Plastic versus self-expanding metallic stents for malignant hilar biliary obstruction: a prospective multicenter observational cohort study.

BACKGROUND: There are few comparative data as to whether plastic or self-expanding metallic stents are preferable for palliating malignant hilar biliary obstruction. METHODS: Thirty-day outcomes of consecutive endoscopic retrograde cholangiopancreatographies performed for malignant hilar obstruction at 6 private and 5 university centers were assessed prospectively. RESULTS: Patients receiving plastic (N=28) and metallic stents (N=34) were similar except that metallic stent recipients more often had: Bismuth III or IV tumors (16/34 vs. 5/28 P=0.043), higher Charlson comorbidity scores (P=0.003), metastatic disease (P=0.006), and management at academic centers (P=0.018). The groups had similar rates of bilateral stent placement (4/28 vs. 5/34), and similar frequency of opacified but undrained segmental ducts (7/28 vs. 5/34). Adverse outcomes including cholangitis, stent occlusion, migration, perforation, and/or the need for unplanned endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography occurred in 11/28 (39.3%) patients with plastic versus 4/34 (11.8%) with metal stents (P=0.017). By logistic regression, factors associated with adverse outcomes included plastic stent placement (odds ratio 6.32; 95% confidence interval 1.23, 32.56) and serum bilirubin (1.11/mg/dL above normal: 1.01, 1.22) but not center type or Bismuth class. CONCLUSIONS: Metallic stent performance was superior to plastic for hilar tumor palliation with respect to short-term outcomes, independent of disease severity, Bismuth class, or drainage quality.

Integrated psychological care in head and neck cancer: Views from health care providers, patients, and supports.

OBJECTIVES/HYPOTHESIS: An evaluation by head-and-neck cancer (HNC) staff, patients, and patient support feedback regarding integrated psychological care and perceived benefit based on patient characteristics. STUDY DESIGN: Cross-sectional survey of HNC staff, patients, and their primary supports; and retrospective chart review of psychiatric characteristics of HNC patients. METHODS: HNC staff, patients (who were evaluated by the integrated psychologist), and their primary supports were given questionnaires on their perception of benefit of including a psychologist in the evaluation and treatment of HNC patients. Also, a retrospective chart review on patients who were psychiatrically evaluated by the psychologist on sociodemographics and psychiatric characteristics. RESULTS: Overall, integration of a psychologist was well received by patients, supports, and staff. Younger patients reported greater satisfaction with the availability of the psychologist than older patients (P = .04), and patients with reported psychiatric histories (diagnoses in remission) indicated more satisfaction with the psychologist in relation to managing distress than patients who denied psychiatric histories (P = .03); however, patients who were currently smoking tended to report lower satisfaction with the psychologist helping with distress than those who were past/never smokers (P = .06). CONCLUSIONS: Integrated psychological care has the potential to improve care provided for HNC patients. LEVEL OF EVIDENCE: Level 4.

Pitfalls in HIV testing.

Preview Inaccurate results on HIV tests are rare, but they do occur. Therefore, it is important that primary care physicians understand the laboratory techniques involved. Which assays are used for detection of the virus? How are results of such tests interpreted? What factors cause false-positive and falsenegative results? Drs Cordes and Ryan answer these questions and clarify the uncertainty surrounding HIV testing.

New strategies in nonoperative management of meconium ileus.

PURPOSE: The aim of this study was to develop new nonoperative strategies for the management of meconium ileus in an attempt to improve on the current unacceptable failure rate. METHODS: Mice were constipated with subcutaneous morphine injection. Each then received an enema solution (perflubron, surfactant, Tween-80, Gastrografin, Golytely, DNase, N-Acetylcysteine, Viokase, or normal saline). After the enema solution was administered, stool output was quantitated. Histologic examination of the intestines was performed on a second group of mice that also received enemas. Finally, viscosity measurements were taken of human meconium at baseline and after variable incubation periods with each test solution. RESULTS: For relieving constipation in vivo, Gastrografin enema was most efficacious. All agents were equally benign to the intestinal mucosa. In vitro, only 4% N-Acetylcysteine and perflubron were less effective at decreasing meconium viscosity than normal saline at T = 0 hours, with N-Acetylcysteine producing greater reduction in viscosity than normal saline at T = 6 hours. CONCLUSIONS: Our results show that surfactant and Gastrografin are the most effective for the in vivo relief of constipation. This is accomplished without mucosal damage. These agents also significantly reduce viscosity in vitro, and we speculate that they may be beneficial in relieving constipation caused by meconium ileus in cystic fibrosis patients.

Endoscopic balloon dilation compared with sphincterotomy for extraction of bile duct stones.

BACKGROUND AND AIMS: Endoscopic retrograde cholangiopancreatography is commonly performed to remove bile duct stones. The aim of this study was to determine short-term outcomes of endoscopic balloon dilation of the sphincter of Oddi compared with sphincterotomy for stone extraction. METHODS: A randomized, controlled multicenter study of 117 patients assigned to dilation and 120 to sphincterotomy was performed in a spectrum of clinical and academic practices. RESULTS: Characteristics of the patients, procedures, and endoscopists were similar except that dilation patients were younger. Procedures were successful in 97.4% and 92.5% of the dilation and sphincterotomy patients, respectively. Overall morbidity occurred in 17.9% and 3.3% ( P < .001; difference, 14.6; 95% confidence interval, 7-22.3) and severe morbidity, including 2 deaths, in 6.8% and 0%( P < .004; difference, 6.8; 95% confidence interval, 2.3-11.4) for dilation and sphincterotomy, respectively. Complications for dilation and sphincterotomy, respectively, included: pancreatitis, 15.4% and .8% ( P < .001; difference, 14.6; 95% confidence interval, 7.8-21.3); cystic duct fistula, 1.7% and 0%; cholangitis, .9% and .8%; perforation, 0% and .8%; and cholecystitis, 0% and .8%. There were 2 deaths (1.7%) due to pancreatitis following dilation and none with sphincterotomy. The study was terminated at the first interim analysis. Dilation patients required significantly more invasive procedures, longer hospital stays, and longer time off from normal activities. CONCLUSIONS: In a broad spectrum of patients and practices, endoscopic balloon dilation compared with sphincterotomy for biliary stone extraction is associated with increased short-term morbidity rates and death due to pancreatitis. Balloon dilation of the sphincter of Oddi for stone extraction should be avoided in routine practice.