Efficacy and safety of transpapillary drainage for pancreatic pseudocysts

'3501 EFFICACY AND SAFETY OF TRANSPAPILLARY DRAINAGE FOR PANCREATIC PSEUDOCYSTS Michael J. Levy, Mayo Clin, Rochester, MN; Steve Goldschmid, Emory Univ, Atlanta, GA; Maurits J. Wiersema, Mayo Clin, Rochester, MN; Kie N. Lira, Stuart Soroka, Emory Univ, Atlanta, GA; Joseph E. Geenen, Marc F Catalano, St Luke's Medical Ctr, Milwaukee, WI BACKGROUND: The formation of a pancreatic pseudocyst may complicate the course of acute or chronic pancreatitis. Although many spontaneously regress, a symptomatic pseudocyst may persist and mandate therapeutic intervention. Drainage may be performed radiologically, surgically, via endoscopic cystenterostomy, or endoscopic transpapillary drainage. This later form of therapy is generally reserved for patients with a pseudocyst that freely communicates with the pancreatic duct. The aim of this study was to review the utility and safety of transpapillary pancreatic duct stenting in the therapy of communicating pseudocysts. METHODS: We retrospectively reviewed the records of 42 patients, 24 males and 18 females, mean age 58Y (range 21-83Y), who underwent pancreatic duct stenting for a symptomatic communicating pseudocyst. The pseudocysts developed as a result of alcohol abuse (n=18), gallstones (n-12), idiopathic acute recurrent pancreatitis (n=5), post-ERCP (n=3), pancreas divisum and acute recurrent pancreatitis (n=2), and trauma (n=2). RESULTS: The pseudocysts were located in the pancreatic head (n=13), body (n=19), or tail (n=10). They ranged in size from 3-12 cm (mean 8.4 cm). The pancreatogram revealed downstream obstruction in 15 patients; 3 as a result of PD stones, and 12 resulting from pancreatic duct (PD) strictures. Patients with PD stones underwent an endoscopic sphincterotomy and stone removal via balloon or basket. Patients with PD strictures underwent endoscopic sphincterotomy (n=3), balloon dilatation with a 4mm balloon (n=7), or 6ram balloon (n=2), or catheter dilatation with a 7 Fr catheter (n=3). Only one stent was necessary to achieve cyst drainage in 21/42 (50%) of patients, while 16/42 (38%) required subsequent placement of a second stent, and 5/42 (12%) required serial placement of three stents. Successful resolution of the pseudocyst was initially observed in 35/42 (83%), with long-term pseudocyst resolution occurring in 30/42 (71%). Pseudocyst recurrence developed in 6/42 (14%} and surgical intervention was ultimately required in 8/42 (19%). Mild pancreatitis developed in 3/42 (7%) of patients. CONCLUSION: Transpapillary pseudocyst drainage is a safe and effective ~ueans of therapy for pancreatic pseudocysts that freely communicate with die pancreatic duct and may obviate the need for risky surgical or endoscopic therapy. Downstream obstruction frequently complicates pseudocyst communicating with the main pancreatic duct and may result in failure of uther drainage options. *3502 IMPROVING TREATMENT STATEGIES IN PANCREATIC DUCT STENTING: IS A FIXED SCHEDULE THE CLUE? Boris Brand, Vc Nam, Nicolette Domschke, Univ Hasp Eppendorf, Hamburg Germany; Gerald Gurakuqi, Landeskrankenhaus, Graz Austria; Mathias Kahl, Sabine Bohnacker, Uwe Seitz, Stefan Seewald, Univ Hasp Eppendorf, Hamburg Germany; Andreas Tiran, Landeskrankenhaus, Graz Austria; Detlev Ameis, Andreas De Weerth, Nib Soehendra, Univ Hasp Eppendorf, Hamburg Germany OBJECTIVES: Endoscopic pancreatic stenting has been reported th be effective in selected patients, presenting with symptomatic chronic pancreatitis. As prolonged placement has been associated with an increased risk of side effects, we assessed the potential of a fixed protocol to minimise ~he duration of stenting required to achieve persistent stricture resolution. METHODS: Fourty patients with symptomatic proximal pancreatic ductal strictures (additional pancreaticolithiasis: n=25; pancreas divisum: n=8) were aimed to be treated according to a prospective protocol: endoscopic pancreatic sphincterotomy, optional stricture dilation, ESWL or placement ,~f 5 or 7F stents for 3 months, to allow 10F stenting for <3 month until stricture resolution. RESULTS: Median 2(1-6) stents were placed for 182 <6-435) days to achieve initial resolution of strictures in 34 cases. Treatment groups: <7F stent (n=7); protocol fulfilled (n=23); prolonged stenting using <10F stents (n=6). Four patients did not tolerate stenting clue to immediate pain aggravation, seventeen of 24 patients with an avail~ble ERP at a median of 6 (1-9) months after stent extraction decreased pancreatic duct diameter. Thirteen patients maintained free of ductal strictures. Total time of stenting, but not the maximum diameter of stents placed, appeared to predict a relaps of symptomatic stenosis. Stent malfunction was not associated with prolonged stenting. Twentysix and 34 of the 36 patients with successful stenting reported sustained pain relieve and weight gain, respectively (median follow-up: 22 months, 11-32). CONCLUSIONS: A fixed stenting protocol might help to identify a subgroup of patients, which persistently benefits from short term stenting. However, this might not reduce the risk of stent related complications.

VOLUME 53, NO. 5, 2001

*3503 EUS/EUS-FNA DIAGNOSTIC DATA SUPPORTS PANCREATIC ADENOCARCINOMA B E I N G A S E X - H O R M O N E S E N S I T I V E TUMOR Richard A. Erickson, Scott and White Clinic; Texas A&M Univ Sys Hlth Sci Ctr, Temple, 'rx PURPOSE: Although controversial, some animal and human studies suggest that androgenic hormones may be a growth factor for pancreatic adenocarcinoma. This study uses the unique tumor-specific data provided by EUS/EUS-FNA to help assess this issue. METHODS: Data from the last 5 yrs. on all pancreatic neoplasms examined by EUS/EUS-FNA were prospectively collected in an electronic database. 173 consecutive patients having EUS-FNA for non-cystic pancreatic adenocarcinomas were examined for sex differences between the following tumor aggressiveness attributes at initial EUS diagnosis: primary tumor size and cytologic differentiation and EUS-FNA documented nodal, hepatic or peritoneal spread. Subanalyses were also done of patient smoking habits and clinical presentation. RESULTS: All tumor aggressiveness factors were more frequent in males (table). The same pattern of more aggressive tumor attributes in males was seen regardless of smoking status or presentation with jaundice where men and women presented with similar average bilirubin levels (10.6 mg/dl). CONCLUSIONS: EUS/EUS-FNA offers a unique look at the presenting aggressive attributes of pancreatic adenocarcinomas by providing data on precise primary tumor size and differentiation and the presence of cytologically-documented nodal]liver metastasis. This data consistently supports males having more aggressive pancreatic cancers as evidenced by larger size, poorer differentiation and a higher incidence of extrapancreatic spread. These aggressive attributes are not explained by patient age, smoking or mode of presentation. This study supports the hypothesis that pancreatic adenocarcinoma may indeed be an androgensensitive tumor and may encourage reassessing the role of hormonal manipulation in treating this tumor.

Number of patients I Avg Age EUS.FNA dx'd metastases to NodeslLIverlAscltes: Total 1° tumor cross-sectional area (cm2)_ 10 tumor cytologic differentiation Well or moderate Moderate to poor or poor

Males

Females

96 (88.6)

77 (68.4)

14/13/2 29 (30%) 9. t4 ± 4.87 (SD)

4/4/2 10 (13%} p=O.OO4 6.73 ± 3.38 p
26 38

39 30 p=O.03

*3504 CLINICAL OUTCOMES OF ENDOSCOPIC PANCREATITIC PSEUDOCYST DRAINAGE. Helgi Kr Sigmundsson, William B. Silverman, Univ of Iowa Hospitals and Clinics, Iowa City, IA BACKGROUND: Endoscopic drainage of pancreatic pseudocysts (PC) may be the preferred method of drainage in selected patients. We retrospectively evaluated 25 patients with PCs that had undergone endoscopic PC drainage and assessed both the success of the drainage, as well as the rate of complications. METHODS: From 1997 to the present, 25 patients with PCs and endoscopic cyst drainage were identified by chart review and are the subject of this review. Endoscopic transpapillary stent (ETPS) was placed in 20 patients, endoscopic cystgastrostomy (ECG) in 5, endoscopic cystduodenostomy (ECD) in 4. A combination of ETPS with either ECG or ECD was performed on 4 patients. Etiology of PC was related to chronic pancreatitis in 23 cases (92%), while one patient had a post surgical PC and one had pancreatic adenocarcinoma compressing the pancreatic duct. 20 (80%) of the patients had abdominal pain as the indication for the procedure. RESULTS: 22 (88%) patients had complete resolution of PCs treated endoscopically. Each patient required on average 2.4 drainage procedures on PCs. The PCs resolved after a mean of 117 days. Two patients redeveloped PCs, but with repeated endoscopic interventions these PCs resolved. Three (12%) did not completely resolve their PCs. Of these, two (8%) failed endoscopic management and were referred for surgery. One patient with persistent PC was asymptomatic and had no further therapy. Complications occurred in 7 patients (28%). Complications observed were: infected PCs in 3, bleeding in 2, perforation in 1, and the proximal stent migration above the ampulla in 1. Four of the nine patients with ECG or ECD drainage had a complication, while three of the twenty patients with ETPS had a complication (p>0.05). There was no procedure related mortality. CONCLUSION: Endoscopic drainage was effective in resolving the PCs in 88% of the cases. While the complication rate observed was higher than expected, only two required surgery or CT/US guided percutaneous drainage to treat the complications. No procedure related mortality occurred. The difference in complication rates for ECG and ECD vs. ETPS was not statistically significant, presumably due to the small sample size.

GASTROINTESTINAL ENDOSCOPY

AB137