Madhukar Kaw

Long-term follow-up of consequences of percutaneous endoscopic gastrostomy (PEG) tubes in nursing home patients

PEG (percutaneous endoscopic gastrostomy) tubes are frequently placed in nursing home patients. The aim of this study was to assess retrospectively the long-term changes in functional and nutritional statuses, tube-related complications, and factors influencing survival in 46 nursing home residents, mean age 73.6 years (range 19–96). Functional status was evaluated by a standard rehabilitation medicine scale. Nutritional status was evaluated by serum albumin and cholesterol concentrations and by weight. PEG-related complications requiring hospitalization or emergency room or clinic evaluations were noted. Additionally, changes in resuscitation status were noted. The predominant indication for PEG placement was dementia (52%). At PEG placement, 48% of patients had total functional impairment. Regardless of the severity of impairment, no patients functional status improved after PEG. Nutritional status did not improve significantly. Mortality approached 50% and 60% at 12 and 18 months, respectively, and was significantly related to age, resuscitation status, and serum albumin concentration. All patients under 40 years of age at PEG survived, in contrast to 41.3% of patients over 40 years of age (P<0.001). Sixty-three percent of patients who were “full code” at PEG placement survived, in contrast to 10% of “no code” patients (P<0.001). Albumin ≥3.5 g/dl at PEG or thereafter was associated with improved survival (P<0.001) as compared to albumin <3.5 g/dl. PEG-related complications occurred in 34.7% of patients, and the first occurred four months after PEG. We conclude that realistic expectations of what PEG can accomplish be a factor in the decision to place a PEG tube in nursing home patients.

Infectious complications of endoscopic procedures in bone marrow transplant recipients

The prevalence of clinically relevant bacteremia after endoscopic procedures in bone marrow transplant recipients was assessed retrospectively. Bacteremia, within 24 hr of procedure, was defined as positive blood cultures, while hypotension and temperature greater than 38° C were taken as possible indicators of bacteremia. Sixty-seven procedures were performed in 53 endoscopic sessions (upper endoscopy 37, flexible sigmoidoscopy 7, upper endoscopy + flexible sigmoidoscopy 8, colonoscopy 1). Twenty-five endoscopic sessions were performed in patients receiving broad-spectrum antibiotics and 28 sessions in patients not receiving antibiotics. Both groups were comparable with respect to patient characteristics, procedures performed, and immune status. No patient in either group developed hypotension. One patient developed fever after flexible sigmoidoscopy; no source of fever was identified. We conclude that: (1) there were no episodes of clinically relevant bacteremia attributable to endoscopic procedures, and (2) not all bone marrow transplant recipients require routine antibiotic prophylaxis prior to endoscopic procedures.

A Comparison of Sampling Techniques of Suspected Malignant Biliary Strictures

A Comparison of Sampling Techniques of Suspected Malignant Biliary Strictures Sanjeev M. Wasan, Madhukar Kaw BACKGROUND: It remains difficult to determine whether biliary strictures are malignant or benign. Tissue sampling by brush cytology and forceps biopsy during Endoscopic Retrograde Cholangiopancreatography (ERCP) has been the common practice. This study aims to compare sampling sensitivity of Fine Needle Aspiration (FNA) by Endoscopic Ultrasound (EUS) of a suspected malignant lesion with the yield from sampling strictures at ERCP. METHODS: In this retrospective study, 147 patients with indeterminate bile duct strictures, who underwent ERCP and tissue sampling and/or EUS with FNA of the suspected malignant lesion from September 2001 to November 2003, were evaluated. Final diagnoses of malignant strictures were confirmed histopathogically based on all sampling methods. Tissue specimens were reported as normal, suspicious, or malignant. Suspicious and malignant were considered positive samples. Comparisons were made between multimodal sampling techniques and bimodal or unimodal methods, and by neoplasm type. RESULTS: Of the 147 patients, 121 had cancer proven. Sixty-seven percent of the patients with cancer had positive tissue sampling by at least one of the three techniques. Tissue sampling sensitivity varied by cancer type with the highest yield seen in pancreatic cancer (79%) compared with cholangiocarcinoma (56%) and other cancer types (41%). FNA had the greatest yield: positive in 81% of malignancies compared with 42% by forceps biopsy and 33% by brushings. FNA also was most sensitive in pancreatic cancer: 89% vs. 50% in cholangiocarcinomas. Finally, there was no improved yield seen in triple-modal sampling with FNA, brushing, and biopsy, compared with FNA and brushing, brushing and biopsy, FNA alone, or brushing alone: 71%, 86%, 60%, 92%, 29%, respectively, in proven cancers. CONCLUSIONS: Tissue sampling sensitivity by fine needle aspiration of the suspected lesion is far superior to sampling of suspectedmalignant strictures by brush cytology or biopsy at ERCP. The combination of three methods of sampling does not increase yield compared with FNA alone. In addition, tissue sampling sensitivity varied by type of neoplasm. Therefore, in patients with biliary strictures, fine needle aspiration of the suspected malignancy itself is recommended.

4612 Role of ercp techniques in the management of idiopathic recurrent pancreatitis.

IP accounts for 10-30% of acute pancreatitis. Purpose: To assess the role of ERCP, biliary crystal analysis, sphincter of Oddi manometry (SOM), endoscopic sphincterotomy (ES) and minor papilla (MP) therapeutics in IP. Methods: 126 patients with IP (mean age: 44 yrs.) were identified. Mean episodes of pancreatitis were 3.2(range 2-7). Papillary stenosis was defined as dilated duct (CBD >10mm and/or PD >5mm) with delayed drainage (CBD >45 min. and/or PD >10 min.). Patients with normal ERCP underwent SOM with IV CCK provocation and with gallbladder (GB) in situ also had bile collection after CCK stimulation for crystal (cholesterol and/or calcium bilirubinate) analysis. Results: (see table below). Conclusions: ERCP techniques: MP cannulation, bile crystal analysis and SOM in selected patients identified an etiology in 79% (endoscopically treatable in 75%) of patients with IP, with or without cholecystectomy.

3357 Complications of diagnostic and therapeutic ercp.

Background: Studies suggest that therapeutic intervention during ERCP increases the procedure related complication rate. Aim: To report our experience with complication rate secondary to diagnostic and therapeutic ERCP at a tertiary care referral center. Methods: 1182 ERCP s were done between July 1995 and September 1999. Patients were divided into five groups: ERCP alone: n=387, ERCP and endoscopic sphincterotomy (ES): n=436, ERCP and sphincter of Oddi manometry (SOM): n=105, ERCP+ SOM+ ES: n=102, and needle knife sphincterotomy (NKS) ± ES: n=152. Complications were assessed using Cotton et al. criteria by review of hospital records and direct follow-up phone calls. Results: See table below. The total morbidity was 9.8%. Three of the 8 with retroperitoneal perforation required surgical management. No mortality was observed. Multifactor analysis revealed risk groups for pancreatitis to be obesity (16.8%) vs. nonobese (3.6%), pancreatic SOM (35.2%) vs. biliary SOM (12.5%), and common bile duct diameter: ≤ 5mm (18.7%), 6-9mm (5.3%), ≥ 10mm (1.7%). All except one perforation occurred in cases with duct diameter of ≤ 5mm. Conclusions: SOM especially pancreatic is associated with a significant risk of pancreatitis. NKS, although an effective biliary access technique in experienced hands, should be reserved only when therapeutic intervention is suspected.

7258 Comparison of metal stents in the management of malignant biliary obstruction.

Background: Studies suggest more technical difficulty and less patency rate for new ultraflex diamond stent (DS) compared to schneider wallstent (WS) for malignant biliary obstruction (MBO). Aim: To report our experience with new DS vs. WS in the management of MBO. Methods: Between 9/95 and 9/97, 14 patients had 18 WS (8 or 10mm in diameter/6.8 or 8cm long) and between 9/97 and 8/99, 19 patients had 26 DS (10mm in diameter/6 or 8cm long)for palliation of MBO. Patients with death due to prior cholangitis, death due to liver failure and those lost to follow-up were excluded. Results: See table below. Conclusion: Our experience suggests that for matched population of patient with MBO, there is no significant difference between DS and WS with the exception of better fluoroscopic visualization with WS over DS.

6983 Serum lipase, c-reactive protein (crp) and interleukin 6 (il6) levels in ercp-induced pancreatitis.

Background: Several markers have been studied to assess the severity of acute pancreatitis. Studies linking specific markers to the severity of ERCP induced pancreatitis are limited. Aim:To assess role of serum lipase, CRP, and IL6 levels in ERCP induced pancreatitis. Methods: 85 patients (62F, 23M), mean age 43 (range 16-85) were entered into this prospective study. Serum levels of lipase by Triolene assay (normal

4678 Management of gallstone pancreatitis: cholecystectomy or ercp and endoscopic sphincterotomy.

Background: Currently, laparoscopic (lap.) CCX is the recommended treatment of gallstone pancreatitis. ERCP and ES within 24-48 hours is suggested in the treatment of acute biliary pancreatitis. Aim: To assess role of lap. CCX after ERCP and ES in patients with gallstone pancreatitis. Methods: 118 patients with gallstone pancreatitis (mean age: 44, range: 18-68 yrs.), 102-F, 16-M were identified. Inclusion criteria were typical abdominal pain, serum amylase ≥ twice normal (normal ≤ 128), and gallbladder (GB) stones, dilated common bile duct (CBD) ±CBD stone by ultrasound (US), CT scan or ERCP. Results: 81 patients underwent CCX after initial evaluation including ERCP in 43 (53%) and ERCP + ES in 38 (47%). Of the 34 patients with no CCX, 33 underwent successful ERCP + ES only . Mean follow-up was 22 months (range 8-49). Recurrent pancreatitis was seen in 3 (3.7%) in CCX group (CBD stone in 2, papillary stenosis in 1), and in 2 (5.8%) in ERCP + ES only group (CBD stone and papillary restenosis in one, alcohol induced in other - this patient also had cholecystitis). 10 patients in ERCP + ES only group had follow-up US and showed persistent GB stones in 8 and disappearance of GB stones in 2. Procedure related complications included one patient with cystic duct leak in CCX group and one with mild ERCP induced pancreatitis in ERCP + ES only group. Conclusions: Recurrent pancreatitis after ERCP + ES only for gallstone pancreatitis is rare. In patients who have undergone ERCP + ES only for gallstone pancreatitis, CCX should be considered only in presence of symptomatic GB disease such as cholecystitis, cystic duct obstruction, etc. and not just to prevent recurrent gallstone pancreatitis.

6997 Cholecystokinin sonogram (cck us) and sphincter of oddi manometry (som): comparison and in the management of biliary dyskinesia (bd).

BD is classified as either gallbladder dyskinesia (GBD) or sphincter of Oddi dysfunction (SOD). Purpose: To assess the role of CCK-US and SOM in diagnosing BD in patients with unexplained biliary pain. Methods: 116 patients with biliary pain (89-F, 17-M, mean age: 38 yrs.) underwent CCKUS. 99 (85%) had successful SOM. GBD was defined as 40mm Hg. Clinical response to cholecystectomy (CCX) or endoscopic sphincterotomy (ES) was assessed (mean F/U: 14 mos.). Results: (see table below). CCK-US identified a cause in 48%. If SOM were considered as gold standard, the positive and negative predictive value of CCK-US for SOD were 94% and 71%. 14 (70%) of 20 patients who underwent CCX for GBD and 20 (45%) of 44 patients who underwent ES for SOD are asymptomatic. Conclusions: CCK-US should be used as an initial test in unexplained biliary pain and invasive endoscopic SOM should be reserved only for patient with normal CCK-US study.