Daphne Antillon

Endoscopic gallbladder stent placement for treatment of symptomatic cholelithiasis in patients with end-stage liver disease

OBJECTIVES:Symptomatic cholelithiasis is a common disease in the general population with an increased prevalence in patients with cirrhosis. While cholecystectomy is the procedure of choice for the treatment of symptomatic cholelithiasis, cirrhotics have an increased risk of complications associated with this therapy. We have found that placement of an endoscopic gallbladder stent is an alternative, less invasive treatment for cirrhotic patients with symptomatic gallbladder disease and describe our experience here.METHODS:A retrospective medical record review of 23 patients with cirrhosis who underwent endoscopic retrograde cholangiography with gallbladder stent placement for symptomatic gallbladder disease from July 1994 to August 2004.RESULTS:Indications for stent placement included recurrent biliary colic (56.5%), acute calculous cholecystitis (39%), acalculous cholecystitis (8.6%), and gallstone pancreatitis (8.6%). All patients experienced resolution of their symptoms following stent placement. Twenty patients (87%) were asymptomatic from 5 days to 3 years post-procedure until transplantation, death, or end of study period. Nine patients (39%) underwent liver transplantation, 5 days to 34 months after the procedure. Eleven patients are well, with ten patients awaiting liver transplantation. Three patients developed late complications and were treated successfully with antibiotics.CONCLUSION:Endoscopic stenting of the gallbladder may be a potential treatment for symptomatic gallbladder disease in patients with cirrhosis awaiting liver transplantation, considered to be high-risk for cholecystectomy.

Impact of Endoscopist's Experience On Success Rate of En-Bloc and En Bloc-Cure of Large Colorectal Polyps By Endoscopic Submucosal Dissection: A Meta-Analysis and Systematic Review

Impact of Endoscopist’s Experience On Success Rate of En-Bloc and En Bloc-Cure of Large Colorectal Polyps By Endoscopic Submucosal Dissection: A Meta-Analysis and Systematic Review Srinivas R. Puli, Yasuo Kakugawa, Takuji Gotoda, Jyotsna Bk Reddy, Daphne Antillon, Yutaka Saito, Mainor R. Antillon Background: Endoscopic submucosal dissection (ESD) has emerged as an alternative to surgery for the resection of large (O 2 cm) colorectal polyps. ESD is a technically demanding procedure. From published data, it is not clear how endoscopists’ experience affects successful en-block resection of large colonic polyps. Aim: To evaluate how endoscopists experience in performing ESD affects the proportion of successful en-block resection of large colonic polyps. Method: Study Selection Criteria: Studies using ESD technique to resect large colonic polyps were selected. Successful cure en-block resection was defined as margins free polyp resection. Data collection & extraction: Articles were searched in Medline, Japanese language literature, and Cochrane control trial registry. Two reviewers independently searched and extracted data. Statistical Method: Summary estimates are expressed as pooled proportions. Studies were grouped into !100 ESD’s performed and O 100 ESD’s performed. First, the individual study proportions of successful resection are transformed into a quantity using Freeman-Tukey variant of the arcsine square root transformed proportion. The pooled proportion is calculated as the back-transform of the weighted mean of the transformed proportions, using inverse arcsine variance weights for the fixed effects model and DerSimonian-Laird weights for the random effects model. Results: Initial search identified 2,120 reference articles, in which, 389 relevant articles were selected and reviewed. Data was extracted from 13 studies (N Z 1,080) which met the inclusion criteria. 9 Studies had !100 ESD’s (N Z 394) and 4 studies had O100 ESD’s (N Z 686). The mean size of the polyps was 30.65 SE 2.88 mm. The pooled proportions are shown in table 1. The fixed effect model was not used because of the heterogeneity among studies. The publication bias calculated by BeggMazumdar bias indicator for successful en-bloc resection gave a Kendall’s tau b value of -0.22 (p Z 0.32) and the same for successful cure en-block resection was -0.23 (p Z 0.25). Conclusion: ESD is an innovative technique for resection of large colonic polyps that offers an alternative to surgery. Our meta-analysis shows that the success rate for both en-bloc and en-bloc cure improves with O100 ESDs. Endoscopist’s experience significantly improves the success rates of this technique to treat large colorectal polyps.