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New criteria for ERCP prior to laparoscopic cholecystectomy in patients with non severe acute gallstone pancreatitis
COLON AND R E C T U M / E R C P - - B I L I A R Y 7365
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RANDOMIZED, PROSPECTIVE STUDY OF BIPOLAR ELECTROCOAGULATION (BPEC) VS. INFRARED COAGULATION(IRC) FOR BLEEDING INTERNAL HEMORRHOIDS (IH). R. Yang, T. Ha, J. Roque, L. Laine. USC School of Medicine, LAVAOPC, Los Angeles, CA. Non-surgical treatment of bleeding I H is gaining popularity. We compared the efficacy of two such techniques, BPEC and IRC, in patients with bleeding IH. Methods: Patients were enrolled if their IH continued to bleed despite >6 weeks of medical management (fiber, stool softeners and local therapy). IH were graded using a slotted anoscope and patients were followed every 2-4 weeks. Treatment parameters were BPEC: 20 Watts x 2 see x 3 applications/IH segment and IRC: 3 see x 3 applieations/IH segment. Study end-points were cessation of bleeding and/or obliteration of hemorrhoids (reduction to < grade 1). Failures were those patients who continued to bleed after _>6 treatment sessions. Results: Treatment groups did not differ in bleeding severity or IH grade. BPEC (N=25) IRC (N=25) P value Hemorrhoid grade 1.7+0.1 1.8+0.2 >0.20 #sessions to end point 1.9+0.2 2.4+0.3 0.19 Treatment time per session (see) 31.0+4.1 55.5+7.4 <0.001 Procedural pain 5 (20%) 2(8%) >0.20 Rectal ulcers 5 (20%) 1(4%) 0.19 Failures 2 (8%) 2(8%) >0.20 Conclusion: BPEC and IRC techniques showed equal efficacy in the treatment of bleeding IH. Although IRC took slightly longer to perform, BPEC may be associated with more pain and rectal ulceration. We conclude that BPEC and IRC are similar and can be used safely and effectively to treat bleeding IH.
NEW CRITERIA FOR ERCP PRIOR TO LAPAROSCOPIC CHOLECYSTECTOMY IN PATIENTS WITH NON SEVERE ACUTE GALLSTONE PANCREATITIS. A. Abu-Hammour, K.P. Etzkorn, R.P. Venu, R.D. Brown, D.E. McGuire, and LL. Watkins. , University of Illinois at Chicago, Chicago, Illinois 60612, The incidence of bile duct stones (BDS) in patients with non severe acute gallstone pancreatitis (NSAGP) is considered low. Hence, routine ERCP prior to laparoscopic cholecystectomy (LC) is felt to be unnecessary. AIM. To determine specific biochemical criteria in patients with NSAGP which can better identify patients with BDS prior to LC. METHODS. NSAGP was defined as patients with a clinical presentation compatible with acute pancreatitis, a > 3-fold elevation of serum amylase, the presence of gallstones by abdominal ultrasound, and clinical defervescence within 48 hours after initial presentation. All patients underwent ERCP within 4 days of initial presentation. RESULTS. Over a 2year period, 24 patients met the criteria for NSAGP. Biochemical assessment within the first 48 hours of admission identified two groups of patients. Group A: patients with isolated elevations of alkaline phosphatase (AP) and serum bilimbin (Bil) with no elevations of either AST[ALT. Group B: patients with elevations of all 4 biochemical parameters (AP, Bil, AST/ALT). Nine out of 24 (37%) of the patients with NSAGP had BDS. None of the 13 Group A patients had BDS. Nine out of 11 (80%) of Group B had BDS. Group A Group B # With/Without BDS 0/13 912 AP U/L 240 • 20 280 • 20 Bil mg]dl 2 • 0.6 6 • 0.8 AST U]L 50 • 10 160 • 20 ALT U/L 40 :~ 10 300 :t 60 SUMMARY. Elevation of all 4 biochemical parameters is a good indicator for the presence of BDS, and ill such patients ERCP prior to LC should be considered.
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THE LONG TERM RESULTS OF E N D O S C O P I C SPHINCTEROTOMY (ES) FOR COMMON BILE DUCT LITHIASIS. N. Abdel Malak, F. Prat, G. Pellctier, C. Buffet, J. Fritsch, A.D. Choury, J.P. Etienne. BicStre Hospital, 94275 Le Kremlin-Bic&re, France.
ERCP REFERRALS TO A SPECIALIST CENTER FOR PRIOR FAILURE DOUBLE IN 6 YEARS I Affron~i, MS Branch, PS IoweU, S Guarisco, J Leung, PB Cotton, J Baillie, Division of Gastroenterology, Duke University Medical Center, Durham, NC Background: Increasingly, ERCP is performed in the community by private physicians who are usually - but not always gastroenterologists. Changes in the pattern of ERCP referrals to specialist centers have occurred due to (1) increasing skill in the community and (2) economic and payor pressure to limit such referrals. Aka: To determine the trend in referrals for prior failed ERCP to our specialist center over the last 6 years. Method: Retrospective analysis of computerized reports on 5,782 ERCPs performed at our institution between January 1989 and November 1994. Patients reported to have had failed, inadequate or equivocal ERCPs prior to being studied by us were included. Descriptive data were also retrieved. Results: 446/5782 patients in this 6 year period had an unsuccessful ERCP prior to being studied by us. The yearly percentage of patients with prior ERCP failure was:
Although short term follow-up after ES has been thoroughly assessed, the long term results of this technique are still poorly estimated, while extensions of the indications of ES are proposed, especially in young patients. Between 1981 and 1986, 169 patients then aged under 70 (55+11.8; range 24-70; sex ratio 1.68) underwent ES for common bile duct lithiasis. 115 patients (68%) had previously undergone cholecystectomy4+7.5 years before ES. Long term data were obtained on standardized questionrtaires directly from the patients (through phone calls and/or mail) or from the general practitioners. Informations were obtained for 156 (92.3%) patients, The mean follow-up was 9.6+3.3 years. Follow-up for patients still alive in 1994 was more than 8 years (range 8-13 years). 35 patients died, 4.9+3.6 years after ES. Only one death was related to ES (a fatal septic sh'ock occurring 15 days after ES). 138 patients (88.5%) had no hepato-biliary symptoms, until 1994 for the 104 patients alive or until death for 34 others. 18 patients (11.5%) presented biliary symptoms during followup. Symptoms were attributed to cholecystolithiasis in 2 cases who underwent cholecystectomy, to malignant strictures in 3 cases, and to a benign stricture related to the cholecystectomy in one case. 12 patients (7.7%) developed potentially ES-related biliary symptoms: ERCP was performed in 10 cases, disclosing papillary stenosis in 3 (with choledocbolithiasis in 2) and recurrent common bile duct stones in 3 others; of the 4 patients with normal ERCP, one had hepatic abscesses; both patients who did not undergo ERCP presented bouts of eholangitis, but they were not explored further. Apart from the natural consequences of cholelithiasis, long term complications directly related to ES appear to be rare.The risk of biliary complications more than 8 years after ES (7.7%) compares favourably with that of primary common bile duct surgery.
V O L U M E 41, NO. 4, 1995
1989 5.2%
1990 5.4%
1991 7.4%
1992 7.2%
1993 10.1%
1994 10.9%
More than 50% of these patients had at least one of the following: pancreas divisum (27%), duodenal diverticulum (11%), prior ERCP complication (9%), prior percutaneous transhepafic cholangiogram (PTC) (6%), post-Billroth I or II gastric surgery (5%), common bile duct stones > 15mm in diameter. Conclusion: Based on retrospective review of procedure reports, the percentage of patients referred to our specialist center following failed ERCP has doubled in the last 6 years. Anatomical problems predominate. These data almost certainly underestimate the prior failure rate as many ERCPs are not attempted in the community due to anticipated difficulties. If the observed trend continues it will undoubtedly have a negative impact on ERCP training of fellows at specialist centers, as trainee input in complex cases is often limited.
GASTROINTESTINAL ENDOSCOPY
387
t367
RANDOMIZED, PROSPECTIVE STUDY OF BIPOLAR ELECTROCOAGULATION (BPEC) VS. INFRARED COAGULATION(IRC) FOR BLEEDING INTERNAL HEMORRHOIDS (IH). R. Yang, T. Ha, J. Roque, L. Laine. USC School of Medicine, LAVAOPC, Los Angeles, CA. Non-surgical treatment of bleeding I H is gaining popularity. We compared the efficacy of two such techniques, BPEC and IRC, in patients with bleeding IH. Methods: Patients were enrolled if their IH continued to bleed despite >6 weeks of medical management (fiber, stool softeners and local therapy). IH were graded using a slotted anoscope and patients were followed every 2-4 weeks. Treatment parameters were BPEC: 20 Watts x 2 see x 3 applications/IH segment and IRC: 3 see x 3 applieations/IH segment. Study end-points were cessation of bleeding and/or obliteration of hemorrhoids (reduction to < grade 1). Failures were those patients who continued to bleed after _>6 treatment sessions. Results: Treatment groups did not differ in bleeding severity or IH grade. BPEC (N=25) IRC (N=25) P value Hemorrhoid grade 1.7+0.1 1.8+0.2 >0.20 #sessions to end point 1.9+0.2 2.4+0.3 0.19 Treatment time per session (see) 31.0+4.1 55.5+7.4 <0.001 Procedural pain 5 (20%) 2(8%) >0.20 Rectal ulcers 5 (20%) 1(4%) 0.19 Failures 2 (8%) 2(8%) >0.20 Conclusion: BPEC and IRC techniques showed equal efficacy in the treatment of bleeding IH. Although IRC took slightly longer to perform, BPEC may be associated with more pain and rectal ulceration. We conclude that BPEC and IRC are similar and can be used safely and effectively to treat bleeding IH.
NEW CRITERIA FOR ERCP PRIOR TO LAPAROSCOPIC CHOLECYSTECTOMY IN PATIENTS WITH NON SEVERE ACUTE GALLSTONE PANCREATITIS. A. Abu-Hammour, K.P. Etzkorn, R.P. Venu, R.D. Brown, D.E. McGuire, and LL. Watkins. , University of Illinois at Chicago, Chicago, Illinois 60612, The incidence of bile duct stones (BDS) in patients with non severe acute gallstone pancreatitis (NSAGP) is considered low. Hence, routine ERCP prior to laparoscopic cholecystectomy (LC) is felt to be unnecessary. AIM. To determine specific biochemical criteria in patients with NSAGP which can better identify patients with BDS prior to LC. METHODS. NSAGP was defined as patients with a clinical presentation compatible with acute pancreatitis, a > 3-fold elevation of serum amylase, the presence of gallstones by abdominal ultrasound, and clinical defervescence within 48 hours after initial presentation. All patients underwent ERCP within 4 days of initial presentation. RESULTS. Over a 2year period, 24 patients met the criteria for NSAGP. Biochemical assessment within the first 48 hours of admission identified two groups of patients. Group A: patients with isolated elevations of alkaline phosphatase (AP) and serum bilimbin (Bil) with no elevations of either AST[ALT. Group B: patients with elevations of all 4 biochemical parameters (AP, Bil, AST/ALT). Nine out of 24 (37%) of the patients with NSAGP had BDS. None of the 13 Group A patients had BDS. Nine out of 11 (80%) of Group B had BDS. Group A Group B # With/Without BDS 0/13 912 AP U/L 240 • 20 280 • 20 Bil mg]dl 2 • 0.6 6 • 0.8 AST U]L 50 • 10 160 • 20 ALT U/L 40 :~ 10 300 :t 60 SUMMARY. Elevation of all 4 biochemical parameters is a good indicator for the presence of BDS, and ill such patients ERCP prior to LC should be considered.
t366
368
THE LONG TERM RESULTS OF E N D O S C O P I C SPHINCTEROTOMY (ES) FOR COMMON BILE DUCT LITHIASIS. N. Abdel Malak, F. Prat, G. Pellctier, C. Buffet, J. Fritsch, A.D. Choury, J.P. Etienne. BicStre Hospital, 94275 Le Kremlin-Bic&re, France.
ERCP REFERRALS TO A SPECIALIST CENTER FOR PRIOR FAILURE DOUBLE IN 6 YEARS I Affron~i, MS Branch, PS IoweU, S Guarisco, J Leung, PB Cotton, J Baillie, Division of Gastroenterology, Duke University Medical Center, Durham, NC Background: Increasingly, ERCP is performed in the community by private physicians who are usually - but not always gastroenterologists. Changes in the pattern of ERCP referrals to specialist centers have occurred due to (1) increasing skill in the community and (2) economic and payor pressure to limit such referrals. Aka: To determine the trend in referrals for prior failed ERCP to our specialist center over the last 6 years. Method: Retrospective analysis of computerized reports on 5,782 ERCPs performed at our institution between January 1989 and November 1994. Patients reported to have had failed, inadequate or equivocal ERCPs prior to being studied by us were included. Descriptive data were also retrieved. Results: 446/5782 patients in this 6 year period had an unsuccessful ERCP prior to being studied by us. The yearly percentage of patients with prior ERCP failure was:
Although short term follow-up after ES has been thoroughly assessed, the long term results of this technique are still poorly estimated, while extensions of the indications of ES are proposed, especially in young patients. Between 1981 and 1986, 169 patients then aged under 70 (55+11.8; range 24-70; sex ratio 1.68) underwent ES for common bile duct lithiasis. 115 patients (68%) had previously undergone cholecystectomy4+7.5 years before ES. Long term data were obtained on standardized questionrtaires directly from the patients (through phone calls and/or mail) or from the general practitioners. Informations were obtained for 156 (92.3%) patients, The mean follow-up was 9.6+3.3 years. Follow-up for patients still alive in 1994 was more than 8 years (range 8-13 years). 35 patients died, 4.9+3.6 years after ES. Only one death was related to ES (a fatal septic sh'ock occurring 15 days after ES). 138 patients (88.5%) had no hepato-biliary symptoms, until 1994 for the 104 patients alive or until death for 34 others. 18 patients (11.5%) presented biliary symptoms during followup. Symptoms were attributed to cholecystolithiasis in 2 cases who underwent cholecystectomy, to malignant strictures in 3 cases, and to a benign stricture related to the cholecystectomy in one case. 12 patients (7.7%) developed potentially ES-related biliary symptoms: ERCP was performed in 10 cases, disclosing papillary stenosis in 3 (with choledocbolithiasis in 2) and recurrent common bile duct stones in 3 others; of the 4 patients with normal ERCP, one had hepatic abscesses; both patients who did not undergo ERCP presented bouts of eholangitis, but they were not explored further. Apart from the natural consequences of cholelithiasis, long term complications directly related to ES appear to be rare.The risk of biliary complications more than 8 years after ES (7.7%) compares favourably with that of primary common bile duct surgery.
V O L U M E 41, NO. 4, 1995
1989 5.2%
1990 5.4%
1991 7.4%
1992 7.2%
1993 10.1%
1994 10.9%
More than 50% of these patients had at least one of the following: pancreas divisum (27%), duodenal diverticulum (11%), prior ERCP complication (9%), prior percutaneous transhepafic cholangiogram (PTC) (6%), post-Billroth I or II gastric surgery (5%), common bile duct stones > 15mm in diameter. Conclusion: Based on retrospective review of procedure reports, the percentage of patients referred to our specialist center following failed ERCP has doubled in the last 6 years. Anatomical problems predominate. These data almost certainly underestimate the prior failure rate as many ERCPs are not attempted in the community due to anticipated difficulties. If the observed trend continues it will undoubtedly have a negative impact on ERCP training of fellows at specialist centers, as trainee input in complex cases is often limited.
GASTROINTESTINAL ENDOSCOPY
387