Rishi Pawa

Difficult biliary cannulation: use of physician-controlled wire-guided cannulation over a pancreatic duct stent to reduce the rate of precut sphincterotomy (with video)

BACKGROUND Successful cannulation of the common bile duct (CBD) remains the benchmark for ERCP. Use of a pancreatic duct (PD) stent to facilitate biliary cannulation has been described, although the majority of patients require precut sphincterotomy to achieve CBD cannulation. OBJECTIVE To report the performance characteristics of using a PD stent in conjunction with physician-controlled wire-guided cannulation (WGC) to facilitate bile duct cannulation. DESIGN Retrospective cohort. SETTING Two tertiary care, academic medical centers. PATIENTS All undergoing ERCP with native papillae. INTERVENTION In cases of difficult biliary access in which the PD is cannulated, a pancreatic stent is placed. After this, physician-controlled WGC is attempted by using the PD stent to direct the sphincterotome into the biliary orifice. If cannulation is unsuccessful after several minutes, a precut sphincterotomy is performed over the PD stent or the procedure is terminated. MAIN OUTCOME MEASUREMENTS Frequency of successful bile duct cannulation and precut sphincterotomy. RESULTS A total of 2345 ERCPs were identified, 1544 with native papillae. Among these, CBD and PD cannulation failed in 16 (1.0%) patients, whereas 76 (4.9%) patients received a PD stent to facilitate biliary cannulation. Successful cannulation was achieved in 71 (93.4%) of 76 patients, 60 (78.9%) of whom did not require precut sphincterotomy. Complications included mild post-ERCP pancreatitis in 4 (5.3%) and aspiration in 1 (1.3%). Precut sphincterotomy was complicated by hemorrhage, controlled during the procedure in 2 (13.3%) of 15. CONCLUSIONS Physician-controlled WGC over a PD stent facilitates biliary cannulation while maintaining a low rate of precut sphincterotomy.

Endoscopic Ultrasound–guided Pancreatic Fiducial Placement: How Important Is Ideal Fiducial Geometry?

Objective Image-guided radiation therapy allows precise tumor targeting using real-time tracking of radiopaque fiducial markers. To enable appropriate tracking, it is recommended to place fiducials with “ideal fiducial geometry” (IFG). Our objectives were to determine the proportion of patients in whom IFG can be achieved when fiducials are placed by endoscopic ultrasound (EUS) and surgery and to determine if attaining IFG is necessary for delivering radiation. Methods This single-center retrospective cohort study included 77 patients with biopsy-proven advanced pancreatic cancer who underwent either EUS-guided or laparotomy/laparoscopy-assisted fiducial placement between September 2005 and July 2009. Results Gold fiducials were implanted by EUS in 39 patients (51%) and by surgery in 38 patients (49%). The proportion of patients with IFG was significantly higher for surgical placement [18/38, 47%; 95% confidence interval (CI), 32%–63%] compared with EUS-guided placement (7/39, 18%; 95% CI, 8%–32%), P = 0.0011. However, fiducial tracking was successfully used for Cyberknife therapy in 35 (90%) of 39 (95% CI, 77%–97%) patients in the EUS group compared with 31 (82%) of 38 (95% CI, 67%–92%) patients in the surgery group. There were 5 procedure-related complications in the EUS group. Conclusions Achieving IFG appears unnecessary for successful tracking and delivery of radiation.

Periductal hypoechoic sign: an endosonographic finding associated with pancreatic malignancy.

BACKGROUND Despite advances in imaging, differentiating benign from malignant causes of pancreatic duct dilation is difficult. OBJECTIVE The aim of our study was to assess the accuracy of the periductal hypoechoic sign (PHS), defined as patchy hypoechoic areas adjacent to a dilated pancreatic duct, for the diagnosis of pancreatic malignancy. DESIGN Single-center, retrospective analysis. SETTING Tertiary care university hospital. PATIENTS All patients who underwent EUS from 2006 to 2008 for evaluation of pancreatic pathology were identified. Those with pancreatic duct dilation of 4 mm or more in the head of the pancreas or 3 mm or more in the body or tail were included. Digitally recorded EUS images were analyzed for PHS by 1 endoscopist blinded to final results. The final diagnosis was based on pathology results or clinical follow-up. RESULTS During the study period, 84 of 427 patients who underwent EUS for pancreas pathology had dilated pancreatic ducts. Of these, 42 patients had benign disease and 42 had pancreatic malignancy. The PHS was noted in 31 (73.8%) of 42 patients with malignancy compared with 6 (14.3%) of 42 patients with benign disease (P < .001). The PHS had a sensitivity of 73.8%, a specificity of 85.7%, and an accuracy of 79.8% for the diagnosis of pancreatic malignancy. After adjusting for age, patients with the PHS were 17 times more likely to have a malignancy (odds ratio 16.66; 95% CI, 5.01-55.44). Pancreatic duct diameter or dilation of both bile and pancreatic ducts were not predictive of malignancy. LIMITATION A retrospective design. CONCLUSIONS The PHS was an accurate and independent predictor of pancreatic malignancy in patients with a dilated pancreatic duct.

Endoscopic ultrasound-guided choledochoduodenostomy with a lumen-apposing, self-expandable fully covered metal stent for palliative biliary drainage.

In addition to the poor prognosis associated with pancreatic adenocarcinoma, it can also lead to several other conditions including obstructive jaundice that can affect a patient’s quality of life. This is a major concern in non-operative patients where palliation is considered the main therapeutic goal. Traditionally, there are several ways to pursue palliative biliary drainage including endoscopic methods, a variety of surgical procedures, and percutaneous techniques. Generally, endoscopic methods such as endoscopic retrograde cholangiopancreatography (ERCP) with transpapillary stent placement are considered first-line therapies. Unfortunately, ERCP is not always possible due to several potential reasons. Although endoscopic ultrasound-guided biliary puncture has been well described for several years, there are limitations to its usefulness in biliary drainage, in part due to complication concerns. However, more recently a lumen-apposing, self-expandable fully covered metal stent has been employed for such situations. We describe two cases in which this type of stent was used in patients for palliative biliary drainage in pancreatic adenocarcinoma where standard ERCP was not feasible. In both cases, stent deployment was successful without immediate complications related to the procedure or the stent. Furthermore, the main goal of these therapies was palliation and in both cases the patient chose this procedure for quality of life reasons. In the future, randomized trials are needed to better define the long-term effectiveness and safety of these stents compared to more standard therapies.

Sarcoidosis Presenting as Necrotizing Sarcoid Granulomatosis of the Liver, Sclerosing Cholangitis, and Gastric Ulcer

Sarcoidosis is a multisystem granulomatous disease. The liver is affected in up to 50–90% of cases. Sarcoidosis typically presents as non-necrotizing epithelioid granuloma. The occurrence of non-infective necrotizing sarcoid granuloma (NSG) is infrequent, and the finding of NSG in the liver is rare. We report a case of NSG of the liver and lymph nodes, granulomatous gastric ulcer, and secondary cholangitis coexisting in a patient. We discuss the clinical features of the case and briefly review NSG. There is only 1 previously reported case of NSG of the liver in literature.

Characteristic endoscopic ultrasound findings of ampullary lesions that predict the need for surgical excision or endoscopic ampullectomy

Background and Objectives: The management of ampullary lesions has evolved to include endoscopic ampullectomy (EA) as a curative approach to cancers of the ampulla of Vater. With this change comes a need to risk-stratify patients at initial diagnosis. Materials and Methods: Patients with verified ampullary lesions (N = 50) were analyzed in a case-control design. We evaluated endoscopic ultrasound (EUS) data to define characteristics that yield a high sensitivity in selecting candidates for EA. Results: Using data from previously published studies yielded a sensitivity of 0.765 in appropriately identifying the 34 surgical cases. Expanding these characteristics increased the sensitivity of EUS to 0.971 in identifying surgical candidates. Additionally, of advanced disease cases, the expanded characteristics correctly identified these cases with a sensitivity of 1.0-improved over 0.708 using prior published data. Conclusion: EA should be strongly considered if ampullary lesions are found to fit the following characteristics after EUS evaluation: lesion size <2.5 cm, invasion ≤4 mm, pancreatic duct dilatation ≤3 mm, ≤T1 lesion, no lymph nodes present, and no ductal stent in place. Furthermore, EUS data can be used to identify all high-risk lesions. With these characteristics identified, clinicians are better able to risk-stratify patients using EUS as either appropriate for or too high-risk for endoscopic resection.

Endoscopic Ultrasonography: Staging and Therapeutic Interventions

Pancreatic cancer (PC) continues to vex and frustrate clinicians largely due to their inability to impact this sinister disease, which is often metastatic upon presentation. Endoscopic ultrasound (EUS) has rapidly cemented its role in the armamentarium of diagnostic tools available for accurate staging of PC. Initial euphoria touting EUS’ superiority in staging accuracy for EUS was soon met by the stark reality that EUS was no better than the latest cross-sectional imaging available for assessing vascular invasion. Endosonographers recommend that EUS should be performed when no detectable mass lesion is identified on CT in the face of clinical suspicion of PC. Patients and clinicians should take solace when EUS fails to detect a pancreatic mass as the likelihood of a pancreatic cancer is near zero. Contrast enhancement, sonoelastography, and confocal laser endomicroscopy represent few extensions of EUS in the ongoing quest to differentiate benign from malignant masses. The unlimited therapeutic potential of EUS is just now being realized. EUS has been used to access the bile and/or pancreatic duct to help relieve malignant biliary obstruction when ERCP has been unsuccessful or in the setting of altered anatomy. Initial reports of EUS-directed fiducial placement and/or direct intratumoral injection offer hope as a combined partner to conventional treatment for attacking and dissolving tumors. Finally, EUS-guided celiac plexus neurolysis allows ablation of the ganglion to relieve the crippling pain encountered by our patients.

Trends in the Use of Endoscopic Retrograde Cholangiopancreatography for the Management of Chronic Pancreatitis in the United States.

Goals:The aim of this study was to characterize current trends in the use of endoscopic retrograde cholangiopancreatography (ERCP) in the United States for patients hospitalized with chronic pancreatitis. Background:Historically, ERCP was the primary tool for diagnostic and therapeutic management of chronic pancreatitis. With increased availability of magnetic resonance imaging and endoscopic ultrasound, indications for ERCP are being redefined. Study:We performed a retrospective cohort study using the Nationwide Inpatient Sample from 1998 to 2010. We identified patients with a primary discharge diagnosis of chronic pancreatitis who underwent ERCP. We excluded patients diagnosed with biliary, gallbladder, or pancreatic neoplasm and patients who underwent gallbladder or pancreatic operation during the same admission. We analyzed patient and hospital characteristics, length of stay, and in-hospital mortality, and adjusted for weighted sample schema. Results:During the study period, 29,318 patients with chronic pancreatitis (mean age 52 y, 57.2% female) underwent ERCP during their hospitalization. The majority of patients were white (56.1%). The majority of procedures were performed at large (72.4%), urban (95.2%), and academic (69.0%) hospitals. Mean hospital charges were

Endoscopic retrograde cholangiopancreatography in octogenarians: A population-based study using the nationwide inpatient sample

32,929 (SE=

A Bleeding Duodenal GIST Masquerading as Refractory Peptic Ulcer Disease

1605). Mean length of stay was 6 days (SE=0.3), with in-hospital mortality of 0.76%. Over the study period, the number of procedures has decreased significantly (P<0.001). Conclusions:In the United States, ERCP has been an important diagnostic and therapeutic tool for chronic pancreatitis. Over the last decade, ERCP has become an uncommon inpatient procedure for chronic pancreatitis.