E. Alcocer

Treatment of symptomatic distal common bile duct stenosis secondary to chronic pancreatitis: comparison of single vs. multiple simultaneous stents

BACKGROUND Common bile duct stenosis occurs in up to 30% of patients with chronic pancreatitis. Most such stenoses are found incidentally during ERCP, but others manifest as obstructive jaundice, recurrent cholangitis, secondary biliary cirrhosis, or choledocholithiasis. Operative drainage has been the main treatment despite the potentially high morbidity in patients with chronic pancreatitis. Endoscopic biliary drainage with a single stent has been successful in the short term. The aim of this study was to determine the long-term benefit of a single stent vs. multiple simultaneous stents for treatment of patients with chronic pancreatitis and symptoms because of distal common bile duct stenosis. METHODS Twelve consecutive patients with chronic pancreatitis and common bile duct stenosis underwent endoscopic placement of multiple simultaneous stents and were followed prospectively (Group II). Results were compared with a group of 34 patients in whom a single stent was placed before the start of the present study (Group I). All 46 patients (35 men, 11 women; age range 30-71 years) had chronic pancreatitis and common bile duct stenosis, and presented with symptoms indicative of obstruction (abdominal pain, jaundice, elevated biochemical tests of liver function, acute pancreatitis, cholangitis). The 34 patients in Group I had single stent (10F, 7-9 cm) placement, with exchange at 3 to 6 month intervals (1-4 exchanges) over a mean of 21 months. The 12 patients in Group II underwent placement of multiple simultaneous stents at 3-month intervals (single 10F stents added sequentially) over a mean of 14 months. Mean follow-up was 4.2 years in Group I and 3.9 years for Group II. Factors assessed included symptoms, biochemical tests of liver function, diameter of common bile duct stenosis, and complications. RESULTS In Group I, (34 patients), a total of 162 single stent placement/exchanges were performed (mean 5/patient). In Group II (12 consecutive patients), 8 patients had 4 (10F) stents placed simultaneously, and 4 patients had 5 (10F) stents. At the end of the treatment period, near normalization of biochemical tests of liver function was observed for all patients in Group II, whereas only marginal benefit was noted for patients in Group I. Four patients in Group I had recurrent cholangitis (6 episodes), whereas no patient in Group II had post-procedure cholangitis. In the 12 patients with multiple stents, distal common bile duct stenosis diameter increased from a mean of 1.0 mm to 3.0 mm after treatment; no change in diameter was noted in patients treated with a single stent. CONCLUSIONS Distal common bile duct stenosis secondary to chronic pancreatitis can be treated long term by stent placement. Multiple, simultaneous stents appear to be superior to single stent placement and may provide good long-term benefit. The former resulted in near normalization of biochemical tests of liver function and an increase in distal common bile duct diameter. Multiple stent placement may obviate the need for surgical diversion procedures.

Obliteration of esophageal varices using EUS-guided sclerotherapy with color Doppler

BACKGROUND The current standard treatment of bleeding esophageal varices is band ligation. Although endoscopic sclerotherapy has largely been supplanted by band ligation, there are still clinical situations in which injection methods are useful. Endoscopic ultrasound (EUS) may allow for a more complete evaluation of esophageal varices and perforating veins and may allow for more effective delivery of sclerosant. Our aim was to evaluate the use of color Doppler EUS-guided sclerotherapy for the obliteration of esophageal varices. METHODS Five patients with esophageal varices (Childs A = 1, B = 2, C = 2) underwent dynamic EUS-guided sclerotherapy with color flow Doppler. EUS sclerotherapy was performed using Varijet (2.5 mm catheter) injector needles and sodium morrhuate directed at the perforating vessels until flow was completely impeded (2 to 4 mL per injection site). Data collected included (1) sessions to obliteration, (2) episodes of recurrent bleeding, (3) complications, and (4) mortality. RESULTS Patients undergoing EUS-sclerotherapy required 2.2 sessions to achieve obliteration of varices. No patient had a recurrence of bleeding and no deaths occurred. One patient developed an esophageal stricture that responded to balloon dilation. CONCLUSIONS Dynamic EUS-guided sclerotherapy with color flow Doppler may be safely and effectively used for the treatment of esophageal varices. It allows for effective delivery of sclerosant with favorable outcomes. Prospective, multicenter, randomized trials are warranted.

Dynamic imaging of the pancreas using real-time endoscopic ultrasonography with secretin stimulation ☆ ☆☆

BACKGROUND Obstructive disorders of the pancreas, including strictures, stones, sphincter of Oddi dysfunction, and pancreas divisum, are diagnostic and therapeutic challenges. Conventional extracorporeal ultrasound with secretin stimulation has been used as a noninvasive study to detect obstruction and predict outcome of therapy. Inconsistent results have been obtained because of the inherent limitations of standard ultrasonography. The aim of this study was to evaluate the behavior of the main pancreatic duct by endoscopic ultrasonography during secretin stimulation and to diagnose obstructive disorders of the pancreas. METHODS Secretin-stimulated endoscopic ultrasound (SSEUS, 1 IU/kg secretin) was performed in 20 control subjects (no pancreatic or biliary disease), 40 patients with symptomatic chronic pancreatitis, 40 patients with symptomatic pancreas divisum, 20 patients with suspected sphincter of Oddi dysfunction, and 20 patients with suspected occlusion of pancreatic duct stents. Ductal diameter was measured by endoscopic ultrasonography at baseline and at 1-minute intervals, after administration of secretin, for 15 minutes. A result was determined to be abnormal when a 1 mm or greater dilation of the pancreatic duct was observed from baseline after secretin administration. RESULTS Of the 40 patients with symptomatic chronic pancreatitis, SSEUS correctly predicted obstructive pathology (stones, strictures) in 12 of 13 patients (92%). Of the 40 patients with symptomatic pancreas divisum, 22 underwent stent therapy (16 of 22 with resolution of symptoms). SSEUS accurately predicted response to stent therapy in 13 patients (81%). Seven of twenty patients with suspected sphincter of Oddi dysfunction had abnormal sphincter manometry. SSEUS accurately predicted sphincter dysfunction in only 4 of 7 patients (57%). Finally, 20 patients with suspected occlusion of pancreatic duct stents were studied. Of the 14 stent occlusions confirmed at ERCP, SSEUS correctly predicted premature occlusion in 12 patients (86%). CONCLUSIONS SSEUS appears to be a useful diagnostic modality in the evaluation of patients with suspected obstructive disorders of the pancreas and it can predict which patients may respond to endoscopic therapy.