Hong Ja Kim

Is the addition of choleretic agents in multiple double-pigtail biliary stents effective for difficult common bile duct stones in elderly patients? A prospective, multicenter study

BACKGROUND Temporary biliary stenting is both technically easy and feasible, and choleretic agents such as ursodeoxycholic acid (UDCA) and a terpene preparation may promote a reduction in stone size. However, there are few comparative data on the effectiveness of choleretic agents available. OBJECTIVE To investigate the efficacy of multiple double-pigtail stents with or without UDCA and terpene on difficult common bile duct (CBD) stones. DESIGN A prospective, multicenter study. SETTING Four tertiary-care referral centers. PATIENTS This study involved 51 patients. INTERVENTION In total, 51 elderly patients with comorbidities who had difficult CBD stones refractory to conventional methods were randomized to receive either multiple 7F double-pigtail stents (group A) or stents in combination with UDCA and terpene (group B) for a period of 6 months. MAIN OUTCOME MEASUREMENTS Stone size reduction, successful duct clearance, and complications. RESULTS Complete endoscopic duct clearance was achieved in 14 patients (73.7%) in group A and 19 patients (86.4%) in group B (P = .826). The mean size of CBD stones (transverse/longitudinal diameter, mean ± SD) was 19.12 ± 4.48 mm/20.47 ± 3.86 mm in group A and 21.30 ± 7.08 mm/22.58 ± 7.61 mm in group B. Stone size decreased significantly to 12.04 ± 3.26 mm/13.31 ± 5.12 mm and 13.67 ± 5.40 mm/14.04 ± 6.12 mm, respectively (P < .01). However, there was no statistical difference in stone size reduction between the two groups (P = .685, P = .289). No serious complications related to the stent or endoscopic procedures were observed, except for cholangitis (n = 1, group A) and distal stent migration (n = 2, group B). LIMITATIONS Small number of patients in East Asia. CONCLUSION Temporary multiple double-pigtail biliary stenting was a safe and feasible method of treating difficult and large CBD stones in elderly patients and contributed to a reduction in stone size and successful duct clearance. However, the addition of choleretic agents did not result in a statistical difference in stone size or rate of successful duct clearance.

Vigorous Periprocedural Hydration With Lactated Ringer’s Solution Reduces the Risk of Pancreatitis After Retrograde Cholangiopancreatography in Hospitalized Patients

BACKGROUND & AIMS: Vigorous intravenous fluid resuscitation (IVFR) was reported to reduce post–endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in a pilot study. We performed a randomized, double‐blind controlled trial to establish whether periprocedural vigorous IVFR reduces the risk of post‐ERCP pancreatitis. METHODS: A total of 510 patients with native papilla at 3 tertiary referral centers in Korea were randomly assigned (1:1) to groups given vigorous IVFR (lactated Ringers solution in an initial bolus of 10 mL/kg before the procedure, 3 mL/kg/h during the procedure, for 8 hours after the procedure, and a post‐procedure bolus of 10 mL/kg) or a standard IVFR (lactated Ringers solution at 1.5 mL/kg/h during and for 8 hours after the procedure). The primary end point of the study was the development of post‐ERCP pancreatitis, and the secondary end point was severity of pancreatitis, hyperamylasemia, and fluid overload. RESULTS: The main indications for ERCP were choledocholithiasis (58%) and malignant biliary stricture (27%). Post‐ERCP pancreatitis developed in 11 patients in the vigorous IVFR group (4.3%) and 25 patients in the standard IVFR group (9.8%) (relative risk, 0.41; 95% CI, 0.20–0.86; P = .016). Moderate or severe acute pancreatitis occurred in a significantly smaller proportion of patients in the vigorous IVFR group (0.4%) than in the standard IVFR group (2.0%; P = .040). One patient in the vigorous IVFR group developed peripheral edema. CONCLUSIONS: In a double‐blind, randomized controlled trial, we found vigorous periprocedural intravenous hydration with lactated Ringers solution to reduce the incidence and severity of post‐ERCP pancreatitis in average‐risk and high‐risk cases. IVFR is not associated with increased adverse events. ClinicalTrials.gov number: NCT02308891.

A pancreatic pseudocyst-portal vein fistula closed by endoscopic pancreatic stent insertion

w arcinae ssp has not been previously described. Sarcina entriculi is a strictly anaerobic, carbohydrate-fermenting, O2 and ethanol producing bacterium able to grow at a pH s low as 2.3,5 Its pathogenic status is unclear.6 It is possible hat Sarcinae can only thrive in the human stomach when astric emptying is delayed.7 Sarcinae cluster in packages of or 8 cells. Cultivation of Sarcina ventriculi is difficult beause of the complex nutritional requirements of the bacteium,8 which explains our inability to culture the pathogen. actors contributing to a favorable outcome for our patient nclude early treatment with an antibiotic effective against naerobes. Because Sarcinae requires carbohydrates for ferentation, another contributing factor may have been to eep the patient with nothing by mouth. In conclusion, infection with Sarcina ventriculi should e considered in the differential diagnosis for cases of nexplained emphysematous gastritis.

Differential expression of E-cadherin, β-catenin, and S100A4 in intestinal type and nonintestinal type ampulla of Vater cancers.

Background/Aims Epithelial-mesenchymal transition (EMT)-related proteins may exhibit differential expression in intestinal type or pancreatobiliary type ampulla of Vater carcinomas (AVCs). We evaluated the expression of E-cadherin, β-catenin, and S100A4 in intestinal and nonintestinal type AVCs and analyzed their relationships with clinicopathological variables and survival. Methods A clinicopathological review of 105 patients with AVCs and immunohistochemical staining for E-cadherin, β-catenin, and S100A4 were performed. The association between clinicopathological parameters, histological type, and expression of EMT proteins and their effects on survival were analyzed. Results Sixty-five intestinal type, 35 pancreatobiliary type, and five other types of AVCs were identified. The severity of EMT changes differed between the AVC types; membranous loss of E-cadherin and β-catenin was observed in nonintestinal type tumors, whereas aberrant nonmembranous β-catenin expression was observed in intestinal type tumors. EMT-related changes were more pronounced in the invasive tumor margin than in the tumor center, and these EMT-related changes were related to tumor aggressiveness. Among the clinicopathological parameters, a desmoplastic reaction was related to overall survival, and the reaction was more severe in nonintestinal type than in intestinal type AVCs. Conclusions Dysregulation of E-cadherin, β-cadherin, and S100A4 expression may play a role in the carcinogenesis and tumor progression of AVCs.