Endoscopic ultrasound-guided biliary drainage in benign biliary pathology with normal foregut anatomy: a multicenter study.

BACKGROUND AND AIMS: Biliary drainage using endoscopic ultrasound (EUS-BD) has been developed as a novel technique to obtain biliary access and drainage when ERCP fails. Numerous studies have demonstrated its safety and efficacy specifically pertaining to those with malignant distal biliary obstruction or altered foregut anatomy. The aim of this study is to evaluate the safety and efficacy of EUS-BD in benign indications in patients with normal foregut anatomy. METHODS: We performed a retrospective comparative study from 5 academic medical centers (2008-2018) involving patients with benign biliary obstruction and native foregut anatomy who had an initial failed ERCP with subsequent attempt at biliary decompression via EUS-BD or by repeating ERCP. RESULTS: 36 patients (mean age 61.6 ± 2.2, 38.9% female) who underwent attempted EUS-BD following initial failed ERCP were compared to 50 patients (mean age 62.7 ± 2.3, 73.5% female) who underwent repeat ERCP following an initial failed cannulation. EUS-BD was technically successful in 28 (77.8%) patients with rendezvous being the most common approach (86.1%). A higher level of pre-procedural bilirubin was found to be associated with technical success of EUS-BD (3.65 ± 0.63 versus 1.1 ± 0.4, p value 0.04). Success of repeat ERCP following failed cannulation was 86%. Adverse events were significantly more frequent in the EUS-BD cohort when compared to the repeat ERCP (10 (27.8%) versus 4 (8.0%), p = 0.02, OR 4.32. CONCLUSIONS: EUS-BD remains a viable therapeutic option in the setting of benign biliary disease, with success rates of 77.8%. Adverse events were significantly more common with EUS-BD vs. repeat ERCP, emphasizing the need to perform in expert centers with appropriate multidisciplinary support and to strongly consider the urgency of biliary decompression before considering same session EUS-BD after failed initial biliary access.

Impact of fellowship training level on colonoscopy quality and efficiency metrics.

BACKGROUND AND AIMS: Previous studies have described variable effects of fellow involvement on the adenoma detection rate (ADR), but few have stratified this effect by level of training. We aimed to evaluate the "fellow effect" on multiple procedural metrics including a newly defined adenoma management efficiency index, which may have a role in documenting colonoscopy proficiency for trainees. We also describe the impact of level of training on moderate sedation use. METHODS: We performed a retrospective review of 2024 patients (mean age, 60.9 ± 10 years; 94% men) who underwent outpatient colonoscopy between June 2012 and December 2014 at our Veterans Affairs Medical Center. Colonoscopies were divided into 5 groups. The first 2 groups were first-year fellows in the first 6 months and last 6 months of the training year. Second- and third-year fellows and attending-only procedures accounted for 1 group each. We collected data on doses of sedatives used, frequency of adjunctive agent use, procedural times, and location, size, and histology of polyps. We defined the adenoma management efficiency index as average time required per adenoma resected during withdrawal. RESULTS: Of the colonoscopies performed, 1675 involved a fellow and 349 were performed by the attending alone. There was no difference in ADR between fellows according to level of training (P = .8) or between fellows compared with attending-only procedures (P = .67). Procedural times decreased consistently during training and declined further for attending-only procedures. This translated into improvement in the adenoma management efficiency index (fellow groups by ascending level of training: 23.5 minutes vs 18.3 minutes vs 13.7 minutes vs 13.4 minutes vs attending group 11.7 minutes; P < .001). There was no difference in the average doses of midazolam and fentanyl used among fellow groups (P = .16 and P = .1, respectively). Compared with attending-only procedures, fellow involvement was associated with higher doses of fentanyl and midazolam and more frequent use of diphenhydramine and glucagon (P < .0001, P = .0002, P < .0001, and P = .01, respectively). CONCLUSIONS: ADR was similar at different stages of fellowship training and comparable with the attending group. Efficiency of detecting and resecting polyps improved throughout training without reaching the attending level. Fellow involvement led to a greater use of moderate sedation, which may relate to a longer procedure duration and an evolving experience in endoscopic technique.

Diabetics on Narcotics Are Less Likely to Achieve Excellent Bowel Preparation Than Are Patients with Either Condition.

BACKGROUND: Diabetes and chronic narcotic use negatively affect the quality of bowel preparation before colonoscopy. AIM: To investigate whether narcotic use and diabetes have an additive negative impact on bowel preparation. PATIENTS AND METHODS: We performed a retrospective study of 2841 patients (mean age 61 ± 10.2; 94% male) who received outpatient colonoscopies at our Veterans Affairs Medical Center between June 2012 and December 2014. We collected information related to demographics, body mass index, indications, and medical/surgical history (diabetes mellitus, stroke, cirrhosis, dementia, constipation, hypothyroidism, and use of narcotics or antidepressants/anxiolytics for more than three months). Patients were classified into four groups: (1) diabetics on narcotics, (2) diabetics only, (3) on narcotics only, and (4) neither diabetic nor using narcotics. Quality of the bowel preparation was scored using the Boston Bowel Preparation Scale (BBPS) and categorized as either excellent (BBPS ≥7, with no individual segment scoring <2) or not excellent (BBPS <7). Multivariate logistic regression analysis was performed to identify the combined impact of narcotic use and diabetes on bowel preparation. RESULTS: Bowel preparation quality was excellent in 49%. Thirty-eight percent of patients with diabetes who were using narcotics (adjusted OR 0.6, CI [0.4, 0.8]) achieved excellent bowel preparation compared with 44% (adjusted OR 0.7, CI [0.6, 0.9]) of patients on narcotics only, 48% (adjusted OR 0.8, CI [0.7, 0.9]) of diabetics only, and 54% of patients with neither condition. CONCLUSION: Concomitant narcotic use and diabetes have a compounding effect on the quality of bowel preparation prior to colonoscopy.

Outpouching in the Esophagus: An Uncommon Endoscopic Finding of Esophageal Intramural Pseudodiverticulosis in the Absence of Esophageal Candidiasis.

We present a case of a 51-year-old female with a history of acquired immunodeficiency syndrome (AIDS) and medication non-compliance who experienced progressively worsening dysphagia to both solids and liquids over a three-month period. The patient underwent an esophagogastroduodenoscopy (EGD), which revealed multiple small pseudodiverticula without any other notable abnormalities. Subsequently, a barium esophagogram was performed, confirming the presence of multiple esophageal pseudodiverticula. Biopsies taken during the procedure showed chronic inflammatory changes, with no evidence of viral or fungal elements. In light of the patient's HIV history and the absence of esophageal candidiasis, the diagnosis of esophageal intramural pseudodiverticulosis (EIP) was made. The patient was initiated on highly active antiretroviral therapy (HAART) and received high-dose proton pump inhibitors (PPIs). Remarkably, the patient reported a complete resolution of her dysphagia symptoms during the follow-up visit. Risk factors associated with EIP include HIV infection, diabetes mellitus (DM), and esophageal candidiasis. To confirm the diagnosis, a barium esophagogram is considered the preferred imaging study. The management of EIP focuses on PPI therapy, the dilation of strictures if present, and addressing the underlying etiology. Given the association between EIP and esophageal malignancies, surveillance endoscopy may be recommended in these patients. This case highlights the importance of considering EIP as a potential cause of dysphagia, particularly in individuals with HIV/AIDS, even in the absence of esophageal candidiasis. Prompt diagnosis and appropriate management can lead to symptom resolution and improved quality of life for affected patients.

An Update on the Management of Esophageal Variceal Hemorrhage.

Content available: Author Audio Recording.

Is early correction of congenital ventricular septal defect a better option in a developing country?

OBJECTIVE: To assess and evaluate the effectiveness of early ventricular septal defect (VSD) repair in a developing country by comparing the outcomes in two age groups. METHODS: A total of 39 patients underwent VSD repair at a tertiary care hospital in Karachi over a period of 2.5 years. Patients were divided into Group 1 (<2 years) and Group 2 (2-18 yrs). Perioperative and postoperative variables were reviewed retrospectively for each patient and compared with the development of complications and the effect on postoperative recovery times. The data was analyzed using Mann Whitney test for continuous variables and Fischer's exact test for categorical variables. RESULTS: Mean age at surgery was 10.1 +/- 7.0 months and 108.5 +/- 54.0 months for both groups, respectively. Two patients died. Procedure time was not affected by decreasing age (p = 0.622) but Cardio pulmonary Bypass duration (p = 0.040) and Aortic Cross Clamp time (p = 0.063) were significantly affected. No associated significance was obtained when hospital stay (p = 0.085) was observed. Increased duration of ventilation (p = 0.000) and length of ICU stay (p = 0.003) were highly significant for the younger age group. Presence of residual VSD (p = 0.025) was also significantly affected by lower age. There was no significant difference in the number of patients with complications (p = 1.000) among the 2 groups. CONCLUSION: Age does not increase morbidity rates after VSD repair although postoperative recovery times are increased with decreasing age. Hence, there is no justification in delaying VSD repair.

Lubiprostone in the treatment of chronic idiopathic constipation: an update on health-related quality of life and patient-reported outcomes.

Chronic idiopathic constipation, if inadequately treated, can be bothersome with a detrimental effect on patients' quality of life (QOL). This may also result in frequent health care visits, increasing the burden of this ailment's medical cost. Management strategies, focused on lifestyle changes, include increased exercise, a high-fiber diet, and toilet training. Pharmacologic options include fiber supplementation, laxatives, serotonergic agents, and prosecretory agents such as lubiprostone. In this review, we were able to conclude that lubiprostone, when used for chronic idiopathic constipation, has a significantly beneficial effect on both patients' symptoms and their QOL. In multiple randomized controlled trials, it has been found to have increased the number of spontaneous bowel movements at different time endpoints. Corresponding improvements were also observed for abdominal bloating, discomfort, stool frequency, and straining symptoms among patients.

Pancreaticopericardial Fistula: A Case Report and Literature Review.

Purpose. Pancreaticopericardial fistula (PPF) is an extremely rare complication of acute or chronic pancreatitis. This paper presents a rare case of PPF and provides systematic review of existing cases from 1970 to 2014. Methods. A PubMed search using key words was performed for all the cases of PPF from January 1970 to December 2014. Fourteen cases were included in the study. The cases were reviewed for demographic characteristics, diagnostic modalities, and treatment. Descriptive analysis of these variables was performed. Results. Median age was 43 years. 78% were known alcoholics and 73.3% had chronic pancreatitis. Dyspnea was present in 78%. Cardiac tamponade was present in 53%; 75% of patients had known chronic pancreatitis (RR = 0.74). Surgery was associated with best treatment outcomes and 50% of patients who underwent endoscopic treatment survived. Conclusion. PPF is a rare disease. This paper indicates that acute cardiac tamponade in patients with history of alcoholism and chronic pancreatitis could be a sign of an existing pancreaticopericardial fistula and early surgical intervention could be life-saving.