Biomedical subjects
D Wechter
Publications and source records attributed to D Wechter.
Recurrent pancreatitis in Gardner variant familial polyposis: etiology, diagnostic approach, and interventional results.
HYPOTHESIS: Pancreatitis arising from an obstructing ampullary neoplasm in patients with Gardner variant familial polyposis is an infrequently described clinical entity. We reviewed all patients with Gardner variant polyposis presenting with pancreatitis during a 12-year period in our institution, hoping to better define etiology and the appropriate diagnostic and interventional approach. METHODS: A retrospective record review (1986-1998) defined patient demographics, presenting features, initial and subsequent endoscopic retrograde cholangiopancreatography (ERCP) findings, subsequent treatments, and both immediate and long-term outcomes. Particular consideration was given to initial post-ERCP diagnosis and to endoscopic interventions undertaken at that time. We also looked at those patients who eventually required surgical intervention after long-term failure of medical and endoscopic therapy, the indications for surgery, final pathological characteristics, and follow-up results. RESULTS: Eight patients (6 women and 2 men), with a mean age of 42 years at initial presentation, were found. Each patient was known to have Gardner variant familial polyposis at the time of the initial bout of pancreatitis. All had undergone prior colectomy and 4 of 8 had undergone prior cholecystectomy. None were known to be taking medications or ingesting pancreatoxic substances. Five of 8 patients had obstructing focal or diffuse adenomatous disease involving the ampulla. Two of 8 patients had pancreatitis attributed to other causes (divisum, stones) and a single patient had no clear etiology. Three of 5 patients with ampullary adenomatous disease underwent pancreaticoduodenectomy for recurrent adenomatous encroachment and ampullary stenosis, despite repetitive snare resection and papillotomy. All of these patients had ampullary and other duodenal adenomas, and none had malignant disease. CONCLUSIONS: Patients presenting with pancreatitis in the setting of Gardner variant familial polyposis will frequently have an obstructing ampullary neoplasm, although additional etiologies should be sought. Initial endoscopic therapy affords transient relief but may not be definitive. The abnormal scarring and fibrosis (keloid formation, desmoid reaction) that characterize this disease likely play a large role in endoscopic or subsequent surgical failure. A significant number of these patients will go on to require surgical referral and intervention.
Presentation and treatment of annular pancreas in an adult population.
OBJECTIVE: To describe a series of adult patients with annular pancreas, their presentation, and treatment modalities. METHOD: A retrospective chart review of patients seen at a multispecialty referral center from 1977 to 1994. RESULTS: Seven adult patients (ages ranging from 33 to 77 yr, four females and three males) presented with various symptoms and signs: abdominal pain (six patients) gastric outlet obstruction (two), pancreatitis (two), pancreatic mass (two), gastric/duodenal ulcer (one), and/or postoperative obstructive jaundice (one). The duration of symptoms ranged from 1 wk to 16 yr before diagnosis (median 18 months). Upper GI radiography was consistent with annular pancreas in two cases, CT scan in two cases (neither of which actually depicted the annulus), and four of six successful endoscopic retrograde cholangiopancreatographies. Three patients were diagnosed during operative procedures. Five of the seven patients required therapeutic operative procedures that included transduodenal sphincteroplasty, duodenojejunostomy, gastrojejunostomy, subtotal gastrectomy, or Whipple procedure. Four of the five had significant symptomatic relief. In one case, endoscopic sphincterotomy and biliary stent placement was therapeutic. CONCLUSIONS: 1) Annular pancreas occasionally presents in the adult population. 2) Although gastric outlet obstruction was seen in two of seven patients, a plethora of additional presentations included pancreatic mass, pancreatitis, peptic ulcer disease, and post-operative obstructive jaundice. 3) Diagnosis of annular pancreas was most commonly suggested by upper GI series or endoscopic retrograde cholangiopancreatography. However, fully 40% of diagnoses required surgery for confirmation. 4) In contrast to the pediatric population in whom gastrojejunostomy or duodenojejunostomy is the treatment of choice, a variety of surgical as well as interventional endoscopic procedures were utilized for effective treatment in adults with annular pancreas.