Pradermchai Kongkam

Outcome of second interventions for occluded metallic stents in patients with malignant biliary obstruction.

BackgroundAlthough self-expandable metallic stent (SEMS) has a longer patency than plastic stent (PS) for malignant biliary obstruction, stent occlusion can occur and drainage has to be reestablished in a patient with expected long survival. However, the choices are still controversial among restenting with SEMS, PS, and percutaneous transhepatic biliary drainage (PTBD). This study was designed to determine the efficacy and outcome of PS, SEMS, and PTBD for patients with occluded SEMS.MethodsA total of 154 ERCPs with SEMS insertion were performed at the Endoscopy Unit of Chulalongkorn University. The causes of obstructive jaundice were cholangiocarcinoma (nxa0=xa0110), pancreatic cancer (nxa0=xa041), and metastatic carcinoma (nxa0=xa03). Thirty-two patients (20.9%) with occluded SEMS (uncovered SEMSxa0=xa022 and covered SEMSxa0=xa010) were identified. PS, SEMS, and PTBD were used to reestablish drainage in 11, 14, and 7 patients, respectively. The second stent was inserted as stent-in-stent. Patients with less advanced disease were preferably opted to have a second SEMS.ResultsThe median stent patency of second SEMS (100xa0days) was significantly longer than PS (60xa0days) and PTBD (75xa0days; pxa0<xa00.05). The median survival time for patients with second SEMS (230xa0days) was significantly longer than patients with PS (130xa0days) and PTBD (150xa0days; pxa0<xa00.05). Subgroup analysis in hilar obstructions showed no statistical difference in second stent patency and survival between PS and SEMS. Pain that required oral narcotic developed in 71% (5/7) of PTBD patients.ConclusionsIn general, a second SEMS insertion in occluded SEMS provides a significant longer patency time than PS and PTBD. However, the benefit of SEMS as a second intervention in hilar obstructed patients is still doubtful.

Flexible spectral imaging color enhancement plus probe-based confocal laser endomicroscopy for gastric intestinal metaplasia detection

Probe‐based confocal laser endomicroscope (pCLE) has been applied for the early detection and confirmation of many gastrointestinal neoplasms; however, its use in gastric intestinal metaplasia (GIM) detection has not yet been validated. The objective of this study was to assess the diagnostic yield of magnifying flexible spectral imaging color enhancement (ME‐FICE) plus pCLE for GIM detection.

A combination of clinical risk stratification and fecal immunochemical test results to prioritize colonoscopy screening in asymptomatic participants

BACKGROUNDnStool-based colonoscopy is the preferred strategy for colorectal cancer (CRC) screening. The Asia-Pacific Colorectal Screening System (APCS) score also is helpful in stratifying the risk for advanced neoplasia in the asymptomatic population. The combination of the fecal immunochemical test (FIT) result and clinical risk stratification may be more helpful in stratifying the risk.nnnOBJECTIVEnTo evaluate the value of the combination of FIT and APCS scores in stratifying asymptomatic participants for colonoscopy.nnnDESIGNnCross-sectional study.nnnSETTINGnUniversity hospital.nnnPATIENTSnA total of 948 asymptomatic participants eligible for screening colonoscopy.nnnINTERVENTIONSnFIT, APCS score evaluation, screening colonoscopy.nnnMAIN OUTCOME MEASUREMENTSnThe prevalence of colorectal neoplasia in 4 different groups of participants according to FIT and APCS score evaluations.nnnRESULTSnThe prevalence of non-advanced and advanced neoplasia in the 4 groups (high risk with positive FIT result, high risk with negative FIT result, moderate risk with positive FIT result, and moderate risk with negative FIT result) was 44% versus 36.9%, 30.1% versus 11.6%, 27.1% versus 12%, and 22.6% versus 6.4%, respectively (Pxa0< .001). Participants with both high-risk scores and positive FIT results had a significantly higher detection rate of advanced neoplasia (6.15-fold, 95% confidence interval, 3.72-10.17) compared with the other 3 groups. Seven cancers were discovered; 4 were in the high-risk with positive FIT result group.nnnLIMITATIONSnHospital-based study.nnnCONCLUSIONnIn countries with limited resources, participants with positive FIT results and high-risk scores by APCS should be given priority for colonoscopy because this group is most likely to have advanced neoplasia. However, this strategy needs to be confirmed for its cost-effectiveness in a large, population-based study. (nnnCLINICAL TRIAL REGISTRATION NUMBERnTCTR20140228001.).

Outcome of self-expandable metallic stents in low-grade versus advanced hilar obstruction

Background:u2002 Self‐expandable metallic stents (SEMS) are known to provide a longer patency time than plastic stents for malignant biliary obstructions including hilar obstruction. However, studies that focus on the efficacy of SEMS in low‐grade and advanced hilar obstructions are still scanty.

Urgent double balloon endoscopy provides higher yields than non-urgent double balloon endoscopy in overt obscure gastrointestinal bleeding

Background and study aims: In overt obscure gastrointestinal bleeding (OV), double balloon endoscopy (DBE) is recommended as one of the most important investigations as it can provide both diagnosis and treatment. However, there is no set standard on the timing of DBE in OV. The aim of this study was to compare the diagnostic and therapeutic yields between urgent and non-urgent DBE in patients with OV. Patients and methods: Between January 2006 and February 2013, 120 patients with OV who underwent DBE were retrospectively reviewed. An urgent DBE was defined as DBE performed within 72u200ah from the last visible gastrointestinal bleeding (nu200a=u200a74) whereas a non-urgent DBE was defined as DBE performed after 72u200ah (nu200a=u200a46). Diagnostic yields, therapeutic impact and clinical outcomes were evaluated. Results: Diagnostic yield in urgent DBE was significantly higher than that in non-urgent DBE (70u200a% versus 30u200a%; Pu200a<u200a0.05). Urgent DBE offered significantly more therapies including endoscopic, angiographic embolization, and surgery than non-urgent DBE (54u200a% versus 15u200a%; Pu200a<u200a0.001). Endoscopic therapy was performed in 43u200a% of urgent-DBE patients whereas only 13u200a% of patients in the other group received endoscopic therapy (Pu200a<u200a0.01). In patients with identified bleeding sources, the rebleeding rate was lower in patients who underwent urgent DBE than in those who underwent non-urgent DBE (10u200a% versus 29u200a%, NS). Conclusions: Regarding diagnostic and therapeutic impacts in OV, our retrospective study showed that urgent DBE is better than non-urgent DBE. The recurrent bleeding rate in patients undergoing urgent DBE tended to be lower.

Cocktail sedation containing propofol versus conventional sedation for ERCP: a prospective, randomized controlled study.

BackgroundERCP practically requires moderate to deep sedation controlled by a combination of benzodiazepine and opiod. Propofol as a sole agent may cause oversedation. A combination (cocktail) of infused propofol, meperidine, and midazolam can reduce the dosage of propofol and we hypothesized that it might decrease the risk of oversedation. We prospectively compare the efficacy, recovery time, patient satisfactory, and side effects between cocktail and conventional sedations in patients undergoing ERCP.MethodsERCP patients were randomized into 2 groups; the cocktail group (nu2009=u2009103) and the controls (nu2009=u2009102). For induction, a combination of 25u2009mg of meperidine and 2.5u2009mg of midazolam were administered in both groups. In the cocktail group, a bolus dose of propofol 1u2009mg/kg was administered and continuously infused. In the controls, 25u2009mg of meperidine or 2.5u2009mg/kg of midazolam were titrated to maintain the level of sedation.ResultsIn the cocktail group, the average administration rate of propofol was 6.2u2009mg/kg/hr. In the control group; average weight base dosage of meperidine and midazolam were 1.03u2009mg/kg and 0.12u2009mg/kg, respectively. Recovery times and patients’ satisfaction scores in the cocktail and control groups were 9.67u2009minutes and 12.89u2009minutes (Pu2009=u20090.045), 93.1and 87.6 (P <0.001), respectively. Desaturation rates in the cocktail and conventional groups were 58.3% and 31.4% (P <0.001), respectively. All desaturations were corrected with temporary oxygen supplementation without the need for scope removal.ConclusionsCocktail sedation containing propofol provides faster recovery time and better patients’ satisfaction for patients undergoing ERCP. However, mild degree of desaturation may still develop.Trial registrationClinicalTrials.gov, NCT01540084

Outcome of endoscopic retrograde cholangiopancreatography during live endoscopy demonstrations

BackgroundA number of factors may result in lower than expected success rates for endoscopic retrograde cholangiopancreatography (ERCP) performed by overseas experts during live demonstrations (LDs). Stratifying the degree of ERCP difficulty may help in the assessment of procedure outcomes, but no prior reports have done so. This study aimed to compare the success rate and complications of ERCP between procedures performed in live demonstrations and for matched control subjects.MethodsFrom 2004 to 2011, a total of 82 patients who underwent ERCP during live demonstrations at the Endoscopy Unit of King Chulalongkorn Memorial Hospital were reviewed. The control for each patient was a patient admitted to the same ERCP unit with matched indications at the time closest to the demonstration course who had matching gender and techniques in therapeutic interventions during ERCP. The success rates and complications between the two groups were compared based on the grading scale for the degree of difficulty according to Cotton and colleagues.ResultsFor standard ERCP cases (levels 1–2), the success rate, complication rate, and duration of the procedure (DOP) did not differ significantly. In contrast, the success rate for complex ERCPs (levels 3–4) performed during LD was significantly lower (73% vs. 90%; Pxa0=xa00.006). The complication rates and DOP were not significantly different (Pxa0=xa00.31 and 0.23, respectively). The overall success rate was significantly lower for LD procedures than for control procedures (81% vs. 91%; Pxa0=xa00.02).ConclusionsIn this series, the standard ERCP performed during LD was associated with success and complication rates similar to those for the control subjects. Complex ERCP cases were, however, associated with lower success rates than those for the control subjects. A high proportion of complex ERCP cases during live demonstration can influence the overall success rate of ERCPs performed by overseas experts.

Trimming a Metallic Biliary Stent Using an Argon Plasma Coagulator

BackgroundDistal migration is one of the common complications after insertion of a covered metallic stent. Stent repositioning or removal is not always possible in every patient. Therefore, trimming using an argon plasma coagulator (APC) may be a good alternative method to solve this problem.MethodsMetallic stent trimming by APC was performed in 2 patients with biliary Wallstent migration and in another patient with esophageal Ultraflex stent migration. The power setting was 60–100 watts with an argon flow of 0.8 l/min.ObservationsThe procedure was successfully performed and all distal parts of the stents were removed. No significant collateral damage to the nearby mucosa was observed.ConclusionsIn a patient with a distally migrated metallic stent, trimming of the stent is possible by means of an APC. This new method may be applicable to other sites of metallic stent migration.

Endoscopic ultrasound-guided needle-based confocal laser endomicroscopy for diagnosis of solid pancreatic lesions (ENES): a pilot study

Background and study aims: Endoscopic ultrasound-guided needle-based confocal laser endomicroscopy (EUS-nCLE) has been shown to aid in the diagnosis of cystic pancreatic lesions. This is a pilot project to study its findings in patients with solid pancreatic lesions (SPLs) with a prospective single-blinded study design. Methods: Patients with SPLs undergoing trans-gastric EUS fine needle aspiration (EUS-FNA) from July 2013 to March 2014 were prospectively enrolled. The nCLE diagnoses were compared with the final diagnoses. Researchers learned about the EUS-nCLE findings from previously published studies and applied it to diagnose SPLs. In the meantime, the findings were recorded. Results: In total, 22 patients were recruited (mean age 62.7 years, SD 13.8 years; 14 men and eight women). The mean maximal tumor diameter was 36.0u200amm (SD 10.9u200amm). EUS-nCLE yielded satisfactory images in all patients during the first EUS procedure and diagnosed benign and malignant SPLs in 3 and 19 patients, respectively. Final diagnoses of malignant SPLs were made in 19 patients. Benign SPLs were eventually diagnosed in three patients, with confirmed the cytology and disease stability during the 12-month follow-up period. At the end of the project, based on the results of this current study, EUS-nCLE findings for malignant SPLs were dark clumping with or without dilated vessels (>u200a40u200aμm). There were two criteria for diagnosing benign lesions which were white fibrous bands and normal acini cells. The accuracy rate of EUS-nCLE was 90.9u200a% (20/22). One falsely diagnosed malignant SPL was an inflammatory mass from a recent acute pancreatitis. Another one with a pancreatic neuroendocrine tumor presenting with a symptomatic pseudocyst was incorrectly diagnosed as an inflammatory mass. This was likely from sampling error of the EUS-nCLE probe in an inflammatory area. Only one patient had post EUS-FNA bleeding but did not require a blood transfusion. The inter-observer agreement among three blinded endoscopists was almost perfect (Kappa 0.82). Conclusion: EUS-nCLE is a promising technique for the diagnosis of SPLs with good inter-observer agreement. Study registrationu200e: TCTR20140402001

Current status on the diagnosis and evaluation of pancreatic tumor in Asia with particular emphasis on the role of endoscopic ultrasound

In Asia, the incidence of pancreatic cancer in some countries has been increasing. Owing to most cases being diagnosed late, prognosis for pancreatic cancer remains dismal. It is clear that the future for pancreatic cancer lies in early detection. While the possible presence of pancreatic masses is often first raised by non‐invasive abdominal imaging, such as computerized tomography and magnetic resonance imaging, smaller lesions and locoregional lymph node metastases are often not detectable by these means. Endoscopic ultrasonography (EUS) offers a higher sensitivity (93–100%) for detection of small potentially curable pancreatic masses than other existing imaging modalities. It is also recommended for the evaluation of portal vein confluence, portal vein, celiac axis, and superior mesentric artery origin, and exclusion of resectability. Due to the closer proximity of EUS to the target structure, and lower rate of needle tract seeding, EUS‐guided fine‐needle aspiration of pancreatic mass is considered the most suitable tissue acquisition technique. Lastly, EUS also enables the performance of endoscopic interventions. Its performance can be further enhanced with newer techniques, including contrast‐enhanced ultrasound and elastrography. It is anticipated that in the near future, molecular technologies may make it possible to detect microscopic amounts of cancer in tissue or blood, predict relapse and survival after therapy, as well as determine optimal therapy.