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Therapeutic endoscopy for severe acute pancreatitis complicatons
Endorcopy
13
15
SELF-EXF’ANDABLE METAL STEN’TSAND POLYETHYLENE STENTS IN THE PALLIATION OF MALIGNANT BJLIARY OBSTRUCTION CasadeiA.*, Billi p.*, Maiolo P.‘, Polifemo A.M.*, Sibad V.‘, Valpiani D.‘, D’lmpmo N.*. ‘U.0. di Gastmentemlogiaed EndoscopiaDig. Osp. Morgagni Farli Relatore:CasadeiA.
RDi Placido,D.Plucbino,S.Reccbia.
Effective palliationofmaligrunt biliary obstruction with endopmsthesisis limited by stem occlusion. Previousstudieshave shown thatthe use of self-exoandablemetal stats (SEMS) is associatedwith less episodesof occlusion comparedwith pol&thylene stats. Be&se is nit economicalto placemetal stentsin all the patientswith tnaligne.ntobstmctivc jaundice,the longer time survivcm shouldbe selectedfor SEMSplacement.The aim of our study was to evaluatethe effectivenessof polyethyleneandmetallic biliary endopmsthcsisin the palliation of malignant obstructive jaundice.BetweenJanuary 1999andApril 2001, 157biliay endopmsthesiswere placed in 133pts with obstmctivc jaundicedue to umesectablemalignmcy: 61 patientshad pancreatic carcinoma,59 hadchokmgiocarcinoma, 11had ampullarycarcinoma andthe remaining 2 had intestinalneoplasms.Thirty-six of thesepatientsundenventto surgical treatmentwhereasthe other 97were submittedto a clinical andlaboratory follow-up. In 42 of these 97 patients(43.3%). who werejudged to have a betterpmgnosis, a SEMS was positioned(Group A); in the other 55 (56.7%) was placeda plastic stent (Gmup B). Despitelittle evidenceof diseaseprogression in patimts of the Gmup A, there were not significant differences in the diagnosisbetweenthe two groups. The mediantime of patency of endopmsulssisin patientsof Group A was 148days (range60-185) and in thoseof Group B was 63 days (range 30.110): this differencewas statistically significant (wO.05). Nine of the 42wtients of the Gmuo A (21.4%) had stentwclusion and/orchobmeitis &ring follow-up: 4 of &se (9.5%) were s&ess&lly heatedwith a polyethylenestent i&ion insidethe occludedSEMS. Thirty-seven oftbe 55 patientsofthe Group B (67%) had cloggingof thestent with occlusion and/or &&ngitis: 20 of thex (36.3%) were endoscopicallyretreatedwith placementofa xcondpclyethylene stemin 13(23.6%) orofa SEMS in 7 (12.7%). At present time 14of the 42 patientsin the Group A (33%) and39 of the55 in the Group B (70%) died. Our results contim the longer patencyof SEMS in respect to that of polyethylenestents. The lower incidence of endoecopicntreatment in patientswith SBMS may be cost-effective in patientsliving enoughto needrehospitalizationdueto cloggingof the stem. To optimisecost-effectiveness, a careful selectionofpatients to be submittedto placementof SEMS is mandatory.
Osp SanGiovanni Bosco BACKGROUND: endoscopictrammural and/ortrampapillary approachis an acceptedtherapeutic modality when apseudocyst or ductal damwe occur, movidedthat favorable anatomiccondition arepresent.Patientswho undergothesep&dues, &rally show stableclinical conditions, anda periodof more thmt 6 weeks has elapsedsince the initial episcdeof acutepanneatiti&4P). A group of patients,however, show a recurrence of pseudocyst fommtion afta a tint endoscopicapproach, smolderingpanereatitis,pancreatic abscessandother complications.Endoscopictxabnent in this subsetof patientsis under debate. MATEPJAL AND METHODS: since Ws we have endoscop&allytreated36 cases ofcomplications after AP. 13pts bad a less favoumbleoutcome: I IM, ZF(meanage40),1I AP, 2 chmeic pawn&is. 5 out of 13 pts had beenundergonea surgical urncAm of dmbae. 4 ms showedclinical featuresof smolderinn~awmatitis when refeedinnwas koduced, 3 pts r&nre&ze of large PPC after extraction of end&& stat left in situ for 3 months,2 showedPPC of the tail, 1pancreaticabscess, 1intracystic hemormgedue to traumaTranspapillary appmachwas usedin 7 pts, tmnsmuml in 6. RESULTS: 6/7pts treatedby tanspapillaty techniquesshowedcompleteresolution ofpancreatic collstions or internal fist& or the subsidenceofsymptoms due to smolderingpancreatitis.516pts treatedby trammural approach showedresolution. 3 large (E&%1638;20 cm) recurrent PPC were treatedby a stent left in situ for I year Pancreaticabscesswas treatedby drainageand lavageof thecavity anthe intracystic hemonaeeshowedbeneficialeffects. l/13 was owxted on due to failed endoscooicmaneuver.We obsewed2 complicationssurgically treatedin 1 &e andconservatively treatedh the other. CONCLUSIONS: largeand rec,me,,t PP may beswcasfully treatedby long term intx,ductal stem Ptswith smolderingpancreatitisshow completerelief if the ductald&ge isbridged by a stat. Ductal damagedueto tissue necrosis is ofparamount importancefor the explanationof symptoms in thesecases,probably in associationto 80hypertonic SO activity.Tbese conditions favor pemistenceof symptoms as occurs in biliary drainage.
THERAPEUTIC ENDOSCOPY FOR SEVERE ACUTE PANCREATITTSCOMPLICATONS
14 ENDOSCOPICTREATMENT OF BILIARY LEAK AFTER LAPAROSCOPIC CHOLECISTECTOMY (LC) G. Di Mattea, P. Giorgio Digestive EndoscopyUmt, 1.RC.C.S“S. De Bellis”, CastelImaGmtte (Ban) Italy ReMore: Dr. P. Giorgio IRCCS ‘S. deBELLIS’ Background: Biliiuy leak is aninfrequentbut serious complicationof Lapamscopic Choleciatcctomy(LC). Endorcopic therapy hasbeenrepated to be effective. Aim : To assessthe overaUsafety andefficacy of this tlmapeutic approach.PatientsandMethods: BetweenNovember 1993andApril 2000 36 consecutivepatients(11 M, 25 F; mean age55 yrs) with post-LC biliay leakwen obsewedand treated by endoscopy.A biliary leak was diagnosedby clinical parameters (abdominalrain. fever. iandice) and imatin techniaws labdomiml CT scan ultmsoundl.All &ients u&m&t ER&. Res&s : Theme& time &w&n LC end ERCP was 8 days. ERCP was success8.dlyperformedin all cases.In tnoEtpatients(80.5 “%)the site of leakagewas localized to the cystic stump. There was distal obstmctioncased by retained stonesin 1I patients(30.5 %). Endoscopictherapy includedsphinctemtomy,stonesremoval @y basket extraction) andmwobiliay tube(11 uts), s&nctemtomy andnasowbiliw tube (13 pts), spbinctemtomyand stent(4 pts), required No.&jor morbidity r&d to the endoscop~cprocedureswas encountered. Healingofthc leak occurred in 97% of patients.Following cholangioaraDhiccontrol, nasobiliar tubeswere removed7 days after insert& Stentsremain~~mplace for 2-6 weeks. Mean hospital stay was 10.5* 7.5days (range3-24). Afier a mean follow-up of 13mm&s (rangeS-27) all survivors remainedasymptom& with normalliver function tests. Conclusions:Endoswpic treaImemshouldbe consideredas the therapeuticmethodofchoice in patientswith post-LC biliary k&S.
A42
STOMAL SEEDING AFTER PERCUTANEOUS ENDOSCOPIC GASTROSTOMY IN ESOPHAGEAL ADENOCARCINOMA: A CASE REPORT. Balla+ Ml, Orsello M.1, Del Piano Ml, Occhipinti PI, Montino Fl: Krengli M2, BagnasaccoP2, Gambam G2. (1)Divisionc di Gastmentemlogia,(2)Divisione Universittia di Radiaterapia,AZ. Osp. ‘W&ore della &it&“, Novera. Osp. Maggiore della Cariti Background. The occurrence of neoplasticting at the site of previous surgery, biopsy or tine needleaspirationbiopsy can be considereda rare but not exceptional event.The percutaneous endoscopicgastmstomy (PEG) is a common prcadw used for supportive enteml feeding in patient.8affected by tumors of the wwr aem-digestivetract. We rewrt a case of tumoral seedingat the site of the PEG in a patient&t&i by em&gal adenocarcin~ma Casereport. A 76 y&Id male esophagealcancer of the lower third of the esophagus( adenaucinoma, Brade2; T4 NO MO) was evaluatedby a multidisciplii team.Before s&&g the treatment(che&bempy + radiotherapy),a PEG was paformed. A Bard Traction Removal PEG of 2OF was placed without pmblems.The h’@mcnt was well tolerated.At the end of the treatment,endoscopy and CT-ran showedcompleteresponse at the site of the primary lesion.Fourtern months afler the endof the treatment,8 vegetmt, ulceratedlesion, 4 cm in diameter,w’a found at the level of the stoma of the PEGwithout evidenceof recurrence in the esophagus.Biopsy weaperformed andpathology was adenocarcinoma,grade 2. Chemotherapywas plarad possibly followed by swgety andior local radiotherapy.A month after completion of chemotherapy,the patient died fmm polmonaty thmmboembolism.Conclusions. The seedingat PEG site by neoplasticcells is reported in fifteen cases only. two of them from eeavhazealhmwm. The ~ultiuah technique,was used in all the cases. T&possible mechanismsbf &mwl seedingat-tie PEGsi& can be hypothesized one is directly relatedto the mmcuver of ins&on of the catheterthrough the amdigestive tract, the other dependson lymphatic or hematogenow spreads.In our case, the PEG was placedby conventioml pull-tbmugb techniquebefore stating radiothempy and the tumor implantation was very likely directly related to the PEG maneuva, considering that no distant metestaseswere present at that time.
13
15
SELF-EXF’ANDABLE METAL STEN’TSAND POLYETHYLENE STENTS IN THE PALLIATION OF MALIGNANT BJLIARY OBSTRUCTION CasadeiA.*, Billi p.*, Maiolo P.‘, Polifemo A.M.*, Sibad V.‘, Valpiani D.‘, D’lmpmo N.*. ‘U.0. di Gastmentemlogiaed EndoscopiaDig. Osp. Morgagni Farli Relatore:CasadeiA.
RDi Placido,D.Plucbino,S.Reccbia.
Effective palliationofmaligrunt biliary obstruction with endopmsthesisis limited by stem occlusion. Previousstudieshave shown thatthe use of self-exoandablemetal stats (SEMS) is associatedwith less episodesof occlusion comparedwith pol&thylene stats. Be&se is nit economicalto placemetal stentsin all the patientswith tnaligne.ntobstmctivc jaundice,the longer time survivcm shouldbe selectedfor SEMSplacement.The aim of our study was to evaluatethe effectivenessof polyethyleneandmetallic biliary endopmsthcsisin the palliation of malignant obstructive jaundice.BetweenJanuary 1999andApril 2001, 157biliay endopmsthesiswere placed in 133pts with obstmctivc jaundicedue to umesectablemalignmcy: 61 patientshad pancreatic carcinoma,59 hadchokmgiocarcinoma, 11had ampullarycarcinoma andthe remaining 2 had intestinalneoplasms.Thirty-six of thesepatientsundenventto surgical treatmentwhereasthe other 97were submittedto a clinical andlaboratory follow-up. In 42 of these 97 patients(43.3%). who werejudged to have a betterpmgnosis, a SEMS was positioned(Group A); in the other 55 (56.7%) was placeda plastic stent (Gmup B). Despitelittle evidenceof diseaseprogression in patimts of the Gmup A, there were not significant differences in the diagnosisbetweenthe two groups. The mediantime of patency of endopmsulssisin patientsof Group A was 148days (range60-185) and in thoseof Group B was 63 days (range 30.110): this differencewas statistically significant (wO.05). Nine of the 42wtients of the Gmuo A (21.4%) had stentwclusion and/orchobmeitis &ring follow-up: 4 of &se (9.5%) were s&ess&lly heatedwith a polyethylenestent i&ion insidethe occludedSEMS. Thirty-seven oftbe 55 patientsofthe Group B (67%) had cloggingof thestent with occlusion and/or &&ngitis: 20 of thex (36.3%) were endoscopicallyretreatedwith placementofa xcondpclyethylene stemin 13(23.6%) orofa SEMS in 7 (12.7%). At present time 14of the 42 patientsin the Group A (33%) and39 of the55 in the Group B (70%) died. Our results contim the longer patencyof SEMS in respect to that of polyethylenestents. The lower incidence of endoecopicntreatment in patientswith SBMS may be cost-effective in patientsliving enoughto needrehospitalizationdueto cloggingof the stem. To optimisecost-effectiveness, a careful selectionofpatients to be submittedto placementof SEMS is mandatory.
Osp SanGiovanni Bosco BACKGROUND: endoscopictrammural and/ortrampapillary approachis an acceptedtherapeutic modality when apseudocyst or ductal damwe occur, movidedthat favorable anatomiccondition arepresent.Patientswho undergothesep&dues, &rally show stableclinical conditions, anda periodof more thmt 6 weeks has elapsedsince the initial episcdeof acutepanneatiti&4P). A group of patients,however, show a recurrence of pseudocyst fommtion afta a tint endoscopicapproach, smolderingpanereatitis,pancreatic abscessandother complications.Endoscopictxabnent in this subsetof patientsis under debate. MATEPJAL AND METHODS: since Ws we have endoscop&allytreated36 cases ofcomplications after AP. 13pts bad a less favoumbleoutcome: I IM, ZF(meanage40),1I AP, 2 chmeic pawn&is. 5 out of 13 pts had beenundergonea surgical urncAm of dmbae. 4 ms showedclinical featuresof smolderinn~awmatitis when refeedinnwas koduced, 3 pts r&nre&ze of large PPC after extraction of end&& stat left in situ for 3 months,2 showedPPC of the tail, 1pancreaticabscess, 1intracystic hemormgedue to traumaTranspapillary appmachwas usedin 7 pts, tmnsmuml in 6. RESULTS: 6/7pts treatedby tanspapillaty techniquesshowedcompleteresolution ofpancreatic collstions or internal fist& or the subsidenceofsymptoms due to smolderingpancreatitis.516pts treatedby trammural approach showedresolution. 3 large (E&%1638;20 cm) recurrent PPC were treatedby a stent left in situ for I year Pancreaticabscesswas treatedby drainageand lavageof thecavity anthe intracystic hemonaeeshowedbeneficialeffects. l/13 was owxted on due to failed endoscooicmaneuver.We obsewed2 complicationssurgically treatedin 1 &e andconservatively treatedh the other. CONCLUSIONS: largeand rec,me,,t PP may beswcasfully treatedby long term intx,ductal stem Ptswith smolderingpancreatitisshow completerelief if the ductald&ge isbridged by a stat. Ductal damagedueto tissue necrosis is ofparamount importancefor the explanationof symptoms in thesecases,probably in associationto 80hypertonic SO activity.Tbese conditions favor pemistenceof symptoms as occurs in biliary drainage.
THERAPEUTIC ENDOSCOPY FOR SEVERE ACUTE PANCREATITTSCOMPLICATONS
14 ENDOSCOPICTREATMENT OF BILIARY LEAK AFTER LAPAROSCOPIC CHOLECISTECTOMY (LC) G. Di Mattea, P. Giorgio Digestive EndoscopyUmt, 1.RC.C.S“S. De Bellis”, CastelImaGmtte (Ban) Italy ReMore: Dr. P. Giorgio IRCCS ‘S. deBELLIS’ Background: Biliiuy leak is aninfrequentbut serious complicationof Lapamscopic Choleciatcctomy(LC). Endorcopic therapy hasbeenrepated to be effective. Aim : To assessthe overaUsafety andefficacy of this tlmapeutic approach.PatientsandMethods: BetweenNovember 1993andApril 2000 36 consecutivepatients(11 M, 25 F; mean age55 yrs) with post-LC biliay leakwen obsewedand treated by endoscopy.A biliary leak was diagnosedby clinical parameters (abdominalrain. fever. iandice) and imatin techniaws labdomiml CT scan ultmsoundl.All &ients u&m&t ER&. Res&s : Theme& time &w&n LC end ERCP was 8 days. ERCP was success8.dlyperformedin all cases.In tnoEtpatients(80.5 “%)the site of leakagewas localized to the cystic stump. There was distal obstmctioncased by retained stonesin 1I patients(30.5 %). Endoscopictherapy includedsphinctemtomy,stonesremoval @y basket extraction) andmwobiliay tube(11 uts), s&nctemtomy andnasowbiliw tube (13 pts), spbinctemtomyand stent(4 pts), required No.&jor morbidity r&d to the endoscop~cprocedureswas encountered. Healingofthc leak occurred in 97% of patients.Following cholangioaraDhiccontrol, nasobiliar tubeswere removed7 days after insert& Stentsremain~~mplace for 2-6 weeks. Mean hospital stay was 10.5* 7.5days (range3-24). Afier a mean follow-up of 13mm&s (rangeS-27) all survivors remainedasymptom& with normalliver function tests. Conclusions:Endoswpic treaImemshouldbe consideredas the therapeuticmethodofchoice in patientswith post-LC biliary k&S.
A42
STOMAL SEEDING AFTER PERCUTANEOUS ENDOSCOPIC GASTROSTOMY IN ESOPHAGEAL ADENOCARCINOMA: A CASE REPORT. Balla+ Ml, Orsello M.1, Del Piano Ml, Occhipinti PI, Montino Fl: Krengli M2, BagnasaccoP2, Gambam G2. (1)Divisionc di Gastmentemlogia,(2)Divisione Universittia di Radiaterapia,AZ. Osp. ‘W&ore della &it&“, Novera. Osp. Maggiore della Cariti Background. The occurrence of neoplasticting at the site of previous surgery, biopsy or tine needleaspirationbiopsy can be considereda rare but not exceptional event.The percutaneous endoscopicgastmstomy (PEG) is a common prcadw used for supportive enteml feeding in patient.8affected by tumors of the wwr aem-digestivetract. We rewrt a case of tumoral seedingat the site of the PEG in a patient&t&i by em&gal adenocarcin~ma Casereport. A 76 y&Id male esophagealcancer of the lower third of the esophagus( adenaucinoma, Brade2; T4 NO MO) was evaluatedby a multidisciplii team.Before s&&g the treatment(che&bempy + radiotherapy),a PEG was paformed. A Bard Traction Removal PEG of 2OF was placed without pmblems.The h’@mcnt was well tolerated.At the end of the treatment,endoscopy and CT-ran showedcompleteresponse at the site of the primary lesion.Fourtern months afler the endof the treatment,8 vegetmt, ulceratedlesion, 4 cm in diameter,w’a found at the level of the stoma of the PEGwithout evidenceof recurrence in the esophagus.Biopsy weaperformed andpathology was adenocarcinoma,grade 2. Chemotherapywas plarad possibly followed by swgety andior local radiotherapy.A month after completion of chemotherapy,the patient died fmm polmonaty thmmboembolism.Conclusions. The seedingat PEG site by neoplasticcells is reported in fifteen cases only. two of them from eeavhazealhmwm. The ~ultiuah technique,was used in all the cases. T&possible mechanismsbf &mwl seedingat-tie PEGsi& can be hypothesized one is directly relatedto the mmcuver of ins&on of the catheterthrough the amdigestive tract, the other dependson lymphatic or hematogenow spreads.In our case, the PEG was placedby conventioml pull-tbmugb techniquebefore stating radiothempy and the tumor implantation was very likely directly related to the PEG maneuva, considering that no distant metestaseswere present at that time.