Triple-tissue sampling at ERCP in malignant biliary obstruction

BACKGROUND

Procurement of cytologic samples by brushing is common practice at endoscopic retrograde cholangiopancreatography (ERCP) but has low sensitivity for cancer detection. Limited data are available on other techniques, including endoluminal fine-needle aspiration and forceps biopsy. This series reviews the yield of these three stricture sampling methods.

METHODS

In this prospective study, patients with biliary obstruction with a clinical suspicion of malignancy underwent triple-tissue sampling at one ERCP session. Final cancer diagnosis was based on all sampling methods plus surgery, autopsy, and clinical follow-up. Tissue specimens were reported as normal, atypia, or malignant.

RESULTS

A total of 133 patients were evaluated: 104 had cancer and 29 had benign strictures. Tissue sampling sensitivity varied according to the type of cancer; the highest yield was seen in ampullary cancers (62% to 85%). The cumulative sensitivity of triple-tissue sampling in the cancer patients was as follows: sensitivity was 52% if atypia was considered benign and 77% if it was considered malignant. The addition of a second or third technique increased sensitivity rates in most instances. No serious complications occurred from the tissue sampling methods.

CONCLUSIONS

Tissue sampling sensitivity varied according to the type of cancer. Combining a second or third method increased sensitivity; general use of at least two sampling methods is therefore recommended.

Role of EUS in the preoperative staging of pancreatic cancer: a large single-center experience

BACKGROUND

Current methods for staging pancreatic cancer can be inaccurate, invasive, and expensive. Endoscopic ultrasound (EUS) is reported to be highly accurate for local staging of gastrointestinal tumors including pancreatic cancer. The aim of this study was to assess the utility of EUS and CT for staging pancreatic cancer by comparing staging accuracies in surgical patients and evaluating the potential impact of EUS staging and training.

METHODS

This was a preoperative comparison of the diagnostic operating characteristics of these procedures in a referral-based academic medical center. Data were collected on 151 consecutive patients referred with confirmed pancreatic cancer between April 1990 and November 1996. All patients had preoperative CT and EUS performed for staging. In patients undergoing surgery, the surgical staging and/or findings were used to confirm EUS and CT staging.

RESULTS

Eighty-one (60%) of 151 patients underwent surgery and made up the study subset. In these 81 patients, surgical exploration provided a final T staging in 93% (75 of 81), N staging in 88% (71 of 81) and data on vascular invasion in 93% (75 of 81). In the surgical patient group, with surgical correlation, EUS accuracy for T staging was as follows: T1 92%, T2 85%, T3 93%, and for N staging was: N0 72%, and N1 72%. CT accuracy for T staging was as follows: T1 65%, T2 67%, T3 38%, and for N staging was as follows: N0 52% and N1 100%. CT failed to detect a mass in 26% of patients with a confirmed tumor at surgery. Overall accuracy for T and N staging was 85% and 72% for EUS and 30% and 55% for CT, respectively. The ability to accurately predict vascular invasion was 93% for EUS and 62% for CT (p < 0.001). EUS was 93% accurate for predicting local resectability versus 60% for CT (p < 0.001). Last, the data were divided into two groups for the senior endosonographer's experience: procedures performed between 1990 and 1992 (98 cases) and 1993 and 1994 (53 cases). This analysis revealed that 7 of 9 instances of mis-staging (78%) occurred in the earlier group, during the learning phase for EUS.

CONCLUSIONS

EUS is more accurate than CT for staging pancreatic malignancies, including predicting vascular invasion and local resectability. EUS staging was significantly better than CT for T1, T2, and T3 tumors. EUS staging accuracy improved after 100 cases, thus suggesting a correlation between the accuracy of EUS staging and the number of procedures performed.

Frequency of abnormal pancreatic and biliary sphincter manometry compared with clinical suspicion of sphincter of Oddi dysfunction

BACKGROUND

Sphincter of Oddi manometry as performed at ERCP is the most accepted method to evaluate for sphincter of Oddi dysfunction. To fully assess for sphincter of Oddi dysfunction, both the pancreatic and the bile ducts must be evaluated. We assessed the frequency of pancreatic and biliary sphincter abnormalities in a large series of patients.

METHODS

A total of 593 patients underwent manometry of the biliary and pancreatic ducts at one endoscopic retrograde cholangiopancreatography session. Basal sphincter pressure greater than or equal to 40 mm Hg was considered abnormal. Phasic waves were not evaluated. Manometric abnormalities were correlated with the clinical presentation as categorized using a modified Geenen/Hogan classification.

RESULTS

Of 360 patients with intact sphincters, 18.9% had abnormal pancreatic sphincter basal pressure alone, 11.4% had abnormal biliary basal sphincter pressure alone, and in 31.4% the basal pressure was abnormal for both sphincters; thus, 60.1% of the patients had sphincter dysfunction. The frequency of sphincter of Oddi dysfunction did not differ whether typed by biliary or pancreatic criteria: approximately 65% type II and 59% type III. Of patients without pancreatitis, 55.9% had an abnormal basal sphincter pressure, whereas sphincter dysfunction was present in 72.3% of those with idiopathic pancreatitis and 53.9% of patients with chronic pancreatitis. Of patients with an ablated biliary sphincter, 45.9% had abnormal basal pancreatic sphincter pressure and only 0.6% had an abnormal biliary sphincter pressure alone. Abnormal pressure in both sphincters was found in 9.3%.

CONCLUSION

If both portions of the sphincter of Oddi are studied simultaneously, abnormalities are found very commonly (55% to 72%). Assessment of both sides of the sphincter is necessary. Classifying patients according to both pancreatic and biliary sphincter segments is cumbersome, and may be replaced by an overall type. Using this modified classification, the frequency of sphincter of Oddi dysfunction is similar in both type II and type III patients (59% to 67%).

Endoscopic therapy in anomalous pancreatobiliary duct junction

BACKGROUND

Anomalous pancreaticobiliary duct junction is associated with bile duct strictures, pancreatitis, choledochal cysts, and biliary carcinoma. Limited data are available for outcomes of endoscopic therapy.

METHODS

Review of 7537 patients undergoing endoscopic retrograde cholangiopancreatography from 1988 to 1997 yielded 18 patients with anomalous pancreaticobiliary duct junction. Therapeutic responses were tallied by chart review and phone calls.

RESULTS

There were 13 women and 5 men, with a mean age of 36 years. Twelve patients had no ductographic evidence of pancreatitis and 6 had chronic pancreatitis. Seven had choledochal cysts. Fifteen patients (83%) underwent endoscopic biliary sphincterotomy, two of whom underwent repeat endoscopic biliary sphincterotomy for recurrence of symptoms. The other therapies included stent placement for benign biliary strictures in 5 patients, lithotripsy of pancreatic stones in 1 patient, and choledochal cyst removal in 4 patients. Three cases with malignant biliary strictures are excluded from endoscopic outcome studies. The 12 patients with pancreatitis had a mean of 2.0 episodes per year before any treatment. After endoscopic therapy 7 patients had no further episodes of pancreatitis, whereas 5 patients had further episodes, with a mean of one additional attack per year, over 3 years mean follow-up.

CONCLUSIONS

Patients with anomalous pancreaticobiliary duct junction have complex pathology associated with strictures, choledochal cysts, pancreatitis, and malignancies. Endoscopic therapy appeared to benefit 13 of 15 patients without malignant disease with elimination of or decreased frequency of pancreatitis. Endoscopic therapy appears to be a logical first step in the management of most symptomatic patients with anomalous pancreaticobiliary duct junction.

Classification and management of perforations complicating endoscopic sphincterotomy

BACKGROUND

The management of perforations after endoscopic sphincterotomy (ES) is controversial. The purpose of this study was to analyze the treatments and outcome of patients with ES perforations.

METHODS

Between January 1994 and July 1998, in a series of 6040 endoscopic retrograde cholangiopancreatographies, 2874 (48%) ESs were performed: 40 patients (0.6%) with perforation were identified and retrospectively reviewed.

RESULTS

All patients (n = 14) with guidewire perforation (group I) were recognized early, managed medically, and discharged after a mean hospital stay of 3.5 days. Twenty of 22 patients with periampullary perforation (group II) were identified early; 18 patients (90%) had aggressive endoscopic drainage, and none required operation. Of the 2 patients identified late, 1 patient required operation and subsequently died. Mean hospital stay for this group was 8.5 days. Only 1 of 4 patients with duodenal perforations (group III) was identified early; all required operation; 1 patient died, and the mean hospital stay was 19.5 days.

CONCLUSIONS

ES perforation has 3 distinct types: guidewire, periampullary, and duodenal. Guidewire perforations are recognized early and resolve with medical treatment. Periampullary perforations diagnosed early respond to aggressive endoscopic drainage and medical treatment. Postsphincterotomy perforations diagnosed late (particularly duodenal) require surgical drainage, which carries a high morbidity and mortality rate.

Classification and management of perforations complicating endoscopic sphincterotomy

BACKGROUND

The management of perforations after endoscopic sphincterotomy (ES) is controversial. The purpose of this study was to analyze the treatments and outcome of patients with ES perforations.

METHODS

Between January 1994 and July 1998, in a series of 6040 endoscopic retrograde cholangiopancreatographies, 2874 (48%) ESs were performed: 40 patients (0.6%) with perforation were identified and retrospectively reviewed.

RESULTS

All patients (n = 14) with guidewire perforation (group I) were recognized early, managed medically, and discharged after a mean hospital stay of 3.5 days. Twenty of 22 patients with periampullary perforation (group II) were identified early; 18 patients (90%) had aggressive endoscopic drainage, and none required operation. Of the 2 patients identified late, 1 patient required operation and subsequently died. Mean hospital stay for this group was 8.5 days. Only 1 of 4 patients with duodenal perforations (group III) was identified early; all required operation; 1 patient died, and the mean hospital stay was 19.5 days.

CONCLUSIONS

ES perforation has 3 distinct types: guidewire, periampullary, and duodenal. Guidewire perforations are recognized early and resolve with medical treatment. Periampullary perforations diagnosed early respond to aggressive endoscopic drainage and medical treatment. Postsphincterotomy perforations diagnosed late (particularly duodenal) require surgical drainage, which carries a high morbidity and mortality rate.

Pancreatitis and cystic fibrosis gene mutations

Cystic fibrosis (CF) is a genetic disease with multisystem involvement in which defective chloride transport across membranes causes dehydrated secretions. The protein encoded by the CF gene--the cystic fibrosis transmembrane conductance regulator (CFTR)--functions as a cyclic adenosine monophosphate-regulated chloride channel. The ability to detect CFTR mutations has led to the recognition of its association with a variety of conditions, including chronic bronchitis, sinusitis with nasal polyps, pancreatitis, and, in men, infertility. This article reviews the impact of CF on the pancreas, the role of the CFTR protein in pancreatic secretion, and some of the exciting research identifying mutations in the CFTR gene as a risk factor for idiopathic acute and chronic pancreatitis.

Maxillary canine restoration: a case report

The replacement of a single tooth with osseointegrated dental implants presents a unique challenge to both the prosthodontist and the surgeon. When anterior teeth are replaced, it is difficult to design an occlusal scheme that will direct forces down the long axis of an implant. This is especially true when the canine is involved. Wide-diameter implants offer advantages, such as increased surface area of implant to bone, stronger prosthetics, stronger implants, and less screw loosening or breakage when compared to standard-diameter implants. The single-stage technique is advantageous in terms of soft-tissue predictability, and it eliminates the need for second-stage surgery.

Z-stent for malignant esophageal obstruction

The Z-stent was one of the first self-expanding metal prostheses used for palliation of malignant esophageal obstruction and respiratory esophageal fistula. Its placement has proved to be effective and relatively safe. This article reviews the evolution of the Z-stent; its multiple designs, placement technique, efficacy, complications, and assets and limitations.

Therapeutic biliary endoscopy

Therapeutic biliary endoscopy continues to evolve; some small but important developments were seen during the last year. Competing technologies are continuing to develop.

Contemporary treatment strategies for external pancreatic fistulas

BACKGROUND

Optimal treatment strategies for patients with external pancreatic fistulas have evolved with improved radiographic imaging and the development of transpapillary pancreatic duct stents. The aim of this study was to examine factors affecting fistula closure and develop a classification scheme to guide therapeutic interventions.

METHODS

Retrospective chart review was made of all patients with external pancreatic fistulas treated at our institution from January 1991 to January 1997. Side (partial) fistulas maintained continuity with the gastrointestinal tract; end (complete) fistulas had no continuity with the gastrointestinal tract.

RESULTS

Postoperative side fistulas resolved with medical treatment in 13 (86%) of 15 patients after a mean of 11 weeks of conservative management. Inflammatory side fistulas resolved with medical treatment in only 8 (53%) of 15 patients after a mean of 22 weeks; those that did not close initially did so with transpapillary stenting. End pancreatic fistulas never closed with medical treatment and were unable to be stented; therefore internal drainage or pancreatic resection was necessary to achieve closure. There were no differences in sepsis rates, Acute Physiology and Chronic Health Evaluation II scores, fistula site, total parenteral nutrition, somatostatin treatment, or initial fistula output between groups.

CONCLUSIONS

Classifying external pancreatic fistulas as to their pancreatic duct relationship and cause provides important prognostic and therapeutic information.

Hypertensive pancreatic sphincter

Major papilla pancreatic sphincter dysfunction, a variant of sphincter of Oddi dysfunction, causes pancreatitis or pancreatic-type pain. Endoscopic manometry as performed at endoscopic retrograde cholangiography is the most commonly used method to identify sphincter dysfunction. Noninvasive testing, such as secretin-stimulated ultrasound analysis of duct diameter, is less reliable and of relatively low sensitivity. Two-thirds of patients with sphincter of Oddi dysfunction have elevated pancreatic basal sphincter pressure. Patients with suspected or documented sphincter of Oddi dysfunction may respond to biliary sphincterotomy alone, but warrant evaluation of their pancreatic sphincter if symptoms persist after therapy. Whether such pancreatic and biliary sphincters should be treated at the first treatment session is controversial. Pancreatic sphincterotomy is associated with a complication rate very similar to that of biliary sphincterotomy except that the pancreatitis rate is two- to fourfold higher. Prophylactic pancreatic stenting diminishes such pancreatitis by approximately 50%.

Increased selective biliary cannulation rates in the setting of periampullary diverticula: main pancreatic duct stent placement followed by pre-cut biliary sphincterotomy

BACKGROUND

Selective biliary cannulation is often difficult when there is a periampullary diverticulum, especially when the papilla is within the diverticulum. We report eight such cases in which a new technique was used to achieve biliary access.

METHODS

Among 4138 ERCPs, there were 246 cases (5.9%) with periampullary diverticula. Biliary cannulation initially failed in eight patients (3.3%), five of whom had previously undergone six failed attempts at other institutions. A technique was used whereby the papilla was kept out of the diverticulum by placement of a pancreatic duct stent. Needle-knife sphincterotomy was then performed followed by attempts to achieve biliary access.

RESULTS

Biliary entry was immediately successful in five patients and successful at a second ERCP in two (overall success 87.5%). Two patients developed post-ERCP pancreatitis.

CONCLUSIONS

When the papilla is within the periampullary diverticulum, placement of a main pancreatic duct stent keeps the papilla out of the diverticulum, thereby facilitating pre-cut needle-knife sphincterotomy and selective biliary cannulation.

Endoscopic intervention for biliary leaks after laparoscopic cholecystectomy: a multicenter review

BACKGROUND

Endoscopic therapy of biliary tract leaks was uncommon before laparoscopic cholecystectomy. Studies have demonstrated the efficacy of endoscopic drainage by endoscopic sphincterotomy or stent placement. Various endoscopic therapeutic modalities and long-term follow-up of this problem were studied.

METHODS

Members of the Midwest Pancreaticobiliary Group reviewed all patients referred for endoscopic therapy of biliary leaks after laparoscopic cholecystectomy from 1990 to 1994. Long-term follow-up was by direct patient contact.

RESULTS

Fifty patients were referred for endoscopic therapy of biliary leaks. Abdominal pain was present in 94%. The mean time from laparoscopic cholecystectomy to referral was 6.9 days. Therapy consisted of sphincterotomy only in 6 patients, stent only in 13, and sphincterotomy with stent in 31. Biliary leaks were healed in 44 patients at a mean of 5.4 weeks. A second or third endoscopic procedure was necessary to achieve healing in five patients. Two stent-related complications were noted. Percutaneous or surgical drainage of biliary fluid collections was required in 16 patients. The mean hospital stay for treatment of the leak was 11.1 days after endoscopic therapy. On follow-up (mean 17.5 months), all patients were well except two with mild abdominal discomfort.

CONCLUSIONS

Endoscopic sphincterotomy, stent placement, or sphincterotomy with stent are effective in healing biliary leaks after laparoscopic cholecystectomy. Despite prolonged treatment for the leak, patients did well on long-term follow-up.

Endoscopic sphincterotomy for stones by experts is safe, even in younger patients with normal ducts

OBJECTIVE

To provide current information on the risks of endoscopic sphincterotomy for stone.

SUMMARY BACKGROUND DATA

In recent years (since the popularity of laparoscopic cholecystectomy), endoscopic sphincterotomy has been used increasingly for the management of bile duct stones in relatively young and healthy patients. The validity of this trend has been questioned using data on short-term complications derived from earlier decades that involved more elderly and high-risk patients.

METHODS

Seven academic centers collected data prospectively using a common database. Complications within 30 days of the procedures were documented by standard criteria.

RESULTS

Of 1921 patients, 112 (5.8%) developed complications; two thirds of these events were graded as mild (<3 days in hospital). There was no evidence of increased risk in younger patients or in those with smaller bile ducts. There was only one severe complication and there were no fatalities in 238 patients age <60, with bile duct diameters of <9 mm.

CONCLUSION

Sphincterotomy for stones can be performed very safely by experienced endoscopists.

Endoscopic pancreatic sphincterotomy: techniques and complications

Endoscopic pancreatic sphincterotomy of the major and minor papilla has expanded our approach to the management of a variety of pancreatic disorders. Analysis of the complication rates of this therapy is difficult, however, because a variety of techniques are often used in conjunction with the pancreatic sphincterotomy. This article reviews the techniques and complications of endoscopic pancreatic sphincterotomy. Based on the currently available data, it appears that the complication rates of pancreatic sphincterotomy are probably higher than those of biliary sphincterotomy. Should application of this technique become more widespread, methods to reduce the incidence of post-procedure pancreatitis will demand further investigation.

Diagnosis and therapy of pancreas divisum

Pancreas divisum patients make up a small but problematic portion of ERCP cases. Minor papilla cannulation techniques have been improved. Recurrent pancreatitis patients generally benefit from minor papilla therapy. Methods to select patients who are likely to respond to invasive therapy need refinement. Clinicians and endoscopists are strongly encouraged to be cautious and conservative with this patient group until stronger data indicate optimal management schemes.

Endoscopic therapy of pancreatic disease

Endoscopic management of a variety of benign and malignant biliary tract diseases is now a well-established alternative to surgery. Similar techniques are now applied to the pancreas and are being used in the setting of acute pancreatitis, chronic pancreatitis, complications of pancreatitis, and pancreas divisum. This review analyzes the current state of the art of these exciting applications of endoscopy. Selection of appropriate candidates for the various treatment modalities appears important for optimal results of therapy. However, definite recommendations are difficult to make because there are limited controlled studies, follow-up in most series is brief, and there are no comparison studies of endoscopic versus surgical therapy. At present, careful case selection and conservatism are the appropriate general rule in these therapeutic endeavors. Further prospective random studies are awaited.