Endoscopic Drainage of >50% of Liver in Malignant Hilar Biliary Obstruction Using Metallic or Fenestrated Plastic Stents.

OBJECTIVES: Endoscopic drainage of complex hilar tumors has generally resulted in poor outcomes. Drainage of >50% of liver volume has been proposed as optimal, but not evaluated using long multifenestrated plastic stents (MFPS) or self-expanding metal stents (SEMS). We evaluated outcomes of endoscopic drainage of malignant hilar strictures using optimal strategy and stents, and determined factors associated with stent patency, survival, and complications. METHODS: Cross-sectional study was conducted at an academic center over 5 years. MFPS (10 French or 8.5 French) or open-cell SEMS were used for palliation of unresectable malignant hilar strictures, with imaging-targeted drainage of as many sectors as needed to drain >50% of viable liver volume. Risk factors were evaluated using regression analysis. The cumulative risk was assessed using Kaplan-Meier analysis. RESULTS: 77 patients with malignant hilar biliary strictures (median Bismuth IV) underwent targeted stenting (41 MFPS and 36 SEMS). Comparing MFPS vs. SEMS, technical success (95.1 vs. 97.2%, P=0.64), clinical success (75.6 vs. 83.3%, P=0.40), frequency of multiple stents (23/41 vs. 25/36, P=0.19), survival and adverse events were similar, but stent patency was significantly shorter (P<0.0001). Factors associated with survival were Karnofsky score and serum bilirubin level at presentation. Outcomes were independent of Bismuth class with acceptable results in Bismuth III and IV. CONCLUSIONS: Endoscopic biliary drainage with MFPS or open-cell SEMS targeting >50% of viable liver resulted in effective palliation in patients with complex malignant hilar biliary strictures. Patency was shorter in the MFPS group, but similar survival and complications were found when comparing MFPS and SEMS group.

"Wet suction technique (WEST)": a novel way to enhance the quality of EUS-FNA aspirate. Results of a prospective, single-blind, randomized, controlled trial using a 22-gauge needle for EUS-FNA of solid lesions.

BACKGROUND: Contemporary EUS-guided FNA techniques involve the use of a needle, with an air column within the lumen, with or without suction. We describe a novel technique with an aim to improve the quality of the aspirate. OBJECTIVE: To compare a novel "wet suction" technique (WEST) with the conventional FNA technique (CFNAT) of EUS-guided FNA using a 22-gauge FNA needle. DESIGN: Prospective, single-blind, and randomized trial. SETTING: Two large tertiary-care hospitals. PATIENTS: All consecutive adult patients presenting for EUS with possible FNA of solid lesions were offered the chance to participate in the study. METHODS: All lesions were sampled with the same needle by using alternating techniques. Patients were randomized to the WEST versus the CFNAT for the first pass. If the first pass was made with the WEST, the second pass was made with the CFNAT, and subsequent passes were made in an alternating manner by using the same sequence. All FNAs were performed using 22-gauge needles. MAIN OUTCOME MEASUREMENTS: Specimen adequacy, cellularity, and blood contamination of EUS-guided FNA aspirates graded on a predefined scale. RESULTS: The WEST yielded significantly higher cellularity in a cell block compared with the CFNAT, with a mean cellularity score of 1.82±0.76 versus 1.45±0.768 (P<.0003). The WEST cell block resulted in a significantly better specimen adequacy of 85.5% versus 75.2% (P<.035). There was no difference in the amount of blood contamination between the 2 techniques. LIMITATIONS: Lack of cross check and grading by a second cytopathologist. CONCLUSION: The novel WEST resulted in significantly better cellularity and specimen adequacy in cell blocks of EUS-guided FNA aspirate of solid lesions than the CFNAT.

Urgent ERCP with pancreatic stent placement or replacement for salvage of post-ERCP pancreatitis.

BACKGROUND AND STUDY AIMS: Urgent placement or replacement of pancreatic stents shortly after endoscopic retrograde cholangiopancreatography (ERCP) might attenuate the course of evolving post-ERCP pancreatitis (PEP). PATIENTS AND METHODS: Salvage ERCP with de novo pancreatic stent placement or replacement of outwardly migrated stents was performed within 2 - 48 hours in patients with evolving PEP accompanied by severe pain, systemic inflammatory response syndrome (SIRS), and major elevations in serum amylase and lipase. Serial pain scores, amylase and lipase levels, and hospital course were studied. RESULTS: PEP according to Cotton consensus criteria developed after 64 (2 %) of 3216 ERCPs over 3 years. Of the 64 patients with PEP, 14 underwent salvage ERCP (5 without and 9 with prior pancreatic stents, 7 of which had migrated outwards prematurely). All patients had SIRS and a high score (≥ 3) for the bedside index for severity in acute pancreatitis. Median clinical onset of PEP was at 5 hours (range 0 - 68 hours) in patients with prophylactic pancreatic stents vs. 2 hours (range 0.5 - 2.5 hours) in patients without prophylactic pancreatic stents (P < 0.05). Salvage ERCP was performed at a median of 10 hours (interquartile range [IQR] 2.4 - 22.7 hours). Improvement in pain, amylase, lipase, and resolution of SIRS were statistically significant at 24 hours after salvage ERCP (P = 0.003). Median length of hospital stay was 2 days (IQR 1 - 4.75). No necrotizing pancreatitis or late complications occurred. CONCLUSION: Urgent salvage ERCP with de novo pancreatic stent placement or replacement of a migrated stent is a novel approach in the setting of early PEP, and was associated with rapid resolution of clinical pancreatitis and reduction in levels of amylase and lipase.

Difficult biliary access at ERCP.

Endoscopic retrograde cholangiopancreatography allows intervention for a variety of diseases of the biliary tract. Cannulation of the bile duct is the prerequisite step for biliary intervention. Although obtaining biliary access is straightforward in many cases, it can occasionally be challenging. Multiple devices, all with additional wire-guided techniques, have been developed to aid cannulation. More advanced techniques have also been developed to aid biliary access if it is unsuccessful with standard devices. Multimodality techniques can be used if other approaches fail. This article provides an evidence-based discussion of these approaches, and provides insight into their appropriate application.

Update on biliary and pancreatic sphincterotomy.

PURPOSE OF REVIEW: To summarize the indications, success rates and complications associated with endoscopic sphincterotomy and endoscopic balloon dilation (EBD). RECENT FINDINGS: Pancreatic and/or biliary sphincterotomies are essential components of most current therapeutic endoscopic retrograde cholangiopancreatography (ERCP). A current large body of evidence has established biliary sphincterotomy as effective in extraction of bile duct stones. The most common complications of biliary sphincterotomy are post-ERCP pancreatitis, as well as acute or delayed hemorrhage, the risks for which can be stratified according to well described patient and procedure related factors. Evidence is accumulating that pancreatic sphincterotomy is useful in at least some settings for treatment of sphincter of Oddi dysfunction, chronic pancreatitis, and pancreas divisum. EBD provides an adjunct or an alternative to biliary sphincterotomy for extraction of stones from the bile duct when routine biliary sphincterotomy is inadequate or risk excessive. SUMMARY: Sphincterotomy and EBD are useful in managing a variety of pancreatobiliary conditions. Attention to risks of these procedures is essential for their efficacy and safety.

Clinical Significance of Isolated Peri-Appendiceal Lesions in Patients With Left Sided Ulcerative Colitis.

BACKGROUND: Ulcerative colitis is classically described as a condition originating in the rectum and extending proximally towards the cecum. In recent years, a discontinuous peri-appendiceal lesion has been described. Our aim was to evaluate the risk of progression to pancolitis in patients presenting with an isolated peri-appendiceal lesion on ileocolonoscopy. METHODS: Endoscopy databases at three tertiary care centers were searched for patients undergoing ileocolonoscopy for diagnosis or surveillance of ulcerative colitis. Patients with isolated periappendiceal lesions as well as histologically confirmed left sided colitis were enrolled. Controls were defined as patients with left-sided ulcerative colitis without evidence of peri-appendiceal inflammation. The main outcome was the need for escalation of therapy to systemic corticosteroids, immunomodulators or biologic agents. Secondary outcomes were progression to pancolitis or requirement for colectomy. A secondary analysis of other risk factors for proximal extension/progression of colitis was also performed. RESULTS: We identified 228 patients with ulcerative colitis, 123 were included in the analysis. Four point eight percent of patients had isolated peri-appendiceal lesions. In the group with peri-appendiceal lesions, 47.4% required escalation of therapy vs. 70% in the control group (P = 0.53). There was no difference in progression to pan-colitis or colectomy rates between the two groups. Progression was not predicted by inflammatory markers, age, gender, initial Mayo UC score or IBD therapy utilization. CONCLUSIONS: The presence of isolated peri-appendiceal lesions is not a risk factor for future escalation of therapy for ulcerative colitis and is not correlated with proximal extension of disease.

Impact of preoperative endoscopic ultrasound on non-small cell lung cancer staging.

AIM: To determine if the addition of preoperative endoscopic ultrasound (EUS) to non-small cell lung cancer staging can reduce the proportion of patients in whom malignant mediastinal lymph nodes (inoperable disease) are discovered at surgery. METHODS: All patients with lung cancer who underwent mediastinoscopy or thoracotomy for cancer diagnosis, staging, or treatment from 1999 to 2005 were identified. Patients who had undergone preoperative EUS were designated as the EUS group. The control group was composed of similar patients who had not undergone preoperative EUS, and were frequency matched to those in the EUS group in a 3:1 ratio by preoperative cancer stage. The proportion of patients in whom malignant mediastinal lymph nodes were diagnosed at surgery was the primary outcome. RESULTS: Forty-four patients (average age, 67.8 years) met criteria for the EUS group, and 132 patients (average age, 67.4 years) were selected as control subjects. Overall, in the EUS group, 3 of 44 patients (6.8%) were found to have malignant mediastinal lymph nodes at surgery, compared with 41 of 132 patients (31.1%) in the control group (p = 0.003). In patients undergoing thoracotomy for cancer resection, 3% in the EUS group, compared with 20% in the control group, were found to have malignant mediastinal lymph nodes at surgery (p = 0.01). There was also a trend toward lower yield of mediastinoscopy done for cancer diagnosis or staging in the EUS group (p = 0.08). CONCLUSIONS: Preoperative EUS in lung cancer patients may reduce unnecessary surgery at which advanced inoperable disease is discovered.