Rama P. Venu

Endoscopic transpapillary drainage of pancreatic abscess: technique and results.

BACKGROUND Pancreatic abscess is one of the serious complications of acute pancreatitis. Traditionally, pancreatic abscess has been treated by operative drainage. Based on experience with endoscopic transpapillary drainage of pseudocysts, a similar technique was used in patients with pancreatic abscess. METHOD Patients were evaluated by endoscopic retrograde cholangiopancreatography. In those with pancreatic abscess communicating with the main pancreatic duct, pancreatic sphincterotomy, saline irrigation of the abscess cavity, and catheter dilation followed by 10F pancreatic stent placement were done. Instillation of gentamicin and nasopancreatic catheter drainage were used in difficult cases. RESULTS Of 22 patients with pancreatic abscess, 11 underwent endoscopic transpapillary drainage with technical success in 10 patients (90%); 8 patients (74%) had resolution of pancreatic abscess, clinically and radiographically. Intracavitary instillation of gentamicin and nasopancreatic catheter drainage were used in 2 patients. Two patients in whom endoscopic transpapillary drainage failed underwent operative drainage with a favorable outcome, and the one patient in whom endoscopic treatment was technically unsuccessful underwent successful percutaneous drainage. One patient had mild pancreatitis. CONCLUSION Endoscopic transpapillary drainage is an effective nonoperative therapy for selected cases of pancreatic abscess and is associated with minimal morbidity and no mortality.

CASE REPORT: Crohn's Disease Involving the Lung

Crohn’s disease is a chronic inflammatory disorder commonly involving the gastrointestinal tract. However, Crohn’s disease may also have several extraintestinal manifestations, such as pyoderma gangrenosum, erythema nodosum, polyarthritis, episcleritis, pericholangitis, and thromboembolism. Pulmonary involvement, although rare, has also been reported in association with inflammatory bowel disease. We report a patient with Crohn’s ileocolitis who presented with multiple pulmonary nodules on chest radiograph, nonproductive cough, and shortness of breath. The diagnosis of pulmonary Crohn’s disease was established by histological examination of the pulmonary nodule following open lung biopsy. The patient was treated with infliximab infusion with a successful clinical outcome and radiographic resolution.

The role of endoscopic retrograde cholangiopancreatography in acute and chronic pancreatitis.

Endoscopic retrograde cholangiopancreatography (ERCP) plays a pivotal role in the management of patients with acute and chronic pancreatitis. Whereas endoscopic observation during ERCP permits recognition of abnormalities involving the major and minor duodenal papillae such as papillary tumors or choledochocele, radiographic evaluation enables the detection of structural abnormalities of pancreaticobiliary ducts like strictures or calculi. Sphincter of Oddi manometry, a technical advance of ERCP, is essential for the diagnosis of sphincter of Oddi dysfunction, which may present clinically as recurrent pancreatitis. Because structural alterations of the pancreatic duct forms the hallmark of chronic pancreatitis, ERCP is highly sensitive and specific in diagnosing chronic pancreatitis. Apart from its diagnostic role, ERCP offers a variety of possibilities for therapeutic interventions in selected problems associated with pancreatitis. Endoscopic papillectomy and mucosal resection for tumors of the papilla, unroofing of a choledochocele, and sphincterotomy for sphincter ablation in sphincter of Oddi dysfunction are some of the therapeutic interventions possible during ERCP. Pancreatic ductal hypertension, which is considered to be the major pathophysiologic mechanism for disabling abdominal pain in chronic pancreatitis, also can be managed by ERCP-directed treatments. Pancreatic sphincterotomy, dilation of strictures, lithotripsy, extraction of calculi, and deployment of endoprosthesis constitute the commonly used therapeutic techniques in this situation. Besides offering a noninvasive alternative, these treatments are associated with a favorable clinical outcome comparable with that of operative treatments. Nevertheless, complications such as acute pancreatitis, bleeding, perforation, or sepsis may occur in 5% to 10% of patients undergoing these procedures. Therefore, careful selection of patients, appropriate preoperative care, and a team approach, including surgeon, interventional radiologist, and endoscopist, are important.

The role of pancreatoscopy in the preoperative evaluation of intraductal papillary mucinous tumor of the pancreas.

Background Intraductal papillary mucinous tumor of the pancreas is a rare neoplasm managed by operative resection of the affected segment of the pancreas. Goals To evaluate the role of peroral pancreatoscopy in the diagnosis and preoperative localization of the affected region of the pancreatic duct and to undertake the appropriate operation for each patient. Study Five patients with suspected intraductal papillary mucinous tumor of the pancreas were studied using endoscopic retrograde cholangiopancreatography, computed tomography of the abdomen, endoscopic ultrasonography, and peroral pancreatoscopy. The findings from these studies were compared, and operative resection was performed in each patient based on pancreatoscopic findings. Results Of the five patients with suspected intraductal papillary mucinous tumor, only four had histologically confirmed tumor, and the remaining one patient had a retention cyst of the pancreas. Pancreatoscopy correctly identified all four patients with the tumor while excluding the diagnosis of papillary tumor in one. Conclusion Peroral pancreatoscopy is valuable in the preoperative evaluation of intraductal papillary mucinous tumor of the pancreas, especially in the localization of such tumor.

Chronic pancreatitis resulting from primary hydatid disease of the pancreas: a case report and review of the literature

A 24-year-old Jordanian man presented with epigastric pain radiating to the back associated with vomiting; identical episodes had been occurring since age 12 years. He had no weight loss, jaundice or diarrhea, and there was no history of alcohol abuse, abdominal trauma, hyperlipidemia, or family history of pancreatitis. Physical examination revealed an acutely ill man with a temperature of 100° F. The abdominal examination demonstrated hypoactive bowel sounds, epigastric tenderness, and no rebound or guarding. Laboratory data revealed a white blood cell count of 13,700/mm3, a hematocrit of 40%, and 395,000/ mm3 platelets. There was no eosinophilia. His amylase was 571 units/L (normal 25-125), lipase 757 units/L (normal 8-70), and liver function tests were normal. US of the abdomen showed no stones in the gallbladder or biliary ductal dilation but did reveal a dilated pancreatic duct (PD) with calcifications. CT disclosed enlargement of the head of the pancreas with atrophy and calcifications in the body and tail. There was marked dilation of the main PD, and a 2.5 × 3.5 cm cystic lesion was seen projecting from the tail (Fig. 1). A diagnosis of idiopathic chronic pancreatitis and pseudocyst of the pancreas was made and endoscopic therapy was considered. ERCP revealed a dilated main PD with multiple filling defects consistent with stones (Fig. 2). A stricture was seen in the PD in the head, with upstream dilation of the remaining duct. An abrupt “cutoff ” of the duct was observed in the region of the presumed pseudocyst. A PD sphincterotomy to facilitate stone extraction was performed, followed by placement of a 7F × 9 cm PD stent. The cholangiogram was normal. The patient was readmitted for recurrent pain 1 month later, and ERCP was repeated. The PD stent was removed and found to be occluded. Several filling defects thought to be pancreatic stones were again observed, and on sweeping the pancreatic duct with an 11.5 mm balloon-tipped catheter, copious amounts of milky white gelatinous secretions poured out of the papillary orifice. This material had given rise to the filling defects in the duct, as contrast instillation at the termination of the procedure showed a dilated PD but no filling defects. The patient improved clinically, only to return with pancreatitis again, and surgery was consulted. At laparotomy, a cystic mass was present in the body and tail of the pancreas that was adherent to the spleen. A partial pancreatectomy followed by pancreaticojejunostomy was performed. Opening of the cystic mass disclosed a hydatid cyst containing multiple daughter cysts (Fig. 3), and the histopathologic findings were consistent with Echinococcus granulosus. There was a communication between the cyst cavity and the main PD through a defect in the cyst wall. Postoperatively the patient was treated with albendazole at an oral dose of 400 mg BID for 12 weeks. He has remained symptom free to date (12 months).

3481 Novel applications of soehendra stent retriever in therapeutic ercp.

Introduction: Soehendra stent retrievers (SSR,Wilson-Cook Inc) were originally designed for stent retrieval. Recently SSR has been employed for dilation of strictures, but experience is limited.We have found SSR to be a valuable tool in several other maneuvers during therapeutic ERCP. Aim: To analyze the success, complications and clinical outcomes of newer applications of SSR during ERCP. Method: Patients with tight strictures of the bile and pancreatic ducts were studied. These strictures allowed guide wire access, but defied 5Fr catheter advancement and conventional balloon or catheter dilation. After wire access was achieved, The SSR was passed up to the distal margin of the stricture. Rotation and forward pressure were applied to the SSR to traverse the stricture slowly. Following dilation, stent placement was performed, and cytology obtained from the SSR threads. Patients with hilar tumors had Wallstent (WS) mesh space dilation using SSR for placement of a second WS. Patient demographics, indications, success of dilation and stenting, complications and procedure outcome were studied. Results: 37 patients underwent SSR use in the study period, 13 for stent retrieval alone. Twenty-four patients underwent SSR dilation as shown in the table below. 3 patients had pain during dilation requiring additional meperidine. In majority of patients (12/20), it was possible to place a stent of identical diameter to that of the SSR used. Cytology was positive for malignancy in 3 of 5 patients with cancer. Conclusions: Dilation using the Soehendra stent retriever is safe and highly successful (83%) for strictures defying conventional techniques. Novel applications including transpapillary pseudocyst drainage,Wallstent mesh dilation and tissue acquisition for cytology can also be performed successfully using this device.

4690 Can response to stent placement help to select patients for operative management in chronic pancreatitis

Introduction: Patients with chronic pancreatitis (CP) and severe abdominal pain are often managed by operation or stent placement. However, the outcome of surgery is not always predictable. It has been suggested that patients who respond favorably to stent therapy may have satisfactory outcomes after surgery. Aim: In this prospective study, we sought to determine whether response to endoscopic pancreatic duct (PD) stent placement can predict outcome after surgery and thus help to select patients for operative management, and determine what other factors may predict clinical outcome. Methods: Patients referred with CP and pain underwent ERCP, sphincterotomy and PD stent placement. Outcome was considered good if pain relief was complete or allowed =50% decrease in pain medication and no hospitalizations. Patients with good response after 3 months of stent therapy who opted for surgery and those with poor response to stent therapy underwent operation. Baseline clinical data, outcome of surgery and complications were compared between the two groups. Results: A total of 56 patients (age 37-67, 36M, 20F) underwent ERCP. PD stent placement was successful in 39 patients. Four patients had mild pancreatitis. 32 patients had a good response to stent therapy. 20 of these patients had endoscopic therapy alone. The remaining 12 patients with good response opted for surgery (“good” group). All 7 patients with poor response to stenting underwent surgery (“poor” group). Response to surgery and follow-up are shown in the table below. There were no major surgical complications. Only 2 of 8 patients with alcoholic CP and narcotic use were able to stop narcotics completely after surgery. Conclusions: Response to short term endoscopic pancreatic duct therapy does not appear to predict outcome after surgery in patients with chronic pancreatitis and pain. Patients with multiple PD calculi who respond to stent therapy may do well after surgery, while those with alcoholic pancreatitis and narcotic use do not.

7164 Endoscopic sphincterotomy is safe and well tolerated in orthotopic liver transplantation (olt) patients.

Introduction Biliary complications such as bile leak (BL) and anastomotic strictures (AS) occurs in 15-20% of patients undergoing orthotopic liver transplant(OLT), and can be treated successfully by endoscopic techniques of stent placement and dilation, respectively. Endoscopic sphincterotomy (ES) is commonly performed during therapeutic endoscopic retrograde cholangiopancreatography (ERCP) to facilitate repeated cannulation and stent placement. Given concerns for bacterial contamination and stasis at the anastomotic site, some endoscopists avoid ES in these immunocompromised patients. Aim To determine the safety and clinical outcome of ES in OLT patients(“ES Group”) and to compare their course to OLT patients who underwent ERCP without ES (“No ES Group”) Methods Patients who received OLT between 1994-98 and required ERCP were included in the study. Patient demographics, ERCP indications, complications and post- ERCP course were analyzed. Complications of ERCP were catagorized as procedure-related and delayed(=30 days). Late adverse events recorded were related to biliary tract disease. Results Twenty-seven post OLT patients(17M, 10F, mean age 49 yrs, range 31-68) who required ERCP were studied. Mean follow up was 30 mos. in the ES group, and 35 mos. in the No ES group. ERCP indications, complications and clinical course are noted in the table below. Most (14/15) patients in the ES group underwent multiple ERCPs with stents and dilation for AS as per our protocol. Delayed ERCP complications occurred in 3 of 15 in the ES group(20%); all 3 had stones or sludge which predated ERCP/ES. The 3 patients who suffered late adverse events had recurrence of AS without new stones or sludge. No deaths were attributable to ES. Conclusion Endoscopic sphincterotomy in orthotopic liver transplant patients undergoing ERCP is safe, with a complication rate comparable to published data for non-OLT patients. Delayed complications and late adverse events (Stent occlusion, restenosis, death) in these patients appear to be unrelated to sphincterotomy per se, but common to all OLT patients.