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Pancreato-biliary manometry and outcome in patients with suspected sphincter of Oddi dysfunction
*3377 BOLUS INTRAVENOUS SOMATOSTATIN IN THE PREVENTION OF POST-ERCP PANCREATITIS Chi Pong Kwan, Wal Fan Luk, Tai Nin Chau, Ka Man Ng, Yu Wai Chan, Sik To Lai, Hon Yuen, Princess Margaret Hosp, Hong Kong Aim : To test the efficacy of bolus intravenous somatostatin in the prevention of post-ERCP pancreatitis. Method : This was a randomised double blind placebo controlled trial. From Jan 1999 to Dec 2000, patients undergoing ERCP in the department of Medicine and Geriatrics, Princess Margaret Hospital, were invited to participate in the study. The exclusion criteria included pregnancy, presence of other serious medical illness, previous sphincterotomy and allergy to somatostatin. After signing the informed consent, they were given either bolus intravenous somatostatin 200 mcg or normal saline just before canulation of the papilla. The age, sex, diagnosis, procedures performed, frequency of pancreatic duct canulation, frequency of pancreatic duct injection, degree and extent of pancreatic duct opacification and duration of the procedure were recorded. Amylase levels were checked before, 4 hours and 18 hours after the procedure. Acute pancreatitis was defined as presence of abdominal pain or discomfort lasting more than 18 hours after the procedure and associated with blood amylase level > 600 in/ml. Result: 150 patients were enrolled into the study. The age ranged from 28-83 and the male to female ratio was 1.3. There were no statistically significant difference in the age and sex distribution, diagnosis, procedures performed, duration of procedure, frequency of pancreatic duct canulation, frequency of pancreatic duct injection,degree and extent of pancreatic duct opacification between the 2 groups. There were 4 patients (5%) with clinically acute post_ERCP pancreatitis in the somatestatin group and 6 pancreatitis patients (8.3%) in the placebo group. The difference was not statistically significant. Conclusions: Although the incidence of pancreatitis was slightly lower in the somatostatin group (5%) as compared to that of the placebo group (8.3%), the difference was not statistically significant.
Comparisonof Post-ERCP PancreatJtJsin the SomatoslaSnGroup with the PlaceboGroup
Pancreatitis Number of patients Median Duration PD canulaUon
Somatostatin Group
Placebo group
P value
5% 78 28rain 2.5(mean)
8.3% 72 27 min 2.8(mean)
> 0.05 not significant not significant
*3378 PANCREATO-BILIARY MANOMETRY AND OUTCOME IN PATIENTS WITH SUSPECTED SPHINCTER OF ODDI DYSFUNCTION Abraham Mathew, Thomas J. McGarrity, Christopher C. Thompson, Pennsylvania State University/Hershey Medical Ctr, Hershey, PA; James C. Hobley, Penn State Univ, Hershey, PA ERCP and manometry are useful in diagnosing Sphincter of Oddi dysfunction [SOD]. In patients(pts) with type 2 & 3 SOD, endoscopic sphineterotomy is recommended when basal sphincter pressure is greater than 40ram of Hg. However, data on the outcome and correlation with manometric findings are scant. The cohort of pts and response to endoscopic therapy with suspected SOD need to be better characterized. Aim: Describe the patient population and outcome after endoscopic therapy in pts with clinically suspected SOD. Methods: Data was collected retrospectively from pts who had evaluation for suspected SOD by review of charts. Demographics, indications and outcome data was collected. SAS statistical software was used for data analysis. Results: 54 pts were referred for suspected SOD. 10 pts were excluded from the analysis as no manometry was performed. 53 ERCP's with manometry were done in the 44 pts. Right upper quadrant pain was the indication for 48 procedures and pancreatitis tbr 5. Prior ERCP evaluation without manometry were done in 11 pts. 39/43 were females. The mean age was 39 (range 19 - 64). 39/53 (73%) ~delded a diagnosis of SOD of either pancreatic or biliary origin. On 21 occasions dual sphincter manometry was performed while biliary or pancreatic manometry alone were done on 20 and 10 occasions respectively. A 2nd manometry was done in 7 pts and a 3 rd in 2. LFT's were known prior to 45 procedures and were abnormal on 11 occasions (25%). Biliary sphincter hypertension(HTN) was detected in 7/11 and Pancreatic sphincter HTN ia 1]11. Post procedure pancreatitis occurred less often in pts without SOD 1/14) compared to pts with SOD (10/39) but was not statistically different Ip=.25). Follow up data was available on 34(77%) pts (25 with and 9 without SOD). The prevalence of SOD was similar (73%) in the cohorts with and without follow up data. Recurrent symptoms were reported in 30 (88%) pts (21 with SOD and 9 without SOD) reported while 4(12%) were syrup-
VOLUME 53, NO. 5, 2001
tom free (all with SOD). Absence of post ERCP pancreatitis was not associated with better outcome. All 6 pts with abnormal LFT's on whom followup was available had recurrent symptoms. 3/6 pts were later diagnosed with NASH. Conclusion: Recurrence of symptoms is common in pts after endoscopic therapy for suspected SOD. A high recurrence rate of symptoms in pts with and without SOD raises question about the etiology of pain. The presence or absence of SOD is not associated with resolution of symptoms. Larger prospective evaluation of the outcome after ERCP in pts with suspected SOD is needed. *3379 CONVERTION FROM PERCUTANEOUS TO TRANSPAPI1.I.ARY DRAINAGE IN NON-RESECTABLE BILE DUCT CANCER IS POSSIBLE AFTER PHOTODYNAMIC THERAPY (PDT) Thomas Zoepf, Anika Rosenbaum, Arne J. Schneider, Dariusz Apel, Ralf Jakobs, Joachim C. Arnold, Axel S. Eickhoff, Juergen F. Riemarm, Medical Dept C, Clin Ludwigshafen, Ludwigshafen Germany Introduction: Preliminary experience with PDT for the treatment of nonresectable bile duct cancer (BDC) showed remarkable results in relieving jaundice, improvement of the quality of life and even in prolonging survival time. In patients with reduced life expectancy life quality improves by avoiding percutaneous drainage systems. Therefore we investigated the feasibility of replacing the percutaneous drains with transpapillary endoprostheses in non-resectable BDC after percutaneous PDT Methods: 8 patients (3 female, 5 male; 54-79 years) with non-resectable bile duct cancer Bismuth IV were treated. All patients required percutaneous drainage. 48 hours after intravenous application of 2mg/kg b.w. of Photosan-3®, light activation was performed by percutaneous access with a diode laser system (CeramOptec, Germany). We used a cylindrical diffusor tip and illuminated with a wavelength of 633+/-3 nm and a total energy of 200 J/cm 2. All patients were additionally provided with percutaneous bile duct endoprostheses, initially after PDT Results: 4 weeks after first PDT all patients showed an almost complete elimination of the bile duct stenosis in the treated area by radiograph. In 7/8 pts. we could replace the percutaneous drains with transpapillary endoprostheses 4 and 12 weeks after PDT respectively. We did not observe any phototoxicity. In 4 patients we performed a second, transpapillary PDT 6 months after initial PDT Follow-up is 3-17 months, 4 patients are still alive. Discussion: To our knowledge this is the first report on changing the access route of drainage from pereutaneous to transpapillary after PDT PDT of non-resectable bile duct cancer is a minimally invasive method with only minor side effects. Replacement of percutaneous drainage with transpapillary endoprostheses following PDT is a further step in effective palliative treatment of BDC. *3380 DILATION OF PANCREATIC DUCT STRICTURES USING THE SOEHENDRA STENT RETRIEVER Arun Naik, Seth A. Cohen, Franklin E. Kasmin, Jerome H. Siegel, Beth Israel Medical Ctr, North Div, New York, NY Pain in chronic pancreatitis may at times be due to obstruction by fibrous strictures or stones. While endoscopic decompression may offer pain relief, this technique is sometimes unsuccessful due to overly tight stricture formation. We report the use of the screw tip of the Soehendra stent remover(Wilson Cook Co) to core through these strictures and facilitate stent placement. METHODS: We prospectively analyzed the results of 16 patients who underwent stricture dilation between 6/99 and 7/00. All had chronic pain or chronic pancreatitis with an acute exacerbation. All patients underwent pancreatic sphineterotomy and attempted but failed dilation of strictures with a 7 french Siegel-Cohen dilating catheter. A 7 french Soehendra dilator was passed over a gnidewire up to the stricture, and rotated until the stricture was traversed. Stenting with either a 7 or 5 french plastic prosthesis was then carried out. Patients were hospitalized overnight to observe for complications. 30 day followup was obtained for all patients. RESULTS: Sixteen patients were treated, 8 males and 8 females, with a mean age of 56 yrs(28-88). 13 patients had chronic pancreatitis with stricture, 2 had pancreatic pseudocyst, and 1 had chronic pancreatitis with obstructing stones. Successful dilation and stenting was achieved in 14 of 16 patients(87.5%). Of these, 10 continued to have good symptom relief through the follow-up period(mean = 6.7month), although 4 patients required follow-up ERCP for further stricture dilation and stent change. 3 of the successfully dilated patients were referred for surgery for persistent symptoms, and one for suspicion of malignancy. 6 patients had post-ERCP pancreatitis(37.5%), 5 mild, 1 moderate. CONCLUSION: The Soehendra stent remover is an effective therapeutic tool for resistant pancreatic duct strictures. There is a significant likelihood of post-ERCP pancreatitis after this intervention, most often mild, In patients where the procedure is technically successful, follow-up stent change and dilation is frequently needed to maintain symptom relief.
G A S T R O I N T E S T I N A L ENDOSCOPY
AB101
Comparisonof Post-ERCP PancreatJtJsin the SomatoslaSnGroup with the PlaceboGroup
Pancreatitis Number of patients Median Duration PD canulaUon
Somatostatin Group
Placebo group
P value
5% 78 28rain 2.5(mean)
8.3% 72 27 min 2.8(mean)
> 0.05 not significant not significant
*3378 PANCREATO-BILIARY MANOMETRY AND OUTCOME IN PATIENTS WITH SUSPECTED SPHINCTER OF ODDI DYSFUNCTION Abraham Mathew, Thomas J. McGarrity, Christopher C. Thompson, Pennsylvania State University/Hershey Medical Ctr, Hershey, PA; James C. Hobley, Penn State Univ, Hershey, PA ERCP and manometry are useful in diagnosing Sphincter of Oddi dysfunction [SOD]. In patients(pts) with type 2 & 3 SOD, endoscopic sphineterotomy is recommended when basal sphincter pressure is greater than 40ram of Hg. However, data on the outcome and correlation with manometric findings are scant. The cohort of pts and response to endoscopic therapy with suspected SOD need to be better characterized. Aim: Describe the patient population and outcome after endoscopic therapy in pts with clinically suspected SOD. Methods: Data was collected retrospectively from pts who had evaluation for suspected SOD by review of charts. Demographics, indications and outcome data was collected. SAS statistical software was used for data analysis. Results: 54 pts were referred for suspected SOD. 10 pts were excluded from the analysis as no manometry was performed. 53 ERCP's with manometry were done in the 44 pts. Right upper quadrant pain was the indication for 48 procedures and pancreatitis tbr 5. Prior ERCP evaluation without manometry were done in 11 pts. 39/43 were females. The mean age was 39 (range 19 - 64). 39/53 (73%) ~delded a diagnosis of SOD of either pancreatic or biliary origin. On 21 occasions dual sphincter manometry was performed while biliary or pancreatic manometry alone were done on 20 and 10 occasions respectively. A 2nd manometry was done in 7 pts and a 3 rd in 2. LFT's were known prior to 45 procedures and were abnormal on 11 occasions (25%). Biliary sphincter hypertension(HTN) was detected in 7/11 and Pancreatic sphincter HTN ia 1]11. Post procedure pancreatitis occurred less often in pts without SOD 1/14) compared to pts with SOD (10/39) but was not statistically different Ip=.25). Follow up data was available on 34(77%) pts (25 with and 9 without SOD). The prevalence of SOD was similar (73%) in the cohorts with and without follow up data. Recurrent symptoms were reported in 30 (88%) pts (21 with SOD and 9 without SOD) reported while 4(12%) were syrup-
VOLUME 53, NO. 5, 2001
tom free (all with SOD). Absence of post ERCP pancreatitis was not associated with better outcome. All 6 pts with abnormal LFT's on whom followup was available had recurrent symptoms. 3/6 pts were later diagnosed with NASH. Conclusion: Recurrence of symptoms is common in pts after endoscopic therapy for suspected SOD. A high recurrence rate of symptoms in pts with and without SOD raises question about the etiology of pain. The presence or absence of SOD is not associated with resolution of symptoms. Larger prospective evaluation of the outcome after ERCP in pts with suspected SOD is needed. *3379 CONVERTION FROM PERCUTANEOUS TO TRANSPAPI1.I.ARY DRAINAGE IN NON-RESECTABLE BILE DUCT CANCER IS POSSIBLE AFTER PHOTODYNAMIC THERAPY (PDT) Thomas Zoepf, Anika Rosenbaum, Arne J. Schneider, Dariusz Apel, Ralf Jakobs, Joachim C. Arnold, Axel S. Eickhoff, Juergen F. Riemarm, Medical Dept C, Clin Ludwigshafen, Ludwigshafen Germany Introduction: Preliminary experience with PDT for the treatment of nonresectable bile duct cancer (BDC) showed remarkable results in relieving jaundice, improvement of the quality of life and even in prolonging survival time. In patients with reduced life expectancy life quality improves by avoiding percutaneous drainage systems. Therefore we investigated the feasibility of replacing the percutaneous drains with transpapillary endoprostheses in non-resectable BDC after percutaneous PDT Methods: 8 patients (3 female, 5 male; 54-79 years) with non-resectable bile duct cancer Bismuth IV were treated. All patients required percutaneous drainage. 48 hours after intravenous application of 2mg/kg b.w. of Photosan-3®, light activation was performed by percutaneous access with a diode laser system (CeramOptec, Germany). We used a cylindrical diffusor tip and illuminated with a wavelength of 633+/-3 nm and a total energy of 200 J/cm 2. All patients were additionally provided with percutaneous bile duct endoprostheses, initially after PDT Results: 4 weeks after first PDT all patients showed an almost complete elimination of the bile duct stenosis in the treated area by radiograph. In 7/8 pts. we could replace the percutaneous drains with transpapillary endoprostheses 4 and 12 weeks after PDT respectively. We did not observe any phototoxicity. In 4 patients we performed a second, transpapillary PDT 6 months after initial PDT Follow-up is 3-17 months, 4 patients are still alive. Discussion: To our knowledge this is the first report on changing the access route of drainage from pereutaneous to transpapillary after PDT PDT of non-resectable bile duct cancer is a minimally invasive method with only minor side effects. Replacement of percutaneous drainage with transpapillary endoprostheses following PDT is a further step in effective palliative treatment of BDC. *3380 DILATION OF PANCREATIC DUCT STRICTURES USING THE SOEHENDRA STENT RETRIEVER Arun Naik, Seth A. Cohen, Franklin E. Kasmin, Jerome H. Siegel, Beth Israel Medical Ctr, North Div, New York, NY Pain in chronic pancreatitis may at times be due to obstruction by fibrous strictures or stones. While endoscopic decompression may offer pain relief, this technique is sometimes unsuccessful due to overly tight stricture formation. We report the use of the screw tip of the Soehendra stent remover(Wilson Cook Co) to core through these strictures and facilitate stent placement. METHODS: We prospectively analyzed the results of 16 patients who underwent stricture dilation between 6/99 and 7/00. All had chronic pain or chronic pancreatitis with an acute exacerbation. All patients underwent pancreatic sphineterotomy and attempted but failed dilation of strictures with a 7 french Siegel-Cohen dilating catheter. A 7 french Soehendra dilator was passed over a gnidewire up to the stricture, and rotated until the stricture was traversed. Stenting with either a 7 or 5 french plastic prosthesis was then carried out. Patients were hospitalized overnight to observe for complications. 30 day followup was obtained for all patients. RESULTS: Sixteen patients were treated, 8 males and 8 females, with a mean age of 56 yrs(28-88). 13 patients had chronic pancreatitis with stricture, 2 had pancreatic pseudocyst, and 1 had chronic pancreatitis with obstructing stones. Successful dilation and stenting was achieved in 14 of 16 patients(87.5%). Of these, 10 continued to have good symptom relief through the follow-up period(mean = 6.7month), although 4 patients required follow-up ERCP for further stricture dilation and stent change. 3 of the successfully dilated patients were referred for surgery for persistent symptoms, and one for suspicion of malignancy. 6 patients had post-ERCP pancreatitis(37.5%), 5 mild, 1 moderate. CONCLUSION: The Soehendra stent remover is an effective therapeutic tool for resistant pancreatic duct strictures. There is a significant likelihood of post-ERCP pancreatitis after this intervention, most often mild, In patients where the procedure is technically successful, follow-up stent change and dilation is frequently needed to maintain symptom relief.
G A S T R O I N T E S T I N A L ENDOSCOPY
AB101