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Muniraj T, Desir G, Gorelick FS, Guo X, Ciarleglio MM, Deng Y, Jamidar PA, Farrell J, Aslanian HR, Laine L. Clinical predictive value of renalase in post-ERCP pancreatitis. Gastrointest Endosc 2024; 99:822-825.e1. [PMID: 38103747 DOI: 10.1016/j.gie.2023.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 11/17/2023] [Accepted: 12/09/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND AND AIMS Plasma levels of renalase decrease in acute experimental pancreatitis. We aimed to determine if decreases in plasma renalase levels after ERCP predict the occurrence of post-ERCP pancreatitis (PEP). METHODS In this prospective cohort study conducted at a tertiary hospital, plasma renalase was determined before ERCP (baseline) and at 30 and 60 minutes after ERCP. Native renalase levels, acidified renalase, and native-to-acidified renalase proportions were analyzed over time using a longitudinal regression model. RESULTS Among 273 patients, 31 developed PEP. Only 1 PEP patient had a baseline native renalase >6.0 μg/mL, whereas 38 of 242 without PEP had a native renalase > 6.0 μg/mL, indicating a sensitivity of 97% (30/31) and specificity of 16% (38/242) in predicting PEP. Longitudinal models did not show differences over time between groups. CONCLUSIONS Baseline native renalase levels are very sensitive for predicting PEP. Further studies are needed to determine the potential clinical role of renalase in predicting and preventing PEP.
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Affiliation(s)
- Thiruvengadam Muniraj
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Gary Desir
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Department of Medicine, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Fred S Gorelick
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Department of Medicine, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Xiaojia Guo
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Department of Medicine, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Maria M Ciarleglio
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Yanhong Deng
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Priya A Jamidar
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - James Farrell
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Harry R Aslanian
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Loren Laine
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Department of Medicine, VA Connecticut Healthcare System, West Haven, Connecticut, USA
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2
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Kahaleh M, Tyberg A, Sameera S, Sarkar A, Shahid HM, Abdelqader A, Gjeorgjievski M, Gaidhane M, Muniraj T, Jamidar PA, Aslanian HR, Abraham M, Lajin M, Kedia P, Nieto J, Parsa N, Andalib I, Bashir M, Kowalski TE, Loren DE, Kumar A, Schlachterman A, Chiang A, Holmes I, Mendoza Ladd AH, Oleas R, Zolotarevsky E, Robles-Medranda C, Barthet M. EUS-guided Gastroenterostomy: A Multicenter International Study Comparing Benign and Malignant Diseases. J Clin Gastroenterol 2023:00004836-990000000-00204. [PMID: 37646532 DOI: 10.1097/mcg.0000000000001903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 07/14/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Endoscopic ultrasound (EUS)-guided gastroenterostomy (EUS-GE) is a minimally invasive therapy for patients with gastric outlet obstruction without the risks of surgical bypass and the limited long-term efficacy of enteral self-expanding metal stent placement. However, due to its novelty, there is a lack of significant data comparing long-term outcomes of patients with EUS-GE, based on the underlying disease. In this study, we compare outcomes of EUS-GE on benign versus malignant indications. METHODS Consecutive patients from 12 international, tertiary care centers who underwent EUS-GE over 3 years were extracted in a retrospective registry. Demographic characteristics, procedure-related information and follow-up data was collected. Primary outcome was the rate of adverse events associated with EUS-GE and the comparison of the rate of adverse events in benign versus malignant diseases. Secondary outcomes included technical and clinical success as well as hospitalization admission. RESULTS A total of 103 patients were included: 72 malignant and 31 benign. The characteristics of the patients undergoing EUS-GE is shown in Table 1. The mean age of the cohort was 68 years and 58 years for malignant and benign etiology. Gender distribution was 57% and 39% being females in malignant and benign etiology group, respectively. Clinical success, technical success, average procedure time, and hospital length of stay were similar in both groups. Patients with benign underlying etiology had significantly higher number of surgically altered midgut anatomy (P=0.0379). CONCLUSION EUS-GE is equally efficient regardless of the underlying etiology (malignant vs. benign), and the adverse events both groups were comparable.
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Affiliation(s)
- Michel Kahaleh
- Department of Gastroenterology, Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Amy Tyberg
- Department of Gastroenterology, Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Sohini Sameera
- Department of Gastroenterology, Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Avik Sarkar
- Department of Gastroenterology, Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Haroon M Shahid
- Department of Gastroenterology, Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Abdelhai Abdelqader
- Department of Gastroenterology, Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Mihajlo Gjeorgjievski
- Department of Gastroenterology, Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Monica Gaidhane
- Department of Gastroenterology, Robert Wood Johnson University Hospital, New Brunswick, NJ
| | | | | | | | - Mathew Abraham
- Penn State Health Milton S. Hershey Medical Center, Hershey, PA
| | | | | | - Jose Nieto
- Borland Groover Clinic, PA, Jacksonville, FL
| | | | - Iman Andalib
- South Nassau Communities Hospital, Oceanside, NY
| | | | | | | | - Anand Kumar
- Thomas Jefferson University, Philadelphia, PA
| | | | | | - Ian Holmes
- Thomas Jefferson University, Philadelphia, PA
| | | | - Roberto Oleas
- Ecuadorian Institute of Digestive Diseases (IECED), Guayaquil, Guayas, Ecuador
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3
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Chhoda A, Yousaf MN, Madhani K, Aslanian H, Jamidar PA, Suarez AL, Salem RR, Muniraj T, Kunstman JW, Farrell JJ. Comorbidities Drive the Majority of Overall Mortality in Low-Risk Mucinous Pancreatic Cysts Under Surveillance. Clin Gastroenterol Hepatol 2022; 20:631-640.e1. [PMID: 33309984 DOI: 10.1016/j.cgh.2020.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 10/31/2020] [Accepted: 12/06/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The Charlson Comorbidity Index (CACI) has been suggested as a tool to determine comorbidity burden and guide management for patients with mucinous pancreatic cysts (Intrapapillary Mucinous Neoplasms and Mucinous Cystic Neoplasms), but has not been studied well among "low-risk" mucinous pancreatic cysts i.e. without worrisome features (WF) and high-risk stigmata (HRS). This study sought to determine the comorbidity burden among surveillance population of low-risk pancreatic cysts and provide their follow-up mortality outcomes. METHODS A single center study retrospectively reviewed a prospective pancreatic cyst database and included individuals with low-risk cysts undergoing serial imaging during 2016. Electronic medical records were reviewed to determine their baseline age-adjusted CACI (age-CACI). After 4 years, their progression to WF, disease specific (pancreatic malignancy-related, DSM), extra-pancreatic (EPM), and overall mortalities (OM) were determined using Kaplan-Meir Survival Analysis. RESULTS 502 individuals underwent prospective surveillance. The study included 440 individuals with low-risk suspected or presumed mucinous cysts and excluded 50 and 12 individuals with WF and HRS respectively. Over a median follow-up of 56 months, 12 WF progressions, 2 DSMs, 42 EPMs, and 44 OMs were observed. Baseline age-CACI had good predictive capacity for 4-year EPM (Area-Under Curve: 0.87; p< .0001). The median age-CACI of 4 enabled cohort stratification into Low (age-CACI <4) and High CACI (age-CACI ≥4) groups. A significantly higher OM (p< .001) was observed among the High CACI group as compared to the Low CACI group. CONCLUSION Through real-time application of CACI to patient outcomes, our analysis supports incorporation of this comorbidity assessment tool in making shared surveillance decisions among low-risk pancreatic cyst population.
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Affiliation(s)
- Ankit Chhoda
- Department of Internal Medicine, Bridgeport Hospital, Yale New Haven Health, New Haven, Connecticut
| | - Muhammad N Yousaf
- Department of Internal Medicine, Medstar Union Memorial Hospital, Baltimore, Maryland
| | - Kamraan Madhani
- Department of Internal Medicine, Yale Waterbury Internal Medicine Program, Yale School of Medicine, New Haven, Connecticut
| | - Harry Aslanian
- Section of Digestive Disease, Yale School of Medicine, New Haven, Connecticut
| | - Priya A Jamidar
- Section of Digestive Disease, Yale School of Medicine, New Haven, Connecticut
| | - Alejandro L Suarez
- Section of Digestive Disease, Yale School of Medicine, New Haven, Connecticut
| | - Ronald R Salem
- Section of Surgical Oncology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | | | - John W Kunstman
- Section of Surgical Oncology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - James J Farrell
- Section of Digestive Disease, Yale School of Medicine, New Haven, Connecticut.
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4
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Shankar U, Bhandari P, Panchal A, Weeks D, Wu H, Chen F, Maheshwari N, Bansal R, Walfish A, Baum J, Jamidar PA, Aron J. Juxta-papillary duodenal diverticula are associated with pyogenic liver abscesses: a case control study. BMC Gastroenterol 2022; 22:52. [PMID: 35130860 PMCID: PMC8822858 DOI: 10.1186/s12876-022-02120-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 01/25/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Juxta-papillary duodenal diverticulum (JPDD) has been associated with obstructive jaundice and ascending cholangitis. Potential mechanisms include periampullary colonization of pathogenic bacteria and mechanical obstruction. However, the relation of JPDD with pyogenic liver abscess (PLA) has not been reported. Moreover, approximately one third of patients with PLA have no identifiable risk factors and are labelled as "cryptogenic". We hypothesized that JPDD is an unidentified risk factor for cryptogenic PLA and the aim of this study was to examine this association. METHODS We conducted a retrospective chart review to identify cases of PLA (n = 66) and compare those to matched controls (n = 66). 66 patients met the study inclusion criteria of a diagnosis of PLA using computerized tomography (CT) imaging and either positive culture or confirmed resolution after antibiotic therapy. Patients with diagnoses of amebic liver abscess, traumatic liver abscess, post cholecystectomy liver abscess, concurrent acute cholecystitis, and hepatobiliary malignancy were excluded. Controls were identified from a radiology database and matched one-to-one with the cases by age and sex. Demographic and clinical data was extracted from electronic medical records. CT scan images of all cases and controls were reviewed by a single expert radiologist to identify the presence of JPDD. Statistical tests including Chi-square and t-test with multiple logistic regression were used to examine the group differences in JPDD and other factors. RESULTS Among 132 study samples, 13.6% (9/66) of the cases were found to have JPDD, compared to 3.0% (2/66) among controls (p = 0.03). This corresponded to an odds ratio (OR) of 5.05 [OR 5.05; CI 1.05-24.4] on multiple logistic regression analysis. In addition, 1/3rd of PLA cases with JPDD had no other traditional risk factors (cryptogenic PLA). However, a statistically significant association of JPDD with cryptogenic PLA could not be established possibly because of a small number of cases. We found significantly high rate of diabetes mellitus (DM) (42.4%; n = 28/66) among cases compared to controls (21.2%; n = 14/66; p = 0.01). CONCLUSION We found a significant association between JPDD and PLA. We need studies with larger sample sizes to confirm this relationship and to explore if JPDD could be related to cryptogenic liver abscesses.
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Affiliation(s)
- Uday Shankar
- Gastroenterology Division, Department of Medicine, Icahn School of Medicine at Elmhurst Hospital, Elmhurst, NY, 11373, USA. .,Digestive Disease Center, Trinity Health of New England and St. Mary's Hospital, 133 Scovill Street, Suite 101, Waterbury, CT, 06706, USA.
| | - Priyanka Bhandari
- Department of Medicine, Icahn School of Medicine at Elmhurst Hospital, Elmhurst, NY, 11373, USA
| | - Ankur Panchal
- Department of Medicine, Icahn School of Medicine at Elmhurst Hospital, Elmhurst, NY, 11373, USA
| | - David Weeks
- Department of Radiology, Icahn School of Medicine at Elmhurst Hospital, Elmhurst, NY, 11373, USA
| | - Helen Wu
- Connecticut Convergence Institute, Department of Psychiatry, University of Connecticut Health Center, Farmington, CT, 06312, USA
| | - Fufei Chen
- Connecticut Convergence Institute, University of Connecticut Health Center, Farmington, CT, 06312, USA
| | - Narinder Maheshwari
- Department of Medicine, University of Connecticut Health Center, Farmington, CT, USA
| | - Raghav Bansal
- Gastroenterology Division, Department of Medicine, Icahn School of Medicine at Elmhurst Hospital, Elmhurst, NY, 11373, USA
| | - Aaron Walfish
- Gastroenterology Division, Department of Medicine, Icahn School of Medicine at Elmhurst Hospital, Elmhurst, NY, 11373, USA
| | - Joel Baum
- Gastroenterology Division, Department of Medicine, Icahn School of Medicine at Elmhurst Hospital, Elmhurst, NY, 11373, USA
| | - Priya A Jamidar
- Division of Digestive Diseases and Advanced Endoscopy, Yale University School of Medicine, New Haven, CT, USA
| | - Joshua Aron
- Gastroenterology Division, Department of Medicine, Icahn School of Medicine at Elmhurst Hospital, Elmhurst, NY, 11373, USA
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5
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Kahaleh M, Gaidhane M, Shahid HM, Tyberg A, Sarkar A, Ardengh JC, Kedia P, Andalib I, Gress F, Sethi A, Gan SI, Suresh S, Makar M, Bareket R, Slivka A, Widmer JL, Jamidar PA, Alkhiari R, Oleas R, Kim D, Robles-Medranda CA, Raijman I. Digital single-operator cholangioscopy interobserver study using a new classification: the Mendoza Classification (with video). Gastrointest Endosc 2022; 95:319-326. [PMID: 34478737 DOI: 10.1016/j.gie.2021.08.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 08/14/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Digital single-operator cholangioscopy (DSOC) allows direct visualization of the biliary tree for evaluation of biliary strictures. Our objective was to assess the interobserver agreement (IOA) of DSOC interpretation for indeterminate biliary strictures using newly refined criteria. METHODS Fourteen endoscopists were asked to review an atlas of reference clips and images of 5 criteria derived from expert consensus. They then proceeded to score 50 deidentified DSOC video clips based on the visualization of tortuous and dilated vessels, irregular nodulations, raised intraductal lesions, irregular surface with or without ulcerations, and friability. The endoscopists then diagnosed the clips as neoplastic or non-neoplastic. Intraclass correlation (ICC) analysis was done to evaluate inter-rater agreement for both criteria sets and final diagnosis. RESULTS Clips of 41 malignant lesions and 9 benign lesions were scored. Three of 5 revised criteria had almost perfect agreement. ICC was almost perfect for presence of tortuous and dilated vessels (.86), raised intraductal lesions (.90), and presence of friability (.83); substantial agreement for presence of irregular nodulations (.71); and moderate agreement for presence of irregular surface with or without ulcerations (.44). The diagnostic ICC was almost perfect for neoplastic (.90) and non-neoplastic (.90) diagnoses. The overall diagnostic accuracy using the revised criteria was 77%, ranging from 64% to 88%. CONCLUSIONS The IOA and accuracy rate of DSOC using the new Mendoza criteria shows a significant increase of 16% and 20% compared with previous criteria. The reference atlas helps with formal training and may improve diagnostic accuracy. (Clinical trial registration number: NCT02166099.).
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Affiliation(s)
- Michel Kahaleh
- Department of Gastroenterology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Monica Gaidhane
- Department of Gastroenterology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Haroon M Shahid
- Department of Gastroenterology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Amy Tyberg
- Department of Gastroenterology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Avik Sarkar
- Department of Gastroenterology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | | | | | - Iman Andalib
- Mount Sinai South Nassau, Oceanside, New York, USA
| | - Frank Gress
- Mount Sinai South Nassau, Oceanside, New York, USA
| | - Amrita Sethi
- Columbia University Medical Center, New York, New York, USA
| | - S Ian Gan
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Michael Makar
- Department of Gastroenterology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Romy Bareket
- Department of Gastroenterology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Adam Slivka
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | | | - Resheed Alkhiari
- Department of Gastroenterology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA; Department of Medicine, Qassim University, Saudi Arabia
| | - Roberto Oleas
- Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil, Ecuador
| | - Dongchoon Kim
- Soon Chun Hyang University Hospital, Seoul, Republic of Korea
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6
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Chua TY, Kyanam Kabir Baig KR, Leung FW, Ashat M, Jamidar PA, Mulki R, Singh A, Yu JX, Lightdale JR. GIE Editorial Board top 10 topics: advances in GI endoscopy in 2020. Gastrointest Endosc 2021; 94:441-451. [PMID: 34147512 DOI: 10.1016/j.gie.2021.06.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 06/14/2021] [Indexed: 02/08/2023]
Abstract
The American Society for Gastrointestinal Endoscopy's Gastrointestinal Endoscopy Editorial Board reviewed a systematic literature search of original endoscopy-related articles published during 2020 in Gastrointestinal Endoscopy and 10 other high-impact medical and gastroenterology journals. Votes from each individual board member were tallied to identify a consensus list of the 10 most significant topic areas in GI endoscopy over the calendar year of study using 4 criteria: significance, novelty, impact on national health, and impact on global health. The 10 areas identified were as follows: artificial intelligence in endoscopy, coronavirus disease 2019 and GI practice, third-space endoscopy, lumen-apposing metal stents, single-use duodenoscopes and other disposable equipment, endosonographic needle technology and techniques, endoscopic closure devices, advances in GI bleeding management, improvements in polypectomy techniques, and bariatric endoscopy. Each board member contributed a summary of important articles relevant to 1 to 2 topic areas, leading to a collective summary that is presented in this document of the "top 10" endoscopic advances of 2020.
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Affiliation(s)
- Tiffany Y Chua
- Division of Digestive Diseases, Harbor-University of California Los Angeles, Torrance, California, USA
| | - Kondal R Kyanam Kabir Baig
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Felix W Leung
- VA Sepulveda Ambulatory Care Center, North Hills, California, USA
| | - Munish Ashat
- Division of Gastroenterology and Hepatology, Indiana School of Medicine, Indianapolis, Indiana, USA
| | - Priya A Jamidar
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ramzi Mulki
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ajaypal Singh
- Division of Digestive Diseases and Nutrition, Rush University Medical Center, Chicago, Illinois, USA
| | - Jessica X Yu
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Jenifer R Lightdale
- Division of Pediatric Gastroenterology and Nutrition, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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7
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Muniraj T, Aslanian HR, Laine L, Jamidar PA, Farrell JF, Mitchell KA, Salem RR. Resection of pancreatic cystic neoplasms in recurrent acute pancreatitis prevents recurrent pancreatitis but does not identify more malignancies. World J Gastroenterol 2021; 27:1630-1642. [PMID: 33958848 PMCID: PMC8058652 DOI: 10.3748/wjg.v27.i15.1630] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/24/2021] [Accepted: 03/22/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Recurrent acute pancreatitis (RAP) may be a presenting feature of and an indication for resection of pancreatic cysts, including intra-ductal papillary mucinous neoplasm (IPMN). Few data are available regarding the prevalence of malignancy and post-operative RAP in this population.
AIM To study the role of resection to help prevent RAP and analyze if presentation as RAP would be a predictor for malignancy.
METHODS This retrospective study assessed 172 patients who underwent surgical resection of pancreatic cystic neoplasms at a university hospital between 2002 and 2016. The prevalence of preoperative high-risk cyst features, and of neoplasia was compared between patients with and without RAP. To identify the cause of pancreatitis, all the patients had a detailed history of alcohol, smoking, medications obtained, and had cross-sectional imaging (contrast-enhanced computed tomography/magnetic resonance imaging) and endoscopic ultrasound to look for gallstone etiology and other structural causes for pancreatitis. The incidence of RAP post-resection was the primary outcome.
RESULTS IPMN accounted for 101 cases (58.7%) {[branch duct (BD) 59 (34.3%), main duct (MD) 42] (24.4%)}. Twenty-nine (16.9%) presented with RAP (mean 2.2 episodes): 15 had BD-IPMN, 8 MD-IPMN, 5 mucinous cystic neoplasm and 1 serous cystic neoplasm. Malignancy was similar among those with vs without RAP for all patients [6/29 (20.7%) vs 24/143 (16.8%)] and IPMN patients [6/23 (26.1%) vs 23/78 (29.5%)], although tended to be higher with RAP in BD-IPMN, [5/15 (33.3%) vs 3/44 (6.8%), P = 0.04]. At mean follow-up of 7.2 years, 1 (3.4%) RAP patient had post-resection RAP. The mean episodes of acute pancreatitis before vs after surgery were 3.4 vs 0.02 (P < 0.0001).
CONCLUSION Malignancy was not increased in patients with pancreatic cystic neoplasms who have RAP compared to those without RAP. In addition, specific cyst charac-teristics were not clearly associated with RAP. The incidence of RAP was markedly decreased in almost all patients following cyst resection.
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Affiliation(s)
- Thiruvengadam Muniraj
- Section of Digestive Diseases, Department of Medicine, Yale University School of Medicine, New Haven, CT 06510, United States
| | - Harry R Aslanian
- Section of Digestive Diseases, Department of Medicine, Yale University School of Medicine, New Haven, CT 06510, United States
| | - Loren Laine
- Section of Digestive Diseases, Department of Medicine, Yale University School of Medicine, New Haven, CT 06510, United States
| | - Priya A Jamidar
- Section of Digestive Diseases, Department of Medicine, Yale University School of Medicine, New Haven, CT 06510, United States
| | - James F Farrell
- Section of Digestive Diseases, Department of Medicine, Yale University School of Medicine, New Haven, CT 06510, United States
| | - Kisha A Mitchell
- Department of Pathology, Yale University School of Medicine, New Haven, CT 06510, United States
| | - Ronald R Salem
- Department of Surgery, Yale University School of Medicine, New Haven, CT 06510, United States
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8
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Lam R, Jamidar PA, Aslanian HR, Muniraj T. The Reply. Am J Med 2020; 133:e612. [PMID: 33004185 DOI: 10.1016/j.amjmed.2020.05.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 05/20/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Robert Lam
- Section of Digestive Disease, Yale School of Medicine, New Haven, Conn
| | - Priya A Jamidar
- Section of Digestive Disease, Yale School of Medicine, New Haven, Conn
| | - Harry R Aslanian
- Section of Digestive Disease, Yale School of Medicine, New Haven, Conn
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9
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Lam R, Jamidar PA, Aslanian HR, Muniraj T. Fitz-Hugh-Curtis Syndrome Presenting as Acute Abdomen. Am J Med 2020; 133:e596. [PMID: 32277885 DOI: 10.1016/j.amjmed.2020.02.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 02/26/2020] [Accepted: 02/26/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Robert Lam
- Section of Digestive Disease, Yale School of Medicine, New Haven, Conn
| | - Priya A Jamidar
- Section of Digestive Disease, Yale School of Medicine, New Haven, Conn
| | - Harry R Aslanian
- Section of Digestive Disease, Yale School of Medicine, New Haven, Conn
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10
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Njei B, McCarty TR, Muniraj T, Sharma P, Jamidar PA, Aslanian HR, Varadarajulu S, Navaneethan U. Comparative effectiveness of pharmacologic and endoscopic interventions for prevention of post-ERCP pancreatitis: a network meta-analysis. Endosc Int Open 2020; 8:E29-E40. [PMID: 31921982 PMCID: PMC6949176 DOI: 10.1055/a-1005-6366] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 08/12/2019] [Indexed: 02/06/2023] Open
Abstract
Background and study aims While several interventions may decrease risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, it remains unclear whether one strategy is superior to others. The purpose of this study was to compare the effectiveness of pharmacologic and endoscopic interventions to prevent post-ERCP pancreatitis among high-risk patients. Methods A systematic review was performed to identify randomized controlled trials from PubMed, Embase, Web of Science, and Cochrane database through May 2017. Interventions included: rectal non-steroidal anti-inflammatory drugs (NSAIDs), aggressive hydration with lactated ringer's (LR) solution, and pancreatic stent placement compared to placebo. Only studies with patients at high-risk for post-ERCP pancreatitis were included. Bayesian network meta-analysis was performed and relative ranking of treatments was assessed using surface under the cumulative ranking (SUCRA) probabilities. Results We identified 29 trials, comprising 7,862 participants comparing four preventive strategies. On network meta-analysis, compared with placebo, rectal NSAIDs (B = - 0.69, 95 % CI [-1.18; - 0.21]), pancreatic stent (B = - 1.25, 95 % CI [-1.81 to -0.69]), LR (B = - 0.67, 95 % CI [-1.20 to -0.13]), and combination of LR plus rectal NSAIDs (B = - 1.58; 95 % CI [-3.0 to -0.17]), were all associated with a reduced risk of post-ERCP pancreatitis. Pancreatic stent placement had the highest SUCRA probability (0.81, 95 % CI [0.83 to 0.80]) of being ranked the best prophylactic treatment. Conclusions Based on this network meta-analysis, pancreatic stent placement appears to be the most effective preventive strategy for post-ERCP pancreatitis in high-risk patients.
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Affiliation(s)
- Basile Njei
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Thomas R. McCarty
- Department of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston, Massachusetts, United States,Harvard Medical School, Boston, Massachusetts, United States
| | - Thiruvengadam Muniraj
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Prabin Sharma
- Department of Gastroenterology and Hepatology, Yale New Haven Health-Bridgeport Hospital, Bridgeport, Connecticut, United States
| | - Priya A. Jamidar
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Harry R. Aslanian
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Shyam Varadarajulu
- Center for Interventional Endoscopy, Florida Hospital, University of Central Florida College of Medicine, Orlando, Florida, United States
| | - Udayakumar Navaneethan
- Center for Interventional Endoscopy, Florida Hospital, University of Central Florida College of Medicine, Orlando, Florida, United States
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11
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Yaghoobi M, Pauls Q, Durkalski V, Romagnuolo J, Fogel EL, Tarnasky PR, Aliperti G, Freeman ML, Kozarek RA, Jamidar PA, Wilcox CM, Elta GH, Hawes RH, Wood-Williams A, Cotton PB. Incidence and predictors of post-ERCP pancreatitis in patients with suspected sphincter of Oddi dysfunction undergoing biliary or dual sphincterotomy: results from the EPISOD prospective multicenter randomized sham-controlled study. Endoscopy 2015; 47:884-90. [PMID: 26165739 DOI: 10.1055/s-0034-1392418] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND STUDY AIM Pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP) is a significant and potentially life-threatening adverse event and is common in patients with suspected sphincter of Oddi dysfunction (SOD). Here we aimed to identify predictors of the risk in this population. PATIENTS AND METHODS The Evaluating Predictors and Interventions in SOD (EPISOD) study prospectively enrolled 214 post-cholecystectomy patients with SOD type III in seven US centers. Patients were randomized, using a 2:1 allocation, to sphincterotomy or sham procedure, irrespective of the results of sphincter of Oddi manometry. Patients in the sphincterotomy arm who had elevated pancreatic sphincter pressure were randomized to biliary only or to dual (biliary and pancreatic) sphincterotomy. All but one patient received prophylactic pancreatic stents, but none received pharmacological prophylaxis. Post ERCP pancreatitis (PEP) was defined as acute pancreatitis within the subsequent 7 days. Blinded research coordinators at each site called patients at 1 week post-procedure. RESULTS PEP occurred in 26 patients, in 10.6 % (15/141) in the sphincterotomy arm and 15.1 % (11/73) in the sham arm; unadjusted relative risk 0.71 (95 % confidence interval [95 %CI] 0.34 - 1.46). PEP rate was not significantly different in patients who received sphincterotomy compared with those undergoing sham treatment. In addition, the proportion was not statistically different in those who received biliary sphincterotomy alone (12/94; 12.8 % [95 %CI 6.0 % - 19.5 %]) compared with dual sphincterotomy (3/47; 6.4 % [95 %CI 0.0 % - 13.4 %]). Multivariate analysis identified an interaction between duration of ERCP and sedation type (P < 0.02). CONCLUSION The performance of biliary or dual sphincterotomy does not increase the risk of PEP in patients suspected of SOD. However, the high rate of PEP in patients with suspected SOD, despite pancreatic stenting in expert centers, is confirmed in this prospective study. The combined effect of duration of ERCP and sedation type on the development of PEP should be further explored.Clinicaltrials.gov registration: NCT00688662.
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Affiliation(s)
- Mohammad Yaghoobi
- Division of Gastroenterology, McMaster University, Hamilton Ontario, Canada
| | - Qi Pauls
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Valerie Durkalski
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Joseph Romagnuolo
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Evan L Fogel
- Division of Gastroenterology/Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Paul R Tarnasky
- Gastroenterology, Methodist Dallas Medical Center, Dallas, Texas, USA
| | | | - Martin L Freeman
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Richard A Kozarek
- Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Priya A Jamidar
- Department of Endoscopy, School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Charles M Wilcox
- Gastroenterology and Hepatology, University of Alabama, Birmingham, Alabama, USA
| | - Grace H Elta
- Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Robert H Hawes
- Division of Gastroenterology and Hepatology, Florida Hospital, Orlando, Florida, USA
| | | | - Peter B Cotton
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
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12
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Abstract
Endoscopic stenting is a widely accepted strategy for providing effective drainage in both extrahepatic and intrahepatic malignant strictures. In patients with extrahepatic malignancies, uncovered self-expanding metal stents (SEMS) provide excellent palliation. Hilar malignancies are probably best palliated by placement of uncovered SEMS although some disagreement exists among experts regarding the type and number of stents for optimal palliation. Preoperative biliary drainage (PBD) is commonly performed although a higher risk of complications and the lack of clear benefit raise questions about this practice. Certain groups of patients such as those with markedly elevated bilirubin levels, and in those in whom neoadjuvant therapy is planned, are good candidates for PBD. Considerable controversy exists regarding the optimal method as well as type of stent for PBD in patients with hilar malignancies. Novel endoscopic therapies, including photodynamic therapy and radiofrequency ablation, have emerged as potential adjuvant therapies in the management of malignant bile duct strictures but need further long-term evaluation to establish survival benefit. This review focuses on the current status of endoscopic therapies for malignant biliary obstructions.
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Affiliation(s)
- Tarun Rustagi
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, PO Box 208019, New Haven, CT, 06520, USA,
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13
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Affiliation(s)
- Harry R Aslanian
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut
| | - Ali M Ahmed
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut
| | - Priya A Jamidar
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut.
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Muniraj T, Aslanian HR, Laine L, Farrell J, Ciarleglio MM, Deng Y, Ho H, Jamidar PA. A double-blind, randomized, sham-controlled trial of the effect of a radiation-attenuating drape on radiation exposure to endoscopy staff during ERCP. Am J Gastroenterol 2015; 110:690-6. [PMID: 25823765 DOI: 10.1038/ajg.2015.85] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 02/17/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Endoscopic retrograde cholangiopancreatography (ERCP) is associated with radiation exposure to the endoscopist and staff that may be significant in high-volume centers. We investigated whether a radiation-attenuating drape over the fluoroscopy image intensifier reduces radiation exposure during ERCP. METHODS We performed a prospective, randomized, double-blind trial of 100 therapeutic ERCPs at a tertiary-care university center. Procedures were randomly assigned to groups receiving lead-free radiation-attenuating drapes (n=50) or identical sham drapes (n=50). The drapes were suspended around the fluoroscopy image intensifier during ERCP. The primary end point was the effective dose of radiation measured at the endoscopist's eye and neck, and at the assisting nurse's neck. The cumulative annual radiation exposure was also estimated. RESULTS Fluoroscopy time, absorbed radiation dose, and dose area product were similar in the study groups. Mean effective dose for sham vs. radiation-attenuating drape was 0.21±0.27 vs. 0.02±0.02 mSv at the endoscopist's eye, 0.35±0.44 vs. 0.03±0.03 mSv at the endoscopist's neck, and 0.27±0.34 vs. 0.02±0.02 mSv at the nurse's neck (P<0.0001 for all comparisons). The relative risk reduction in radiation was 90%, 91%, and 93% at the three sites. At a high-volume center in which an endoscopist performs 500 therapeutic ERCPs per year, the estimated cumulative annual effective dose at the endoscopist's eye level is 126 mSv with conventional protection and 12 mSv with a radiation-attenuating drape, with the recommended limit being 20 mSv. CONCLUSIONS The addition of a radiation-attenuating drape around the image intensifier during ERCP significantly decreases radiation exposure to endoscopists and staff by ∼90%.
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Affiliation(s)
| | - Harry R Aslanian
- Section of Digestive Disease, Yale School of Medicine, New Haven, Connecticut, USA
| | - Loren Laine
- 1] Section of Digestive Disease, Yale School of Medicine, New Haven, Connecticut, USA [2] VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - James Farrell
- Section of Digestive Disease, Yale School of Medicine, New Haven, Connecticut, USA
| | - Maria M Ciarleglio
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Yanhong Deng
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut, USA
| | - Henry Ho
- Section of Digestive Disease, Yale School of Medicine, New Haven, Connecticut, USA
| | - Priya A Jamidar
- Section of Digestive Disease, Yale School of Medicine, New Haven, Connecticut, USA
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15
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Muniraj T, Aslanian HR, Farrell J, Jamidar PA. Chronic pancreatitis, a comprehensive review and update. Part I: epidemiology, etiology, risk factors, genetics, pathophysiology, and clinical features. Dis Mon 2015; 60:530-50. [PMID: 25510320 DOI: 10.1016/j.disamonth.2014.11.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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16
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Muniraj T, Aslanian HR, Farrell J, Jamidar PA. Chronic pancreatitis, a comprehensive review and update. Part II: Diagnosis, complications, and management. Dis Mon 2015; 61:5-37. [PMID: 25681098 DOI: 10.1016/j.disamonth.2014.12.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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17
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Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) represents a monumental advance in the management of patients with pancreaticobiliary diseases, but is a complex and technically demanding procedure with the highest inherent risk of adverse events of all routine endoscopic procedures. Overall adverse event rates for ERCP are typically reported as 5-10%. The most commonly reported adverse events include post-ERCP pancreatitis, bleeding, perforation, infection (cholangitis), and cardiopulomary or "sedation related" events. This article evaluates patient-related and procedure-related risk factors for ERCP-related adverse events, and discusses strategies for the prevention, diagnosis and management of these events.
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Affiliation(s)
- Tarun Rustagi
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06520, USA
| | - Priya A Jamidar
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06520, USA.
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18
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Abstract
Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP), and not uncommonly is the reason behind ERCP-related lawsuits. Patients at high risk for PEP include young women with abdominal pain, normal liver tests, and unremarkable imaging. Procedure-related factors include traumatic and persistent cannulation attempts, multiple injections of the pancreatic duct, pancreatic sphincterotomy, and, possibly, use of precut sphincterotomy. Aggressive hydration, use of rectal indomethacin, and prophylactic pancreatic stenting can diminish the risk (and likely severity) of PEP. Though hugely beneficial, these measures do not supersede careful patient selection and technique.
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Affiliation(s)
- Tarun Rustagi
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06520, USA
| | - Priya A Jamidar
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06520, USA.
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Abstract
Self-expandable metal stents (SEMS) are the current standard of care for the palliative management of malignant biliary strictures. Recently, endoscopic ablative techniques with direct affect to local tumor have been developed to improve SEMS patency. Several reports have demonstrated the technical feasibility and safety of intraductal radiofrequency ablation (RFA), by both endoscopic and percutaneous approaches, in palliation of malignant strictures of the bile duct. Intraductal RFA has also been used in the treatment of occlusion of both covered and uncovered SEMS occlusion from tumor ingrowth or overgrowth. This article provides a comprehensive review of intraductal RFA in the management of malignant biliary obstruction.
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Affiliation(s)
- Tarun Rustagi
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT, 06520-8019, USA,
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20
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Romagnuolo J, Cotton PB, Durkalski V, Pauls Q, Brawman-Mintzer O, Drossman DA, Mauldin P, Orrell K, Williams AW, Fogel EL, Tarnasky PR, Aliperti G, Freeman ML, Kozarek RA, Jamidar PA, Wilcox CM, Serrano J, Elta GH. Can patient and pain characteristics predict manometric sphincter of Oddi dysfunction in patients with clinically suspected sphincter of Oddi dysfunction? Gastrointest Endosc 2014; 79:765-72. [PMID: 24472759 PMCID: PMC4409681 DOI: 10.1016/j.gie.2013.11.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 11/25/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Biliopancreatic-type postcholecystectomy pain, without significant abnormalities on imaging and laboratory test results, has been categorized as "suspected" sphincter of Oddi dysfunction (SOD) type III. Clinical predictors of "manometric" SOD are important to avoid unnecessary ERCP, but are unknown. OBJECTIVE To assess which clinical factors are associated with abnormal sphincter of Oddi manometry (SOM). DESIGN Prospective, cross-sectional. SETTING Tertiary. PATIENTS A total of 214 patients with suspected SOD type III underwent ERCP and pancreatic SOM (pSOM; 85% dual SOM), at 7 U.S. centers (from August 2008 to March 2012) as part of a randomized trial. INTERVENTIONS Pain and gallbladder descriptors, psychosocial/functional disorder questionnaires. MAIN OUTCOME MEASUREMENTS Abnormal SOM findings. Univariate and multivariate analyses assessed associations between clinical characteristics and outcome. RESULTS The cohort was 92% female with a mean age of 38 years. Baseline pancreatic enzymes were increased in 5%; 9% had minor liver enzyme abnormalities. Pain was in the right upper quadrant (RUQ) in 90% (48% also epigastric); 51% reported daily abdominal discomfort. Fifty-six took narcotics an average of 33 days (of the past 90 days). Less than 10% experienced depression or anxiety. Functional disorders were common. At ERCP, 64% had abnormal pSOM findings (34% both sphincters, 21% biliary normal), 36% had normal pSOM findings, and 75% had at least abnormal 1 sphincter. Demographic factors, gallbladder pathology, increased pancreatobiliary enzymes, functional disorders, and pain patterns did not predict abnormal SOM findings. Anxiety, depression, and poorer coping were more common in patients with normal SOM findings (not significant on multivariate analysis). LIMITATIONS Generalizability. CONCLUSIONS Patient and pain factors and psychological comorbidity do not predict SOM results at ERCP in suspected type III SOD. ( CLINICAL TRIAL REGISTRATION NUMBER NCT00688662.).
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Affiliation(s)
- Joseph Romagnuolo
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Peter B. Cotton
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Valerie Durkalski
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Qi Pauls
- Medical University of South Carolina, Charleston, South Carolina, USA
| | | | | | - Patrick Mauldin
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Kyle Orrell
- Digestive Health Associates of Texas, Dallas, Texas, USA
| | - April W Williams
- Medical University of South Carolina, Charleston, South Carolina, USA
| | | | | | | | | | | | | | | | - Jose Serrano
- National Institute of Diabetes and Digestive and Kidney Diseases, Division of Digestive Diseases and Nutrition, National Institutes of Health, Bethesda, Maryland, USA
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22
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Aslanian HR, Shieh FK, Chan FW, Ciarleglio MM, Deng Y, Rogart JN, Jamidar PA, Siddiqui UD. Nurse observation during colonoscopy increases polyp detection: a randomized prospective study. Am J Gastroenterol 2013; 108:166-72. [PMID: 23381064 DOI: 10.1038/ajg.2012.237] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To determine whether a second observer during colonoscopy increases adenoma detection. METHODS Consecutive patients undergoing screening colonoscopy were prospectively randomized to routine colonoscopy or physician and nurse observation during withdrawal. RESULTS Of 502 patients, 249 were randomized to routine colonoscopy, and 253 to physician plus nurse observation during withdrawal. A total of 592 polyps were detected, 40 identified by the endoscopy nurse only. With nurse observation, 1.32 polyps and 0.82 adenomas were found per colonoscopy, vs. 1.03 polyps and 0.64 adenomas in the routine group, demonstrating a 1.29-fold and a 1.28-fold increase in the average number of polyps and of adenomas detected, respectively. The overall adenoma detection rate (ADR) was 44.1%, with trends toward increased ADR and all-polyp detection rate with nurse observation. CONCLUSIONS Nurse observation during colonoscopy resulted in an increase in the number of polyps and adenomas found per colonoscopy, along with a trend toward improved overall ADR and all-polyp detection rate.
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Affiliation(s)
- Harry R Aslanian
- Digestive Diseases Section, Yale University School of Medicine, New Haven, Connecticut, USA
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23
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Talreja JP, Sethi A, Jamidar PA, Singh SK, Kwon RS, Siddiqui UD, Sawhney M, Bakhru MR, Gaidhane M, Kline P, Sauer BG, Kahaleh M. Interpretation of probe-based confocal laser endomicroscopy of indeterminate biliary strictures: is there any interobserver agreement? Dig Dis Sci 2012; 57:3299-302. [PMID: 22875310 DOI: 10.1007/s10620-012-2338-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2012] [Accepted: 07/20/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Probe-based confocal laser endomicroscopy (pCLE) has enabled in vivo histopathology by obtaining high resolution images of the mucosal layers of the gastrointestinal tract. For indeterminate bile duct strictures, biopsy, cytologic brushing and needle aspiration have low levels of diagnostic accuracy. AIM The objective of this multi-center pilot study was to assess the interobserver agreement in interpretation of pCLE imaging. METHODS Twenty-five de-identified pCLE video clips of indeterminate biliary strictures were sent to 6 observers at 5 institutions. Miami Classification was used to standardize image interpretation. Seven variables were assessed for interobserver agreement using the Fleiss kappa statistic which included: presence of thick (>20 μm) or thin (<20 μm) dark or white bands, dark clumps, epithelium including glandular structures, interstitial fluorescein leakage, ease of interpretation, and final diagnosis. Based on operator experience, observers were categorized into 3 categories of experience (Category 1: 0-10; Category 2: 11-20; Category 3: >21 cases). RESULTS Upon stratification, Category 1 interobserver agreement ranged from "Poor" to "Fair" (κ = 0.277, κ = -0.079, κ = -0.025, κ = -0.066, κ = 0.128, κ = 0.088), and for the final diagnosis variable, the agreement was slight (κ = 0.033). Category 2 and 3 interobserver agreement ranged from "Poor" to "Fair" (κ = 0.211, κ = 0.181, κ = 0.347, κ = 0.238, κ = -0.050, κ = 0.092), and for the final diagnosis variable, the agreement was slight (κ = 0.195). CONCLUSION The overall interobserver agreement for pCLE image interpretation in indeterminate biliary strictures ranges from poor to fair. Interpretation criteria as well as training require further standardization toward improving inter-rater reliability.
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Affiliation(s)
- Jayant P Talreja
- Department of Digestive Health, University of Virginia, Charlottesville, VA, USA
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24
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Abstract
BACKGROUND Probe-based confocal laser endomicroscopy (pCLE) of the common bile duct (CBD) is a new procedure that can be used for assessing indeterminate billiary strictures. The CBD has been examined using the CholangioFlex miniprobe (Mauna Kea Technologies, Paris, France), which has a lateral resolution of 3.5 μm and diameter of <1.0 mm. However, larger-diameter higher-resolution confocal probes are available. We aimed to determine if pCLE of the CBD with the high-definition GastroFlex(UHD) miniprobe (UHDp) was feasible. This probe has a lateral resolution of 1 μm and an outer diameter of 2.6 mm. METHODS Eleven consecutive patients undergoing endoscopic retrograde cholangiopancreatography for various indications at a single, large, academic center were included in the study. Examination of the CBD was attempted with the UHDp after injection of 2.5 mL of 10% fluorescein. A 0.035 inch guidewire was first placed into the CBD and the confocal probe was subsequently inserted adjacent to the guidewire. Position of the miniprobe was identified fluoroscopically. RESULTS The GastroFlex(UHD) miniprobe was successfully introduced into the CBD in 10 of 11 patients. Cellular structures and individual cell morphology seemed to be more clearly visualized with the UHDp compared with the CholangioFlex probe. No significant side effects except 1 case of mild pancreatitis. CONCLUSIONS We demonstrate that high-definition pCLE of the CBD by the GastroFlex(UHD) miniprobe is feasible and may offer improved image quality over the standard CholangioFlex probe. Further studies are needed to see if this improves the diagnostic accuracy of bile duct lesions.
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Affiliation(s)
- Frederick K Shieh
- Digestive Diseases Section, Yale University School of Medicine, New Haven, CT 06520-8019, USA
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25
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Aslanian HR, Jamidar PA. Ongoing challenges in the endoscopic management of hilar cholangiocarcinoma. Dig Dis Sci 2011; 56:1255-6. [PMID: 21394459 DOI: 10.1007/s10620-011-1664-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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Abstract
BACKGROUND Adenoma detection rate (ADR) is increasingly used as a quality indicator for screening/surveillance colonoscopy. Recent investigations to identify factors that affect ADR have focused on the technical aspects of the procedure or the equipment. OBJECTIVE To assess whether gastroenterology (GI) fellow participation during colonoscopy affects ADR. METHODS This is a retrospective study of data prospectively collected on 309 patients enrolled in a different study not involving polyp detection. In total, 126 colonoscopies were performed by a GI attending alone, and 183 by a GI fellow supervised by one of the same four GI attendings. RESULTS The ADR was significantly higher when a fellow was involved (37% vs 23%, P < 0.01), as was the total number of adenomas detected (0.56 per patient vs 0.30 per patient, P < 0.05). The percentage of patients with two and three or more adenomas was also higher for fellows versus attendings alone (13.1% vs 5.6%, and 6% vs 1.6%, respectively; P < 0.05), though there was no difference in the detection of advanced adenomas (7.1% vs 5.6%, P = 0.16). The adenomas detected when fellows participated were smaller (mean size 4.4 mm vs 5.8 mm, P < 0.05), and more likely to be sessile (80.6% vs 64.9%, P < 0.05). There were no significant differences in the age, gender, indication for colonoscopy, or procedure time for the two groups. CONCLUSIONS In this retrospective study, fellow involvement in colonoscopy may increase not only the ADR, but also the detection of more subtle adenomas. Further investigation into whether this is a "fellow effect," or simply a matter of more efficient visual scanning and recognition with two people, should be considered.
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Affiliation(s)
- Jason N Rogart
- Department of Medicine, Section of Digestive Diseases, Yale University School of Medicine, Yale University, New Haven, Connecticut 06520-8019, USA
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Roberts KE, Panait L, Duffy AJ, Jamidar PA, Bell RL. Laparoscopic-assisted transgastric endoscopy: current indications and future implications. JSLS 2008; 12:30-6. [PMID: 18402736 PMCID: PMC3016032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Endoscopic access to the proximal gastrointestinal tract may prove difficult for a variety of anatomic reasons. Under laparoscopic visualization, trocars can be placed into the stomach with the subsequent introduction of a flexible endoscope directly into the body of the stomach. The purpose of this study was to describe this technique and demonstrate that it is safe, effective, and feasible. METHODS Six patients with altered proximal foregut anatomy were examined. Five patients had previously undergone laparoscopic Roux-Y gastric bypass, and one patient had severe distal esophageal stenosis precluding distal passage of an endoscope. All patients required endoscopic retrograde cholangiopancreatography (ERCP), and one patient underwent closure of a symptomatic gastrogastric fistula. In each patient, two 5-mm ports were inserted and tacking sutures placed between the gastric body and the anterior abdominal wall. Subsequently, a flexible endoscope was inserted into the stomach through a gastrotomy under direct visualization. Picture-in-picture technology enabled simultaneous monitoring of the laparoscopic and endoscopic field. RESULTS The operative time ranged from 64 minutes to 93 minutes. All therapeutic endoscopic procedures were successful. The anterior gastrotomies were either closed primarily or a feeding tube was placed. Patients reported minimal postoperative pain. No complications resulted from the procedures. CONCLUSION In an age where surgeons and gastroenterologists are focusing on the stomach as an access point for transgastric endoscopic surgery, we view the stomach as a portal into the gastrointestinal tract. In patients with limited access for traditional endoluminal therapy, laparoscopic-assisted transgastric endoscopy can be performed safely and efficiently.
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Affiliation(s)
- Kurt E. Roberts
- Yale University School of Medicine, Department of Surgery, New Haven, Connecticut, USA
| | - Lucian Panait
- Saint Mary's Hospital, Department of Surgery, Waterbury, Connecticut, USA
| | - Andrew J. Duffy
- Yale University School of Medicine, Department of Surgery, New Haven, Connecticut, USA
| | - Priya A. Jamidar
- Yale University School of Medicine, Department of Medicine, New Haven, Connecticut, USA
| | - Robert L. Bell
- Yale University School of Medicine, Department of Surgery, New Haven, Connecticut, USA
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Siddiqui UD, Jamidar PA. Endoscopic therapy for the treatment of pain in chronic pancreatitis: a success story in tropical pancreatitis. Gastrointest Endosc 2007; 66:76-8. [PMID: 17591477 DOI: 10.1016/j.gie.2007.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2007] [Accepted: 05/06/2007] [Indexed: 12/10/2022]
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Vargo JJ, Ahmad AS, Aslanian HR, Buscaglia JM, Das AM, Desilets DJ, Dunkin BJ, Inkster M, Jamidar PA, Kowalski TE, Marks JM, McHenry L, Mishra G, Petrini JL, Pfau PR, Savides TJ, Savides TA. Training in patient monitoring and sedation and analgesia. Gastrointest Endosc 2007; 66:7-10. [PMID: 17591466 DOI: 10.1016/j.gie.2007.02.028] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Disario JA, Freeman ML, Bjorkman DJ, Macmathuna P, Petersen BT, Jaffe PE, Morales TG, Hixson LJ, Sherman S, Lehman GA, Jamal MM, Al-Kawas FH, Khandelwal M, Moore JP, Derfus GA, Jamidar PA, Ramirez FC, Ryan ME, Woods KL, Carr-Locke DL, Alder SC. Endoscopic balloon dilation compared with sphincterotomy for extraction of bile duct stones. Gastroenterology 2004; 127:1291-9. [PMID: 15520997 DOI: 10.1053/j.gastro.2004.07.017] [Citation(s) in RCA: 291] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Endoscopic retrograde cholangiopancreatography is commonly performed to remove bile duct stones. The aim of this study was to determine short-term outcomes of endoscopic balloon dilation of the sphincter of Oddi compared with sphincterotomy for stone extraction. METHODS A randomized, controlled multicenter study of 117 patients assigned to dilation and 120 to sphincterotomy was performed in a spectrum of clinical and academic practices. RESULTS Characteristics of the patients, procedures, and endoscopists were similar except that dilation patients were younger. Procedures were successful in 97.4% and 92.5% of the dilation and sphincterotomy patients, respectively. Overall morbidity occurred in 17.9% and 3.3% ( P < .001; difference, 14.6; 95% confidence interval, 7-22.3) and severe morbidity, including 2 deaths, in 6.8% and 0%( P < .004; difference, 6.8; 95% confidence interval, 2.3-11.4) for dilation and sphincterotomy, respectively. Complications for dilation and sphincterotomy, respectively, included: pancreatitis, 15.4% and .8% ( P < .001; difference, 14.6; 95% confidence interval, 7.8-21.3); cystic duct fistula, 1.7% and 0%; cholangitis, .9% and .8%; perforation, 0% and .8%; and cholecystitis, 0% and .8%. There were 2 deaths (1.7%) due to pancreatitis following dilation and none with sphincterotomy. The study was terminated at the first interim analysis. Dilation patients required significantly more invasive procedures, longer hospital stays, and longer time off from normal activities. CONCLUSIONS In a broad spectrum of patients and practices, endoscopic balloon dilation compared with sphincterotomy for biliary stone extraction is associated with increased short-term morbidity rates and death due to pancreatitis. Balloon dilation of the sphincter of Oddi for stone extraction should be avoided in routine practice.
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Affiliation(s)
- James A Disario
- Division of Gastroenterology, Hepatology and Nutrition, University of Utah Health Science Center, Salt Lake City, UT 84132, USA.
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Freeman ML, Nelson DB, Sherman S, Haber GB, Fennerty MB, DiSario JA, Ryan ME, Kortan PP, Dorsher PJ, Shaw MJ, Herman ME, Cunningham JT, Moore JP, Silverman WB, Imperial JC, Mackie RD, Jamidar PA, Yakshe PN, Logan GM, Pheley AM. Same-day discharge after endoscopic biliary sphincterotomy: observations from a prospective multicenter complication study. The Multicenter Endoscopic Sphincterotomy (MESH) Study Group. Gastrointest Endosc 1999; 49:580-6. [PMID: 10228255 DOI: 10.1016/s0016-5107(99)70385-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Same-day discharge after endoscopic biliary sphincterotomy (ES) is a common clinical practice, but there have been few data to guide appropriate selection of patients. Using a prospective, multicenter database of complications, we examined outcomes after same-day discharge as it was practiced by a variety of endoscopists and evaluated the ability of a multivariate risk factor analysis to predict which patients would require readmission for complications. METHODS A 150-variable database was prospectively collected at time of ES, before discharge and again at 30 days in consecutive patients undergoing ES at 17 centers. Complications were defined by consensus criteria and included all specific adverse events directly or indirectly related to ES requiring more than 1 night of hospitalization. RESULTS Six hundred fourteen (26%) of 2347 patients undergoing ES were discharged on the same day as the procedure, ranging from none at 6 centers to about 50% at 2 centers. After initial observation and release, readmission to the hospital for complications occurred in 35 (5.7%) of 614 same-day discharge patients (20 pancreatitis and 15 other complications, 3 severe). Of the same-day discharge patients, readmission was required for 14 (12.2%) of 115 who had at least one independently significant multivariate risk factor for overall complications (suspected sphincter of Oddi dysfunction, cirrhosis, difficult bile duct cannulation, precut sphincterotomy, or combined percutaneous-endoscopic procedure) versus 21 (4.2%) of 499 without a risk factor (odds ratio 3.1: 95% confidence interval [1.6, 6.3], p < 0.001). Of complications presenting within 24 hours after ES, only 44% presented within the first 2 hours, but 79% presented within 6 hours. CONCLUSIONS Same-day discharge is widely utilized and relatively safe but results in a significant number of readmissions for complications. For patients at higher risk of complications, as indicated by the presence of at least one of five independent predictors, observation for 6 hours or overnight may reduce the need for readmission.
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Affiliation(s)
- M L Freeman
- Hennepin County Medical Center and Minneapolis Veterans Administration Medical Center, MN 55415, USA
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Carr-Locke DL, al-Kawas FH, Branch MS, Edmundowicz SA, Jamidar PA, Petersen BT, Stein TN. Technology assessment status evaluation: bipolar and multipolar accessories, February 1996. Gastroenterol Nurs 1998; 21:187-9. [PMID: 9849185 DOI: 10.1097/00001610-199807000-00009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Kimmey MB, Al-Kawas FH, Gannan RM, Saeed ZA, Carr-Locke DL, Edmundowicz SA, Jamidar PA, Stein TN. Technology assessment status evaluation: balloon dilation of gastrointestinal tract strictures. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc 1995; 42:608-11. [PMID: 8674941 DOI: 10.1016/s0016-5107(95)70025-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Balloon dilation is an acceptable modality for the dilation of stenoses at various sites in the gastrointestinal tract. In the esophagus its reported efficacy and safety is similar to bougienage; in other sites it offers an alternative to surgical treatment, in most cases as the definitive therapy.
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Kimmey MB, Al-Kawas FH, Gannan RM, Saeed ZA, Carr-Locke DL, Edmundowicz SA, Jamidar PA, Stein TN. Technology assessment status evaluation: monitoring equipment for endoscopy. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc 1995; 42:615-7. [PMID: 8674943 DOI: 10.1016/s0016-5107(95)70027-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
An understanding of the principles and limitations of monitoring devices is valuable for their appropriate use and interpretation. Reliable monitoring de available as an adjunct to skilled personnel to detect changes in patient condition during endoscopy. Combination units that provide pulse oximetry, automated sphygmomanometry and ECG monitoring appear to be the most convenient and cost effective products.
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Kimmey MB, Al-Kawas FH, Gannan RM, Saeed ZA, Carr-Locke DL, Edmundowicz SA, Jamidar PA, Stein TN. Technology assessment status evaluation: disposable endoscopic accessories. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc 1995; 42:618-9. [PMID: 8674944 DOI: 10.1016/s0016-5107(95)70028-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Data supporting the preferential use of disposable endoscopic accessories is limited. These devices have been widely disseminated without careful evaluation of their impact on the environment and medical costs. In addition, current facility reimbursement for endoscopic procedures does not adequately cover the costs of these accessories. Re-use of accessories labelled "for single use only" as a potential means to reduce costs has not been carefully evaluated. More prospective data comparing the efficacy, safety, and cost effectiveness of disposable versus reusable accessories is needed.
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Kimmey MB, Al-Kawas FH, Gannan RM, Saeed ZA, Carr-Locke DL, Edmundowicz SA, Jamidar PA, Stein TN. Technology Assessment status evaluation: endoscopic feeding tubes. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc 1995; 42:612-4. [PMID: 8674942 DOI: 10.1016/s0016-5107(95)70026-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Jamidar PA, Beck GJ, Hoffman BJ, Lehman GA, Hawes RH, Agrawal RM, Ashok PS, Ravi TJ, Cunningham JT, Troiano F. Endoscopic retrograde cholangiopancreatography in pregnancy. Am J Gastroenterol 1995; 90:1263-7. [PMID: 7639227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreaticobiliary disease in pregnancy is relatively uncommon. The frequency of choledocholithiasis in pregnancy requiring intervention has been reported to be as low as one in 1200 deliveries. Traditionally, intervention in these patients has been surgical. Although surgery has an overall low morbidity and mortality for the expectant mother, it carries with it a 4- to 6-wk recovery period and a possibly increased risk of fetal wastage. Published information regarding the role and safety of ERCP in pregnancy is limited. This series of 23 pregnant patients undergoing ERCP was collected from six different medical centers. METHODS Twenty-three pregnant patients with symptomatic pancreaticobiliary disease underwent a total of 29 ERCPs (three patients had diagnostic ERCP, and 20 had therapeutic ERCP). Fifteen, eight, and six procedures were performed in the first, second, and third trimesters, respectively. The only ERCP complication was pancreatitis in one patient. There was one spontaneous abortion (3 months after ERCP) and one neonatal death; however, casual relationship to ERCP was not apparent. CONCLUSION Diagnostic and therapeutic ERCP appears reasonably safe and effective in pregnancy. Cautious and selective use of this procedure offers a viable alternative to surgery or observation in patients with emergent pancreaticobiliary problems.
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Affiliation(s)
- P A Jamidar
- Hospital of the Good Samaritan, Los Angeles, California, USA
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Affiliation(s)
- B J Kendall
- Division of Gastroenterology, University of California Los Angeles Medical Center, USA
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Abstract
Peritoneal coccidioidomycosis is extremely rare. This report describes a patient infected with the human immunodeficiency virus who presented with unexplained ascites and was found to have peritoneal coccidioidomycosis. The ascites had a low serum-ascites albumin gradient, and laparoscopy showed peritoneal implants that grew Coccidioides immitis. This case is unique in several ways; this is the first case in which a patient's acquired immunodeficiency syndrome-defining illness was peritoneal coccidioidomycosis, and the serum-ascites albumin gradient determination as well as laparoscopy provided information critical to the diagnosis. This patient's dramatic response to systemic antifungal therapy, as evidenced by resolution of ascites and constitutional symptoms, underscores the importance of timely diagnosis and prompt therapy. In summary, this report reviews the previous cases of coccidioidal peritonitis and reports the first case in which localized peritoneal coccidioidomycosis was the acquired immunodeficiency syndrome-defining illness in a human immunodeficiency virus-infected patient.
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Affiliation(s)
- P A Jamidar
- Department of Medicine, Department of Veterans Affairs Medical Center, Kansas City, Missouri
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