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Bofill-Garcia A, Lupianez-Merly C. Endoscopic Retrograde Cholangiopancreatography for Management of Chronic Pancreatitis. Gastrointest Endosc Clin N Am 2024; 34:449-473. [PMID: 38796292 DOI: 10.1016/j.giec.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
Management of symptomatic chronic pancreatitis (CP) has shifted its approach from surgical procedures to minimally invasive endoscopic procedures. Increased experience and advanced technology have led to the use of endoscopic retrograde cholangiopancreatography (ERCP) as a therapeutic tool to provide pain relief and treat CP complications including pancreatic stones, strictures, and distal biliary strictures, pseudocysts, and pancreatic duct fistulas. In this article the authors will discuss the use of ERCP for the management of CP, its complications, recent advancements, and techniques from the most up to date literature available.
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Affiliation(s)
- Aliana Bofill-Garcia
- Department of Gastroenterology and Hepatology, Mayo Clinic Rochester, 200 First Street Southwest, Rochester, MN 55905, USA.
| | - Camille Lupianez-Merly
- Department of Gastroenterology and Hepatology, Mayo Clinic Rochester, 200 First Street Southwest, Rochester, MN 55905, USA
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Han S, Keswani RN, Hall M, Wani S. Limited exposure to pancreatic ERCP during advanced endoscopy training impacts competence and performance in independent practice. Pancreatology 2024; 24:184-187. [PMID: 38176963 DOI: 10.1016/j.pan.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 12/04/2023] [Accepted: 12/26/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND/OBJECTIVES The impact of competency-based training programs on pancreatic endoscopic retrograde cholangiopancreatography (ERCP) performance remains unclear. This study aimed to describe the learning curves of pancreatic ERCP and subsequent performance during independent practice. METHODS This was a multicenter prospective cohort study involving advanced endoscopy trainees (AETs). In the 1st phase, trainees were assessed on every 5th ERCP using the ERCP and EUS Skills Assessment Tool (TEESAT). Cumulative sum (CUSUM) analysis of pancreatic ERCP evaluations was used to establish learning curves. During the 2nd phase (1st year of independent practice), now-graduated participants documented their performance on key ERCP quality indicators. RESULTS A total of 24 AETs (20 training programs) received sufficient evaluations for CUSUM analysis. Pancreatic ERCP accounted for 14.6 % (196/1339) of all ERCPs evaluated with 45 % of pancreatic ERCPs carrying a Grade 3 level of complexity. A minority of AETs (16.7 %) performed enough pancreatic ERCPs to generate meaningful learning curves with no AETs achieving competence in pancreatic cannulation, sphincterotomy, or stone clearance during Phase 1. In Phase 2, a total of 3620 ERCPs were performed, of which 281 (7.8 %) were pancreatic ERCPs. While the overall pancreatic duct cannulation rate was 92.2 %, the native papilla pancreatic duct cannulation rate was 85.7 %, which was below the recommended 90 % threshold. CONCLUSIONS Advanced endoscopy training offers a low level of exposure to pancreatic ERCP, which is mirrored in independent practice, highlighting the inadequate training in pancreatic ERCP. Given the complexity of pancreatic ERCP, novel strategies are warranted to improve training in pancreatic ERCP.
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Affiliation(s)
- Samuel Han
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Rajesh N Keswani
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL, USA
| | - Matt Hall
- Biostatistics, Children's Hospital Association, Overland Park, KS, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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Park J, Han K, Kwon JH, Kim MD, Won JY, Moon S, Kim GM. Feasibility of Percutaneous Pancreatic Stent Placement in Postoperative Pancreaticojejunostomy Stenosis. Korean J Radiol 2023; 24:1241-1248. [PMID: 38016683 DOI: 10.3348/kjr.2023.0459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 07/28/2023] [Accepted: 08/27/2023] [Indexed: 11/30/2023] Open
Abstract
OBJECTIVE To evaluate the role of percutaneous pancreatic stent placement in postoperative pancreaticojejunostomy stenosis (PJS). MATERIALS AND METHODS This retrospective single-center study included seven procedures in five patients (four males and one female; median age, 63 years) who underwent percutaneous pancreatic stent placement for postoperative PJS between January 2005 and December 2021. The patients were referred to interventional radiology because of unfavorable anatomy or bowel abnormalities. The pancreatic duct was accessed under ultrasound and/or computed tomography guidance. A stent was placed after balloon dilatation of the PJS. Moreover, plastic stents were placed for the first two procedures, whereas bare-metal stents were used for the remaining five procedures. Technical success was defined as the successful placement of stents for the PJS, meanwhile, clinical success was defined as the normalization of pancreatic enzymes without recurrence of pancreatitis. RESULTS Pancreatic duct access and stent placement were successfully performed in all patients (technical success rate: 100%). All the procedures initially yielded clinical success. However, recurrence of pancreatitis was observed after two procedures that used plastic stents because of stent migration at 0.3 and 3 months after the procedure. In contrast, no instances of recurrent pancreatitis were noted after metal stent placement for a follow-up duration of 1-36 months. No serious procedure-related adverse events were observed. CONCLUSION Percutaneous pancreatic stent placement may be a viable option for patients with postoperative PJS in whom an endoscopic approach is not feasible. Metal stents may be considered over plastic stents for the management of PJS, considering the possible lower stent migration and infeasibility of frequent endoscopic stent exchange due to the altered anatomy.
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Affiliation(s)
- Juil Park
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kichang Han
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Joon Ho Kwon
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Man-Deuk Kim
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Yun Won
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sungmo Moon
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Gyoung Min Kim
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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Nelson AC, Bhogadi SK, Hosseinpour H, Stewart C, Anand T, Spencer AL, Colosimo C, Magnotti LJ, Joseph B. There Is No Such Thing as Too Soon: Long-Term Outcomes of Early Cholecystectomy for Frail Geriatric Patients with Acute Biliary Pancreatitis. J Am Coll Surg 2023; 237:712-718. [PMID: 37350474 DOI: 10.1097/xcs.0000000000000790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
BACKGROUND Early cholecystectomy (CCY) for acute biliary pancreatitis (ABP) is recommended but there is a paucity of data assessing this approach in frail geriatric patients. This study compares outcomes of frail geriatric ABP patients undergoing index admission CCY vs nonoperative management (NOM) with endoscopic retrograde cholangiopancreatography (ERCP). STUDY DESIGN Retrospective analysis of the Nationwide Readmissions Database (2017). All frail geriatric (65 years or older) patients with ABP were included. Patients were grouped by treatment at index admission: CCY vs NOM with endoscopic retrograde cholangiopancreatography. Propensity score matching was performed in a 1:2 ratio. Primary outcomes were 6-month readmissions, mortality, and length of stay. Secondary outcomes were 6-month failure of NOM defined as readmission for recurrent ABP, unplanned pancreas-related procedures, or unplanned CCY. Subanalysis was performed to compare outcomes of unplanned CCY vs early CCY. RESULTS A total of 29,130 frail geriatric patients with ABP were identified and 7,941 were matched (CCY 5,294; NOM 2,647). Patients in the CCY group had lower 6-month rates of readmission for pancreas-related complications, unplanned readmissions for pancreas-related procedures, overall readmissions, and mortality, as well as fewer hospitalized days (p < 0.05). NOM failed in 12% of patients and 7% of NOM patients were readmitted within 6 months to undergo CCY, of which 56% were unplanned. Patients who underwent unplanned CCY had higher complication rates and hospital costs, longer hospital lengths of stay, and increased mortality compared with early CCY (p < 0.05). CONCLUSIONS For frail geriatric patients with ABP, early CCY was associated with lower 6-month rates of complications, readmissions, mortality, and fewer hospitalized days. NOM was unsuccessful in nearly 1 of 7 within 6 months; of these, one-third required unplanned CCY. Early CCY should be prioritized for frail geriatric ABP patients when feasible.
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Affiliation(s)
- Adam C Nelson
- From the Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ
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Cui Y, Kozarek RA. Evolution of Pancreatic Endotherapy. Gastrointest Endosc Clin N Am 2023; 33:679-700. [PMID: 37709404 DOI: 10.1016/j.giec.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
In the last half century, endotherapy for pancreatic diseases has changed considerably. Although endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) were introduced initially as diagnostic tools, they quickly evolved into therapeutic tools for preventing and managing complications of pancreatitis. More recently, therapeutic endoscopy has shown potential in palliation and cure of pancreatic neoplasms. This article discusses the changing landscape of pancreatic endotherapy as therapeutic ERCP and EUS were introduced and because they have evolved to treat different diseases.
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Affiliation(s)
- YongYan Cui
- Department of Gastroenterology, Virginia Mason Medical Center
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Rivas A, Pherwani S, Mohamed R, Smith ZL, Elmunzer BJ, Forbes N. ERCP-related adverse events: incidence, mechanisms, risk factors, prevention, and management. Expert Rev Gastroenterol Hepatol 2023; 17:1101-1116. [PMID: 37899490 DOI: 10.1080/17474124.2023.2277776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/27/2023] [Indexed: 10/31/2023]
Abstract
INTRODUCTION Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly performed procedure for pancreaticobiliary disease. While ERCP is highly effective, it is also associated with the highest adverse event (AE) rates of all commonly performed endoscopic procedures. Thus, it is critical that endoscopists and caregivers of patients undergoing ERCP have clear understandings of ERCP-related AEs. AREAS COVERED This narrative review provides a comprehensive overview of the available evidence on ERCP-related AEs. For the purposes of this review, we subdivide the presentation of each ERCP-related AE according to the following clinically relevant domains: definitions and incidence, proposed mechanisms, risk factors, prevention, and recognition and management. The evidence informing this review was derived in part from a search of the electronic databases PubMed, Embase, and Cochrane, performed on 1 May 20231 May 2023. EXPERT OPINION Knowledge of ERCP-related AEs is critical not only given potential improvements in peri-procedural quality and related care that can ensue but also given the importance of reviewing these considerations with patients during informed consent. The ERCP community and researchers should aim to apply standardized definitions of AEs. Evidence-based knowledge of ERCP risk factors should inform patient care decisions during training and beyond.
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Affiliation(s)
- Angelica Rivas
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Simran Pherwani
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rachid Mohamed
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Zachary L Smith
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Nauzer Forbes
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Forbes N, Elmunzer BJ, Allain T, Parkins MD, Sheth PM, Waddell BJ, Du K, Douchant K, Oladipo O, Saleem A, Cartwright S, Chau M, Howarth M, McKay J, Nashad T, Ruan Y, Bishay K, Gonzalez-Moreno E, Meng ZW, Bass S, Bechara R, Cole MJ, Jalink DW, Mohamed R, Turbide C, Belletrutti PJ, Kayal A, Kumar PR, Hilsden RJ, Buret AG, Hookey L, Heitman SJ. Effect of Disposable Elevator Cap Duodenoscopes on Persistent Microbial Contamination and Technical Performance of Endoscopic Retrograde Cholangiopancreatography: The ICECAP Randomized Clinical Trial. JAMA Intern Med 2023; 183:191-200. [PMID: 36689215 PMCID: PMC9871945 DOI: 10.1001/jamainternmed.2022.6394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 11/23/2022] [Indexed: 01/24/2023]
Abstract
Importance Infection transmission following endoscopic retrograde cholangiopancreatography (ERCP) can occur due to persistent contamination of duodenoscopes despite high-level disinfection to completely eliminate microorganisms on the instrument. Objective To determine (1) contamination rates after high-level disinfection and (2) technical performance of duodenoscopes with disposable elevator caps compared with those with standard designs. Design, Setting, and Participants In this parallel-arm multicenter randomized clinical trial at 2 tertiary ERCP centers in Canada, all patients 18 years and older and undergoing ERCP for any indication were eligible. Intervention The intervention was use of duodenoscopes with disposable elevator caps compared with duodenoscopes with a standard design. Main Outcomes and Measures Coprimary outcomes were persistent microbial contamination of the duodenoscope elevator or channel, defined as growth of at least 10 colony-forming units of any organism or any growth of gram-negative bacteria following high-level disinfection (superiority outcome), and technical success of ERCP according to a priori criteria (noninferiority outcome with an a priori noninferiority margin of 7%), assessed by blinded reviewers. Results From December 2019 to February 2022, 518 patients were enrolled (259 disposable elevator cap duodenoscopes, 259 standard duodenoscopes). Patients had a mean (SD) age of 60.7 (17.0) years and 258 (49.8%) were female. No significant differences were observed between study groups, including in ERCP difficulty. Persistent microbial contamination was detected in 11.2% (24 of 214) of standard duodenoscopes and 3.8% (8 of 208) of disposable elevator cap duodenoscopes (P = .004), corresponding to a relative risk of 0.34 (95% CI, 0.16-0.75) and number needed to treat of 13.6 (95% CI, 8.1-42.7) to avoid persistent contamination. Technical success using the disposable cap scope was noninferior to that of the standard scope (94.6% vs 90.7%, P = .13). There were no differences between study groups in adverse events and other secondary outcomes. Conclusions and Relevance In this randomized clinical trial, disposable elevator cap duodenoscopes exhibited reduced contamination following high-level disinfection compared with standard scope designs, without affecting the technical performance and safety of ERCP. Trial Registration ClinicalTrials.gov Identifier: NCT04040504.
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Affiliation(s)
- Nauzer Forbes
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - B. Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston
| | - Thibault Allain
- Department of Biological Science, University of Calgary, Calgary, Alberta, Canada
| | - Michael D. Parkins
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
- Division of Infectious Diseases, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Prameet M. Sheth
- Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, Ontario, Canada
- Department of Pathology and Molecular Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Barbara J. Waddell
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Kristine Du
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Katya Douchant
- Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Olajumoke Oladipo
- Department of Translational Medicine, Queen’s University, Kingston, Ontario, Canada
| | - April Saleem
- Department of Pathology and Molecular Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Shane Cartwright
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Millie Chau
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Megan Howarth
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jackie McKay
- Department of Cancer Epidemiology and Prevention Research, Cancer Care Alberta, Alberta Health Services, Calgary, Alberta, Canada
| | - Tamim Nashad
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Yibing Ruan
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Cancer Epidemiology and Prevention Research, Cancer Care Alberta, Alberta Health Services, Calgary, Alberta, Canada
| | - Kirles Bishay
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Emmanuel Gonzalez-Moreno
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Zhao Wu Meng
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sydney Bass
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert Bechara
- Division of Gastroenterology, Department of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Martin J. Cole
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Rachid Mohamed
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christian Turbide
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul J. Belletrutti
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ahmed Kayal
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Puja R. Kumar
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert J. Hilsden
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - André G. Buret
- Department of Biological Science, University of Calgary, Calgary, Alberta, Canada
| | - Lawrence Hookey
- Division of Gastroenterology, Department of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Steven J. Heitman
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Bouça-Machado T, Bouwense SAW, Brand M, Demir IE, Frøkjær JB, Garg P, Hegyi P, Löhr JM, de-Madaria E, Olesen SS, Pandanaboyana S, Pedersen JB, Rebours V, Sheel A, Singh V, Smith M, Windsor JA, Yadav D, Drewes AM. Position statement on the definition, incidence, diagnosis and outcome of acute on chronic pancreatitis. Pancreatology 2023; 23:143-150. [PMID: 36746714 DOI: 10.1016/j.pan.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 01/09/2023] [Accepted: 01/23/2023] [Indexed: 02/08/2023]
Abstract
BACKGROUND Acute on chronic pancreatitis (ACP) is a relatively common condition, but there are significant gaps in our knowledge on the definition, incidence, diagnosis, treatment and prognosis. METHODS A systematic review that followed PICO (Population; Intervention; Comparator; Outcome) recommendation for quantitative questions and PICo (Population, Phenomenon of Interest, Context) for qualitative research was done to answer 10 of the most relevant questions about ACP. Quality of evidence was judged by the GRADE criteria (Grades of Recommendation, Assessment, Development and Evaluation). The manuscript was sent for review to 12 international experts from various disciplines and continents using a Delphi process. RESULTS The quality of evidence, for most statements, was low to very low, which means that the recommendations in general are only conditional. Despite that, it was possible to reach strong levels of agreement by the expert panel for all 10 questions. A new consensus definition of ACP was reached. Although common, the real incidence of ACP is not known, with alcohol as a major risk factor. Although pain dominates, other non-specific symptoms and signs can be present. Serum levels of pancreatic enzymes may be less than 3 times the upper limit of normal and cross-sectional imaging is considered more accurate for the diagnosis in many cases. It appears that it is less severe and with a lower mortality risk than acute pancreatitis. CONCLUSIONS Although the evidence base is poor, this position statement provides a foundation from which to advance management of ACP.
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Affiliation(s)
| | - Stefan A W Bouwense
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Martin Brand
- Department of Surgery, University of Pretoria, Pretoria, South Africa
| | - Ihsan Ekin Demir
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | | | - Pramod Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Péter Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary. Centre for Translational Medicine, Division of Pancreatic Diseases, Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
| | - J-Matthias Löhr
- Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Enrique de-Madaria
- Gastroenterology Department, Dr. Balmis General University Hospital, ISABIAL, Alicante, Spain
| | - Søren Schou Olesen
- Mech-Sense & Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Jan Bech Pedersen
- Department of Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Vinciane Rebours
- Pancreatology Department and Digestive Oncology, Beaujon Hospital, AP-HP, Clichy, Paris-Cité University, Paris, France
| | - Andrea Sheel
- Institute of Translational Medicine, University of Liverpool, United Kingdom
| | - Vikesh Singh
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Martin Smith
- Department of Surgery, Chris Hani Baragwanath Academic Hospital, Johannesburg, Gauteng, South Africa
| | - John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh and UPMC, Pittsburgh, PA, USA
| | - Asbjørn Mohr Drewes
- Mech-Sense & Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.
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Per-oral pancreatoscopy-guided lithotripsy vs. extracorporeal shock wave lithotripsy for treating refractory main pancreatic duct stones in chronic pancreatitis: Protocol for an open-label multi-center randomized clinical trial. Pancreatology 2022; 22:1120-1125. [PMID: 36273991 DOI: 10.1016/j.pan.2022.09.245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 08/26/2022] [Accepted: 09/29/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUNDS/OBJECTIVES Patients with chronic pancreatitis may develop pancreatic duct stones that can obstruct outflow leading to ductal hypertension and pain. Both endoscopic retrograde pancreatography (ERP) with per-oral pancreatoscopy (POP) and intraductal lithotripsy and extracorporeal shock wave lithotripsy (ESWL) are feasible options to attempt ductal stone clearance. This study aims to compare POP-guided lithotripsy with ESWL in the management of refractory symptomatic main pancreatic duct stones. METHODS This is an open-label, multi-center, parallel, randomized clinical trial. Patients with chronic pancreatitis and main pancreatic duct stones ≥5 mm who fail standard ERP methods for stone removal will be eligible for this study. In total, 150 subjects will be randomized 1:1 to either ESWL or POP. A maximum of 4 sessions of either ESWL or POP will be allowed in each arm, with crossover permitted thereafter. The primary outcome is complete stone clearance and secondary outcomes include quality of life, pain scores, number of interventions, and daily opiate requirements. CONCLUSIONS This study aims to answer the question of which lithotripsy method is superior in removing refractory pancreatic duct stones while addressing the effects of lithotripsy on quality of life and pain in patients with chronic calcific pancreatitis (ClinicalTrials.gov NCT04115826).
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10
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Strand DS, Law RJ, Yang D, Elmunzer BJ. AGA Clinical Practice Update on the Endoscopic Approach to Recurrent Acute and Chronic Pancreatitis: Expert Review. Gastroenterology 2022; 163:1107-1114. [PMID: 36008176 DOI: 10.1053/j.gastro.2022.07.079] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/08/2022] [Accepted: 07/01/2022] [Indexed: 02/07/2023]
Abstract
DESCRIPTION The purpose of this American Gastroenterological Association (AGA) Clinical Practice Update Expert Review is to provide practical, evidence-based guidance to clinicians regarding the role of endoscopy for recurrent acute and chronic pancreatitis. METHODS This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide guidance on a topic of clinical importance to the AGA membership, underwent internal peer review by the Clinical Practice Updates Committee (CPUC), and external peer review through standard procedures of Gastroenterology. This review is framed around the 8 best practice advice points agreed upon by the authors, based on the results of randomized controlled trials, observational studies, systematic reviews and meta-analyses, as well expert consensus in this field. Best Practice Advice Statements BEST PRACTICE ADVICE 1: After an unrevealing initial evaluation, endoscopic ultrasound is the preferred diagnostic test for unexplained acute and recurrent pancreatitis. Magnetic resonance imaging with contrast and cholangiopancreatography is a reasonable complementary or alternative test to endoscopic ultrasound, based on local expertise and availability. BEST PRACTICE ADVICE 2: The role of endoscopic retrograde cholangiopancreatography (ERCP) for reducing the frequency of acute pancreatitis episodes in patients with pancreas divisum is controversial, but minor papilla endotherapy may be considered, particularly for those with objective signs of outflow obstruction, such as a dilated dorsal pancreatic duct and/or santorinicele. There is no role for ERCP to treat pain alone in patients with pancreas divisum. BEST PRACTICE ADVICE 3: The role of ERCP for reducing the frequency of pancreatitis episodes in patients with unexplained recurrent acute pancreatitis and standard pancreatic ductal anatomy is controversial and should only be considered after a comprehensive discussion of the uncertain benefits and potentially severe procedure-related adverse events. When pursued, ERCP with biliary sphincterotomy alone may be preferable to dual sphincterotomy. BEST PRACTICE ADVICE 4: Surgical intervention should be considered over endoscopic therapy for long-term treatment of patients with painful obstructive chronic pancreatitis. Endoscopic intervention is a reasonable alternative to surgery for suboptimal operative candidates or those who favor a less invasive approach, assuming they are clearly informed that the best practice advice primarily favors surgery. BEST PRACTICE ADVICE 5: When ERCP is pursued, small (≤5mm) main pancreatic duct stones can be treated with pancreatography and conventional stone extraction maneuvers. For larger stones, extracorporeal shockwave lithotripsy and/or pancreatoscopy with intraductal lithotripsy may be required. BEST PRACTICE ADVICE 6: When ERCP is pursued, prolonged stent therapy (6-12 months) is effective for treating symptoms and remodeling main pancreatic duct strictures. The preferred approach is to place and sequentially add multiple plastic stents in parallel (upsizing); emerging evidence suggests that fully covered self-expanding metal stents may have a role for this indication, but additional research is necessary. BEST PRACTICE ADVICE 7: ERCP with stent insertion is the preferred treatment for benign biliary stricture due to chronic pancreatitis. FCSEMS placement is favored over multiple plastic stents whenever feasible, given similar efficacy but significantly reduced need for stent exchange procedures during the treatment course. BEST PRACTICE ADVICE 8: Celiac plexus block should not be routinely performed for the management of pain due to chronic pancreatitis. The decision to proceed with celiac plexus block in selected patients with debilitating pain in whom other therapeutic measures have failed can be considered on a case-by-case basis, but only after discussion of the unclear outcomes of this intervention and its procedural risks.
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Affiliation(s)
- Daniel S Strand
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia
| | - Ryan J Law
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Dennis Yang
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida.
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
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What Can We Learn About Pancreatic Adenocarcinoma from Imaging? Hematol Oncol Clin North Am 2022; 36:911-928. [DOI: 10.1016/j.hoc.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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12
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Al-Moussally F, Fogel EL, Helft PR. An ethical analysis of endoscopic therapy decision-making in patients with refractory substance use disorder and chronic pancreatitis. Pancreatology 2022; 22:671-677. [PMID: 35691886 PMCID: PMC10118247 DOI: 10.1016/j.pan.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 05/15/2022] [Accepted: 05/30/2022] [Indexed: 12/11/2022]
Affiliation(s)
- Feras Al-Moussally
- Indiana University School of Medicine, United States; Charles Warren Fairbanks Center of Medical Ethics, Indiana University Health, United States
| | - Evan L Fogel
- Indiana University School of Medicine, United States; Lehman, Bucksot and Sherman Section of Pancreatobiliary Endoscopy, United States
| | - Paul R Helft
- Indiana University School of Medicine, United States; Charles Warren Fairbanks Center of Medical Ethics, Indiana University Health, United States.
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13
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Dirweesh A, Trikudanathan G, Freeman ML. Endoscopic Management of Complications in Chronic Pancreatitis. Dig Dis Sci 2022; 67:1624-1634. [PMID: 35226223 DOI: 10.1007/s10620-022-07391-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Management of complications in patients with chronic pancreatitis is often suboptimal. This review discusses detailed endoscopic approaches for managing complications in CP. LITERATURE FINDINGS CP is characterized by progressive and irreversible destruction of pancreatic parenchyma and ductal system resulting in fibrosis, scarring, and loss of glandular function. Abdominal pain remains is the most common symptom of the disease and the main aim of medical, endoscopic, and surgical therapy is to help relieve symptoms, prevent disease progression, and manage complications related to CP. In fact, advances in our understanding of CP have improved medical care and quality of life in these patients. With significant sequela, morbidity and a progressive nature, a thorough understanding of the pathophysiology, natural course, diagnostic approaches, and optimal management strategies for this disease is warranted. The existing modalities and new innovations in this field are safe, effective, and likely to have a positive impact on management of complication in CP whenever used in the right context.
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Affiliation(s)
- Ahmed Dirweesh
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, MMC 36, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, MMC 36, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Martin L Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, MMC 36, 420 Delaware St SE, Minneapolis, MN, 55455, USA.
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14
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Jang DK, Kim J, Paik CN, Kim JW, Lee TH, Jang JY, Yoon SB, Lee JK. Endoscopic retrograde cholangiopancreatography-related adverse events in Korea: A nationwide assessment. United European Gastroenterol J 2021; 10:73-79. [PMID: 34953054 PMCID: PMC8830275 DOI: 10.1002/ueg2.12186] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 11/21/2021] [Indexed: 01/16/2023] Open
Abstract
Background Although endoscopic retrograde cholangiopancreatography (ERCP) is a pivotal procedure for the diagnosis and treatment of a variety of pancreatobiliary diseases, it has been known that the risk of procedure‐related adverse events (AEs) is significant. Objective We conducted this nationwide cohort study since there have been few reports on the real‐world data regarding ERCP‐related AEs. Methods Patients who underwent ERCP were identified between 2012 and 2015 using Health Insurance Review and Assessment database generated by the Korea government. Incidence, annual trends, demographics, characteristics according to the types of procedures, and the risk factors of AEs were assessed. Results A total of 114,757 patients with male gender of 54.2% and the mean age of 65.0 ± 15.2 years were included. The most common indication was choledocholithiasis (49.4%) and the second malignant biliary obstruction (22.8%). Biliary drainage (33.9%) was the most commonly performed procedure, followed by endoscopic sphincterotomy (27.4%), and stone removal (22.0%). The overall incidence of ERCP‐related AEs was 4.7% consisting of post‐ERCP pancreatitis (PEP; 4.6%), perforation (0.06%), and hemorrhage (0.02%), which gradually increased from 2012 to 2015. According to the type of procedures, ERCP‐related AEs developed the most commonly after pancreatic stent insertion (11.4%), followed by diagnostic ERCP (5.9%) and endoscopic sphincterotomy (5.7%). Younger age and diagnostic ERCP turned out to be independent risk factors of PEP. Conclusions ERCP‐related AEs developed the most commonly after pancreatic stent insertion, diagnostic ERCP and endoscopic sphincterotomy. Special caution should be used for young patients receiving diagnostic ERCP due to increased risk of PEP.
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Affiliation(s)
- Dong Kee Jang
- Department of Internal Medicine, Seoul Metropolitan Government Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Jungmee Kim
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Nyol Paik
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung-Wook Kim
- Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Tae Hee Lee
- Institute for Digestive Research, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jae-Young Jang
- Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Seung Bae Yoon
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jun Kyu Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
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15
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Approach to management of pancreatic strictures: the gastroenterologist's perspective. Clin J Gastroenterol 2021; 14:1587-1597. [PMID: 34405382 DOI: 10.1007/s12328-021-01503-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 08/13/2021] [Indexed: 12/15/2022]
Abstract
Pancreatic strictures represent a complex clinical problem which often requires multidisciplinary management with a team of gastroenterologists, surgeons and radiologists. Dominant strictures are largely due to inflammatory processes of the pancreas like chronic pancreatitis. However, differentiating benign from malignant processes of the pancreas, leading to strictures is imperative and remains a challenge. With advances in endoscopic management, options for therapy include endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasound-guided pancreatic drainage (EUS-PD) in situations where ERCP is not feasible or fails. However, endoscopic therapy is suited for a select group of patients and surgery remains key to management in many patients. In this narrative review, we look at the gastroenterologist's perspective and approach to pancreatic ductal strictures, including endoscopic and surgical management.
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16
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Forbes N, Leontiadis GI, Vaska M, Elmunzer BJ, Yuan Y, Bishay K, Meng ZW, Iannuzzi J, O'Sullivan DE, Mah B, Partridge ACR, Henderson AM, Qureshi A, Keswani RN, Wani S, Bridges RJ, Heitman SJ, Hilsden RJ, Ruan Y, Brenner DR. Adverse events associated with endoscopic retrograde cholangiopancreatography: protocol for a systematic review and meta-analysis. BMJ Open 2021; 11:e053302. [PMID: 34404717 PMCID: PMC8372880 DOI: 10.1136/bmjopen-2021-053302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 07/28/2021] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Endoscopic retrograde cholangiopancreatography (ERCP) is performed to diagnose and manage conditions of the biliary and pancreatic ducts. Though effective, it is associated with common adverse events (AEs). The purpose of this study is to systematically review ERCP AE rates and report up-to-date pooled estimates. METHODS AND ANALYSIS A comprehensive electronic search will be conducted of relevant medical databases through 10 November 2020. A study team of eight data abstracters will independently determine study eligibility, assess quality and abstract data in parallel, with any two concordant entries constituting agreement and with discrepancies resolved by consensus. The primary outcome will be the pooled incidence of post-ERCP pancreatitis, with secondary outcomes including post-ERCP bleeding, cholangitis, perforation, cholecystitis, death and unplanned healthcare encounters. Secondary outcomes will also include rates of specific and overall AEs within clinically relevant subgroups determined a priori. DerSimonian and Laird random effects models will be used to perform meta-analyses of these outcomes. Sources of heterogeneity will be explored via meta-regression. Subgroup analyses based on median dates of data collection across studies will be performed to determine whether AE rates have changed over time. ETHICS AND DISSEMINATION Ethics approval is not required for this study as it is a planned meta-analysis of previously published data. Participant consent is similarly not required. Dissemination is planned via presentation at relevant conferences in addition to publication in peer-reviewed journals.PROSPERO registration numberCRD42020220221.
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Affiliation(s)
- Nauzer Forbes
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Grigorios I Leontiadis
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Marcus Vaska
- Knowledge Resource Service, Alberta Health Services, Calgary, Alberta, Canada
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Yuhong Yuan
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Kirles Bishay
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Zhao Wu Meng
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jordan Iannuzzi
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Dylan E O'Sullivan
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brittany Mah
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Arun C R Partridge
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Amanda M Henderson
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Aatif Qureshi
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Rajesh N Keswani
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Ronald J Bridges
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Steven J Heitman
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Robert J Hilsden
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Yibing Ruan
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Cancer Epidemiology and Prevention Research, Cancer Control Alberta, Alberta Health Services, Calgary, Alberta, Canada
| | - Darren R Brenner
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Cancer Epidemiology and Prevention Research, Cancer Control Alberta, Alberta Health Services, Calgary, Alberta, Canada
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Long-term outcomes of fully covered self-expandable metal stents versus plastic stents in chronic pancreatitis. Sci Rep 2021; 11:15637. [PMID: 34341385 PMCID: PMC8329149 DOI: 10.1038/s41598-021-94726-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/30/2021] [Indexed: 11/21/2022] Open
Abstract
Chronic pancreatitis (CP) related main pancreatic duct (MPD) stricture has been a challenge for endoscopists. Fully covered self-expandable metal stents (FC-SEMS) has been tried in CP patients, but the efficacy and safety are still controversial. Thus, we aim to compare the long-term clinical efficacy of FC-SEMS vs. plastic stent placement in persistent MPD strictures secondary to CP. Between 2007 and 2018, 80 chronic pancreatitis patients (58 males, median age 49 years), who underwent endoscopic placement of FC-SEMS (n = 26) and plastic stent (n = 54) for persistent MPD strictures after at least 3 months of initial single plastic stenting, were retrospectively analyzed during a median follow-up duration of 33.7 months. As a result, MPD stricture resolution rate was statistically higher in FC-SEMS group (87.0% vs. 42.0%, p < 0.001). Although immediate complications occurred similarly (38.5% vs. 37.0%, p = 0.902), spontaneous migration (26.9%) and de novo strictures (23.1%) were pronounced delayed complications in FC-SEMS group. Pain relief during follow-up was significantly higher in FC-SEMS group (76.9% vs. 53.7%, p = 0.046). The total procedure cost was similar in both groups ($1,455.6 vs. $1,596.9, p = 0.486). In comparison with plastic stent, FC-SEMS placement for persistent MPD strictures had favorable long-term clinical efficacy, with its typical complications like spontaneous migration and de novo strictures.
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Ramchandani M, Lakhtakia S, Costamagna G, Tringali A, Püspöek A, Tribl B, Dolak W, Devière J, Arvanitakis M, van der Merwe S, Laleman W, Ponchon T, Lepilliez V, Gabbrielli A, Bernardoni L, Bruno MJ, Poley JW, Arnelo U, Lau J, Roy A, Bourke M, Kaffes A, Neuhaus H, Peetermans J, Rousseau M, Reddy DN. Fully Covered Self-Expanding Metal Stent vs Multiple Plastic Stents to Treat Benign Biliary Strictures Secondary to Chronic Pancreatitis: A Multicenter Randomized Trial. Gastroenterology 2021; 161:185-195. [PMID: 33741314 DOI: 10.1053/j.gastro.2021.03.015] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/01/2021] [Accepted: 03/06/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Benign biliary strictures (BBS) are complications of chronic pancreatitis (CP). Endotherapy using multiple plastic stents (MPS) or a fully covered self-expanding metal stent (FCSEMS) are acceptable treatment options for biliary obstructive symptoms in these patients. METHODS Patients with symptomatic CP-associated BBS enrolled in a multicenter randomized noninferiority trial comparing 12-month treatment with MPS vs FCSEMS. Primary outcome was stricture resolution status at 24 months, defined as absence of restenting and 24-month serum alkaline phosphatase not exceeding twice the level at stenting completion. Secondary outcomes included crossover rate, numbers of endoscopic retrograde cholangiopancreatography (ERCPs) and stents, and stent- or procedure-related serious adverse events. RESULTS Eighty-four patients were randomized to MPS and 80 to FCSEMS. Baseline technical success was 97.6% for MPS and 98.6% for FCSEMS. Eleven patients crossed over from MPS to FCSEMS, and 10 from FCSEMS to MPS. For MPS vs FCSEMS, respectively, stricture resolution status at 24 months was 77.1% (54/70) vs 75.8% (47/62) (P = .008 for noninferiority intention-to-treat analysis), mean number of ERCPs was 3.9 ± 1.3 vs 2.6 ± 1.3 (P < .001, intention-to-treat), and mean number of stents placed was 7.0 ± 4.4 vs 1.3 ± .6 (P < .001, as-treated). Serious adverse events occurred in 16 (19.0%) MPS and 19 (23.8%) FCSEMS patients (P = .568), including cholangitis/fever/jaundice (9 vs 7 patients respectively), abdominal pain (5 vs 5), cholecystitis (1 vs 3) and post-ERCP pancreatitis (0 vs 2). No stent- or procedure-related deaths occurred. CONCLUSIONS Endotherapy of CP-associated BBS has similar efficacy and safety for 12-month treatment using MPS compared with a single FCSEMS, with FCSEMS requiring fewer ERCPs over 2 years. (ClinicalTrials.gov, Number: NCT01543256.).
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Affiliation(s)
| | | | - Guido Costamagna
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Digestive Endoscopy Unit, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Andrea Tringali
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Digestive Endoscopy Unit, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Andreas Püspöek
- Centre for Endoscopic Research Therapeutics and Training (CERTT), St. John's Hospital, Eisenstadt, Austria
| | | | | | | | | | | | - Wim Laleman
- University Hospitals Leuven, Leuven, Belgium
| | | | | | | | - Laura Bernardoni
- Università degli Studi Verona Policlinico G.B. Rossi, Verona, Italy
| | | | | | - Urban Arnelo
- CLINTEC, Division of Surgery, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - James Lau
- Prince of Wales Hospital, New Territories, Hong Kong
| | - André Roy
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Michael Bourke
- Western Clinical School, University of Sydney, Westmead Hospital, Sydney, NSW, Australia
| | - Arthur Kaffes
- Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Horst Neuhaus
- Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Joyce Peetermans
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts
| | - Matthew Rousseau
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts
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Mann R, Boregowda U, Vyas N, Gajendran M, Umapathy CP, Sayana H, Echavarria J, Patel S, Saligram S. Current advances in the management of chronic pancreatitis. Dis Mon 2021; 67:101225. [PMID: 34176572 DOI: 10.1016/j.disamonth.2021.101225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Chronic pancreatitis is characterized by irreversible destruction of pancreatic parenchyma and its ductal system resulting from longstanding inflammation, leading to fibrosis and scarring due to genetic, environmental, and other risk factors. The diagnosis of chronic pancreatitis is made based on a combination of clinical features and characteristic findings on computed tomography or magnetic resonance imaging. Abdominal pain is the most common symptom of chronic pancreatitis. The main aim of treatment is to relieve symptoms, prevent disease progression, and manage complications related to chronic pancreatitis. Patients who do not respond to medical treatment or not a candidate for surgical treatment are usually managed with endoscopic therapies. Endoscopic therapies help with symptoms such as abdominal pain and jaundice by decompression of pancreatic and biliary ducts. This review summarizes the risk factors, pathophysiology, diagnostic evaluation, endoscopic treatment of chronic pancreatitis, and complications. We have also reviewed recent advances in endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-guided therapies for pancreatic duct obstruction due to stones, strictures, pancreatic divisum, and biliary strictures.
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Affiliation(s)
- Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, 1303 E Herndon Ave, Fresno, CA 93720, USA
| | - Umesha Boregowda
- Department of Internal Medicine, Bassett Healthcare Network, Columbia Bassett Medical School, 1 Atwell Road, Cooperstown, NY 13326, USA
| | - Neil Vyas
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Mahesh Gajendran
- Department of Internal Medicine, Texas Tech University Health Science Center El Paso, 2000B Transmountain Road, El Paso, TX 79911, USA
| | - Chandra Prakash Umapathy
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Hari Sayana
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Juan Echavarria
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Sandeep Patel
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Shreyas Saligram
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA.
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Forbes N, Koury HF, Bass S, Cole M, Mohamed R, Turbide C, Gonzalez-Moreno E, Kayal A, Chau M, Lethebe BC, Hilsden RJ, Heitman SJ. Characteristics and Outcomes of ERCP at a Canadian Tertiary Centre: Initial Results from a Prospective High-Fidelity Biliary Endoscopy Registry. J Can Assoc Gastroenterol 2021; 4:78-83. [PMID: 33855265 PMCID: PMC8023809 DOI: 10.1093/jcag/gwaa007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 02/06/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is an essential procedure in the management of pancreatic and biliary disease. While its role is firmly established, further well-designed prospective ERCP research is required, as a large portion of previous work has employed retrospective or administrative methodologies, both prone to potential biases. The aim of the Calgary Registry for Advanced and Therapeutic Endoscopy (CReATE) is to be a high-fidelity prospective multicentre registry. METHODS The study population consisted of consecutive adult ERCP patients from September 2018 to September 2019. Informed consent was acquired for each patient. All relevant preprocedural, procedural, peri-procedural and postprocedural data were captured in real time by a full-time third-party research assistant directly observing procedures. Outcomes were ascertained by comprehensive medical record review and patient phone interview 30 days after the index procedure. RESULTS Five endoscopists performed 895 ERCP procedures, 90.1% of which were deemed successful. Suspected choledocholithiasis was the most common indication for ERCP, followed by suspected or confirmed stricture(s), at 61.0% and 29.5%, respectively. 61.0% of procedures were performed on ERCP-naive patients. Post-ERCP pancreatitis occurred following 4.9% of procedures, with clinically significant bleeding or perforation occurring following 1.8% and 0.1% of procedures, respectively. DISCUSSION Through 12 months, CReATE captured 895 procedures prospectively, with each entry containing over 300 data fields. Active expansion to additional tertiary centres is underway, and this will enhance the existing data pool. CReATE has the potential to improve multiple facets of ERCP, including training, optimal procedural techniques, mitigation of adverse events and personalized patient care.
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Affiliation(s)
- Nauzer Forbes
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Hannah F Koury
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sydney Bass
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Martin Cole
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Rachid Mohamed
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Christian Turbide
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Emmanuel Gonzalez-Moreno
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Ahmed Kayal
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Millie Chau
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - B Cord Lethebe
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert J Hilsden
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Steven J Heitman
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Han S, Attwell AR, Tatman P, Edmundowicz SA, Hammad HT, Wagh MS, Wani S, Shah RJ. Adverse Events Associated With Therapeutic Endoscopic Retrograde Pancreatography. Pancreas 2021; 50:378-385. [PMID: 33835969 PMCID: PMC8041157 DOI: 10.1097/mpa.0000000000001769] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Data regarding the safety of endoscopic retrograde pancreatography (ERP) are limited compared with biliary endoscopic retrograde cholangiopancreatography. The aim of this study was to determine adverse events (AEs) associated with therapeutic ERP. METHODS This single-center retrospective study examined consecutive therapeutic ERPs with the primary intention of cannulating the pancreatic duct. Multivariate logistic regression was performed to identify risk factors for AEs. RESULTS A total of 3023 ERPs were performed in 1288 patients (mean age, 50.3 years; 57.8% female) from January 2000 to January 2017. Overall AE rate was 18.9% with abdominal pain requiring admission (9.8%) and post-ERP pancreatitis (5.7%) being most common. On multivariate analysis, female sex (adjusted odds ratio [aOR], 2.3; 95% confidence interval [CI], 1.9-2.9), acute recurrent pancreatitis (aOR, 5.0; 95% CI, 1.7-15.3), chronic pancreatitis (aOR, 1.8; 95% CI, 1.3-2.6), and pancreatic sphincter of Oddi dysfunction (aOR, 2.1; 95% CI, 1.4-3.3) were associated with an increased risk of overall AEs. Pancreatic sphincterotomy (aOR, 1.9; 95% CI, 1.5-2.4) and therapeutic stenting (aOR, 1.6; 95% CI, 1.2-2.2) also increased the risk of AEs. CONCLUSIONS Nearly 1 in 5 patients who undergo therapeutic ERP will experience an AE; however, the rates of major AEs, including post-ERP pancreatitis, bleeding, and perforation, are low.
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Affiliation(s)
- Samuel Han
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Augustin R. Attwell
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Philip Tatman
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Steven A. Edmundowicz
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Hazem T. Hammad
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Mihir S. Wagh
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Raj J. Shah
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
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Sagami R, Yamao K, Nakahodo J, Minami R, Tsurusaki M, Murakami K, Amano Y. Pre-Operative Imaging and Pathological Diagnosis of Localized High-Grade Pancreatic Intra-Epithelial Neoplasia without Invasive Carcinoma. Cancers (Basel) 2021; 13:cancers13050945. [PMID: 33668239 PMCID: PMC7956417 DOI: 10.3390/cancers13050945] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/08/2021] [Accepted: 02/19/2021] [Indexed: 12/11/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) arises from precursor lesions, such as pancreatic intra-epithelial neoplasia (PanIN) and intraductal papillary mucinous neoplasm (IPMN). The prognosis of high-grade precancerous lesions, including high-grade PanIN and high-grade IPMN, without invasive carcinoma is good, despite the overall poor prognosis of PDAC. High-grade PanIN, as a lesion preceding invasive PDAC, is therefore a primary target for intervention. However, detection of localized high-grade PanIN is difficult when using standard radiological approaches. Therefore, most studies of high-grade PanIN have been conducted using specimens that harbor invasive PDAC. Recently, imaging characteristics of high-grade PanIN have been revealed. Obstruction of the pancreatic duct due to high-grade PanIN may induce a loss of acinar cells replaced by fibrosis and lobular parenchymal atrophy. These changes and additional inflammation around the branch pancreatic ducts (BPDs) result in main pancreatic duct (MPD) stenosis, dilation, retention cysts (BPD dilation), focal pancreatic parenchymal atrophy, and/or hypoechoic changes around the MPD. These indirect imaging findings have become important clues for localized, high-grade PanIN detection. To obtain pre-operative histopathological confirmation of suspected cases, serial pancreatic-juice aspiration cytologic examination is effective. In this review, we outline current knowledge on imaging characteristics of high-grade PanIN.
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Affiliation(s)
- Ryota Sagami
- Department of Gastroenterology, Oita San-ai Medical Center, 1213 Oaza Ichi, Oita, Oita 870-1151, Japan
- Pancreatic Cancer Research for Secure Salvage Young Investigators (PASSYON), Osaka-Sayama, Osaka 589-8511, Japan; (K.Y.); (J.N.); (R.M.)
- Correspondence: ; Tel.: +81-97-541-1311; Fax: +81-97-541-5218
| | - Kentaro Yamao
- Pancreatic Cancer Research for Secure Salvage Young Investigators (PASSYON), Osaka-Sayama, Osaka 589-8511, Japan; (K.Y.); (J.N.); (R.M.)
- Department of Gastroenterology and Hepatology, Kindai University, Osaka-Sayama, Osaka 589-8511, Japan
| | - Jun Nakahodo
- Pancreatic Cancer Research for Secure Salvage Young Investigators (PASSYON), Osaka-Sayama, Osaka 589-8511, Japan; (K.Y.); (J.N.); (R.M.)
- Department of Gastroenterology Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
| | - Ryuki Minami
- Pancreatic Cancer Research for Secure Salvage Young Investigators (PASSYON), Osaka-Sayama, Osaka 589-8511, Japan; (K.Y.); (J.N.); (R.M.)
- Department of Gastroenterology, Tenri Hospital, 200 Mishimacho, Tenri, Nara 632-0015, Japan
| | - Masakatsu Tsurusaki
- Department of Diagnostic Radiology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka 589-8511, Japan;
| | - Kazunari Murakami
- Department of Gastroenterology, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasamacho, Yufu, Oita 879-5593, Japan;
| | - Yuji Amano
- Department of Endoscopy, Urawa Kyosai Hospital, 3-15-31 Harayama, Midoriku, Saitama 336-0931, Japan;
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23
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Li S, Monachese M, Salim M, Arya N, Sahai AV, Forbes N, Teshima C, Yaghoobi M, Chen YI, Lam E, James P. Standard reporting elements for the performance of EUS: Recommendations from the FOCUS working group. Endosc Ultrasound 2021; 10:84-92. [PMID: 33666183 PMCID: PMC8098847 DOI: 10.4103/eus-d-20-00234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background and Objectives Quality indicators for the performance of EUS have been developed to monitor and improve service value and patient outcomes. To support the incorporation of these indicators and standardize EUS documentation, we propose standard EUS reporting elements for endosonographers and endoscopy units. Methods A comprehensive literature search and review was performed to identify EUS quality indicators and key components of high-quality standardized EUS reporting. Guidance statements regarding standard EUS reporting elements were developed and reviewed at the Forum for Canadian Endoscopic Ultrasound (FOCUS) 2019 Annual Meeting. Results EUS reporting elements can be divided into preprocedural, intraprocedural, and postprocedural items. Preprocedural components include the type, indication, and urgency of the procedure and patient clinical information and consent. Intraprocedural components include the adequacy and extent of examination, relevant landmarks, lesion characteristics, sampling method, specimen quality, and intraprocedural adverse events. Postprocedural components include a summary and synthesis of relevant findings as well as recommended management and follow-up. Conclusions Standardizing reporting elements may help improve the care of patients undergoing EUS procedures. Our review provides a practical guide and compilation of recommended reporting elements to ensure ongoing best practices and quality improvement in EUS.
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Affiliation(s)
- Suqing Li
- Division of Gastroenterology and Hepatology, University Health Network, University of Toronto, Toronto, Canada
| | - Marc Monachese
- Division of Gastroenterology and Hepatology, University Health Network, University of Toronto, Toronto, Canada
| | - Misbah Salim
- Division of Gastroenterology and Hepatology, University Health Network, University of Toronto, Toronto, Canada
| | - Naveen Arya
- Division of Gastroenterology, Oakville Trafalgar Memorial Hospital, Oakville, Ontario, Canada
| | - Anand V Sahai
- Division of Gastroenterology, University of Montreal, Montreal, Quebec, Canada
| | - Nauzer Forbes
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - Christopher Teshima
- Department of Medicine, Division of Gastroenterology, St. Michael's Hospital, University of Calgary, Toronto, Canada
| | - Mohammad Yaghoobi
- Division of Gastroenterology, McMaster University Medical Center, McMaster University, Hamilton, Canada
| | - Yen-I Chen
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Canada
| | - Eric Lam
- Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
| | - Paul James
- Division of Gastroenterology and Hepatology, University Health Network, University of Toronto, Toronto, Canada
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25
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Han S, Shah RJ. No flare(s), no problem: treating recalcitrant pancreatic duct strictures with short fully covered metal stents. Gastrointest Endosc 2020; 91:834-836. [PMID: 32204816 DOI: 10.1016/j.gie.2019.12.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 12/27/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Samuel Han
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Raj J Shah
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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26
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Forbes N, Elmunzer BJ, Allain T, Chau M, Koury HF, Bass S, Belletrutti PJ, Cole MJ, Gonzalez-Moreno E, Kayal A, Kumar P, Mohamed R, Turbide C, Buret AG, Heitman SJ. Infection control in ERCP using a duodenoscope with a disposable cap (ICECAP): rationale for and design of a randomized controlled trial. BMC Gastroenterol 2020; 20:64. [PMID: 32164535 PMCID: PMC7066768 DOI: 10.1186/s12876-020-01200-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 02/20/2020] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Endoscopic retrograde cholangio-pancreatography (ERCP) is commonly performed in the management of pancreatic and biliary disease. Duodenoscopes are specialized endoscopes used to perform ERCP, and inherent to their design, a high rate of persistent bacterial contamination exists even after automated reprocessing and disinfection. Consequently, in recent years, ERCP has been associated with infection transmission, leading to several fatal patient outbreaks. Due to increasing fears over widespread future duodenoscope-related outbreaks, regulatory bodies have called for alterations in the design of duodenoscopes. A duodenoscope has recently been developed that employs a disposable cap. This novel design theoretically eliminates the mechanism behind persistent bacterial contamination and infection transmission. However, there are no data demonstrating persistent bacterial contamination rates, technical success rates, or clinical outcomes associated with these duodenoscopes. METHODS A parallel arm randomized controlled trial will be performed for which 520 patients will be recruited. The study population will consist of consecutive patients undergoing ERCP procedures for any indication at a high-volume tertiary care centre in Calgary, Alberta, Canada. Patients will be randomized to an intervention group, that will undergo ERCP with a novel duodenoscope with disposable cap, or to a control group who will undergo ERCP with a traditional duodenoscope. Co-primary outcomes will include persistent bacterial contamination rates (post automated reprocessing) and ERCP technical success rates. Secondary outcomes include clinical success rates, overall and specific early and late adverse event rates, 30-day mortality and healthcare utilization rates, procedure and reprocessing times, and ease of device use. DISCUSSION The ICECAP trial will answer important questions regarding the use of a novel duodenoscope with disposable cap. Specifically, persistent bacterial contamination, technical performance, and relevant clinical outcomes will be assessed. Given the mortality and morbidity burden associated with ERCP-related infectious outbreaks, the results of this study have the capacity to be impactful at an international level. TRIAL REGISTRATION This trial was registered on clinicaltrials.gov (NCT04040504) on July 31, 2019.
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Affiliation(s)
- Nauzer Forbes
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Canada.
- Department of Community Health Sciences, University of Calgary, Calgary, Canada.
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Thibault Allain
- Department of Biological Sciences, University of Calgary, Calgary, AB, Canada
| | - Millie Chau
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Canada
| | - Hannah F Koury
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Sydney Bass
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Canada
| | - Paul J Belletrutti
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Canada
| | - Martin J Cole
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Canada
| | - Emmanuel Gonzalez-Moreno
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Ahmed Kayal
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Puja Kumar
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Canada
| | - Rachid Mohamed
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Canada
| | - Christian Turbide
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Canada
| | - Andre G Buret
- Department of Biological Sciences, University of Calgary, Calgary, AB, Canada
| | - Steven J Heitman
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
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27
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Bansal R, Khan R, Scaffidi MA, Gimpaya N, Genis S, Bukhari A, Dhillon J, Dao K, Bonneau C, Grover SC. Undisclosed payments by pharmaceutical and medical device manufacturers to authors of endoscopy guidelines in the United States. Gastrointest Endosc 2020; 91:266-273. [PMID: 31738925 DOI: 10.1016/j.gie.2019.11.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 11/03/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Payments from pharmaceutical and medical device manufacturers to authors of clinical practice guidelines (CPGs) may influence practice recommendations. It is therefore important to evaluate the completeness of financial conflict of interest (FCOI) declarations among CPG authors. METHODS We performed a cross-sectional analysis of industry payments to authors of endoscopy guidelines published by 5 GI societies between 2014 and 2017. For each author we identified payments using the disclosure section of CPGs and the Centers for Medicare & Medicaid Services Open Payments (CMS-OP) database. We calculated the prevalence, monetary value, and type of declared and undeclared payments among authors. Payments were assessed for the calendar year of and before publication. RESULTS Thirty-seven CPGs were included in the analysis comprising 569 author entries (91 unique individuals; 66.43% men, 92.6% physicians, 66.4% academically affiliated). Four hundred fifty-one episodes (79%) involved FCOIs, 451 (79%) had undisclosed FCOIs in the CMS-OP, and 445 (77%) had FCOIs relevant to a CPG recommendation. The median undisclosed payment value was $4807.26 (interquartile range, $334.84-$20,579.75). Male authors (odds ratio, 2.23; 95% confidence interval, 1.47-3.39) and academically affiliated authors (odds ratio, 8.87; 95% confidence interval, 5.57-14.13) were significantly more likely to have undeclared payments (P < .001). No CPGs met all National Academy of Medicine criteria. CONCLUSIONS Recognizing concerns about the accuracy of the CMS-OP, there are substantial discrepancies between industry-reported payments and author self-disclosure. Additionally, there is a high prevalence of undisclosed payments by pharmaceutical and medical device manufacturers to these authors. Given the potential impact of these discrepancies and undisclosed payments on CPGs, more accurate reporting and alternative strategies for managing FCOI are needed.
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Affiliation(s)
- Rishi Bansal
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
| | - Rishad Khan
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
| | - Michael A Scaffidi
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
| | - Nikko Gimpaya
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
| | - Shai Genis
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
| | - Abbas Bukhari
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
| | - Jeevan Dhillon
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
| | - Kathy Dao
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
| | - Chris Bonneau
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
| | - Samir C Grover
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
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28
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Lakhtakia S, Reddy N, Dolak W, Ponchon T, Bruno MJ, Bourke MJ, Neuhaus H, Roy A, González-Huix Lladó F, Kortan PP, Peetermans J, Rousseau M, Costamagna G, Devière J. Long-term outcomes after temporary placement of a self-expanding fully covered metal stent for benign biliary strictures secondary to chronic pancreatitis. Gastrointest Endosc 2020; 91:361-369.e3. [PMID: 31494135 DOI: 10.1016/j.gie.2019.08.037] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 08/19/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Temporary single, fully covered self-expanding metal stent (FCSEMS) placement for benign biliary strictures (BBSs) associated with chronic pancreatitis (CP) may require fewer interventions than endotherapy with multiple plastic stents and may carry less morbidity than biliary diversion surgery. This study aimed to assess long-term outcomes in CP-associated BBSs after FCSEMS placement and removal. METHODS In this open-label, multinational, prospective study, subjects with CP and a BBS treated with FCSEMS placement with scheduled removal at 10 to 12 months were followed for 5 years after FCSEMS indwell. Kaplan-Meier analyses assessed BBS resolution and cumulative probability of freedom from recurrent stent placement to 5 years after FCSEMS indwell. RESULTS One hundred eighteen patients were eligible for FCSEMS removal. At a median of 58 months (interquartile range, 44-64) post-FCSEMS indwell, the probability of remaining stent-free was 61.6% (95% confidence interval [CI], 52.5%-70.7%). In 94 patients whose BBSs resolved at the end of FCSEMS indwell, the probability of remaining stent-free 5 years later was 77.4% (95% CI, 68.4%-86.4%). Serious stent-related adverse events occurred in 27 of 118 patients (22.9%); all resolved with medical therapy or repeated endoscopy. Multivariate analysis identified severe CP (hazard ratio, 2.4; 95% CI, 1.0-5.6; P = .046) and longer stricture length (hazard ratio, 1.2; 95% CI, 1.0-1.4; P = .022) as predictors of stricture recurrence. CONCLUSION In patients with symptomatic BBSs secondary to CP, 5 years after placement of a single FCSEMS intended for 10 to 12 months indwell, more than 60% remained asymptomatic and stent-free with an acceptable safety profile. Temporary placement of a single FCSEMS may be considered as first-line treatment for patients with CP and BBSs. (Clinical trial registration number: NCT01014390.).
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Affiliation(s)
- Sundeep Lakhtakia
- Gastroenterology and Therapeutic Endoscopy, Asian Institute of Gastroenterology, Hyderabad, India
| | - Nageshwar Reddy
- Gastroenterology and Therapeutic Endoscopy, Asian Institute of Gastroenterology, Hyderabad, India
| | - Werner Dolak
- Klinische Abteilung für Gastroenterologie und Hepatologie, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Vienna, Austria
| | - Thierry Ponchon
- Service de Gastroentérologie et d'Endoscopie Digestive, Hôpital Edouard Herriot, Lyon, France
| | - Marco J Bruno
- Maag-, Darm- en Leverziekten, Erasmus Universitair Medisch Centrum, Rotterdam, The Netherlands
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Horst Neuhaus
- Medizinische Klinik, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - André Roy
- Département de Chirurgie, Hôpital Saint-Luc, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Ferrán González-Huix Lladó
- Unidad de Endoscopia, Servicio de Aparato Digestivo, Hospital Universitari Doctor Josep Trueta, Girona, Catalunya, Spain
| | - Paul P Kortan
- Division of Gastroenterology, Centre for Therapeutic Endoscopy and Endoscopic Oncology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Joyce Peetermans
- Maag-, Darm- en Leverziekten, Erasmus Universitair Medisch Centrum, Rotterdam, The Netherlands; Endoscopy Division, Boston Scientific Corp, Marlborough, Massachusetts, USA
| | - Matthew Rousseau
- Endoscopy Division, Boston Scientific Corp, Marlborough, Massachusetts, USA
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli - IRCCS, Catholic University, Rome, Italy; Digestive Endoscopy, IHU-USIAS, University of Strasbourg, Strasbourg, France
| | - Jacques Devière
- Service de Gastro-Entérologie et d'Hépato Pancréatologie, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
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29
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Tringali A, Reddy DN, Ponchon T, Neuhaus H, Lladó FGH, Navarrete C, Bruno MJ, Kortan PP, Lakhtakia S, Peetermans J, Rousseau M, Carr-Locke D, Devière J, Costamagna G. Treatment of post-cholecystectomy biliary strictures with fully-covered self-expanding metal stents - results after 5 years of follow-up. BMC Gastroenterol 2019; 19:214. [PMID: 31830897 PMCID: PMC6909597 DOI: 10.1186/s12876-019-1129-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 11/22/2019] [Indexed: 12/24/2022] Open
Abstract
Background Endoscopic treatment of post-cholecystectomy biliary strictures (PCBS) with multiple plastic biliary stents placed sequentially is a minimally invasive alternative to surgery but requires multiple interventions. Temporary placement of a single fully-covered self-expanding metal stent (FCSEMS) may offer safe and effective treatment with fewer re-interventions. Long-term effectiveness of treatment with FCSEMS to obtain PCBS resolution has not yet been studied. Methods In this prospective multi-national study in patients with symptomatic benign biliary strictures (N = 187) due to various etiologies received a FCSEMS with scheduled removal at 6–12 months and were followed for 5 years. We report here long-term outcomes of the subgroup of patients with PCBS (N = 18). Kaplan Meier analyses assessed long-term freedom from re-stenting. Adverse events were documented. Results Endoscopic removal of the FCSEMS was achieved in 83.3% (15/18) of patients after median indwell of 10.9 (range 0.9–13.8) months. In the remaining 3 patients (16.7%), the FCSEMS spontaneously migrated and passed without complications. At the end of FCSEMS indwell, 72% (13/18) of patients had stricture resolution. At 5 years after FCSEMS removal, 84.6% (95% CI 65.0–100.0%) of patients who had stricture resolution at FCSEMS removal remained stent-free. In addition, at 75 months after FCSEMS placement, the probability of remaining stent-free was 61.1% (95% CI 38.6–83.6%) for all patients. Stent or removal related serious adverse events occurred in 38.9% (7/18) all resolved without sequalae. Conclusions In patients with symptomatic PCBS, temporary placement of a single FCSEMS intended for 10–12 months indwell is associated with long-term stricture resolution up to 5 years. Temporary placement of a single FCSEMS may be considered for patients with PCBS not involving the main hepatic confluence. Trial registration numbers NCT01014390; CTRI/2012/12/003166; Registered 17 November 2009.
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Affiliation(s)
- Andrea Tringali
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Digestive Endoscopy Unit, Rome, Italy. .,Università Cattolica del Sacro Cuore, Centre for Endoscopic Research Therapeutics and Training (CERTT), Rome, Italy.
| | - D Nageshwar Reddy
- Gastroenterology and Therapeutic Endoscopy, Asian Institute of Gastroenterology, Hyderabad, India
| | - Thierry Ponchon
- Service de Gastroentérologie et d'Endoscopie Digestive, Hôpital Edouard Herriot, Lyon, France
| | - Horst Neuhaus
- Medizinische Klinik, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Ferrán González-Huix Lladó
- Unidad de Endoscopia, Servicio de Aparato Digestivo, Hospital Universitari Doctor Josep Trueta, Girona, Catalunya, Spain
| | - Claudio Navarrete
- Servicio de Endoscopía, Clínica Alemana de Santiago. Jefe de Departamento de Cirugia, Clinica Santa Maria, Santiago, Chile
| | - Marco J Bruno
- Maag-, Darm- en Leverziekten, Erasmus Universitair Medisch Centrum, Rotterdam, The Netherlands
| | - Paul P Kortan
- Division of Gastroenterology, Centre for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Sundeep Lakhtakia
- Service de Gastroentérologie et d'Endoscopie Digestive, Hôpital Edouard Herriot, Lyon, France
| | - Joyce Peetermans
- Boston Scientific Corporation, Marlboro, Massachusetts, United States
| | - Matthew Rousseau
- Boston Scientific Corporation, Marlboro, Massachusetts, United States
| | - David Carr-Locke
- The Center for Advanced Digestive Care, Weill Cornell Medicine, New York Presbyterian Hospital, New York, USA
| | - Jacques Devière
- Gastro-Entérologie et d'Hépato-Pancréatologie, Universite Libre de Bruxelles Hôpital Erasme, Brussels, Belgium
| | - Guido Costamagna
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Digestive Endoscopy Unit, Rome, Italy.,Università Cattolica del Sacro Cuore, Centre for Endoscopic Research Therapeutics and Training (CERTT), Rome, Italy
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30
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García de la Filia Molina I, García García de Paredes A, Martínez Ortega A, Marcos Carrasco N, Rodríguez De Santiago E, Sánchez Aldehuelo R, Foruny Olcina JR, González Martin JÁ, López Duran S, Vázquez Sequeiros E, Albillos A. Biliary sphincterotomy reduces the risk of acute gallstone pancreatitis recurrence in non-candidates for cholecystectomy. Dig Liver Dis 2019; 51:1567-1573. [PMID: 31151894 DOI: 10.1016/j.dld.2019.05.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/28/2019] [Accepted: 05/01/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Population aging and comorbidity are leading to an increase in patients unfit for cholecystectomy. AIMS To evaluate whether endoscopic biliary sphincterotomy after a first episode of acute gallstone pancreatitis reduces the risk of pancreatitis recurrence and gallstone-related events in non-surgical candidates. METHODS Retrospective study of patients admitted for a first episode of acute gallstone pancreatitis rejected for cholecystectomy between 2013-2018. The role of endoscopic sphincterotomy was evaluated by adjusting for age, severity of pancreatitis, and presence of choledocholithiasis. RESULTS We included 247 patients (mean age 80 ± 12 years; Charlson index: 5; severity of pancreatitis: 72% mild). Sphincterotomy was performed in 23.9%. Recurrence of pancreatitis occurred in 17.4% patients (median follow-up: 426 days). The one-year cumulative incidence of a new episode of pancreatitis was 1.8% (95% confidence interval [CI]: 0.2-12%) and 23% (95% CI: 17-31%) in patients with and without sphincterotomy, respectively (p = 0.006). In multivariate analysis, sphincterotomy showed a protective role for recurrence of pancreatitis (adjusted hazard ratio [HR]: 0.29, 95% CI: 0.08-0.92, p = 0.037) and for any gallstone-related event (HR 0.46, 95% CI: 0.21-0.98, p = 0.043). CONCLUSIONS Endoscopic biliary sphincterotomy reduced the risk of gallstone pancreatitis recurrence and other biliary-related disorders in patients with a first episode of pancreatitis non-candidates for cholecystectomy.
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Affiliation(s)
- Irene García de la Filia Molina
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain
| | - Ana García García de Paredes
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain; Ramón y Cajal Institute of Biosanitary Research (IRYCIS), Madrid, Spain.
| | - Antonio Martínez Ortega
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain
| | - Natalia Marcos Carrasco
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain
| | - Enrique Rodríguez De Santiago
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain; Ramón y Cajal Institute of Biosanitary Research (IRYCIS), Madrid, Spain
| | - Rubén Sánchez Aldehuelo
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain
| | - Jose Ramón Foruny Olcina
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain; Ramón y Cajal Institute of Biosanitary Research (IRYCIS), Madrid, Spain
| | - Juan Ángel González Martin
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain; Ramón y Cajal Institute of Biosanitary Research (IRYCIS), Madrid, Spain
| | - Sergio López Duran
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain
| | - Enrique Vázquez Sequeiros
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain; Ramón y Cajal Institute of Biosanitary Research (IRYCIS), Madrid, Spain
| | - Agustín Albillos
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain; Ramón y Cajal Institute of Biosanitary Research (IRYCIS), Madrid, Spain; Biomedical Research Center in Liver and Digestive Diseases Network (CIBERehd), Carlos III Health Institute, Madrid, Spain
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31
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Kapila N, Singh H, Kandragunta K, Castro FJ. Open Access Colonoscopy for Colorectal Cancer Prevention: An Evaluation of Appropriateness and Quality. Dig Dis Sci 2019; 64:2798-2805. [PMID: 30955174 DOI: 10.1007/s10620-019-05612-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 04/02/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Open access colonoscopy (OAC) has gained widespread acceptance and has the potential to increase colorectal cancer (CRC) screening. However, there is little data evaluating its appropriateness for CRC prevention. AIMS The aim of this study is to evaluate the appropriateness of OAC in CRC screening and polyp surveillance by comparing to procedures ordered by gastroenterologists (NOAC). As secondary outcomes, we compared the quality of bowel preparation and adenoma detection rate (ADR) between OAC and NOAC. METHODS It is retrospective single-center study. Inclusion criteria included patients > 50 years of age undergoing a colonoscopy for CRC screening and surveillance. Appropriateness was defined as those colonoscopies performed within 12 months of the recommended 2012 consensus guidelines. Secondary outcomes included the quality of bowel preparation and ADR. RESULTS 5211 colonoscopies met inclusion criteria, and 64.9% were OAC. Screening OAC was appropriately 91.6% and NOAC 92.9% of the time (p = 0.179). Surveillance NOAC were inappropriate in 26.4% of cases, and surveillance OAC was 32.6% (p = 0.008). Multivariate analysis demonstrated that OAC did not influence ADR (OR for NOAC 0.97; 95% CI 0.86-1.1; p = 0.644) or an adequate bowel preparation (OR for NOAC 1.11; 95% CI 0.91-1.36; p = 0.306). CONCLUSION OAC performed similarly to NOAC for screening indications, quality of bowel preparation, and ADR. However, more surveillance procedures were inappropriate in the OAC group although both groups had a high number of inappropriate indications. Although OAC can be efficiently performed for screening indications, measures to decrease inappropriate surveillance colonoscopies are needed.
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Affiliation(s)
- Nikhil Kapila
- Department of Gastroenterology, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL, USA.
| | - Harjinder Singh
- Department of Gastroenterology, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL, USA
| | - Kiranmayee Kandragunta
- Department of Gastroenterology, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL, USA
| | - Fernando J Castro
- Department of Gastroenterology, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL, USA
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Krafft MR, Nasr JY. Anterograde Endoscopic Ultrasound-Guided Pancreatic Duct Drainage: A Technical Review. Dig Dis Sci 2019; 64:1770-1781. [PMID: 30734236 DOI: 10.1007/s10620-019-05495-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 01/24/2019] [Indexed: 12/27/2022]
Abstract
The advancement of pancreatic endotherapy has increased the availability of minimally invasive endoscopic pancreatic ductal drainage techniques. In this regard, familiarity with endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD) is critical for treatment of obstructed pancreatic ductal systems, especially in nonsurgical candidates and in patients desiring a minimally invasive approach. Two distinct forms of EUS-PDD exist, viz. rendezvous-assisted endoscopic retrograde pancreatography (rendezvous-assisted ERP) and anterograde EUS-PDD. Anterograde EUS-PDD refers to transmural anterograde passage of a pancreatic drainage catheter or stent directly into the main pancreatic duct, through either the gastric or enteral wall. Rendezvous-assisted ERP should be attempted after failed conventional ERP, and anterograde EUS-PDD should be considered if rendezvous-assisted ERP fails or is not technically feasible. Common clinical scenarios that fulfil these conditions are chronic pancreatitis with high-grade main pancreatic duct obstruction, surgically altered anatomy with ductal/anastomotic obstruction, pancreas divisum, and disconnected pancreatic duct syndrome. The focus of this review article is anterograde EUS-PDD and its indications, technique, and outcomes. It also provides a summary of our own experience with this procedure, and a video demonstration of the technique.
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Affiliation(s)
- Matthew R Krafft
- Section of Digestive Diseases, West Virginia University Medicine, PO Box 9161, One Medical Center Drive, Morgantown, WV, 26506-9161, USA
| | - John Y Nasr
- Section of Digestive Diseases, West Virginia University Medicine, PO Box 9161, One Medical Center Drive, Morgantown, WV, 26506-9161, USA.
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Sánchez Rodríguez E, García García de Paredes A, Albillos A. Current management of acute idiopathic pancreatitis and acute recurrent pancreatitis. Rev Clin Esp 2019. [DOI: 10.1016/j.rceng.2019.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Sánchez Rodríguez E, García García de Paredes A, Albillos A. Manejo actual de la pancreatitis aguda idiopática y la pancreatitis aguda recurrente. Rev Clin Esp 2019; 219:266-274. [DOI: 10.1016/j.rce.2018.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 12/28/2018] [Indexed: 02/07/2023]
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35
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Han S, Shah RJ. ERCP with Digital Pancreatoscopy-Guided Stone Fragmentation: Breaking Up Is Easy to Do. Dig Dis Sci 2019; 64:1059-1061. [PMID: 30788682 PMCID: PMC6499632 DOI: 10.1007/s10620-019-05502-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Samuel Han
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado Anschutz Medical Center, 1635 Aurora Ct, Mail Stop F735, Rm. AIP 2.031, Aurora, CO, 80045, USA
| | - Raj J Shah
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado Anschutz Medical Center, 1635 Aurora Ct, Mail Stop F735, Rm. AIP 2.031, Aurora, CO, 80045, USA.
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Shih HY, Hsu WH, Kuo CH. Postendoscopic retrograde cholangiopancreatography pancreatitis. Kaohsiung J Med Sci 2019; 35:195-201. [PMID: 30887733 DOI: 10.1002/kjm2.12040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 01/09/2019] [Indexed: 12/11/2022] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) has been a mainstay examination to clarify the biliary and pancreatic system. Not just diagnostic purpose, it could achieve therapeutic goal. Under the trend of more and more procedures about ERCP being interventional, the rate of adverse events after the procedure is increasing. Among them, post-ERCP pancreatitis (PEP) is the most common and sometimes tremendous complication. This mini-review will overview the PEP from definition, pathogenesis, and risk factors to prevention.
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Affiliation(s)
- Hsiang-Yao Shih
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Wen-Hung Hsu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chao-Hung Kuo
- Department of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan
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Li J, Chen J, Tang W. The consensus of integrative diagnosis and treatment of acute pancreatitis-2017. J Evid Based Med 2019; 12:76-88. [PMID: 30806495 DOI: 10.1111/jebm.12342] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Indexed: 01/11/2023]
Abstract
Acute pancreatitis (AP) is one of the most common acute abdominal diseases. The digestive disease committee, Chinese Association of Integrative Medicine, released Integrated traditional Chinese and Western medicine for diagnosis and treatment of acute pancreatitis in 2010.1 Since then, further studies and great progress have been made by domestic and foreign counterparts from the perspective of both Chinese and Western medicine in AP, including the classification, fluid resuscitation, organ function maintenance, surgery intervention, enteral nutrition (EN), and syndrome differentiation and treatment. It is necessary to update the consensus on diagnosis and treatment of integrated Chinese and Western medicine to meet clinical needs. Therefore, the 2012 Revision of the Atlanta Classification Standard (RAC) by the International AP Consensus,2 the 2013 the Management of Acute Pancreatitis by the American College of Gastroenterology,3, 4 the 2014 Guidelines for diagnosis and treatment of the acute pancreatitis guide (2014) by the Chinese medical association branch,5 the 2014 Guidelines on Integrative Medicine for Severe Acute Pancreatitis by the General Surgery Committee of the Chinese Society of Integrated Traditional Chinese and Western Medicine,6 and Traditional Chinese Medicine Consensus on the Diagnosis and Treatment for Acute Pancreatitis by the Spleen and Stomach committee of China Association of Traditional Chinese Medicine7, 8 were taken into account for the revision of the consensus published in 2010. The digestive specialists in Chinese and Western medicine had a discussion on traditional Chinese medicine (TCM) types, syndrome differentiation, the main points of integrative medicine, and so on. According to the Delphi method, Consensus of Integrative Diagnosis and Treatment of Acute Pancreatitis (the 2017 revision) has been passed after three rounds votes. (The voting options are as follows: (a) totally agree; (b) agree, but with some reservations; (c) agree, but with larger reservations; (d) disagree, but reserved; and (e) absolutely disagree. If more than two out of three choose (a), or over 85% choose (a) + (b), the consensus will be passed.) The final validation was carried out by the core expert group in Taizhou, Jiangsu on June 9, 2017. The full text is as follows.
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Affiliation(s)
- Junxiang Li
- Digestive Disease Committee, Chinese Association of Integrative Medicine
| | - Jing Chen
- Digestive Disease Committee, Chinese Association of Integrative Medicine
| | - Wenfu Tang
- Digestive Disease Committee, Chinese Association of Integrative Medicine
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De Luca L, Repici A, Koçollari A, Auriemma F, Bianchetti M, Mangiavillano B. Pancreatoscopy: An update. World J Gastrointest Endosc 2019; 11:22-30. [PMID: 30705729 PMCID: PMC6354109 DOI: 10.4253/wjge.v11.i1.22] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 12/21/2018] [Accepted: 12/30/2018] [Indexed: 02/06/2023] Open
Abstract
Per-oral pancreatoscopy (POPS) is an endoscopic procedure to visualize the main pancreatic duct. POPS specifically has the advantage of direct visualization of the pancreatic duct, allowing tissue acquisition and directed therapies such as stones lithotripsy. The aim of this review is to analyze and summarize the literature around pancreatoscopy. Pancreatoscopy consists of the classic technique of the mother-baby method in which a mini-endoscope is passed through the accessory channel of the therapeutic duodenoscope. Pancreatoscopy has two primary indications for diagnostic purpose. First, it is used for visualization and histological diagnosis of intraductal papillary mucinous neoplasms. In these cases, POPS is very useful to assess the extent of malignancy and for the study of the intraductal papillary mucinous neoplasm in order to guide the surgery resection margins. Second, it is used to determine pancreatic duct strictures, particularly important in cases of chronic pancreatitis, which is associated with both benign and malignant strictures. Therefore POPS allows differentiation between benign and malignant disease and allows mapping the extent of the tumor prior to surgical resection. Also tissue sampling is possible, but it can be technically difficult because of the limited maneuverability of the biopsy forceps in the pancreatic ducts. Pancreatoscopy can also be used for therapeutic purposes, such as pancreatoscopy-guided lithotripsy in chronic painful pancreatitis with pancreatic duct stones. The available data for the moment suggests that, in selected patients, pancreatoscopy has an important and promising role to play in the diagnosis of indeterminate pancreatic duct strictures and the mapping of main pancreatic duct intraductal papillary mucinous neoplasms. However, further studies are necessary to elucidate and validate the pancreatoscopy role in the therapeutic algorithm of chronic pancreatitis.
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Affiliation(s)
- Luca De Luca
- Gastroenterology and Digestive Endoscopy Unit, Ospedali Riuniti Marche Nord, Piazzale Cinelli, Pesaro 61121, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Italy
- Humanitas University, Pieve Emanuele 20090, Italy
| | - Adea Koçollari
- Gastroenterology Unit, University Medical Center “Mother Theresa” Hospital, Tirana 1000, Albania
| | - Francesco Auriemma
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza 21053, Italy
| | - Mario Bianchetti
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza 21053, Italy
| | - Benedetto Mangiavillano
- Humanitas University, Pieve Emanuele 20090, Italy
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza 21053, Italy
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Abstract
PURPOSE OF REVIEW To provide an overview of the field of pancreatoscopy and to summarize the data informing its clinical utility. RECENT FINDINGS Regarding the technological advance of pancreatoscopy, recent studies are the first to report the use of digital, single-operator pancreatoscopy (SpyGlass DS; Boston Scientific, Natick, MA). New data on the use of preoperative pancreatoscopy offer promising results for the potential to optimize treatment of intraductal papillary mucinous neoplasms and to differentiate between benign and malignant pancreatic strictures. Finally, there has been accumulating evidence for the use of pancreatoscopy-guided lithotripsy for the management of painful chronic calcific pancreatitis. SUMMARY Endoscopic pancreatoscopy offers the advantage of direct visualization of the pancreatic duct, allowing for optimal macroscopic assessment, targeted tissue acquisition and guided therapies such as lithotripsy of pancreatic duct stones. The data informing some aspects remain limited, but the accumulating literature forms our understanding of the current and future role of pancreatoscopy in the management of pancreatic disease.
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Bhanthumkomol P, Hara K, Mizuno N, Hijioka S, Okuno N, Yoshida T, Tokuhisa J, Siramolpiwat S, Vilaichone RK, Pornthisarn B, Niwa Y, Tajika M, Tanaka T, Ishihara M, Hirayama Y, Yamao K. Feasibility of the unilateral-flange stent for the treatment of benign pancreatic duct stricture: a pilot study. NAGOYA JOURNAL OF MEDICAL SCIENCE 2017; 79:453-458. [PMID: 29238101 PMCID: PMC5719204 DOI: 10.18999/nagjms.79.4.453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Endoscopic placement of the plastic stent has been adopted as an initial treatment for chronic pancreatitis with pancreatic duct stricture. Stent fracture while attempting removal is one of the complications of stent exchange. The use of the unilateral-flange stent in these patients has never been reported. We investigated the outcomes associated with the use of this stent with regard to stent exchange and stent-related adverse events. From 2011 to 2015, 9 patients with chronic pancreatitis and main pancreatic duct (MPD) stricture treated with the unilateral-flange stent were included. Eleven endoscopic treatment sessions, 53 endoscopic stent deployments or exchange procedures were analyzed. Technical success rate was 100%. Forty-eight stents were exchanged on a regular basis in 1 to 6-month intervals. Another 5 stent exchange procedures were urgently performed due to stent obstruction and caused pancreatitis (n=2), symptomatic external stent migration (n=2), and concurrent cholangitis (n=1). The rate of symptomatic migration was 3.7%. The mean duration for stent exchange was 29 minutes and no stent fracture occurred during the procedure. Of 11 endoscopic treatment sessions, 7 were successful, 3 were changed to the metallic stents, and 1 was lost to follow-up. According to this study, unilateral-flange stent placement for benign MPD stricture is technically feasible and effective. Stent removal during the exchange period is unchallenging and without stent fracture.
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Affiliation(s)
| | - Kazuo Hara
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nobumasa Mizuno
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Susumu Hijioka
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nozomi Okuno
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Tsukasa Yoshida
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Junya Tokuhisa
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Sith Siramolpiwat
- Gastroenterology Unit, Thammasat University Hospital, Pathumthani, Thailand
| | | | - Bubpha Pornthisarn
- Gastroenterology Unit, Thammasat University Hospital, Pathumthani, Thailand
| | - Yasumasa Niwa
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Masahiro Tajika
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Tsutomu Tanaka
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Makoto Ishihara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yutaka Hirayama
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Kenji Yamao
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
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41
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Endoscopic ultrasound–guided biliary and pancreatic duct access and intervention. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2017. [DOI: 10.1016/j.tgie.2017.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Krishnamoorthi R, Jayaraj M, Kozarek R. Endoscopic Stents for the Biliary Tree and Pancreas. ACTA ACUST UNITED AC 2017; 15:397-415. [DOI: 10.1007/s11938-017-0139-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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43
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Kolasinski NT, Johannsen MT, Hollon JR. Fifteen-Year-Old Male with Type 2 Autoimmune Pancreatitis: An Argument for Endoscopy. Case Rep Gastroenterol 2017. [PMID: 28626379 PMCID: PMC5471753 DOI: 10.1159/000453659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Type 2 autoimmune pancreatitis, an increasingly recognized etiology of pancreatitis in patients less than 20 years old, has characteristically been diagnosed with the histological finding of duct-centric pancreatitis in a patient who lacks elevated serum immunoglobulin G4. We present the case of a nonobese 15-year-old male, without any chronic medical conditions, who presented with the chief complaint of abdominal pain. The laboratory study results were remarkable for a lipase level of 5,419 U/L and a γ-glutamyl transferase level of 373 U/L. Magnetic resonance cholangiopancreatography revealed delayed contrast enhancement of the pancreas, diffuse parenchymal enlargement, and lack of normal lobulation. The patient's serum immunoglobulin G4 level was found to be 66 mg/dL, which was within normal limits and supportive of a diagnosis of type 2 autoimmune pancreatitis. Despite the absence of intestinal complaints, the patient underwent subsequent endoscopy due to the correlation of type 2 autoimmune pancreatitis with inflammatory bowel disease that has been described in recent literature. Pan-colonic mild colitis was visualized, and the patient began treatment with steroids, to which he quickly responded. Performing endoscopy on this patient allowed for confident initiation of early therapy for both autoimmune pancreatitis and inflammatory bowel disease, and may have limited further surgical intervention and disease progression. For these reasons, this case highlights the utility of endoscopy in pediatric patients with suspected type 2 autoimmune pancreatitis, even in the absence of intestinal symptoms.
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Affiliation(s)
- Nathan T Kolasinski
- Department of Pediatrics, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
| | - Marc T Johannsen
- Department of Radiology, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
| | - Justin R Hollon
- Department of Pediatrics, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
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Lai X, Wang M, McElyea SD, Sherman S, House M, Korc M. A microRNA signature in circulating exosomes is superior to exosomal glypican-1 levels for diagnosing pancreatic cancer. Cancer Lett 2017; 393:86-93. [PMID: 28232049 PMCID: PMC5386003 DOI: 10.1016/j.canlet.2017.02.019] [Citation(s) in RCA: 234] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 02/13/2017] [Accepted: 02/13/2017] [Indexed: 12/12/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a deadly malignancy that often presents clinically at an advanced stage and that may be confused with chronic pancreatitis (CP). Conversely, CP may be misdiagnosed as PDAC leading to unwarranted pancreas resection. Therefore, early PDAC diagnosis and clear differentiation between PDAC and CP are crucial for improved care. Exosomes are circulating microvesicles whose components can serve as cancer biomarkers. We compared exosomal glypican-1 (GPC1) and microRNA levels in normal control subjects and in patients with PDAC and CP. We report that exosomal GPC1 is not diagnostic for PDAC, whereas high exosomal levels of microRNA-10b, (miR-10b), miR-21, miR-30c, and miR-181a and low miR-let7a readily differentiate PDAC from normal control and CP samples. By contrast with GPC1, elevated exosomal miR levels decreased to normal values within 24 h following PDAC resection. All 29 PDAC cases exhibited significantly elevated exosomal miR-10b and miR-30c levels, whereas 8 cases had normal or slightly increased CA 19-9 levels. Thus, our exosomal miR signature is superior to exosomal GPC1 or plasma CA 19-9 levels in establishing a diagnosis of PDAC and differentiating between PDAC and CP.
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MESH Headings
- Area Under Curve
- Biomarkers, Tumor/blood
- Biomarkers, Tumor/genetics
- CA-19-9 Antigen/blood
- Carcinoma, Pancreatic Ductal/blood
- Carcinoma, Pancreatic Ductal/diagnosis
- Carcinoma, Pancreatic Ductal/genetics
- Carcinoma, Pancreatic Ductal/surgery
- Case-Control Studies
- Chromatography, Liquid
- Diagnosis, Differential
- Exosomes/metabolism
- Gene Expression Profiling/methods
- Glypicans/blood
- Humans
- MicroRNAs/blood
- MicroRNAs/genetics
- Oligonucleotide Array Sequence Analysis
- Pancreatic Neoplasms/blood
- Pancreatic Neoplasms/diagnosis
- Pancreatic Neoplasms/genetics
- Pancreatic Neoplasms/surgery
- Pancreatitis, Chronic/blood
- Pancreatitis, Chronic/diagnosis
- Pancreatitis, Chronic/genetics
- Predictive Value of Tests
- ROC Curve
- Reproducibility of Results
- Tandem Mass Spectrometry
- Transcriptome
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Affiliation(s)
- Xianyin Lai
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN 46202, USA; Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
| | - Mu Wang
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Samantha Deitz McElyea
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Stuart Sherman
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA; Pancreatic Cancer Signature Center, Indiana University Simon Cancer Center, Indianapolis, IN 46202, USA
| | - Michael House
- Pancreatic Cancer Signature Center, Indiana University Simon Cancer Center, Indianapolis, IN 46202, USA; Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Murray Korc
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN 46202, USA; Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA; Pancreatic Cancer Signature Center, Indiana University Simon Cancer Center, Indianapolis, IN 46202, USA.
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Specialized Imaging and Procedures in Pediatric Pancreatology: A North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Clinical Report. J Pediatr Gastroenterol Nutr 2017; 64:472-484. [PMID: 28230608 DOI: 10.1097/mpg.0000000000001371] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES An increasing number of children are being diagnosed with pancreatitis and other pancreatic abnormalities. Dissemination of the information regarding existing imaging techniques and endoscopic modalities to diagnose and manage pancreatic disorders in children is sorely needed. METHODS We conducted a review of the medical literature on the use of the following imaging and procedural modalities in pediatric pancreatology: transabdominal ultrasonography (TUS), computed tomography (CT), magnetic resonance imaging (MRI)/magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasonography (EUS), and endoscopic retrograde cholangiopancreatography (ERCP). Recommendations for current use and future research were identified. RESULTS TUS offers noninvasive images of the pancreas but has limitations to details of parenchyma and ductal structures. CT offers improved detail of pancreatic parenchyma, solid masses, and traumatic injuries, but requires relatively high levels of ionizing radiation and does not adequately assess ductal anatomy. MRI/MRCP offers detailed intrinsic tissue assessment and pancreatic ductal characterization, but requires longer image acquisition time and is relatively poor at imaging calcifications. EUS provides excellent evaluation of pancreatic parenchyma and ductal anatomy, but can be subjective and operator dependent and requires sedation or anesthesia. EUS offers the capacity to obtain tissue samples and drain fluid collections and ERCP offers the ability to improve drainage by performing sphincterotomy or placing pancreatic stents across duct injuries and strictures. CONCLUSIONS Various imaging modalities may be used in pediatric pancreatology, but TUS and MRI/MRCP are favored. Interventional therapeutic maneuvers primarily involve use of ERCP and EUS. Future research is necessary to optimize equipment, expertise, and appropriate indications.
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46
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Chandrasekhara V, Khashab MA, Muthusamy VR, Acosta RD, Agrawal D, Bruining DH, Eloubeidi MA, Fanelli RD, Faulx AL, Gurudu SR, Kothari S, Lightdale JR, Qumseya BJ, Shaukat A, Wang A, Wani SB, Yang J, DeWitt JM. Adverse events associated with ERCP. Gastrointest Endosc 2017; 85:32-47. [PMID: 27546389 DOI: 10.1016/j.gie.2016.06.051] [Citation(s) in RCA: 438] [Impact Index Per Article: 62.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 06/30/2016] [Indexed: 02/07/2023]
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47
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Matsubara S, Sasahira N, Isayama H, Takahara N, Mizuno S, Kogure H, Yamamoto N, Nakai Y, Tada M, Koike K. Prospective pilot study of fully covered self-expandable metal stents for refractory benign pancreatic duct strictures: long-term outcomes. Endosc Int Open 2016; 4:E1215-E1222. [PMID: 27853749 PMCID: PMC5110351 DOI: 10.1055/s-0042-115934] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 08/01/2016] [Indexed: 12/14/2022] Open
Affiliation(s)
- Saburo Matsubara
- Graduate School of Medicine, The University of Tokyo – Gastroenterology, Tokyo, Japan
| | - Naoki Sasahira
- Graduate School of Medicine, The University of Tokyo – Gastroenterology, Tokyo, Japan
| | - Hiroyuki Isayama
- Graduate School of Medicine, The University of Tokyo – Gastroenterology, Tokyo, Japan,Corresponding author: Hiroyuki Isayama Graduate School of MedicineThe University of Tokyo – Gastroenterology7-3-1 Hongo, Bunkyo-kuTokyo 113-8655Japan+81-3-3815-5411+81-3-5800-9801
| | - Naminatsu Takahara
- Graduate School of Medicine, The University of Tokyo – Gastroenterology, Tokyo, Japan
| | - Suguru Mizuno
- Graduate School of Medicine, The University of Tokyo – Gastroenterology, Tokyo, Japan
| | - Hirofumi Kogure
- Graduate School of Medicine, The University of Tokyo – Gastroenterology, Tokyo, Japan
| | - Natsuyo Yamamoto
- Graduate School of Medicine, The University of Tokyo – Gastroenterology, Tokyo, Japan
| | - Yousuke Nakai
- Graduate School of Medicine, The University of Tokyo – Gastroenterology, Tokyo, Japan
| | - Minoru Tada
- Graduate School of Medicine, The University of Tokyo – Gastroenterology, Tokyo, Japan
| | - Kazuhiko Koike
- Graduate School of Medicine, The University of Tokyo – Gastroenterology, Tokyo, Japan
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48
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Abstract
PURPOSE OF REVIEW Endoscopy plays a central role in the evaluation and management of patients with pancreatic disease. This review focuses on recent clinically relevant developments and timely research questions related to endoscopy in acute and chronic pancreatitis. RECENT FINDINGS Endoscopic ultrasound (EUS) has moved to the forefront of the evaluation of unexplained pancreatitis; endoscopic retrograde cholangiopancreatography (ERCP) for recurrent acute pancreatitis remains controversial but commonly practiced; fully covered metallic stents are challenging traditional stent therapy in the treatment of benign biliary and pancreatic strictures due to chronic pancreatitis; endoscopic drainage has become central in the therapeutic algorithm for pancreatic fluid collections; EUS-guided access to the pancreatic duct in cases of unsuccessful ERCP is a promising new platform that requires additional research and development. The evidence in these areas is discussed, with an emphasis on recent high-impact publications. SUMMARY There have been significant recent advances in our endoscopic approach to pancreatic disease; however, additional research is necessary toward providing high-quality, evidence-based care in this area. VIDEO ABSTRACT.
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49
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Prospective Endoscopic Ultrasound-Based Approach to the Evaluation of Idiopathic Pancreatitis: Causes, Response to Therapy, and Long-term Outcome. Am J Gastroenterol 2016; 111:1339-48. [PMID: 27325219 DOI: 10.1038/ajg.2016.240] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 05/11/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Although idiopathic pancreatitis is common, the natural history is not well studied, and the best diagnostic approach to both single and multiple attacks remains undefined. METHODS We prospectively evaluated patients with idiopathic pancreatitis over a 10-year period, and clinical information for each episode was reviewed. Endoscopic ultrasound (EUS) was performed in all patients. Patients with microlithiasis or bile duct stones were referred for cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP), respectively. For those with a single attack, if EUS was normal or chronic pancreatitis or pancreas divisum was diagnosed, the patient was followed up for recurrence. For those with multiple attacks and a negative EUS, ERCP and sphincter of Oddi manometry with endoscopic therapy as appropriate were recommended. All patients were followed up in the long term to evaluate for recurrent pancreatitis, the primary study end point. RESULTS Over the study period, 201 patients were identified (80 single attack, 121 multiple attacks; mean age 53 years, range 17-95 years, s.d. 16.3 years; and 53% female). After EUS, 54% of patients with a single attack were categorized as idiopathic, and for multiple attacks sphincter of Oddi dysfunction (SOD) was the most common diagnosis (41%). Long-term follow-up (median 37 months; interquartile range 19-70 months) documented recurrence of pancreatitis in 15 (24%; 95% confidence interval (CI), 15-38%) patients with a single attack and in 48 (49%; 95% CI, 38-62%) patients with multiple attacks. Despite endoscopic therapy, patients with pancreas divisum and SOD had relapse rates of 50% (95% CI, 35 to 68%) and 55% (95% CI, 31 to 82%), respectively. CONCLUSIONS Following a single idiopathic attack of pancreatitis and a negative EUS examination, relapse was infrequent. Despite endoscopic therapy, patients with multiple attacks, especially those attributed to pancreas divisum and SOD, had high rates of recurrence. EUS may be a useful, minimally invasive tool for the diagnostic evaluation of idiopathic pancreatitis. The study was listed in Clinicaltrials.gov NCT00609726.
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50
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Elmunzer BJ, Foster LD, Durkalski V. Should We Still Administer Prophylactic Rectal NSAIDs to Average-Risk Patients Undergoing ERCP? Gastroenterology 2016; 151:566-7. [PMID: 27487170 DOI: 10.1053/j.gastro.2016.05.055] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 05/11/2016] [Accepted: 05/20/2016] [Indexed: 02/04/2023]
Affiliation(s)
- B Joseph Elmunzer
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | - Lydia D Foster
- Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Valerie Durkalski
- Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina
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