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Endoscopic removal of pancreatic duci stones-better patient selection by endoscopic ultrasound?
ERCP-PANCREAS ~ENDOSCOPIC ULTRASOUND 493
"7495
RISK FACTORS FOR PANCREATITIS AFTER ENDOSCOPIC MANIPULATION OF THE PANCREATIC DUCT. J.Vandervoort, T C K.Tham, R.C.K.Wong, ADRoston, A.Slivka, A.P.Ferran Jr., A.Musa, D.R.Lichtenstem, J.Van Dam, F.Ruymann, M.Hughes, DLCarr-Locke. Gastroenterology Division, Brigham & Women's Hospital, Harvard Medical School and School of Public Health, Boston, MA AIM : To identify specific risk factors which might increase the incidence of post-ERP pancreatitis alter mampulation of the pancreatic duct (PD) METHODS: In a prospective database of 817 patients of early post-ERCP complications, 127 pataents with PD-rcampulations were sdentffied We excluded all patients who underwent transpapillary manometry PDmampulation (PDM) waS defined as deep cannulation of the PD with a Glidewire (GW); brush cytology of the PD (PC); PD stentrng aRer brush cytology (PC+PS); catheter dilatation of the PD (CPD); PD stentmg after catheter dilatation (CPD+PS); insertion of a hasp-pancreatic tube (NPT); balloon dilatation of the PD (BDPD); pancreatac mampulatton with stenting (PDMWS); pancreatic mampulation vnthout stentmg (PDMSS). The incidence of pancreatitis was compared to a control group of 641 ERCPs without pancreatic duct mampulation (= NON PM). Seventy of panereatltls was graded according to published criteria RESULTS : The overall incidence of post-ERCP pancreatitis was 63/817 (7 7%). Accessory Pancreatitis Mild Moderate Severe GW 3/28 (10.7%) 3 0 0 PC 5/28 (17.9~ 3 2 0 PC+PS 0/7 ( 0%} 0 0 0 CPD 3/24 (12.5%) 2 1 0 CPD+PS 1/18 (5.5~ 0 1 0 NPT 3/10 (30%) 1 2 0 BDPD 1/1 (100%) 0 1 0 PDMSS 12/67 (18%) 8 4 0 PDMWS 5/60 (8.3%) 2 3 0 PDM 17/127(14 1%) 10 7 0 NON PDM 37/641 (5.7%) 22 13 2 CONCLUSIONS : The risk of post-ERCP pancreatitis is higher if the PD has been mampulated. There ts a sigmficant trend towards a lower incidence when the pancreatic duct is stented after mampulation.
COST EFFECTIVENESS OF ENDOSCOPIC ULTRASONOGRAPHY WITH FINE NEEDLE ASPIRATION V. MED1ASTINOSCOPY IN THE STAGING OF PATIENTS WITH LUNG CANCER. L. Aabakken. G. Silvestri, R. Hawes, C. Reed, A.Van Velse, B. Hoffinan Digestive Disease Center, Dept. of Pulmonary Medicine and Dept. of Thoracic Surgery, Medical Umversity of South Carolina, Charleston, US The use of endoscopic ultrasonographie (EUS) guidance for fine needle aspiration (FNA) of mediastinal lymph nodes has become an important adjunct in the staging of bronchogenic carcinoma. In many cases, it may be an alternative to mediastinoscopy (MED), but the costeffectiveness of the techniques has not been compared. Methods: A decision model was developed to compare EUS/FNA and MED in patients with known or suspected lung cancer to stage the mediastinum. Based on available literature, the baseline esti-mates for negative predictive value of EUS/FNA and MED were 0.87 and 0.91. respectively. Baseline cost estimates, derived from prevailing Medicare reimbursement rates, were $ 20 000 for thoracotomy, $15 300 for mediastinoscopy and $ 765 for EUS with FNA. The mean hfe expectancy for resected non-disseminated disease was 5 years, and for non-reseutable disease 1 year. Baseline pickup-rate of EUS and MED was 0.59 Sensitivity analysis was performed on all probabilities and utilities in the model. Results: Using our baseline estimates, cost/efficacy analysis favored EUS/FNA over medlastinoscopy with a marginal cost/effectiveness of $ 285 000.- / year of survival. The average cost per year survival was $ 3 810.- and $ 9 757- in the EUS/FNA and MED arm, respectively The cost-effectiveness advantage of EUS/FNA increases when enlarged lymph nodes are documented prior to the sampling procedure Conclusion: This decision analysis, strongly favors EUS/FNA over mediastinoscopy for staging of patients with lung cancer The advantage is even more pronounced when lymph nodes are visualized before the procedure.
494
r
MINOR PANCREATIC PSEUDOCYSTS-ENDOSCOPIC DIAGNOSIS AND THERAPY DS. Zimmon Depts of Medicine and Radiology, St Vincent's Hospital, New York, NY Minor pancreatic pseudocyst (MPP) is a term coined to distinguish small (<1 cm) painful pseudecysts in the pancreatic head invisible to current ultrasound or CT that are associated with a clinical syndrome of prolonged severe pancreatic pain with distinctive findings on pancreatography and response to endoscopic therapy All 4 padents(ages 39-75) with MPPs had prior cholecystectomy and long standing obscure abdominal pain. Repeatedly normal serum amylase and lipase in 3 contrasted with a 39 year old female with 10 years of recurrent pancreatitis. A 68 year old surgeon was referred for pancreatic cancer. The severity, deep mid-line character, duration(> 1 year), and reqmrement for narcotics suggested pancreatic pain. lu all MPPs communicated poorly with a radiologically normal main pancreatic duct. A Smm stone formed in one MPP passed into the mare duct and was removed endoscopically. Stone formation m a MPP explains pancreatic stones in apparently normal ducts since the stone remains if the pseudocyst healed or was not visualized. In 2 patients pancreatograpyprior to referral failed to visualize the MPP Biliary and pancreatic sphincterotomy with insertion of 5F pigtail-flap pancreatic stents into the communicating secondary, duct without complication relieved pain in 3. Failure to dilate the commtmlcating duct left 1 patient without relief. Duringfollowup ranging from 0 5 to 9 years none of the MPP healed Stenosed secondary communicating ducts limit filling at diagnostic pancreatography and may account for the persistence of MPPs. MPPs are small intraparenchymal persistent pseudocysts that cause obscure pancreatic pain with a prolonged unremitting course that are invisible to current imaging methods and may respond to endoscopic therapy
ENDOSCOPIC REMOVALOF PANCREATIC DUCI STONES - BETTER PATIENTSELECTIONBY ENDOSCOPICULTRASOUND?. L. Aabakken, B J Hoffman, M. Bhutani, R.H. Hawes, P.R. Tamasky, J.T. Cunningham, P.B. Cotton Digestive Disease Center, Medical University of South Carolina, Charleston, US Pancreatic duct stones are usually well visualized with endoscopic ultrasound (EUS). Acoustic shadowing indicates hard, calcific stones, and may be a predictor of failure to remove the stone endoscopically. Methods: During 12 months, 14 patients (pts) were found to have one or more stones in the main pancreatic duct (MPD) by EUS, utilizing the Olympus UM20 radial scanning echoendoscope. ERCP was done for attempted stone removal after EUS in 1 lpts and preEUS in 4 pts. ERCP success was recorded, as well as the EUS findings by reviewing video tapes of the procedures. Results: Twelve of the 14 stones had an unequivocal acoustic shadow, and only one of these was successfully removed at initial ERCP, utilizing a snare piecemeal-technique. The other patients were treated with pancreatic sphincterotomy and stent placement. Two stones without an acoustic shadow were both successfully removed, p=0.03. This successrate was significantly higher (Fischers exact test) than for the shadowing stones. Conclusion: These preliminary data indicate that EUS may be used to aid the patient selection to ERP and endoscopic stone removal, Stones with distinct acoustic shadowing may be better managed by initial shock wave lithotripsy.
414
GASTROINTESTINAL ENDOSCOPY
VOLUME 43, NO. 4, 1996
"7495
RISK FACTORS FOR PANCREATITIS AFTER ENDOSCOPIC MANIPULATION OF THE PANCREATIC DUCT. J.Vandervoort, T C K.Tham, R.C.K.Wong, ADRoston, A.Slivka, A.P.Ferran Jr., A.Musa, D.R.Lichtenstem, J.Van Dam, F.Ruymann, M.Hughes, DLCarr-Locke. Gastroenterology Division, Brigham & Women's Hospital, Harvard Medical School and School of Public Health, Boston, MA AIM : To identify specific risk factors which might increase the incidence of post-ERP pancreatitis alter mampulation of the pancreatic duct (PD) METHODS: In a prospective database of 817 patients of early post-ERCP complications, 127 pataents with PD-rcampulations were sdentffied We excluded all patients who underwent transpapillary manometry PDmampulation (PDM) waS defined as deep cannulation of the PD with a Glidewire (GW); brush cytology of the PD (PC); PD stentrng aRer brush cytology (PC+PS); catheter dilatation of the PD (CPD); PD stentmg after catheter dilatation (CPD+PS); insertion of a hasp-pancreatic tube (NPT); balloon dilatation of the PD (BDPD); pancreatac mampulatton with stenting (PDMWS); pancreatic mampulation vnthout stentmg (PDMSS). The incidence of pancreatitis was compared to a control group of 641 ERCPs without pancreatic duct mampulation (= NON PM). Seventy of panereatltls was graded according to published criteria RESULTS : The overall incidence of post-ERCP pancreatitis was 63/817 (7 7%). Accessory Pancreatitis Mild Moderate Severe GW 3/28 (10.7%) 3 0 0 PC 5/28 (17.9~ 3 2 0 PC+PS 0/7 ( 0%} 0 0 0 CPD 3/24 (12.5%) 2 1 0 CPD+PS 1/18 (5.5~ 0 1 0 NPT 3/10 (30%) 1 2 0 BDPD 1/1 (100%) 0 1 0 PDMSS 12/67 (18%) 8 4 0 PDMWS 5/60 (8.3%) 2 3 0 PDM 17/127(14 1%) 10 7 0 NON PDM 37/641 (5.7%) 22 13 2 CONCLUSIONS : The risk of post-ERCP pancreatitis is higher if the PD has been mampulated. There ts a sigmficant trend towards a lower incidence when the pancreatic duct is stented after mampulation.
COST EFFECTIVENESS OF ENDOSCOPIC ULTRASONOGRAPHY WITH FINE NEEDLE ASPIRATION V. MED1ASTINOSCOPY IN THE STAGING OF PATIENTS WITH LUNG CANCER. L. Aabakken. G. Silvestri, R. Hawes, C. Reed, A.Van Velse, B. Hoffinan Digestive Disease Center, Dept. of Pulmonary Medicine and Dept. of Thoracic Surgery, Medical Umversity of South Carolina, Charleston, US The use of endoscopic ultrasonographie (EUS) guidance for fine needle aspiration (FNA) of mediastinal lymph nodes has become an important adjunct in the staging of bronchogenic carcinoma. In many cases, it may be an alternative to mediastinoscopy (MED), but the costeffectiveness of the techniques has not been compared. Methods: A decision model was developed to compare EUS/FNA and MED in patients with known or suspected lung cancer to stage the mediastinum. Based on available literature, the baseline esti-mates for negative predictive value of EUS/FNA and MED were 0.87 and 0.91. respectively. Baseline cost estimates, derived from prevailing Medicare reimbursement rates, were $ 20 000 for thoracotomy, $15 300 for mediastinoscopy and $ 765 for EUS with FNA. The mean hfe expectancy for resected non-disseminated disease was 5 years, and for non-reseutable disease 1 year. Baseline pickup-rate of EUS and MED was 0.59 Sensitivity analysis was performed on all probabilities and utilities in the model. Results: Using our baseline estimates, cost/efficacy analysis favored EUS/FNA over medlastinoscopy with a marginal cost/effectiveness of $ 285 000.- / year of survival. The average cost per year survival was $ 3 810.- and $ 9 757- in the EUS/FNA and MED arm, respectively The cost-effectiveness advantage of EUS/FNA increases when enlarged lymph nodes are documented prior to the sampling procedure Conclusion: This decision analysis, strongly favors EUS/FNA over mediastinoscopy for staging of patients with lung cancer The advantage is even more pronounced when lymph nodes are visualized before the procedure.
494
r
MINOR PANCREATIC PSEUDOCYSTS-ENDOSCOPIC DIAGNOSIS AND THERAPY DS. Zimmon Depts of Medicine and Radiology, St Vincent's Hospital, New York, NY Minor pancreatic pseudocyst (MPP) is a term coined to distinguish small (<1 cm) painful pseudecysts in the pancreatic head invisible to current ultrasound or CT that are associated with a clinical syndrome of prolonged severe pancreatic pain with distinctive findings on pancreatography and response to endoscopic therapy All 4 padents(ages 39-75) with MPPs had prior cholecystectomy and long standing obscure abdominal pain. Repeatedly normal serum amylase and lipase in 3 contrasted with a 39 year old female with 10 years of recurrent pancreatitis. A 68 year old surgeon was referred for pancreatic cancer. The severity, deep mid-line character, duration(> 1 year), and reqmrement for narcotics suggested pancreatic pain. lu all MPPs communicated poorly with a radiologically normal main pancreatic duct. A Smm stone formed in one MPP passed into the mare duct and was removed endoscopically. Stone formation m a MPP explains pancreatic stones in apparently normal ducts since the stone remains if the pseudocyst healed or was not visualized. In 2 patients pancreatograpyprior to referral failed to visualize the MPP Biliary and pancreatic sphincterotomy with insertion of 5F pigtail-flap pancreatic stents into the communicating secondary, duct without complication relieved pain in 3. Failure to dilate the commtmlcating duct left 1 patient without relief. Duringfollowup ranging from 0 5 to 9 years none of the MPP healed Stenosed secondary communicating ducts limit filling at diagnostic pancreatography and may account for the persistence of MPPs. MPPs are small intraparenchymal persistent pseudocysts that cause obscure pancreatic pain with a prolonged unremitting course that are invisible to current imaging methods and may respond to endoscopic therapy
ENDOSCOPIC REMOVALOF PANCREATIC DUCI STONES - BETTER PATIENTSELECTIONBY ENDOSCOPICULTRASOUND?. L. Aabakken, B J Hoffman, M. Bhutani, R.H. Hawes, P.R. Tamasky, J.T. Cunningham, P.B. Cotton Digestive Disease Center, Medical University of South Carolina, Charleston, US Pancreatic duct stones are usually well visualized with endoscopic ultrasound (EUS). Acoustic shadowing indicates hard, calcific stones, and may be a predictor of failure to remove the stone endoscopically. Methods: During 12 months, 14 patients (pts) were found to have one or more stones in the main pancreatic duct (MPD) by EUS, utilizing the Olympus UM20 radial scanning echoendoscope. ERCP was done for attempted stone removal after EUS in 1 lpts and preEUS in 4 pts. ERCP success was recorded, as well as the EUS findings by reviewing video tapes of the procedures. Results: Twelve of the 14 stones had an unequivocal acoustic shadow, and only one of these was successfully removed at initial ERCP, utilizing a snare piecemeal-technique. The other patients were treated with pancreatic sphincterotomy and stent placement. Two stones without an acoustic shadow were both successfully removed, p=0.03. This successrate was significantly higher (Fischers exact test) than for the shadowing stones. Conclusion: These preliminary data indicate that EUS may be used to aid the patient selection to ERP and endoscopic stone removal, Stones with distinct acoustic shadowing may be better managed by initial shock wave lithotripsy.
414
GASTROINTESTINAL ENDOSCOPY
VOLUME 43, NO. 4, 1996