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Biomedical subjects

P B Cotton

Publications and source records attributed to P B Cotton.

At least 19 recordsLinked to original sources
PubMed2000

Therapeutic ERCP in the management of pancreatitis in children.

BACKGROUND: The use of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is increasing in the management of pancreatobiliary diseases in children. METHODS: Over a 32-month period, we performed 34 ERCP procedures for the treatment of pancreatitis in 22 children at two university hospitals. Demographics and clinical data and ERCP findings were documented. Clinical status was assessed 6 months before the first ERCP and 6 months after the last ERCP, according to general condition, severity and frequency of pain, and health care encounters (emergency department visits, clinic visits, and hospital admissions related to the pancreatitis). RESULTS: Mean age of the patients was 10.7 years (range 1.5 to 17 years). Abdominal pain was the main presenting symptoms with hyperamylasemia and hyperlipasemia. Clinical diagnoses included acute pancreatitis (6), recurrent pancreatitis (5), and chronic pancreatitis (11). The mean follow-up was 16.4 months. Nine patients had sphincter manometry, with abnormal results leading to biliary sphincterotomy in 4. Fifteen patients underwent a total of 23 therapeutic ERCP procedures unrelated to sphincter dysfunction. There were 2 complications of 34 procedures (6%), both being mild pancreatitis after sphincter manometry. There were no deaths. There was a significant reduction in frequency (p < 0.01) and severity of pain (p < 0.01) after intervention. Patients without pancreatographic changes of chronic pancreatitis had the most marked clinical improvement (p < 0.05). In those with ductal changes of chronic pancreatitis, clinical improvement was not predicted by the extent of ductal changes. There was a significant decrease in health care encounters (p < 0.05) and improvement in general condition (p < 0.01) after endoscopic therapy, especially in those with a normal pancreatogram. CONCLUSIONS: Therapeutic ERCP is safe in pediatric patients with pancreatitis. Significant clinical improvement is achieved in patients with biliary or pancreatic stone disease. Prospective studies with long-term follow-up are needed to determine the impact of endoscopic therapy in patients with chronic pancreatitis and sphincter of Oddi dysfunction.

Acute Disease↗
PubMed2000

Virtual endoscopy--comparison with colonoscopy in the detection of space-occupying lesions of the colon.

BACKGROUND AND STUDY AIMS: A new technique has been described which combines abdominal helical computed tomography (CT) scanning and virtual reality computer technology, known as virtual colonoscopy (VC); the reconstructed images provide a simulation of the interior of the colon as viewed by endoscopy. We compared VC with conventional colonoscopy in patients with suspected or known colonic neoplasia. PATIENTS AND METHODS: A total of 38 patients, in whom there was a high likelihood of colonic polyps or cancer, underwent a noncontrast helical CT scan of the abdomen and pelvis after regular colonoscopy bowel preparation. The images were reconstructed into a VC presentation and compared with the subsequent conventional colonoscopy in a blinded manner. RESULTS: Conventional colonoscopy identified a total of 24 polyps 5 mm or greater. VC correctly identified five of 13 polyps 5-9 mm in size, and ten of 11 lesions greater than or equal to 10 mm in diameter. The reasons for four missed lesions were identified as being secondary to a collapsed rectum in two patients and stool in the right colon in two patients. The sensitivity and specificity per patient of VC for lesions greater than or equal to 5 mm were 66.7% and 75.0% respectively, and for lesions greater than 1 cm were 90.0% and 82.1%, respectively. CONCLUSIONS: Virtual colonoscopy is feasible, well tolerated, and capable of detecting most lesions greater than 10 mm in diameter. This technique is continuing to be developed and warrants further evaluation as a diagnostic and screening tool in colorectal neoplasia.

Adult↗
PubMed2000

Randomization is not the (only) answer: a plea for structured objective evaluation of endoscopic therapy.

Endoscopic therapy clearly has a primary role in many clinical conditions (such as dysphagia, obstructive jaundice, bleeding, and colonic polyps). There is much less certainty about the role of endoscopy in many other clinical contexts (e.g. management of chronic pancreatitis). Randomization is the gold standard for evaluation of competing therapies. Unfortunately, there are many difficulties in mounting meaningful randomized controlled trials of endoscopic methods. Many have been done, but few have provided us with real practical answers. This article argues that the evidence we need to advise patients is often better obtained through very stringent observational studies, provided that all necessary data elements are defined and documented and independent objective arbiters (referees) are fully involved in the process.

Digestive System Diseases↗
PubMed1999

Recurrent pancreatitis in a child with pancreas divisum. Endoscopic therapy of a Santorinicele.

Pancreas divisum is a rare congenital anomaly of the pancreatic ducts that has been implicated in pancreatitis. In addition, the finding of a Santorinicele, which is a cystic dilatation of the dorsal duct, suggests that there is an obstruction associated with a congenital or acquired weakness of the mucosa. We used an endoscopic technique to treat a child with recurrent pancreatitis who was found to have pancreas divisum and a large Santorinicele.

Acute Disease↗
PubMed1999

Comparative costs of metal versus plastic biliary stent strategies for malignant obstructive jaundice by decision analysis.

BACKGROUND: For palliation of patients with malignant obstructive jaundice, expansile metal stents provide longer patency than plastic stents but are more expensive. The optimal cost-effective strategy has not been established. Our aim was to compare the relative costs of 3 strategies: (1) plastic stent, with exchange on occlusion; (2) metal stent initially, with coaxial plastic stent insertion in the event of occlusion; or (3) plastic stent initially, with metal stent exchange in the event of occlusion. METHODS: A decision analysis model was created using DATA 2.6 software to assess the relative costs of the three strategies. Values for variables including the probabilities of reintervention and patient survival were obtained from published data. Costs were based on Medicare reimbursements of hospital charges, and the model was evaluated from the perspective of a third-party payer. One-way and two-way sensitivity analysis of the variables was performed over a wide range. RESULTS: The outcome is highly sensitive to the ratio of metal stent cost relative to endoscopic retrograde cholangiopancreatography cost (cost ratio M:ERCP) and to the length of survival of the patient. The most economical strategies were (2), (3) and (1) for M:ERCP cost ratios of <0.5, 0.5 to 0.7, and >0.7, respectively. CONCLUSIONS: The choice of stent should be guided by the relative local costs of ERCP and metal stents and by the prognosis of the patient. At current metal stent costs and Medicare reimbursement rates, initial placement of a plastic stent, followed by metal stent placement at first occlusion in longer survivors, is an economical option. If metal stent cost is less than half of ERCP cost, then initial insertion of a metal stent would be most economical. Use of plastic stents is preferable for patients surviving less than 4 months, whereas metal stents are more economical for patients with longer survival.

Biliary Tract Neoplasms↗
PubMed1998

Pancreatic stenting prevents pancreatitis after biliary sphincterotomy in patients with sphincter of Oddi dysfunction.

BACKGROUND & AIMS: Patients with sphincter of Oddi dysfunction are at high risk of developing pancreatitis after endoscopic biliary sphincterotomy. Impaired pancreatic drainage caused by pancreatic sphincter hypertension is the likely explanation for this increased risk. A prospective, randomized controlled trial was conducted to determine if ductal drainage with pancreatic stenting protects against pancreatitis after biliary sphincterotomy in patients with pancreatic sphincter hypertension. METHODS: Eligible patients with pancreatic sphincter hypertension were randomized to groups with pancreatic duct stents (n = 41) or no stents (n = 39) after biliary sphincterotomy. The primary measured outcome was pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). RESULTS: Pancreatic stenting significantly decreased the risk of pancreatitis from 26% to 7% (10 of 39 in the no stent group and 3 of 41 in the stent group; P = 0.03). Only 1 patient in the stent group developed pancreatitis after sphincterotomy, and 2 others developed pancreatitis at the time of stent extraction. Patients in the no stent group were 10 times more likely to develop pancreatitis immediately after sphincterotomy than those in the stent group (relative risk, 10.5; 95% confidence interval, 1.4-78.3). CONCLUSIONS: Pancreatic duct stenting protects significantly against post-ERCP pancreatitis in patients with pancreatic sphincter hypertension undergoing biliary sphincterotomy. Stenting of the pancreatic duct should be strongly considered after biliary sphincterotomy for sphincter of Oddi dysfunction; pancreatic sphincter of Oddi manometry identifies which high-risk patients may benefit from pancreatic stenting.

Adult↗
PubMed1998

Feasibility of stent placement above the sphincter of Oddi ("inside-stent") for patients with malignant biliary obstruction.

BACKGROUND AND STUDY AIMS: Animal studies suggest that placement of endobiliary stents wholly above the papilla (the "inside-stent") prolongs the duration of stent patency. We reviewed the cholangiographic characteristics of patients with malignant obstructive jaundice in order to evaluate the feasibility of this approach and to assist in the design of a new stent. PATIENTS AND METHODS: A review was conducted of 270 patients who had undergone endoscopic retrograde cholangiopancreatography (ERCP) for malignant obstructive jaundice at our hospital, to determine the relative frequencies of the types of cancers. The ERCP films of 59 relevant consecutive patients with malignant obstructive jaundice were studied to determine the length of the stricture, the distance between the stricture and the papilla, and the angulation of the common duct. RESULTS: The most frequent primary cancers causing malignant obstructive jaundice were pancreatic cancer (57%), biliary cancer involving the hilum (19%, including metastatic disease), nonhilar biliary cancer (14%), and papillary cancer (10%). The length between the lower end of the stricture and the sphincter was more than 2 cm for all hilar biliary cancer, representing two-thirds of nonhilar biliary cancer cases, while it was less than 1 cm for most pancreatic cancers. There was an average angulation of 30-40 degrees in the axis of the distal common bile duct. CONCLUSIONS: For most biliary cancers, the stricture is high enough to allow the placement of a stent fully above the papilla, but this is not possible for most pancreatic cancers (or any papillary cancers). An "inside-stent" approach would be possible in about one-third of patients with malignant obstructive jaundice if a clearance length of over 2 cm between the stricture and the sphincter is required, and in about 45% of patients if a minimum clearance of 1 cm is required. A 30-40 degrees flexion in the distal part of the stent would approximate the average angulation in the axis of the common bile duct and help to prevent dislocation.

Bile Duct Neoplasms↗
PubMed1998

Pancreatic-biliary imaging and triage.

The pancreas and biliary tree (and their confluence at the papilla of Vater) are frequent sites for disease. In recent years there has been a proliferation of relevant technologies. Diagnostic methods include percutaneous ultrasound, standard CT scans, helical CT, magnetic resonance imaging, MRCP, endoscopic ultrasound, angiography, ERCP, laparoscopy, and laparoscopic ultrasound. Cytology and biopsy specimens can be taken in conjunction with many of these techniques. In addition to standard open surgical intervention, there are now many alternative therapeutic approaches wielded by endoscopists, interventional radiologists and laparoscopic surgeons. Novel chemotherapy and radiation oncology techniques and further dimensions. Many studies have attempted to evaluate the role of one particular modality, or to compare two diagnostic or therapeutic techniques. It is more important (and more difficult) to devise and test relevant management algorithms. These assessments are bedevilled by the problem of generalizability, since the results of many techniques are operator-dependent. This raises another issue-whether patients with these problems should be managed in regional specialty centers. Another complexity is that the management of a particular problem is influenced not only by the disease and its stage but also by the type of patient in whom it occurs (age, comorbidities, etc.). Multidisciplinary collaboration is a great challenge (12, 13).

Algorithms↗
PubMed1998

Endoscopic sphincterotomy for stones by experts is safe, even in younger patients with normal ducts.

OBJECTIVE: To provide current information on the risks of endoscopic sphincterotomy for stone. SUMMARY BACKGROUND DATA: In recent years (since the popularity of laparoscopic cholecystectomy), endoscopic sphincterotomy has been used increasingly for the management of bile duct stones in relatively young and healthy patients. The validity of this trend has been questioned using data on short-term complications derived from earlier decades that involved more elderly and high-risk patients. METHODS: Seven academic centers collected data prospectively using a common database. Complications within 30 days of the procedures were documented by standard criteria. RESULTS: Of 1921 patients, 112 (5.8%) developed complications; two thirds of these events were graded as mild (<3 days in hospital). There was no evidence of increased risk in younger patients or in those with smaller bile ducts. There was only one severe complication and there were no fatalities in 238 patients age <60, with bile duct diameters of <9 mm. CONCLUSION: Sphincterotomy for stones can be performed very safely by experienced endoscopists.

Age Factors↗
PubMed1998

Outcome after laparoscopic cholecystectomy for chronic acalculous cholecystitis.

Patients with typical symptoms of biliary tract disease but no gallstones on ultrasonography may benefit from cholecystectomy for presumed chronic acalculous cholecystitis. We retrospectively analyzed the outcome of 50 patients with a preoperative diagnosis of chronic acalculous cholecystitis based upon history (chronic or recurrent, postprandial right upper quadrant abdominal pain), the absence of acid-peptic disease, and normal biliary sonography treated with laparoscopic cholecystectomy (LC) and transcholecystic cholangiography from 1991 to 1996. All patients had preoperative cholecystokinin-stimulated hepatobiliary scintigraphy (CCK-HBS). There were 42 women and 8 men with a mean age of 43 years. CCK-HBS was abnormal in 45 patients (< or = 35 per cent gallbladder ejection fraction or nonfilling of the gallbladder). There was no postoperative mortality and one morbidity (urinary retention). All patients had microscopic evidence of chronic cholecystitis. At mean follow-up of 30 months, (range, 7-62 months) 39 patients (78%) were free of abdominal pain. Thirty-five of 45 patients with abnormal CCK-HBS were pain free (positive predictive value, 0.78). Four of five patients with normal CCK-HBS were pain free (negative predictive value, 0.20). The positive and negative likelihood ratios for CCK-HBS were 0.99 and 1.13, respectively, confirming that this test was not useful for predicting benefit from LC. Seven patients with persistent right upper quadrant pain had abnormal postoperative sphincter of Oddi manometry; they improved after endoscopic sphincterotomy. Patients with symptoms typical of biliary colic with normal gallbladder sonography and absence of acid-peptic disease benefit from LC in the majority of cases. Those who remain symptomatic after LC may benefit from endoscopic retrograde cholangiopancreatography with sphincter of Oddi manometry and endoscopic sphincterotomy when manometry is abnormal.

Adult↗
PubMed1997

[Initial experiences with magnetic resonance endoscopy].

BACKGROUND: In contrast to endorectal surface coils used to assess pelvic tumors, the magnetic resonance endoscope (MR) has all the features of a standard endoscope. In ex-vivo imaging of the porcine gastrointestinal tract, endoscopic MR demonstrates distinct histological layers of the gastrointestinal wall. The aim of this study was to assess the feasibility and the accuracy of endoscopic MR in local staging of patients with esophageal and rectal cancer. METHODS: From April to August 1996, 12 patients (5 female and 7 male, mean age 63 [range 44-84] years) with histologically proven esophageal (n = 6) and rectal (n = 6) cancer prospectively underwent endoscopic ultrasound (EUS) followed by endoscopic MR. The two radiologists reviewing the endoscopic MR images were blinded to the EUS results. Assessment of T and N stages was compared to EUS and histology. RESULTS: Endoscopic MR was well tolerated in all patients and there were no complications. Image quality was sufficient in 75%. Endoscopic MR T-staging correlated with EUS and histology in 7/12 and 5/7 patients respectively. Discordance was due to overstaging by endoscopic MR. N-staging correlated with EUS and histology in 10/12 and 6/8 cases respectively. Non-correlation was due to a number of false negative results at endoscopic MR. CONCLUSION: These early results demonstrate endoscopic MR to be feasible and to produce comparable local staging to EUS in patients with esophageal and rectal cancer. The ultimate goal will be to combine endoscopic MR with body coil MR imaging (for the assessment of distant metastases) in order to provide "one-step staging" for the entire evaluation of gastrointestinal tumors.

Adult↗