Ali Akbar

Rectal Nonsteroidal Anti-inflammatory Drugs Are Superior to Pancreatic Duct Stents in Preventing Pancreatitis After Endoscopic Retrograde Cholangiopancreatography: A Network Meta-analysis

BACKGROUND & AIMS Placement of pancreatic duct (PD) stents prevents pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). There is evidence that rectal administration of nonsteroidal anti-inflammatory drugs (NSAIDs) also prevents post-ERCP pancreatitis, but the 2 approaches alone have not been compared directly. We conducted a network meta-analysis to indirectly compare the efficacies of these procedures. METHODS PubMed and Embase were searched by 2 independent reviewers to identify full-length clinical studies, published in English, investigating use of PD stent placement and rectal NSAIDs to prevent post-ERCP pancreatitis. We identified 29 studies (22 of PD stents and 7 of NSAIDs). We used network meta-analysis to compare rates of post-ERCP pancreatitis among patients who received only rectal NSAIDs, only PD stents, or both. RESULTS Placement of PD stents and rectal administration of NSAIDs were each superior to placebo in preventing post-ERCP pancreatitis. The combination of rectal NSAIDs and stents was not superior to either approach alone. Pooled results showed that rectal NSAIDs alone were superior to PD stents alone in preventing post-ERCP pancreatitis (odds ratio, 0.48; 95% confidence interval, 0.26-0.87). CONCLUSIONS Based on a network meta-analysis, rectal NSAIDs alone are superior to PD stents alone in preventing post-ERCP pancreatitis, and should be considered first-line therapy for selected patients. However, these findings were limited by the small number of studies assessed (only 29 studies), potential publication bias, and the indirect nature of the comparison. High-quality, randomized, controlled trials are needed to compare these 2 interventions and confirm these findings.

Endoscopic treatment of nonstricture-related benign biliary diseases using covered self-expandable metal stents.

BACKGROUND AND STUDY AIMS Nonstricture benign biliary diseases (BBDs) such as leaks, perforations, and bleeding, have been traditionally managed by placement of one or more plastic stents. Emerging data support the use of covered, self-expandable, metal stents (CSEMSs). The aim of this study was to assess the outcomes of endoscopic temporary placement of CSEMS in patients with nonstricture BBD. PATIENTS AND METHODS This was a retrospective study of CSEMS placement for BBD between May 2005 and August 2013 at two tertiary care centers. The main outcome measures were resolution of perforation, bleeding, leak, and adverse events related to CSEMS treatment. RESULTS A total of 87 patients were included (median age 62 years [range 18 - 86]). Indications for stent placement were bile leaks (n = 35, 40 %), bleeding (n = 27, 31 %), perforation (n = 18, 21 %), and other conditions (n = 7, 8 %). Fully and partially covered 8 - 10-mm diameter CSEMS were placed and subsequently removed in all 87 patients (100 %). Resolution of the underlying problem was achieved for 33 bile leaks (94 %), 25 bleedings (93 %), 18 perforations (100 %), and for 3 cases with other indications (43 %). The median duration of stenting was 9 weeks in patients with biliary leaks, 3 weeks for bleeding, and 9.5 weeks for perforations. Median follow-up was 82 weeks after stent removal. Seven adverse events occurred, including cholangitis in six patients (7 %), and tissue hyperplasia leading to difficulty in the removal of a partially covered SEMS in one patient. CONCLUSIONS Nonstricture BBD can be effectively and safely treated with the short term placement of CSEMS. .

Placement of fully covered self-expandable metal stents to control entry-related bleeding during transmural drainage of pancreatic fluid collections (with video)

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Use of covered self-expandable metal stents for endoscopic management of benign biliary disease not related to stricture (with video)

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Covered self-expanding metal stent use in the pancreatic duct: a case series.

Plastic stents have been used in the pancreatic duct for a variety of indications. However, unlike in the bile duct, the use of covered self-expanding metal stents (CSEMSs) has been discouraged because multiple side branches drain into main pancreatic duct (MPD) and the ductal diameter is relatively small. This report aims to describe our experience using CSEMSs in the pancreatic duct in a series of nine patients, with special focus on adverse events. Indications were strictures (n = 5), intraductal mucinous neoplasm (IMPN; n = 1), pancreatic duct leak (n = 1), disconnected duct syndrome (n = 1), and severe acute pancreatitis/necrosis with disrupted duct (n = 1). Eight patients had symptomatic improvement, or radiological resolution of or improvement in their strictures, leaks, perforation, and necrosis. Two of these have indwelling CSEMSs for ongoing treatment. One patient (disconnected duct syndrome) was considered a treatment failure as the stent migrated and the patient underwent distal pancreatectomy for refractory pain. Two patients underwent pancreaticoduodenectomy for their malignancies after their CSEMSs had been in place for 43 and 49 days, respectively. Importantly no patients, including those with indwelling CSEMSs, developed stent-related acute pancreatitis with a median follow-up of 4 months. One patient developed post-procedure pain requiring hospitalization for 1 day. Median stent duration was 77 days. These observations suggest there is a potential role for the use of CSEMSs in the MPD in selected patients with pancreatic pathology.

Ischemic biliary injury following extra-corporeal membrane oxygenation (ECMO)

Extra-corporeal membrane oxygenation (ECMO) is occasionally sed in adults with acute lung failure. We report an association etween ischemic biliary duct injury (IBDI) and ECMO, successfully reated endoscopically. A 22-year-oldwomanwith systemic lupus erythematosus (SLE) nd anti-phospholipid antibody syndrome developed lupus flare f severe myocarditis and pulmonitis. Computed tomography evealed normal liver parenchyma and no hepatic artery thrombois (HAT) or ductal dilation. After central ECMO support and 3week ospitalization she returned three months later with cholestatic ymptoms. Magnetic resonance cholangiopacreatography revealed highrade bifurcation stricture with a distal filling defect (Fig. 1). ndoscopic retrograde cholangiopacreatography confirmed these ndings and revealedabiliary cast, removedendoscopically (Fig. 2).

Severe ischemic pancreatitis following the use of extracorporeal membrane oxygenation.

FIGURE 2. Fluoroscopic ERCP image showing changes of severe chronic pancreatitis with a main ductal stricture (white arrow) and filling defects (black arrows). Note coils from earlier embolization related to bleeding. FIGURE 1. Three-dimensional MRCP image showing changes of pancreatitis with diffuse duct irregularities (3 small white arrows), stricture at the neck of pancreas (1 large white arrow), and distal common bile duct with a filling defect (1 black arrow) consistent