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Further comments on cannulation
170
our
respond
Further comments on cannulation The comments by Dr. Melvin Schapiro speaking for the Southern California Endoscopic Society are well taken (see GASTROINTESTINAL ENDOSCOPY 20:129, 1974). That society knows transduodenal pancreatography is a new technic currently being evaluated. It is necessary that wide clinical experience with it relative to the diagnosis of pancreatic disease eventually must be gathered, analyzed, and carefully evaluated in order to place it in its proper perspective. Such an evaluation must include any risks ofthe procedure. These accumulate slowly in the literature and consequently are much more slowly defined because of their infrequent occurrence. The purpose of our paper "Is Transduodenal Pancreatoggraphy Ever Contraindicated?" (GASTROINTESTINAL ENDOSCOPY 20:28, 1973) was to point out that complications to the procedure do occur and may be severe as in our case. From the previous literature only brief mention has been given to some mild serum amylase elevations with an occasional report of abdominal pain after the procedure. However, a fatality has recently been reported from Europe in a patient similar to ours. 1 Silvis et aJ2 recently reported another exceptional problem in a patient with recurrent pancreatitis and pseudocyst and suggested that patients with pseudocysts filled during cannulation should have surgical drainage within the next 24 hours if the cyst is large and drains poorly. Our publication is directed specifically to acute relapsing pancreatitis with recent exacerbations. It is in such patients that extra precautions would seem to be desirable because these individuals may very well be more susceptible to the procedure of cannulation than the usual patients. Although numerous series of catheterized patients have been reported, they do not yet provide statistically satisfactory numbers of the specific problem we were speaking of. Hence, it would seem that extra care is still in order when dealing with them. Dr. Schapiro mentions the panel's combined experience of over 1,000 cases of this procedure. Were these all cases of recurrent pancreatitis? If so, what was their complication rate, or were there any complications? The panel accepted the idea of" the theoretical possibility of a hyperosmotic effect" but rejected the idea as not important since "it does not appear to be borne out in clinical practice." What is the panel's evidence for such a statement? We would be pleased to know how the hyperosmotic effect of contrast solution placed in the ductal system of the pancreas was ruled out by the panel as a possible cause
of pancreatitis. We agree that limitation of ductal injections to one is preferable but often not possible. We are, however, suggesting caution specifically for this high risk group of patients. We are pleased to know that Dr. Kasugai is doing intra-ampullary pressure studies. Aspiration of contrast material before withdrawing the cannula is certainly difficult but when possible may decrease risk to the patient. The length of time contrast material stays in the duct may be of importance particularly if patients have pseudocysts and these are filled with contrast material, and more so if the pseudocyst drains poorly. This appeared to be a factor in the case of the death reported by Dr. Silvis. After all studies are completed and manipulation has ceased when contrast material cannot be aspirated, flushing the duct with secretin conceivably could speed the emptying of the duct if no obstruction is present. This could also conceivably decrease the hyperosmotic effect by diluting the intraductal contents. We do not advocate the use of secretin flush to look for the orifice prior to cannulation since manipulations of the ampulla and injections into it during an actively secreting pancreas are probably undesirable. Keeping patients on nothing by mouth after cannulation is an additonal extra precaution only in selected patients with a previous history of recurrent pancreatitis especially if there was pain during the procedure or pain appeared shortly thereafter. We do not feel it is necessary for other patients. We have provided a list of suggestions that may decrease the incidence of pancreatitis in this particular group of patients. This select group, perhaps, was not sufficiently emphasized in our report. This to us does not seem to be in direct opposition to the standards of practice throughout the world but in the best interests of the patients undergoing the procedure. If a risk or hazard is theoretically possible in any new procedure, the pliysician should consider all possible pathophysiological mechanisms that might contribute to this risk in an attempt to reduce or eliminate it. In our opinion the risk of any of the complications we have conjectured would certainly be minimal in most patients reported to date. In conclusion, we would suggest that the questions raised in the letter from the Southern California Endoscopic Society are understandable reactions, but that a final clinical evaluation of the specific problem to which we have addressed ourselves is as yet incomplete and hence should not be considered a closed book.
REFERENCES I. AMMANN RW, DEYHLE P, BUTIKOFER E: Fatal necrotizing pancrea-
titis after peroral cholangiopancreatography. Gastroenterology 64 (2): 320, 1973 2. SILVIS SE. ROHRMANN CA. VENNES JA: Diagnostic criteria for the evaluation of the endoscopicpancreatogram. Gastrointestinal Endoscopy 20:51, 1973
Alonso Galvan, M.D. 3333 East Central, Suite 404 Wichita, Kansas 67208
Arthur P. Klotz, M.D. University of Kansas Medical Center Kansas City, Kansas 66103 GASTROINTESTINAL ENDOSCOPY
our
respond
Further comments on cannulation The comments by Dr. Melvin Schapiro speaking for the Southern California Endoscopic Society are well taken (see GASTROINTESTINAL ENDOSCOPY 20:129, 1974). That society knows transduodenal pancreatography is a new technic currently being evaluated. It is necessary that wide clinical experience with it relative to the diagnosis of pancreatic disease eventually must be gathered, analyzed, and carefully evaluated in order to place it in its proper perspective. Such an evaluation must include any risks ofthe procedure. These accumulate slowly in the literature and consequently are much more slowly defined because of their infrequent occurrence. The purpose of our paper "Is Transduodenal Pancreatoggraphy Ever Contraindicated?" (GASTROINTESTINAL ENDOSCOPY 20:28, 1973) was to point out that complications to the procedure do occur and may be severe as in our case. From the previous literature only brief mention has been given to some mild serum amylase elevations with an occasional report of abdominal pain after the procedure. However, a fatality has recently been reported from Europe in a patient similar to ours. 1 Silvis et aJ2 recently reported another exceptional problem in a patient with recurrent pancreatitis and pseudocyst and suggested that patients with pseudocysts filled during cannulation should have surgical drainage within the next 24 hours if the cyst is large and drains poorly. Our publication is directed specifically to acute relapsing pancreatitis with recent exacerbations. It is in such patients that extra precautions would seem to be desirable because these individuals may very well be more susceptible to the procedure of cannulation than the usual patients. Although numerous series of catheterized patients have been reported, they do not yet provide statistically satisfactory numbers of the specific problem we were speaking of. Hence, it would seem that extra care is still in order when dealing with them. Dr. Schapiro mentions the panel's combined experience of over 1,000 cases of this procedure. Were these all cases of recurrent pancreatitis? If so, what was their complication rate, or were there any complications? The panel accepted the idea of" the theoretical possibility of a hyperosmotic effect" but rejected the idea as not important since "it does not appear to be borne out in clinical practice." What is the panel's evidence for such a statement? We would be pleased to know how the hyperosmotic effect of contrast solution placed in the ductal system of the pancreas was ruled out by the panel as a possible cause
of pancreatitis. We agree that limitation of ductal injections to one is preferable but often not possible. We are, however, suggesting caution specifically for this high risk group of patients. We are pleased to know that Dr. Kasugai is doing intra-ampullary pressure studies. Aspiration of contrast material before withdrawing the cannula is certainly difficult but when possible may decrease risk to the patient. The length of time contrast material stays in the duct may be of importance particularly if patients have pseudocysts and these are filled with contrast material, and more so if the pseudocyst drains poorly. This appeared to be a factor in the case of the death reported by Dr. Silvis. After all studies are completed and manipulation has ceased when contrast material cannot be aspirated, flushing the duct with secretin conceivably could speed the emptying of the duct if no obstruction is present. This could also conceivably decrease the hyperosmotic effect by diluting the intraductal contents. We do not advocate the use of secretin flush to look for the orifice prior to cannulation since manipulations of the ampulla and injections into it during an actively secreting pancreas are probably undesirable. Keeping patients on nothing by mouth after cannulation is an additonal extra precaution only in selected patients with a previous history of recurrent pancreatitis especially if there was pain during the procedure or pain appeared shortly thereafter. We do not feel it is necessary for other patients. We have provided a list of suggestions that may decrease the incidence of pancreatitis in this particular group of patients. This select group, perhaps, was not sufficiently emphasized in our report. This to us does not seem to be in direct opposition to the standards of practice throughout the world but in the best interests of the patients undergoing the procedure. If a risk or hazard is theoretically possible in any new procedure, the pliysician should consider all possible pathophysiological mechanisms that might contribute to this risk in an attempt to reduce or eliminate it. In our opinion the risk of any of the complications we have conjectured would certainly be minimal in most patients reported to date. In conclusion, we would suggest that the questions raised in the letter from the Southern California Endoscopic Society are understandable reactions, but that a final clinical evaluation of the specific problem to which we have addressed ourselves is as yet incomplete and hence should not be considered a closed book.
REFERENCES I. AMMANN RW, DEYHLE P, BUTIKOFER E: Fatal necrotizing pancrea-
titis after peroral cholangiopancreatography. Gastroenterology 64 (2): 320, 1973 2. SILVIS SE. ROHRMANN CA. VENNES JA: Diagnostic criteria for the evaluation of the endoscopicpancreatogram. Gastrointestinal Endoscopy 20:51, 1973
Alonso Galvan, M.D. 3333 East Central, Suite 404 Wichita, Kansas 67208
Arthur P. Klotz, M.D. University of Kansas Medical Center Kansas City, Kansas 66103 GASTROINTESTINAL ENDOSCOPY