Impact of COVID-19 Infection on Pancreato-Biliary Diseases Requiring Endoscopic Retrograde Cholangiopancreatography.

BACKGROUND: Viral infections are known to impact the pancreato-biliary system; however, there are limited data showing that the same is true of COVID-19. Endoscopic retrograde cholangiopancreatography (ERCP) can safely be performed in patients with COVID-19 infection, but outcomes of patients with COVID-19 infections and concomitant pancreatic and biliary disease requiring endoscopic intervention are unknown. AIMS: This study aims to evaluate the severity of pancreaticobiliary diseases and post-ERCP outcomes in COVID-19 patients. METHODS: Patients with pancreato-biliary disease that required inpatient ERCP from five centers in the United States and South America between January 1, 2020, and October 31, 2020 were included. A representative cohort of patients from each month were randomly selected from each site. Disease severity and post-ERCP outcomes were compared between COVID-19 positive and COVID-19 negative patients. RESULTS: A total of 175 patients were included: 95 COVID positive and 80 COVID negative. Mean CTSI score for the patients who had pancreatitis was higher in COVID-positive cohort by 3.2 points (p < .00001). The COVID-positive group had more cases with severe disease (n = 41) versus the COVID-negative group (n = 2) (p < .00001). Mortality was higher in the COVID-19 positive group (19%) compared to COVID-negative group (7.5%) even though the COVID-19-negative group had higher incidence of malignancy (n = 17, 21% vs n = 7, 7.3%) (p = 0.0455). CONCLUSIONS: This study shows that patients with COVID infection have more severe pancreato-biliary disease and worse post-ERCP outcomes, including longer length of stay and higher mortality rate. These are important considerations when planning for endoscopic intervention. CLINICALTRIALS: gov: (NCT05051358).

Endoscopic Ultrasound-Guided Gallbladder Drainage Versus Percutaneous Drainage in Patients With Acute Cholecystitis Undergoing Elective Cholecystectomy.

INTRODUCTION: Cholecystectomy (CCY) is the gold standard treatment of acute cholecystitis (AC). Nonsurgical management of AC includes percutaneous transhepatic gallbladder drainage (PT-GBD) and endoscopic ultrasound-guided gallbladder drainage (EUS-GBD). This study aims to compare outcomes of patients who undergo CCY after having received EUS-GBD vs PT-GBD. METHODS: A multicenter international study was conducted in patients with AC who underwent EUS-GBD or PT-GBD, followed by an attempted CCY, between January 2018 and October 2021. Demographics, clinical characteristics, procedural details, postprocedure outcomes, and surgical details and outcomes were compared. RESULTS: One hundred thirty-nine patients were included: EUS-GBD in 46 patients (27% male, mean age 74 years) and PT-GBD in 93 patients (50% male, mean age 72 years). Surgical technical success was not significantly different between the 2 groups. In the EUS-GBD group, there was decreased operative time (84.2 vs 165.4 minutes, P < 0.00001), time to symptom resolution (4.2 vs 6.3 days, P = 0.005), and length of stay (5.4 vs 12.3 days, P = 0.001) compared with the PT-GBD group. There was no difference in the rate of conversion from laparoscopic to open CCY: 5 of 46 (11%) in the EUS-GBD arm and 18 of 93 (19%) in the PT-GBD group ( P value 0.2324). DISCUSSION: Patients who received EUS-GBD had a significantly shorter interval between gallbladder drainage and CCY, shorter surgical procedure times, and shorter length of stay for the CCY compared with those who received PT-GBD. EUS-GBD should be considered an acceptable modality for gallbladder drainage and should not preclude patients from eventual CCY.

Technical and clinical success rates of WallFlex duodenal stents in unresectable malignant gastric outlet obstruction. A retrospective observational study from a tertiary cancer hospital in India.

Introduction: Gastric outlet obstruction (GOO) is one of the common symptoms/complications of many cancers. Endoscopic placement of a self-expandable metal stent has emerged as one of the best alternative treatment options for surgical gastrojejunostomy. Aim: We took up this study to find the technical and clinical success, and complication rates of duodenal stenting in such patients presented at India's largest tertiary care cancer hospital. Material and methods: This retrospective observational study included all patients who underwent endoscopic placement of an enteral WallFlex stent for malignant GOO between April 2013 and February 2019 at Tata Memorial Cancer Hospital, Mumbai, India. For estimation and improvement of symptoms, a GOO scoring system (GOOS) was used. The endpoints were defined as technical success, improvement of the GOO scoring system, and safety. Results: Technical and clinical success rates were 98.13% (210/214) and 91.42% (192/210), respectively. Complications included bleeding in 12 (5.60%), pancreatitis in 4 (1.86%), and sedation-related complications in 25 (11.68%) of the patients. In the mean follow-up period of 120 days (range: 90 to 270 days), recurrence of obstructive symptoms was observed in 66 (31.42%) of the patients. Tumour ingrowth in 59.09% (39/66), food impaction in 31.81% (21/66), and migration of the stent in 15.15% (10/66) of patients were reasons for recurrence. The median time between clinical success and recurrence of obstructive symptoms was 148 days (95% confidence interval (CI): 0-328). Conclusions: Placement of an enteral WallFlex stent in patients with malignant GOO is a practical, easy, and safe alternative to surgical gastrojejunostomy in malignant GOO.

Efficacy of levofloxacin, omeprazole, nitazoxanide, and doxycycline (LOAD) regimen compared with standard triple therapy to eradicate Helicobacter pylori infection: a prospective randomized study from a tertiary hospital in India.

AIM: In this study, the efficacy of 14-day triple therapy was compared with that of a novel ten-day LOAD regimen to eradicate Helicobacter pylori infection in India. BACKGROUND: Helicobacter pylorus infection is widespread in India. Resistance to antibiotics commonly used against Helicobacter pylori is increasing rapidly, leading to traditional triple therapy's lower success. Therefore, a search for a new regimen is needed. METHODS: In this randomized trial, patients with Helicobacter pylori infection were randomized to a group receiving LOAD therapy (levofloxacin 250 mg OD, omeprazole 40 mg BD, nitazoxanide 500 mg BD, and doxycycline 100 mg OD) for ten days or a group receiving standard triple therapy (pantoprazole 80 mg, amoxicillin 2000 mg, and clarithromycin 1000 mg daily) in divided doses for 14 days). Gastric biopsy/RUT was done 10-12 weeks after completing therapy to confirm Helicobacter pylori eradication. RESULTS: Eradication rates were significantly greater with the LOAD regimen than with standard triple therapy on both intention-to-treat analysis (82.75% vs. 60.26%, p = 0.001; difference, 22.49% [95% CI, 8.5-18%] and per-protocol analysis (83.3% vs. 62.75%, p = 0.002; difference, 20.55% [95% CI, 7.1-22.5%]). Both treatment regimens were well tolerated. CONCLUSION: Although the rate of eradication of H. pylori infection was significantly higher with the LOAD regimen than triple therapy, the efficacy was still suboptimal, possibly because of fluoroquinolone resistance or the short course of treatment.

Is endoscopist-directed sedation for endoscopic retrograde cholangiopancreatography with balanced propofol solution (BPS) practical and safe? A prospective study from a tertiary care centre in India.

INTRODUCTION: Endoscopist-directed, nurse-administered sedation using propofol, midazolam, and fentanyl for endoscopic retrograde cholangiopancreatography (ERCP) is being utilized worldwide. However, this is not usually employed in India by endoscopists. AIM: To assess the efficacy, acceptability, and safety of this sedation in low to moderate risk patients undergoing ERCP. MATERIAL AND METHODS: This was a prospective study involving 500 patients with any indication for ERCP. The sedation was given by trained nurses. RESULTS: The sedative dosages per patient were as follows: propofol = 90 ±20 mg, fentanyl 0.75 ±0.25 mg (range: 0.25-1.00 mg), and midazolam 2 ±0.5 mg (range: 1-3 mg). Ninety-seven percent of patients achieved Richmond agitation sedation score of ≥ -3, and 96.8% achieved Gloucester comfort score of ≤ 2. 4.22% of the patients had mild adverse events (AE), and 2.11% had moderate AE. Two (0.4%) patients required intubation and intensive care unit admission. Mean recovery time was 15.3 min. 98.3% of the endoscopists were satisfied with the sedation achieved. 31.2% of the patients remembered the procedure. 93% of the patients were satisfied with the type of sedation. 92.75% of ERCPs were successful. 7.59% had procedure-related complications: in the form PEP - 5.290%, significant bleeding - 1.08%, and perforation - 0.43%. CONCLUSIONS: Endoscopist-directed, nurse-administered sedation for ERCP with balanced propofol solution is practical, efficient, time saving, safe, and acceptable to patients.

Transradial versus transfemoral approach for coronary angiography and angioplasty - A prospective, randomized comparison.

BACKGROUND: PCI has been done traditionally through transfemoral route. But now transradial and transbrachial routes are also coming up in practice. We compared transradial versus transfemoral routes for ease of operability, time for procedure, complications, and failure rates through a prospective study. METHODS: Four hundred Patients admitted in department of cardiology for percutaneous interventions were enrolled in the study. 200 patients were assigned to each group randomly. A single team did all the procedures. Pre procedure, intra procedure and post procedure data of all the patients was collected, tabulated and analysed properly. RESULTS: Access time (6.0 ± 1vs 4.2 ± 0.7; P =0.001); Fluoroscopy time and overall procedure time (29 ± 11.3 Vs. 27.3 ± 12.4 min) were more with trans radial than transfemoral route, respectively. The most common post procedure complication, ecchymosis was seen in 20.5% in transfemoral group compared to 12.5% in transradial group (P 0.031). Thrombophelibites (17.5 VS 8%, P0.004); Hematoma (14.5 Vs 0%, P 0.005); post procedure access bleed (7 VS 3%, P 0.039) were seen in transfemoral than transradial group, respectively. Failure rates were almost similar. None of our patients had post procedure myocardial infarction, stroke, acute renal failure and infections. CONCLUSION: Transradial approach of PCI is better than transfemoral route with respect to complications like bleeding, haematoma formation, thrombophelebites and ecchymosis is concerned. However access and fluoroscopic time is more with the former. We recommend the transradial route for PCI. TRIAL REGISTRATION: Trial is retrospectively registered in ClinicalTrials.gov with the Identifier: NCT02983721 , Date of registration is December 2, 2016.

Osmotic Demyelination Syndrome; Treated with Re Lowering of Serum Sodium.

PURPOSE: This case report demonstrates that if serum sodium is re lowered early in the course of Osmotic demyelination syndrome (ODS), many of its devastating consequences may be avoided. In animal models, initiation of re-lowering within four hours of symptom onset has been associated with better outcomes than initiation within eight to ten hours of symptom onset. As there is no effective therapy for the condition we suggest a trial of re lowering of serum sodium early in its course. CASE REPORT: A 33 years old woman who was on diuretics presented to us with delirium in the form of hypo responsiveness for two to three days after suffering from an acute gastroenteritis. On evaluation she was found to have hyponatremia that was corrected too rapidly and was followed by an initial improvement and later worsening of neurological signs. T2 weighted MRI of the brain showed hyperintense lesions in pons and in extra pontine areas including thalamus and cerebellum. The patient was diagnosed to be suffering from osmotic demyelinating syndrome. Re-lowering of the patient's serum sodium with dextrose 5% and desmopressin was tried along with aggressive supportive treatment. Patient was reassessed after regular intervals and at 6 months post treatment patient has recovered almost completely and is living an independent life. CONCLUSION: Based on the absence of other effective therapies, and the poor prognosis associated with ODS, it is suggested re-lowering the serum sodium to a level that is just below the maximal target value at 48 hours of less than 18 meq/L above the initial serum sodium. Re-lowering therapy should be initiated as quickly as possible after the onset of neurologic symptoms that are attributed to ODS.

Carcinoma of the breast presenting as deep vein thrombosis of the axillary vein.

BACKGROUND: Breast cancer is the most common type of malignancy in the female population, rarely is reported by thromboembolic events during the course of the disease. In this case, we present a rare case of breast cancer presenting as deep vein thrombosis of the axillary vein. CASE PRESENTATION: A 40-year- old female was admitted due to pain and swelling of her right arm and forearm of two months' duration. The right arm was grossly edematous with pitting edema. Breast examination showed non-tender fixed nodules in the right outer quadrant of the right breast. Doppler ultrasonography showed right axillary vein thrombosis. The pathologic examination of the nodules confirmed infiltrating ductal adenocarcinoma. CONCLUSION: This case highlights the procoagulant state of malignancies and it is important to remember that though rare, breast malignancies can present as deep venous thrombosis. This case also highlights the early and aggressive evaluation of any breast discharge to rule out carcinoma of the breast.