Long-term outcomes associated with pancreatic extracorporeal shock wave lithotripsy for chronic calcific pancreatitis.

BACKGROUND: Most outcomes data on pancreatic extracorporeal shock wave lithotripsy (P-ESWL) for chronic calcific pancreatitis (CCP) are based on studies with <4 years' follow-up, and U.S. long-term studies are lacking. OBJECTIVE: To report long-term P-ESWL outcomes for CCP and to assess whether smoking or alcohol use influences P-ESWL outcomes. DESIGN: Cross-sectional study, retrospective chart review. SETTING: Virginia Mason Medical Center, Seattle, Washington. PATIENTS: This study involved 120 patients who underwent P-ESWL and ERCP for CCP and completed an outcomes questionnaire. INTERVENTION: P-ESWL and ERCP, outcomes survey. MAIN OUTCOME MEASUREMENTS: Pain, quality of life, narcotics use, diabetes status, pancreatic enzyme requirement, repeat P-ESWL, repeat ERCP, surgery. RESULTS: A total of 120 patients underwent P-ESWL followed by ERCP (mean ± standard deviation [SD] follow-up 4.3 [± 3.7] years) and completed a survey. The mean (± SD) before-P-ESWL pain score was 7.9 (± 2.6) compared with 2.9 (± 2.6) after P-ESWL (P < .001). Improved pain was reported by 102 patients (85%); 60 (50%) reported complete pain relief and no narcotic use. The mean (± SD) before-P-ESWL quality-of-life score was 3.7 (± 2.4) compared with 7.3 (± 2.7) after P-ESWL (P < .001). In patients with ≥ 4 years' follow-up, repeat procedures included P-ESWL (29%), ERCP (84%), and surgery (16%). Smokers who quit smoking after P-ESWL had improved narcotic requirements compared with those who continued smoking (95% vs 67%; P = .014), and a trend suggested a decreased need for repeat ERCPs (68% vs 84%; P = .071). LIMITATIONS: Single center, retrospective, recall bias, nonvalidated pain and quality-of-life scales. CONCLUSION: P-ESWL as the initial therapy for CCP may lead to more lifetime procedures; however, partial pain relief in 85%, complete pain relief with no narcotic use in 50%, and avoidance of surgery in 84% of patients may be achieved. Quitting smoking after P-ESWL may improve outcomes.

Laparoscopy-assisted versus balloon enteroscopy-assisted ERCP in bariatric post-Roux-en-Y gastric bypass patients.

BACKGROUND: Data on balloon enteroscopy-assisted ERCP (BEA-ERCP) versus laparoscopy-assisted ERCP (LA-ERCP) in post-Roux-en-Y gastric bypass (RYGB) patients are lacking. OBJECTIVES: To compare BEA-ERCP with LA-ERCP in post-RYGB patients and to identify factors that predict therapeutic success with BEA-ERCP. DESIGN: Retrospective chart review. SETTING: A single North American tertiary referral center. PATIENTS: The review included 56 bariatric post-RYGB patients who underwent ERCP. INTERVENTIONS: BEA-ERCP or LA-ERCP. MAIN OUTCOME MEASUREMENTS: Cannulation rate, therapeutic success, hospital stay, complications, procedure duration, endoscopist time, and cost. RESULTS: A total of 32 patients underwent BEA-ERCP, and 24 underwent LA-ERCP. LA-ERCP was superior to BEA-ERCP in papilla identification (100% vs 72%, P = .005), cannulation rate (100% vs 59%, P < .001), and therapeutic success (100% vs 59%, P < .001). The total procedure time was shorter (P < .001) and endoscopist time was longer (P = .006) for BEA-ERCP. There was no difference in postprocedure hospital stay (P = .127) or complication rate (P = .392) between the 2 groups. In the BEA-ERCP group, in patients having a Roux limb + biliopancreatic (from ligament of Treitz to jejunojejunal anastomosis), a limb length less than 150 cm was associated with therapeutic success. Starting with BEA-ERCP and continuing with LA-ERCP after a failed BEA-ERCP saved $1015 compared with starting with LA-ERCP. LIMITATIONS: Single center, retrospective study. CONCLUSIONS: In centers with expertise in deep enteroscopy and ERCP, post-RYGB patients with a Roux + ligament of Treitz to jejunojejunal anastomosis limb length less than 150 cm should first be offered deep enteroscopy-assisted ERCP. In patients with Roux + ligament of Treitz to jejunojejunal anastomosis (LTJJ) limb length 150 cm or longer, LA-ERCP should be the preferred approach because of the lack of need for a second procedure, equivalent morbidity and hospital stay, decreased endoscopist time, and decreased cost.

Proximal and large hyperplastic and nondysplastic serrated polyps detected by colonoscopy are associated with neoplasia.

BACKGROUND & AIMS: The family of serrated lesions includes hyperplastic polyps and sessile serrated adenomas without dysplasia, as well as traditional serrated adenoma with dysplasia. We investigated whether detection of proximal nondysplastic serrated polyps (ND-SP) at screening and surveillance colonoscopies is associated with advanced neoplasia. METHODS: The study included 3121 asymptomatic patients (aged 50-75 years) who had screening colonoscopies; 1371 had subsequent surveillance. The proximal colon was defined as segments proximal to the descending colon. Large ND-SP were defined as ≥ 10 mm. We compared rates of detection of any neoplasia and advanced neoplasia at screening and surveillance colonoscopies (within 5.5 years) in patients with and without proximal or large ND-SP. RESULTS: At baseline screening, 248 patients (7.9%) had at least 1 proximal ND-SP. They were more likely than patients with no proximal ND-SP to have advanced neoplasia (17.3% vs 10.0%; odds ratio [OR], 1.90; 95% confidence interval [CI], 1.33-2.70). Patients with large ND-SP (n = 44) were also more likely to have synchronous advanced neoplasia (OR, 3.37; 95% CI, 1.71-6.65). During surveillance, 39 patients with baseline proximal ND-SP and no neoplasia were more likely to have neoplasia compared with subjects who did not have polyps (OR, 3.14; 95% CI, 1.59-6.20). Among patients with advanced neoplasia at baseline, those with proximal ND-SP (n = 43) were more likely to have advanced neoplasia during surveillance (OR, 2.17; 95% CI, 1.03-4.59). CONCLUSIONS: Detection of proximal and large ND-SP at a screening colonoscopy is associated with an increased risk for synchronous advanced neoplasia. Detection of proximal ND-SP in a baseline colonoscopy is associated with an increased risk for interval neoplasia during surveillance.

Endoscopy in the obese patient.

Obese patients present many unique challenges to the endoscopist. Special consideration should be given to these patients, and endoscopists need to be aware of the additional challenges that may be present while performing endoscopic procedures on obese patients. This article reviews the special risks that obese patients face while undergoing endoscopy, endoscopic management of patients postbariatric surgery, and future role of endoscopy in the management of obese patients.

Bravo capsule placement in the gastric cardia: a novel method for analysis of proximal stomach acid environment.

BACKGROUND: Intragastric pH monitoring is currently done using catheter-based pH systems. This study assessed the feasibility of proximal intragastric pH recording with the Bravo wireless pH monitoring system using novel methodology. METHODS: Nine asymptomatic volunteers and 9 symptomatic patients were studied. One pH capsule was positioned under direct endoscopic visualization so that the device straddled the squamocolumnar junction (SCJ) with the attachment well positioned on squamous mucosa and the pH electrode 1.5-2 cm distal to the SCJ. A second capsule was placed 6 cm proximal to the SCJ. The signal from each capsule was recorded by a separate receiver synchronized for time. RESULTS: Successful placement and interpretable recording for >42 h from both pH capsules was achieved in 16 (88%) of 18 subjects. Data capture were 98.3% in the cardia and 97.7% in the esophagus. Two failures occurred due to premature capsule detachment (one esophageal and one gastric). The acid environment in the cardia was similar in asymptomatic controls and symptomatic patients and exhibited less meal-related buffering than is typical of more distal intragastric recordings. In addition, nadir gastric cardia pH was almost always less than nadir esophageal pH during reflux events. CONCLUSIONS: Twenty-four hour gastric cardia pH monitoring is feasible with the Bravo system and can be added to esophageal pH monitoring to assess concomitant cardia acidity. Instantaneous cardia pH defines the potential nadir esophageal pH during reflux events.

Comparison of the Bravo wireless and Digitrapper catheter-based pH monitoring systems for measuring esophageal acid exposure.

INTRODUCTION: We compared esophageal acid exposure data obtained during simultaneous esophageal pH studies using the Bravo wireless and the Slimline catheter-Mark III Digitrapper pH systems. METHODS: Twenty-five asymptomatic subjects underwent endoscopy with endoclip placement at the squamocolumnar junction (SCJ) and manometry to localize the lower esophageal sphincter (LES). A Bravo capsule was placed 6 cm above the SCJ and a Slimline catheter 5 cm above the LES. Relative positions were checked fluoroscopically. Synchronized pH data were compared by manual extraction into Excel spreadsheets. An in vivo pH reference was established with swallows of orange juice (pH 3.88). RESULTS: Median acid exposure time was greater with the Slimline compared to the Bravo system (Slimline, 3.4%; Bravo, 1.76%, p < 0.05) but electrode positions were similar. The dominant source of discrepancy between systems was an offset in recorded pH values around pH 4 as evidenced by the recorded values of the swallowed orange juice. Bench-top testing suggested that this offset was mainly attributable to the software designed to compensate for the difference in electrode recording characteristics between room and body temperature. After adjusting the pH data sets to accurately reflect actual orange juice pH, acid exposure between systems was similar (Slimline, 0.90%; Bravo, 1.15%). CONCLUSION: The Slimline system on average over-recorded esophageal acid exposure compared to the Bravo system largely because of a flawed software scheme for electrode thermal calibration. Accuracy of pH data sets from both systems can be improved by scrutiny for artifacts and use of an in vivo pH reference.