Jayant P. Talreja

Transenteric drainage of pancreatic-fluid collections with fully covered self-expanding metallic stents (with video)

BACKGROUND Drainage of pancreatic-fluid collections (PFCs) by using fully covered self-expanding metallic stents (CSEMSs) offers the option of providing a larger-diameter access fistula for drainage when compared with plastic stents. OBJECTIVE To evaluate the efficacy and safety of transenteric drainage of PFCs by using CSEMSs. DESIGN A prospective case series. SETTING A tertiary-referral center. PATIENTS Between January 2007 and September 2007, 18 patients underwent drainage of PFCs by using CSEMSs. Follow-up and final results were prospectively recorded until May 2008. INTERVENTIONS Placement of CSEMSs with a double-pigtail stent placed alongside (4 cases) or into the CSEMS (14 cases) to prevent migration. MAIN OUTCOME MEASUREMENTS The number of sessions and time to resolution of the PFCs. RESULTS A median of 1 session was required to achieve drainage (range 1-4) when using CSEMSs. Complications included superinfection (5), bleeding (2), and inner migration (1). A total of 17 of 18 patients (95%) responded successfully, with 14 patients (78%) achieving complete resolution of their PFC. The mean (+/- SD) time of follow-up until final resolution was 77 +/- 80 days (range 15-310 days). CONCLUSIONS Placement of CSEMSs seems to offer an effective and safe alternative for the drainage of PFCs. A randomized controlled trial should be performed to compare this technique with plastic-stent drainage.

Success and complications associated with placement of fully covered removable self-expandable metal stents for benign esophageal diseases (with videos)

BACKGROUND Fully covered esophageal self-expandable metal stents (FCSEMSs) are thought to induce less mucosal hyperplasia and are potentially removable. They may constitute an attractive alternative for the treatment of benign esophageal diseases. OBJECTIVE To evaluate the efficacy and safety of FCSEMSs in the treatment of benign esophageal diseases. DESIGN Patients referred for management of benign esophageal disease underwent placement of an FCSEMS and were entered into a prospective database and analyzed retrospectively for clinical response, efficacy, and morbidity. SETTING Two tertiary care centers with long-standing experience in the management of benign esophageal strictures. PATIENTS Between January 2006 and September 2007, 35 patients (mean age 61 years, range 20-85 years) underwent FCSEMS placement for benign esophageal diseases at 2 tertiary academic medical centers. There were 19 patients with benign esophageal strictures and 16 patients with leaks/perforations. INTERVENTION Temporary placement of FCSEMS until stricture resolution. MAIN OUTCOME MEASUREMENTS Clinical response, efficacy, and morbidity. RESULTS Indications for stent placement were esophageal leak/fistulae (n = 12), refractory benign strictures (n = 10), anastomotic strictures (n = 7), perforations (n = 4), and radiation-induced strictures (n = 2). Immediate complications were chest pain (2 patients), stent migration (2 patients), dysphagia (1 patient), respiratory compromise (1 patient), and arrhythmia (1 patient). Long-term complications included recurrent dysphagia (6 patients), aspiration pneumonia (2 patients), globus sensation (2 patients), abdominal pain (2 patients), and fever (1 patient). Stent migration was observed in 12 patients (34%). After placement, dysphagia scores at 1 month improved significantly from 3.1 ± 1.0 to 1.2 ± 1.3 (P < .0001). A total of 11 of 35 patients (31%) were treated successfully. Specifically, 21% of patients with refractory strictures and 44% of patients with leaks/fistulae had successful long-term outcomes without any need for reinterventions. All stents were retrieved successfully, except for 1 stent, which fractured and was retrieved in 2 pieces without any complications. CONCLUSION Use of FCSEMSs for benign esophageal conditions was associated with frequent stent migration and long-term improvement in only one third of patients. Further investigation is required before recommending FCSEMS placement to treat benign diseases of the esophagus and to further characterize the subgroup that might benefit from these interventions.

Temporary placement of a fully covered self-expandable metal stent in the pancreatic duct for management of symptomatic refractory chronic pancreatitis: preliminary data (with videos)

BACKGROUND Pancreatic duct (PD) stenting is beneficial for the treatment of pain in patients with PD strictures associated with chronic pancreatitis. Placement of metal stents has been reported but failed secondary to hyperplasia or migration. OBJECTIVE To investigate the outcome of patients with symptomatic and refractory PD strictures who had temporary placement of a covered self-expandable metal stent (CSEMS). DESIGN Patients with refractory PD strictures were offered temporary CSEMS placement. Pain scores were evaluated before and after CSEMS placement. SETTING A tertiary-care center. PATIENTS Six patients (4 men, mean age +/- SD 55 +/- 8 years) received a CSEMS, and 5 patients had removal of a CSEMS after a mean time of 92 days. INTERVENTION Placement of CSEMS (8-mm or 10-mm diameter VIABIL) in the PD, with removal after 3 months. MAIN OUTCOME MEASUREMENTS The pain score before and after stent placement and the sustained response after removal. Morbidity associated with stent placement and removal was also noted. RESULTS Pain scores after CSEMS placement significantly improved (P = .024), from 6.4 to 1.6. Of the 5 patients who underwent CSEMS removal, 3 developed recurrent symptomatic pancreatic stricture, of whom 2 required repeat stenting with a larger-diameter CSEMS (10 mm) and 2 remained pain free. The CSEMS was not removed in 1 patient because pancreatic malignancy was diagnosed. There were no complications during placement or removal of CSEMSs. LIMITATION This was a pilot study. CONCLUSION Temporary placement of CSEMSs in patients with symptomatic refractory PD stricture offers transient relief of pain. Further investigation is needed to determine the optimal diameter and duration of placement.

Multicenter trial evaluating the use of covered self-expanding metal stents in benign biliary strictures: time to revisit our therapeutic options?

Background: Covered self-expanding metal stents are being used more frequently in benign biliary strictures (BBS). We report the results of a multicenter study with fully covered self-expanding metal stent (FCSEMS) placement for the management of BBS. Aim: To prospectively evaluate the efficacy and safety of FCSEMS in the management of BBS. Patients and Methods: Patients with BBS from 6 tertiary care centers who received FCSEMS with flared ends between April 2009 and October 2010 were included in this retrospective study. Efficacy was measured after removal of FCSEMS by evaluating stricture resolution on the basis of symptom resolution, imaging, laboratory studies, and/or choledochoscopy at removal. Safety profile was evaluated by assessing postprocedural complications. Results: A total of 133 patients (78, 58.6% males) with a mean age of 59.2±14.8 years with BBS received stents. Of the 133 stents placed, 97 (72.9%) were removed after a mean stent duration of 95.5±48.7 days. Stricture resolution after FCSEMS removal was as follows: postsurgical, 11/12 (91.6%); gallstone-related disease, 16/19 (84.2%); chronic pancreatitis, 26/31 (80.7%); other etiology, 4/5 (80.0%); and anastomotic strictures, 19/31(61.2%). Ninety-four patients were included in the logistic regression analyses. Patients who had indwelling stents for >90 days were 4.3 times more likely to have resolved strictures [odds ratio, 4.3 (95% confidence interval, 1.24-15.09)] and patients with nonmigrated stents were 5.4 times more likely to have resolved strictures [odds ratio, 5.4 (95% confidence interval, 1.001-29.29)]. Conclusions: FCSEMS for BBS had an acceptable rate of stricture resolution for postsurgical strictures, gallstone-related strictures, and those due to chronic pancreatitis. Predictors for stricture resolution include longer indwell time and absence of migration. Further study is warranted to assess long-term efficacy in a prospective manner with longer than 3-month time of stent indwelling time.

Endotherapy for pancreatic necrosis and abscess: endoscopic drainage and necrosectomy

Pancreatic necrosis and abscess are among the most severe complications of acute pancreatitis. Endoscopic drainage of pancreatic fluid collections has been increasingly performed in many tertiary care centers. The type of fluid collection that is being intervened upon determines the outcome. The development of endoscopic ultrasonography (EUS) has expanded the safety and efficacy of this modality by allowing one to access and drain more challenging fluid collections. The technique and review of current literature regarding endoscopic therapy of pancreatic necrosis and abscess will be discussed.

Photodynamic therapy for unresectable cholangiocarcinoma: contribution of single operator cholangioscopy for targeted treatment

Photodynamic therapy (PDT) for unresectable cholangiocarcinoma is associated with improvement in cholestasis and survival. Single operator cholangioscopy (SOC) has been used for targeted laser illumination. We analyzed our growing experience of SOC with direct PDT. This is a retrospective analysis of a consecutive series of patients prospectively entered into a registry. Forty-five patients (24 male, aged 67.3 ± 10.6 years) were treated with PDT for cholangiocarcinoma during a five-year period. Thirty-two patients were treated with ERCP and PDT alone, and 13 were treated with ERCP and PDT using SOC. The two groups were then compared to observe any statistically significant difference in regards to age, gender, serum bilirubin, MELD score, adverse effects, or survival. An overall median of 1 PDT session per patient (range: 1-9) was performed. Twenty-six total sessions of PDT using SOC were performed in 13 patients with a median of 2.0 sessions per patient (range: 1-6). Median global survival was 168 days (range: 26-1353). Median survival for the PDT-only group was 200 days, and median survival for the PDT-with-SOC group was 386 days (p = 0.45). There was a statistically significant difference (p < 0.0001) between the two groups in regards to fluoroscopy time, with the PDT-only group having a median time of 21.1 min and the PDT-with-SOC group having a median time of 11.1 min. PDT related complications included 7 cases of mild phototoxicity and one case of moderate phototoxicity requiring hospitalization. SOC permits targeted therapy during PDT and can be successfully performed without adverse events while simultaneously reducing exposure to radiation.

Pre- and post-training session evaluation for interobserver agreement and diagnostic accuracy of probe-based confocal laser endomicroscopy for biliary strictures

Current diagnostic modalities for indeterminate biliary strictures offer low accuracy. Probe‐based confocal laser endomicroscopy (pCLE) permits microscopic assessment of mucosal structures by obtaining real‐time high‐resolution images of the mucosal layers of the gastrointestinal tract. Previously, an interobserver study demonstrated poor to fair agreement even among experienced confocal endomicroscopy operators. Our objective was to assess interobserver agreement and diagnostic accuracy upon completion of a pCLE training session.

Presence of Lymph Node Vasculature: A New EUS Criterion for Benign Nodes?

Objectives Lymph nodes normally have prominent centrally located blood vessels, which may become obliterated with tumor infiltration. The presence of intranodal vasculature has been noted to coincide with benign cytology. We sought to determine the test characteristics of the presence of intranodal mediastinal vasculature during endoscopic ultrasound (EUS). Methods 67 mediastinal lymph nodes evaluated by EUS in 66 patients over a 1-year period were evaluated for the presence of intranodal vasculature, which was considered benign when it traversed through the node without disruption. Results Of the 67 lymph nodes evaluated, 29 (43%) were found to be malignant on cytopathologic review. Benign vascular markings were present in 15/67 (22.4%) lymph nodes evaluated. All 15 (100%) of these nodes were found to have benign fine-needle aspiration (FNA) results. The presence of benign vasculature had a negative predictive value of 100%. Conclusions The presence of intranodal vasculature was universally associated with a benign diagnosis. The addition of this EUS finding improves the ability to characterize lymph nodes and predict the likelihood of malignant involvement.

Interobserver agreement for confocal imaging of ampullary lesions: a multicenter single-blinded study.

Background: Malignant ampullary lesions can be difficult to classify by endoscopy alone. Probe-based confocal laser endomicroscopy (pCLE) permits in vivo assessment of mucosal structures in the gastrointestinal tracts in the real time. Aim: The objective of this pilot multicenter study was to assess the interobserver agreement and variance in interpretation of pCLE of ampullary lesions. Methods: Twelve pCLE video clips of ampullary lesions were distributed to 6 gastrointestinal specialists at 5 medical centers, blinded to final pathologic results. Six variables were assessed for interobserver agreement using &kgr; statistics. Variables included an epithelial outer border with irregular thickness, dark epithelium without discernable individual cells, heterogenously distributed elongated crypts, reduced number of goblet cells, neovascularization, and final diagnosis. Results: The overall interobserver agreement for all observers was poor to slight for all variables (&kgr;=0.02, 0.05, −0.01, 0.04, 0.018) except for the first variable with fair degree of agreement (&kgr;=0.27). On the basis of experience, 3 observers were classified as less experienced, whereas 3 were classified as most experienced. Upon stratification, the less experienced observers had poor interobserver agreement for all variables, except 1. The most experienced observers had poor agreement for 2 variables, slight agreement for 3 variables, and fair agreement for the final diagnosis variable. Conclusions: The overall interpersonal agreement on pCLE for ampullary lesions was poor. The interobserver agreement was not substantially improved for experienced raters. Further standardization of pCLE image criteria is needed for ampullary lesions. Standardized training may improve interrater reliability to an acceptable level.

Photodynamic Therapy in Unresectable Cholangiocarcinoma: Not for the Uncommitted

Background/Aims Photodynamic therapy (PDT) in unresectable cholangiocarcinoma has been associated with improved survival. We report a single tertiary care center experience over the past 6 years. Methods Fifty-five patients with unresectable cholangiocarcinoma received PDT between 2004 and 2010. Plastic stents were placed after PDT to prevent cholangitis. Results Twenty-seven patients (49%) showed Bismuth type IV, 22 (41%) showed Bismuth type III, and six (10%) showed Bismuth type I and II. Twenty patients (37%) received chemotherapy and radiation therapy, five (9%) received chemotherapy only; and one (2%) received radiation therapy only. Mean number of PDT sessions was 1.9±1.5 sessions (range, 1 to 9). Mean survival duration was 293±266 days (median, 190; range, 25 to 1,332). PDT related complications included three (5%) facial burn, three (5%) photosensitivity, and two (3%) rash. Kaplan-Meier analysis comparing the survival means of patients who received PDT and chemotherapy/radiation therapy (median survival 257 days; 95% confidence interval [CI], 166 to 528) versus who received PDT only (median survival 183 days; 95% CI, 129 to 224) showed no significant difference (log-rank p=0.20). Conclusions PDT has a measurable impact on survival in unresectable cholangiocarcinoma but requires aggressive stenting posttherapy.