diagnose DPDS since it allows study the MPD upstream the disruptions and the pancreatic tissue[ 13 ].…”

“…Additionally, strictures of the MPD may be treated using pancreatic stenting[ 8 , 20 , 28 , 40 , 53 ]. Although this remains a reasonable approach, there is no com-parative study demonstrating the impact of stricture treatment for EPCs management.…”