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A prospective study on the long-term fate of metallic clips used during laparoscopy cholecistectomy
A408
AGA ABSTRACTS
GASTROENTEROLOGY, Vol. 108, No. 4
RESUI.TS OF ENDOSCOPY INTUBATION FOR EXPANDABLE METALS OR PLASTICS STENTS IN THE TREATMENT OF MAI.IGNANT BILE DUCT OBSTRUCTION. JM CANARD**, R CHOLLET*.* Service d'Hdpato-Gastroentdrologie, groupe hospitalier Pitid-salpdtri~re; ** Clinique du Trocaddro, 62 rue de la Tour, 7_5016 Paris, France. The aim of this retrospective study was to appreciate the differences between plastic or expandable metal stent for the management of patients with an irresectable malignant obstruction of the common duct. Patients and methods : Between January 1992 and December 1993, 44 patients, 19 males and 25 females, with a median age of 71 years (range,26-93), were treated for endoscopic placement of metal stents (group 1. n=24. Strenker stent (16) and Wallstent (8)) or polyethylene stents ( group 2, n=24). Lesions were pancreatic tumor (n=24), ampullary (n=7), cholangiocarcinoma (n=3), metastatic tumors (n--9). Results : The mean period of follow-up was 184 days (range, 3-425). No statistical difference was observed between the 2 groups regarding age, sex, duration of jaundice and laboratory findings. Stent implantation was unsuccessful in 5 cases ( unsuccessful introduction due stenosis, using the metalic guide (n---3) orthe stens himself (n=2). At D 30, 3 complications (12,5%) was observed in group 1 ( 1 stent migration. 1 bleeding, insufficiente expansion) and 5 (20,8%) in the group 2 ( 4 cholangitis, 1 cholecystis) (NS). After 30 days, 5 and 9 stent obstructions was observed respectively in group I and 9 (NS).The occlusion of metal stent was treated using plastic stent implantation (n=5). The mean patency of metal and plastic stents were 158+ 102 and 95_+75 days (p--0,02). The median survival in group I and 2 were respectively 154_+132 and 140-+121 days (NS). Conclusion : The metal stent patency duration is greater than that of plastic one, most patients died with a functional metal stent. There was no difference between the two stents concerning complication rate. but the improvement of the material could decrease of the metal stent complications
COMPARISON OF SPHINCTER OF ODDI MANOMETRY(SOM), FATTY MEAL ULTRASOUND AND HEPATOBILIARY SCINTIGRAPHY IN THE DIAGNOSIS OF SPHINCTER OF ODD! DYSFUNCTION (SOD) MP Catalano, JE Geenen, P Pmessing, GK Johnson, MJ Schmalz, WJ Hogan. Pancreatic Biliary Center, St Luke's Medieal Center, Milwaukee, Wisconsin. SOD affects approximately 1-5% of post-¢holeeysteetomy pts. The "gold standard" diagnosis is SOM, whleh is clinically difficult, invasive and frequently complicated by pancreatitis (5-10%). A sensitive, non-invasive imaging modality is needed for the diagnosis of SOD. Quantitative hepatobiliary seintlgraphy CRIBS)and fatty-meal ultrasound (FMUS) are two frequently used tests; varying results are reported in the literature. AIM: To compare the results of SOM, HBS, FMUS in the diagnosis of SOD in a large pt population. METHOD: 304 pts (3gM, 266W, age 17-72) with suspected SOD ware evaluated by SOM/FMUS/HBS. Basal SO pressure >40mmHg obtained at ERCP was considered abnormal. FMUS was done using Lipomul (1.5cc/kg), with the CBD diameter measured at baseline and 45 rain post-fatty meal. An increase o f > 2 ram was considered abnormal. Quantitative HBS was done using Tc99m labeled radionoclide. Sequential images were obtained every 5 rain for 90 rain to monltor excretion of radionuclide and graphed over time. Time-to-peak, half-time and down slope were calculated according to predetermined ranges. 73 pts we.re diagnosed with SOD by SOM; ttBS was abnormal in 36 of these while FMUS was abnormal in 15. RESULTS: Comparison of the 3 modalities ate shown. F M U S
S O M
HBS
N
A
T
S
N
224
7
231
O
A
58
15
73
T
282
22
304
M
F M U S / H B S
N
A
T
~S
N
181
50
231
O
A
37
36
73
T
218
86
304
nal,A-Abnormal,'l FMUS=21%/97/6g/79; ttBS=49%Flg142183.
M
At
N
A
T
N
1.77
54
231
A
34
39
73
T
211
93
304
least
one
abnormal
radiographic study fill]S, FMUS) was seen in 90% of type I SOD, 50% type II, 45% type III pts. CONCLUSIONS: In the largest series reported to date, correlation of FMUS and HBS with SOM in the diagnosis of SOD is poor. When HBS and FMUS are used in conjunction, slight increase in sensitivity can be expected. The diagnostic accuracy of FMUS/I-IBS decreases from Type I to Type III SOD patients.
Q SPHINCTER OF ODDI DYSFUNCTION AND PAPILLARY STENOSIS: DIAGNOSIS BY SF_L"RE'I/N-STIMULATED ENDOSCOPIC ULTRASOUND (SSEUS). M.F. Catalano, J.E. Geeaen, M.J. Schmalz, G.K. Johnson, D.J. Geenen, L. Jacob, W.J. Hogan, St. Luke's Hospital, Racine, St. Luke's Medical Center, Milwaukee, Wisconsin. Sphincter of Oddi dysfunction (SOD) affects approximately 1-5% of post-eholecystectomy pts. Diagnosis includes clinical prasentation, radiologic (fatty meal ultrasound and hepatebiliary seintigtaphy) and invasive manometric studies of the sphincter of Oddi (SOM). SOM is complicated by pancreatitis in up to 10% of pts. A sensitive, minimally invasive endoscopic imaging modality for the diagnosis of SOD would be a useful alternative to manometry. AIM: To evaluate the affect of secretin stimulation on the parmreatie duct (PD) diameter in pts with suspected SOD using EUS. METHOD: 20 pts with no pancreatic disorder underwent SSEUS to identify a normal response to seeretin stimulation. EUS visualized the entire pancreas in all pts. PD diamete.rs were measured at baseline and at l-rain intervals for 15 min. SSEUS in 20 control pts showed no change in 16 while 4 had a 1 mm dilation at 2-3 rain but was not sustained (_.~.10 min). 20 pts (15W,5M, age 42-73) with suspected SOD were subsequently studied by SSEUS. RESULTS: 13 of 20 study patients had normal SOM (basal pressure < 40mmHg) while 7 pts had abnormal SOM consistent with SOD. Of the 13 pts with normal SOM, 12 had negative and 1 positive SSEOS response. Of the 7 pts with abnormal SOM, SSEUS results identified 4 positive and 3 negative responses. There were no EUS-related complications identified in this study. SOM RESULT Normal
PT (n) 13
SECRETIN STIMULATED EUS (SSEUS)
Neg Pns 12
SENS
SPEC
PPV
NPV
1
57~ 92% 80% 80% 3* 4** BD sphmcter; CONCLUSION: SSEUS is safe, easy to perform and may provide an alternative endoscopic diagnostic modality for the diagnosis of SOD. Diagnosis of SOD by SSEUS is highly specific with less than optimal sensitivity. It may be more useful in pts with suspected SOD involving the pancreatic duct segment of the sphincter of Oddi. Abnormal
7
A PROSPECTIVE STUDY ON THE LONG-TERM FATE OF METALLIC CLIPS USED DURING LAPAROSCOPY CHOLECISTECTOMY.
Cetta 17, Lombardo F, Baldi C, Cappelli ,4, Giubbolini M Institute of Surgical Clinics, University of Siena Italy. The long-term fate (in terms of migration) of metallic clips (MC), used for cystic duct (CD) and cystic artery (CA) ligation during laparoscopic cholecystectomy (LC) is not well known. In a previous report (D we have described preliminary results in 71 patients, who underwent LC and who gave informed consent to have serial plain addomiual X-ray to document the location of clips placed during LC. In order to distinguish MCsplaced around CD from those around CA, different types of MCs (12ram for CD and 8-9mm for CA) were used. The placement of supplementary MCs (in addition to the usal 4, i.e. 2 for CD and 2 for CA) was also recorded. Patients had a minimum follow-up of 1 year (maximum 28 months). 13 patients had evidence of clip migration. In particular, 7 migrated within I month, 2 at 6 months and 2 at I year. Predisposing factors for clip migration were identified. They included: short cystic stump, inappropriate clip placement, local infection or suppurative complications. In particular, the great majority of clips (10 of 13) were sinai/clips placed around small branches of the cystic artery or other small vessels, with a very short stump. A second group of 82 patient also underwent serial plain eddominal X-ray after LC. X-ray were performed postoperatively at: (1) 1-3 days, (2) 1 month, (3) 6 months, (4) 1 year, and were planned every 2 years thereafter. In the latter group CD and CA were isolated for at least 0.g-lcm and only 2 clips were placed on each one of the 2 stumps, without additional clips on smaller vessels. In this group ) only 1 patient~ was found with clip migration . . . . . . within 1 month (vs 7 m the l~ormer group) ( x ~ 3 . 6 3 ; ~ . 0 5 ) . One addlttonal patient had clip migratition within 1 year. During follow-up, a 72-year--old male developed a recurrent brown pigment stone in the common bile duet 26 months post-operatively. The stone had formed around a MC that had protruded into the duct. It is suggested that: (1) MCs can migrate from their initial sites at various intervals, (2) clips may erode or migrate into the CD and may serve as a nidus for GS formation, (3) in some cases, factors predisposing to clip migration can be identified and prevented, but it is not possible to prevent migration in all eases, (4) further follow-up studies to determine the late fate of clips used during LC am warranted. (1) Lombardo et at. Gastroenterology 1994; 106: A347.
AGA ABSTRACTS
GASTROENTEROLOGY, Vol. 108, No. 4
RESUI.TS OF ENDOSCOPY INTUBATION FOR EXPANDABLE METALS OR PLASTICS STENTS IN THE TREATMENT OF MAI.IGNANT BILE DUCT OBSTRUCTION. JM CANARD**, R CHOLLET*.* Service d'Hdpato-Gastroentdrologie, groupe hospitalier Pitid-salpdtri~re; ** Clinique du Trocaddro, 62 rue de la Tour, 7_5016 Paris, France. The aim of this retrospective study was to appreciate the differences between plastic or expandable metal stent for the management of patients with an irresectable malignant obstruction of the common duct. Patients and methods : Between January 1992 and December 1993, 44 patients, 19 males and 25 females, with a median age of 71 years (range,26-93), were treated for endoscopic placement of metal stents (group 1. n=24. Strenker stent (16) and Wallstent (8)) or polyethylene stents ( group 2, n=24). Lesions were pancreatic tumor (n=24), ampullary (n=7), cholangiocarcinoma (n=3), metastatic tumors (n--9). Results : The mean period of follow-up was 184 days (range, 3-425). No statistical difference was observed between the 2 groups regarding age, sex, duration of jaundice and laboratory findings. Stent implantation was unsuccessful in 5 cases ( unsuccessful introduction due stenosis, using the metalic guide (n---3) orthe stens himself (n=2). At D 30, 3 complications (12,5%) was observed in group 1 ( 1 stent migration. 1 bleeding, insufficiente expansion) and 5 (20,8%) in the group 2 ( 4 cholangitis, 1 cholecystis) (NS). After 30 days, 5 and 9 stent obstructions was observed respectively in group I and 9 (NS).The occlusion of metal stent was treated using plastic stent implantation (n=5). The mean patency of metal and plastic stents were 158+ 102 and 95_+75 days (p--0,02). The median survival in group I and 2 were respectively 154_+132 and 140-+121 days (NS). Conclusion : The metal stent patency duration is greater than that of plastic one, most patients died with a functional metal stent. There was no difference between the two stents concerning complication rate. but the improvement of the material could decrease of the metal stent complications
COMPARISON OF SPHINCTER OF ODDI MANOMETRY(SOM), FATTY MEAL ULTRASOUND AND HEPATOBILIARY SCINTIGRAPHY IN THE DIAGNOSIS OF SPHINCTER OF ODD! DYSFUNCTION (SOD) MP Catalano, JE Geenen, P Pmessing, GK Johnson, MJ Schmalz, WJ Hogan. Pancreatic Biliary Center, St Luke's Medieal Center, Milwaukee, Wisconsin. SOD affects approximately 1-5% of post-¢holeeysteetomy pts. The "gold standard" diagnosis is SOM, whleh is clinically difficult, invasive and frequently complicated by pancreatitis (5-10%). A sensitive, non-invasive imaging modality is needed for the diagnosis of SOD. Quantitative hepatobiliary seintlgraphy CRIBS)and fatty-meal ultrasound (FMUS) are two frequently used tests; varying results are reported in the literature. AIM: To compare the results of SOM, HBS, FMUS in the diagnosis of SOD in a large pt population. METHOD: 304 pts (3gM, 266W, age 17-72) with suspected SOD ware evaluated by SOM/FMUS/HBS. Basal SO pressure >40mmHg obtained at ERCP was considered abnormal. FMUS was done using Lipomul (1.5cc/kg), with the CBD diameter measured at baseline and 45 rain post-fatty meal. An increase o f > 2 ram was considered abnormal. Quantitative HBS was done using Tc99m labeled radionoclide. Sequential images were obtained every 5 rain for 90 rain to monltor excretion of radionuclide and graphed over time. Time-to-peak, half-time and down slope were calculated according to predetermined ranges. 73 pts we.re diagnosed with SOD by SOM; ttBS was abnormal in 36 of these while FMUS was abnormal in 15. RESULTS: Comparison of the 3 modalities ate shown. F M U S
S O M
HBS
N
A
T
S
N
224
7
231
O
A
58
15
73
T
282
22
304
M
F M U S / H B S
N
A
T
~S
N
181
50
231
O
A
37
36
73
T
218
86
304
nal,A-Abnormal,'l FMUS=21%/97/6g/79; ttBS=49%Flg142183.
M
At
N
A
T
N
1.77
54
231
A
34
39
73
T
211
93
304
least
one
abnormal
radiographic study fill]S, FMUS) was seen in 90% of type I SOD, 50% type II, 45% type III pts. CONCLUSIONS: In the largest series reported to date, correlation of FMUS and HBS with SOM in the diagnosis of SOD is poor. When HBS and FMUS are used in conjunction, slight increase in sensitivity can be expected. The diagnostic accuracy of FMUS/I-IBS decreases from Type I to Type III SOD patients.
Q SPHINCTER OF ODDI DYSFUNCTION AND PAPILLARY STENOSIS: DIAGNOSIS BY SF_L"RE'I/N-STIMULATED ENDOSCOPIC ULTRASOUND (SSEUS). M.F. Catalano, J.E. Geeaen, M.J. Schmalz, G.K. Johnson, D.J. Geenen, L. Jacob, W.J. Hogan, St. Luke's Hospital, Racine, St. Luke's Medical Center, Milwaukee, Wisconsin. Sphincter of Oddi dysfunction (SOD) affects approximately 1-5% of post-eholecystectomy pts. Diagnosis includes clinical prasentation, radiologic (fatty meal ultrasound and hepatebiliary seintigtaphy) and invasive manometric studies of the sphincter of Oddi (SOM). SOM is complicated by pancreatitis in up to 10% of pts. A sensitive, minimally invasive endoscopic imaging modality for the diagnosis of SOD would be a useful alternative to manometry. AIM: To evaluate the affect of secretin stimulation on the parmreatie duct (PD) diameter in pts with suspected SOD using EUS. METHOD: 20 pts with no pancreatic disorder underwent SSEUS to identify a normal response to seeretin stimulation. EUS visualized the entire pancreas in all pts. PD diamete.rs were measured at baseline and at l-rain intervals for 15 min. SSEUS in 20 control pts showed no change in 16 while 4 had a 1 mm dilation at 2-3 rain but was not sustained (_.~.10 min). 20 pts (15W,5M, age 42-73) with suspected SOD were subsequently studied by SSEUS. RESULTS: 13 of 20 study patients had normal SOM (basal pressure < 40mmHg) while 7 pts had abnormal SOM consistent with SOD. Of the 13 pts with normal SOM, 12 had negative and 1 positive SSEOS response. Of the 7 pts with abnormal SOM, SSEUS results identified 4 positive and 3 negative responses. There were no EUS-related complications identified in this study. SOM RESULT Normal
PT (n) 13
SECRETIN STIMULATED EUS (SSEUS)
Neg Pns 12
SENS
SPEC
PPV
NPV
1
57~ 92% 80% 80% 3* 4** BD sphmcter; CONCLUSION: SSEUS is safe, easy to perform and may provide an alternative endoscopic diagnostic modality for the diagnosis of SOD. Diagnosis of SOD by SSEUS is highly specific with less than optimal sensitivity. It may be more useful in pts with suspected SOD involving the pancreatic duct segment of the sphincter of Oddi. Abnormal
7
A PROSPECTIVE STUDY ON THE LONG-TERM FATE OF METALLIC CLIPS USED DURING LAPAROSCOPY CHOLECISTECTOMY.
Cetta 17, Lombardo F, Baldi C, Cappelli ,4, Giubbolini M Institute of Surgical Clinics, University of Siena Italy. The long-term fate (in terms of migration) of metallic clips (MC), used for cystic duct (CD) and cystic artery (CA) ligation during laparoscopic cholecystectomy (LC) is not well known. In a previous report (D we have described preliminary results in 71 patients, who underwent LC and who gave informed consent to have serial plain addomiual X-ray to document the location of clips placed during LC. In order to distinguish MCsplaced around CD from those around CA, different types of MCs (12ram for CD and 8-9mm for CA) were used. The placement of supplementary MCs (in addition to the usal 4, i.e. 2 for CD and 2 for CA) was also recorded. Patients had a minimum follow-up of 1 year (maximum 28 months). 13 patients had evidence of clip migration. In particular, 7 migrated within I month, 2 at 6 months and 2 at I year. Predisposing factors for clip migration were identified. They included: short cystic stump, inappropriate clip placement, local infection or suppurative complications. In particular, the great majority of clips (10 of 13) were sinai/clips placed around small branches of the cystic artery or other small vessels, with a very short stump. A second group of 82 patient also underwent serial plain eddominal X-ray after LC. X-ray were performed postoperatively at: (1) 1-3 days, (2) 1 month, (3) 6 months, (4) 1 year, and were planned every 2 years thereafter. In the latter group CD and CA were isolated for at least 0.g-lcm and only 2 clips were placed on each one of the 2 stumps, without additional clips on smaller vessels. In this group ) only 1 patient~ was found with clip migration . . . . . . within 1 month (vs 7 m the l~ormer group) ( x ~ 3 . 6 3 ; ~ . 0 5 ) . One addlttonal patient had clip migratition within 1 year. During follow-up, a 72-year--old male developed a recurrent brown pigment stone in the common bile duet 26 months post-operatively. The stone had formed around a MC that had protruded into the duct. It is suggested that: (1) MCs can migrate from their initial sites at various intervals, (2) clips may erode or migrate into the CD and may serve as a nidus for GS formation, (3) in some cases, factors predisposing to clip migration can be identified and prevented, but it is not possible to prevent migration in all eases, (4) further follow-up studies to determine the late fate of clips used during LC am warranted. (1) Lombardo et at. Gastroenterology 1994; 106: A347.