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OC1.11.6 ROLE OF SECOND GENERATION CONTRAST-ENHANCED ULTRASONOGRAPHY (CEUS) IN DIAGNOSIS OF PANCREATIC LESIONS
Abstracts / Digestive and Liver Disease 40S (2008), S1–S195 is to evaluate technical results of PRV in a large retrospective series of patients. Material and methods: From 1994 to May 2007, PRV was attempted by expert endoscopists in 36 patients with chronic pancreatitis (23 males, median age 44 years, range 11-79) due to a difficult access to the MPD through the major papilla. PRV was performed as follows: a dorsal and ventral duct connection was identified at pancreatography from the major papilla; an angled-tip hydrophilic guidewire (0.035”/0.018”), inserted form the major papilla, was manoeuvred to pass through the accessory duct and minor papilla into the duodenum; the tip of the wire was grasped with a foreign-body forceps and retracted from the accessory channel; minor papilla was cannulated over-the-wire. Other operative procedures were performed as clinically requested. Results: Indications to drain the MPD through the minor papilla were: incomplete pancreas divisum (n=18); easier access to the MPD through the minor papilla due to a tortuous ventral duct (ansa pancreatica and “H-configuration”) (n=9); normal anatomy with strictures or stones hindering drainage from the major papilla (n=9). The PRV was successfully performed in 32 (89%) patients; in 4 cases (13%) only after a second attempt. No specific complications after PRV occurred. PRV failed in 4 patients. Direct minor papilla cannulation was unsuccessfully attempted in all 4 patients. Minor papilla precut was performed in 2 of these patients. MPD drainage was achieved only in 1 case. In the other 3 patients MPD drainage was completed from the major papilla after several attempts. Conclusions: The PRV is a feasible, reliable and safe procedure. It can allow a quick cannulation of the minor papilla when the drainage of the MPD through the major papilla is difficult. The PRV can theoretically reduce the risk of complications due to traumatic manoeuvres on the minor papilla or precut. # R. Therapeutic endoscopy 5. ERCP
OC1.11.5 A PROSPECTIVE RANDOMIZED STUDY ON THE SAFETY OF PRECUT PAPILLOTOMY WITH ANALYSIS OF THE FACTORS ASSOCIATED TO THE DEVELOPMENT OF COMPLICATIONS DURING ERCP G. Manes ∗ ,1 , P. Di Giorgio 2 , S. Ardizzone 1 , F. Giannattasio 2 , G. Bianchi Porro 1 1 Ospedale
L. Sacco, Milano; 2 Ospedale Loreto Mare, Napoli
Background and aim: Needle knife precut papillotomy is employed as a rescue technique when conventional methods fail to gain biliary access at ERCP. Precut is often regarded as an unsafe procedure carrying increased complications rates, mainly pancreatitis. Many authors suggest, however, that the high complications rate is likely to be determined not by precut per se, but by the several attempts to cannulate the papilla that precede precutting. This is a prospective randomized study aiming at evaluating the safety of precut papillotomy and the factors associated to the development of complications. Material and methods: Patients undergoing ERCP, in which after 10 minutes the cannulation in the conventional methods failed, were prospectively randomized in 2 groups: Group A (n=27) that immediately underwent precut and group B (n=26) in which cannulation was attempted for at least 10 further minutes before the endoscopist was free to decide to perform precut or to continue in the conventional method. Incidence and severity of pancreatitis, hyperamylasemia and other complications were recorded, as well as factors associated to their development. Results: The two study-groups were similar in term of age, sex, indication to ERCP and risk factors for pancreatitis. Cannulation was successful in all patients but 3 (94%). Precut was performed in all patients of group A and in 17/26 (65%) of B. Incidence of pancreatitis was 0/27 in group A and 4/26 (15%) in B (p<0.05). Amylase levels increased of 309.2+516.5 in group A and 1106.7+2076.3 in group B
S33
(p<0.05). No differences were observed for the other complications (abdominal pain: 4 vs 2; haemorrhage 1 vs 0; perforation 0 vs 1). Number of attempts to cannulate the papilla and of pancreatic duct injections were significantly higher in group B. Conclusions: Precut papillotomy is a safe procedure which does not bring an adjunctive risk of developing pancreatitis and other complications. Pancreatitis is likely to develop as a consequence of the many attempts to cannulate the papilla and of pancreatic duct injection, while does not seem to be correlated to precutting per se. # R. Therapeutic endoscopy 5. ERCP
OC1.11.6 ROLE OF SECOND GENERATION CONTRAST-ENHANCED ULTRASONOGRAPHY (CEUS) IN DIAGNOSIS OF PANCREATIC LESIONS F. Terracciano ∗ , A. Ippolito, D. Siena, M. Sperandeo, M. Piattelli, V. Annese, A. Andriulli Casa Sollievo della Sofferenza, San Giovanni Rotondo Background and aim: The development of CEUS has contributed to major breakthroughs in the diagnosis of pancreatic lesions. However, only few controlled studies are available. We aimed to prospectively evaluate the role of CEUS in characterization of pancreatic lesions. Material and methods: 28 patients (18 male, median age 73 yrs, range 45-83) with 33 histologically proven pancreatic lesions detectable at the US were investigated. At the final diagnosis 8 were adenocarcinoma, 3 insulinomas, 5 mass forming pancreatitis (MFP), and 17 cystic lesions (2 intraductal papillary mucinous tumors [IPMT], 7 pseudocystis, 2 serous [SCA] and 2 mucinous [MCA]cystadenoma). After standard US, 2,4 mL of Sonovue i.v. was administered. Perfusion images of CEUS were evaluated to detect the lesions and parenchymal vascularity. The CEUS findings were compared with those obtained by computed tomography (CT) or magnetic resonance (MRI). The histological diagnosis in all cases was obtained either from biopsy or surgical specimens. Results: Based on CEUS findings, solid lesions showing hypovascular pattern were diagnosed as carcinomas, those with hypervascular pattern as neuroendocrin tumors, and the hysovascular ones as MFP. All lesions fit these US criteria according to final diagnosis (sensitivity, specificity and accuracy:100%).CT or MRI findings in all cases were also confirmed at the final diagnosis (sensitivity, specificity and accuracy: 100%). Concerning the cystic lesions, all except one were non vascular, even when a corpuscular content was found at basal US (sensitivity 90%). More interestingly, in all cases of SCA and MCA with intralesional septis, CEUS demonstrated a vascular enhancement (sensitivity 100%). In contrast, in the absence of intralesional features within cystic lesions differential diagnosis could not be achieved (sensitivity 65%). Conclusions: Our data, although preliminary, demonstrate that the study of the pancreas is a promising application of CEUS. In case of solid lesions, a 100% accuracy and concordance with CT/MRI imaging and histologic diagnosis was obtained. In contrast, in presence of cystic lesions the accuracy of CEUS compared to CT/MRI and histologic diagnosis was 75% and 70%. However, when intralesional septis were found, the accuracy of CEUS increased to 90%. Based on these findings CEUS should be further assessed as a complementary imaging modality in the characterization of pancreatic lesions. # T. Imaging techniques 1. Ultrasounds
OC1.11.5 A PROSPECTIVE RANDOMIZED STUDY ON THE SAFETY OF PRECUT PAPILLOTOMY WITH ANALYSIS OF THE FACTORS ASSOCIATED TO THE DEVELOPMENT OF COMPLICATIONS DURING ERCP G. Manes ∗ ,1 , P. Di Giorgio 2 , S. Ardizzone 1 , F. Giannattasio 2 , G. Bianchi Porro 1 1 Ospedale
L. Sacco, Milano; 2 Ospedale Loreto Mare, Napoli
Background and aim: Needle knife precut papillotomy is employed as a rescue technique when conventional methods fail to gain biliary access at ERCP. Precut is often regarded as an unsafe procedure carrying increased complications rates, mainly pancreatitis. Many authors suggest, however, that the high complications rate is likely to be determined not by precut per se, but by the several attempts to cannulate the papilla that precede precutting. This is a prospective randomized study aiming at evaluating the safety of precut papillotomy and the factors associated to the development of complications. Material and methods: Patients undergoing ERCP, in which after 10 minutes the cannulation in the conventional methods failed, were prospectively randomized in 2 groups: Group A (n=27) that immediately underwent precut and group B (n=26) in which cannulation was attempted for at least 10 further minutes before the endoscopist was free to decide to perform precut or to continue in the conventional method. Incidence and severity of pancreatitis, hyperamylasemia and other complications were recorded, as well as factors associated to their development. Results: The two study-groups were similar in term of age, sex, indication to ERCP and risk factors for pancreatitis. Cannulation was successful in all patients but 3 (94%). Precut was performed in all patients of group A and in 17/26 (65%) of B. Incidence of pancreatitis was 0/27 in group A and 4/26 (15%) in B (p<0.05). Amylase levels increased of 309.2+516.5 in group A and 1106.7+2076.3 in group B
S33
(p<0.05). No differences were observed for the other complications (abdominal pain: 4 vs 2; haemorrhage 1 vs 0; perforation 0 vs 1). Number of attempts to cannulate the papilla and of pancreatic duct injections were significantly higher in group B. Conclusions: Precut papillotomy is a safe procedure which does not bring an adjunctive risk of developing pancreatitis and other complications. Pancreatitis is likely to develop as a consequence of the many attempts to cannulate the papilla and of pancreatic duct injection, while does not seem to be correlated to precutting per se. # R. Therapeutic endoscopy 5. ERCP
OC1.11.6 ROLE OF SECOND GENERATION CONTRAST-ENHANCED ULTRASONOGRAPHY (CEUS) IN DIAGNOSIS OF PANCREATIC LESIONS F. Terracciano ∗ , A. Ippolito, D. Siena, M. Sperandeo, M. Piattelli, V. Annese, A. Andriulli Casa Sollievo della Sofferenza, San Giovanni Rotondo Background and aim: The development of CEUS has contributed to major breakthroughs in the diagnosis of pancreatic lesions. However, only few controlled studies are available. We aimed to prospectively evaluate the role of CEUS in characterization of pancreatic lesions. Material and methods: 28 patients (18 male, median age 73 yrs, range 45-83) with 33 histologically proven pancreatic lesions detectable at the US were investigated. At the final diagnosis 8 were adenocarcinoma, 3 insulinomas, 5 mass forming pancreatitis (MFP), and 17 cystic lesions (2 intraductal papillary mucinous tumors [IPMT], 7 pseudocystis, 2 serous [SCA] and 2 mucinous [MCA]cystadenoma). After standard US, 2,4 mL of Sonovue i.v. was administered. Perfusion images of CEUS were evaluated to detect the lesions and parenchymal vascularity. The CEUS findings were compared with those obtained by computed tomography (CT) or magnetic resonance (MRI). The histological diagnosis in all cases was obtained either from biopsy or surgical specimens. Results: Based on CEUS findings, solid lesions showing hypovascular pattern were diagnosed as carcinomas, those with hypervascular pattern as neuroendocrin tumors, and the hysovascular ones as MFP. All lesions fit these US criteria according to final diagnosis (sensitivity, specificity and accuracy:100%).CT or MRI findings in all cases were also confirmed at the final diagnosis (sensitivity, specificity and accuracy: 100%). Concerning the cystic lesions, all except one were non vascular, even when a corpuscular content was found at basal US (sensitivity 90%). More interestingly, in all cases of SCA and MCA with intralesional septis, CEUS demonstrated a vascular enhancement (sensitivity 100%). In contrast, in the absence of intralesional features within cystic lesions differential diagnosis could not be achieved (sensitivity 65%). Conclusions: Our data, although preliminary, demonstrate that the study of the pancreas is a promising application of CEUS. In case of solid lesions, a 100% accuracy and concordance with CT/MRI imaging and histologic diagnosis was obtained. In contrast, in presence of cystic lesions the accuracy of CEUS compared to CT/MRI and histologic diagnosis was 75% and 70%. However, when intralesional septis were found, the accuracy of CEUS increased to 90%. Based on these findings CEUS should be further assessed as a complementary imaging modality in the characterization of pancreatic lesions. # T. Imaging techniques 1. Ultrasounds