Feasibility of placing a modified fully covered self-expandable metal stent above the papilla to minimize stent-induced bile duct injury in patients with refractory benign biliary strictures (with videos).

BACKGROUND: Endoscopic placement of fully covered self-expandable metal stents (FCSEMS) has been attempted to manage benign biliary strictures, but currently available FCSEMSs may be associated with unintended complications, including de novo strictures, in patients with normal life expectancy. OBJECTIVE: To evaluate the feasibility of an intraductally placed modified FCSEMS to minimize stent-induced bile duct injury in patients with benign biliary strictures. DESIGN: Prospective observational clinical feasibility study. SETTING: Tertiary-care academic center. PATIENTS: This study involved 21 patients with symptomatic benign biliary strictures in whom conventional endoscopic management failed. INTERVENTION: Strictured segments were 15 mm above the ampulla of Vater. The modified FCSEMS has convex margins, a lasso, and an anti-migrating waist on the central portion. Stents were placed entirely above the papilla and removed after 3 to 5 months. MAIN OUTCOME MEASUREMENTS: Success, complications, removability, midterm outcome. RESULTS: FCSEMSs were successfully placed inside the bile duct in all patients. No episodes of pancreatitis, cholangitis, or sepsis were noted during the stenting period. Stent migration occurred in 4 patients (19.0%), but 3 were asymptomatic during follow-up. All stents were removed successfully with rat-tooth forceps without complications. Post-stenting cholangiograms showed improvement of strictures in 20 of 21 patients, without de novo focal stricture. The clinical success rate was 95.2%, with one recurrent stricture. LIMITATIONS: The small number and lack of comparison with other types of FCSEMSs. CONCLUSION: Temporary intraductal placement of a newly modified FCSEMS effectively improved strictures and prevented potential stent-induced complications in patients with benign biliary strictures. Controlled large-scale trials are needed to confirm the long-term efficacy.

Prophylactic temporary 3F pancreatic duct stent to prevent post-ERCP pancreatitis in patients with a difficult biliary cannulation: a multicenter, prospective, randomized study.

BACKGROUND: Post-ERCP pancreatitis (PEP) is the most common and serious complication of ERCP. Difficult biliary cannulation can be a procedure-related risk factor for PEP. Recent studies reported that a prophylactic pancreatic stent (PS) can reduce the frequency and severity of PEP. OBJECTIVE: To evaluate the efficacy and usefulness of a temporary 3F PS to prevent PEP in patients with difficult biliary cannulations. DESIGN: A multicenter, prospective, randomized study. SETTING: Two tertiary-care academic medical centers. PATIENTS: In total, 101 patients with a difficult biliary cannulation were randomly divided into the 3F PS placement group (PS group, n = 50) or the nonstent (NS) group (NS group, n = 51). INTERVENTIONS: Endoscopic placement of a 3F unflanged PS. MAIN OUTCOME MEASUREMENTS: The incidence and severity of PEP in the 2 groups, spontaneous dislodgment of stents, and procedure-related complications. RESULTS: The technical success rate of 3F PS placement was 96% (48/50). The lengths of the stents were 4 cm (n = 21), 6 cm (n = 15), and 8 cm (n = 12). Spontaneous stent dislodgment within 7 days occurred in 94% of patients (45/48). The mean duration until spontaneous dislodgment was 3.5 days. The incidence rate of PEP was 12% (6/50: mild, 5; moderate, 1) in the PS group and 29.4% (15/51: mild, 12; moderate, 2; severe, 1) in the NS group. Severe pancreatitis occurred in only 1 patient in the NS group. In a multivariate analysis, prophylactic placement of PS was the only prophylactic factor for PEP (odds ratio, 0.126; 95% CI, 0.025-0.632, P = .012). LIMITATIONS: No comparative results for stent size and diameter and a low-risk cohort group. CONCLUSIONS: Prophylactic temporary 3F PS placement in patients with a difficult biliary cannulation during ERCP seems to be a safe and effective method for reducing PEP and results in a high rate of spontaneous passage of stents without complications.

The role of intraductal US in the management of idiopathic recurrent pancreatitis without a definite cause on ERCP.

BACKGROUND: The cause of pancreatitis is unknown in as many as 30% of cases of recurrent acute pancreatitis, even after ERCP. OBJECTIVE: To investigate the role of intraductal US (IDUS) for managing idiopathic recurrent pancreatitis (IRP). DESIGN: Prospective study. SETTING: Tertiary referral hospital. PATIENTS: Thirty-one patients with suspicious IRP with negative findings on ERCP. INTERVENTIONS: IDUS during ERCP. MAIN OUTCOME MEASUREMENTS: IDUS findings showing any possible cause of pancreatitis. RESULTS: IDUS revealed small bile duct stones (≤3 mm) in 5 patients (16.1%) and sludge in 3 patients (9.7%). The detection rate for a bile duct stone and sludge was significantly higher in patients with a dilated CBD than a nondilated CBD on ERCP (71.4 vs 12.5%; P < .05). Recurrent pancreatitis did not develop in 7 of 8 patients with biliary stones or sludge after an endoscopic sphincterotomy (EST). Two patients (6.5%) demonstrated a small polypoid lesion on the distal end of the pancreatic duct. One patient underwent surgery for intra-ampullary cancer, and another one underwent EST without another attack of pancreatitis. Three patients (9.7%) showed evidence of chronic pancreatitis with small pancreatic stones and/or calcifications on IDUS. LIMITATIONS: Small number of patients. IDUS results were not compared with those of conventional EUS. There was no reference standard for chronic pancreatitis as diagnosed by IDUS. CONCLUSIONS: IDUS identified a possible cause of idiopathic recurrent pancreatitis in 42% of patients with negative findings on ERCP. The IDUS-guided approach combined with ERCP and EST may be useful for decreasing recurring attacks of pancreatitis.

Successful eradication of relapsed primary effusion lymphoma with high-dose chemotherapy and autologous stem cell transplantation in a patient seronegative for human immunodeficiency virus.

Primary effusion lymphoma (PEL) is a recently recognized disease that occurs most often in immunosuppressed patients, either with human immunodeficiency virus (HIV) or in the posttransplantation setting, and it occasionally occurs in nonimmunosuppressed patients. Patients present with lymphomatous effusions in serous cavities--pleura, pericardium, or peritoneum--without any identifiable tumor mass. PEL rarely responds to systemic chemotherapy, and the prognosis is poor, with a median survival time of less than 6 months for most cohorts. A standard treatment for PEL has not yet been identified. We describe a patient with HIV-seronegative PEL who relapsed after combination chemotherapy and then underwent successful treatment with high-dose chemotherapy (HDC) and autologous stem cell transplantation (ASCT). The treatment was well tolerated, and the patient has been in remission for 12 months after HDC and ASCT.

Preparation of quality control materials for the determination of mercury in rice.

This study was performed to determine the feasibility of using Hg-spiked rice as a quality control material for Hg content analyses. Rice was coated with halogen compounds prior to the addition of Hg to increase the homogeneity and stability, both of which are important factors in the development of reference materials (RMs), relative to currently available RMs. The coating materials CCl4, CH2CHCH2Br, and CH3I were used to generate Hg-spiked rice RMs at the desired Hg concentrations. The coating materials were tested to determine the extent to which they were able to affect the adsorption of Hg onto the rice. The in-lab prepared Hg-spiked rice RMs using proposed RM production method exhibited good homogeneity (within- and between-bottle) and stability (short- and long-term) with respect to the evaluated coating materials, storage temperature (20°C or 40°C), and storage periods (from 0 days up to 24 months).

The early onset of disease may be a risk factor for decreased bone mineral density in patients with inflammatory bowel disease.

BACKGROUND/AIMS: The pathogenesis of bone loss in patients with inflammatory bowel disease (IBD) is complex, multifactorial, and only partly understood. We aimed to examine the extent and risk factors of bone mass reduction and to analyze the impact of early onset of a disease before attaining peak bone mass in IBD patients. METHODS: We compared the risk factors for osteoporosis and BMD at the lumbar spine and the hip bone in IBD patients. RESULTS: A total of 44 patients with IBD were enrolled. Twenty-one and 23 patients were diagnosed as IBD before and after the age of 30 and designated as group A and group B, respectively. Group A had significant bone mass reduction at the lumbar spine than group B (BMD, 1.01±0.10 vs. 1.14±0.17, p<0.01; T-score, -1.22±0.84 vs. -0.08±1.39, p<0.01; Z-score, -1.11±0.81 vs. -0.03±1.32, p<0.01, respectively). Multivariate analysis showed that patients diagnosed as IBD before the age of 30 had possible risk factor of bone mass reduction (hazard ratio, 3.96; p=0.06). CONCLUSIONS: Bone mass reduction was more severe in patients who were diagnosed with IBD before the age of 30 than in those diagnosed after the age of 30.

[Transient lower esophageal sphincter relaxation and the related esophageal motor activities].

Transient lower esophageal sphincter (LES) relaxation (TLESR) is defined as LES relaxation without a swallow. TLESRs are observed in both of the normal individuals and the patients with gastroesophageal reflux disorder (GERD). However, TLESR is widely considered as the major mechanism of the GERD. The new equipments such as high resolution manometry and impedance pH study is helped to understand of TLESR and the related esophageal motor activities. The strong longitudinal muscle contraction was observed during development of TLESR. Most of TLESRs are terminated by TLESR related motor events such as primary peristalsis and secondary contractions. The majority of TLESRs are associated with gastroesophageal reflux. Upper esophageal sphincter (UES) contraction is mainly associated with liquid reflux during recumbent position and UES relaxation predominantly related with air reflux during upright position. The frequency of TLESR in GERD patients seems to be not different compared to normal individuals, but the refluxate of GERD patients tend to be more acidic during TLESR.

Correlation of narrow band imaging with magnifying colonoscopy and histology in colorectal tumors.

BACKGROUND/AIMS: Narrow band imaging (NBI) is a new technique that uses optical filters for imaging of mucosal morphology. The aim of this study was to correlate findings of NBI with magnifying colonoscopy and histology for prediction of neoplastic colorectal lesion. METHODS: Between September 2005 and December 2007, 107 colon polyps from 68 patients were detected by conventional colonoscopy and subsequently evaluated by NBI with magnifying colonoscopy and analyzed for a pit pattern and a capillary pattern. More analysis was done regarding thickness and irregularity of capillary features. RESULTS: Pit pattern with NBI magnification to discriminate between neoplastic and non-neoplastic lesions had a sensitivity of 88.9% and a specificity of 87.5%; capillary pattern yielded test performance characteristics of 91.9% and 87.5%. In respect of capillary thickness, invisible capillaries were found significantly more often in hyperplastic lesions. All thick capillaries were found in neoplastic polyps, and found significantly more often in carcinomas with submucosal massive invasion (sm-m) (p<0.01). In respect of capillary irregularity, invisible capillaries were found significantly more often in hyperplasic lesions, and severely irregular capillaries were found significantly more often in sm-m lesions (p<0.01). CONCLUSIONS: Observation of capillary thickness and irregularity by NBI magnification is useful for correlating histological grade with carcinoma, especially with depth of submucosal invasion.