Specialist Endoscopists Are Associated with a Decreased Risk of Incomplete Polyp Resection During Endoscopic Mucosal Resection in the Colon.

BACKGROUND: Endoscopic experience is known to correlate with outcomes of endoscopic mucosal resection (EMR), particularly complete resection of the polyp tissue. Whether specialist endoscopists can protect against incomplete polypectomy in the setting of known risk factors for incomplete resection (IR) is unknown. AIMS: We aimed to characterize how specialist endoscopists may help to mitigate the risk of IR of large sessile polyps. METHODS: This is a retrospective cohort study of patients who underwent EMR at the University of Michigan from January 1, 2006, to November 15, 2015. The primary outcome was endoscopist-reported polyp tissue remaining at the end of the initial EMR attempt. Specialist endoscopists were defined as endoscopists who receive tertiary referrals for difficult colonoscopy cases and completed at least 20 EMR colonic polyp resections over the study period. RESULTS: A total of 257 patients with 269 polyps were included in the study. IR occurred in 40 (16%) cases. IR was associated with polyp size ≥ 40 mm [adjusted odds ratio (aOR) 3.31, 95% confidence interval (CI) 1.38-7.93], flat/laterally spreading polyps (aOR 2.61, 95% CI 1.24-5.48), and difficulty lifting the polyp (aOR 11.0, 95% CI 2.66-45.3). A specialist endoscopist performing the initial EMR was protective against IR, even in the setting of risk factors for IR (aOR 0.13, 95% CI 0.04-0.41). CONCLUSIONS: IR is associated with polyp size ≥ 40 mm, flat and/or laterally spreading polyps, and difficulty lifting the polyp. A specialist endoscopist initiating the EMR was protective of IR.

A randomized trial of rectal indomethacin to prevent post-ERCP pancreatitis.

BACKGROUND: Preliminary research suggests that rectally administered nonsteroidal antiinflammatory drugs may reduce the incidence of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). METHODS: In this multicenter, randomized, placebo-controlled, double-blind clinical trial, we assigned patients at elevated risk for post-ERCP pancreatitis to receive a single dose of rectal indomethacin or placebo immediately after ERCP. Patients were determined to be at high risk on the basis of validated patient- and procedure-related risk factors. The primary outcome was post-ERCP pancreatitis, which was defined as new upper abdominal pain, an elevation in pancreatic enzymes to at least three times the upper limit of the normal range 24 hours after the procedure, and hospitalization for at least 2 nights. RESULTS: A total of 602 patients were enrolled and completed follow-up. The majority of patients (82%) had a clinical suspicion of sphincter of Oddi dysfunction. Post-ERCP pancreatitis developed in 27 of 295 patients (9.2%) in the indomethacin group and in 52 of 307 patients (16.9%) in the placebo group (P=0.005). Moderate-to-severe pancreatitis developed in 13 patients (4.4%) in the indomethacin group and in 27 patients (8.8%) in the placebo group (P=0.03). CONCLUSIONS: Among patients at high risk for post-ERCP pancreatitis, rectal indomethacin significantly reduced the incidence of the condition. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT00820612.).

Predicting the likelihood of a persistent bile duct stone in patients with suspected choledocholithiasis: accuracy of existing guidelines and the impact of laboratory trends.

BACKGROUND: Existing guidelines aim to stratify the likelihood of choledocholithiasis to guide the use of ERCP versus a lower-risk diagnostic study such as EUS, MRCP, or intraoperative cholangiography. OBJECTIVE: To assess the performance of existing guidelines in predicting choledocholithiasis and to determine whether trends in laboratory parameters improve diagnostic accuracy. DESIGN: Retrospective cohort study. SETTING: Tertiary-care hospital. PATIENTS: Hospitalized patients presenting with suspected choledocholithiasis over a 6-year period. INTERVENTIONS: Assessment of the American Society for Gastrointestinal Endoscopy (ASGE) guidelines, its component variables, and laboratory trends in predicting choledocholithiasis. MAIN OUTCOME MEASUREMENTS: The presence of choledocholithiasis confirmed by EUS, MRCP, or ERCP. RESULTS: A total of 179 (35.9%) of the 498 eligible patients met ASGE high-probability criteria for choledocholithiasis on initial presentation. Of those, 99 patients (56.3%) had a stone/sludge on subsequent confirmatory test. Of patients not meeting high-probability criteria on presentation, 111 (34.8%) had a stone/sludge. The overall accuracy of the guidelines in detecting choledocholithiasis was 62.1% (47.4% sensitivity, 73% specificity) based on data available at presentation. The accuracy was unchanged when incorporating the second set of liver chemistries obtained after admission (63.2%), suggesting that laboratory trends do not improve performance. LIMITATIONS: Retrospective study, inconsistent timing of the second set of biochemical markers. CONCLUSION: In our cohort of patients, existing choledocholithiasis guidelines lacked diagnostic accuracy, likely resulting in overuse of ERCP. Incorporation of laboratory trends did not improve performance. Additional research focused on risk stratification is necessary to meet the goal of eliminating unnecessary diagnostic ERCP.

Transpapillary Gallbladder Stents Can Stabilize or Improve Decompensated Cirrhosis in Patients Awaiting Liver Transplantation.

GOALS: To describe the short-term and long-term outcomes in 34 consecutive decompensated cirrhotic patients with symptomatic gallbladder disease undergoing transpapillary gallbladder stent (TGS) placement. BACKGROUND: Endoscopic TGS placement is a minimally invasive means of treating symptomatic gallbladder disease in poor surgical candidates. STUDY: Between June 2005 and June 2011, 34 patients with cirrhosis and symptomatic gallbladder disease underwent attempted TGS placement. RESULTS: Median patient age was 52 years, 56% were hospitalized, and 48% were listed for liver transplantation. The median model for end-stage liver disease (MELD) score was 15 (range, 6 to 40) and 88% were Child-Turcotte-Pugh class B/C. A double pigtailed stent was successfully placed in 94% of the patients. At 1-month follow-up, clinical improvement was noted in 82% of the treated subjects and the MELD scores in 14 of 22 (64%) evaluable subjects improved or stabilized. Actuarial transplant-free survival was 53% in the liver transplant candidates with a mean follow-up of 352 days, whereas survival was 44% in the 18 nontransplant candidates with a mean follow-up of 1.5 years. Periprocedural complications included pancreatitis in 5 patients, cholangitis in 3, and 1 patient with cystic duct perforation. In addition, 2 subjects had symptomatic bleeding from traumatic duodenal ulcerations 2 years after TGS placement that necessitated stent removal. CONCLUSIONS: Endoscopic TGS placement was technically feasible in 94% of decompensated cirrhotics and was associated with a relatively low rate of periprocedural (26%) and long-term complications (6%). Stabilization or improvement in clinical status and MELD scores was seen in the majority of treated patients.

Endoscopic Transpapillary Gallbladder Stent Placement Is Safe and Effective in High-Risk Patients Without Cirrhosis.

BACKGROUND: Endoscopic transpapillary gallbladder stent (ETGS) placement is a proposed minimally invasive alternative to cholecystectomy in high-risk patients with symptomatic gallbladder disease. AIMS: To describe the safety and efficacy of ETGS placement in 29 consecutive patients without cirrhosis. METHODS: A retrospective analysis of consecutive ETGS cases from 2005 to 2013 at a referral center was undertaken. RESULTS: The mean age was 70 years (range 40-91), and 62 % were hospitalized. The most common indication for ETGS was acute calculus cholecystitis (52 %). Comorbidities precluding cholecystectomy included advanced cancer (45 %), severe cardiopulmonary disease (21 %), and advanced age/frailty (17 %). Eighty-six percent of the patients had an ASA class of III or IV, and the Charlson comorbidity index was >3 in 55 %. An ETGS was successfully placed in 22 patients (76 %) with 18 being successful on the first attempt. A percutaneous rendezvous approach was required to obtain cystic duct access in six patients (21 %). During a mean follow-up of 376 days, a sustained clinical response was noted in 90 % of the patients with a stent placed. No peri-procedural complications were noted. However, two patients developed delayed complications of abdominal pain and cholangitis. Six patients were alive with their original stent still in place at a mean follow-up of 2.5 years. CONCLUSIONS: ETGS is an effective and safe alternative to cholecystectomy in high-risk patients. Technical success can be facilitated by a percutaneous rendezvous technique. Our data and those of others suggest that scheduled stent exchanges may not be required unless a clinical change occurs.

A survey of expert follow-up practices after successful endoscopic eradication therapy for Barrett's esophagus with high-grade dysplasia and intramucosal adenocarcinoma.

BACKGROUND: Despite the increasing number of patients undergoing endoscopic therapy for Barrett's esophagus (BE) with high-grade dysplasia (HGD) or intramucosal cancer (IMC), there are few data to guide clinical decision making and research initiatives in the area of posttreatment follow-up. OBJECTIVES: We aimed to define expert practice patterns regarding follow-up after endoscopic treatment of BE with HGD and IMC. DESIGN: Electronic survey. SUBJECTS: Forty-eight endoscopists in the United States with expertise in BE endotherapy based on high-impact publications and national reputation. INTERVENTION: A 21-item Web-based survey inquiring about post-BE endotherapy follow-up practices. RESULTS: Of 48 expert endoscopists, 42 completed the survey. After successful treatment of BE with HGD or IMC, all experts perform surveillance upper endoscopy, most commonly at 3-month intervals in the first posttreatment year, every 6 months during the second year, and annually thereafter. None of the experts perform surveillance EUS after treatment of HGD, and only 19% perform EUS after treatment of IMC. After cancer eradication, only 36% of experts refer patients for CT, and 24% refer patients for positron emission tomography. Thirty-eight percent of experts refer patients for a surgical opinion when IMC extends into the muscularis mucosa; 100% refer when IMC extends into submucosa. LIMITATIONS: Not a consensus document; only U.S. experts included. CONCLUSIONS: This study reports the follow-up practices of expert endoscopists after successful endotherapy for BE with HGD and IMC. Additional research is necessary to establish optimal surveillance intervals, the role of follow-up EUS, CT, and positron emission tomography, as well as the surgical implications of low-risk IMC extending into the muscularis mucosa.

Percutaneous cholecystostomy as a bridge to definitive endoscopic gallbladder stent placement.

BACKGROUND & AIMS: Percutaneous cholecystostomy (PC) is an effective treatment for acute cholecystitis (AC) in patients who are poor surgical candidates, although it is generally used as a bridge to cholecystectomy, given its long-term risks, the need for repeated procedures, and patient dissatisfaction. Ongoing patient comorbidity, however, might preclude cholecystectomy after recovery from the acute illness. METHODS: Four patients with AC who were poor immediate and long-term candidates for cholecystectomy underwent PC as primary therapy for AC, followed by endoscopic placement of a transpapillary gallbladder stent as definitive long-term management. RESULTS: All 4 patients were successfully treated for AC with PC. After recovery, the patients underwent endoscopic gallbladder stent placement and removal of the PC. In 2 cases, endoscopic transpapillary access to the gallbladder was facilitated by advancing a guidewire through the cholecystostomy tract into the duodenum. All patients had favorable outcomes. CONCLUSIONS: PC as a bridge to permanent therapy with endoscopic gallbladder stenting appears to be a viable strategy in the management of patients with AC who are poor immediate and long-term candidates for cholecystectomy.

Factors associated with esophageal stricture formation after endoscopic mucosal resection for neoplastic Barrett's esophagus.

BACKGROUND: EMR for early neoplastic Barrett's esophagus is gaining favor over esophagectomy. Esophageal stricture development has been reported as a common complication of EMR, photodynamic therapy, and combination endoscopic therapy. OBJECTIVE: To determine clinical and procedural predictors of symptomatic stricture formation after EMR. DESIGN: Retrospective analysis. SETTING: Tertiary-care referral university hospital. PATIENTS: Data were retrospectively reviewed on 73 patients at our institution who underwent EMR monotherapy for Barrett's esophagus with high-grade dysplasia or intramucosal cancer since January 2006. INTERVENTION: EMR. MAIN OUTCOME MEASUREMENTS: Symptomatic esophageal stricture formation. RESULTS: Symptomatic esophageal stricture formation was noted in 24.7% of patients undergoing EMR. Stricture formation on univariate analysis was associated with percentage of circumference of esophageal lumen resected, total pieces resected, number of EMR sessions, and tobacco use. A threshold effect was found at 50% of esophageal circumference resected (66.7% vs 27.2% developed strictures above and below the threshold, respectively; P = .004). A 25-pack-year or greater history of tobacco use had a threshold effect on esophageal stricture formation (77.8% vs 7.2% developed strictures above and below the threshold, respectively; P = .02). In multivariate analysis, resection of >50% of the circumference was strongly associated with stricture formation (odds ratio [OR] 4.17; 95% confidence interval [CI], 1.27-13.7). A 25-pack-year or greater history of tobacco use also trended toward stricture formation (OR 3.33; 95% CI, 0.929-12.1). LIMITATIONS: Retrospective design, sample size. CONCLUSION: Resection of at least 50% of the esophageal mucosal circumference is strongly associated with stricture formation. Patients with strong histories of tobacco use also may be more likely to develop esophageal strictures following EMR.

Multicenter comparison of the interobserver agreement of standard EUS scoring and Rosemont classification scoring for diagnosis of chronic pancreatitis.

BACKGROUND: EUS has less than optimal interobserver agreement for the diagnosis of chronic pancreatitis. The newly developed Rosemont consensus scoring system includes weighted criteria and stricter definitions for individual features. OBJECTIVE: The primary aim was to compare the interobserver agreement of standard and Rosemont scoring. SETTING: Multiple tertiary-care institutions. INTERVENTION: Fifty EUS videos were interpreted by 14 experts. Each expert interpreted the videos on two occasions: First, the videos were read by using standard scoring (9 criteria). Second, after viewing a presentation of the Rosemont classification, the same experts re-read the videos by using Rosemont scoring. MAIN OUTCOME MEASUREMENTS: Fleiss' kappa (K) statistics are reported with 95% confidence intervals (CI). RESULTS: The interobserver agreement was "substantial" (K = 0.65 [95% CI, 0.52-0.77]) for Rosemont scoring and "moderate" (K = 0.54 [95% CI, 0.44-0.66]) for standard scoring; however, the difference was not statistically significant (P = 0.12). LIMITATIONS: The sample size does not allow detection of differences in K of <0.25. CONCLUSION: Use of the Rosemont classification did not significantly increase interobserver agreement for EUS diagnosis of chronic pancreatitis compared with standard scoring.

Hydroperitoneum-facilitated EUS-guided peritoneal entry and closure of alternate access sites for NOTES.

BACKGROUND: Access sites other than the anterior gastric wall may provide improved ergonomics for natural orifice transluminal endoscopic surgery (NOTES). Endoscopic ultrasound (EUS) guidance significantly reduces, but does not eliminate, risk of access through these alternate sites. This study evaluates the utility of hydroperitoneum as an adjunct to EUS-guided access and closure of alternate access sites for NOTES. METHODS: Access and closure procedures were initially performed with EUS guidance alone, and subsequently, because of complications resulting from this technique, the procedures were performed with the aid of a transabdominal hydroperitoneum. RESULTS: In this nonrandomized study, 6 access and closure procedures performed with EUS guidance alone resulted in 4 complications. After modifying the technique to incorporate pre-access hydroperitoneum, 7 EUS-guided access and closure procedures were performed without significant complications. CONCLUSIONS: Hydroperitoneum appears to be an effective adjunct to ensure the safety of EUS-guided peritoneal entry and closure of alternate access sites for NOTES.