Clinical spotlight review for the management of choledocholithiasis.

Choledocholithiasis is a common presentation of symptomatic cholelithiasis that can result in biliary obstruction, cholangitis, and pancreatitis. A systematic English literature search was conducted in PubMed to determine the appropriate management strategies for choledocholithiasis. The following clinical spotlight review is meant to critically review the available evidence and provide recommendations for the work-up, investigations as well as the endoscopic, surgical and percutaneous techniques in the management of choledocholithiasis.

Surgeon-performed endoscopic retrograde cholangiopancreatography. Outcomes of 2392 procedures at two tertiary care centers.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a common procedure that, in the United States, is traditionally performed by gastroenterologists. We hypothesized that when performed by well-trained surgeons, ERCP can be performed safely and effectively. The objectives of the study were to assess the rate of successful cannulation of the duct of interest and to assess the 30-day complication and mortality rates. METHODS: We retrospectively reviewed the charts of 1858 patients who underwent 2392 ERCP procedures performed by five surgeons between August 2003 and June 2016 in two centers. Demographic and historical data, indications, procedure-related data and 30-day complication and mortality data were collected and analyzed. RESULTS: The mean age was 53.4 (range 7-102) years and 1046 (56.3%) were female. 1430 (59.8%) of ERCP procedures involved a surgical endoscopy fellow. The most common indication was suspected or established uncomplicated common bile duct stones (n = 1470, 61.5%), followed by management of an existing biliary or pancreatic stent (n = 370, 15.5%) and acute biliary pancreatitis (n = 173, 7.2%). A therapeutic intervention was performed in 1564 (65.4%), a standard sphincterotomy in 1244 (52.0%), stent placement in 705 (29.5%) and stone removal in 638 (26.7%). When cannulation was attempted, the rate of successful cannulation was 94.1%. When cannulation was attempted during the patient's first ERCP the cannulation rate was 92.4%. 94 complications occurred (5.4%); the most common complication was post-ERCP pancreatitis in 75 (4.2%), significant gastrointestinal bleeding in 7 (0.4%), ascending cholangitis in 11 (0.6%) and perforation in 1 (0.05%). 11 mortalities occurred (0.5%) but none of which were ERCP-related. CONCLUSION: When performed by well-trained surgical endoscopists, ERCP is associated with high success rate and acceptable complication rates consistent with previously published reports and in line with societal guidelines.

Incidence of abdominal wall metastases following percutaneous endoscopic gastrostomy placement in patients with head and neck cancer.

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) tubes are an effective modality for enteral nutrition in patients with head and neck cancer; however, there have been documented case reports of "seeding" of the abdominal wall by the theoretic risk of dragging the tube along the tumor during PEG placement. The objective of this study is to determine the incidence and contributing risk factors leading to metastasis to the abdominal wall following PEG placement in patients with head and neck cancer. METHODS: A retrospective chart review was performed on patients diagnosed with head and neck malignancy who underwent PEG placement between 1/5/2009 and 12/22/2014. Variables collected included development of abdominal wall metastases, type of malignancy and tumor characteristics, smoking history, PEG placement technique, and survival following recurrence. Data were then analyzed for overall trends. RESULTS: Out of 777 patients analyzed, a total of five patients with head and neck malignancy were identified with abdominal wall metastasis following PEG tube placement with an overall incidence of 0.64% over an average follow-up of 27.55 months. All of these patients underwent PEG tube insertion via a Pull technique. One patient was found to have a clinically evident and symptomatic stomal metastasis, while the other four patients had radiologically detected metastases either on CT or PET scan. All of the identified patients were found to have stage IV oral cancer at time of initial diagnosis of their head and neck malignancy, followed by widespread distant metastatic disease at time of presentation with their PEG site stomal metastasis. CONCLUSION: Abdominal wall metastases following PEG placement are a rare but serious complication in patients with head and neck malignancy.

Placement technique impacts gastrostomy tube-related complications amongst head and neck cancer patients.

OBJECTIVES: Percutaneous endoscopic gastrostomy (PEG) placement is essential for the provision of enteral nutrition in select head and neck cancer (HNC) patients. Minimally invasive tube placement is facilitated through one of two techniques, push or pull, but there have been conflicting results regarding safety profiles of these procedures. The objectives of this study were to determine the association of PEG insertion technique with gastrostomy tube complications, including stomal metastases. METHODS: A multi-institutional retrospective cohort study of patients with HNC undergoing PEG insertion by either the pull (gastroscope assisted) or push (fluoroscopy assisted) technique was performed. Tube-related complications included infection, dislodgement, deterioration, leak, and other. Adjusted analysis was performed via a multivariable logistic regression model. RESULTS: 1,575 patients were included across three institutions. Tube-related complications occurred in 36% of patients, the most common being peristomal leak (13%) and infection (16%). The push technique (OR 2.66, 95% CI: 1.42-4.97), and the presence of T4 disease (OR 4.62, 95% CI: 1.58-13.51), were associated with a greater risk of developing any tube-related complication. Infection rates were similar between pull and push cohorts. All detected stoma metastases occurred with the pull technique, with an overall prevalence of 0.32% amongst the cohort. CONCLUSIONS: The push technique is associated with a greater risk of developing any tube-related complication, but the rate of stomal metastases may be higher with the pull technique. There is potential for quality improvement measures to improve tube-related complications associated with either technique.

Polypectomy Techniques.

Polyps in the upper and lower gastrointestinal tract can be premalignant or malignant lesions that can be treated endoscopically in early stages to prevent morbidity and more invasive procedures. This article critically reviews the techniques available and provides recommendations for endoscopic polypectomy.

Comparative outcome analysis of the management of pediatric intussusception with or without surgical admission.

BACKGROUND: Controversy persists about the need to admit patients after successful reduction of intussusception. Our hypothesis is that pediatric intussusception can be managed with discharge from the emergency department (ED) after reduction without increasing morbidity, yielding significant cost savings. METHODS: A chart review over 10 years was performed at two Canadian institutions. Data abstracted included: demographics, length of stay (LOS), initial and recurrence management. Primary outcome was early recurrence and resultant management, including LOS and need for operative intervention. Costs were calculated using hospital-specific data. RESULTS: 584 patient records were assessed: 329 patients were managed with admission after reduction, 239 as outpatients. In the admission group, 28 patients had at least one recurrence (8.5%), with 8 after discharge. In the outpatient group, 21 patients had at least one recurrence (8.8%), with 19 after discharge. The difference post-discharge was significant (p=0.004). Outcomes of recurrence did not differ, with 2 patients in each group requiring operative intervention. Average LOS in the admission group was 90 h, with additional average cost of $1771 per non-operated patient. CONCLUSIONS: Pediatric intussusception can be safely managed as an outpatient with reliable follow up. Discharge from the ED reduces hospital charges without increasing morbidity. This approach should be considered in managing patients with intussusception.