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El Bacha H, Harizi R, Laugier R, Lorenzo D, Rivallin P, Leblanc S, Barange K, Fumex F, Laquière A, Napoléon B, Vedrenne B, Grabar S, Prat F. Identification of endoscopic predictors of biliary malignancy during digital cholangioscopy. Dig Endosc 2022; 34:1224-1233. [PMID: 35138664 DOI: 10.1111/den.14259] [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: 04/19/2021] [Revised: 01/26/2022] [Accepted: 01/30/2022] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Biliary brushings and biopsies obtained during endoscopic retrograde cholangiopancreatography (ERCP) have a low sensitivity for the diagnosis of malignant biliary strictures. While cholangioscopic analysis is useful, visual criteria have not yet been defined. The aim of this study was to identify visual criteria for the diagnosis of indeterminate biliary strictures (IDBS). METHODS A multicenter study was conducted based on the analysis of cholangioscopic recordings of IBDS. Diagnostic criteria were identified in a study group and verified in a validation group. RESULTS Four criteria were identified to be associated with malignancy, one negatively ("endobiliary material," odds ratio [OR] 0.62, 95% confidence interval [CI] 0.41-0.92) and three positively ("vascularized villous projections," OR 1.52, 95% CI 1.03-2.24; "twisted or dilated vessels," OR 2.18, 95% CI 1.47-3.24; and "dark color of the mucosa," OR 1.82, 95% CI 1.23-2.70). Between two playbacks, the mean (95% CI) sensitivity of the observer's visual diagnosis increased from 66.1% (60-72) to 73.8% (69-78) (P = 0.004); in the second playback, the kappa value for interobserver agreement ranged between 0.36 (color) and 0.56 (endobiliary material), with a significant improvement (P = 0.0031-0.0001) between the first and second playbacks. Blind assessment by endoscopists not involved in this study had a diagnostic accuracy of 73% (71.4-74.5). CONCLUSION The four identified cholangioscopic features are easy to implement in clinical practice and have the potential to increase the level of diagnostic confidence during the workup of IDBS.
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Affiliation(s)
- Hicham El Bacha
- Gastroenterology and Endoscopy Unit Medicine B, Mohammed V University in Rabat, Ibn Sina University Hospital, Rabat, Morocco
| | - Rafik Harizi
- Department of Biostatistics and Epidemiology, Cochin-Hôtel Dieu, University Hospitals of Paris (AP-HP), Paris, France
| | - René Laugier
- Gastroenterology and Endoscopy Unit, La Timone University Hospital, Marseilles, France
| | - Diane Lorenzo
- Endoscopy Unit, Beaujon Hospital, University Hospitals of Paris (AP-HP) and University of Paris, Clichy, France
| | - Paul Rivallin
- Endoscopy Unit, Beaujon Hospital, University Hospitals of Paris (AP-HP) and University of Paris, Clichy, France
| | - Sarah Leblanc
- Digestive Endoscopy Unit, Jean Mermoz Clinic, Lyon, France
| | - Karl Barange
- Gastroenterology and Endoscopy Unit, Toulouse University Hospital, Toulouse, France
| | - Fabien Fumex
- Digestive Endoscopy Unit, Jean Mermoz Clinic, Lyon, France
| | - Arthur Laquière
- Gastroenterology and Endoscopy Unit, Saint Joseph Hospital, Marseilles, France
| | | | - Bruno Vedrenne
- Gastroenterology and Endoscopy Unit, Mulhouse and Southern Alsace Regional Hospital, Mulhouse, France
| | - Sophie Grabar
- Department of Biostatistics and Epidemiology, Cochin-Hôtel Dieu, University Hospitals of Paris (AP-HP), Paris, France
| | - Frederic Prat
- Endoscopy Unit, Beaujon Hospital, University Hospitals of Paris (AP-HP) and University of Paris, Clichy, France
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Ahmed W, Jeyaraj R, Reffitt D, Devlin J, Suddle A, Hunt J, Heneghan MA, Harrison P, Joshi D. Nasobiliary drainage: an effective treatment for pruritus in cholestatic liver disease. Frontline Gastroenterol 2022; 13:416-422. [PMID: 36051950 PMCID: PMC9380771 DOI: 10.1136/flgastro-2021-102025] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 12/21/2021] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Nasobiliary drains (NBDs) have been successfully used to manage intrahepatic cholestasis, bile leaks and obstructive cholangitis. It allows external drainage of bile, bypassing the ileum where bile salts are reabsorbed. We assessed the utility of placement with effect on markers of cholestasis and patient symptoms. METHODS Consecutive patients undergoing NBD over 12 years for the management of pruritus were retrospectively analysed. Recorded variables included patient demographics, procedural characteristics and response to therapy. RESULTS Twenty-three patients (14, 61% male) underwent 30 episodes of NBD. The median age was 26 years old (range 2-67 years old). A single procedure was carried out in 20. One patient each had two, three and five episodes of NBD. The most common aetiologies were hereditary cholestatic disease (n=17, 74%) and drug-induced cholestasis (n=5, 22%),NBD remained in situ for a median of 8 days (range 1-45 days). Significant improvement in bilirubin was seen at 7 days post-NBD (p=0.0324), maintained at day 30 (335 μmol/L vs 302 µmol/L vs 167 µmol/L). There was symptomatic improvement in pruritus in 20 (67%, p=0.0494) episodes. One patient underwent NBD during the first trimester of pregnancy after medical therapy failure with a good symptomatic response. The catheters were well tolerated in 27 (90%) of cases. Mild pancreatitis occurred in 4 (13%) cases. CONCLUSION NBD can be used to provide symptomatic improvement to patients with pruritus associated with cholestasis. It is well tolerated by patients. They can be used in pregnancy where medical management has failed.
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Affiliation(s)
- Wafaa Ahmed
- Institute of Liver Studies, King's College Hospital NHS Trust, London, UK
| | - Rebecca Jeyaraj
- Institute of Liver Studies, King's College Hospital NHS Trust, London, UK
| | - David Reffitt
- Institute of Liver Studies, King's College Hospital NHS Trust, London, UK
| | - John Devlin
- Institute of Liver Studies, King's College Hospital NHS Trust, London, UK
| | - Abid Suddle
- Institute of Liver Studies, King's College Hospital NHS Trust, London, UK
| | - John Hunt
- Institute of Liver Studies, King's College Hospital NHS Trust, London, UK
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital NHS Trust, London, UK
| | - Phillip Harrison
- Institute of Liver Studies, King's College Hospital NHS Trust, London, UK
| | - Deepak Joshi
- Institute of Liver Studies, King's College Hospital NHS Trust, London, UK
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Parker AM, Schaefer D, Royer A, Sonani H, Grunes D, Glover SC. A Spy took a bite to get the diagnosis right: the benefit of SpyGlass technology in the diagnosis of autoimmune pancreatitis evading traditional diagnostic methods. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000694. [PMID: 34479950 PMCID: PMC8420695 DOI: 10.1136/bmjgast-2021-000694] [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: 04/27/2021] [Accepted: 08/12/2021] [Indexed: 11/15/2022] Open
Abstract
Autoimmune pancreatitis (AIP) is a rare form of chronic pancreatitis that is often overlooked and is usually characterised clinically by frequent presentations with obstructive jaundice. Serum IgG4 testing as a means to ‘rule out’ IgG4-related disease may not be as helpful as initially thought and may lead to a missed diagnosis if suspicion is low. We present a patient with a years long history of recurrent pancreatitis ultimately found to have AIP after undergoing evaluation with a relatively new technology, SpyGlass, which allows for direct cholangioscopy and enabled us to make the correct diagnosis.
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Affiliation(s)
- Adam Matthew Parker
- Digestive Diseases, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - David Schaefer
- Digestive Diseases, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Amor Royer
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Hardik Sonani
- Department of Pathology, University of Mississippi Department of Medicine, Jackson, Mississippi, USA
| | - Dianne Grunes
- Department of Pathology, University of Mississippi Department of Medicine, Jackson, Mississippi, USA
| | - Sarah Camille Glover
- Digestive Diseases, University of Mississippi Medical Center, Jackson, Mississippi, USA
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Abstract
Introduction: PSC is a rare liver disease that leads frequently to cirrhosis and need for liver transplantation. No medical treatment is of proven value. Liver transplantation is the only curative therapy available. There is a big medical need to find medical therapy that can alter the natural history of the disease.Areas covered: The authors highlight advances in PSC, based on recent literature retrieved from PubMed until September 2020 regarding both medical and endoscopic biliary therapy.Future possibilities for treatment of PSC are discussed.Expert opinion: Biliary endoscopy is the cornerstone in the treatment of dominant strictures. Single-user peroral cholangioscopy is an emerging modality. Balloon dilatation therapy is the treatment of choice of dominant strictures. The most promising medical therapies showing efficacy in phase II trials are nor-Ursodeoxycholic acid, obethicolic acid, the non-steroidal FXR agonist Cilofexor and Aldafermin, a synthetic analogue of FGF-19. Antibiotics, particularly vancomycin have shown potential benefits, particularly in children but phase III studies are lacking. In observational studies of effects of biological therapy in patients with IBD/PSC adalimumab was associated with reduction in ALP. Results of liver transplantation are favorable but recurrence can be of clinical relevance particularly in patients transplanted before the age of 40.
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Affiliation(s)
- Einar S Björnsson
- Department of Internal Medicine, Faculty of Medicine, University of Iceland, Division of Gastroenterology and Hepatology, Landspitali University Hospital of Iceland
| | - Evangelos Kalaitzakis
- Department of Internal Medicine, University Hospital Heraklion, Faculty of Medicine, University of Crete, Rethymno, Greece
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Tepox-Padrón A, Bernal-Mendez RA, Duarte-Medrano G, Romano-Munive AF, Mairena-Valle M, Ramírez-Luna MÁ, Marroquin-Reyes JD, Uscanga L, Chan C, Domínguez-Rosado I, Hernandez-Calleros J, Pelaez-Luna M, Tellez-Avila F. Utility of endoscopic ultrasound in idiopathic acute recurrent pancreatitis. BMJ Open Gastroenterol 2021; 8:bmjgast-2020-000538. [PMID: 33402380 PMCID: PMC7786795 DOI: 10.1136/bmjgast-2020-000538] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 09/07/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 12/19/2022] Open
Abstract
Idiopathic acute recurrent pancreatitis (IARP) is defined as at least two episodes of acute pancreatitis with the complete or near-complete resolution of symptoms and signs of pancreatitis between episodes, without an identified cause. There is a paucity of information about the usefulness of endoscopic ultrasound (EUS) in IARP.
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Affiliation(s)
- Alejandra Tepox-Padrón
- Gastrointestinal Endoscopy Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico, Mexico
| | - Rafael Ambrosio Bernal-Mendez
- Gastrointestinal Endoscopy Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico, Mexico
| | - Gilberto Duarte-Medrano
- Gastrointestinal Endoscopy Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico, Mexico
| | - Adriana Fabiola Romano-Munive
- Gastrointestinal Endoscopy Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico, Mexico
| | - Milton Mairena-Valle
- Gastrointestinal Endoscopy Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico, Mexico
| | - Miguel Ángel Ramírez-Luna
- Gastrointestinal Endoscopy Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico, Mexico
| | - Jose Daniel Marroquin-Reyes
- Gastrointestinal Endoscopy Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico, Mexico
| | - Luis Uscanga
- Gastroenterology Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Tlalpan, Mexico
| | - Carlos Chan
- Surgery Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico, Mexico
| | - Ismael Domínguez-Rosado
- Surgery Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico, Mexico
| | - Jorge Hernandez-Calleros
- Gastroenterology Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Tlalpan, Mexico
| | - Mario Pelaez-Luna
- Gastroenterology Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Tlalpan, Mexico
| | - Felix Tellez-Avila
- Gastrointestinal Endoscopy Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico, Mexico
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Liwinski T, Zenouzi R, John C, Ehlken H, Rühlemann MC, Bang C, Groth S, Lieb W, Kantowski M, Andersen N, Schachschal G, Karlsen TH, Hov JR, Rösch T, Lohse AW, Heeren J, Franke A, Schramm C. Alterations of the bile microbiome in primary sclerosing cholangitis. Gut 2020; 69:665-672. [PMID: 31243055 DOI: 10.1136/gutjnl-2019-318416] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [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: 01/31/2019] [Revised: 06/03/2019] [Accepted: 06/06/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Patients with primary sclerosing cholangitis (PSC) display an altered colonic microbiome compared with healthy controls. However, little is known on the bile duct microbiome and its interplay with bile acid metabolism in PSC. METHODS Patients with PSC (n=43) and controls without sclerosing cholangitis (n=22) requiring endoscopic retrograde cholangiography were included prospectively. Leading indications in controls were sporadic choledocholithiasis and papillary adenoma. A total of 260 biospecimens were collected from the oral cavity, duodenal fluid and mucosa and ductal bile. Microbiomes of the upper alimentary tract and ductal bile were profiled by sequencing the 16S-rRNA-encoding gene (V1-V2). Bile fluid bile acid composition was measured by high-performance liquid chromatography mass spectrometry and validated in an external cohort (n=20). RESULTS The bile fluid harboured a diverse microbiome that was distinct from the oral cavity, the duodenal fluid and duodenal mucosa communities. The upper alimentary tract microbiome differed between PSC patients and controls. However, the strongest differences between PSC patients and controls were observed in the ductal bile fluid, including reduced biodiversity (Shannon entropy, p=0.0127) and increase of pathogen Enterococcus faecalis (FDR=4.18×10-5) in PSC. Enterococcus abundance in ductal bile was strongly correlated with concentration of the noxious secondary bile acid taurolithocholic acid (r=0.60, p=0.0021). CONCLUSION PSC is characterised by an altered microbiome of the upper alimentary tract and bile ducts. Biliary dysbiosis is linked with increased concentrations of the proinflammatory and potentially cancerogenic agent taurolithocholic acid.
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Affiliation(s)
- Timur Liwinski
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Roman Zenouzi
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Clara John
- Biochemistry and Molecular Cell Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hanno Ehlken
- Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Malte C Rühlemann
- Christian-Albrechts-Universität zu Kiel, Institute of Clinical Molecular Biology, Kiel, Germany
| | - Corinna Bang
- Institute for Clinical Molecular Biology, Christian Albrechts University of Kiel, Kiel, Germany
| | - Stefan Groth
- Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Lieb
- Institute of Epidemiology and Biobank PopGen, Christian-Albrechts-University of Kiel, Kiel, Germany
| | - Marcus Kantowski
- Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nils Andersen
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Guido Schachschal
- Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tom H Karlsen
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Johannes R Hov
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Norwegian PSC Research Center, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Thomas Rösch
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ansgar W Lohse
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joerg Heeren
- Biochemistry and Molecular Cell Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Franke
- Institute for Clinical Molecular Biology, Christian Albrechts University of Kiel, Kiel, Germany
| | - Christoph Schramm
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Rupp C, Hippchen T, Bruckner T, Klöters-Plachky P, Schaible A, Koschny R, Stiehl A, Gotthardt DN, Sauer P. Effect of scheduled endoscopic dilatation of dominant strictures on outcome in patients with primary sclerosing cholangitis. Gut 2019; 68:2170-2178. [PMID: 30910856 PMCID: PMC6872453 DOI: 10.1136/gutjnl-2018-316801] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [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: 05/14/2018] [Revised: 02/16/2019] [Accepted: 03/08/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Scheduled endoscopic dilatation of dominant strictures (DS) in primary sclerosing cholangitis (PSC) might improve outcome relative to endoscopic treatment on demand, but evidence is limited. Since randomisation is difficult in clinical practice, we present a large retrospective study comparing scheduled versus on-demand endoscopic retrograde cholangiopancreatography (ERCP) based on patient preferences. DESIGN Between 1987 and 2017, all new patients with PSC had been offered scheduled ERCP with dilatation of a DS if diagnosed; the latter was repeated at defined intervals until morphological resolution, independent of clinical symptoms (treatment group). Patients who refused participation were clinically evaluated annually and received endoscopic treatment only on demand (control group). The primary clinical endpoint was transplantation-free survival. Secondary outcomes were overall survival, bacterial cholangitis episodes, hepatic decompensation of liver cirrhosis and endoscopy-related adverse events. RESULTS The final study included 286 patients, 133 (46.5%) receiving scheduled ERCP and 153 (53.5%) receiving on-demand ERCP. After a mean follow-up of 9.9 years, the rate of transplantation-free survival was higher in patients receiving scheduled ERCP (51% vs 29.3%; p<0.001), as was transplantation-free survival time (median: 17.9 vs 15.2 years; log-rank: p=0.008). However, the benefit of scheduled ERCP was significant only in patients with the initial (17.1%) or later (45.5%) diagnosis of a DS (17.8 vs 11.1 years; log-rank: p<0.001). IBD (p=0.03), DS (p=0.006), higher Mayo Risk Score (p=0.02) and non-adherence to scheduled endoscopy (p=0.005) were independently associated with transplantation-free survival. CONCLUSION In our large retrospective study, regular ERCP with endoscopic balloon dilatation significantly benefits patients with PSC with DS, diagnosed both at initial presentation and during surveillance, even if asymptomatic. Further studies have to find out how to best identify stricture patients non-invasively.
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Affiliation(s)
- Christian Rupp
- Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany,Department of Internal Medicine IV, Interdisciplinary Endoscopy Center, University Hospital Heidelberg, Heidelberg, Germany
| | - Theresa Hippchen
- Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Petra Klöters-Plachky
- Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany
| | - Anja Schaible
- Department of General, Visceral and Transplantation Surgery, Interdisciplinary Endoscopy Center, University Hospital of Heidelberg, Heidelberg, Germany
| | - Ronald Koschny
- Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany,Department of Internal Medicine IV, Interdisciplinary Endoscopy Center, University Hospital Heidelberg, Heidelberg, Germany
| | - Adolf Stiehl
- Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany
| | - Daniel Nils Gotthardt
- Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany
| | - Peter Sauer
- Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany,Department of Internal Medicine IV, Interdisciplinary Endoscopy Center, University Hospital Heidelberg, Heidelberg, Germany
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Keegan MJ, Bell J, Westwood A, Cairns A, Albazaz R, Huggett MT. Painless jaundice with pancreatic mass in 79-year-old man receiving bortezomib for relapsed multiple myeloma. Frontline Gastroenterol 2019; 11:335-336. [PMID: 32587677 PMCID: PMC7307266 DOI: 10.1136/flgastro-2018-101163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 05/02/2019] [Accepted: 05/03/2019] [Indexed: 02/04/2023] Open
Affiliation(s)
- Mathew James Keegan
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Joshua Bell
- Department of Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Alice Westwood
- Department of Histopathology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Alison Cairns
- Department of Histopathology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Raneem Albazaz
- Department of Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Matthew T Huggett
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Anderson J, Lockett M. Training in therapeutic endoscopy: meeting present and future challenges. Frontline Gastroenterol 2019; 10:135-140. [PMID: 31205653 PMCID: PMC6540612 DOI: 10.1136/flgastro-2018-101086] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 10/30/2018] [Revised: 12/30/2018] [Accepted: 01/10/2019] [Indexed: 02/04/2023] Open
Abstract
Medical endoscopy trainees face numerous, often conflicting demands on their time. This can result in suboptimal endoscopy training and in difficulty achieving certification in basic endoscopy within the existing 5-year training programme. Endoscopic management of acute gastrointestinal bleeding and basic polypectomy are integral to basic service provision. Competence in these and other therapeutic procedures, including dealing with complications, is currently acquired opportunistically, or through experiential independent practice. This article proposes several potential solutions that may help with endotherapy training in the current UK training programmes. It also addresses issues relating to speciality training when reduced to 4 years in 2022. Advanced endotherapy training needs to be optimised by understanding how to select individuals with the appropriate skills and how to accelerate therapeutic training at the appropriate time. Training programmes will need to adapt and can learn from countries where the pathway is more developed and established. Future training will include a dedicated subspeciality training programme for advanced therapy with competitive entry. Advanced therapy training will be matched to service needs. Scoring systems for case complexity integrated with regional and supraregional networks, would allow referral of selected cases to the most appropriate specialised units.
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Affiliation(s)
- John Anderson
- Department of Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust, Gloucestershire, UK
| | - Melanie Lockett
- Department of Gastroenterology, North Bristol NHS Trust, Bristol, UK
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10
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El-Sherif Y, Hunt J, Suddle A, Prater B, Reffitt D, Devlin J, Harrison P, Joshi D. Day case 'treat and transfer' ERCP service under general anaesthesia. Frontline Gastroenterol 2018; 9:317-322. [PMID: 30245796 PMCID: PMC6145430 DOI: 10.1136/flgastro-2017-100880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 07/24/2017] [Revised: 01/21/2018] [Accepted: 02/24/2018] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE General anaesthesia (GA) has been increasingly used for advanced endoscopic procedures in particular endoscopic retrograde cholangiopancreatography (ERCP). Given the increasing pressure on many hospitals, the delivery of such service on a regular basis may not always be possible. We established a new day case 'GA ERCP' service. We describe our experience in evaluating the safety and overall feasibility of this new service. DESIGN Prospective database has been interrogated for the period from March 2015 to December 2016. We documented patients' demographics, ERCP indications, American Society of Anesthesiologists (ASA) status, Cotton grade and complications. RESULTS 67 patients were referred to endoscopy unit at King's College Hospital (KCH), for urgent day case GA ERCP from nine referring hospitals. The main indications were failed ERCP under sedation 47.8% (32/67), and unavailability of ERCP locally 41.8% (28/67). A total of 64 patients were actually transferred to KCH; 57.8% (37/64) women with a median age 55.8 years (range 23-90). 78.1% (50/64) of patients had a virgin papilla, with 39% (25/64) were ASA ≥3. The Cotton grade was ≥ 3 in 50% (32/64) patients. ERCP was completed successfully in 87.5% (56/64). For patients with previous failed ERCP, repeat ERCP under GA was successful in 75% (24/32). All patients were safely discharged back to their referring hospitals after the short observation period post-ERCP. CONCLUSIONS Urgent inpatient transfers between hospitals for performing ERCP under GA as a day case is safe and feasible. The new GA ERCP pathway can be replicated by other UK centres.
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Affiliation(s)
- Yasser El-Sherif
- Institute of Liver Studies, King’s College Hospital, London, UK,National Liver Institute, Menoufia University, Shebin El-Kom, Egypt
| | - John Hunt
- Institute of Liver Studies, King’s College Hospital, London, UK
| | - Abid Suddle
- Institute of Liver Studies, King’s College Hospital, London, UK
| | - Brian Prater
- Department of Anaesthetics, King’s College Hospital, London, UK
| | - David Reffitt
- Institute of Liver Studies, King’s College Hospital, London, UK
| | - John Devlin
- Institute of Liver Studies, King’s College Hospital, London, UK
| | | | - Deepak Joshi
- Institute of Liver Studies, King’s College Hospital, London, UK
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11
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Teoh AYB, Dhir V, Kida M, Yasuda I, Jin ZD, Seo DW, Almadi M, Ang TL, Hara K, Hilmi I, Itoi T, Lakhtakia S, Matsuda K, Pausawasdi N, Puri R, Tang RS, Wang HP, Yang AM, Hawes R, Varadarajulu S, Yasuda K, Ho LKY. Consensus guidelines on the optimal management in interventional EUS procedures: results from the Asian EUS group RAND/UCLA expert panel. Gut 2018; 67:1209-1228. [PMID: 29463614 DOI: 10.1136/gutjnl-2017-314341] [Citation(s) in RCA: 128] [Impact Index Per Article: 21.3] [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: 04/18/2017] [Revised: 12/22/2017] [Accepted: 01/17/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Interventional endoscopic ultrasonography (EUS) procedures are gaining popularity and the most commonly performed procedures include EUS-guided drainage of pancreatic pseudocyst, EUS-guided biliary drainage, EUS-guided pancreatic duct drainage and EUS-guided celiac plexus ablation. The aim of this paper is to formulate a set of practice guidelines addressing various aspects of the above procedures. METHODS Formulation of the guidelines was based on the best scientific evidence available. The RAND/UCLA appropriateness methodology (RAM) was used. Panellists recruited comprised experts in surgery, interventional EUS, interventional radiology and oncology from 11 countries. Between June 2014 and October 2016, the panellists met in meetings to discuss and vote on the clinical scenarios for each of the interventional EUS procedures in question. RESULTS A total of 15 statements on EUS-guided drainage of pancreatic pseudocyst, 15 statements on EUS-guided biliary drainage, 12 statements on EUS-guided pancreatic duct drainage and 14 statements on EUS-guided celiac plexus ablation were formulated. The statements addressed the indications for the procedures, technical aspects, pre- and post-procedural management, management of complications, and competency and training in the procedures. All statements except one were found to be appropriate. Randomised studies to address clinical questions in a number of aspects of the procedures are urgently required. CONCLUSIONS The current guidelines on interventional EUS procedures are the first published by an endoscopic society. These guidelines provide an in-depth review of the current evidence and standardise the management of the procedures.
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Affiliation(s)
- Anthony Y B Teoh
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Vinay Dhir
- Baldota Institute of Digestive Sciences, Mumbai, Maharashtra, India
| | - Mitsuhiro Kida
- Department of Gastroenterology, Kitasato University Hospital, Sagamihara City, Japan
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | - Zhen Dong Jin
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Dong Wan Seo
- Department of Gastroenterology, Asan Medical Center, Seoul, Republic of Korea
| | - Majid Almadi
- Department of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Ida Hilmi
- Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Takao Itoi
- Department of Gastroenterology, Tokyo Medical University, Tokyo, Japan
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Koji Matsuda
- St Marianna University School of Medicine, Yokohama City Seibu Hospital, Kawasaki, Japan
| | - Nonthalee Pausawasdi
- Department of Internal Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Rajesh Puri
- Department of Gastroenterology, Institute of Digestive and Hepatobiliary Sciences Medanta, The Medicity, Gurgaon, India
| | - Raymond S Tang
- Institute of Digestive Disease, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Ai Ming Yang
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Dongcheng-qu, Beijing, China
| | - Robert Hawes
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Shyam Varadarajulu
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Kenjiro Yasuda
- Department of Gastroenterology, Kyoto Second Red Cross Hospital, Kyoto, Japan
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Tieu AH, Kumbhari V, Jakhete N, Onyimba F, Patel Y, Shin EJ, Li Z. Diagnostic and therapeutic utility of SpyGlass(®) peroral cholangioscopy in intraductal biliary disease: single-center, retrospective, cohort study. Dig Endosc 2015; 27:479-485. [PMID: 25394296 DOI: 10.1111/den.12405] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [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: 09/20/2014] [Accepted: 11/10/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM SpyGlass® cholangiopancreatoscopy system has shown early success in aiding diagnosis and management of pancreaticobiliary diseases. We aimed to assess the technical success, clinical success, diagnostic yield, therapeutic yield, and safety of the SpyGlass® system at a single institution. METHODS A retrospective, single-center review of consecutive patients who underwent endoscopic retrograde cholangiopancreatography with SpyGlass® between January 2008 and August 2013 for a variety of indications. Technical success was defined as the procedure being completed as planned. Clinical success was defined as a successful outcome using diagnostic, clinical, laboratory, or imaging evidence. RESULTS SpyGlass® cholangioscopy was carried out in 88 patients (49 females, mean age 56.9 ± 15.5 years). Indications were diagnostic in 67 and therapeutic in 21. Overall, technical success was seen in 87.5% and clinical success in 77.3%. Thirty-nine patients with indeterminate biliary stricture had technical and clinical success rates of 92.3% and 74.4%, respectively. In this subgroup, malignancy was ultimately diagnosed in 13 with 12 patients diagnosed by SpyGlass® and confirmed by surgical specimens in 12/12 cases; positive predictive value 100%). In the 23 remaining patients with indeterminate biliary strictures, one was later found to have malignancy (negative predictive value 95.8%) after 1 year of follow up. In the 13 therapeutic cases of stone removal, technical and clinical success was seen in 77.0% for both. Overall, adverse events were seen in 15.9%. CONCLUSIONS SpyGlass® demonstrated acceptable technical and clinical success rates in both diagnostic and therapeutic procedures. In particular, it allows for an accurate rate of diagnosis of indeterminate biliary strictures.
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Affiliation(s)
- Alan H Tieu
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Neha Jakhete
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Frances Onyimba
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Yuval Patel
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Eun Ji Shin
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Zhiping Li
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, USA
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