Prabhleen Chahal

Peroral Endoscopic Drainage/Debridement of Walled-off Pancreatic Necrosis

Background:Experience with minimal access, transoral/transmural endoscopic drainage/debridement of walled-off pancreatic necrosis (WOPN) after necrotizing pancreatitis is limited. We sought to determine outcome using this technique. Methods:Retrospective analysis. Results:From 1998 to 2006, 53 patients underwent transoral/transmural endoscopic drainage/debridement of sterile (27, 51%) and infected (26, 49%) WOPN. Intervention was performed a median of 49 days (range, 20–300 days) after onset of acute necrotizing pancreatitis. A median of 3 endoscopic procedures/patient (range, 1–12) were performed. Twenty-one patients (40%) required concurrent radiologic-guided catheter drainage of associated or subsequent areas of peripancreatic fluid and/or WOPN. Twelve patients (23%) required open operative intervention a median of 47 days (range, 5–540) after initial endoscopic drainage/debridement, due to persistence of WOPN (n = 3), recurrence of a fluid collection (n = 2), cutaneous fistula formation (n = 2), or technical failure, persistence of pancreatic pain, colonic obstruction, perforation, and flank abscess (n = 1 each). Final outcome after initial endoscopic intervention (median, 178 days) revealed successful endoscopic therapy in 43 (81%) and persistence of WOPN in 10 (19%). Preexistent diabetes mellitus, size of WOPN, and extension of WOPN into paracolic gutter were significant predictive factors for need of subsequent open operative therapy. Conclusions:Successful resolution of symptomatic, sterile, and infected WOPN can be achieved using a minimal access endoscopic approach. Adjuvant percutaneous drainage is necessary in up to 40% of patients, especially when WOPN extends to paracolic gutters or pelvis. Operative intervention for failed endoscopic treatment is required in about 20% of patients.

A comparison of direct endoscopic necrosectomy with transmural endoscopic drainage for the treatment of walled-off pancreatic necrosis

BACKGROUND Endoscopic therapy of walled-off pancreatic necrosis (WOPN) via direct intracavitary debridement is described. OBJECTIVE To compare direct endoscopic necrosectomy with conventional transmural endoscopic drainage for the treatment of WOPN. DESIGN Retrospective, comparative study. SETTING Academic tertiary-care center. PATIENTS Patients referred to Mayo Clinic, Rochester, Minnesota, since April 1998 for endoscopic drainage of WOPN. INTERVENTIONS Each patient underwent standard endoscopic drainage that consisted of transmural cavity puncture, dilation of the fistula tract, and placement of a large-bore stent(s). Patients were classified into the direct endoscopic necrosectomy group if, during any of their procedures, adjunctive direct endoscopic necrosectomy was performed; all others were in the standard drainage group. MAIN OUTCOME MEASUREMENTS Success was defined as resolution of the necrotic cavity without the need for operative or percutaneous intervention. RESULTS Forty-five patients were identified who met study criteria: 25 underwent direct endoscopic necrosectomy, and 20 underwent standard endoscopic drainage. There were no differences in baseline patient or cavity characteristics. Successful resolution was accomplished in 88% who underwent direct endoscopic necrosectomy versus 45% who received standard drainage (P < .01), without a change in the total number of procedures. The maximum size of tract dilation was larger in the direct endoscopic necrosectomy group (17 mm vs 14 mm, P < .02). Complications were limited to mild periprocedural bleeding with equivalent rates between groups. LIMITATIONS Retrospective, referral bias, single center. CONCLUSIONS Direct endoscopic necrosectomy achieves higher rates of resolution, without a concomitant change in the number of endoscopic procedures, complication rate, or time to resolution compared with standard endoscopic drainage for WOPN. The need for fewer postprocedural inpatient hospital days and a decrease in the rate of cavity recurrence are also likely benefits of this technique.

CT findings of walled-off pancreatic necrosis (WOPN): differentiation from pseudocyst and prediction of outcome after endoscopic therapy

Computed tomography (CT) findings that may differentiate walled-off pancreatic necrosis (WOPN) from pancreatic pseudocyst were investigated. CT examinations performed before endoscopic therapy of pancreatic fluid collection (PFC) in 73 patients (45 WOPN, 28 pseudocysts) were evaluated retrospectively by two radiologists. PFC was evaluated for size, extension to paracolic space, characteristics of wall and internal structure. The pancreas was evaluated for deformity or discontinuity, and pancreatic duct dilation. CT findings that were associated with WOPN or pseudocyst were identified. CT score (number of CT findings associated with WOPN minus number of findings associated with pseudocyst) was calculated for each PFC. PFC was categorized as WOPN or pseudocyst using a CT score threshold. Larger size, extension to paracolic space, irregular wall definition, presence of fat attenuation debris in PFC, pancreatic deformity or discontinuity (P < 0.05–0.0001) were findings associated with WOPN. Presence of pancreatic duct dilation was associated with pseudocyst. Using a CT score of 2 or higher as a threshold, CT differentiated WOPN from pseudocyst with an accuracy of 79.5–83.6%. Thus, CT can differentiate WOPN from pseudocysts.

Endoscopic retrograde cholangiography in post–orthotopic liver transplant population with Roux-en-Y biliary reconstruction

Endoscopic retrograde cholangiography (ERC) is a well‐established modality for diagnostic and therapeutic maneuvers in pancreaticobiliary disorders. However, it is technically more challenging in patients with postsurgical anatomy like Roux‐en‐Y anastomoses. Its effectiveness in post–orthotopic liver transplantation (OLT) patients with Roux‐en‐Y biliary reconstruction has not been reported. We sought to assess the efficacy and safety of ERC in this patient population. A total of 132 OLTs with Roux‐en‐Y biliary reconstruction were performed at our institution from June 1998 to August 2005. Data from consenting patients who underwent ERC were reviewed once they were identified through computerized medical index system. Of 132 OLT patients with Roux‐en‐Y biliary reconstruction, 31 patients (9 female and 22 male subjects ranging in age from 11 months to 70 years) underwent ERC. The indication for liver transplant was end‐stage liver disease or occurrence of cholangiocarcinoma from primary sclerosing cholangitis in 28 patients and a case each of chronic hepatitis C, alcoholic liver disease, and metastatic islet cell carcinoma. A variable‐stiffness pediatric colonoscope was used in most cases. ERC indications were both diagnostic and therapeutic and included the following: evaluation of increased liver biochemistries and fever in 12 patients, dilation of anastomotic biliary strictures in 10 patients, removal of fractured biliary tube or retained biliary stent in 6 patients, and in 1 patient each, biliary stone removal, management of bile leak, and jejunal tube extension placement for nutritional purpose. ERC was successful in 22 patients (71%). There were no postprocedural complications. Although ERC is technically more difficult and time‐consuming in OLT patients with Roux‐en‐Y anastomoses, these data suggest that ERC is an effective and safe diagnostic and therapeutic modality with few or no complications when performed by experienced endoscopists. ERC was successful in most patients and allowed therapeutic interventions that obviated the need for percutaneous radiological intervention or surgery. Liver Transpl 13:1168–1173, 2007.

Short 5Fr vs Long 3Fr Pancreatic Stents in Patients at Risk for Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

BACKGROUND & AIMS Prophylactic placement of pancreatic duct (PD) stents reduces the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) in high-risk patients. Some endoscopists prefer longer length, unflanged 3Fr PD stents because they are supposedly more effective and have a higher rate of spontaneous dislodgement; we compared outcomes of patients with these 2 types of stents. METHODS Patients at high risk for PEP were randomly assigned to groups given either a straight, 5Fr, 3 cm long, unflanged PD stent (n = 116) or a 3Fr, 8 cm or longer, unflanged PD stent (n = 133). Abdominal radiographs were obtained at 24 hours, 7 days, and 14 days following stent placement to assess spontaneous stent dislodgement. PEP was defined according to consensus criteria. RESULTS After 14 days, the spontaneous stent dislodgement rates were 98% for 5Fr stents and 88% for 3Fr stents (P = .0001). PEP occurred in 12% of patients. The incidence of PEP was higher in the 3Fr group (14%) than the 5Fr group (9%), although this difference was not statistically significant (P = .3). Placement failure did not occur in any patients in the 5Fr stent group, but did occur in 11 of the 133 patients in the 3Fr stent group (P = .0003). CONCLUSIONS Among patients at high-risk for PEP, the spontaneous dislodgement rate of unflanged, short-length, 5Fr PD stents is significantly higher than for unflanged, long-length, 3Fr stents. This decreases the need for endoscopic removal. A higher rate of PD stent placement failure and PEP was observed in patients with 3Fr stents. To view this articles video abstract, go to the AGAs YouTube Channel.

Expandable metal stents for endoscopic bilateral stent-within-stent placement for malignant hilar biliary obstruction

BACKGROUND Placement of biliary stents is effective for palliation of unresectable hilar malignant biliary obstruction. However, when bilateral self-expandable metal stents (SEMSs) are used, placement can be technically challenging. In many studies, side-by-side placement is performed, although it is unclear whether this is the most anatomical and functional approach. OBJECTIVE We sought to assess the technical feasibility and effectiveness of deploying bilateral SEMSs with a stent-within-stent approach using commercially available stents with a large cell width. DESIGN Retrospective study. SETTING Tertiary care medical center. PATIENTS Patients with malignant biliary hilar obstruction referred for endoscopic palliation of obstructive jaundice. MAIN OUTCOME MEASUREMENTS Technical success, ie, successful bilateral SEMS placement across the stricture; functional success, ie, decrease in pretreatment bilirubin level; early and late complications; and stent patency. RESULTS Bilateral biliary drainage was attempted and successfully established in 21 patients with malignant hilar obstruction (15 men, 6 women; mean age 63.7 [standard deviation 13.9] years), resulting in clinical improvement of obstructive symptoms. Median follow-up was 6.14 months (interquartile range 3.5-9.5 months). There were 1 (5%) early and 7 (33%) late stent occlusions that required endoscopic reintervention. The 30-day mortality rate was 10% (2 deaths). LIMITATIONS Retrospective study of a series of cases treated at a tertiary care center by expert endoscopists. CONCLUSIONS This simple technique was performed by using an open-cell expandable metal stent is technically feasible and easy and allows bilateral placement of SEMSs in patients with unresectable hilar malignancy.

Endoscopic palliation of cholangiocarcinoma.

Purpose of review The current endoscopic palliative modalities for unresectable cholangiocarcinoma are reviewed, focusing on the emergent methods of endoscopic palliation. Recent findings Cholangiocarcinoma is a rare malignant tumor arising from biliary epithelium. Endoscopic retrograde cholangiopancreaticography can provide histological diagnosis through brush cytology of the bile duct, and newer cytologic techniques such as digital image analysis and fluorescent in-situ hybridization may improve the cytologic accuracy for diagnosing cholangiocarcinoma. Endoscopic ultrasonography can play an adjunctive role in the diagnosis and staging by facilitating tissue acquisition through fine needle aspiration of the tumor and surrounding lymph nodes. Most patients present with unresectable disease and features of biliary obstruction. This has led to an emphasis on the role of palliative care. Biliary stent placement is an effective method of palliating obstructive jaundice. Newer modalities such as photodynamic therapy, intraluminal brachytherapy, and high-intensity ultrasound therapy may result in improved survival and play a future role as an adjunctive therapy to surgical resection. Summary Several endoscopic palliative modalities have recently emerged. Among these, photodynamic therapy in addition to biliary stent placement appears to be a promising step towards the management of locally unresectable cholangiocarcinoma. Randomized, controlled trials are required, however, to further evaluate these therapies.

Endoscopic resection of nonadenomatous ampullary neoplasms

The safety and effectiveness of endoscopic management of ampullary adenomas is well known. However, data on the endoscopic treatment and long-term outcome of nonadenomatous ampullary neoplasms are lacking. We describe our experience with the endoscopic management and the follow-up of 4 patients with nonadenomatous ampullary neoplasms viz, ampullary carcinoid, gangliocytic paraganglioma, ampullary hamartoma in patients with Peutz-Jegher syndrome and Cowdens syndrome.

Biliary cryptosporidiosis in a patient without HIV infection: endosonographic, cholangiographic, and histologic features (with video)

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EUS-guided double cystgastrostomy of 2 infected pseudocysts in series: a novel case of endoscopic cystocystgastrostomy

I read the case of Dr Gaffney and colleagues entitled “EUS-guided double cystgastrostomy of 2 infected pseudocysts in series: a novel case of endoscopic cystocystgastrostomy”1 with great interest. This indeed is a very practical solution to a frequently encountered scenario of multiple peripancreatic fluid collections, which are not in the imminent vicinity of the gastric or duodenal walls. This was found to be one of the factors predictive of failure of endoscopic therapy related to incomplete drainage of these distant fluid collections in our study.2 However, the authors reported deploying a 10F Solus stent via a 9-mm GIFH gastroscope, which has a working channel of 2.8 mm. As a reader, I seek clarification on this matter.