Octreotide in the prevention of hyperamylasemia following ERCP (a controlled multicenter study)

The aim of the multicentric trial was to study the effect of octreotide (Sandostatin) on the rise of pancreatic amylase in the serum after ERCP based on a large number of patients. The study was carried out in a prospective random manner in 2102 patients in 11 endoscopic centers. Patients in the treated group received 0.1 mg octreotide acetate, and those of the nontreated (control) group received isotonic sodium-chloride subcutaneously before the ERCP and 45 minutes after. Serum amylase and blood sugar were checked before the endoscopic procedure, 6 and 24 hours later. Out of the total number of patients involved, data of 1199 patients (599 in the treated group, and 600 in the control group) were evaluated. Octreotide diminished the percentual increase of serum amylase levels following ERCP. However, the frequency of hyperamylasaemia was decreased only after in patients with chronic obstructive pancreatitis or in such patients after endoscopic sphincterotomy. The peak serum level of blood sugar was higher in the treated group compared to the controls. There was no difference in the clinical symptoms following ERCP between the two groups. Conclusion: the prophylactic use of long-acting somatostatin may diminish the frequency of hyperamylasemia after ERCP in patients with chronic obstructive pancreatitis or in those patients who subsequently underwent EST.     

The effect of octreotide on the prevention of acute pancreatitis and hyperamylasemia after diagnostic and therapeutic ERCP

BACKGROUND/AIMS: Acute pancreatitis is a serious complication of diagnostic and therapeutic Endoscopic Retrograde Cholangiopancreatography (ERCP). In addition, serum pancreatic enzymes increase without symptoms in about 40-50% of patients undergoing these endoscopic procedures. In order to evaluate the efficacy of octreotide in the prevention of these complications, we performed this randomised, prospective study. METHODOLOGY: We studied 73 patients (31 males, 42 females), mean age 63.3 +/- 12.9 years (range 28-87 yrs). The patients were randomly allocated into two groups (A and B). Group A (37 patients) was given 0.1 mg of octreotide subcutaneously 30 min before and 8 and 16 hours after the procedure, and group B (36 patients) was given a placebo. Serum amylase was measured 30 min before and 3 and 6 hrs after ERCP. All patients were subjected to ultrasonography for signs of pancreatic inflammation. There was no statistically significant difference between the two groups concerning age, sex and indication for ERCP. Endoscopic sphincterotomy (ES) was performed in 14 patients of group A and 10 patients of group B. RESULTS: There were 4 cases of acute pancreatitis in each group and the mean serum amylase at 3 and 6 hrs was comparable (494/676 and 429/582 IU/L, respectively). In comparing patients who were subjected to either diagnostic or therapeutic ERCP, there was no statistically significant difference concerning episodes of acute pancreatitis and the level of serum amylase. CONCLUSION: Octreotide does not seem to prevent acute pancreatitis and hyperamylasaemia after diagnostic and therapeutic ERCP.     

Gabexate for the prevention of pancreatic damage related to endoscopic retrograde cholangiopancreatography. Gabexate in digestive endoscopy--Italian Group

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is associated with elevated levels of pancreatic enzymes and pancreatitis. Gabexate, a protease inhibitor, has been used to prevent pancreatic damage related to ERCP. METHODS: We conducted a multicenter, double-blind comparison of gabexate (1 g given by intravenous infusion starting 30 to 90 minutes before endoscopy and continuing for 12 hours afterward) with placebo (mannitol and sodium chloride, administered in the same fashion). A total of 435 adults scheduled to undergo ERCP and, when indicated, endoscopic sphincterotomy underwent randomization; 17 were excluded from the final analysis for various reasons. The remaining 418 patients (mean age, 60.4 years)--208 in the gabexate group and 210 in the placebo group--were analyzed. Acute pancreatitis was considered to be present if serum amylase or lipase levels (or both) were five times greater than the upper limits of normal in association with the onset of pancreatic pain. RESULTS: After the procedures, 276 patients (66 percent) had elevated pancreatic-enzyme levels; the frequency was similar in the two groups. Mean serum amylase values were higher in the placebo group than in the gabexate group through 24 hours of observation (P=0.03). Twelve patients in the gabexate group and 29 in the placebo group had abdominal pain (6 percent vs. 14 percent, P=0.009). Sixteen patients in the placebo group and five in the gabexate group had acute pancreatitis (8 percent vs. 2 percent, P=0.03). Two patients treated with gabexate and six given placebo had adverse events, all of which resolved. Two patients given placebo died of acute pancreatitis; one was excluded from the evaluation because pancreatitis was present before endoscopy. One patient in the gabexate group died, from a myocardial infarction. CONCLUSION: Prophylactic treatment with gabexate reduced pancreatic damage related to ERCP, as reflected by reductions in the extent but not the frequency of elevated enzyme levels and in the frequency of pancreatic pain and acute pancreatitis.     

Effects of high dose octreotide on retrograde bile salt-induced pancreatitis in rats

The effects of somatostatin and octreotide (a long acting somatostatin analogue) in acute pancreatitis are inconclusive. This study examined the prophylactic and therapeutic effects of different doses of octreotide on retrograde sodium taurodeoxycholate-induced acute necrotizing pancreatitis in rats. The rats were divided into 4 groups receiving subcutaneous injection of saline, octreotide 10 microg/kg, 20 microg/kg at 0, 8 and 16 h and octreotide 20 microg/kg at 5, 13 and 21 h, separately. The serum levels of amylase and lipase, pancreatic histopathology, mortality and hemodynamics were examined. Octreotide significantly reduced serum levels of amylase and lipase at 12 h and the degree of pancreatic edema, necrosis and hemorrhage at 18-24 h as compared to the control group. Prophylactic octreotide 10 microg/kg significantly decreased the 24-h mortality from 100% to 44.4% (p < 0.05). The 24-h mortality further reduced to 12.5% and 10% with prophylactic and therapeutic octreotide 20 microg/kg, respectively. The decrease of mean arterial pressure at 12 h was significantly lower in octreotide groups than in the control group. We conclude that octreotide improves pancreatic histopathology and survival in acute necrotizing pancreatitis in rats.     

A new member of the MER2 repeat family is detected in the promoter region of the human X11 gene

AIMS: To evaluate the clinical utility of two new tests for serum trypsinogen 2 and trypsin 2-alpha 1 antitrypsin complex (trypsin 2-AAT) in diagnosing and assessing the severity of acute pancreatitis (AP) induced by endoscopic retrograde cholangiopancreatography (ERCP). PATIENTS: Three hundred and eight consecutive patients undergoing ERCP at Helsinki University Central Hospital in 1994 and 1995. METHODS: Patients were followed prospectively for pancreatitis and clinical outcome. They were tested for serum trypsinogen 2, trypsin 2-AAT, and amylase in samples obtained before and one, six, and 24 hours after ERCP. RESULTS: Pancreatitis developed in 31 patients (10%). Their median serum trypsinogen 2 increased 26-fold to 1401 micrograms/l at six hours after the procedure and trypsin 2-AAT showed an 11-fold increase to 88 micrograms/l at 24 hours. The increase in both markers was stronger in severe than in mild pancreatitis, and in patients without pancreatitis there was no significant increase. Baseline trypsinogen 2 and trypsin 2-AAT concentrations were elevated in 29% and 32% of patients, respectively. The diagnostic accuracy of a threefold elevation over the baseline value was therefore analysed. The sensitivity and specificity of these parameters in the diagnosis of post-ERCP pancreatitis was 93% and 91%, respectively, for serum trypsinogen 2 at six hours after the examination, and 93% and 90%, for trypsin 2-AAT at 24 hours. CONCLUSIONS: Serum trypsinogen 2 and trypsin 2-AAT reflect pancreatic injury after ERCP. High concentrations are associated with severe pancreatic damage. The delayed increase in trypsin 2-AAT compared with trypsinogen 2 appears to reflect the pathophysiology of AP. A greater than threefold increase in trypsinogen 2 six hours after ERCP is an accurate indicator of pancreatitis.     

What place for endoscopic sphincterotomy in treatment of acute pancreatitis?

STUDY AIM: A prospective study was undertaken in order to evaluate the effects of endoscopic sphincterotomy on the evolution of biliary and idiopathic acute pancreatitis. PATIENTS AND METHODS: Among 320 patients with acute pancreatitis observed from 1986 to 1996, 118 were excluded from the study for etiological reasons and 137 were included for an endoscopic sphincterotomy within 72 hours from their admission. There were nine technical failures and 128 endoscopic sphincterotomies were performed. Sixty-five eligible patients were not included for logistic problems or patients' refusal; they can be considered as a "control group". RESULTS: The mortality rate of endoscopic sphincterotomy was 0 and the morbidity rate 2.1%. The mortality rate of acute pancreatitis was 3.1% in the sphincterotomy group vs 7.6% in the control group (P = 0.1) (NS) and the morbidity rate 25% versus 32% (P > or = 0.1) (NS). CONCLUSION: These results suggest that endoscopic sphincterotomy could be beneficial in acute biliary or idiopathic pancreatitis but they are not statistically significant. Endoscopic sphincterotomy does not increase the severity of acute pancreatitis and can be considered particularly in cases of gallstone pancreatitis but it should be performed less than 48 hours after the onset of acute pancreatitis.     

Endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy for symptomatic choledocholithiasis after recent myocardial infarction

In the general population, endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy is preferable to surgery as therapy for gallstone pancreatitis and acute cholangitis. It is particularly attractive to perform therapeutic. ERCP for symptomatic choledocholithiasis after recent myocardial infarction because of the increased risk of the alternative therapy of cholecystectomy and choledochal exploration. However, after myocardial infarction, patients might theoretically be particularly susceptible to the cardiopulmonary risks of ERCP. The safety of therapeutic ERCP after myocardial infarction is unknown, with only one previously reported case. In a review of 11,367 patients with acute myocardial infarction at four hospitals, four patients (0.04%) underwent therapeutic ERCP after recent myocardial infarction, for indications of recent biliary pancreatitis in three of the patients and recent cholangitis in all four. Cholangitis occurred before, simultaneous with, or after myocardial infarction in the four cases. Initially, the cholangitis was managed medically in three patients. The fourth patient underwent cholecystostomy with local anesthesia. ERCP was performed at 15, 25, 30, or 56 days after myocardial infarction. Endoscopic cholangiography revealed multiple choledocholithiasis in all cases. The calculi were successfully extracted by endoscopic papillotomy and by sweeping the choledochus with a balloon-tipped catheter or basket in all cases. During ERCP, the vital signs remained stable; no cardiac arrhythmias or cardiovascular complications occurred. However, one patient developed mild pancreatitis after ERCP, which rapidly resolved with medical therapy. The four patients rapidly improved after ERCP, with normalization of serum levels of routine biochemical parameters of liver function. These four cases and the one prior case report demonstrate that therapeutic ERCP is not absolutely contraindicated after myocardial infarction and suggest that therapeutic ERCP is preferable to surgery for symptomatic choledocholithiasis after myocardial infarction because of the increased mortality of surgery after myocardial infarction.     

Serum Amylase elevation following hepatic resection in patients with chronic liver disease

BACKGROUND: Factors liable to cause hyperamylasemia after hepatectomy were studied retrospectively in 140 patient with chronic liver disease. METHODS: The pringle maneuver was performed in 113 patients (Pringle group), the hemihepatic vascular occlusion technique in 21 (hemihepatic group), and no vascular occlusion in 6 (no-occlusion group). RESULTS: In the Pringle group, postoperative serum amylase levels were elevated significantly in comparison with the preoperative levels, but were not elevated in hemihepatic and no-occlusions groups. In the Pringle group, there were 4 patients whose postoperative serum amylase levels exceeded 3.5 times the upper limit of the normal range together with serum pancreatic isoamylase or lipase elevation or both. When compared with the other 109 patients, these 4 patients had a significantly longer vascular occlusion time (51 +/-3 minutes versus 94 +/- 8 minutes P<0.005). One of them developed pancreatitis and died from hepatic failure. CONCLUSION: Prolongation of portal congestion carries a potential risk of serum amylase elevation and pancreatitis after hepatectomy in patients with underlying liver disease.     

Mucin-hypersecreting intraductal neoplasms of the pancreas: a precursor to cystic pancreatic malignancies

BACKGROUND: Muncin-hypersecreting intraductal pancreatic neoplasms were first described in 1982 and have been observed in increasing numbers since. They are observed primarily by endoscopic retrograde cholangiopancreatography (ERCP) and are characterized by an intraductal papillary neoplasm that secretes thick mucin, causing pancreatic duct dilatation and obstructive pancreatitis. METHODS: Twenty patients are presented, 14 male and six female, with an average age of 59 +/- 11 years. All patients presented with abdominal pain, and most had nausea and vomiting, weight loss, and documented pancreatitis. Of the preoperative studies, ERCP was positive in all patients. Computed tomography scan, endoscopic ultrasonogram, and cytologic findings were less sensitive. Tumor markers were only positive in one patient. All 20 patients were treated surgically. Nine underwent Whipple procedure, one patient had a total pancreatectomy, and nine had distal pancreatic resections. The first patient in the series did not have a pancreatic resection, and his disease evolved into a lethal cystadenocarcinoma causing his death 99 months later. RESULTS: Histopathologic findings were interpreted as borderline malignant in 17 of the 20 patients, and three patients had evidence of invasive adenocarcinoma. Two of these three patients had nodal or distant metastases at the time of diagnosis, and all three died of adenocarcinoma. Seventeen of the patients are alive and well, although two of three with positive pancreatic margins have had recurrent symptoms and have been successfully reresected. CONCLUSIONS: The mucin-producing intraductal papillary tumor of the pancreas is a newly described variant of pancreatic cancer. It presents with symptoms of pancreatitis and has a progressive but more indolent course than the more lethal invasive ductal cancers. Patients with unexplained pancreatitis should undergo ERCP investigation, and aggressive surgical therapy should be carried out because the prognosis for this lesion, when appropriately treated, is more favorable than the usual pancreatic cancer.     

Endoscopic therapy of pancreas divisum

Pancreas divisum is the most frequent congenital ductal anomaly of the pancreas: it occurs in 5-10% of the population. In the majority of patients, this congenital anomaly is of no clinical importance. In a certain subset of patients, however, pancreas divisum is clinically important as a cause of abdominal pain, acute recurrent pancreatitis or chronic obstructive pancreatitis. The authors, experience on endoscopic drainage of the minor papilla is reported. In the history of patient 1., three episodes of recurrent pancreatitis and permanent upper abdominal pain were explored. ERP revealed a pancreas divisum and a mild irregularity and dilation of the dorsal pancreatic duct. A 7 F stent (length: 6 cm) was implanted in the dorsal pancreatic duct following a papillotomy on the stenotic minor papilla. A repeated Lundh test revealed a 58% improvement in the exocrine pancreatic function. No recurrence of pancreatitis has been observed in spite of the moderate continuous abdominal pain. In patient 2., ERP demonstrated a pancreas divisum and a severely dilated dorsal pancreatic duct as causes of the previous permanent abdominal pain. An 8 F stent (length: 5 cm) was inserted through the minor papilla without endoscopic sphincterotomy. A significant improvement in exocrine pancreatic function (70%) ensued. No abdominal pain has since been observed. In conclusion, dorsal pancreatic duct stenting (mainly in cases involving a dilated pancreatic duct) seems to have a beneficial effect in patients with both recurrent acute pancreatitis or chronic obstructive pancreatitis evoked by pancreas divisum.     

Identification and molecular characterization of a small 11q23.3 de novo duplication in a patient with Rett syndrome manifestations

BACKGROUND AND STUDY AIMS: Modern fine-caliber endoscopes enable clinicians to directly visualize the pancreatic duct. They allow intraductal manipulation under optical control. We tried to evaluate the additional diagnostic potential of pancreatoscopy in assessing inconclusive intraductal pancreatic changes. PATIENTS AND METHODS: We prospectively performed 20 pancreatoscopies in 18 patients with inconclusive ductal abnormalities that had been previously investigated by computed tomography (CT) scan, abdominal ultrasound and endoscopic retrograde cholangiopancreatography (ERCP). The CHF-BP 30 (Olympus Optical Co., Japan) endoscope with an outer diameter of 3.1 mm and an instrumentation channel of 1.2 mm was used. Biopsies, cytological brushing and fluid collection were carried out, and the site of ductal abnormality was visualized. Endoscopic sphincterotomy (EST) was carried out in every patient prior to insertion of the pancreatoscope. RESULTS: Seven intraductal tumors were histologically confirmed, i.e. five intraductal papillary mucinous tumors and two adenocarcinomas. Benign appearance of the intraductal lesion plus negative histopathological examinations were confirmed by a follow-up of two years in eight patients. Five had chronic pancreatitis, and a further three had pancreatitis with strictures, blood clot obstruction, and idiopathic benign stricture, respectively. There were no complications with the exception of one bleeding episode after EST; no pancreatitis occurred. CONCLUSIONS: Pancreatoscopy is of diagnostic value in addition to CT, transabdominal ultrasound and ERCP in the differential diagnosis of poorly defined pancreatic lesions, particularly when assessing alterations of the ductal caliber without parenchymatous lesions.     

The clinical significance of hyperamylasemia in organophosphate poisoning

OBJECTIVE: Hyperamylasemia with a presumptive diagnosis of acute pancreatitis has been reported following organophosphate poisoning but there are no large-scale studies incorporating more specific diagnostic criteria. METHODS: Retrospective review of the medical records of 159 patients with a diagnosis of organophosphate poisoning over 3 years. Serum amylase, pancreatic amylase, salivary amylase, lipase and cholinesterase levels, and the clinical manifestations were analyzed. RESULTS: Serum amylase data was available for 121 of the 159 study patients. Hyperamylasemia (amylase > or = 360 U/L) was found in 44 patients (36%). Lipase was measured in 28 patients with hyperamylasemia; 9 of 28 had hyperlipasemia (lipase > or = 380 U/L). The finding of hyperamylasemia was closely related to clinical severity and presence of shock. A presumptive diagnosis of painless acute pancreatitis was diagnosed by hyperlipasemia associated with hyperamylasemia, clinical severity, serum LDH, and leukocyte counts. Two patients with presumptive pancreatitis died. Shock, coma, and hypoalbuminemia were the factors predicting fatality. CONCLUSIONS: Hyperamylasemia is frequent in severe organophosphate poisoning. However, hyperamylasemia is not synonymous with acute pancreatitis and pancreatic amylase is not a reliable parameter in the diagnosis of organophosphate-induced pancreatitis due to its low sensitivity and specificity. Lipase assay is indicated in patients with hyperamylasemia for early diagnosis of pancreatitis. Proper image studies and even pathological examination are also needed to confirm the extent of pancreatic injury. With prompt diagnosis and appropriate treatment, a complete recovery can be anticipated unless the patient has otherwise unrelated complications.     

Thoracoscopic surgery using voice controlled robot for spontaneous pneumothorax

Although there is abundant literature on the association of L-asparaginase and acute pancreatitis in patients undergoing chemotherapy, few studies have investigated the usefulness of pancreatic enzyme measurement in the early diagnosis of L-asparaginase-induced acute pancreatitis. We measured levels of serum pancreatic enzymes before, during, and after L-asparaginase therapy in nine children with acute lymphocytic leukaemia or non-Hodgkin lymphoma. Serum levels of amylase, pancreatic isoamylase, and lipase did not change between the 1st and 30th day of L-asparaginase administration. However, the serum trypsin and elastase- levels, 10 and 20 days after beginning L-asparaginase therapy, were significantly higher than those prior to therapy. CONCLUSION: L-asparaginase may induce subclinical pancreatitis and the estimation of serum trypsin and elastase-1 may be useful in the early diagnosis of L-asparaginase-induced acute pancreatitis.     

Endoscopic therapy of chronic pancreatitis

BACKGROUND/AIMS: Endoscopic therapy of chronic obstructive pancreatitis is an indubitable contribution to patients which brings immediate pain relief, enables an increased caloric food intake and improves the quality of patient's life. The authors describe their experience in a set of 42 subjects, in whom endoscopic papillotomy of the pancreatic duct was carried out after diagnosis of chronic obstructive pancreatitis. MATERIAL AND METHODS: Endoscopic papillotomy was performed in 42 patients. In 17 patients, papillotomy was followed by the drainage of the pancreatic duct. RESULTS: The treatment led to disappearance or significant decrease of the epigastric pain in 85.7% patients shortly after the treatment; in 47.1% of patients the painless period lasted for further 24 months after the therapy. Increase in body weight of about 2 kg occurred in 53% of treated subjects during the 2 years since the therapy. Complications in treatment, such as acute pancreatitis in 3 patients and bleeding in 2 were mastered conservatively. CONCLUSION: Endoscopic therapy of chronic pancreatitis is an alternative approach of managing the algic form of chronic obstructive pancreatitis. Changes in the area of Vater papilla, pathological content of pancreatic duct, structure or complications of chronic pancreatitis could be solved endoscopically with a minimum burden on patient. According to the experience of the authors, endoscopic papillotomy of pancreatic duct with contingent drainage led to the pain disappearence nearly in 50% of patients in the set of 42 subjects 24 months after the performance. This fact was followed with an increase in body weight in more than 50% of treated subjects. Minimum of complications put the endoscopic therapy among relatively safe and at the same time effective approach to chronic pancreatitis.     

Endogenous levels of somatostatin, C-peptide and insulin in acute pancreatitis

The authors compared in seven patients with acute pancreatitis the levels of endogenous somatostatin, insulin and C-peptide to assess their mutual correlation and relation to the development of the disease and serum amalyse levels. The results were compared with values recorded in 11 healthy volunteers. The levels of endogenous somatostatin were in patients with acute pancreatitis significantly higher (p < 0.05) than in the control group. The authors found an inverse relationship between the somatostatin and amylase level (correlation coefficient 0.75). They did not observe a significant correlation between somatostatin and insulin levels nor between somatostatin and C-peptide levels. The elevated somatostatin level may be due to the counteregulatory reaction during secretion, stimulated by endogenous or exogenous factors (cholecystokinin, alcohol, food).     

Management of choledocholithiasis in patients undergoing laparoscopic cholecystectomy

The development of laparoscopic cholecystectomy has rekindled the issue of management of choledocholithiasis. A number of options exist including pre or postoperative endoscopic sphincterotomy (ERCP-ES), laparoscopic common duct exploration or open common duct exploration. We present here our experience with the management of choledocholithiasis in patients treated with laparoscopic cholecystectomy. From January 1991 to January 1995, 900 patients underwent laparoscopic cholecystectomy. 71 ERCP were carried out in 71 patients with suspicion or evidence of choledocholithiasis. Common duct stones were detected in 44 patients. Preoperative ERCP was done in 56 patients, with suspicion of choledocholithiasis, based on clinical, laboratory or ultrasonographic findings. 29 of these patients (51.7%) had common duct stones, that were successfully removed by endoscopic sphincterotomy. One patient suffered mild pancreatitis and a second one had transient hyperamylasemia. Postoperative ERCP was performed in 15 patients. Indications for ERCP were the evidence of common duct stones in intraoperative cholangiography in 7 cases, and clinical or laboratory suspicion of choledocholithiasis, 3 months to 3 years after laparoscopic cholecystectomy. Stones were detected in 100% of the patients. In 11 patients (73.3%), the stones were extracted by endoscopic sphincterotomy and 4 patients underwent open common duct exploration. Two patients had transient hyperamylasemia. ERCP is a safe and effective method for detection and treatment of common duct stones. ERCP prior to laparoscopic cholecystectomy in patients suspected of having choledocholithiasis, is safe and offers with good results. Rutinary intraoperative cholangiography is recommended, for the detection of unsuspected choledocholithiasis and as an effective treatment (postoperative-ERCP, open or laparoscopic common duct exploration) can be chosen depending on surgeon's skills and patient's characteristics.     

Effects of glycosaminoglycans on the glomerular changes induced by Adriamycin

BACKGROUND: A model of moderate acute necrotizing pancreatitis is essential for the study of the pathophysiology of the disease and novel therapies. We tried to establish a model of bile salt-induced acute necrotizing pancreatitis in rats. METHODS: Acute pancreatitis was induced by retrograde infusion of bile salt into the cannulated pancreatobiliary duct. Twenty-six rats wee divided into 3 groups. Group I (n = 8) received 0.2 ml of glycodeoxycholic acid (GDOC) 10 mmol/l; group II (n = 10) 0.2 ml of 2.5% sodium taurodeoxycholate (NaTDC); group III (n = 8) the mixture of 0.2 ml GDOC 10 mmol/l and 10 U enterokinase. Serum levels of amylase and lipase, hematocrit, mean arterial pressure and heart rate were determined at baseline and 5 hours later. Then the pancreas was removed for histopathology and grading (0-3; absent-severe) with regard to leukocyte infiltration, edema, necrosis, hemorrhage and acinar cell vacuolization. RESULTS: Serum levels of amylase and lipase increased significantly in 5 hours in all the groups. Serum amylase levels were significantly lower in group III than in group II. No significant difference of serum lipase was found among the groups. Group II had the highest scores of necrosis and acinar cell vacuolization, whereas group III had the highest scores of leukocyte infiltration and edema. The degree of necrosis was significantly more severe in group II than in group I. The hematocrit increased significantly in 5 hours in groups I and II. The mean arterial pressure in 5 hours decreased significantly in group I. There was no significant difference of the changes of heart rate in 5 hours among 3 groups. CONCLUSIONS: Intraductal infusion of NaTDC was a good method to induce moderate acute necrotizing pancreatitis in rats. GDOC caused mild pancreatitis, and pancreatic injury was aggravated when enterokinase was added. The severity of pancreatic histopathology was not correlated with the changes of serum levels of pancreatic enzymes, hematocrit or mean arterial pressure at the early stage of pancreatitis.     

Magnetic resonance imaging assessment of disc degeneration 10 years after anterior lumbar interbody fusion

OBJECTIVE: Insulin-like growth factor (IGF-I) action is influenced by circulating as well as tissue levels of its binding proteins. Because serum IGF binding protein-1 (IGFBP-1) levels have been found to be decreased in patients with polycystic ovary syndrome (PCOS), we tested the hypothesis that regulation of IGFBP-1 secretion may be different in patients with PCOS compared with normal women. METHODS: We studied 15 normal ovulatory women and 15 women with PCOS of similar age (21 +/- 1 and 22 +/- 1 years, respectively). All subjects were studied after an overnight fast between days 5-8 after spontaneous or progestin-induced menses. Perturbations included the administration of insulin intravenously, maintenance of a euglycemic clamp, and, in a subsequent cycle, the administration of a long-acting somatostatin analogue (octreotide, 100 micrograms) given subcutaneously. Blood samples were collected before treatment, every 15 minutes for 6 hours after insulin, and every 30 minutes for 3 hours after octreotide administration. Serum levels of IGF-I, IGFBP-1, IGFBP-3, and insulin were measured by specific immunoassays. RESULTS: Compared with the controls, patients with PCOS had significantly higher insulin levels, similar IGF-I and IGFBP-3 levels, and significantly lower IGFBP-1. Insulin did not change serum IGF-I levels in either group, although a significant decrease in IGFBP-1 levels occurred in normal women but not in patients with PCOS. Octreotide treatment also did not change serum IGF-I levels in either group, but serum insulin levels decreased significantly and IGFBP-1 levels increased significantly in both groups; this response was significantly greater in controls. CONCLUSIONS: Our data are compatible with the notion that regulation of IGFBP-1 is altered in women with PCOS and that several factors may be involved.     

Combined laparoscopic and endoscopic management of cholelithiasis and choledocholithiasis

With the advent of laparoscopic cholecystectomy, optimal management of common duct stones remains controversial. Seven hundred six patients underwent laparoscopic cholecystectomy in our institution from January 1990 through January 1992. From this group of patients, 50 were identified as having clinical or radiographic evidence of common duct stones. Thirty-one patients demonstrated preoperative risk factors for common duct stones and underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP). The risk factors included jaundice (19%), pancreatitis (23%), elevated liver function tests (52%), and ultrasound evidence of choledocholithiasis (6%). Preoperative ERCP was performed in 94% of patients. There were two failures due to periampullary diverticula. Common duct stones were identified in 18 patients (62%) and successfully removed by endoscopic sphincterotomy in all of these patients. Nineteen patients were found to have unsuspected common duct stones on intraoperative cholangiography. Eighteen patients (95%) underwent successful ERCP and endoscopic sphincterotomy with stone extraction. Overall, major morbidity was 2% and included one patient who experienced endoscopic sphincteroplasty. The three endoscopic failures were managed by open common duct exploration, laparoscopic duct exploration, and combined laparoscopic and open common duct exploration. We conclude that combined laparoscopic and endoscopic therapy is a viable option for the management of cholelithiasis with choledocholithiasis.     

The benefits of endoscopic nasobiliary drainage without sphincterotomy for acute cholangitis

OBJECTIVE: Endoscopic nasobiliary drainage for acute cholangitis is performed with or without endoscopic sphincterotomy. However, sphincterotomy carries a small but important risk of complications. We evaluated the benefits of endoscopic nasobiliary drainage without sphincterotomy for acute cholangitis. METHODS: A total of 166 patients underwent endoscopic nasobiliary drainage with sphincterotomy (73 patients, sphincterotomy group) or without (93 patients, nonsphincterotomy group). The indications were acute cholangitis due to choledocholithiasis (120 patients) or benign (10 patients) or malignant (36 patients) biliary stricture. Patient backgrounds were similar in the two groups. The outcomes of nasobiliary drainage were compared between the groups. RESULTS: Nasobiliary drainage was successful in 69 patients (95%) in the sphincterotomy group and in 89 (96%) in the nonsphincterotomy group. Efficient drainage was achieved in 67 patients (92%) in the sphincterotomy group and in 87 (94%) in the nonsphincterotomy group. Procedure-related complications developed in eight sphincterotomy-group patients (hemorrhage in three, acute cholecystitis in three, acute pancreatitis in one, catheter withdrawal in one) and in two nonsphincterotomy patients (pancreatitis in one, catheter withdrawal in one) (11% vs 2%; p < 0.05). There were no deaths. CONCLUSIONS: Endoscopic nasobiliary drainage without endoscopic sphincterotomy is a simple, safe, and effective treatment for acute cholangitis. This procedure is especially useful for critically ill patients and those with coagulopathy.