Effects of intravenous administration of magnesium sulfate in propofol-based sedation for ERCP in elderly patients: a randomized, double-blind, placebo-controlled study.

BACKGROUND: Propofol-based sedations are widely used in elderly patients for endoscopic retrograde cholangiopancreatography (ERCP) procedure, but respiratory depression and cardiovascular adverse events commonly occur. Magnesium administered intravenously can alleviate pain and decrease propofol requirements during surgery. We hypothesized that intravenous magnesium was used as adjuvant to propofol might be beneficial in elderly patients undergoing ERCP procedures. METHODS: Eighty patients aged from 65 to 79 years who were scheduled for ERCP were enrolled. All patients were intravenously administered 0.1 µg/kg sufentanil as premedication. The patients were randomized to receive either intravenous magnesium sulfate 40 mg/kg (group M, n = 40) or the same volume of normal saline (group N, n = 40) over 15 min before the start of sedation. Intraoperative sedation was provided by propofol. Total propofol requirement during ERCP was the primary outcome. RESULTS: The total propofol consumption were reduced by 21.4% in the group M compared with the group N (151.2 ± 53.3 mg vs. 192.3 ± 72.1 mg, P = 0.001). The incidences of respiratory depression episodes and involuntary movement were less in the group M than those in the group N (0/40 vs. 6/40, P = 0.011; 4/40 vs. 11/40, P = 0.045; respectively). In the group M, the patients experienced less pain than those in the group N at 30 min after the procedure (1 [0-1] vs. 2 [1-2], P < 0.001). Correspondingly, the patients' satisfaction was clearly higher in the group M (P = 0.005). There was a tendency towards lower intraoperative heart rate and mean arterial pressure in group M. CONCLUSIONS: A single bolus of 40 mg/kg of intravenous magnesium can significantly reduce propofol consumption during ERCP, with higher sedation success and lower adverse events. TRIAL REGISTRATION: ID UMIN000044737. Registered 02/07/2021.

Use of a novel self-assembling hemostatic gel as a complementary therapeutic tool for endoscopic sphincterotomy-related bleeding.

PuraStat is a novel self-assembling peptide hydrogel developed as a hemostatic agent for endoscopic and surgical procedures which can be applied to bleeding from various lesions of the gastrointestinal tract. Yamamoto and colleagues present a video showing the actual endoscopic hemostasis using PuraStat for endoscopic sphincterotomy-related bleeding.

Pancreatitis in Children.

Pediatric pancreatitis describes a spectrum covering acute pancreatitis, acute recurrent pancreatitis, and chronic pancreatitis, each with varying clinical manifestations and risk factors requiring a tailored diagnostic approach. We emphasize management strategies based on age, risk factors, recurrence, and complications. A discussion of the role of therapeutic endoscopy is reviewed and highlights the growing role of endoscopic ultrasound and endoscopic retrograde cholangiopancreatography in children with pancreatitis. Particular diagnostic challenges in autoimmune pancreatitis are reviewed with an emphasis on differentiating this entity from alternate pancreaticobiliary pathologies. Finally, we explore a multidisciplinary approach to acute recurrent and chronic pancreatitis.

Combination of Electronic Choledochoscopy and Holmium Laser Lithotripsy for Complicated Biliary Calculus Treatment: A New Exploration.

The safety and efficacy of the combination of electronic choledochoscopy and holmium laser lithotripsy for complicated bile duct stones were assessed. In total, 20 patients participated in this study, which was conducted between 2012 and 2017. None of the patients were candidates for endoscopic retrograde cholangiopancreatography with stone extraction. Outcome measures included complete stone clearance and complications postprocedure. Mean stone size was 17±5.2 mm (8 to 30 mm) and mean number of stones was 1.7±1.3 (1 to 5). The mean number of laser sessions was 1.3±0.7 (1 to 4). A mean of 1.0 to 1.5 J/20 to 25 Hz was applied during laser lithotripsy sessions with a mean operative time of 67.8±24.8 minutes. The clearance rate of stone was 18/20 (90%). No mortality existed in this study; however, 1 patient developed acute pancreatitis. The combination of holmium laser lithotripsy and electronic choledochoscopy for complicated biliary calculi is safe, reliable, and minimally invasive and has low residual stone rate.

Microbiological Assessment of Bile and Corresponding Antibiotic Treatment: A Strobe-Compliant Observational Study of 1401 Endoscopic Retrograde Cholangiographies.

The aim of this study was to determine the antibiotic susceptibility profiles of bacteria in bile samples and to analyze the clinical relevance of the findings as only limited information about risk factors for elevated frequence of bacterial and fungal strains in routinely collected bile samples has been described so far.A prospective cohort study at a tertiary care center was conducted. Seven hundred forty-four patients underwent 1401 endoscopic retrograde cholangiographies (ERCs) as indicated by liver transplantation (427/1401), primary sclerosing cholangitis (222/1401), choledocholithiasis only (153/1401), obstruction due to malignancy (366/1401), or other conditions (233/1401). Bile samples for microbiological analysis were obtained in all patients.The 71.6% (823/1150) samples had a positive microbiological finding, and 57% (840/1491) of the bacterial isolates were gram-positive. The main species were Enterococcus spp (33%; 494/1491) and Escherichia coli (12%; 179/1491). Of the samples, 53.8% had enteric bacteria and 24.7% had Candida spp; both were associated with clinical and laboratory signs of cholangitis (C-reactive proteins 35.0 ±â€Š50.1 vs 44.8 ±â€Š57.6; 34.5 ±â€Š51.2 vs 52.9 ±â€Š59.7; P < 0.001), age, previous endoscopic intervention, and immunosuppression. Multi-resistant (MR) strains were found in 11.3% of all samples and were associated with clinical and laboratory signs of cholangitis, previous intervention, and immunocompromised status. In subgroup analysis, strain-specific antibiotic therapy based on bile sampling was achieved in 56.3% (89/158) of the patients. In cases with a positive bile culture and available blood culture, blood cultures were positive in 29% of cases (36/124), and 94% (34/36) of blood cultures had microbial species identical to the bile cultures.Bactobilia and fungobilia can usually be detected by routine microbiological sampling, allowing optimized, strain-specific antibiotic treatment. Previous endoscopic intervention, clinical and laboratory signs of cholangitis, and age are independent risk factors. MR bacteria and fungi are an evolving problem in cholangitis, especially in immunocompromised patients.

Preliminary report on a new hybrid metal stent for EUS-guided biliary drainage (with videos).

BACKGROUND: EUS-guided biliary drainage (EUS-BD) may be a feasible and useful alternative in patients with malignant biliary obstruction after failed ERCP. One of the main limitations of EUS-BD is the lack of devices specifically tailored to this technique. OBJECTIVE: To evaluate a newly developed hybrid metal stent customized for EUS-BD. DESIGN: A prospective, observational study. SETTING: A tertiary academic referral center. PATIENTS: A total of 27 consecutive patients with malignant biliary obstruction who were candidates for alternative techniques for biliary drainage because of failed ERCP were enrolled. INTERVENTIONS: EUS-BD with a newly developed hybrid metal stent. MAIN OUTCOME MEASUREMENTS: The technical and clinical success rates and adverse events, including proximal or distal stent migration and cholangitis. RESULTS: EUS-guided hepaticogastrostomy was performed in 10 patients, and EUS-guided choledochoduodenostomy was performed in 17 patients. The technical success rate of EUS-BD with the hybrid metal stent was 100% (27/27), and clinical success was achieved in 96.3% (26/27) of the cases. Adverse events developed in 5 patients (5/27, 18.5%), including a self-limited pneumoperitoneum in 3 patients, minor bleeding in 1 patient, and abdominal pain in 1 patient. During the follow-up period (median 134 days), proximal or distal stent migration was not observed. LIMITATIONS: This study was performed at a single center by a single experienced operator with a relatively small number of patients. CONCLUSION: EUS-BD with a hybrid metal stent is technically feasible and can be an effective treatment for malignant biliary obstruction after failed ERCP. Hybrid metal stents may be used safely in EUS-BD, and they can prevent stent-related adverse events.

Antioxidant supplementation for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a meta-analysis of randomized controlled trials.

BACKGROUND: Acute pancreatitis remains the most common major complication of endoscopic retrograde cholangiopancreatography (ERCP). The pathogenesis of post-ERCP acute pancreatitis may be mediated by oxygen-derived free radicals, which could be ameliorated by antioxidants. Antioxidant supplementation may potentially prevent post-ERCP pancreatitis. We performed a meta-analysis of randomized controlled trials to evaluate the effect of prophylactic antioxidant supplementation compared with control on the prevention of post-ERCP pancreatitis. METHODS: PubMed and Embase databases were searched to identify relevant trials. A standardized Excel file was used to extract data by two independent authors. Results were expressed as risk ratio (RR) with accompanying 95% confidence interval (CI). The meta-analysis was performed with the fixed-effects model or random-effects model according to heterogeneity. RESULTS: Eleven studies involving 3,010 patients met our inclusion criteria. Antioxidant supplementation did not significantly decrease the incidence of post-ERCP pancreatitis (RR, 0.92; 95% CI, 0.65-1.32; P = 0.665). There was also no statistical difference in the severity grades between the antioxidant group and control group. CONCLUSIONS: Based on current evidence, antioxidant supplementation shows no beneficial effect on the incidence and the severity of post-ERCP pancreatitis; thus, there is currently a lack of evidence to support using antioxidants for the prevention of post-ERCP pancreatitis.

Esencia de menta al 1, 6% como espasmolítico intestinalen la colangiopancreatografía retrógrada endoscópica / 1.6% Peppermint oil solution as intestinal spasmolytic in retrograde endoscopic cholangiopancreatography

Objetivos: La aparición de peristaltismo intestinal puede dificultar la realización de exploraciones o intervenciones mediante colangiopancreatografía retrógrada endoscópica(CPRE). Con el fin de disminuirlo es frecuente la utilización de espasmolíticos sistémicos, pese a los efectos adversos anticolinérgicos que presentan. Se propuso formular una preparación de esencia de menta al 1,6% de uso local para evitar estos efectos adversos. Método: Se formuló la preparación de la esencia de menta al 1,6% según la bibliografía encontrada. La efectividad de la fórmula fue valorada de manera semicualitativa según la disminución del peristaltismo. Resultados: Se ensayaron 2 emulgentes siendo polisorbato el más adecuado. El estudio piloto llevado a cabo en 8 pacientes demostró su efectividad y seguridad en la disminución del peristaltismo intestinal. Conclusiones: La esencia de menta al 1,6% constituye una alternativa efectiva y segura a la utilización de espasmolíticos sistémicos. Se requieren posteriores estudios incluyendo un mayor número de pacientes para establecer su utilidad en la práctica clínica habitual (AU)

Objectives: Intestinal peristalsis can impede explorations and interventions using retrograde endoscopic cholangiopancreatography. Systemic spasmolytics are frequently employed to reduce this phenomenon, in spite of the adverse anti-cholinergic effects they are associated with. We proposed a formula using 1.6% peppermint oil solution with local use in order to avoid these adverse side effects. Method: We formulated a preparation of 1.6% peppermint oil solution in accordance with the medical literature. The effectiveness of the formula was evaluated in a semi-qualitative manneraccording to the reduction in peristalsis. Results: We tested two different emulgents, and polysorbate provided the best results. The pilot study carried out with 8 patients demonstrated its effectiveness and safety in reducing intestinal peristalsis. Conclusions: 1.6% peppermint oil solution constitutes an effective and safe alternative to the use of systemic spasmolytics. More studies are needed with a larger sample size in order to establish its usefulness in normal clinical practice (AU)

Successful management of cholecystocolic fistula by endoscopic retrograde cholangiopancreatography: a report of two cases.

Cholecystocolic fistula is a rare cause of diarrhoea, and the diagnosis may be significantly delayed. Air in the biliary tree on imaging should raise suspicion, and barium enema or endoscopic retrograde cholangiopancreatography will be diagnostic. Cholestyramine should provide effective symptomatic relief until definitive treatment is arranged. We report on two patients with cholecystocolic fistula presenting with severe diarrhoea. They were treated successfully by endoscopic retrograde cholangiopancreatography.

EUS-guided hepaticogastrostomy with a fully covered metal stent as the biliary diversion technique for an occluded biliary metal stent after a failed ERCP (with videos).

BACKGROUND: Percutaneous transhepatic biliary drainage (PTBD) may be the last resort for an occluded biliary metal stent when the ERCP was unsuccessful. OBJECTIVE: Because an EUS-guided biliary drainage has been proposed as an effective alternative for PTBD after a failed ERCP, we conducted this study to determine the feasibility and usefulness of an EUS-guided hepaticogastrostomy (EUS-HG) with a fully covered self-expandable metal stent (FCSEMS) for an occluded biliary metal stent after a failed ERCP. DESIGN: A case study. SETTING: A tertiary referral center. PATIENTS AND INTERVENTIONS: Five patients who had an occluded biliary metal stent inserted after a hilar bilateral metal stent or a combined duodenal and biliary metal stent insertion and for whom reinterventional ERCP was unsuccessful underwent an EUS-HG with an FCSEMS for alternative PTBD. MAIN OUTCOME MEASUREMENTS: Technical and functional success, procedural complications, reinterventional rate after EUS-HG with an FCSEMS, and short-term stent patency. RESULTS: In all 5 patients, an EUS-HG with an FCSEMS was technically successful. No procedural complications, such as bile peritonitis, cholangitis, and pneumoperitoneum, were observed. Functional success was also 100% (5/5). During the follow-up period (median 152 days, range 64-184 days), no late complications, such as stent migration and occlusion, were observed. Thus, no biliary reintervention was performed during the follow-up period. LIMITATIONS: A small series of patients without a control group. CONCLUSIONS: The EUS-HG with an FCSEMS may be feasible, effective, and an alternative PTBD for an occluded biliary metal stent after a failed ERCP.

Endoscopic sealing of pancreatic fistulas: four case reports and review of the literature.

We report four patients with pancreatic fistulas that failed to respond to conservative treatment. The fistulas were closed by endoscopic injection of N-butyl-2-cyanoacrylate (Histoacryl) diluted with an oily contrast agent (Lipiodol). A literature review revealed 32 similar cases in which endoscopic treatment with fibrin sealants (n = 11) or cyanoacrylate (n = 21) was used to close the fistulas. Based on our own experience and the literature review, we conclude that endoscopic sealing of pancreatic fistulas can be performed safely and effectively by experienced endoscopists in a tertiary centre. The procedure seems useful in the management of complicated pancreatic fistulas which do not respond to conservative treatment and may obviate the need for surgery.

Treating delayed endoscopic sphincterotomy-induced bleeding: epinephrine injection with or without thermotherapy.

AIM: To compare the hemostatic efficacy between epinephrine injection alone and epinephrine injection combined with thermotherapy for delayed post-endoscopic sphincterotomy (ES) bleeding. METHODS: Cases with delayed post-ES bleeding undergoing epinephrine injection alone (epinephrine injection group, n = 26) or epinephrine combined with thermotherapy (combination therapy group, n = 33) in our institution between 1999 and 2007 were retrospectively investigated. The main outcome measurements were: initial endoscopic hemostasis, re-bleeding, complications, requirement of angiographic embolization or surgery, requirement for blood transfusion, and mortality. RESULTS: The initial hemostatic efficacy was 96.2% for epinephrine injection alone and 100% for combination therapy (P = 0.44). There were four patients with re-bleeding in each group (16.0% vs 12.1%, P = 0.72). There was only one complication of pancreatitis from the combination therapy group. Three patients (11.5%) in the epinephrine injection group and one patient (3%) in the combination therapy group required angiographic embolization or surgery (P = 0.31). The total number of blood transfusions was not significantly different between the two groups (3.5 +/- 4.6 U vs 3.5 +/- 4.5 U, P = 0.94). There was no bleeding-related death in either group. CONCLUSION: Epinephrine injection alone is as effective as epinephrine injection combined with thermotherapy for the management of delayed post-ES bleeding.

Pneumobilia, chronic diarrhea, vitamin K malabsorption: a pathognomonic triad for cholecystocolonic fistulas.

Cholecystocolonic fistula (CF) is an uncommon type of internal biliary-enteric fistulas, which comprise rare complications of cholelithiasis and acute cholecystitis, with a prevalence of about 2% of all biliary tree diseases. We report a case of a spontaneous CF in a 75-year-old diabetic male admitted to hospital for the investigation of chronic watery diarrhea and weight loss. Massive pneumobilia demonstrated on abdominal ultrasound and computerized tomography, along with chronic, bile acid-induced diarrhea and a prolonged prothrombin time due to vitamin K malabsorption, led to the clinical suspicion of the fistula. Despite further investigation with barium enema and magnetic resonance cholangio-pancreatography, diagnosis of the fistulous tract between the gallbladder and the hepatic flexure of the colon could not be established preoperatively. Open cholecystectomy with fistula resection and exploration of the common bile duct was the preferred treatment of choice, resulting in an excellent postoperative clinical course. The incidence of biliary-enteric fistulas is expected to increase due to the parallel increase of iatrogenic interventions to the biliary tree with the use of endoscopic retrograde cholangio-pancreatography and the increased rate of cholecystectomies performed. Taking into account that advanced imaging techniques fail to demonstrate the fistulas tract in half of the cases, and that CFs usually present with non-specific symptoms, our report could assist physicians to keep a high index of clinical suspicion for an early and valid diagnosis of a CF.

Confirmation of the antispasmodic effect of shakuyaku-kanzo-to (TJ-68), a Chinese herbal medicine, on the duodenal wall by direct spraying during endoscopic retrograde cholangiopancreatography.

The purpose of the study was to evaluate the suppressive effect of TJ-68 on duodenal spasms during endoscopic retrograde cholangiopancreatography (ERCP). At the point when the duodenal papilla was confirmed after insertion of the endoscope during ERCP, 5.0 g TJ-68 (Tsumura Co., Tokyo, Japan) was dissolved in 50 ml of saline at 36 degrees C, and the whole volume was sprayed slowly using a spray tube from the orifice of the forceps to the duodenal papilla of the 50 patients who demonstrated peristalsis of the digestive tract ("duodenal spasm"). The endoscopic procedure was not performed during that time, and the time until the spasm was suppressed was determined. After the arrest of the spasm, the intended tests and treatment were conducted, and the time until the duodenal spasm started again was determined. The suppressive effect on duodenal spasm was observed in 38 (76%) of 50 patients. The duration from the spraying of TJ-68 of the patients who observed the suppressive effect on duodenal spasm was 50-182 s (mean 122 +/- 21 s). The spasm arrest duration was 7.2-21 min (mean 9.6 +/- 1.2 min). Direct spraying of TJ-68 on the duodenal mucosa suppressed duodenal spasm, and it may be useful during ERCP when anticholinergic agents are contraindicated.

Management of infected pancreatic necrosis.

The past two decades have seen major advances in the understanding and clinical management of acute pancreatitis, yet it still lacks a specific treatment, and management is largely supportive and reactive. Surgery is seeing a diminishing role in the early phase of acute pancreatitis but still predominates in the management of infected pancreatic necrosis--the most lethal complication. This review focuses on recent literature but begins with an account of the evolution of infected necrosis management, which serves to place current treatment into context. Although surgeons initially emphasized less invasive approaches to pancreatic necrosis, they now compete with new techniques developed by pioneering physicians, radiologists, and interventional endoscopists. Clinicians adopting the new techniques will need to emulate the dedication and commitment that the current pioneers demonstrate. Although new techniques are still evolving, they should be evaluated against existing standards of treatment.

Percutaneous cholangiography for the treatment of parenteral nutrition-associated cholestasis in surgical neonates: preliminary experience.

OBJECTIVE: Parenteral nutrition-associated cholestasis (PNAC) occurs in up to 60% of surgical neonates with intestinal failure, and 10% will develop end-stage liver failure. Our aim was to evaluate the effectiveness of percutaneous transhepatic transcholecystic cholangiography (PTTC) in the treatment of PNAC in surgical neonates. METHODS: A retrospective double cohort study of surgical neonates with PNAC was conducted. Patients with PNAC who received PTTC were compared to controls matched by gestational age, birth weight, sex, and parenteral nutrition duration. Percutaneous transhepatic transcholecystic cholangiography was performed under general anesthesia with ultrasound guidance. Analysis was performed using paired Student's t test and McNemar chi2 test. RESULTS: Nine PTTC patients and 9 controls were similar in mean age (35.5 +/- 3.1 vs 35.6 +/- 4.2 weeks, P = .85), birth weight (2531 +/- 879 vs 2692 +/- 1052 g, P = .28), sex (all males), and parenteral nutrition duration (51.2 +/- 29.8 vs 53.3 +/- 33.3 days, P = .74). Percutaneous transhepatic transcholecystic cholangiography was performed in 9 patients at mean corrected age of 5.5 +/- 3.4 weeks and weight of 3621 +/- 546 g. All control patients and 8 (88.9%) of 9 PTTC patients had eventual resolution of hyperbilirubinemia. Percutaneous transhepatic transcholecystic cholangiography patients experienced a more rapid rate of resolution of their cholestasis, and the mean time to resolution of conjugated bilirubin was less in the PTTC group (8.5 +/- 3.2 vs 18.5 +/- 7.6 weeks, P = .02). CONCLUSION: Therapeutic PTTC results in a 50% reduction in the time to PNAC resolution. Percutaneous transhepatic transcholecystic cholangiography may have a role as active therapy to slow progression of PNAC in surgical neonates with intestinal failure.

Gallbladder adenosquamous cell carcinoma: report of two cases.

Adenocarcinoma is the usual histological presentation of the very rare gallbladder carcinoma. Adenosquamous cell carcinoma accounts for less than 3.5% of gallbladder carcinomas, and is characterised by invasive growth, a reduced tendency for lymph node metastasis, an increased tendency for hepatic infiltration or liver metastasis, and a poorer prognosis than adenocarcinoma. We present two cases. The first patient presented to our institution with increased bilirubin levels and dilated intra- and extrahepatic bile ducts. Adenosquamous carcinoma of the gallbladder was diagnosed on the post-operative pathological specimen. After surgery, bilirubin levels decreased, but hepatic metastases occurred that did not respond to conventional chemotherapy. The second patient was admitted to our hospital with jaundice and abdominal pain. Abdominal computed tomography (CT) imaging showed marked thickening of the gallbladder with direct extension of a mass into the left liver lobe. Cytology specimens obtained with an endoscopic retrograde cholangiopancreatography (ERCP) procedure revealed a malignant epithelial tumour. The patient underwent surgery but the tumour was incompletely resected. A regimen of oral UFT (Tegafur + uracil) chemotherapy was begun. Serum bilirubin levels increased due to occlusion in the surgical area 15 weeks after the start of chemotherapy.

Alternative methods for management of the complicated gallbladder.

Laparoscopic cholecystectomy is the procedure of choice for symptomatic cholelithiasis. However, in the presence of acute cholecystitis, 10% to 15% of patients face conversion to laparotomy. Alternatives to conventional therapy may therefore help to improve the clinical outcome of patients with complicated gallbladder disease. In selecting patients for alternative therapies, preoperative and intraoperative factors must be considered. Preoperative factors include the severity of biliary disease and preexisting medical risk factors; whereas intraoperative factors include conditions at the time of surgery that make dissection difficult or unsafe. Alternative therapies provide the least invasive management to safely temporize or definitively treat the acute condition. These alternatives include percutaneous cholecystostomy alone or followed by laparoscopic cholecystectomy, laparoscopic cholecystostomy followed by laparoscopic cholecystectomy, laparoscopic subtotal cholecystectomy, endoscopic retrograde cannulation of the gallbladder, and extracorporeal shockwave lithotripsy. By appropriate selection of the initial therapeutic approach, the surgeon may ultimately improve the clinical outcome in these complicated patients.

Estudio del cáncer de páncreas IGBJ / Study of cancer of the pancreas at the Bolivian Japanese Gastroenterology Institute

El objetivo del presente estudio fue evaluar cuales de los métodos diagnósticos realizados en el Instituto fueron los mas utiles, para diagnósticar a los enfermos con cáncer de páncreas, ademas de comparar los resultados de los diferentes manejos terapéuticos. Se realizo un estudio retrospectivo de 36 pacientes con diagnóstico de cáncer de páncreas, hospitalizados en el I.G.B.J., entre los años 1981 a 1992, se describen los resultados de las variables que fueron observados (edad, sexo, antecedentes, métodos diagnósticos, tipo de tratamiento, complicaciones y estancia hospitalaria).