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There Are Benefits of Overnight Observation After Outpatient ERCP
*T1536 There Are Benefits of Overnight Observation After Outpatient ERCP Jeffrey D. Linder, Paul R. Tarnasky There is debate regarding whether patients require overnight observation (OBS) after outpatient ERCP. Independent of whether pts develop complications, there may be benefit from inpatient OBS. The purpose of this study was to assess utilization of iv fluids, parenteral analgesics (PA) and anti-emetics (AE), as well as patient satisfaction following outpatient ERCP. Methods: 77 consecutive pts undergoing outpatient ERCP from 7/2003 to 11/2003 where included in this prospective study. Medications, endoscopic interventions and iv fluids during endoscopy were recorded. Pts were evaluated for possible discharge from recovery based on low risk for PEP, lack of symptoms of pain, nausea/vomiting, and ability to tolerate oral fluids. PA, AE, iv and oral fluid intake were recorded during recovery and OBS period if admitted. Pain scores (5 point scale) were obtained at both recovery and OBS periods. Pts were queried for satisfaction at discharge for OBS pts and at 24 hours after discharge for pts discharged from the recovery room. Results: 27 pts were discharged home after recovery and 50 pts were admitted for OBS. There were 3 pts who developed PEP (1 OBS, 2 discharged). Pts undergoing sphincterotomy or sphincter of Oddi manometry were more likely to be admitted (p=0.01 and 0.001, respectively). Similar volumes of iv fluids (median 900cc) were administered to both discharged and OBS pts during recovery. Compared to discharged pts, those who were admitted following recovery were significantly more likely to receive PA (36 vs 11%, p=0.02) or AE (30% vs 14%, p=0.01). 10 OBS pts vs. 2 discharged pts had emesis during recovery. Pain scores were higher in OBS vs discharged pts (3.1 vs. 0.7, p=0.0005). The OBS pts received an average of 1338 cc of iv fluids. 10 pts vomited within 24hr after admission. Patient satisfaction scores were higher in the admitted pts than in the discharged pts. Conclusions: Pts with post-procedure symptoms of pain and nausea/vomiting are more likely to benefit from overnight OBS, however, even pts who do not require PA or AE in recovery may require these medications during an overnight OBS. The need for PA or AE is most frequently from post-procedure symptoms that are not from PEP. Patient satisfaction is improved by admission for overnight OBS following ERCP.
*T1537 Disconnected Pancreatic Tail Syndrome (DPTS): Clinical Features, Management, & Outcome Christopher Lawrence, Douglas A. Howell, Andreas M. Stefan, Donald E. Conklin, Frank J. Lukens, Ronald F. Martin, Andrew Landes, Becky Benz Background: The literature has inadequately reported the poor outcome of patients following complete pancreatic ductal disruption that produces a disconnected segment of viable functioning pancreas; the DPTS. Patients & Methods: From 3/97—6/03, 189 pts with pancreatic fluid collections and/or pancreatic fistulae were identified from our ERCP database. CT scans, ERCP images, and pt records were reviewed for evidence of the DPTS. A minimum of 6 month follow-up was required. Results: 30/189 pts (16%) met the criteria for the DPTS (mean age=48, range 31-80 yr; M:20/F:10). Presentations included pancreatic pseudocyst (n=22), post-operative fistula (n=3), pancreatic abscess/sepsis (n=2), and recurrent pancreatitis (n=3). Etiologies of pancreatitis were alcohol (40%), biliary (20%), hypertriglyceridemia (20%), idiopathic (10%), post-operative injury (7%), and pancreas divisum (7%). 26/30 (86%) of pts had necrotizing pancreatitis. Median follow-up was 38 months (range 6-94 mo). Outcome to date is as follows: 36 drainage procedures were performed on 27 pts (endoscopic transmural n=18, ERCP transpapillary n=12, surgical n=4, percutaneous n=2). Complete initial drainage was successful in 22/27 (81.5%) of pts. In long-term f/u, fluid collections recurred in 2/4 (50%) pts drained surgically and in 9/18 (50%) pts drained endoscopically. 12/30 (40%) pts have been managed successfully thus far without the need for operation. 18/30 (60%) pts have required a cumulative 48 surgical procedures (mean 2.7/pt). 4/30 (13%) pts have undergone resective surgery (L-sided pancreatectomy n=3, Whipple’s resection n=1). 7/18 pts required multiple debridements. Surgical intervention was required in 67% of pts with disruption within the head of the gland, 60% within the body, and none within the tail. 93 ERCPs have been performed (mean 3.1/pt). 13/30 (43%) pts have developed diabetes mellitus, 15/30 (50%) pts have developed L-sided portal hypertension, and 14/30 (47%) remain in active f/u for recurrent pancreatic symptoms and/or observation of a persistent fluid collection. Conclusions: The disconnected pancreatic tail syndrome (DPTS) deserves better recognition since affected patients and clinicians must anticipate a prolonged illness. The role of earlier, more aggressive surgical resection may shorten the illness, but also may increase the rate of diabetes, and may not be indicated in the majority. Multidisciplinary expertise is required to optimize outcome.
P208
GASTROINTESTINAL ENDOSCOPY
*T1538 Patent Accessory Pancreatic Duct Prevent Post-ERCP pancreatitis Terumi Kamisawa, Naoto Egawa, Hitoshi Nakajima, Atsutake Okamoto Background/Aims: Pancreatitis is the most important complication of ERCP. Moreover, efforts to understand its pathogenesis and to identify ways to reduce the frequency and severity of this complication have shown no convincing benefit to date. Although very complex factors are involved in the development of postERCP pancreatitis, mechanical injury to the papilla causing papillary edema and restriction of pancreatic juice flow, and hydrostatic injury from over-injection are the most common causes. We have prospectively examined patency of the accessory pancreatic duct (APD) by dye-injection ERP. We examined the role of the APD in vivo, and proposed a new way to prevent post-ERCP pancreatitis. Methods: During ERP, 2 or 3 ml of contrast medium containing indigo carmine was injected through a catheter in the main pancreatic duct (MPD) with usual pressure in 443 cases. Dye excretion from the minor papilla was then observed endoscopically. Results: Of 312 controls, patency of the APD was observed in 43%, whereas in 51 patients with acute pancreatitis, only 8 (16%) had a patent APD (p<0.01). In particular, patency of the APD was seen in only one of 17 patients with acute biliary pancreatitis. Patency of the APD showed a close relationship to the course and terminal shape of the APD. The long-type APD, which joined the MPD at its neck portion and ran straight from the upper dorsal pancreatic duct, was more frequently patent than the short-type APD which joined the MPD near its first inferior branch and followed a descending course (75.5% patency vs. 36.0%, p<0.01). Regarding terminal shape of the APD, patency of the cudgel (89.2%) and spindle type (92.0%) was more frequent than of the branch type (5.9%) or saccular type (16.7%) (p<0.01). According to the above findings, we retrospectively examined patency of the APD in 25 patients with acute pancreatitis after diagnostic ERP (6500 cases). Patency of the APD was estimated at only 8% (2/25). Furthermore, 3 cases showing acute pancreatitis after stone extraction with endoscopic balloon dilatation, exhibited nonpatent APD. Conclusions: A patent APD may prevent acute pancreatitis by lowering the pressure in the MPD. During ERCP, in cases with short type APD or APD with branch or saccular terminal shape, endoscopists should be more cautious and never persist when selective cannulation is difficult, or alternatively consider prophylactic pancreatic stenting.
*T1539 The Use of Corticosteroids in the Prevention of ERCP-Induced Pancreatitis: A Meta Analysis Ma Cecilia M. Sison, Jade D. Jamias, Ma Lourdes O. Daez RESEARCH QUESTION: Among patients undergoing ERCP, how effective are corticosteroids in reducing the incidence and severity of ERCP-induced pancreatitis? BACKGROUND: Pancreatitis is the most common major complication of ERCP occurring in 8% of cases. Most cases are fatal. Due to its anti-inflammatory effects, corticosteroids may reduce the frequency & severity of this complication. OBJECTIVES: To evaluate the effects of corticosteroids versus placebo in reducing the incidence of ERCP-induced pancreatitis in patients undergoing ERCP. Secondary objectives: To determine the effect of corticosteroids in reducing the severity of pancreatitis & its effect on pancreatitis incidence in sphincterotomy patients; to detect a difference between oral and IV steroids in the prevention of pancreatitis. INCLUSION CRITERIA: Randomized controlled trials comparing hydrocortisone, methylprednisolone or prednisone with placebo in reducing the frequency and severity of ERCP-induced pancreatitis were included. SEARCH STRATEGY: Electronic search of MEDLINE 1966-2003 & review of related articles STUDY MANEUVERS: Inclusion criteria, trial quality assessment and data extraction were done in duplicate. Subgroup analyses based on type of steroid and endoscopic intervention were done. STATISTICAL ANALYSIS: Relative risks (RR) were calculated using RevMan 4.2. Heterogeneity was checked via forest plots, chi-square & I2 tests. RESULTS: Five fair quality trials (n=2334) met the inclusion criteria. Pooled analysis of 5 homogenous trials showed that corticosteroids were not different from placebo in reducing ERCP-induced pancreatitis (RR=1.19; 95%CI 0.95,1.49). Subgroup analysis of patients with sphincterotomy during ERCP preserved this lack of effect (n=545 RR=1.42; 95%CI 0.88, 2.29). But 2 homogenous trials using prednisone showed a significant direction of effect favoring placebo (n=394 RR=1.89; 95% CI 1.06,3.36) in this subgroup of patients. Analysis of 4 homogenous trials showed that corticosteroids had no effect regardless of pancreatitis severity: mild, RR=1.25 (95%CI 0.92, 1.70); moderate, RR=0.96 (95%CI 0.62, 1.49); severe, 2.10 (95%CI 0.83, 5.33) but it showed an effect favoring placebo. CONCLUSION: There is no benefit in using corticosteroids to prevent ERCP-induced pancreatitis. There is even a tendency towards harm. Furthermore, the use of prednisone in patients with sphincterotomy is not recommended. Prospective studies for an agent to treat this complication should be conducted.
VOLUME 59, NO. 5, 2004
*T1537 Disconnected Pancreatic Tail Syndrome (DPTS): Clinical Features, Management, & Outcome Christopher Lawrence, Douglas A. Howell, Andreas M. Stefan, Donald E. Conklin, Frank J. Lukens, Ronald F. Martin, Andrew Landes, Becky Benz Background: The literature has inadequately reported the poor outcome of patients following complete pancreatic ductal disruption that produces a disconnected segment of viable functioning pancreas; the DPTS. Patients & Methods: From 3/97—6/03, 189 pts with pancreatic fluid collections and/or pancreatic fistulae were identified from our ERCP database. CT scans, ERCP images, and pt records were reviewed for evidence of the DPTS. A minimum of 6 month follow-up was required. Results: 30/189 pts (16%) met the criteria for the DPTS (mean age=48, range 31-80 yr; M:20/F:10). Presentations included pancreatic pseudocyst (n=22), post-operative fistula (n=3), pancreatic abscess/sepsis (n=2), and recurrent pancreatitis (n=3). Etiologies of pancreatitis were alcohol (40%), biliary (20%), hypertriglyceridemia (20%), idiopathic (10%), post-operative injury (7%), and pancreas divisum (7%). 26/30 (86%) of pts had necrotizing pancreatitis. Median follow-up was 38 months (range 6-94 mo). Outcome to date is as follows: 36 drainage procedures were performed on 27 pts (endoscopic transmural n=18, ERCP transpapillary n=12, surgical n=4, percutaneous n=2). Complete initial drainage was successful in 22/27 (81.5%) of pts. In long-term f/u, fluid collections recurred in 2/4 (50%) pts drained surgically and in 9/18 (50%) pts drained endoscopically. 12/30 (40%) pts have been managed successfully thus far without the need for operation. 18/30 (60%) pts have required a cumulative 48 surgical procedures (mean 2.7/pt). 4/30 (13%) pts have undergone resective surgery (L-sided pancreatectomy n=3, Whipple’s resection n=1). 7/18 pts required multiple debridements. Surgical intervention was required in 67% of pts with disruption within the head of the gland, 60% within the body, and none within the tail. 93 ERCPs have been performed (mean 3.1/pt). 13/30 (43%) pts have developed diabetes mellitus, 15/30 (50%) pts have developed L-sided portal hypertension, and 14/30 (47%) remain in active f/u for recurrent pancreatic symptoms and/or observation of a persistent fluid collection. Conclusions: The disconnected pancreatic tail syndrome (DPTS) deserves better recognition since affected patients and clinicians must anticipate a prolonged illness. The role of earlier, more aggressive surgical resection may shorten the illness, but also may increase the rate of diabetes, and may not be indicated in the majority. Multidisciplinary expertise is required to optimize outcome.
P208
GASTROINTESTINAL ENDOSCOPY
*T1538 Patent Accessory Pancreatic Duct Prevent Post-ERCP pancreatitis Terumi Kamisawa, Naoto Egawa, Hitoshi Nakajima, Atsutake Okamoto Background/Aims: Pancreatitis is the most important complication of ERCP. Moreover, efforts to understand its pathogenesis and to identify ways to reduce the frequency and severity of this complication have shown no convincing benefit to date. Although very complex factors are involved in the development of postERCP pancreatitis, mechanical injury to the papilla causing papillary edema and restriction of pancreatic juice flow, and hydrostatic injury from over-injection are the most common causes. We have prospectively examined patency of the accessory pancreatic duct (APD) by dye-injection ERP. We examined the role of the APD in vivo, and proposed a new way to prevent post-ERCP pancreatitis. Methods: During ERP, 2 or 3 ml of contrast medium containing indigo carmine was injected through a catheter in the main pancreatic duct (MPD) with usual pressure in 443 cases. Dye excretion from the minor papilla was then observed endoscopically. Results: Of 312 controls, patency of the APD was observed in 43%, whereas in 51 patients with acute pancreatitis, only 8 (16%) had a patent APD (p<0.01). In particular, patency of the APD was seen in only one of 17 patients with acute biliary pancreatitis. Patency of the APD showed a close relationship to the course and terminal shape of the APD. The long-type APD, which joined the MPD at its neck portion and ran straight from the upper dorsal pancreatic duct, was more frequently patent than the short-type APD which joined the MPD near its first inferior branch and followed a descending course (75.5% patency vs. 36.0%, p<0.01). Regarding terminal shape of the APD, patency of the cudgel (89.2%) and spindle type (92.0%) was more frequent than of the branch type (5.9%) or saccular type (16.7%) (p<0.01). According to the above findings, we retrospectively examined patency of the APD in 25 patients with acute pancreatitis after diagnostic ERP (6500 cases). Patency of the APD was estimated at only 8% (2/25). Furthermore, 3 cases showing acute pancreatitis after stone extraction with endoscopic balloon dilatation, exhibited nonpatent APD. Conclusions: A patent APD may prevent acute pancreatitis by lowering the pressure in the MPD. During ERCP, in cases with short type APD or APD with branch or saccular terminal shape, endoscopists should be more cautious and never persist when selective cannulation is difficult, or alternatively consider prophylactic pancreatic stenting.
*T1539 The Use of Corticosteroids in the Prevention of ERCP-Induced Pancreatitis: A Meta Analysis Ma Cecilia M. Sison, Jade D. Jamias, Ma Lourdes O. Daez RESEARCH QUESTION: Among patients undergoing ERCP, how effective are corticosteroids in reducing the incidence and severity of ERCP-induced pancreatitis? BACKGROUND: Pancreatitis is the most common major complication of ERCP occurring in 8% of cases. Most cases are fatal. Due to its anti-inflammatory effects, corticosteroids may reduce the frequency & severity of this complication. OBJECTIVES: To evaluate the effects of corticosteroids versus placebo in reducing the incidence of ERCP-induced pancreatitis in patients undergoing ERCP. Secondary objectives: To determine the effect of corticosteroids in reducing the severity of pancreatitis & its effect on pancreatitis incidence in sphincterotomy patients; to detect a difference between oral and IV steroids in the prevention of pancreatitis. INCLUSION CRITERIA: Randomized controlled trials comparing hydrocortisone, methylprednisolone or prednisone with placebo in reducing the frequency and severity of ERCP-induced pancreatitis were included. SEARCH STRATEGY: Electronic search of MEDLINE 1966-2003 & review of related articles STUDY MANEUVERS: Inclusion criteria, trial quality assessment and data extraction were done in duplicate. Subgroup analyses based on type of steroid and endoscopic intervention were done. STATISTICAL ANALYSIS: Relative risks (RR) were calculated using RevMan 4.2. Heterogeneity was checked via forest plots, chi-square & I2 tests. RESULTS: Five fair quality trials (n=2334) met the inclusion criteria. Pooled analysis of 5 homogenous trials showed that corticosteroids were not different from placebo in reducing ERCP-induced pancreatitis (RR=1.19; 95%CI 0.95,1.49). Subgroup analysis of patients with sphincterotomy during ERCP preserved this lack of effect (n=545 RR=1.42; 95%CI 0.88, 2.29). But 2 homogenous trials using prednisone showed a significant direction of effect favoring placebo (n=394 RR=1.89; 95% CI 1.06,3.36) in this subgroup of patients. Analysis of 4 homogenous trials showed that corticosteroids had no effect regardless of pancreatitis severity: mild, RR=1.25 (95%CI 0.92, 1.70); moderate, RR=0.96 (95%CI 0.62, 1.49); severe, 2.10 (95%CI 0.83, 5.33) but it showed an effect favoring placebo. CONCLUSION: There is no benefit in using corticosteroids to prevent ERCP-induced pancreatitis. There is even a tendency towards harm. Furthermore, the use of prednisone in patients with sphincterotomy is not recommended. Prospective studies for an agent to treat this complication should be conducted.
VOLUME 59, NO. 5, 2004