Endoscopic approach to the patient with motility disorders of the bile duct and sphincter of Oddi.

Since its original description by Oddi in 1887, the sphincter of Oddi has been the subject of much study. Furthermore, the clinical syndrome of sphincter of Oddi dysfunction (SOD) and its therapy are controversial areas. Nevertheless, SOD is commonly diagnosed and treated by physicians. This article reviews the epidemiology, clinical manifestations, and current diagnostic and therapeutic modalities of SOD.

Does leaving a main pancreatic duct stent in place reduce the incidence of precut biliary sphincterotomy-associated pancreatitis? A randomized, prospective study.

BACKGROUND: Pancreatitis is the most common major complication of ERCP and precut endoscopic sphincterotomy (ES). Prophylactic pancreatic duct (PD) stent placement has been shown to reduce the incidence and severity of post-ERCP pancreatitis (PEP) in high-risk settings. OBJECTIVE: To determine whether leaving a main PD stent in place after precut ES would reduce the incidence and severity of PEP. DESIGN: Single-center, randomized, prospective study. SETTING: Tertiary care ERCP referral center. PATIENTS: Consecutive patients who underwent ERCP with a clear indication for biliary access and standard biliary ES whereby free cannulation of the bile duct was not possible and precut ES was undertaken. INTERVENTIONS: When free bile duct cannulation for ES was not possible and selective PD cannulation was achieved, a PD stent was placed. Using the PD stent as a guide, we used a needle-knife sphincterotome to perform precut ES. The patients were then randomized to either leaving the PD stent in place for 7 to 10 days (stent group) or immediate removal after the procedure (stent removed group). The remaining patients who did not undergo selective PD cannulation and stent placement were not randomized (no stent group) and had a free-hand needle-knife ES performed. MAIN OUTCOME MEASUREMENTS: Patients were prospectively followed for the development of complications. Standardized criteria were used to diagnose and grade the severity of PEP. RESULTS: A total of 151 patients were enrolled. The groups were similar with regard to patient demographics and patient and procedure risk factors for PEP. The overall incidence of PEP was 13.2% (20/151). It occurred in 4.3% (2/46), 21.3% (10/47), and 13.8% (8/58) of patients in the stent, stent removed, and no stent groups, respectively. The stent group had a significantly lower frequency and severity of PEP compared with the stent removed group (4.3% vs 21.3%; P = .027 for frequency and 0% vs 12.8%; P = .026 for moderate and severe pancreatitis). LIMITATIONS: Single center. Randomization scheme not optimal. CONCLUSIONS: These data suggest that placing and maintaining a PD stent for needle-knife precut ES reduces the frequency and severity of postprocedure pancreatitis.

Pancreatic stent migration into the portal vein causing portal vein thrombosis: a rare complication of a prophylactic pancreatic stent.

This report describes the first case of a novel complication of prophylactic pancreatic stents used to reduce the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis, whereby the stent migrated into the portal vein resulting in portal vein thrombosis. We review the literature and discuss the potential mechanisms that caused this complication. The approach and prompt treatment that resulted in a favorable clinical outcome are described.

Comparison of endoscopic and surgical resection of intramucosal carcinoma in Barrett's esophagus.

The optimal management of intramucosal carcinoma in Barrett's esophagus continues to be controversial. To date, there has not been a lot of research directly comparing endoscopic versus surgical management of intramucosal carcinoma. Previous studies have shown that both modalities to have excellent outcomes. The reviewed article is a matched retrospective cohort study from two high-volume centers, which shows both modalities to be effective, but an associated higher morbidity rate and risk for procedure-related mortality in the surgical group, and higher recurrence rate in the endoscopic therapy group. The study is discussed in the context of the current state of knowledge regarding Barrett's esophagus and intramucosal carcinoma, in particular outcomes and limitations of the present study.