Botulinum toxin injection after biliary sphincterotomy

BACKGROUND AND STUDY AIMS

Endoscopic biliary sphincterotomy in patients with sphincter of Oddi dysfunction (SOD) is associated with a high risk of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP), which may be secondary to residual pancreatic sphincter hypertension. It was hypothesized that botulinum toxin injection could be used to reduce pancreatic sphincter hypertension temporarily in SOD patients after biliary sphincterotomy, thereby reducing the rate of procedure-induced pancreatitis.

PATIENTS AND METHODS

All patients undergoing ERCP with manometry due to a suspected biliary SOD were asked to participate in the study. Patients with elevated basal sphincter pressures were randomly assigned to receive either botulinum toxin or a sham saline injection after biliary sphincterotomy. Fifty units of botulinum toxin were delivered via a sclerotherapy needle in the form of two 25-U injections of 0.25 ml each into the pancreatic sphincter. In patients in the sham arm, 0.50 ml of saline was injected into the duodenal lumen.

RESULTS

Between 12 February 1999 and 29 November 2000, a total of 98 patients were referred for ERCP with manometry; 86 consented to participate in the study, and 26 had elevated baseline pressures and underwent random assignment. Twelve received botulinum toxin injection and 14 were randomly assigned to receive the sham injection. A total of six patients in the sham group (43 %) developed procedure-induced pancreatitis, compared with three patients in the botulinum toxin group (25 %; P = 0.34).

CONCLUSIONS

Biliary sphincterotomy in patients with sphincter of Oddi dysfunction without pancreatic protection is risky and should no longer be carried out. This study demonstrates that botulinum toxin injection into the residual pancreatic sphincter after biliary sphincterotomy is technically feasible and safe, showing a trend toward a reduced post-ERCP pancreatitis rate in patients with sphincter of Oddi dysfunction. Further studies will need to confirm the validity of these experimental results before this technique can be used routinely.

First cut, then blend: an electrocautery technique affecting bleeding at sphincterotomy

BACKGROUND AND STUDY AIMS

The use of pure cut electrocautery current for endoscopic sphincterotomy lowers pancreatitis rates following endoscopic retrograde cholangiopancreatography (ERCP), but at the expense of greater localized bleeding which partially obscures the endoscopic view. We hypothesized that localized bleeding could be decreased by using blended current at the end of the sphincterotomy, without losing the benefit associated with pure cut current of lower post-ERCP pancreatitis benefit.

PATIENTS AND METHODS

Patients undergoing sphincterotomy were randomly allocated to receive pure cut current alone or a sequential combination of pure cut then blended current. In the sequential combination patients, the first 75 - 80 % of the sphincterotomy was done using pure cut current at 30 W and the remainder completed at a blend 2 setting (pure cut plus coagulation current), also at 30 W.

RESULTS

142 patients were enrolled in the study. No statistical difference was noted between the two groups in the rates of overall pancreatitis or bleeding requiring transfusion. When comparing visible bleeding rates (more than a few drops), we found that there was significantly more bleeding (P < 0.05) in the pure cut group (31/75, 41 %) at the time of sphincterotomy compared with the sequential combination group (16/67, 23 %).

CONCLUSIONS

A sequential combination of pure cut and blended current for sphincterotomy caused less visible bleeding than pure cut alone. This occurred without a change in the rate of post-ERCP pancreatitis.

Ontogeny of membrane cofactor protein: phenotypic divergence in the fetal heart

Human adult cells are protected from complement-induced damage in part by membrane cofactor protein (MCP, CD46). To examine fetal characteristics which might influence autoantibody-mediated diseases acquired in utero, such as heart block in neonatal lupus, the tissue expression of MCP was studied. Using a high ratio of acrylamide:bisacrylamide, immunoblots of tissues from six fetuses (aged 19-24 weeks) probed with rabbit anti-MCP antibodies revealed a band at 60 KD in addition to the known 65 KD and 55 KD isoforms which comprise the codominant allelic system of MCP. Five fetuses expressed the most common MCP polymorphism (predominance of the 65 KD isoform, upper band alpha-phenotype) in the kidney, spleen, liver and lung. In contrast, all hearts from these five fetuses demonstrated a different pattern in which there was a marked decrease in the intensity of the 65 KD band and accentuation of the lower molecular weight bands. In a sixth fetus, which expressed the second most common polymorphism (equal expression of the 65 KD and 55 KD MCP isoforms, alpha beta-phenotype), the heart was similar to the other tissues. These studies confirm the expression of MCP in early gestational life. Preferential expression of the MCP beta-isoform in the majority of fetal hearts irrespective of the phenotype of other organs, suggests tissue-specific RNA splicing or post-translational modification which may relate to autoantibody-mediated injury in diseases such as neonatal lupus.

SCID-PANSS: two-tier diagnostic system for psychotic disorders

The SCID-PANSS was developed as a two-tier diagnostic system for psychotic disorders to supplement categorical diagnosis with functional-dimensional assessment. The procedure combines the DSM-III-R Structured Clinical Interview and Rating Criteria (SCID) with those from the Positive and Negative Syndrome Scale (PANSS). The comprehensive 50- to 60-minute interview yields diagnostic classification, plus a profile of 30 symptoms and 10 dimensional scales, including positive and negative syndromes, depression, thought disturbance, and severity of illness. A study of 34 psychotic inpatients assessed by five psychiatrists showed strong interrater correlations (0.85 to 0.97 for summary scales, P less than .0001), supporting the reliability of the SCID-PANSS for clinical and research applications.