Direct Pancreatoscopy

Abstract

Objectives and Basic Principles Several imaging procedures, including transabdominal and endoscopic ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI) and endoscopic retrograde cholangiopancreatography (ERCP), have been established for the diagnosis of pancreatic diseases. Among them, ERCP is the current gold standard for diagnosis of pancreatic cancer as well as other diseases involving the pancreatic duct. However, it may fail to differentiate strictures or intraluminal filling defects of the pancreatic duct. It may also fail to detect minimal change, and chronic pancreatitis may not be well visualized with contrast medium. Given these limitations, it is necessary to have a modality with a direct approach to the pancreatic duct. Based on this concept, Japanese endoscopists, including Takekoshi et al. [1], first developed peroral pancreatoscopy through the accessory channel of a duodenal fiberscope in 1975. However, this device proved unpopular in clinical use because of problems which included instrument expense, fragility, low visibility, and its relatively large diameter relative to the duodenal papilla. Pancreatoscopy was reassessed and found to be useful for a variety of conditions, including intraductal papillary mucinous tumor (IPMT), first described by Ohashi et al. [2] in 1982. Initial pancreatoscope prototypes had no channel or tip deflection, although subsequent devices of more than 3 or 4 mm in diameter were manufactured with one-or two-way tip deflection, and with an accessory channel with potential use for biopsy or lithotripsy [3, 4]. To make insertion of the scope easier, an ultrathin pancreatoscope (0.8 mm in diameter) was developed by decreasing the number of image guide fibers [3, 5]. Finally, the peroral electronic pancreatoscope (PEPS), the smallest known electronic endoscope, was developed re

Pancreatoscopy: Present and future role

“…Due to the associated risks of procedure-related pancreatitis [13], the American Society for Gastrointestinal Endoscopy (ASGE) recommends reserving ERCP for patients in whom a diagnosis remains uncertain after the less invasive tests, such as CT, MRI, or EUS, have been performed [14]. Furthermore, pancreatography is relatively insensitive for diagnosis of early chronic pancreatitis and may not reliably differentiate chronic pancreatitis from pancreatic malignancy [15]. Thus, a growing proportion of ERCPs are now being performed primarily for therapeutic indications.…”

“…IPMT was first described in 1982 and since that time has been recognized with increasing frequency [15]. These mucinproducing and premalignant tumors of the pancreatic ducts have a unique profile, progressing more slowly than adenocarcinoma of the pancreas.…”

“…An ultrathin pancreatoscope (PF-8P; Olympus, Tokyo, Japan) was developed by reducing the number of image guide fibers (2000 to 3000 image guide fibers), thereby reducing the overall diameter (0.8 mm) [15]. This instrument has a fixed focus range of 1 to 50 mm and a 75-degree visual field.…”

Diagnostic Endoscopic Retrograde Cholangiopancreatography

“…Technical issues involved in this procedure were assessed by Kodama et al [50]. Peroral pancreatoscopy was evaluated by Yamao et al [51] in the diagnosis of pancreatic diseases.…”

Burning Issues in Gastrointestinal Endoscopy at the Start of the New Millenium

“…Rightly, diagnostic ERCP has been replaced by other techniques, among them recently magnetic resonance cholangiopancreatography (MRCP) [107,108], although I personally think that MRCP is over-rated since it may not dramatically decrease the ERCP workload [109]. Some refinement, with manometry [110,111], small-duct endoscopy [112], intraductal ultrasound [113,114], or optical coherence tomography [115] and tissue diagnosis [107,116], still gives ERCP some place in the diagnosis of pancreaticobiliary disease but, due to its risk [117 -122] and that of sphincterotomy [123 -126], the indications should be strict and clear. I am also disappointed to see, that risk management and prophylaxis of ERCP-induced pancreatitis by drugs has not really progressed [118,127,128]; pancreatic stents may be better [129], but only in selected patients.…”