Polyethylene pancreatic duct stent-induced changes in the normal dog pancreas

This study was undertaken to evaluate the frequency, severity, and reversibility of stent-induced pancreatic ductal and parenchymal changes in the normal dog pancreas. Six adult mongrel dogs underwent duodenotomy and placement of 5F polyethylene pancreatic duct stents into the main pancreatic duct. After 8 weeks of stenting, the animals were randomly assigned to one of three groups: group I (n = 2), sacrifice; group II (n = 2), stent removal followed by sacrifice after an 8-week recovery period; group III (n = 2), the stent was exchanged and kept in place for an additional 8 weeks. In group III at 16 weeks the stent was removed, and the animals were allowed to recover for 8 weeks before sacrifice. Pancreatograms were obtained at each operation and were normal before stent placement. Gross and histologic evaluation was performed at the time of sacrifice. All stented animals developed radiographic, gross, and histologic abnormalities. Pancreatograms showed duct dilation in the stented region associated with a short stenosis at the mid to upstream segment of the stent. Group III animals had more advanced radiographic changes than group I and II animals. The radiographic findings were associated with gross evidence of fibrosis, which increased proportionately with the length of the stenting period. Group III animals developed moderate to severe pancreas atrophy. Histologic changes of obstructive pancreatitis were present in most experimental dogs. The results of this study suggest that pancreatic stenting may cause permanent damage in the normal dog pancreas. The cause of the damage appears to be related to stent occlusion, perhaps exacerbated by local stent-induced trauma.

Pancreatic cancer presenting with resolving pseudocyst during octreotide therapy

Pancreatic cancer presenting as acute pancreatitis is relatively uncommon. Pancreatic cancer should be included in the differential diagnosis of "idiopathic" acute pancreatitis, particularly in the elderly. The following case report describes a patient in whom pancreatic cancer presented as acute pancreatitis with pseudocyst formation and subsequent resolution with octreotide therapy. Various implications of this case are reviewed.

Colonic neoplasia in asymptomatic persons with negative fecal occult blood tests: influence of age, gender, and family history

Six hundred twenty-one asymptomatic persons with negative fecal occult blood tests (ages 50-75 yr), including 496 with no known risk factors for colorectal cancer and 125 with a single first-degree relative with a history of colonic neoplasia developed after age 40, underwent screening colonoscopy. Three Dukes A cancers were detected in average-risk persons. The overall prevalence of adenomatous polyps was 27%. Multiple logistic regression analysis revealed that increasing age and male gender were both strong predictors of colonic neoplasia (p < 0.001). A positive family history of a single first-degree relative with colorectal cancer was not associated with an increased prevalence of colonic neoplasia (p = 0.29), although an effect may be present if the relative was < 60 yr at diagnosis. Overall 16% of males and 7% of women > or = 60 yr had at least one adenoma that was large (> or = 1 cm in size), villous or tubulovillous, or had grade 3 dysplasia. We conclude that the prevalence of colonic neoplasia in asymptomatic persons with negative fecal occult blood tests is substantial, particularly in elderly males. A family history of a single first-degree relative diagnosed at age > or = 60 yr with colorectal cancer is not associated with an increased prevalence of colonic adenomas.

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 beginning to be applied to the pancreas. Endoscopic therapy is now being utilized in the setting of acute pancreatitis, chronic pancreatitis, complications of pancreatitis, and pancreas divisum. In this review, we will analyze the current state of the art of these exciting new 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 few controlled studies, follow-up in most series is brief, and there are no comparison studies of endoscopic versus surgical therapy. At present, conservatism is the appropriate general rule in these therapeutic endeavors.

Pancreas divisum: results of minor papilla sphincterotomy

A subpopulation of pancreas divisum patients may have pancreatic pain or pancreatitis as a result of a stenotic minor papilla. This study was undertaken to evaluate the efficacy of minor papilla sphincterotomy in 52 pancreas divisum patients who had disabling chronic pancreatic pain (n = 24), acute recurrent pancreatitis (n = 17), or chronic pancreatitis (n = 11). Patients were symptomatic for a mean time of 5.1 years and had failed to respond to conservative therapy. Minor papilla sphincterotomy was performed with a needle knife over a previously placed minor papilla/dorsal pancreatic duct stent. Clinical improvement was assessed by comparison of symptoms (using a 0 to 10 scale) and number of hospital days per month required for pain or pancreatitis for an equal period of time before and after therapy. The average duration of follow-up was 1.7 years. As compared with the chronic pain and chronic pancreatitis groups, the acute recurrent pancreatitis group had a significant reduction in the mean symptom score and number of hospital days per month. Patients with acute recurrent pancreatitis benefited from minor papilla sphincterotomy more frequently than those with chronic pancreatitis (76.5% versus 27.3%, p = 0.01) or chronic pain (76.5% versus 26.1%, p = 0.002). Complications followed 15% of the procedures; they consisted primarily of mild pancreatitis, although one additional patient died of a pancreatic abscess after a failed cannulation. Fifty percent of patients evaluated at the time of stent removal had stent-induced dorsal duct changes. The results of this study support the performance of minor papilla therapy in pancreas divisum patients who have acute recurrent pancreatitis.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of intraoperative and endoscopic manometry of the sphincter of Oddi

Despite the potential utility of intraoperative manometry of the sphincter of Oddi, limited data are available validating its use. The current study was undertaken to validate the method of intraoperative sphincter of Oddi manometry by comparing the pressure tracings obtained at operation (transduodenal sphincteroplasty and transampullary septoplasty) and endoscopy (preoperative) in the same group of patients. Seventy-four patients with idiopathic pancreatitis or unexplained disabling pancreaticobiliary pain had sphincter of Oddi manometry performed endoscopically and intraoperatively within six weeks of each other. Thirty-five patients had manometric evaluation of the bile duct segment of the sphincter of Oddi. The mean basal sphincter pressure determined endoscopically and intraoperatively was 41.1 +/- 6.4 millimeters of mercury (mean plus or minus standard error of the mean) and 42.0 +/- 6.8 millimeters of mercury (not significantly different, p > 0.05), respectively. There was no significant difference between the biliary sphincter phasic pressure, phasic frequency and phasic duration, as recorded by the two techniques. Fifty-five patients had manometric evaluation of the pancreatic duct sphincter. The mean basal sphincter pressure determined endoscopically and intraoperatively (after biliary sphincteroplasty) was 111.9 +/- 9.9 millimeters of mercury and 102.7 +/- 8.7 millimeters of mercury, respectively (not significantly different, p > 0.05). There was no significant difference in the pancreatic sphincter phasic duration and phasic frequency determined by the two techniques. However, the pancreatic sphincter phasic pressure was significantly higher when measured endoscopically (p < 0.001). Overall, 70 percent of patients benefited from surgical sphincter ablation therapy. Patients with an elevated basal sphincter pressure determined intraoperatively were more likely to improve than those with a normal basal sphincter pressure.(ABSTRACT TRUNCATED AT 250 WORDS)

Correlation of basal sphincter pressures measured from the bile duct and the pancreatic duct in patients with suspected sphincter of Oddi dysfunction

If basal sphincter of Oddi pressures measured from the pancreatic duct and the bile duct are essentially equal, then measurement of basal pressures from only one duct would be adequate in evaluating sphincter of Oddi dysfunction. We report a series of 88 patients whom we evaluated with sphincter of Oddi manometry. Cannulation of both the biliary sphincter segment and pancreatic sphincter segment was achieved in these patients. Basal sphincter pressures were measured (normal, less than 40 mm Hg). In 45 of the 88 patients (51%), normal sphincter of Oddi basal pressures were seen in both ducts. Elevated basal sphincter of Oddi pressures were seen in both ducts in 28 of 88 patients (32%). In 15 of 88 cases (17%) there was an elevation of only one sphincter segment. Elevation in only the biliary sphincter segment occurred in 7 of 88 patients (8%). Elevation in the pancreatic sphincter segment alone occurred in 8 of 88 patients (9%). We conclude that sphincter of Oddi manometry of both the pancreatic and bile ducts is needed if complete manometric information is desired.

Pancreatitis following bile duct sphincter of Oddi manometry: utility of the aspirating catheter

The aspirating sphincter of Oddi manometry (SOM) catheter was shown to reduce the frequency of post-procedure pancreatitis from 31% to 4% following a pancreatic duct evaluation. This study was designed to prospectively evaluate the utility of the aspirating manometry catheter in reducing the frequency of pancreatic enzyme elevation and clinical pancreatitis following isolated bile duct manometry. Thirty-eight patients were randomly assigned to undergo bile duct SOM with the standard perfusion (infused group) catheter or the aspirating catheter (aspirated group). Overall, the frequency of both amylase and lipase level elevation at least two times the upper limits of normal was 30% at 2 hours, 25% at 6 hours, and 18% at 18 hours after the procedure and was similar for the aspirated and infused groups. No episodes of clinical pancreatitis occurred in either group. The SOM catheter was perfused with full-strength contrast in 12 consecutive patients undergoing a bile duct evaluation. Only one patient had any contrast material identified in the pancreatic duct. The results of this study support the theory that increased pancreatic duct hydrostatic pressure is the major cause for post-SOM pancreatitis and suggests that SOM evaluation of the bile duct alone appears to be safe.

Endoscopic sphincterotomy-induced hemorrhage: treatment with multipolar electrocoagulation

Multipolar electrocoagulation is an effective therapy for patients with endoscopic evidence of active upper gastrointestinal hemorrhage or a non-bleeding visible vessel in an ulcer crater. The use of this therapy for endoscopic sphincterotomy-induced hemorrhage has not been reported previously. This prospective study attempted to assess the efficacy of multipolar electrocoagulation in patients with endoscopic sphincterotomy-induced hemorrhage not responding to conservative and/or other endoscopic measures. Nine patients with moderate or severe bleeding following endoscopic sphincterotomy (one, immediate; eight, delayed 12 to 144 hours) were treated by multipolar electrocoagulation. Prior to endoscopic therapy with multipolar electrocoagulation, the mean hematocrit drop was 14.5% and the mean number of packed red blood cells transfused was 4.8 units. Complete hemostasis was achieved in eight (89%) patients. Re-bleeding occurred in two (25%) and was controlled by a second course of multipolar electrocoagulation in one in whom it was attempted. There were no complications or deaths from multipolar electrocoagulation and surgical therapy was avoided in all nine patients. We recommend proceeding with multipolar electrocoagulation (if possible) after injection therapy and/or balloon tamponade fail to control the hemorrhage and before considering angiographic or surgical intervention.

Laparoscopic cholecystectomy and ERCP with sphincterotomy in an elderly patient with situs inversus

Situs inversus viscerum (transposition of the viscera) is a rare condition with a genetic predisposition that is autosomal recessive. We present a patient with situs inversus, cholelithiasis, and choledocholithiasis who was successfully treated via laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography with sphincterotomy. This paper further expands the application of these techniques and shows that they can be safely and effectively applied in the setting of situs inversus, although attention must be paid to the details of left-right reversal.

Distal colonic hyperplastic polyps do not predict proximal adenomas in asymptomatic average-risk subjects

The significance of distal colonic hyperplastic polyps was investigated in 482 asymptomatic average-risk subjects, aged 50-75 years, in whom fecal occult blood test results were negative and who underwent screening colonoscopy. The incidence of adenomas in the colon proximal to the sigmoid-descending colon junction in subjects with hyperplastic polyps distal to that point was 18% and was similar to the incidence of proximal colonic adenomas in subjects with no distal colonic polyps (15%). The incidence of proximal colonic adenomas in subjects with no distal colonic adenomas was 38% and was significantly greater than the incidence found in individuals with no distal colonic polyps or only hyperplastic polyps. Our data do not support distal colonic hyperplastic polyps as markers for proximal colonic adenomas in asymptomatic average-risk subjects.

Endoscopic ultrasonography as an adjunct to fine needle aspiration cytology of the upper and lower gastrointestinal tract

Twenty consecutive patients with either extrinsic or submucosal masses or gastric ulcers suspicious for malignancy with previously negative conventional forceps biopsies and/or brush cytology underwent a combined approach of endoscopic ultrasound (EUS) followed by fine needle aspiration cytology. Diagnostic results were obtained in 17 of 20 patients. The three patients with indeterminate aspirates had EUS findings strongly supportive of the final diagnosis. EUS combined with fine needle aspiration cytology appears to be of value in the evaluation of extrinsic, submucosal, and ulcerative lesions of the gastrointestinal tract.

Complications of endoscopic sphincterotomy. A prospective series with emphasis on the increased risk associated with sphincter of Oddi dysfunction and nondilated bile ducts

Mostly retrospective series with limited use of sphincter of Oddi manometry have indicated that early complications are more common when endoscopic sphincterotomy is performed for sphincter of Oddi dysfunction than for common duct stones. The current study was undertaken to prospectively evaluate the frequency and type of complications of endoscopic sphincterotomy performed for sphincter of Oddi dysfunction compared with endoscopic sphincterotomy performed for other conditions. Four hundred twenty-three patients underwent sphincterotomy for sphincter of Oddi dysfunction (166), common duct stone(s) (163), tumor (60), and miscellaneous reasons (34). Patients were observed in the hospital for at least 24 hours after the procedure, and 30-day follow-up data were obtained. The overall complication rate was 6.9%, but complications were more frequent when sphincterotomy was performed for sphincter of Oddi dysfunction than for all other indications (10.8% vs. 4.3%; P = 0.009). Precut sphincterotomy was more frequently required in the sphincter of Oddi dysfunction group (21.1% vs. 11.7%, P = 0.009) but was no more likely to result in a complication (6.2%) than standard sphincterotomy. The risk of a complication was considerable for a small-diameter common bile duct (less than or equal to 5 mm), particularly when sphincterotomy was performed for sphincter of Oddi dysfunction (37.5%). The overall 30-day mortality rate was 1.7%, but the procedure-related mortality rate was believed to be 0.2%. It is concluded that endoscopic sphincterotomy for sphincter of Oddi dysfunction is more hazardous than for other conditions, particularly when a small common bile duct is present.

Pancreatic ductal stones: frequency of successful endoscopic removal and improvement in symptoms

Pancreatic ductal stones may be responsible for attacks of acute pancreatitis (chronic relapsing pancreatitis) or exacerbations of chronic pain in patients with chronic pancreatitis. This study was undertaken to identify those patients with predominantly main pancreatic duct stones most amenable to endoscopic removal and to determine the effects on the patients' clinical course with such removal. Thirty-two patients with ductographic evidence of chronic pancreatitis and pancreatic duct stones underwent attempted endoscopic removal. Of the patients, 71.9% had complete or partial stone removal and 67.7% improved after endoscopic therapy. Symptomatic improvement was most evident in the group of patients with chronic relapsing pancreatitis. Factors favoring stone removal included (1) three or less stones, (2) stones confined to the head and/or body of the pancreas, (3) absence of a downstream stricture, (4) stone diameter less than or equal to 10 mm, and (5) absence of impacted stones. After successful stone removal, 25% of patients had regression of the ductographic changes of chronic pancreatitis and 41.7% had a decrease in the main pancreatic duct diameter. The only complication from therapy was mild pancreatitis in 8.2%. These data suggest that removal of pancreatic duct stones may result in symptomatic improvement. A longer follow-up will be necessary to determine whether endoscopic success results in long-standing clinical improvement and/or permanent regression of the morphologic changes of chronic pancreatitis.

ERCP- and endoscopic sphincterotomy-induced pancreatitis

Acute pancreatitis may occur after the performance of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy. During ERCP and endoscopic sphincterotomy, the pancreas is subjected to many types of potential injury--mechanical, chemical, hydrostatic, enzymatic, microbiological, allergic, and thermal. These factors may act independently or in concert to induce postprocedure pancreatitis. The potential role of each etiologic factor in the development of ERCP- and endoscopic sphincterotomy-induced pancreatitis is detailed. The management of this complication is reviewed. Patient factors that increase the risk for pancreatitis and techniques to prevent or limit this complication are described. A variety of agents have been shown to prevent or treat pancreatitis in animal models, but extrapolation to humans has been almost uniformly unsuccessful. Although postprocedure pancreatitis is unlikely to be completely eliminated, careful patient selection and attention to detail may reduce the incidence of this untoward event.

Frequency of abnormal sphincter of Oddi manometry compared with the clinical suspicion of sphincter of Oddi dysfunction

Patients with pancreaticobiliary pain or idiopathic pancreatitis have been classified as having definitive (type I), presumptive (type II), or possible (type III) sphincter of Oddi dysfunction (SOD) based on clinical, laboratory, and ERCP data. This study was undertaken to determine the frequency of abnormal sphincter of Oddi manometry (SOM) when patients are classified by this system. Two hundred and thirteen patients with pancreaticobiliary pain were evaluated clinically; SOM, ERCP, and ductal contrast drainage time tests were performed. For biliary types I, II, and III, the frequency of abnormal SOM was 85.7%, 55.1%, and 28.1%, respectively. Similarly, for pancreatic types I, II, and III, an elevated basal sphincter pressure occurred in 92.3%, 58.2%, and 35.1%, respectively. When patients with an abnormal basal sphincter pressure were characterized by the magnitude of the elevation, the manometric profiles were similar for types I, II, and III. These data suggest that elevated sphincter pressure occurs more frequently in type III patients than previously reported, and supports consideration of SOM when evaluating and treating type II and type III patients.

Screening colonoscopy in asymptomatic average-risk persons with negative fecal occult blood tests

Colonoscopy was performed on 210 asymptomatic average-risk persons, aged 50-75 years, who had negative fecal occult blood test results. Colonoscopy was complete to the cecum in 209 subjects. Fifty-three subjects (25%) had adenomas and two had cancer. All of the adenomas greater than or equal to 1 cm in size and both cancers occurred in subjects aged greater than or equal to 60 years. Fifty-one percent of subjects with adenomas and one with cancer had no neoplasms distal to the sigmoid-descending colon junction. One subject had a major postpolypectomy hemorrhage that stopped spontaneously. Screening colonoscopy, therefore, has a high yield for detection of neoplasms in asymptomatic average-risk persons aged greater than or equal to 60 years with negative fecal occult blood test results. The yield is low in persons aged 50-54 years and intermediate in persons aged 55-59 years.