John S. Goff

Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding esophageal varices

Abstract Background. Endoscopic sclerotherapy is an accepted treatment for bleeding esophageal varices, but it is associated with substantial local and systemic complications. Endoscopic ligation, a new form of endoscopic treatment for bleeding varices, may be safer. We compared the effectiveness and safety of the two techniques. Methods. In this randomized trial we compared endoscopic sclerotherapy and endoscopic ligation in 129 patients with cirrhosis who had proved bleeding from esophageal varices. Sixty-five patients were treated with sclerotherapy, and 64 with ligation. Initial treatment for acute bleeding was followed by elective retreatment to eradicate varices. The patients were followed for a mean of 10 months, during which we determined the incidence of complications and recurrences of bleeding, the number of treatments needed to eradicate varices, and survival. Results. Active bleeding at the first treatment was controlled by sclerotherapy in 10 of 13 patients (77 percent) and by ligation in 12...

Risk factors for post-ERCP pancreatitis: a prospective multicenter study.

OBJECTIVES:Pancreatitis is the most common and serious complication of diagnostic and therapeutic ERCP. The aim of this study is to examine the potential patient- and procedure-related risk factors for post-ERCP pancreatitis in a prospective multicenter study.METHODS:A 160-variable database was prospectively collected by a defined protocol on patients undergoing diagnostic or therapeutic ERCP at 15 centers in the Midwest Pancreaticobiliary Group and participating in a randomized controlled study evaluating whether prophylactic corticosteroids will reduce the incidence of post-ERCP pancreatitis. Data were collected prior to the procedure, at the time of procedure, and 24–72 h after discharge. Post-ERCP pancreatitis was diagnosed and its severity graded according to consensus criteria.RESULTS:Of the 1,115 patients enrolled, diagnostic ERCP with or without sphincter of Oddi manometry (SOM) was performed in 536 (48.1%) and therapeutic ERCP in 579 (51.9%). Suspected sphincter of Oddi dysfunction (SOD) was the indication for the ERCP in 378 patients (33.9%). Pancreatitis developed in 168 patients (15.1%) and was graded mild in 112 (10%), moderate in 45 (4%), and severe in 11(1%). There was no difference in the incidence of pancreatitis or the frequency of investigated potential pancreatitis risk factors between the corticosteroid and placebo groups. By univariate analysis, the incidence of post-ERCP pancreatitis was significantly higher in 19 of 30 investigated variables. In the multivariate risk model, significant risk factors with adjusted odds ratios (OR) were: minor papilla sphincterotomy (OR: 3.8), suspected SOD (OR: 2.6), history of post-ERCP pancreatitis (OR: 2.0), age <60 yr (OR: 1.6), ≥2 contrast injections into the pancreatic duct (OR: 1.5), and trainee involvement (OR: 1.5). Female gender, history of recurrent idiopathic pancreatitis, pancreas divisum, SOM, difficult cannulation, and major papilla sphincterotomy (either biliary or pancreatic) were not multivariate risk factors for post-ERCP pancreatitis.CONCLUSION:This study emphasizes the role of patient factors (age, SOD, prior history of post-ERCP pancreatitis) and technical factors (number of PD injections, minor papilla sphincterotomy, and operator experience) as the determining high-risk predictors for post-ERCP pancreatitis.

Endoscopist-Directed Administration of Propofol: A Worldwide Safety Experience

BACKGROUND & AIMS Endoscopist-directed propofol sedation (EDP) remains controversial. We sought to update the safety experience of EDP and estimate the cost of using anesthesia specialists for endoscopic sedation. METHODS We reviewed all published work using EDP. We contacted all endoscopists performing EDP for endoscopy that we were aware of to obtain their safety experience. These complications were available in all patients: endotracheal intubations, permanent neurologic injuries, and death. RESULTS A total of 646,080 (223,656 published and 422,424 unpublished) EDP cases were identified. Endotracheal intubations, permanent neurologic injuries, and deaths were 11, 0, and 4, respectively. Deaths occurred in 2 patients with pancreatic cancer, a severely handicapped patient with mental retardation, and a patient with severe cardiomyopathy. The overall number of cases requiring mask ventilation was 489 (0.1%) of 569,220 cases with data available. For sites specifying mask ventilation risk by procedure type, 185 (0.1%) of 185,245 patients and 20 (0.01%) of 142,863 patients required mask ventilation during their esophagogastroduodenoscopy or colonoscopy, respectively (P < .001). The estimated cost per life-year saved to substitute anesthesia specialists in these cases, assuming they would have prevented all deaths, was

Endoscopic Sclerotherapy for Bleeding Esophageal Varices: Effects and Complications

5.3 million. CONCLUSIONS EDP thus far has a lower mortality rate than that in published data on endoscopist-delivered benzodiazepines and opioids and a comparable rate to that in published data on general anesthesia by anesthesiologists. In the cases described here, use of anesthesia specialists to deliver propofol would have had high costs relative to any potential benefit.

Oral allopurinol does not prevent the frequency or the severity of post-ERCP pancreatitis.

Endoscopic esophageal vein sclerosis recently has been revived as a treatment for bleeding varices because long-term results with portacaval shunts have been poorer than suggested by initial short-term studies. Esophageal vein thrombosis secondary to endothelial damage has been considered the result of the activity of the sclerosing agents, but until 1981 there had been little pathologic documentation. Autopsy findings in ten patients who died after variceal sclerosis suggest that variceal obliteration is achieved by mural necrosis followed by fibrosis, and that thrombosis is only a transient phenomenon. Complications of sclerotherapy that were found included ulceration, hemorrhage, perforation, and stricture.

Esophageal Ulceration and Bleeding After Flexible Fiberoptic Esophageal Vein Sclerosis

BACKGROUND Pancreatitis is the most common major complication of ERCP. Efforts have been made to identify pharmacologic agents capable of reducing its incidence and severity. The aim of this trial was to determine whether prophylactic allopurinol, an inhibitor of oxygen-derived free radical production, would reduce the frequency and severity of post-ERCP pancreatitis. Methods A total of 701 patients were randomized to receive either allopurinol or placebo 4 hours and 1 hour before ERCP. A database was prospectively collected by a defined protocol on patients who underwent ERCP. Standardized criteria were used to diagnose and grade the severity of postprocedure pancreatitis. RESULTS The groups were similar with regard to patient demographics and to patient and procedure risk factors for pancreatitis. The overall incidence of pancreatitis was 12.55%. It occurred in 46 of 355 patients in the allopurinol group (12.96%) and in 42 of 346 patients in the control group (12.14%; p = 0.52). The pancreatitis was graded mild in 7.89%, moderate in 4.51%, and severe in 0.56% of the allopurinol group, and mild in 6.94%, moderate in 4.62%, and severe in 0.58% of the control group. There was no significant difference between the groups in the frequency or the severity of pancreatitis. CONCLUSIONS Prophylactic oral allopurinol did not reduce the frequency or the severity of post-ERCP pancreatitis.

Two-stage triolein breath test differentiates pancreatic insufficiency from other causes of malabsorption

Three patients with portal hypertension and variceal hemorrhage were treated with flexible fiberoptic esophageal vein sclerosis by injection of sodium morrhuate. Each of these patients bled after sclerotherapy, and deep esophageal ulcers were found at the previous injection sites. Postsclerotherapy pathologic features are presented in 2 patients. It is suggested that the sclerotherapy caused esophageal ulceration and bleeding. Careful evaluation of the sclerosing technique and its histopathologic consequences is needed.

Prospective multicenter evaluation of an initially placed button gastrostomy

In 24 patients with malabsorption, [14C]triolein breath tests were conducted before and together with the administration of pancreatic enzymes (Pancrease, Johnson and Johnson, Skillman, N.J.). Eleven patients with pancreatic insufficiency had a significant rise in peak percent dose per hour 14CO2 excretion after Pancrease, whereas 13 patients with other causes of malabsorption had no increase in 14CO2 excretion (2.61 +/- 0.96 vs. 0.15 +/- 0.45, p less than 0.001). The two-stage [14C]triolein breath test appears to be an accurate and simple noninvasive test of fat malabsorption that differentiates steatorrhea secondary to pancreatic insufficiency from other causes of steatorrhea.

Bipolar electrocoagulation versus Nd-YAG laser photocoagulation for upper gastrointestinal bleeding lesions

Eight-six patients were prospectively evaluated following placement of the One-Step gastric button. Placement problems, most commonly caused by the stoma measurement device, were noted in 17%. In an additional 30% of patients, peristomal infection, leakage, or migration developed within the first 90 days of placement. The authors conclude that although this gastric button can be placed in the majority of patients, potential design and placement problems may produce significant intraprocedural and postprocedural complications.

Surgical treatment of nutcracker esophagus

Nd-YAG laser photocoagulation and bipolar electrocoagulation may be useful for controlling upper gastrointestinal bleeding or preventing rebleeding from ulcers with visible vessels. To determine if one of these methods is superior to the other, data from a small randomized trial and from a nonrandomized experience were evaluated. Altogether, 33 patients underwent 37 coagulation sessions; 19 of the patients were randomized (8 laser and 11 bipolar). In the randomized group, 47.4% had no rebleeding after therapy (laser=37.5% and bipolar=54.5%, P>0.1). In the nonrandomized group 56.8% had no further bleeding. Eleven (33%) of the patients required surgery. No patients died of bleeding or complications related to the study. From these data and those in the literature, it is concluded that the Nd-YAG laser and the bipolar coagulator are equally effective for the treatment of solitary upper gastrointestinal bleeding lesions. Since the bipolar unit is cheaper and more easily transported than the laser unit, it may be the method of choice for cauterizing upper gastrointestinal sources until a more effective method is developed.