Impact of biliary metal and plastic stents on preoperative staging for pancreatic cancer

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Background: Multiple studies have shown the superiority of biliary metal compared with plastic stents for pre-operative (preop) biliary drainage in pancreatic cancer (PDAC). Despite the importance of preop cross-sectional imaging, particularly in the era of neoadjuvant treatment, there is no data on the impact of such stents on the quality of preop cross-sectional imaging. We hypothesis, that biliary metal stents negatively impact the accuracy of preop cross-sectional imaging in pancreatic cancer, with unknown impact for the adequacy of surgical candidacy. Methods: Data of all patients undergoing pancreatic resection for PDAC between 1/1/2012 and 1/1/2018 was retrospectively abstracted. Clinical staging based on preop cross-sectional imaging following biliary stent placement (within 2 months prior surgical resection) was compared with the surgical pathology (staging gold standard). Accuracy of clinical and surgical pathology staging was compared. Logistic regression was performed to control for biliary stent type, neoadjuvant treatment and patient baseline characteristics including BMI and type of imaging. Results: 312 patients underwent pancreatic resections. 118 patients required preop biliary drainage in setting of PDAC, including 92 ERCPs of which 83 were successful (46 plastic and 37 metal stents). 76 patients underwent neoadjuvant chemoradiation therapy. Surgical pathology revealed following stages: 0 n = 4, 1A n = 5, 1B n = 8, 2A n = 20, 2B n = 24, 3 n = 1, 4 n = 14. 96% underwent preop CT and 4% MRI pancreas protocol imaging. Exact correlation between clinical and surgical pathology was present in only 48% of cases (57% plastic, 46% metal stent), with 28% of clinical T overstaging, 4% clinical T understaging, 16% clinical N understaging and 4% unable to stage due to artefacts. More importantly, 8% patients were incorrectly staged to be surgical candidates (14% plastic, 6% metal). Controlling for stent type, neoadjuvant treatment and BMI did not impact preop cross-sectional imaging accuracy. Conclusions: Despite their impact on preop cross-imaging biliary metal stents did not negatively impact the accuracy and patient selection for surgical candidacy compared with biliary plastic stents in PDAC.

Multicenter evaluation of the clinical utility of laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass

BACKGROUND AND AIMS

The obesity epidemic has led to increased use of Roux-en-Y gastric bypass (RYGB). These patients have an increased incidence of pancreaticobiliary diseases, yet standard ERCP is not possible because of surgically altered gastroduodenal anatomy. Laparoscopy-assisted ERCP (LA-ERCP) has been proposed as an option, but supporting data are derived from single-center small case series. Therefore, we conducted a large multicenter study to evaluate the feasibility, safety, and outcomes of LA-ERCP.

METHODS

This is a retrospective cohort study of adult patients with RYGB who underwent LA-ERCP in 34 centers. Data on demographics, indications, procedure success, and adverse events were collected. Procedure success was defined when all the following were achieved: reaching the papilla, cannulating the desired duct, and providing endoscopic therapy as clinically indicated.

RESULTS

A total of 579 patients (median age, 51; 84% women) were included. Indication for LA-ERCP was biliary in 89%, pancreatic in 8%, and both in 3%. Procedure success was achieved in 98%. Median total procedure time was 152 minutes (interquartile range [IQR], 109-210), with a median ERCP time of 40 minutes (IQR, 28-56). Median hospital stay was 2 days (IQR, 1-3). Adverse events were 18% (laparoscopy related, 10%; ERCP related, 7%; both, 1%) with the clear majority (92%) classified as mild/moderate, whereas 8% were severe and 1 death occurred.

CONCLUSIONS

Our large multicenter study indicates that LA-ERCP in patients with RYGB is feasible with a high procedure success rate comparable with that of standard ERCP in patients with normal anatomy. The ERCP-related adverse events rate is comparable with conventional ERCP, but the overall adverse event rate was higher because of the added laparoscopy-related events.

Percutaneous transhepatic vs. endoscopic retrograde biliary drainage for suspected malignant hilar obstruction: study protocol for a randomized controlled trial

Background

The optimal approach to the drainage of malignant obstruction at the liver hilum remains uncertain. We aim to compare percutaneous transhepatic biliary drainage (PTBD) to endoscopic retrograde cholangiography (ERC) as the first intervention in patients with cholestasis due to suspected malignant hilar obstruction (MHO).

Methods

The INTERCPT trial is a multi-center, comparative effectiveness, randomized, superiority trial of PTBD vs. ERC for decompression of suspected MHO. One hundred and eighty-four eligible patients across medical centers in the United States, who provide informed consent, will be randomly assigned in 1:1 fashion via a web-based electronic randomization system to either ERC or PTBD as the initial drainage and, if indicated, diagnostic procedure. All subsequent clinical interventions, including crossover to the alternative procedure, will be dictated by treating physicians per usual clinical care. Enrolled subjects will be assessed for successful biliary drainage (primary outcome measure), adequate tissue diagnosis, adverse events, the need for additional procedures, hospitalizations, and oncological outcomes over a 6-month follow-up period. Subjects, treating clinicians and outcome assessors will not be blinded.

Discussion

The INTERCPT trial is designed to determine whether PTBD or ERC is the better initial approach when managing a patient with suspected MHO, a common clinical dilemma that has never been investigated in a randomized trial.

Trial registration

ClinicalTrials.gov, Identifier: NCT03172832. Registered on 1 June 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2473-2) contains supplementary material, which is available to authorized users.

White Paper AGA: Advanced Imaging in Barrett's Esophagus

Enhanced imaging technologies such as narrow band imaging, flexible spectral imaging color enhancement, i-Scan, confocal laser endomicroscopy, and optical coherence tomography are readily available for use by endoscopists in routine clinical practice. In November 2014, the American Gastroenterological Association's Center for GI Innovation and Technology conducted a 2-day workshop to discuss endoscopic image enhancement technologies, focusing on their role in 2 specific clinical conditions (colon polyps and Barrett's esophagus) and on issues relating to training and implementation of these technologies (white papers). Although the majority of the studies that use enhanced imaging technologies have been positive, these techniques ideally need to be validated in larger cohorts and in community centers. As it stands today, detailed endoscopic examination with high-definition white-light endoscopy and random 4-quadrant biopsy remains the standard of care. However, the workshop panelists agreed that in the hands of endoscopists who have met the preservation and incorporation of valuable endoscopic innovation thresholds (diagnostic accuracy) with enhanced imaging techniques (specific technologies), use of the technique in Barrett's esophagus patients is appropriate.

Management of Diminutive Colon Polyps Based on Endoluminal Imaging

Diminutive colon polyps, defined as 5 mm or less, are encountered increasingly at colonoscopy. The risk of serious pathology in such polyps is low. There is a risk and cost of resecting all such polyps and sending tissue for pathologic evaluation. Enhancement of endoluminal imaging may enable discrimination of neoplastic vs non-neoplastic polyps. If this discrimination can be performed accurately with high confidence, it may be possible to either resect and discard diminutive adenomas, or inspect and do-not-resect diminutive hyperplastic polyps. In 2011, an expert group recommended thresholds of 90% negative predictive value for adenomas, and 90% accuracy in predicting appropriate surveillance intervals. Since 2011, criteria for polyp discrimination have been published and validated by experts and nonexperts. In vivo studies have been performed to compare endoscopic impression and pathologic diagnosis. An expert panel was convened in late 2014 to review the literature to determine if the proposed thresholds for discrimination can be attained and to recommend the next steps for introducing changes in clinical practice. We conclude that threshold levels can be achieved with several endoscopic image enhancements. The next steps to implementation of practice change include acquiring data on training and competence, determining best practices for auditing performance, understanding patient education needs, and the potential cost benefit of such changes.

Variation in Aptitude of Trainees in Endoscopic Ultrasonography, Based on Cumulative Sum Analysis

BACKGROUND & AIMS

Studies have reported substantial variation in the competency of advanced endoscopy trainees, indicating a need for more supervised training in endoscopic ultrasound (EUS). We used a standardized, validated, data collection tool to evaluate learning curves and measure competency in EUS among trainees at multiple centers.

METHODS

In a prospective study performed at 15 centers, 17 trainees with no prior EUS experience were evaluated by experienced attending endosonographers at the 25th and then every 10th upper EUS examination, over a 12-month training period. A standardized data collection form was used (using a 5-point scoring system) to grade the EUS examination. Cumulative sum analysis was applied to produce a learning curve for each trainee; it tracked the overall performance based on median scores at different stations and also at each station. Competency was defined by a median score of 1, with acceptable and unacceptable failure rates of 10% and 20%, respectively.

RESULTS

Twelve trainees were included in the final analysis. Each of the trainees performed 265 to 540 EUS examinations (total, 4257 examinations). There was a large amount of variation in their learning curves: 2 trainees crossed the threshold for acceptable performance (at cases 225 and 245), 2 trainees had a trend toward acceptable performance (after 289 and 355 cases) but required continued observation, and 8 trainees needed additional training and observation. Similar results were observed at individual stations.

CONCLUSIONS

A specific case load does not ensure competency in EUS; 225 cases should be considered the minimum caseload for training because we found that no trainee achieved competency before this point. Ongoing training should be provided for trainees until competency is confirmed using objective measures.

Double balloon enteroscopy: effective and minimally invasive method for removal of retained video capsules

BACKGROUND AND AIM

Prior case series document removal of retained video capsules predominantly via surgical intervention. Data on endoscopic removal of retained capsules are limited. Our aim was to describe an endoscopic method of retrieval using double balloon enteroscopy (DBE).

METHODS

A retrospective case series examination found 10 patients who underwent DBE for retrieval of a retained video capsule at two large tertiary referral academic centers from May 2007 to June 2013.

RESULTS

Mean age of patients was 64.9 ± 18.1 years (four females, six males). Five patients failed to pass the capsule as a result of an ileal or jejunal stricture (one patient with ulcerative colitis; four patients with Crohn's disease); two patients had a small bowel stricture as a result of non-steroidal anti-inflammatory drug enteropathy; one patient had intermittent partial small bowel obstruction without evidence of a stricture; one patient had an obstructing malignant jejunal mass and one patient had a small bowel stricture as a result of radiation enteritis. Endoscopic removal via DBE was successful in eight of 10 patients (80%). The remaining two patients underwent surgical removal of the retained capsule. The two failed cases of capsule retrieval were both patients with suspected ileal disease.

CONCLUSIONS

The most common cause of capsule retention was underlying Crohn's disease. DBE is an effective and minimally invasive method of capsule retrieval, including those patients with ileal disease, which has not been previously described. DBE can prevent unnecessary surgery while providing endoscopic therapy of inflammatory strictures by dilation.

Symptomatic cardiac toxicity is predicted by dosimetric and patient factors rather than changes in 18F-FDG PET determination of myocardial activity after chemoradiotherapy for esophageal cancer

PURPOSE

To determine factors associated with symptomatic cardiac toxicity in patients with esophageal cancer treated with chemoradiotherapy.

MATERIAL AND METHODS

We retrospectively evaluated 102 patients treated with chemoradiotherapy for locally advanced esophageal cancer. Our primary endpoint was symptomatic cardiac toxicity. Radiation dosimetry, patient demographic factors, and myocardial changes seen on (18)F-FDG PET were correlated with subsequent cardiac toxicity. Cardiac toxicity measured by RTOG and CTCAE v3.0 criteria was identified by chart review.

RESULTS

During the follow up period, 12 patients were identified with treatment related cardiac toxicity, 6 of which were symptomatic. The mean heart V20 (79.7% vs. 67.2%, p=0.05), V30 (75.8% vs. 61.9%, p=0.04), and V40 (69.2% vs. 53.8%, p=0.03) were significantly higher in patients with symptomatic cardiac toxicity than those without. We found the threshold for symptomatic cardiac toxicity to be a V20, V30 and V40 above 70%, 65% and 60%, respectively. There was no correlation between change myocardial SUV on PET and cardiac toxicity, however, a greater proportion of women suffered symptomatic cardiac toxicity compared to men (p=0.005).

CONCLUSIONS

A correlation did not exist between percent change in myocardial SUV and cardiac toxicity. Patients with symptomatic cardiac toxicity received significantly greater mean V20, 30 and 40 values to the heart compared to asymptomatic patients. These data need validation in a larger independent data set.

Enteral stents

The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, with a MEDLINE literature search to identify pertinent clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but in many cases, data from randomized, controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the Governing Board of the ASGE. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review, the MEDLINE database was searched through August 2010 for articles related to enteral, esophageal, duodenal, and colonic stents. Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.

Complications associated with double balloon enteroscopy at nine US centers

BACKGROUND & AIMS

Double balloon enteroscopy (DBE) was introduced into the US in 2004. Potential complications include perforation, pancreatitis, and gastrointestinal bleeding. Prevalence and risk factors for complications have not been described in a US population.

METHODS

We conducted a retrospective study of DBE complications in 9 US centers. We obtained detailed information for each complication including patient history, maneuvers performed during the DBE, and presence of altered surgical anatomy.

RESULTS

We collected data from 2478 DBE examinations performed from 2004 to 2008. The dataset included 1691 (68%) anterograde DBE, 722 (29%) retrograde DBE (including 5 per-stomal DBEs), and 65 (3%) DBE-facilitated endoscopic retrograde cholangiopancreatography ERCP cases. There were a total of 22 (0.9%) major complications including perforation in 11 (0.4%), pancreatitis in 6 (0.2%), and bleeding in 4 (0.2%) patients. One of 6 cases of pancreatitis occurred post retrograde DBE. Perforations occurred in 3/1691 (0.2%) anterograde examinations and 8/719 (1.1%) retrograde DBEs (P = .004). Eight (73%) perforations occurred during diagnostic DBE examinations. Four of 8 retrograde DBE perforations occurred in patients with prior ileoanal or ileocolonic anastomoses. In the subset of 219 examinations performed in patients with surgically altered anatomy, perforations occurred in 7 (3%), including 1/159 (0.6%) anterograde DBE examinations, 6/60 (10%) retrograde DBEs, and 1 of 5 (20%) peristomal DBE examinations (P < .005 compared with patients without surgically altered anatomy).

CONCLUSIONS

DBE is associated with a higher complication rate compared with standard endoscopic procedures. The perforation rate was significantly elevated in patients with altered surgical anatomy undergoing diagnostic retrograde DBE examinations.

Double balloon enteroscopy detects small bowel mass lesions missed by capsule endoscopy

BACKGROUND

Small bowel mass lesions (SBML) are a relatively common cause of obscure gastrointestinal bleeding (OGIB). Their detection has been limited by the inability to endoscopically examine the entire small intestine. This has changed with the introduction of capsule endoscopy (CE) and double balloon enteroscopy (DBE) into clinical practice.

STUDY AIM

To evaluate the detection of SBML by DBE and CE in patients with OGIB who were found to have SBML by DBE and underwent both procedures.

METHODS

A retrospective review of a prospectively collected database of all patients undergoing DBE for OGIB at seven North American tertiary centers was performed. Those patients who were found to have SBML as a cause of their OGIB were further analyzed.

RESULTS

During an 18 month period, 183 patients underwent DBE for OGIB. A small bowel mass lesion was identified in 18 patients. Of these, 15 patients had prior CE. Capsule endoscopy identified the mass lesion in five patients; fresh luminal blood with no underlying lesion in seven patients, and non-specific erythema in three patients. Capsule endoscopy failed to identify all four cases of primary small bowel adenocarcinoma.

CONCLUSIONS

Double balloon enteroscopy detects small bowel mass lesions responsible for OGIB that are missed by CE. Additional endoscopic evaluation of the small bowel by DBE or intraoperative enteroscopy should be performed in patients with ongoing OGIB and negative or non-specific findings on CE.

Temporary placement of covered self-expandable metal stents in benign biliary strictures: a new paradigm? (with video)

BACKGROUND

Benign biliary strictures (BBS) are usually managed with plastic stents, whereas placement of uncovered metallic stents has been associated with failure related to mucosal hyperplasia.

OBJECTIVE

We analyzed the efficacy and safety of temporary placement of a covered self-expanding metal stent (CSEMS) in BBS.

DESIGN

Patients with BBS received temporary placement of CSEMSs until adequate drainage was achieved; confirmed by resolution of symptoms, normalization of liver function tests, and imaging.

SETTING

Tertiary-care center with long-standing experience with CSEMSs.

PATIENTS

Seventy-nine patients with BBS secondary to chronic pancreatitis (32), calculi (24), liver transplant (16), postoperative biliary repair (3), autoimmune pancreatitis (3), and primary sclerosing cholangitis (1).

INTERVENTION

ERCP with temporary CSEMS placement. Removal of CSEMSs was performed with a snare or a rat-tooth forceps.

MAIN OUTCOME MEASUREMENTS

End points were efficacy, morbidity, and clinical response.

RESULTS

CSEMSs were removed from 65 patients. Resolution of the BBS was confirmed in 59 of 65 patients (90%) after a median follow-up of 12 months after removal (range 3-26 months). If patients who were lost to follow-up, developed cancer, or expired were considered failures, then an intent-to-treat global success rate of 59 of 79 (75%) was obtained. Complications associated with placement included 3 post-ERCP pancreatitis (4%), 1 postsphincterotomy bleed (1%), and 2 pain that required CSEMS removal (2%). In 11 patients (14%), the CSEMS migrated. In 1 patient, CSEMS removal was complicated by a bile leak that was successfully managed with plastic stents.

LIMITATION

Pilot study from a single center.

CONCLUSIONS

Temporary CSEMS placement in patients with BBS offers a potential alternative to surgery.

Temporary placement of covered self-expandable metallic stents in patients with biliary leak: midterm evaluation of a pilot study

BACKGROUND

Management of biliary leaks includes ERCP and stent placement. The ability to temporarily place a partially covered self-expandable metallic stent (CSEMS) might offer an advantage in the treatment of biliary leaks.

OBJECTIVE

We analyzed our 2 years' experience when using this innovative technique.

DESIGN

Patients in whom a previous ERCP had failed to resolve a bile leak or patients with severe comorbidities were offered CSEMS and were followed prospectively for clinical and radiologic responses.

SETTING

Tertiary-care center with long-standing experience of using CSEMS.

PATIENTS

A total of 16 patients were included. Of these, 7 had previously undergone unsuccessful plastic stent placement, 3 had previously failed ERCP, and 7 had severe comorbidities that prevented multiple interventions.

INTERVENTION

ERCP with placement of a CSEMS covering the cystic duct take-off in the case of a cystic-stump leak. CSEMS were removed after resolution of the leak.

MAIN OUTCOME MEASUREMENTS

Efficacy and safety of the CSEMS in bile leaks; complications were also evaluated.

RESULTS

Of the patients studied, 15 responded to CSEMS placement with complete resolution of the leak on imaging. One patient with partial cholecystectomy relapsed and underwent drainage; another patient responded to the treatment but required revision because of migration. CSEMS were left in place for a median time of 3 months (range, 1-17 months). Complications included 1 proximal and 1 distal migration.

LIMITATIONS

Pilot study from a single center.

CONCLUSIONS

CSEMS is an excellent option in this subgroup of patients not responding to plastic stent placement or with severe comorbidities.

Covered self-expandable metal stents in pancreatic malignancy regardless of resectability: a new concept validated by a decision analysis

BACKGROUND AND STUDY AIMS

The current treatment model for the management of malignant biliary obstruction is to place a plastic stent for unstaged pancreatic cancer. In patients with unresectable disease but a life expectancy of more than 6 months, self-expandable metal stents (SEMS) are favored because of their more prolonged patency. We analyzed the efficacy and cost-effectiveness of covered SEMS (CSEMS) in patients with pancreatic cancer and distal biliary obstruction without regard to surgical resectability.

PATIENTS AND METHODS

Between March 2001 and March 2005, 101 consecutive patients with obstructive jaundice secondary to pancreatic cancer underwent placement of a CSEMS. Patients with resectable tumor were offered pancreaticoduodenectomy. A model was developed to compare the costs of CSEMS and polyethylene and DoubleLayer stents.

RESULTS

A total of 21 patients underwent staging laparoscopy, of whom 16 had a resection (76%). The 85 patients who did not have a resection had a mean survival of 5.9 months (range 1-25 months) and a mean CSEMS patency duration of 5.5 months (range 1-16 months). Life-table analysis demonstrated CSEMS patency rates of 97% at 3 months, 85% at 6 months, and 68% at 12 months. In a cost model that accounted for polyethylene and DoubleLayer stent malfunction and surgical resections, initial CSEMS placement (3177 euros per patient) was a less costly intervention than either DoubleLayer stent placement (3224 euros per patient) or polyethylene stent placement with revision (3570 euros per patient).

CONCLUSIONS

Covered SEMS are an effective treatment for distal biliary obstructions caused by pancreatic carcinoma. Their prolonged patency and removability makes them an attractive option for biliary decompression, regardless of resectability. The strategy of initial covered SEMS placement might be the most cost-effective strategy in these patients.

EUS-guided pancreaticogastrostomy: analysis of its efficacy to drain inaccessible pancreatic ducts

BACKGROUND

EUS-guided pancreaticogastrostomy (EPG) has been reported as an alternative to surgery in cases of pancreatic stricture where ERCP is unsuccessful.

OBJECTIVE

We analyzed our 3-year experience with this innovative technique.

DESIGN

Patients with failed ERCP for pancreatic drainage were offered EPG over a 3-year period and were followed up prospectively in terms of clinical and radiologic response.

SETTING

Tertiary care center offering ERCP and interventional EUS.

PATIENTS

Thirteen patients were included in this study. Seven had surgical diversion Six patients had unaltered enteral anatomy and stricture related to chronic pancreatitis (3), gallstone pancreatitis (2), and intraductal pancreatic mucinous neoplasm (1).

INTERVENTION

EUS-guided puncture and opacification of the pancreatic duct was performed, creating a transgastric fistula with placement of a guidewire into the main pancreatic duct and subsequent ductal decompression with a plastic endoprosthesis.

MAIN OUTCOME MEASUREMENTS

Mean main pancreatic duct size, pain score, and weight before and after intervention.

RESULTS

Ten patients had successful endoprosthesis placement across the pancreaticogastric fistula. One patient underwent brush cytologic study, which diagnosed pancreatic malignancy, and underwent surgical resection. After a mean follow-up of 14 months, the mean pancreatic duct size in treated patients decreased from 4.6 to 3.0 mm (P = .01); the pain score decreased from 7.3 to 3.6 (P = .01). Complications included one case of bleeding requiring hemoclip placement and 1 case of contained perforation.

LIMITATIONS

Pilot study from a single center.

CONCLUSIONS

EPG is a safe and feasible alternative to surgical intervention in this subgroup of patients where conventional ERCP is not possible.

Interventional EUS-guided cholangiography: evaluation of a technique in evolution

BACKGROUND

Interventional EUS-guided cholangiography (IEUC) has been increasingly used as an alternative to percutaneous transhepatic cholangiography (PTC) in cases of biliary obstruction when ERCP is unsuccessful.

OBJECTIVE

We reviewed our experience and technique used for this procedure.

DESIGN

Over a 3-year period, ending July 2005, patients with a failed ERCP were offered an IEUC.

SETTING

Tertiary care center offering ERCP and interventional EUS.

PATIENTS

Twenty-eight patients were candidates for IEUC. Two patients had bleeding masses and were referred to interventional radiology, 1 patient had a large mass occupying the duodenal lumen, and 2 patients refused IEUC.

INTERVENTION

EUS was used to access the biliary system after which a guidewire was advanced antegrade across the obstruction. Either rendezvous with retrograde or antegrade drainage was then accomplished.

MAIN OUTCOME MEASUREMENTS

Efficacy and safety of IEUC for biliary decompression.

RESULTS

IEUC was successfully performed in 23 patients, with a transgastric-transhepatic (intrahepatic) approach in 13 cases and transenteric-transcholedochal (extrahepatic) approach in 10 cases. Therapeutic benefit was achieved in 21 patients: 18 underwent successful stent deployment across the stricture, whereas 3 patients required a choledochoenteric fistula formation. Complications included 1 case of bile leak, 2 cases of self-limited pneumoperitoneum, and 1 case of minor bleeding.

LIMITATIONS

Single-center experience of 2 operators.

CONCLUSIONS

IEUC appears efficacious in patients in whom ERCP is unsuccessful and is evolving as an attractive alternative to PTC. Intrahepatic access to the biliary system appears safer than the extrahepatic approach.

Endoscopic ultrasound drainage of pancreatic pseudocyst: a prospective comparison with conventional endoscopic drainage

BACKGROUND AND STUDY AIMS

Pancreatic pseudocysts are a complication in up to 20% of patients with pancreatitis. Endoscopic management of pseudocysts by a conventional transenteric technique, i. e. conventional transmural drainage (CTD), or by endoscopic ultrasound-guided drainage (EUD), is well described. Our aim was to prospectively compare the short-term and long-term results of CTD and EUD in the management of pseudocysts.

PATIENTS AND METHODS

A total of 99 consecutive patients underwent endoscopic management of pancreatic pseudocysts according to this predetermined treatment algorithm: patients with bulging lesions without obvious portal hypertension underwent CTD; all remaining patients underwent EUD. Patients were followed prospectively, with cross-sectional imaging during clinic visits. We compared short-term and long-term results (effectiveness and complications) at 1 and 6 months post procedure.

RESULTS

46 patients (37 men) underwent EUD and 53 patients (39 men) had CTD. The mean age of the entire group was 50 +/- 13 years. There were no significant differences between the two groups regarding short-term success (93% vs. 94%) or long-term success (84% vs. 91%); 68 of the 99 patients completed 6 months of follow-up. Complications occurred in 19% of EUD vs. 18% of CTD patients, and consisted of bleeding in three, infection of the collection in eight, stent migration into the pseudocyst in three, and pneumoperitoneum in five. All complications but one could be managed conservatively.

CONCLUSIONS

No clear differences in efficacy or safety were observed between conventional and EUS-guided cystenterostomy. The choice of technique is likely best predicated by individual patient presentation and local expertise.

Efficacy and complications of covered Wallstents in malignant distal biliary obstruction

BACKGROUND

This study evaluated the efficacy and the complications associated with the use of the covered Wallstent in the setting of unresectable malignant biliary obstruction.

METHODS

Between March 2001 and January 2003, all patients with distal malignant biliary obstruction that required drainage were treated with a covered Wallstent. Every 2 months, the patients were evaluated clinically and biochemical tests of liver function were obtained. Data were recorded for the following variables: early complications (within 30 days of stent placement), early and late stent occlusion, duration of stent patency, need for subsequent biliary intervention, and patient survival.

RESULTS

A total of 88 covered Wallstents were inserted in 80 patients. Stent patency rates at 3, 6, and 12 months were 90%, 82%, and 78%, respectively. Complications included stent migration (5), stent occlusion (12), episodes of cholecystitis (3), and episodes of post-ERCP pancreatitis (5). Biliary intervention was required in 9 patients subsequent to placement of the initial covered Wallstent.

CONCLUSIONS

Deployment of a covered Wallstent is safe and relatively easy. It achieves biliary drainage with an acceptable risk to benefit ratio in the majority of patients with distal malignant biliary obstruction.

Drainage of gallbladder fossa fluid collections with endoprosthesis placement under endoscopic ultrasound guidance: a preliminary report of two cases

Collections of fluid in the gallbladder fossa can be detected by ultrasound in as many as 29% of patients following cholecystectomy. Traditionally, persistent collections are treated by percutaneous drainage and bile duct decompression. We present two cases of persistent gallbladder fossa fluid collections which were refractory to bile duct decompression but which were successfully drained by endoscopic ultrasound-guided endoprosthesis placement. Under endoscopic ultrasound (EUS) control, a 19-gauge needle was inserted through the duodenal wall into the gallbladder fossa fluid collection. A guide wire was coiled within the collection, and an endoprosthesis was placed over the wire. Endoprosthesis insertion was successful in both cases, resulting in rapid symptomatic and radiographic improvement. EUS-guided drainage offers a minimally invasive alternative to percutaneous treatment of persistent gallbladder fossa fluid collections following cholecystectomy.

EUS-guided transhepatic cholangiography: report of 6 cases

BACKGROUND

This report describes a novel application of EUS-guided cholangiography in which a transhepatic approach was used to alleviate perihilar and distal biliary obstructions when this could not be accomplished at ERCP.

METHODS

EUS-guided transhepatic cholangiography was used to alleviate symptoms of biliary obstruction in 6 patients. In 4 cases, after transgastric puncture of an intrahepatic branch of the obstructed bile duct with a 19- or a 22-gauge EUS needle, a guidewire was advanced antegrade across both the biliary stricture and the papilla. Subsequently, a rendezvous procedure was performed, allowing ERCP and stent placement.

OBSERVATIONS

EUS-guided transhepatic cholangiography was performed in 6 patients, with successful rendezvous ERCP and stent placement in 4, and transduodenal stent placement in another patient. Stent placement was unsuccessful in one patient, because of the inability to advance a guidewire into the common hepatic duct. There was no immediate complication of the procedures.

CONCLUSIONS

EUS-guided transhepatic cholangiography can be used to access and to drain bile ducts that are obstructed by proximal, as well as distal lesions when ERCP is unsuccessful.

Factors predictive of malignancy and endoscopic resectability in ampullary neoplasia

OBJECTIVE

Endoscopic treatment of ampullary lesions has been well described, though it remains uncertain if specific features predict malignancy, and whether identifiable factors are associated with successful endoscopic resection of benign lesions.

METHODS

Fifty-six consecutive patients undergoing endoscopic evaluation of ampullary neoplasia between March 2000 and May 2004 were included in the study. Clinical presentation, underlying medical conditions, endoscopic treatment, endoscopic ultrasound (EUS) to define extent of local involvement, pathology results, and outcome were documented. Data elements for analysis included EUS findings, lesion lifting with submucosal injection, age, gender, tumor size, and endoscopic intervention. Analyses were performed to determine the ability to predict malignancy and the ability to extirpate benign lesions.

RESULTS

Thirty-one males and 25 females were included; mean age was 62 yr. Final diagnoses included 29 adenomas, 20 adenocarcinomas, 4 adenomyomas, 2 paragangliomas, and 1 neuroendocrine tumor. Thirty of 35 patients with benign lesions had extirpation with a mean of two endoscopic procedures. Complications of endoscopic resection included cholangitis (1), bleeding (2), and pancreatitis (4). The presence of malignancy was associated by multivariate analysis with the inability to obtain a cleavage plane with saline injection. Univariate analysis also identified EUS T stage as a predictor of malignancy. In benign lesions, none of the analyzed variables predicted successful endoscopic resection.

CONCLUSION

In ampullary lesions, failure to achieve a cleavage plane with submucosal injection is the strongest predictor of malignancy followed by EUS T stage. Endoscopic treatment of benign ampullary neoplasia is effective; no factor was predictive of successful extirpation.

Prospective evaluation of pancreatic sphincterotomy as a precut technique for biliary cannulation

BACKGROUND & AIMS

Pancreatic sphincterotomy has been described as an effective technique to obtain biliary access after standard methods fail. This prospective study evaluates its efficacy and compares its complication rate to conventional biliary sphincterotomy (BS).

METHODS

Between January 2001 and January 2004, patients in whom biliary cannulation failed underwent a pancreatic precut sphincterotomy (PPS) and were analyzed prospectively. Multivariate analysis was performed on the following variables with regard to their ability to predict successful biliary cannulation: age, gender, time to access bile duct after precut (< or =10 or >10 minutes), final diagnosis, and operator. Complications of PPS were then compared with those resulting from endoscopic retrograde cholangiopancreatography with BS in 120 patients examined during the same period of time and matched by sex, gender, and disease process.

RESULTS

One hundred sixteen patients (50 male), mean age 58 +/- 16 years, underwent PPS. Immediate biliary access was achieved after pancreatic precut in 99 cases (85%). Complications occurred in 14 patients (12%): 3 (2.6%) postsphincterotomy bleeding, 9 (8%) pancreatitis (8 mild, 1 moderate), and 2 (1.7%) retroperitoneal perforation managed conservatively. The factor statistically associated with successful biliary cannulation was the amount of elapsed time between completing the PPS and obtaining biliary access. No statistical difference was identified in the complication rate of pancreatitis between the PPS and BS groups.

CONCLUSIONS

PPS is an effective precut technique to facilitate biliary cannulation. Success is correlated to the speed of biliary access after precut. In expert hands, its rate of pancreatitis is similar to endoscopic retrograde cholangiopancreatography with BS.

Removal of self-expandable metallic Wallstents

BACKGROUND

The self-expandable metallic stent is increasingly being used for management of malignant biliary strictures. In certain clinical situations, it also may be an alternative treatment for benign strictures. The ability to remove a metallic stent would be advantageous to the management of many biliary strictures, regardless of etiology.

METHODS

Stent removal was considered in 18 patients with either covered or uncovered Wallstents placed for biliary obstruction. Indications for placement were the following: unresectable cancer (10), chronic pancreatitis (3), benign biliary stricture (3), impacted stone (1), and papillary adenoma (1).

OBSERVATIONS

Stent removal was successful in 17 patients. Mean follow-up after removal was 9 months. Thirteen removed stents were covered. Indications for removal were the following: occlusion (5), migration (3), facilitation of hemostasis (2), malposition (3), persistent cholestasis (1), stone extraction (1), stricture revision (1), gallbladder fossa abscess (1), and abdominal pain (1). Devices and techniques used for successful removal included a snare, an extraction balloon, and electrocoagulation combined with forceps.

CONCLUSIONS

Removal of uncovered Wallstents is difficult and typically requires a combination of techniques. Removal of covered Wallstents with a snare is relatively simple and safe, and can be followed immediately by corrective therapy. Insertion of a covered Wallstent should be considered as initial therapy when malignant biliary obstruction is suspected but unconfirmed.