Quantifying Radiation Doses in Common Endoscopic Retrograde Cholangiopancreatography Scenarios: An Evaluation of Radiation Safety Measures in a Real-World Environment.

Introduction Radiation safety training remains variable among gastroenterologists performing endoscopic retrograde cholangiopancreatography (ERCP). This study sought to ascribe dosimeter readings to various real-world ERCP scenarios to provide data supporting the 3 pillars of radiation safety: distance, time, and shielding. Methods An ERCP fluoroscopy unit was used to generate radiation scatter from 2 differently sized anthropomorphic phantoms. Radiation scatter was measured at various distances from the emitter, with and without a lead apron, and at various frame rates (measured in frames per second, fps) and degrees of fluoroscopy pedal actuation. An image quality phantom was used to assess resolution at various frame rates and air gaps. Results Increasing the distance resulted in a decrease in measured scatter (from 0.75 mR/h at 1.5 ft to 0.15 mR/h at 9 ft with the average phantom and from 50 mR/h at 1.5 ft to 3.06 mR/h at 9 ft with the large phantom). Depressing the fluoroscopy pedal less frequently, or decreasing the frame rate (ie, increasing the time per frame), resulted in a linear decrease in scatter (from 55 mR/h at 8 fps to 24.5 mR/h at 4 fps and 13.60 mR/h at 2 fps). Providing shielding through the presence of a 0.5-mm lead apron reduced scatter (from 4.10 to 0.11 mR/h with the average phantom; from 15.30 mR/h to 0.43 mR/h with the large phantom). However, decreasing the frame rate from 8 fps to 2 fps did not change the number of line pairs identified on the image phantom. A greater air gap increased the number of line pairs resolved. Conclusions Implementing the 3 pillars of radiation safety led to a quantifiable, clinically significant decrease in radiation scatter. The authors hope that these findings spark greater implementation of radiation safety measures among practitioners utilizing fluoroscopy.

Polypectomy for Large Polyps with Endoscopic Mucosal Resection.

Beginning in 1955, when the saline injection was first described to prevent transmural injury during polyp fulguration, endoscopic mucosal resection (EMR) has grown exponentially, both in scope and in practice. Because EMR is an organ-preserving technique even for large polyps, this allows for comparable outcomes to surgery, but substantially improved cost savings and significantly reduced morbidity and mortality. To achieve this, however, one must master the 4 fundamental components that are critical to the success of EMR- time, team, tools, and technique. This article aims to provide a compendium of state of the art updates within the field of endoluminal resection.

Long-term follow-up of branch-duct intraductal papillary mucinous neoplasms with No change in first 5 Years of diagnosis.

BACKGROUND: Discontinuation of branch-duct intraductal papillary mucinous neoplasm (BD-IPMN) surveillance after 5 years of no change remains controversial. Long-term outcomes of BD-IPMN without significant changes in the first 5 years were evaluated. METHODS: We performed a multi-center retrospective analysis of patients with BD-IPMN diagnosis from 2005 to 2011 (follow-up until 2017). Significant changes were defined as pancreatic cancer (PC), pancreatectomy, high-risk stigmata (HRS), worrisome features (WF) and worrisome EUS features (WEUS). RESULTS: Of 982 patients who had no significant changes, 5 (0.5%), 7 (0.7%), 99 (10.1%), 4 (0.4%) patients developed PC, HRS, WF, WEUS, respectively, post-5 years. PC and HRS/WF/WEUS incidences at 12 years were 1.0% and 29.0%, respectively. Patients that developed HRS/WF/WEUS had larger cyst size in first 5 years compared to those that did not [16 (12-23) vs. 12 (9-17) mm, p = 0.0001], cyst size of >15 mm having higher cumulative incidence of HRS/WF/WEUS. PC mortality was 0.8%; all-cause mortality was 32%. Incidence of mortality due to PC was higher in HRS/WF/WEUS group, p < 0.0001. The mortality rate at 12 years for ACCI (age-adjusted Charlson Comorbidity Index) of ≤3, 4-6, and ≥7 were 3.5%, 19.9%, and 57.6% (p < 0.0001), respectively. CONCLUSIONS: Incidence of PC in patients with BD-IPMN without significant changes in first 5 years of diagnosis remains low at 1.0%. Incidence of HRS/WF/WEUS was higher at 29.0%. PC-related mortality was higher in HRS/WF/WEUS group. These risks should be weighed against patients' overall mortality (utilizing scoring systems such as ACCI) when making surveillance decision of BD-IPMN beyond 5 years.

Society Guidelines-Where Is the Consensus?

With reports of ongoing duodenoscope contamination and pathogen transmission despite strict adherence to manufacturer reprocessing instructions, professional societies continue to release updated recommendations. Despite general guideline similarities, there are differences. Although adherence to guidelines does not entirely eliminate pathogen contamination or transmission, it is critical to strictly adhere to updated guidelines for maximum risk reduction. In the United States, the Food and Drug Administration and Centers for Disease Control and Prevention continue to offer updates regarding improved duodenoscope reprocessing techniques and endoscope design. This article critically analyzes currently available national and international duodenoscope reprocessing guidelines.

The effect of prophylactic hemoclips on the risk of delayed post-endoscopic mucosal resection bleed for upper and lower gastrointestinal lesions: a retrospective cohort study.

BACKGROUND: Endoscopic mucosal resection (EMR) is a minimally invasive procedure used for the treatment of lesions in the gastrointestinal (GI) tract. There is increased usage of hemoclips during EMR for the prevention of delayed bleeding. This study aimed to evaluate the effect of hemoclips in the prevention of delayed bleeding after EMR of upper and lower GI tract lesions. METHOD: This is a retrospective cohort study using the Kaiser Permanente Southern California (KPSC) EMR registry. Lesions in upper and lower GI tracts that underwent EMR between January 2012 and December 2015 were analyzed. Rates of delayed bleeding were compared between the hemoclip and no-hemoclip groups. Analysis was stratified by upper GI and lower GI lesions. Lower GI group was further stratified by right and left colon. We examined the relationship between clip use and several clinically-relevant variables among the patients who exhibited delayed bleeding. Furthermore, we explored possible procedure-level and endoscopist-level characteristics that may be associated with clip usage. RESULTS: A total of 18 out of 657 lesions (2.7%) resulted in delayed bleeding: 7 (1.1%) in hemoclip group and 11 (1.7%) in no-hemoclip group (p = 0.204). There was no evidence that clip use moderated the effects of the lesion size (p = 0.954) or lesion location (p = 0.997) on the likelihood of delayed bleed. In the lower GI subgroup, clip application did not alter the effect of polyp location (right versus left colon) on the likelihood of delayed bleed (p = 0.951). Logistic regression analyses showed that the clip use did not modify the likelihood of delayed bleeding as related to the following variables: use of aspirin/NSAIDs/anti-coagulants/anti-platelets, pathologic diagnoses (including different types of colon polypoid lesions), ablation, piecemeal resection. The total number of clips used was 901 at a minimum additional cost of $173,893. CONCLUSION: Prophylactic hemoclip application did not reduce delayed post-EMR bleed for upper and lower GI lesions in this retrospective study performed in a large-scale community practice setting. Routine prophylactic hemoclip application during EMR may lead to significantly higher healthcare cost without a clear clinical benefit.

From Dyspepsia to Diagnosis: A Rare Gastric Subepithelial Lesion Definitively Diagnosed via Endoscopic Submucosal Dissection and Immunohistochemistry.

INTRODUCTION: Peripheral nerve sheath tumors, known as perineuriomas, are typically found on the trunk and extremities. They are less commonly described in the gastrointestinal tract (GI), and extremely rarely are described in the stomach. CASE PRESENTATION: We present a case of a 2-cm gastric perineurioma in a 42-year-old patient with nonspecific GI complaints of chronic dyspepsia and epigastric discomfort. Esophagogastroduodenoscopy, followed by endoscopic ultrasound, revealed a 2-cm umbilicated lesion in the stomach, which was subsequently removed with endoscopic submucosal dissection and sent for pathology. Immunohistochemical staining revealed a rare entity known as a gastric perineurioma. CONCLUSION: Since the first case of gastric perineurioma was first described in 2004, there have only been 4 reported cases in the English literature. This case highlights the crucial interdisciplinary multidisciplinary effort between pathologists and GI specialists required to reach this diagnosis and showcases endoscopic diagnosis using endoscopic dissection, which allows for complete lesion resection and complete resolution of the patient's symptoms.

Endoscopic ultrasound-guided transmural gallbladder drainage in malignant obstruction using a novel lumen-apposing stent: a case series (with video).

Background and aims Current endoscopic methods of biliary decompression in malignant pancreatic neoplasms are often limited by anatomical and technical challenges. In this case series, we report our experience with endoscopic ultrasound (EUS)-guided placement of an electrocautery-enhanced, lumen-apposing self-expandable metallic stent (LAMS) via transmural gallbladder drainage. Methods This is a retrospective case series of nine patients (five male, mean age 63.1 years) who underwent EUS-guided LAMS placement for malignant, obstructive jaundice in the pancreatic head. All nine cases were performed by an experienced interventional endoscopist at a single, tertiary medical center. We review the technical and clinical success rates as well as the incidence of procedural adverse events across the nine patients. Results LAMS placement was technically successful in all cases and there were no procedural adverse events. Seven of nine (77.78 %) patients showed clinical and laboratory improvement immediately following the procedure. One case required re-intervention with interventional radiology guided biliary drain placement. The mean fluoroscopy time was 1.02 minutes. Conclusions EUS-guided LAMS placement for transmural gallbladder drainage in malignant obstruction appears to be a safe and effective technique, allowing patients to proceed to surgery, chemotherapy, or hospice care.

Competing Risks for Mortality in Patients With Asymptomatic Pancreatic Cystic Neoplasms: Implications for Clinical Management.

OBJECTIVES: Pancreatic cystic neoplasms (PCNs) are being detected with increased frequency. Current clinical practice guidelines emphasize management based on cyst-related features. We aimed to evaluate the impact of comorbidity on mortality in PCN patients via competing risk analysis. METHODS: We analyzed a retrospective cohort of patients diagnosed between 2005-2010, with follow-up through 2015, for overall and cause-specific mortality. Comorbidities were classified by the Charlson comorbidity index. We used Cox proportional hazards regression to evaluate the independent effect of cyst features, age, gender, and comorbidities on cause-specific mortality. Subgroup analysis was performed to determine the cause-specific mortality based on four a priori clinical profiles-healthy patients with low- or high-risk cysts, and high-comorbidity patients with low- or high-risk cysts. RESULTS: A total of 1,800 patients with PCNs comprised the study cohort (median follow-up 5.7 years). A total of 402 deaths (22.3%) occurred during the study period: 43 pancreatic cancer and 359 non-pancreatic cancer deaths. Compared to healthy patients without any high-risk cyst features (reference group), patients with high comorbidity as well as high-risk cyst features had an increased risk of overall mortality (Cox hazard ratio 6.30, 95% confidence interval (CI) 4.71, 8.42, P<0.01), pancreatic cancer mortality (subdistribution hazard ratio (SHR) 51.13, 95% CI 6.35, 411.29, P<0.01), as well as non-pancreatic cancer mortality (SHR 5.24, 95% CI 3.85, 7.12, P<0.01). Meanwhile, low-risk patients with a high-risk cyst were more likely to experience pancreatic cancer mortality (SHR 68.14, 95% CI 9.27, 501.01, P<0.01) rather than non-pancreatic cancer mortality (SHR 1.22, 95% CI 0.88, 1.71, P=0.23), compared to the reference group. Similarly, compared to the reference group, high-risk patients with a low-risk cyst were more likely to experience non-pancreatic cancer mortality (SHR 3.96, 95% CI 2.98, 5.26, P<0.01) rather than pancreatic cancer mortality (SHR 2.35, 95% CI 0.14, 38.82, P=0.55). CONCLUSIONS: Most of the deaths in the study were unrelated to pancreatic cancer. This has implications for clinical management. By applying patient-related factors in conjunction with cyst features, we defined commonly encountered patient profiles to help guide PCN clinical management.

Patient Preferences for Management of Cystic Neoplasms of the Pancreas: A Cross-Sectional Survey Study.

OBJECTIVE: The aim of this study was to determine how patient anxiety, knowledge, and cancer worry influence preferences for management of pancreatic cysts. METHODS: We performed a prospective, cross-sectional study using a disease-specific survey instrument. We included patients older than 18 years who were diagnosed with a pancreatic cyst. A telephone survey instrument was developed to assess baseline anxiety using the Hospital Anxiety and Depression Scale (HADS), knowledge regarding pancreatic cysts, cancer worry, and patient preferences using a standard gamble. RESULTS: Of the 100 studied participants (median age, 65 years; 72% women), median Hospital Anxiety and Depression Scale score was 4 (normal range). In terms of knowledge, 96% of the patients were not aware of their specific cyst type, and 58% were unaware of the possibility of any cyst-related malignancy. Overall, 8% of respondents had some degree of cancer worry. Respondents were more willing to undergo magnetic resonance imaging surveillance compared with endoscopic ultrasound or surgery. Knowledge of cyst type was a significant predictor of willingness to undergo invasive testing. CONCLUSIONS: There is a significant gap in patient knowledge with respect to pancreatic cysts. Greater emphasis on patient education can help patients make informed decisions regarding cyst management.

Prediction of malignancy in cystic neoplasms of the pancreas: a population-based cohort study.

OBJECTIVES: Pancreatic cystic neoplasms (PCNs) are being detected with increased frequency. The aims of this study were to determine the incidence of malignancy and develop an imaging-based system for prediction of malignancy in PCN. METHODS: We conducted a retrospective cohort study of patients ≥18 years of age with confirmed PCN from January 2005 to December 2010 in a community-based integrated care setting in Southern California. Patients with history of acute or chronic pancreatitis were excluded. Malignancy diagnosed within 3 months of cyst diagnosis was considered as pre-existing. Subsequent incidence of malignancy during surveillance was calculated based on person-time at risk. Age- and gender-adjusted standardized incidence ratio (SIR) was calculated with the non-cyst reference population. Recursive partitioning was used to develop a risk prediction model based on cyst imaging features. RESULTS: We identified 1,815 patients with confirmed PCN. A total of 53 (2.9%) of patients were diagnosed with cyst-related malignancy during the study period. The surveillance cohort consisted of 1,735 patients with median follow-up of 23.4 months. Incidence of malignancy was 0.4% per year during surveillance. The overall age- and gender-adjusted SIR for pancreatic malignancy was 35.0 (95% confidence level 26.6, 46.0). Using recursive partitioning, we stratified patients into low (<1%), intermediate (1-5%), and high (9-14%) risk of harboring malignant PCN based on four cross-sectional imaging features: size, pancreatic duct dilatation, septations with calcification as well as growth. Area under the receiver operator characteristic curve for the prediction model was 0.822 (training) and 0.808 (testing). CONCLUSIONS: Risk of pancreatic malignancy was lower than previous reports from surgical series but was still significantly higher than the reference population. A risk stratification system based on established imaging criteria may help guide future management decisions for patients with PCN.