Sanjay Salgado

Endoscopic Ultrasound (EUS)-Directed Transgastric Endoscopic Retrograde Cholangiopancreatography or EUS: Mid-Term Analysis of an Emerging Procedure

Background/Aims Performing endoscopic retrograde cholangiopancreatography (ERCP) in patients who have undergone Rouxen-Y gastric bypass (RYGB) is challenging. Standard ERCP and enteroscopy-assisted ERCP are associated with limited success rates. Laparoscopy- or laparotomy-assisted ERCP yields improved efficacy rates, but with higher complication rates and costs. We present the first multicenter experience regarding the efficacy and safety of endoscopic ultrasound (EUS)-directed transgastric ERCP (EDGE) or EUS. Methods All patients who underwent EDGE at two academic centers were included. Clinical success was defined as successful ERCP and/or EUS through the use of lumen-apposing metal stents (LAMS). Adverse events related to EDGE were separated from ERCP- or EUS-related complications and were defined as bleeding, stent migration, perforation, and infection. Results Sixteen patients were included in the study. Technical success was 100%. Clinical success was 90% (n=10); five patients were awaiting maturation of the fistula tract prior to ERCP or EUS, and one patient had an aborted ERCP due to perforation. One perforation occurred, which was managed endoscopically. Three patients experienced stent dislodgement; all stents were successfully repositioned or bridged with a second stent. Ten patients (62.5%) had their LAMS removed. The average weight change from LAMS insertion to removal was negative 2.85 kg. Conclusions EDGE is an effective, minimally invasive, single-team solution to the difficulties associated with ERCP in patients with RYGB.

Prostate Cancer Risk Estimation Tool Use by Members of the American Urological Association: A Survey Based Study

PURPOSE Prostate cancer risk estimation tools have been developed to help guide patients and physicians with clinical decision making across all disease states. We assessed use patterns of these tools using an online survey sent to AUA (American Urological Association) members. MATERIALS AND METHODS We distributed a 21-question online survey to 5,674 AUA members to query prostate cancer risk estimation tool use. The survey was divided into 4 categories, including 1) demographics, 2) prebiopsy risk assessment, 3) pretreatment risk assessment and 4) risk estimation tool use. RESULTS A total of 565 members (10%) responded to the online survey, of whom 31% reported using a risk estimation tool in the prebiopsy decision setting. Providers who spent more than 20 minutes counseling patients were more likely to use a risk estimation tool (OR 2.2, p <0.01). After the prostate cancer diagnosis 70% of providers used a risk estimation tools to guide treatment recommendations. The total time spent counseling a patient (greater than 30 minutes) and the number of years in practice (fewer than 10) predicted prostate cancer risk tool use (OR 2.4, p <0.01 and 3.4, p <0.01, respectively). CONCLUSIONS AUA respondents use risk estimation tools more frequently in the pretreatment setting than in the prebiopsy setting. The time spent counseling patients and the time since graduation from residency predicted the likelihood of using risk estimation tools.

Endoscopic palliation of malignant biliary strictures

Malignant biliary strictures often present late after the window for curative resection has elapsed. In such patients, the goal of therapy is typically focused on palliation. While historically, palliative measures were performed surgically, the advent of endoscopic intervention offers minimally invasive options to provide relief of symptoms, improve quality of life, and in some cases, increase survival of these patients. Some of these therapies, such as endoscopic biliary decompression, have become mainstays of treatment for decades, whereas newer modalities, including radiofrequency ablation, and photodynamic therapy offer additional options for patients with incurable biliary malignancies.