Kulwinder S. Dua

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.

Coordination of Deglutitive Glottal Function and Pharyngeal Bolus Transit During Normal Eating

BACKGROUND & AIMS Deglutitive glottal function during the preparatory phase of swallowing and its coordination with bolus transit during normal eating are important for airway protection. The aim of this study was to examine this coordination during consumption of a normal meal. METHODS Fifteen healthy volunteers were studied using a videoendoscopic and videofluoroscopic technique. RESULTS A total of 207 liquid and 470 solid bolus swallows were analyzed. In 60% of liquid and 76% of solid food swallows, the bolus was seen in the pharynx before a swallow was initiated. Entry of boluses into the pharynx was associated with brief partial adduction of the vocal cords. Solid food entered and traversed the pharynx at the midline, whereas liquid bolus was split around the larynx and rejoined in the hypopharynx. Swallowing was initiated significantly earlier when bolus made contact with the upper third of the epiglottis compared with vallecula or pyriform sinuses. CONCLUSIONS In more than half of the instances, during normal eating, food enters the pharynx during the preparatory phase before a swallow is initiated, the path of pharyngeal transit of solid bolus is different from that of liquid bolus, and the epiglottal edge appears to be the most sensitive trigger zone for swallowing.

Removable Self-Expanding Plastic Esophageal Stent as a Continuous, Non-Permanent Dilator in Treating Refractory Benign Esophageal Strictures: A Prospective Two-Center Study

BACKGROUND:Refractory benign esophageal strictures (RBES) are difficult to treat requiring frequent dilatations or surgery. Conceptually, while maintaining luminal patency, if a dilator is kept in place continuously for several weeks, the benefits may be longer lasting. An expandable esophageal stent will be ideal in achieving the above. Preliminary results on using a removable self-expanding plastic esophageal stent, Polyflex stent (PS), for treating RBES have been mixed.AIM:To evaluate the efficacy of PS in the treatment of RBES.METHODS:Forty patients with RBES [mean age 60 ± 15 SD yrs, female 14, male 26, Anastomotic 12 (fistula 4), Corrosive 8, Radiation 7, Pill induced 4, Post trauma 3 (fistula 3), Peptic 2, Others 4 (fistula 1)] were prospectively studied. Continuous non-permanent dilation was performed by placing a PS and removing it after 4 wk. The patients were then followed at regular intervals. Pre-insertion baseline data and post-removal information on dysphagia status, complications, and change in outcome were prospectively collected.RESULTS:The technical success in stent placement and stent removal were 95% and 94%, respectively. Mean post-stent dysphagia score was 0.6 ± 0.7 SD, which was significantly better than pre-stent scores (3.0 ± 0.8 SD; P < 0.001). At median follow-up of 53 wk (range 11–156), only 40% (intention to treat 30%) patients were dysphagia-free. However, the overall change in outcome from baseline options (ongoing dilatations, or surgery) was 66% (dysphagia-free 12, did not want removal 2, did not remove 1, preferred long-term stenting 10). The stent was successful in closing the fistula in five of eight (63%) patients. Complications observed were migration eight (22%), severe chest pain four (11%), bleeding three (8%), perforation two (5.5%), GE reflux two (5.5%), impaction two (5.5%), and new fistula one (2.7%). There was one mortality from massive bleeding.CONCLUSIONS:It was feasible to deploy and remove PS stents in the majority of patients with RBES. Some patients achieved long-term relief without further re-interventions while several others re-strictured and preferred long-term stenting over repeated dilations or surgery. The procedure carries significant risks and hence should only be considered in carefully selected patients.

Fully covered self-expandable metal stents (SEMS), partially covered SEMS and self-expandable plastic stents for the treatment of benign esophageal ruptures and anastomotic leaks

BackgroundBenign esophageal ruptures and anastomotic leaks are life-threatening conditions that are often treated surgically. Recently, placement of partially and fully covered metal or plastic stents has emerged as a minimally invasive treatment option. We aimed to determine the clinical effectiveness of covered stent placement for the treatment of esophageal ruptures and anastomotic leaks with special emphasis on different stent designs.MethodsConsecutive patients who underwent placement of a fully covered self-expandable metal stent (FSEMS), a partially covered SEMS (PSEMS) or a self-expanding plastic stent (SEPS) for a benign esophageal rupture or anastomotic leak after upper gastrointestinal surgery in the period 2007-2010 were included. Data on patient demographics, type of lesion, stent placement and removal, clinical success and complications were collectedResultsA total of 52 patients received 83 esophageal stents (61 PSEMS, 15 FSEMS, 7 SEPS) for an anastomotic leak (n = 32), iatrogenic rupture (n = 13), Boerhaaves syndrome (n = 4) or other cause (n = 3). Endoscopic stent removal was successful in all but eight patients treated with a PSEMS due to tissue ingrowth. Clinical success was achieved in 34 (76%, intention-to-treat: 65%) patients (PSEMS: 73%, FSEMS: 83%, SEPS: 83%) after a median of 1 (range 1-5) stent and a median stenting time of 39 (range 7-120) days. In total, 33 complications in 24 (46%) patients occurred (tissue in- or overgrowth (n = 8), stent migration (n = 10), ruptured stent cover (all Ultraflex; n = 6), food obstruction (n = 3), severe pain (n = 2), esophageal rupture (n = 2), hemorrhage (n = 2)). One (2%) patient died of a stent-related cause.ConclusionsCovered stents placed for a period of 5-6 weeks may well be an alternative to surgery for treating benign esophageal ruptures or anastomotic leaks. As efficacy between PSEMS, FSEMS and SEPS is not different, stent choice should depend on expected risks of stent migration (SEPS and FSEMS) and tissue in- or overgrowth (PSEMS).

Pharyngoglottal Closure Reflex: Characterization in Healthy Young, Elderly and Dysphagic Patients with Predeglutitive Aspiration

Background: Mechanism(s) of aspiration, a common complication of oropharyngeal dysphagia, is not completely elucidated. Since the pharyngoglottal closure reflex induces vocal cord adduction in healthy young humans, it may help prevent aspiration during premature spill of oral content. Objective: The objective of this study was to characterize this reflex in normal young and elderly humans and dysphagic patients with predeglutitive aspiration; a potential group for developing abnormalities of this reflex. Methods: We used a concurrent video endoscopic and manometric technique for recording of the vocal cords’ response to pharyngeal water stimulation. We first studied 9 young (26 ± 2 years) and 9 elderly (77 ± 14 years) healthy volunteers to characterize and determine the effect of aging on the pharyngoglottal closure reflex. Subsequently, we studied 8 patients (65 ± 16 years) with predeglutitive aspiration and 7 age-matched controls to characterize this reflex among patients with compromised airway safety during swallowing. Results: The threshold volume of water for triggering both glottal closure and reflexive pharyngeal swallow in the elderly volunteers for rapid pulse injection was significantly larger than that for the young (p < 0.05). Neither glottal closure reflex nor pharyngeal reflexive swallow could be induced in any of the dysphagic patients with volumes of injected water as large as 1 ml. In contrast, in all age-matched controls, both the pharyngoglottal reflex and reflexive pharyngeal swallow were stimulated with threshold volumes of 0.3 ± 0.07 and 0.6 ± 0.05 ml, respectively. Conclusions: Pharyngeal stimulation by water induces vocal cord adduction in humans; the pharyngoglottal closure reflex. Although preserved, a significantly larger volume of water is required to stimulate this reflex by rapid pulse injection in the elderly, suggesting some deterioration in this age group. The pharyngoglottal closure reflex induced by rapid pulse injection is absent in dysphagic patients with predeglutitive aspiration, suggesting its contribution to airway protection against aspiration.

Efficacy and safety of self-expandable metal stents for biliary decompression in patients receiving neoadjuvant therapy for pancreatic cancer: a prospective study

BACKGROUND Increasing numbers of patients with resectable pancreatic cancer are receiving neoadjuvant therapy. Biliary drainage with plastic stents during this period can be associated with recurrent episodes of stent occlusion resulting in unplanned ERCPs and interruptions in therapy. OBJECTIVE To evaluate the efficacy and safety of self-expandable metal stents (SEMSs) during the neoadjuvant period for resectable pancreatic cancer. DESIGN Patients with proven pancreatic adenocarcinoma with biliary obstruction underwent placement of SEMSs, and data on stent patency and complication rates were collected prospectively. SETTING Tertiary-care referral center. PATIENTS This study involved 55 patients with resectable and borderline resectable pancreatic duct adenocarcinoma who were recruited between March 2009 and December 2010. INTERVENTION SEMSs were placed for biliary decompression. The shortest length of stent required to bridge the stricture was used so as to leave enough of the normal bile duct above the stent available for subsequent surgical anastomosis. Endoscopic reintervention was performed in those with stent malfunction. Stents were not removed before surgery. MAIN OUTCOME MEASUREMENTS Stent patency rate during the neoadjuvant period, stent malfunction rate, and complication rates. Information on stent-related difficulties, if any, during surgery. RESULTS Fifty-five patients were recruited (29 men, 26 women; age, mean [± SD] 65.9 ± 11 years; resectable 23, borderline resectable 32). Median time for neoadjuvant therapy and restaging before surgery was 104 days (range 70-260 days). At the median time of 104 days, 88% of SEMSs remained patent. By 260 days, stent malfunction occurred in 15% of patients. These included stent occlusion in 13% and stent migration in 2%. SEMS malfunction occurred in 3 of 27 patients (11%) who ultimately underwent pancreaticoduodenectomy and in 5 of 21 patients (24%) with disease progression (P = not significant). The presence of SEMSs did not interfere with pancreaticoduodenectomy in any patients who underwent surgery. LIMITATIONS Nonrandomized study. CONCLUSION SEMSs are effective and safe in achieving durable biliary drainage in patients with pancreatic cancer receiving neoadjuvant therapy. It is not necessary to remove SEMSs before surgery if the shortest length of stent required to bridge the stricture is used.

Principles of training in GI endoscopy

E This document, prepared by the American Society for Gastrointestinal Endoscopy Committee on Training, was undertaken to provide general guidelines for endoscopy training and written primarily for individuals involved in teaching endoscopic procedures to fellows/trainees. This updates the previous Principles of Training document.1 Research in objective evaluation of procedural skills makes revision of the guidelines at this time highly appropriate.

Unsedated transnasal EGD: an alternative approach to conventional esophagogastroduodenoscopy for documenting Helicobacter pylori eradication

BACKGROUND The aim of this study was to assess the yield of antral biopsies performed via unsedated transnasal esophagogastroduodenoscopy, a technique that does not require conscious sedation with its concomitant costs and complications, for documentation of Helicobacter pylori eradication. METHODS Nineteen patients who were previously CLO test positive on conventional esophagogastroduodenoscopy and subsequently treated for H pylori infection were enrolled. The subjects had not received antibiotic therapy in the prior month and had no prior gastric surgery. By using a GIF-N30 fiberoptic endoscope and a tiny cup biopsy forceps (1.8 mm diameter), unsedated transnasal endoscopy was performed and antral biopsy specimens were taken for a CLO test, histologic analysis (Dieterle stain), and tissue culture. On the same day, the subjects underwent a carbon 13-labeled area urea breath test. All subjects completed a visual analog scale, rating the acceptability of the unsedated transnasal examination and the previous sedated conventional esophagogastroduodenoscopy. RESULTS There was no statistically significant difference between the results of the CLO tests (5/19 positive) versus the 13C-urea breath test (4/19 positive) (p = 0.96), the CLO tests versus histologic findings (5/19 positive) (p = 0.71), or the 13C-urea breath test versus histologic findings (p = 0.96). All tissue culture results were negative. The overall acceptability of unsedated transnasal esophagogastroduodenoscopy was similar to that of sedated conventional esophagogastroduodenoscopy. CONCLUSION Unsedated transnasal esophagogastroduodenoscopy, a technique that eliminates the costs and complications associated with conscious sedation, is a feasible and accurate alternative to conventional esophagogastroduodenoscopy when documentation of H pylori eradication and confirmation of gastric ulcer healing are both indicated.

Effect of chronic and acute cigarette smoking on the pharyngo-upper oesophageal sphincter contractile reflex and reflexive pharyngeal swallow

Background—Cigarette smoking is known to affect adversely the defence mechanisms against gastro-oesophageal reflux. The effect of smoking on the supraoesophageal reflexes that prevent aspiration of gastric contents has not been previously studied. Aims—To elucidate the effect of cigarette smoking on two of the supraoesophageal reflexes: the pharyngo-upper oesophageal sphincter (UOS) contractile reflex; and the reflexive pharyngeal swallow. Methods—Ten chronic smokers and 10 non-smokers were studied, before and 10 minutes after real or simulated smoking, respectively. UOS pressure and threshold volume for the reflexes were determined using a UOS sleeve assembly. Two modes of fluid delivery into the pharynx were tested: rapid injection and slow injection. Results—For both rapid and slow injections, the threshold volume for triggering the pharyngo-UOS contractile reflex was significantly higher in smokers than in non-smokers (rapid: smokers 0.42 (SE 0.07) ml, non-smokers 0.16 (0.04) ml; slow: smokers 0.86 (0.06) ml, non-smokers 0.38 (0.1) ml; p<0.05). During rapid injection, the threshold volume for reflexive pharyngeal swallow was higher in smokers (smokers 0.94 (0.09) ml, non-smokers 0.46 (0.05) ml; p<0.05). Acute smoking further increased the threshold volume for the pharyngo-UOS contractile reflex and reflexive pharyngeal swallow during rapid injection. Conclusions—Smoking adversely affects stimulation of the pharyngo-UOS contractile reflex and pharyngeal reflexive swallow. These findings may have implications in the development of reflux related respiratory complications among smokers.

Inhibition of resting lower esophageal sphincter pressure by pharyngeal water stimulation in humans

BACKGROUND/AIMS Normal inhibition of lower esophageal sphincter (LES) tone occurs during swallowing and belching. However, it is known that it may occur independently of these functions. The aim of this study was to characterize the effect of pharyngeal water stimulation on resting LES pressure. METHODS The effect of rapid-pulse and slow continuous intrapharyngeal injection of minute increments of water on the resting tone of the upper and LES of 14 healthy young volunteers was evaluated by concurrent manometry, submental electromyography, and respirography. RESULTS At a threshold volume, pharyngeal water injection induced an isolated LES relaxation in all volunteers. The threshold volume inducing LES relaxation by rapid-pulse injection, 0.16 +/- 0.01 mL, was significantly lower than that with slow continuous injection (0.5 +/- 0.05 mL) (P < 0.05). The duration and magnitude of LES relaxation were not volume dependent. The duration of LES relaxation induced by rapid-pulse injection was significantly longer than that of swallows. CONCLUSIONS Minute amounts of liquid injected into the pharynx induce LES relaxation different from that of the normal swallow. Neither the duration nor the magnitude of this relaxation is volume dependent. Whereas the contribution of this finding to the mechanism of transient LES relaxation remains to be ascertained, it may partially explain the variability of the basal LES pressure.