Henry Montes

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.

Accuracy and complication rate of brush cytology from bile duct versus pancreatic duct

BACKGROUND The accuracy and complication rates of brush cytology obtained from pancreaticobiliary strictures have not been fully defined. In this study we compared the accuracy and complications of brush cytology obtained from bile versus pancreatic ducts. METHODS We identified 148 consecutive patients for whom brush cytology was done during an ERCP from a database with prospectively collected data. We compared cytology results with the final diagnosis as determined by surgical pathologic examination or long-term clinical follow-up. We followed all patients and recorded ERCP-related complications. RESULTS Forty-two pancreatic brush cytology samples and 101 biliary brush cytology samples were obtained. The accuracy rate of biliary cytology was 65 of 101 (64.3%) and the accuracy rate of pancreatic cytology was 30 of 42 (71.4%). Overall sensitivity was 50% for biliary cytology and 58.3% for pancreatic cytology. Of 67 patients with pancreatic adenocarcinoma, sensitivity for biliary cytology was 50% versus 66% for pancreatic cytology. Concurrent pancreatic and biliary cytology during the same procedure increased the sensitivity in only 1 of 10 (10%) patients. Pancreatitis occurred in 11 (11%) patients (9 mild cases, 2 moderate cases) after biliary cytology and in 9 (21%) patients (6 mild cases, 3 moderate cases) after pancreatic cytology (p = 0.22). In 10 patients who had pancreatic brush cytology, a pancreatic stent was placed. None of these patients developed pancreatitis versus 9 of 32 (28%) patients in whom a stent was not placed (p = 0.08). Pancreatic cytology samples obtained from the head of the pancreas were correct in 13 of 18 (72%) cases, from the genu in 7 of 7 (100%) cases, from the body in 5 of 9 (55%) cases, and from the tail in 4 of 7 (57%) cases. CONCLUSION The accuracy of biliary brush cytology is similar to the accuracy of pancreatic brush cytology. The yield of the latter for pancreatic adenocarcinoma is similar to that of the former. Complication rates for pancreatic cytology are not significantly higher than the rates for biliary cytology. The placement of a pancreatic stent after pancreatic brushing appears to reduce the risk of postprocedure pancreatitis.

Safety of ERCP during pregnancy.

OBJECTIVES:There are few data in the literature regarding the indications, therapy, and safety of endoscopic management of pancreatico-biliary disorders during pregnancy. We report the largest single center experience with ERCP in pregnancy.METHODS:We reviewed 15 patients that underwent ERCP during pregnancy. In all patients, the pelvis was lead-shielded and the fetus was monitored by an obstetrician. Fluoroscopy was minimized and hard copy radiographs taken only when essential.RESULTS:The mean patient age was 28.9 yr (15–36 yr). The mean duration of gestation was 25 wk (12–33 wk); one patient was in the first, five in the second, and nine in the third trimester. The indications were gallstone pancreatitis (n = 6), choledocholithiasis on ultrasound (n = 5), elevated liver enzymes and a dilated bile duct on ultrasound (n = 2), abdominal pain and gallstones (n = 1), and chronic pancreatitis (n = 1). ERCP findings were bile duct stones (n = 6), patulous papilla (n = 1), bile duct debris (n = 1), normal bile duct and gallstones or gallbladder sludge (n = 3), dilated bile duct and gallstones (n = 1), normal bile duct and no gallstones (n = 2), and chronic pancreatitis (n = 1). Six patients underwent sphincterotomies and one a biliary stent insertion. One sphincterotomy was complicated by mild pancreatitis. All infants delivered to date have had Apgar-scores >8, and continuing pregnancies are uneventful. Mean fluorosocopy time was 3.2 min (SD ± 1.8). An estimated fetal radiation exposure was 310 mrad (SD ± 164) which is substantially below the accepted teratogenic dose.CONCLUSIONS:ERCP in pregnancy seems to be safe for both mother and fetus; however, it should be restricted to therapeutic indications with additional intraprocedure safety measures.

Palliation of malignant gastric outlet obstruction using an endoscopically placed Wallstent

BACKGROUND Treatment options for malignant gastric outlet obstruction are limited. Surgical gastrojejunostomy, commonly performed, has significant morbidity and mortality. METHODS Over 2 years, we prospectively studied the safety, feasibility, and outcomes for use of a newly designed expandable metal stent (Wallstent Enteral; Schneider, Minneapolis, Minn.) to treat malignant gastric outlet obstruction. Stents 16 to 22 mm in diameter and 60 to 90 mm in length were deployed directly through the endoscope. RESULTS Twelve patients (ten women, two men; mean age 59.7 years) underwent stenting. Thereafter, six patients were able to eat a regular diet; three could eat pureed food. In three patients, the procedure was unsuccessful because of multiple obstructions not recognized before stenting (one) and stents deployed too proximally (one) or too distally (one). CONCLUSIONS Placement of a newly designed stent through the endoscope is safe and effective palliation for various types of malignant gastric outlet obstruction and significantly improves many aspects of patient quality of life.

Cecal volvulus in pregnancy

Colonic volvulus is an important entity to consider in any pregnant patient with abdominal pain. X-ray and colonoscopy can be useful to obtain the earliest diagnosis, leading to surgical intervention if necessary. Limited use of x-rays with shielding of the fetus is of minimal risk and useful for early diagnosis of volvulus. Colonoscopy may confirm or exclude the diagnosis of colonic volvulus, detect mucosal ischemia, and avoid the requirement for emergency surgery by reducing the volvulus in cases in which ischemia is not present. If surgery is necessary for a cecal volvulus, cecostomy is a viable option because of a low rate of morbidity and subsequent volvulus recurrence.

Features that may predict hospital admission following outpatient therapeutic ERCP

BACKGROUND Some patients are admitted following outpatient therapeutic ERCP because of adverse events. This study aimed to identify factors that may predict such admissions. METHODS We prospectively studied admissions for post-ERCP adverse events in 415 consecutive patients undergoing outpatient therapeutic ERCP. Potentially relevant predictors of admission were assessed by univariate analysis and in case of significance included in a multivariate analysis. RESULTS Admission was necessary in 41 patients (9.9%) because of complications and in 63 (15.2%) for observation of adverse events that did not progress to definable complications. Potential predictors of admission were evaluated comparing patients who required more than an overnight admission (n = 63) with those who did not (n = 352). Multivariate analysis identified three factors that were significant: pain during the procedure (odds ratio 3.8: 95% CI [1.8, 7.9]), history of pancreatitis (odds ratio 2.3: 95% CI [1.1, 4.7]) and performance of sphincterotomy (odds ratio 2.2: 95% CI [1.1, 4.3]). The presence of all these features was associated with a 66.7% likelihood of admission, whereas the absence of pain during the procedure, history of pancreatitis and performance of sphincterotomy made admission likely in only 11.0%, 9.8% and 10.7%, respectively, of the cases. CONCLUSIONS The occurrence of pain during the procedure, a history of pancreatitis and the performance of sphincterotomy were independent predictors of admission following outpatient therapeutic ERCP.

Endoscopic management of choledocholithiasis.

The first description of endoscopic sphincterotomy 25 years ago spearheaded the widespread use of endoscopic treatment of choledocholithiasis. It is largely accepted that common bile duct stone removal should be endoscopic rather than surgical in patients who have undergone previous cholecystectomy, in the high-risk surgical patient when the gallbladder is still present, in patients with severe acute cholangitis, in selected patients with acute biliary pancreatitis, and in special circumstances for the average risk surgical patient with suspected choledocholithiasis before laparoscopic cholecystectomy. We have summarized a number of endoscopic techniques that are used in the management of bile duct stone disease.

Use of endoscopic band ligation in the treatment of ongoing rectal bleeding

Lower GI bleeding is self-limiting in the majority of cases and only 15% of patients require further diagnostic evaluation and treatment. Although surgery has been the treatment of choice in severe ongoing bleeding of the colon and rectum, new endoscopic treatment modalities are being evaluated as alternatives. One of these is endoscopic band ligation. We report two patients with severe ongoing rectal bleeding successfully treated by band ligation as an alternative to surgery.

Hydatid disease in pregnancy.

Hydatid disease of the liver has generally been managed by surgical removal with cystectomy and or partial hepatectomy. These are not without risk of complications such as anaphylactic reaction, dissemination, and recurrence. Recent advances suggest that surgery combined with chemotherapy can be successful and safe. There is very limited experience in managing hydatidosis during pregnancy. We describe the case of a pregnant woman who underwent surgery because of cysts in the mesentery and liver and also received therapy with albendazole after inadvertent surgical dissemination, with excellent resolution and a healthy infant.