Preliminary experience with pancreatic sphincterotomy as treatment for intraductal papillary mucinous neoplasm-associated recurrent pancreatitis

Abstract

Background and study aims Pancreatic intraductal papillary mucinous neoplasms (IPMN) are cystic tumors of the pancreas characterized by a malignant potential. IPMN have been associated with recurrent pancreatitis (RP). Obstruction of the main pancreatic duct by thick mucus has been postulated to be the cause of pancreatitis. In a few isolated reports, pancreatic sphincterotomy (PS) has been reported to reduce the frequency of pancreatitis. The aim of this study was to assess the efficacy of PS in patients with IPMN-associated RP.

Patients and methods We retrospectively identified patients with RP and IPMN who underwent PS from June 2010 to December 2015. Patients were included in two different groups: (a) main duct/mixed type IPMN (MD-IPMN) and (b) branch duct IPMN (BD-IPMN) with or without worrisome features/high risk stigmata. Other causes of RP were excluded. The number of pancreatitis episodes occurring during a comparable time period before and after PS was evaluated.

Results In total, 16 patients were analyzed (seven included in the MD-IPMN group and nine in the BD-IPMN group). The numbers of pancreatitis episodes occurring before and after PS were 3.5 ± 2.32 and 0.56 ± 1.03, respectively (P < 0.0001). Mean follow-up was 27.4 months (range 6 – 63 months). Complete, partial (reduction of pancreatitis episodes > 50 %), and no response were obtained in 11 (68.7 %), 3 (18.7 %), and 2 patients (12.5 %), respectively. One (6.25 %) case of mild post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis was observed. No cancer was detected in resected patients. None of the BD-IPMN group patients had or developed worrisome features/high risk stigmata during follow-up.

Conclusions PS seems to be effective in reducing the number of episodes of IPMN-associated pancreatitis and should be considered as a treatment option in selected clinical settings. However, active surveillance should be continued considering the malignant potential of IPMN. Further prospective controlled studies are needed to confirm our results.

^* Drs Bernardoni and Crinò contributed equally to this article.

• References

• 1 Farrell JJ. Prevalence, diagnosis and management of pancreatic cystic neoplasms: current status and future directions. Gut Liver 2015; 23: 571-589
• 2 Jang JW, Kim MH, Jeong SU. et al. Clinical characteristics of intraductal papillary mucinous neoplasm manifesting as acute pancreatitis or acute recurrent pancreatitis. J Gastroenterol Hepatol 2013; 28: 731-738
• 3 Venkatesh PG, Navaneethan U, Vege SS. Intraductal papillary mucinous neoplasm and acute pancreatitis. J Clin Gastroenterol 2011; 45: 755-758
• 4 Pelletier AL, Hammel P, Rebours V. et al. Acute pancreatitis in patients operated on for intraductal papillary mucinous neoplasms of the pancreas: frequency, severity, and clinicopathologic correlations. Pancreas 2010; 39: 658-661
• 5 Tanaka M, Fernández-del Castillo C, Adsay V. et al. International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology 2012; 12: 183-197
• 6 Oh YS, Dua K. Pancreatic sphincterotomy for pancreatitis associated with main duct intraductal papillary mucinous neoplasm. Endoscopy UCTN: 2011; 43 (Suppl. 02) E75
• 7 Elton E, Howell DA, Parson WG. et al. Endoscopic pancreatic sphincterotomy: indications, outcome, and a safe stentless technique. Gastrointest Endosc 1998; 47: 240-249
• 8 Nocente R, Gentiloni N, Gasbarrini A. et al. An apparent idiopathic case of relapsing acute pancreatitis. Hepatogastroenterology 2001; 48: 572-573
• 9 Lee SP, Nicholls JF, Park HZ. Biliary sludge as a cause of acute pancreatitis. NEJM 1992; 326: 589-593
• 10 Yadav D, Whitcomb DC. The role of alcohol and smoking in pancreatitis. Nat Rev Gastroenterol Hepatol 2010; 7: 131-145
• 11 Yadav D, Hawes RH, Brand RE. et al. Alcohol consumption, cigarette smoking, and the risk of recurrent acute and chronic pancreatitis. Arch Intern Med 2009; 169: 1035-1045
• 12 Crinò SF, Bernardoni L, Conti Bellocchi MC. et al. Efficacy of endoscopic minor papilla sphincterotomy for symptomatic santorinicele. Clin Gastroenterol Hepatol 2017; 15: 303-306
• 13 Shimosegawa T, Chari ST, Frulloni L. et al. International consensus diagnostic criteria for autoimmune pancreatitis: guidelines of the International Association of Pancreatology. Pancreas 2011; 40: 352-358
• 14 Toskes PP. Hyperlipidemic pancreatitis. Gastroenterol Clin North Am 1990; 19: 783-791
• 15 Raphael KL, Willingham FF. Hereditary pancreatitis: current perspectives. Clin Exp Gastroenterol 2016; 26: 197-207
• 16 Nitsche CJ, Jamieson N, Lerch MM. et al. Drug induced pancreatitis. Best Pract Res Clin Gastroenterol 2010; 24: 143-155
• 17 Hansen TM, Nilsson M, Gram M. et al. Morphological and functional evaluation of chronic pancreatitis with magnetic resonance imaging. World J Gastroenterol 2013; 19: 7241-7246
• 18 Sarner M, Cotton PB. Classification of pancreatitis. Gut 1984; 25: 756-759
• 19 Fernandez-del C, Targarona J, Thayer SP. et al. Incidental pancreatic cysts: clinicopathologic characteristics and comparison with symptomatic patients. Arch Surg 2003; 138: 427-433 ; discussion 433-434
• 20 Tanaka M, Kobayashi K, Mizumoto K. et al. Clinical aspects of intraductal papillary mucinous neoplasm of the pancreas. J Gastroenterol 2005; 40: 669-675
• 21 Ringold DA, Shroff P, Sikka SK. et al. Pancreatitis is frequent among patients with side-branch intraductal papillary mucinous neoplasia diagnosed by EUS. Gastrointest Endosc 2009; 70: 488-494
• 22 Morales-Oyarvide V, Mino-Kenudson M, Ferrone CR. et al. Acute pancreatitis in intraductal papillary mucinous neoplasms: A common predictor of malignant intestinal subtype. Surgery 2015; 158: 1219-1225
• 23 Tsutsumi K, Ohtsuka T, Oda Y. et al. A history of acute pancreatitis in intraductal papillary mucinous neoplasms of the pancreas is a potential predictive factor for malignant papillary subtype. Pancreatology 2010; 10: 707-712
• 24 Roch AM, Parikh JA, Al-Haddad MA. et al. Abnormal serum pancreatic enzymes, but not pancreatitis, are associated with an increased risk of malignancy in patients with intraductal papillary mucinous neoplasms. Surgery 2014; 156: 923-930
• 25 Pelletier AL, Hammel P, Rebours V. et al. Acute pancreatitis in patients operated on for intraductal papillary mucinous neoplasms of the pancreas: frequency, severity, and clinicopathologic correlations. Pancreas 2010; 39: 658-661