S. Ian Gan

Management of antithrombotic agents for endoscopic procedures

This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. This guideline combines and updates 2 previously issued guidelines, ‘‘Guideline on the management of antithrombotic and antiplatelet therapy for endoscopic procedures’’ and ‘‘ASGE guideline: the management of lowmolecular-weight heparin and nonaspirin antiplatelet agents for endoscopic procedures.’’ To prepare this guideline, a search of the medical literature was performed using PubMed. Studies or reports that described fewer than 10 patients were excluded from analysis if multiple series with more than 10 patients addressing the same issue were available. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time the guidelines are drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations are based on reviewed studies and were graded on the strength of the supporting evidence (Table 1). The strength of individual recommendations is based on both the aggregate evidence quality and an assessment of the anticipated benefits and harms. Weaker recommendations are indicated by phrases such as ‘‘we suggest,’’ whereas stronger recommendations are typically stated as ‘‘we recommend.’’ This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient’s condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from this guideline.

The role of endoscopy in ampullary and duodenal adenomas

This is one of a series of statements discussing the use of gastrointestinal endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, MEDLINE and PubMed databases were used to search publications through the last 15 years related to ampullary and duodenal adenomas by using the keyword(s) ‘‘ampullary adenoma’’ and each of the following: ‘‘ampullectomy,’’ ‘‘duodenal adenoma,’’ and ‘‘familial adenomatous polyposis.’’ The search was supplemented by accessing the ‘‘related articles’’ feature of PubMed with articles identified on MEDLINE and PubMed as the references. Pertinent studies published in English were reviewed. Studies or reports that described fewer than 10 patients were excluded from analysis if multiple series with greater than 10 patients addressing the same issue were available. Recommendations were made on the basis of the reviewed studies and were graded as to the strength of the supporting evidence (Table 1). Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies may be needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations.

Laparoscopy–assisted versus balloon enteroscopy–assisted ERCP in bariatric post–Roux-en-Y gastric bypass patients

BACKGROUND Data on balloon enteroscopy-assisted ERCP (BEA-ERCP) versus laparoscopy-assisted ERCP (LA-ERCP) in post-Roux-en-Y gastric bypass (RYGB) patients are lacking. OBJECTIVES To compare BEA-ERCP with LA-ERCP in post-RYGB patients and to identify factors that predict therapeutic success with BEA-ERCP. DESIGN Retrospective chart review. SETTING A single North American tertiary referral center. PATIENTS The review included 56 bariatric post-RYGB patients who underwent ERCP. INTERVENTIONS BEA-ERCP or LA-ERCP. MAIN OUTCOME MEASUREMENTS Cannulation rate, therapeutic success, hospital stay, complications, procedure duration, endoscopist time, and cost. RESULTS A total of 32 patients underwent BEA-ERCP, and 24 underwent LA-ERCP. LA-ERCP was superior to BEA-ERCP in papilla identification (100% vs 72%, P = .005), cannulation rate (100% vs 59%, P < .001), and therapeutic success (100% vs 59%, P < .001). The total procedure time was shorter (P < .001) and endoscopist time was longer (P = .006) for BEA-ERCP. There was no difference in postprocedure hospital stay (P = .127) or complication rate (P = .392) between the 2 groups. In the BEA-ERCP group, in patients having a Roux limb + biliopancreatic (from ligament of Treitz to jejunojejunal anastomosis), a limb length less than 150 cm was associated with therapeutic success. Starting with BEA-ERCP and continuing with LA-ERCP after a failed BEA-ERCP saved

Dual Modality Drainage for Symptomatic Walled-Off Pancreatic Necrosis Reduces Length of Hospitalization, Radiological Procedures, and Number of Endoscopies Compared to Standard Percutaneous Drainage

1015 compared with starting with LA-ERCP. LIMITATIONS Single center, retrospective study. CONCLUSIONS In centers with expertise in deep enteroscopy and ERCP, post-RYGB patients with a Roux + ligament of Treitz to jejunojejunal anastomosis limb length less than 150 cm should first be offered deep enteroscopy-assisted ERCP. In patients with Roux + ligament of Treitz to jejunojejunal anastomosis (LTJJ) limb length 150 cm or longer, LA-ERCP should be the preferred approach because of the lack of need for a second procedure, equivalent morbidity and hospital stay, decreased endoscopist time, and decreased cost.

RETRACTED: Sedation and anesthesia in GI endoscopy

BackgroundSymptomatic walled-off pancreatic necrosis (WOPN) treated with dual modality endoscopic and percutaneous drainage (DMD) has been shown to decrease length of hospitalization (LOH) and use of radiological resources in comparison to standard percutaneous drainage (SPD).AimThe aim of this study is to demonstrate that as the cohort of DMD and SPD patients expand, the original conclusions are durable.MethodsThe database of patients receiving treatment for WOPN between January 2006 and April 2011 was analyzed retrospectively.PatientsOne hundred two patients with symptomatic WOPN who had no previous drainage procedures were evaluated: 49 with DMD and 46 with SPD; 7 were excluded due to a salvage procedure.ResultsPatient characteristics including age, sex, etiology of pancreatitis, and severity of disease based on computed tomographic severity index were indistinguishable between the two cohorts. The DMD cohort had shorter LOH, time until removal of percutaneous drains, fewer CT scans, drain studies, and endoscopic retrograde cholangiopancreatography (ERCPs; p < 0.05 for all). There were 12 identifiable complications during DMD, which were successfully treated without the need for surgery. The 30-day mortality in DMD was 4% (one multi-system organ failure and one out of the hospital with congestive heart failure). Three patients receiving SPD had surgery, and three (7%) died in the hospital.ConclusionDMD for symptomatic WOPN reduces LOH, radiological procedures, and number of ERCPs compared to SPD.

Resolving external pancreatic fistulas in patients with disconnected pancreatic duct syndrome: using rendezvous techniques to avoid surgery (with video)

This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. In preparing this guideline, a search of the medical literature was performed by using MEDLINE and PubMed databases through May 2008 that related to the topic of ‘‘sedation and anesthesia for gastrointestinal endoscopy’’ by using the key word(s) ‘‘sedation,’’ ‘‘anesthesia,’’ ‘‘propofol,’’ ‘‘gastrointestinal endoscopy,’’ ‘‘endoscopy,’’ ‘‘endoscopic procedures,’’ and ‘‘procedures.’’ The search was supplemented by accessing the ‘‘related articles’’ feature of PubMed, with articles identified on MEDLINE and PubMed as the references. Pertinent studies published in English were reviewed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time the guidelines are drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations were based on reviewed studies and were graded on the strength of the supporting evidence (Table 1). This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient’s condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines. BACKGROUND

Use of probe-based confocal laser endomicroscopy (pCLE) in gastrointestinal applications. A consensus report based on clinical evidence

BACKGROUND An external pancreatic fistula (EPF) generally results from an iatrogenic manipulation of a pancreatic fluid collection (PFC), such as walled-off pancreatic necrosis (WOPN). Severe necrotizing pancreatitis can lead to complete duct disruption, causing disconnected pancreatic duct syndrome (DPDS) with viable upstream pancreas draining out of a low-pressure fistula created surgically or by a percutaneous catheter. The EPF can persist for months to years, and distal pancreatectomy, often the only permanent solution, carries a high morbidity and defined mortality. OBJECTIVE To describe 3 endoscopic and percutaneous rendezvous techniques to completely resolve EPFs in the setting of DPDS. DESIGN A retrospective review of a prospective database of 15 patients who underwent rendezvous internalization of EPFs. SETTING Tertiary-care pancreatic referral center. PATIENTS Fifteen patients between October 2002 and October 2011 with EPFs in the setting of DPDS and resolved WOPN. INTERVENTION Three rendezvous techniques that combined endoscopic and percutaneous procedures to internalize EPFs by transgastric, transduodenal, or transpapillary methods. MAIN OUTCOME MEASUREMENTS EPF resolution and morbidity. RESULTS Fifteen patients (12 men) with a median age of 51 years (range 24-65 years) with EPFs and DPDS (cutoff/blowout of pancreatic duct, with inability to demonstrate upstream body/tail of pancreas on pancreatogram) resulting from severe necrotizing pancreatitis underwent 1 of 3 rendezvous procedures to eliminate the EPFs. All patients were either poor surgical candidates or refused surgery. At the time of the rendezvous procedure, WOPN had fully resolved, DPDS was confirmed on pancreatography, and the EPF had persisted for a median of 5 months (range 1-48 months), producing a median output of 200 mL/day (range 50-700 mL/day). The rendezvous technique in 10 patients used the existing percutaneous drainage fistula to puncture into the stomach/duodenum to deliver wires that were captured endoscopically. The transenteric fistula was dilated and two endoprostheses placed into the lesser sac. A second technique was used in 3 patients where EUS was used to avoid large varices and create a fistula to the percutaneous drainage catheter. Wires were delivered transenterally then grasped by an interventional radiologist. The new fistula was dilated, and, again, two endoprostheses were placed. Two patients underwent a rendezvous technique that resulted in transpapillary stents and removal of percutaneous catheters. The median duration to EPF closure was 7 days (range 1-73 days) during a median follow-up of 25 months (range 6-113 months). No EPF has recurred in any patient, although 3 symptomatic fluid collections have occurred. These collections have been successfully treated with combined percutaneous and endoscopic treatment or endoscopic treatment alone. One patient had postprocedural fever. There were no associated deaths. LIMITATIONS Small, selected group of patients without a comparative group. CONCLUSION The management of EPFs in the setting of DPDS is challenging but can be treated effectively by combined endoscopic and percutaneous rendezvous techniques. The rendezvous procedures were associated with minimal morbidity, no mortality, avoidance of surgery, and complete elimination of the EPFs.

Similar Efficacies of Endoscopic Ultrasound Gallbladder Drainage With a Lumen-Apposing Metal Stent Versus Percutaneous Transhepatic Gallbladder Drainage for Acute Cholecystitis

Background Probe-based confocal laser endomicroscopy (pCLE) provides microscopic imaging during an endoscopic procedure. Its introduction as a standard modality in gastroenterology has brought significant progress in management strategies, affecting many aspects of clinical care and requiring standardisation of practice and training. Objective This study aimed to provide guidance on the standardisation of its practice and training in Barrett’s oesophagus, biliary strictures, colorectal lesions and inflammatory bowel diseases. Methods Initial statements were developed by five group leaders, based on the available clinical evidence. These statements were then voted and edited by the 26 participants, using a modified Delphi approach. After two rounds of votes, statements were validated if the threshold of agreement was higher than 75%. Results Twenty-six experts participated and, among a total of 77 statements, 61 were adopted (79%) and 16 were rejected (21%). The adoption of each statement was justified by the grade of evidence. Conclusion pCLE should be used to enhance the diagnostic arsenal in the evaluation of these indications, by providing microscopic information which improves the diagnostic performance of the physician. In order actually to implement this technology in the clinical routine, and to ensure good practice, standardised initial and continuing institutional training programmes should be established.

Probe-based confocal laser endomicroscopy for indeterminate biliary strictures: refinement of the image interpretation classification.

Background & Aims Acute cholecystitis in patients who are not candidates for surgery is often managed with percutaneous transhepatic gallbladder drainage (PT‐GBD). Endoscopic ultrasound‐guided gallbladder drainage (EUS‐GBD) with a lumen‐apposing metal stent (LAMS) is an effective alternative to PT‐GBD. We compared the technical success of EUS‐GBD versus PT‐GBD, and patient outcomes, numbers of adverse events (AEs), length of hospital stay, pain scores, and repeat interventions. Methods We performed a retrospective study to compare EUS‐GBD versus PT‐GBD at 7 centers (5 in the United States, 1 in Europe, and 1 in Asia), from 2013 through 2015, in management of acute cholecystitis in patients who are not candidates for surgery. A total of 90 patients (56 men) with acute cholecystitis (61 calculous, 29 acalculous) underwent EUS‐GBD (n = 45) or PT‐GBD (n = 45). Data were collected on technical success, clinical success (resolution of symptoms or laboratory and/or radiologic abnormalities within 3 days of intervention), and need for repeat intervention. Characteristics were compared using Student t tests for continuous variables and the chi‐square test, or the Fisher exact test, when appropriate, for categorical variables. Adverse events were graded according to American Society for Gastrointestinal Endoscopy definitions and compared using the Fisher exact test. Postprocedure pain scores were compared using the Mann‐Whitney U test. Results Baseline characteristics, type, and clinical severity of cholecystitis were comparable between groups. In the EUS‐GBD group, noncautery LAMS were used in 30 patients and cautery‐enhanced LAMS were used in 15. Technical success was achieved for 98% of patients in the EUS‐GBD and 100% of the patients in the PT‐GBD group (P = .88). Clinical success was achieved by 96% of patients in the EUS‐GBD group and 91% in the PT‐GBD group (P = .20). There was a nonsignificant trend toward fewer AEs in the EUS‐GBD group (5 patients; 11%) than in the PT‐GBD group (14 patients; 32%) (P = .065). There were no significant differences in the severity of the AEs: mild, 2 in the EUS‐GBD group versus 5 in the PT‐GBD group (P = .27); moderate, 4 versus 3 (P = .98); severe, 1 versus 3 (P = .62); or deaths, 1 versus 3 (P = .61). The mean postprocedure pain score was lower in the EUS‐GBD group than in the PT‐GBD group (2.5 vs 6.5; P < .05). The EUS‐GBD group had a shorter average length of stay in the hospital (3 days) than the PT‐GBD group (9 days) (P < .05) and fewer repeat interventions (11 vs 112) (P < .05). The average number of repeat interventions per patients was 0.2 ± 0.4 EUS‐GBD group versus 2.5 ± 2.8 in the PT‐GBD group (P < .05). Median follow‐up after drainage was comparable in EUS‐GBD group (215 days; range, 1–621 days) versus the PT‐GBD group (265 days; range, 1–1638 days). Conclusions EUS‐GBD has similar technical and clinical success compared with PT‐GBD and should be considered an alternative for patients who are not candidates for surgery. Patients who undergo EUS‐GBD seem to have shorter hospital stays, lower pain scores, and fewer repeated interventions, with a trend toward fewer AEs. A prospective, comparative study is needed to confirm these results.

The association between cholecystectomy and gastroesophageal reflux symptoms: a prospective controlled study.

Background. Accurate diagnosis and clinical management of indeterminate biliary strictures are often a challenge. Tissue confirmation modalities during Endoscopic Retrograde Cholangiopancreatography (ERCP) suffer from low sensitivity and poor diagnostic accuracy. Probe-based confocal laser endomicroscopy (pCLE) has been shown to be sensitive for malignant strictures characterization (98%) but lacks specificity (67%) due to inflammatory conditions inducing false positives. Methods. Six pCLE experts validated the Paris Classification, designed for diagnosing inflammatory biliary strictures, using a set of 40 pCLE sequences obtained during the prospective registry (19 inflammatory, 6 benign, and 15 malignant). The 4 criteria used included (1) multiple thin white bands, (2) dark granular pattern with scales, (3) increased space between scales, and (4) thickened reticular structures. Interobserver agreement was further calculated on a separate set of 18 pCLE sequences. Results. Overall accuracy was 82.5% (n = 40 retrospectively diagnosed) versus 81% (n = 89 prospectively collected) for the registry, resulting in a sensitivity of 81.2% (versus 98% for the prospective study) and a specificity of 83.3% (versus 67% for the prospective study). The corresponding interobserver agreement for 18 pCLE clips was fair (k = 0.37). Conclusion. Specificity of pCLE using the Paris Classification for the characterization of indeterminate bile duct stricture was increased, without impacting the overall accuracy.