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Pancreatic polyethylene stents are blocked by a proteinaceous matrix
ERCP--PANCREAS t505
t507
A PROSPECTIVE EVALUATION OF THE SECRETIN ULTRASOUND TEST IN PATIENTS UNDERGOING ENDOSCOPIC THERAPY FOR CHRONIC PANCREATITIS GM Ei$r SD Coleman, RE England, S McGee, MS Branch, J Affronti, PS Jowell, ~ Baillie, PB Cotton, Division of Gastroenterology, Duke University Medical Center, Durham, NC Background: Appropriate selection of patients with chronic pancreatitis for endoscopic therapy remains vexing. The secretinultrasound examination (SUS) has,been advocated by some as a predictor of clinical response to surgical sphincteroplasty. The underlying principle of the SUS is that maximal stimulation of pancreatic secretion will lead to pancreatic duct dilation if flow is impeded by papillary/ductal stenosis. Objective: To assess the ability of SUS to predict abnormalities on ERP and the response to endoscopic intervention. Methods: We prospectively studied patients with chronic pancreatitis (CP) from 8/93 to 11/94 with SUS, subsequent ERCP and clinical follow-up. Results: 62 patients (85% female, median age 45, 74% pancreas divisum) underwent 65 SUS exams. 8 patients were excluded from the analysis because of failed SUS or ERP. A normal SUS exam was defined as a 50% or greater increase in pancreatic duct (PD) diameter that returned to initial PD size within 20 minutes. An abnormal SUS was defined as a >50% increase in PD diameter that persisted 20 minutes into the exam. A nonresponse SUS was a <50% increase throughout the exam. The sensitivity, specificity, positive and negative predictive values for PD abnormality on ERP were respectively: 64%, 52%, 71% and 43%. Endoscopic therapy was performed on 23 patients (14 dorsal stents, 3 dorsal stents/sphincterotomy, 3 dorsal dilations, 3 main PD stents). Mean stenting duration was 19.6 days. 20/23 patients were available for clinical follow-up (telephone interview, 1-3 months after therapy). 5/7 patients with abnormal SUS results described clinical improvement compared to 3/9 with normal results and 1/4 nonresponders (p=.16, Fisher's exact test). Conclusions: 1) SUS is a poor predictor of pancreatic duct abnormalities. 2) The value of SUS in predicting clinical response to endoscopic therapy is not established. 3) A large, multi-center trial is indicated to evaluate the predictive ability of SUS.
PANCREATIC P O L Y E T H Y L E N E STENTS ARE B L O C K E D BY A PROTEINACEOUS MATRIX
t506
were patchily scattered in the protein matrix. Small foci of calcium were seen in 3 stents, yeast in 2, and plant material in 2. Scanning and transmission electron microscopy confirmed the LM findings, and showed an amorphous protein matrix in all stents, sometimes arranged in layers. Lipid was seen in 2 stents, and epithelial cells in one. Cultures of stent contents grew several species of Gram positive and negative bacteria. Average dry weight of 5 s t e n t c o n t e n t s was 7.2 mg. SDS PAGE electrophoresis of stent contents showed that the stent contents had a different pattern compared to secretin stimulated pancreatic juice. Most stents had enrichment of a 66 kD protein band, which is in the process of being identified. Conclusions: Pancreatic stents were all blocked, mainly with protein, admixed with bacteria, lipid, and refluxed duodenal contents. Although bacteria were present, it is difficult to assess the importance of bacteria in the clogging process. SDS-PAGE electrophoresis showed enhancement of an as yet unidentified 66kD protein band in most stents.
508
O~PLICATIONE OF M A J O R P A P I L L A E N D O S C O P I C PANC2KEA2IU SPHIMCTEROTONYI A R E V I E W O F 106 PATIENTS. E Esber, S Sherman, D Earle, J Pezzi, K Gottlieb, G Lehman. Indiana U n i v e r s i t y Medical Center. Pancreatic s p h i n c t e r o t o m y (PS) is u s e d for treating residual pancreatic sphincter stenoeis after biliary s p h i n c t e r o t o m y (BE), and aids in p a n c r e a t i c duct (PD) access for stone removal, b i o p s y and stenting. We reviewed the clinical features and c o m p l i c a t i o n s of a large series of patients u n d e r g o i n g PS at our institution. METHODS; O v e r the past 3 years the charts of all p a t i e n t s who had PS w e r e reviewed. I m d i a t e c o m p l i c a t i o n s w e r e d e t e r m i n e d at t h e time of the procedure. Follow-up phone calls were made w i t h i n 24-72 hours to ~ a t i e n t e d i s c h a r g e d on the day of their procedure, The d x a g n o s i s and s e v e r i t y of p O S t - E R C P ancreatitis was based on s t a n d a r d i z e d c r i t e r i a (GI Endosc. 991;37:383~. Pancreatic stent induced changes were a n a l y z e d at the time of stent removal. PS was p e r f o r m e d in one of 3 fashions: i. Stent p l a c e m e n t followed by needle knife sphincterotemy (ST/NK) (n=41), 2. Pull type s p h i n c t e r o t o m y followed by PD stenting(n=35), 3. Pull type sphincterotomy without subsequent stenting (nffi30). RESULTS: A total of i06 patients, (80 female, 26 male) w e r e i d e n t i f i e d w i t h a m e a n age of 47 (range 10-84). A c o n c u r r e n t de n e r o or e x t e n d e d BS was p e r f o r m e d in 33 (31%) patients. PS was p e r f o r m e d in 76 (72%) p a t i e n t s with m a n o m e t r i c e v i d e n c e of p a n c r e a t i c s p h i n c t e r dysfunction (basal sphincter p r e s s u r e > 40 m m He; n=61), or clinical and endoscopic parameters suggestive of pancreatic sphincter d y s f u n c t i o n (n=15}. PS w a s p e r f o r m e d in 30 (28%) patients with pancreatic stones (n=22), PD leak or pseudocyst (n=4) and to f a c i l i t a t e tumor b i o p s y (n=4). Sixteen p a t i e n t s (15%) d e v e l o p e d p O S t - E R C P p a n c r m a t i t i s graded as: m i l d 13 (81%), m o d e r a t e 2 (13%), end severe 1 (6%; associated with pancreatic etent migration}. P a n o r e a t i t i e o c c u r r e d in 1 3 p a t i e n t s (17%) w i t h p e n c r e a t l c sphincter dysfunction, c o m p a r e d to 3 p a t i e n t s (10%) with chronic p a n c r e a t i t i s (p=0.36). T h e r e was no statistical d i f f e r e n c e in the frequency of p a n c r e a t i t i s w i t h r e g a r d to the m e t h o d of sphincterotomy. Two p a t i e n t s undergoing ST/NK sphincterotomy had m i n i m a l bleeding requxring e p i n e p h r i n e w a s h in 1 and i n j e c t i o n in t h e other. Of the 46 patients e v a l u a t e d at stent r e m o v a l , 15 (33%) had m i n i m a l stent induced PD changes. Three stents m i g r a t e d into the PD, r e q u i r i n g e x t e n s i o n of the PS prior to retrieval in 1 patient, and p e r c u t a n e o u s removal in another. SUMMARY: PS c o m p l i c a t i o n s in this study were p a n c r e a t i t i s (15%), m i n i m a l stent induced c h a n g e s (33%) and b l e e d i n g (1.8%). There was no s i g n i f i c a n t d i f f e r e n c e in the i n c i d e n c e of PS induced p a n c r e a t i t i s in p a t i e n t s with p a n c r e a t i c sphincter of O d d i d y s f u n c t i o n and chronic pancreatitis. CONCLUSION: PS has a similar c o m p l i c a t i o n rate compared to BE. O u t c o m e of this series is reported elsewhere.
~
422
N Gopinath', J vanMarle2, ME Smits ~, KS Mok ~, H vanVeen2, GJA Offerhaus 3, AK Groen ~, EAJ Rauws ~, GNJ Tytgat ~, K Huibregtse ~. Depts. of Gastroenterology~,Electron Microscopy ~, and Pathology3, Academic Medical Centre, Amsterdam, The Netherlands. Introduction: Pancreatic stents are used to treat duct obstruction in a variety of pancreatic disorders. Stents may obstruct with time, and there is little information available on the nature of the clogging process. We analyzed the contents of electively exchanged pancreatic polyethylene (PE) endoprostheses. Methods: Eight 10FG and two 7FG straight Amsterdam PE stents were used to treat pancreatic duct strictures in 9 patients with chronic alcoholic pancreatitis, and were in place for a mean of 9 weeks (range 2-12 weeks). Stents were visually inspected, and the contents were analyzed by light and electron microscopy and SDS-PACE electrophoresis. Results: All stents were occluded at both ends, especially around side holes, with thick, white cheesy material (n=10) and mucous (n=3). Light microscopy (LM) showed that proteinaceous material completely filled the stent lumen. A variable number of bacteria of several species, sometimes in clumps,
GASTROINTESTINAL ENDOSCOPY
M U C I N O U S P A N C R E A T I C DUCT ECTASIA: TWELVE CASES. K. Gottlieb, G. Lehman, S. Sherman, J. Geenen, M. Schmalz, J. Goff, G. Aliperti, S. Silvis, A. Lui, G. Elta. Indiana U n i v e r s i t y Medical Center, Indianapolis, IN; M i d w e s t P a n c r e a t o b i l i a r y Study Group. R e c e n t l y m u c h a t t e n t i o n has focused on p a n c r e a t i c tumors that p r e d o m i n a n t l y grow w i t h i n the p a n c r e a t i c duct system: m u c i n o u s p a n c r e a t i c duct e c t a s i a iMPDE). In some of these rare tumors, severe atypia is p r e s e n t but true invasive growth w i t h m e t a s t a s i s seems to be rare. This study was started to b e t t e r d e f i n e the features and the clinical course of MPDE. METHODS: A letter w i t h cD/estionnaire was send to the members of the M i d w e s t Pancreatobiliary Group inviting submission of case histories. RESULTS: 13 cases were reviewed. One case with atypical features w a s excluded. 9 patients were female, 3 male. The m e a n age at p r e s e n t a t i o n was 73 years, range 55 - 86 years. Typical p r e s e n t i n g symptoms were abdominal pain w i t h r e c u r r e n t acute or chronic pancreatitis in 9 p a t i e n t s and d i a r r h e a and w e i g h t loss without pain in 3 patients. Symptoms were present from 2 months to i0 years with a m e d i a n of 2 years. ERCP findings were: mucus e x t r u s i o n from the papilla, g a p i n g p a p i l l a r y orifice, dilated main p a n c r e a t i c duct w i t h m u l t i p l e filling defects, and chronic pancreatitis. CT was helpful in e x c l u d i n g a c o e x i s t i n g mass lesion. ERCP changes involving the whole pancreas were seen in i0 of 12 patients, changes limited to the head or b o d y / t a i l in 2 patients. 8 of 12 patients were m a n a g e d conservatively: 3 had ERCP's in 3m o n t h l y intervals w i t h cytology, 3 were followed with CA 19-9 levels and 2 clinically. 4 patients had surgery: one patient u n d e r w e n t distal p a n c r e a t e c t o m y when his CA 19-9 levels were rising, histology revealed m u c i n o u s adenocarcinoma; one patient u n d e r w e n t a W h i p p l e r e s e c t i o n w h e n at follow-up his ductal cytology revealed h i g h l y atypical cells, h i s t o l o g y was intraductal p a p i l l a r y carcinoma; one patient was found to have an e n l a r g i n g head of the p a n c r e a s and had a total pancreatectomy, h i s t o l o g y was m u c i n o u s adenocarcinoma; the youngest patient, a 5 5 - y e a r - o l d woman, u n d e r w e n t a Whipple as soon as the d i a g n o s i s of MPDE was made. Mean f o l l o w - u p in this series is 12.3 months, range 1 - 24 months. 2 patients have died of seemingly u n r e l a t e d causes, the fate of 2 is u n k n o w n and the rest (8) is doing well. SUMMARY: MPDE seems to be a disease of elderly females p r e s e n t i n g w i t h recurrent pancreatitis. Its c o u r s e does not seem to be overly a g g r e s s i v e and the need for surgery should be carefully weighed. CA 19-9 levels, brush cytology and repeat CT~scans have been found useful for follow up. Still the data is insufficient and it is our aim to collect and follow 80 - i00 cases nationwide and case submissions are much appreciated.
V O L U M E 41, NO. 4, 1995
t507
A PROSPECTIVE EVALUATION OF THE SECRETIN ULTRASOUND TEST IN PATIENTS UNDERGOING ENDOSCOPIC THERAPY FOR CHRONIC PANCREATITIS GM Ei$r SD Coleman, RE England, S McGee, MS Branch, J Affronti, PS Jowell, ~ Baillie, PB Cotton, Division of Gastroenterology, Duke University Medical Center, Durham, NC Background: Appropriate selection of patients with chronic pancreatitis for endoscopic therapy remains vexing. The secretinultrasound examination (SUS) has,been advocated by some as a predictor of clinical response to surgical sphincteroplasty. The underlying principle of the SUS is that maximal stimulation of pancreatic secretion will lead to pancreatic duct dilation if flow is impeded by papillary/ductal stenosis. Objective: To assess the ability of SUS to predict abnormalities on ERP and the response to endoscopic intervention. Methods: We prospectively studied patients with chronic pancreatitis (CP) from 8/93 to 11/94 with SUS, subsequent ERCP and clinical follow-up. Results: 62 patients (85% female, median age 45, 74% pancreas divisum) underwent 65 SUS exams. 8 patients were excluded from the analysis because of failed SUS or ERP. A normal SUS exam was defined as a 50% or greater increase in pancreatic duct (PD) diameter that returned to initial PD size within 20 minutes. An abnormal SUS was defined as a >50% increase in PD diameter that persisted 20 minutes into the exam. A nonresponse SUS was a <50% increase throughout the exam. The sensitivity, specificity, positive and negative predictive values for PD abnormality on ERP were respectively: 64%, 52%, 71% and 43%. Endoscopic therapy was performed on 23 patients (14 dorsal stents, 3 dorsal stents/sphincterotomy, 3 dorsal dilations, 3 main PD stents). Mean stenting duration was 19.6 days. 20/23 patients were available for clinical follow-up (telephone interview, 1-3 months after therapy). 5/7 patients with abnormal SUS results described clinical improvement compared to 3/9 with normal results and 1/4 nonresponders (p=.16, Fisher's exact test). Conclusions: 1) SUS is a poor predictor of pancreatic duct abnormalities. 2) The value of SUS in predicting clinical response to endoscopic therapy is not established. 3) A large, multi-center trial is indicated to evaluate the predictive ability of SUS.
PANCREATIC P O L Y E T H Y L E N E STENTS ARE B L O C K E D BY A PROTEINACEOUS MATRIX
t506
were patchily scattered in the protein matrix. Small foci of calcium were seen in 3 stents, yeast in 2, and plant material in 2. Scanning and transmission electron microscopy confirmed the LM findings, and showed an amorphous protein matrix in all stents, sometimes arranged in layers. Lipid was seen in 2 stents, and epithelial cells in one. Cultures of stent contents grew several species of Gram positive and negative bacteria. Average dry weight of 5 s t e n t c o n t e n t s was 7.2 mg. SDS PAGE electrophoresis of stent contents showed that the stent contents had a different pattern compared to secretin stimulated pancreatic juice. Most stents had enrichment of a 66 kD protein band, which is in the process of being identified. Conclusions: Pancreatic stents were all blocked, mainly with protein, admixed with bacteria, lipid, and refluxed duodenal contents. Although bacteria were present, it is difficult to assess the importance of bacteria in the clogging process. SDS-PAGE electrophoresis showed enhancement of an as yet unidentified 66kD protein band in most stents.
508
O~PLICATIONE OF M A J O R P A P I L L A E N D O S C O P I C PANC2KEA2IU SPHIMCTEROTONYI A R E V I E W O F 106 PATIENTS. E Esber, S Sherman, D Earle, J Pezzi, K Gottlieb, G Lehman. Indiana U n i v e r s i t y Medical Center. Pancreatic s p h i n c t e r o t o m y (PS) is u s e d for treating residual pancreatic sphincter stenoeis after biliary s p h i n c t e r o t o m y (BE), and aids in p a n c r e a t i c duct (PD) access for stone removal, b i o p s y and stenting. We reviewed the clinical features and c o m p l i c a t i o n s of a large series of patients u n d e r g o i n g PS at our institution. METHODS; O v e r the past 3 years the charts of all p a t i e n t s who had PS w e r e reviewed. I m d i a t e c o m p l i c a t i o n s w e r e d e t e r m i n e d at t h e time of the procedure. Follow-up phone calls were made w i t h i n 24-72 hours to ~ a t i e n t e d i s c h a r g e d on the day of their procedure, The d x a g n o s i s and s e v e r i t y of p O S t - E R C P ancreatitis was based on s t a n d a r d i z e d c r i t e r i a (GI Endosc. 991;37:383~. Pancreatic stent induced changes were a n a l y z e d at the time of stent removal. PS was p e r f o r m e d in one of 3 fashions: i. Stent p l a c e m e n t followed by needle knife sphincterotemy (ST/NK) (n=41), 2. Pull type s p h i n c t e r o t o m y followed by PD stenting(n=35), 3. Pull type sphincterotomy without subsequent stenting (nffi30). RESULTS: A total of i06 patients, (80 female, 26 male) w e r e i d e n t i f i e d w i t h a m e a n age of 47 (range 10-84). A c o n c u r r e n t de n e r o or e x t e n d e d BS was p e r f o r m e d in 33 (31%) patients. PS was p e r f o r m e d in 76 (72%) p a t i e n t s with m a n o m e t r i c e v i d e n c e of p a n c r e a t i c s p h i n c t e r dysfunction (basal sphincter p r e s s u r e > 40 m m He; n=61), or clinical and endoscopic parameters suggestive of pancreatic sphincter d y s f u n c t i o n (n=15}. PS w a s p e r f o r m e d in 30 (28%) patients with pancreatic stones (n=22), PD leak or pseudocyst (n=4) and to f a c i l i t a t e tumor b i o p s y (n=4). Sixteen p a t i e n t s (15%) d e v e l o p e d p O S t - E R C P p a n c r m a t i t i s graded as: m i l d 13 (81%), m o d e r a t e 2 (13%), end severe 1 (6%; associated with pancreatic etent migration}. P a n o r e a t i t i e o c c u r r e d in 1 3 p a t i e n t s (17%) w i t h p e n c r e a t l c sphincter dysfunction, c o m p a r e d to 3 p a t i e n t s (10%) with chronic p a n c r e a t i t i s (p=0.36). T h e r e was no statistical d i f f e r e n c e in the frequency of p a n c r e a t i t i s w i t h r e g a r d to the m e t h o d of sphincterotomy. Two p a t i e n t s undergoing ST/NK sphincterotomy had m i n i m a l bleeding requxring e p i n e p h r i n e w a s h in 1 and i n j e c t i o n in t h e other. Of the 46 patients e v a l u a t e d at stent r e m o v a l , 15 (33%) had m i n i m a l stent induced PD changes. Three stents m i g r a t e d into the PD, r e q u i r i n g e x t e n s i o n of the PS prior to retrieval in 1 patient, and p e r c u t a n e o u s removal in another. SUMMARY: PS c o m p l i c a t i o n s in this study were p a n c r e a t i t i s (15%), m i n i m a l stent induced c h a n g e s (33%) and b l e e d i n g (1.8%). There was no s i g n i f i c a n t d i f f e r e n c e in the i n c i d e n c e of PS induced p a n c r e a t i t i s in p a t i e n t s with p a n c r e a t i c sphincter of O d d i d y s f u n c t i o n and chronic pancreatitis. CONCLUSION: PS has a similar c o m p l i c a t i o n rate compared to BE. O u t c o m e of this series is reported elsewhere.
~
422
N Gopinath', J vanMarle2, ME Smits ~, KS Mok ~, H vanVeen2, GJA Offerhaus 3, AK Groen ~, EAJ Rauws ~, GNJ Tytgat ~, K Huibregtse ~. Depts. of Gastroenterology~,Electron Microscopy ~, and Pathology3, Academic Medical Centre, Amsterdam, The Netherlands. Introduction: Pancreatic stents are used to treat duct obstruction in a variety of pancreatic disorders. Stents may obstruct with time, and there is little information available on the nature of the clogging process. We analyzed the contents of electively exchanged pancreatic polyethylene (PE) endoprostheses. Methods: Eight 10FG and two 7FG straight Amsterdam PE stents were used to treat pancreatic duct strictures in 9 patients with chronic alcoholic pancreatitis, and were in place for a mean of 9 weeks (range 2-12 weeks). Stents were visually inspected, and the contents were analyzed by light and electron microscopy and SDS-PACE electrophoresis. Results: All stents were occluded at both ends, especially around side holes, with thick, white cheesy material (n=10) and mucous (n=3). Light microscopy (LM) showed that proteinaceous material completely filled the stent lumen. A variable number of bacteria of several species, sometimes in clumps,
GASTROINTESTINAL ENDOSCOPY
M U C I N O U S P A N C R E A T I C DUCT ECTASIA: TWELVE CASES. K. Gottlieb, G. Lehman, S. Sherman, J. Geenen, M. Schmalz, J. Goff, G. Aliperti, S. Silvis, A. Lui, G. Elta. Indiana U n i v e r s i t y Medical Center, Indianapolis, IN; M i d w e s t P a n c r e a t o b i l i a r y Study Group. R e c e n t l y m u c h a t t e n t i o n has focused on p a n c r e a t i c tumors that p r e d o m i n a n t l y grow w i t h i n the p a n c r e a t i c duct system: m u c i n o u s p a n c r e a t i c duct e c t a s i a iMPDE). In some of these rare tumors, severe atypia is p r e s e n t but true invasive growth w i t h m e t a s t a s i s seems to be rare. This study was started to b e t t e r d e f i n e the features and the clinical course of MPDE. METHODS: A letter w i t h cD/estionnaire was send to the members of the M i d w e s t Pancreatobiliary Group inviting submission of case histories. RESULTS: 13 cases were reviewed. One case with atypical features w a s excluded. 9 patients were female, 3 male. The m e a n age at p r e s e n t a t i o n was 73 years, range 55 - 86 years. Typical p r e s e n t i n g symptoms were abdominal pain w i t h r e c u r r e n t acute or chronic pancreatitis in 9 p a t i e n t s and d i a r r h e a and w e i g h t loss without pain in 3 patients. Symptoms were present from 2 months to i0 years with a m e d i a n of 2 years. ERCP findings were: mucus e x t r u s i o n from the papilla, g a p i n g p a p i l l a r y orifice, dilated main p a n c r e a t i c duct w i t h m u l t i p l e filling defects, and chronic pancreatitis. CT was helpful in e x c l u d i n g a c o e x i s t i n g mass lesion. ERCP changes involving the whole pancreas were seen in i0 of 12 patients, changes limited to the head or b o d y / t a i l in 2 patients. 8 of 12 patients were m a n a g e d conservatively: 3 had ERCP's in 3m o n t h l y intervals w i t h cytology, 3 were followed with CA 19-9 levels and 2 clinically. 4 patients had surgery: one patient u n d e r w e n t distal p a n c r e a t e c t o m y when his CA 19-9 levels were rising, histology revealed m u c i n o u s adenocarcinoma; one patient u n d e r w e n t a W h i p p l e r e s e c t i o n w h e n at follow-up his ductal cytology revealed h i g h l y atypical cells, h i s t o l o g y was intraductal p a p i l l a r y carcinoma; one patient was found to have an e n l a r g i n g head of the p a n c r e a s and had a total pancreatectomy, h i s t o l o g y was m u c i n o u s adenocarcinoma; the youngest patient, a 5 5 - y e a r - o l d woman, u n d e r w e n t a Whipple as soon as the d i a g n o s i s of MPDE was made. Mean f o l l o w - u p in this series is 12.3 months, range 1 - 24 months. 2 patients have died of seemingly u n r e l a t e d causes, the fate of 2 is u n k n o w n and the rest (8) is doing well. SUMMARY: MPDE seems to be a disease of elderly females p r e s e n t i n g w i t h recurrent pancreatitis. Its c o u r s e does not seem to be overly a g g r e s s i v e and the need for surgery should be carefully weighed. CA 19-9 levels, brush cytology and repeat CT~scans have been found useful for follow up. Still the data is insufficient and it is our aim to collect and follow 80 - i00 cases nationwide and case submissions are much appreciated.
V O L U M E 41, NO. 4, 1995