PREDICTORS OF FAILURE OF ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN CLEARING BILE DUCT STONES DURING INDEX PROCEDURE - A PROSPECTIVE STUDY.

BACKGROUND: Common bile duct (CBD) stones are known to complicate 10-15% of gallstone diseases. Endoscopic retrograde cholangiopancreatography (ERCP) is the therapeutic modality of choice for bile duct clearance in CBD stones but may fail to achieve stone clearance. This prospective study was done to identify the predictors of failure of CBD clearance with ERCP. OBJECTIVE: This prospective study was done to identify the predictors of failure of CBD clearance with ERCP. METHODS: All consecutive patients with bile duct stones undergoing ERCP at a tertiary care center were prospectively included from October 2020 to October 2021. The study's primary outcome was to identify and analyze factors that could predict the failure of complete CBD clearance. RESULTS: A total of 120 patients (50.8% males, median age: 53.5 years) were included in the final analysis. Successful clearance of CBD stones during the index procedure was achieved in 70% of patients. At a cut-off stone diameter of >10.5 mm and CBD diameter of >12.5 mm, the AUC was 0.890 and 0.884, respectively, to predict failed clearance of CBD. On multivariate analysis, stone diameter ≥15 mm [odds ratio (OR) 16.97, 95% confidence interval (CI): 1.629-176.785], location of stones in hepatic ducts (OR 7.74, 95%CI: 2.041-29.332), presence of stricture distal to stone (OR 6.99, 95%CI: 1.402-34.726) and impacted stone (OR 21.61, 95%CI: 1.84-253.058) were independent predictors of failed bile duct clearance. CONCLUSION: Stone size and location are independent predictors of failed bile duct clearance. The endoscopist should consider these factors while subjecting a patient to biliary ductal clearance to plan additional intervention. BACKGROUND: • Failure to clear bile duct stones in the index ERCP can be seen in 15-20% of cases, and identifying the factors associated with failure is important. BACKGROUND: • A prospective analysis was conducted to identify and analyze the factors that could predict the failure of complete CBD clearance. BACKGROUND: • The present study reported a successful clearance of CBD stones during the index procedure in only 70% of patients. BACKGROUND: • A stone diameter ≥15 mm, location of stones in hepatic ducts, presence of stricture distal to stone, and impacted stone were independent predictors of failed bile duct clearance.

Previsores de falha da colangiopancreatografia retrógrada endoscópica na limpeza de cálculos do ducto biliar durante o procedimento inicial - Um estudo prospectivo / Predictors of failure of endoscopic retrograde cholangiopancreatography in clearing bile duct stones during index procedure - a prospective study

ABSTRACT Background: Common bile duct (CBD) stones are known to complicate 10-15% of gallstone diseases. Endoscopic retrograde cholangiopancreatography (ERCP) is the therapeutic modality of choice for bile duct clearance in CBD stones but may fail to achieve stone clearance. This prospective study was done to identify the predictors of failure of CBD clearance with ERCP. Objective: This prospective study was done to identify the predictors of failure of CBD clearance with ERCP. Methods: All consecutive patients with bile duct stones undergoing ERCP at a tertiary care center were prospectively included from October 2020 to October 2021. The study's primary outcome was to identify and analyze factors that could predict the failure of complete CBD clearance. Results: A total of 120 patients (50.8% males, median age: 53.5 years) were included in the final analysis. Successful clearance of CBD stones during the index procedure was achieved in 70% of patients. At a cut-off stone diameter of >10.5 mm and CBD diameter of >12.5 mm, the AUC was 0.890 and 0.884, respectively, to predict failed clearance of CBD. On multivariate analysis, stone diameter ≥15 mm [odds ratio (OR) 16.97, 95% confidence interval (CI): 1.629-176.785], location of stones in hepatic ducts (OR 7.74, 95%CI: 2.041-29.332), presence of stricture distal to stone (OR 6.99, 95%CI: 1.402-34.726) and impacted stone (OR 21.61, 95%CI: 1.84-253.058) were independent predictors of failed bile duct clearance. Conclusion: Stone size and location are independent predictors of failed bile duct clearance. The endoscopist should consider these factors while subjecting a patient to biliary ductal clearance to plan additional intervention.

RESUMO Contexto: Cálculos do ducto biliar comum (CDC) são conhecidos por complicar 10-15% das doenças de cálculos biliares. A colangiopancreatografia retrógrada endoscópica (CPRE) é a modalidade terapêutica de escolha para a limpeza do CDC, mas pode falhar na sua remoção. Objetivo: Este estudo prospectivo foi realizado para identificar os previsores de falha na limpeza do CDC com CPRE. Métodos: Pacientes consecutivos com cálculos no ducto biliar submetidos a CPRE em um centro de atendimento terciário foram incluídos prospectivamente de outubro de 2020 a outubro de 2021. O principal resultado do estudo foi identificar e analisar fatores que poderiam prever a falha na limpeza completa do CDC. Resultados: Um total de 120 pacientes (50,8% homens, idade média: 53,5 anos) foram incluídos na análise final. A limpeza bem-sucedida dos cálculos de CDC durante o procedimento inicial foi alcançada em 70% dos pacientes. Com um diâmetro de corte de cálculos >10,5 mm e de diâmetro de CDC de >12,5 mm, a AUC foi de 0,890 e 0,884, respectivamente, para prever a falha na limpeza do CDC. Na análise multivariada, diâmetro da cálculos ≥15 mm [razão de chances (OR) 16,97, intervalo de confiança de 95% (IC): 1,629-176,785], localização dos cálculos nos ductos hepáticos (OR 7,74, IC95%: 2,041-29,332), presença de estreitamento distal ao cálculo (OR 6,99, IC95%: 1,402-34,726) e cálculo impactado (OR 21,61, IC95%: 1,84-253,058) foram previsores independentes de falha na limpeza do ducto biliar. Conclusão: O tamanho e a localização dos cálculos são previsores independentes de falha na limpeza do ducto biliar. O endoscopista deve considerar esses fatores ao submeter um paciente à limpeza ductal biliar para planejar intervenção adicional.

Role of endoscopic ultrasound-guided tissue acquisition for the diagnosis of gastric wall thickening: a retrospective study with meta-analysis.

Background: Tissue acquisition from a thickened gastric wall using biopsy forceps may not always lead to diagnosis, given the submucosal location of the pathology. Endoscopic ultrasound (EUS)-guided tissue acquisition (TA) may serve as a minimally invasive diagnostic tool in such cases. Hence, we aimed to assess the diagnostic outcome and safety of EUS-TA from thickened gastric walls. Methods: Data from patients with gastric wall thickening undergoing EUS-TA at 5 tertiary care centers from August 2020 to August 2022 were retrospectively analyzed. These data were pooled with studies obtained from a comprehensive search of Medline, Embase and Scopus from January 2000 to November 2022 and a meta-analysis was performed. Pooled event rates were calculated using an inverse variance model. Results: The search strategy yielded 13 studies that were combined with data from 30 patients from our centers; a total of 399 patients were included in the analysis. The pooled rate of sample adequacy was 94.1% (95% confidence interval [CI] 90.0-98.2), while the pooled rate of diagnostic accuracy was 91.3% (95%CI 87.0-95.5). The pooled sensitivity and specificity for diagnosing malignant lesions with EUS-TA from gastric wall thickening were 94.8% (95%CI 91.3-97.2) and 100% (95%CI 93.6-100), respectively. There were no reported adverse events in any of the studies. Conclusions: EUS-TA offers a safe and accurate diagnostic modality for the etiological diagnosis of thickened gastric walls. Further research is required to identify the needle type and optimal technique for improving outcomes.

Efficacy and Safety of Argon Plasma Coagulation for the Ablation of Barrett's Esophagus: A Systemic Review and Meta-Analysis.

Background/Aims: Argon plasma coagulation (APC) is an alternate ablative method to radiofrequency ablation for the treatment of Barrett's esophagus (BE), and it is preferred due to its lower cost and widespread availability. The present meta-analysis aimed to analyze the safety and efficacy of APC for the management of BE. Methods: A literature search from January 2000 to November 2022 was done for studies analyzing the outcome of APC in BE. The primary outcomes were clearance rate of intestinal metaplasia and adverse events (AE). Pooled event rates were expressed with summative statistics. Results: A total of 38 studies were included in the final analysis. The pooled event rate for clearance rate of intestinal metaplasia with APC in BE was 86.8% (95% confidence interval [CI], 83.5% to 90.2%), with high-power and hybrid APC having a higher rate compared to standard APC. The pooled incidence of AE with APC in BE was 22.5% (95% CI, 15.3% to 29.7%), without any significant difference between the subgroups, with self-limited chest pain being the commonest AE. The incidence of serious AE was only 0.4% (95% CI, 0.0% to 1.0%), while stricture development was seen only in 1.7% (95% CI, 0.9% to 2.6%) of cases. The pooled recurrence rate of BE was 16.1% (95% CI, 10.7% to 21.6%), with a significantly lower recurrence with high-power APC than standard APC. Conclusions: High-power and hybrid APC seem to have an advantage over standard APC in terms of clearance rate and recurrence rate. Further studies are required to compare the efficacy and safety of hybrid APC with standard APC and radiofrequency ablation.

Impact of macroscopic on-site evaluation on the diagnostic outcomes of endoscopic ultrasound-guided fine-needle aspiration.

BACKGROUND: Endoscopic ultrasound (EUS)-guided tissue acquisition is the preferred modality for diagnosing pancreatic lesions and mediastinal and abdominal lymph nodes. Rapid on-site cytologic evaluation improves the diagnostic outcome of EUS-guided fine-needle aspiration (FNA) but is unavailable at many centers. Alternatively, macroscopic on-site evaluation (MOSE) may improve the diagnostic outcome of EUS-FNA, but data are limited. Hence, the present study was conducted to assess the efficacy of MOSE in improving adequacy and accuracy. METHODS: We retrospectively analyzed data of consecutive patients with pancreatic or lymph nodal lesions undergoing EUS-guided FNA at a tertiary care center from December 2020 to December 2022. The study's primary outcomes were adequacy and diagnostic accuracy of the EUS-guided tissue acquisition, with secondary analysis of predictors of adequacy and accuracy. RESULTS: Data from 124 patients (44.4% male, median age: 54 years) who underwent EUS-FNA were included in the present analysis. The presence of macroscopic visible core (MVC) on MOSE was reported in 93/124 (75%) cases. An adequate sample for histopathological or cytological examination was obtained in 110/124 (88.7%) cases, while the diagnostic accuracy was 85.5%. On multivariate analysis, the absence of MVC on MOSE was found to be the independent negative predictor of both adequacy (OR 0.092, 95% CI: 0.024-0.349) and accuracy (OR 0.175, 95% CI: 0.057-0.536). CONCLUSION: The presence of MVC on MOSE can be an indicator of specimen adequacy and can improve the diagnostic yield of EUS-FNA.

Effect of 4% nebulized lignocaine versus 2% nebulized lignocaine for awake fibroscopic nasotracheal intubation in maxillofacial surgeries.

INTRODUCTION: Securing a difficult airway during maxillofacial surgeries is a great challenge for anesthetists, and the flexible fiber-optic bronchoscope is the gold standard while managing such cases. While passing the flexible bronchoscope by the nasal route, the success rate is higher as compared with oral approach as the nasopharynx is in line with the larynx and prevents acute angulation in the oropharynx. MATERIALS AND METHODS: A randomized control trial was planned in 73 patients out of whom sixty patients gave consent for the procedure. The patients we randomly divided into two groups (n = 30) with application of 4% nebulized lignocaine in one group and the use of 2% nebulized lignocaine in the other group, and the patient's comfort was noted using five-point Puchner scale. RESULTS: The mean value of patient comfort Puchner scale of Group A was 1.30 ± 0.08 and of Group B was 2.23 ± 0.12. The mean value of Puchner scale of Group B was significantly higher (41.8%) as compared to Group A (t = 6.208; df = 51; P < 0.0001). The secondary outcome measures were optimal intubating conditions and hemodynamic changes during awake fiber-optic nasotracheal intubation. The procedural time of two groups when compared showed that the mean procedural time of Group A was shorter (29.67 ± 5.40 min) than the time consumed in Group B (34.93 ± 5.52 min). CONCLUSION: Four percent nebulized lidocaine provided adequate airway anesthesia and optimal intubating conditions along with stable hemodynamics for awake fiber-optic intubation as compared to 2% nebulized lidocaine.