Jason R. Taylor

A meta-analysis of rectal NSAIDs in the prevention of post-ERCP pancreatitis

Background: Several pharmacological agents for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) have been studied. Clinical trials evaluating the protective effect of non-steroidal anti-inflammatory drugs (NSAIDs) have yielded inconclusive results. Aim: To perform a meta-analysis of studies evaluating the effect of prophylactic rectal NSAIDs on PEP. Methods: By searching Medline, Embase, meeting abstracts and bibliographies, two independent reviewers systematically identified prospective randomised controlled trials (RCTs) examining the effect of rectally administered prophylactic NSAIDs on the incidence of PEP pancreatitis. A meta-analysis of these clinical trials was performed. Results: Four RCTs, enrolling a total of 912 patients, have been published. Meta-analysis of these studies demonstrates a pooled relative risk for PEP after prophylactic administration of NSAIDs of 0.36 (95% CI 0.22 to 0.60); patients who received NSAIDs in the periprocedural period were 64% less likely to develop pancreatitis and 90% less likely to develop moderate to severe pancreatitis. The pooled number needed to treat with NSAIDs to prevent one episode of pancreatitis is 15 patients. No adverse events attributable to the use of NSAIDs were reported in any of the clinical trials. Conclusion: In this meta-analysis, prophylactic NSAIDs were effective in preventing PEP. Widespread prophylactic administration of these agents may significantly reduce the incidence of PEP, resulting in major clinical and economic benefit. Given current scepticism regarding the efficacy of any prophylactic medication for ERCP, additional multicentre studies are needed for confirmation prior to widespread adoption of this strategy.

Is MRCP equivalent to ERCP for diagnosing biliary obstruction in orthotopic liver transplant recipients? A meta-analysis

BACKGROUND Biliary complications are the second leading cause of morbidity and mortality in orthotopic liver transplant (OLT) recipients. Endoscopic retrograde cholangiography (ERC) is considered the diagnostic criterion standard for post-orthotopic liver transplantation biliary obstruction, but incurs significant risks. OBJECTIVE To determine the diagnostic accuracy of MRCP for biliary obstruction in OLT patients. DESIGN A systematic literature search identified studies primarily examining the utility of MRCP in detecting post-orthotopic liver transplantation biliary obstruction. A meta-analysis was then performed according to the Quality of Reporting Meta-Analyses statement. SETTING Meta-analysis of 9 studies originally performed at major transplantation centers. PATIENTS A total of 382 OLT patients with clinical suspicion of biliary obstruction. INTERVENTIONS MRCP and ERCP or clinical follow-up. MAIN OUTCOME MEASUREMENTS Sensitivity and specificity of MRCP for diagnosis of biliary obstruction. RESULTS The composite sensitivity and specificity were 0.96 (95% CI, 0.92-0.98) and 0.94 (95% CI, 0.90-0.97), respectively. The positive and negative likelihood ratios were 17 (95% CI, 9.4-29.6) and 0.04 (95% CI, 0.02-0.08), respectively. LIMITATIONS All but 1 included study had significant design flaws that may have falsely increased the reported diagnostic accuracy. CONCLUSIONS The high sensitivity and specificity demonstrated in this meta-analysis suggest that MRCP is a promising test for diagnosing biliary obstruction in patients who have undergone liver transplantation. However, given the significant design flaws in most of the component studies, additional high-quality data are necessary before unequivocally recommending MRCP in this setting.

Percutaneous Cholecystostomy as a Bridge to Definitive Endoscopic Gallbladder Stent Placement

BACKGROUND & AIMS Percutaneous cholecystostomy (PC) is an effective treatment for acute cholecystitis (AC) in patients who are poor surgical candidates, although it is generally used as a bridge to cholecystectomy, given its long-term risks, the need for repeated procedures, and patient dissatisfaction. Ongoing patient comorbidity, however, might preclude cholecystectomy after recovery from the acute illness. METHODS Four patients with AC who were poor immediate and long-term candidates for cholecystectomy underwent PC as primary therapy for AC, followed by endoscopic placement of a transpapillary gallbladder stent as definitive long-term management. RESULTS All 4 patients were successfully treated for AC with PC. After recovery, the patients underwent endoscopic gallbladder stent placement and removal of the PC. In 2 cases, endoscopic transpapillary access to the gallbladder was facilitated by advancing a guidewire through the cholecystostomy tract into the duodenum. All patients had favorable outcomes. CONCLUSIONS PC as a bridge to permanent therapy with endoscopic gallbladder stenting appears to be a viable strategy in the management of patients with AC who are poor immediate and long-term candidates for cholecystectomy.

Endoscopic full-thickness resection of gastric lesions using a novel grasp-and-snare technique: evaluation in a porcine survival model

BackgroundEndoscopic full-thickness resection (EFTR) is a less-invasive method of en bloc removal of gastrointestinal tumors. In a previous nonsurvival animal experiment, the feasibility of a novel grasp-and-snare EFTR technique using a prototype tissue-lifting device was demonstrated. The objective of this study was to evaluate the safety and outcomes of this EFTR method in a porcine survival model.MethodsEFTR of model stomach tumors was performed in seven pigs using a double-channel endoscope with a prototype tissue-lifting device through one channel and snare through the other. The lifting device was advanced through the snare loop and anchored to the gastric wall adjacent the model tumor. The lifting device was then partially retracted into the endoscope, causing the target tissue, including tumor, to evert into the gastric lumen. The open snare was then placed beyond the tumor around uninvolved gastric tissue. Resection was performed by delivering an electrosurgical current through the snare. EFTR defects were closed by using tissue anchors. After an intended 10-day observation period, the pigs were euthanized and necropsy was performed.ResultsAll seven resections were successful with negative gross margins. No immediate complications occurred. Two defect closures failed during the early postoperative period, leading to infectious complications. The remaining intact closures were complicated by adjacent ulcers, one of which resulted in hemorrhage.ConclusionsEndoscopic full-thickness resection of gastric lesions using the grasp-and-snare technique is feasible in pigs. In this experiment, complications related to closure were significant. Further evaluation and modification of closure technique is necessary before studying this method of EFTR in humans.

Hydroperitoneum-facilitated EUS-guided peritoneal entry and closure of alternate access sites for NOTES.

Background: Access sites other than the anterior gastric wall may provide improved ergonomics for natural orifice transluminal endoscopic surgery (NOTES). Endoscopic ultrasound (EUS) guidance significantly reduces, but does not eliminate, risk of access through these alternate sites. This study evaluates the utility of hydroperitoneum as an adjunct to EUS-guided access and closure of alternate access sites for NOTES. Methods: Access and closure procedures were initially performed with EUS guidance alone, and subsequently, because of complications resulting from this technique, the procedures were performed with the aid of a transabdominal hydroperitoneum. Results: In this nonrandomized study, 6 access and closure procedures performed with EUS guidance alone resulted in 4 complications. After modifying the technique to incorporate pre-access hydroperitoneum, 7 EUS-guided access and closure procedures were performed without significant complications. Conclusions: Hydroperitoneum appears to be an effective adjunct to ensure the safety of EUS-guided peritoneal entry and closure of alternate access sites for NOTES.

Aberrant right hepatic duct with patent ducts of Luschka

Commentary This is an unusual case in that primary herpes infection (gingivostomatitis) most commonly occurs in children or adolescents who have not been previously exposed to the virus. With a human herpes virus (HHV)-1 seroprevalence of approximately 80% in North American adults, it is surprising that this woman had her first exposure at age 21. Oral lesions can be seen with almost all the human herpes viruses, although ulceration is seen only with HHV types 1 and 2, 3 (varicella-zoster virus), and 5 (cytomegalovirus). Although many primary infections are asymptomatic, symptomatic primary infection can present with multiple, small, clustered vesicles that later ulcerate, can occur anywhere in the oral cavity, on the lips and perioral skin, or on the genitalia. Accompanying headache, fever, painful lymphadenopathy, and malaise are common. With resolution, which usually occurs within 2 weeks, the virus becomes latent in sensory ganglia, often the trigeminal ganglion, only to re-emerge at times of stress such as sunlight exposure, physical or emotional stress, and local trauma; such recurrent lesions are commonly referred to as cold sores and usually occur on keratinized mucosa. Most importantly, herpetic esophagitis does not connote immunocompromise. There is no relationship that I can see between Coxsackievirus, which is an RNA virus, and herpesvirus, which is a DNA virus, Nonetheless, I would have to name the boyfriend here as the likely source of contamination, although I would support him if he said it was not his fault, just like the song of similar name (“Not My Fault”) by Youth Brigade. As Bertrand Russell said, “The good life is inspired by love, but guided by knowledge.” The take-home message: Be careful out there in the real world. Lawrence J. Brandt, MD Associate Editor for Focal Points

Endoscopic access to and exploration of the lesser sac in a human cadaver model: opportunity for transgastric endoscopic pancreatic surgery (with video)

BackgroundTransgastric endoscopy may represent a viable platform for diagnostic and therapeutic pancreatic interventions with reduced morbidity. In a human cadaver model, we aimed to determine the feasibility of transgastric endoscopic access to the lesser sac, creation of an adequate working space within the lesser sac, and reliable identification of lesser sac anatomic structures.MethodsIn six human cadavers, endoscopic guidance was used to determine an appropriate access site to the lesser sac. Subsequently, endosonographic guidance was used to introduce an aspiration needle into the potential space between the stomach and the pancreas. After creating a fluid cushion and dilating the needle tract, an endoscope was advanced through the gastrotomy into the lesser sac and air insufflation was used to create a working space. Predetermined anatomic structures were systematically sought and marked when recognized. In the final two cadavers, endoscopic closure of the access site was performed.ResultsAll six procedures were successful in achieving access to the lesser sac and establishing an adequate working space. The access sites appeared amenable to endoscopic closure. Reliable organ identification, however, was not achieved in all cases, representing one of the immediate barriers to clinical application.ConclusionsTransgastric endoscopic access to the lesser sac can be achieved reliably and an adequate working space can be established. Additional research addressing endoscopic orientation and organ recognition within the lesser sac is necessary. The immediate potential applications of this approach include differentiating benign from malignant pancreatic pathology.

Frequency and Significance of Abnormal Pancreatic Imaging in Patients with BRCA1 and BRCA2 Genetic Mutations.

Objective. Pancreatic adenocarcinoma is typically diagnosed in advanced stages resulting in a significant reduction in the number of patients who are candidates for surgical resection. Although the majority of cases are believed to occur sporadically, about 10% show familial clustering and studies have identified an increased frequency of BRCA germline mutations. The role of screening for pancreatic adenocarcinoma in these populations is unclear. Our study aims to identify the abnormal pancreatic imaging findings in BRCA1 and BRCA2 mutation carriers. Methods. A retrospective review of patient medical records with known BRCA1 and BRCA2 mutations was conducted. Data was collected and all available abdominal imaging studies were reviewed. Results. A total of 66 patients were identified, 36 with BRCA1 and 30 with BRCA2 mutations. Only 20/66 (30%) had abdominal imaging (14 BRCA1 and 6 BRCA2 patients). Of those patients with abdominal imaging, abnormal pancreatic imaging findings were detected in 7/20 (35%) cases. Conclusion. Our study shows a high incidence of abnormal pancreatic imaging findings in patients with BRCA genetic mutations (35%). Larger studies are needed to further define the role of pancreatic cancer screening and the significance of abnormal imaging findings in BRCA1 and BRCA2 mutation carriers.