Gastric Pacemaker for Gastroparesis in Patients with Refractory Symptoms After Endoscopic Therapy...
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317 Factors Predictive of Resolution in Pancreatic Duct Disruptions Treated Endoscopically: A 10 Year Single-Center Experience Michel Kahaleh, Patrick Mcdonough, Thomas Rockoff, Jeffrey Tokar, Vanessa M. Shami, Reid B. Adams, Paul Yeaton Objective: The management of pancreatic duct disruption is well described, but no prospective study until now has confirmed factors associated with its resolution. Methods: Between Jan 95 and Sept 05, all patients with pancreatic ductal disruption were followed prospectively to complete resolution after endoscopic treatment. All patients underwent pancreatic sphincterotomy and every effort was made to place a stent if the disruption was crossed. All procedures were performed by 2 dedicated pancreatico-biliary endoscopists (MK and PY). Logistic regression analysis was performed on the following variables with regard to their ability to predict complete resolution (see table): age (!55 or R55 years), gender, etiology (alcoholic or not), chronicity (acute or chronic), pancreatic stenting, disruption type (complete versus partial), disruption location and enteral feeding(yes versus no). P value less than 0.05 were considered statistically significant. Results: 128 consecutive patients (85 male, 43 female), mean age: 51 G 15 years (range:18-88) were included. 103 patients presented with pancreatic fluid collections, 19 with ascites and 6 with pancreatic fistulas. Mean follow-up until resolution was 4.6 G 2.1 months (range:1-12) with enteral tube feeding placement in 78 patients (60%). 69 of the 128 patients (53%) had a stent placed with 63 of them (91%) bridging the disruption (9 from the minor ampulla). 116 patients (90%) had resolution of their pancreatic disruption, 7 patients underwent surgery, 3 required long term percutaneous drainage and 2 died from unrelated causes. Ten patients (8%) developed ERCP related complications: 3 self-limiting bleeding, two stent migrations retrieved endoscopically, two mild post ERCP pancreatitis and three cases of pneumoperitoneum managed conservatively. The factors statistically associated with complete resolution of the ductal disruption were stent placement and age R 55 years. Conclusion: Pancreatic ductal disruption can be effectively treated endoscopically. Resolution appears associated with successful stent placement bridging the disruption and age R 55 years old. Further studies are required to confirm this data. Factors predictive of resolution Predictive Factor Success P Value Odds Ratio 95 % CI Gender (male versus female) 85 vs 43 0.513 1.37 0.45-3.40 Age (!55 versus R55 y-o) 76 vs 52 0.027 ) 0.33 0.12-0.88 Etiology (alcohol versus other) 46 vs 82 0.615 1.33 0.44-4.05 Acute versus chronic 80 vs 48 0.075 2.50 0.91-6.85 Partial versus complete disruption 76 vs 52 0.306 0.40 0.07-2.32 Stent placement (yes versus no) 69 vs 59 0.014 ) 0.10 0.02-0.63 Location leak (body versus other) 58 vs 70 0.722 1.18 0.48-2.89 Enteral feeding (yes versus no) 78 vs 50 0.777 1.14 0.46-2.83 ) statistically significant 318 The Usefulness of Biopsying the Major Duodenal Papilla to Diagnose Autoimmune Pancreatitis: A Prospective Study Using IgG4-Immunostaining Terumi Kamisawa, Naoto Egawa, Hitoshi Nakajima, Kouji Tsuruta, Atsutake Okamoto Background and Aim: Autoimmune pancreatitis (AIP) is characterized by irregular narrowing of the main pancreatic duct, enlargement of the pancreas, increased levels of serum IgG4, and dense lymphoplasmacytic infiltration with fibrosis. In segmental mass-forming cases, the differentiation between AIP and pancreatic carcinoma remains difficult. We previously reported that IgG4-positive plasma cells abundantly infiltrated the various organs, as well as the pancreas, of a patient with AIP, and that an abundant infiltration of IgG4-positve plasma cells was not observed in the organs of patients with pancreatic carcinoma or chronic alcoholic pancreatitis. To find a useful new method to diagnose AIP on the basis of studies of the resected pancreas, we prospectively examined the histological and immunohistochemical findings of biopsy specimens taken from the major duodenal papilla of AIP patients. Materials and Methods: The major duodenal papilla in the resected pancreas of 3 patients with AIP and of 5 control patients (pancreatic carcinoma (n Z 3) and chronic alcoholic pancreatitis (n Z 2)) was immunostained using anti-CD4-T cell, CD8-T cell and IgG4 antibodies. Forceps biopsy specimens taken from the major duodenal papilla of 3 patients with segmental mass-forming AIP and 5 control patients with suspected papillitis were prospectively taken during duodenoscopy and immunohistochemically examined. The major duodenal papilla was normal on duodenoscopy during ERCP. After the biopsy was taken, steroid therapy was given to these patients, who showed marked responsiveness both morphologically and serologically. In 1 patient, rebiopsy from the major duodenal papilla was done after steroid therapy. Results: Moderate or severe lymphoplasmacytic infiltration including many CD4-positive or CD8-positive T lymphocytes and IgG4-positive plasma cells (R10/high power field), was observed in the major duodenal papilla in the resected pancreas of all 3 patients with AIP. The same findings were also detected in the biopsy specimens taken from the major duodenal papilla of 3 patients with AIP, but in controls, there were only a few (%3/high power field) IgG4-positive plasma cells infiltrating the major duodenal papilla. The abundant infiltration of these inflammatory cells disappeared in the biopsy specimen taken from the major duodenal papilla after steroid therapy. Conclusions: An abundant infiltration of IgG4-positive plasma cells was specifically detected in the major duodenal papilla of patients with AIP. IgG4-immunostaining of biopsy specimens taken from the major duodenal papilla may be useful to support the diagnosis of AIP. 319 Gastric Pacemaker for Gastroparesis in Patients with Refractory Symptoms After Endoscopic Therapy for Sphincter of Oddi Dysfunction Or Pancreas Divisum Martin Freeman, Michelle Finke, John Allen, Eric Johnson Background: Gastroparesis may be part of the spectrum of motility disorders associated with sphincter of Oddi dysfunction (SOD) or symptomatic pancreas divisum, and may explain lack of response to endoscopic sphincterotomy (ES) in some patients. Gastric pacemaker is a new modality for treatment of gastroparesis, but has not been reported in this context. Methods: Patients undergoing gastric pacemaker placement for documented gastroparesis with recurrent nausea and vomiting, with or without pain, which persisted after biliary and pancreatic ES for SOD or pancreas divisum were included. Pacers were placed by a single surgeon with O25 case experience. Patients were contacted for long term follow up using 5- point Likert scale to assess response to individual and global symptoms. Results: Of 7 patients, all were female who presented post-cholecystectomy with intractable abdominal pain; all were euthyroid and none were diabetic. EUS showed R4/9 criteria for chronic pancreatitis in 3, but none had pancreatographic evidence of chronic pancreatitis. All had biliary ES for manometrically documented biliary SOD (biliary type II in 4); 6 also had pancreatic ES; 4 major papilla pancreatic ES for manometric pancreatic SOD (persistent pain in all plus unexplained pancreatitis in 2), 2 had minor papillotomy for pancreas divisum and recurrent pain (plus recurrent pancreatitis in 1, plus abnormal secretin MRCP in 1). Pain relief after final sphincter ablation was good to excellent in 4/7, with persistent pain in 3; all 7 had persistent nausea and vomiting, 4 weight loss. Solid phase gastric emptying while off narcotics was abnormal (O90 mins) in all, with median T1/2 407 minutes (range 210-2283 mins). All failed prokinetics; 3/7 required TPN, 4/7 jejunal feeding tube. Gastric pacemakers were placed by laparotomy (3) or laparoscopy (4). After gastric pacemaker, response to nausea and vomiting and global improvement was good or excellent in 4/7, poor in 3, with discontinuation of TPN in 3/3. All patients with T1/2 O 500 minutes responded well to pacemaker; only 1/3 patients on daily narcotic analgesics responded or stopped narcotics. Adverse events included local pain in 3/7 and revision of pacer in 1. Conclusion: Gastroparesis may be an important reason for persistent symptoms after biliary and pancreatic sphincter ablation in patients with SOD or pancreas divisum, with or without possible small duct chronic pancreatitis. Gastric pacemaker offers a potentially effective treatment in this context. Abstracts AB86 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006 www.giejournal.org
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Transcript of Gastric Pacemaker for Gastroparesis in Patients with Refractory Symptoms After Endoscopic Therapy...
317
Factors Predictive of Resolution in Pancreatic Duct Disruptions
Treated Endoscopically: A 10 Year Single-Center ExperienceMichel Kahaleh, Patrick Mcdonough, Thomas Rockoff, Jeffrey Tokar,Vanessa M. Shami, Reid B. Adams, Paul YeatonObjective: The management of pancreatic duct disruption is well described, but noprospective study until now has confirmed factors associated with its resolution.Methods: Between Jan 95 and Sept 05, all patients with pancreatic ductal disruptionwere followed prospectively to complete resolution after endoscopic treatment. Allpatients underwent pancreatic sphincterotomy and every effort was made to placea stent if the disruption was crossed. All procedures were performed by 2 dedicatedpancreatico-biliary endoscopists (MK and PY). Logistic regression analysis wasperformed on the following variables with regard to their ability to predictcomplete resolution (see table): age (!55 or R55 years), gender, etiology(alcoholic or not), chronicity (acute or chronic), pancreatic stenting, disruptiontype (complete versus partial), disruption location and enteral feeding(yes versusno). P value less than 0.05 were considered statistically significant. Results: 128consecutive patients (85 male, 43 female), mean age: 51 G 15 years (range:18-88)were included. 103 patients presented with pancreatic fluid collections, 19 withascites and 6 with pancreatic fistulas. Mean follow-up until resolution was 4.6 G 2.1months (range:1-12) with enteral tube feeding placement in 78 patients (60%). 69of the 128 patients (53%) had a stent placed with 63 of them (91%) bridging thedisruption (9 from the minor ampulla). 116 patients (90%) had resolution of theirpancreatic disruption, 7 patients underwent surgery, 3 required long termpercutaneous drainage and 2 died from unrelated causes. Ten patients (8%)developed ERCP related complications: 3 self-limiting bleeding, two stentmigrations retrieved endoscopically, two mild post ERCP pancreatitis and threecases of pneumoperitoneum managed conservatively. The factors statisticallyassociated with complete resolution of the ductal disruption were stent placementand age R 55 years. Conclusion: Pancreatic ductal disruption can be effectivelytreated endoscopically. Resolution appears associated with successful stentplacement bridging the disruption and age R 55 years old. Further studies arerequired to confirm this data.
Factors predictive of resolution
Predictive Factor Success P Value Odds Ratio 95 % CI
Gender (male versus female) 85 vs 43 0.513 1.37 0.45-3.40Age (!55 versus R55 y-o) 76 vs 52 0.027) 0.33 0.12-0.88Etiology (alcohol versus other) 46 vs 82 0.615 1.33 0.44-4.05Acute versus chronic 80 vs 48 0.075 2.50 0.91-6.85Partial versus complete disruption 76 vs 52 0.306 0.40 0.07-2.32Stent placement (yes versus no) 69 vs 59 0.014) 0.10 0.02-0.63Location leak (body versus other) 58 vs 70 0.722 1.18 0.48-2.89Enteral feeding (yes versus no) 78 vs 50 0.777 1.14 0.46-2.83
)statistically significant
318
The Usefulness of Biopsying the Major Duodenal Papilla
to Diagnose Autoimmune Pancreatitis: A Prospective Study
Using IgG4-ImmunostainingTerumi Kamisawa, Naoto Egawa, Hitoshi Nakajima, Kouji Tsuruta,Atsutake OkamotoBackground and Aim: Autoimmune pancreatitis (AIP) is characterized by irregularnarrowing of the main pancreatic duct, enlargement of the pancreas, increasedlevels of serum IgG4, and dense lymphoplasmacytic infiltration with fibrosis. Insegmental mass-forming cases, the differentiation between AIP and pancreaticcarcinoma remains difficult. We previously reported that IgG4-positive plasma cellsabundantly infiltrated the various organs, as well as the pancreas, of a patient withAIP, and that an abundant infiltration of IgG4-positve plasma cells was not observedin the organs of patients with pancreatic carcinoma or chronic alcoholicpancreatitis. To find a useful new method to diagnose AIP on the basis of studies ofthe resected pancreas, we prospectively examined the histological andimmunohistochemical findings of biopsy specimens taken from the majorduodenal papilla of AIP patients. Materials and Methods: The major duodenalpapilla in the resected pancreas of 3 patients with AIP and of 5 control patients(pancreatic carcinoma (n Z 3) and chronic alcoholic pancreatitis (n Z 2)) wasimmunostained using anti-CD4-T cell, CD8-T cell and IgG4 antibodies. Forcepsbiopsy specimens taken from the major duodenal papilla of 3 patients withsegmental mass-forming AIP and 5 control patients with suspected papillitis were
prospectively taken during duodenoscopy and immunohistochemically examined.The major duodenal papilla was normal on duodenoscopy during ERCP. After thebiopsy was taken, steroid therapy was given to these patients, who showed markedresponsiveness both morphologically and serologically. In 1 patient, rebiopsy fromthe major duodenal papilla was done after steroid therapy. Results: Moderate orsevere lymphoplasmacytic infiltration including many CD4-positive or CD8-positiveT lymphocytes and IgG4-positive plasma cells (R10/high power field), wasobserved in the major duodenal papilla in the resected pancreas of all 3 patientswith AIP. The same findings were also detected in the biopsy specimens taken fromthe major duodenal papilla of 3 patients with AIP, but in controls, there were onlya few (%3/high power field) IgG4-positive plasma cells infiltrating the majorduodenal papilla. The abundant infiltration of these inflammatory cells disappearedin the biopsy specimen taken from the major duodenal papilla after steroid therapy.Conclusions: An abundant infiltration of IgG4-positive plasma cells was specificallydetected in the major duodenal papilla of patients with AIP. IgG4-immunostainingof biopsy specimens taken from the major duodenal papilla may be useful tosupport the diagnosis of AIP.
319
Gastric Pacemaker for Gastroparesis in Patients with Refractory
Symptoms After Endoscopic Therapy for Sphincter of Oddi
Dysfunction Or Pancreas DivisumMartin Freeman, Michelle Finke, John Allen, Eric JohnsonBackground: Gastroparesis may be part of the spectrum of motility disordersassociated with sphincter of Oddi dysfunction (SOD) or symptomatic pancreasdivisum, and may explain lack of response to endoscopic sphincterotomy (ES) insome patients. Gastric pacemaker is a new modality for treatment of gastroparesis,but has not been reported in this context. Methods: Patients undergoing gastricpacemaker placement for documented gastroparesis with recurrent nausea andvomiting, with or without pain, which persisted after biliary and pancreatic ES forSOD or pancreas divisum were included. Pacers were placed by a single surgeonwith O25 case experience. Patients were contacted for long term follow up using 5-point Likert scale to assess response to individual and global symptoms. Results: Of7 patients, all were female who presented post-cholecystectomy with intractableabdominal pain; all were euthyroid and none were diabetic. EUS showed R4/9criteria for chronic pancreatitis in 3, but none had pancreatographic evidence ofchronic pancreatitis. All had biliary ES for manometrically documented biliary SOD(biliary type II in 4); 6 also had pancreatic ES; 4 major papilla pancreatic ES formanometric pancreatic SOD (persistent pain in all plus unexplained pancreatitis in2), 2 had minor papillotomy for pancreas divisum and recurrent pain (plusrecurrent pancreatitis in 1, plus abnormal secretin MRCP in 1). Pain relief after finalsphincter ablation was good to excellent in 4/7, with persistent pain in 3; all 7 hadpersistent nausea and vomiting, 4 weight loss. Solid phase gastric emptying whileoff narcotics was abnormal (O90 mins) in all, with median T1/2 407 minutes (range210-2283 mins). All failed prokinetics; 3/7 required TPN, 4/7 jejunal feeding tube.Gastric pacemakers were placed by laparotomy (3) or laparoscopy (4). After gastricpacemaker, response to nausea and vomiting and global improvement was good orexcellent in 4/7, poor in 3, with discontinuation of TPN in 3/3. All patients withT1/2 O 500 minutes responded well to pacemaker; only 1/3 patients on dailynarcotic analgesics responded or stopped narcotics. Adverse events included localpain in 3/7 and revision of pacer in 1. Conclusion: Gastroparesis may be animportant reason for persistent symptoms after biliary and pancreatic sphincterablation in patients with SOD or pancreas divisum, with or without possible smallduct chronic pancreatitis. Gastric pacemaker offers a potentially effective treatmentin this context.
Abstracts
AB86 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006 www.giejournal.org
