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Su1713 Endoscopic Therapy in Chronic Pancreatitis: What Are the Factors Associated With Successful Response ?
Abstracts
Su1713 Endoscopic Therapy in Chronic Pancreatitis: What Are the Factors Associated With Successful Response ? Monica Gaidhane*, Daniela GonzáLez-ÁVila, Barbara M. Figueroa E, Carlos M. Rondon Clavo, Reem Z. Sharaiha, Michel Kahaleh Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY Introduction: Chronic pancreatitis is a progressive and painful disease, caused by stricture formation, stone disease or pseudocyst formation. ERCP has been shown to be effective and safe for the treatment of chronic pancreatitis and permits sphincterotomy, stone extraction, ESWL, dilation, and stent placement. Technical success is about 85% and clinical success ranges from 70-90%, with relief of pain in 66% of cases. There is scarce published data on predictor factors of symptoms improvement in chronic pancreatitis patients who receive endoscopic therapy. Methods: 772 subjects underwent pancreatic duct stenting at a tertiary care center from 2004 to 2012. Variables collected include ERCP procedure details, etiology, demographics, comorbidities and stent type and size. Logistic regression was conducted to evaluate for predictors. Results: 265 patients (158 males) underwent PD stent placement for chronic pancreatitis from 2004 to 2012. Mean age was 52 years (Range 5 - 99). Mean number of procedures done was 4.7 (range 1-20). 116 patients had alcoholic pancreatitis (44%), 103 had non alcohol related pancreatic duct strictures (39%), 18 had pancreas divisum (7%), 28 had pancreatic pseudocyst (11%), 19 had Pancreatic duct stones (7%) and 8 had pancreatic duct leak (3%). Pancreatic sphincterotomy was done all patients and all stone patients received ESWL. A total of 82 patients received plastic stents sized larger than 7 French (31%). Improvement in symptoms was achieved in 239 patients (90%). Logistic regression was conducted to evaluate predictive factors for symptom improvement. After adjusting for gender, age, number of procedures, and alcoholic pancreatitis; presence of pancreatic duct stricture with upstream dilation [OR 2.9 (1.05-8.4)] and large stent size (larger than 7 Fr) [OR 3.66 (1.02-13.2)] were associated with improved outcome (as manifested by pain control and improvement in symptoms). Conclusion: Patients with pancreatic stricture and who received larger diameter PD stent placement were more likely to have improvement in symptoms after ERCP. Outcome-based prospective studies are needed to further evaluate predictive factors for therapeutic ERCP in chronic pancreatitis patients.
Su1714 A Normal Pancreatogram At Index ERCP Is Associated With Late Minor Papillary Stenosis After Endoscopic Minor Papillotomy in the Setting of Pancreas Divisum Jeffrey J. Easler*, Vladimir M. Kushnir, Daniel Mullady, Dayna S. Early, Steven a. Edmundowicz, Faris Murad Division of Gastroenterology and Hepatology, Washinton University School of Medicine, St. Louis, MO, MO Background: Pancreas divisum (PDv) is an anatomic variant found in 5-10% of the population and associated with idiopathic recurrent acute (RAP) and chronic pancreatitis (CP). Endoscopic minor papillotomy (EMP) has long term efficacy in small prospective trials, particularly in patients with RAP. Stenosis of the minor papilla/dorsal pancreatic duct near the minor papilla (MPS) is a late complication of EMP reported in 11-20% of patients. MPS is often managed by repeat EMP, though efficacy of repeat intervention remains uncertain. To our knowledge no literature exists regarding possible risks of MPS as it relates to initial presentation for index ERCP with EMP. Aims:1) Describe incidence of MPS in the setting of PDv. 2) Identify clinical, diagnostic and therapeutic risk factors prior to and accrued during index intervention for PDv that predict MPS. Methods: Consecutive patients with PDv underwent ERCP between 9/2003 and 7/2013 . Patients with complete PDv managed with therapeutic ERCP of the dorsal pancreatic duct (DPD) were included. Exclusion criteria: failure to access DPD, lack of records, incomplete divisum, and pancreatic malignancy. Records were retrospectively reviewed for clinical data, ERCP findings and outcomes. Pancreatogram findings were categorized by Cambridge Classification*. Late repeat ERCP (lrERCP) was defined as a return for intervention(s) O6 months from index ERCP series. MPS was defined by the endoscopist at lrERCP. Logistic regression was used to evaluate relationships between categorized index ERCP data and MPS. Results:100 consecutive patients (Median Age 49, Female 65%) presented for ERCP for PDv (RAP 59%). MES was performed at index ERCP in 99% of patients with DPD Stent (96%). 55% of patients had Cambridge Classification for a normal index pancreaticogram (Table 1). Post-ERCP pancreatitis (PEP) occurred in 18% of patients. 62% had clinical and/or imaging follow up after index ERCP series in our system O6 months (median 1.2 yrs). Twenty seven % of patients returned for lrERCP (34 months, median) most often for RAP (44%). MPS was identified in 59% and managed with repeat EMP (75%). These patients most often presented with RAP and pain (93.8%). On univariate regression analysis, the absence of Cambridge class DPD changes at index ERCP was associated with development of MPS. (Table 2) Multivariate analysis model including age, sex, failed 1st ERCP, PEP, EMP O5mm and Cambridge classification demonstrated a significant association between a normal index pancreatogram and late MPS (OR 15.2, pZ.05). Discussion: We report 60% incidence of MPS at lrERCP. An association between a normal index pancreatogram and late MPS after EMP was identified. MPS did not correlate with technical aspects
AB270 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014
of or immediate complications after index EMP. MPS represents a frequent finding on lrERCP in patients with recurrent symptoms in setting of PDv. Table 1. Patient Characteristics and Index ERCP in Patients with
Symptomatic Pancreas Divisum
Characteristic Age, Median Gender, Female Race, Caucasion Prior CCY Inititial Indication RAP, Only CP, Any Pain, Only Index ERCP Findings Moderate-Severe, Cambridge* Normal Duct, Cambridge* Index ERCP Procedures Median Size of ES (mm) Median Max Size of DPD Stent, Fr Median # ERCPs, Initial Course Index ERCP Complications Failed 1st Cannulation PEP
Cohort (n[100) ————————— n (%) 49 65 (65) 93 (93) 56 (56)
Late repeat ERCP (lrERCP) (n[27) —————————— n (%) 49 24 (89) 27 (100) 16 (59)
59 (59) 12 (12) 29 (29) 41 (41) 40 (40) 55 (55)
551
12 (12) 18 (18)
Papillary Stenosis (n[16) ———————— n (%) 51 16 (100) 16 (100) 8 (50)
12 (44) 6 (22) 7 (30) 8 (30)
10 (63) 2 (13) 4 (25) 4 (25)
8 (18) 18 (67)
551
2 (13) 14 (88)
551
4 (15) 5 (19)
1 (6) 4 (25)
*Cambridge Classification of Pancreatic Duct Abnormalities: Normal Z normal main pancreatic duct, no abnormal side branches or additional features of CP. Moderate-SevereZ abnormal main pancreatic duct with O orZ 3 abnormal side branches +/- large cavity, obstruction, filling defects, or severe dilation/irregularity. Axon et al. Gut, 1984, 25, 1107-1112
Table 2. Univariate Analysis of Demographics, Indication and Index
ERCP Findings for Association with Late Papillary Stenosis at lrERCP in Pancreas Divisum n[27 Variable Gender, Male Age O50 Initial Indication RAP Only Pain Only CP Any Tobacco Use Index ERCP Findings Normal Pancreatogram * Pancreatic Duct Dilation, Any Index ERCP Complications Failed Cannulation Any Complications PEP Index ERCP Interventions ES O5mm Maximum Stent, O5 Fr Multiple ERCPs
OR (p-Value) 0 (0.99) 1.78 (0.49) 2.64 (0.23) 1.21 (0.82) 0.25 (0.16) 0.55 (0.49) 12.3 (0.01) 0.4 (0.27) 0.18 (0.16) 2.1 (0.45) 3.33 (0.31) 0.3 (0.16) 1.03 (0.97) 0.5 (0.42)
Su1715 Trends in the Use of ERCP for the Management of Chronic Pancreatitis: a Population-Based Study Using the Nationwide Inpatient Sample Clancy J. Clark*1, Norman Clark2, Shuja Ahmed1, Girish Mishra2, Rishi Pawa2 1 General Surgery, Wake Forest Baptist Health, Winston Salem, NC; 2 Gastroenterology, Wake Forest Baptist Health, Winston Salem, NC Introduction: Historically, Endoscopic Retrograde Cholangiopancreatography (ERCP) was the primary tool for diagnostic and therapeutic management of chronic pancreatitis. With increased availability of magnetic resonance imaging (MRI) and endoscopic ultrasound (EUS), indications for ERCP are being redefined. The aim of this study was to characterize current trends in the use of ERCP in the United States for patients hospitalized with chronic pancreatitis. Methods: We performed a retrospective cohort study using the Nationwide Inpatient Sample from 1998-2010. We identified patients with a primary discharge diagnosis of chronic pancreatitis who underwent ERCP. We excluded patients with a diagnosis of a biliary, gallbladder, or pancreatic neoplasm and patients who underwent biliary, gallbladder, or pancreatic resection during the same admission. We analyzed patient and hospital characteristics, length of stay, and in-hospital mortality and adjusted for weighted sample schema. Results: During the study period, 13,182 patients with chronic pancreatitis (mean age 52, 54.4% female) underwent ERCP during their hospitalization. The majority of patients were white (69.3%). The majority of procedures were performed at large (68.8%), urban (94.1%),
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Su1713 Endoscopic Therapy in Chronic Pancreatitis: What Are the Factors Associated With Successful Response ? Monica Gaidhane*, Daniela GonzáLez-ÁVila, Barbara M. Figueroa E, Carlos M. Rondon Clavo, Reem Z. Sharaiha, Michel Kahaleh Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY Introduction: Chronic pancreatitis is a progressive and painful disease, caused by stricture formation, stone disease or pseudocyst formation. ERCP has been shown to be effective and safe for the treatment of chronic pancreatitis and permits sphincterotomy, stone extraction, ESWL, dilation, and stent placement. Technical success is about 85% and clinical success ranges from 70-90%, with relief of pain in 66% of cases. There is scarce published data on predictor factors of symptoms improvement in chronic pancreatitis patients who receive endoscopic therapy. Methods: 772 subjects underwent pancreatic duct stenting at a tertiary care center from 2004 to 2012. Variables collected include ERCP procedure details, etiology, demographics, comorbidities and stent type and size. Logistic regression was conducted to evaluate for predictors. Results: 265 patients (158 males) underwent PD stent placement for chronic pancreatitis from 2004 to 2012. Mean age was 52 years (Range 5 - 99). Mean number of procedures done was 4.7 (range 1-20). 116 patients had alcoholic pancreatitis (44%), 103 had non alcohol related pancreatic duct strictures (39%), 18 had pancreas divisum (7%), 28 had pancreatic pseudocyst (11%), 19 had Pancreatic duct stones (7%) and 8 had pancreatic duct leak (3%). Pancreatic sphincterotomy was done all patients and all stone patients received ESWL. A total of 82 patients received plastic stents sized larger than 7 French (31%). Improvement in symptoms was achieved in 239 patients (90%). Logistic regression was conducted to evaluate predictive factors for symptom improvement. After adjusting for gender, age, number of procedures, and alcoholic pancreatitis; presence of pancreatic duct stricture with upstream dilation [OR 2.9 (1.05-8.4)] and large stent size (larger than 7 Fr) [OR 3.66 (1.02-13.2)] were associated with improved outcome (as manifested by pain control and improvement in symptoms). Conclusion: Patients with pancreatic stricture and who received larger diameter PD stent placement were more likely to have improvement in symptoms after ERCP. Outcome-based prospective studies are needed to further evaluate predictive factors for therapeutic ERCP in chronic pancreatitis patients.
Su1714 A Normal Pancreatogram At Index ERCP Is Associated With Late Minor Papillary Stenosis After Endoscopic Minor Papillotomy in the Setting of Pancreas Divisum Jeffrey J. Easler*, Vladimir M. Kushnir, Daniel Mullady, Dayna S. Early, Steven a. Edmundowicz, Faris Murad Division of Gastroenterology and Hepatology, Washinton University School of Medicine, St. Louis, MO, MO Background: Pancreas divisum (PDv) is an anatomic variant found in 5-10% of the population and associated with idiopathic recurrent acute (RAP) and chronic pancreatitis (CP). Endoscopic minor papillotomy (EMP) has long term efficacy in small prospective trials, particularly in patients with RAP. Stenosis of the minor papilla/dorsal pancreatic duct near the minor papilla (MPS) is a late complication of EMP reported in 11-20% of patients. MPS is often managed by repeat EMP, though efficacy of repeat intervention remains uncertain. To our knowledge no literature exists regarding possible risks of MPS as it relates to initial presentation for index ERCP with EMP. Aims:1) Describe incidence of MPS in the setting of PDv. 2) Identify clinical, diagnostic and therapeutic risk factors prior to and accrued during index intervention for PDv that predict MPS. Methods: Consecutive patients with PDv underwent ERCP between 9/2003 and 7/2013 . Patients with complete PDv managed with therapeutic ERCP of the dorsal pancreatic duct (DPD) were included. Exclusion criteria: failure to access DPD, lack of records, incomplete divisum, and pancreatic malignancy. Records were retrospectively reviewed for clinical data, ERCP findings and outcomes. Pancreatogram findings were categorized by Cambridge Classification*. Late repeat ERCP (lrERCP) was defined as a return for intervention(s) O6 months from index ERCP series. MPS was defined by the endoscopist at lrERCP. Logistic regression was used to evaluate relationships between categorized index ERCP data and MPS. Results:100 consecutive patients (Median Age 49, Female 65%) presented for ERCP for PDv (RAP 59%). MES was performed at index ERCP in 99% of patients with DPD Stent (96%). 55% of patients had Cambridge Classification for a normal index pancreaticogram (Table 1). Post-ERCP pancreatitis (PEP) occurred in 18% of patients. 62% had clinical and/or imaging follow up after index ERCP series in our system O6 months (median 1.2 yrs). Twenty seven % of patients returned for lrERCP (34 months, median) most often for RAP (44%). MPS was identified in 59% and managed with repeat EMP (75%). These patients most often presented with RAP and pain (93.8%). On univariate regression analysis, the absence of Cambridge class DPD changes at index ERCP was associated with development of MPS. (Table 2) Multivariate analysis model including age, sex, failed 1st ERCP, PEP, EMP O5mm and Cambridge classification demonstrated a significant association between a normal index pancreatogram and late MPS (OR 15.2, pZ.05). Discussion: We report 60% incidence of MPS at lrERCP. An association between a normal index pancreatogram and late MPS after EMP was identified. MPS did not correlate with technical aspects
AB270 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014
of or immediate complications after index EMP. MPS represents a frequent finding on lrERCP in patients with recurrent symptoms in setting of PDv. Table 1. Patient Characteristics and Index ERCP in Patients with
Symptomatic Pancreas Divisum
Characteristic Age, Median Gender, Female Race, Caucasion Prior CCY Inititial Indication RAP, Only CP, Any Pain, Only Index ERCP Findings Moderate-Severe, Cambridge* Normal Duct, Cambridge* Index ERCP Procedures Median Size of ES (mm) Median Max Size of DPD Stent, Fr Median # ERCPs, Initial Course Index ERCP Complications Failed 1st Cannulation PEP
Cohort (n[100) ————————— n (%) 49 65 (65) 93 (93) 56 (56)
Late repeat ERCP (lrERCP) (n[27) —————————— n (%) 49 24 (89) 27 (100) 16 (59)
59 (59) 12 (12) 29 (29) 41 (41) 40 (40) 55 (55)
551
12 (12) 18 (18)
Papillary Stenosis (n[16) ———————— n (%) 51 16 (100) 16 (100) 8 (50)
12 (44) 6 (22) 7 (30) 8 (30)
10 (63) 2 (13) 4 (25) 4 (25)
8 (18) 18 (67)
551
2 (13) 14 (88)
551
4 (15) 5 (19)
1 (6) 4 (25)
*Cambridge Classification of Pancreatic Duct Abnormalities: Normal Z normal main pancreatic duct, no abnormal side branches or additional features of CP. Moderate-SevereZ abnormal main pancreatic duct with O orZ 3 abnormal side branches +/- large cavity, obstruction, filling defects, or severe dilation/irregularity. Axon et al. Gut, 1984, 25, 1107-1112
Table 2. Univariate Analysis of Demographics, Indication and Index
ERCP Findings for Association with Late Papillary Stenosis at lrERCP in Pancreas Divisum n[27 Variable Gender, Male Age O50 Initial Indication RAP Only Pain Only CP Any Tobacco Use Index ERCP Findings Normal Pancreatogram * Pancreatic Duct Dilation, Any Index ERCP Complications Failed Cannulation Any Complications PEP Index ERCP Interventions ES O5mm Maximum Stent, O5 Fr Multiple ERCPs
OR (p-Value) 0 (0.99) 1.78 (0.49) 2.64 (0.23) 1.21 (0.82) 0.25 (0.16) 0.55 (0.49) 12.3 (0.01) 0.4 (0.27) 0.18 (0.16) 2.1 (0.45) 3.33 (0.31) 0.3 (0.16) 1.03 (0.97) 0.5 (0.42)
Su1715 Trends in the Use of ERCP for the Management of Chronic Pancreatitis: a Population-Based Study Using the Nationwide Inpatient Sample Clancy J. Clark*1, Norman Clark2, Shuja Ahmed1, Girish Mishra2, Rishi Pawa2 1 General Surgery, Wake Forest Baptist Health, Winston Salem, NC; 2 Gastroenterology, Wake Forest Baptist Health, Winston Salem, NC Introduction: Historically, Endoscopic Retrograde Cholangiopancreatography (ERCP) was the primary tool for diagnostic and therapeutic management of chronic pancreatitis. With increased availability of magnetic resonance imaging (MRI) and endoscopic ultrasound (EUS), indications for ERCP are being redefined. The aim of this study was to characterize current trends in the use of ERCP in the United States for patients hospitalized with chronic pancreatitis. Methods: We performed a retrospective cohort study using the Nationwide Inpatient Sample from 1998-2010. We identified patients with a primary discharge diagnosis of chronic pancreatitis who underwent ERCP. We excluded patients with a diagnosis of a biliary, gallbladder, or pancreatic neoplasm and patients who underwent biliary, gallbladder, or pancreatic resection during the same admission. We analyzed patient and hospital characteristics, length of stay, and in-hospital mortality and adjusted for weighted sample schema. Results: During the study period, 13,182 patients with chronic pancreatitis (mean age 52, 54.4% female) underwent ERCP during their hospitalization. The majority of patients were white (69.3%). The majority of procedures were performed at large (68.8%), urban (94.1%),
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