Peter Matzen

Complications of ERCP: a prospective study

BACKGROUNDnStudies of ERCP-related morbidity seldom include a sufficient patient follow-up. The aim of this study was to characterize and to evaluate the frequency of complications, cardiopulmonary untoward events in particular.nnnMETHODSnAll patients undergoing ERCP during a 2-year period were included in this prospective study. Complications were assessed at the time of ERCP and by postal/telephone contact at 30-days after the procedure.nnnRESULTSnA total of 1177 ERCPs were included in the analysis, of which 56.2% were therapeutic. The 30-day complication rate was 15.9%; the procedure-related mortality rate was 1.0%. Post-ERCP pancreatitis occurred in 3.8% of patients (3 deaths). Hemorrhage or perforation occurred with 0.9% and 1.1%, respectively, of the procedures (3 deaths). One perforation that resulted in the death of the patient occurred after placement of an endoprosthesis. Cholangitis occurred in relation to 5% of the ERCP procedures (3 deaths). Cardiorespiratory complications occurred in 2.3% (2 deaths). Dilated bile duct ( p = 0.0001), placement of stent ( p = 0.001), and use of more than 40 mg of hyoscine-N-butyl bromide ( p < 0.05) were risk factors for complications by multivariate analysis. Risk of pancreatitis was increased with age under 40 years ( p = 0.0078), placement of stent ( p = 0.031), and a dilated bile duct ( p = 0.036).nnnCONCLUSIONSnThis prospective study confirms that the complication rate of ERCP including therapeutic procedures is high. Cardiopulmonary complications were not as common as expected, despite being the special focus of the study.

Preoperative endoscopic stent placement before pancreaticoduodenectomy: A meta-analysis of the effect on morbidity and mortality ☆

BACKGROUNDnPancreaticoduodenectomy is the only potentially curative treatment for peripapillary pancreatic tumors. However, postoperative morbidity and mortality are high, and different approaches have been tried to improve results, such as preoperative biliary drainage in patients with jaundice. This meta-analysis investigated the effect on postoperative outcome of preoperative biliary drainage by endoscopic biliary stent placement in patients who are jaundiced and who have peripapillary pancreatic tumors.nnnMETHODSnA Medline search for the period 1985 to 2001 was performed. Eight retrospective studies and 2 prospective randomized controlled trials were included. Selection criteria for the primary analysis were as follows: patients with peripapillary pancreatic cancer, endoscopic stent placement versus no stent, radical surgery, and assessment of postoperative morbidity and mortality. A secondary analysis included both radical and palliative surgery.nnnRESULTSnIn the primary analysis, 337 patients underwent preoperative endoscopic biliary stent placement, and 412 patients had no endoscopic biliary stent placement (controls). The overall odds ratio for postoperative complications (stent vs. no stent) is estimated as 0.79: 95% CI [0.36, 1.73] and the estimated odds ratio for postoperative mortality is 0.81: 95% CI [0.33, 1.99]. In the secondary analysis, 1008 patients underwent preoperative EBS versus 720 control patients. The odds ratio for postoperative complications in this analysis was 0.93: 95% CI [0.65, 1.33] and for postoperative mortality is 1.12: 95% CI [0.62, 2.01].nnnCONCLUSIONnNo evidence was found of either a positive or adverse effect of preoperative endoscopic biliary stent placement on the outcome of surgery in patients with pancreatic cancer.

Budesonide Enema in Distal Ulcerative Colitis: a Randomized Dose-Response Trial with Prednisolone Enema as Positive Control

The effect of budesonide, 1, 2, and 4 mg/100 ml in daily enemas, on active distal ulcerative colitis was compared with that of prednisolone disodium phosphate enemas, 25 mg/100 ml, in a multicentre, randomized, group-comparative trial. A total of 146 patients with active disease were treated for 2 weeks. Data from 139 were valid for statistical analyses. Bowel habits, proctoscopy findings, and histologic pictures were evaluated, and plasma cortisol was determined for measurement of influence on the hypothalamic-pituitary-adrenal axis. Clinical symptoms and proctoscopy findings improved within all treatment groups. The improvement of these effect variables tended to be less after treatment with the lowest dose of budesonide, 1 mg/100 ml, than after the other treatments. Plasma cortisol did not change in any of the budesonide groups, whereas a mean reduction of 30% (P = 0.07) was observed after prednisolone. It can be concluded that budesonide enemas of 2 mg/100 ml constitute an attractive alternative to prednisolone enemas for topical treatment of distal ulcerative colitis.

Quantitative hepatobiliary scintigraphy and endoscopic sphincter of Oddi manometry in patients with suspected sphincter of Oddi dysfunction: assessment of flow-pressure relationship in the biliary tract.

Objective In the present study, the diagnostic efficacy of quantitative hepatobiliary scintigraphy (QHBS) was compared with that of endoscopic sphincter of Oddi (SO) manometry (ESOM) in patients with a suspected SO dysfunction (SOD) of biliary type II or III. Methods Twenty cholecystectomized patients with SOD biliary types II and III were investigated by QHBS and by ESOM. Twenty asymptomatic cholecystectomized patients served as controls for scintigraphy. ESOM was performed by applying the station pull‐through method. Then SO basal pressure and phasic contraction characteristics were determined. During QHBS, time‐activity curves were generated, and the time‐to‐peak (Tmax), the half‐time of excretion (T½), the duodenal appearance time (DAT) and the hilum‐to‐duodenum transit time (HDTT) were then calculated. At the 60th minute of QHBS, 5 ng/kg body weight/min caerulein was administered. Results In patients with SOD and elevated SO basal pressure (> 40 mmHg), QHBS parameters, such as Tmax and T½ calculated from regions of interest over the hepatic hilum and common bile duct, HDTT and DAT proved to be significantly increased compared to controls: 28.7 ± 4.3 versus 21.1 ± 4.6 min, 39.7 ± 15.4 versus 18.8 ± 2.6 min, 9.0 ± 3.6 versus 2.3 ± 1.3 min and 27.1 ± 4.9 versus 16.6 ± 3.0 min, respectively. In contrast, in patients with SOD and normal SO basal pressure, QHBS parameters did not differ significantly from the controls. For the pooled data on the symptomatic patients with SOD, a statistically significant linear correlation was found between the SO basal pressure and the QHBS parameters. Although HDTT was the most sensitive scintigraphic parameter (89%), the combined sensitivity and specificity of Tmax and T½ of the common bile duct reached 100%. No scintigraphic sign of a paradoxical response to cholecystokinin was detected. Conclusions QHBS is a useful non‐invasive diagnostic method for the selection of SOD patients with an elevated SO basal pressure. A significant correlation has been established between the trans‐papillary bile flow measured by QHBS and the SO basal pressure determined by ESOM. Eur J Gastroenterol Hepatol 12:777‐786

Treatment of Helicobacter pylori in Children With Recurrent Abdominal Pain

The role of Helicobacter pylori remains unclear in children with recurrent abdominal pain (RAP). In this study children with RAP were included in a double blind treatment study to elucidate whether symptoms disappear in children with a H. pylori infection and RAP, if the bacteria are eradicated.

The prevalence and related symptomatology of Helicobacter pylori in children with recurrent abdominal pain

The aim of the study was to assess and compare the IgG seroprevalence of H. pylori in children with recurrent abdominal pain with healthy children and to investigate the related symptoms. IgG antibodies against low‐molecular weight H. pylori antigens were assessed in 438 children with recurrent abdominal pain and in 91 healthy controls. Sera with an ELISA unit‐value above the cut‐off level were confirmed by Western immunoblot. Only seropositive children with recurrent abdominal pain were examined by an oesophago‐gastro‐duodenoscopy. Symptomatology was recorded according to the localization of the abdominal pain, presence of pyrosis, nocturnal pain, relation of pain to meals and bowel irregularities. The seroprevalence was 21% (95% CI: 17‐25%) in the children with recurrent abdominal pain and 10% (95% CI: 5–18%) in the healthy controls (p= 0:30). In seropositive children with RAP H. pylori was found in 46/66 by culture and histology. The presence of H. pylori was significantly associated with active or inactive chronic gastritis. The presence of H. pylori was associated with both parents being born in a country with a high prevalence and a low social class. Helicobacter pylori‐positive children had more often pain related to meals than the H. pylori‐ negative children. No differences among the two groups were seen according to the levels of haemoglobin, leucocytes, thrombocytes, weight and height. In conclusion, the seroprevalence of H. pylori is comparable in children with recurrent abdominal pain and healthy children. No specific symptomatology was seen in H. pylori‐ positive children with RAP.

Danish Patients With Chronic Pancreatitis Have a Four-Fold Higher Mortality Rate Than the Danish Population

BACKGROUND & AIMSnWe investigated mortality of patients with chronic pancreatitis (CP), compared with the Danish population and sought to determine whether clinical presentations of CP can be used in prognosis. We also investigated clinical factors associated with mortality and causes of death among these patients.nnnMETHODSnThe Copenhagen Pancreatitis Study is a prospective study of patients admitted from 1977 to 1982 to the 5 main hospitals in Copenhagen with a diagnosis of acute pancreatitis or CP. In 2008, follow-up data were collected from these patients from the Danish Registries; this subcohort comprised 290 patients with probable (n = 41) or definite CP (n = 249).nnnRESULTSnThe mortality of patients with definite CP was 4-fold that of the Danish population and significantly higher than that of patients with probable CP (P = .003; 95% confidence interval [CI], 1.21-2.57); patients with probable CP had a 2- to 3-fold higher mortality rate than the population. In patients with definite CP, factors significantly associated with mortality included non-employment (P = .015; 95% CI, 0.53-0.93), and being underweight (P = .020; 95% CI, 0.52-0.95). Sex, alcohol use, smoking, single versus co-living, exocrine insufficiency, diabetes, pancreatic calcification, CP inheritance, painless CP, acute exacerbation of CP, or surgery for CP had no impact on survival. The most frequent causes of death were digestive diseases (19.5%), malignancies (19.5%), and cardiovascular diseases (11.3%).nnnCONCLUSIONSnDanish patients with definite CP had a 4-fold higher mortality rate compared with the background population and a higher mortality rate than patients with probable CP. Being nonemployed or underweight had significant impact on survival.

Meta‐analysis: nitroglycerin for prevention of post‐ERCP pancreatitis

Backgroundu2002 Acute pancreatitis after ERCP is a severe side effect.

Physiological Significance of Secretin in the Pancreatic Bicarbonate Secretion: II. Pancreatic Bicarbonate Response to a Physiological Increase in Plasma Secretin Concentration

The pancreatic response to physiological concentrations of secretin obtained after minute boluses of exogenous secretin was studied in 16 normal volunteers. Output of bicarbonate into the duodenum was measured by duodenal aspiration in 5 subjects and by endoscopic cannulation of the pancreatic duct in 11 subjects. Pure natural porcine secretin was injected intravenously in doses of 125, 250, and 500 fmol x kg-1 body weight (0.0013, 0.0027, and 0.0054 clinical units x kg-1). All three doses of secretin increased plasma secretin concentration, duodenal bicarbonate concentration, and duodenal bicarbonate output significantly. The bicarbonate output measured by the two techniques did not differ significantly. The increments in median plasma secretin concentration were 1.6, 3.0, and 6.4 pmol x 1(-1) after secretin, 125, 250 and 500 fmol x kg-1, and the corresponding 15-min bicarbonate output 283, 442, and 1435 micromol, respectively. The concentrations of secretin in plasma found after these doses of secretin are of the same order of magnitude as the secretin concentrations found during physiological conditions in man. It is concluded that the physiological concentrations or secretin influence pancreatic bicarbonate secretion.

Does glyceryl nitrate prevent post-ERCP pancreatitis? A prospective, randomized, double-blind, placebo-controlled multicenter trial

OBJECTIVEnAcute pancreatitis is the most dreaded complication of ERCP. Two studies have shown a significant effect of glyceryl nitrate (GN) in preventing post-ERCP pancreatitis (PEP). We wanted to evaluate this promising effect in a larger study with a realistically precalculated incidence of PEP.nnnDESIGN/PATIENTSnA randomized, double-blind, placebo-controlled multicenter study including patients from 14 European centers was performed. A total of 820 patients were entered; 806 were randomized.nnnINTERVENTIONnThe active drug was transdermal GN (Discotrine/Minitran, 3M Pharma) 15 mg/24 hours; placebo (PL) was an identical-looking patch applied before ERCP. A total of 401 patients received GN; 405 received PL.nnnRESULTSnForty-seven patients had PEP (5.8%), 18 (4.5%) in the GN group and 29 (7.1%) in the PL group. The relative risk reduction of PEP in the GN group of 36% (95% CI, 11%-65%) compared with the PL group was not statistically significant (P = .11). Thirteen had mild pancreatitis (4 in the GN group, 9 in the PL group), 26 had moderate pancreatitis (9 in the GN group, 17 in the PL group), and 8 had severe pancreatitis (5 in the GN group, 3 in the PL group). Headache (P < .001) and hypotension (P = .006) were more common in the GN group. Significant variables predictive of PEP were not having biliary stones extracted; hypotension after ERCP; morphine, propofol, glucagon, and general anesthesia during the procedure; or no sufentanil during the procedure.nnnCONCLUSIONSnThe trial showed no statistically significant preventive effect of GN on PEP. Because of a considerable risk of a type II error, an effect of GN may have been overlooked. (ClinicalTrials.gov ID: NCT00121901.).