Ioannis Pilpilidis

A comparative study of standard ERCP catheter and hydrophilic guide wire in the selective cannulation of the common bile duct.

BACKGROUND AND STUDY AIMS Deep cannulation of the common bile duct (CBD) is paramount for the success of endoscopic biliary intervention. The aim of the present study was to compare standard ERCP catheter and hydrophilic guide wire (HGW) in the selective cannulation of the CBD. PATIENTS AND METHODS A total of 332 patients were randomly assigned to cannulation with a standard catheter (n = 165) or a HGW (n = 167). If cannulation had not succeeded after 10 minutes with the technique assigned at randomization, a further attempt was made for an additional 10 minutes using the alternative technique. The following were assessed: primary and overall selective cannulation, time to cholangiography, number of pancreatic opacifications and guide-wire pancreatic duct insertions, and complication rates. RESULTS The primary success rate of selective CBD cannulation was higher in the HGW (81.4 %) than in the standard catheter group (53.9 %; P < 0.001). The overall cannulation rate after crossover was comparable between the two groups (standard catheter 84 % vs. HGW 83.8 %; P = 0.19). Time required for primary selective CBD cannulation was 3.53 +/- 0.32 minutes in the standard catheter vs. 4.48 +/- 0.32 minutes in the HGW group ( P = 0.04), and the number of insertions of the guide wire into the pancreatic duct was 3.29 +/- 0.47 in the standard catheter vs. 2.7 +/- 0.21 in the HGW group ( P = 0.22). Pancreatic opacifications occurred 3.19 +/- 0.20 times in the standard catheter vs. 1.50 +/- 0.22 times in the HGW group ( P < 0.001). Precut techniques were used in 56 patients (16.9 %) (n = 31 in the standard catheter vs. n = 25 in the HGW group; P = 0.07). The frequency of postinterventional pancreatitis and hemorrhage did not differ between the two groups. A young woman developed post-ERCP hemolytic crisis due to glucose-6-phosphate dehydrogenase deficiency. There was no procedure-related mortality. CONCLUSIONS The use of HGW, as primary technique or as a secondary technique after failure of cannulation with a standard catheter, achieves a high rate of selective CBD cannulation.

The effect of indwelling endoprosthesis on stone size or fragmentation after long-term treatment with biliary stenting for large stones

Background: Endoscopic biliary stenting is often used for large or difficult common bile duct (CBD) stones, but the effect of indwelling endoprosthesis on size or fragmentation of stones after long-term treatment with biliary stenting has not been formally established. We compared the stone size or fragmentation of common bile duct stones after a long period of biliary stenting. Methods: Endoscopic biliary endoprosthesis was performed for 49 high-risk patients with CBD stones too large or difficult to be extracted by conventional endoscopic means. Bile duct drainage was established in all the patients without complications. Of the patients, 24 died with endoprosthesis in situ all from causes unrelated to biliar disease; 22 underwent a second and three patients a third attempt at stone extraction. The largest stone diameter was >12 mm in all patients. Results: In 11 of 25 patients (44%) the endoprosthesis allowed resolution of the problem of unextractable common bile duct stones. Four patients showed no existence of stent, and ERCP complete stone clearance from the CBD on programmized appointment after endoprosthesis insertion. Reduced size or fragmentation of stones was obtained in seven patients, and the stones could be removed endoscopically. The remaining 14 patients demonstrated no significant change in the size or fragmentation of their stones, and endoprostheses were replaced. Conclusions: These results suggest that endoscopic endoprosthesis for large or difficult CBD stones is an effective method to clear the duct in selected cases, as well as an important definitive treatment in high-risk patients.

A comparative study of 10-Fr vs. 7-Fr straight plastic stents in the treatment of postcholecystectomy bile leak

BackgroundBiliary decompression is a key factor in the treatment of postcholecystectomy bile leak. However, the optimal size of the stent introduced by therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is yet to be determined. The aim of the study was to compare the effectiveness of two straight plastic stents with different sizes (10-Fr and 7-Fr) in the treatment of postcholecystectomy bile leak.MethodsBetween January 2003 and August 2006, 63 patients underwent therapeutic ERCP for postcholecystectomy bile leak. After visualization of the bile duct injury, endoscopic sphincterotomy was performed and the patients were randomized to receive either a 7-Fr (31 subjects, group A) or a 10-Fr (32 subjects, group B) straight plastic stent for four weeks. The success of the endoscopic treatment was determined by the elimination of the symptoms and the removal of the drain without any adverse outcomes.ResultsThe endoscopic intervention was successful in 29 patients of group A (93.54%) and in 31 patients of group B (96.87%). In the remaining two patients of group A, the 7-Fr stent was substituted by a 10-Fr stent after 7 days because the leak remained unaffected, resulting in healing of the leaks. Surgery was required in the remaining one patient of group B. Eight patients developed post-ERCP pancreatitis (5 mild, 2 moderate, 1 severe), which was treated conservatively.ConclusionsThis trial suggests that the stent size does not affect the outcome of the endoscopic intervention in postcholecystectomy bile leaks due to minor biliary tract injury; however, larger cohorts are required to confirm the optimal stent size in bile leaks due to major bile duct injury.

A comparative study of 50% dextrose and normal saline solution on their ability to create submucosal fluid cushions for endoscopic resection of sessile rectosigmoid polyps

BACKGROUND EMR traditionally performed by using normal saline solution (NS) plus epinephrine (E) as a submucosal fluid cushion does not maintain the submucosal elevation for a prolonged time. It was hypothesized that 50% dextrose (D(50)) plus E as a hypertonic, inexpensive, and easily available solution might be an ideal alternative for producing and maintaining more-prolonged mucosal elevation. OBJECTIVE To evaluate D(50)+E versus NS+E during an EMR of sessile rectosigmoid polyps (> 10 mm). DESIGN A prospective, double-blind, randomized study that compared EMR by using either D(50)+E or NS+E submucosal fluid cushions. SETTING Four tertiary endoscopic referral centers with 1370 polypectomies in 2006, performed by 5 experienced endoscopists. PATIENTS Patients treated for sessile rectosigmoid polyps (> 10 mm). INTERVENTIONS Polypectomy with D(50)+E or NS+E submucosal fluid cushions. MAIN OUTCOME MEASUREMENTS The duration of submucosal elevation, volume of solution, number of required injections to maintain the elevation, and observations for complications. RESULTS Ninety-two sessile rectosigmoid polyps were removed. Injected solution volumes and the number of injections to maintain submucosal elevation were lower in the D(50)+E group than in the NS+E group (P = .033 and P = .028, respectively). Submucosal elevation had a longer duration in the D(50)+E group (P = .043). This difference mainly included large (> or = 20 mm) and giant (> 40 mm) polyps. There were 6 and 1 cases of postpolypectomy syndrome in the D(50)+E and NS+E groups, respectively (P = .01). LIMITATIONS May be limited by inexperienced endoscopists lack of injection and polypectomy skills. CONCLUSIONS D(50)+E is superior to NS+E for an EMR, particularly in large and giant sessile polyps, but the risk of thermal tissue injury should be considered.

Eradication Therapy in Helicobacter pylori-Positive Patients with Halitosis: Long-Term Outcome

Objective: The aim of this study was to investigate the incidence and long-term outcome of halitosis before and after eradication therapy in patients with functional dyspepsia and Helicobacter pylori infection. Subjects and Methods: Halitosis and dyspepsia-related symptoms were investigated by way of a questionnaire. Only patients with functional dyspepsia, H. pylori infection and no histological evidence of atrophy were included in the study. A total of 18 patients fulfilled these criteria and completed the study. Four to six weeks after the end of eradication treatment, endoscopy or [13C] breath test was performed to check for H. pylori in the gastric mucosa. Halitosis and dyspeptic symptoms were re-evaluated during and at the end of follow-up. Results:H. pylori infection was eradicated in all patients, in the 14/18 patients (77.8%) with triple drug therapy, and the 4/18 patients (22.2%) with quadruple drug therapy. During the follow-up period (mean 55.8 ± 21.3 months (range 6–108 months)) resolution of halitosis was observed in 16/18 patients (88.9%), while 2 patients (11.1%) (p < 0.001) continued to present with halitosis. Also, eradication therapy resulted in statistically significant relief of all dyspeptic symptoms, except bloating. Conclusion: Eradication of H. pylori in patients with functional dyspepsia and halitosis results in sustained resolution of halitosis during long-term follow-up in the majority of cases. This finding supports the existence of a link between H. pylori infection and halitosis and suggests that H. pylori eradication might be considered in patients with halitosis.

Upper gastrointestinal carcinogenesis: H. pylori and stem cell cross-talk.

Chronic inflammation of the gastric epithelium has been associated with the pathogenesis of gastric cancer, as it was postulated by Coreas model of gastric carcinogenesis. Helicobacter pylori (Hp) regulates this inflammatory process and promotes gastric carcinogenesis through induction of gene mutations and protein modulation. Recent data raise the cancer stem cell hypothesis, which implies a central role of multipotent cancer cells in oncogenesis of various solid tumors. This review provides a synopsis of gastric cancer initiation and promotion through Hp and stem cell signaling pathways. The expanding research field of Hp-related cancer stem cell biology may offer novel implications for future treatment of upper gastrointestinal cancer.

Outpatient therapeutic endoscopic retrograde cholangiopancreatography is safe in patients aged 80 years and older.

BACKGROUND AND STUDY AIM The aim of this observational prospective study was to evaluate the safety of outpatient therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in a very elderly cohort. PATIENTS AND METHODS A total of 600 patients were included in the study between June 2006 and June 2009. All underwent first therapeutic ERCP and were scheduled to be discharged on the same day following a postprocedure observation period of 6 hours. Of the 600 patients, 123 patients (group A) were re-admitted due to postprocedure complications that presented during the observation period, and 477 patients (group B) were discharged on the same day. Concomitant diseases, details of ERCP procedures, complications, and outcomes were all evaluated. The accuracy of the 6-hour postprocedure observation period, clinical criteria in predicting those patients aged 80 years and older in whom all therapeutic ERCP can be performed on an outpatient basis, and costs saved were all assessed. RESULTS There was a statistical difference in incidence of concomitant diseases between groups A and B (group A 84.5 % vs. group B 74.6 %; P = 0.020). However, there was no difference between the groups with regard to indication for ERCP and type of intervention. There was no difference in postprocedure complication rate between very elderly patients and younger patients (< 80 years), except for prolonged sedation or hypotension, which occurred more frequently in older (≥ 80 years) than in younger (< 80 years) patients (7.6 % vs. 3.2 %; P = 0.037). In group B, complications necessitating re-admission after the 6-hour observation period occurred in 10 patients (2.09 %) (patients ≥ 80 years 0.8 % and patients < 80 years 2.5 %). The costs saved by performing the procedure on an outpatient basis was calculated as 150 € per patient. CONCLUSION Outpatient therapeutic ERCP with postprocedure observation of 6 hours is a safe and cost-effective procedure in a significant proportion of very elderly patients.

Secondary Aortoduodenal Fistula with a Fatal Outcome: Report of Six Cases

Secondary aortoenteric fistulas (AEFs) are a well-known but uncommon cause of gastrointestinal hemorrhage. They usually occur secondary to reconstructive surgery of an abdominal aneurysm. We report six cases of secondary aortoduodenal fistulas, involving patients who, despite presenting with classic “herald bleeding,” died as a result of delayed operative intervention. We also discuss the pathogenesis, clinical presentation, and diagnosis of AEFs, emphasizing the value of clinical suspicion and negative endoscopy in establishing the diagnosis and the need for early operative intervention.

Treatment of proctalgia fugax with botulinum A toxin.

Two recent studies described a temporal association between a high-amplitude and high-frequency myoelectrical activity of the anal sphincter and the occurrence of proctalgia, which suggest that paroxysmal hyperkinesis of the anus may cause proctalgia fugax. We describe a single case of proctalgia fugax responding to anal sphincter injection of Clostridium botulinum type A toxin. The presumed aetiology of proctalgia fugax is discussed and the possible mechanism of action of botulinum toxin (BTX) in this condition is outlined. Botulinum A toxin seems to be a promising treatment for patients with proctalgia fugax, and further trials appear to be worthwhile for this condition, which has been described as incurable.

Endoclipping for gastric perforation after endoscopic polypectomy: an alternative treatment to avoid surgery.

A 47-year-old woman underwent endoscopic polypectomy of a villous adenoma in the lesser curvature of the gastric antrum. Shortly after the procedure, she complained of severe abdominal pain. An abdominal x-ray showed air under the diaphragm, suggestive of gastric perforation. On re-endoscopy, the cavity at the site of polypectomy was closed using endoscopically applied metallic clips. She was treated with intravenous hyperalimentation, omeprazole, and antibiotics for 10 days. Ingestion of food was started 10 days after admission, and she was discharged without any complaints. She is free of symptoms on follow-up after 8 months, and endoscopy showed complete healing of the perforation. The procedure is the third described for the stomach in the English literature and emphasizes the use of endoclipping in selected cases of small and well-defined perforations.