Gary R. May

Comparative performance of uncoated, self-expanding metal biliary stents of different designs in 2 diameters: final results of an international multicenter, randomized, controlled trial.

BACKGROUND The Wallstent has remained the industry standard for biliary self-expanding metal stents (SEMSs). Recently, stents of differing designs, compositions, and diameters have been developed. OBJECTIVE To compare the new nitinol 6-mm and 10-mm Zilver stents with the 10-mm stainless steel Wallstent and determine the mechanism of obstruction. DESIGN Randomized, prospective, controlled study. SETTING Nine centers experienced in SEMS placement during ERCP. PATIENTS A total of 241 patients presenting between September 2003 and December 2005 with unresectable malignant biliary strictures at least 2 cm distal to the bifurcation. MAIN OUTCOME MEASUREMENT Stent occlusions requiring reintervention and death. RESULTS At interim analysis, a significant increase in occlusions was noted in the 6-mm Zilver group at the P = .04 level, resulting in arm closure but continued follow-up. Final study arms were 64, 88, and 89 patients receiving a 6-mm Zilver, 10-mm Zilver, and 10-mm Wallstent, respectively. Stent occlusions occurred in 25 (39.1%) of the patients in the 6-mm Zilver arm, 21 (23.9%) of the patients in the 10-mm Zilver arm, and 19 (21.4%) of the patients in the 10-mm Wallstent arm (P = .02). The mean number of days of stent patency were 142.9, 185.8, and 186.7, respectively (P = .057). No differences were noted in secondary endpoints, and the study was ended at the 95% censored study endpoints. Biopsy specimens of ingrowth occlusive tissue revealed that 56% were caused by benign epithelial hyperplasia. CONCLUSIONS SEMS occlusions were much more frequent with a 6-mm diameter SEMS and equivalent in the two 10-mm arms despite major differences in stent design, material, and expansion, suggesting that diameter is the critical feature. Malignant tumor ingrowth produced only a minority of the documented occlusions.

Nonsurgical management of an impacted mechanical lithotriptor with fractured traction wires: Endoscopic intracorporeal electrohydraulic shock wave lithotripsy followed by extra-endoscopic mechanical lithotripsy

In a patient with a mid-common bile duct stone, the traction wires of a mechanical lithotriptor snapped, resulting in lithotriptor basket impaction. Simultaneous occurrence of these two potential complications of endoscopic stone extraction is very rarely reported. Extracorporeal shock wave lithotripsy failed to fragment the stone entrapped within the impacted basket. Endoscopic intracorporeal electrohydraulic shock wave lithotripsy successfully fragmented the stone under direct visualization through a cholangioscope. The entrapped stone within the basket could subsequently be pulled into the supra-ampullary bile duct for the final fragmentation with an extra-endoscopic mechanical lithotriptor cable. The present report is the first to describe a safe and effective use of endoscopic intracorporeal electrohydraulic shock wave lithotripsy followed by extra-endoscopic mechanical lithotripsy in the management of an impacted lithotriptor basket.

Progression and Management of Duodenal Neoplasia in Familial Adenomatous Polyposis: A Cohort Study.

OBJECTIVE To describe the natural history and outcomes of surveillance of duodenal neoplasia in familial adenomatous polyposis (FAP). BACKGROUND Duodenal cancer is the most common cause of death in FAP. METHODS Cohort study of patients prospectively enrolled in an upper endoscopic surveillance protocol from 1982 to 2012. The duodenum was assessed by side-viewing endoscopy and classified as stage 1 to 5 disease. Endoscopic and/or operative interventions were performed according to stage. RESULTS There were 218 patients in the protocol (98 with advanced stage). They had a median of 9 endoscopies (range: 2-25) over a median of 11 years (range: 1-26). Median age at diagnosis of stage 3 disease (adenoma: 2.1-10 mm) was 41 years and stage 4 disease (adenoma >10 mm) was 45 years. Median time from first esophagogastroduodenoscopy to stage 4 disease was 22.4 years. The risk of stage 4 disease was 34.3% [95% confidence interval (CI) 23.8-43.4] at 15 years. In multivariate analysis, sex, type of colorectal surgery, years since colorectal surgery, and stage were significantly associated with risk of progression to stage 4 disease. Five of 218 (2.3%) patients developed duodenal cancer at median age of 58 years (range: 51-65). The risk of developing duodenal cancer was 2.1% (95% CI: 0-5.2) at 15 years. CONCLUSIONS Patients with advanced duodenal polyposis progress in the severity of disease (size and degree of dysplasia); however, the rate of progression to carcinoma is slow. Aggressive endoscopic and surgical intervention, especially in the presence of large polyps and high-grade dysplasia, appears to be effective in preventing cancer deaths in FAP.

Endoscopic Ultrasound-Guided Pancreatic Duct Intervention

Endoscopic ultrasound-guided pancreatic duct intervention (EUS-PDI) is an emerging endoscopic approach allowing access and intervention to the pancreatic duct (PD) for patients with failed endoscopic retrograde pancreatography (ERP) or patients with surgically altered anatomy. As opposed to biliary drainage for which percutaneous drainage is an alternative following failed endoscopic retrograde cholangiopancreatography (ERCP), the treatment options after failed ERP are very limited. Therefore, endoscopic ultrasound (EUS)-guided access to the PD and options for subsequent drainage may play an important role as an alternative to surgical intervention. However, this approach is technically demanding with a high risk of complications, and should only be performed by highly experienced endoscopists. In this review, we describe an overview of the current endoscopic approaches, basic technical tips, and outcomes using these procedures.

Outcomes of Flexible Endoscopic Septoplasty With Needle Knife for the Treatment of Zenker Diverticulum

Background: Zenker diverticulum (ZD) is a lesion most often seen in elderly patients. The traditional treatment is surgical but recently endoscopic septoplasty has been described as an alternative approach, especially in high surgical risk patients. We aimed to determine the efficacy and safety of flexible endoscopic septoplasty (FES) for symptomatic ZD. Methods: Retrospective review of all patients who underwent FES for ZD over the previous 5 years at St Michaels Hospital, Toronto were identified. Patient charts were reviewed to record patient demographics, procedure technique, operative times, sedation requirements, and complications. Patients were contacted via telephone to establish postoperative symptoms within 12 months of treatment and to evaluate current symptoms using a validated dysphagia score from 0 (no dysphagia) to 4 (complete dysphagia) and overall symptoms in terms of complete/near complete response, moderate response and complete recurrence. Results: Forty-three patients underwent FES between 2005 and 2010. The median age was 75 years (IQR 68-83). Twenty-nine (67.4%) were male. The mean (range) ZD size was 3.0cm (1 5cm). All patients were treated on an outpatient basis. A total of 90 procedures were performed, with a median of 2 procedures (IQR 1-3) per patient. Procedures were performed with conscious sedation in 88 (97.8%) cases, with median sedation requirements of 3mg (IQR 3-6) of midazolam and 100mcg (IQR 87.5-100) of fentanyl. The mean procedure time was 34 minutes (range 10 65). Thirty patients were contactable to assess response to therapy. Within 12 months of the initial therapy, 15 (50%) had complete/near complete symptom resolution, 10 (33.3%) moderate symptom improvement and 5 (16.7%) complete symptom recurrence. Following retreatment in the latter two groups, at a mean follow-up of 13.5 months, 2 (13.3%) had complete/near complete symptom resolution, 9 (60%) moderate symptom improvement and 3 (20%) complete symptom recurrence. Complications included 2 perforations (one requiring surgical drainage of a neck abscess); 2 cases of minor bleeding and 1 patient admitted with fever post procedure (perforation excluded on imaging). Mean admission duration was 7.8 days (range 1-13). Conclusion: (i) FES using needle-knife papillotome is a safe and effective therapy for ZD. (ii) FES should be considered in patients in whom surgery is considered high-risk or technically difficult. (iii) Repeat FES in poor responders is effective and safe (iv) Further studies to refine this technique are required to improve symptoms. Acknowledgment S.R. has been supported by a UWA Medical Research fellowship and the Faculty of Medicine, Dentistry and Health Sciences in Perth, Western Australia.