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Biomedical subjects

Martin L Freeman

Publications and source records attributed to Martin L Freeman.

At least 19 recordsLinked to original sources
PubMed2007

Predictors of outcomes after biliary and pancreatic sphincterotomy for sphincter of oddi dysfunction.

BACKGROUND: There are few data on combined pancreatic and biliary sphincterotomy for sphincter of Oddi dysfunction (SOD), especially regarding clinical features that might predict outcomes. We sought to examine the relative importance of various clinical features and the presence or absence of objective biliary abnormalities in determining responses to endoscopic therapy. METHODS: A cohort of consecutive patients with suspected SOD was treated with biliary sphincterotomy, with additional pancreatic sphincterotomy at initial or subsequent endoscopic retrograde cholangiopancreatography if there was abnormal pancreatic manometry in conjunction with pain refractory to biliary sphincterotomy, continuous pain, or a history of amylase elevation. Repeat intervention was offered until response was achieved or complete ablation of all treated sphincters was achieved. Response was assessed by patients using a 5-point Likert scale, and multivariate logistic regression analysis used to identify predictors of response. RESULTS: Of 121 patients, 112 (92%) were female, 105 (87%) postcholecystectomy, and by modified Milwaukee biliary classification 18 (15%) were type I, 53 (44%) type II, and 50 (41%) type III. All patients underwent biliary sphincterotomy and 49 (40%) pancreatic sphincterotomy. Good or excellent response at final follow-up was reported by 83 (69%) of 121 patients, including 37 (61%) of 61 patients requiring repeated intervention. Response was not significantly different between biliary types I, II, and III. Patient characteristics (with adjusted odds ratios) that were significant predictors of poor response were normal pancreatic manometry (4.6), delayed gastric emptying (6.0), daily opioid use (4.0), and age <40 (2.7). Abnormal liver function tests or dilated bile duct were not significant. CONCLUSIONS: For the treatment of SOD incorporating pancreatic and biliary sphincterotomy, patient characteristics and pancreatic sphincter manometry may be more important predictors of outcome than the traditional classification based on liver chemistries and bile duct dilation.

Adolescent↗
PubMed2006

Endoscopic approach to acute pancreatitis.

This review focuses on the use of endoscopic techniques in the diagnosis and management of pancreatic disorders. Endoscopic retrograde cholangiopancreatography (ERCP) has been used primarily to evaluate and treat disorders of the biliary tree. Recently, endoscopic techniques have been adapted for pancreatic sphincterotomy, stenting, stricture dilation, treatment of duct leaks, drainage of fluid collections, and stone extraction via the major and minor papillae. In patients with acute and recurrent pancreatitis, ERCP carries a higher than average risk of post-ERCP pancreatitis. This risk can be reduced with the placement of a prophylactic pancreatic stent. Magnetic resonance cholangiopancreatography (MRCP) can establish the anatomy of the biliary and pancreatic ducts, identify pancreas divisum or pancreatic ductal strictures, depict bile duct stones, and demonstrate pancreatic or biliary duct dilation. Endoscopic ultrasound (EUS) provides a safer, less invasive, and often more sensitive measure for evaluating the pancreas and biliary tree, and allows some options for therapy. In acute and recurrent pancreatitis, EUS and MRCP can be used to establish a diagnosis; ERCP can be reserved for therapy.

Acute Disease↗
PubMed2006

Best of DDW 2006.

Highlights from the 2006 Digestive Disease Week May 20-25, 2006, Los Angeles, CA. In this meeting review, many of our editorial board members report on Digestive Disease Week 2006. They highlight the most noteworthy presentations in their respective areas of expertise, including the latest treatments, technologies, and diagnostic advances in ulcerative colitis, Crohn's disease, Helicobacter pylori infection, gastroesophageal reflux disease, irritable bowel syndrome, colorectal cancer, pancreatic and biliary disease, and liver disease.

Digestive System Diseases↗
PubMed2005

Extracorporeal shock wave lithotripsy in the management of chronic calcific pancreatitis: a meta-analysis.

CONTEXT: Main pancreatic duct stones may contribute to pain in chronic pancreatitis. Extracorporeal shock wave lithotripsy (ESWL) has been used alone or in combination with endoscopic therapy for fragmentation of stones. Published studies have shown mixed efficacy due to small sample size. OBJECTIVE: Systematic analysis of all published data evaluating ESWL with or without endoscopic therapy in pancreatic duct clearance and symptom relief. METHODS: Two investigators independently reviewed the computer databases. 31 potential studies were identified. Only studies using ESWL with or without endoscopic therapy were included. Completeness of the search was confirmed by an expert. Studies were independently coded by two investigators and differences rectified by mutual consent. MAIN OUTCOME MEASURES: Pain at follow-up and duct clearance. RESULTS: Seventeen studies published between 1989 and 2002 were included. Sixteen had a measure of pain at follow-up and duct clearance. All studies were case series with a total of 588 subjects, and included varying number of subjects undergoing endoscopic pancreatic sphincterotomy and stone extraction. The mean effect size (weighted correlation coefficient) for pain was 0.6215 and for duct clearance was 0.7432; thus indicating a large effect. All studies showed homogeneity suggesting similar effect size irrespective of the combinations of therapy. CONCLUSIONS: ESWL is effective in clearance of stones from the pancreatic duct and in relief of pain. Published studies showed homogeneity of the effect size of ESWL both in pancreatic duct clearance and relief of pain.

Calcinosis↗
PubMed2005

Endoscopic Biliary and Pancreatic Sphincterotomy.

Endoscopic sphincterotomy is performed on the biliary and pancreatic sphincters for a variety of indications such as removal of stones, as part of treatment of strictures, to facilitate placement of stents, for closure of ductal leaks, and other indications. Pancreatic sphincterotomy has been increasingly performed for the treatment of papillary stenosis, sphincter of Oddi dysfunction, and for chronic and acute recurrent pancreatitis. Efficacy is clear for more traditional indications, but is not as well defined for some of the latter indications. Minor papillotomy is most often performed for acute recurrent pancreatitis associated with pancreas divisum, sometimes for chronic pancreatitis, and for other indications. Equipment, techniques, and safety of sphincterotomy have improved significantly over the past decades. Success rates are substantially higher when a sphincterotomy is performed by high-volume endoscopists. However, complications such as pancreatitis, bleeding, and perforation can still occur in up to 10% of cases and may occasionally be severe. Patients with the least clear indication or chance of benefit from sphincterotomy, such as those with suspected sphincter of Oddi dysfunction or suspected but absent bile duct stones, are at highest risk of complications. Complications are less frequent, but fully not eliminated, with an experienced endoscopist or an expert in the field. Risk of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) with biliary and/or pancreatic sphincterotomy can be substantially reduced by placement of a small-caliber pancreatic stent. Major challenges include defining the settings in which sphincterotomy is most likely to be effective, selection of appropriate patients for therapeutic ERCP by utilization of alternative imaging techniques such as magnetic resonance cholangiopancreatography and endoscopic ultrasound, and dissemination of newer techniques into practice to ensure optimal safety and efficacy for sphincterotomy.

Journal Article↗
PubMed2005

Role of extracorporeal shock wave lithotripsy in the treatment of pancreatic stones.

Calcifications in chronic pancreatitis are usually the result of chronic inflammation or altered metabolism. Calcifications can perpetuate the cycle of ductal obstruction and contribute to pain, worsening of pancreatic inflammation, ductal disruption, and deterioration of the exocrine and endocrine function of the gland. Removal of pancreatic duct calculi can reduce pain and improve glandular function. Purely endoscopic stone removal has limited success, because of stone location, burden, and presence of strictures in the pancreatic duct. Extracorporeal shock wave lithotripsy (ESWL) allows fragmentation of stones refractory to endoscopic methods and facilitates spontaneous stone passage or endoscopic removal. Among the various forms of lithotripters, none is clearly superior to the others. Current data suggest that ESWL is effective in complete duct clearance in up to 50% of patients and in duct decompression and symptomatic improvement in up to 70% of patients. ESWL should be considered as a useful adjunctive tool in the treatment of pancreatic duct calculi.

Calculi↗
PubMed2005

Endoscopic therapy of benign biliary strictures.

Benign biliary strictures result from many etiologies, including postoperative injuries, anastomotic strictures, and chronic pancreatitis. Therapy is generally required to relieve symptoms of cholestasis or cholangitis and prevent secondary cirrhosis. Surgery has been the traditional method for treatment of benign biliary strictures but is associated with significant morbidity and variable long-term outcomes. More research is needed to define the best methods and materials for various patient populations. Endoscopic management, including stricture dilation and stent placement, is more appealing because it is less invasive and better tolerated, but repeated treatments are required. Outcomes of endoscopic management depend on both the etiology and the location of the stricture. Accumulating data suggest that long-term success is substantially greater when multiple rather than single plastic stents are placed. Uncovered metallic stents are problematic and generally not recommended. Emerging alternatives to plastic stents include the placement of removable covered metallic stents.

Biliary Tract Surgical Procedures↗
PubMed2004

EUS-guided rendezvous drainage of obstructed biliary and pancreatic ducts: Report of 6 cases.

BACKGROUND: Only a few cases have been reported of EUS-guided drainage of obstructed pancreatic or bile ducts. An initial experience with EUS-guided rendezvous drainage after unsuccessful ERCP is reported. METHODS: EUS-guided transgastric or transduodenal needle puncture and guidewire placement through obstructed pancreatic (n=4) or bile (n=2) ducts was attempted in 6 patients. Efforts were made to advance the guidewire antegrade across the papilla or surgical anastomosis. If guidewire passage was successful, rendezvous ERCP with stent placement was performed immediately afterward. RESULTS: EUS-guided duct access and intraductal guidewire placement was accomplished in 5 of 6 cases, with successful traversal of the obstruction, and rendezvous ERCP, with stent placement in 3 of 6 cases (two biliary, one pancreatic). The procedure was clinically effective in all successful cases (two patients with malignant obstructive jaundice, one with relapsing pancreatitis after pancreaticoduodenectomy). There was one minor complication (transient fever) but no pancreatitis or duct leak after successful or unsuccessful procedures. CONCLUSIONS: EUS is a feasible technique for allowing rendezvous drainage of obstructed biliary or pancreatic ducts through native papillae or anastomoses after initially unsuccessful ERCP.

Adult↗
PubMed2004

Pancreatic stent insertion: consequences of failure and results of a modified technique to maximize success.

BACKGROUND: Increasingly, pancreatic stents are being placed to prevent post-ERCP pancreatitis. However, guidewire and stent placement may fail if the duct is small or tortuous, potentially exacerbating the risk. This study assessed the impact of unsuccessful pancreatic stent placement on complications and the efficacy of a modified technique for stent insertion when pancreatic ductal anatomy makes stent insertion technically difficult. METHODS: Technical variables and 30-day complications of consecutive therapeutic ERCPs, including attempted major papilla pancreatic stent insertion were prospectively studied. Success rates for pancreatic stent placement were compared for a 1-year period during which conventional deep guidewire insertion was used and another 1-year period in which a modified technique was used as needed in patients with ductal anatomy that made stent placement technically difficult. In the modified technique, a short (2-3 cm) small diameter (3F-5F) stent was placed over a 0.018-in nitinol-tipped guidewire, passed as little as 1 to 2 cm beyond the pancreatic sphincter. RESULTS: In 225 high-risk therapeutic ERCPs, pancreatitis occurred after the procedure in two of 3 (66.7%) patients in whom pancreatic stent insertion failed vs. 32 of 222 (14.4%) patients with successful insertion (p=0.06). Severe pancreatitis occurred only after unsuccessful stent insertion. Significant multivariate risk factors for post-ERCP pancreatitis were unsuccessful pancreatic stent insertion (odds ratio 16.1: 95% CI[1.3, 200]), sphincter of Oddi dysfunction (odds ratio 3.2: 95% CI[1.4, 7.5]), and prior post-ERCP pancreatitis (odds ratio 3.2: 95% CI[1.4, 7.1]). The following were not risk factors: performance of pancreatic, biliary, or needle-knife pre-cut sphincterotomy; number of pancreatic contrast injections; and difficult cannulation. Stent placement was unsuccessful in 3 (3.2%) of 93 attempts during the 1-year period in which a conventional technique was used vs. none of 132 attempts in a subsequent year in which the modified technique was used. CONCLUSIONS: Failed attempts at pancreatic stent placement are associated with an extremely high risk of post-ERCP pancreatitis. Success can be consistently achieved by use of a modified technique.

Adult↗