Angelo Paulo Ferrari

Risk factors for complications after performance of ERCP

BACKGROUND ERCP has become widely available for the diagnosis and treatment of benign and malignant pancreaticobiliary diseases. In this prospective study, the overall complication rate and risk factors for diagnostic and therapeutic ERCP were identified. METHODS Data were collected prospectively on patient characteristics and endoscopic techniques from 1223 ERCPs performed at a single referral center and entered into a database. Univariate and multivariate analyses were used to identify risk factors for ERCP-associated complications. RESULTS Of 1223 ERCPs performed, 554 (45.3%) were diagnostic and 667 (54.7%) therapeutic. The overall complication rate was 11.2%. Post-ERCP pancreatitis was the most common (7.2%) and in 93% of cases was self-limiting, requiring only conservative treatment. Bleeding occurred in 10 patients (0.8%) and was related to a therapeutic procedure in all cases. Nine patients had cholangitis develop, most cases being secondary to incomplete drainage. There was one perforation (0.08%). All other complications totaled 1.5%. Variables derived from cannulation technique associated with an increased risk for post-ERCP pancreatitis were precut access papillotomy (20%), multiple cannulation attempts (14.9%), sphincterotome use to achieve cannulation (13.1%), pancreatic duct manipulation (13%), multiple pancreatic injections (12.3%), guidewire use to achieve cannulation (10.2%), and the extent of pancreatic duct opacification (10%). Patient characteristics associated with an increased risk of pancreatitis were sphincter of Oddi dysfunction (21.7%) documented by manometry, previous ERCP-related pancreatitis (19%), and recurrent pancreatitis (16.2%). Pain during the procedure was an important indicator of an increased risk of post-ERCP pancreatitis (27%). Independent risk factors for post-ERCP pancreatitis were identified as a history of recurrent pancreatitis, previous ERCP-related pancreatitis, multiple cannulation attempts, pancreatic brush cytology, and pain during the procedure. CONCLUSIONS The most frequent ERCP-related complication was pancreatitis, which was mild in the majority of patients. The frequency of post-ERCP pancreatitis was similar for both diagnostic and therapeutic procedures. Bleeding was rare and mostly associated with sphincterotomy. Other complications such as cholangitis and perforation were rare. Specific patient- and technique-related characteristics that can increase the risk of post-ERCP complications were identified.

Brush cytology during ERCP for the diagnosis of biliary and pancreatic malignancies

Endoscopic retrograde cholangiopancreatography is a valuable tool in the diagnosis and management of pancreaticobiliary diseases. The diagnostic sensitivity of brush cytology is reported as between 18% and 70% for malignant bile duct or pancreatic duct strictures. We report our findings in 74 patients with pancreaticobiliary strictures who underwent ERCP. Brush cytology was performed on 55 bile duct specimens and 19 pancreatic duct specimens. No complications related to the procedure occurred; 4 specimens (5.4%) were unsatisfactory for interpretation. Strictures were benign in 22 patients (12 pancreatitis, 5 sclerosing cholangitis, 3 Mirizzi syndrome, and 2 papillitis) and malignant in 52 patients (29 pancreatic carcinoma, 10 cholangiocarcinoma, 6 metastatic disease, 4 pancreatic mucinous ductal ectasia, 1 ampullary carcinoma, and 2 non-functioning islet cell tumors). The nature of the stricture was confirmed by surgery, surgical biopsy, necropsy, or follow-up. The overall results for brush cytology were sensitivity 56.2%, specificity 100%, positive predictive value 100%, negative predictive value 51.2%, and accuracy 70%. Our results confirm the value, safety, and utility of obtaining cytologic specimens at the time of ERCP; confirmation was obtained in 65.5% of pancreatic carcinoma cases. Although a negative result does not exclude pancreaticobiliary malignancy, a positive result confirms this diagnosis.

Role of EUS in the preoperative localization of insulinomas compared with spiral CT

BACKGROUND Preoperative radiologic localization of insulinomas often fails because of the small size of these tumors. Endoscopic ultrasound (EUS) can localize insulinomas in up to 80% of the cases. The aim of this study was to compare EUS and computed tomography (CT) diagnostic accuracy for insulinomas. METHODS We reviewed medical records from 12 patients (10 women) with a biochemical diagnosis of hypoglycemia and hyperinsulinism from 1 university hospital and 1 community hospital. A diagnosis of insulinoma was ultimately made in all cases and before surgery the patients underwent abdominal US, spiral CT and EUS in an attempt to precisely localize the tumor. Surgery was considered the standard for tumor localization. RESULTS Ten tumors were benign (83.3%) and 2 were malignant (16.7%). The overall sensitivity of EUS in identifying insulinomas was 83.3% compared with 16.7% for CT. Tumors not detected by EUS had a mean size of 0.75 cm. EUS-guided fine-needle aspiration was possible in only 3 patients, with a positive cytologic diagnosis in 2 (66.6%). Tumors located in the head and body of the pancreas were identified by EUS in all patients, but those located in the tail were diagnosed in only 50% of the cases. CONCLUSIONS EUS is superior to spiral CT and should replace it for the detection of pancreatic insulinomas. EUS identification depends on the site and size of the tumor.

Improvement of children's nutritional status after enteral feeding by PEG: an interim report

BACKGROUND Enteral feeding by percutaneous endoscopic gastrostomy is indicated as long-term nutritional support for children with neurologic impairment and dysphagia. We report our experience with percutaneous endoscopic gastrostomy and evaluate the age range of children with cerebral palsy who benefit most with weight and height gain. METHODS In a prospective study, from August 1996 to August 1997, 20 endoscopic gastrostomies were performed in 20 children diagnosed with cerebral palsy (16), myopathy (2), and brain trauma (2). The mean age was 6.5 years and the mean follow-up 5.9 months. All patients had severe mental impairment and oropharyngeal dysphagia. They were followed up monthly on an outpatient basis by both the gastroenterologist and the dietitian, who assessed gastrostomy complications and performed anthropometric measurements. RESULTS All 20 patients benefited from enteral nutrition with a statistically significant gain in weight (p < 0.01), and there was a trend toward improved weight/height ratio in children under 4 years of age according to Z-score and mid-arm muscle area (p < 0.01). Triceps skinfold thickness failed to reach statistical significance. There were no immediate complications related to the procedure. Perforations occurred with three (15%) tubes, and the plugs for introduction of food had to be replaced after 4 months of use. All complications, namely formation of granulation tissue at the stoma (7), stoma infection (4), gastroesophageal reflux pneumonia (3), and pneumoperitoneum (1) were managed clinically. CONCLUSIONS Endoscopic gastrostomy is a safe procedure for children. Enteral feeding resulted in a trend toward a normalized weight/height ratio for children with cerebral palsy younger than 4 years and significant weight gain in those older than 12 years.

Prospective study of bacteremia rate after elastic band ligation and sclerotherapy of esophageal varices in patients with hepatosplenic schistosomiasis

BACKGROUND Esophageal band ligation is considered to be as efficient as endoscopic sclerotherapy, with a lower complication rate, including bacteremia. There are few studies comparing the two methods. The aim of this study was to compare the incidence of bacteremia after both treatments in patients with portal hypertension secondary to schistosomiasis. METHODS Endoscopic sclerotherapy and band ligation were performed using standard techniques. Blood samples were obtained 5 and 30 minutes after endoscopic band ligation or sclerotherapy and cultured for aerobic and anaerobic organisms. RESULTS In the sclerotherapy group 2 of 43 (4.6%) blood cultures were positive (Peptostreptococcus sp and Streptococcus mitis). A similar result was obtained in the band ligation group: 2 of 35 (5.7%) had positive cultures, both with Staphylococcus aureus. CONCLUSIONS There is no difference in the frequency of bacteremia after treatment of esophageal varices with endoscopic sclerotherapy or endoscopic band ligation in patients with portal hypertension secondary to schistosomiasis.

Comparison between endoscopic brush cytology performed before and after biliary stricture dilation for cancer detection.

BACKGROUND Confirmation of malignancy within biliary strictures is endoscopically challenging. Dilation of strictures has been reported to enhance cytological diagnosis. AIM To compare brush cytology results before and after biliary stricture dilation. PATIENTS AND METHODS Patients with extra-hepatic biliary stricture at endoscopic retrograde cholangiopancreatography were included in the study. Brushing was performed before and immediately after dilation using a 10 Fr dilating catheter. Cytology samples were classified as: negative for malignancy, presence of atypical cells, insufficient material, suspicious for malignancy or positive for malignancy. Final diagnosis was established by surgery, biopsy or follow-up. RESULTS Biliary brush cytology was performed in 50 patients, with an overall sensitivity of 40% and 27.5%, before and after dilation, respectively. The combination of results increased cancer detection rate to 45%. There were 5/50 (10%) minor complications and one death related to the procedure. CONCLUSIONS Brush cytology performed before biliary stricture dilation has a similar cancer detection rate to that following dilation, although the combination of results enhances sensitivity.

Endoscopic treatment of esophageal varices in advanced liver disease patients: band ligation versus cyanoacrylate injection

Background The results of variceal band ligation (VBL) in patients with advanced liver disease are unknown. Cyanoacrylate injection (CI) might have a better outcome than VBL in the treatment of esophageal varices (EV) in these patients. Aim To compare VBL and CI in the treatment of EV in patients with advanced liver disease. Patients and methods Thirty-eight patients with medium or large EV and Child-Pugh index of at least eight were randomized into two groups: VBL (n=20) and CI (n=18). The patients were followed-up for at least 6 months after the end of treatment. Main outcomes were eradication, bleeding, mortality, complication, and recurrence rates. Results Variceal eradication rates were similar in the VBL and CI groups (90 vs. 72%, P=0.39). Mean number of sessions until eradication was 3.17 and 3, respectively. Bleeding episodes until eradication were equally observed in both groups (P=0.17). Mortality (55 vs. 56%, P=0.52) and major complication rates (5 and 17%, P=0.32) were similar. Chest pain with dysphagia was more frequent in the CI group (55.6 vs. 10%, P=0.004). A higher risk of variceal recurrence was observed in the CI group (33 vs. 57%, P=0.04). Conclusion No significant differences between the VBL and CI groups were observed in the treatment of EV in patients with advanced liver disease regarding mortality, variceal eradication, and major complications rates. However, minor complications and variceal recurrence were significantly more common in the CI group. In addition, there was a clear trend toward more bleeding episodes in patients included in the CI group.

Band ligation or sclerotherapy as endoscopic treatment for oesophageal varices in schistosomotic patients: results of a randomized study.

Endoscopic sclerotherapy and banding ligation are the two preferred methods to treat oesophageal variceal bleeding. There are many reports dealing with such treatment in cirrhotic patients but we do not know how good they are to treat varices secondary to other forms of portal hypertension. Schistosomiais mansoni is the main cause of portal hypertension and oesophageal varices in Brazil. We performed a prospective randomised study to compare: 1) the efficacy of both treatments in eradicating oesophageal varices, and 2) complications secondary to both treatments. Forty patients were divided in two Groups. Both sclerotherapy and banding ligation were performed until variceal eradication. There were no severe complications. Variceal eradication was faster obtained with banding ligation than sclerotherapy although there was no statistical difference (mean number of sessions 3.05 vs 3.72, p=0.053). Benign complications were equally frequent in both Groups, although additional sedation was more common in the sclerotherapy Group. We concluded that both treatments are equally effective in the eradication of oesophageal varices, although banding ligation is better tolerated by the patient and probably faster.

Management of liver transplantation biliary stricture: Results from a tertiary hospital

AIM To review results of endoscopic treatment for anastomotic biliary strictures after orthotopic liver transplantation (OLT) during an 8-year period. METHODS This is a retrospective review of all endoscopic retrograde cholangiopancreatographys (ERCPs) performed between May 2006 and June 2014 in deceased OLT recipients with anastomotic stricture at a tertiary care hospital. Patients were divided into 2 groups, according to the type of stent used (multiple plastic or covered self-expandable metal stents), which was chose on a case-by-case basis and their characteristics. The primary outcome was anastomotic stricture resolution rate determined if there was no more than a minimum waist at cholangiography and a 10 mm balloon could easily pass through the anastomosis with no need for further intervention after final stent removal. Secondary outcomes were technical success rate, number or ERCPs required per patient, number of stents placed, stent indwelling, stricture recurrence rate and therapy for recurrent anastomotic biliary stricture (AS). Stricture recurrence was defined as clinical laboratorial and/or imaging evidence of obstruction at the anastomosis level, after it was considered completely treated, requiring subsequent interventional procedure. RESULTS A total of 195 post-OLT patients were assessed for eligibility. One hundred and sixty-four (164) patients were diagnosed with anastomotic biliary stricture. ERCP was successfully performed in 157/164 (95.7%) patients with AS, that were treated with either multiple plastic (n = 109) or metallic billiary stents (n = 48). Mean treatment duration, number of procedures and stents required were lower in the metal stent group. Acute pancreatitis was the most common procedure related complication, occurring in 17.1% in the covered self-expandable metal stents (cSEMS) and 4.1% in the multiple plastic stent (MPS) group. Migration was the most frequent stent related complication, observed in 4.3% and 5.5% (cSEMS and MPS respectively). Stricture resolution was achieved in 86.8% in the cSEMS group and in 91% in MPS group. Stricture recurrence after a median follow up of 20 mo was observed in 10 (30.3%) patients in the cSEMS and 7 (7.7%) in the plastic stent group, a statistically significant difference (P = 0.0017). Successful stricture resolution after secondary treatment was achieved in 66.6% and 62.5% of patients respectively in the cSEMS and plastic stents groups. CONCLUSION Multiple plastic stents are currently the first treatment option for AS in patients with duct-to-duct anastomosis. cSEMS was associated with increased pancreatitis risk and higher recurrence rate.

Efficacy and safety of endoscopic prophylactic treatment with undiluted cyanoacrylate for gastric varices.

AIM To evaluate the efficacy and safety of undiluted N-butyl-2 cyanoacrylate plus methacryloxysulfolane (NBCM) as a prophylactic treatment for gastric varices (GV) bleeding. METHODS This prospective study was conducted at a single tertiary-care teaching hospital between October 2009 and March 2013. Patients with portal hypertension (PH) and GV, with no active gastrointestinal bleeding, were enrolled in primary prophylactic treatment with NBCM injection without lipiodol dilution. Initial diagnosis of GV was based on endoscopy and confirmed with endosonography (EUS); the same procedure was used after treatment to confirm eradication of GV. After puncturing the GV with a regular injection needle, 1 mL of undiluted NBCM was injected intranasally into GV. The injection was repeated as necessary to achieve eradication or until a maximum total volume of 3 mL of NBCM had been injected. Patients were followed clinically and evaluated with endoscopy at 3, 6 and 12 mo. Later follow-ups were performed yearly. The main outcome measures were efficacy (GV eradication), safety (adverse events related to cyanoacrylate injection), recurrence, bleeding from GV and mortality related to GV treatment. RESULTS A total of 20 patients (15 male) with PH and GV were enrolled in the study and treated with undiluted NBCM injection. Only 2 (10%) patients had no esophageal varices (EV); 18 (90%) patients were treated with endoscopic band ligation to eradicate EV before inclusion in the study. The patients were followed clinically and endoscopically for a median of 31 mo (range: 6-40 mo). Eradication of GV was observed in all patients (13 patients were treated with 1 session and 7 patients with 2 sessions), with a maximum injected volume of 2 mL NBCM. One patient had GV recurrence, confirmed by EUS, at 6-mo follow-up, and another had late recurrence with GV bleeding after 35 mo of follow-up; overall, GV recurrence was observed in 2 patients (10%), after 6 and 35 mo of follow-up, and GV bleeding rate was 5% (1 patient). Mild epigastric pain was reported by 3 patients (15%). No mortality or major complications, including embolism, or damage to equipment were observed. CONCLUSION Endoscopic injection with NBCM, without lipiodol, may be a safe and effective treatment for primary prophylaxis of gastric variceal bleeding.