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interventionist batting cleanup?1
AJG – October, 2001
The surgical techniques for the treatment of morbid obesity have been evolving for many decades, with the goals of both reducing the morbidity and mortality associated with these procedures and reducing weight over a prolonged period. Unfortunately, these goals have not been easily achieved, and many procedures have been abandoned. The recent introduction of ALGB is the newest attempt to address these issues with the advantages of reversibility, adjustability, and low invasiveness. A variety of esophageal and gastric complications have been observed with adjustable gastric banding, and a substantial minority of patients fail to respond to the procedure; also, long term results, especially regarding maintenance of satisfactory weight reduction and potential esophageal and gastric complications, warrant further evaluation of this procedure. David J. Ott, M.D., F.A.C.G. Department of Radiology Wake Forest University School of Medicine Winston-Salem, North Carolina
REFERENCES 1. De Wind LT, Payne JG. Intestinal bypass surgery for morbid obesity. JAMA 1976;236:2298 –301. 2. Mason EE, Ito C. Gastric bypass in obesity. Surg Clin North Am 1967;47:1345–51. 3. Kuzmak L. A review of seven years’ experience with silicone gastric banding. Obes Surg 1991;403– 8. 4. Lise M, Favretti F, Belluco C, et al. Stoma adjustable silicone gastric banding: Results in 111 consecutive patients. Obes Surg 1994;4:274 – 8. 5. Schlumpf R, Lang T, Scho¨ b O, et al. Treatment of the morbidly obese patient with laparoscopic adjustable gastric banding. Dig Surg 1997;14:438 – 43. 6. Favretti F, Cadiere GB, Segato G, et al. Laparoscopic adjustable silicone gastric banding (LAP-BAND®): How to avoid complications. Obes Surg 1997;7:352– 8. 7. Chelala E, Cadiere GB, Favretti F, et al. Conversions and complications in 185 laparoscopic adjustable silicone gastric banding cases. Surg Endosc 1997;11:268 –71. 8. Lundell L, Ruth M, Olbe L. Vertical banded gastroplasty or gastric banding for morbid obesity: Effects on gastro-oesophageal reflux. Eur J Surg 1997;163:525–31. 9. Szucs RA, Turner MA, Kellum JM, et al. Adjustable gastric band for the treatment of morbid obesity: Radiologic evaluation. AJR 1998;170:993– 6.
Complicated Pancreatic Disease Management—Radiologist/Interventionist Batting Cleanup? Cope C, Tuite C, Burke D, Long W Percutaneous Management of Chronic Pancreatic Duct Strictures and External Fistulas With Long-Term Results J Vasc Interv Radiol 2001;12:104 –10
ABSTRACT The long term results of various interventional procedures used in the treatment of patients with chronic pancreatic
World Literature Review
3033
fistulas or severe pancreatic pain syndrome, after failure of both surgery and endoscopic catheterization, are described. Five patients were divided into two groups. Group 1 contained three patients with recurrent severe abdominal pain with superimposed episodes of acute pancreatitis. Two patients had undergone prior Whipple procedures but remained symptomatic. The third had a 6-yr history of alcoholic pancreatitis. All three had failed selective pancreatic endoscopy because of a proximal pancreatic duct stricture. The pancreatic duct was dilated to between 7 and 10 mm by CT or ultrasound imaging. Group 2 patients had pancreaticocutaneous fistulas that developed after surgical and percutaneous pseudocyst drainage. Both patients’ fistulas had been unresponsive to therapy with somatostatin analogues, and had been controlled by means of percutaneous drains. Patients were treated under either general anesthesia (two patients, patient preference) or conscious sedation. Each received preprocedure antibiotics and had normal coagulation profiles. Oral contrast was given to opacify the colon the night before the procedure. Ultrasound or fluoroscopic guidance was used to puncture the pancreatic duct, either directly or through the stomach (after placement of T fasteners). The procedures were then individualized to fit the particular pathology and anatomical situation. At least one procedure required endoscopic assistance (rendezvous procedure) for guidewire stabilization to deliver an angioplasty catheter across a pancreatic duct stricture. The criteria for successful treatment included partial or complete relief of abdominal pain, with normalization of pancreatic duct caliber in group 1 and cure of the pancreatic fistulas in group 2 without recurrent episodes of pancreatitis. All three patients in group 1 had prompt relief of abdominal pain after placement of percutaneous pancreatic duct drains. All had return to normal caliber of the pancreatic duct by imaging. One patient had a recurrent episode of abdominal pain after drain removal, but this was found to be due to a ureteral stricture. The details of the procedures for treating the fistulas have been previously reported (1). Cope and colleagues’ report assesses long term efficacy of these interventions. Both patients with fistulas were cured out to 5-yr follow-up after removal of their drains. None of these percutaneous procedures showed early complications such as leakage of pancreatic juice, sepsis, hemorrhage, or acute pancreatitis, as determined symptomatically by hematological screening and abdominal imaging. The authors conclude that percutaneous pancreatic duct drainage and stent placement is safe in selected cases. It is particularly useful when endoscopic stent placement is unsuccessful and surgery too risky. They also suggest several other situations in which this technique may be beneficial. (Am J Gastroenterol 2001;96:3033–3034. © 2001 by Am. Coll. of Gastroenterology)
3034
World Literature Review
COMMENT The interventional radiologist is often in the position of providing the “last hope” for a patient who has failed standard therapies and is too ill for major surgery. In fact, this is the very situation that leads to many of our most innovative techniques. Along these lines, Dr. Cope is one of the great original interventional pioneers. He has often ventured where no one else has dared to go. Even though this brief report includes only a very small number of patients, the ability to perform these procedures with almost no complication and excellent long term results is truly outstanding. The authors review the pertinent, albeit limited, literature detailing similar procedures as well as the surgical and endoscopic alternatives. Their results compare favorably with the other methods. Historically, interventions involving the pancreatic duct have been avoided because of the belief that there was a high complication rate. These authors have done a good job to dispel that idea. Perhaps, with greater awareness of this method of intervention, patients with complex pancreatic pathologies may be spared surgical therapies that carry high degrees of morbidity and mortality. The authors suggest several clinical scenarios in which the ability to catheterize the pancreatic duct may be useful. These include “1. to obviate surgery in advanced cases in which pancreatic burn out may occur after short term drainage; 2. as a predictive test to ascertain whether surgery can
AJG – Vol. 96, No. 10, 2001
relieve the pain of chronic obstructive pancreatitis; 3. to manage chronic distal pancreatic duct fistulas by creating internal drainage from the tail pancreatic duct to the main duct or bowel; 4. as a rendezvous procedure to aid in the placement of endoscopic stents.” It must be kept in mind, however, that the detailed descriptions of the particular procedures performed are extremely complex. Even from the point of view of a busy interventionist, the authors’ techniques are quite innovative and not necessarily in the armamentaria of all practicing interventional radiologists. Therefore, treating these patients in the community setting may not be possible or, at least, would potentially carry higher complication risks. Close cooperation between the endoscopic, surgical, and radiological services will be necessary to guide appropriate decision making and promote patient safety. Harlan Vingan, M.D. Interventional Radiology Eastern Virginia School of Medicine Norfolk, Virginia
REFERENCE 1. Shlansky-Goldberg RD, Soulen MC, Rosato EF, Cope C. Percutaneous management of external pancreatic fistulas: The use of articulated and metal stents. J Vasc Interv Radiol 1995;6: 191– 6.
The surgical techniques for the treatment of morbid obesity have been evolving for many decades, with the goals of both reducing the morbidity and mortality associated with these procedures and reducing weight over a prolonged period. Unfortunately, these goals have not been easily achieved, and many procedures have been abandoned. The recent introduction of ALGB is the newest attempt to address these issues with the advantages of reversibility, adjustability, and low invasiveness. A variety of esophageal and gastric complications have been observed with adjustable gastric banding, and a substantial minority of patients fail to respond to the procedure; also, long term results, especially regarding maintenance of satisfactory weight reduction and potential esophageal and gastric complications, warrant further evaluation of this procedure. David J. Ott, M.D., F.A.C.G. Department of Radiology Wake Forest University School of Medicine Winston-Salem, North Carolina
REFERENCES 1. De Wind LT, Payne JG. Intestinal bypass surgery for morbid obesity. JAMA 1976;236:2298 –301. 2. Mason EE, Ito C. Gastric bypass in obesity. Surg Clin North Am 1967;47:1345–51. 3. Kuzmak L. A review of seven years’ experience with silicone gastric banding. Obes Surg 1991;403– 8. 4. Lise M, Favretti F, Belluco C, et al. Stoma adjustable silicone gastric banding: Results in 111 consecutive patients. Obes Surg 1994;4:274 – 8. 5. Schlumpf R, Lang T, Scho¨ b O, et al. Treatment of the morbidly obese patient with laparoscopic adjustable gastric banding. Dig Surg 1997;14:438 – 43. 6. Favretti F, Cadiere GB, Segato G, et al. Laparoscopic adjustable silicone gastric banding (LAP-BAND®): How to avoid complications. Obes Surg 1997;7:352– 8. 7. Chelala E, Cadiere GB, Favretti F, et al. Conversions and complications in 185 laparoscopic adjustable silicone gastric banding cases. Surg Endosc 1997;11:268 –71. 8. Lundell L, Ruth M, Olbe L. Vertical banded gastroplasty or gastric banding for morbid obesity: Effects on gastro-oesophageal reflux. Eur J Surg 1997;163:525–31. 9. Szucs RA, Turner MA, Kellum JM, et al. Adjustable gastric band for the treatment of morbid obesity: Radiologic evaluation. AJR 1998;170:993– 6.
Complicated Pancreatic Disease Management—Radiologist/Interventionist Batting Cleanup? Cope C, Tuite C, Burke D, Long W Percutaneous Management of Chronic Pancreatic Duct Strictures and External Fistulas With Long-Term Results J Vasc Interv Radiol 2001;12:104 –10
ABSTRACT The long term results of various interventional procedures used in the treatment of patients with chronic pancreatic
World Literature Review
3033
fistulas or severe pancreatic pain syndrome, after failure of both surgery and endoscopic catheterization, are described. Five patients were divided into two groups. Group 1 contained three patients with recurrent severe abdominal pain with superimposed episodes of acute pancreatitis. Two patients had undergone prior Whipple procedures but remained symptomatic. The third had a 6-yr history of alcoholic pancreatitis. All three had failed selective pancreatic endoscopy because of a proximal pancreatic duct stricture. The pancreatic duct was dilated to between 7 and 10 mm by CT or ultrasound imaging. Group 2 patients had pancreaticocutaneous fistulas that developed after surgical and percutaneous pseudocyst drainage. Both patients’ fistulas had been unresponsive to therapy with somatostatin analogues, and had been controlled by means of percutaneous drains. Patients were treated under either general anesthesia (two patients, patient preference) or conscious sedation. Each received preprocedure antibiotics and had normal coagulation profiles. Oral contrast was given to opacify the colon the night before the procedure. Ultrasound or fluoroscopic guidance was used to puncture the pancreatic duct, either directly or through the stomach (after placement of T fasteners). The procedures were then individualized to fit the particular pathology and anatomical situation. At least one procedure required endoscopic assistance (rendezvous procedure) for guidewire stabilization to deliver an angioplasty catheter across a pancreatic duct stricture. The criteria for successful treatment included partial or complete relief of abdominal pain, with normalization of pancreatic duct caliber in group 1 and cure of the pancreatic fistulas in group 2 without recurrent episodes of pancreatitis. All three patients in group 1 had prompt relief of abdominal pain after placement of percutaneous pancreatic duct drains. All had return to normal caliber of the pancreatic duct by imaging. One patient had a recurrent episode of abdominal pain after drain removal, but this was found to be due to a ureteral stricture. The details of the procedures for treating the fistulas have been previously reported (1). Cope and colleagues’ report assesses long term efficacy of these interventions. Both patients with fistulas were cured out to 5-yr follow-up after removal of their drains. None of these percutaneous procedures showed early complications such as leakage of pancreatic juice, sepsis, hemorrhage, or acute pancreatitis, as determined symptomatically by hematological screening and abdominal imaging. The authors conclude that percutaneous pancreatic duct drainage and stent placement is safe in selected cases. It is particularly useful when endoscopic stent placement is unsuccessful and surgery too risky. They also suggest several other situations in which this technique may be beneficial. (Am J Gastroenterol 2001;96:3033–3034. © 2001 by Am. Coll. of Gastroenterology)
3034
World Literature Review
COMMENT The interventional radiologist is often in the position of providing the “last hope” for a patient who has failed standard therapies and is too ill for major surgery. In fact, this is the very situation that leads to many of our most innovative techniques. Along these lines, Dr. Cope is one of the great original interventional pioneers. He has often ventured where no one else has dared to go. Even though this brief report includes only a very small number of patients, the ability to perform these procedures with almost no complication and excellent long term results is truly outstanding. The authors review the pertinent, albeit limited, literature detailing similar procedures as well as the surgical and endoscopic alternatives. Their results compare favorably with the other methods. Historically, interventions involving the pancreatic duct have been avoided because of the belief that there was a high complication rate. These authors have done a good job to dispel that idea. Perhaps, with greater awareness of this method of intervention, patients with complex pancreatic pathologies may be spared surgical therapies that carry high degrees of morbidity and mortality. The authors suggest several clinical scenarios in which the ability to catheterize the pancreatic duct may be useful. These include “1. to obviate surgery in advanced cases in which pancreatic burn out may occur after short term drainage; 2. as a predictive test to ascertain whether surgery can
AJG – Vol. 96, No. 10, 2001
relieve the pain of chronic obstructive pancreatitis; 3. to manage chronic distal pancreatic duct fistulas by creating internal drainage from the tail pancreatic duct to the main duct or bowel; 4. as a rendezvous procedure to aid in the placement of endoscopic stents.” It must be kept in mind, however, that the detailed descriptions of the particular procedures performed are extremely complex. Even from the point of view of a busy interventionist, the authors’ techniques are quite innovative and not necessarily in the armamentaria of all practicing interventional radiologists. Therefore, treating these patients in the community setting may not be possible or, at least, would potentially carry higher complication risks. Close cooperation between the endoscopic, surgical, and radiological services will be necessary to guide appropriate decision making and promote patient safety. Harlan Vingan, M.D. Interventional Radiology Eastern Virginia School of Medicine Norfolk, Virginia
REFERENCE 1. Shlansky-Goldberg RD, Soulen MC, Rosato EF, Cope C. Percutaneous management of external pancreatic fistulas: The use of articulated and metal stents. J Vasc Interv Radiol 1995;6: 191– 6.