ERCP-related perforations: a population-based study of incidence, mortality, and risk factors.

BACKGROUND: Perforations related to endoscopic retrograde cholangiopancreatography (ERCP) are rare but feared adverse events with highly reported morbidity and mortality rates. The aim was to evaluate the incidence and outcome of ERCP-related perforations and to identify risk factors for death due to perforations in a population-based study. METHODS: Between May 2005 and December 2013, a total of 52,140 ERCPs were registered in GallRiks, a Swedish nationwide, population-based registry. A total of 376 (0.72%) were registered as perforations or extravasation of contrast during ERCP or as perforation in the 30-day follow-up. The patients with perforation were divided into fatal and non-fatal groups and analyzed for mortality risk factors. The case volume of centers and endoscopists were divided into the upper quartile (Q4) and the lower three quartile (Q1-3) groups. Furthermore, fatal group patients' records were reviewed. RESULTS: Death within 90 days after ERCP-related perforations or at the index hospitalization occurred in 20% (75 out of 376) for all perforations and 0.1% (75 out of 52,140) for all ERCPs. The independent risk factors for death after perforation were malignancy (OR 11.2, 95% CI 5.8-21.6), age over 80 years (OR 3.8, 95% CI 2.0-7.4), and sphincterotomy in the pancreatic duct (OR 2.8, 95% CI 1.1-7.5). In Q4 centers, the mortality was similar with or without pancreatic duct sphincterotomy (14% vs. 13%, p = 1.0), but in Q1-3 centers mortality was higher (45% vs. 21%, p = 0.024). CONCLUSIONS: ERCP-related perforations are severe adverse events with low incidence (0.7%) and high mortality rate up to 20%. Malignancy, age over 80 years, and sphincterotomy in the pancreatic duct increase the risk to die after a perforation. The risk of a fatal outcome in perforations after pancreatic duct sphincterotomy was reduced when occurred at a Q4-center. In the case of a complicated perforation a transfer to a Q4-center may be considered.

Long-term risk for acute pancreatitis, cholangitis, and malignancy more than 15 years after endoscopic sphincterotomy: a population-based study.

BACKGROUND AND STUDY AIMS: It has been suggested that endoscopic sphincterotomy predisposes a patient to cholangitis, pancreatitis, and carcinoma in the pancreaticobiliary tract in the long term. Previous studies have shown an increased risk for acute cholangitis and pancreatitis but not for carcinoma. The aim of this study was to analyze these risks by conducting a long-term follow-up study of patients who underwent treatment for gallstone disease, comparing patients who underwent endoscopic sphincterotomy with those who did not. PATIENTS AND METHODS: A cohort of 1113 Swedish patients who were treated with endoscopic sphincterotomy between 1977 and 1990 for common bile duct stones was compared with two age-and sex-matched control groups with a history of cholecystectomy or cholecystectomy and cholangiotomy. RESULTS: Over a median follow-up of more than 15 years after endoscopic sphincterotomy, the hazard ratio for endoscopic sphincterotomy versus cholecystectomy was 5.5 (95% confidence interval [CI] 3.5-8.4) for cholangitis and 4.9 (95%CI 2.8-8.6) for pancreatitis. The hazard ratio for endoscopic sphincterotomy versus cholangiotomy was 1.7 (95%CI 1.3-2.4) for cholangitis and 1.5 (95%CI 1.0-2.4) for pancreatitis. There was no significant increase in risk for malignant diagnoses. CONCLUSION: Patients who underwent endoscopic sphincterotomy for choledocholithiasis had an increased risk for acute pancreatitis and cholangitis in the long term compared with those not treated with endoscopic sphincterotomy. There was no increase in risk for malignancy in the pancreaticobiliary tract.

Monitoring dominant strictures in primary sclerosing cholangitis with brush cytology and FDG-PET.

BACKGROUND & AIMS: Despite a high risk of cholangiocellular adenocarcinoma (CCA) it is unclear how surveillance of patients with primary sclerosing cholangitis (PSC) should be performed. METHODS: We evaluated a follow-up algorithm of brush cytology and positron emission tomography/computed tomography with [(18)F] fluorodeoxyglucose ([(18)F]FDG-PET/CT), measured as maximum standardized uptake values, normalized to the liver background (SUVmax/liver) at 180 min, in PSC patients with dominant bile duct strictures. RESULTS: Brush cytology with high grade dysplasia (HGD) was detected in 12/70 patients (17%), yielding a diagnostic sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 56%, 89%, 75%, and 88%, respectively. Preemptive liver transplantations due to repeated HGD before manifest CCA were performed in six patients. Receiver operating characteristic (ROC) analysis of [(18)F]FDG uptake showed that a SUVmax/liver quotient of 3.3 was able to discriminate between CCA and non-malignant disease with a sensitivity, specificity, PPV and NPV for CCA of 89%, 92%, 62%, 98%, respectively. A SUVmax/liver >3.3 detected CCA in 8/9 patients whereas a quotient <2.4 excluded CCA. Combining brush cytology and quantitative [(18)F]FDG-PET/CT yielded a sensitivity for HGD and/or CCA of 100% and a specificity of 88%. CONCLUSION: Early detection of HGD before manifest CCA is feasible with repeated brush cytology and may allow for preemptive liver transplantation. [(18)F]FDG-PET/CT has a high sensitivity for manifest CCA and a negative scan indicates a non-malignant state of the disease. Brush cytology and [(18)F]FDG-PET/CT are complementary in monitoring and managing PSC patients with dominant strictures.

Gastrointestinal quality-of-life after cholecystectomy: indication predicts gastrointestinal symptoms and abdominal pain.

BACKGROUND: Despite the fact that cholecystectomy is a common surgical procedure, the impact on long-term gastrointestinal quality of life is not fully known. METHODS: All surgical procedures for gallstone disease performed at Mora County Hospital, Sweden, between 2 January 2002 and 2 January 2005, were registered on a standard database form. In 2007, all patients under the age of 80 years at follow-up were requested to fill in a form containing the Gastrointestinal Quality-of-Life Index (GIQLI) questionnaire and a number of additional questions. The outcome was analysed with respect to age, gender, smoking, surgical technique, and original indication for cholecystectomy. RESULTS: A total of 627 patients (447 women, 180 men) underwent cholecystectomy, including laparoscopic cholecystectomy (N = 524), laparoscopic cholecystectomy converted to open cholecystectomy (N = 43), and open cholecystectomy (N = 60). The mean time between cholecystectomy and follow-up with the questionnaire was 49 months. The participation rate was 79 %. Using multivariate analysis in the form of generalised linear modelling, the original indication for cholecystectomy in combination with gender (p = 0.0042) was found to predict the GIQLI score. Female gender in combination with biliary colic as indication for cholecystectomy correlated with low GIQLI scores. Female gender also correlated with a higher risk for pain in the right upper abdominal quadrant after cholecystectomy (p = 0.028). CONCLUSIONS: We found the original indication for cholecystectomy, together with gender, to predict gastrointestinal symptoms and abdominal pain after cholecystectomy. Careful evaluation of symptoms is important before planning elective cholecystectomy.

Ultrasound-guided Percutaneous Irreversible Electroporation for Treatment of Locally Recurrent Pancreatic Cancer After Surgical Resection.

BACKGROUND/AIM: Irreversible electroporation (IRE) has recently been used as an experimental treatment for cancers including locally advanced pancreatic cancer. There is very limited data on IRE in pancreatic cancer that is locally recurrent after surgical resection. The aim of this study was to evaluate the safety and efficacy of IRE in this setting. PATIENTS AND METHODS: Ten patients with locally recurrent pancreatic cancer without distant metastases after surgical resection were included and treated with ultrasound-guided percutaneous IRE. RESULTS: Two patients had severe complications, of whom one died. Median disease-free survival was 3.3 months and overall median survival after IRE and resection was 16.5 and 42.7 months, respectively. Two patients are alive 42.1 and 23.9 months after the IRE without signs of local recurrence. CONCLUSION: Percutaneous IRE in locally recurrent pancreatic cancer following curative resection is feasible, but should be regarded as a high-risk procedure that, at present, cannot be recommended outside of clinical trials. Further research is needed to select patients who might benefit from this treatment.

Validation of Gastrointestinal Quality of Life Index in Swedish for assessing the impact of gallstones on health-related quality of life.

OBJECTIVE: The aim of the present study was to validate a Swedish translation of the Gastrointestinal Quality of Life Index (GIQLI) questionnaire in patients with gallstone disease. METHODS: Sensitivity to change, internal consistency, and test-retest stability were tested in 187 consecutive patients who underwent planned cholecystectomy. Construct validity was assessed by comparing the GIQLI score with the bodily pain scale of SF-36 and four single-item questions in a separate group of 104 patients. RESULTS: A significant increase in all five domains as well as in the overall GIQLI score 6 months after surgery (all P < 0.05) was seen. All five domains correlated significantly with other measures of gallstone-related symptoms except one single-item question. Intraclass correlations ranged from 0.62 to 0.87. Cronbach's alpha ranged from 0.77 to 0.89. CONCLUSION: The Swedish translation of GIQLI has a high validity and reliability for assessing the impact of gallstones on quality of life.

The Value of CA19-9 After Irreversible Electroporation for Pancreatic Cancer.

BACKGROUND/AIM: Carbohydrate antigen 19-9 (CA19-9) is a tumor marker for pancreatic cancer. Irreversible electroporation (IRE) is an experimental treatment modality for pancreatic cancer. The aim of this study was to evaluate whether percutaneous IRE lowers the CA19-9 level in pancreatic cancer and whether this correlates with improved overall survival. PATIENTS AND METHODS: Seventy-one patients with locally advanced pancreatic cancer or local recurrence after resection were treated. Patients with missing data, metastatic disease and normal serum CA19-9 before IRE were excluded. This left 35 cases for analysis. RESULTS: The median CA19-9 did not decrease in the cohort after IRE treatment (282 U/ml before versus 315 U/ml after; p=0.80). The 25th percentile of patients with the best CA19-9 response had improved overall survival compared to the 25th percentile with the worst response (mean 13.1 versus 8.1 months, respectively; p=0.01). CONCLUSION: IRE did not lower the level of CA19-9 in pancreatic cancer cases. However, a response in CA19-9 was correlated with improved survival.

Percutaneous Irreversible Electroporation as First-line Treatment of Locally Advanced Pancreatic Cancer.

BACKGROUND/AIM: Irreversible electroporation (IRE) has recently been used as an experimental ablation treatment following systemic chemotherapy in locally advanced pancreatic cancer (LAPC). The primary aim of this study was to evaluate survival of LAPC patients after IRE prior to chemotherapy. The secondary aim was to examine the complication rates. PATIENTS AND METHODS: Twenty-four patients with LAPC were included and treated with percutaneous ultrasound-guided IRE under general anesthesia. Survival data from the National Quality Registry for Pancreatic and Periampullary Cancer for LAPC during the same period were used for comparison. RESULTS: The median survival after diagnosis was 13.3 months in the IRE group compared to 9.9 months in the registry group (p=0.511). Six patients had a severe complication after IRE treatment. CONCLUSION: No obvious gain in survival was observed with IRE as the first line treatment of LAPC and IRE was associated with severe complications. This study does not support percutaneous IRE in this setting.

Biliary pancreatic portal fistula as a complication of chronic pancreatitis: a case report with review of the literature.

In this study we describe an unusual complication in a patient suffering from chronic calcifying pancreatitis. The patient had a fistula between the common bile duct, the pancreatic duct, and the portal vein. He received supportive medical treatment and achieved long-term survival. A review of the literature including diagnosis, treatment and outcome of this rare complication is presented.

Severe complications with irreversible electroporation of the pancreas in the presence of a metallic stent: a warning of a procedure that never should be performed.

Irreversible electroporation (IRE) is an ablation technique that is being investigated as a potential treatment of pancreatic cancer. However, many of these patients have a metallic stent in the bile duct, which is recognized as a contraindication for IRE ablation. We report a case in which an IRE ablation in the region of the pancreatic head was performed on a patient with a metallic stent which led to severe complications. After the treatment, the patient suffered from several complications including perforation of the duodenum and transverse colon, and bleeding from a branch of the superior mesenteric artery which eventually lead to her death. Therefore, we believe it is important to be aware of this if an IRE ablation close to a metallic stent is considered.

Safety and preliminary efficacy of ultrasound-guided percutaneous irreversible electroporation for treatment of localized pancreatic cancer.

BACKGROUND: Irreversible electroporation (IRE) is a local tumor treatment. Thin needles are placed percutaneously around the tumor under ultrasound guidance. Short pulses of direct current sent through the tissue irreversibly increase cell membrane permeability leading to cell death. We report a phase 1 study assessing the safety of ultrasound guided percutaneous IRE in patients with localized pancreatic cancer (LPC). PATIENTS AND METHODS: Five patients (three males) with LPC, judged unsuitable for surgery, chemotherapy, or non-resectable after standard oncological treatment, were treated with IRE. The treatment was given under general anesthesia with muscle relaxation. RESULTS: No serious treatment-related adverse events were observed. There was no 30-day mortality. One patient went on to laparotomy and had a R0 pancreaticoduodenectomy with portal vein resection. Six months after the treatment, two patients had no signs of recurrence on computed tomography or contrast-enhanced ultrasound. CONCLUSION: IRE for LPC can be safely performed percutaneously under ultrasound guidance, with promising initial results regarding efficacy.

An unusual presentation of a solid pseudopapillary pancreatic tumor.

Solid pseudopapillary pancreatic tumor (SPPT) is a rare tumor that constitutes 1-2% of all pancreatic tumors and most of the patients are young females. SPPT has low malignancy potential and radical resection is associated with good results and a high survival rate, even in cases with large tumors: the 5-year survival rate is estimated as 95%. This paper describes an unusual presentation of an SPPT discovered after blunt trauma to the abdomen during a basketball game. Computed tomography revealed a large tumor in the pancreatic head and the patient was operated by pylorus-preseving pancreaticoduodenectomy. The histopathologic examination indicated an SPPT with R0-resection and after 4 years there were no signs of recurrence.

Low mortality in bariatric surgery 1995 through 2005 in Sweden, in spite of a shift to more complex procedures.

BACKGROUND: Bariatric surgery is expanding worldwide. In a previous study, we found a threefold increase in the annual incidence in Sweden between 1987 and 1996. The aim of the present study was to describe the nationwide practice of bariatric surgery until 2005 and determine the perioperative mortality. METHODS: All bariatric procedures were identified through linkage to the Swedish Inpatient Registry, kept by the National Board of Health and Welfare. Mortality data were obtained from the Swedish National Death Registry RESULTS: A total of 8,129 bariatric procedures were identified. Seventy-eight percent of the patients were women and the mean age was 40.3 years. Hospital stay averaged 6 days. There was a 27% increase in the number of procedures performed in 2005 compared to 1995. After a decline in the beginning of the century, an increase of 119% is noted from 2001 to 2005. In the beginning of the study period, simple gastric restrictive procedures dominated (79%), but these procedures declined gradually. Gastric bypass has had the opposite development and reached 79% of all performed bariatric procedures in 2005. Laparoscopy has been introduced under the study period and in 2005, 42% of all gastric bypasses were performed by laparoscopy. The 30-day mortality was 0.16%. CONCLUSION: In spite of the shift to more complex procedures, the operative mortality was low.