T. Qaseem

Endoscopic pancreatic sphincterotomy: indications, outcome, and a safe stentless technique

BACKGROUND Endoscopic pancreatic sphincterotomy is less widely practiced than biliary sphincterotomy, in part because of the lack of firm data regarding its indications and safety. In addition, recent reports of ductal and parenchymal changes occurring after pancreatic stenting raise concerns about the standard practice of stent placement at the time of pancreatic sphincterotomy. We report our experience with pancreatic sphincterotomy and describe the use of a technique involving overnight nasopancreatic drainage rather than stenting. METHODS We reviewed the records of the 164 pancreatic sphincterotomies performed on 160 patients at our institution between January 1, 1991, and October 1, 1996, comparing procedures done with overnight nasopancreatic catheter placement with those done with stenting or no drainage. We also examined the long-term clinical outcome of patients after pancreatic sphincterotomy. RESULTS Of the 164 sphincterotomies, 98 were done with overnight nasopancreatic drainage, 50 with stent placement, and 16 with no drainage. Complications (all pancreatitis) were significantly more frequent in the group with no drainage (12.5%) as compared with those with drainage (0.7%); p < 0.003. Nasopancreatic drainage was as safe as stent placement, with no complications after 98 procedures. Pancreatic sphincterotomy was effective when used as primary therapy, with 64% of patients so treated experiencing complete and long-lasting resolution of symptoms after the procedure. CONCLUSIONS Pancreatic sphincterotomy is safe and effective, although pancreatic drainage is required to reduce the incidence of pancreatitis. Overnight nasopancreatic drainage is the method of choice, as it carries as low a complication rate as stent placement, but without the need for a repeat procedure, and presumably without the risk of ductal and parenchymal damage.

Diagnostic and therapeutic ERCP using an enteroscope and a pediatric colonoscope in long-limb surgical bypass patients

Diagnostic and therapeutic ERCP has nearly the same high success and low complication rates in Billroth II gastroenterostomy patients as in patients with normal anatomy.1,2 However, long-limb surgical bypasses have, in general, precluded endoscopic access for retrograde cannulation. Patients who have undergone these operations have usually been evaluated and treated with interventional radiologic procedures or surgery. With the advent and refinement of push enteroscopes and pediatric colonoscopes, however, endoscopic access to the papilla is now possible. We describe here our initial experience in using these endoscopes for retrograde cannulation and therapeutic ERCP in patients who have undergone long-limb bypasses.

The site distribution and characteristics of colorectal adenomas in Hispanics: a comparative study

OBJECTIVES:No data are available about the site distribution and characteristics of colorectal adenomas in Hispanics. The purpose of this study is to study the site distribution and characteristics of adenomas in Hispanics as compared to whites.METHODS:We retrospectively reviewed the records of all patients who had colonoscopies with resection of adenomatous polyps. Patients were classified by age, sex, and race. Polyps were classified by site and histology.RESULTS:Nine hundred ninety-four patients were included in the final analysis. These included 541 whites and 453 Hispanics. The mean age was 60 yr. The site distributions of adenomas were similar (p = 0.32), and adenoma histologies were similar (p = 0.16). Thirty percent of patients had no polyps in the descending colon (27%, Hispanics; 31%, whites).CONCLUSION:Hispanics and whites have similar site distributions of colorectal adenomas and similar adenoma histologies. Screening modalities excluding the area proximal to the splenic flexure would miss about 30% of the polyps in both populations.