- Email: [email protected]
CT-targeted “Road mapping” for endoscopic drainage of pancreatic pseudocysts
ERCP--PANCREAS 529
531
LoNG-TERM RESULTS OF PANCREATIC STONE ESWL IN PATIENTS WITH DEFIANT PANCREATIC STONES. MJ Schmalz, L Jacob, JE Geenen, GK Johnson, MF Catalano, St. Luke's Hospital Racine, Pancreatic Biliary Center, St. Luke's Medical Center, Milwaukee, WI. Extracorporeal Shockwave lithotripsy (ESWL) has been shown to be a useful tool for fragmenting biliary and pancreatic duct (PD) calculi. The aim of this study was to determine the long term success rate of ESWL in treating patients with symptomatic PD stones refractory to convention therapeutic ERCP. Methods: 70 patients underwent ERCP for chronic pancreatitis and pain due to obstructing PD stones between 1/90 and 6/94. Ten patients; 6 male, 4 female - mean age 44(22-71), had obstructing stones refractory to ERCP management alone and were subsequently treated with ESWL using a Medstone| STS lithotriptor. Stone size varied from 4 to 15mm (mean 9mm). Six patients had PD strictures, one had a small pseudocyst. All patients were treated with one session consisting of 2,000 shocks delivered in a prone position using x-ray guidance and under conscious sedation. All patients with incomplete fragmentation were offered a second ESWL session at least 30 days later. ERCP was performed following each lithotripsy session to clear the duct of remaining fragments. Results: Successful fragmentation of stones was achieved in 7/10 patients (70%) with complete clearance of stone fragments at ERCP in 5 patients. Six patients had one ESWL session only, and 4 patients underwent a second session. Immediate pain relief was seen in 5/10 patients (50%) with eventual long term pain relief in 6/10 patients (60%). Mean follow-up was 21 months (2-50 months). One patient developed recurrent PD stones but remains asymptomatic. No ESWL related complications were noted. Three patients who did not have successful fragmentation after the initial ESWL refused a second treatment. All of these patients opted for surgical management. Two patients continue to experience pain despite surgery. Conclusion: 1) ESWL is a safe technique for treating pancreatic stones. 2) ESWL facilitates endoscopic removal of difficult pancreatic duct stones. 3) Successful clearance of obstructing pancreatic stones can provide long term pain relief in patients with chronic pancreatitis.
E N D O S C O P I C TREATMENT OF P A N C R E A T I C FISTULAS AND A B S C E S S E S R. Schoefl/ S. Pongratz, R. Poetzi, ch. stain, P. Ferenci, A. Gangl, IV. Medical Clinic, U n i v e r s i t y of V i e n n a P a n c r e a t i c fistulas and a b s c e s s e s are a d o m a i n e of surgical therapy. Since it has a s u b s t a n t i a l rate of c o m p l i c a t i o n s and m o r t a l i t y and often n e c e s s i t a t e s the removal of parts of the gland less invasive t r e a t m e n t m o d a l i t i e s w o u l d be desirable. L o w e r i n g of the i n t r a d u c t a l pressure might not only reduce p a n c r e a t i c pain but also support healing of fistulas and d r a i n a g e of a b s c e s s e s might w o r k like that of cysts. In our c o n c e p t i o n t h e r a p y consists of short t e r m (1-4 weeks) drainage of abscesses or f i s t u l a - b e a r i n g ducts and long term drainage (6-12 months) of stenoses of ducts w i t h plastic endoprostheses. Up to now we have t r e a t e d 4 patients: Patient 1 s u f f e r e d from chronic p a n c r e a t i t i s w i t h a fistula each from the p a n c r e a t i c and the bile duct into a s u b h e p a t i c abscess and an a d d i t i o n a l s u b d i a p h r a g m a l abscess c o m m u n i c a t i n g w i t h a right intrahepatic duct. Patient 2 had acute n e c r o t i z i n g p a n c r e a t i t i s with a fistula from the bile duct into an abscess in the head of the pancreas. Patient 3 s u f f e r e d from p a n c r e a t i c c a r c i n o m a w i t h a fistula b e t w e e n p a n c r e a tic and bile duct. Patient 4 had c h r o n i c p a n c r e a t i t i s w i t h an abscess beside the head of the pancreas. Drainage was o b t a i n e d after p a p i l l o t o m y of b o t h sphincteres with bile duct e n d o p r o s t h e s e s in p a t i e n t s i, 2 and 3, w i t h p a n c r e a t i c e n d o p r o s t h e s e s in p a t i e n t s i and 4. A d d i t i o n a l drainage of abscesses was done in p a t i e n t 2 and 4 w i t h nasocystic catheters and later p l a s t i c endoprostheses. Patients i, 3 and 4 could be t r e a t e d s u c c e s s f u l l y and without complications. 3 to l0 m o n t h s later n e i t h e r r e c u r r e n c e of fistulas or abscesses nor abdominal p a i n have been observed. Drainage of the abscess in p a t i e n t 2 did not s u c c e e d due to a large sequester w i t h i n the abscess and s u r g e r y had to be performed. E n d o s c o p i c drainage of the bile duct and the p a n c r e a t i c duct for healing of fistulas and e n d o s c o p i c d r a i n a g e of p a n c r e a t i c abscesses might be an a l t e r n a t i v e to surgery in selected cases.
53O
~532
CT-TARGETED "ROAD MAPPING" FOR E N D O S C O P I C D R A I N A G E OF P A N C R E A T I C PSEUDOCYSTS R. Schoefl, G. Mostbeck, Ch. Stain, R. Poetzi, A. Gangl, IV. M e d i c a l Clinic, U n i v e r s i t y of V i e n n a
DOES L E A V I N G A M A I N P A N C R E A T I C DUCT STENT IN PLACE R E D U C E THE INCIDENCE OF P R E C U T BILIARY SPHINCTEROTOMY (ES)-INDUCED pANCREATITIS?: R A N D O M I Z E D P R O S P E C T I V E STUDY. S. Sherman. D. Earle, L. Bucksot, C. Weber, K. Gottlieb, G. Lehman, Indiana U n i v e r s i t y Medical Center, Indianapolis, IN P a n c r e a t i t i s is the most common c o m p l i c a t i o n of precut ES. The o b j e c t i v e of this study was to d e t e r m i n e w h e t h e r leaving a p a n c r e a t i c duct stent in place f o l l o w i n g p r e c u t ES w o u l d reduce the incidence and severity of post-procedure pancreatitis. METHODS: D u r i n g the past 28 months, free c a n n u l a t i o n of the bile duct for s t a n d a r d ES was not p o s s i b l e in 129 of 985 p a t i e n t s (12%). In 80, s e l e c t i v e p a n c r e a t i c duct c a n n u l a t i o n was achieved and a 5-7 French, 2-2.5 cm main p a n c r e a t i c duct stent was placed. U s i n g t h e p a n c r e a t i c stent as a guide, a n e e d l e - k n i f e (NK) s p h i n c t e r o t o m e was used to cut 5-10 m m in the 11-12 o ' c l o c k direction. Once access to the bile duct was obtained, the ES was u s u a l l y c o m p l e t e d using a standard sphincterotome. F o l l o w i n g c o m p l e t i o n of the ES, these 80 patients were randomized to leaving the p a n c r e a t i c stent in place (stent) for 7-10 days or immediate removal (stent removed). The r e m a i n i n g 49 who did not undergo p a n c r e a t i c duct stent p l a c e m e n t (no stent), had a NK ES p e r f o r m e d in a similar fashion. P a t i e n t s were p r o s p e c t i v e l y followed up for complications. S t a n d a r d i z e d criteria were used to diagnose and grade the s e v e r i t y of p o s t p r o c e d u r e p a n c r e a t i t i s (GI Endosc 1991;37:383). R E S U L T S :
Pancreatic pseudocysts, a c o m p l i c a t i o n of acute or chronic pancreatitis, should u n d e r g o t r e a t m e n t w h e n p e r s i s t i n g pain, infection of the cyst or c o m p r e s s i o n of n e i g h b o u r i n g structures occur. Less invasive p r o c e d u r e s like p e r c u t a n e o u s or e n d o s c o p i c d r a i n a g e p r o c e d u r e s have b e c o m e the treatment of c h o i c e w h e r e a s s u r g e r y is r e s t r i c t e d to primary or s e c u n d a r y failures of them. E n d o s c o p i c t r a n s g a s t r i c or t r a n s d u o d e n a l d r a i n a g e of pancreatic p s e u d o c y s t s has been limited by t h e n e c e s s i t y of bulging of the cyst into stomach or duodenum. Since two patients with symptomatic p s e u d o c y s t s of 3 and 8 cm in diameter, both located in the b o d y of t h e p a n c r e a s and without b u l g i n g into the s t o m a c h r e f u s e d p e r c u t a n e o u s as well as surgical treatment, we chose the f o l l o w i n g c o m b i n e d procedure. D u r i n g c o m p u t e r i z e d t o m o g r a p h y (CT) a thin 22G p u n c t u r e needle was inserted p e r c u t a n e o u s l y t h r o u g h t h e stomach into the pseudocyst under local anesthesia. D u r i n g the following endoscopic t r a n s g a s t r i c p u n c t u r e of t h e cyst with a n e e d l e - k n i f e p a p i l l o t o m e the p e r c u t a n e o u s l y inserted needle served as a guide for correct targeting. Both cysts could be s u c c e s s f u l l y punctured, each at the first attempt. No c o m p l i c a t i o n s o c c u r r e d and the p e r c u t a n e o u s puncture was r e p o r t e d as p a i n l e s s by the patients. After enlargement of the fistula w i t h a coaxial diathermic c a t h e t e r a 1OF double pigtail p l a s t i c endoprosthesis was inserted in each patient. It was r e m o v e d 3 weeks later when both cysts had vanished, as d e m o n s t r a t e d by sonography and CT scan. Our m e t h o d can be recon~nended for d r a i n a g e of p a n c r e a t i c p s e u d o c y s t s near the stomach but w i t h o u t b u l g i n g into it, w h e n e v e r endoscopic drainage of the cysts seems to be the appropriate treatment.
428
GASTROINTESTINAL ENDOSCOPY
ES INDICATION Stones Sphincter Of Oddl Dysfunction Tumor Miscellaneous
STENT
# PANCREATITIS/TOTAL# PATIENTS STENT NO STENT REMOVED
TOTAL
0/6 0/18
1/9 3/16
1/9 5/15
2/24 ( 8 % ) 8/49 (16%)
On
2110 2/6
0117 1/8
2/34 ( 6 % ) 3/22 (14%)
0/8
TOTAL 0/39(0%)* * P = ,O04, s ~ n t v s , stentremoved;P
8~1(19.5%} 7N9(14.3%) = . 0 1 4 s t e n t v s . nogtent
151129(11.6%}
P a n c r e a t i t i s was g r a d e d m i l d in 4 and m o d e r a t e in 4 in the stent removed group, and m i l d in 4, m o d e r a t e in i, and severe in 2 in the no stent group. The n u m b e r of p a n c r e a t i c duct injections, frequency of p a n c r e a t i c acinarization, and the use of sphincter of Oddi m a n o m e t r y were similar for all three groups. SUMMARy: i) L e a v i n g a p a n c r e a t i c duct stent in place following NK ES reduced the p a n c r e a t i t i s rate from 19.5% to 0%. 2) The p a n c r e a t i t i s rates were similar for the no stent and stent removed groups. CONCLUSION: These data suggest that p l a c i n g and m a i n t a i n i n g a p a n c r e a t i c duct stent for NK ES reduces the frequency of p o s t p r o c e d u r e pancreatitis. Until greater safety data are available, these t e c h n i q u e s should b e reserved for e x p e r i e n c e d endoscopists.
VOLUME 41, NO. 4, 1995
531
LoNG-TERM RESULTS OF PANCREATIC STONE ESWL IN PATIENTS WITH DEFIANT PANCREATIC STONES. MJ Schmalz, L Jacob, JE Geenen, GK Johnson, MF Catalano, St. Luke's Hospital Racine, Pancreatic Biliary Center, St. Luke's Medical Center, Milwaukee, WI. Extracorporeal Shockwave lithotripsy (ESWL) has been shown to be a useful tool for fragmenting biliary and pancreatic duct (PD) calculi. The aim of this study was to determine the long term success rate of ESWL in treating patients with symptomatic PD stones refractory to convention therapeutic ERCP. Methods: 70 patients underwent ERCP for chronic pancreatitis and pain due to obstructing PD stones between 1/90 and 6/94. Ten patients; 6 male, 4 female - mean age 44(22-71), had obstructing stones refractory to ERCP management alone and were subsequently treated with ESWL using a Medstone| STS lithotriptor. Stone size varied from 4 to 15mm (mean 9mm). Six patients had PD strictures, one had a small pseudocyst. All patients were treated with one session consisting of 2,000 shocks delivered in a prone position using x-ray guidance and under conscious sedation. All patients with incomplete fragmentation were offered a second ESWL session at least 30 days later. ERCP was performed following each lithotripsy session to clear the duct of remaining fragments. Results: Successful fragmentation of stones was achieved in 7/10 patients (70%) with complete clearance of stone fragments at ERCP in 5 patients. Six patients had one ESWL session only, and 4 patients underwent a second session. Immediate pain relief was seen in 5/10 patients (50%) with eventual long term pain relief in 6/10 patients (60%). Mean follow-up was 21 months (2-50 months). One patient developed recurrent PD stones but remains asymptomatic. No ESWL related complications were noted. Three patients who did not have successful fragmentation after the initial ESWL refused a second treatment. All of these patients opted for surgical management. Two patients continue to experience pain despite surgery. Conclusion: 1) ESWL is a safe technique for treating pancreatic stones. 2) ESWL facilitates endoscopic removal of difficult pancreatic duct stones. 3) Successful clearance of obstructing pancreatic stones can provide long term pain relief in patients with chronic pancreatitis.
E N D O S C O P I C TREATMENT OF P A N C R E A T I C FISTULAS AND A B S C E S S E S R. Schoefl/ S. Pongratz, R. Poetzi, ch. stain, P. Ferenci, A. Gangl, IV. Medical Clinic, U n i v e r s i t y of V i e n n a P a n c r e a t i c fistulas and a b s c e s s e s are a d o m a i n e of surgical therapy. Since it has a s u b s t a n t i a l rate of c o m p l i c a t i o n s and m o r t a l i t y and often n e c e s s i t a t e s the removal of parts of the gland less invasive t r e a t m e n t m o d a l i t i e s w o u l d be desirable. L o w e r i n g of the i n t r a d u c t a l pressure might not only reduce p a n c r e a t i c pain but also support healing of fistulas and d r a i n a g e of a b s c e s s e s might w o r k like that of cysts. In our c o n c e p t i o n t h e r a p y consists of short t e r m (1-4 weeks) drainage of abscesses or f i s t u l a - b e a r i n g ducts and long term drainage (6-12 months) of stenoses of ducts w i t h plastic endoprostheses. Up to now we have t r e a t e d 4 patients: Patient 1 s u f f e r e d from chronic p a n c r e a t i t i s w i t h a fistula each from the p a n c r e a t i c and the bile duct into a s u b h e p a t i c abscess and an a d d i t i o n a l s u b d i a p h r a g m a l abscess c o m m u n i c a t i n g w i t h a right intrahepatic duct. Patient 2 had acute n e c r o t i z i n g p a n c r e a t i t i s with a fistula from the bile duct into an abscess in the head of the pancreas. Patient 3 s u f f e r e d from p a n c r e a t i c c a r c i n o m a w i t h a fistula b e t w e e n p a n c r e a tic and bile duct. Patient 4 had c h r o n i c p a n c r e a t i t i s w i t h an abscess beside the head of the pancreas. Drainage was o b t a i n e d after p a p i l l o t o m y of b o t h sphincteres with bile duct e n d o p r o s t h e s e s in p a t i e n t s i, 2 and 3, w i t h p a n c r e a t i c e n d o p r o s t h e s e s in p a t i e n t s i and 4. A d d i t i o n a l drainage of abscesses was done in p a t i e n t 2 and 4 w i t h nasocystic catheters and later p l a s t i c endoprostheses. Patients i, 3 and 4 could be t r e a t e d s u c c e s s f u l l y and without complications. 3 to l0 m o n t h s later n e i t h e r r e c u r r e n c e of fistulas or abscesses nor abdominal p a i n have been observed. Drainage of the abscess in p a t i e n t 2 did not s u c c e e d due to a large sequester w i t h i n the abscess and s u r g e r y had to be performed. E n d o s c o p i c drainage of the bile duct and the p a n c r e a t i c duct for healing of fistulas and e n d o s c o p i c d r a i n a g e of p a n c r e a t i c abscesses might be an a l t e r n a t i v e to surgery in selected cases.
53O
~532
CT-TARGETED "ROAD MAPPING" FOR E N D O S C O P I C D R A I N A G E OF P A N C R E A T I C PSEUDOCYSTS R. Schoefl, G. Mostbeck, Ch. Stain, R. Poetzi, A. Gangl, IV. M e d i c a l Clinic, U n i v e r s i t y of V i e n n a
DOES L E A V I N G A M A I N P A N C R E A T I C DUCT STENT IN PLACE R E D U C E THE INCIDENCE OF P R E C U T BILIARY SPHINCTEROTOMY (ES)-INDUCED pANCREATITIS?: R A N D O M I Z E D P R O S P E C T I V E STUDY. S. Sherman. D. Earle, L. Bucksot, C. Weber, K. Gottlieb, G. Lehman, Indiana U n i v e r s i t y Medical Center, Indianapolis, IN P a n c r e a t i t i s is the most common c o m p l i c a t i o n of precut ES. The o b j e c t i v e of this study was to d e t e r m i n e w h e t h e r leaving a p a n c r e a t i c duct stent in place f o l l o w i n g p r e c u t ES w o u l d reduce the incidence and severity of post-procedure pancreatitis. METHODS: D u r i n g the past 28 months, free c a n n u l a t i o n of the bile duct for s t a n d a r d ES was not p o s s i b l e in 129 of 985 p a t i e n t s (12%). In 80, s e l e c t i v e p a n c r e a t i c duct c a n n u l a t i o n was achieved and a 5-7 French, 2-2.5 cm main p a n c r e a t i c duct stent was placed. U s i n g t h e p a n c r e a t i c stent as a guide, a n e e d l e - k n i f e (NK) s p h i n c t e r o t o m e was used to cut 5-10 m m in the 11-12 o ' c l o c k direction. Once access to the bile duct was obtained, the ES was u s u a l l y c o m p l e t e d using a standard sphincterotome. F o l l o w i n g c o m p l e t i o n of the ES, these 80 patients were randomized to leaving the p a n c r e a t i c stent in place (stent) for 7-10 days or immediate removal (stent removed). The r e m a i n i n g 49 who did not undergo p a n c r e a t i c duct stent p l a c e m e n t (no stent), had a NK ES p e r f o r m e d in a similar fashion. P a t i e n t s were p r o s p e c t i v e l y followed up for complications. S t a n d a r d i z e d criteria were used to diagnose and grade the s e v e r i t y of p o s t p r o c e d u r e p a n c r e a t i t i s (GI Endosc 1991;37:383). R E S U L T S :
Pancreatic pseudocysts, a c o m p l i c a t i o n of acute or chronic pancreatitis, should u n d e r g o t r e a t m e n t w h e n p e r s i s t i n g pain, infection of the cyst or c o m p r e s s i o n of n e i g h b o u r i n g structures occur. Less invasive p r o c e d u r e s like p e r c u t a n e o u s or e n d o s c o p i c d r a i n a g e p r o c e d u r e s have b e c o m e the treatment of c h o i c e w h e r e a s s u r g e r y is r e s t r i c t e d to primary or s e c u n d a r y failures of them. E n d o s c o p i c t r a n s g a s t r i c or t r a n s d u o d e n a l d r a i n a g e of pancreatic p s e u d o c y s t s has been limited by t h e n e c e s s i t y of bulging of the cyst into stomach or duodenum. Since two patients with symptomatic p s e u d o c y s t s of 3 and 8 cm in diameter, both located in the b o d y of t h e p a n c r e a s and without b u l g i n g into the s t o m a c h r e f u s e d p e r c u t a n e o u s as well as surgical treatment, we chose the f o l l o w i n g c o m b i n e d procedure. D u r i n g c o m p u t e r i z e d t o m o g r a p h y (CT) a thin 22G p u n c t u r e needle was inserted p e r c u t a n e o u s l y t h r o u g h t h e stomach into the pseudocyst under local anesthesia. D u r i n g the following endoscopic t r a n s g a s t r i c p u n c t u r e of t h e cyst with a n e e d l e - k n i f e p a p i l l o t o m e the p e r c u t a n e o u s l y inserted needle served as a guide for correct targeting. Both cysts could be s u c c e s s f u l l y punctured, each at the first attempt. No c o m p l i c a t i o n s o c c u r r e d and the p e r c u t a n e o u s puncture was r e p o r t e d as p a i n l e s s by the patients. After enlargement of the fistula w i t h a coaxial diathermic c a t h e t e r a 1OF double pigtail p l a s t i c endoprosthesis was inserted in each patient. It was r e m o v e d 3 weeks later when both cysts had vanished, as d e m o n s t r a t e d by sonography and CT scan. Our m e t h o d can be recon~nended for d r a i n a g e of p a n c r e a t i c p s e u d o c y s t s near the stomach but w i t h o u t b u l g i n g into it, w h e n e v e r endoscopic drainage of the cysts seems to be the appropriate treatment.
428
GASTROINTESTINAL ENDOSCOPY
ES INDICATION Stones Sphincter Of Oddl Dysfunction Tumor Miscellaneous
STENT
# PANCREATITIS/TOTAL# PATIENTS STENT NO STENT REMOVED
TOTAL
0/6 0/18
1/9 3/16
1/9 5/15
2/24 ( 8 % ) 8/49 (16%)
On
2110 2/6
0117 1/8
2/34 ( 6 % ) 3/22 (14%)
0/8
TOTAL 0/39(0%)* * P = ,O04, s ~ n t v s , stentremoved;P
8~1(19.5%} 7N9(14.3%) = . 0 1 4 s t e n t v s . nogtent
151129(11.6%}
P a n c r e a t i t i s was g r a d e d m i l d in 4 and m o d e r a t e in 4 in the stent removed group, and m i l d in 4, m o d e r a t e in i, and severe in 2 in the no stent group. The n u m b e r of p a n c r e a t i c duct injections, frequency of p a n c r e a t i c acinarization, and the use of sphincter of Oddi m a n o m e t r y were similar for all three groups. SUMMARy: i) L e a v i n g a p a n c r e a t i c duct stent in place following NK ES reduced the p a n c r e a t i t i s rate from 19.5% to 0%. 2) The p a n c r e a t i t i s rates were similar for the no stent and stent removed groups. CONCLUSION: These data suggest that p l a c i n g and m a i n t a i n i n g a p a n c r e a t i c duct stent for NK ES reduces the frequency of p o s t p r o c e d u r e pancreatitis. Until greater safety data are available, these t e c h n i q u e s should b e reserved for e x p e r i e n c e d endoscopists.
VOLUME 41, NO. 4, 1995