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Effect of somatostatin on the incidence of pancreatic endoscopic sphincterotomy-induced pancreatitis in patients with pancreatic sphincter dysfunction and normal pancreas
ERCP-PANCREAS II 461
463
PRE-PROCEDURE ct-I-ANTITRYPSIN LEVELS AND POST-ERCP PANCREATITIS K Gottlieb, M Hasan, S Sherman, M Olsson, D Earle, G A Lehman, Indiana University Medical Center, Indianapolis, IN Alpha-l-antitrypsin (A-l-AT) is responsible for approximately 90% of the anti-protease activity in serum. This enzyme, and others, such as alpha 2-macroglobulin (A-2-MG) are thought to have important functions in the containment of inflammatory processes. METHODS: 355 consecutive outpatients scheduled to undergo ERCP had A-l-AT and A-2-MG levels done prior to the procedure. Normal range for A-l-AT and A-2-MG are 85-215 mg/dl and 110-300 mg/dl, respectively. Patients were followed by next day phone call or in the hospital. Pancreatitis was diagnosed and graded as previously published (Gastrointest Endosc 1990;36:462). RESULTS: No Pancreatitis Pancreatitis p-Value n=303 n=52 A-l-AT (mg/dl) 194 +_56 170 _+39 0.003 A-2-MG (mg/dl) 228 • 68 211 • 64 NS mean _+SD two-tailed t-test
ENDOSCOPIC CYSTOGASTROSTOMY AND BLEEDING: IS THERE HISTOLOGIC EVIDENCE FOR A PREDISPOSITION TO BLEED? S. Harvey, M. Michalov, K.P. Etzkorn, M. Sawhney, R.D. Brown, D. Resnick, J. Vitello, R.P. Venu. Section of Digestive and Liver Diseases, University of Illinois at Chicago, IL Bleeding constitutes the most serious complications associated with endoscopic cystogastrostomy (ECG), it may be related to abnormal submucosal vasularity directly adjacent to the pseudocyst. Little literature is available regarding the vascularity of this region. AIM. Histological evaluation of the submucosal vasculature of gastric wall adjacent to pseudocyst in comparison with vascular anatomy of normal gastric wall. METHOD. Gastric specimens were obtained from 5 patients (Pts) with pseudocyst ( > 6 cm) undergoing surgical cystogastrostomy (SCG). Five pts who had surgical specimens from normal posterior gastric wall (no pancreatic abnormalities) served as controls. All specimens were fLxed, and processed in the usual fashion and stained with H&E and EVG stains. Microscopic examination was performed under high power (40 x objective) and the diameter of all the vascular space was measured. The aggregate value (AG) of all vascular structures in mm was determined. The total submucosal area (SMA) and the length of submucosa (SML) was determined. The ratio of AG to SMA and AG to SML were calculated. RESULTS. The ratio of AG to SMA was similar in specimens from pseudocyst and controls, however, the ratio of AG to SML was higher in specimens from SCG compared to control, AG Imm~ AG ~num SMA (mm2) SML (nun)
Quintiles of A-I-AT-Levels with percent cases of pancreatitis: Cases of pancreatitis A-l-AT Level (mg/dl) expected observed 78 - 148 20% 29% 149 - 171 20% 25% 172 -192 20% 30% 193 - 224 20% 8% 225 - 492 20% 8%
Indications, types of therapeutic intervention, frequency of manometry, etc., are not different between these quintiles. SUMMARY: 1. Pre-procedure A-l-AT levels but not A-2-MG levels are lower in patients who subsequently develop pancreatitis. 2. The percentile tables reveal that the highest A-l-AT levels are associated with the lowest pancreatitis incidence. CONCLUSION: Higher endogenous A-l-AT levels, possibly secondary to an acute phase reaction, seem to confer a degree of protection against procedure associated pancreatitis. Further studies in this direction are required.
7462 EFFECT OF SOMATOSTATIN ON THE INCIDENCE OF PANCREA'HC ENDOSCOPIC SPHINCTEROTOMY-INDUCED PANCREATITIS IN PATIENTS WITH PANCREATIC SPHINCTER DYSFUNCTION AND NORMAL PANCREAS. M Guelrud, J Plaz, S Mendoza, I Herrera.. GI "tInit, Hospital General del Oeste, Los Magallanes, Caracas, Venezuela. Pancreatitis is a common complication after pancreatic sphineterotomy (PS). Its incidence depends on the status of the gland. A normal pancreas is more likely to react violently than is a gland with chrome pancreatitis. The purpose of this open, nonrandomized, controlled study is to evaluate the efficacy of prophylactic Somatostatin infusion (SI) to prevent the occurrence of acute pancreatitis after PS in a normal pancreas. METHODS: Inclusion cri'eria: Patients with idiopathic recurrent pancreatitis,normal pancreatic duct on ERCP and hypertensive pancreatic sphincter on manometry. A dual sphinctero'omy of both pancreatic and common duct sphincters was performed. SI at a dese of 250 ttg/h was started 1 hour prior to PS and maintained for 24 hours. Stat sties were done by Fisher exact test and Mann-Whitney rank sum test. RESU,TS: 29 patients were studied. Nine received saline infusion (S) and 20 rectived prophylactic SI. The S group was halted when an analysis revealeai an increased incidence of post-PS pancreatitis. A rate of 44% (4/9) of acute pancreatitis was observed in the S compared with 15% (3/20) in the SI jtaup (p=0.15). The mean number of hospital days required to treat pancreatitis ~xas 15 days in the S group with a median stay of 2 days compared with a mean of 1.6 days and a median of 1 day in the SI group. Table: Serum amylase afte: PS Pancreatitis Saline Somatostatina
no yes no
n
Pre
2h
5 4 17 3
86 85 66 ~
190 545 143 526
4h
12h
438 1" 488 ~f 1712' 2 7 7 7 ' 158 + 186 t" ~ 920'
24h 371 l" 2775 * 125 ~" 87~ *
~-p < 0.001 * p<0.01 A cut-off value of >252 UI/L (N'V 115 UI/L) for the 2-hour amylase ideu ,fled all patients who developed post-PS panereatitis. None of the patients wl't~ had an amylase < 252 UI/L developed pancreatitis. A trend towards more swere panereatitis was seen in the S group who had moderate and severe panere, xitis in 22% of the time. None of the SI patients developed moderate or s~/ere panereatitis. CONCLUSION: These data show no significant decrease in post PS-induced panereatitis with prophylactic SI. However, there is a t.end towards decreased incidence and severity of post PS-induced pancreatitis.
406
GASTROINTESTINAL ENDOSCOPY
SCG .706 (mean) 1.41 (mean) Control .606 (mean) .83 (mean) CONCLUSIONS. Since the aggregate vascular diameter per unit length of submucosa is higher in gastric wall specimens adjacent to pseudocyst, there seems to be increased vascularity of the stomach wall in pts with pseudocysts. The lack of difference in aggregate vascular diameter per unit area of submucosa between the two groups may be related to submueosal edema which is seen histologically in pseudocyst pts. This increased vascularity may account for a predisposition to bleed during ECG.
464 STRECKER-STENTS TM IN CHRONIC OBSTRUCTIVE PANCREATITIS - A NEW THERAPEUTIC MODALITY N. Hoepffner. H. Losch, W. Domschke, E. C. Foevste~ Dept. of Medicine B, University of Mnenster, Muenster, Germany Chronic pancw,afitis is characterized by the development of stenosis o f the pancreatic duct, pres~notic dilatation of the duct, inWaductaI conc~cments, pancreatic pseudocysts and recun~nt inflammatory attacks wich are painful for the patient. For this reason, the main target of an intervenfional endoscopic treatment, also in combination with ESWL, should be the fascilitation of free duct drainab~ by means of endoscopic papillotomy or transient prosthesis implantation. We are reportin$ r initial experience concerning implantation o f ballon-expandable StmckerTM stents into stenoses of the pancreatic duct in patients suffering from more severe chronic panematitis. From September 1993 imtil September 1994 6 patients (1 female, 5 male; age 47 [32-58] years) with histologically confirmed benign stenosis of the pancreatic duct (5x chronic panereatitis, l x acutely stenosing panematitis) were provided with ballon-ex~dable metal slents (StmckvrTM Stent, Microvasive| Boston Scientific; 0 21F; 40, 60 or 80 mm length) and observed over a mean period of 9 months (2,5 up to 27 months). Prior to implantation the patients with chronic pancreatitis exhibited pancreatic attacks on average once a week up to every three months for a petiod of 2 up to 11 years. In all cases implantation uneventfully proved to be a success and was completed in three patients by an additional ESWL follow implantation. In one patient the stent was again removed endoscopically after 2,5 months. During this endoscopy a pronotmf2d epill~liazationof rite stem was found the histological inverstigation of wich revealed the presence of a pancreatic carcinoma wich in spite of initially negative histology was w~onsible for the acutely stenosing pancreatitis. Like another patient in whom,the stent was removed due to persistent attacks of pain after 5 months this patient was provided with surgical treatment. Two patients suffered an attack after 3 and 5 months, respectivly, but were symptom-free during further follow-up examinations (15 and 25 months). Two other patients have been symptomfree since implantation (20 and 27 months). These initial results possibly indicate a new endoscopic interventional therapeutic possibility of more severe chronic pancreafitis and justify further inverstigations, even prospective randemised ones.
VOLUME 43, NO. 4, 1996
463
PRE-PROCEDURE ct-I-ANTITRYPSIN LEVELS AND POST-ERCP PANCREATITIS K Gottlieb, M Hasan, S Sherman, M Olsson, D Earle, G A Lehman, Indiana University Medical Center, Indianapolis, IN Alpha-l-antitrypsin (A-l-AT) is responsible for approximately 90% of the anti-protease activity in serum. This enzyme, and others, such as alpha 2-macroglobulin (A-2-MG) are thought to have important functions in the containment of inflammatory processes. METHODS: 355 consecutive outpatients scheduled to undergo ERCP had A-l-AT and A-2-MG levels done prior to the procedure. Normal range for A-l-AT and A-2-MG are 85-215 mg/dl and 110-300 mg/dl, respectively. Patients were followed by next day phone call or in the hospital. Pancreatitis was diagnosed and graded as previously published (Gastrointest Endosc 1990;36:462). RESULTS: No Pancreatitis Pancreatitis p-Value n=303 n=52 A-l-AT (mg/dl) 194 +_56 170 _+39 0.003 A-2-MG (mg/dl) 228 • 68 211 • 64 NS mean _+SD two-tailed t-test
ENDOSCOPIC CYSTOGASTROSTOMY AND BLEEDING: IS THERE HISTOLOGIC EVIDENCE FOR A PREDISPOSITION TO BLEED? S. Harvey, M. Michalov, K.P. Etzkorn, M. Sawhney, R.D. Brown, D. Resnick, J. Vitello, R.P. Venu. Section of Digestive and Liver Diseases, University of Illinois at Chicago, IL Bleeding constitutes the most serious complications associated with endoscopic cystogastrostomy (ECG), it may be related to abnormal submucosal vasularity directly adjacent to the pseudocyst. Little literature is available regarding the vascularity of this region. AIM. Histological evaluation of the submucosal vasculature of gastric wall adjacent to pseudocyst in comparison with vascular anatomy of normal gastric wall. METHOD. Gastric specimens were obtained from 5 patients (Pts) with pseudocyst ( > 6 cm) undergoing surgical cystogastrostomy (SCG). Five pts who had surgical specimens from normal posterior gastric wall (no pancreatic abnormalities) served as controls. All specimens were fLxed, and processed in the usual fashion and stained with H&E and EVG stains. Microscopic examination was performed under high power (40 x objective) and the diameter of all the vascular space was measured. The aggregate value (AG) of all vascular structures in mm was determined. The total submucosal area (SMA) and the length of submucosa (SML) was determined. The ratio of AG to SMA and AG to SML were calculated. RESULTS. The ratio of AG to SMA was similar in specimens from pseudocyst and controls, however, the ratio of AG to SML was higher in specimens from SCG compared to control, AG Imm~ AG ~num SMA (mm2) SML (nun)
Quintiles of A-I-AT-Levels with percent cases of pancreatitis: Cases of pancreatitis A-l-AT Level (mg/dl) expected observed 78 - 148 20% 29% 149 - 171 20% 25% 172 -192 20% 30% 193 - 224 20% 8% 225 - 492 20% 8%
Indications, types of therapeutic intervention, frequency of manometry, etc., are not different between these quintiles. SUMMARY: 1. Pre-procedure A-l-AT levels but not A-2-MG levels are lower in patients who subsequently develop pancreatitis. 2. The percentile tables reveal that the highest A-l-AT levels are associated with the lowest pancreatitis incidence. CONCLUSION: Higher endogenous A-l-AT levels, possibly secondary to an acute phase reaction, seem to confer a degree of protection against procedure associated pancreatitis. Further studies in this direction are required.
7462 EFFECT OF SOMATOSTATIN ON THE INCIDENCE OF PANCREA'HC ENDOSCOPIC SPHINCTEROTOMY-INDUCED PANCREATITIS IN PATIENTS WITH PANCREATIC SPHINCTER DYSFUNCTION AND NORMAL PANCREAS. M Guelrud, J Plaz, S Mendoza, I Herrera.. GI "tInit, Hospital General del Oeste, Los Magallanes, Caracas, Venezuela. Pancreatitis is a common complication after pancreatic sphineterotomy (PS). Its incidence depends on the status of the gland. A normal pancreas is more likely to react violently than is a gland with chrome pancreatitis. The purpose of this open, nonrandomized, controlled study is to evaluate the efficacy of prophylactic Somatostatin infusion (SI) to prevent the occurrence of acute pancreatitis after PS in a normal pancreas. METHODS: Inclusion cri'eria: Patients with idiopathic recurrent pancreatitis,normal pancreatic duct on ERCP and hypertensive pancreatic sphincter on manometry. A dual sphinctero'omy of both pancreatic and common duct sphincters was performed. SI at a dese of 250 ttg/h was started 1 hour prior to PS and maintained for 24 hours. Stat sties were done by Fisher exact test and Mann-Whitney rank sum test. RESU,TS: 29 patients were studied. Nine received saline infusion (S) and 20 rectived prophylactic SI. The S group was halted when an analysis revealeai an increased incidence of post-PS pancreatitis. A rate of 44% (4/9) of acute pancreatitis was observed in the S compared with 15% (3/20) in the SI jtaup (p=0.15). The mean number of hospital days required to treat pancreatitis ~xas 15 days in the S group with a median stay of 2 days compared with a mean of 1.6 days and a median of 1 day in the SI group. Table: Serum amylase afte: PS Pancreatitis Saline Somatostatina
no yes no
n
Pre
2h
5 4 17 3
86 85 66 ~
190 545 143 526
4h
12h
438 1" 488 ~f 1712' 2 7 7 7 ' 158 + 186 t" ~ 920'
24h 371 l" 2775 * 125 ~" 87~ *
~-p < 0.001 * p<0.01 A cut-off value of >252 UI/L (N'V 115 UI/L) for the 2-hour amylase ideu ,fled all patients who developed post-PS panereatitis. None of the patients wl't~ had an amylase < 252 UI/L developed pancreatitis. A trend towards more swere panereatitis was seen in the S group who had moderate and severe panere, xitis in 22% of the time. None of the SI patients developed moderate or s~/ere panereatitis. CONCLUSION: These data show no significant decrease in post PS-induced panereatitis with prophylactic SI. However, there is a t.end towards decreased incidence and severity of post PS-induced pancreatitis.
406
GASTROINTESTINAL ENDOSCOPY
SCG .706 (mean) 1.41 (mean) Control .606 (mean) .83 (mean) CONCLUSIONS. Since the aggregate vascular diameter per unit length of submucosa is higher in gastric wall specimens adjacent to pseudocyst, there seems to be increased vascularity of the stomach wall in pts with pseudocysts. The lack of difference in aggregate vascular diameter per unit area of submucosa between the two groups may be related to submueosal edema which is seen histologically in pseudocyst pts. This increased vascularity may account for a predisposition to bleed during ECG.
464 STRECKER-STENTS TM IN CHRONIC OBSTRUCTIVE PANCREATITIS - A NEW THERAPEUTIC MODALITY N. Hoepffner. H. Losch, W. Domschke, E. C. Foevste~ Dept. of Medicine B, University of Mnenster, Muenster, Germany Chronic pancw,afitis is characterized by the development of stenosis o f the pancreatic duct, pres~notic dilatation of the duct, inWaductaI conc~cments, pancreatic pseudocysts and recun~nt inflammatory attacks wich are painful for the patient. For this reason, the main target of an intervenfional endoscopic treatment, also in combination with ESWL, should be the fascilitation of free duct drainab~ by means of endoscopic papillotomy or transient prosthesis implantation. We are reportin$ r initial experience concerning implantation o f ballon-expandable StmckerTM stents into stenoses of the pancreatic duct in patients suffering from more severe chronic panematitis. From September 1993 imtil September 1994 6 patients (1 female, 5 male; age 47 [32-58] years) with histologically confirmed benign stenosis of the pancreatic duct (5x chronic panereatitis, l x acutely stenosing panematitis) were provided with ballon-ex~dable metal slents (StmckvrTM Stent, Microvasive| Boston Scientific; 0 21F; 40, 60 or 80 mm length) and observed over a mean period of 9 months (2,5 up to 27 months). Prior to implantation the patients with chronic pancreatitis exhibited pancreatic attacks on average once a week up to every three months for a petiod of 2 up to 11 years. In all cases implantation uneventfully proved to be a success and was completed in three patients by an additional ESWL follow implantation. In one patient the stent was again removed endoscopically after 2,5 months. During this endoscopy a pronotmf2d epill~liazationof rite stem was found the histological inverstigation of wich revealed the presence of a pancreatic carcinoma wich in spite of initially negative histology was w~onsible for the acutely stenosing pancreatitis. Like another patient in whom,the stent was removed due to persistent attacks of pain after 5 months this patient was provided with surgical treatment. Two patients suffered an attack after 3 and 5 months, respectivly, but were symptom-free during further follow-up examinations (15 and 25 months). Two other patients have been symptomfree since implantation (20 and 27 months). These initial results possibly indicate a new endoscopic interventional therapeutic possibility of more severe chronic pancreafitis and justify further inverstigations, even prospective randemised ones.
VOLUME 43, NO. 4, 1996