Diagnostic and therapeutic ERCP are beneficial in the management of pancreatic necrosis

There is considerable debate regarding the optimal management of pancreatic necrosis (PN). The timing and utility of endoscopic retrograde cholangiopancreatograms (ERCP) in the subset of acute pancreatitis who have PN is unclear. Objectives: It To determine if diagnostic ERCP helps guide further management (endoscopic, surgical) of patients with PN and 2) to evaluate the role of therapeutic ERCP in this patient population. Methods: All patients presenting with acute pancreatitis at our medical center from 1986 to 1996 were reviewed for evidence of PN. To be eligible for inclusion in our study, PN had to be demonstrated by either computerized tomography (CT) showing lack of parenchymal enhancement after intravenous contrast or by histological confirmation of necrosis in surgically resected pancreatic tissue. Data on patients with PN were cross-referenced with the endoscopy database to identify individuals who had ERCP. Results: 34 patients (22M/11F) with an average age of 53 years (SD13) were identified as having PN and ERCP. Alcohol and biliary stones were the most common causes of pancreatitis. CT demonstrated pseudocysts in 20 patients and pancreatic phlegmon alone in 14. Cannulation of the pancreatic duct (PD) failed in 3 patients. The most common pancreatographic findings were communicating pseudocyst ( 17), ductal changes of chronic pancreatitis (9), pancreas divisum (5) and pancreatic stricture (3). Therapeutic endoscopic procedures were performed in 14 (41%) patients, thus: PD stenting (7), pancreatic sphincterotomy (2) and biliary stent or sphincterotomy (5). 24 patients came to surgery; 2 (6%) died of complications of pancreatitis. Conclusions: 1 ) Patients with PN who undergo ERCP are likely to have pancreatic pathology which may be amenable to endoscopic therapy. 2) Endoscopists performing ERCP on patients with PN require therapeutic skills. 3) In this select group of patients with PN, mortality was low despite high morbidity. 4) The majority of patients with PN can be expected to need surgery (68% in our series).

Duke Scholars

Author Rendon C. Nelson Radiology

Author Erik Karl Paulson Radiology, Abdominal Imaging

Author Paul Simon Jowell Medicine, Gastroenterology

Author Malcolm Stanley Branch Medicine, Gastroenterology