Subject(s)
Bile Duct Neoplasms , Cholestasis , Catheters , Humans , Metals , Stents , Treatment OutcomeABSTRACT
Background and study aims The COVID-19 pandemic has had a profound impact on gastroenterology training programs. We aimed to objectively evaluate procedural training volume and impact of COVID-19 on gastroenterology fellowship programs in the United States. Methods This was a retrospective, multicenter study. Procedure volume data on upper and lower endoscopies performed by gastroenterology fellows was abstracted directly from the electronic medical record. The study period was stratified into 2 time periods: Study Period 1, SP1 (03/15/2020 to 06/30/2020) and Study Period 2, SP2 (07/01/2020 to 12/15/2020). Procedure volumes during SP1 and SP2 were compared to Historic Period 1 (HP1) (03/15/2019 to 06/30/2019) and Historic Period 2 (HP2) (07/01/2019 to 12/15/2019) as historical reference. Results Data from 23 gastroenterology fellowship programs (total proceduresâ=â127,958) with a median of 284 fellows (range 273-289; representing 17.8â% of all trainees in the United States) were collected. Compared to HP1, fellows performed 53.6â% less procedures in SP1 (total volume: 28,808 vs 13,378; mean 105.52â±â71.94 vs 47.61â±â41.43 per fellow; P â<â0.0001). This reduction was significant across all three training years and for both lower and upper endoscopies ( P â<â0.0001). However, the reduction in volume was more pronounced for lower endoscopy compared to upper endoscopy [59.03â% (95â% CI: 58.2-59.86) vs 48.75â% (95â% CI: 47.96-49.54); P â<â0.0001]. The procedure volume in SP2 returned to near baseline of HP2 (total volume: 42,497 vs 43,275; mean 147.05â±â96.36 vs 150.78â±â99.67; P â=â0.65). Conclusions Although there was a significant reduction in fellows' endoscopy volume in the initial stages of the pandemic, adaptive mechanisms have resulted in a return of procedure volume to near baseline without ongoing impact on endoscopy training.
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Background and study aims Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) using a 15-mm lumen apposing metal stent (LAMS) has emerged as a viable alternative to surgical gastrojejunostomy for management of gastric outlet obstruction (GOO). However, given the size of the anastomosis created with a 15-mm LAMS, long-term luminal patency and clinical outcomes may be suboptimal. The aim of this study was to evaluate the technical feasibility, efficacy, and safety of EUS-GE with a large-diameter (20âmm) LAMS (LLAMS). Patients and methods A retrospective analysis of a prospectively maintained database of all patients undergoing EUS-GE with LLAMS between December 1, 2018 and September 30, 2020 was performed. All EUS-GEs were performed using a cautery-enhanced LLAMS. Results Thirty-three patients were referred for endoscopic management of GOO. Two patients were excluded due to a lack of an adequate window for EUS-GE. The remaining 31 patients (93.94â%) (mean age: 61.35â±â16.52 years; 54.84â% males) underwent EUS-GE using LLAMS for malignant (nâ=â23) and benign (nâ=â8) GOO. Technical success was achieved in all patients (100â%) with attempted EUS-GE. Complete clinical success (tolerance of regular diet) was achieved in 93.55â% of patients (nâ=â29). Two patients (6.45â%) had partial clinical success and died of unrelated causes prior to advancing diet beyond full liquids. Overall mean follow-up was 140.84â±â160.41 days (median 70, range 4-590). All stents remained patent with no evidence of recurrent GOO symptoms. One patient (3.23â%) developed an asymptomatic clean-based jejunal ulcer on 3-month follow-up endoscopy. Conclusions EUS-GE with LLAMS is a technically feasible, effective and safe option for patients with GOO allowing for tolerability of regular diet. Future prospective, ideally randomized studies comparing long-term outcomes of EUS-GE with 20- and 15-mm LAMS are required.
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BACKGROUND/AIMS: Endoscopic transpapillary gallbladder drainage (ETPGBD) is gaining popularity for the management of acute cholecystitis (AC) in high-risk patients. However, the stents placed during the procedure are not immune to obstruction. Here we describe a novel technique of stenting with two transpapillary stents and evaluate its technical feasibility, safety, and efficacy in AC. METHODS: A retrospective analysis of all patients undergoing ETPGBD using dual stents for AC at our institution between November 1, 2017 and August 31, 2020 was conducted. We abstracted patient data to evaluate technical and clinical success, adverse events, and long-term outcomes. Two stents were placed either during the index procedure or during an interval procedure performed 4-6 weeks after the index procedure. RESULTS: A total of 21 patients underwent ETPGBD with dual stenting (57.14% male, mean age: 62.14±17.21 years). The median interval between the placement of the first and the second stents was 37 days (range: 0-226 days). Technical and clinical success rates were 100%, with a recurrence rate of 4.76% (n=1) and adverse event rate of 9.52% (n=2) during a mean follow-up period of 471.74±345.64 days (median: 341 days, range: 55-1084 days). CONCLUSION: ETPGBD with dual gallbladder stenting is a safe and effective technique for long-term gallbladder drainage in non-surgical candidates. Larger controlled studies are needed to validate our findings for the widespread implementation of this technique.
Subject(s)
Cholangiopancreatography, Endoscopic Retrograde , Gastric Bypass , Endosonography , Gastrostomy , HumansABSTRACT
The mainstay of management of acute cholecystitis has been surgical, with percutaneous gallbladder drainage in patients deemed high risk for surgical intervention. Endoscopic management of acute cholecytitis with transpapillary and transmural drainage of the gall bladder is emerging as a viable alternative in high-risk surgical patients. In this article, we discuss the background, current status, technical challenges and strategies to overcome them, adverse events, and outcomes of endoscopic transpapillary gallbladder drainage for management of acute cholecystitis.
Subject(s)
Cholecystitis, Acute/therapy , Drainage , Endoscopy, Digestive System , Cholecystitis, Acute/diagnostic imaging , Cholecystitis, Acute/economics , Cost-Benefit Analysis , Drainage/adverse effects , Drainage/economics , Drainage/instrumentation , Endoscopy, Digestive System/adverse effects , Endoscopy, Digestive System/economics , Endoscopy, Digestive System/instrumentation , Health Care Costs , Humans , Stents , Time Factors , Treatment OutcomeABSTRACT
The mainstay of management of acute cholecystitis is surgical. Despite the advances in anesthesia and laparoscopic surgery, there is a significant pool of patients that are not candidates for surgery given their significant comorbidities and limited functional reserve. Historically percutaneous gallbladder drainage has been utilized to temporize these patients. Recently, endoscopic approaches are being explored with transpapillary and transmural drainage. In this article, we discuss the background, current status, technical challenges, adverse events, and outcomes of endoscopic ultrasound-guided gallbladder drainage for management of acute cholecystitis.
Subject(s)
Cholecystitis, Acute/surgery , Drainage/methods , Endosonography , Surgery, Computer-Assisted , Ultrasonography, Interventional/methods , Cholecystitis, Acute/diagnostic imaging , Gallbladder , Humans , Treatment OutcomeSubject(s)
Median Arcuate Ligament Syndrome/diagnosis , Abdominal Pain/etiology , Adult , Anesthetics, Local/therapeutic use , Aortography , Bupivacaine/therapeutic use , Celiac Plexus/surgery , Digestive System Surgical Procedures , Endosonography , Female , Ganglia, Sympathetic , Glucocorticoids/therapeutic use , Humans , Median Arcuate Ligament Syndrome/complications , Median Arcuate Ligament Syndrome/physiopathology , Median Arcuate Ligament Syndrome/therapy , Nausea/etiology , Nerve Block , Postprandial Period , Triamcinolone/therapeutic use , Ultrasonography, Doppler , Vomiting/etiologySubject(s)
Deglutition Disorders , Diverticulum, Esophageal , Eosinophilic Esophagitis , Esophageal Stenosis , Esophagoscopy/methods , Esophagus/surgery , Foreign Bodies/therapy , Administration, Oral , Alcoholism/complications , Budesonide/administration & dosage , Budesonide/therapeutic use , Deglutition Disorders/diagnosis , Deglutition Disorders/etiology , Deglutition Disorders/therapy , Diverticulum, Esophageal/diagnosis , Diverticulum, Esophageal/etiology , Diverticulum, Esophageal/therapy , Eosinophilic Esophagitis/complications , Eosinophilic Esophagitis/diagnosis , Eosinophilic Esophagitis/therapy , Esophageal Stenosis/diagnosis , Esophageal Stenosis/etiology , Esophageal Stenosis/therapy , Esophagus/diagnostic imaging , Esophagus/drug effects , Food/adverse effects , Foreign Bodies/diagnosis , Glucocorticoids/administration & dosage , Glucocorticoids/therapeutic use , Humans , Male , Middle Aged , Proton Pump Inhibitors/administration & dosage , Proton Pump Inhibitors/therapeutic use , Radiography, ThoracicSubject(s)
Acute-On-Chronic Liver Failure , Liver Cirrhosis , Liver , alpha 1-Antitrypsin Deficiency , Acute-On-Chronic Liver Failure/blood , Acute-On-Chronic Liver Failure/diagnosis , Acute-On-Chronic Liver Failure/etiology , Acute-On-Chronic Liver Failure/physiopathology , Diagnosis, Differential , Humans , Image-Guided Biopsy/methods , Liver/diagnostic imaging , Liver/pathology , Liver Cirrhosis/diagnosis , Liver Cirrhosis/etiology , Liver Function Tests/methods , Male , Middle Aged , Patient Care Management/methods , alpha 1-Antitrypsin/blood , alpha 1-Antitrypsin Deficiency/complications , alpha 1-Antitrypsin Deficiency/diagnosisABSTRACT
BACKGROUND/AIMS: Literature on the safety of endoscopic retrograde cholangiopancreatography (ERCP) in elderly patients is divided. Based on this we decided to examine the safety of ERCP in nonagenarian patients. METHODS: A total of 1,389 patients, with a mean age of 63.94±19.62 years, underwent ERCP during the study period. There were 74 patients aged 90 years or older with a mean age of 92.07±1.8. Logistic regression showed that nonagenarian patients had a significantly increased odds of in-patient mortality (adjusted odds ratio [AOR]=9.6; 95% confidence interval [CI]=4, 23; p≤0.001). Charlson Comorbidity Index (CCI) ≥2 was also an independent predictor of in-patient mortality (AOR=2.4; 95% CI=1.2, 5.2; p=0.021). Age ≥90 was not associated with increased adverse events; however emergency procedures (AOR=2.4; 95% CI=1.5, 4; p<0.001) and CCI ≥2 (AOR=2.6; 95% CI=1.7, 4.0; p<0.001) were more likely to have adverse events. CONCLUSIONS: Age ≥90 and CCI ≥2 are independently associated with increased odds of in-patient mortality in patients undergoing ERCP, whereas emergency procedures and CCI ≥2 are associated with an increased adverse event rate. Caution must be exercised when considering ERCP in patients aged ≥90 years and those with a CCI ≥2.
