Aspirin exposure and its association with metal stent patency in malignant distal biliary obstruction: a large international multicenter propensity score-matched study.

BACKGROUND AND AIMS: Stent dysfunction is common after ERCP with self-expandable metal stent (SEMS) insertion for malignant distal biliary obstruction (MDBO). Chronic aspirin (acetylsalicylic acid; ASA) exposure has been previously shown to potentially decrease this risk. We aim to further ascertain the protective effect of ASA and to identify other predictors of stent dysfunction. METHODS: This multicenter retrospective cohort study was conducted at 9 sites in Canada and 1 in the United States. Patients with MDBO who underwent ERCP with SEMS placement between January 2014 and December 2019 were included and divided into 2 cohorts: ASA exposed (ASA-E) and ASA unexposed (ASA-U). Propensity-score matching (PSM) was performed to limit selection bias. Matched variables were age, sex, tumor stage, and type of metal stent. The primary outcome was the hazard rate of stent dysfunction. A multivariable Cox proportional hazards model was used to identify independent predictors of stent dysfunction. RESULTS: Of 1396 patients assessed, after PSM 496 patients were analyzed (248 ASA-E and 248 ASA-U). ERCP with SEMS placement was associated with a high clinical success of 82.2% in ASA-E and 81.2% in ASA-U cohorts (P = .80). One hundred eighty-four patients had stent dysfunction with a mean stent patency time of 229.9 ± 306.2 days and 245.4 ± 241.4 days in ASA-E and ASA-U groups, respectively (P = .52). On multivariable analysis, ASA exposure did not protect against stent dysfunction (hazard ratio [HR], 1.25; 95% confidence interval [CI], .96-1.63). An etiology of pancreatic cancer (HR, 1.36; 95% CI, 1.15-1.61) predicted stent dysfunction, whereas cancer therapy was protective (HR, .73; 95% CI, .55-.96). Chronic ASA use was not associated with an increased risk for adverse events including bleeding, post-ERCP pancreatitis, and perforation. CONCLUSIONS: In this large, multicenter study using PSM, chronic exposure to ASA did not protect against stent dysfunction in MDBO. Instead, the analysis revealed that the etiology of pancreatic cancer was an independent predictor of stent dysfunction and cancer therapy was protective.

Endoscopic Ultrasound-Guided Biliary Drainage of First Intent With a Lumen-Apposing Metal Stent vs Endoscopic Retrograde Cholangiopancreatography in Malignant Distal Biliary Obstruction: A Multicenter Randomized Controlled Study (ELEMENT Trial).

BACKGROUND & AIMS: Endoscopic ultrasound-guided choledochoduodenostomy with a lumen-apposing metal stent (EUS-CDS) is a promising modality for management of malignant distal biliary obstruction (MDBO) with potential for better stent patency. We compared its outcomes with endoscopic retrograde cholangiopancreatography with metal stenting (ERCP-M). METHODS: In this multicenter randomized controlled trial, we recruited patients with MDBO secondary to borderline resectable, locally advanced, or unresectable peri-ampullary cancers across 10 Canadian institutions and 1 French institution. This was a superiority trial with a noninferiority assessment of technical success. Patients were randomized to EUS-CDS or ERCP-M. The primary end point was the rate of stent dysfunction at 1 year, considering competing risks of death, clinical failure, and surgical resection. Analyses were performed according to intention-to-treat principles. RESULTS: From February 2019 to February 2022, 144 patients were recruited; 73 were randomized to EUS-CDS and 71 were randomized to ERCP-M. The mean (SD) procedure time was 14.0 (11.4) minutes for EUS-CDS and 23.1 (15.6) minutes for ERCP-M (P < .01); 40% of the former was performed without fluoroscopy. Technical success was achieved in 90.4% (95% CI, 81.5% to 95.3%) of EUS-CDS and 83.1% (95% CI, 72.7% to 90.1%) of ERCP-M with a risk difference of 7.3% (95% CI, -4.0% to 18.8%) indicating noninferiority. Stent dysfunction occurred in 9.6% vs 9.9% of EUS-CDS and ERCP-M cases, respectively (P = .96). No differences in adverse events, pancreaticoduodenectomy and oncologic outcomes, or quality of life were noted. CONCLUSIONS: Although not superior in stent function, EUS-CDS is an efficient and safe alternative to ERCP-M in patients with MDBO. These findings provide evidence for greater adoption of EUS-CDS in clinical practice as a complementary and exchangeable first-line modality to ERCP in patients with MDBO. CLINICALTRIALS: gov, Number: NCT03870386.

EUS-guided biliary drainage in malignant distal biliary obstruction: An international survey to identify barriers of technology implementation.

Background and Objectives: EUS-guided biliary drainage (EUS-BD) is a promising alternative to ERCP in malignant distal biliary obstruction (MDBO). Despite accumulating data, however, its application in clinical practice has been impeded by undefined barriers. This study aims to evaluate the practice of EUS-BD and its barriers. Methods: An online survey was generated using Google Forms. Six gastroenterology/endoscopy associations were contacted between July 2019 and November 2019. Survey questions measured participant characteristics, EUS-BD in different clinical scenarios, and potential barriers. The primary outcome was the uptake of EUS-BD as a first-line modality, without previous ERCP attempts, in patients with MDBO. Results: Overall, 115 respondents completed the survey (2.9% response rate). Respondents were from North America (39.2%), Asia (28.6%), Europe (20%), and other jurisdictions (12.2%). Regarding the uptake of EUS-BD as first-line treatment for MDBO, only 10.5% of respondents would consider EUS-BD as a first-line modality regularly. The main concerns were the lack of high-quality data, fear of adverse events, and limited access to EUS-BD dedicated devices. On multivariable analysis, lack of access to EUS-BD expertise was an independent predictor against the use of EUS-BD, odds ratio 0.16 (95% confidence interval, 0.04-0.65). In salvage situations following failed ERCP, most favored EUS-BD (40.9%) over percutaneous drainage (21.7%) in unresectable cancer. In borderline resectable or locally advanced disease, however, most favored the percutaneous approach due to fear of EUS-BD complicating future surgery. Conclusions: EUS-BD has not reached widespread clinical adoption. Identified barriers include lack of high-quality data, fear of adverse events, and lack of access to EUS-BD dedicated devices. Fear of complicating future surgery was also identified as a barrier in potentially resectable disease.

Learning curves in ERCP during advanced endoscopy training: a Canadian multicenter prospective study.

Background and study aims Growing emphasis on quality and patient safety has supported the shift toward competency-based medical education for advanced endoscopy trainees (AETs). In this study, we aimed to examine Canadian AETs learning curves and achievement of competence using an ERCP assessment tool with strong evidence of validity. Methods This prospective study was conducted at five institutions across Canada from 2017-2018. Data on every fifth procedure performed by trainees were collected using the United Kingdom Joint Advisory Joint Advisory Group of Gastrointestinal Endoscopy (JAG) ERCP Direct Observation of Procedural Skills (DOPS) tool, which includes a four-point rating scale for 27 items. Cumulative sum (CUSUM) analysis was used to create learning curves for overall supervision ratings and ERCP DOPS items by plotting scores for procedures performed during training. Results Eleven trainees who were evaluated for 261 procedures comprised our sample. The median number of evaluations by site was 49 (Interquartile range (IQR) 31-76) and by trainee was 15 (IQR 11-45). The overall cannulation rate by trainees was 82 % (241/261), and the native papilla cannulation rate was 78 % (149/191). All trainees achieved competence in the "overall supervision" domain of the ERCP DOPS by the end of their fellowship. Trainees achieved competency in all individual domains, except for tissue sampling and sphincteroplasty. Conclusions Canadian AETs are graduating from fellowship programs with acceptable levels of competence for overall ERCP performance and for the most specific tasks. Learning curves may help identify areas of deficiency that may require supplementary training, such as tissue sampling.

Outcomes Following Extrahepatic and Intraportal Pancreatic Islet Transplantation: A Comparative Cohort Study.

BACKGROUND: Preliminary studies show promise for extrahepatic islet transplantation (ITx). However, clinical comparisons with intraportal ITx outcomes remain limited. METHODS: This single-center cohort study evaluates patients receiving extrahepatic or intraportal ITx between 1999 and 2018. Primary outcome was stimulated C-peptide level. Secondary outcomes were fasting plasma glucose, BETA-2 scores, and fasting C-peptide level. Multivariable logistic modeling evaluated factors independently associated with a composite variable of early graft failure and primary nonfunction within 60 d of ITx. RESULTS: Of 264 patients, 9 (3.5%) received extrahepatic ITx (gastric submucosal = 2, subcutaneous = 3, omental = 4). Group demographics were similar at baseline (age, body mass index, diabetes duration, and glycemic control). At 1-3 mo post-first infusion, patients receiving extrahepatic ITx had significantly lower stimulated C-peptide (0.05 nmol/L versus 1.2 nmol/L, P < 0.001), higher fasting plasma glucose (9.3 mmol/L versus 7.3 mmol/L, P < 0.001), and lower BETA-2 scores (0 versus 11.6, P < 0.001) and SUITO indices (1.5 versus 39.6, P < 0.001) compared with those receiving intraportal ITx. Subjects receiving extrahepatic grafts failed to produce median C-peptide ≥0.2 nmol/L within the first 60 d after transplant. Subsequent intraportal infusion following extrahepatic transplants achieved equivalent outcomes compared with patients receiving intraportal transplant alone. Extrahepatic ITx was independently associated with early graft failure/primary non-function (odds ratio 1.709, confidence interval 73.8-39 616.0, P < 0.001), whereas no other factors were independently predictive. CONCLUSIONS: Using current techniques, intraportal islet infusion remains the gold standard for clinical ITx, with superior engraftment, graft function, and glycemic outcomes compared with extrahepatic transplantation of human islets.

Performance Characteristics of a Lumen-Apposing Metal Stent for Pancreatic Fluid Collections: A Prospective Cohort Study.

BACKGROUND: Endoscopic ultrasound-guided transmural drainage is the preferred management of pancreatic fluid collections (PFCs). Optimizing drainage is important and there remains debate as to the choice of stent. A recent trend towards the use of lumen-apposing metal stents (LAMS) has emerged. AIM: To evaluate the performance characteristics of a LAMS based on a prospective protocol (CT scan 1 week after placement to assess for resolution and need for necrosectomy followed by stent removal within 3 weeks). METHODS: This is a descriptive prospective cohort study performed at a single centre. The primary outcome was clinical success. Secondary outcomes were technical success, procedure time, total number of endoscopic procedures with or without necrosectomy, stent indwell time, stent functionality and adverse events. RESULTS: Thirty-seven patients (21 males, mean age 46.5 years) underwent placement of LAMS for 41 PFCs (median size 12 cm). There were 18 pseudocysts and 23 walled-off necrosis. Clinical success was seen in 33 of 41 (80%) PFCs. Of the remaining eight patients, six underwent surgery and two patients died from underlying malignant disease (although their PFC had completely resolved). Technical success and stent functionality were 100%. The median procedure time was 14 min (interquartile range 11 min to 20 min). Of the 23 walled-off necrosis, 9 (39%) required necrosectomy. The median stent indwell time was 19 days (interquartile range 14 to 22 days). There were no serious adverse events. CONCLUSIONS: Our protocol demonstrates excellent performance characteristics of LAMS. Their clinical efficacy and favourable safety profile suggest that they may be the preferred modality for endoscopic ultrasound-guided management of PFCs.

The Evolution of EUS-Guided Transluminal Drainage for the Treatment of Pancreatic Fluid Collections: A Comparison of Clinical and Cost Outcomes with Double-Pigtail Plastic Stents, Conventional Metal Stents and Lumen-Apposing Metal Stents.

BACKGROUND: While most pancreatic fluid collections (PFCs) resolve spontaneously, endoscopic ultrasound-guided transluminal drainage (EUS-TD) may be necessary. EUS-TD has evolved from multiple double-pigtail plastic stents (DPPS) to fully covered self-expanding metal stents (FCSEMS) and lumen-apposing metal stents (LAMS). This study compares clinical attributes of DPPS, FCSEMS and LAMS. METHODS: This is a single-centre retrospective review of EUS-TD for PFCs. The primary outcome was clinical success. Secondary outcomes were technical success, procedure time, hospital length of stay (HLOS), number of endoscopies, need for necrosectomy, adverse events (AEs) and overall cost. RESULTS: Fifty-eight patients (37 male, average age 49 years) underwent a total of 60 EUS-TD procedures for PFCs (average size 11.2 cm with 29 pseudocysts and 29 walled-off necrosis). Ten patients (17%) underwent EUS-TD with DPPS and 48 patients (83%) with metal stents (32 FCSEMS, 16 LAMS). Overall technical and clinical success was 100% and 84%, respectively. Lumen-apposing metal stents had shorter procedure times (14.9 versus 63.6 DPPS, 39.1 min FCSEMS, P < 0.001), and no difference in AEs (3 of 16 versus 4 of 10 DPPS, 12 of 34 FCSEMS, ns). Double-pigtail plastic stents required more endoscopies (3.7 versus 2.3 LAMS, 2.3 FCSEMS, P = 0.013) and necrosectomies (4 of 10 [40%]) compared with 5 of 34 [15%] in the FCSEMS group and 3 of 16 [19%] in the LAMS group, respectively, P = 0.001) to achieve clinical resolution. The overall cost and HLOS was not significantly different between groups. CONCLUSION: The use of LAMS for PFCs is not associated with any significant increase in cost despite technical (shorter procedure time) and clinical advantages (shorter indwell time, reduced need for necrosectomy and no increase in AEs).

ELEMENT TRIAL: study protocol for a randomized controlled trial on endoscopic ultrasound-guided biliary drainage of first intent with a lumen-apposing metal stent vs. endoscopic retrograde cholangio-pancreatography in the management of malignant distal biliary obstruction.

BACKGROUND & AIMS: Endoscopic ultrasound guided-biliary drainage (EUS-BD) is a promising alternative to endoscopic retrograde cholangiopancreatography (ERCP); however, its growth has been limited by a lack of multicenter randomized controlled trials (RCT) and dedicated devices. A dedicated EUS-BD lumen- apposing metal stent (LAMS) has recently been developed with the potential to greatly facilitate the technique and safety of the procedure. We aim to compare a first intent approach with EUS-guided choledochoduodenostomy with a dedicated biliary LAMS vs. standard ERCP in the management of malignant distal biliary obstruction. METHODS: The ELEMENT trial is a multicenter single-blinded RCT involving 130 patients in nine Canadian centers. Patients with unresectable, locally advanced, or borderline resectable malignant distal biliary obstruction meeting the inclusion and exclusion criteria will be randomized to EUS-choledochoduodenostomy using a LAMS or ERCP with traditional metal stent insertion in a 1:1 proportion in blocks of four. Patients with hilar obstruction, resectable cancer, or benign disease are excluded. The primary endpoint is the rate of stent dysfunction needing re-intervention. Secondary outcomes include technical and clinical success, interruptions in chemotherapy, rate of surgical resection, time to stent dysfunction, and adverse events. DISCUSSION: The ELEMENT trial is designed to assess whether EUS-guided choledochoduodenostomy using a dedicated LAMS is superior to conventional ERCP as a first-line endoscopic drainage approach in malignant distal biliary obstruction, which is an important and timely question that has not been addressed using an RCT study design. TRIAL REGISTRATION: Registry name: ClinicalTrials.gov. Registration number: NCT03870386. Date of registration: 03/12/2019.

Pancreatic pseudocyst-portal vein fistula with refractory hepatic pseudocyst: Two cases treated with EUS cyst-gastrostomy and review of the literature.

Background and study aims Pseudocysts are the most common pancreatic cystic lesions and they usually develop in association with pancreatitis of at least 4 weeks' duration. Extra-pancreatic pseudocysts, although reported, are relatively uncommon. Secondary liver pseudocysts are recognized within the literature, and most patients described have required percutaneous or surgical drainage due to infection or symptoms. The mechanism of hepatic pseudocyst formation is not entirely clear but it is postulated that this phenomenon may occur through pseudocyst-portal vein fistulization. We describe two cases of patients presenting with pancreatic pseudocysts invading the portal venous system with embolization of pancreatic fluid to the liver and subsequent hepatic pseudocyst formation. Interestingly, liver pseudocyst resolution was incomplete with antibiotics and percutaneous drainage alone, and only occurred following endoscopic ultrasonography-guided pancreatic cyst-gastrostomy and metal stent insertion. We have reviewed the current literature on the diagnosis and management of pseudocyst-portal vein fistula formation and we believe that our cases represent the first published within the literature to describe this treatment approach.

Single-operator cholangioscopy for diagnosis of cholangioadenoma (bile duct adenoma) and its potential impact on surgical management.

Background and study aims Cholangioadenoma is not recognized commonly and is often only diagnosed on surgical specimens. Direct per oral single-operator cholangioscopy (SOC) allows characterization of common bile duct (CBD) lesions through direct visualization and directed forceps biopsies with potential for impacting surgical management decisions. This is a retrospective review of all SOC cases diagnosed with cholangioadenoma. Patient demographics and outcomes were recorded. Three patients (all male), average age 68 years (range 62 - 76 years), were identified to have a cholangioadenoma. The clinical indication for SOC was deranged liver enzymes with a dilated CBD and a CBD abnormality identified on biliary imaging. The site of cholangioadenoma was proximal, mid and distal CBD, respectively. All patients had a successful SOC with targeted biopsy-proven diagnosis. One patient had a synchronous cholangiocarcinoma and underwent palliative stenting whereas the other two patients underwent appropriate curative resection based on cholangioadenoma location. We conclude that SOC is safe and effective for diagnosis of cholangioadenoma and has potential impact on decisions for surgical management.

Acute acalculous cholecystitis of an intrahepatic gallbladder causing Mirizzi's syndrome.

We present the case of a young female with symptoms of biliary colic and a biochemical profile consistent with biliary obstruction. Imaging was suspicious for Mirizzi's syndrome. Intraoperatively, the patient was found to have a complete intrahepatic gallbladder causing common hepatic duct compression with final pathology confirming acute cholecystitis. We review the embryological development of the gallbladder as well as clinical presentation of Mirizzi's syndrome. Special consideration for clinical workup and surgical management is discussed.

A Cholangioscopy-Based Novel Classification System for the Phenotypic Stratification of Dominant Bile Duct Strictures in Primary Sclerosing Cholangitis-the Edmonton Classification.

BACKGROUND: Primary sclerosing cholangitis (PSC) is a chronic inflammatory condition causing bile duct strictures. Differentiating inflammatory strictures from malignant transformation is challenging. Cholangioscopy allows direct visualization with the option to biopsy. We describe our experience of cholangioscopy in PSC and propose a novel stricture classification system based on cholangioscopic findings. METHODS: All patients with PSC and a dominant stricture referred for cholangioscopy were reviewed. Based on visual characteristics with direct cholangioscopy, we propose a novel classification system for the extrahepatic form of PSC. RESULTS: The proposed Edmonton Classification system for extrahepatic PSC strictures consists of the following phenotypes: 1) 'inflammatory type', with mucosal erythema and active inflammatory exudate, 2) 'fibro-stenotic type', with concentric fibrotic scars, and 3) 'nodular or mass-forming type', with a mass in the involved segment of extrahepatic bile duct. From 2011-2017, 30 patients with PSC and a dominant stricture (21 M, mean age 46 years) underwent 32 cholangioscopy procedures. Cholangioscopy was technically successful in 29 of 32 procedures (91%). In these 29 stricture cases, inflammatory type was seen in 16 (55%), fibro-stenotic type in seven (24%) and nodular or mass-forming type in five (17%). In one (4%) procedure, there was no stricture or abnormality identified. CONCLUSION: Cholangioscopy is effective and safe for the evaluation of dominant biliary strictures in PSC. Based on our experience with cholangioscopy, we propose a novel classification system of extrahepatic PSC phenotypes: the Edmonton Classification.

The Safety and Efficacy of Single-Operator Cholangioscopy in the Treatment of Difficult Common Bile Duct Stones after Failed Conventional ERCP.

BACKGROUND: Common bile duct (CBD) stones are extracted with a basket or balloon during ERCP with sphincterotomy. However, some stones are difficult to extract by conventional means. Cholangioscopy with lithotripsy is a modality to treat these difficult stones. We describe the clinical efficacy of single-operator per oral cholangioscopy (SOPOC) for difficult stones and discuss cost savings by avoiding surgical intervention. METHODS: Retrospective chart review was performed for all patients referred for difficult CBD stones. Clinical success was defined as clearing the duct of all stones. The cost of cholangioscopy (in $CDN) was calculated by adding all costs associated with the procedure(s), surgery, hospital stay or treatment of adverse events. This cost was compared with the projected cost of surgical bile duct exploration. RESULTS: A total of 51 patients (35 female) with a mean age of 66 years underwent 58 SOPOC procedures. Median procedure time was 67 minutes (95% CI, 61.5-73.5). The CBD was successfully cleared in 47 of 51 patients (93%). Minor adverse events were seen in seven patients (14%). The actual average per procedure cost was $4555±$2647. This compares with a projected cost of $7766 and $6175 for open and laparoscopic bile duct exploration, with a cost-per-case saving of $3210 and $1619, respectively. CONCLUSION: SOPOC with lithotripsy is highly effective and safe for the treatment of difficult common bile duct stones. In addition, significant cost savings may be realized by avoiding surgical bile duct exploration.

Percutaneous transhepatic cholangioscopy for indeterminate biliary strictures using the SpyGlass system: a case series.

Peroral cholangioscopy is useful in differentiating benign from malignant biliary strictures. However, when conventional biliary access via endoscopic retrograde cholangiopancreatography (ERCP) fails, percutaneous transhepatic cholangioscopy (PTCS) via the SpyGlass cholangioscopy system can be used to achieve a diagnosis. Four patients with biliary strictures in whom conventional ERCP was not possible and percutaneous brushings were either nondiagnostic or unsatisfactory were investigated with PTCS. The technique of PTCS involves insertion of the SpyGlass cholangioscope through a percutaneous transhepatic sheath, placed just prior to the procedure, to visualize the stricture and obtain biopsies with the SpyBite forceps. On the basis of our early observations, we conclude that PTCS using the SpyGlass cholangioscopy system for the assessment of biliary strictures is feasible, safe, and provides high diagnostic accuracy.

Gastric antral vascular ectasia: a prospective study of treatment with endoscopic band ligation.

Gastric antral vascular ectasia (GAVE) is characterized by red, angiomatous lesions in the antrum organized either in stripes or in a diffuse pattern that can be associated with upper gastrointestinal bleeding. Endoscopic band ligation (EBL) has been reported as an effective alternative therapy for patients with GAVE. Consecutive patients with a diagnosis of GAVE were prospectively followed while undergoing EBL every 2 months. Hemoglobin, ferritin, and iron levels were frequently recorded, and clinical follow-up was performed. A total of 21 patients with GAVE were enrolled, and 17 of these patients (81 %) had associated co-morbidities, most frequently cirrhosis and chronic renal failure. A clinical response was achieved in 19 patients (91 %). A significant improvement in the mean hemoglobin level was noted after EBL (P < 0.001), and a significant decrease in blood transfusion requirements per month (P = 0.001). No major complications were observed during the study period. The mean follow-up was 10 months. EBL is an effective and safe treatment for GAVE. Randomized, controlled trials comparing EBL with other endoscopic therapies are warranted.

Magnetic imaging-assisted colonoscopy vs conventional colonoscopy: a randomized controlled trial.

AIM: To compare magnetic imaging-assisted colonoscopy (MIC) with conventional colonoscopy (CC). METHODS: Magnetic imaging technology provides a computer-generated image of the shape and position of the colonoscope onto a monitor to give visual guidance to the endoscopist. It is designed to improve colonoscopy performance and tolerability for patients by enabling visualization of loop formation and endoscope position. Recently, a new version of MIC technology was developed for which there are limited data.To evaluate this latest generation of MIC among experienced rather than inexperienced or trainee endoscopists, a prospective randomized trial was performed using only gastroenterologists with therapeutic endoscopy training. Consecutive patients undergoing elective outpatient colonoscopy were randomized to MIC or CC, with patients blinded to their group assignment. Endoscopic procedural metrics and quantities of conscious sedation medications were recorded during the procedures. The procedure was classified as "usual" or "difficult" by the endoscopist at the conclusion of each case based on the need for adjunctive maneuvers to facilitate endoscope advancement. After more than one hour post-procedure, patients completed a 10 cm visual analogue pain scale to reflect the degree of discomfort experienced during their colonoscopy. The primary outcome was patient comfort expressed by the visual analogue pain score. Secondary outcomes consisted of endoscopic procedural metrics as well as a sedation score derived from standardized dose increments of the conscious sedation medications. RESULTS: Two hundred fifty-three patients were randomized and underwent MIC or CC between September 2011 and October 2012. The groups were similar in terms of the indications for colonoscopy and patient characteristics. There were no differences in cecal intubation rates (100% vs 99%), insertion distance-to-cecum (82 cm vs 83 cm), time-to-cecum (6.5 min vs 7.2 min), or polyp detection rate (47% vs 52%) between the MIC and CC groups. The primary outcome of mean pain score (1.0 vs 0.9 out of 10, P = 0.41) did not differ between MIC and CC groups, nor did the mean sedation score (8.2 vs 8.5, P = 0.34). Within the subgroup of cases considered more challenging or difficult, time-to-cecum was significantly faster with MIC compared to CC, 10.1 min vs 13.4 min respectively (P = 0.01). Sensitivity analyses confirmed a similar pattern of overall findings when each endoscopist was considered separately, demonstrating that the mean results for the entire group were not unduly influenced by outlier results from any one endoscopist. CONCLUSION: Although the latest version of MIC resulted in faster times-to-cecum within a subgroup of more challenging cases, overall it was no better than CC in terms of patient comfort, sedation requirements and endoscopic procedural metrics, when performed in experienced hands.

Endoscopic ultrasound in the diagnosis and treatment of pancreatic disease.

Endoscopic ultrasound (EUS) is an important part of modern gastrointestinal endoscopy and now has an integral role in the diagnostic evaluation of pancreatic diseases. Furthermore, as EUS technology has advanced, it has increasingly become a therapeutic procedure, and the prospect of multiple applications of interventional EUS for the pancreas is truly on the near horizon. However, this review focuses on the established diagnostic and therapeutic roles of EUS that are used in current clinical practice. In particular, the diagnostic evaluation of acute pancreatitis, chronic pancreatitis, cystic pancreatic lesions and solid masses of the pancreas are discussed. The newer enhanced imaging modalities of elastography and contrast enhancement are evaluated in this context. The main therapeutic aspects of pancreatic EUS are then considered, namely celiac plexus block and celiac plexus neurolysis for pain control in chronic pancreatitis and pancreas cancer, and EUS-guided drainage of pancreatic fluid collections.

Clinical application of a single-operator direct visualization system improves the diagnostic and therapeutic yield of endoscopic retrograde cholangiopancreatography.

BACKGROUND: Single-operator cholangioscopy enables direct diagnostic visualization and therapeutic intervention in the biliary tree. There is increasing evidence of its clinical utility in the assessment of biliary strictures and treatment of difficult stones. OBJECTIVE: To describe the first reported Canadian experience with managing biliary disease using single-operator cholangioscopy. METHODS: The present study was a retrospective analysis of data collected from all sequential patients undergoing single-operator cholangioscopy for assessment of biliary strictures and treatment of biliary stones. The main outcome measures were the ability to make an overall diagnosis of stricture (based on visual appearances and tissue histology), and to fragment and extract biliary stones. RESULTS: Thirty patients (17 women), mean age 66 years (range 41 to 89 years) underwent single-operator cholangioscopy. In biliary strictures (20 patients), overall accuracy for visual and tissue diagnosis was 84% and 81%, respectively. Successful electrohydraulic lithotripsy with stone clearance was achieved in 90% of the 10 patients who failed previous conventional therapy. The mean (± SD) procedure time was 61±21 min (range 20 min to 119 min). One patient developed mild postendoscopic retrograde cholangioscopy pancreatitis. CONCLUSION: The results of this experience reaffirms the clinical utility and safety of single-operator cholangioscopy for the management of biliary pathology. Further improvements can be achieved with increasing operator experience and refinements in optical technology.

A randomized controlled trial of four precolonoscopy bowel cleansing regimens.

BACKGROUND: The ideal bowel cleansing regimen for colonoscopy has yet to be determined. OBJECTIVE: To compare the cleansing efficacy, and patient tolerability and safety of four bowel preparation regimens. METHODS: A total of 834 patients undergoing outpatient colonoscopy were randomly assigned to one of four regimens: 4 L polyethylene glycol (PEG); 2 L PEG + 20 mg bisacodyl; 90 mL of sodium phosphate (NaP); or two sachets of a commercially available bowel cleansing solution (PSMC) + 300 mL of magnesium citrate (M). The primary outcome measure was cleansing efficacy, which was scored by blinded endoscopists using the Ottawa Bowel Preparation Scale. Secondary outcome measures were bowel preparation quality according to time of colonoscopy, and patient tolerability and safety. RESULTS: The mean total cleansing score was significantly worse in the NaP group compared with the other three groups (P<0.0001). The mean cleansing scores were worse in patients who underwent morning versus afternoon colonoscopy, a finding that was consistent in all four groups. PSMC + M was the best tolerated regimen. No clinically significant mean changes in creatinine or electrolyte levels were identified, although a significantly higher proportion of patients in the NaP group developed hypokelemia (P<0.0001). CONCLUSIONS: 2 L PEG + 20 mg bisacodyl, or PSMC + M was as efficacious as 4 L PEG and superior to NaP for bowel cleansing. A short interval between the completion of bowel preparation and the start of colonoscopy (ie, 'runway time'), irrespective of bowel preparation regimen, appeared to be a more important predictor of bowel cleanliness than the cathartic agents used.