Transpapillary drainage has no added benefit on treatment outcomes in patients undergoing EUS-guided transmural drainage of pancreatic pseudocysts: a large multicenter study.

BACKGROUND AND AIMS: The need for transpapillary drainage (TPD) in patients undergoing transmural drainage (TMD) of pancreatic fluid collections (PFCs) remains unclear. The aims of this study were to compare treatment outcomes between patients with pancreatic pseudocysts undergoing TMD versus combined (TMD and TPD) drainage (CD) and to identify predictors of symptomatic and radiologic resolution. METHODS: This is a retrospective review of 375 consecutive patients with PFCs who underwent EUS-guided TMD from 2008 to 2014 at 15 academic centers in the United States. Main outcome measures included TMD and CD technical success, treatment outcomes (symptomatic and radiologic resolution) at follow-up, and predictors of treatment outcomes on logistic regression. RESULTS: A total of 375 patients underwent EUS-guided TMD of PFCs, of which 174 were pseudocysts. TMD alone was performed in 95 (55%) and CD in 79 (45%) pseudocysts. Technical success was as follows: TMD, 92 (97%) versus CD, 35 (44%) (P = .0001). There was no difference in adverse events between the TMD (15%) and CD (14%) cohorts (P = .23). Median long-term (LT) follow-up after transmural stent removal was 324 days (interquartile range, 72-493 days) for TMD and 201 days (interquartile range, 150-493 days) (P = .37). There was no difference in LT symptomatic resolution (TMD, 69% vs CD, 62%; P = .61) or LT radiologic resolution (TMD, 71% vs CD, 67%; P = .79). TPD attempt was negatively associated with LT radiologic resolution of pseudocyst (odds ratio, 0.11; 95% confidence interval, 0.02-0.8; P = .03). CONCLUSIONS: TPD has no benefit on treatment outcomes in patients undergoing EUS-guided TMD of pancreatic pseudocysts and negatively affects LT resolution of PFCs.

Low vitamin D level is an independent predictor of poor outcomes in Clostridium difficile-associated diarrhea.

BACKGROUND: The incidence, recurrence, and all-cause mortality rate for Clostridium difficile-associated diarrhea (CDAD) has increased markedly over the past 10 years despite treatment. Low vitamin D levels are known to impair immune responses to infection and are associated with increased mortality. We compared the role of patient comorbidity measured by the Charlson Comorbidity Index (CCI) with vitamin D levels to ascertain whether vitamin D levels were an independent variable affecting the outcome of CDAD or a marker of overall comorbidity. METHODS: A prospective cohort study studied 62 patients hospitalized between 2008 and 2009 with manifestations of CDAD and a positive C. difficile toxin assay. All patients received standard antibiotics (metronidazole and/or vancomycin). Their status at 30-day follow up was classified as resolved or recurred/expired. Patients' CCI was calculated using their medical history. Logistic regression analysis of variables including 25-hydroxyvitamin D, CCI, age, gender, white blood cell count (WBC), albumin and residence type were performed. RESULTS: There were 62 patients (43.6% men, 56.4% women) with CDAD; mean age was 75 ± 17 years. At 30-day follow up, 28 (45.2%) expired, 10 (16.1%) had persistent or recurrent diarrhea and 24 (38.7%) resolved. Nonresolution was seen in 38 (61.3%). There was no significant association between 30-day resolution status and CCI, gender, WBC, albumin level or residence type. Two variables were found to be independent predictors of resolution of CDAD: normal vitamin D levels (p = 0.028) and age <70 years (p = 0.024). Subjects with low vitamin D were 4.75 times more likely to fail to resolve CDAD than subjects with normal Vitamin D. CONCLUSION: In this study, vitamin D level and age are independent predictors of CDAD resolution in hospitalized patients. Low vitamin D levels and age >70 years old are associated with increased likelihood of recurrence. Low vitamin D levels are not a marker of comorbidity or advanced age.