Prospective assessment of the effectiveness of standard high-level disinfection for echoendoscopes.

BACKGROUND AND AIMS: Duodenoscopes have been implicated in the transmission of multidrug-resistant organisms (MDROs). Echoendoscopes could potentially transmit infection. The aim of this study was to assess the effectiveness of standard high-level disinfection (HLD) for radial and linear echoendoscopes and to compare it with that of duodenoscopes. METHODS: We performed a prospective single-center study sampling echoendoscopes immediately before use, from the working channel (radial and linear echoendoscopes) and the transducer (radial echoendoscope) or elevator mechanism and transducer (linear echoendoscope). The primary outcome was the proportion of echoendoscopes with any culture showing ≥1 MDRO; secondary outcomes included bacterial growth >0 colony forming units (CFUs) and ≥10 CFUs on either sampling location. We compared these findings with duodenoscope cultures from the previously published DISINFECTS trial. RESULTS: During the study period, 101 echoendoscopes were sampled (n = 50 radial echoendoscopes, n = 51 linear echoendoscopes). No MDROs were recovered. Bacterial growth >0 CFUs was noted in 6% and ≥10 CFUs in 3% of all echoendoscopes. There was no significant difference in growth between radial and linear echoendoscopes (P = .4 for >0 CFU growth; P = .6 for ≥10 CFUs growth). The proportion of transducer and/or elevator mechanism positive for bacterial growth was significantly higher in duodenoscopes as compared with echoendoscopes (P = .02). CONCLUSIONS: After standard HLD, no echoendoscope showed MDRO growth, 6% showed >0 CFUs, and 3% showed ≥10 CFUs bacterial growth. Bacterial growth was higher in duodenoscopes at the level of the transducer and/or elevator mechanism when compared with echoendoscopes.

Prospective assessment of consensus criteria for evaluation of patients with suspected choledocholithiasis.

BACKGROUND AND AIM: American Society for Gastrointestinal Endoscopy (ASGE) guidelines have proposed criteria to stratify patients into low, intermediate and high risk of choledocholithiasis. The criteria include variables that are readily available in clinical practice. The objective of the present study was to prospectively assess the accuracy of these criteria. METHODS: A prospective observational cohort study was conducted at Beth Israel Deaconess Medical Center. All adult patients referred for endoscopic retrograde cholangiopancreatography (ERCP) with suspected choledocholithiasis were considered for inclusion. ASGE criteria were applied, and each patient was categorized as high, intermediate or low risk for choledocholithiasis. Presence of stone at ERCP served as criteria standard. RESULTS: During the study period, 402 patients met study inclusion criteria and 336 were reported in the final analysis. Of the 244 patients in the high risk for choledocholithiasis group, 185 were found to have stones at ERCP (75.8%, 95% CI 70.2-80.1%). Of the 92 patients in the intermediate risk for choledocholithiasis group, 45 had stones at ERCP (48.9%, 95% CI 38.8-59.1%); P-value for difference between groups = 0.001. Diagnostic accuracy for choledocholithiasis in the high-risk group was 69.05%, and for the intermediate group was 39.95%. Presence of choledocholithiasis on pre-ERCP imaging (OR: 3.6; 95% CI 2.2-6.0; P < 0.01), and bilirubin >1.8 but <4 mg/dL (OR: 1.69; 95% CI 1.0-2.8; P < 0.04) were the strongest predictors of choledocholithiasis. No additional variable that improved accuracy of ASGE criteria was identified. CONCLUSION: ASGE criteria stratify patients by risk for choledocholithiasis and can be used in routine clinical practice.

Pancreatic and biliary stents.

Biliary and pancreatic stents are used in a variety of benign and malignant conditions including strictures and leaks and in the prevention of post-ERCP pancreatitis.Both plastic and metal stents are safe, effective, and easy to use. SEMSs have traditionally been used for inoperable malignant disease. Covered SEMSs are now being evaluated for use in benign disease. Increasing the duration of patency of both plastic and metal stents remains an important area for future research.

A prospective assessment of sedation-related adverse events and patient and endoscopist satisfaction in ERCP with anesthesiologist-administered sedation.

BACKGROUND: Despite the increasing use of anesthesiologist-administered sedation for monitored anesthesia care (MAC) or general anesthesia in patients undergoing ERCP, limited prospective data exist on the effectiveness, safety, and cost of this approach. OBJECTIVE: To prospectively assess sedation-related adverse events (SRAEs), patient- and procedure-related risk factors associated with SRAEs, and endoscopist and patient satisfaction with anesthesiologist-administered sedation. DESIGN: Single-center, prospective cohort study. SETTING: Tertiary-care referral center. PATIENTS: A total of 528 consecutive patients undergoing ERCP. INTERVENTIONS: Anesthesiologist-administered MAC or general anesthesia. MAIN OUTCOME MEASUREMENTS: SRAEs, endoscopist and patient satisfaction. RESULTS: There were 120 intraprocedure SRAEs during 109 of the 528 ERCPs (21% of cases). Intraprocedure SRAEs included hypotension (38 events), arrhythmia (20 events), O(2) desaturation to less than 85% (66 events), unplanned intubation (16 events), and procedure termination (1 event). Thirty postprocedure SRAEs occurred in a total of 22 patients (4% of cases), including hypotension (5 events), endotracheal intubation (2 events), and arrhythmia (12 events). Patient-related variables associated with adverse intraprocedure events were American Society of Anesthesiologists class (P = .004) and body mass index (kg/m(2)) (P = .02). On a 10-point scale, mean endoscopist satisfaction with sedation was 9.2 (standard deviation 1.8) and patient satisfaction with sedation was 9.9 (standard deviation 0.7). LIMITATIONS: The approach to sedation was not randomized. CONCLUSIONS: Higher American Society of Anesthesiologists class and body mass index are associated with an increased rate of cardiac and respiratory events during ERCP. Cardiac and respiratory events are generally minor, and MAC can be considered a safe option for most ERCP patients. Despite the frequency of minor sedation-related events, procedure interruption or premature termination was rare in the setting of anesthesiologist-administered sedation.