Sabrina G. Testoni

Guidewire biliary cannulation does not reduce post-ERCP pancreatitis compared with the contrast injection technique in low-risk and high-risk patients

BACKGROUND Guidewire (GW) cannulation can reduce the risk of post-ERCP pancreatitis (PEP) by avoiding the opacification of the main pancreatic duct. OBJECTIVE To compare the effects of conventional contrast ERCP and GW cannulation of the common bile duct on the rate of PEP in low- and high-risk patients. DESIGN Prospective, comparative-intervention single-center study. SETTING Tertiary referral center. PATIENTS Patients with biliary disease with an intact papilla were prospectively examined by ERCP. INTERVENTIONS Biliary cannulation using a sphincterotome with contrast injection (ConI) or a hydrophilic GW without contrast injection. MAIN OUTCOME MEASUREMENTS Pancreatitis rate in the GW group and the contrast injection (ConI) group. RESULTS PEP occurred in 60 of 1249 patients (4.8%), 35 of 678 (5.2%) in the GW group and 25 of 571 (4.4%) in the ConI group (not significant). The overall rate of PEP was significantly higher in high-risk patients (12.2%) than in low-risk patients (3.5%) (P < .001), but was similar for the 2 techniques within each of these 2 groups. In patients with unintended main pancreatic duct (MPD) cannulation or opacification, the rate of PEP was not significantly different with the GW (15.2%) and ConI (8.4%) techniques but was associated with a significantly higher rate of pancreatitis (11.9%) than in patients in whom the contrast medium or GW did not enter the MPD (3.5%) (P < .001). Multivariate analysis indicated that more than 10 papillary cannulation attempts, MPD cannulation or opacification, suspected sphincter of Oddi dysfunction, and precut methods were significant risk factors independently associated with PEP. LIMITATIONS Lack of randomization. CONCLUSIONS For selective cannulation of the CBD, the risk of inducing PEP is similar with the ConI and GW techniques in high-risk and low-risk patients. Any manipulation of the MPD must be considered a high-risk factor for PEP, such as multiple attempts on the papilla or use of the precut method.

Difficult biliary cannulation during ERCP: How to facilitate biliary access and minimize the risk of post-ERCP pancreatitis

Endoscopic retrograde cholangio-pancreatography (ERCP) is one of the most technically challenging procedures in therapeutic endoscopy; difficulties in biliary cannulation and post-ERCP pancreatitis are still significant problems. Deep cannulation of Vaters papilla may fail in up to 5% of cases; selective biliary cannulation reportedly fails in 15-35% of cases, even in experienced hands; repeated and prolonged attempts at cannulation increase the risk of post-procedure pancreatitis. Therefore, cannulation technique plays a pivotal role in successful cannulation and occurrence of post-procedure pancreatitis. This review presents and discusses the techniques that can be used for achieving biliary cannulation after an initial failure and for minimizing the risk of pancreatitis, including guide wire assisted technique, needle knife precutting, trans-pancreatic sphincterotomy, and pancreatic stenting.

A single-centre prospective, cohort study of the natural history of acute pancreatitis

BACKGROUND The natural history of acute pancreatitis is based on clinical studies that aim to elucidate the course of disease on the basis of predicted risk factors. AIMS To evaluate the long-term occurrence of recurrent acute pancreatitis and chronic pancreatitis in a cohort of patients following an initial episode of acute pancreatitis. METHODS 196 patients were enrolled consecutively and studied prospectively. Clinical characteristics, exogenously/endogenously-associated factors, and evolution to recurrent acute pancreatitis and chronic pancreatitis were analyzed. RESULTS 40 patients developed recurrent acute pancreatitis 13 of whom developed chronic pancreatitis. In a univariate analysis, recurrent acute pancreatitis was associated with an idiopathic aetiology (p<0.001), pancreas divisum (p=0.001), and higher usage of cigarettes and alcohol (p<0.001; p=0.023). Chronic pancreatitis was associated with a severe first episode of acute pancreatitis (p=0.048), PD (p=0.03), and cigarette smoking (p=0.038). By multivariate analysis, pancreas divisum was an independent risk factor for recurrent acute pancreatitis (OR 11.5, 95% CI 1.6-83.3). A severe first-episode of acute pancreatitis increased the risk of progressing to chronic pancreatitis by nine-fold. CONCLUSIONS Special attention should be given to patients who experience a severe first attack of acute pancreatitis as there appears to be an increased risk of developing chronic pancreatitis over the long term.

Single-step versus two-step endo–ultrasonography-guided drainage of pancreatic pseudocyst

OBJECTIVE:  The aim of this prospective study was to compare the feasibility, technical success rate and complication between single‐step endo‐ultrasonography (EUS)‐guided and two‐step EUS‐guided drainage technique for symptomatic pancreatic pseudocyst (PP).

Transoral incisionless fundoplication for gastro-esophageal reflux disease: Techniques and outcomes

Gastro-esophageal reflux disease (GERD) is a very common disorder that results primarily from the loss of an effective antireflux barrier, which forms a mechanical obstacle to the retrograde movement of gastric content. GERD can be currently treated by medical therapy, surgical or endoscopic transoral intervention. Medical therapy is the most common approach, though concerns have been increasingly raised in recent years about the potential side effects of continuous long-term medication, drug intolerance or unresponsiveness, and the need for high dosages for long periods to treat symptoms or prevent recurrences. Surgery too may in some cases have consequences such as long-lasting dysphagia, flatulence, inability to belch or vomit, diarrhea, or functional dyspepsia related to delayed gastric emptying. In the last few years, transoral incisionless fundoplication (TIF) has proved an effective and promising therapeutic option as an alternative to medical and surgical therapy. This review describes the steps of the TIF technique, using the EsophyX(®) device and the MUSE(TM) system. Complications and their management are described in detail, and the recent literature regarding the outcomes is reviewed. TIF reconfigures the tissue to obtain a full-thickness gastro-esophageal valve from inside the stomach, by serosa-to-serosa plications which include the muscle layers. To date the procedure has achieved lasting improvement of GERD symptoms (up to six years), cessation or reduction of proton pump inhibitor medication in about 75% of patients, and improvement of functional findings, measured by either pH or impedance monitoring.

No increase in prevalence of Barrett's oesophagus in a surgical series of obese patients referred for laparoscopic gastric banding ☆

INTRODUCTION Obesity is a risk factor for gastroesophageal reflux and oesophageal adenocarcinoma. However, only a few studies have examined obesity and lifestyle risk factors in relation to Barretts oesophagus. In this prospective study we assessed the presence of oesophagitis and Barretts oesophagus in obese patients selected for laparoscopic gastric banding. METHODS 1049 obese patients were referred for laparoscopic gastric banding (233 males; mean age 41.0±10.7 years). oesophagogastroduodenoscopy was performed before surgery to check for upper gastrointestinal tract disorders, especially hiatal hernia, signs of inflammation and/or erosions and/or ulcers of the oesophageal mucosa, and Barretts epithelium. RESULTS Mean body mass index was 45.15±6.46 kg/m(2). Overall 86/1049 (8.2%) patients had endoscopic signs of oesophagitis: 84 grade A, 1 grade B and 1 grade C, according to the Los Angeles classification. Hiatal hernia was detected in 127 patients (12.1%), with a mean size of 2.1±0.7 cm (range 1-4 cm); of these, 38 (29.9%) had oesophagitis (37 grade A and 1 grade B). No patients had any visible length of columnar epithelium. CONCLUSIONS We could not confirm a high prevalence of Barretts oesophagus in this series of obese patients.

EUS-guided FNA for proliferative rate in pancreatic neuroendocrine tumors: a single center experience over a 11-year period.

Context Pancreatic neuroendocrine tumors (PNTs) are rare, representing 1% to 2% of all pancreatic neoplasms. Endoscopic ultrasonography in combination with fine needle aspiration (EUS-FNA) has been shown to be an highly accurate method for the preoperative localization and diagnosis of PNTs and several studies have shown that proliferative activity index (Ki-67) represents one of the most important criteria of malignancy. Objective The aim of this study was to evaluate the role of EUS-FNA in the assessment of the proliferation index (Ki-67) expression on cytological material in a consecutive cohort with histologically confirmed PNT. Methods Data of all consecutive patients undergone EUS-FNA of pancreatic mass over a 11-year period, were prospectively stored in a data base. All cases with both cytological and histological diagnosis of PNT were evaluated for the present study. Pre-surgical FNAs’ immunocytochemical results (Ki-67) were compared to the corresponding findings obtained from surgical specimens. We categorized Ki-67 expression using a cut-off of 2% (Ki-67≤2% and Ki-67>2%). Results About 2,000 pancreatic mass FNAs were performed over a 11-year period. Eighty-two patients (mean age 55.6±14.3 years) had cytological diagnosis of PNT, of whom 78 had confirmed histopathology. Sensitivity of EUS-FNA for the diagnosis of a PNT was 87.5%. The mean number of needle passes to obtain adequate sample was 2.6±0.98. Proliferative index was evaluable in 35 FNAs (44.8%); in the remaining patients we could not measure Ki-67 because not enough material was left after performing routine staining. When using a cut-off of 2%, Ki-67 expression measured was concordant in 17 out of 22 and the remaining 5 cases were discordant. When using a cut-off >2%, Ki-67 expression was concordant in 11 out of 13. Overall concordance between cytological and histological samples for Ki-67 was 80% (28/35). Kappa statistics was 0.64 (95% CI: 0.25-0.83). Sensitivity and specificity of FNAs for Ki-67 were 0.79 (95% CI: 0.61-0.91) and 0.69 (95% CI: 0.48-0.83), respectively (P value=0.007). Conclusion It is possible to determine proliferative index in PNTs on cytological material obtained by EUS-FNAs with an overall good agreement in the expression of Ki-67 measured either on cellular material and on histological tissue. The cytological Ki-67 may effectively improve the preoperative assessment of PNTs. A careful quantitative analysis of specimens at the time of FNA should be done in order to ensure sufficient material for Ki-67 assessment.

Novel lumen-apposing metal stent for the drainage of pancreatic fluid collections: An Italian multicentre experience

Background Endoscopic ultrasound (EUS)-guided drainage is the procedure of choice for pancreatic fluid collection (PFC) management. Recently developed lumen-apposing fully covered self-expandable metal stents (LAMSs) may facilitate drainage, especially of necrotic and complex PFCs. Objective To evaluate the feasibility and efficacy of a newly developed LAMS (Nagi, Taiwong Medical Co. Ltd, South Korea) in the drainage of PFCs. Methods Retrospective analysis of LAMS drainage of PFCs from seven centres. Patient demographic, EUS and radiological findings, PFCs aetiology, procedural technical and clinical success, and adverse events were evaluated. Results Sixty-seven patients with mean age 58.8 ± 14 years (68.7% males) were included in the analysis. Of these, 44 patients had pseudocyst (PP) and 23 patients had walled-off pancreatic necrosis (WOPN). Technical success was achieved in 98.5% of cases and clinical success in 94%. The adverse event rate was 24.2%, higher and mostly due to stent migration and occlusion in the WOPN group as compared to the PP group, despite the time to stent removal being significantly lower in the WOPN group. Conclusions PFC drainage using the Nagi stent is highly feasible and effective, with a relatively safe profile. Future studies enrolling more patients with complex PFCs are needed to clearly establish the role of this stent in PFC management.

Endoluminal Therapy for Treatment of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a common disorder that is currently treated by medical therapy and surgical or endoscopic transoral interventions. Medical therapy is the most common approach, though concerns have been raised in recent years about the potential side effects of continuous long-term medication, drug intolerance, or unresponsiveness and the need for high dosages for long periods to treat symptoms or prevent recurrences. Surgery too may have consequences such as long-lasting dysphagia, flatulence, inability to belch or vomit, diarrhea, or functional dyspepsia related to delayed gastric emptying. For these reasons in the last 15 years, a variety of transoral endoscopic techniques have been developed as alternatives to antisecretory therapy or antireflux surgery. Endoluminal techniques included three categories (implantation or injection of foreign materials, application of radiofrequency ablation, and endoscopic tissue apposition techniques) and showed significant symptom control in the short-term period in the majority of published studies. However, most of them had disappointing long-term results or did not demonstrate long-lasting benefits and have been abandoned. In the last years, transoral incisionless fundoplication has been shown to be an effective and promising therapeutic option, allowing endoscopists to bring the surgical principles of an anterior partial fundoplication to patients with fewer post-fundoplication complications than surgery. Two FDA-approved endoluminal platforms are currently available, namely, the EsophyX® device and the MUSE™ system: improvement of GERD symptoms up to 6 years, cessation or reduction of proton pump inhibitor medication in about 75 % of patients, and improvement of functional findings, measured by either pH or impedance monitoring, have been shown with these techniques.

Manometric evaluation of anorectal function in patients treated with neoadjuvant chemoradiotherapy and total mesorectal excision for rectal cancer.

BACKGROUND An altered anorectal function is reported after chemoradiotherapy (CRT) and surgery for rectal cancer. AIM The aim of this study was to clarify the relative contribution of neoadjuvant chemoradiation and surgical resection on the impairment of anorectal function as evaluated by anorectal manometry. METHODS Thirty-nine patients with rectal cancer, who underwent neoadjuvant CRT and laparoscopic rectal resection, were evaluated with the Pescatori Faecal Incontinence score, and with anorectal manometry: before neoadjuvant therapy (T0), after neoadjuvant therapy and before surgery (T1), 12 months after stoma closure (T2). RESULTS Resting and/or maximum squeeze pressure and/or volume thresholds for urgency were below the normal values in 12 (30%) patients at baseline. After CRT the mean resting pressure significantly decreased (p=0.007). Surgery determined a significantly decrease of the resting pressure (p=0.001), of the maximum squeeze pressure (p=0.001) and of the volume threshold for urgency (p=0.001). Impairment of continence was reported by 5, 11 and 18 patients at T0, T1 and T2, with a mean incontinence score of 3, 3.8 and 3.9 respectively. CONCLUSIONS CRT is detrimental to the function of the internal anal sphincter. Rectal resection significantly affects both internal and external anal sphincter function and the maximum tolerated volume of the neo-rectum, particularly in patients with low rectal cancer, significantly impairing anal continence.