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Techniques for Pancreatic Sphincterotomy; Lack of Expert Consensus
*T1544 Pancreatographic Findings of Idiopathic Acute Pancreatitis Terumi Kamisawa, Naoto Egawa, Masami Yoshiike, Hitoshi Nakajima, Atsutake Okamoto
*T1546 Idiopathic Recurrent Pancreatitis (IRP): Does It Progress to Chronic Pancreatitis? Miriam Thomas, Marc F. Catalano, Joseph E. Geenen
Background/Aims: Despite extensive evaluation based on clinical history, biochemical tests, and noninvasive imaging studies, a cause is not established in 10 to 30% of acute pancreatitis cases and a diagnosis of idiopathic acute pancreatitis is made. Aim of this study is to clarify the pancreatographic findings of patients with idiopathic acute pancreatitis. Methods: We performed ERCP in 187 patients with acute pancreatitis after clinical and biochemical resolution of pancreatitis. Thirty-six patients (20 males and 16 females, average age 48.1 years at diagnosis) were diagnosed as having idiopathic acute pancreatitis. Exclusion criteria for idiopathic acute pancreatitis were a history of alcohol abuse; evidence of cholelithiasis and/or choledocholithiasis on US, CT, and ERCP; hypercalcemia; hyperlipidemia; history of trauma; postoperative state; chronic pancreatitis; and having ingested a drug known to be associated with pancreatitis within 1 month of examination. No patients had family histories of pancreatitis. Pancreatographic findings of these 36 patients were examined. Patency of the accessory pancreatic duct was examined by dye-injection ERP in 17 of the patients. After routine ERP studies, contrast medium containing indigo carmine was injected into the main pancreatic duct through a catheter under usual pressure, and the egress of the dye from the minor duodenal papilla was examined endoscopically. Results: In 13 patients (36%), the following anatomic abnormalities of the pancreatic or biliary system were demonstrated: complete pancreas divisum (n=5), incomplete pancreas divisum (n=2), congenital choledochal cyst (n=2), high confluence of pancreaticobiliary ducts (n=2), choledochocele (n=1), and giant periampullary diverticle (n=1). Marked narrow main pancreatic duct was demonstrated in 3 patients, and 3 patients showed a slightly dilated entire main pancreatic duct suggesting papillary stenosis. Pancreatographic findings were normal in the remaining17 patients. Eleven of these 17 patients were examined by dye-injection ERP, and all were found to have nonpatent accessory pancreatic duct. Conclusions: Anatomic abnormality of the pancreatic or biliary system was one of the major causes of idiopathic acute pancreatitis. Nonpatency of the accessory pancreatic duct might play a role in the development of idiopathic acute pancreatitis in the normal cholangiopancreatic ductal system.
Up to 15% of patients (pts) with acute recurrent pancreatitis fall into the category of IRP (two or more episodes of pancreatitis with no identifiable etiology). Currently there is no well-established Rx available to prevent recurrent attacks of pain or pancreatitis in pts with IRP nor is there information regarding the proportion of these pts who develop CP. AIM: To determine the occurrence of CP in a group of IRP pts. METHOD: 59 pts (37 w, 22 m), age 20-78(mean 45.2) with diagnosis of IRP were identified from our ERCP computer database. Pts who were lost to F/U and those who were initially identified with coexisting CP 20 of 59 pts (33.9%) were excluded from the study. The remaining 33 pts were followed for a period of 18 mos to 14 yrs to assess complete recovery versus the development of either ARP versus CP. The following information was obtained about all pts: The number of subsequent hospitalizations or emergency visits for pain or pancreatitis and the endoscopic or surgical intervention that may have occurred since the initial encounter. These pts underwent diagnostic imaging including ERCP, EUS and standard secretin test. RESULTS: All pts at the initial encounter had NL standard diagnostic imaging (CT, ERCP, EUS). 14 of 33 pts (42.4%) had complete recovery with no further hospitalization, 8 of 33 pts (24.2%) developed recurrent attacks of pancreatitis. 11 of 33 pts (33.3%) developed CP over a mean period of 6.5yrs. 28 of 33 pts (84.8%) underwent Rx with PD stents with 3 exchanges over a 4-5 MO period. 11 of 28 pts (39.3%) who had stent treatment did not require subsequent hospitalization while 19 of 28 pts (67.6%) in this same category are currently pain free. 4 of 5 pts (80%) in the non stent group did not have subsequent hospitalization while 5 of 5 pts (100%) remained pain free. 18 of 33 pts (54.5%) required subsequent hospitalization for pain and pancreatitis since the initial encounter while 15 of 33 pts (45.5%) had no further episodes of pain or pancreatitis. 4 of 33 pts developed complications which included pseudocysts (1 pt), steatorrhea (2 pts), diabetes (1 pt). Complications of CP that required surgical intervention occurred in only 1 pt who presented with IRP. CONCLUSION: Nearly 50% of pts with IRP following initial presentation remain asymptomatic. Approximately 1/4 of patients have recurrent attacks of pancreatitis, whereas 1/3 of pts progress to chronic pancreatitis.
*T1545 Techniques for Pancreatic Sphincterotomy; Lack of Expert Consensus Mohammad Alsolaiman, Peter Cotton, Robert Hawes, Giuseppe Aliperti, David L. Carr-Locke, Evan L. Fogel, Martin L. Freeman, Gregory G. Ginsberg, Douglas A. Howell, Richard A. Kozarek, Glen L. Lehman, Lee McHenry, Stuart Sherman, James Watkins, Charles M. Wilcox Background. Pancreatic sphincterotomy is being used increasingly in several clinical contexts. Less than ideal clinical results (e.g. restenosis, stent-induced strictures) suggest that techniques are not optimal. In preparation for a prospective study of sphincterotomy techniques, we sought expert opinion on variations in technique, focussing on patients without gross ductal pathology or stones. Methods. A 9 item questionnaire was completed by 14 expert endoscopists in 9 US Centers. Variables included the cutting technique (pull sphincterotome or needle knife), the type of current, and the size, length and duration of stenting. Results. Answers relating to pancreatic sphincterotomy at the major papilla are shown, (table I). Most responders used 3F stents at least 5cm long, without internal retaining flaps. Responses for pancreatic sphincterotomy at the minor papilla were very similar. Conclusion. Established experts showed a diversity of opinion about techniques for performing minor and major pancreatic sphincterotomy. Whilst most used blended current, and placed 3FG stents designed to pass spontaneously, there was no consensus on the type of sphincterotome, ie pull-type or needle knife. Such questions should be addressed by randomized trials, examining both shortand long-term outcomes.
P210
GASTROINTESTINAL ENDOSCOPY
*T1547 Management of Pancreatic Pleural Effusion, Ascites and External Pancreatic Fistulae by Endoscopic Retrograde Pancreatography and Nasopancreatic Drain Placement Deepak K. Bhasin, Ismail Siyad, Surinder Rana, Babu R. Thapa, Ujjal Poddar, Birinder Nagi Materials and Methods:Two groups were studied over 7 years.GroupI-nine cases,1-44yr,7M(pancreatic pleural effusion 3, pancreatic ascites 4, and pancreatic ascites and pleural effusion 2), etiology of pancreatitis was alcohol in 4, tropical, post traumatic, gall stones, chronic renal failure and idiopathic in one patient each.Group II, ten cases of external pancreatic fistulae(EPF),15-37yr,6M.Eight patients had EPF due to radiological drainage of pseudocysts(post traumatic 4, gall stones 1, alcohol 1, drug induced 1, idiopathic1) and two cases due to drainage of acute fluid collections.After informed consent endoscopic retrograde pancreatography(ERP)was performed.Pancreatic duct was selectively cannulated and a pancreatogram was obtained.Over a 0.025/0.035 inch hydrophilic guide wire 5F/ 7F nasopancreatic drain(NPD)was placed across/near the site of disruption.NPD was removed when pleural effusion/ascites had resolved, drainage from EPF had ceased & pancreatic disruption had sealed.Results:In group I, pancreatic duct disruption was seen at the head body junction, body and tail in 1, 4 and 4 cases respectively. Pancreatic pleural effusion and ascites resolved in all cases in 2-4 weeks without recurrence over a follow up period of 4 months to 7 yrs.In group II, pancreatic duct disruption was seen at head body junction, body and tail in 2, 6 and 2 cases respectively. EPF healed in 9 cases in 2-8 weeks.In one patient guide wire could not be negotiated past the tight stricture in the pancreatic duct.Pseudocyst recurred in 2 patients after removal of NPD, requiring placement of a 5F pancreatic stent in one & surgery in the other.In 7 cases no recurrence occurred over a follow up period of 3 months to 6 yrs.Conclusion:Pancreatic pleural effusion, ascites and external pancreatic fistulae can be effectively treated by ERP and NPD placement which permits assessment of healing of pancreatic duct disruption by performing nasopancreatogram & removal of NPD without repeat ERP.
VOLUME 59, NO. 5, 2004
*T1546 Idiopathic Recurrent Pancreatitis (IRP): Does It Progress to Chronic Pancreatitis? Miriam Thomas, Marc F. Catalano, Joseph E. Geenen
Background/Aims: Despite extensive evaluation based on clinical history, biochemical tests, and noninvasive imaging studies, a cause is not established in 10 to 30% of acute pancreatitis cases and a diagnosis of idiopathic acute pancreatitis is made. Aim of this study is to clarify the pancreatographic findings of patients with idiopathic acute pancreatitis. Methods: We performed ERCP in 187 patients with acute pancreatitis after clinical and biochemical resolution of pancreatitis. Thirty-six patients (20 males and 16 females, average age 48.1 years at diagnosis) were diagnosed as having idiopathic acute pancreatitis. Exclusion criteria for idiopathic acute pancreatitis were a history of alcohol abuse; evidence of cholelithiasis and/or choledocholithiasis on US, CT, and ERCP; hypercalcemia; hyperlipidemia; history of trauma; postoperative state; chronic pancreatitis; and having ingested a drug known to be associated with pancreatitis within 1 month of examination. No patients had family histories of pancreatitis. Pancreatographic findings of these 36 patients were examined. Patency of the accessory pancreatic duct was examined by dye-injection ERP in 17 of the patients. After routine ERP studies, contrast medium containing indigo carmine was injected into the main pancreatic duct through a catheter under usual pressure, and the egress of the dye from the minor duodenal papilla was examined endoscopically. Results: In 13 patients (36%), the following anatomic abnormalities of the pancreatic or biliary system were demonstrated: complete pancreas divisum (n=5), incomplete pancreas divisum (n=2), congenital choledochal cyst (n=2), high confluence of pancreaticobiliary ducts (n=2), choledochocele (n=1), and giant periampullary diverticle (n=1). Marked narrow main pancreatic duct was demonstrated in 3 patients, and 3 patients showed a slightly dilated entire main pancreatic duct suggesting papillary stenosis. Pancreatographic findings were normal in the remaining17 patients. Eleven of these 17 patients were examined by dye-injection ERP, and all were found to have nonpatent accessory pancreatic duct. Conclusions: Anatomic abnormality of the pancreatic or biliary system was one of the major causes of idiopathic acute pancreatitis. Nonpatency of the accessory pancreatic duct might play a role in the development of idiopathic acute pancreatitis in the normal cholangiopancreatic ductal system.
Up to 15% of patients (pts) with acute recurrent pancreatitis fall into the category of IRP (two or more episodes of pancreatitis with no identifiable etiology). Currently there is no well-established Rx available to prevent recurrent attacks of pain or pancreatitis in pts with IRP nor is there information regarding the proportion of these pts who develop CP. AIM: To determine the occurrence of CP in a group of IRP pts. METHOD: 59 pts (37 w, 22 m), age 20-78(mean 45.2) with diagnosis of IRP were identified from our ERCP computer database. Pts who were lost to F/U and those who were initially identified with coexisting CP 20 of 59 pts (33.9%) were excluded from the study. The remaining 33 pts were followed for a period of 18 mos to 14 yrs to assess complete recovery versus the development of either ARP versus CP. The following information was obtained about all pts: The number of subsequent hospitalizations or emergency visits for pain or pancreatitis and the endoscopic or surgical intervention that may have occurred since the initial encounter. These pts underwent diagnostic imaging including ERCP, EUS and standard secretin test. RESULTS: All pts at the initial encounter had NL standard diagnostic imaging (CT, ERCP, EUS). 14 of 33 pts (42.4%) had complete recovery with no further hospitalization, 8 of 33 pts (24.2%) developed recurrent attacks of pancreatitis. 11 of 33 pts (33.3%) developed CP over a mean period of 6.5yrs. 28 of 33 pts (84.8%) underwent Rx with PD stents with 3 exchanges over a 4-5 MO period. 11 of 28 pts (39.3%) who had stent treatment did not require subsequent hospitalization while 19 of 28 pts (67.6%) in this same category are currently pain free. 4 of 5 pts (80%) in the non stent group did not have subsequent hospitalization while 5 of 5 pts (100%) remained pain free. 18 of 33 pts (54.5%) required subsequent hospitalization for pain and pancreatitis since the initial encounter while 15 of 33 pts (45.5%) had no further episodes of pain or pancreatitis. 4 of 33 pts developed complications which included pseudocysts (1 pt), steatorrhea (2 pts), diabetes (1 pt). Complications of CP that required surgical intervention occurred in only 1 pt who presented with IRP. CONCLUSION: Nearly 50% of pts with IRP following initial presentation remain asymptomatic. Approximately 1/4 of patients have recurrent attacks of pancreatitis, whereas 1/3 of pts progress to chronic pancreatitis.
*T1545 Techniques for Pancreatic Sphincterotomy; Lack of Expert Consensus Mohammad Alsolaiman, Peter Cotton, Robert Hawes, Giuseppe Aliperti, David L. Carr-Locke, Evan L. Fogel, Martin L. Freeman, Gregory G. Ginsberg, Douglas A. Howell, Richard A. Kozarek, Glen L. Lehman, Lee McHenry, Stuart Sherman, James Watkins, Charles M. Wilcox Background. Pancreatic sphincterotomy is being used increasingly in several clinical contexts. Less than ideal clinical results (e.g. restenosis, stent-induced strictures) suggest that techniques are not optimal. In preparation for a prospective study of sphincterotomy techniques, we sought expert opinion on variations in technique, focussing on patients without gross ductal pathology or stones. Methods. A 9 item questionnaire was completed by 14 expert endoscopists in 9 US Centers. Variables included the cutting technique (pull sphincterotome or needle knife), the type of current, and the size, length and duration of stenting. Results. Answers relating to pancreatic sphincterotomy at the major papilla are shown, (table I). Most responders used 3F stents at least 5cm long, without internal retaining flaps. Responses for pancreatic sphincterotomy at the minor papilla were very similar. Conclusion. Established experts showed a diversity of opinion about techniques for performing minor and major pancreatic sphincterotomy. Whilst most used blended current, and placed 3FG stents designed to pass spontaneously, there was no consensus on the type of sphincterotome, ie pull-type or needle knife. Such questions should be addressed by randomized trials, examining both shortand long-term outcomes.
P210
GASTROINTESTINAL ENDOSCOPY
*T1547 Management of Pancreatic Pleural Effusion, Ascites and External Pancreatic Fistulae by Endoscopic Retrograde Pancreatography and Nasopancreatic Drain Placement Deepak K. Bhasin, Ismail Siyad, Surinder Rana, Babu R. Thapa, Ujjal Poddar, Birinder Nagi Materials and Methods:Two groups were studied over 7 years.GroupI-nine cases,1-44yr,7M(pancreatic pleural effusion 3, pancreatic ascites 4, and pancreatic ascites and pleural effusion 2), etiology of pancreatitis was alcohol in 4, tropical, post traumatic, gall stones, chronic renal failure and idiopathic in one patient each.Group II, ten cases of external pancreatic fistulae(EPF),15-37yr,6M.Eight patients had EPF due to radiological drainage of pseudocysts(post traumatic 4, gall stones 1, alcohol 1, drug induced 1, idiopathic1) and two cases due to drainage of acute fluid collections.After informed consent endoscopic retrograde pancreatography(ERP)was performed.Pancreatic duct was selectively cannulated and a pancreatogram was obtained.Over a 0.025/0.035 inch hydrophilic guide wire 5F/ 7F nasopancreatic drain(NPD)was placed across/near the site of disruption.NPD was removed when pleural effusion/ascites had resolved, drainage from EPF had ceased & pancreatic disruption had sealed.Results:In group I, pancreatic duct disruption was seen at the head body junction, body and tail in 1, 4 and 4 cases respectively. Pancreatic pleural effusion and ascites resolved in all cases in 2-4 weeks without recurrence over a follow up period of 4 months to 7 yrs.In group II, pancreatic duct disruption was seen at head body junction, body and tail in 2, 6 and 2 cases respectively. EPF healed in 9 cases in 2-8 weeks.In one patient guide wire could not be negotiated past the tight stricture in the pancreatic duct.Pseudocyst recurred in 2 patients after removal of NPD, requiring placement of a 5F pancreatic stent in one & surgery in the other.In 7 cases no recurrence occurred over a follow up period of 3 months to 6 yrs.Conclusion:Pancreatic pleural effusion, ascites and external pancreatic fistulae can be effectively treated by ERP and NPD placement which permits assessment of healing of pancreatic duct disruption by performing nasopancreatogram & removal of NPD without repeat ERP.
VOLUME 59, NO. 5, 2004