Interobserver agreement for evaluation of imaging with single operator choledochoscopy: what are we looking at?

BACKGROUND: Single operator choledochoscopy is a platform used to assist in the confirmation of diagnosis of biliary lesions. However, there are little data regarding the interobserver agreement of imaging interpretation. Our objective was to assess the interobserver agreement in single operator choledochoscopy interpretation. METHODS: 38 De-identified SPY Choledochoscopy video clips were sent to 7 interventional endoscopists. They were asked to score the videos on presence of four criteria selected by the investigators: growth, stricture, hyperplasia, and ulceration. Observers also chose a final diagnosis from the categories of cancer, hyperplasia, inflammation, or normal. Kappa scores were calculated for the scoring of the four criteria and for the selection of the final diagnosis. RESULTS: The overall interobserver agreement was fair in scoring for the presence of a growth (K=0.28, SE 0.035) and stricture (K=0.32, SE 0.035). Scoring for ulceration was slight to fair (K=0.17, SE 0.035). There was only slight agreement for the presence of hyperplasia (K=0.11, SE 0.035); and presumed final diagnosis based on imaging (K=0.18, SE 0.022). CONCLUSION: The results of this study support the need for an effort to identify and validate cholangioscopy imaging criteria for biliary pathology. This may assist in improving the reliability of the diagnostic value of cholangioscopy as its use becomes more widespread.

Bleeding after percutaneous endoscopic gastrostomy is linked to serotonin reuptake inhibitors, not aspirin or clopidogrel.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is an invasive procedure that can result in bleeding. Guidelines recommend discontinuing clopidogrel for 7 to 10 days, but not withholding aspirin, before PEG. Serotonin reuptake inhibitors (SRIs) have been associated with an increased risk of GI bleeding. OBJECTIVE: To determine whether there is an association between periprocedural aspirin, clopidogrel, or SRI use and bleeding in patients who underwent PEG tube placement. DESIGN: Retrospective cohort study. SETTING: Large quaternary-care academic medical center. PATIENTS: A total of 990 patients (525 men) with a median age of 69.8 years who underwent PEG from January 1999 to April 2009. INTERVENTIONS: PEG tube placement. MAIN OUTCOME MEASUREMENTS: GI bleeding. RESULTS: Sixteen patients (1.6%) had evidence of bleeding during the first 48 hours after PEG, and 12 patients (1.2%) had evidence of bleeding between 48 hours and 14 days after PEG. Thirty-six patients (3.6%) received high-dose aspirin (>325 mg), 27 patients (2.7%) received clopidogrel (75 mg), and 99 patients (10%) received an SRI before PEG. Twenty-four patients (2.4%) received high-dose aspirin, 25 patients (2.5%) received clopidogrel, and 130 patients (13.1%) received an SRI after PEG. Multivariate analysis demonstrated no association between periprocedural use of aspirin (at any dose) or clopidogrel and post-PEG bleeding. However, SRIs administered 24 hours or less before PEG were associated with a significantly higher odds of post-PEG bleeding (adjusted odds ratio 4.1; 95% CI, 1.1-13.4; P = .04). LIMITATIONS: Retrospective, single-center study with limited statistical power despite a relatively large cohort of patients. CONCLUSIONS: Use of aspirin or clopidogrel before or after PEG was not associated with procedure-related bleeding. SRI use in the 24 hours before PEG was associated with an increased risk of bleeding.

Bridge to surgery using partially covered self-expandable metal stents (PCMS) in malignant biliary stricture: an acceptable paradigm?

BACKGROUND AND AIM: Partially covered self-expanding metal stents (PCMS) have been extensively used for palliation of malignant distal biliary stricture. Many centers have been using them as a bridge to surgery (BTS) regardless of resectability with or without eventual neoadjuvant therapy. We analyzed the outcome of all patients receiving PCMS and subsequently referred for surgery in our institution. METHODS: Our prospectively established pancreaticobiliary database was retrospectively analyzed to retrieve all patients with malignant biliary stricture who underwent PCMS placement and subsequently went for curative surgical attempt at our institution. Cancer type and staging, adverse events related to stent placement or surgery, type of surgery performed, time between stenting and surgery, length of postoperative hospitalization, and postoperative follow-up were recorded. RESULTS: 27 patients (21 men; median age 66 years, range 39-82 years) received PCMS. Indications for placement included biliary stricture related to pancreatic cancer (n=23) or other malignancies (n=4). Median time between stenting and surgery was 32 days (range 6-569 days). Median time of hospitalization post surgery was 7 days (1-40 days). All patients underwent exploratory laparoscopy, followed in 9 (33.3%) by Whipple procedure with uneventful removal of the PCMS. Eighteen patients (66.6%) had their attempted curative resection terminated early due to intraoperative evidence of metastatic spread, with 8 (30%) patients undergoing peritoneal or liver metastasis biopsy. PCMS were left in place in those 18 patients. Complications related to PCMS in the bridge-to-surgery period included migration (n=2, 7.4%) and tissue overgrowth (n=1, 3.4%), all of them managed by endoscopic removal and replacement with PCMS. Median follow-up post surgery was 210 days (range 9-1,642 days). CONCLUSION: PCMS are an appropriate BTS option. For resectable patients, PCMS results in biliary drainage and allows for neoadjuvant treatment without portending subsequent curative resection (Whipple). For unresectable patients, long-term biliary drainage is provided by PCMS.

Duplicate presentations on prostate cancer at American Urological Association and European Association of Urology annual meetings.

PURPOSE: We determined the rate of duplicate research presentations at recent American Urological Association and European Urological Association annual meetings. MATERIALS AND METHODS: We cross-referenced all clinical research presentations related to prostate cancer presented at the 2006 American Urological Association and European Urological Association annual meetings with those presented at the corresponding annual meetings in 2005, 2006 and 2007 using a defined search strategy based on author names, abstract titles, study design and objectives. All data abstraction was performed in duplicate by 2 independent reviewers to ensure accuracy. RESULTS: We identified 282 and 312 abstracts on prostate cancer clinical research at the 2006 European Urological Association and American Urological Association annual meetings, respectively. The overall duplication rate of American Urological Association abstracts was 19.2% (60 of 312). Of duplicated abstracts 80.0% (48 of 60) were presented at the European Urological Association annual meeting the same year. Duplication of European Urological Association abstracts was identified in 20.9% (59 of 282). Authors who presented the same research (71 duplicate abstracts) at the 2 meetings altered the presentations in various ways, including a different study title in 40.8%, a different first and senior author in 14.1% and 18.3%, and increased or decreased sample size in 8.5% and 14.1%, respectively. CONCLUSIONS: Approximately a fifth of clinical research abstracts on prostate cancer presented at the American Urological Association annual meeting were also presented at the European Urological Association meeting and vice versa. Inconsistencies between duplicate abstracts raise concerns about the integrity of the underlying studies. Stricter submission guidelines and improved dissemination of research findings from the 2 meetings may help limit this practice.