- Email: [email protected]
tail lesions and metastatic disease
AJG – September, Suppl., 2002
200 BIOABSORBABLE SELF–EXPANDING BILIARY ENDOPROSTHESES: LONG TERM EVALUATION IN A PORCINE MODEL Gregory G. Ginsberg, M.D.*, Janak N. Shah, M.D., Constantine Cope, M.D., Tanisha Martin, D.V.M., Anthony Carty, D.V.M., Perry Habecker, D.V.M., Carol Kaufmann and Claude Clerc. University of Pennsylvania, Philadelphia, PA; Secant Medical, LLC, Perkasie, PA and Bionx Implants, Blue Bell, PA. Purpose: Bioabsorbable stents may offer advantages over current stents for benign and malignant biliary strictures, including freedom from stent removal and the prospect of pharmaceutical impregnation. The BioStent (Bionx Implants, Blue Bell, PA) is composed of biocompatible polylactide (PLA) filaments, impregnated with barium sulfate for radiopacity. The braided stent is reinforced with biostable elastomeric axial runners providing improved radial force and full diameter recovery. We evaluated this stent in a porcine model. Methods: Endoscopic biliary stent (10mm d x 50mm l) placement was performed in 11 swine to achieve a cohort of 8 subjects. Ease of stent delivery, deployment, and radiological visualization were rated. Cholangiograms & serum bilirubin were assessed, and necropsy for histopathology was performed in pairs at 2, 4, 6, & 12 months. Results: 8 stents were easily deployed without a sphincterotomy. Immediate stent expansion was ⬎50% in 6, ⬎75%. Radiopacity was rated good in all cases. On follow– up, all stents fully expanded and bilirubin levels were normal. At 2 months (n⫽8), cholangiography showed 7 patent stents (1 with filling defects), 1 obstructed, and 2 dilated bile ducts. At 4 months (n⫽6): 6 stents patent (3 with filling defects including the obstructed stent at 2 months); 3 dilated bile ducts. At 6 months (n⫽4): 4 stents patent (3 with filling defects); 2 dilated bile ducts. One of the 12–month survival subjects died at 9 months. At necropsy, ductal dilation was observed, but the stent was not present. Its paired subject was sacrificed at 10 months. The bile duct appeared normal, but organized sludge occluded the structurally intact stent. On histopathology no bile duct integration or proliferative changes were seen at 2, 4, 6, or 9/10 mos. Conclusions: The BioStent bioabsorbable biliary stent modified with axial runners: 1) is effectively deployed endoscopically and is self– expanding 2) demonstrates satisfactory radiopacity due to barium sulfate impregnation 3) remains patent up to 6 mo. 4) is NOT associated with epithelial integration, inflammation, or proliferation 5) sludge accumulation and stent migration remain concerns 6) bioabsorption rate could not be determined. 201 PERFORATIONS OF THE GALL BLADDER: A REPORT OF TWO CASES Steven Ugbarugba, M.D.*, Mitchell Duterte, M.D., Mitchell Chorost, M.D. and Swaminath Iyer, M.D. Gastroenterology, State University of New York, Brooklyn, NY; Gastroenterology, State University of New York, Brooklyn, NY; Surgery, VA Medical Center, Brooklyn, NY and Gastroenterology, State University of New york, Brooklyn, NY. Background: Perforation of the gall bladder may develop early in the course of acute cholecystitis or as late as several weeks after onset. Depending on the rate and site of perforation, it may lead to peritonitis, pericholecystic abscess or bilioenteric fistula. We report two unusual cases of this rare condition. Case 1: A 52 year old man with history of diabetes mellitus and gallstone disease presented with right upper quadrant pain and fever. Jaundice,spider naevi, and ascites were noted on examination. His laboratory data revealed a WBC of 17,000/mm3, Bilirubin of 7.3mg/dl and ALP of 366 IU/L. CT scan showed dilated common bile duct, hepatic abscess with extensive intra and extra hepatic biliary air. EGD demonstrated exudation of bile from an antral opening at 7O’clock position. After a course of antibiotics, a repeat CT scan was ordered, which showed disappearance of previously noted pneumobilia and partial resolution of hepatic abscess. Following two failed ERCPs, percutaneous transhepatic cholangiogram was done which dem-
Abstracts
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onstrated cholecystogastric fistula with a large calculi obstructing the infundibulum of the gall bladder. He eventually had hepaticojejunostomy and was discharged home. Case 2: An 84 – year old male with history of diabetes presented with 1– month history of poor apetite, early satiety and weight loss. A day before admission,he had several episodes of hematemesis. Physical examination was remarkable for melena on digital rectal examination. His laboratory data is significant only for leukocytosis. EGD was then done, showing a mass–like lesion in the posterior duodenal bulb, with purulent exudates from an ulcerated site. Abdominal CT demonstrated air collections in the intrahepatic biliary system, distended gallbladder with calculus, and a fistulous tract between the gallbladder and the duodenum. Emergency laparotomy was performed. The histopathology of the resected gallbladder revealed adenocarcinoma and suppurative cholecystitis superimposed on perforated chronic cholecystitis. After a course of antibiotics, the patient was discharged home. Conclusion: Perforated gall badder with fistula formation is uncommon. Our two cases demonstrate a rare subtype (Case 1) and a rare etiology (Case 2). Management of bilioenteric fistula is tailored to the suspected etiology and type of fistula. Good outcome can be expected in early surgical intervention. 202 PRIOR BILIARY STENTING: AN ADJUNCT TO CRYOSURGICAL AND/OR RADIOFREQUENCY ABLATION OF METASTATIC LIVER DISEASE Ian Renner, M.D.,FACG*, Lori Rezabek–Kells, Ph.D., Mimi Chang, M.S.N., Kristina Neagos, R.N. and Linda Kinsolving, B.S.N. California Pnacreatico–Biliary Institute, Century City Hospital, Los Angeles, CA. Purpose: Recent advances in ablation of primary or metastatic liver tumor in patients with terminal metastatic disease are often stymied for fear of biliary leak or biloma. The issue of bile duct leak has become even more germaine with the advent of minimally–invasive CT– guided radio–frequency ablation (RFA) of metastatic liver lesions. Methods: We have treated a total of 16 patients over the past six years (1996 –2002) with hepatic metastatic tumor who were deemed inoperable since surgery would compromise the ductal system because of bifurcational tumor involvement. This heterogeneous group included metastatic disease from melanoma, breast, colon, ovary, renal, and others. Endoscopic retrograde cholangiogram (ERC) with sphincterotomy followed by metal or plastic stenting across the threatened biliary duct system was carried out in each case prior to cryosurgery and/or RFA. Nine patients had external RFA alone and seven patients underwent surgery with RFA and/or cryosurgical ablation to metastatic liver lesions. Results: Stenting allowed both radio–frequency ablation and/or cryoablation to be performed without seriously compromising biliary drainage in all patients. No biliary fistulas or bilomas occurred post–stenting. One patient with multiple liver metastases and jaundice from gastric leiomyosarcoma is alive six years post–metal stenting and cryosurgical ablation. Conclusions: Precise endoscopic stenting of tumor– compromised biliary structures can allow cryosurgical ablation and/or RFA of hepatic metastatic lesions. Although not curative, the reduction in tumor burden, with preservation of biliary drainage and often amelioration of jaundice, allows for reintroduction of chemotherapy. The increasing use of CT– guided RFA to palliate metastatic liver disease can be augmented by prior biliary stenting. 203 YOUNG PERSONS WITH PANCREATIC CANCER ARE MORE LIKELY TO HAVE BODY/TAIL LESIONS AND METASTATIC DISEASE Amar Al–Juburi, M.D., Daniel K. Brown, M.D. and Jean–Pierre Raufman, M.D.*. Department of Internal Medicine, Division of Gastroenterology, University of Arkansas for Medical Sciences, Little Rock, AR. Purpose: To compare the clinical presentation and course of young and older persons with pancreatic cancer.
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Abstracts
Methods: A chart review of all patients diagnosed with pancreatic cancer from January 1995 to December 2001 was performed with the objective of looking for differences between younger and older patients with pancreatic cancer. Factors examined included age, sex, race, past medical history, ethanol use, family history, histology and location of carcinoma (head or body/tail), and survival. For the purposes of this analysis we arbitrarily designated young patients as less than 45 years. Results: Fifty–nine patients were diagnosed with pancreatic cancer during this interval and of these 16 (9 men and 7 women) were young (mean age 34 yrs, range 20 – 44 yrs). Forty three patients (21 men and 22 women) were older (mean age 63 yrs, range 45– 87 yrs). Body/tail lesions occurred in 8 young patients (50%) and in 8 older patients (18%), (P⫽0.02, Fisher’s exact test). Diabetes mellitus was present in 8 of 43 older patients (18%) and in none of the young patients (P⫽ 0.07). Three of the young patients (19%) and none of the older patients had a family history of pancreatic cancer (P⫽ 0.02). When comparing the two age groups, differences in sex, race, ethanol use, and survival following diagnosis were not significant. At diagnosis, regardless of age, all 16 patients with body/tail lesions had metastases, compared to 29 of 43 patients (67%) with head lesions (P⬍0.01). Conclusions: Young persons with pancreatic cancer are more likely to have body/tail lesions and metastases at diagnosis. Characterization of genetic abnormalities associated with pancreatic cancer may elucidate the reasons for the differences observed in these age groups.
204 AN ENDOSCOPIC PANCREATIC FUNCTION TEST (EPFT) USING SYNTHETIC PORCINE SECRETIN (SPS) FOR THE ASSESSMENT OF CHRONIC PANCREATITIS (CP) AND CHRONIC ABDOMINAL PAIN (CAP): COMPARISON TO RETROGRADE PANCREATOGRAM (ERCP) AND ENDOSCOPIC ULTRASOUND (EUS) Darwin L. Conwell, M.D.*, Gregory Zuccaro, M.D., John J. Vargo, M.D., Frederick VanLente, M.D., Ph.D., Patricia Trolli, B.S.N., R.N.,C.G.RN. and John A. Dumot, D.O. The Pancreas Clinic, Departments of Gastroenterology and Laboratory Medicine, Section of Endoscopy and Pancreatic Diseases, Cleveland Clinic Foundation, Cleveland, OH. Purpose: Diagnosing early CP is challenging. ERCP, the radiologic gold standard, allows classification of CP but has significant potential complications. EUS identifies parenchymal and duct morphology changes seen in CP but does not assess pancreatic secretory function. We have developed an endoscopic function test (ePFT) that can be done at the time of upper endoscopy/endosonography using synthetic porcine secretin (SecreFlo, Repligen, Waltham, MA) as the pancreatic stimulant. AIMS: 1) Validate the ePFT and 2) Determine the accuracy of combined ePFT and EUS in establishing the diagnosis of CP. Methods: Pts referred to The Pancreas Clinic for the evaluation of CAP and symptomatic CP underwent ePFT and ERCP. A subset of pts also underwent EUS with ePFT. All final diagnoses (CP or normal) were based on duct morphological changes on retrograde pancreatogram. Established EUS ductal/parenchymal features for CP were determined at the time of EUS by a single examiner. ePFT procedure: 1) IV synthetic secretin test dose (0.2 mcg), 2) Full dose secretin(0.2 mcg/kg), 3) Upper endoscopy with conscious sedation, 4) Duodenal fluid aspiration @ 0, 15, 30, 45, and 60 minutes and 5) Fluid analysis with lab autoanalyzer for peak bicarbonate concentration (Normal ⬎ 80 meq/L). Results: 19 pts had CP with abnormal pancreatograms and 17 pts had CAP with normal pancreatograms. All pts underwent ePFT. Peak bicarbonate occurred by 30 minutes in 60% of pts. There was little change in bicarbonate concentrations after the 30 minute collection period. A single aspiration during the 30 minute collection period would yield a correct diagnosis in 34/36 (94.4%) pts. 10 pts (8 abnormal / 2 normal pancreatogram) had EUS in addition to ePFT. The sensitivities and specificities of ePFT, EUS and combined EUS–PFT are shown in Table.
AJG – Vol. 97, No. 9, Suppl., 2002
Comparison of ePFT, EUS and EUS–PFT in the evaluation of Chronic Abdominal Pain (CAP) and Chronic Pancreatitis (CP) Test
Sensitivity
Specificity
EPFT only (n⫽36) EUS only (n⫽10) EUS and Epft
95 100 100
76 50 100
Conclusions: 1) The ePFT with sPS has excellent correlation to ERCP for the diagnosis of CP. 2) The ePFT one hour collection period can be shortened to a timed aspiration at 30 minutes with good accuracy. 3) Combining EUS and ePFT provides perfect agreement with retrograde pancreatogram and eliminates the need for ERCP in patients with chronic abdominal pain.
205 PERCUTANEOUS CHOLECYSTOSTOMY IN PATIENTS WITH ACUTE CHOLECYSTITIS–––EXPERIENCE OF 45 PATIENTS AT A US REFERRAL CENTER Michael F. Byrne, M.D., Paul Suhocki, M.D., Robert M. Mitchell, M.B.B.Ch., Theodore N. Pappas, M.D., Helen L. Stiffler, B.S.N., Paul S. Jowell, M.D., Malcolm S. Branch, M.D. and John Baillie, M.B.Ch.B.*. Division of Gastroenterology, Department of Medicine, Duke University Health System, Durham, NC. Purpose: The standard treatment for acute cholecystitis is cholecystectomy but some patients (pts) are high risk for immediate surgery. Percutaneous cholecystostomy may be the procedure of choice in this group. We reviewed the experience in a large tertiary center. Methods: Retrospective analysis of pts who had percutaneous cholecystostomy from Jul ‘99 to Mar ‘02 was performed. Information was collected regarding reasons for cholecystostomy and duration of placement, clinical outcome, death within 30 days of procedure, complications, aspirated bile culture, gallbladder contents, and incidence of subsequent cholecystectomy. Results: 45 pts (19 F) had cholecystostomies over study period. Mean age was 63 yrs (range 3– 89). The indication for cholecystostomy was confirmed or presumed acute cholecystitis in all pts. Procedures were done under fluoroscopic and sonographic guidance. Technical success rate was 100%. Average duration of tube insertion was 54.3 days (range 1–357 days). 35 pts (78%) improved clinically within 5 days. The remaining 9 pts (20%) deteriorated and died within 30 days; only one of these deaths was directly related to a gallbladder source of sepsis. 9 pts (20%) subsequently had laparoscopic cholecystectomy; 8 pts (18%) had open cholecystectomy; 2 pts (4.5%) had a cholecystoenterostomy. Cholecystectomy was planned in a further 5 pts (lost to follow– up or continued follow– up). There were 2 pts with leaking and 4 with blocked cholecystostomies. In 1 pt, the tube became dislodged, and 1 pt developed a hemoperitoneum. Bile aspirated at cholecystostomy had positive culture in 12 (27%) pts, negative culture in 16 (36%), and was not sent/recorded in 17 (38%) pts. 22 pts (49%) had gallstones alone, 10 (22%) had sludge alone, 4 (9%) had both, and 4 (9%) had neither. Conclusions: Percutaneous cholecystostomy is relatively easy to perform with a low complication and high success rate. It is probably the procedure of choice in pts with acute cholecystitis who are unfit for early surgery. It often allows the patient improve clinically such that cholecystectomy can be done electively.
206 INFLUENCE OF PREOPERATIVE GASTRIC EMPTYING ASSESSMENT ON OUTCOME OF CHOLECYSTECTOMY DONE FOR IMPAIRED GALLBLADDER EMPTYING Angela Cole and Philip B. Miner, Jr., M.D., FACG*. Oklahoma Foundation for Digestive Research, Oklahoma City, OK.
200 BIOABSORBABLE SELF–EXPANDING BILIARY ENDOPROSTHESES: LONG TERM EVALUATION IN A PORCINE MODEL Gregory G. Ginsberg, M.D.*, Janak N. Shah, M.D., Constantine Cope, M.D., Tanisha Martin, D.V.M., Anthony Carty, D.V.M., Perry Habecker, D.V.M., Carol Kaufmann and Claude Clerc. University of Pennsylvania, Philadelphia, PA; Secant Medical, LLC, Perkasie, PA and Bionx Implants, Blue Bell, PA. Purpose: Bioabsorbable stents may offer advantages over current stents for benign and malignant biliary strictures, including freedom from stent removal and the prospect of pharmaceutical impregnation. The BioStent (Bionx Implants, Blue Bell, PA) is composed of biocompatible polylactide (PLA) filaments, impregnated with barium sulfate for radiopacity. The braided stent is reinforced with biostable elastomeric axial runners providing improved radial force and full diameter recovery. We evaluated this stent in a porcine model. Methods: Endoscopic biliary stent (10mm d x 50mm l) placement was performed in 11 swine to achieve a cohort of 8 subjects. Ease of stent delivery, deployment, and radiological visualization were rated. Cholangiograms & serum bilirubin were assessed, and necropsy for histopathology was performed in pairs at 2, 4, 6, & 12 months. Results: 8 stents were easily deployed without a sphincterotomy. Immediate stent expansion was ⬎50% in 6, ⬎75%. Radiopacity was rated good in all cases. On follow– up, all stents fully expanded and bilirubin levels were normal. At 2 months (n⫽8), cholangiography showed 7 patent stents (1 with filling defects), 1 obstructed, and 2 dilated bile ducts. At 4 months (n⫽6): 6 stents patent (3 with filling defects including the obstructed stent at 2 months); 3 dilated bile ducts. At 6 months (n⫽4): 4 stents patent (3 with filling defects); 2 dilated bile ducts. One of the 12–month survival subjects died at 9 months. At necropsy, ductal dilation was observed, but the stent was not present. Its paired subject was sacrificed at 10 months. The bile duct appeared normal, but organized sludge occluded the structurally intact stent. On histopathology no bile duct integration or proliferative changes were seen at 2, 4, 6, or 9/10 mos. Conclusions: The BioStent bioabsorbable biliary stent modified with axial runners: 1) is effectively deployed endoscopically and is self– expanding 2) demonstrates satisfactory radiopacity due to barium sulfate impregnation 3) remains patent up to 6 mo. 4) is NOT associated with epithelial integration, inflammation, or proliferation 5) sludge accumulation and stent migration remain concerns 6) bioabsorption rate could not be determined. 201 PERFORATIONS OF THE GALL BLADDER: A REPORT OF TWO CASES Steven Ugbarugba, M.D.*, Mitchell Duterte, M.D., Mitchell Chorost, M.D. and Swaminath Iyer, M.D. Gastroenterology, State University of New York, Brooklyn, NY; Gastroenterology, State University of New York, Brooklyn, NY; Surgery, VA Medical Center, Brooklyn, NY and Gastroenterology, State University of New york, Brooklyn, NY. Background: Perforation of the gall bladder may develop early in the course of acute cholecystitis or as late as several weeks after onset. Depending on the rate and site of perforation, it may lead to peritonitis, pericholecystic abscess or bilioenteric fistula. We report two unusual cases of this rare condition. Case 1: A 52 year old man with history of diabetes mellitus and gallstone disease presented with right upper quadrant pain and fever. Jaundice,spider naevi, and ascites were noted on examination. His laboratory data revealed a WBC of 17,000/mm3, Bilirubin of 7.3mg/dl and ALP of 366 IU/L. CT scan showed dilated common bile duct, hepatic abscess with extensive intra and extra hepatic biliary air. EGD demonstrated exudation of bile from an antral opening at 7O’clock position. After a course of antibiotics, a repeat CT scan was ordered, which showed disappearance of previously noted pneumobilia and partial resolution of hepatic abscess. Following two failed ERCPs, percutaneous transhepatic cholangiogram was done which dem-
Abstracts
S67
onstrated cholecystogastric fistula with a large calculi obstructing the infundibulum of the gall bladder. He eventually had hepaticojejunostomy and was discharged home. Case 2: An 84 – year old male with history of diabetes presented with 1– month history of poor apetite, early satiety and weight loss. A day before admission,he had several episodes of hematemesis. Physical examination was remarkable for melena on digital rectal examination. His laboratory data is significant only for leukocytosis. EGD was then done, showing a mass–like lesion in the posterior duodenal bulb, with purulent exudates from an ulcerated site. Abdominal CT demonstrated air collections in the intrahepatic biliary system, distended gallbladder with calculus, and a fistulous tract between the gallbladder and the duodenum. Emergency laparotomy was performed. The histopathology of the resected gallbladder revealed adenocarcinoma and suppurative cholecystitis superimposed on perforated chronic cholecystitis. After a course of antibiotics, the patient was discharged home. Conclusion: Perforated gall badder with fistula formation is uncommon. Our two cases demonstrate a rare subtype (Case 1) and a rare etiology (Case 2). Management of bilioenteric fistula is tailored to the suspected etiology and type of fistula. Good outcome can be expected in early surgical intervention. 202 PRIOR BILIARY STENTING: AN ADJUNCT TO CRYOSURGICAL AND/OR RADIOFREQUENCY ABLATION OF METASTATIC LIVER DISEASE Ian Renner, M.D.,FACG*, Lori Rezabek–Kells, Ph.D., Mimi Chang, M.S.N., Kristina Neagos, R.N. and Linda Kinsolving, B.S.N. California Pnacreatico–Biliary Institute, Century City Hospital, Los Angeles, CA. Purpose: Recent advances in ablation of primary or metastatic liver tumor in patients with terminal metastatic disease are often stymied for fear of biliary leak or biloma. The issue of bile duct leak has become even more germaine with the advent of minimally–invasive CT– guided radio–frequency ablation (RFA) of metastatic liver lesions. Methods: We have treated a total of 16 patients over the past six years (1996 –2002) with hepatic metastatic tumor who were deemed inoperable since surgery would compromise the ductal system because of bifurcational tumor involvement. This heterogeneous group included metastatic disease from melanoma, breast, colon, ovary, renal, and others. Endoscopic retrograde cholangiogram (ERC) with sphincterotomy followed by metal or plastic stenting across the threatened biliary duct system was carried out in each case prior to cryosurgery and/or RFA. Nine patients had external RFA alone and seven patients underwent surgery with RFA and/or cryosurgical ablation to metastatic liver lesions. Results: Stenting allowed both radio–frequency ablation and/or cryoablation to be performed without seriously compromising biliary drainage in all patients. No biliary fistulas or bilomas occurred post–stenting. One patient with multiple liver metastases and jaundice from gastric leiomyosarcoma is alive six years post–metal stenting and cryosurgical ablation. Conclusions: Precise endoscopic stenting of tumor– compromised biliary structures can allow cryosurgical ablation and/or RFA of hepatic metastatic lesions. Although not curative, the reduction in tumor burden, with preservation of biliary drainage and often amelioration of jaundice, allows for reintroduction of chemotherapy. The increasing use of CT– guided RFA to palliate metastatic liver disease can be augmented by prior biliary stenting. 203 YOUNG PERSONS WITH PANCREATIC CANCER ARE MORE LIKELY TO HAVE BODY/TAIL LESIONS AND METASTATIC DISEASE Amar Al–Juburi, M.D., Daniel K. Brown, M.D. and Jean–Pierre Raufman, M.D.*. Department of Internal Medicine, Division of Gastroenterology, University of Arkansas for Medical Sciences, Little Rock, AR. Purpose: To compare the clinical presentation and course of young and older persons with pancreatic cancer.
S68
Abstracts
Methods: A chart review of all patients diagnosed with pancreatic cancer from January 1995 to December 2001 was performed with the objective of looking for differences between younger and older patients with pancreatic cancer. Factors examined included age, sex, race, past medical history, ethanol use, family history, histology and location of carcinoma (head or body/tail), and survival. For the purposes of this analysis we arbitrarily designated young patients as less than 45 years. Results: Fifty–nine patients were diagnosed with pancreatic cancer during this interval and of these 16 (9 men and 7 women) were young (mean age 34 yrs, range 20 – 44 yrs). Forty three patients (21 men and 22 women) were older (mean age 63 yrs, range 45– 87 yrs). Body/tail lesions occurred in 8 young patients (50%) and in 8 older patients (18%), (P⫽0.02, Fisher’s exact test). Diabetes mellitus was present in 8 of 43 older patients (18%) and in none of the young patients (P⫽ 0.07). Three of the young patients (19%) and none of the older patients had a family history of pancreatic cancer (P⫽ 0.02). When comparing the two age groups, differences in sex, race, ethanol use, and survival following diagnosis were not significant. At diagnosis, regardless of age, all 16 patients with body/tail lesions had metastases, compared to 29 of 43 patients (67%) with head lesions (P⬍0.01). Conclusions: Young persons with pancreatic cancer are more likely to have body/tail lesions and metastases at diagnosis. Characterization of genetic abnormalities associated with pancreatic cancer may elucidate the reasons for the differences observed in these age groups.
204 AN ENDOSCOPIC PANCREATIC FUNCTION TEST (EPFT) USING SYNTHETIC PORCINE SECRETIN (SPS) FOR THE ASSESSMENT OF CHRONIC PANCREATITIS (CP) AND CHRONIC ABDOMINAL PAIN (CAP): COMPARISON TO RETROGRADE PANCREATOGRAM (ERCP) AND ENDOSCOPIC ULTRASOUND (EUS) Darwin L. Conwell, M.D.*, Gregory Zuccaro, M.D., John J. Vargo, M.D., Frederick VanLente, M.D., Ph.D., Patricia Trolli, B.S.N., R.N.,C.G.RN. and John A. Dumot, D.O. The Pancreas Clinic, Departments of Gastroenterology and Laboratory Medicine, Section of Endoscopy and Pancreatic Diseases, Cleveland Clinic Foundation, Cleveland, OH. Purpose: Diagnosing early CP is challenging. ERCP, the radiologic gold standard, allows classification of CP but has significant potential complications. EUS identifies parenchymal and duct morphology changes seen in CP but does not assess pancreatic secretory function. We have developed an endoscopic function test (ePFT) that can be done at the time of upper endoscopy/endosonography using synthetic porcine secretin (SecreFlo, Repligen, Waltham, MA) as the pancreatic stimulant. AIMS: 1) Validate the ePFT and 2) Determine the accuracy of combined ePFT and EUS in establishing the diagnosis of CP. Methods: Pts referred to The Pancreas Clinic for the evaluation of CAP and symptomatic CP underwent ePFT and ERCP. A subset of pts also underwent EUS with ePFT. All final diagnoses (CP or normal) were based on duct morphological changes on retrograde pancreatogram. Established EUS ductal/parenchymal features for CP were determined at the time of EUS by a single examiner. ePFT procedure: 1) IV synthetic secretin test dose (0.2 mcg), 2) Full dose secretin(0.2 mcg/kg), 3) Upper endoscopy with conscious sedation, 4) Duodenal fluid aspiration @ 0, 15, 30, 45, and 60 minutes and 5) Fluid analysis with lab autoanalyzer for peak bicarbonate concentration (Normal ⬎ 80 meq/L). Results: 19 pts had CP with abnormal pancreatograms and 17 pts had CAP with normal pancreatograms. All pts underwent ePFT. Peak bicarbonate occurred by 30 minutes in 60% of pts. There was little change in bicarbonate concentrations after the 30 minute collection period. A single aspiration during the 30 minute collection period would yield a correct diagnosis in 34/36 (94.4%) pts. 10 pts (8 abnormal / 2 normal pancreatogram) had EUS in addition to ePFT. The sensitivities and specificities of ePFT, EUS and combined EUS–PFT are shown in Table.
AJG – Vol. 97, No. 9, Suppl., 2002
Comparison of ePFT, EUS and EUS–PFT in the evaluation of Chronic Abdominal Pain (CAP) and Chronic Pancreatitis (CP) Test
Sensitivity
Specificity
EPFT only (n⫽36) EUS only (n⫽10) EUS and Epft
95 100 100
76 50 100
Conclusions: 1) The ePFT with sPS has excellent correlation to ERCP for the diagnosis of CP. 2) The ePFT one hour collection period can be shortened to a timed aspiration at 30 minutes with good accuracy. 3) Combining EUS and ePFT provides perfect agreement with retrograde pancreatogram and eliminates the need for ERCP in patients with chronic abdominal pain.
205 PERCUTANEOUS CHOLECYSTOSTOMY IN PATIENTS WITH ACUTE CHOLECYSTITIS–––EXPERIENCE OF 45 PATIENTS AT A US REFERRAL CENTER Michael F. Byrne, M.D., Paul Suhocki, M.D., Robert M. Mitchell, M.B.B.Ch., Theodore N. Pappas, M.D., Helen L. Stiffler, B.S.N., Paul S. Jowell, M.D., Malcolm S. Branch, M.D. and John Baillie, M.B.Ch.B.*. Division of Gastroenterology, Department of Medicine, Duke University Health System, Durham, NC. Purpose: The standard treatment for acute cholecystitis is cholecystectomy but some patients (pts) are high risk for immediate surgery. Percutaneous cholecystostomy may be the procedure of choice in this group. We reviewed the experience in a large tertiary center. Methods: Retrospective analysis of pts who had percutaneous cholecystostomy from Jul ‘99 to Mar ‘02 was performed. Information was collected regarding reasons for cholecystostomy and duration of placement, clinical outcome, death within 30 days of procedure, complications, aspirated bile culture, gallbladder contents, and incidence of subsequent cholecystectomy. Results: 45 pts (19 F) had cholecystostomies over study period. Mean age was 63 yrs (range 3– 89). The indication for cholecystostomy was confirmed or presumed acute cholecystitis in all pts. Procedures were done under fluoroscopic and sonographic guidance. Technical success rate was 100%. Average duration of tube insertion was 54.3 days (range 1–357 days). 35 pts (78%) improved clinically within 5 days. The remaining 9 pts (20%) deteriorated and died within 30 days; only one of these deaths was directly related to a gallbladder source of sepsis. 9 pts (20%) subsequently had laparoscopic cholecystectomy; 8 pts (18%) had open cholecystectomy; 2 pts (4.5%) had a cholecystoenterostomy. Cholecystectomy was planned in a further 5 pts (lost to follow– up or continued follow– up). There were 2 pts with leaking and 4 with blocked cholecystostomies. In 1 pt, the tube became dislodged, and 1 pt developed a hemoperitoneum. Bile aspirated at cholecystostomy had positive culture in 12 (27%) pts, negative culture in 16 (36%), and was not sent/recorded in 17 (38%) pts. 22 pts (49%) had gallstones alone, 10 (22%) had sludge alone, 4 (9%) had both, and 4 (9%) had neither. Conclusions: Percutaneous cholecystostomy is relatively easy to perform with a low complication and high success rate. It is probably the procedure of choice in pts with acute cholecystitis who are unfit for early surgery. It often allows the patient improve clinically such that cholecystectomy can be done electively.
206 INFLUENCE OF PREOPERATIVE GASTRIC EMPTYING ASSESSMENT ON OUTCOME OF CHOLECYSTECTOMY DONE FOR IMPAIRED GALLBLADDER EMPTYING Angela Cole and Philip B. Miner, Jr., M.D., FACG*. Oklahoma Foundation for Digestive Research, Oklahoma City, OK.