Everson L. Artifon

Guidewire Cannulation Reduces Risk of Post-ERCP Pancreatitis and Facilitates Bile Duct Cannulation

OBJECTIVE:To evaluate if using a soft-tipped guidewire to cannulate the common bile duct may ameliorate development of post-ERCP pancreatitis and facilitate cannulation of the CBD.DESIGN AND SETTING:A single-center, blinded, randomized trial of conventional cannulation technique using sphinctertome and contrast injection versus guidewire cannulation technique.METHODS:We prospectively randomized 300 patients to conventional cannulation (group I) or guidewire cannulation (group II) technique.OUTCOME MEASURES:Primary outcome measure was incidence of acute pancreatitis and secondary outcome measures were ease of cannulation of common bile duct (assessed by attempts required for common bile duct cannulation & rates of precut sphincterotomy) and overall complication rates.RESULTS:Guidewire cannulation was associated with significantly lower likelihood of post-ERCP pancreatitis (adjusted OR 0.43, 95% CI 0.21–0.89, P = 0.02). Twenty-five patients (16.6%) in group I and thirteen patients (8.6%) in group II developed acute pancreatitis, P = 0.037. All instances of pancreatitis were mild. There were more women in group II; 41 in group I and 59 in group II, P = 0.028. Otherwise the two groups were comparable for age, age under 35 yr, indication for ERCP, diagnosis, and number of patients with SOD. The number of patients requiring 0–3, 4–6, and 7–10 attempts for successful cannulation of the common bile duct were 87, 48, and 15 in group I and 117, 24, and 9 in group II, respectively, P = 0.001. A total of 33 patients in group I and 13 patients in group II required precut sphincterotomy, P = 0.007. Rates of accidental pancreatic duct cannulation were 21 in group I and 27 in group II, P = 0.34. Rates of overall complication were not significantly different in the two groups.CONCLUSIONS:Guidewire technique for bile duct cannulation lowers likelihood of post-ERCP pancreatitis by facilitating cannulation and reducing need for precut sphincterotomy.

Biliary drainage in patients with unresectable, malignant obstruction where ERCP fails: endoscopic ultrasonography-guided choledochoduodenostomy versus percutaneous drainage.

Background: Endoscopic retrograde cholangiopancreatography may fail because of malignant involvement of the second portion of the duodenum and the major papilla. Alternatives include percutaneous transhepatic biliary drainage (PTBD) or surgical bypass. Endoscopic ultrasonography-guided choledochoduodenostomy (EUS-CD) has been reported as an alternative. Objective: To prospectively compare EUS-CD and PTBD in patients with unresectable malignant biliary obstruction. Design: Prospective and randomized study. Setting: Tertiary center. Main Outcome Measurements: Success and efficacy comparison EUS-CD with PTBD. Results: Twenty-five subjects were randomized (13 EUS-CD and 12 PTBD). Mean age was 67 years (SD, 11.9). The 2 groups were similar before intervention in terms of quality of life [EUS-CD (58.3) vs. PTBD (57.8); P=0.78], total bilirubin (16.4 vs. 17.2; P=0.7), alkaline phosphatase (539 vs. 518; P=0.7), and gamma-glutamyl transferase (554.3 vs. 743.5; P=0.56). All procedures were technically and clinically successful in both groups. At 7-day follow-up there was a significant reduction in total bilirubin in both the groups (EUS-CD, 16.4 to 3.3; P=0.002 and PTBD, 17.2 to 3.8; P=0.01), although no difference was noted comparing the 2 groups (EUS-CD to PTBD; 3.3 vs. 3.8; P=0.2). There was no difference between the complication rates in the 2 groups (P=0.44), EUS-CD (2/13; 15.3%) and PTBD (3/12; 25%). Costs were similar in the 2 groups also (

Surgery or Endoscopy for Palliation of Biliary Obstruction Due to Metastatic Pancreatic Cancer

5673—EUS-CD vs.

Multicenter study on endoscopic ultrasound-guided expandable biliary metal stent placement: Choice of access route, direction of stent insertion, and drainage route

7570—PTBD; P=0.39). Limitations: Small sample size and single center study. Conclusions: EUS-CD can be an effective and safe alternative to PTBD with similar success, complication rate, cost, and quality of life.

Endoscopic Ultrasound-assisted Bile Duct Access and Drainage Multicenter, Long-term Analysis of Approach, Outcomes, and Complications of a Technique in Evolution

BACKGROUND AND AIMS:Both endoscopic and surgical drainage procedures are effective palliative methods for malignant biliary obstruction. Surgical drainage is still preferred in developing countries due to the high cost of procuring metal biliary stents. The aim of this study was to evaluate the quality of life and the cost of care in patients with metastatic pancreatic cancer after endoscopic biliary drainage and surgical drainage.PATIENTS AND METHODS:This is a prospective, randomized controlled trial conducted in a tertiary referral center in Brazil. Patients with biliary obstruction due to metastatic pancreatic cancer and liver metastasis, but without gastric outlet obstruction, were included in the study. Endoscopic biliary drainage with the insertion of a metal stent into the bile duct was compared with the surgical drainage procedure (choledochojejunostomy and gastrojejunostomy). Quality of life was assessed before, and 30 days, 60 days, and 120 days after the drainage procedure. The cost of drainage procedure, cost during the first 30 days and the total cost from drainage procedure to death were calculated.RESULTS:Of the 273 patients with pancreatic malignancy seen at our hospital between July 2001 and October 2004, 35 patients were eligible for the study, and 30 agreed to participate in the study. Both surgical and endoscopic drainage procedures were successful, without any mortality in the first 30 days. The cost of biliary drainage procedure (US

Endoscopic sphincterotomy before deployment of covered metal stent is associated with greater complication rate: a prospective randomized control trial.

2,832 ± 519 vs 3,821 ± 1,181, p = 0.031), the cost of care during the first 30 days after drainage (US

Kras mutation analysis of fine needle aspirate under EUS guidance facilitates risk stratification of patients with pancreatic mass

3,122 ± 877 vs 6,591 ± 711, p = 0.001), and the overall total cost of care that included initial care and subsequent interventions and hospitalizations until death (US

A decision support system to facilitate management of patients with acute gastrointestinal bleeding

4,271 ± 2,411 vs 8,321 ± 1,821, p = 0.0013) were lower in the endoscopy group compared with the surgical group. In addition, the quality of life scores were better in the endoscopy group at 30 days (p = 0.042) and 60 days (p = 0.05). There was no difference between the two groups in complication rate, readmissions for complications, and duration of survival.CONCLUSIONS:Endoscopic biliary drainage is cheaper and provides better quality of life in patients with biliary obstruction and metastatic pancreatic cancer.

Echoguided hepatico-gastrostomy: a case report

Endoscopic ultrasonography‐guided biliary drainage (EUS‐BD) using expandable biliary metal stents has emerged as an acceptable alternative in patients with failed endoscopic retrograde cholangiopancreatography for malignant biliary obstruction. However, there is no consensus over the preferred access route (transhepatic or extrahepatic), direction of stent insertion (antegrade or retrograde) or drainage route (transluminal or transpapillary) in patients potentially suitable for multiple methods. The present study compares success and complication rates in patients undergoing EUS‐BD via different methods.

A pilot study to evaluate the safety, tolerance, and efficacy of a novel stationary antral balloon (SAB) for obesity.

Background and Study Aims: When endoscopic retrograde cholangio-pancreatography fails, the bile duct is drained percutaneously or surgically. Evolution of endoscopic ultrasound (EUS) has provided the ability to visualize and also drain the biliary tree. The aim of this study was to review different techniques of EUS-guided bile duct access and drainage, and compare extrahepatic (EH) and intrahepatic (IH) approaches and benign with malignant indications. Patients and Methods: EUS-guided attempts at bile duct drainage from 6 international centers were reviewed. This is a multicenter, nonrandomized retrospective study. Results: Two hundred forty patients underwent EUS-guided bile duct access and drainage (EUS-BD) with a mean age of 67.3 years. The IH approach was used in 60% of the cases. In 99% of the subjects, a 19-G needle was used. Success was achieved in 87% cases, with a similar success rate in EH and IH approaches (84.3% vs. 90.4%; P=0.15). Metal stents were placed in 60% and plastic stents in 27% of the cases. A higher success rate was noted in malignant diseases compared with benign diseases (90.2% vs. 77.3%; P=0.02). Complications for all techniques included pneumoperitoneum 5%, bleeding 11%, bile leak/peritonitis 10%, and cholangitis 5%. No significant difference was noted between the IH and the EH approaches (32.6% vs. 35.6%; P=0.64), with similar rates in benign and malignant diseases (26.7% vs. 37.1%; P=0.19). Conclusions: The EUS-BD technique is currently limited by a lack of dedicated devices and large data reporting outcomes and complications. Larger prospective and multicenter studies are needed to better define the indications, outcomes, and complications. With greater experience and dedicated devices, EUS-BD can be an effective alternative.