What\'s New in Pancreaticobiliary Disease?
John Baillie, MB, ChB, FRCP, FASGE
Philadelphia, PA; Monday, October 17, 2007 -- The Pancreatic/Biliary Plenary Seion presented on Monday, October 15 at the annual meeting of the American College of
Gastroenterology (ACG) featured submiions that received some of the highest scores from the ACG Education Committee.This report will highlight some of the more topical of these data, with a view toward the potential clinical implications.
Correlation Between Pancreatic Ductal Changes on MRCP and Maximum Bicarbonate Levels During Secretin Stimulated ePFT
Pancreatic exocrine function has always been difficult and time consuming to measure.It has
also been unclear if changes in measurable components of pancreatic juice, such as bicarbonate, correlate in any useful way with anatomic abnormalities seen on cro-sectional imaging or endoscopic retrograde cholangiopancreatography.Alkaade and colleagues,[1] from the Saint
Louis University School of Medicine, used exocrine pancreatic functional testing (ePFT) to look at the relationship between maximal bicarbonate levels achieved during secretin-stimulated ePFT and the severity of pancreatic ductal changes seen on magnetic resonance
cholangiopancreatography (MRCP) according to the Cambridge claification.
In this retrospective study, 62 patients were identified who underwent secretin stimulated ePFT between January 2005 and March 2007; of these, 38 patients underwent MRCP and ePFT within a period of 4 weeks.MRCP images revealed chronic pancreatitis (graded between \"equivocal\" and \"severe\" according to the Cambridge claification) in 16 patients.During ePFT, 26 patients had maximum bicarbonate levels greater than the cut-off value of 80 mmol/L; 12 had levels ≤ 80 mmol/L.A strong correlation was found between the level of bicarbonate secretion as determined by ePFT and MRCP scores on Cambridge claification (P = .00001).Additionally, there was a significant difference between the mean values of maximum bicarbonate concentration during ePFT and the MRCP findings (normal [Cambridge] 0 vs equivocal [Cambridge] 1-4).The authors concluded that there is a high degree of correlation between the pancreatic duct changes as measured on MRCP (by Cambridge claification) and maximal bicarbonate level achieved during ePFT.Further studies -- conducted prospectively -- will be needed to establish the true clinical significance of these findings.
Safety and Efficacy of EUS-Guided Ethanol Lavage of Pancreatic Cystic Lesions
Brugge and colleagues[2] reported the much-anticipated results of a prospective, multicenter, randomized, double-blinded study investigating the safety and effectivene of injecting 80% ethanol into pancreatic cystic lesions for nonsurgical ablation.
They hypothesized that the rate of pancreatic cyst ablation would be greater as a result of
injecting 80% ethanol solution as compared with physiologic (normal) saline.Fifty-four patients were consented for the study, but 12 had to be excluded due to prior interventions.The remaining 42 patients (mean age, 69 years; 26 women, 16 men) with suspected benign mucinous (n=35) or nonmucinous (n=4) pancreatic cystic lesions and pseudocysts (n=3) were randomized to
endoscopic ultrasound with alcohol (EUS-ETOH) or saline (EUS-SL) injection.The median cyst size was 19 mm (range, 10-40mm).The cyst locations were head/uncinate (n=18), body (n=16), and tail (n=8).The change in size and rate of ablation were recorded: 10/23 (43%) subjects had complete ablation of their cystic lesion as determined by imaging, all as a result of ethanol lavage (EUS-ETOH).There were 2 episodes of pancreatitis complicating this intervention; 3 patients had their cysts surgically resected after lavage (1 intrapancreatic mucinous neoplasm that was 50% to
75% ablated by ethanol injection, 1 mucinous cyst that was 100% ablated with ethanol, and 1 that remained intact after saline lavage).The authors concluded that EUS-ETOH decreased
pancreatic cyst size and resulted in an ablation rate greater than that achieved with EUS-SL.This is an important study, as pancreatic cysts are being encountered with increasing frequency due to the ever-increasing resolution of computed tomography and magnetic resonance imaging, and due to the sensitivity of EUS.The $64,000 question is: do these ablated cysts \"stay away\" after ablation? Hopefully, Dr.Brugge and his team will follow these patients and report back in perhaps 5 years\' time.
Long-term Outcomes of Endoscopic Papillary Balloon Dilation vs Endoscopic Sphincterotomy
DiSario and colleagues[3] reported their results from the long-term follow-up of endoscopic
papillary balloon dilation compared with endoscopic sphincterotomy for the extraction of bile duct stones.
This study provides data on the long-term outcome of patients who participated in a previous pivotal study that unfavorably compared endoscopic papillary balloon dilation of the duodenal papilla vs standard endoscopic sphincterotomy.In that study, 237 patients were randomized to endoscopic papillary balloon dilation or endoscopic sphincterotomy for biliary stone retrieval; 30-day morbidity was 18% (7% severe, with 2 deaths) for endoscopic papillary balloon dilation and 3% (zero severe) for endoscopic sphincterotomy (P
participants have been located and 34 (14%) are known to be deceased.The mean follow-up was 9.7 (8.3-11.0) years; 63 endoscopic papillary balloon dilation and 68 endoscopic
sphincterotomy participants were located.None of the deaths following the study were related to pancreatic or biliary disease.Reliable data were available for 97 patients (70 women and 27 men) with a mean age of 44 years (26-95).The treatment groups were evenly matched.Multivariate regreion analysis was performed on age, sex, cholecystectomy status, and presence or
absence of periampullary diverticula.None of these factors contributed to complications.Results showed that 18 of 63 (29%) endoscopic papillary balloon dilation patients and 14 of 68 (21%) endoscopic sphincterotomy patients had delayed complications related to their procedures, such as recurrent abdominal pain, bile duct stones, and/or jaundice.There was no statistical difference between the endoscopic papillary balloon dilation and endoscopic sphincterotomy patients overall, nor in individual category of complication.The authors concluded that (1) long-term complications of endoscopic papillary balloon dilation and endoscopic sphincterotomy occur at similar rates; and
(2) these findings do not support endoscopic papillary balloon dilation as the preferred treatment for bile duct stones to prevent long-term complications of endoscopic sphincterotomy.
Hypertriglyceridemic Acute Pancreatitis
Finally, Nachnani and Campbell[4] conducted a nice study showing that acute pancreatitis
aociated with hypertriglyceridemia has a different clinical profile than other forms of this disease.Data regarding the behavior of hypertriglyceridemic acute pancreatitis are limited.This study was designed to compare the clinical course and severity of hypertriglyceridemic acute pancreatitis and acute pancreatitis due to other causes, to determine whether the admiion triglyceride level influences or predicts the course of hypertriglyceridemic acute pancreatitis, to ae how the severity of hypertriglyceridemic acute pancreatitis in patients with diabetes mellitus compares with that in nondiabetics, and to look at serum amylase and lipase values in hypertriglyceridemic acute pancreatitis.
The study was a retrospective review of all patients discharged from 2 academic medical centers with a diagnosis of acute pancreatitis and hypertriglyceridemia over a 5-year period; 2576
episodes of pancreatitis were identified, 27 of which were attributed to high serum triglycerides.Patients with hypertriglyceridemic acute pancreatitis were younger (38 ± 11 years) compared with those with acute pancreatitis of other causes (46 ± 14 years; P
hospitalizations (10.44 vs 3.96 days).It is interesting to note that nondiabetic patients with
hypertriglyceridemic acute pancreatitis had longer hospitalizations and required more intensive care unit care than those with diabetes.Up to one third of hypertriglyceridemic acute pancreatitis patients had a normal serum amylase or lipase level on admiion, 11% had both normal amylase and lipase levels, and those who did have enzyme elevations showed serum lipase values generally much higher than amylase levels (often a 10-fold difference).These findings confirm the authors\' impreion, as their abstract title suggests, that \"hypertriglyceridemic acute pancreatitis is (a) different (disease proce compared with other form of acute pancreatitis).\" References
1.Alkaade S, Balci NC, Momtahen A, et al.The severity of pancreatic ductal changes on
standard MRCP according to Cambridge claification correlate with the maximum
bicarbonate level achieved during secretin-stimulated pancreatic functional testing
(ePFT).Am J Gastroenterol.2007;102:S179.[#171]
2.Brugge WR, Collier K, McGreevy K, et al.Ethanol pancreatic injection of cysts: results of
a prospective, multicenter, randomized, double-blinded study.Am J Gastroenterol.
2007;102:S192.[#209]
3.DiSario JA, Ogara MM, Price S, Hilden K, EDES group.Long term follow up on
endoscopic papillary balloon dilation compared to endoscopic sphincterotomy for the
extraction of bile duct stones.Am J Gastroenterol.2007;102:S188.[#195]
4.Nachnani J, Campbell DR.Hypertriglyceridemic acute pancreatitis is different.Am J
Gastroenterol.2007;102:S179.[#173]
