Mark Mcloughlin

Prospective analysis of fluoroscopy duration during ERCP: critical determinants

BACKGROUND Fluoroscopy during ERCP has a linear relationship with radiation, carrying risk of exposure. OBJECTIVE To determine patient, physician, and procedural factors affecting fluoroscopy duration. DESIGN Prospective analysis of ERCPs with evaluation of patient, physician, and procedural variables. SETTING Two tertiary-care hospitals. PATIENTS Consecutive patients undergoing ERCP. INTERVENTIONS ERCP. MAIN OUTCOME MEASUREMENTS Variables associated with prolonged fluoroscopy duration. RESULTS Mean fluoroscopy time (388 ERCPs) was 6.77 minutes (95% CI, 6.15-7.39). No patient factors were found to significantly affect fluoroscopy duration. Fluoroscopy duration was significantly lower for 2 endoscopists compared with the reference endoscopist (average of 4.16 minutes less; 95% CI, -5.48 to -2.48). Multivariable analysis identified variables associated with longer fluoroscopy duration; stent insertion (+3.11 minutes; 95% CI, 1.91-4.30), lithotripsy (+5.74 minutes; 95% CI, 0.931-10.5), needle-knife sphincterotomy (+4.44 minutes; 95% CI, 2.20-6.67), biopsies (+2.11 minutes; 95% CI, 0.025-4.18), use of a guidewire (+1.55 minutes; 95% CI, 0.025-3.07), additional guidewires (+5.61 minutes; 95% CI, 2.69-8.51), and balloon catheter (+4.27 minutes; 95% CI, 3.00-5.53). Mean fluoroscopy duration when a gastroenterology fellow was involved (n = 318) was 7.05 minutes (95% CI, 6.35-7.76) compared with 5.44 minutes (95% CI, 4.26-6.63) when no fellow present (n = 70) (P < .0451). LIMITATIONS Only 2 centers; others may have different results. Not blinded; investigators may change their practice because fluoroscopy was duration studied. Irrelevance of measuring fluoroscopy duration because endoscopists using protection may not have increased radiation exposure. CONCLUSIONS In this prospective analysis, factors associated with fluoroscopy duration included endoscopists; stent insertion; lithotripsy; biopsies; use of a needle-knife, guidewire, and balloon catheter; and involvement of a gastroenterology fellow. These identified variables may help endoscopists predict which procedures are associated with prolonged fluoroscopy duration and may lead to appropriate precautions.

The fate of patients who undergo "preoperative" ERCP to clear known or suspected bile duct stones.

BackgroundThere is debate as to whether recurrent biliary complications are more common in patients who do not have elective cholecystectomy after endoscopic retrograde cholangiopancreatography (ERCP) management of common bile duct (CBD) stones. The aim of this study was to determine the fate of patients with intact gallbladders who have had CBD stones removed at ERCP, and to assess their risk of recurrent biliary symptoms.MethodsWe retrospectively identified all patients in our large tertiary center population with intact gallbladders who had an ERCP for CBD stones from December 1999 to March 2002. We determined which patients had subsequent elective cholecystectomy, and the outcomes of patients who did not have elective surgery.Results309 patients had CBD stones at ERCP during the study period, of which 139 had intact gallbladders at the time of ERCP. Of these 139 patients 59 had subsequent elective cholecystectomy, 11 by open operation and 48 laparoscopically. Of these 139 patients, 27 had cholecystectomy planned; 47 patients were managed with a wait-and-see strategy, 30 of whom were poor surgical candidates. Of these 47 patients in whom a wait-and-see policy was adopted, 9 (19%) developed complications including recurrent pain and/or abnormal liver function tests (LFTs), recurrent biliary colic, and pancreatitis. Eight of these nine patients were from the poor surgical candidate group. Sphincterotomy had been performed at initial ERCP in all patients.ConclusionsOver half of our population of 139 patients with CBD stones at ERCP and intact gallbladders had actual or planned elective cholecystectomy. For those patients in whom a decision to wait-and-see was made, almost 20% developed complications. Elective cholecystectomy after a finding of choledocholithiasis is supported by many and is a common strategy in our experience. Recurrent biliary complications are relatively common in those who do not undergo elective cholecystectomy, especially those patients who represent a high operative risk.

Positive occult blood and negative colonoscopy – should we perform gastroscopy?

Colorectal cancer (CRC) is the fourth most commonly diagnosed type of cancer and the second leading cause of cancer death in Canada. It has been estimated that there will be 20,800 new cases of CRC in Canada in 2007 and 8700 deaths (1). Overall, Canadian men have a one in 14 lifetime risk and women have a one in 12 lifetime risk of developing CRC; these risks are among the highest worldwide. The five-year survival rate for early cancer is more than 90%, but this number falls to below 10% for those diagnosed with widespread disease (2). Early cancers and precancerous polyps are often asymptomatic, and because early diagnosis and treatment may significantly affect prognosis, there is strong support for population screening for CRC. CRC screening has also been shown to be cost effective, with a cost of less than US

Endoscopic stenting-Where are we now and where can we go？

20,000 per life saved compared with no screening (3). Screening with fecal occult blood testing (FOBT) followed by colonoscopy for positive FOBT, reduces CRC mortality by 15% to 33% (4–6). There is no formal screening program for CRC in Canada, but the National Committee on Colorectal Cancer Screening, supported by Health Canada, recommends biennial FOBT for individuals aged 50 to 74 years (7). If the test is positive, then a follow-up test (usually colonoscopy, but possibly flexible sigmoidoscopy and/or barium enema depending on local resources) should be performed. In a screening population, approximately 40% of positive FOBT will lead to a positive diagnosis (CRC or adenoma) at the time of colonoscopy (8,9). It is reasonable to assume that some cases of positive FOBT with negative colonoscopy may be due to an upper gastrointestinal (GI) malignancy. Therefore, should we be performing a gastroscopy on all patients who have a negative colonoscopy following positive FOBT? No method of screening for gastric cancer has been shown to be cost-effective or reliable in Western countries in detecting potentially curable disease. To date, there are no formal guidelines on whether routine esophagogastroduodenoscopy (EGD) should be performed for FOBT-positive, colonoscopy-negative patients.