Endoscopic Pancreatic Sphincterotomy Research Articles

Extracorporeal shock wave lithotripsy and endoscopic pancreatic stenting without pancreatic sphincterotomy for the treatment of pancreatolithiasis: a case series.

Endoscopic therapy and extracorporeal shock wave lithotripsy (ESWL) are recommended as the first choice in treating pancreatolithiasis. Endoscopic therapy is generally performed using endoscopic pancreatic sphincterotomy (EPST). Herein, we report our experience implementing a treatment protocol, combining endoscopic therapy and ESWL without EPST, for pancreatolithiasis. The inpatient treatment plan was performed every 3months with a set number of sessions of ESWL with endoscopic pancreatic stenting (EPS) implanted or replaced. Finally, treatment was terminated when the stone was removed after implantation of a 10-Fr stent and crushed to approximately 3mm or after spontaneous stone discharge. Eight patients were included in this study; the median time to stone disappearance was 208.5days. The median number of inpatient treatment cycles, endoscopic retrograde cholangiopancreatography, and ESWL sessions was 2.5, 3, and 3, respectively. No serious adverse events were observed in all patients. Therefore, combining ESWL and EPS without EPST can safely treat pancreatolithiasis.

The "squeezing with forceps" method for emergency endoscopic removal of an impacted pancreatic stone in the papilla of a patient on antithrombotic therapy.

Endoscopic pancreatic sphincterotomy or needle-knife precut sphincterotomy is an essential procedure when removing a large impacted pancreatic stone in the papilla [1] [2] [3]. However, sometimes it is not feasible to perform such procedures, especially in emergency settings in patients receiving antithrombotic therapy. Herein, we report an alternative method that can be used for emergency endoscopic removal of an impacted pancreatic stone in the papilla of patients undergoing antithrombotic therapy.

An Atypical Complication of Chronic Pancreatitis

An Atypical Complication of Chronic Pancreatitis

906 To Cut or Not to Cut – Clinical Efficacy of Endoscopic Sphincterotomy in Recurrent Acute Pancreatitis From Functional Biliary Sphincter of Oddi Disorder: A Systematic Review and Meta-Analysis

INTRODUCTION: Functional biliary Sphincter of Oddi disorder, previously referred to as Sphincter of Oddi Dysfunction, is an established cause of recurrent acute pancreatitis which is defined as two or more episodes of documented acute pancreatitis per year. Data on the efficacy of endoscopic sphincterotomy in preventing future episodes of pancreatitis is limited. We performed a systematic review and meta-analysis to evaluate the clinical efficacy of index endoscopic sphincterotomy in patients with Recurrent Acute Pancreatitis secondary to manometrically proven functional biliary Sphincter of Oddi disorder. Our goal was to assess reduction in episodes of pancreatitis following sphincterotomy, and not to assess chronic pain in these patients. METHODS: We conducted a search of several databases including PubMed, EMBASE, Google-Scholar, Scopus and Cochrane Review (from 1960 to October 2018). Random-effects model was used for analysis. Heterogeneity between study-specific estimates was calculated using Cochran Q statistical test, 95% confidence interval (CI) and I2 statistics. Publication bias was ascertained, qualitatively, by visual inspection of funnel plot and quantitatively, by the Egger test. RESULTS: Our initial search yielded 3201 results. Of 1936 studies screened, 12 met inclusion criteria. A total of 396 patients with recurrent acute pancreatitis and abnormal manometry findings were included from these studies in the final analysis. The interventions performed were as follows: Endoscopic biliary sphincterotomy in 212 (53.5%), endoscopic pancreatic sphincterotomy in 19 (4.8%) and dual biliary and pancreatic sphincterotomy in 165 (41.6%) patients. Technical success ranged from 99 to 100%.The pooled estimate for clinical success following index sphincterotomy was 68.4% (95% CI 57.6-77.4; I2 = 71.4%). Lone endoscopic biliary sphincterotomy was successful in 43/60 (71.6%) patients. The pooled estimate for proportion of patients with post-ERCP pancreatitis was 23.2% (95% CI 16.6-31.4; I2 = 44.4%). The follow up duration ranged from 6 to 120 months. There was no evidence of publication bias, based on funnel plot analysis and Egger’s test. CONCLUSION: Our study highlights the utility and clinical efficacy of endoscopic sphincterotomy in patients with recurrent acute pancreatitis secondary to Functional biliary Sphincter of Oddi disorder. We conclude that 68.4% of patients improved after endoscopic sphincterotomy and that it can be considered in patients with recurrent acute pancreatitis.

Pancreatic sphincterotomy improves pain symptoms due to branch-duct intrapapillary mucinous neoplasia without worrisome features: a multicenter study.

Abstract Introduction Branch duct intraductal papillary mucinous neoplasms (BD-IPMNs) require follow-up to detect worrisome features (WF). Data are missing about endoscopic pancreatic sphincterotomy (PS) for symptomatic IPMN. Patients and methods This was a retrospective multicenter study in four expert centers. Patients treated with endoscopic PS for symptomatic (painful) BD-IPMN without WF were included. Age, sex, follow-up time, characteristics of IPMNs and endoscopic retrograde cholangiopancreatographies (ERCPs), and indications for surgery were recorded. Results In total, 21 patients were included (median age 68 years, range 45 – 87 years). The median number of cysts was 2 (range 1 – 10), located in the head (59 %), body/tail (17 %), or multifocal (24 %). ERCP including PS was completed in all of the cases, with biliary sphincterotomy in 33 %. Clinical efficacy after one session was 81 % (17/21). Among the failures, one had a second successful PS and three were operated. The final efficacy was 86 % (18/21). Seven patients were operated after a mean of 19 months: four for WF, three for pain. The histopathology showed four low grade dysplasia, one high grade dysplasia, and two no dysplasia. No adenocarcinoma occurred during a follow-up of 99 months (range 14 – 276 months). Conclusions Endoscopic PS for symptomatic IPMN without WF is effective in more than 80 % of cases, without increasing the risk for adenocarcinoma.

ESWL for large pancreatic calculi: Report of over 5000 patients

IntroductionThe primary aim of this study was to evaluate efficacy, safety and short-term pain relief after ESWL for large pancreatic calculi in over 5000 patients at a single center. MethodsThis is a retrospective analysis of prospectively collected data. Patients with painful calculi >5 mm, located in the head, neck and body region in the MPD, who were not amenable for extraction by the standard procedure of endoscopic pancreatic sphincterotomy were subjected to ESWL using a third generation dual focus lithotripter. Patients were followed up at 6 months for outcome evaluation. ResultsA total of 5124 patients (66% males) were subjected to ESWL. Majority of stones (79.2%) were radiopaque. Single calculi were seen in 3851 (75.1%).The majority of stones were located in head region of MPD in 2824 (55.1%) patients. 4386 (85.5%) patients required 3 or less sessions for fragmentation and complete stone clearance was achieved in 3722 (72.6%). EPS was performed in 5022 (98%) while PD stenting was required in 3536 (69%) patients. Of the 4280 patients followed up for 6 months, 3529 (82.6%) patients were pain free. Another 512 (11.9%) patients had significant reduction in VAS score. In 229 (5.3%) there was no decrease in pain intensity. Minor and self-limiting complications were reported in 1153 (22.5%). DiscussionOur study confirms the safety and efficacy and short-term pain relief of ESWL for large calculi in the MPD. In properly selected patients, this should be offered as the first line of therapy for all large MPD calculi not amenable to the standard techniques of stone extraction.

Adverse Events and Reinterventions Following Pancreatic Endoscopic Sphincterotomy.

Pancreatic endoscopic sphincterotomy (PES) is an independent risk factor for short- and long-term adverse events (AEs) of endoscopic retrograde cholangiopancreatography. We sought to measure PES-specific AEs and trends in the use of PES. This was a retrospective cohort of consecutive patients who underwent first-time PES between June 2008 and June 2015. Indications for PES were dichotomized: (1) structural pathology (chronic pancreatitis and local complications of acute pancreatitis) and (2) suspected sphincter pathology (idiopathic recurrent acute pancreatitis and sphincter of Oddi dysfunction). Rates of AEs and pancreatic orifice reinterventions were measured, with reintervention rates limited to those having a minimum of 12-month follow-up. Of 567 patients, 198 (34.9%) underwent PES for structural and 369 (65.1%) for suspected sphincter pathology. Rates of post-endoscopic retrograde cholangiopancreatography pancreatitis and unplanned hospitalization were high when PES was originally performed for suspected sphincter pathology (12.6% and 14.6%, respectively). The overall reintervention rate was 28.9% and significantly greater for sphincter (41.7%) compared with structural pathology (13.5%, P = 0.005). The likelihood of reintervention after PES is high, particularly when the primary indication is suspected sphincter pathology such as idiopathic recurrent acute pancreatitis. Further prospective studies are needed to clarify if and when this maneuver confers significant benefit to patients.

Endoscopic pancreatic balloon sphincteroplasty for difficult to treat pancreatic stones and strictures: experience in 80 patients.

Background and aim There is paucity of data about endoscopic pancreatic sphincteroplasty (EPS) after endoscopic pancreatic sphincterotomy (EPST) in the treatment of chronic pancreatitis. The aim of this study was to establish the indications for EPS, complications related to it, and to examine its effectiveness in managing chronic pancreatitis after a year of follow-up. Methods We evaluated the safety and efficacy of pancreatic balloon dilation coupled with sphincterotomy for the treatment of chronic pancreatitis. The technical success rate of balloon dilation, stone clearance, frequency of pancreatic stenting, and procedure-related adverse events were recorded. Results Out of 580 patients who underwent pancreatic endotherapy between July 2014 and February 2016, 80 patients underwent EPS. The mean age of these 80 patients was 34 ± 11 years, and 80 % (n = 64) were males. The common indications were removal of large radiolucent stones in 31 patients; unyielding radiopaque stones post extracorporeal shock wave lithotripsy (ESWL) in 20 patients, and pancreatic duct stricture combined with stones in 29 patients. EPS could be successfully completed in 98.75 % of patients. Complete ductal clearance in a single session was achieved in only 25 patients, while 26 patients required two sessions. There were two adverse events of pain requiring admission for more than 24 hours and one procedure related bleeding, all of which were managed conservatively. The patients had an average follow-up of 8 months (6 – 12 months) and all the patients were pain free. Conclusions Endoscopic pancreatic sphincteroplasty is a relatively safe procedure with a low incidence of complications and a high rate of treatment success.

Treatment outcomes of endoscopic pancreatic sphincterotomy combined with pancreatic duct stent for acute recurrent pancreatitis caused by biliary microlithiasis

Objective To investigate the clinical efficiency of endoscopic pancreatic sphincterotomy (EPS) combined with pancreatic duct stent for acute recurrent pancreatitis (ARP) caused by biliary microlithiasis. Methods A total of 71 patients were diagnosed as having ARP resulting from biliary microlithiasis from April 2005 to November 2016, and their clinical data were retrospectively analyzed. Patients were divided into two groups according to different endoscopic therapy, EPS (n=34) and EST group (n=37), respectively. The rate of pancreatitis recurrence, post-ERCP pancreatitis (PEP) and biliary complications were compared by Chi-square test and the influencing factors of recurrence were evaluated by survival analysis. Results The follow-up time ranged from 2 to 108 months (median 21.5 months) in EPS group and ranged from 5 to 120 months (median 39 months) in EST group. Twelve months after endoscopic therapy, 2 patients in EPS group and 5 in EST group suffered recurrent pancreatitis(χ2=0.461, P=0.497). Recurrence occurred in 13 patients in 60 months after endoscopic therapy, 4 patients in EPS group and 9 in EST group. Cox regression analysis indicated different endoscopic treatment (RR=6.808, 95%CI: 1.389-33.356, P=0.018) and type 2 diabetes (RR=0.134, 95%CI: 0.029-0.608, P=0.009) were statistically significant factors. There were no significant difference in incidence of PEP (20.6% in EPS group, 10.8% in EST group, χ2=1.294, P=0.255) and biliary complications between two groups (11.8% in EPS group, 24.3% in EST group, χ2=1.869, P=0.172). Conclusion EPS combined with pancreatic stenting is effective for acute recurrent pancreatitis caused by microlithiasis. Type 2 diabetes may also lead to recurrence of acute pancreatitis. Key words: Pancreatitis; Biliary microlithiasis; Endoscopic pancreatic sphincterotomy; Endoscopic sphincteropapillotomy

Sa1391 Endoscopic Pancreatic Sphincterotomy Combined With Pancreatic Duct Stent Can Effectively Prevent Recurrence of Acute Recurrent Pancreatitis Caused by Biliary Microlithiasis --- A Single-Center Study From Beijing, China

Sa1391 Endoscopic Pancreatic Sphincterotomy Combined With Pancreatic Duct Stent Can Effectively Prevent Recurrence of Acute Recurrent Pancreatitis Caused by Biliary Microlithiasis --- A Single-Center Study From Beijing, China

Sa1211 Indications, Safety, and Re-intervention of Pancreatic Endoscopic Sphincterotomy

Sa1211 Indications, Safety, and Re-intervention of Pancreatic Endoscopic Sphincterotomy

Endoscopic Intervention through Endoscopic Retrograde Cholangiopancreatography in the Management of Symptomatic Pancreas Divisum: A Long-Term Follow-Up Study.

Background/AimsTo evaluate the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) for the treatment of symptomatic pancreas divisum (PD) and to discuss whether ERCP procedures and outcomes in younger patients differ from those of adults.MethodsSymptomatic patients with PD were included in the study and divided into underaged (age ≤17 years) and adult (age ≥18 years) group. The clinical information of each patient was reviewed, and then the patients were contacted by telephone or their medical records were reviewed to determine their long-term follow-up outcomes.ResultsA total of 141 procedures were performed in 82 patients (17 underaged and 65 adult patients). The ERCP indications included abdominal pain (39.02%), pancreatitis (12.20%), recurrent pancreatitis (36.59%), and other discomfort (12.20%). The endoscopic interventions included endoscopic pancreatic sphincterotomy in 44.68% of the patients, bouginage in 26.95%, pancreatic ductal stone extraction in 19.15%, endoscopic nasopancreatic drainage in 21.99%, and endoscopic retrograde pancreatic drainage in 56.74%. After a median follow-up of 41 months, the overall response rate was 62.32%. Between the underaged group and the adult group, significant differences were not observed in the ERCP procedures, complications and long-term follow-up results.ConclusionsERCP is a safe and effective treatment for symptomatic PD. Based on the details, complications, and follow-up results, the ERCP procedure did not present differences between the underaged and adult groups.

Novel covered pancreatic metal stents for the treatment of bleeding after endoscopic pancreatic sphincterotomy

Novel covered pancreatic metal stents for the treatment of bleeding after endoscopic pancreatic sphincterotomy

ERCP in the Management of Symptomatic Pancreas Divisum: A Long-term Follow-up Study

ObjectivesTo evaluate the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in dealing with pancreas divisum (PD), and discuss whether ERCP in the underaged was different from that of adult.MethodsSymptomatic patients with PD were included, and divided into the underaged and adult group. Patients’ clinical information was viewed, and then they were contacted through telephone and by searching for medical records to get long-term follow-up outcomes.ResultsA total of 141 procedures were performed in 82 patients, of whom 17 were underaged, and 65 were adults. ERCP indications included abdominal pain (39.02%), pancreatitis (12.20%), recurrent pancreatitis (36.59%) and other discomfort (12.20%). Endoscopic interventions included endoscopic pancreatic sphincterotomy in 44.68%, bouginage in 26.95%, pancreatic ductal stones extraction in 19.15%, endoscopic nasopancreatic drainage in 21.99%, and endoscopic retrograde pancreatic drainage in 56.74%. Fourteen (9.93%) patients had pancreatitis, 5 (3.55%) had biliary infection, and 1 (0.71%) had haemorrhage. After a median follow-up of 41 months, the overall response rate was 72.88%.ConclusionsERCP is safe and can achieve good outcomes for symptomatic PD, though multiple procedures may be required; the ERCP details, adverse events and follow-up results had no difference between the underaged and the adult groups. ObjectivesTo evaluate the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in dealing with pancreas divisum (PD), and discuss whether ERCP in the underaged was different from that of adult. To evaluate the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in dealing with pancreas divisum (PD), and discuss whether ERCP in the underaged was different from that of adult. MethodsSymptomatic patients with PD were included, and divided into the underaged and adult group. Patients’ clinical information was viewed, and then they were contacted through telephone and by searching for medical records to get long-term follow-up outcomes. Symptomatic patients with PD were included, and divided into the underaged and adult group. Patients’ clinical information was viewed, and then they were contacted through telephone and by searching for medical records to get long-term follow-up outcomes. ResultsA total of 141 procedures were performed in 82 patients, of whom 17 were underaged, and 65 were adults. ERCP indications included abdominal pain (39.02%), pancreatitis (12.20%), recurrent pancreatitis (36.59%) and other discomfort (12.20%). Endoscopic interventions included endoscopic pancreatic sphincterotomy in 44.68%, bouginage in 26.95%, pancreatic ductal stones extraction in 19.15%, endoscopic nasopancreatic drainage in 21.99%, and endoscopic retrograde pancreatic drainage in 56.74%. Fourteen (9.93%) patients had pancreatitis, 5 (3.55%) had biliary infection, and 1 (0.71%) had haemorrhage. After a median follow-up of 41 months, the overall response rate was 72.88%. A total of 141 procedures were performed in 82 patients, of whom 17 were underaged, and 65 were adults. ERCP indications included abdominal pain (39.02%), pancreatitis (12.20%), recurrent pancreatitis (36.59%) and other discomfort (12.20%). Endoscopic interventions included endoscopic pancreatic sphincterotomy in 44.68%, bouginage in 26.95%, pancreatic ductal stones extraction in 19.15%, endoscopic nasopancreatic drainage in 21.99%, and endoscopic retrograde pancreatic drainage in 56.74%. Fourteen (9.93%) patients had pancreatitis, 5 (3.55%) had biliary infection, and 1 (0.71%) had haemorrhage. After a median follow-up of 41 months, the overall response rate was 72.88%. ConclusionsERCP is safe and can achieve good outcomes for symptomatic PD, though multiple procedures may be required; the ERCP details, adverse events and follow-up results had no difference between the underaged and the adult groups. ERCP is safe and can achieve good outcomes for symptomatic PD, though multiple procedures may be required; the ERCP details, adverse events and follow-up results had no difference between the underaged and the adult groups.

Endoscopic surgeries and correction of homeostasis disorders in patients with obstructive jaundice

Aim. To improve the treatment results of patients with obstructive jaundice using endoscopic methods for restoring biliary tract patency. Methods. A retrospective analysis of treatment results of 636 patients, treated in the surgical departments of City Clinical Hospital №7, Kazan, Russia in 2004-2014 with obstructive jaundice induced by tumors and other diseases was performed. Results. It was revealed that using endoscopic techniques for biliary system decompression allows to improve the treatment results. Our observations of patients 2014 with obstructive jaundice induced by tumors and other diseases suggest that the most important element of a comprehensive treatment of such patients is the earliest possible biliary tract decompression using minimally invasive approach, including endoscopic papillotomy and biliary tract stenting. The liver failure stage is an important criterion that defines patient management in case of obstructive jaundice. In patients with obstructive jaundice, treatment of endogenous toxemia and liver failure, according to the contemporary approaches, is based on drug administration and infusions of the required volume and contents, associated with one of the methods for biliary decompression therapy adequate in its formula and size. Conclusion. Endoscopic surgeries are indicated in the majority of acute, recurrent, and chronic large duodenal papilla obstruction cases. Performing endoscopic retrograde cholangiopancreatography, endoscopic pancreatic sphincterotomy in obstructive jaundice not associated with biliary tumors may refuse the surgical approach or reduce its volume and surgical injury.

Risk Factors for Migration, Fracture, and Dislocation of Pancreatic Stents

Aim. To analyze the risk factors for pancreatic stent migration, dislocation, and fracture in chronic pancreatitis patients with pancreatic strictures. Materials and Methods. Endoscopic stent placements (total 386 times) were performed in 99 chronic pancreatitis patients with pancreatic duct stenosis at our institution between April 2006 and June 2014. We retrospectively examined the frequency of stent migration, dislocation, and fracture and analyzed the patient factors and stent factors. We also investigated the retrieval methods for migrated and fractured stents and their success rates. Results. The frequencies of stent migration, dislocation, and fracture were 1.5% (5/396), 0.8% (3/396), and 1.2% (4/396), respectively. No significant differences in the rates of migration, dislocation, or fracture were noted on the patient factors (etiology, cases undergoing endoscopic pancreatic sphincterotomy, location of pancreatic duct stenosis, existence of pancreatic stone, and approach from the main or minor papilla) and stent factors (duration of stent placement, numbers of stent placements, stent shape, diameter, and length). Stent retrieval was successful in all cases of migration. In cases of fractured stents, retrieval was successful in 2 of 4 cases. Conclusion. Stent migration, fracture, and dislocation are relatively rare, but possible complications. A good understanding of retrieval techniques is necessary.

Features of Chronic Pancreatitis – A Focus on ERP

Endoscopic retrograde cholangiopancreatography (ERCP) offers an effective interventional option for treating symptomatic chronic pancreatitis. Endoscopic pancreatic sphincterotomy is performed to facilitated endoscopic treatment. Pancreatic duct strictures can be treated by inserting plastic stents, and a 10Fr endoprosthesis is adequate in many cases. Before stent insertion, hydrostatic balloon dilation is needed in some cases. Pancreatic stones can be removed with a dormia basket, but combining ERCP and extracorporeal shockwave lithotripsy (ESWL) is often most effective.Standard and advanced endoscopic treatment approaches are delineated in this article and include stricture dilation with a Soehendra retriever, cSEMS placement and multi-stenting.

Endotherapy in chronic pancreatitis

Chronic pancreatitis (CP) is a progressive disease with irreversible changes in the pancreas. Patients commonly present with pain and with exocrine or endocrine insufficiency. All therapeutic efforts in CP are directed towards relief of pain as well as the management of associated complications. Endoscopic therapy offers many advantages in patients with CP who present with ductal calculi, strictures, ductal leaks, pseudocyst or associated biliary strictures. Endotherapy offers a high rate of success with low morbidity in properly selected patients. The procedure can be repeated and failed endotherapy is not a hindrance to subsequent surgery. Endoscopic pancreatic sphincterotomy is helpful in patients with CP with minimal ductal changes while minor papilla sphincterotomy provides relief in patients with pancreas divisum and chronic pancreatitis. Extracorporeal shock wave lithotripsy is the standard of care in patients with large pancreatic ductal calculi. Long term follow up has shown pain relief in over 60% of patients. A transpapillary stent placed across the disruption provides relief in over 90% of patients with ductal leaks. Pancreatic ductal strictures are managed by single large bore stents. Multiple stents are placed for refractory strictures. CP associated benign biliary strictures (BBS) are best treated with multiple plastic stents, as the response to a single plastic stent is poor. Covered self expanding metal stents are increasingly being used in the management of BBS though further long term studies are needed. Pseudocysts are best drained endoscopically with a success rate of 80%-95% at most centers. Endosonography (EUS) has added to the therapeutic armamentarium in the management of patients with CP. Drainage of pseudcysts, cannulation of inaccessible pancreatic ducts and celiac ganglion block in patients with intractable pain are all performed using EUS. Endotherapy should be offered as the first line of therapy in properly selected patients with CP who have failed to respond to medical therapy and require intervention.

Covering the Cover

Covering the Cover

Su1395 Pancreatic Sphincter Hypertension Treated by Endoscopic Sphincterotomy (ES) of the Pancreatic Segment of the Sphincter of Oddi (SO): Role of Repeat Sphincter Oddi (SO) Manometry (SOM) Following Short-Term Pancreatic Duct Stenting

SO dysfunction (SOD) is a syndrome previously described in postcholecystectomy pts presenting w/ abd pain only (type III) w/ or w/o high LFTs & dilated CBD (Type I, Type II).Controversies still exist in biliary SOD, pancreatic SOD presents a greater diagnostic & therapeutic challenge. ancreatic sphincter hypertension of the major papilla, a variant of SOD, is a potential cause of acute recurrent (ARP), chronic pancreatitis (CP) & pancreatic-type pain.Little long-term data exists describing pancreatic SOD including presentation, ES technique & long-term outcome.Response rates of ES vary (64-91%). Experience suggests failure to respond to pancreatic ES include: 1.Inadequate pancreatic ES. 2.Recurrent pancreatic stenosis. 3.Presence of CP. AIM:Determine long-term outcome of pancreatic ES in pts w/ pancreatic SO hypertension.Determine rate of residual sphincter hypertension in pts following pancreatic ES.