3799 Pancreatic sepsis as a late complication of endoscopic pancreatic duct stone removal.

Abstract

INTRODUCTION: Multiple authors have reported success in removing pancreatic duct stones using endoscopic techniques. To date, there has been little recognition of late pancreatic sepsis (PS) following such treatments. PATIENTS & METHODS: From April 1991 to July 1999, 70 patients underwent endoscopically directed efforts to remove pancreatic duct stones at our center. TREATMENTS: 43 males, 27 females, age 3 to 90 (median 62) were treated with pull type pancreatic sphincterotomy,then variably with mechanical lithotripsy, electro-hydraulic intraductal lithotripsy, ESWL, PD stents, and fragment extraction using balloons or baskets. RESULTS: In follow-up there were 7 episodes of PS in 6 patients from 1 month to 20 months following initial intervention. In 4 of the 6 cases, complete stone clearance was felt to have been accomplished.In 2, partial removal or stenting led to resolution of symptoms. All 6 patients presented with upper abdominal pain and fever. All 6 were found to have recurrent PD stone obstruction. In 3 cases, these appeared to be sidebranch stones, as the patients had multiple calcifications at the completion of previous endoscopic RX. In the remaining cleared patient, the recurrent stone was of unclear source suggesting an incorrect assumption of clearance or new stone formation. In 3 episodes, ERCP documented purulent pancreatic ductal discharge above the impacted stone without leakage or pseudocyst formation. In 3, infected pseudocysts were documented by percutaneous drainage in 1 and surgery in 2. The final episode was prompt recurrence of sepsis 1 month after an episode of sepsis treated with ERCP and recurrent stone extraction. 1 patient developed a septic fistula at the tip of a PD stent, which was placed around an incompletely fragmented stone. This resolved with a longer stent at repeat ERCP. 2 patients have undergone elective surgery after clearance of their PS with repeat stent placement at ERCP. CONCLUSIONS: Late pancreatic sepsis following pancreatic sphincterotomy for pancreatic duct stone clearance has been little recognized. Bacterial colonization of the duct following pancreatic sphincterotomy likely predisposes to significant pancreatic sepsis following reobstruction. This late complication needs better documentation, particularly in patients with incomplete stone clearance. These patients may well require more definitive surgical drainage on an elective basis. INTRODUCTION: Multiple authors have reported success in removing pancreatic duct stones using endoscopic techniques. To date, there has been little recognition of late pancreatic sepsis (PS) following such treatments. PATIENTS & METHODS: From April 1991 to July 1999, 70 patients underwent endoscopically directed efforts to remove pancreatic duct stones at our center. TREATMENTS: 43 males, 27 females, age 3 to 90 (median 62) were treated with pull type pancreatic sphincterotomy,then variably with mechanical lithotripsy, electro-hydraulic intraductal lithotripsy, ESWL, PD stents, and fragment extraction using balloons or baskets. RESULTS: In follow-up there were 7 episodes of PS in 6 patients from 1 month to 20 months following initial intervention. In 4 of the 6 cases, complete stone clearance was felt to have been accomplished.In 2, partial removal or stenting led to resolution of symptoms. All 6 patients presented with upper abdominal pain and fever. All 6 were found to have recurrent PD stone obstruction. In 3 cases, these appeared to be sidebranch stones, as the patients had multiple calcifications at the completion of previous endoscopic RX. In the remaining cleared patient, the recurrent stone was of unclear source suggesting an incorrect assumption of clearance or new stone formation. In 3 episodes, ERCP documented purulent pancreatic ductal discharge above the impacted stone without leakage or pseudocyst formation. In 3, infected pseudocysts were documented by percutaneous drainage in 1 and surgery in 2. The final episode was prompt recurrence of sepsis 1 month after an episode of sepsis treated with ERCP and recurrent stone extraction. 1 patient developed a septic fistula at the tip of a PD stent, which was placed around an incompletely fragmented stone. This resolved with a longer stent at repeat ERCP. 2 patients have undergone elective surgery after clearance of their PS with repeat stent placement at ERCP. CONCLUSIONS: Late pancreatic sepsis following pancreatic sphincterotomy for pancreatic duct stone clearance has been little recognized. Bacterial colonization of the duct following pancreatic sphincterotomy likely predisposes to significant pancreatic sepsis following reobstruction. This late complication needs better documentation, particularly in patients with incomplete stone clearance. These patients may well require more definitive surgical drainage on an elective basis.