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Sphincter of Oddi Dysfunction in Patients with Post Cholecystectomy Syndrome (PCS) and Acute Recurrent Pancreatitis (ARP): Efficacy of Repeat SOM After Recurrence of Symptoms
Abstracts
T1190 MRCP Frequently Misses Pancreas Divisum in Routine Practice Gregory Borak, David J. Bohler, Peter B. Cotton, Joseph Romagnuolo Background: Detection of pancreas divisum is important in patients with obscure pain and idiopathic pancreatitis, but there are risks to diagnostic ERCP. MRCP has recently become widely used in the investigation of patients with suspected pancreatic diseases, and MRCPs accuracy has been reported to be up to 100% accurate in detecting pancreas divisum (PDIV)(1). Our experience at a referral center anecdotally suggested otherwise, leading to this formal retrospective review. Aim: To assess the MRCP miss-rate of PDIV in patients with confirmed PDIV at ERCP. Methods: Using the GI Trac database, patients diagnosed with PDIV between January 2001 and October 2004 were identified. Using the radiology database and by performing a chart review, the patients who also had MRCP were identified and those reports were manually reviewed. Fisher exact p-values and binomial 95% confidence intervals (CIs) were calculated. Results: During the time frame, PDIV had been diagnosed by ERCP in 328 patients and 40 had undergone prior MRCP, 30 at outside centers. Secretin stimulation was used in 7 of the 10 MUSC cases, and none elsewhere (p ! 0.001). These results were tabulated:
The trend in the sensitivity difference in MRCP with and without secretin was not significant (fisher exact p Z 0.14). In 2 outside cases, our review of the MRCP films revealed PDIV, which had not been reported, and there was a trend towards MRCPs read at MUSC having higher sensitivity for PDIV. Conclusion: The data indicate that MRCP without secretin often missed pancreas divisum (at least 49% based on the 95% CI). There is some suggestion that the use of secretin facilitates the detection of pancreas divisum by MRCP. 1) Bret PM et al. Pancreas divisum: evaluation with MR cholangiopancreatography. Radiology 1996;199:99-103.
T1191 Prophylactic Pancreatic Duct Stents: Survey of Physician Practices Stephen Brackbill, Philip Schoenfeld, Scott Young, Grace Elta Background: Pancreatitis is the most common complication of ERCP. Several prospective studies and one meta-analysis confirm that prophylactic temporary stenting of the pancreatic duct (PD) during high-risk procedures decreases the risk of post-ERCP pancreatitis. However, there is no consensus on the indications or the techniques for stent placement, including: type of stent, methods of placement, and follow-up. The purpose of this study is to survey the practice methods of expert biliary endoscopists to identify areas of consensus and areas of disagreement. Methods: An anonymous survey on the use of prophylactic PD stents was sent by mail to 54 expert biliary endoscopists in the United States and Canada. The survey assessed volume of procedures, indications for prophylactic stent placement, type of stent, methods of placement, and follow-up. 61% (33/54) surveys were returned and analyzed. Results: 3% (1/33) of respondents did not perform prophylactic PD stenting. All of the remainder (32 respondents) agreed on prophylactic PD stenting for the following indications: pancreatic sphincterotomy and ampullectomy. There was disagreement on other potential indications, including prior history of post-ERCP pancreatitis, traumatic biliary sphincterotomy, confirmed Sphincter of Oddi (SO) dysfunction, suspected SO dysfunction, minor papilla sphincterotomy, and pre-cut papillotomy. There were a variety of stent designs used, including straight (41%), single pigtail (25%), or a combination (31%), while 3% (1/33) used naso-pancreatic drains exclusively. Stents with (13%), or without internal flanges (62%), or a combination (25%), were used. There was wide variation in the length of time stents were left in place: 1 day (6%); 2-4 days (28%), 5-8 days (47%), 9-14 days (22%), and O14 days (13%). The use of radiographs to monitor stent position and the timing of endoscopic retrieval also varied widely. Conclusions: Most expert biliary endoscopists use prophylactic PD stenting during ERCP in high-risk patients. However, there is wide variation in indications and stenting technique, which indicates the need for further study to define optimal indications and technique.
AB188 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
T1192 Pancreatic Endoscopic-Percutaneous Rendezvous Through Jejunostomy for Treating Complex Pancreatic Postsurgical Fistula Rafel Campo, Joan Falco, Enric Brullet, Felix Junquera, Valentı´ Puig-Divı´, Mercedes Vergara, Mireia Miquel, Xavier Calvet Introduction: Management of complex pancreatic fistula can be challenging, especially in patients with gastrointestinal anatomy distorted by prior surgery. To our knowledge, this is the first time a combined endoscopic-percutaneous procedure has been used to treat pancreatic fistula. Case report: A 44-year-old male underwent subtotal esophagectomy and esophagogastric anastomosis for Boerhaave syndrome in 1994. Afterwards, he required surgical repair of a gastrocutaneous fistula on three occasions. Finally, in 2004 total gastrectomy, esophagostomy, and feeding jejunostomy were performed after a surgical attempt to repair a retroesternal gastrocutaneous fistula. A pancreato-cutaneous fistula appearing in the postoperative period did not respond to conservative management with octreotide and total parenteral nutrition. Due to the impossibility of standard ERCP, a radiological percutaneous puncture of the Wirsung duct in the pancreatic tail was performed in order to insert a drainage catheter to the duodenum. However, a Wirsung duct stenosis impeded this procedure, and it was only possible to position a guide-wire in the Wirsung duct and exit through the orifice of the cutaneous fistula. Therefore, a combined endoscopic-percutaneous procedure was performed. The jejunostomy was dilated with a 15-mm pneumatic balloon and a videogastroscope was introduced to the papilla. After cannulation of the Wirsung duct, it was only possible to place a guide-wire through the fistulous tract and exit through the cutaneous orifice, in parallel with the previously placed percutaneous guide-wire. The percutaneous guide-wire was replaced by a catheter and the endoscopic guide-wire was then introduced into the catheter until it exited through the tip of the catheter on the side of the percutaneous puncture. The catheter was withdrawn and the two extremes of the guide-wire were pulled so that it was aligned in the Wirsung duct. This made it possible to insert a 7 F plastic prosthesis through the pancreatic stenosis and resolved the fistula. Discussion: The interest of the present case is centered in three aspects not previously published: 1) The combined pancreatic endoscopic-percutaneous rendezvous to treat a pancreatic fistula, 2) the procedure to reach the papilla through a feeding jejunostomy, and 3) the technique of exchanging two guidewires that run in parallel through the cutaneous orifice of a pancreatic fistula.
T1193 Sphincter of Oddi Dysfunction in Patients with Post Cholecystectomy Syndrome (PCS) and Acute Recurrent Pancreatitis (ARP): Efficacy of Repeat SOM After Recurrence of Symptoms Marc F. Catalano, Urooj Ahmed, Shailendra S. Chauhan, Sandeep N. Patel, Joseph E. Geenen Sphincter of Oddi dysfunction is believed to be the paramount cause of PCS and idiopathic ARP. Manometry of the biliary and/or pancreatic sphincters can reliably establish the diagnosis. Endoscopic sphincterotomy (ES) to ablate the sphincter is the treatment choice and results in resolution of symptoms in the majority of patients. A subset of pts present with recurrent symptoms after initial treatment response. Aim: To determine the value of repeat SOM in pts with PCS and ARP caused by SOD with initial symptom resolution after ES. Methods: Over a 16-yr period, 2497 pts underwent SOM. 1873 pts presented with PCS, while 624 pts presented with ARP. Seventy-seven pts with prior abn SOM, treated by ES presented for repeat SOM following recurrence of symptoms at 8 months-4.2 years following initial treatment. This included 35 pts with PCS and 42 pts with ARP and are the subject of this study. SOM was performed in standard fashion using a perfusion manometry catheter with 3 ports. SO pressures R40 mmHg, high frequency contractions, high amplitude contractions, and/or paradoxical response to CCK was considered abnormal study. Results: Of the 35 pts with PCS presenting for repeat SOM, 13 (37%) had abn SOM, this included 10 with biliary SOD, 1 with PD SOD, and 2 pts with dual SOD. All pts underwent ES of appropriate sphincters. 11/13 pts had resolution of symptoms (87%). In the ARP group, of the 42 pts presenting for repeat SOM, 25 (60%) had abn SOM, this included 18 with PD SOD, 2 with CBD SOD, and 5 with dual SOD. Following ES in all pts, 17/25 pts (68%) had resolution of symptoms (F/U 6 month-6.5 yrs). Conclusions: Pts with PCS and ARP occasionally present with recurrent symptoms following initial treatment of SOD. Repeat SOM in these pts often reveals abn pressures of both the CBD and PD segments of the S.O. Incomplete prior manometric studies, sphincter stenosis, and/or insufficient sphincter ablation are believed to be the cause of recurrent symptoms. Repeat dual sphincter manometry is recommended in pts with PCS and ARP who present with recurrent symptoms. Sphincterotomy of intact sphincters or extension of prior sphincterotomy results in substantial clinical response in both groups.
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T1190 MRCP Frequently Misses Pancreas Divisum in Routine Practice Gregory Borak, David J. Bohler, Peter B. Cotton, Joseph Romagnuolo Background: Detection of pancreas divisum is important in patients with obscure pain and idiopathic pancreatitis, but there are risks to diagnostic ERCP. MRCP has recently become widely used in the investigation of patients with suspected pancreatic diseases, and MRCPs accuracy has been reported to be up to 100% accurate in detecting pancreas divisum (PDIV)(1). Our experience at a referral center anecdotally suggested otherwise, leading to this formal retrospective review. Aim: To assess the MRCP miss-rate of PDIV in patients with confirmed PDIV at ERCP. Methods: Using the GI Trac database, patients diagnosed with PDIV between January 2001 and October 2004 were identified. Using the radiology database and by performing a chart review, the patients who also had MRCP were identified and those reports were manually reviewed. Fisher exact p-values and binomial 95% confidence intervals (CIs) were calculated. Results: During the time frame, PDIV had been diagnosed by ERCP in 328 patients and 40 had undergone prior MRCP, 30 at outside centers. Secretin stimulation was used in 7 of the 10 MUSC cases, and none elsewhere (p ! 0.001). These results were tabulated:
The trend in the sensitivity difference in MRCP with and without secretin was not significant (fisher exact p Z 0.14). In 2 outside cases, our review of the MRCP films revealed PDIV, which had not been reported, and there was a trend towards MRCPs read at MUSC having higher sensitivity for PDIV. Conclusion: The data indicate that MRCP without secretin often missed pancreas divisum (at least 49% based on the 95% CI). There is some suggestion that the use of secretin facilitates the detection of pancreas divisum by MRCP. 1) Bret PM et al. Pancreas divisum: evaluation with MR cholangiopancreatography. Radiology 1996;199:99-103.
T1191 Prophylactic Pancreatic Duct Stents: Survey of Physician Practices Stephen Brackbill, Philip Schoenfeld, Scott Young, Grace Elta Background: Pancreatitis is the most common complication of ERCP. Several prospective studies and one meta-analysis confirm that prophylactic temporary stenting of the pancreatic duct (PD) during high-risk procedures decreases the risk of post-ERCP pancreatitis. However, there is no consensus on the indications or the techniques for stent placement, including: type of stent, methods of placement, and follow-up. The purpose of this study is to survey the practice methods of expert biliary endoscopists to identify areas of consensus and areas of disagreement. Methods: An anonymous survey on the use of prophylactic PD stents was sent by mail to 54 expert biliary endoscopists in the United States and Canada. The survey assessed volume of procedures, indications for prophylactic stent placement, type of stent, methods of placement, and follow-up. 61% (33/54) surveys were returned and analyzed. Results: 3% (1/33) of respondents did not perform prophylactic PD stenting. All of the remainder (32 respondents) agreed on prophylactic PD stenting for the following indications: pancreatic sphincterotomy and ampullectomy. There was disagreement on other potential indications, including prior history of post-ERCP pancreatitis, traumatic biliary sphincterotomy, confirmed Sphincter of Oddi (SO) dysfunction, suspected SO dysfunction, minor papilla sphincterotomy, and pre-cut papillotomy. There were a variety of stent designs used, including straight (41%), single pigtail (25%), or a combination (31%), while 3% (1/33) used naso-pancreatic drains exclusively. Stents with (13%), or without internal flanges (62%), or a combination (25%), were used. There was wide variation in the length of time stents were left in place: 1 day (6%); 2-4 days (28%), 5-8 days (47%), 9-14 days (22%), and O14 days (13%). The use of radiographs to monitor stent position and the timing of endoscopic retrieval also varied widely. Conclusions: Most expert biliary endoscopists use prophylactic PD stenting during ERCP in high-risk patients. However, there is wide variation in indications and stenting technique, which indicates the need for further study to define optimal indications and technique.
AB188 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
T1192 Pancreatic Endoscopic-Percutaneous Rendezvous Through Jejunostomy for Treating Complex Pancreatic Postsurgical Fistula Rafel Campo, Joan Falco, Enric Brullet, Felix Junquera, Valentı´ Puig-Divı´, Mercedes Vergara, Mireia Miquel, Xavier Calvet Introduction: Management of complex pancreatic fistula can be challenging, especially in patients with gastrointestinal anatomy distorted by prior surgery. To our knowledge, this is the first time a combined endoscopic-percutaneous procedure has been used to treat pancreatic fistula. Case report: A 44-year-old male underwent subtotal esophagectomy and esophagogastric anastomosis for Boerhaave syndrome in 1994. Afterwards, he required surgical repair of a gastrocutaneous fistula on three occasions. Finally, in 2004 total gastrectomy, esophagostomy, and feeding jejunostomy were performed after a surgical attempt to repair a retroesternal gastrocutaneous fistula. A pancreato-cutaneous fistula appearing in the postoperative period did not respond to conservative management with octreotide and total parenteral nutrition. Due to the impossibility of standard ERCP, a radiological percutaneous puncture of the Wirsung duct in the pancreatic tail was performed in order to insert a drainage catheter to the duodenum. However, a Wirsung duct stenosis impeded this procedure, and it was only possible to position a guide-wire in the Wirsung duct and exit through the orifice of the cutaneous fistula. Therefore, a combined endoscopic-percutaneous procedure was performed. The jejunostomy was dilated with a 15-mm pneumatic balloon and a videogastroscope was introduced to the papilla. After cannulation of the Wirsung duct, it was only possible to place a guide-wire through the fistulous tract and exit through the cutaneous orifice, in parallel with the previously placed percutaneous guide-wire. The percutaneous guide-wire was replaced by a catheter and the endoscopic guide-wire was then introduced into the catheter until it exited through the tip of the catheter on the side of the percutaneous puncture. The catheter was withdrawn and the two extremes of the guide-wire were pulled so that it was aligned in the Wirsung duct. This made it possible to insert a 7 F plastic prosthesis through the pancreatic stenosis and resolved the fistula. Discussion: The interest of the present case is centered in three aspects not previously published: 1) The combined pancreatic endoscopic-percutaneous rendezvous to treat a pancreatic fistula, 2) the procedure to reach the papilla through a feeding jejunostomy, and 3) the technique of exchanging two guidewires that run in parallel through the cutaneous orifice of a pancreatic fistula.
T1193 Sphincter of Oddi Dysfunction in Patients with Post Cholecystectomy Syndrome (PCS) and Acute Recurrent Pancreatitis (ARP): Efficacy of Repeat SOM After Recurrence of Symptoms Marc F. Catalano, Urooj Ahmed, Shailendra S. Chauhan, Sandeep N. Patel, Joseph E. Geenen Sphincter of Oddi dysfunction is believed to be the paramount cause of PCS and idiopathic ARP. Manometry of the biliary and/or pancreatic sphincters can reliably establish the diagnosis. Endoscopic sphincterotomy (ES) to ablate the sphincter is the treatment choice and results in resolution of symptoms in the majority of patients. A subset of pts present with recurrent symptoms after initial treatment response. Aim: To determine the value of repeat SOM in pts with PCS and ARP caused by SOD with initial symptom resolution after ES. Methods: Over a 16-yr period, 2497 pts underwent SOM. 1873 pts presented with PCS, while 624 pts presented with ARP. Seventy-seven pts with prior abn SOM, treated by ES presented for repeat SOM following recurrence of symptoms at 8 months-4.2 years following initial treatment. This included 35 pts with PCS and 42 pts with ARP and are the subject of this study. SOM was performed in standard fashion using a perfusion manometry catheter with 3 ports. SO pressures R40 mmHg, high frequency contractions, high amplitude contractions, and/or paradoxical response to CCK was considered abnormal study. Results: Of the 35 pts with PCS presenting for repeat SOM, 13 (37%) had abn SOM, this included 10 with biliary SOD, 1 with PD SOD, and 2 pts with dual SOD. All pts underwent ES of appropriate sphincters. 11/13 pts had resolution of symptoms (87%). In the ARP group, of the 42 pts presenting for repeat SOM, 25 (60%) had abn SOM, this included 18 with PD SOD, 2 with CBD SOD, and 5 with dual SOD. Following ES in all pts, 17/25 pts (68%) had resolution of symptoms (F/U 6 month-6.5 yrs). Conclusions: Pts with PCS and ARP occasionally present with recurrent symptoms following initial treatment of SOD. Repeat SOM in these pts often reveals abn pressures of both the CBD and PD segments of the S.O. Incomplete prior manometric studies, sphincter stenosis, and/or insufficient sphincter ablation are believed to be the cause of recurrent symptoms. Repeat dual sphincter manometry is recommended in pts with PCS and ARP who present with recurrent symptoms. Sphincterotomy of intact sphincters or extension of prior sphincterotomy results in substantial clinical response in both groups.
www.mosby.com/gie