Jack A. Vennes

Résumé of a seminar on endoscopic retrograde sphincterotomy (ERS)

This report summarizes the discussion of a three-day seminar on endoscopic retrograde sphincterotomy (ERS). Before the seminar a survey of the experience of 21 centers was collected. There were 1250 patients in whom ERS was attempted. It was successful in 89%. The 137 failures were primarily related to large stones or to difficulty in positioning the papillotome. The indications were for common duct stones in 1106 (88.5%), papillary stenosis in 126 (10%), and miscellaneous in 18 (1.5%). The discussions at the seminar revealed marked variation in some aspects of individual techniques. The authors have described indications, contraindications, technique, and complications with an attempt to indicate where concensus was reached. The numerous questions and problems with the procedure are described. ERS has merit, but its precise role in clinical medicine remains to be defined.

Comparison of covered versus uncovered wire mesh stents in the canine biliary tract.

Abstract Self-expanding wire mesh stents have been developed for endoscopic placement across malignant biliary strictures, but tumor ingrowth may limit the usefulness of open mesh stents. We reasoned that coating the wire mesh might prevent tumor ingrowth. Tissue response to covered and uncovered stents was compared in dogs. Stents were surgically placed in the bile ducts of 22 mongrel dogs through the sphincter of Oddi. Either a silicone-covered stent or an uncovered stent was inserted. Liver function test values remained normal throughout a 1- or 3-month study. Necropsy revealed that all ducts were unobstructed. Bile duct histologic examination revealed mild-to-moderate cellular infiltration in all animals. Mucosal hyperplasia was more marked in the animals with uncovered stents and the bare wires became deeply embedded in bile duct epithelium, whereas the wires of covered stents did not. We conclude that covered stents are well tolerated by the canine bile duct. These results suggest that such stents may be removable, making self-expanding metal stents an appropriate treatment for both benign and malignant biliary strictures. (Gastrointest Endosc 1994; 40:17-21.)

Endoscopic cholangiography for biliary system diagnosis.

Abstract We evaluated the results of endoscopic cholangiography in 108 patients who were examined for possible biliary tract obstruction. The clinical diagnosis of extrahepatic obstruction was conf...

Evaluation of the Endoscopic Pancreatogram

Of 300 endoscopic attempts at cannulation of the biliary and/or pancreatic ducts, 265 were successful and pancreatograms obtained in 203. The duct of clinical interest was visualized in 67% of the initial 150 studies and in 93% of the rest. In 75 proved cases of pancreatic disease, the pancreatographic features of the following disorders were identified: (a) Acute recurrent pancreatitis: 66% of these studies were normal. (b) Chronic pancreatitis: 93% of these were abnormal. (c) Pancreatic cyst: consistently abnormal studies were seen, with filling of the cyst cavity in 62%. (d) Pancreatic neoplasm: abnormal studies were demonstrated in 74% of cases. With use of combined ductal characteristics, the ultimate diagnosis can be suggested in most of these cases.

The Normal Endoscopic Pancreatogram

Pancreatograms of 102 patients with proved normal pancreatic status were reviewed to establish normal standards of pancreatic ductal morphology, and precise details of ductal course, position, length, caliber, and variant anatomy were analyzed. The ampulla was found at the level of the second lumbar vertebra in 75% of cases, while the pancreatic duct crossed the spine at L1 in most cases. Mean ductal diameters were 3.1, 2.0 and 0.9 mm in the head, body, and tail of the pancreas, respectively.

Cleaning and Disinfection of Fiberoptic Endoscopes: Evaluation of Glutaraldehyde Exposure Time and Forced-Air Drying

Several alternative schedules of cleaning and disinfection of flexible fiberoptic endoscopes were evaluated during actual use in paired endoscopy suites. Thorough mechanical cleaning with detergent and alcohol was compared with the same cleaning with the addition of 5-, 10-, or 20-min immersion of the endoscope insertion tube in 2% alkaline glutaraldehyde solution. Endoscopes were cultured quantitatively and qualitatively for aerobic bacteria at three different times relative to procedures: after use, immediately after cleaning alone or cleaning plus disinfection, and after storage unused in a cabinet for 20-72 h. Cleaning plus glutaraldehyde immersion for 5 min significantly reduced bacterial contamination both immediately and after storage when compared with cleaning alone. Results of cleaning plus 10- and 20-min glutaraldehyde immersion were not statistically different from cleaning plus 5-min glutaraldehyde immersion. The addition of forced-air drying following disinfection significantly reduced bacterial contamination following storage when compared with storage without previous drying. Cleaning plus brief (5-20 min) glutaraldehyde immersion significantly reduced bacterial contamination of endoscopes when compared with cleaning alone (p less than 0.001) and, when combined with forced-air drying before storage, resulted in 59/63 (94%) negative endoscope cultures by the methods used in this study. These measures do not ensure sterility, but are superior to mechanical cleaning alone and sufficiently practical to be used routinely without undue interruption of busy endoscopy schedules.

Endoscopic visualization of bile and pancreatic ducts

This study reports the first 80 attempts at cannulation of the biliary and pancreatic ducts by these investigators. Sixty of these attempts were successful; in 49 instances the desired duct was demonstrated. Success increased with experience. Technical details of the procedure are described. Endoscopic cannulation of the duodenal ampulla will be a valuable addition to the diagnosis of biliary and pancreatic disease.

Diagnostic Accuracy of Endoscopic Retrograde Cholangiopancreatography in Hepatic, Biliary, and Pancreatic Malignancy

This paper reports the radiographic findings in 84 cases of biopsy-proven pancreatic and biliary malignancies studied by endoscopic retrograde cholangiopancreatography. In the 73 successful studies a diagnosis of tumor could be made in 67 patients (92%). The study was successful in 40 of 43 patients with pancreatic carcinoma and the diagnosis could be made in 37 on the basis of stenosis or obstruction of the ducts. There were 33 successful studies in the 41 patients with miscellaneous tumors including primary bile duct, ampullary, gallbladder, metastatic carcinoma, lymphoma, and hepatoma. A diagnosis of tumor was made in 30 studies. As has been observed in carcinoma of other hollow structures, the hallmark of malignancy in the pancreatic and biliary tract is obstruction and stenosis. This study indicates that malignant disease of the pancreas and tract is accurately assessed by this endoscopic method.

Preoperative endoscopic retrograde cholangiopancreatography in the surgical management of pancreatic pseudocysts

Preoperative ERCP was performed on 39 patients treated surgically for pancreatic pseudocysts from 1970 to 1982 at the Minneapolis Veterans Administration Medical Center. ERCP-related sepsis was rare (4 percent of patients) and only occurred when surgery was delayed for more than 24 hours. The primary benefit of preoperative ERCP was to provide detailed information on pancreatic and biliary ductal anatomic characteristics other than those specifically related to the pancreatic pseudocyst. These data influenced the choice of operation in 49 percent of the patients. Specific preoperative surgical planning was facilitated and intraoperative pancreatography and cholangiography were obviated. Major postoperative complications occurred in 21 percent of the patients (0 percent mortality) but none were considered to be related to preoperative ERCP. ERCP before operation is a safe and important adjunct to surgical management of pancreatic pseudocysts. We strongly believe, however, that the interval from ERCP to surgery should not exceed 24 hours.

A comparison of upper gastrointestinal endoscopy and radiography

One hundred symptomatic patients were evaluated independently with upper gastrointestinal radiography and fiberoptic endoscopy, and the results were compared. Of the two endoscopists sequentially examining the same patient, one was informed of available clinical and radiographic details and the other was not. Knowledge of the x-ray examination by the informed endoscopist did not improve his accuracy. Each endoscopist made four errors of interpretation. The endoscopic and x-ray findings agreed in 46 of the 100 patients, most often (68%) in the eophagus, least often (29%) in the stomach and half the time (45%) in the duodenum. Ulcer craters seen endoscopically were detected radio-graphically in 36% of patients. We conclude that: 1) knowledge of results of prior upper gastrointestinal radiography did not alter endoscopic results; 2) experienced endoscopists are accurate but make mistakes; and 3) endoscopic findings would have been unaltered had radiography not been performed.