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Pancreatic stents: Are two barbs better than four?
ERCP-PANCREAS i'453
455
IS PRE-EXISTING PANCREATITIS A RISK FACTOR FOR ERCPINDUCED PANCREAT1TIS? Yane K. Chen. Michael H. Walter, Timothy L. McCarter, M.Anthony C. Frankson. Loma Linda University Medical Center, Division of Gastroenterology, Loma Linda, California.
ENDOSCOPIC TREATMENT OF PANCREATIC PSEUDOCYSTS: CYSTOENTEROSTOMY AND TRANSPAPILLARY DRAINAGE E Della Libera Jr, ES Siqueira, CQ Brant, M Morais, AP Ferrari Jr, DL Carr-Loeke. Division of Gastroenterology - Universidade de Sio Panlo - Sio Paulo Brazil
There is limited data to support the conventional wisdom that patients with pre-existing pancreatitis are more susceptible to ERCP-induced pancreatic injury. The purpose of this prospective study was to determine the influence of antecedent pancreatic history on the risk of ERCP-induced pancreatitis. All patients undergoing ERCP were followed for development of complications. Diagnosis of ERCP-induced pancreatitis was based on previously published criteria (GastrointestEndosc 1991;37:383). RESULTS: 39 of 787 patients (5.0%) developed pancreatitis after ERCP: 12 of 280 patients (4.3%) after diagnostic ERCP, 27 of 507 patients (5.3%) after therapeutic ERCP; p=,~0.001. 246 of 787 patients (31.2%) had a documented history of antecedent pancreatic injury. Etiologies of antecedent pancreatitis were: idiopathic (n=91), gallstones (n=50), alcoholic (n=35), ERCP (n=20), Sphincter of Oddi dysfunction (n=6), and other (n=44). ERCP-induced pancreatitis occurred in 6.1% of patients with a history of pancreatitis, and in 4.4% of patients without a history of pancreatitis; p = NS.
Pancreatic History None Acute < 6 wks Acute > 6 wks Chronic. TQTAL *p=0.02, chi-square test
# of Patients ERCP-InducedPancreatitis (%) 541 82 88 76 787
24(4.4) 7(8.5) 8(9.1) 0(0) :~9(5.0)
Patients with a history of acute pancreatitis were more susceptible to pancreatic complications. In contrast, patients with chronic pancreatitis were relatively immune. CONCLUSION: Antecedenthistoryofpancreaticdisease is an important factor in predicting the risk of ERCP-induced pancreatitis.
Pancreatic pseudoeysts have been successfully treated by endoscopic drainage (cystogastrostomy or duodenostomy, and transpapillary drainage) We report our experience with endoscopic therapy of panereatie pseudocysts. From July/94 to August/95, 16 patients with pancreatic pseudocysts were referred to ERCP because of persistent pain and/or jaundice. In 4/16 (25%) endoscopic therapy was not performed because we were not able to place a guide wire beyond a pancreatic stenosis and there was no indentation of gastric or duodenal wall. In the remaining 12 patients (9/3 male/femaie ratio), mean age 38.2 years (range 24 - 64 years), 15 pseudocysts were treated with eystogastrostomy (5), eystoduodenostomy (2) and/or transpapillary drainage (8). Etiology was: alcoholic chronic pancreatitis (8), blunt abdominal trauma (2) or surgical trauma (2). Pseudoeysts mean size was 7 8 3 cm (range 3,5 - 18 cm) and they were located in the head (4), body (8) or tail (3). Complications were present in 7/16 patients: 2 early stent occlusion, 1 fever, 1 pneum0peritoneum, 1 bleeding, 1 proximal migration and 1 perforation Except for the perforation that required surgery, all complications were minor and medically and/or endoseopically managed There were no deaths. Mean follow up was 150 days (range 15 - 360 days) and mean stent period was 134 days (range 30 - 210 days). Clinical improvement was noted in 11/12 (91%) patients. All but one pseudoeyst resolved, 8 patients are asymptomatie and 3 are taking small doses of analgesics In the only patient that persisted with pain, stent was removed and she was sent to surgery because of chronic pancreatitis. We concluded that endoscopic therapy of pancreatic pseudocysts is a safe and efficient way of drainage, resulting in clinical improvement in most of the patients,
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+456
PANCREATIC STENTS: ARE TWO BARBS BETTER THAN FOUR? B Dalunan, JE Geenen, WJ Hogan, MF Catalano, DJ Geenen, MJ Schmalz, GK Johnson. Pancreatic Biliary Center, St. Luke's Medical Center, Milwaukee, WI Endoscopic placement of stents is frequently performed to relieve obstruction and improve drainage of the biliary and pancreatic duct systems. Migration of the stent occurs in 5-10% of stents inserted. Inward migration is of greater concern than outward migration because retrieval of the stent may be difficult and complications can be serious. Removing the 2 proximal barbs from the stent has been suggested as a solution to inward migration. AI._MM: To determine the migration rate (inward/outward) of modified pancreatic stents and the various factors that may lead to this problem. METHODS: Modified stents with only 2 barbs located at the distal end were used over 3 years. Each stent placement was considered a separate event. A total of 178 stents were placed in 102 pts (76 female; 26 male). 46 had chronic pancreatitis (CP), 76 pancreas divisum, 17 sphincter of Oddi Dysfunction (SOD), 24 idiopathic recurrent pancreatitis, and 3 idiopathic stricture. 12 pts were lost to follow-up. The influence of the diagnosis, length and diameter of the stent, end doctal size on migration was evaluated. RESULTS: Only 1 of 166 stents migrated inward (0.6%). 80, however, migrated outward (48%). This is compared to an inward rate of 5.2% and outward rate of 7.5% for 4 barbed stents previously reported by our group. A higher rate of outward migration was seen with smaller and shorter stents. Pts with SOD also had a higher risk than patients with CP. Migration Out Statistical Significance 5F 59 (54%) Size 7F 21 (37%) p < 0.05
IS THE INITIAL SUCCESS OF ENDOSCOPIC THERAPY (ET) OF CHRONIC PANCREATrrls (CP) SUSTAINED IN LONG-TERM FOLLOW- UP?. t"i~A['hnVal|~GB Haber, P Kortan,, M Ciroeco. The WeUesley Hospital, Toronto. INTRODUCTION: The results of ET for CP do not often distinguish between early response during treatment and long-term ontcome after *he completion of ET. PURPOSE: To evaluate the long-term success of ET of CP in those pts who have an initial positive response. PATIENTS & METHODS: Ninety pts with ET for CP between 10/1987 and 6/1994 were identified in a retrospective chart review. Among these 80 (44 male, mean age 45.5 yrs) were available for follow up by direct telephone interview. The etiology was alcohol (32), pancreas divisum(17), both(5), idiopathle(17), gallstone (5), and other(4). Endoscopic findings were a dominant stricture(42), stones(l 1), combiuallon(16), and other(ll). 17 pts had prior panereatlc surgery. 15 pts who underwent subsequent pancreatic surgery and 2 pts with endoecopie cyst drainage were exelnded from this analysis, leaving 63 evaluable patients. Treatment consisted of panerearie sphincterotomy, stent placement and stone removal. Initial success was evaluated according to pain, whieh was classified as diminished or absent (success) vs. unchanged or worse (failure). In a similar fashion success was evaluated at long-term follow up. Long-term pain relief was correlated with ability to work prior to ET and at follow up. ~TS: Among the 63 pts, the mean number of procederes was 3.55 (1-14) and mean duration of treatment was 14 me. There were 27 panereatie sphincterotomies, 54 stent placemenst, and 23 stone extractions.The mean leagterm follow up after the conelnsion of ET was 28 me. Upon completion of ET pain relief was suecessful in 52 (83%) and failed in 11 (17%). Among the 52 initially suecessfal pts,at Iongterm follow up 46 (88.5%) had sustained pain relief and the other 6 had deteriorated. Among the 11 initial failures, 9 continued to do poorly and 2 improved (I)<0.{301). Among 22 pts not working prior to ET: 11/12 pts with initial endoscopic success had long-term pain relief and were working fnlltime, whereas only 2/10 failures were working fnlltime (p<0.001). Among the 17 pts who had subsequent pancreatic surgery and endoseepie cyst drainage, they were evenly divided with 9 initial endoscopic success and 8 initial endoscopic failure. CONCLUSION: This data suggest that the early success of endoscopie therapy for chronic panereatitis is durable in the long-term.
25 (71%) 55 (42%) p<0.01 oval of internal barbs fro a't pancreatic stents results in a very low inward migration rate suggesting that proximal barbs may play a role in the inward migration of stents. The outward migration rate of these stents, however, is very high which may preclude its usage except in cases where short term drainage is desired. Length
404
<3era >..._~m
GASTROINTESTINAL ENDOSCOPY
VOLUME 43, NO. 4, 1996
455
IS PRE-EXISTING PANCREATITIS A RISK FACTOR FOR ERCPINDUCED PANCREAT1TIS? Yane K. Chen. Michael H. Walter, Timothy L. McCarter, M.Anthony C. Frankson. Loma Linda University Medical Center, Division of Gastroenterology, Loma Linda, California.
ENDOSCOPIC TREATMENT OF PANCREATIC PSEUDOCYSTS: CYSTOENTEROSTOMY AND TRANSPAPILLARY DRAINAGE E Della Libera Jr, ES Siqueira, CQ Brant, M Morais, AP Ferrari Jr, DL Carr-Loeke. Division of Gastroenterology - Universidade de Sio Panlo - Sio Paulo Brazil
There is limited data to support the conventional wisdom that patients with pre-existing pancreatitis are more susceptible to ERCP-induced pancreatic injury. The purpose of this prospective study was to determine the influence of antecedent pancreatic history on the risk of ERCP-induced pancreatitis. All patients undergoing ERCP were followed for development of complications. Diagnosis of ERCP-induced pancreatitis was based on previously published criteria (GastrointestEndosc 1991;37:383). RESULTS: 39 of 787 patients (5.0%) developed pancreatitis after ERCP: 12 of 280 patients (4.3%) after diagnostic ERCP, 27 of 507 patients (5.3%) after therapeutic ERCP; p=,~0.001. 246 of 787 patients (31.2%) had a documented history of antecedent pancreatic injury. Etiologies of antecedent pancreatitis were: idiopathic (n=91), gallstones (n=50), alcoholic (n=35), ERCP (n=20), Sphincter of Oddi dysfunction (n=6), and other (n=44). ERCP-induced pancreatitis occurred in 6.1% of patients with a history of pancreatitis, and in 4.4% of patients without a history of pancreatitis; p = NS.
Pancreatic History None Acute < 6 wks Acute > 6 wks Chronic. TQTAL *p=0.02, chi-square test
# of Patients ERCP-InducedPancreatitis (%) 541 82 88 76 787
24(4.4) 7(8.5) 8(9.1) 0(0) :~9(5.0)
Patients with a history of acute pancreatitis were more susceptible to pancreatic complications. In contrast, patients with chronic pancreatitis were relatively immune. CONCLUSION: Antecedenthistoryofpancreaticdisease is an important factor in predicting the risk of ERCP-induced pancreatitis.
Pancreatic pseudoeysts have been successfully treated by endoscopic drainage (cystogastrostomy or duodenostomy, and transpapillary drainage) We report our experience with endoscopic therapy of panereatie pseudocysts. From July/94 to August/95, 16 patients with pancreatic pseudocysts were referred to ERCP because of persistent pain and/or jaundice. In 4/16 (25%) endoscopic therapy was not performed because we were not able to place a guide wire beyond a pancreatic stenosis and there was no indentation of gastric or duodenal wall. In the remaining 12 patients (9/3 male/femaie ratio), mean age 38.2 years (range 24 - 64 years), 15 pseudocysts were treated with eystogastrostomy (5), eystoduodenostomy (2) and/or transpapillary drainage (8). Etiology was: alcoholic chronic pancreatitis (8), blunt abdominal trauma (2) or surgical trauma (2). Pseudoeysts mean size was 7 8 3 cm (range 3,5 - 18 cm) and they were located in the head (4), body (8) or tail (3). Complications were present in 7/16 patients: 2 early stent occlusion, 1 fever, 1 pneum0peritoneum, 1 bleeding, 1 proximal migration and 1 perforation Except for the perforation that required surgery, all complications were minor and medically and/or endoseopically managed There were no deaths. Mean follow up was 150 days (range 15 - 360 days) and mean stent period was 134 days (range 30 - 210 days). Clinical improvement was noted in 11/12 (91%) patients. All but one pseudoeyst resolved, 8 patients are asymptomatie and 3 are taking small doses of analgesics In the only patient that persisted with pain, stent was removed and she was sent to surgery because of chronic pancreatitis. We concluded that endoscopic therapy of pancreatic pseudocysts is a safe and efficient way of drainage, resulting in clinical improvement in most of the patients,
?454
+456
PANCREATIC STENTS: ARE TWO BARBS BETTER THAN FOUR? B Dalunan, JE Geenen, WJ Hogan, MF Catalano, DJ Geenen, MJ Schmalz, GK Johnson. Pancreatic Biliary Center, St. Luke's Medical Center, Milwaukee, WI Endoscopic placement of stents is frequently performed to relieve obstruction and improve drainage of the biliary and pancreatic duct systems. Migration of the stent occurs in 5-10% of stents inserted. Inward migration is of greater concern than outward migration because retrieval of the stent may be difficult and complications can be serious. Removing the 2 proximal barbs from the stent has been suggested as a solution to inward migration. AI._MM: To determine the migration rate (inward/outward) of modified pancreatic stents and the various factors that may lead to this problem. METHODS: Modified stents with only 2 barbs located at the distal end were used over 3 years. Each stent placement was considered a separate event. A total of 178 stents were placed in 102 pts (76 female; 26 male). 46 had chronic pancreatitis (CP), 76 pancreas divisum, 17 sphincter of Oddi Dysfunction (SOD), 24 idiopathic recurrent pancreatitis, and 3 idiopathic stricture. 12 pts were lost to follow-up. The influence of the diagnosis, length and diameter of the stent, end doctal size on migration was evaluated. RESULTS: Only 1 of 166 stents migrated inward (0.6%). 80, however, migrated outward (48%). This is compared to an inward rate of 5.2% and outward rate of 7.5% for 4 barbed stents previously reported by our group. A higher rate of outward migration was seen with smaller and shorter stents. Pts with SOD also had a higher risk than patients with CP. Migration Out Statistical Significance 5F 59 (54%) Size 7F 21 (37%) p < 0.05
IS THE INITIAL SUCCESS OF ENDOSCOPIC THERAPY (ET) OF CHRONIC PANCREATrrls (CP) SUSTAINED IN LONG-TERM FOLLOW- UP?. t"i~A['hnVal|~GB Haber, P Kortan,, M Ciroeco. The WeUesley Hospital, Toronto. INTRODUCTION: The results of ET for CP do not often distinguish between early response during treatment and long-term ontcome after *he completion of ET. PURPOSE: To evaluate the long-term success of ET of CP in those pts who have an initial positive response. PATIENTS & METHODS: Ninety pts with ET for CP between 10/1987 and 6/1994 were identified in a retrospective chart review. Among these 80 (44 male, mean age 45.5 yrs) were available for follow up by direct telephone interview. The etiology was alcohol (32), pancreas divisum(17), both(5), idiopathle(17), gallstone (5), and other(4). Endoscopic findings were a dominant stricture(42), stones(l 1), combiuallon(16), and other(ll). 17 pts had prior panereatlc surgery. 15 pts who underwent subsequent pancreatic surgery and 2 pts with endoecopie cyst drainage were exelnded from this analysis, leaving 63 evaluable patients. Treatment consisted of panerearie sphincterotomy, stent placement and stone removal. Initial success was evaluated according to pain, whieh was classified as diminished or absent (success) vs. unchanged or worse (failure). In a similar fashion success was evaluated at long-term follow up. Long-term pain relief was correlated with ability to work prior to ET and at follow up. ~TS: Among the 63 pts, the mean number of procederes was 3.55 (1-14) and mean duration of treatment was 14 me. There were 27 panereatie sphincterotomies, 54 stent placemenst, and 23 stone extractions.The mean leagterm follow up after the conelnsion of ET was 28 me. Upon completion of ET pain relief was suecessful in 52 (83%) and failed in 11 (17%). Among the 52 initially suecessfal pts,at Iongterm follow up 46 (88.5%) had sustained pain relief and the other 6 had deteriorated. Among the 11 initial failures, 9 continued to do poorly and 2 improved (I)<0.{301). Among 22 pts not working prior to ET: 11/12 pts with initial endoscopic success had long-term pain relief and were working fnlltime, whereas only 2/10 failures were working fnlltime (p<0.001). Among the 17 pts who had subsequent pancreatic surgery and endoseepie cyst drainage, they were evenly divided with 9 initial endoscopic success and 8 initial endoscopic failure. CONCLUSION: This data suggest that the early success of endoscopie therapy for chronic panereatitis is durable in the long-term.
25 (71%) 55 (42%) p<0.01 oval of internal barbs fro a't pancreatic stents results in a very low inward migration rate suggesting that proximal barbs may play a role in the inward migration of stents. The outward migration rate of these stents, however, is very high which may preclude its usage except in cases where short term drainage is desired. Length
404
<3era >..._~m
GASTROINTESTINAL ENDOSCOPY
VOLUME 43, NO. 4, 1996