Gennadiy Bakis

A multicenter, U.S. experience of single-balloon, double-balloon, and rotational overtube–assisted enteroscopy ERCP in patients with surgically altered pancreaticobiliary anatomy (with video)

BACKGROUND Data on overtube-assisted enteroscopy to facilitate ERCP in patients with surgically altered pancreaticobiliary anatomy, or long-limb surgical bypass, is limited. OBJECTIVE To evaluate and compare ERCP success by using single-balloon (SBE), double-balloon (DBE), or rotational overtube enteroscopy. DESIGN Consecutive patients identified retrospectively. SETTING Eight U.S. referral centers. PATIENTS Long-limb surgical bypass patients with suspected pancreaticobiliary diseases. INTERVENTION Overtube-assisted enteroscopy ERCP. MAIN OUTCOME MEASUREMENTS Enteroscopy success: visualizing the pancreaticobiliary-enteric anastomosis or papilla. ERCP success: completing the intended pancreaticobiliary intervention. Clinical success: greater than 50% reduction in abdominal pain or level of hepatic enzyme elevations or resolution of jaundice. RESULTS From January 2008 through October 2009, 129 patients had 180 enteroscopy-ERCPs. Anatomy was Roux-en-Y: gastric bypass (n = 63), hepaticojejunostomy (n = 45), postgastrectomy (n = 6), Whipple procedure (n = 10), and other (n = 5). ERCP success was 81 of 129 (63%). Enteroscopy success: 92 of 129 (71%), of whom 81 of 92 (88%) achieved ERCP success. Reasons for ERCP failure (n = 48): afferent limb entered but pancreaticobiliary anastomosis and/or papilla not reached (n = 23), cannulation failure (n = 11), afferent limb angulation (n = 8), and jejunojejunostomy not identified (n = 6). Select interventions: anastomotic stricturoplasty (cautery ± dilation, n = 16), stone removal (n = 21), stent (n = 25), and direct cholangioscopy (n = 11). ERCP success rates were similar between Roux-en-Y gastric bypass and other long-limb surgical bypass and among SBE, DBE, and rotational overtube enteroscopy. Complications were 16 of 129, 12.4%. LIMITATIONS Retrospective study. CONCLUSION (1) ERCP is successful in nearly two-thirds of long-limb surgical bypass patients and in 88% when the papilla or pancreaticobiliary-enteric anastomosis is reached. (2) Enteroscopy success in long-limb surgical bypass is similar among SBE, DBE, and rotational overtube enteroscopy methods. (3) Referral of long-limb surgical bypass patients who require ERCP to high-volume institutions may be considered before more invasive percutaneous or surgical alternatives.

Principles of training in GI endoscopy

E This document, prepared by the American Society for Gastrointestinal Endoscopy Committee on Training, was undertaken to provide general guidelines for endoscopy training and written primarily for individuals involved in teaching endoscopic procedures to fellows/trainees. This updates the previous Principles of Training document.1 Research in objective evaluation of procedural skills makes revision of the guidelines at this time highly appropriate.

Small-bowel endoscopy core curriculum.

This is one of a series of documents prepared by the ASGE Training Committee. This curriculum document contains recommendations for training, intended for use by endoscopy training directors, endoscopists involved in teaching endoscopy, and trainees in endoscopy. It was developed as an overview of techniques currently favored for the performance and training of small-bowel endoscopy and to serve as a guide to published references, videotapes, and other resources available to the trainer. By providing information to endoscopy trainers about the common practices used by experts in performing the technical aspects of the procedure, the ASGE hopes to improve the teaching and performance of small-bowel endoscopy.

Intraprocedural tissue diagnosis during ERCP employing a new cytology preparation of forceps biopsy (Smash protocol).

OBJECTIVES:Techniques of tissue sampling at endoscopic retrograde cholangiopancreatography (ERCP) have been underutilized due to technical demands, low yield, and lack of immediate intraprocedural diagnosis. The objective of this study was to describe a new inexpensive, highly efficient ERCP tissue processing, and interpretation technique to address these issues.METHODS:A retrospective, institutional review board approved, single-center study was done at a tertiary-care medical center. Between June 2004 and February 2009, 133 patients (age 38–95 years; men 53%) with suspicious biliary strictures underwent ERCP with tissue sampling using a new technique. Small forceps biopsy specimens were forcefully smashed between two dry glass slides, immediately fixed, stained with rapid Papanicolaou, and interpreted by an on-site pathologist during the procedure (Smash protocol).RESULTS:Of the 117 proven to have cancer, true-positive Smash preps included pancreatic cancer 49/66 (74%), cholangiocarcinoma 23/29 (79%), metastatic cancer 8/15 (53%), and other 4/7 (57%). The median number of Smash biopsies to diagnosis was 3 (range 1–17). Suspicious or atypical results were considered to be negative in this study. There were no false positives and no complications. Smash had an overall sensitivity of 89/117 (76%) for all cases. The true-positive yield of immediate Smash prep cytology, combined with ERCP fine needle aspirate (FNA) and forceps biopsy histology was 77/95 (81%) for primary pancreaticobiliary cancers.CONCLUSIONS:Immediate cytopathologic diagnosis at ERCP was established in 72% of patients presenting with suspected malignant biliary obstruction using a new cytological preparation of forceps biopsies. This approach to ERCP tissue sampling permits immediate diagnosis and avoids the need for subsequent procedures, adds little cost and time, and is safe to perform.

Multicenter evaluation of the clinical utility of laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass

BACKGROUND AND AIMS The obesity epidemic has led to increased use of Roux-en-Y gastric bypass (RYGB). These patients have an increased incidence of pancreaticobiliary diseases, yet standard ERCP is not possible because of surgically altered gastroduodenal anatomy. Laparoscopy-assisted ERCP (LA-ERCP) has been proposed as an option, but supporting data are derived from single-center small case series. Therefore, we conducted a large multicenter study to evaluate the feasibility, safety, and outcomes of LA-ERCP. METHODS This is a retrospective cohort study of adult patients with RYGB who underwent LA-ERCP in 34 centers. Data on demographics, indications, procedure success, and adverse events were collected. Procedure success was defined when all the following were achieved: reaching the papilla, cannulating the desired duct, and providing endoscopic therapy as clinically indicated. RESULTS A total of 579 patients (median age, 51; 84% women) were included. Indication for LA-ERCP was biliary in 89%, pancreatic in 8%, and both in 3%. Procedure success was achieved in 98%. Median total procedure time was 152 minutes (interquartile range [IQR], 109-210), with a median ERCP time of 40 minutes (IQR, 28-56). Median hospital stay was 2 days (IQR, 1-3). Adverse events were 18% (laparoscopy related, 10%; ERCP related, 7%; both, 1%) with the clear majority (92%) classified as mild/moderate, whereas 8% were severe and 1 death occurred. CONCLUSIONS Our large multicenter study indicates that LA-ERCP in patients with RYGB is feasible with a high procedure success rate comparable with that of standard ERCP in patients with normal anatomy. The ERCP-related adverse events rate is comparable with conventional ERCP, but the overall adverse event rate was higher because of the added laparoscopy-related events.

Interventional Activism in Gastroenterology

To the Editors, Medical activism is the excessive emphasis of medical intervention instead of expectant management in a selflimited disease with a tendency for spontaneous resolution. Such behavior is driven by fear of poor outcome if no action is taken. The fear may also be nurtured by concerns about subsequent litigation for not having intervened in a treatable medical condition [1]. Because gastroenterologists and surgeons are both professionally married to a variety of interventional procedures and excel at treating diseases based on their procedural proficiency, they tend to be biased toward favorably judging the therapeutic outcomes of their procedures. Lastly, there is also a remunerative incentive to seek therapeutic solutions to medical problems through well-paid interventions. In a recent morbidity and mortality conference (M&M) at our institution, we discussed three consecutive cases that may serve to illustrate these points. A 31-year-old man with small bowel Crohn’s disease in clinical remission with adalimumab underwent ‘‘re-staging’’ evaluation prior to a planned extended trip to Europe. Bidirectional endoscopy and MR enterography were normal. After a patency capsule passed through the small intestine without difficulty, a capsule endoscopy was performed and resulted in retention in the proximal ileum at an ulcerated stricture. Despite the retained capsule, the patient remained completely asymptomatic. An antegrade doubleballoon enteroscopy (DBE) to extract the capsule resulted in a localized contained ileal perforation at the site of the stricture. In the M&M, the diagnostic yield and therapeutic consequence of the capsule endoscopy were questioned. Since the patient had remained asymptomatic, it was also questioned whether one could have waited longer for the capsule to pass spontaneously [2]. The second case presentation concerned a 65-year-old female who underwent an en bloc saline lift hot snare polypectomy of a 3-cm flat ascending colon adenoma. The submucosal muscle layer appeared intact, and no immediate bleeding was seen. Three hemostatic clips were prophylactically placed. One day later, the patient presented to the emergency department with clinically stable severe right-sided abdominal pain, but no signs for an acute abdomen and no free air on abdominal imaging. Although the clinical presentation seemed to be consistent with a benign post-polypectomy syndrome, a consulting surgeon decided to perform a rightsided hemicolectomy [3]. The last case concerned a 67-year-old man who underwent a resection of a 10-mm sessile serrated polyp in the cecal cap. One day later, he presented with hematochezia and a drop in his hemoglobin from 14.5 to 11.1 g/dl. A repeat colonoscopy revealed a blood clot at the prior polypectomy site without active bleeding, but three hemostatic clips were placed nevertheless [4]. There are no a priori right or wrong decisions to such clinical conundrums. Gastroenterologists struggle daily with the risk–benefit ratios of therapeutic interventions [5–7]. The decision tree of Fig. 1 illustrates the general decision making underlying many such instances. The physicians must decide in favor of or against a procedural intervention. Both decisions could result in a poor or good outcome. The probability of poor outcome after an & Amnon Sonnenberg sonnenbe@ohsu.edu

Probability of Iatrogenesis in Gastroenterology

The term iatrogenesis refers to the inadvertent and preventable induction of disease or complications by the medical treatment or procedures of a physician or surgeon [1]. It is more likely to occur in patients with vague symptoms or ill-defined diagnoses that defy clear pathophysiological mechanisms [2–4]. Although common to all areas of medicine, gastroenterologists are frequently exposed to iatrogenesis as a result of managing unexplained abdominal pain. Every medical intervention carries the risk of adverse events. As serious adverse events may warrant their own intervention, one single medical problem can sometimes initiate a cascade of many more.