Challenges of Endoscopic Management of Pancreaticobiliary Complications in Surgically Altered Gastrointestinal Anatomy

Pancreaticobiliary complications following various surgical procedures, including liver transplantation, are not uncommon and are important causes of morbidity and mortality. Therapeutic endoscopy plays a substantial role in these patients and can help to avoid the need for reoperation. However, the endoscopic approach in patients with surgically altered gastrointestinal (GI) anatomy is technically challenging because of the difficulty in entering the enteral limb to reach the target orifice to manage pancreaticobiliary complications. Additional procedural complexity is due to the need of special devices and accessories to obtain successful cannulation and absence of an elevator in forward-viewing endoscopes, which is frequently used in this situation. Once bilioenteric anastomosis is reached, the technical success rates achieved in expert hands approach those of patients with intact GI anatomy. The success of endoscopic therapy in patients with surgically altered GI anatomy depends on multiple factors, including the expertise of the endoscopist, understanding of postoperative anatomic changes, and the availability of suitable scopes and accessories for endoscopic management. In this issue of Clinical Endoscopy, the focused review series deals with pancreatobiliary endoscopy in altered GI anatomy such as bilioenteric anastomosis and post-gastrectomy.

The efficacy of sequential treatment for Helicobacter Pylori eradication.

Myanmar is a high prevalence area of H pylori infection with sero-prevalence rate of 69%. The clarithromycin-based triple therapy is commonly used as empiric first line treatment for H pylori infection in Myanmar. However, the efficacy of sequential treatment for Myanmar patients with H pylori infection has not been investigated. The objective of the present study is to determine the efficacy and safety of sequential treatment for Helicobacter pylori eradication in dyspeptic patients. A total of 100 dyspeptic patients aged > 18 years with proved Helicobacter pylori infection were randomly assigned to receive either 10 day sequential therapy or 10 day triple therapy. After completion of treatment, compliance and side effects were assessed. The outcomes of the eradication therapy were assessed 4 weeks after treatment by the 13C urea breath test. The success rate of H pylori eradication between the sequential therapy and the triple therapy was not significant (85.7% Vs 95.1%, p = 0.147). The triple therapy had 66.7% relative risk reduction (RRR), 9.4% absolute risk reduction (ARR) and 11 number need to treat (NNT). The adverse events between two study groups did not differ significantly (23.8% Vs 31.7%, P = 0.422). Good compliance was achieved in all patients of two study population. The result of this study could not prove that the efficacy of sequential treatment was superior to that of triple treatment for H pylori eradication in Myanmar dyspeptic patients.

H. pylori infection among Buddhist monks in the selected regions of Myanmar.

Background: The prevalence of H. pylori infection is different in various regions of Myanmar, and the results of studies are contradictory regarding incidence of H. pylori infection. The infection rate of H. pylori among the monks could reflect the prevalence of the particular region studied. Objectives: The present study was aimed to determine the Helicobacter pylori status among asymptomatic Buddhist monks in Myanmar, and to observe the efficacy of clarithromycin based first line therapy by using C14 Urea Breath Test (PY test). Method: The Buddhist monks 17 years of age and above from the monasteries of both middle and lower Myanmar were selected by purposive sampling method. After filling out the questionnaire,H.pylori infection was detected by 14C-UBT (PY test, microCOUNTLite Liquid Scintillation Counter). H.pylori positive subjects were treated with 10 days' course of clarithromycin containing standard triple therapy as a first line.14C-UBT test was repeated at week 4 to check for H.pylori eradication status. Results: A total of 399 monks (from Bago and Mandalay city) were enrolled in this study. The mean age was 23.51+/ 8.907 years (range: 18 - 97). Urea breath test was positive in 65.4% of the monks. The prevalence of H. pylori infection was radically similar in different monasteries of different cities: Bago and Mandalay (67.52% ν 63.18%, p = 0.33). Among H. pylori infected monks, 67.7% achieved eradication with clarithromycin containing standard triple therapy. Conclusion: High H. pylori infection rates were found in asymptomatic Buddhist Myanmar monks and the standard triple therapy had moderate efficacy.