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Su1424 Long Term Outcomes Associated With Extracorporeal Shock Wave Lithotripsy for Chronic Calcific Pancreatitis
Abstracts
Su1422 Usefulness of Endoscopic Biopsy Using FOXP3ⴙTreg Upregulation in the Major Duodenal Papilla for Differential Diagnosis Between Autoimmune Pancreatitis and Pancreatic Cancer Kensuke Kubota, Akito Oshima, Shingo Kato, Seitaro Watanabe, Takeshi Shimamura, Noritoshi Kobayashi, Atsushi Nakajima Gastroenterology, Yokohama City University graduate school of medicine, Yokohama, Japan
Su1424 Long Term Outcomes Associated With Extracorporeal Shock Wave Lithotripsy for Chronic Calcific Pancreatitis Mitchal Schreiner, Otto S. Lin, Michael Gluck, S. Ian Gan, Shayan Irani, Andrew S. Ross, John Brandabur, David Patterson, Christian Kuhr, Richard A. Kozarek Virginia Mason Medical Center, Seattle, WA
Background: Appearance of regulatory T cells (Treg) showing expression of FOXP3, a member of the forkhead/winged helix family of transcription factors and a master gene of Treg (FOXP3⫹Treg) in the duodenal papilla has been reported in patients with autoimmune pancreatitis (AIP). Aim: To investigate the usefulness of detection of FOXP3⫹Treg in the main duodenal papilla in the differential diagnosis between AIP and pancreatic cancer (Pca). Methods: First, we determined the cutoff value of FOXP3 expression in biopsies of the duodenal papilla obtained from patients with AIP (n⫽22) and chronic pancreatitis (n⫽21). Then, the data of 32 patients with AIP and 30 patients with Pca who had undergone endoscopic biopsy were studied. The numbers of FOXP3⫹ Treg and IgG4⫹ plasma cells per high-power field (HPF) were counted in all the histopathological specimens Results: The areas under the receiver-operating characteristic (AUROC) curves for FOXP3 and IgG4 expression were 0.934 and 0.953, respectively. The cutoff values calculated based on the AUROC data were 14cells/HPF for FOXP3 and 10cells/HPF for IgG4, respectively. Seropositivity for IgG4 was observed in 22 out of the 31 patients with AIP (sensitivity, 71.0%; specificity, 84.6%; accuracy, 75.0%). Significant infiltration of the major duodenal papilla by FOXP3⫹ lymphocytes (ⱖ14/HPF) was recognized in 18 of the 32 patients with AIP (sensitivity, 56.3%; specificity, 100%; accuracy, 77.4%). Significant infiltration of the major duodenal papilla by IgG4⫹ plasma cells (ⱖ10/HPF) was recognized in 27 of the 32 patients with AIP (sensitivity, 84.4%; specificity, 80.0%; accuracy, 82.3%). The observation of FOXP3 upregulation in the main duodenal papilla showed a reasonable degree of sensitivity, higher specificity and equuivalent accuracy to IgG4 upregulation in the main duodenal papilla for differential diagnosis between AIP and Pca. Conclusions: Observation of FOXP3⫹ cells in the main duodenal papilla may be useful in the differential diagnosis between AIP and Pca.
Su1423 Effective “Short” DBE for Diagnostic and Therapeutic ERCP in Patients With Altered Gastrointestinal Anatomy Masaaki Shimatani, Makoto Takaoka, Mitsunobu Matsushita, Tsukasa Ikeura, Hideaki Miyoshi, Kazuichi Okazaki Department of gastroenterology, kansai Medical University, Hirakata, Japan Background: ERCP is technically challenging in patients with altered gastrointestinal anatomy. A recently introduced double balloon enteroscope permits the examination of a much longer segment of the small bowel compared with a conventional endoscope, and may be used to perform ERCP in these patients. Objective: Because diagnostic and therapeutic interventions for the pancreato-billiary system in previously operated patients by conventional endoscopes are difficult, we described our experience of ERCP with a short double balloon enteroscope (S-DBE; EC-450BI5, FTS, Osaka, Japan) in these patients. Because S-DBE has a 2.8mm working channel and working length of 152 cm, all conventional ERCP devices are available. Patients and Methods: Between February 2006 and November 2010, we performed ERCP with the use of s-DBE in 157 patients with various anatomic variations (260 procedures; 140 procedures for Roux-en-Y total gastorectomy, 53 procedures for Billroth II gastorectomy, 55 procedures for pancreatoduoderectomy, 12 procedures for others), and evaluated the technique. Result: Deep insertion of the s-DBE to the ductal anastomosis or papilla was successful in 252 of 260 procedures (96.9%). Cannulation of the bile duct was successful in 245 of 252 procedures (97.2%). Therapeutic intervention was achieved in all of the 245 procedures of successful biliary cannulation (100%). Endoscopic interventions included stones extraction (115 procedures), placement of a nasobilialy drainage tube (102 procedures), placement of biliary stents (97 procedures; 71 plastic and 26 metallic stents), balloon dilatation of choledochojejunostomy (70 procedures), sphincterotomy (70 procedures), biopsy (34 procedures), balloon dilatation of pancreatojejunostomy (5 procedures), placement of a nasopancreatic drainage tube (5 procedure), and placement of a pancreatic stent (3 procedures). Conclusions: ERCP by s-DBE is highly effective in patients with altered gastrointestinal anatomy.
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Background: Extracorporeal shock wave lithotripsy (ESWL) is a well-established therapy for patients with chronic calcific pancreatitis, however data on long term follow-up for these patients is lacking. Methods: Outcomes questionnaires were mailed to all currently living patients who have undergone ESWL for chronic calcific pancreatitis at our institution between 1990 and present. Questionnaires included before and after numerical pain and quality of life scales, as well as questions on smoking, alcohol use, diabetes, and use of pain medications and pancreatic enzymes. A retrospective chart review was also performed on all patients who returned a completed questionnaire. Results: A total of 217 patients underwent ESWL for chronic calcific pancreatitis, and 178 (82%) are still living. Of the 178 questionnaires that were mailed out, 55 (30.9%) have been completed and returned, 22 were returned as non-deliverable, and 101 remain unreturned at this point. Only data on the 55 patients who returned a completed questionnaire were analyzed, and the mean follow-up period for these patients was 4 years. All patients underwent ERCP following ESWL for clearance of pancreatic duct stone debris.76.4% patients reported smoking prior to undergoing ESWL and 38.2% continue to smoke. 27.3% reported drinking at least one alcohol drink each day prior to undergoing ESWL and 9.1% continue to drink at least one alcohol drink each day.46 out of 55 (83.6%) patients reported an improvement in their pancreas pain following ESWL (p⬍0.001), and 42 out of 55 (76.4%) reported an improvement in their quality of life with regard to their pancreas (p⬍0.001). Of the 38 patients who were taking narcotic pain medications prior to undergoing ESWL, 25 (65.8%) had a decrease in their narcotic pain medication requirement following ESWL (p⬍0.001). There was not a significant improvement in pancreatic enzyme replacement requirement or status of diabetes in patients following ESWL.Following their initial ESWL and ERCP, 29.1% of patients required repeat ESWL (range 1-3), 76.1% required repeat ERCP (range 1-10), and 10.9% ultimately required pancreas surgery. Looking only at post-ESWL followup data of ⬎4 years, 23.1% of those patients ultimately required pancreas surgery. In post-pancreas surgery patients, 0% required repeat ESWL, 50% required repeat ERCP (range 1-6), and 16.7% required repeat pancreas surgery. Conclusion: ESWL of the pancreas for chronic calcific pancreatitis results in significant improvement in pancreas pain and quality of life related to the pancreas. Although a portion of patients with chronic calcific pancreatitis will ultimately require pancreas surgery, due to the positive outcomes and avoidance of surgery in the majority of patients, ESWL should be considered the preferred first line therapy.
Su1425 Efficacy of Endotherapy in Chronic Pancreatitis Pain: A Systemic Review and Meta-Analysis Mikram Jafri, Javed N. Sadiq, Pallav K. Parakh, Frank G. Gress, David S. Lee Gastroenterology, SUNY Downstate Medical Center, Brooklyn, NY Background: Endotherapy is important in the management of chronic pancreatitis pain. However, its use is controversial due to limited available data. The aim of this study was to assess the efficacy of endotherapy for alleviating pain in patients with chronic pancreatitis through a systemic review and meta-analysis. Methods: A search of Medline, Pubmed, and Embase databases between 1988 to August 2010 for studies that analyzed the use of endotherapy for pain relief in chronic pancreatitis. We included large prospective blinded studies, randomized controlled trials (RCT) and retrospective analyses. Exclusion criteria included: studies not in English or those with less than 10 patients, case series/reports and the studies that enrolled patients in alternate therapies such as surgery or celiac plexus neurolysis. In addition, a subgroup analysis was conducted on studies that included only patients with pancreatic duct strictures. A model of meta-analysis was developed and the data on pain relief was subsequently extracted, pooled, and analyzed. The Chi-square tests of homogeneity of estimate across studies showed significant heterogeneity (p⬍0.001 for both immediate and late response). The results were calculated and based on logits with inverse-variance weights and back-transformed normaltheory confidence intervals. Results: Our final analysis included sixteen studies; comprising 1498 patients. Eleven studies included data for immediate relief of pain after endotherapy while twelve studies had data available for both immediate and sustained pain relief on follow-up. The compiled result of the sixteen studies for immediate pain relief is 75.7% (95% NT CI[67.0%, 82.7%]). Similarly, on long term follow up the result is 76.1% (95% NT CI[67.2%, 83.1%]). The data is displayed in the form of forest plots (Table 1 and 2). In the subgroup analysis, we included nine studies, comprising 536 patients. Seven studies included data for immediate pain relief and eight studies had data available for sustained pain relief on follow up. The compiled results for the immediate pain relief is 74.7 %( 95 NT CI [62.4%, 84.0%] while the results for sustained pain
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB261
Su1422 Usefulness of Endoscopic Biopsy Using FOXP3ⴙTreg Upregulation in the Major Duodenal Papilla for Differential Diagnosis Between Autoimmune Pancreatitis and Pancreatic Cancer Kensuke Kubota, Akito Oshima, Shingo Kato, Seitaro Watanabe, Takeshi Shimamura, Noritoshi Kobayashi, Atsushi Nakajima Gastroenterology, Yokohama City University graduate school of medicine, Yokohama, Japan
Su1424 Long Term Outcomes Associated With Extracorporeal Shock Wave Lithotripsy for Chronic Calcific Pancreatitis Mitchal Schreiner, Otto S. Lin, Michael Gluck, S. Ian Gan, Shayan Irani, Andrew S. Ross, John Brandabur, David Patterson, Christian Kuhr, Richard A. Kozarek Virginia Mason Medical Center, Seattle, WA
Background: Appearance of regulatory T cells (Treg) showing expression of FOXP3, a member of the forkhead/winged helix family of transcription factors and a master gene of Treg (FOXP3⫹Treg) in the duodenal papilla has been reported in patients with autoimmune pancreatitis (AIP). Aim: To investigate the usefulness of detection of FOXP3⫹Treg in the main duodenal papilla in the differential diagnosis between AIP and pancreatic cancer (Pca). Methods: First, we determined the cutoff value of FOXP3 expression in biopsies of the duodenal papilla obtained from patients with AIP (n⫽22) and chronic pancreatitis (n⫽21). Then, the data of 32 patients with AIP and 30 patients with Pca who had undergone endoscopic biopsy were studied. The numbers of FOXP3⫹ Treg and IgG4⫹ plasma cells per high-power field (HPF) were counted in all the histopathological specimens Results: The areas under the receiver-operating characteristic (AUROC) curves for FOXP3 and IgG4 expression were 0.934 and 0.953, respectively. The cutoff values calculated based on the AUROC data were 14cells/HPF for FOXP3 and 10cells/HPF for IgG4, respectively. Seropositivity for IgG4 was observed in 22 out of the 31 patients with AIP (sensitivity, 71.0%; specificity, 84.6%; accuracy, 75.0%). Significant infiltration of the major duodenal papilla by FOXP3⫹ lymphocytes (ⱖ14/HPF) was recognized in 18 of the 32 patients with AIP (sensitivity, 56.3%; specificity, 100%; accuracy, 77.4%). Significant infiltration of the major duodenal papilla by IgG4⫹ plasma cells (ⱖ10/HPF) was recognized in 27 of the 32 patients with AIP (sensitivity, 84.4%; specificity, 80.0%; accuracy, 82.3%). The observation of FOXP3 upregulation in the main duodenal papilla showed a reasonable degree of sensitivity, higher specificity and equuivalent accuracy to IgG4 upregulation in the main duodenal papilla for differential diagnosis between AIP and Pca. Conclusions: Observation of FOXP3⫹ cells in the main duodenal papilla may be useful in the differential diagnosis between AIP and Pca.
Su1423 Effective “Short” DBE for Diagnostic and Therapeutic ERCP in Patients With Altered Gastrointestinal Anatomy Masaaki Shimatani, Makoto Takaoka, Mitsunobu Matsushita, Tsukasa Ikeura, Hideaki Miyoshi, Kazuichi Okazaki Department of gastroenterology, kansai Medical University, Hirakata, Japan Background: ERCP is technically challenging in patients with altered gastrointestinal anatomy. A recently introduced double balloon enteroscope permits the examination of a much longer segment of the small bowel compared with a conventional endoscope, and may be used to perform ERCP in these patients. Objective: Because diagnostic and therapeutic interventions for the pancreato-billiary system in previously operated patients by conventional endoscopes are difficult, we described our experience of ERCP with a short double balloon enteroscope (S-DBE; EC-450BI5, FTS, Osaka, Japan) in these patients. Because S-DBE has a 2.8mm working channel and working length of 152 cm, all conventional ERCP devices are available. Patients and Methods: Between February 2006 and November 2010, we performed ERCP with the use of s-DBE in 157 patients with various anatomic variations (260 procedures; 140 procedures for Roux-en-Y total gastorectomy, 53 procedures for Billroth II gastorectomy, 55 procedures for pancreatoduoderectomy, 12 procedures for others), and evaluated the technique. Result: Deep insertion of the s-DBE to the ductal anastomosis or papilla was successful in 252 of 260 procedures (96.9%). Cannulation of the bile duct was successful in 245 of 252 procedures (97.2%). Therapeutic intervention was achieved in all of the 245 procedures of successful biliary cannulation (100%). Endoscopic interventions included stones extraction (115 procedures), placement of a nasobilialy drainage tube (102 procedures), placement of biliary stents (97 procedures; 71 plastic and 26 metallic stents), balloon dilatation of choledochojejunostomy (70 procedures), sphincterotomy (70 procedures), biopsy (34 procedures), balloon dilatation of pancreatojejunostomy (5 procedures), placement of a nasopancreatic drainage tube (5 procedure), and placement of a pancreatic stent (3 procedures). Conclusions: ERCP by s-DBE is highly effective in patients with altered gastrointestinal anatomy.
www.giejournal.org
Background: Extracorporeal shock wave lithotripsy (ESWL) is a well-established therapy for patients with chronic calcific pancreatitis, however data on long term follow-up for these patients is lacking. Methods: Outcomes questionnaires were mailed to all currently living patients who have undergone ESWL for chronic calcific pancreatitis at our institution between 1990 and present. Questionnaires included before and after numerical pain and quality of life scales, as well as questions on smoking, alcohol use, diabetes, and use of pain medications and pancreatic enzymes. A retrospective chart review was also performed on all patients who returned a completed questionnaire. Results: A total of 217 patients underwent ESWL for chronic calcific pancreatitis, and 178 (82%) are still living. Of the 178 questionnaires that were mailed out, 55 (30.9%) have been completed and returned, 22 were returned as non-deliverable, and 101 remain unreturned at this point. Only data on the 55 patients who returned a completed questionnaire were analyzed, and the mean follow-up period for these patients was 4 years. All patients underwent ERCP following ESWL for clearance of pancreatic duct stone debris.76.4% patients reported smoking prior to undergoing ESWL and 38.2% continue to smoke. 27.3% reported drinking at least one alcohol drink each day prior to undergoing ESWL and 9.1% continue to drink at least one alcohol drink each day.46 out of 55 (83.6%) patients reported an improvement in their pancreas pain following ESWL (p⬍0.001), and 42 out of 55 (76.4%) reported an improvement in their quality of life with regard to their pancreas (p⬍0.001). Of the 38 patients who were taking narcotic pain medications prior to undergoing ESWL, 25 (65.8%) had a decrease in their narcotic pain medication requirement following ESWL (p⬍0.001). There was not a significant improvement in pancreatic enzyme replacement requirement or status of diabetes in patients following ESWL.Following their initial ESWL and ERCP, 29.1% of patients required repeat ESWL (range 1-3), 76.1% required repeat ERCP (range 1-10), and 10.9% ultimately required pancreas surgery. Looking only at post-ESWL followup data of ⬎4 years, 23.1% of those patients ultimately required pancreas surgery. In post-pancreas surgery patients, 0% required repeat ESWL, 50% required repeat ERCP (range 1-6), and 16.7% required repeat pancreas surgery. Conclusion: ESWL of the pancreas for chronic calcific pancreatitis results in significant improvement in pancreas pain and quality of life related to the pancreas. Although a portion of patients with chronic calcific pancreatitis will ultimately require pancreas surgery, due to the positive outcomes and avoidance of surgery in the majority of patients, ESWL should be considered the preferred first line therapy.
Su1425 Efficacy of Endotherapy in Chronic Pancreatitis Pain: A Systemic Review and Meta-Analysis Mikram Jafri, Javed N. Sadiq, Pallav K. Parakh, Frank G. Gress, David S. Lee Gastroenterology, SUNY Downstate Medical Center, Brooklyn, NY Background: Endotherapy is important in the management of chronic pancreatitis pain. However, its use is controversial due to limited available data. The aim of this study was to assess the efficacy of endotherapy for alleviating pain in patients with chronic pancreatitis through a systemic review and meta-analysis. Methods: A search of Medline, Pubmed, and Embase databases between 1988 to August 2010 for studies that analyzed the use of endotherapy for pain relief in chronic pancreatitis. We included large prospective blinded studies, randomized controlled trials (RCT) and retrospective analyses. Exclusion criteria included: studies not in English or those with less than 10 patients, case series/reports and the studies that enrolled patients in alternate therapies such as surgery or celiac plexus neurolysis. In addition, a subgroup analysis was conducted on studies that included only patients with pancreatic duct strictures. A model of meta-analysis was developed and the data on pain relief was subsequently extracted, pooled, and analyzed. The Chi-square tests of homogeneity of estimate across studies showed significant heterogeneity (p⬍0.001 for both immediate and late response). The results were calculated and based on logits with inverse-variance weights and back-transformed normaltheory confidence intervals. Results: Our final analysis included sixteen studies; comprising 1498 patients. Eleven studies included data for immediate relief of pain after endotherapy while twelve studies had data available for both immediate and sustained pain relief on follow-up. The compiled result of the sixteen studies for immediate pain relief is 75.7% (95% NT CI[67.0%, 82.7%]). Similarly, on long term follow up the result is 76.1% (95% NT CI[67.2%, 83.1%]). The data is displayed in the form of forest plots (Table 1 and 2). In the subgroup analysis, we included nine studies, comprising 536 patients. Seven studies included data for immediate pain relief and eight studies had data available for sustained pain relief on follow up. The compiled results for the immediate pain relief is 74.7 %( 95 NT CI [62.4%, 84.0%] while the results for sustained pain
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB261