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Marlon F. Levy - One of the best experts on this subject based on the ideXlab platform.
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A study of the clinical utility of a 20-minute secretin-stimulated endoscopic Pancreas Function test and performance according to clinical variables
Gastrointestinal Endoscopy, 2017Co-Authors: Luis F. Lara, Morihito Takita, James S. Burdick, Daniel C. Demarco, Ronnie Pimentel, Tolga Erim, Marlon F. LevyAbstract:Background and Aims Direct Pancreas juice testing of bicarbonate, lipase, or trypsin after stimulation by secretin or cholecystokinin is used to determine exocrine Function, a surrogate for diagnosing chronic pancreatitis (CP). Endoscopic Pancreas Function tests (ePFTs), where a peak bicarbonate concentration (PBC) ≥80 mEq/L in Pancreas juice is considered normal, are now used more frequently. In this ePFT, aspirates start 35 minutes after secretin administration because Pancreas output peaks 30 minutes after secretagogue administration. The performance of ePFT in a cohort of patients with a presumptive diagnosis of CP referred to a Pancreas clinic for consideration of an intervention including total pancreatectomy and islet autotransplantation was studied, compared with EUS, ERCP, histology, and consensus diagnosis. The effect of sedation, narcotic use, aspirate volume, body mass index, age, and proton pump inhibitors (PPIs) on test performance is reported. Methods After a test dose, synthetic human secretin was administered intravenously, and 30 minutes later sedation was achieved with midazolam and fentanyl or propofol. A gastroscope was advanced to the major papilla where 4 continuous aspiration samples were performed at 5-minute intervals in sealed bottles. PBC ≥80 mEq/L was normal. Results Eighty-one patients had ePFTs from August 2010 through October 2015. Twenty-seven patients (33%) were diagnosed with CP. Eighteen of the 27 patients with CP and 1 of the 54 patients without CP had an abnormal ePFT, producing a sensitivity of 66% (95% CI, 46.0-83.5), specificity 98% (95% CI, 90.1-99.9), positive predictive value 94.7% (95% CI, 74-99.9), and negative predictive value 85.5% (95% CI, 74.2-93.1). ERCP and PBC concordance was generally poor, but none of the patients without CP had major EUS changes, and only 3 patients with a PBC Conclusion A 20-minute ePFT after secretin administration had a marginal sensitivity for diagnosis of CP. The diagnosis of CP should not rely on a single study and certainly not a PFT. The duodenal aspirate volume did not correlate with the PBC, which contrasts with current secretin-enhanced MRCP knowledge; therefore, further studies on this subject are warranted. Neither type of sedation, BMI, nor age affected test performance. Narcotics and PPIs may affect the PBC, so borderline results should be interpreted with caution in these groups
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Su1704 Implication of Secretin Endoscopic Pancreas Function Test for Patient Undergoing Autologous Islet Transplantation for Chronic Pancreatitis
Gastrointestinal Endoscopy, 2014Co-Authors: Morihito Takita, Rauf Shahbazov, Luis F. Lara, Bruce M. Miller, Bashoo Naziruddin, Marlon F. Levy, James S. BurdickAbstract:Su1703 Endoscopic Report Card of a 10-Year Experience in 100 Patients With Walled-off Pancreatic Necrosis Ji Young Bang*, C. Mel Wilcox, John D. Christein, Muhammad Hasan, Pablo J. Arnoletti, Sebastian De La Fuente, Robert Hawes, Shyam Varadarajulu Center for Interventional Endoscopy, Florida Hospital, Orlando, FL; Gastroenterology-Hepatology, University of Alabama, Birmingham, AL; Surgery, Florida Hospital, Orlando, FL; Surgery, University of Alabama, Birmingham, AL Background: Given the high morbidity and procedure-related risks, endoscopic management of walled-off pancreatic necrosis (WOPN) remains a therapeutic challenge. Aim: To evaluate the clinical outcomes of 100 consecutive patients undergoing endoscopic management of WOPN over a 10-year period. Methods: This is a retrospective study of 100 patients (Median age 53 yrs, Male 63%) with WOPN treated endoscopically over 10 years from 2004-2013. During the initial period (20042009), pancreatitis was categorized using the 1992 Atlanta classification, access to WOPN was first attempted by conventional transmural drainage (CTD) with EUS being reserved only for failed cases and predominant treatment was by placement of transluminal stent and drainage catheters or necrosectomy. In the later period (2010-2013), pancreatitis was categorized using the (proposed) revised Atlanta classification, access was mainly under EUS-guidance and treatment approach was more HYBRID. The HYBRID approach involves endoscopic creation of multiple internal conduits for improved drainage of necrotic contents and multidisciplinary collaboration with interventional radiologists for percutaneous placement of largebore drainage catheters and pancreatic surgeons for minimally invasive percutaneous debridement. To track outcomes in relation to time, patients were divided into two groups: Group IZ2004-2009 vs. Group IIZ2010-2013. Main outcome measures: To compare clinical outcomes between two time periods (groups) and identify predictors of treatment success in patients undergoing endoscopic management of WOPN. Treatment success was defined as resolution of WOPN without the need for open surgical necrosectomy and discharge from the hospital with favorable clinical evolution. Results: There was no significant difference in pretreatment clinical parameters or WOPN characteristics between group I (NZ47) and group II (NZ53) patients. When compared to group I, patients in group II underwent more EUS-guided drainage (63.8 vs. 96.2%, p!0.001), received more HYBRID treatment (10.6 vs. 43.4%, p!0.001) and had higher treatment success (59.6% vs. 90.6%, p!0.001). On multivariate logistic regression analysis, undertaking treatment via HYBRID approach (OR 5.72, 95% CIZ 1.25-26.2; pZ0.025) was the only factor predictive of treatment success (Figure) when adjusted for the patient/disease characteristics, size/location of WOPN, access modality (EUS vs. CTD), enteral nutrition, number of endoscopic interventions and placement of transpapillary pancreatic duct stent. Conclusions: There has been an incremental improvement in the clinical outcomes of patients with WOPN managed by endoscopy over the past 10 years with a HYBRID multidisciplinary approach being the major determinant of treatment success.
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Su1705 Secretin Endoscopic Pancreas Function Test Correlates With Pancreatic Endocrine Function Post Autologous Islet Transplantation for Refractory Chronic Pancreatitis
Gastrointestinal Endoscopy, 2014Co-Authors: Rauf Shahbazov, Morihito Takita, Luis F. Lara, Bruce M. Miller, Bashoo Naziruddin, Marlon F. Levy, James S. BurdickAbstract:Figure 2. Scatter plot of islet yield by ePFT result. Solid bar shows median and interquartile range.
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The Duodenal Aspirate Volume Does Not Correlate With the PEAK Bicarbonate Concentration During Secretin Stimulated Endoscopic Pancreas Function Testing. A Note of Caution for Secretin MRCP
Gastroenterology, 2011Co-Authors: Luis F. Lara, Morihito Takita, Marlon F. Levy, Robert D. Anderson, Damien Mallat, Steven J. Burdick, Bhavani Moparty, Shinichi Matsumoto, Daniel C. DemarcoAbstract:Background. Abnormal exocrine Function precedes most imaging changes of CP so stimulated Pancreas Function tests (PFT) are used as a surrogate for early diagnosis as histology is rarely obtained. Endoscopic PFT (ePFT) have shown promise as a less technically challenging PFT but may last one hour and require special equipment. Peak Pancreas exocrine output takes at least 30 minutes to occur after secretagogue stimulation so we tested if a shorter endoscopic aspiration could differentiate patients with and without chronic pancreatitis. Methods. Synthetic secretin 0.2 μg/kg (ChiRhoClin,Inc.,Burtonsville,MD) was administered IV, and sedation started 30 minutes afterwards. After gastric fluid aspiration the endoscope was advanced to the major papilla and four continuous duodenal aspirations were done at 5 minute intervals, starting 35 minutes after secretin administration, collected in a sealed polyp trap on ice, and delivered to the laboratory. The first four samples were analyzed by an autoanalyzer (Corning 965, USA) calibrated to a bicarbonate of 80 mEq/L and compared to pH back titration. Variance between the methods was ±0.02 mEq/L so subsequent measurements were done with the auto-analyzer only. Peak bicarbonate concentration (PBC) >80 mEq/L during any collection is normal. ERCP and EUS were compared to ePFT and all three to a final diagnosis of CP which was established by considering history, imaging, histology and ePFT. Results. Twenty seven ePFT have been performed (16 females). Indications were suspected CP (17), abdominal pain (7), steatorrhea (2), idiopathic recurrent acute pancreatitis (1). Nine patients (pts) received a final diagnosis of CP and 18 no CP. 15 pts had ERCP (two had one, 9 pts had 2, 2 pts had 3 and 2 pts had 5). Seven pts had a normal pancreatogram. Cambridge class was I in one pt, II in 4 pts, III in 2 pts and IV in one pt. Two pts with Cambridge II and one with Cambridge III had normal PBC. 23 pts had EUS (21 had one, one pt had two, and one pt had 3). Ten pts had > 4 criteria for CP, and 6/10 pts had an abnormal ePFT. 13 pts had a normal EUS, and 11/13 had normal PBC (one pt had PBC 78.9 mEq/L). PBC was 80 mEq/ L in 17/18 pts without CP. The sensitivity and specificity of ePFT compared to ERCP and EUS and of all three compared to a final diagnosis of CP are in the tables. Conclusion. The ePFT was as good as EUS and ERCP in predicting CP. ePFT and EUS were non-statistically superior to ERCP in ruling out CP. The final diagnosis of CP was enhanced by combining numerous tests, but this proposed shorter ePFT requires less expertise, involves routine upper endoscopy, and may be more practical for regular use. More data is needed to determine how well it predicts early chronic pancreatitis, and if results decrease the ordering of other tests when CP is suspected. Comparison of ePFT to ERCP and EUS
Luis F. Lara - One of the best experts on this subject based on the ideXlab platform.
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A study of the clinical utility of a 20-minute secretin-stimulated endoscopic Pancreas Function test and performance according to clinical variables
Gastrointestinal Endoscopy, 2017Co-Authors: Luis F. Lara, Morihito Takita, James S. Burdick, Daniel C. Demarco, Ronnie Pimentel, Tolga Erim, Marlon F. LevyAbstract:Background and Aims Direct Pancreas juice testing of bicarbonate, lipase, or trypsin after stimulation by secretin or cholecystokinin is used to determine exocrine Function, a surrogate for diagnosing chronic pancreatitis (CP). Endoscopic Pancreas Function tests (ePFTs), where a peak bicarbonate concentration (PBC) ≥80 mEq/L in Pancreas juice is considered normal, are now used more frequently. In this ePFT, aspirates start 35 minutes after secretin administration because Pancreas output peaks 30 minutes after secretagogue administration. The performance of ePFT in a cohort of patients with a presumptive diagnosis of CP referred to a Pancreas clinic for consideration of an intervention including total pancreatectomy and islet autotransplantation was studied, compared with EUS, ERCP, histology, and consensus diagnosis. The effect of sedation, narcotic use, aspirate volume, body mass index, age, and proton pump inhibitors (PPIs) on test performance is reported. Methods After a test dose, synthetic human secretin was administered intravenously, and 30 minutes later sedation was achieved with midazolam and fentanyl or propofol. A gastroscope was advanced to the major papilla where 4 continuous aspiration samples were performed at 5-minute intervals in sealed bottles. PBC ≥80 mEq/L was normal. Results Eighty-one patients had ePFTs from August 2010 through October 2015. Twenty-seven patients (33%) were diagnosed with CP. Eighteen of the 27 patients with CP and 1 of the 54 patients without CP had an abnormal ePFT, producing a sensitivity of 66% (95% CI, 46.0-83.5), specificity 98% (95% CI, 90.1-99.9), positive predictive value 94.7% (95% CI, 74-99.9), and negative predictive value 85.5% (95% CI, 74.2-93.1). ERCP and PBC concordance was generally poor, but none of the patients without CP had major EUS changes, and only 3 patients with a PBC Conclusion A 20-minute ePFT after secretin administration had a marginal sensitivity for diagnosis of CP. The diagnosis of CP should not rely on a single study and certainly not a PFT. The duodenal aspirate volume did not correlate with the PBC, which contrasts with current secretin-enhanced MRCP knowledge; therefore, further studies on this subject are warranted. Neither type of sedation, BMI, nor age affected test performance. Narcotics and PPIs may affect the PBC, so borderline results should be interpreted with caution in these groups
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Su1704 Implication of Secretin Endoscopic Pancreas Function Test for Patient Undergoing Autologous Islet Transplantation for Chronic Pancreatitis
Gastrointestinal Endoscopy, 2014Co-Authors: Morihito Takita, Rauf Shahbazov, Luis F. Lara, Bruce M. Miller, Bashoo Naziruddin, Marlon F. Levy, James S. BurdickAbstract:Su1703 Endoscopic Report Card of a 10-Year Experience in 100 Patients With Walled-off Pancreatic Necrosis Ji Young Bang*, C. Mel Wilcox, John D. Christein, Muhammad Hasan, Pablo J. Arnoletti, Sebastian De La Fuente, Robert Hawes, Shyam Varadarajulu Center for Interventional Endoscopy, Florida Hospital, Orlando, FL; Gastroenterology-Hepatology, University of Alabama, Birmingham, AL; Surgery, Florida Hospital, Orlando, FL; Surgery, University of Alabama, Birmingham, AL Background: Given the high morbidity and procedure-related risks, endoscopic management of walled-off pancreatic necrosis (WOPN) remains a therapeutic challenge. Aim: To evaluate the clinical outcomes of 100 consecutive patients undergoing endoscopic management of WOPN over a 10-year period. Methods: This is a retrospective study of 100 patients (Median age 53 yrs, Male 63%) with WOPN treated endoscopically over 10 years from 2004-2013. During the initial period (20042009), pancreatitis was categorized using the 1992 Atlanta classification, access to WOPN was first attempted by conventional transmural drainage (CTD) with EUS being reserved only for failed cases and predominant treatment was by placement of transluminal stent and drainage catheters or necrosectomy. In the later period (2010-2013), pancreatitis was categorized using the (proposed) revised Atlanta classification, access was mainly under EUS-guidance and treatment approach was more HYBRID. The HYBRID approach involves endoscopic creation of multiple internal conduits for improved drainage of necrotic contents and multidisciplinary collaboration with interventional radiologists for percutaneous placement of largebore drainage catheters and pancreatic surgeons for minimally invasive percutaneous debridement. To track outcomes in relation to time, patients were divided into two groups: Group IZ2004-2009 vs. Group IIZ2010-2013. Main outcome measures: To compare clinical outcomes between two time periods (groups) and identify predictors of treatment success in patients undergoing endoscopic management of WOPN. Treatment success was defined as resolution of WOPN without the need for open surgical necrosectomy and discharge from the hospital with favorable clinical evolution. Results: There was no significant difference in pretreatment clinical parameters or WOPN characteristics between group I (NZ47) and group II (NZ53) patients. When compared to group I, patients in group II underwent more EUS-guided drainage (63.8 vs. 96.2%, p!0.001), received more HYBRID treatment (10.6 vs. 43.4%, p!0.001) and had higher treatment success (59.6% vs. 90.6%, p!0.001). On multivariate logistic regression analysis, undertaking treatment via HYBRID approach (OR 5.72, 95% CIZ 1.25-26.2; pZ0.025) was the only factor predictive of treatment success (Figure) when adjusted for the patient/disease characteristics, size/location of WOPN, access modality (EUS vs. CTD), enteral nutrition, number of endoscopic interventions and placement of transpapillary pancreatic duct stent. Conclusions: There has been an incremental improvement in the clinical outcomes of patients with WOPN managed by endoscopy over the past 10 years with a HYBRID multidisciplinary approach being the major determinant of treatment success.
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Su1705 Secretin Endoscopic Pancreas Function Test Correlates With Pancreatic Endocrine Function Post Autologous Islet Transplantation for Refractory Chronic Pancreatitis
Gastrointestinal Endoscopy, 2014Co-Authors: Rauf Shahbazov, Morihito Takita, Luis F. Lara, Bruce M. Miller, Bashoo Naziruddin, Marlon F. Levy, James S. BurdickAbstract:Figure 2. Scatter plot of islet yield by ePFT result. Solid bar shows median and interquartile range.
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The Duodenal Aspirate Volume Does Not Correlate With the PEAK Bicarbonate Concentration During Secretin Stimulated Endoscopic Pancreas Function Testing. A Note of Caution for Secretin MRCP
Gastroenterology, 2011Co-Authors: Luis F. Lara, Morihito Takita, Marlon F. Levy, Robert D. Anderson, Damien Mallat, Steven J. Burdick, Bhavani Moparty, Shinichi Matsumoto, Daniel C. DemarcoAbstract:Background. Abnormal exocrine Function precedes most imaging changes of CP so stimulated Pancreas Function tests (PFT) are used as a surrogate for early diagnosis as histology is rarely obtained. Endoscopic PFT (ePFT) have shown promise as a less technically challenging PFT but may last one hour and require special equipment. Peak Pancreas exocrine output takes at least 30 minutes to occur after secretagogue stimulation so we tested if a shorter endoscopic aspiration could differentiate patients with and without chronic pancreatitis. Methods. Synthetic secretin 0.2 μg/kg (ChiRhoClin,Inc.,Burtonsville,MD) was administered IV, and sedation started 30 minutes afterwards. After gastric fluid aspiration the endoscope was advanced to the major papilla and four continuous duodenal aspirations were done at 5 minute intervals, starting 35 minutes after secretin administration, collected in a sealed polyp trap on ice, and delivered to the laboratory. The first four samples were analyzed by an autoanalyzer (Corning 965, USA) calibrated to a bicarbonate of 80 mEq/L and compared to pH back titration. Variance between the methods was ±0.02 mEq/L so subsequent measurements were done with the auto-analyzer only. Peak bicarbonate concentration (PBC) >80 mEq/L during any collection is normal. ERCP and EUS were compared to ePFT and all three to a final diagnosis of CP which was established by considering history, imaging, histology and ePFT. Results. Twenty seven ePFT have been performed (16 females). Indications were suspected CP (17), abdominal pain (7), steatorrhea (2), idiopathic recurrent acute pancreatitis (1). Nine patients (pts) received a final diagnosis of CP and 18 no CP. 15 pts had ERCP (two had one, 9 pts had 2, 2 pts had 3 and 2 pts had 5). Seven pts had a normal pancreatogram. Cambridge class was I in one pt, II in 4 pts, III in 2 pts and IV in one pt. Two pts with Cambridge II and one with Cambridge III had normal PBC. 23 pts had EUS (21 had one, one pt had two, and one pt had 3). Ten pts had > 4 criteria for CP, and 6/10 pts had an abnormal ePFT. 13 pts had a normal EUS, and 11/13 had normal PBC (one pt had PBC 78.9 mEq/L). PBC was 80 mEq/ L in 17/18 pts without CP. The sensitivity and specificity of ePFT compared to ERCP and EUS and of all three compared to a final diagnosis of CP are in the tables. Conclusion. The ePFT was as good as EUS and ERCP in predicting CP. ePFT and EUS were non-statistically superior to ERCP in ruling out CP. The final diagnosis of CP was enhanced by combining numerous tests, but this proposed shorter ePFT requires less expertise, involves routine upper endoscopy, and may be more practical for regular use. More data is needed to determine how well it predicts early chronic pancreatitis, and if results decrease the ordering of other tests when CP is suspected. Comparison of ePFT to ERCP and EUS
Martin T Swain - One of the best experts on this subject based on the ideXlab platform.
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transcriptomic analysis of the lesser spotted catshark scyliorhinus canicula Pancreas liver and brain reveals molecular level conservation of vertebrate Pancreas Function
BMC Genomics, 2014Co-Authors: John F Mulley, Adam D Hargreaves, Matthew J Hegarty, Scott R Heller, Martin T SwainAbstract:Understanding the evolution of the vertebrate Pancreas is key to understanding its Functions. The chondrichthyes (cartilaginous fish such as sharks and rays) have often been suggested to possess the most ancient example of a distinct Pancreas with both hormonal (endocrine) and digestive (exocrine) roles. The lack of genetic, genomic and transcriptomic data for cartilaginous fish has hindered a more thorough understanding of the molecular-level Functions of the chondrichthyan Pancreas, particularly with respect to their “unusual” energy metabolism (where ketone bodies and amino acids are the main oxidative fuel source) and their paradoxical ability to both maintain stable blood glucose levels and tolerate extensive periods of hypoglycemia. In order to shed light on some of these processes, we carried out the first large-scale comparative transcriptomic survey of multiple cartilaginous fish tissues: the Pancreas, brain and liver of the lesser spotted catshark, Scyliorhinus canicula. We generated a mutli-tissue assembly comprising 86,006 contigs, of which 44,794 were assigned to a particular tissue or combination of tissues based on mapping of sequencing reads. We have characterised transcripts encoding genes involved in insulin regulation, glucose sensing, transcriptional regulation, signaling and digestion, as well as many peptide hormone precursors and their receptors for the first time. Comparisons to mammalian Pancreas transcriptomes reveals that mechanisms of glucose sensing and insulin regulation used to establish and maintain a stable internal environment are conserved across jawed vertebrates and likely pre-date the vertebrate radiation. Conservation of pancreatic hormones and genes encoding digestive proteins support the single, early evolution of a distinct pancreatic gland with endocrine and exocrine Functions in jawed vertebrates. In addition, we demonstrate that chondrichthyes lack pancreatic polypeptide (PP) and that reports of PP in the literature are likely due cross-reaction with PYY and/or NPY in the Pancreas. A three hormone islet organ is therefore the ancestral jawed vertebrate condition, later elaborated upon only in the tetrapod lineage. The cartilaginous fish are a great untapped resource for the reconstruction of patterns and processes of vertebrate evolution and new approaches such as those described in this paper will greatly facilitate their incorporation into the rank of “model organism”.
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transcriptomic analysis of the lesser spotted catshark scyliorhinus canicula Pancreas liver and brain reveals molecular level conservation of vertebrate Pancreas Function
bioRxiv, 2014Co-Authors: John F Mulley, Adam D Hargreaves, Matthew J Hegarty, Scott R Heller, Martin T SwainAbstract:Background Understanding the evolution of the vertebrate Pancreas is key to understanding its Functions. The chondrichthyes (cartilaginous fish such as sharks and rays) have been suggested to possess the most ancient example of a distinct Pancreas with both hormonal (endocrine) and digestive (exocrine) roles, although the lack of genetic, genomic and transcriptomic data for cartilaginous fish has hindered a more thorough understanding of the molecular-level Functions of the chondrichthyan Pancreas, particularly with respect to their unusual energy metabolism (where ketone bodies and amino acids are the main oxidative fuel source) and their paradoxical ability to both maintain stable blood glucose levels and tolerate extensive periods of hypoglycemia. In order to shed light on some of these processes we have carried out the first large-scale comparative transcriptomic survey of multiple cartilaginous fish tissues: the Pancreas, brain and liver of the lesser spotted catshark, Scyliorhinus canicula. Results We generated a mutli-tissue assembly comprising 86,006 contigs, of which 44,794 were assigned to a particular tissue or combination of tissue based on mapping of sequencing reads. We have characterised transcripts encoding genes involved in insulin regulation, glucose sensing, transcriptional regulation, signaling and digestion, as well as many peptide hormone precursors and their receptors for the first time. Comparisons to published mammalian Pancreas transcriptomes reveals that mechanisms of glucose sensing and insulin regulation used to establish and maintain a stable internal environment are conserved across jawed vertebrates and likely pre-date the vertebrate radiation. Conservation of pancreatic hormones and genes encoding digestive proteins support the single, early evolution of a distinct pancreatic gland with endocrine and exocrine Functions in vertebrates, although the peptide diversity of the early vertebrate Pancreas has been overestimated as a result of the use of cross-reacting antisera in earlier studies. A three hormone islet organ is therefore the basal vertebrate condition, later elaborated upon only in the tetrapod lineage. Conclusions The cartilaginous fish are a great untapped resource for the reconstruction of patterns and processes of vertebrate evolution and new approaches such as those described in this paper will greatly facilitate their incorporation into the rank of model organism.
Morihito Takita - One of the best experts on this subject based on the ideXlab platform.
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A study of the clinical utility of a 20-minute secretin-stimulated endoscopic Pancreas Function test and performance according to clinical variables
Gastrointestinal Endoscopy, 2017Co-Authors: Luis F. Lara, Morihito Takita, James S. Burdick, Daniel C. Demarco, Ronnie Pimentel, Tolga Erim, Marlon F. LevyAbstract:Background and Aims Direct Pancreas juice testing of bicarbonate, lipase, or trypsin after stimulation by secretin or cholecystokinin is used to determine exocrine Function, a surrogate for diagnosing chronic pancreatitis (CP). Endoscopic Pancreas Function tests (ePFTs), where a peak bicarbonate concentration (PBC) ≥80 mEq/L in Pancreas juice is considered normal, are now used more frequently. In this ePFT, aspirates start 35 minutes after secretin administration because Pancreas output peaks 30 minutes after secretagogue administration. The performance of ePFT in a cohort of patients with a presumptive diagnosis of CP referred to a Pancreas clinic for consideration of an intervention including total pancreatectomy and islet autotransplantation was studied, compared with EUS, ERCP, histology, and consensus diagnosis. The effect of sedation, narcotic use, aspirate volume, body mass index, age, and proton pump inhibitors (PPIs) on test performance is reported. Methods After a test dose, synthetic human secretin was administered intravenously, and 30 minutes later sedation was achieved with midazolam and fentanyl or propofol. A gastroscope was advanced to the major papilla where 4 continuous aspiration samples were performed at 5-minute intervals in sealed bottles. PBC ≥80 mEq/L was normal. Results Eighty-one patients had ePFTs from August 2010 through October 2015. Twenty-seven patients (33%) were diagnosed with CP. Eighteen of the 27 patients with CP and 1 of the 54 patients without CP had an abnormal ePFT, producing a sensitivity of 66% (95% CI, 46.0-83.5), specificity 98% (95% CI, 90.1-99.9), positive predictive value 94.7% (95% CI, 74-99.9), and negative predictive value 85.5% (95% CI, 74.2-93.1). ERCP and PBC concordance was generally poor, but none of the patients without CP had major EUS changes, and only 3 patients with a PBC Conclusion A 20-minute ePFT after secretin administration had a marginal sensitivity for diagnosis of CP. The diagnosis of CP should not rely on a single study and certainly not a PFT. The duodenal aspirate volume did not correlate with the PBC, which contrasts with current secretin-enhanced MRCP knowledge; therefore, further studies on this subject are warranted. Neither type of sedation, BMI, nor age affected test performance. Narcotics and PPIs may affect the PBC, so borderline results should be interpreted with caution in these groups
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Su1704 Implication of Secretin Endoscopic Pancreas Function Test for Patient Undergoing Autologous Islet Transplantation for Chronic Pancreatitis
Gastrointestinal Endoscopy, 2014Co-Authors: Morihito Takita, Rauf Shahbazov, Luis F. Lara, Bruce M. Miller, Bashoo Naziruddin, Marlon F. Levy, James S. BurdickAbstract:Su1703 Endoscopic Report Card of a 10-Year Experience in 100 Patients With Walled-off Pancreatic Necrosis Ji Young Bang*, C. Mel Wilcox, John D. Christein, Muhammad Hasan, Pablo J. Arnoletti, Sebastian De La Fuente, Robert Hawes, Shyam Varadarajulu Center for Interventional Endoscopy, Florida Hospital, Orlando, FL; Gastroenterology-Hepatology, University of Alabama, Birmingham, AL; Surgery, Florida Hospital, Orlando, FL; Surgery, University of Alabama, Birmingham, AL Background: Given the high morbidity and procedure-related risks, endoscopic management of walled-off pancreatic necrosis (WOPN) remains a therapeutic challenge. Aim: To evaluate the clinical outcomes of 100 consecutive patients undergoing endoscopic management of WOPN over a 10-year period. Methods: This is a retrospective study of 100 patients (Median age 53 yrs, Male 63%) with WOPN treated endoscopically over 10 years from 2004-2013. During the initial period (20042009), pancreatitis was categorized using the 1992 Atlanta classification, access to WOPN was first attempted by conventional transmural drainage (CTD) with EUS being reserved only for failed cases and predominant treatment was by placement of transluminal stent and drainage catheters or necrosectomy. In the later period (2010-2013), pancreatitis was categorized using the (proposed) revised Atlanta classification, access was mainly under EUS-guidance and treatment approach was more HYBRID. The HYBRID approach involves endoscopic creation of multiple internal conduits for improved drainage of necrotic contents and multidisciplinary collaboration with interventional radiologists for percutaneous placement of largebore drainage catheters and pancreatic surgeons for minimally invasive percutaneous debridement. To track outcomes in relation to time, patients were divided into two groups: Group IZ2004-2009 vs. Group IIZ2010-2013. Main outcome measures: To compare clinical outcomes between two time periods (groups) and identify predictors of treatment success in patients undergoing endoscopic management of WOPN. Treatment success was defined as resolution of WOPN without the need for open surgical necrosectomy and discharge from the hospital with favorable clinical evolution. Results: There was no significant difference in pretreatment clinical parameters or WOPN characteristics between group I (NZ47) and group II (NZ53) patients. When compared to group I, patients in group II underwent more EUS-guided drainage (63.8 vs. 96.2%, p!0.001), received more HYBRID treatment (10.6 vs. 43.4%, p!0.001) and had higher treatment success (59.6% vs. 90.6%, p!0.001). On multivariate logistic regression analysis, undertaking treatment via HYBRID approach (OR 5.72, 95% CIZ 1.25-26.2; pZ0.025) was the only factor predictive of treatment success (Figure) when adjusted for the patient/disease characteristics, size/location of WOPN, access modality (EUS vs. CTD), enteral nutrition, number of endoscopic interventions and placement of transpapillary pancreatic duct stent. Conclusions: There has been an incremental improvement in the clinical outcomes of patients with WOPN managed by endoscopy over the past 10 years with a HYBRID multidisciplinary approach being the major determinant of treatment success.
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Su1705 Secretin Endoscopic Pancreas Function Test Correlates With Pancreatic Endocrine Function Post Autologous Islet Transplantation for Refractory Chronic Pancreatitis
Gastrointestinal Endoscopy, 2014Co-Authors: Rauf Shahbazov, Morihito Takita, Luis F. Lara, Bruce M. Miller, Bashoo Naziruddin, Marlon F. Levy, James S. BurdickAbstract:Figure 2. Scatter plot of islet yield by ePFT result. Solid bar shows median and interquartile range.
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The Duodenal Aspirate Volume Does Not Correlate With the PEAK Bicarbonate Concentration During Secretin Stimulated Endoscopic Pancreas Function Testing. A Note of Caution for Secretin MRCP
Gastroenterology, 2011Co-Authors: Luis F. Lara, Morihito Takita, Marlon F. Levy, Robert D. Anderson, Damien Mallat, Steven J. Burdick, Bhavani Moparty, Shinichi Matsumoto, Daniel C. DemarcoAbstract:Background. Abnormal exocrine Function precedes most imaging changes of CP so stimulated Pancreas Function tests (PFT) are used as a surrogate for early diagnosis as histology is rarely obtained. Endoscopic PFT (ePFT) have shown promise as a less technically challenging PFT but may last one hour and require special equipment. Peak Pancreas exocrine output takes at least 30 minutes to occur after secretagogue stimulation so we tested if a shorter endoscopic aspiration could differentiate patients with and without chronic pancreatitis. Methods. Synthetic secretin 0.2 μg/kg (ChiRhoClin,Inc.,Burtonsville,MD) was administered IV, and sedation started 30 minutes afterwards. After gastric fluid aspiration the endoscope was advanced to the major papilla and four continuous duodenal aspirations were done at 5 minute intervals, starting 35 minutes after secretin administration, collected in a sealed polyp trap on ice, and delivered to the laboratory. The first four samples were analyzed by an autoanalyzer (Corning 965, USA) calibrated to a bicarbonate of 80 mEq/L and compared to pH back titration. Variance between the methods was ±0.02 mEq/L so subsequent measurements were done with the auto-analyzer only. Peak bicarbonate concentration (PBC) >80 mEq/L during any collection is normal. ERCP and EUS were compared to ePFT and all three to a final diagnosis of CP which was established by considering history, imaging, histology and ePFT. Results. Twenty seven ePFT have been performed (16 females). Indications were suspected CP (17), abdominal pain (7), steatorrhea (2), idiopathic recurrent acute pancreatitis (1). Nine patients (pts) received a final diagnosis of CP and 18 no CP. 15 pts had ERCP (two had one, 9 pts had 2, 2 pts had 3 and 2 pts had 5). Seven pts had a normal pancreatogram. Cambridge class was I in one pt, II in 4 pts, III in 2 pts and IV in one pt. Two pts with Cambridge II and one with Cambridge III had normal PBC. 23 pts had EUS (21 had one, one pt had two, and one pt had 3). Ten pts had > 4 criteria for CP, and 6/10 pts had an abnormal ePFT. 13 pts had a normal EUS, and 11/13 had normal PBC (one pt had PBC 78.9 mEq/L). PBC was 80 mEq/ L in 17/18 pts without CP. The sensitivity and specificity of ePFT compared to ERCP and EUS and of all three compared to a final diagnosis of CP are in the tables. Conclusion. The ePFT was as good as EUS and ERCP in predicting CP. ePFT and EUS were non-statistically superior to ERCP in ruling out CP. The final diagnosis of CP was enhanced by combining numerous tests, but this proposed shorter ePFT requires less expertise, involves routine upper endoscopy, and may be more practical for regular use. More data is needed to determine how well it predicts early chronic pancreatitis, and if results decrease the ordering of other tests when CP is suspected. Comparison of ePFT to ERCP and EUS
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A study of the clinical utility of a 20-minute secretin-stimulated endoscopic Pancreas Function test and performance according to clinical variables
Gastrointestinal Endoscopy, 2017Co-Authors: Luis F. Lara, Morihito Takita, James S. Burdick, Daniel C. Demarco, Ronnie Pimentel, Tolga Erim, Marlon F. LevyAbstract:Background and Aims Direct Pancreas juice testing of bicarbonate, lipase, or trypsin after stimulation by secretin or cholecystokinin is used to determine exocrine Function, a surrogate for diagnosing chronic pancreatitis (CP). Endoscopic Pancreas Function tests (ePFTs), where a peak bicarbonate concentration (PBC) ≥80 mEq/L in Pancreas juice is considered normal, are now used more frequently. In this ePFT, aspirates start 35 minutes after secretin administration because Pancreas output peaks 30 minutes after secretagogue administration. The performance of ePFT in a cohort of patients with a presumptive diagnosis of CP referred to a Pancreas clinic for consideration of an intervention including total pancreatectomy and islet autotransplantation was studied, compared with EUS, ERCP, histology, and consensus diagnosis. The effect of sedation, narcotic use, aspirate volume, body mass index, age, and proton pump inhibitors (PPIs) on test performance is reported. Methods After a test dose, synthetic human secretin was administered intravenously, and 30 minutes later sedation was achieved with midazolam and fentanyl or propofol. A gastroscope was advanced to the major papilla where 4 continuous aspiration samples were performed at 5-minute intervals in sealed bottles. PBC ≥80 mEq/L was normal. Results Eighty-one patients had ePFTs from August 2010 through October 2015. Twenty-seven patients (33%) were diagnosed with CP. Eighteen of the 27 patients with CP and 1 of the 54 patients without CP had an abnormal ePFT, producing a sensitivity of 66% (95% CI, 46.0-83.5), specificity 98% (95% CI, 90.1-99.9), positive predictive value 94.7% (95% CI, 74-99.9), and negative predictive value 85.5% (95% CI, 74.2-93.1). ERCP and PBC concordance was generally poor, but none of the patients without CP had major EUS changes, and only 3 patients with a PBC Conclusion A 20-minute ePFT after secretin administration had a marginal sensitivity for diagnosis of CP. The diagnosis of CP should not rely on a single study and certainly not a PFT. The duodenal aspirate volume did not correlate with the PBC, which contrasts with current secretin-enhanced MRCP knowledge; therefore, further studies on this subject are warranted. Neither type of sedation, BMI, nor age affected test performance. Narcotics and PPIs may affect the PBC, so borderline results should be interpreted with caution in these groups
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Su1704 Implication of Secretin Endoscopic Pancreas Function Test for Patient Undergoing Autologous Islet Transplantation for Chronic Pancreatitis
Gastrointestinal Endoscopy, 2014Co-Authors: Morihito Takita, Rauf Shahbazov, Luis F. Lara, Bruce M. Miller, Bashoo Naziruddin, Marlon F. Levy, James S. BurdickAbstract:Su1703 Endoscopic Report Card of a 10-Year Experience in 100 Patients With Walled-off Pancreatic Necrosis Ji Young Bang*, C. Mel Wilcox, John D. Christein, Muhammad Hasan, Pablo J. Arnoletti, Sebastian De La Fuente, Robert Hawes, Shyam Varadarajulu Center for Interventional Endoscopy, Florida Hospital, Orlando, FL; Gastroenterology-Hepatology, University of Alabama, Birmingham, AL; Surgery, Florida Hospital, Orlando, FL; Surgery, University of Alabama, Birmingham, AL Background: Given the high morbidity and procedure-related risks, endoscopic management of walled-off pancreatic necrosis (WOPN) remains a therapeutic challenge. Aim: To evaluate the clinical outcomes of 100 consecutive patients undergoing endoscopic management of WOPN over a 10-year period. Methods: This is a retrospective study of 100 patients (Median age 53 yrs, Male 63%) with WOPN treated endoscopically over 10 years from 2004-2013. During the initial period (20042009), pancreatitis was categorized using the 1992 Atlanta classification, access to WOPN was first attempted by conventional transmural drainage (CTD) with EUS being reserved only for failed cases and predominant treatment was by placement of transluminal stent and drainage catheters or necrosectomy. In the later period (2010-2013), pancreatitis was categorized using the (proposed) revised Atlanta classification, access was mainly under EUS-guidance and treatment approach was more HYBRID. The HYBRID approach involves endoscopic creation of multiple internal conduits for improved drainage of necrotic contents and multidisciplinary collaboration with interventional radiologists for percutaneous placement of largebore drainage catheters and pancreatic surgeons for minimally invasive percutaneous debridement. To track outcomes in relation to time, patients were divided into two groups: Group IZ2004-2009 vs. Group IIZ2010-2013. Main outcome measures: To compare clinical outcomes between two time periods (groups) and identify predictors of treatment success in patients undergoing endoscopic management of WOPN. Treatment success was defined as resolution of WOPN without the need for open surgical necrosectomy and discharge from the hospital with favorable clinical evolution. Results: There was no significant difference in pretreatment clinical parameters or WOPN characteristics between group I (NZ47) and group II (NZ53) patients. When compared to group I, patients in group II underwent more EUS-guided drainage (63.8 vs. 96.2%, p!0.001), received more HYBRID treatment (10.6 vs. 43.4%, p!0.001) and had higher treatment success (59.6% vs. 90.6%, p!0.001). On multivariate logistic regression analysis, undertaking treatment via HYBRID approach (OR 5.72, 95% CIZ 1.25-26.2; pZ0.025) was the only factor predictive of treatment success (Figure) when adjusted for the patient/disease characteristics, size/location of WOPN, access modality (EUS vs. CTD), enteral nutrition, number of endoscopic interventions and placement of transpapillary pancreatic duct stent. Conclusions: There has been an incremental improvement in the clinical outcomes of patients with WOPN managed by endoscopy over the past 10 years with a HYBRID multidisciplinary approach being the major determinant of treatment success.
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Su1705 Secretin Endoscopic Pancreas Function Test Correlates With Pancreatic Endocrine Function Post Autologous Islet Transplantation for Refractory Chronic Pancreatitis
Gastrointestinal Endoscopy, 2014Co-Authors: Rauf Shahbazov, Morihito Takita, Luis F. Lara, Bruce M. Miller, Bashoo Naziruddin, Marlon F. Levy, James S. BurdickAbstract:Figure 2. Scatter plot of islet yield by ePFT result. Solid bar shows median and interquartile range.
