Long-term risk of recurrent pancreatitis in patients with acute billary pancreatitis treated by endoscopic sphinclerotomy alone

was compared with a control group of patients having proved conjugated pancreasand AGP (three control patients treated over the same period for each PD patients identified). All the patients were treated by endoscopic biliary sphincterotomy. The amylases, lipases, white blood cells (WBC) and C-reactiveprotein (CRP)serum levelswere measuredbeforeendoscopic retrograde cholangio-pancreatography(ERCP)and compared in the two groups. The severity of the pancreatitis was assessed by the CRP serum level, the Ranson score, the CT-scan Balthazar s grade, the need for intensive care unit (ICU) admission and for endoscopic and/ or surgical drainageof collections or necrosis,the duration of hospitalization,and the number of deaths, and comparison was performed between the two groups. Results: A total of 52 patients with AGP, 13 with PD (divisum group) and 39 without PD (control group) ware included. The two groups were comparable for sex and age. A significant difference was identified for three of the above mentioned variables: namely a lower severity at CT-scan (p=O,O05), a shorter duration of hospitalization (5-+1,9 vs 11,6-+1,6 nights), and a lower mortality (p =0,048) in the divisum group. The amylases, lipases and WBC serum levels as well as the Ranson s score tended to be lower in the divisum group although the difference was not significant. Conclusion: Patients with pancreas divisum (PD) disclose less severe acute gallstone pancreatitis (AGP), associated with a lower duration of hospitalizationand a lower mortality than the patients with conjugated pancreatic duct. 2389 Percutaneous Necrosectomyin the Treatment of Infected Pancreatic N e m i s Reduces the Need for Post-Operative Intensive Care. Ross Carter, Colin J. McKay, Peter S. Chong, Clem W. Imrie, Glasgow Royal Infirmary, Glasgow United Kingdom INTRODUCTION: Secondaryinfection of pancreaticnecrosis remainsthe most feared surgical complication of severe acute pancreatitis. The standard managementof open necrosectomy with surgical debridementof devitalisedtissue and post-up drainageis associatedwith a high mortality and almost all patients require admission into an intensive care unit (ICU) postoperatively for ventilatory support. Minimally invasive procedures may reduce the massive secondary inflammatory "hit" of an open pancreatic necrosectomy. We hypothesisedthat a percutaneous procedure may reducethe incidenceof organ dysfunction and ICU stay in this group of critically ill patients. METHODS : A consecutive series of patients with infected pancreatic necrosis (IPN) who subsequently underwent a percutaneous necrosectomy ware studied. Patients received supportive care as clinically indicated. Organfailure score (MacArthur) and C-reactive protein (CRP) were charted pro-operatively and for 3 days post-up. Number of repeat necrosectomies, ITU stay and outcome were recorded. RESULTS : 32 patients were included. 20 patients undergoing percutanaous necrosectomy for IPN ware managed entirely outwith an ICU setting in a high dependencyward (HDU). Only one patient going to theatrefrom the ward required ICU admission for ventitetorysupport post-operatively. There were two conversions to open necrosectomy for intra-operetive bleeding. 8 petlauts died. (ICU gp: 7, HDU gp: 1, Overall mortality 25%). CRP levels fell markedly following the first percutaneousnecrosectomy.Patientswho did not haveorgan dysfunction pre-opem'dvely did not tend to develop it after the procedure. CONCLUSION : Percutaneous necrosactomy achieves adequate drainage of necrotic material and reduces the need for post-operative intensive care, This method therefore has evident resource implications as well as potential benefits to clinical care.

2391 Acute Pancreatitis: Ask the Patient When the SymptomsBegan as the Time Interval Between Onset of Symptoms and Admission to Hospital Is a Strong Indicator for the Severity of the Disease Paul G. Lankisch, Torsten G. Blum, Municipal Clin of Lueneburg, Lueneburg Germany; Patrick Maisonneuve,European Institute of Oncology, Milan Italy; Albert 6. Lowenfels, New York Medical Coil, Valhalla, NY Acute pancreatitis (AP) is a dreaded emergencydisease. It has a high mortality rate despite all therapeutical interventions. The APACHE II score on admission permits early recognition of severeand/or necrotizing pancreatitisas well as a contrast-enhancedcomputedtomography (CT) performed within 72 hours after admission and staged according to 8althazar. The APACHE II score is unpopular becauseit is so complicatedand the CT examinationexpensive and not readily availableat all hospitals at any time of day or night. Consequently,we decided to determinewhether asking the patient at admission about the time of the onset of symptoms would be of value for assessingthe severity of the disease. Methods: The study included 284 patieuts (173 males and 111 females) admitted with a first attack of AP to our hospital between 1988 and 1999. Etiology was biliary for 119 (42%) patients, alcohol abuse for 91 (32%), unlmown for 58 (20%), and other in the remaining 16 (6%) patients were divided into those who experienced the first symptoms within 24 hours before admission (early gronp) and those who had the first symptoms >24 hours before admission (late group). A CT was performedfor 203 patients within 72 hours of admission. Severityassessmentfactors used were days spent on the intensive care unit (ICU; >3 days), total hospital stay (>2 weeks), pancreatic necrosis found on CT, indication for artificial ventilation, dialysis and surgery, and mortality rate. Results: The early group" showed more signs of peritonitis (rebound pain or guarding) (37% versus 26%; p = 0.007). Furthermore,the early group stayed longer on the ICU and in hospital, had pancreatic necrosis more frequently and was more likely to require artificial ventilation or to die. These results compared favourable with the APACHE II scores, a score of ->8 indicating severe pancreatitis according to the Atlanta classification, it was found that the APACHE II estimations and those for the time interval between onset of symptoms and admission to hospital had the same prognostic value. Conclusion: Even in times of complicated scores and high-tech estimations, simple questions like the one posed in the title about the onset of symptoms are still of therapeutic help for estimating the severity of AP. Patients referred to hospital later than 24 hours after the first symptoms have generally a better prognosis so that a CT on admission seems unnecessary for these patients. Z~ Is ERCP a Uufol Dlopnoutlc Tout in Idlopa~lc PaneveaUtis? Andrea LJebscher-Biegel,Christian-Rene Ha De Mas, Claudia Chalybaeus,Tayfun Bozkurt, Community & Teaching Hosp Kemperhof, KoblenzGermany Introduction: There are only a few controversial data concerning the value of endoscopic retrograde cholangio-pancreatography(ERCP) in cases of acute idiopathic pancreatitis. The prospective study was undertakento evaluatethe diagnostic benefit of ERCPin patients with acute pancreatitis not caused by gallstones or alcohol consumption. Methods: ERCP was performed in all pa~entswith acute pancreatitisin whom patient's history, clinical examination and further procedures such as laboratory findings, ultrasound and computed tomography ware not able to find out the causeof the pancreatifis. Patientswith biliary or alcohol-induced pancreat~s were excluded. All ERCPswere carried out within a period of four weeks after the diagnosis. Results: The present data of 42 patients [m:f = 17:25, age = 47 (18-78) years] were analysed.In one case (2%) pancreaticduct examinationwas not possible. ERCPinduced complications were not observed. Pancreas divisum with pathological dilatation of Oucfus Santoitni was found in 14% of patients. 33% of the patients showed a singular stenosis of the main pancreatic duct with pre-stenotic dilatation. Pancreaticcarcinoma was found in one case. Microlithiasis was detected in 10% of the patients. In 12% of the patients a chronic pancreatitis was diagnosed for the first time. ERCPcould not clarify the etiology in 26% of the cases. 53% of ERCP findings resulted in therapeutic interventions (stent implantation, surgery). Discussion: In the majority (70%) of casesof so-calledacute idiopathic pancreatftis, ERCP enables etiological classification, often followed by therapeutic consequences.The results of the study confirm that the benefit of this invasive procedureconsiderably predominates possible complications of the method.

2390 Long-Term Risk Of Recurrent Pancreutitiu In Patients With ACUteBilia~/Pancreat~s Treated By EndoscopicSphincterotomyAlone. Ioanois T. Virlos, Garfh C. Beattie, Ajith K. Siriwardena, Manchester Royal Infirmary, Manchester United Kingdom Objectives: Cholecystectomyis acceptedas definitive treatment for patients with acute biliary pancreatitis (AP)with endoscopic retrograde ¢holangiopancreatographyplus sphincterotomy (ERCP+ ES) being reservedfor patients with significant co-morbidity. The aim of this study is to assessthe long-term risk of recurrentAP and symptomatic gallbladderdiseasein patients with an index attack of biliary AP treated by ERCP+ES alone. Methods: 203 patients with a discharge diagnosis of biliary AP identified from the Lothian Surgical Audit database (LSA) for the period November 1994 to August 1999 constitute the study population. LSA is a computerised clinical dataset covering a geographically distinct region (with relatively little population flux)with a population of > 1 million. Biliary AP was defined on the basis of uitrasonograpbic demonstration of gallstones, biochemical evidence of biliary obstruction, ERCPor operativefindings. 134 (66%) underwent cholecystectomyduring their index admissign (or shortly thereafter). 41 (20%) were treated by ERCP without cholecystectomy with 18 of these undergoing ERCPalone and 23 undergoing ERCP+ES. The median age of the cholecystectomy group was 59 years (29-92) compared to a median of 72 (37-91)years for the ERCPgroup [P
idiopathic Acute Recurrent Pancraatftls: a prospective long-term follow-up Giorgio Talamini, Alberto Fantin, Vincenzo Oi Francesco, Laura Ring, Paolo 6ovo, Bruna Vaona, Cecilia Liani, Silvia Carrara, Claudio Bassi, Giorgio Cavallini, Paolo Pederzoli,Univ of Verona, Verona Italy Background:Idiopathic Acute RecurrentPancreatitis(ARP) is not well known from the clinicopathological point of view. The aim of our work was to follow-up our series of patients with ARP. Methods: In our referral centrefor pancreaticdiseases,we prospectivelyfollowed patients with at least two episodes of acute pancreatitis and without stigmata of chronic pancreatitis at the onset of symptoms. To select a homogeneoussubgroup, patients drinking more than 40 grams of alcohol/day, with a history of cholelithiasis or with detectable biliary stones at US, MR or ERCPwere excluded. Results: From 1982 to Nov. 2000 we followed 76 patients, 39 males (51%) and 37 females, with a mean age of 38.3 (SD 15.7; range 12 - 75). In 96% of cases the pain was typical for pancreatic diseases; 50% of the patients had 4 or more attacks (range 2-20) during a median follow-up of 48 months (range 1-96). Fifteen patients ware smokers, 4 had a CTRF gone alteration, 6 (8%) had pancreas divisum at ERCPand 4 a paraveteriandiverticulum. Mean BMI was 22.9 (SD 3.3); none had BMI > 30. At ERCPthe outflow of pancreaticcontrast medium was slow in 29 patients. In 33 patients a monometry of sphincer of Oddi was performed: in 16 stenosis (basel value > 40 mmHg), in 3 dyskinesia and in 7 normal results were obtained. Eventuallyin 9 cases sclerotic papilla was diagnosed. Thirteen patients had a post-ERCP acute pancrectitis. In 58 patients a duodenal intubation was performed: in 28 cases it was positive, in 27 for cholesterol and in 1 for bilirubin crystals.

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