Franklin E. Kasmin

Needle-knife sphincterotomy in a tertiary referral center: efficacy and complications

BACKGROUND The use of needle-knife sphincterotomy as a method of precut sphincterotomy has been criticized as potentially unsafe. Despite this, a number of tertiary referral centers have reported their successful use of this technique to increase the rate of common bile duct cannulation. METHODS We assessed the safety and efficacy of needle-knife sphincterotomy in 72 consecutive patients in whom attempts at standard common bile duct cannulation were unsuccessful. Bile duct diameters were correlated to the complication rate. RESULTS Cannulation of the common bile duct was successful immediately after needle-knife sphincterotomy in 50 patients (67%), and was successful in 17 of the 20 patients who underwent repeat ERCP, for a total cannulation rate of 93%. Eight patients (11%) experienced complications. Retroduodenal perforation during guide wire cannulation attempts and bleeding occurred as frequently as pancreatitis. Small duct size was a risk factor for complications. There was no procedure-related mortality, and all complications were managed medically. CONCLUSIONS Needle-knife sphincterotomy was effective in facilitating cannulation in patients in whom standard cannulation attempts failed. Limiting guide wire manipulation of the fresh sphincterotomy site and excluding patients with small duct size may further reduce the complication rate.

Biliary tract diseases in the elderly: management and outcomes

Elderly people commonly present with biliary tract disease. Gallstone disease is an important cause of recurrent abdominal symptoms, and we advocate an aggressive approach in stable patients not at risk to improve the quality of their lives. Choledocholithiasis is optimally treated by ERCP (98% success) even in patients who are at great risk. Endoscopic intervention often obviates the need for emergency biliary tract surgery in the elderly, is better tolerated, and is associated with significantly less risk and a lower mortality. In contrast, emergency surgery in the elderly is poorly tolerated. Even cholecystitis and biliary pancreatitis (not discussed here) are amenable to endoscopic treatment. Malignant biliary obstruction should not and cannot be treated as aggressively as benign disorders affecting the biliary tree as the long term outlook is poor. Endoscopic palliation usually suffices in maximising treatment and improving the patients quality of life with few associated complications or postprocedural machinations (drainage bags or tubes). The afflicted population in general and the elderly in particular benefit from minimally invasive endoscopic decompression techniques.

Endoscopic sphincterotomy for biliary pancreatitis: an alternative to cholecystectomy in high-risk patients

Recurrent biliary pancreatitis frequently is associated with an intact gallbladder containing stones. This condition has been effectively treated by removing the gallbladder, but there is evidence that endoscopic sphincterotomy might obviate the need for cholecystectomy in some patients. We performed prophylactic sphincterotomy in 49 patients who presented with biliary pancreatitis more than once and who were considered at risk for surgery. The majority (39 patients) were treated electively after resolution of pancreatitis, while the remainder (10 patients) were treated urgently during their index admission because of continuing symptoms. No patient experienced recurrent pancreatitis over a mean follow-up period of 48 months. No mortality occurred in this endoscopic series, and no significant morbidity was experienced. Based on our results, we advocate performing sphincterotomy in the aged patient or younger patients considered at high risk for surgery who present with a history of recurrent pancreatitis and cholelithiasis.

Central pancreatectomy without anastomosis

BackgroundCentral pancreatectomy has a unique application for lesions in the neck of the pancreas. It preserves the distal pancreas and its endocrine functions. It also preserves the spleen.MethodsThis is a retrospective review of 10 patients who underwent central pancreatectomy without pancreatico-enteric anastomosis between October 2005 and May 2009. The surgical indications, operative outcomes, and pathologic findings were analyzed.ResultsAll 10 lesions were in the neck of the pancreas and included: 2 branch intraductal papillary mucinous neoplasms (IPMNs), a mucinous cyst, a lymphoid cyst, 5 neuroendocrine tumors, and a clear cell adenoma.ConclusionCentral pancreatectomy without pancreatico-enteric anastomosis for lesions in the neck and proximal pancreas is a safe and effective procedure. Morbidity is low because there is no anastomosis. Long term endocrine and exocrine function has been maintained.

Endoscopic Stenting and Sphincterotomy of the Minor Papilla in Symptomatic Pancreas Divisum: Results and Complications

Pancreas divisum has been postulated as a cause of acute pancreatitis and a chronic pain syndrome in a small subgroup of patients and can be treated with endoscopic dorsal pancreatic duct stent placement and minor papilla sphincterotomy. Twenty patients (9 with at least one attack of idiopathic pancreatitis, and 11 with severe pancreatic-type pain) were treated endoscopically. Dorsal duct stents were placed in 19 patients with subsequent needle knife sphincterotomy of the minor papilla over the stent. Clinical response was judged by comparison of symptoms (using a 0-to-l0 scale and the patients overall assessment). The symptom score improved from 9.3 to 5.1 in the pancreatitis group and from 9.3 to 5.7 in the pain group. A good clinical response was observed in 3 of 7 patients in the pancreatitis group and in 6 of 11 in the pain group at a mean follow-up of 22 months. Complications of sphincterotomy were limited to pancreatitis in 6 patients (29%), 5 mild and 1 moderate according to published criteria. No patient required more than 4 days hospitalization. Two of 39 stents migrated into the pancreas, and another stent fractured and remained lodged in the pancreas. Eight of 9 patients evaluated demonstrated new morphologic duct changes on follow-up pancreatograms. Endoscopic stenting and sphincterotomy of the minor papilla are feasible and may be effective in some patients with pancreas divisum but carries a significant complication rate. The subjective improvement in patients with chronic pain warrants further controlled study.

Surgery and cancer of the pancreas: will common sense become common practice?

Pancreatic cancer is a systemic disease for most patients. Operations with the intent to cure may be done safely (mortality, < 3%) with shorter hospital stays. Surgery has been minimally effective as a long-term cure. Endoscopic palliation of jaundice is becoming standard practice. Common sense dictates a defined and clear role for surgery (i.e., strict patient selection criteria). Surgery is of great value for small, localized lesions; of clear value as palliative therapy when nonoperative measures fail; and perhaps best applied after neoadjuvant chemoradiotherapy. Surgery is just part of the armamentarium available to treat pancreatic cancer. Novel systemic therapies, including chemotherapy, immunotherapy, and so-called targeted therapies, are becoming increasingly valuable in the management of this systemic disease and are discussed in detail in other articles in this issue.

Re: ERCP during pregnancy.

rhosis was subsequently confirmed histologically in all. We suggested in our report that these patients represented an unexplained exacerbation of silent and previously unrecognized nonalcoholic steatohepatitis (NASH) with cirrhosis. We believe that the syndrome represents a severe disorder within the spectrum of nonalcoholic fatty liver (NAFL) and warrants increased awareness of latent liver disease in obese patients. However, Dr. Azer has pointed out that the antidepressant drug nefazodone (Serzone), which was used by patient 2, has been associated with acute and severe liver injury. Two other patients had a history of depression but were not on antidepressant drug therapy. We agree with Dr. Azer that our statement regarding the lack of toxicity with nefazodone has, subsequent to preparation of our manuscript, been proved inaccurate. However, this agent was unlikely to have played a role, as only one of our patients was using the medication and she had been stable on the drug for 1 yr. In addition, the clinical and histological findings were very different from those associated with nefazodone toxicity. As noted by Dr. Azer, toxicity from this agent usually occurs within the first 6–9 months of treatment, and histologically it is typically characterized by severe necrosis and collapse of the liver. The necrosis is usually prominent in zone 3 and eosinophils are often noted (2–4). In contrast, the most prominent histological finding in our patients was cirrhosis with features of NASH. Only one of our patients (who was not using any medications) had substantial necrosis (patient 5). In addition, nefazodone toxicity is usually associated with severe aminotransferase elevation—a finding that was observed only in patient 5 in our series (she was on no medications). Two of our patients had exposure to corticosteroids in the period before presentation. As we discussed in the article, this could have contributed to an acute exacerbation of steatohepatitis by promoting steatosis. Thus, although we appreciate Dr. Azer’s correcting our comment regarding nefazodone, the agent, which was used by only one of our patients, was unlikely to have been a significant factor in her course. The absence of a temporal relationship and the absence of compatible clinical findings make a drug-induced etiology unlikely (5). The features that we described (an indolent but slowly progressive course over a few months, associated usually with only mild liver enzyme abnormalities and characterized histologically by cirrhosis with features of NASH) were distinct from those associated with nefazodone toxicity. We speculate that these patients have a subacute form of nonalcoholic steatohepatitis—rare, but within the spectrum of NAFL.

Endoscopic retrograde cholangiopancreatography treatment of cholecystitis: possible? Yes; practical??

Classically, until now, the management of cholecystitis has consisted of immediate and judicious clinical assessment of the affected patient, interpolating into the assessment of the physical findings and results from appropriate laboratory, x-ray, and scanning techniques (sonography and scintigraphy) to formulate a clinical impression. Usually, after the diagnosis has been established, the patient is subjected to a cholecystectomy, although the timing of the surgery may vary depending on the clinical condition of the patient. Alternatives to this management (cholecystectomy, medical management) scheme have been suggested, but these are dependent upon the clinical condition ofthe patient and considerations of risks. Percutaneous drainage of the gallbladder or cholecystostomy is sufficient enough to provide drainage, relieve obstruction, and the consequences of infection, i.e., sepsis, and prevent perforation. A contributory role of endoscopic retrograde cholangiopancreatography (ERCP) in this schema has not been a consideration. An ERCP is rarely employed for therapy (or diagnosis) when cholecystitis is suspected but it might assume a more significant role if it is considered an efficacious alternative in specific conditions. We have had the unusual experience of managing 11 patients with cholecystitis employing ERCP and its therapeutic modalities, i.e., sphincterotomy, selective cannulation of the cystic duct, and relieving obstruction of that structure by catheter displacement of an obstructing stone. Endoscopic techniques providing decompression of the gallbladder are described, and the feasibility of utilizing endoscopic procedures for treatment of cholecystitis will be given consideration.

Cancer of the Pancreas—Actual 5, 10, and 20+Year Survival: The Lucky and Fortunate Few

Cancer of the pancreas (CaP) is a dismal, uncommon, systemic malignancy. This article updates an earlier experience of actual long-term survival of CaP in patients treated between 1991 to 2000, and reviews the literature. Survival is expressed as actual, not projected, survival.

Experience and volume: the ingredients for successful therapeutic endoscopic outcomes, especially ERCP and postgastrectomy patients

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