Jeffrey D. Linder

Endoscopic management of adenoma of the major duodenal papilla

BACKGROUND It is well established that adenoma of the major duodenal papilla has a potential for malignant transformation. Standard treatment has been surgical (duodenotomy/local resection, pancreaticoduodenectomy). Endoscopic management is described, but there is no established consensus regarding the approach to papillectomy or the need for surveillance. This study describes endoscopic management and long-term follow-up of papillary tumors by 4 groups of expert pancreaticobiliary endoscopists. METHODS Consecutive patients with papillary tumors referred to 4 pancreaticobiliary endoscopy centers for evaluation for endoscopic papillectomy were reviewed. For each patient, an extensive questionnaire was completed, which included 19 preoperative and 15 postoperative data points. A total of 103 patients (53 women, 50 men, age range 24-93) who underwent attempted endoscopic resection were included. Of these, 72 had sporadic adenoma, and the remaining patients had familial adenomatous polyposis, including Gardners variant. Presenting symptoms were jaundice/cholangitis/pain (n=59), pancreatitis (n=18), and bleeding (n=12). Twenty-six patients were asymptomatic. RESULTS Endoscopic treatment was successful, long term, in 83 patients (80%) and failed (initial failure or recurrent tumor) in 20 (20%) patients. Success was significantly associated with older age (54.7 [16.6] vs. 46.6 [21.7] years; p=0.08) and smaller lesions (21.1 [8.3] vs. 29.7 [7.2] mm; p<0.0001). Success rate was higher for sporadic lesions compared with genetically determined lesions (63 of 72 [86%] vs. 20 of 31 [67%]; p=0.02). There were 10 initial failures, which was more common for sporadic lesions (7 of 10). The overall success rate for papillectomy was similar in patients who had adjuvant thermal ablation (81%) compared with those who did not (78%). However, recurrence (n=10) was more common in the former group (9 of 10, [90%]; p=0.22). Complications (n=10) included acute pancreatitis (n=5), bleeding (n=2), and late papillary stenosis (n=3). Acute pancreatitis was more common in patients who did not have pancreatic duct stents placed (17% vs. 3.3%). Papillary stenosis was more frequent without short-term pancreatic duct stent placement (15.4% vs. 1.1%), although the difference was not statistically significant, because this complication was infrequent. CONCLUSIONS Endoscopic treatment of papillary adenoma in selected patients appears to be highly successful. The majority can undergo complete resection after ERCP. In expert hands, complications are infrequent and may be avoided by routine placement of a pancreatic duct stent.

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.

Commitment, confirmation, and clearance: new techniques for nonradiation ERCP during pregnancy (with videos).

BACKGROUND Symptomatic choledocholithiasis during pregnancy can be treated with ERCP, but fluoroscopy may pose a risk to the fetus. Nonradiation ERCP may be a safer form of treatment, but its performance has not been optimized. OBJECTIVES The purpose of this study was to evaluate new methods of nonradiation ERCP during pregnancy, including wire-guided cannulation techniques to achieve bile-duct access without the use of fluoroscopy, and the use of peroral choledochoscopy to confirm ductal clearance. STUDY DESIGN A retrospective review of consecutive ERCPs performed on pregnant women. SETTING Urban referral hospital. PATIENTS Pregnant women with symptomatic choledocholithiasis. INTERVENTIONS All patients underwent therapeutic ERCP without any use of fluoroscopy. Endoscopist-controlled wire-guided cannulation was performed to achieve biliary access. MAIN OUTCOME MEASUREMENTS The rate of successful biliary cannulation and short-term outcomes. LIMITATIONS ERCP procedures were performed by a single endoscopist. RESULTS Successful bile-duct cannulation with sphincterotomy and the removal of biliary stones or sludge was performed without fluoroscopy in 21 pregnant women. There was one case of mild post-ERCP pancreatitis. Choledochoscopy confirmed ductal clearance in 5 cases. CONCLUSIONS Nonradiation ERCP is a safe and effective treatment for symptomatic choledocholithiasis during pregnancy. Wire-guided biliary cannulation and choledochoscopy may enhance the performance of ERCP in this setting.

ACID PEPTIC DISEASE IN THE ELDERLY

GERD and peptic ulcer disease are important diseases in the elderly. GERD presents similarly in the elderly and the young, although elderly patients may have less severe symptoms yet more severe mucosal disease and a higher prevalence of BE. Although the prevalence of H. pylori is falling, the elderly remain at risk for peptic ulcer because of the widespread use of NSAIDS. The presentation of peptic ulcer disease in the elderly can be subtle and atypical when compared with younger patients, leading to a delay in diagnosis. Because of comorbidity in the aged, peptic ulcer disease and its complications result in increased morbidity and mortality rates.

Diagnostic yield and clinical implications of push enteroscopy: results from a nonspecialized center.

Background Push enteroscopy is increasingly used as an investigative tool for the evaluation of gastrointestinal bleeding, and studies from specialized centers have shown an overall diagnostic yield of push enteroscopy in such patients ranging from 38% to 75%. The aim of our study was to characterize the yield and clinical effect of push enteroscopy to determine the applicability of prior observations to other academic centers. Study We retrospectively studied patients who underwent push enteroscopy between January 1995 and December 2000 at our institution. Detailed clinical history, endoscopic findings, endoscopic therapy, and subsequent medical treatment were obtained through review of medical records and our endoscopic database. Medications prescribed after enteroscopy and whether medical management was affected by the findings of push enteroscopy were also recorded. Results Over the 6-year study period, 126 patients (48% men; mean age, 62 years; range, 15–91 years) underwent push enteroscopy. The most common indications for push enteroscopy were gastrointestinal bleeding in 57 patients (45%) and iron-deficiency anemia in 32 (25%). The results of push enteroscopy were normal in 44 patients (35%), and the most frequent endoscopic lesions were angiectasias in 24 patients (19%), gastric erosions in 10 (8%), gastric ulcer in four (3%), jejunal ulcer in three (2%), and esophagitis in three (2%). The identified lesions (n = 89) were within reach of a standard upper endoscope in 42 patients (47%). Endoscopic therapy was performed in 12 patients (13%), and the management of 50 patients (40%) was changed based on findings at push enteroscopy. Conclusions Push enteroscopy has a high diagnostic yield, similar to reports from specialized centers suggesting the potential clinical benefit of more widespread use.

Prevalence of sphincter of Oddi dysfunction: Can results from specialized centers be generalized?

Recent studies suggest a high prevalence of sphincter of Oddi dysfunction (SOD) in patients referred to specialized centers for sphincter of Oddi manometry (SOM). Whether these results can be generalized to other centers is unknown. From September 1998 to April 2000, patients undergoing SOM were prospectively identified. Patients were classified as having either biliary or pancreatic SOD, according to the modified Milwaukee classification, and underwent SOM of either the biliary or pancreatic sphincter based on clinical history. SOD was diagnosed when the mean basal sphincter pressure was >40 mm Hg. Standard cholangiography and/or pancreatography were performed following manometry. Fifty-one patients were studied (43 women, median age 46 years, range 7–74 years). Prior to SOM, patients were classified by the modified Milwaukee classification as biliary type I in 1 patient, type II in 8, and type III in 20; pancreatic type I in 4 patients, type II in 14, and type III in 3; and biliary type III and pancreatic type III in 1 patient. Indications for SOM included abdominal pain in 35 patients (69%), recurrent idiopathic pancreatitis in 12 (24%), chronic pancreatitis in 3 (7%), and acute pancreatitis in 1 (2%). Overall, 30 patients (59%; 95% CI 41.1–76.9%) were found to have SOD; abnormal biliary sphincter pressure in 16 of 29 patients (55%) undergoing biliary manometry, and abnormal pancreatic sphincter pressures in 14 of 21 patients (67%) undergoing pancreatic sphincter manometry, and abnormal biliary and pancreatic sphincter pressures in 1. SOD was diagnosed in 1 biliary type I patient (100%), 4 type II patients (50%), and 11 type III patients (52.4%) with a mean pressures of 92, 47, and 80 mm Hg, respectively. SOD was identified in 4 pancreatic type I patients (100%), 7 type II patients (50%), and 3 type III patients (100%) with mean sphincter pressures of 83 mm Hg, 96 mm Hg, and 102 mm Hg, respectively. In conclusion, the prevalence of SOD in patients with suspected biliary disease was 55%, suspected pancreatic disease 66%, yielding an overall prevalence of SOD of 59%. These results confirm the high prevalence of SOD in patients referred for SOM.

Incomplete response to endoscopic sphincterotomy in patients with sphincter of Oddi dysfunction: evidence for a chronic pain disorder.

OBJECTIVE:The efficacy of endoscopic treatment of sphincter of Oddi dysfunction (SOD) with endoscopic sphincterotomy (ES) remains controversial. Although some studies have shown a positive impact on patient symptoms after treatment, these reports have been largely qualitative and evaluated on short-term response. The aim of our study was to quantitatively measure the long-term outcomes of endoscopic therapy in patients with SOD.METHODS:Thirty-three patients with suspected SOD underwent selective sphincter of Oddi manometry (SOM) of the biliary and/or pancreatic sphincter. Each patient completed a telephone-based survey measuring symptomatic pain before and after SOM ± ES. The questioner was blinded to the results of SOM. The patients with normal SOM or SOD but who did not undergo ES served as controls.RESULTS:Of these 33 patients (27 women, mean age 48.7 yr, range 13–74), 19 (57.5%) were found to have SOD (12 biliary, six pancreatic, one both). The average follow-up was 18.1 months (range 7–34). Of the patients with SOD, 17 (89%) underwent ES. At follow-up of the 19 patients undergoing ES, five were taking narcotics for persistent pain, two were taking antidepressants, and 15 identified the endoscopic therapy as the reason for their relief. Of the 14 controls, seven were taking narcotics, seven were taking antidepressants, and two identified the endoscopy as the reason for their relief; some patients were taking both antidepressants and narcotics.CONCLUSIONS:Patients found to have SOD who undergo ES are more likely to be improved on long-term follow-up when compared with patients with suspected SOD but normal manometry without ES. However, almost uniformly, despite ES, patients continue to have pain, which is consistent with most chronic pain disorders and which suggests a multifactorial cause for the pain.

Hepatopancreaticobiliary (HPB) surgery: what is the right fellowship for the right training?

BACKGROUND Reduced resident work hours over the last several years have led to inadequate exposure to hepatopancreaticobiliary (HPB) and complex upper gastrointestinal (UGI) surgical procedures. Therefore, residents are seeking additional training in this field. The purpose of this study is to determine the role of a new fellowship model in the training of general surgery residents in complex HPB/UGI diseases. METHODS We propose a surgical training model in benign as well as malignant diseases of the UGI tract. The proposed model would focus on an integrated approach that involves allied specialties such as gastroenterology (GI) and radiology. RESULTS The fellowship was set as 1-year duration with 1-month rotations on interventional GI and transplantation. The fellow spent the remaining 10 months on a UGI laparoscopic and open surgery service caring for complex benign and malignant disease of the esophagus, stomach, bile duct, pancreas, and liver. Didactic conferences were focused specifically at an organ-based approach to diseases of these organs. During a 12-month fellowship, exposure to complex diseases of the UGI tract was accomplished without negatively impacting the general surgery residency program. CONCLUSION This new mode of advanced training provides a bridge between surgical oncology and transplantation, and it is an excellent model for postgraduate surgical training in UGI diseases.

Prospective evaluation of droperidol on sphincter of Oddi motility

BACKGROUND Droperidol increasingly is used as an effective adjunct for conscious sedation during endoscopic procedures. Given the concern for the effects of narcotics and benzodiazepines on sphincter of Oddi motility, and the potential difficulty in sedating patients undergoing sphincter of Oddi manometry, droperidol could be an ideal agent in this setting. METHODS Over a 43-month period, consecutive patients undergoing sphincter of Oddi manometry were studied prospectively. Sphincter of Oddi manometry was performed under general anesthesia in all but 10 patients. Standard retrograde pull-through techniques were used to examine the biliary and/or pancreatic sphincter, depending on the indication for sphincter of Oddi manometry. After the initial two pull-throughs, 5 mg of droperidol were given intravenously and measurements were repeated 5 minutes later. RESULTS A total of 55 patients were studied (42 women [76%], 13 men; mean age 43 years). The basal biliary sphincter pressures measured in 35 patients before and after droperidol were, respectively, 56 mm Hg and 48 mm Hg (p = 0.02); the basal pancreatic sphincter pressures measured in 22 patients before and after droperidol were, respectively, 92 mm Hg and 67 mm Hg (p = 0.29). By using a definition for sphincter of Oddi dysfunction of a basal pressure greater than 40 mm Hg, droperidol would have resulted in a change in diagnosis in 5 patients undergoing biliary manometry (one misclassified as sphincter of Oddi dysfunction, 4 misclassified as normal), and 6 patients undergoing pancreatic sphincter manometry (5 misclassified as sphincter of Oddi dysfunction, one misclassified as normal) (total 19% of procedures). No complication was associated with droperidol use. CONCLUSIONS Droperidol alters basal sphincter pressures, which in some patients was clinically significant and would have resulted in misclassification. Although safe and well tolerated, droperidol appears to have subtle but clinically significant effects on the sphincter of Oddi.

CASE REPORT: Giant Cell Arteritis and Intestinal Angina

A 72-year-old Caucasian female presented for evaluation of a one-year history of progressive anorexia, nausea, and postprandial abdominal pain with an associated 20-lb weight loss. She described her abdominal pain as crampy, diffuse, and occurring 30 min after meals and lasting for approximately 60 min. Therefore, she had learned to avoid meals because of fear of developing abdominal pain. She underwent an evaluation by an outside physician four months prior to presenting to our institution. The evaluation consisted of an esophagogastroduodenoscopy (EGD), colonoscopy, and small bowel series with negative results. She had a history of peripheral vascular disease and had undergone aortofemoral bypass surgery four weeks prior to our evaluation. In addition to the above symptoms, she reported malaise, intermittent subjective fever, and headaches for the last six months and recalled being diagnosed with anemia. Physical examination disclosed a normal cardiopulmonary exam; the abdomen was soft and nontender with an abdominal bruit best auscultated in the epigastrium. Laboratory studies on admission included a normal white blood cell count, hematocrit of 34% with a normal mean corpuscular volume, and platelet count of 490,000/mm. The erythrocyte sedimentation rate (ESR) was 38 mm/hr. Electrolytes, creatinine, glucose, and liver function tests were within normal limits. Chest x-ray showed mild bilateral pulmonary hyperinflation. The diagnosis of chronic mesenteric ischemia (intestinal angina) was entertained based on her symptomatology, physical examination, and past medical history. Therefore, a visceral angiogram was performed, which showed diffuse irregularities consistent with vasculitis in both carotids and superior mesenteric artery where an abrupt caliber cutoff was observed (Figure 1). A temporal artery biopsy was performed that showed giant cells in the media of the artery consistent with giant cell arteritis (GCA) (Figure 2). The patient was placed on steroids and methotrexate with resolution of her symptoms within three days. Unfortunately, she was readmitted four weeks later with recurrent abdominal pain and weight loss despite therapy. Vascular surgery performed a right iliac-to-superior mesenteric bypass and the postoperative course was complicated by an acute myocardial infarction. A left-heart catheterization showed diffuse irregularities consistent with vasculitis. A dominant left anterior descending artery lesion was stented. On post-operative day 18, she was transferred to a rehabilitation center for further convalescence.