A water-soluble alternative to simethicone for gastrointestinal endoscopy: Results of a clinical trial.

During endoscopy, simethicone defoaming agents are commonly used to improve visualization, but they leave residues and impact drying. This clinical trial involved patients undergoing colonoscopy procedures with substantial bubbles that impeded mucosal wall visibility. As an alternative to simethicone, investigators evaluated a water-soluble, ginger-based gastrointestinal supplement (GI-Ease) that did not contain sugars, thickeners, or binding agents. In 112/114 cases (98%), the bubbles were reduced sufficiently to allow visualization of the gastrointestinal tract, with no adverse events.

Resolving external pancreatic fistulas in patients with disconnected pancreatic duct syndrome: using rendezvous techniques to avoid surgery (with video).

BACKGROUND: An external pancreatic fistula (EPF) generally results from an iatrogenic manipulation of a pancreatic fluid collection (PFC), such as walled-off pancreatic necrosis (WOPN). Severe necrotizing pancreatitis can lead to complete duct disruption, causing disconnected pancreatic duct syndrome (DPDS) with viable upstream pancreas draining out of a low-pressure fistula created surgically or by a percutaneous catheter. The EPF can persist for months to years, and distal pancreatectomy, often the only permanent solution, carries a high morbidity and defined mortality. OBJECTIVE: To describe 3 endoscopic and percutaneous rendezvous techniques to completely resolve EPFs in the setting of DPDS. DESIGN: A retrospective review of a prospective database of 15 patients who underwent rendezvous internalization of EPFs. SETTING: Tertiary-care pancreatic referral center. PATIENTS: Fifteen patients between October 2002 and October 2011 with EPFs in the setting of DPDS and resolved WOPN. INTERVENTION: Three rendezvous techniques that combined endoscopic and percutaneous procedures to internalize EPFs by transgastric, transduodenal, or transpapillary methods. MAIN OUTCOME MEASUREMENTS: EPF resolution and morbidity. RESULTS: Fifteen patients (12 men) with a median age of 51 years (range 24-65 years) with EPFs and DPDS (cutoff/blowout of pancreatic duct, with inability to demonstrate upstream body/tail of pancreas on pancreatogram) resulting from severe necrotizing pancreatitis underwent 1 of 3 rendezvous procedures to eliminate the EPFs. All patients were either poor surgical candidates or refused surgery. At the time of the rendezvous procedure, WOPN had fully resolved, DPDS was confirmed on pancreatography, and the EPF had persisted for a median of 5 months (range 1-48 months), producing a median output of 200 mL/day (range 50-700 mL/day). The rendezvous technique in 10 patients used the existing percutaneous drainage fistula to puncture into the stomach/duodenum to deliver wires that were captured endoscopically. The transenteric fistula was dilated and two endoprostheses placed into the lesser sac. A second technique was used in 3 patients where EUS was used to avoid large varices and create a fistula to the percutaneous drainage catheter. Wires were delivered transenterally then grasped by an interventional radiologist. The new fistula was dilated, and, again, two endoprostheses were placed. Two patients underwent a rendezvous technique that resulted in transpapillary stents and removal of percutaneous catheters. The median duration to EPF closure was 7 days (range 1-73 days) during a median follow-up of 25 months (range 6-113 months). No EPF has recurred in any patient, although 3 symptomatic fluid collections have occurred. These collections have been successfully treated with combined percutaneous and endoscopic treatment or endoscopic treatment alone. One patient had postprocedural fever. There were no associated deaths. LIMITATIONS: Small, selected group of patients without a comparative group. CONCLUSION: The management of EPFs in the setting of DPDS is challenging but can be treated effectively by combined endoscopic and percutaneous rendezvous techniques. The rendezvous procedures were associated with minimal morbidity, no mortality, avoidance of surgery, and complete elimination of the EPFs.

Laparoscopy-assisted versus balloon enteroscopy-assisted ERCP in bariatric post-Roux-en-Y gastric bypass patients.

BACKGROUND: Data on balloon enteroscopy-assisted ERCP (BEA-ERCP) versus laparoscopy-assisted ERCP (LA-ERCP) in post-Roux-en-Y gastric bypass (RYGB) patients are lacking. OBJECTIVES: To compare BEA-ERCP with LA-ERCP in post-RYGB patients and to identify factors that predict therapeutic success with BEA-ERCP. DESIGN: Retrospective chart review. SETTING: A single North American tertiary referral center. PATIENTS: The review included 56 bariatric post-RYGB patients who underwent ERCP. INTERVENTIONS: BEA-ERCP or LA-ERCP. MAIN OUTCOME MEASUREMENTS: Cannulation rate, therapeutic success, hospital stay, complications, procedure duration, endoscopist time, and cost. RESULTS: A total of 32 patients underwent BEA-ERCP, and 24 underwent LA-ERCP. LA-ERCP was superior to BEA-ERCP in papilla identification (100% vs 72%, P = .005), cannulation rate (100% vs 59%, P < .001), and therapeutic success (100% vs 59%, P < .001). The total procedure time was shorter (P < .001) and endoscopist time was longer (P = .006) for BEA-ERCP. There was no difference in postprocedure hospital stay (P = .127) or complication rate (P = .392) between the 2 groups. In the BEA-ERCP group, in patients having a Roux limb + biliopancreatic (from ligament of Treitz to jejunojejunal anastomosis), a limb length less than 150 cm was associated with therapeutic success. Starting with BEA-ERCP and continuing with LA-ERCP after a failed BEA-ERCP saved $1015 compared with starting with LA-ERCP. LIMITATIONS: Single center, retrospective study. CONCLUSIONS: In centers with expertise in deep enteroscopy and ERCP, post-RYGB patients with a Roux + ligament of Treitz to jejunojejunal anastomosis limb length less than 150 cm should first be offered deep enteroscopy-assisted ERCP. In patients with Roux + ligament of Treitz to jejunojejunal anastomosis (LTJJ) limb length 150 cm or longer, LA-ERCP should be the preferred approach because of the lack of need for a second procedure, equivalent morbidity and hospital stay, decreased endoscopist time, and decreased cost.

Long-term outcomes associated with pancreatic extracorporeal shock wave lithotripsy for chronic calcific pancreatitis.

BACKGROUND: Most outcomes data on pancreatic extracorporeal shock wave lithotripsy (P-ESWL) for chronic calcific pancreatitis (CCP) are based on studies with <4 years' follow-up, and U.S. long-term studies are lacking. OBJECTIVE: To report long-term P-ESWL outcomes for CCP and to assess whether smoking or alcohol use influences P-ESWL outcomes. DESIGN: Cross-sectional study, retrospective chart review. SETTING: Virginia Mason Medical Center, Seattle, Washington. PATIENTS: This study involved 120 patients who underwent P-ESWL and ERCP for CCP and completed an outcomes questionnaire. INTERVENTION: P-ESWL and ERCP, outcomes survey. MAIN OUTCOME MEASUREMENTS: Pain, quality of life, narcotics use, diabetes status, pancreatic enzyme requirement, repeat P-ESWL, repeat ERCP, surgery. RESULTS: A total of 120 patients underwent P-ESWL followed by ERCP (mean ± standard deviation [SD] follow-up 4.3 [± 3.7] years) and completed a survey. The mean (± SD) before-P-ESWL pain score was 7.9 (± 2.6) compared with 2.9 (± 2.6) after P-ESWL (P < .001). Improved pain was reported by 102 patients (85%); 60 (50%) reported complete pain relief and no narcotic use. The mean (± SD) before-P-ESWL quality-of-life score was 3.7 (± 2.4) compared with 7.3 (± 2.7) after P-ESWL (P < .001). In patients with ≥ 4 years' follow-up, repeat procedures included P-ESWL (29%), ERCP (84%), and surgery (16%). Smokers who quit smoking after P-ESWL had improved narcotic requirements compared with those who continued smoking (95% vs 67%; P = .014), and a trend suggested a decreased need for repeat ERCPs (68% vs 84%; P = .071). LIMITATIONS: Single center, retrospective, recall bias, nonvalidated pain and quality-of-life scales. CONCLUSION: P-ESWL as the initial therapy for CCP may lead to more lifetime procedures; however, partial pain relief in 85%, complete pain relief with no narcotic use in 50%, and avoidance of surgery in 84% of patients may be achieved. Quitting smoking after P-ESWL may improve outcomes.

Role of Endoscopic Retrograde Cholangiopancreatography in the Diagnosis and Management of Cholestatic Liver Diseases.

Cholestatic liver diseases (CLDs) occur as a result of bile duct injury, emanating into duct obstruction and bile stasis. Advances in radiological imaging in the last decade has replaced endoscopic retrograde cholangiopancreatography (ERCP) as the first diagnostic tool, except in certain groups of patients, such as those with ischemic cholangiopathy (IsC) or early stages of primary sclerosing cholangitis (PSC). ERCP provides an opportunity for targeted tissue acquisition for histopathological evaluation and carries a diverse therapeutic profile to restore bile flow. The aim of this review article is to appraise the diagnostic and therapeutic roles of ERCP in CLDs.

Spiral overtube-assisted colonoscopy after incomplete colonoscopy in the redundant colon.

BACKGROUND: A redundant colon can lead to incomplete colonoscopy. A variety of tools and techniques are available to complete colonoscopy but have limitations. OBJECTIVE: To determine the feasibility and safety of using a spiral overtube to complete a difficult colonoscopy. DESIGN: Retrospective review of a prospectively collected database. SETTING: Single tertiary institution. PATIENTS: Twenty-four patients with incomplete colonoscopy because of redundant colons underwent 26 procedures. The median age was 68 years, and 58% were men. INTERVENTIONS: All patients underwent colonoscopy performed with a 90-cm flexible threaded overtube and a variable-stiffness pediatric colonoscope. Four individuals (18%) required exchanging the colonoscope for an enteroscope. MAIN OUTCOME MEASUREMENTS: Successful cecal intubation, polyp identification and removal, time to reach the cecum, sedation needed, and complications. RESULTS: Cecal intubation was achieved in 22 patients (92%). Failures occurred in 2 patients with large hernias. The median time from insertion of the colonoscope to reaching the cecum was 14.5 minutes. All procedures were performed by using conscious sedation with midazolam (median dose 7 mg) and fentanyl (median dose 150 µg). Significant findings were encountered in 17 of 22 patients (77%) including 1 cancer and 2 advanced polyps. A median of 3 polyps was removed from each patient who had polyps. All noncancerous polyps were removed during the procedure. There were no complications. LIMITATIONS: Retrospective design, no control group, single center. CONCLUSION: Spiral overtube-assisted colonoscopy can enable cecal intubation in the majority of patients in whom standard colonoscopy fails because of a redundant colon.

Afferent limb syndrome and delayed GI problems after pancreaticoduodenectomy for pancreatic cancer: single-center, 14-year experience.

BACKGROUND: There are limited data on the incidence of afferent limb syndrome and other delayed GI problems in pancreatic cancer (PaC) patients, especially among long-term survivors (>2 years). OBJECTIVE: To evaluate the incidence of afferent limb syndrome (chronic afferent limb obstruction resulting in pancreatobiliary obstruction) and delayed GI problems in PaC patients after pancreaticoduodenectomy (PD). DESIGN: Retrospective case series. SETTING: Tertiary referral center. PATIENTS: PaC patients treated with PD (N = 186) over a 14-year period (January 1995-October 2009). INTERVENTIONS: Endoscopic balloon dilation and stent placement, percutaneous biliary drainage. MAIN OUTCOME MEASUREMENTS: Incidence of afferent limb syndrome and delayed GI complications (marginal ulcers, radiation enteropathy, anastomotic strictures). RESULTS: Mean age was 63 ± 10 years; 55% of patients were male. Afferent limb syndrome was noted in 24 patients (13%). Median time to diagnosis was 1.2 years (range 0.03-12.3 years); obstruction was primarily caused by recurrent PaC (8 patients, 33%) and radiation enteropathy (9 patients, 38%). Afferent limb syndrome was more likely to develop in patients with 2 years or longer of follow-up (n = 71, [38%]) compared with patients with 2 years or less of follow-up, after controlling for age, sex, surgery type, and adjuvant treatment (adjusted odds ratio, 4.5; 95% CI, 1.8-11.7). Other delayed GI problems included radiation enteropathy (6%), marginal ulcers (5%), anastomotic strictures (4%), cholangitis/liver abscesses (5%), and GI bleeding (6%). LIMITATIONS: Retrospective, single-center study. CONCLUSIONS: GI problems, including afferent limb syndrome, are relatively common in PaC patients after surgery and adjuvant therapy. Clinicians should recognize and effectively treat these delayed GI problems, especially in long-term survivors.

Semiautomated Glasgow-Blatchford Bleeding Score helps direct bed placement for patients with upper gastrointestinal bleeding.

OBJECTIVE: The Glasgow-Blatchford Bleeding Score (GBS) was designed to identify patients with upper gastrointestinal bleeding (UGIB) who do not require hospitalisation. It may also help stratify patients unlikely to benefit from intensive care. DESIGN: We reviewed patients assigned a GBS in the emergency room (ER) via a semiautomated calculator. Patients with a score ≤7 (low risk) were directed to an unmonitored bed (UMB), while those with a score of ≥8 (high risk) were considered for MB placement. Conformity with guidelines and subsequent transfers to MB were reviewed, along with transfusion requirement, rebleeding, length of stay, need for intervention and death. RESULTS: Over 34 months, 1037 patients received a GBS in the ER. 745 had an UGIB. 235 (32%) of these patients had a GBS ≤7. 29 (12%) low-risk patients were admitted to MBs. Four low-risk patients admitted to UMB required transfer to MB within the first 48 hours. Low-risk patients admitted to UMBs were no more likely to die, rebleed, need transfusion or require more endoscopic, radiographic or surgical procedures than those admitted to MBs. No low-risk patient died from GIB. Patients with GBS ≥8 were more likely to rebleed, require transfusion and interventions to control bleeding but not to die. CONCLUSION: A semiautomated GBS calculator can be incorporated into an ER workflow. Patients with a GBS ≤7 are unlikely to need MB care for UGIB. Further studies are warranted to determine an ideal scoring system for MB admission.

Improved oral intake after palliative duodenal stenting for malignant obstruction: a prospective multicenter clinical trial.

OBJECTIVES: We sought to test the hypothesis that placement of a new nitinol duodenal self-expandable metallic stent (SEMS) for palliation of malignant gastroduodenal obstruction is effective and safe in allowing patients to tolerate an oral diet. METHODS: In a prospective multicenter study, SEMSs (Duodenal WallFlex, Boston Scientific) were placed to alleviate gastroduodenal obstruction in inoperable patients without the ability to tolerate solid food. The primary study end point was improvement in oral intake monitored according to the 4-point Gastric Outlet Obstruction Scoring System (GOOSS) up to 24 weeks after stent placement. RESULTS: Forty-three patients received SEMSs, which were successfully deployed on the first attempt in 41 cases (95%) and the second attempt in two (5%). Within 1 day and 7 days after SEMS placement, 52% and 75% of patients, respectively, benefited from a GOOSS increase > or =1. Resumption of solid food intake (GOOSS 2-3) was attained by 56% of patients within 7 days and 80% by 28 days. Of the patients attaining GOOSS 2-3, 48% remained on solid food until death or last follow-up. Device-related adverse events included stent occlusion/malfunction in 9% of patients and perforation in 5% of patients. CONCLUSIONS: Duodenal WallFlex stent placement promptly improves oral intake in a majority of inoperable patients with malignant gastroduodenal obstruction. In approximately half the patients achieving GOOSS 2-3, the capacity for solid food intake endures until death or last follow-up.

Good stents gone bad: endoscopic treatment of proximally migrated pancreatic duct stents.

BACKGROUND: Pancreatic duct stents are used for a variety of endoscopic pancreatic manipulations, and small surgical stents are used prophylactically to bridge pancreatic-enteric anastomoses. With increasing use of pancreatic stents, many complications have been recognized. OBJECTIVE: To determine the complications and outcomes of pancreatic stent migration. DESIGN: Case series from a retrospective review of all cases of upstream or proximally migrated pancreatic duct stents, placed either endoscopically or surgically, identified between 2000 and 2007. SETTING: Tertiary referral center. PATIENTS: This study involved 33 patients; 23 postendoscopic and 10 postsurgical stents. MAIN OUTCOME MEASUREMENTS: Retrieval rates, minor/major complications. RESULTS: Endoscopic stents had a successful retrieval rate of 78%. Most patients were asymptomatic. The most common procedure was balloon extraction (8 of 18; 44%). Nine patients required multiple procedures (3 patients, 2 attempts; 5 patients, 3 attempts; 1 patient, 4 attempts). Five stents could not be retrieved. Of these, 4 were associated with downstream stenosis. Four patients underwent surgery, and 1 patient was treated with observation. Complications included pancreatic duct disruption (1 of 23), stent fragmentation (1 of 23), and postprocedure pancreatitis (1 of 23). Surgically placed stents had a successful retrieval rate of 80%. Most surgical stents had migrated into the biliary tree (8 of 10). All of these patients were symptomatic with pain or fever. Two stents could not be retrieved; 1 of those patients underwent surgery. LIMITATION: Retrospective study. CONCLUSION: The majority of upstream-migrated stents can be endoscopically removed. Despite manipulation of the pancreatic duct, pancreatitis was infrequent. Surgically placed pancreatic stents migrate downstream and into the open biliary anastomosis and are associated with pain, cholangitis, or liver abscesses.

Papillectomy for ampullary neoplasm: results of a single referral center over a 10-year period.

BACKGROUND: Tumors arising from the duodenal papilla account for approximately 5% of GI neoplasms, but are increasingly identified. OBJECTIVE: To describe the clinical characteristics and outcomes in a large single-center experience with patients referred for ampullary lesions. DESIGN: A retrospective review of the Virginia Mason Medical Center endoscopy and hospital service database. SETTING: Tertiary referral center. PATIENTS: One hundred ninety-three patients referred for ampullary lesions from 1997 to 2007. INTERVENTIONS: Endoscopic management of ampullary lesions. MAIN OUTCOME MEASUREMENTS: The relationship of demographic and clinical data with endoscopic treatment and clinical outcomes in these patients. RESULTS: One hundred ninety-three patients underwent endoscopy for ampullary lesions. Fifteen juxta-ampullary lesions and 10 normal variants were excluded. Among 168 patients, there were 112 (67%) adenomas, 38 (23%) adenocarcinomas, and 18 (10%) nonadenomatous lesions. There were 88 men and 80 women, with a mean age of 64 years. Clinical presentation included cholestasis/cholangitis (72 patients), abdominal pain (54 patients), incidental/asymptomatic (51 patients), pancreatitis (9 patients), and bleeding (7 patients). Of the 57 patients referred to surgery, 42 were sent directly without papillectomy, and 16 were sent after papillectomy. Papillectomies were performed in 102 patients with adenomatous lesions. The mean tumor size was 2.4 cm (range 0.5-6 cm). The papillectomy complication rate was 21%: mild pancreatitis in 10 (10%) patients, cholangitis in 1, retroperitoneal perforation in 1 (adenocarcinoma), intraperitoneal perforation in 1 (lateral extension), bleeding in 5 (lateral extension in 2 of these 5), and delayed papillary stenosis in 3. Recurrences were seen in 8%. The endoscopic success rate was 84%. Factors affecting success were a smaller adenoma size and the absence of dilated ducts. CONCLUSIONS: Most ampullary adenomas are amenable to endoscopy. Underlying malignancy and lateral extension may be risk factors for bleeding and perforation. Smaller lesion size and the absence of dilated ducts are factors favorably affecting success.

A twenty-year experience with endoscopic therapy for symptomatic primary sclerosing cholangitis.

GOALS: The current study presents 1 tertiary endoscopy center's 20-year experience using endoscopic therapy to treat patients with symptomatic primary sclerosing cholangitis (PSC). BACKGROUND: Endoscopic therapy for patients with PSC and dominant strictures has been used for more than 20 years, but there is concern that instrumenting a sclerotic biliary tree induces risks that outweigh anticipated benefits. STUDY: In this retrospective chart review, 117 patients with PSC were identified using ICD-9 codes. Patients had a mean age of 47 years (range: 15 to 86 y). Mean duration of follow-up was 8 years (range: 2 to 20 y). Of the 117 identified patients, 106 underwent endoscopic retrograde cholangiopancreatography on one or more occasions (for a total of 317 endoscopic retrograde cholangiopancreatographies), and a subset of 84 patients received endoscopic therapy for treatment of dominant strictures and/or deteriorating clinical status. Actual survival for endoscopically treated patients was compared with predicted survival using the Mayo Clinic natural history model for PSC. RESULTS: Our chart review revealed 23 recognized complications among the 317 procedures performed (7.3%), and no procedure-related deaths. Observed patient survival at years 3 and 4 was significantly higher than that predicted by the Mayo Clinic natural history model for PSC (P=0.021). CONCLUSIONS: Patients with PSC who have a deteriorating clinical course benefited from endoscopic therapy to provide drainage of bile ducts, removal of stones, and/or temporary relief from obstructions, with acceptable procedure-related complications and higher than expected 3-year and 4-year survival.

Acute symptomatic small bowel obstruction due to capsule impaction.

BACKGROUND: Capsule impaction is a well-recognized complication of capsule endoscopy, with an incidence rate of 0.75% to 21%, depending on indication. There have been only 2 reported cases of capsule impaction causing symptomatic obstruction. OBJECTIVE: We present 3 cases of capsule impaction causing acute symptomatic obstruction and/or perforation. DESIGN: Case series. SETTING: Teaching hospital. PATIENTS: A 71-year-old woman had iron deficiency anemia in the setting of negative upper endoscopy, colonoscopy, enteroclysis, and enteroscopy. She developed severe abdominal pain, vomiting, and leukocytosis 20 hours after capsule ingestion. Emergent surgery was performed to remove the capsule, which was impacted at a previously undiagnosed ileal Crohn's stricture leading to perforation. A 64-year-old woman with Gardner's syndrome and a history of colectomy and subsequent episodes of small bowel obstruction underwent capsule endoscopy to define the site of obstruction. She experienced severe abdominal pain 24 hours after capsule ingestion, and emergent enteroscopy was done to retrieve the capsule, which was impacted at a previously undiagnosed annular mass in the distal duodenum. An 85-year-old man with episodic small bowel obstruction due to radiation enteritis underwent capsule endoscopy to localize the site of obstruction in anticipation of surgery. He returned with severe abdominal pain and vomiting 3 days later. At surgery, the capsule was found to be impacted at an ileal radiation stricture. MAIN OUTCOME MEASUREMENTS: Acute symptomatic bowel obstruction. RESULTS: These cases show that bowel obstruction and even possibly perforation can occur as a result of capsule impaction. CONCLUSIONS: The possibility of acute symptomatic small bowel obstruction should be included in the informed consent for capsule endoscopy.

Blinded comparison of esophageal capsule endoscopy versus conventional endoscopy for a diagnosis of Barrett's esophagus in patients with chronic gastroesophageal reflux.

BACKGROUND: Esophageal capsule endoscopy (ECE) is an alternative to EGD for Barrett's esophagus screening. A multicenter study found ECE to be safe, well tolerated, and accurate; however, a post hoc adjudication process was used that may have biased results. OBJECTIVE: To assess the accuracy of ECE for the diagnosis of Barrett's esophagus. DESIGN: Prospective and blinded, with no adjudication. PATIENTS: Screening patients with chronic gastroesophageal reflux and surveillance patients with known Barrett's esophagus. INTERVENTIONS: ECE followed by EGD in each subject. MAIN OUTCOME MEASUREMENTS: Sensitivity, specificity, and positive and negative predictive values of ECE for Barrett's esophagus by using EGD results, with histologic confirmation as the criterion standard. RESULTS: Ninety-six subjects were enrolled, of whom 90 (94%) completed the study, including 66 screening and 24 surveillance patients. ECE was 67% sensitive and 84% specific for identifying Barrett's esophagus, diagnosing 14 of 21 cases of biopsy-confirmed Barrett's esophagus. Positive and negative predictive values were 22% and 98%, respectively (calculated for screening patients only). Sensitivity for short- and long-segment Barrett's esophagus was similar. CONCLUSIONS: Our blinded, unadjudicated study shows that ECE had only moderate sensitivity and specificity for identifying Barrett's esophagus. ECE in its present form is not suitable as a primary screening tool for Barrett's esophagus but may be used in patients unwilling to undergo EGD. Inadequate visualization of the gastroesophageal junction may be the cause of suboptimal ECE accuracy; this may be improved by advances in ingestion protocol and capsule calibration.

Palliation of gastric outlet obstruction and proximal small bowel obstruction with self-expandable metal stents: a single center series.

BACKGROUND: Self-expandable metal stents (SEMS) are being increasingly used to palliate malignant stenoses of the gastric outlet and proximal small bowel. Accordingly, we reviewed our experience in this setting. METHODS: Patients with gastric outlet or proximal small bowel stents were identified by reviewing hospital charts. Outcome criteria included survival data, need for reintervention, and clinical improvement. RESULTS: A total of 52 SEMS were placed in 36 patients with nonesophageal upper GI stenosis. Initial stent placement was successful in 92% and clinical improvement documented in 75%. Mean survival of patients who eventually died was 3.5 months. Seven patients are alive (mean follow-up, 5.0 months). Stent dysfunction occurred in 36% and required subsequent interventions. Biliary obstruction was documented in 50% of patients, 12 of whom had previously undergone biliary stenting and 5 who needed subsequent biliary decompression. CONCLUSIONS: Enteral stent placement has been reported to be an effective alternative for palliation of high-risk surgical patients with malignant gastric outlet and small bowel obstruction. Considering the short life expectancy of these patients and significant complications including stent migration, perforation, biliary obstruction, and need for subsequent endoscopic, radiologic and surgical interventions, the authors suggest that this procedure be performed in experienced centers on selected patients only and that biliary decompression be ensured early.

Use of self-expandable metallic stents in benign GI diseases.

BACKGROUND: The self-expandable metallic stent is of proven benefit in patients with malignant disease; however, its use in patients with benign disease is not well established. There are few data available regarding long-term complications and outcomes with use of self-expandable metallic stents in benign disease and virtually none regarding attempted removal once the acute problem is resolved. METHODS: Thirteen patients who had a self-expandable metallic stent placed for benign GI disorders were included in a retrospective analysis. Data collected included patient demographics, indication for procedure, type of stent used, complications, and patient outcomes. RESULTS: Thirteen patients (7 women, 6 men; mean age 67 years, range 34-84 years) had one or more self-expandable metallic stents placed for benign disease and were followed for a mean of 3.4 years (3 weeks to 10 years). Of the 13 patients, 8 had esophageal stents, 4 biliary stents, and 1 had dual stents placed in the pancreaticobiliary tree. Complications developed in 8 (62%) patients; 4 (31%) ultimately died, either from the primary disease process (3) or from stent-related complications (1). CONCLUSIONS: Self-expandable metallic stent placement is effective treatment for benign esophageal leaks, providing the stent can be removed. It also may be used in either the esophagus or biliary tree in patients who are poor candidates for surgery and short expected survival. However, a self-expandable metallic stent should not be placed in a patient with a benign GI disorder who has a significant life expectancy and is a good candidate for surgery.

Clinical outcomes in patients who undergo extracorporeal shock wave lithotripsy for chronic calcific pancreatitis.

BACKGROUND: There is controversy as to whether extracorporeal shock wave lithotripsy fragmentation and ERCP retrieval of pancreatic stones are associated with relief of chronic pain or relapsing attacks of pancreatitis. Our most recent experience with this technology is reviewed. METHODS: Forty patients with chronic calcific pancreatitis who required extracorporeal shock wave lithotripsy between 1995 and 2000 to facilitate pancreatic duct stone removal were retrospectively reviewed. Data collected included patient presentation, number of lithotripsy and ERCP sessions required, complications, and outcomes measures to include pre- and post-ESWL pain scale, monthly oxycodone (5 mg)-equivalent pills ingested, yearly hospitalizations, and need for subsequent surgery. RESULTS: A single extracorporeal shock wave lithotripsy session was required for 35 patients who underwent a total of 86 ERCPs to achieve complete stone extraction from the main pancreatic duct. Minor complications occurred in 20%. There was one episode of pancreatic sepsis that was treated with antibiotics and removal of an occluded pancreatic prosthesis. At a mean [SD] follow-up of 2.4 (0.6) years, 80% of patients had avoided surgery and there was a statistically significant decrease in pain scores (6.9 [1.3] vs. 2.9 [1.1]; p = 0.001), yearly hospitalizations for pancreatitis (3.9 [1.9] vs. 0.9 [0.9]; p = 0.001), and oxycodone-equivalent narcotic medication ingested monthly (125 [83] vs. 81 [80]; p = 0.03). CONCLUSIONS: Extracorporeal shock wave lithotripsy fragmentation of pancreatic duct calculi in conjunction with endoscopic clearance of the main pancreatic duct is associated with significant improvement in clinical outcomes in most patients with chronic pancreatitis.