Comparison of lumen-apposing metal stents versus endoscopic balloon dilation for the management of benign colorectal anastomotic strictures.

BACKGROUND AND AIMS: Limited data exist evaluating lumen-apposing metal stents (LAMSs) with endoscopic balloon dilation (EBD) for the treatment of benign colorectal anastomotic strictures (BCASs). This study compares outcomes of both interventions. METHODS: Patients with left-sided BCAS treated with LAMSs versus EBD were identified retrospectively. The primary outcome was a composite of crossover to another intervention to achieve clinical success or recurrence requiring reintervention. RESULTS: Twenty-nine patients (11 LAMS and 18 EBD) were identified with longer follow-up in the EBD group (734 vs 142 days; P = .003). No significant differences were found in the composite outcome, technical success, clinical success, or components of composite outcome. With LAMS, there was a nonsignificant trend toward fewer procedures (2.4 vs 3.3; P = .06) and adverse events (0% vs 16.7%; P = .26). CONCLUSIONS: LAMS appears to be as effective as EBD for the treatment of BCAS but may require fewer procedures and may be safer than EBD.

A Preliminary Controlled Trial of Endoscopic Ultrasound-guided Fiducial Markers to Guide Pancreas Surgery.

OBJECTIVE: Endoscopic ultrasound (EUS) is routinely used for fiducial marker placement (FMP) to guide stereotactic radiation of pancreatic tumors, but EUS-FMP explicitly to guide surgery has not been studied in a prospective, controlled manner. Multipurpose EUS systems have been developed that facilitate simultaneous EUS-FMP at the time of biopsy. We aimed to evaluate the feasibility of EUS-FMP to guide pancreatic resection. METHODS: In this prospective trial, we enrolled patients with resectable pancreas masses undergoing tissue sampling and placed preloaded fiducials immediately after biopsy. Intraprocedure confirmation of carcinoma, neuroendocrine, and nonlymphomatous neoplasia by rapid on-site evaluation and lesion size <4 cm was required. The main outcomes were the feasibility and ease of preoperative placement and intraoperative detection of the markers using predefined Likert scales. RESULTS: In 20 patients, EUS-FMP was successful before planned surgery and placement was technically straightforward (Likert Scale: 9.1 ± 1.3; range: 1, most challenging to 10, most facile). Intraoperative detection was feasible and improved when compared with a pre-established comparator of 5 representing an equivalent lesion without a marker (Likert Scale: 7.8 ± 2.2; range: 1, most difficult to 10, most facile; P = 0.011). The mean tumor size on EUS was 1.7 ± 0.9 (range: 0.5 to 3.6) cm. CONCLUSION: EUS-FMP is feasible and safe for resectable pancreatic tumors before surgery and may assist in perioperative detection. Preloaded fiducials may be considered for placement at the time of initial referral for EUS-fine needle biopsy.

High-risk symptoms do not predict gastric cancer precursors.

BACKGROUND & STUDY AIMS: Gastric intestinal metaplasia (GIM) is the most common precursor of gastric cancer. Our aim is to determine if presenting symptoms predict gastric cancer precursor lesions in a high-risk population. PATIENT AND METHODS: Consecutive unique patients evaluated by endoscopy for upper gastrointestinal symptoms at the Los Angeles County Hospital between 2010 and 2014 were evaluated. Presenting symptoms were classified as low- or high-risk depending on the procedure indication as coded using the Clinical Outcomes Research Initiative (CORI) system. Endoscopy and histology results were used to classify findings as benign, GIM, high-risk GIM, or malignant. The primary outcome was the proportion of patients with premalignant or malignant gastric findings who had high-risk clinical indications for endoscopy relative to those with benign results. RESULTS: A total of 3699 patients underwent endoscopy to evaluate upper gastrointestinal symptoms. There were 373 (10.1%) patients with GIM of which 278 had high-risk GIM. One hundred and sixty (4.3%) patients were diagnosed with gastric cancer. High-risk indications for upper endoscopy predicted gastric cancer (OR 1.8 [95% CI 1.3-2.6]) but not GIM (OR 1.0 [0.8-1.3]) or high-risk GIM (OR 0.9 [0.7-1.2]). Hispanic or Asian patients and patients >50 years old were more likely to have GIM, high-risk GIM, and cancer. CONCLUSIONS: Performance of upper endoscopy for high-risk indications is inadequate to detect GIM and marginal for malignancy. At risk patients should undergo upper endoscopy for both low- and high-risk symptoms. Screening certain populations deserve additional study and may, in fact, be cost-effective.

Randomized trial of cholangioscopy-guided laser lithotripsy versus conventional therapy for large bile duct stones (with videos).

BACKGROUND AND AIMS: Bile duct stones >1 cm have a decreased incidence of successful endoscopic extraction and often require lithotripsy. Although previous guidelines suggested mechanical lithotripsy for large common bile duct stones, current guidelines suggest cholangioscopy-guided lithotripsy as an adjunct with or without balloon dilation or mechanical lithotripsy. However, no randomized trials have assessed the usefulness of this practice. METHODS: Patients with bile duct stones >1 cm in diameter were randomized in a 2:1 ratio to cholangioscopy-guided laser lithotripsy versus conventional therapy only. Conventional therapies such as mechanical lithotripsy or balloon dilation were also allowed in the laser lithotripsy group. Randomization was stratified by history of ERCP in the past 3 months. The primary outcome was endoscopic clearance of the bile duct stones. RESULTS: Endoscopic clearance was achieved in 39 (93%) of 42 patients treated with cholangioscopy-guided laser lithotripsy and 12 (67%) of 18 treated with conventional therapy only (P = .009). The 9 patients in whom ERCP was unsuccessful underwent surgical common duct exploration with stone removal. Mean procedure time was 120.7 ± 40.2 minutes for the cholangioscopy-guided laser lithotripsy group compared with 81.2 ± 49.3 minutes for the conventional therapy group (P = .0008). There was no significant difference in fluoroscopy time, number of procedures, or adverse events (cholangitis) (cholangioscopy, 2; conventional, 1) and post-ERCP pancreatitis (cholangioscopy, 2; conventional, 1). CONCLUSION: Cholangioscopy-guided laser lithotripsy increases the incidence of endoscopic clearance of large bile duct stones and decreases the need for surgery compared with conventional therapy alone. However, it is associated with longer procedure times. (Clinical trial registration number: NCT0175997.).

Bacteriophage K antimicrobial-lock technique for treatment of Staphylococcus aureus central venous catheter-related infection: a leporine model efficacy analysis.

PURPOSE: To determine whether a bacteriophage antimicrobial-lock technique can reduce bacterial colonization and biofilm formation on indwelling central venous catheters in a rabbit model. MATERIALS AND METHODS: Cuffed central venous catheters were inserted into the jugular vein of female New Zealand White rabbits under image guidance. Catheters were inoculated for 24 hours with broth culture of methicillin-sensitive Staphylococcus aureus. The inoculum was aspirated, and rabbits were randomly assigned to two equal groups for 24 hours: (i) untreated controls (heparinized saline lock), (ii) bacteriophage antimicrobial-lock (staphylococcal bacteriophage K, propagated titer > 10(8)/mL). Blood cultures were obtained via peripheral veins, and the catheters were removed for quantitative culture and scanning electron microscopy. RESULTS: Mean colony-forming units (CFU) per cm(2) of the distal catheter segment, as a measure of biofilm, were significantly decreased in experimental animals compared with controls (control, 1.2 × 10(5) CFU/cm(2); experimental, 7.6 × 10(3); P = .016). Scanning electron microscopy demonstrated that biofilms were present on the surface of five of five control catheters but only one of five treated catheters (P = .048). Blood culture results were not significantly different between the groups. CONCLUSIONS: In a rabbit model, treatment of infected central venous catheters with a bacteriophage antimicrobial-lock technique significantly reduced bacterial colonization and biofilm presence. Our data represent a preliminary step toward use of bacteriophage therapy for prevention and treatment of central venous catheter-associated infection.

Successful retrieval of a retained fractured ERCP guidewire in the pancreatic duct.

Video 1Demonstration of endoscopic retrieval of fractured wire in pancreatic duct.

Bariatric embolization for suppression of the hunger hormone ghrelin in a porcine model.

PURPOSE: To prospectively test in a porcine model the hypothesis that bariatric embolization with commercially available calibrated microspheres can result in substantial suppression of systemic ghrelin levels and affect weight gain over an 8-week period. MATERIALS AND METHODS: The institutional animal care and use committee approved this study. Twelve healthy growing swine (mean weight, 38.4 kg; weight range, 30.3-47.0 kg) were evaluated. Bariatric embolization was performed by infusion of 40-µm calibrated microspheres selectively into the gastric arteries that supply the fundus. Six swine underwent bariatric embolization, while six control animals underwent a sham procedure with saline. Weight and fasting plasma ghrelin and glucose levels were obtained in animals at baseline and at weeks 1-8. Statistical testing for differences in serum ghrelin levels and weight at each time point was performed with the Wilcoxon signed rank test for intragroup differences and the Wilcoxon rank sum test for intergroup differences. RESULTS: The pattern of change in ghrelin levels over time was significantly different between control and experimental animals. Weekly ghrelin levels were measured in control and experimental animals as a change from baseline ghrelin values. Average postprocedure ghrelin values increased by 328.9 pg/dL ± 129.0 (standard deviation) in control animals and decreased by 537.9 pg/dL ± 209.6 in experimental animals (P = .004). The pattern of change in weight over time was significantly different between control and experimental animals. The average postprocedure weight gain in experimental animals was significantly lower than that in control animals (3.6 kg ± 3.8 vs 9.4 kg ± 2.8, respectively; P = .025). CONCLUSION: Bariatric embolization can significantly suppress ghrelin and significantly affect weight gain. Further study is warranted before this technique can be used routinely in humans.

Full metal jacket: salvage of EUS-guided gallbladder drainage.

Video 1Full metal jacket: salvage of EUS-guided gallbladder drainage.

Endoscopic Ultrasound Assessment of Pancreatic Duct Diameter Predicts Neuroendocrine Tumors and Other Pancreas Masses.

OBJECTIVES: Distinguishing neuroendocrine tumors (NETs) and other pancreas lesions from adenocarcinomas via endoscopic ultrasound (EUS) requires additional tissue for special staining and processing. Our aim was to determine if main pancreatic duct (PD) diameter on EUS helps to differentiate NET and other unusual tumors from adenocarcinoma. METHODS: We evaluated 30 consecutive patients diagnosed with NET or other pancreas lesions by EUS with 90 matched patients who were found to have adenocarcinoma. Dilated PD was defined as greater than 3 mm. Multivariate logistic regression was used to evaluate associations between lesion type and PD diameter. RESULTS: Among the 30 patients with NET/other pancreas lesions, 21 had NETs, 7 had metastases, and 2 had lymphomas. A dilated PD was demonstrated in only 3.3% of pancreatic NET/other lesions but present in 88.9% of cases of primary adenocarcinoma (P < 0.01). In multivariate analysis, a normal PD diameter and absence of clinical symptoms strongly predicted the presence of pancreatic NET/other versus adenocarcinoma (P < 0.01). CONCLUSIONS: The absence of PD dilation upstream of the lesion suggests NET or other lesions rather than adenocarcinoma. This finding should prompt endosonographers to obtain additional tissue at the time of EUS to send for special studies.

Bacteriophage K for reduction of Staphylococcus aureusbiofilm on central venous catheter material.

The purpose of this project was to determine whether bacteriophage can reduce bacterial colonization and biofilm formation on central venous catheter material. Twenty silicone discs were inoculated for 24 h with broth culture of Methicillin sensitive staphylococcus aureus (0.5 McFarland standard). The inoculate was aspirated and discs placed into two equal groups for 24 h: (1) untreated controls; (2) bacteriophage treatment (staphylococcal bacteriophage K, propagated titer > 108). At the completion of the experiment discs were processed for quantitative culture. Statistical testing was performed using the rank sum test. Mean colony forming units (CFU) were significantly decreased in experimental compared with controls (control 6.3 × 105 CFU, experimental 6.7 × 101, P ≤ 0.0001). Application of bacteriophage to biofilm infected central venous catheter material significantly reduced bacterial colonization and biofilm presence. Our data suggests that bacteriophage treatment may be a feasible strategy for addressing central venous catheter staph aureus biofilm infections.