H.T. Schneider

Is endoscopic drainage of common bile duct stenoses in chronic pancreatitis up-to-date?

OBJECTIVE:Common bile duct (CBD) stenoses often complicate chronic pancreatitis (CP). Although endoscopic drainage is employed as a standard procedure in malignant CBD stenoses, it is not yet the approved standard therapy of CBD stenosis in CP.METHODS:The records of 31 patients with CBD stenosis in CP who had undergone endoscopic placement of plastic endoprostheses into the bile duct between January 1991 and February 1997 were analyzed retrospectively. In all, 18 patients suffered from jaundice and 13 patients exclusively showed serological cholestasis. Upstream dilation of the CBD (19 ± 6.6 mm, 12–35 mm) was detected by ERCP in all patients. In total, 101 endoprostheses were implanted endoscopically, exchanged after 3 ± 2 months, and removed after 10 ± 8 months.RESULTS:All jaundiced patients showed immediate improvement of cholestasis after drainage. At the time of last exchange or after stent removal, prestenotic CBD dilation was reduced in 55% of all patients. Complete regression of stenosis and prestenotic dilation was accomplished only in 13%; dilation remained unchanged in 10%, and even showed progression in 22%. A total of 29 patients were followed-up over 24 months. Cholestatic parameters remained normal in all patients with complete normalization of the CBD, and were only moderately increased in another 10 patients, 7 and 28 months after stent removal, respectively.CONCLUSIONS:Technical and immediate clinical success of CBD stenting in patients with CBD stenoses due to CP is high; however, long-term complete normalization of the bile duct is rare. Endoscopic drainage of CBD-stenosis in patients with CP can be recommended to alleviate acute cholestasis, but not yet as a definite treatment.

Low-molecular-weight heparin does not prevent acute post-ERCP pancreatitis.

BACKGROUND Studies suggest that heparin has anti-inflammatory effects that could prevent acute post-ERCP pancreatitis. The aim of this investigator-initiated, prospective, randomized, double-blind, multicenter study was to determine whether low-molecular-weight heparin can prevent acute post-ERCP pancreatitis. METHODS Patients at increased risk for acute post-ERCP pancreatitis based on assessment of known risk factors were randomized to receive low-molecular-weight heparin (Certoparin 3000 IU subcutaneously) or placebo (saline solution 0.3 mL subcutaneously) the day before ERCP. The drug was given 2 hours before and 22 hours after ERCP. Documentation and follow-up included patient history, risk factors for acute post-ERCP pancreatitis, procedure-related data, assessment of pain (visual analogue scale, need for pain medication), laboratory findings before and after ERCP (0, 4, and 24 hours), as well as post-ERCP complications. The two-sided Fisher exact test was used for statistical comparison, and a p value < or =0.05 was considered significant. RESULTS A total of 458 patients were enrolled in the study. Data from 10 patients could not be evaluated, leaving 221 patients in the low-molecular-weight heparin group and 227 in the placebo group (total 448 patients; 135 men, 313 women; mean age 58 [15] years). Low-molecular-weight heparin and placebo groups were comparable with regard to risk factors for acute post-ERCP pancreatitis (gender distribution, age <65 years, history of pancreatitis, pancreas divisum, disorders of sphincter of Oddi) and procedure-related data (difficult cannulation, diagnostic or therapeutic ERCP, needle-knife papillotomy, endoscopic sphincterotomy, biliary or pancreatic procedure, pancreatic contrast injection, success and final diagnosis of ERCP). Acute post-ERCP pancreatitis occurred in 8.5% (38/448), with one death resulting from severe pancreatitis. Low-molecular-weight heparin offered no benefit compared with placebo based on the frequency of acute post-ERCP pancreatitis (low-molecular-weight heparin, 18/221 vs. placebo, 20/227; p=0.87) and the severity of acute post-ERCP pancreatitis (low-molecular-weight heparin, 14 mild, 3 moderate, one severe; placebo, 18 mild, two moderate, 0 severe). The 24-hour serum amylase values and 24-hour pain scores did not differ significantly between the low-molecular-weight heparin group and the placebo group. Bleeding complications occurred in two patients, both in the low-molecular-weight heparin group (one mild, one moderate). CONCLUSIONS Prophylactic subcutaneous administration of low-molecular-weight heparin does not prevent acute post-ERCP pancreatitis.

Comparison of tree-based methods for prognostic stratification of survival data

Tree-based methods can be used to generate rules for prognostic classification of patients that are expressed as logical combinations of covariate values. Several splitting algorithms have been proposed for generating trees from survival data. However, the choice of an appropriate algorithm is difficult and may also depend on clinical considerations. By means of a prognostic study of patients with gallbladder stones and of a simulation study, we compare the following splitting algorithms: log-rank statistic adjusted for measurement scale with (AP) and without (AU) pruning, exponential log-likelihood loss (EP), Kaplan-Meier (KP) distance of survival curves, unadjusted log-rank statistic (LP), martingale residuals (MP), and node impurity (ZP). With the exception of the AU algorithm (based on a Bonferroni-adjusted p-value driven stopping rule), trees are pruned using the measure of split-complexity, and optimally-sized trees are selected using cross-validation. The integrated Brier score is used for the evaluation of predictive models. According to the results of our simulation study and of the clinical example, we conclude that the AU, AP, EP, and LP algorithm may yield superior predictive accuracy. The choice among these four algorithms may be based on the required parsimonity and on medical considerations.

Contrast-enhanced ultrasound improves hepatic vessel visualization after orthotopic liver transplantation

AbstractBackground: We investigated whether color-coded Doppler sonography combined with an ultrasound contrast medium would improve the assessment of liver-supplying vessels after orthotopic liver transplantation. Methods: Forty-seven patients after orthotopic liver transplantation participated. Examinations were done without and then with the ultrasound contrast medium Levovist. Visualization of the liver-supplying vessels was assessed with a scoring system. Results: Visualization of the portal vein was similar without and with contrast medium. Hepatic arteries were visualized in 39 patients without contrast medium and 46 patients with contrast medium. The remaining patient showed hepatic artery thrombosis, which was confirmed angiographically. With the use of Levovist, the examination took 3.7 min rather than the usual 6.4 min. Conclusion: Imaging of hepatic arteries after liver transplantation improved significantly with the use of ultrasound contrast medium. These findings are important because the early detection of blood flow through the liver after transplantation affects prognosis.

Ten years experience with piezoelectric extracorporeal shockwave lithotripsy of gallbladder stones.

Background A critical review of the experience with extracorporeal shockwave lithotripsy (ESWL) of gallbladder stones is needed to clarify whether this method should continue to be applied to patients. Methods Patients with symptomatic gallbladder stones were treated by piezoelectric ESWL according to a prospective protocol between 1988 and 1997. ESWL treatment was limited to a maximum of three (solitary stones <20 mm diameter) to five sessions (larger solitary or multiple stones) and 3000 pulses per session. Univariate and multivariate analyses of pretreatment and treatment variables were performed to investigate their impact on fragmentation efficacy and stone clearance. A tree-based analysis was used to identify prognostically homogenous subgroups of individuals with maximum benefit from ESWL. Results Four hundred and eight patients, 76% female and 24% male, with a mean age of 46 (SD, 13) years, were selected for evaluation. Cox regression analysis identified three pretreatment variables with significant prognostic impact: (1) number of gallstones >1 (relative risk, 2.6 (95% CI, 1.9–3.5)), (2) size of stones >17 mm (1.7 (1.4–2.2)), and (3) computed tomography (CT) density of stones >55 Hounsfield units (H) (1.4 (1.1–1.8)). According to tree-based analysis, the stone clearance rate after 1 year was 85% (95% CI, 75–91%) for solitary stones <16 mm, 79% (70–86%) for solitary stones ≥16 mm with a CT density <84 H, 45% (32–55%) for solitary stones ≥16 mm with a CT density ≥84 H, and 42% (30–51%) for multiple stones. Five years after stone clearance, recurrence occurred in 43% of patients (95% CI, 39–47%). Conclusions ESWL treatment showed an acceptable stone clearance in the case of small solitary gallbladder stones (<16 mm) or larger solitary stones with a CT density <84 H, but a very low success rate in the case of multiple stones. The poor long-term success, however, is an important argument against the use of ESWL of gallbladder stones.

Changes in hepatic hemodynamics after orthotopic liver transplantation: color Doppler sonography

AbstractBackground: Liver perfusion has an influence on therapy results in patients undergoing orthotopic liver transplantation (OLT). The objective of the present study was to investigate changes in hepatic hemodynamics in patients after OLT with color-coded Doppler sonography (CCDS). Methods: Forty-five consecutive patients were included. The examinations were done before, on postoperative day 1, and then weekly until the patients were discharged. Mean velocity of the portal (PV-V) and splenic (SV-V) veins and the maximum velocity and resistance index of the hepatic artery were determined. Results: After OLT a significant increase in PV-V and SV-V was observed. Twenty-five patients had normal perfusion of the hepatic artery, whereas 16 patients had abnormal flow patterns. In these patients prostaglandin I2 was used until flow rates normalized. In four patients, CCDS could not detect perfusion of the hepatic artery. Conclusions: CCDS is a suitable method for evaluating hepatic hemodynamics before and after OLT. Changes in blood flow velocities in the liver-supplying vessels are detectable, but perfusion of the hepatic artery is seldom detectable. These observations are of special interest after OLT, where liver circulation has an influence on therapy results.

Piezoelectric Lithotripsy of Gallbladder Stones

Non-surgical procedures for the treatment of gallbladder stones must be measured against the effectiveness of cholecystectomy, with its low morbidity and mortality rates. For non-invasive alternative procedures to cholecystectomy, however, apart from adequate effectiveness, freedom from anaesthesia and analgesia is a requirement that needs to be met. This latter feature applies in particular when partial successes on initial treatment, or with recurrent stones, make renewed lithotripsy necessary.

4619 Hemorrhage after endoscopic sphincterotomy: risk factors and endoscopic managenent - final results of a prospective study.

To determine risk factors (RF) for hemorrhage after endoscopic sphincterotomy (EST) and to evaluate the outcome of therapeutic modalities. METHODS: In all consecutive EST procedures between 09/94 and 12/98 indications, techniques, success, complications of EST, and possible RF for hemorrhage were evaluated prospectively. Pts. were followed up by physical examination and blood samples at 4, 24 and 48 hours after EST. Complications were classified according to commonly accepted criteria (Gastrointest Endosc 1991: 338). Risk factor analysis was performed using univariate methods. RESULTS: In 815 pts. (53.3% m, 46.7% f, 61±17 y); complications occured in 9.9% (81/815; 69 mild-moderate; 11 severe; 4 fatal). Bleeding during the procedure was seen in 50 pt. (self-limiting in 35 cases, successful injection therapy in 15 pt). The incidence of hemorrhage (drop of hemoglobin of at least 2 g/dl and clinical signs of hemorrhage) was 1.6% (14/815; 7 mild-moderate; 5 severe; 2 fatal). Hemorrhage was detected only in 2 pt., who showed bleeding during EST (both with prior injection therapy), and in 12 pt. without signs of bleeding during EST. The clinical onset of hemorrhage was within 4 hours after EST in 5 pt., within 2 days in 4 pt., and within 4 to 10 days in 5 pt. Univariate analysis obtained 2 RF for hemorrhage: coagulopathy (thrombocytes

4622 The endoscopist is the major risk factor for complications of endoscopc sphincterotomy: final results of a prospective study.

To determine risk factors (RF) for complications of endoscopic sphincterotomy (EST). METHODS: In all consecutive EST procedures between 09/94 and 12/98 indications, techniques, success, complications of EST and possible RF were evaluated prospectively. Pts. were followed up by physical examination and blood samples at 4, 24 and 48 hours after EST. Complications were classified according to commonly accepted criteria (Gastrointest Endosc 1991: 338). Analysis of RF was performed by uni- and multivariate methods. RESULTS: In 815 pts. (53.3% m, 46.7% f, 61±17 y); complications occured in 9.9% (81/815; 69 mild-moderate; 11 severe; 4 fatal): Pancreatitis: 6.4% (52/815; 48 mild-moderate; 4 severe; 0 fatal), Hemorrhage: 1.6% (14/815; 7 mild-moderate; 5 severe; 2 fatal), infections 1.7% (15/815; 11 mild-moderate; 2 severe; 2 fatal), perforation 0.2% (2/815; 2 mild-moderate). Others 0.1% (1/815; 1 mild). Multivariate analysis obtained a frequency of ≤40 EST/y as the only RF for complications in total (15.2% vs. 7.8%, p=0.002), and diabetes mellitus as independent protective factor (5.1% vs. 11.3%, p=0.02). No other variables reached significant levels in univariate analysis regarding complications in total. Coagulopathy (thrombocytes

4615 Prevention of acute post-ercp pancreatitis with heparin? final results of a prospective study on risk factors for ap.

Explorative analysis obtained a very low incidence of AP in patients who received heparin prior to ERCP with EST. Experimental data showed that heparin has anti-inflammatory effects, improves pancreatic microcirculation during AP and inhibits pancreatic proteases. METHODS: Potential risk factors for AP were prospectively analysed in all consecutive ERCP with EST between 09/94 and 12/98. Pts. were followed up by physical examination and blood samples at 4, 24 and 48 hours af-ter EST. Complications were classified according to commonly accepted criteria (Gastrointest Endosc 1991: 338). Confirmative analysis of RF for AP was performed by uni- and multivariate methods, and the incidence of AP was compared between pts. who received heparin (HEP) and pts. without heparin (CON; control) considering known and suspected confounding variables (RF-analysis for AP). RESULTS: 815 pts. (53.3% m, 46.7% f, 61±17 y); complications 9.9% (81/815; 69 mild-moderate; 11 severe; 4 fatal). The incidence of AP was 6.4% (52/815; 48 mild-moderate; 4 severe; 0 fatal). Heparin was administered in 33.0% (269/815). Multivariate analysis identified 4 independent RF for AP: endoscopist-frequency ≤ 40EST/y (11.8% vs. 4.2%, p=0.002), female sex (9.2% vs. 3.9%, p=0.005), SOD (37.5% vs. 6.1%; p=0.011), pancreas divisum (18.7% vs. 5.9%, p=0.013), and one independent protective factor: heparin administration (3.3% vs. 7.9%; p=0.002). Additionally, prior laparoscopic cholecystectomy (14.3% vs. 6.0%, p=0.044) and pancreatic cannulation (7.8% vs. 4.3%, p=0.057) univariately showed an increased risk for AP. Pt.-age