Rajat Garg

A Guidewire May Save the Day

Endoscopic gallbladder drainage (EGBD) has been used to treat acute cholecystitis or to relieve malignant biliary obstruction as an alternative to percutaneous gallbladder drainage and patients are poor surgical candidates. This is currently being performed by placement of lumen apposing metallic stent (LAMS) with electrocautery mounted tip delivery system also called as hot technique. We had reported a case of self-expanding metallic stent (SEMS) within LAMS after stent migration during EGBD using hot technique and propose routine use of guidewire in patients undergoing the procedure.

Pre-endoscopic retrograde cholangiopancreatography (ERCP) administration of rectal indomethacin in unselected patients to reduce post-ERCP pancreatitis: A systematic review and meta-analysis

IntroductionPrevious studies have reported that peri-procedural administration of rectal indomethacin reduces the risk of pancreatitis in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Based on these studies, gastrointestinal (GI) societies recommend prophylactic rectal indomethacin for all patients undergoing ERCP. However, recent studies have reported contradictory results. The aim of this study was to perform a systematic review and meta-analysis to estimate the pooled relative risk (RR) of post-ERCP pancreatitis (PEP) in unselected patients who received rectal indomethacin before the ERCP (pre-ERCP) compared to patients who received pre-ERCP rectal placebo.MethodsWe conducted a comprehensive search of multiple electronic databases and conference proceedings (from inception through September 1, 2017) to identify randomized control trials (RCTs) investigating the role of pre-ERCP rectal indomethacin in reducing the risk of PEP in unselected patients undergoing ERCP. The databases included Ovid, Medline, In-Process, and Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, Scopus, and Web of Science. We calculated a pooled estimate of the RR of PEP in patients who received pre-ERCP rectal indomethacin compared to patients who received pre-ERCP rectal placebo. The meta-analysis was performed using the random effects model.ResultsSix RCTs with a total of 2229 patients were included in the final meta-analysis. There were 1143 patients in the rectal indomethacin group and 1086 patients in the rectal placebo group. There were 71 events of PEP in the rectal indomethacin group and 114 events of PEP in the rectal placebo group. Pre-ERCP administration of rectal indomethacin significantly reduced the risk of PEP compared to pre-ERCP rectal placebo (RR 0.60, 95% CI, 0.45–0.80; p<0.0001). There was no heterogeneity between the studies (I2xa0=u20090).ConclusionThe results of this meta-analysis support the routine pre-ERCP administration of rectal indomethacin in unselected patients to prevent PEP.

Endoscopic Treatment of Colonic Duplication Cyst: A Case Report and Review of the Literature

Colonic duplication cysts are a rare congenital abnormality commonly presenting before two years of age. In adults, it has been rarely reported, most often as an incidental finding. We report a case of 42-year-old female complaining of constipation and lower abdominal pain. Patients CT scan of the abdomen showed a cystic lesion at hepatic flexure and the diagnosis was confirmed endoscopically using endoscopic ultrasound (EUS). The cyst was treated employing hot snare to expose the cyst cavity. On our literature search, there have been no reported cases of colonic duplication cyst treated endoscopically. We here discuss incidence, diagnosis, characteristics, and treatment of duplication cysts with special emphasis on endoscopic therapy.

Management of Hypertriglyceridemia Induced Acute Pancreatitis

Hypertriglyceridemia is an uncommon but a well-established etiology of acute pancreatitis leading to significant morbidity and mortality. The risk and severity of acute pancreatitis increase with increasing levels of serum triglycerides. It is crucial to identify hypertriglyceridemia as the cause of pancreatitis and initiate appropriate treatment plan. Initial supportive treatment is similar to management of other causes of acute pancreatitis with additional specific therapies tailored to lower serum triglycerides levels. This includes plasmapheresis, insulin, heparin infusion, and hemofiltration. After the acute episode, diet and lifestyle modifications along with hypolipidemic drugs should be initiated to prevent further episodes. Currently, there is paucity of studies directly comparing different modalities. This article provides a comprehensive review of management of hypertriglyceridemia induced acute pancreatitis. We conclude by summarizing our treatment approach to manage hypertriglyceridemia induced acute pancreatitis.

Endoscopic Ultrasound-guided Portal Venous Access: Diagnostic and Therapeutic Implications

Endoscopic ultrasound (EUS) has evolved from a purely diagnostic to an interventional modality offering minimally invasive alternatives to surgical and radiologic interventions. This has led to a rapidly growing interest in EUS-guided vascular interventions. EUS-guided portal venous access is an emerging technique which opens a new arena for interventional vascular EUS. Portal vein can be accessed under EUS guidance with high precision and low risk of complications thus expanding its application for both benign and malignant conditions. Potential applications of EUS-guided portal vein access include: fine needle aspiration of portal vein thrombus and portal venous blood sampling for circulating tumor cells for diagnosis and staging of occult and known malignancies; portal vein angiography, portal pressure measurement, and creation of endoscopic intrahepatic portosystemic shunt; portal vein embolization and targeted drug delivery. This article will review the current literature on EUS-guided portal vein access, its feasibility and safety in animal and human studies, and current diagnostic and therapeutic applications with future directions.