Kostas Fasoulas

Combination of diclofenac plus somatostatin in the prevention of post-ERCP pancreatitis: a randomized, double-blind, placebo-controlled trial

BACKGROUND AND STUDY AIMS Pancreatitis is the most common complication of therapeutic endoscopic retrograde cholangiopancreatography (ERCP), and many pharmacoprophylactic approaches have been suggested, though not without controversy. The aim was to investigate the impact of combined therapy with diclofenac plus somatostatin on reducing the frequency and severity of post-ERCP pancreatitis (PEP). PATIENTS AND METHODS A prospective, double-blind, placebo-controlled trial was conducted in two tertiary referral centers, with 540 eligible patients randomized to receive either combined therapy with diclofenac 100 mg rectally 30 to 60 minutes before ERCP plus somatostatin 0.25 mg/h for 6 hours (group A), or a placebo suppository identical in appearance to the diclofenac along with saline solution (group B). Patients were clinically evaluated and serum amylase levels were determined before ERCP and at 6 and 24 hours post-procedure. Standardized criteria were used to diagnose and grade the severity of PEP. Adverse events were recorded prospectively. RESULTS There were no statistical differences between the groups regarding demographic data, ERCP findings, and procedure risk factors for PEP. The overall incidence of acute pancreatitis was 7.2 %. The PEP rate was significantly lower in the patients who received the combination therapy than in controls (4.7 % vs. 10.4 %, P = 0.015). Previous history of acute pancreatitis (P = 0.001), pancreatic opacification of first-class branches and beyond (P = 0.008), and absence of pharmacoprophylaxis (P = 0.023) were identified as independent risk factors for PEP in multivariate analysis. CONCLUSION Although combined prophylactic therapy with diclofenac plus somatostatin was promising in reducing frequency of PEP, further comparative large-scale studies are needed to confirm our findings before definitive conclusions can be drawn.

Endoscopic mucosal resection of giant laterally spreading tumors with submucosal injection of hydroxyethyl starch: comparative study with normal saline solution.

Background: Normal saline (NS) plus epinephrine (E) is the traditionally used solution as submucosal fluid cushion for a safe and effective endoscopic mucosal resection (EMR) of sessile colorectal polyps. It was hypothesized that hydroxyethyl starch (HES), an inexpensive and easily available solution might be an ideal solution for prolonged elevation of submucosal cushion for an easy and safe EMR of giant colorectal lateral spreading tumors (LSTs). Patients and Methods: During a 6-year period, patients suffering from colorectal LSTs with a diameter of ≥30 mm were randomized to undergo EMR by using either HES+E (group A) or NS+E (group B) for submucosal fluid cushion. All patients who had undergone a colonoscopy set the diagnosis of LSTs. The LSTs were examined with standard white light and narrow-band imaging to accurately delinate their margins before resection. The initial volume of injected solution, the additional amount to maintain the submucosal cushion, the duration of submucosal elevation and post–EMR-related complications were recorded. After EMR, patients had a standard follow-up at 3, 6, and 12 months and further if it was necessary using total colonoscopy. Results: Forty-nine patients suffering from giant LSTs were included in the study. No difference between the 2 groups was observed in patients’ characteristics, size of LSTs, and the initial volume of injected solution. However, the additional amount of solution to maintain submucosal elevation was lower in group A (median, 4 mL; range, 2 to 25) than in group B (median, 6 mL; range, 3 to 8; P=0.001). Moreover, submucosal elevation had a statistically longer duration in group A (median, 18.5 min; range, 14.5 to 28.4) than in group B (median, 20.15 min, range, 9.6 to 13.4; P<0.001), and there was a statistical difference on total procedure time in favor of group A [group A, 20.15 min (12 to 32.5) vs. group B, 22.8 min (18 to 34.5)]. One case of macroperforation, 2 cases of postpolypectomy syndrome, and 1 case of EMR-related bleeding were observed in the HES+E group, whereas 6 cases of EMR-related bleeding were observed in the NS+E group. During a median follow-up of 32 and 34 months, for HES+E and NS+E groups, respectively, 5 and 7 recurrences were observed, which were all treated endoscopically. Conclusions: HES+E injection produces a more prolonged submucosal elevation and lowers total procedure time than NS+E; however, the safety of EMR is not influenced.

Diagnostic yield and clinical impact of wireless capsule endoscopy in patients with chronic abdominal pain with or without diarrhea: a Greek multicenter study.

BACKGROUND Wireless capsule endoscopy has become the gold standard for the examination of small bowel. However, its role in the evaluation of patients suffering from chronic abdominal pain is not yet clearly defined. We conducted an open-label prospective multi-center study to evaluate the yield and clinical outcome of capsule endoscopy in patients with chronic abdominal pain with/without diarrhea. METHODS Seventy-two patients with chronic (>3months) abdominal pain with/without diarrhea in whom the underlying pathology could not be diagnosed by conventional modalities, underwent capsule endoscopy in either of the 6 participating centers. Patients were then followed up for clinical outcomes. RESULTS The overall diagnostic yield of capsule endoscopy was 44.4%. More specifically, its diagnostic yield was 21.4% in patients with abdominal pain and negative inflammatory markers (C-reactive protein and erythrocyte sedimentation rate), 66.7% in patients with abdominal pain and positive inflammatory markers, 0% in patients with abdominal pain, diarrhea and negative inflammatory markers, and 90.1% in patients with abdominal pain, diarrhea and positive inflammatory markers. Both univariate and multivariate regression analyses showed that abnormal C-reactive protein and erythrocyte sedimentation rate were significant factors related with positive capsule endoscopy findings. CONCLUSIONS Chronic abdominal pain with/without diarrhea should be accompanied by elevated inflammatory markers to be regarded as a valid indication for capsule endoscopy. The yield of capsule endoscopy in such patients is reasonably high and clinical outcomes of patients treated with capsule endoscopy findings as a guide are significant.

Diagnostic yield and clinical impact of capsule endoscopy in obscure gastrointestinal bleeding during routine clinical practice: a single-center experience.

Objective: This study assessed the diagnostic yield of capsule endoscopy (CE) and its impact on patients with obscure gastrointestinal bleeding (OGIB). Subjects and Methods: Between May 2007 and May 2009, 63 patients with OGIB (overt bleeding: 25, and occult blood loss with chronic ferropenic anemia: 38) and normal upper and lower endoscopy were studied by CE. Demographic characteristics, prior diagnostic tests, CE findings, therapeutic interventions, medical treatment and clinical outcomes following CE were evaluated. Results: The overall diagnostic yield was 44.44% of patients and included findings of angiectasia in 11 (17.46%) patients, nonsteroidal anti-inflammatory drugs enteropathy in 6 (9.52%) patients, celiac disease in 3 (4.76%) patients, tumors in 2 (3.17%) patients, and a variety of other diagnoses ranging from varices to ulcers (due to congenital afibrinogenemia and amyloidosis). The diagnostic yield was notably higher in overt bleeders (15/25, 60%) compared to occult bleeders (13/38, 34.21%; p = 0.044), and in patients with overt bleeding who had CE within the first 10 days (14/16, 87.5%) after the bleeding episode in comparison to overt bleeders who underwent CE >10 days after the bleeding episode (2/16, 11.1%; p < 0.0001). During follow-up (11.8 ± 7 months), CE findings led to specific therapy that resolved the underlying disease or improved the clinical condition in 45 of 63 patients, thus having a positive clinical impact of 71.43%. Conclusion: CE has a high diagnostic yield and a positive influence on clinical management in a significant proportion of patients with OGIB. These data further support the role of CE in routine clinical practice.

Efficacy of colchicine in the treatment of mesenteric panniculitis in a young patient.

Mesenteric panniculitis (MP) is a rare inflammatory and fibrotic disease of the mesentery of unknown etiology. It has various clinical and radiological manifestations, posing a diagnostic challenge for clinicians. Its diagnosis is indicated via radiologic imaging and is usually confirmed via peritoneal biopsies. We describe a case of a patient with histopathologically proven MP, in which steroid dependence was successfully managed with colchicine.

Prophylactic clip application before endoscopic resection of large pedunculated colorectal polyps in patients receiving anticoagulation or antiplatelet medications.

Background: The aim of the present study was to evaluate the safety of prophylactic endoclipping before resection of large pedunculated colorectal polyps in patients with uninterrupted anticoagulation or antiplatelet therapy. Patients and Methods: In a single tertiary referral center, patients with normal coagulation parameters and those with uninterrupted anticoagulation or antiplatelet medications, who underwent prophylactic endoclipping before resection of large pedunculated colorectal polyps (polyp’s head diameter >10 mm), were evaluated retrospectively. Demographic, clinical, and laboratory parameters, polyp characteristics, number of clips used for endoclipping, histology of resected polyps, the polypectomy technique, and postpolypectomy complications were recorded and compared. Results: In 64 patients with large pedunculated colorectal polyps, successful endoclipping before resection was achieved. Eleven patients (17.2%) had uninterrupted anticoagulation (n=4) or antiplatelet (n=7) medications. Statistical analysis showed no significant differences in age, sex, indications for colonoscopy, location of polyps, size of polyp head or stalk, coexisting small polyps, histology of resected polyps, and polypectomy techniques among patients with normal coagulation parameters (group A) and patients on uninterrupted anticoagulant or antiplatelet treatment (group B). Coronary artery disease, hypertension, and atrial fibrillation were significantly more prevalent in group B. No immediate or delayed postpolypectomy hemorrhage occurred in either group. One patient (1.9%) in group A developed postpolypectomy coagulation syndrome and was successfully treated conservatively. Follow-up evaluation demonstrated no recurrence of polyps or cancer development. Conclusions: According to our experience, uncomplicated polypectomy of large pedunculated colorectal polyps can be performed by prophylactic endoclipping in patients receiving anticoagulation or antiplatelet medications.

Large-balloon dilation of the biliary orifice for the management of basket impaction: a case series of 6 patients

ERCP with endoscopic sphincterotomy (ES) and stone extraction remains the treatment of choice for bile duct stones 1,2 ; 85% to 90% of all CBD stones can be effectively treated by ES and stone extraction by using balloon catheters or baskets. 3 Regarding the latter devices, impaction of a Dormia basket or fracture of the basket’s traction wires during endoscopic mechanical lithotripsy with an entrapped stone in the distal CBD is an uncommon but well-known complication, 4-6 presenting a challenge to most endoscopists. Reported management strategies include the use of a mechanical lithotriptor to capture the impacted basket and crush the stone, extracorporeal shock-wave lithotripsy, endoscopic laser lithotripsy, or other sophisticated methods. 7-12 This case series describes, for the first time, the safe and effective use of large-diameter balloon dilation of the biliary orifice in the management of impacted baskets in the distal CBD.

Sequential or simultaneous placement of self-expandable metallic stents for palliation of malignant biliary and duodenal obstruction due to unresectable pancreatic head carcinoma.

Background Pancreatic cancer is generally not amenable to curative resection, and self-expanding metallic stents have been used to relieve obstruction of bile duct and duodenum in patients with unresectable pancreatic cancer. However, both relative experience with sequential or simultaneous endoscopic stents placement in biliary and duodenal stricture and long-term efficacy of these stents are limited. The aim of this study was to present our experience on the effectiveness of this form of endoscopic treatment. Patients and Methods We performed a retrospective review of all patients undergoing sequential or simultaneous biliary and duodenal stent placement for biliary and symptomatic duodenal obstruction due to unresectable pancreatic head carcinomas in 4 tertiary endoscopic centers. Data were collected from endoscopy and outpatient clinic reports, x-rays, and telephone calls. All patients were followed until their death. Endpoints included technical and clinical success, stent long-term patency, and survival. Results Thirty-nine patients with unresectable pancreatic head cancer were included. Biliary or duodenal stenting was unsuccessful in 7 patients (17.9%). The remaining 32 patients (median age: 77 y; range: 52 to 82 y), with locally advanced (n=21) or metastatic disease (n=11), were studied. Twenty-one patients (65.6%) received at least first-line chemotherapy. Overall median survival was 9 months (range: 2 to 22 mo), being higher in locally advanced (median survival: 11.5 mo, range: 4 to 22 mo) than metastatic disease (median survival: 3 mo, range: 2 to 5.5 mo) (P<0.001). Median duodenal and biliary patency was 3 months (range: 1 to 12 mo) and 9 months (range: 2 to 22 mo), respectively (P<0.05). Nine of 32 patients (28.1%) required reintervention for recurrent symptoms. No major complications or death occurred in relation to endoscopic treatment. Conclusions Placement of self-expandable metal stents is a safe and efficacious palliation method for biliary and duodenal obstruction due to unresectable pancreatic head carcinoma. The majority of patients do not require reintervention and those who require can usually be managed nonoperatively.

Endoscopic management of occluded biliary uncovered metal stents：A multicenter experience

AIM To compare diverse endoscopic interventions in the management of occluded uncovered self-expanding metal stents (SEMSs) that had been placed for palliative treatment of unresectable malignant biliary obstruction. METHODS A retrospective review was undertaken in 4 tertiary endoscopic centers to determine optimal management of different types of occluded SEMSs. The technical success of performed treatment in occluded SEMSs, the patency of the stent, the need for re-intervention and the financial costs of each treatment were analyzed. RESULTS Fifty four patients were included in the analysis; 21 received Hanaro, 19 Wallstent and 14 Flexus. For the relief of obstruction, a plastic stent was inserted in 24 patients, a second SEMS in 25 and mechanical cleaning was performed in 5 patients. The overall median second patency rates between second SEMSs and plastic stents did not differ (133 d for SEMSs vs 106 d for plastic stents; P=0.856). Similarly, no difference was found between the overall survival of SEMS and plastic stent groups, and no procedure-related complications occurred. Incremental cost analysis showed that successive plastic stenting was a cost-saving strategy at least in Greece. CONCLUSION Insertion of uncovered SEMSs or plastic stents is a safe and effective treatment for occluded uncovered SEMSs; insertion of plastic stents appears to be the most cost-effective strategy.

Endoscopic hemostasis using monopolar coagulation for postendoscopic sphincterotomy bleeding refractory to injection treatment.

Background Endoscopic sphincterotomy (ES) is the cornerstone of therapeutic ERCP and bleeding is one of its most frequent and serious complications. Monopolar coagulation has been used effectively for many causes of gastrointestinal hemorrhages. We investigated the efficacy and safety of endoscopically delivered monopolar coagulation through a polypectomy snare in patients with ES-induced bleeding not responding to injection treatment. Patients and Methods The study included 672 consecutive patients who underwent ES between June 2007 and January 2009. Bleeding patterns (trickle, oozing, spurting) were recorded. Patients with bleeding not responding to spray irrigation or injection of 0.9% NaCl+epinephrine 1: 10,000 solution were treated with monopolar coagulation. Complications related to the technique were assessed. Results ES-induced bleeding occurred in 59 patients (8.78%). Visible bleeding patterns immediately after ES were: 32 trickle, 21 oozing, and 4 spurting. Delayed bleeding was observed in 2 patients. In 11 patients with intraprocedural bleeding (7 oozing and 4 spurting) not responding to spray irrigation and injection treatment with epinephrine solution, bleeding was successfully treated with monopolar coagulation. There were no procedure-related complications in this series. Conclusions Monopolar coagulation is an effective and safe treatment modality and is recommended as an alternative method to other therapeutic modalities for post-ES bleeding not responding to injection treatment.