Pancreaticobiliary maljunction in Turkish patients: a multicenter case series.

BACKGROUND AND AIMS: Pancreaticobiliary maljunction (PBM) is a malformation in which the pancreatic and bile ducts join outside the duodenal wall. It is associated with various biliary and pancreatic diseases. In addition, patients with PBM carry a substantial lifetime risk of developing biliary or gallbladder carcinoma. We aimed to present a multicenter case series of PBM from Turkey. METHODS: This study was conducted in adult and pediatric PBM patients who were referred to three tertiary reference centers of Turkey for endoscopic retrograde cholangiopancreatography (ERCP) between July 2007 and May 2020. The clinical presentations, types of PBM, ERCP findings, surgical histories, and the postoperative courses, including the development of biliary malignancies, were retrospectively reviewed. RESULTS: The study group included 47 (31 adult and 16 children) patients. Type D PBM was more frequent (13/41: 27.7%) than that reported in Eastern studies. Type A PBM was more common in the adults (51.6% vs. 12.5%, p < 0.05), whereas type C was more common in pediatric patients (31.3% vs. 13.2%, p < 0.05). Although fusiform anatomy was predominant in both of the groups, cystic dilatation was more common (25.8% vs. 12.5%) in adults and the common bile duct diameter was greater [22 mm (range 11-58) vs. 12 mm (range 5-33)] in adult patients compared to pediatric patients. Resective surgeries were more frequently done in pediatric patients (73.3% vs. 53.6%), whereas cholecystectomy was more frequently performed in adult patients (21.4% vs. 6.7%). CONCLUSION: Although our findings were compatible with Eastern studies, type D PBM (associated with pancreas divisum) was more frequent in our study population.

Endoscopic treatment of patients with bile duct stricture after cholecystectomy: factors predicting recurrence in the long term.

BACKGROUND AND AIMS: Endoscopic treatment is effective in the treatment of patients with bile duct injury after cholecystectomy. We aimed to investigate the long-term results of endoscopic treatment, factors predicting the recurrence of the stricture, and to determine the optimal endoscopic treatment. METHODS: The study was a retrospective cohort analysis and conducted at a tertiary referral center in patients with major bile duct injury (Strasberg E1-4 and E5 patients with main bile duct injury). Patients with minor injury (Luschka and cystic duct leakage), complete transection, and isolated aberrant bile duct injuries were excluded. RESULTS: The study group included 156 patients. The median follow-up period after stent removal was 6.5 years (range 1-16.5). Recurrence was seen in 18 patients (11 %) after a median duration of 9 months (range 2-96). Multivariate regression analysis revealed that the most important factors predicting the success of endoscopic treatment were: Rome type of treatment (inserting increasing number of stents every 3-4 months) (odds ratio 23.8, 95 % CI 1.46-390.7, p = 0.026) instead of Amsterdam-type treatment (replacing two 10F biliary stents every 3-4 months) and dilation of the stricture diameter to at least 76 % of the common bile duct diameter at the end of stent treatment (odds ratio 25.9, 95 % CI 2.46-272.7, p = 0.007). CONCLUSIONS: Endoscopic treatment is an effective method in the treatment of patients with bile duct stricture after cholecystectomy. Inserting multiple stents as much as possible without leaving a scar in the bile ducts should be aimed.

Additional biliary cannulation methods in patients with juxtapapillary duodenal diverticula.

BACKGROUND AND AIMS: Juxtapapillary diverticula (JPD) can increase the difficulty of biliary cannulation. A number of additional methods have been defined in case of failed cannulation attempt by standard technique. We aimed to investigate the more commonly preferred and practical additional methods among them. METHODS: A total of 1,205 endoscopic retrograde cholangiopancreatographies (ERCP) performed during a study period of 14 months were prospectively entered into a database. Of these, 222 (18 %) had JPD (123 women, 99 men, mean age 69 years) and 983 had no diverticula (523 women, 460 men, mean age 57 years). Additional cannulation methods used in patients with JPD were recorded. Biliary cannulation time, total procedure time, use of pre-cut papillotomy, and therapeutic success of ERCP were compared between the groups as well. RESULTS: Biliary cannulation was performed by standard technique in 210 patients with JPD (94.5 %). Cannulation was achieved by placement of a guidewire into the pancreatic duct in 6 (2.7 %) and use of two devices in one channel in 2 (0.9 %) patients. There was no significant difference between the total procedure time and therapeutic success of ERCP between the groups. Cannulation time was significantly longer in patients with JPD. Pre-cut papillotomy was performed less in patients with JPD. CONCLUSION: Presence of JPD does not decrease the therapeutic success of ERCP. Placement of a guidewire in the pancreatic duct or use of two-devices-in-one-channel are practical, successful, safe, and preferred methods which can be used in patients with failed cannulation by standard technique.

What to do if a transesophageal echocardiography probe buckled in esophagus?

A 65-year-old man was consulted because of buckling of transesophageal echocardiography (TEE) probe in the esophagus. A forward-viewing endoscope was inserted to the esophagus alongside the TEE probe. TEE probe was pushed to the stomach while the retroflexed tip portion was pushed by the endoscope in order to prevent retroflexion. The TEE probe was advanced into the stomach by this method where the buckled part was unfolded and then withdrawn. Cardiologists performing TEE and the referred gastroenterologists could perform such a method of solution in case of buckling of TEE probe in the esophagus.

ERCP experience in patients with choledochoduodenostomy: diagnostic findings and therapeutic management.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP), besides reducing the need for surgery in a wide spectrum of biliary disease, is increasingly be used for the treatment of biliary complications of surgery. In this paper, we review our experience with postoperative ERCPs required after biliary surgery with a special focus on side-to-side choledochoduodenostomy (CD). METHODS: The records of 70 patients with a history of CD who underwent ERCP from May 2000 to February 2006 were analyzed. RESULTS: There were 70 patients, 32 (45.7%) women and 38 (35.6%) men, with a mean age of 56 (range, 21-80) years. Indications for ERCP were cholangitis in 46 (65.7%), abnormal liver function tests with abdominal pain and abnormal USG in 22 (31.4%), and abnormal liver function tests and abnormal USG in 2 (2.9%). Overall 133 ERCP were performed. Anastomotic stenosis was found in 14 (20%), benign biliary stricture above the anastomosis in 13 (18.6%), sump syndrome in 11 (15.7%), common bile duct stone in 8 (11.4%), malignancy in 4 (5.7%), hepatolithiasis in 1 (1.4%), and secondary sclerosing cholangitis in 1 (1.4%). ERCP was normal in 18 (25.8%). Patients were managed by stone extraction in 8 (11%), stent insertion in 22 (36%), balloon dilatation in 15 (21%), nasobiliary drainage in 11 (16%), and bougie dilatation in 2 (3%) patients. CONCLUSIONS: We have reported one of the largest groups of patients with CD in the literature and showed that ERCP is a very important diagnostic and therapeutic tool for the management of biliary problems after CD.

Low incidence of colorectal dysplasia and cancer among patients with ulcerative colitis: a Turkish referral centre study.

OBJECTIVES: To determine the incidences of dysplasia, adenomatous polyp and colon cancer in patients with ulcerative colitis (UC) and to evaluate the risk factors. MATERIAL AND METHODS: We retrospectively reviewed the medical records of patients with UC admitted to the Turkiye Yuksek Ihtisas Hospital between 1994 and 2008 and who subsequently developed colorectal cancer (CRC). RESULTS: Between 1994 and 2008, a total of 844 UC patients were followed in our clinic. A total of 275 patients entered our surveillance programme. The duration of UC was as follows: 10-15 years, n = 173 (62.9%); 15-20 years, n = 55 (20.0%); 20-25 years, n = 26 (9.5%), 25-30 years, n = 9 (3.3%); and > 30 years, n = 12 (4.4%). In terms of localization, 80 patients (29.1%) had distal disease, 107 (38.9%) had left-sided disease and 88 (32.0%) had extensive colitis. Adenomatous polyp was found in six patients (2.2%). Five cases (83.3% of the polyps) were in the diseased segment and one case (16.7%) was in the non-diseased segment. Endoscopy revealed dysplasia in 11 cases (4.0%). Of the 275 UC patients, CRC was diagnosed in only three (1.1%) during follow-up. Adenomatous polyp was not found in cases with colon cancer. CONCLUSIONS: In our cases with UC, rates of dysplasia and CRC were much lower than in other reports. The difference in rates may be explained by racial factors, specific environmental factors, intensive control of disease activity through medical therapy and effective colonoscopic surveillance programmes.

Ectopic opening of the common bile duct and duodenal stenosis: an overlooked association.

BACKGROUND: Ectopic opening of the common bile duct into the duodenal bulb (EO-CBD-DB) is a rare disease that may be complicated by duodenal ulcer, deformity, stenosis and biliary stones. The aim of this study is to report clinical presentations, endoscopic diagnosis and treatment of this entity as well as to investigate its association with duodenal stenosis. METHODS: Gastroduodenoscopic findings and radiological imaging were evaluated for ectopic papilla and duodenal stenosis. Diagnostic methods, endoscopic procedures and long-term outcomes of the endoscopic treatment were presented. RESULTS: EO-CBD-DB was found in 74 (77.1%) of the 96 patients with duodenal deformity/stenosis (79 male, 17 female, mean age: 58.5, range: 30-87 years). The papilla with normal appearance was retracted to the bulb in 11 while it was at its usual location in the remaining 11. The history of biliodigestive surgery was more common in patients with EO-CBD-DB who were frequently presented with the common bile duct stone-related symptoms than the other patients. Thirteen (17.6%) of the patients with EO-CBD-DB were referred to surgery. Endoscopic treatment was completed in 60 (81.1%) patients after an average of 1.7 (range: 1-6) procedures. These patients were on follow-up for 24.8 (range: 2-46) months. Endoscopic intervention was required in 12 (20%) of them because of recurrent biliary problems. Treatment of the patient who had stricture due to biliary injury during laparoscopic cholecystectomy is still continued. CONCLUSIONS: The presence of EO-CBD-DB should be considered particularly in middle-aged male patients who have duodenal deformity/stenosis. Endoscopic treatment is feasible in these patients. The long-term outcomes of endoscopic therapy need to be compared with surgical treatment.

Endoscopic retrograde cholangiography by double balloon enteroscopy in patients with Roux-en-Y hepaticojejunostomy.

BACKGROUND: In patients with Roux-en-Y hepaticojejunostomy (HJ), endoscopic retrograde cholangiography (ERC) cannot usually be achieved since the anastomosis is not reachable via standard duodenoscope. In this study, we report our experience with ERC using double balloon enteroscope (DBE) (DBE-ERC) in patients with HJ. METHODS: The DBE-ERC procedures performed since the index case done dated May 3, 2006 have been overviewed. RESULTS: Fourteen patients underwent the procedure. DBE-ERC was successful in all but one patient, for whom the anastomosis could not be reached (success rate to reach anastomosis: 92.9%). The remaining 13 patients (7 female, 6 male; age 28-61 years, mean 45.3 years) had 20 sessions of DBE-ERC. The cannulation of the bile duct was achieved in all patients. The procedures, such as sphincteroplasty, dilatation, stone extraction and stent placement, were performed. Therapeutic procedures were all successful, except for in a single patient, who had the common bile duct filled with multiple stones and was referred for surgery. Three patients who had anastomotic stenosis treated by stenting are symptom free on follow-up at 3, 9 and 12 months, respectively, after stent removal. Retroperitoneal air was detected in a patient following stricturoplasty, but recovery was attained with medical treatment alone. Mean duration of the procedures was 75 +/- 62 min. CONCLUSION: DBE-ERCP enables us to perform ERC in a group of patients for whom it was impossible previously. Further experience is needed to evaluate its therapeutic efficacy compared with alternative methods.

Factors predicting outcome of balloon dilatation in achalasia.

BACKGROUND: Balloon dilatation of the lower esophageal sphincter (LES) is one of the effective nonsurgical treatment options in the management of achalasia. We aimed to determine the long-term results of graded balloon dilatation and the factors predicting outcome. PATIENTS: Patients followed for more than 12 months between January 1995 to March 2005, without history of endoscopic or surgical therapy before the study, were included (n = 111, mean age 46.3 +/- 16.9 years; follow-up period 46.3 [12-150] months). Patients were evaluated by barium swallow contrast studies, upper endoscopy, and esophageal manometry. Pneumatic dilatation was performed with the use of polyethylene balloon system. Patient outcome was evaluated according to manometric studies and Van Trappen staging as determined following face-to-face interviews with the patients. RESULTS: We determined clinical response rates of 98%, 85.7%, and 75% at months 24, 48, and 60. According to receiver-operating characteristics (ROC) analysis, age or=30.5 mmHg, LESP after first balloon dilatation >or=17.5 mmHg, and balloon number >2 were found to negatively affect treatment response. Young age and higher esophageal body pressure at admission were determined to be negative predictive factors (P = 0.038, relative risk (RR) 2.6, 95% confidence interval [CI] 1.05-6.4 and P = 0.05, RR 1.069, 95% CI 0.99-1.14, respectively). CONCLUSION: Balloon dilatation is an effective treatment of achalasia. Young age, higher esophageal body pressure, and high LESP after first balloon dilatation are negative predictive factors. Patients with young age requiring more than two balloon dilatations are likely to be unresponsive to the treatment.

Expression of p53, VEGF, microvessel density, and cyclin-D1 in noncancerous tissue of inflammatory bowel disease.

We aimed to evaluate the carcinogenesis risk in inflammatory bowel disease via p53 mutation and its relation with hyperproliferation (cyclin-D1) and angiogenesis (with vascular endothelial growth factor [VEGF] and microvessel density) and whether these events play important roles in pathogenesis of inflammatory bowel disease. Colonic tissue samples of 26 ulcerative colitis, 6 Crohn's disease, and 8 amoebic colitis patients as well as samples of 10 healthy controls were stained with p53, cyclin-D1, CD34, and VEGF monoclonal antibodies by immunohistochemistry and evaluated semiquantitatively. Expression of p53 was higher in ulcerative colitis than in the healthy control and amoebic colitis groups (4.15 +/- 2.07, 1.4 +/- 1.5, 1.3 +/- 1.5; P < 0.001). The Crohn's disease group had the highest p53 expression (4.6 +/- 1.6). The Crohn's disease, ulcerative colitis, and amoebic colitis groups all had higher VEGF expression than did the healthy controls (respectively, 4.3 +/- 1.2, 2.92 +/- 2.0, 2.3 +/- 1.5, 0.6 +/- 0.97; P < 0.001). Also, microvessel density was statistically higher in all three colitis groups than in healthy controls. Cyclin-D1 expression in all four groups was similar. The study showed that p53 mutation was present in nonneoplastic mucosa of inflammatory bowel disease patients. Detecting strong p53 overexpression with VEGF overexpression may help in differentiating inflammatory bowel disease from other colitis.

Primary sclerosing cholangitis in Turkish patients: characteristic features and prognosis.

BACKGROUND: Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease characterized by destruction and fibrosis of the bile ducts. This study aimed to demonstrate the hepatic and extrahepatic characteristic findings and prognostic outcomes of Turkish patients with PSC. METHODS: The medical records of 35 consecutive patients with PSC from January 1988 to June 2007 were recorded prospectively. From the time of diagnosis, clinical features and laboratory data were collected. RESULTS: The mean age of the 35 patients was 41.69 years (range 15-80 years) at the time of diagnosis; 14 (40%) were female, and 21 (60%) were male. The mean duration of follow-up was 58.86 months (1-180 months). Twenty (57.1%) of the patients with PSC were asymptomatic and 22 (62.9%) had inflammatory bowel disease. At the time of diagnosis, 20 (57.1%) of the patients had both intra- and extra-hepatic PSC. Twenty-one (60%) of the patients, who had undergone ERCP for stent placement, had dominant bile duct stenosis. Cholangiocarcinoma was found in 2 (5.7%) of the patients and cirrhosis was detected in 7 (20%); 5 (14.3%) underwent liver transplantation. The median follow-up time after liver transplantation was 23 months and all are still alive. Six (17.1%) patients died. CONCLUSIONS: PSC has a clinical course varied from advanced liver disease requiring liver transplantation within a short time to being asymptomatic for decades. The prognosis of Turkish patients with PSC is also disappointing as described in other studies.

Bile reflux index after therapeutic biliary procedures.

BACKGROUND: Therapeutic biliary procedures disrupt the function of the sphincter of Oddi. Patients are potential "bile refluxers". The aim of this study was to assess how these procedures affect the histology-based bile reflux index (BRI), which can be used to reflect duodenogastric reflux (DGR). METHODS: Gastric antrum and corpus biopsies were collected from 131 subjects (56 men, 75 women; mean age, 55.9 +/- 15.6 years). Group 1 (Biliary group-BG; n = 66) had undergone endoscopic sphincterotomy, endoscopic stenting, or choledochoduodenostomy for benign pathology; Group 2 (n = 20) had undergone cholecystectomy alone; and Group 3 (n = 6) Billroth II gastroenterostomy. Group 4 (no cholecystectomy; n = 39) had upper endoscopy with normal findings and served as controls. BRI > 14 indicated DGR (BRI [+]). To eliminate confounding effects of Helicobacter pylori (Hp) infection, comparisons were made according to Hp colonization. RESULTS: Fifty-nine subjects (45%) were Hp (+). The frequencies of BRI (+) status in antrum and corpus specimens from Hp (-) BG patients were 74.3% and 71.4%, respectively (85.7% for both antrum and corpus for choledochoduodenostomy). Corresponding results were 60% and 60% for Group 2, 100% (only corpus) for Group 3, and 57.1% and 38.1% for controls (BG, Group 2, and Group 3 vs controls - p > 0.05 antrum, p < 0.05 corpus). Fifty-four BG patients had previously undergone cholecystectomy. Excluding those, the rates of BRI (+) in Hp (-) BG patients were 75% antrum and 62.5% corpus (p > 0.05 for both vs. Group 2). CONCLUSION: Patients who had undergone biliary procedures showed similar bile-related histological changes in both corpus and antrum biopsies, but the changes seen in controls were more prominent in the antrum than corpus. Therapeutic biliary procedures increase the rate of BRI (+) especially in the case of choledochoduodenostomy. Therapeutic biliary procedures without cholecystectomy also increase the rate of BRI (+) similar to that observed in patients with cholecystectomy.

Etiology and portal vein thrombosis in Budd-Chiari syndrome.

AIM: To research the etiology, portal vein thrombosis and other features of Budd-Chiari syndrome (BCS) patients prospectively. METHODS: A total of 75 patients (40 female, 35 male) who were diagnosed between January 2002 and July 2004 as having BCS were studied prospectively. Findings from on physical examination, ultrasonography, duplex ultrasonography and venography were analyzed. Hemogram and blood chemistry were studied at the time of diagnosis and on each hospital visit. Bone marrow examination and immune phenotyping were performed by a hematologist when necessary. Protein C, S, antithrombin III, activated protein C resistance, and anticardiolipin antibodies, antinuclear antibodies, and anti ds-DNA were studied twice. The presence of ascite, esophageal varices, and portal thrombosis were evaluated at admission and on every visit. RESULTS: At least one etiological factor was determined in 54 (72%) of the patients. The etiology could not be defined in 21 (28%) patients. One etiological factor was found in 39, 2 factors in 14 and 3 factors in 1 patient. The most common cause was the web (16%), the second was Hydatid disease (11%), the third was Behcet's disease (9%). Portal vein thrombosis was present in 11 patients and at least one etiology was identified in 9 of them (82%). CONCLUSION: Behcet's disease and hydatid disease are more prominent etiological factors in Turkey than in other countries. Patients with web have an excellent response to treatment without signs of portal vein thrombosis while patients having thrombofilic factors more than one are prone to develop portal vein thrombosis with worse clinical outcome.

Intermittent versus continuous pantoprazole infusion in peptic ulcer bleeding: a prospective randomized study.

BACKGROUND AND AIM: Rebleeding has remained the most important determinant of poor prognosis in peptic ulcer bleeding. Gastric acid plays an important role in the pathogenesis of rebleeding. We aimed to compare the efficiency of intermittent and continuous pantoprazole infusion treatment on peptic ulcer rebleeding after endoscopic therapy. MATERIALS AND METHOD: In this prospective study, patients with active peptic ulcer bleeding or non-bleeding visible vessel were treated initially with endoscopic therapy. They were randomized to receive intermittent or continuous intravenous pantoprazole treatment. Rebleeding rate, duration of hospital stay, need for total blood transfusion and need for urgent surgery were compared among both groups. RESULTS: Rebleeding rate (6.1 vs. 8.3%), duration of hospital stay (4.17 vs. 4.41), need for total blood transfusion (2.18 vs. 2.59) and need for urgent surgery (4.1 vs. 4.2%) were similar in intermittent and continuous pantoprazole infusion therapy groups, respectively. There was no bleeding-related death in either group. CONCLUSION: In patients with peptic ulcer bleeding, intermittent and continuous pantoprazole infusion after successful endoscopic therapy have comparable outcomes in reducing rebleeding. Both have similar effects on hospital stay, need for blood transfusion and urgent surgery. Intermittent administration has application and cost advantages over continuous infusion.

Management of pancreatic lithiasis in a 5-year-old girl.

Pancreatic lithiasis causing chronic pancreatitis is a very rare entity in childhood. A five-year-old girl presenting with pancreatic lithiasis was treated successfully with a well-organized diagnostic and therapeutic algorithm. The authors emphasize that early diagnosis followed by appropriate therapeutic pancreatographic procedures instead of primary invasive surgical approach can certainly ameliorate progressive and irreversible pancreatic damage. The clinicopathologic features of this rare entity are discussed, with emphasis on diagnosis and treatment.

Anomalous opening of the common bile duct into the duodenal bulb: endoscopic treatment.

BACKGROUND: Anomalous biliary opening especially the presence of the ampulla of Vater in the duodenal bulb is a very rare phenomenon. We report clinical implications, laboratory and ERCP findings and also therapeutic approaches in 53 cases. METHODS: The data were collected from the records of 12.158 ERCP. The diagnosis was established as an anomalous opening of the common bile duct (CBD) into the duodenal bulb when there is an orifice observed in the bulb with the absence of a papillary structure at its normal localization and when the CBD is visualized by cholangiography through this orifice without evidence of any other opening. RESULTS: A total of 53 cases were recruited. There was an obvious male preponderance (M/F: 49/4). Demographic data and ERCP findings were available for all, but clinical characteristics and laboratory findings could be obtained from 39 patients with full records. Thirty-seven of 39 cases had abdominal pain (95%) and 23 of them (59%) had cholangitis as well. Elevated AP and GGT were found in 97.4% (52/53). History of cholecystectomy was present in 64% of the cases, recurrent cholangitis in 26% and duodenal ulcer in 45%. Normal papilla was not observed in any of the patients and a cleft-like opening was evident instead. The CBD was hook shaped at the distal part that opens to the duodenal bulb. Pancreatic duct (PD) was opening separately into the bulb in all the cases when it was possible to visualize. Dilated CBD in ERCP was evident in 94% and the CBD stone was demonstrated in 51%. PD was dilated in four of 12 (33%) cases. None of them has a history of pancreatitis. Endoscopically, Papillary Balloon Dilatation instead of Sphincterotomy carried out in 19 of 27 patients (70%) with choledocholithiazis. Remaining eight patients had undergone surgery (30%). Clinical symptoms were resolved with medical treatment in 16(32%) patients with dilated CBD but no stone. Perforation and bleeding were occurred only in two patients, which stones extracted with sphincterotomy (each complication in 1 patient). CONCLUSION: The opening of the CBD into the duodenal bulb is a rare event that may be associated with biliary and gastric/duodenal diseases. To date, surgical treatment has been preferred. In our experience, sphincterotomy has a high risk since it may lead to bleeding and perforation by virtue of the fact that a true papillary structure is absent. However, we performed balloon dilatation of the orifice successfully without any serious complication and suggest this as a safe therapeutic modality.

Conscious sedation during endoscopic retrograde cholangiopancreatography: midazolam or midazolam plus meperidine?

BACKGROUND AND OBJECTIVE: No consensus exists for the safest and most effective agent and for optimal drug doses for sedation during endoscopic retrograde cholangiopancreatography (ERCP). We aimed to compare the efficacy of midazolam with that of midazolam+meperidine, which provided comfort for the patient during ERCP. MATERIALS AND METHODS: The patients were randomized to sedation with midazolam only (2.87+/-0.67 mg) (n=48, median age 55.54+/-14.66, 21 women, 27 men) or midazolam (1.82+/-0.71 mg) with meperidine (42.81+/-14.61 mg) (n= 48, median age 55.48+/-2.57, 20 women, 28 men). Procedure-related parameters and the efficacy of sedation as assessed by the endoscopist and the patients were compared. RESULTS: Prior endoscopic history, preprocedure anxiety scores, age, sex, baseline vital signs and type of interventions were similar in both groups. Sedation level, duration of procedure and recovery time were comparable in both groups. Sedation quality assessment scale was significantly higher in the midazolam with meperidine group. Degree of pain sensed during the procedure was significantly lower in the midazolam with meperidine group. Midazolam with meperidine group had better patient satisfaction. Twenty-four hours after the procedure, the degree of amnesia between both sedation groups was similar. The number of patients unwilling to repeat the procedure was distinctly higher in midazolam group. Development of hypoxia and arrythmia in the midazolam and midazolam with meperidine groups were comparable. Two patients in the midazolam group developed paradoxical agitation. CONCLUSIONS: Conscious sedation for ERCP can be successfully and safely achieved by using either only midazolam or a low dose of midazolam with meperidine. Adding of meperidine to midazolam resulted in better patient and endoscopist comfort.

Endoscopic Treatment of the Zenker Diverticulum With Flexible Endoscopic Myotomy: A Single Tertiary Center Experience.

INTRODUCTION: The Zenker diverticulum (ZD) is the most common type of esophageal diverticula. Management of ZD has different options; however, there is a recent increase in treatment with flexible endoscopic myotomy (FEM). In our study, we aimed to investigate the efficacy and safety of FEM among patients with ZD. MATERIALS AND METHODS: The data of patients who underwent FEM for ZD in our clinic between January 2008 and May 2016 were retrospectively analyzed. Myotomy was performed with a needle-knife sphincterotome by using pulse-cut or forced coagulation electrocautery mode. Myotomy was performed on the common wall of the diverticulum up to 0.5 to 1 cm of the distal end. A handmade diverticuloscope, which was modified from an overtube, was used in most of the patients to focus more carefully on the septum. Dysphagia scores of the patients before and after the procedure were compared and complications were evaluated. RESULTS: A total of 17 patients were enrolled in the study. The mean age was 65.3 years, and mean diverticular diameter was 3.2 cm. The most common symptoms were dysphagia and regurgitation. The mean in-hospital stay was 5 days. The dysphagia score was significantly decreased after FEM among the patients (0.17±0.39 vs. 2±0.79; P=0.0001). Complications were observed in 3 patients (17.6%); however, there was no procedure-related mortality. DISCUSSION: FEM is an efficient and safe procedure as a treatment modality for ZD. However, lack of a standard algorithm is a remarkable disadvantage.

Is there a safer electrosurgical current for endoscopic sphincterotomy in patients with liver cirrhosis?

BACKGROUND: Endoscopic sphincterotomy has a higher risk of bleeding in patients with cirrhosis. Advanced Child stage and coagulopathy are well-known risk factors. We aimed to determine the role of electrosurgical currents in the development of endoscopic sphincterotomy bleeding in cirrhotic patients. METHODS: The study was a retrospective observational study and included 19,642 patients who underwent endoscopic retrograde cholangiopancreatography between 2004 and 2013. The incidence of endoscopic sphincterotomy bleeding in cirrhotic patients who underwent sphincterotomy after 2009 with an electrosurgical generator applying alternating current in the pulse cut mode (Group 2) was compared with a historical control group who underwent endoscopic sphincterotomy between 2004 and 2009 via blended current (Group 1). RESULTS: Group 1 included 15 patients (six women, nine men, mean age: 62.2 ± 12.9 years). Group 2 included 14 patients (six women, eight men, mean age: 63.6 ± 16.9 years). There was no statistically significant difference between the demographic and clinical characteristics of the two groups. Endoscopic sphincterotomy bleeding was observed in three patients in Group 1 (two endoscopic bleeding and one clinically significant bleeding) and none of the patients in Group 2 (p = 0.77). There were no cases of perforation or pancreatitis in both groups. One patient in Group 2 developed cholangitis. CONCLUSIONS: Endoscopic sphincterotomy bleeding is less frequently observed in patients with cirrhosis who underwent sphincterotomy with alternating mixed current in the pulse cut mode compared with those with blended current.