Endoscopic Interventions and Jejunal Feeding in the Management of Acute Biliary Pancreatitis

Abstract

Endoscopic Interventions and Jejunal Feeding in the Management of Acute Biliary Pancreatitis Tibor Gyokeres, Maria Burai, Eszter Schafer, Richard Schwab, Akos Pap Introduction: Acute biliary pancreatitis (ABP) is one of the most severe complications of the biliary stone disease. Its management is early endoscopic papillotomy followed by stone extraction if necessary, and conservative treatment of pancreatitis. Patients: During last four years we have treated twenty-nine patients (age: 21-92 years) with ABP, 17 of them had severe pancreatitis evaluated bymodified Imrie score. Twenty-six patients had stones in the gallbladder, twohad previous cholecystectomy and in one patient the gallbladder was stonefree. Methods: In case of suspected biliary origin of the pancreatitis we have performed duodenoscopy, endoscopic retrograde cholangiography and endoscopic papillotomy followed by stone extraction. At the end of the procedure we inserted feeding tube into the second loop of the jejunum. At the first day we have administered saline, on the second day diluted nutrient and from the third day to the healing we applied 1 ml/kcal nutrient in continuous infusion into the jejunum. Results: We performed 25 papillotomy, followed by stone extraction in 11 patients, and jejunal feeding was applied in 26 patients. The median time from the start of the symptoms to the interventionwas 1.5 (1-21) days. The hospital staywas 11 (2-81) days in average. One old patient died of pneumonia with healed pancreatitis and five died of complicated pancreatitis. All patient with fatal outcome had severe pancreatitis. Suprisingly not only the modified Imrie score, but the initial amylase value and the rate of the decrease had prognostic value: the higher initial amylase and the slow decrease was associated with poor outcome. In summary: Our results confirmed that acute biliary pancreatitis has a significant mortality even in case of proper timing of endoscopic papillotomy and with the best conservative treatment. *T1540 Endoscopic Treatment for Main Pancreatic Duct Rupture Following Silastic Ring Vertical Banded Gastroplasty Marianna Arvanitakis, Reza Chamlou, Myriam Delhaye, Celso Matos, Jean Closset, Jacques Deviere Background: Acute pancreatitis (AP) has been described as a rare complication of Silastic ring vertical banded gastroplasty (SRVG). It can be attributed to a pancreatic trauma occurring during surgery leading to segmental injury, AP and formation of pancreatic fluid collections (PFC). Endoscopic therapy is technically difficult in these patients, because of the presence of the small outlet channel formed by the ring, which limits the access to the distal part of the stomach and the transmural endoscopic approach of adjacent PFC. Patients and Methods: Four cases of patients having had SRVG (4 women, median age: 33 years (19-50)) for morbid obesity who presented post-operative AP, accompanied by main pancreatic duct disruption (MPDD) and PFC were managed endoscopically. Results: During a period of 16 months, out of 150 SRVG performed in our institution, AP associated with MPDD was recorded in 2 patients. Another two similar patients were referred fromother institutions. AP occurred at amedian of 4 (4-6) days after SRVG and MPDD (located at the body and tail junction) was documented 10 (6-35) days after SRVG by means of S-MRCP. Median interval between SRVG and endoscopic treatment was 15 (7-45) days. Indications for drainage were pain (n=2) and sepsis (n=2). All four patients had transmural drainage of PFC (median maximal diameter: 80mm (70-100)) under endoscopic guidance (n=4), associated with endoscopic ultrasonography (n=2) and/or fluoroscopic guidance (n=4) guidance, followed by the insertion of one or more plastic stents. Two patients had complementary transpapillary drainage including pancreatic sphincterotomy (n=2) and pancreatic stenting (n=1). Access to the distal gastric cavity through the outlet channel with the duodenoscope was technically difficult in all patients requiring the use of a guidewire, associated with pneumatic dilation up to 20 mm of the outlet channel in 2 patients and we performed a distal cystogastrostomy through the retroperitoneal cavity in one patient. Endoscopic therapy was successful in all patients, with subsequent resolution of PFC. One patient required drainage of a recurring collection 6 months following initial treatment. They are all asymptomatic with resolution of collections during a median follow up of 11 months (5-23). Conclusions: Endoscopic therapy is particularly useful in post SRVG AP with MPDD and, although technically difficult, should be considered as a first-line approach in the management of these patients.