Outcome of emergency ERCP in the intensive care unit.

There are limited data on the outcome of emergency endoscopic retrograde cholangiopancreatography (ERCP) performed in the intensive care unit (ICU). We sought to assess the frequency, indications, and clinical outcomes of ERCPs performed in ICU patients who were too unstable to be transported to the endoscopy unit. An electronic endoscopy database was used to identify the patients (n = 22) and to assess procedural success, complications, and mortality. The indications for ERCP included suspected biliary sepsis, suspected gallstone pancreatitis, and known choledocholithiasis with cholangitis. Biliary cannulation, which was attempted in all patients, was successful in 19 patients (86 %), and of these 18 (95 %) underwent a technically successful endoscopic therapy. There were no apparent endoscopic complications. Therefore, emergency bedside ERCP in ICU patients, which is primarily performed for the management of suspected biliary sepsis and gallstone pancreatitis, can achieve high technical success rates when performed by experienced endoscopists, although the 30-day mortality rate remains high due to multiorgan dysfunction.

Endoscopic retrograde cholangiopancreatography using a single-balloon enteroscope in patients with altered Roux-en-Y anatomy.

BACKGROUND AND STUDY AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is challenging to perform in patients with postsurgical gastrointestinal anatomy. We assessed the diagnostic and therapeutic success rates using single-balloon enteroscopy in patients with Roux-en-Y anastomosis. PATIENTS AND METHODS: Patients who underwent single-balloon ERCP between April 2008 and February 2010 were retrospectively identified using a computerized endoscopy database. Diagnostic success was defined as successful duct cannulation or securing the diagnosis, and therapeutic success was defined as the ability to successfully carry out endoscopic therapy. Complications of ERCP were defined according to standard criteria. RESULTS: A total of 50 patients (34-male, mean age 57 years, range 19 - 85 years) with Roux-en-Y anastomosis underwent ERCP using a single-balloon enteroscope on 56 occasions. Indications for ERCP were cholestasis, acute cholangitis, recurrent primary sclerosing cholangitis with strictures, and choledocholithiasis. Overall diagnostic success was achieved in 39 / 56 cases (70 %). Therapeutic success was achieved in 21/23 cases (91 %). In 16 cases therapeutic intervention was not required. Therapeutic interventions included balloon dilation of strictures (n = 14), retrieval of retained biliopancreatic stents (n = 5), biliary stone extraction (n = 2), insertion of biliopancreatic stents (n = 4), and biliary and pancreatic sphincterotomy (n = 5). No major complications occurred. Importantly, in 22 / 56 procedures (39 %) a prior attempt at ERCP failed using conventional colonoscopes; single-balloon ERCP was successful in 15 / 22 (68 %) of these cases. CONCLUSIONS: Single-balloon ERCP is feasible in patients with complex postsurgical Roux-en-Y anastomosis, allows diagnostic evaluation and therapeutic intervention in patients with pancreaticobiliary disease, and is a useful salvage technique in the majority of patients in whom ERCP using colonoscopies has failed.

Risk of pancreatitis following endoscopically placed large-bore plastic biliary stents with and without biliary sphincterotomy for management of postoperative bile leaks.

BACKGROUND: Endoscopic transpapillary biliary stent placement is effective for closure of postoperative bile leaks. Large-bore stents (10 French) may transiently obstruct the adjacent pancreatic duct orifice causing acute pancreatitis. Endoscopic biliary sphincterotomy may reduce this risk, but it introduces separate risks of bleeding and perforation. The objective of this study was to compare complications after large-bore biliary stent placement (10 Fr) with and without sphincterotomy in patients with bile leaks. METHODS: The institutional endoscopy database was queried to identify patients who had undergone endoscopic retrograde cholangiopancreatogrpahy (ERCP) for bile leak between March 1996 and August 2006. Procedural reports were reviewed for evidence of biliary sphincterotomy, cholangiographic and pancreatographic findings, transpapillary stent placement, and procedural complications. Patients with prior biliary sphincterotomy, choledochoenteric anastomosis, placement of multiple biliary stents and expandable metal biliary stents, biliary stents smaller than 10 Fr, and patients in whom a stent was not placed were excluded. The chi-square test was used for categorical variables. Probability

Endoscopic transpapillary gallbladder drainage: 10-year single center experience.

AIM: A subset of patients with acute cholecystitis is severely ill and extremely high-risk to undergo cholecystectomy. Data on the use of endoscopic transpapillary gallbladder drainage (ETGBD) in the treatment of acute cholecystitis are limited. This article reviews the 10-year experience of ETGBD at Mayo Clinic and evaluated patient and procedure characteristics. METHODS: A retrospective review of the endoscopy database from 1998-2007 was performed to identify patients who had undergone ETGBD. Clinical information and procedure details were abstracted from the electronic medical record. RESULTS: Fifty one patients underwent ETGBD for acute cholecystitis between 1998 to July 2007. The mean age was 62+/-19 years and 67% of patients were males. The median number of comorbid medical conditions was two (range 0-5) and 27% had underlying diabetes mellitus. Acute calculous cholecystitis was the predominant indication for ETGBD (78%). A gallbladder stent was used in 33 (65%) patients, nasocholecystic drain in 14 (27%) patients, and both in four patients (8%). Bleeding (4%) and sedation-related complications (4%) were the most common complications noted. Among patients who underwent cholecystectomy, the majority (76%) needed an open procedure. The median time to cholecystectomy was 15 days (range 1-352 days). Four patients (8%) succumbed to septic shock during their hospitalization. CONCLUSIONS: ETGBD is a valuable alternative therapeutic modality for the treatment of patients with acute cholecystitis who are at high-risk for early cholecystectomy, and/or those who have contraindications to percutaneous gallbladder drainage.

Frequency of visualization of presumed celiac ganglia by endoscopic ultrasound.

BACKGROUND AND STUDY AIMS: Celiac ganglia can be visualized by endoscopic ultrasound (EUS). It is unknown how often ganglia are visualized during EUS, and what clinical factors are associated with ganglion visualization. The aim of this study was to prospectively evaluate the frequency of visualization of presumed celiac ganglia by EUS and to identify factors that predict their visualization. PATIENTS AND METHODS: Clinical, demographic, EUS, and cytologic data were collected prospectively from 200 unselected patients who were undergoing EUS in a tertiary referral centre. When presumed celiac ganglia were visualized, their size, number, location, and echo features were noted. When presumed ganglia were aspirated, the results of cytology were recorded. RESULTS: The most common indication for EUS was investigation of a pancreatic mass or cyst (25 %). Presumed celiac ganglia were identified in 81 % of patients overall. Logistic regression analysis determined that female sex and having no prior history of gastrointestinal surgery were independently associated with ganglion visualization. Among patients whose ganglia were visualized, more ganglia were seen per patient with linear echo endoscopes (2, range 0 - 5) than with radial echo endoscopes (1, range 0 - 4) ( P = 0.001). Presumed celiac ganglia were aspirated in 10 patients; and cytologic examination revealed neural ganglia in all of these. CONCLUSIONS: Celiac ganglia can be visualized by EUS in most patients who undergo upper gastrointestinal EUS examinations, and are best seen with linear-array echo endoscopes. Ganglia can usually be differentiated from lymph nodes on the basis of their endosonographic appearance.

Pancreatic stent prophylaxis of post endoscopic retrograde cholangiopancreatography pancreatitis: spontaneous migration rates and clinical outcomes.

AIM: Pancreatic duct (PD) stents diminish the risk of post endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in high-risk patients; 3 Fr stents are reported to spontaneously migrate at a significantly higher rate than 5 Fr stents in a cohort of mostly sphincter of Oddi (SOD) patients. We sought to assess spontaneous migration rates of 5 Fr and 7 Fr stents and effectiveness in preventing PEP in a diverse group of high risk patients. METHODS: A total of 4,332 ERCP exams performed between January 2002 and August 2005 were reviewed to identify patients undergoing PD stent placement. Follow-up was obtained from electronic medical records and contact with referring MDs. Plain abdominal radiographs were used to document stent passage. RESULTS: PD stents for PEP prophylaxis were placed in 246 exams (232 patients) undergoing: PD (major or minor) sphincterotomy (84), ampullectomy (50), SOD (46), bile duct precut (35), papillary stenosis balloon dilation (9) and difficult cannulation (8). Stents placed: 218 5-Fr (140 were 3 cm long and 78 =or> 5 cm long) and 28 7-Fr (12 were 3 cm long, 16=or> 5cm long). Follow-up was available in 197 (171 5-Fr, 26 7-Fr) of 246 placements (80%). Twenty of 171 5-Fr stents were electively removed via EGD within=or< 24 h per endoscopist preference and were not included in analysis; 128 of the remaining 151 5-Fr stents (85%) spontaneously migrated by (or within) median of 8 days and 23 failed to pass and required EGD removal. Of 26 7-Fr stents one was electively removed =or< 24 h later; of the remaining 25, 15 (60%) spontaneously migrated by median of 16 days, 10 required EGD removal. The spontaneous migration rate of 5 Fr stents was: 1) significantly higher than 7 Fr stents; 2) significantly higher than the previously reported 67% passage rate of 5 Fr stents; and 3) similar to the previously reported 86% passage rate of 3 Fr stents. PEP occurred in 15% (n=36: 24 mild, 11 moderate, 1 severe). CONCLUSION: The spontaneous dislodgement rate of 5 Fr stents in patients where the indication is primarily non-SOD is approximately 85% - significantly higher than previously reported and similar to the reported rate of spontaneous dislodgement of 3 Fr stents in SOD patients; 5 Fr stents migrate spontaneously earlier and more frequently than 7 Fr stents.

Endoscopic retrograde cholangiopancreatography catheter and accessory exchange using a short hydrophilic guide wire: a prospective study.

BACKGROUND AND STUDY AIMS: Although hydrophilic guide wires can be used to facilitate stricture cannulation during endoscopic retrograde cholangiopancreatography (ERCP), some endoscopists avoid using them because of concerns about wire loss during exchange. There are no data available on the outcomes of using a short hydrophilic guide wire during ERCP. The aim of this study was to assess the outcomes of therapeutic ERCP procedures in which a short, completely hydrophilic guide wire was used exclusively. PATIENTS AND METHODS: A total of 100 patients undergoing ERCP were studied prospectively. A 0.035-inch, 260-cm long, angled-tip hydrophilic wire (Terumo Glidewire) was used initially. Hydraulic catheter exchange was performed as follows: during catheter withdrawal the assistant advanced all the available wire into the catheter; a 12-ml syringe was then attached to the catheter and water was flushed under pressure to "float the wire" and maintain its position during catheter removal. Variables evaluated included exchange times and wire loss rates. RESULTS: A total of 223 catheter exchanges were performed, 132 (59%) using the Olympus V-Scope (which held the wire in 62% of cases): 15% of exchanges were with catheters/accessories designed for short-wire use (Boston Scientific Rapid Exchange Biliary System or Rx System), and 85% were with a variety of standard-length accessories. Overall, the mean exchange time was 26 seconds (range 6 - 90 seconds, standard deviation 12 seconds). The mean exchange time was faster with the V-Scope and with non-Rx-System accessories. Wire loss occurred in 5 % of all exchanges. Desired ductal/stricture access was achieved in all the patients. CONCLUSIONS: Exchange of short hydrophilic wires is quick and reliable. The Olympus V-Scope is able to hold the wire in some cases. Monorail-type devices and accessories slow catheter exchange down slightly because hydraulic exchange cannot be performed using these systems.

Endoscopic retrograde cholangiopancreatography in post-Whipple patients.

BACKGROUND AND STUDY AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is an established modality for evaluation and treatment of pancreaticobiliary disorders. However, it is technically more challenging in patients with post-surgical anatomy. The success rate of ERCP in patients with prior pancreaticoduodenectomy (Whipple resection) is unknown. We assessed the technical success and safety of ERCP in this patient population. PATIENTS AND METHODS: Post pancreaticoduodenectomy patients who had undergone ERCP between January 2002 and May 2005 were identified through a computerized medical index system. ERCP was considered successful if the duct of clinical interest had been cannulated and endoscopic therapy had been performed when indicated. RESULTS: ERCP was attempted 88 times in 51 patients with prior pancreaticoduodenectomy, including 37 procedures for pancreatic indications, 44 for biliary obstruction, and 7 for both biliary and pancreatic indications. The overall technical success rate of ERCP based on the intention behind the procedure was 51 % (45 of the 88 procedures). Success was significantly more likely for biliary indications (37/44, 84 %) than for pancreatic indications (3/37, 8 %) ( P < or = .001). Complications occurred in 2 % of the procedures and included one self- contained perforation treated medically and one Mallory-Weiss tear. CONCLUSIONS: When performed by experienced endoscopists, ERCP in patients with prior pancreaticoduodenectomy is safe, with a high success rate for biliary indications and a low success rate for pancreatic duct indications. Better methods of achieving pancreatic duct cannulation after pancreaticoduodenectomy are needed.

Absence of human papillomavirus in esophageal carcinomas from southwestern Kenya.

Esophageal squamous cell cancer is highly prevalent in south-western Kenya. The role of human papillomavirus (HPV) in esophageal cancers from this region was evaluated. Biopsies of 29 esophageal squamous cell cancers were assayed for HPV DNA sequences by reverse line blot polymerase chain reaction, using 27 HPV type-specific probes. Viral sequences were found in none of the specimens. These results suggest the HPV is unlikely to be an etiologic factor for esophageal squamous cell cancers in this region.

The utility of Ki-ras mutation analysis in the cytologic diagnosis of pancreatobiliary neoplasma.

PURPOSE: Mutations involved in neoplastic progression may be able to serve as markers for the presence of small numbers of neoplastic cells that would otherwise escape detection in diagnostic assays. Previous retrospective studies have suggested that the sensitivity of the cytologic diagnosis of pancreatic and biliary tract carcinomas is improved when analysis includes Ki-ras exon 1, which is commonly mutated in these neoplasms. We report our experience with the systematic prospective application of Ki-ras gene analysis to the evaluation of fine-needle aspirates and brushings from the pancreatobiliary tract. MATERIALS AND METHODS: Between September 1996 and April 1999, 75 pancreatic fine-needle aspirates and common bile duct brushings submitted for routine cytologic diagnosis were also evaluated for mutations in Ki-ras exon 1 by polymerase chain reaction/single-strand conformation polymorphism analysis. After routine preparation of the specimens, residual material was used for molecular analysis. Results are compared with the morphologic diagnosis and available clinical information. RESULTS: Single-strand conformation polymorphism mutation patterns in Ki-ras were detected in 22 of the 70 consecutive clinical specimens with adequate DNA and at least 6 months of available clinical follow-up. Sensitivity, specificity, and positive predictive value for the presence of concurrent or subsequent pancreatobiliary carcinoma were 33%, 97%, and 93%, respectively, for definitive cytologic diagnosis alone, and 53%, 97%, and 95% for positive Ki-ras single-strand conformation polymorphism mutation pattern alone. If definitive positive cytology or atypical/suspicious cytology with a positive Ki-ras single-strand conformation polymorphism mutation pattern is used, sensitivity is 55%, specificity is 97%, and positive predictive value is 96% for the presence of pancreatobiliary carcinoma. DISCUSSION: Results support the routine use of Ki-ras mutational analysis to increase the sensitivity of the cytologic evaluation of pancreatobiliary fine-needle aspirates and common bile duct brushings with atypical or suspicious morphology without compromising specificity.