Allopurinol to prevent pancreatitis after endoscopic retrograde cholangiopancreatography: a randomized placebo-controlled trial.

BACKGROUND & AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is associated with a risk of pancreatitis (PEP). Animal studies suggest that (single-dose) allopurinol (xanthine oxidase inhibitor with high oral bioavailability and long-lasting active metabolites) may reduce this risk; human study results are conflicting. The aim of this study was to determine if allopurinol decreases the rate of PEP. METHODS: Patients referred for ERCP to 9 endoscopists at 2 tertiary centers were randomized to receive either allopurinol 300 mg or identical placebo orally 60 minutes before ERCP, stratified according to high-risk ERCP (manometry or pancreatic therapy). The primary outcome (PEP) was adjudicated blindly; pancreatitis was defined according to the Cotton consensus, and evaluated at 48 hours and 30 days. Secondary outcomes included severe PEP, length of stay, and mortality (nil). The trial was terminated after the blinded (midpoint) interim analysis, as recommended by the independent data and safety monitoring committee. RESULTS: We randomized 586 subjects, 293 to each arm. The crude PEP rates were 5.5% (allopurinol) and 4.1% (placebo), (P = .44; difference = 1.4%; 95% confidence interval, -2.1% to 4.8%). The Mantel-Haenszel combined risk ratio for PEP with allopurinol, considering stratification, was 1.37 (95% confidence interval, 0.65-2.86). Subgroup analyses suggested nonsignificant trends toward possible benefit in the high-risk group, and possible harm for the remaining subjects. Logistic regression found pancreatic therapy, pancreatic injection, and prior PEP to be the only independent predictors of PEP. CONCLUSIONS: Allopurinol does not appear to reduce the overall risk of PEP; however, its potential benefit in the high-risk group (but potential harm for non-high-risk patients) means further study is required.

Endoscopic ultrasound in the diagnosis and treatment of pancreatic disease.

Endoscopic ultrasound (EUS) is an important part of modern gastrointestinal endoscopy and now has an integral role in the diagnostic evaluation of pancreatic diseases. Furthermore, as EUS technology has advanced, it has increasingly become a therapeutic procedure, and the prospect of multiple applications of interventional EUS for the pancreas is truly on the near horizon. However, this review focuses on the established diagnostic and therapeutic roles of EUS that are used in current clinical practice. In particular, the diagnostic evaluation of acute pancreatitis, chronic pancreatitis, cystic pancreatic lesions and solid masses of the pancreas are discussed. The newer enhanced imaging modalities of elastography and contrast enhancement are evaluated in this context. The main therapeutic aspects of pancreatic EUS are then considered, namely celiac plexus block and celiac plexus neurolysis for pain control in chronic pancreatitis and pancreas cancer, and EUS-guided drainage of pancreatic fluid collections.

Magnetic imaging-assisted colonoscopy vs conventional colonoscopy: a randomized controlled trial.

AIM: To compare magnetic imaging-assisted colonoscopy (MIC) with conventional colonoscopy (CC). METHODS: Magnetic imaging technology provides a computer-generated image of the shape and position of the colonoscope onto a monitor to give visual guidance to the endoscopist. It is designed to improve colonoscopy performance and tolerability for patients by enabling visualization of loop formation and endoscope position. Recently, a new version of MIC technology was developed for which there are limited data.To evaluate this latest generation of MIC among experienced rather than inexperienced or trainee endoscopists, a prospective randomized trial was performed using only gastroenterologists with therapeutic endoscopy training. Consecutive patients undergoing elective outpatient colonoscopy were randomized to MIC or CC, with patients blinded to their group assignment. Endoscopic procedural metrics and quantities of conscious sedation medications were recorded during the procedures. The procedure was classified as "usual" or "difficult" by the endoscopist at the conclusion of each case based on the need for adjunctive maneuvers to facilitate endoscope advancement. After more than one hour post-procedure, patients completed a 10 cm visual analogue pain scale to reflect the degree of discomfort experienced during their colonoscopy. The primary outcome was patient comfort expressed by the visual analogue pain score. Secondary outcomes consisted of endoscopic procedural metrics as well as a sedation score derived from standardized dose increments of the conscious sedation medications. RESULTS: Two hundred fifty-three patients were randomized and underwent MIC or CC between September 2011 and October 2012. The groups were similar in terms of the indications for colonoscopy and patient characteristics. There were no differences in cecal intubation rates (100% vs 99%), insertion distance-to-cecum (82 cm vs 83 cm), time-to-cecum (6.5 min vs 7.2 min), or polyp detection rate (47% vs 52%) between the MIC and CC groups. The primary outcome of mean pain score (1.0 vs 0.9 out of 10, P = 0.41) did not differ between MIC and CC groups, nor did the mean sedation score (8.2 vs 8.5, P = 0.34). Within the subgroup of cases considered more challenging or difficult, time-to-cecum was significantly faster with MIC compared to CC, 10.1 min vs 13.4 min respectively (P = 0.01). Sensitivity analyses confirmed a similar pattern of overall findings when each endoscopist was considered separately, demonstrating that the mean results for the entire group were not unduly influenced by outlier results from any one endoscopist. CONCLUSION: Although the latest version of MIC resulted in faster times-to-cecum within a subgroup of more challenging cases, overall it was no better than CC in terms of patient comfort, sedation requirements and endoscopic procedural metrics, when performed in experienced hands.

Endoscopic therapy for bile leak based on a new classification: results in 207 patients.

BACKGROUND: Bile leak is among the most common complications of cholecystectomy. Endoscopic therapy is empiric; a systematic approach to management of bile leak has not been established. METHODS: The severity of bile leak was classified by endoscopic retrograde cholangiography into low grade (leak identified only after intrahepatic opacification) or high grade (leak observed before intrahepatic opacification). Therapy was based on this distinction: biliary sphincterotomy alone for low-grade leaks and stent placement for high-grade leaks. The success of this strategy in consecutive patients treated between 1989 and 1999 was reviewed. RESULTS: A total of 207 patients (127 women, 80 men; median age 57 years) with bile leak were referred for endoscopic management; 134 had undergone laparoscopic, and 72 had open cholecystectomy. Patients presented at a median of 9 days (range 1-50 days) after surgery. Symptoms included pain (56%), jaundice (16%), fever (11%), and abdominal distension (7%). Persistent percutaneous drainage was present in 48%. Endoscopic retrograde cholangiography identified the leak site in 204 patients: cystic duct stump, 159 patients (78%); duct of Luschka, 26 (13%); other, 19 (9%). Of 104 patients with low-grade leaks, 75 had sphincterotomy alone; improvement occurred in 68 patients (91%). Subsequent treatment was required in 7 patients (6 stent, 1 surgery). Stents were placed in the remaining 29/104 patients for the following reasons: biliary stricture (11/29); coagulopathy, precluding sphincterotomy (8/29); severe sepsis (3/29); inadequate drainage after prior sphincterotomy (2/29); and unclear reasons (5/29). Of 100 patients with high-grade leaks, 97 had stent placement. Persistent leakage necessitated another stent insertion in 4 patients. Closure of the leak was documented by endoscopic retrograde cholangiography in all 97 patients. Three patients with leaks not amenable to endoscopic treatment were referred for surgery. Bile-duct stones were identified in 41 patients (28, low-grade group; 13, high-grade group) and were extracted in all cases. Overall, complications occurred in 3 patients (2 pancreatitis, 1 perforation) and were managed conservatively with no mortality. CONCLUSIONS: A simple, practical endoscopic classification system for bile leak after cholecystectomy is proposed. This classification has clinical relevance for selection of optimal endoscopic management.