Shayan Irani

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

Use of an over-the-scope clipping device: multicenter retrospective results of the first U.S. experience (with videos)

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.

Combined endoscopic and percutaneous drainage of organized pancreatic necrosis

y t w f O c p t Through-the-scope (TTS) clipping devices have been available for nearly 20 years, and applications include the treatment of GI bleeding, closure of perforations and fistulae, and anchoring of feeding tubes. Although these evices are relatively inexpensive and easy to use, they ave limited opening widths and closing strengths and are sually ineffective in the setting of fibrotic tissue. Recently, publications emerged demonstrating the feaibility and use of a novel over-the-scope clip (OTSC) evice.5 Experimental studies have demonstrated the abilty of the OTSC to close perforations6-8 and control arterial leeding.9 Comparative animal trials have shown the sueriority of OTSCs relative to TTS clips for closure of erforations10,11 and natural orifice transluminal endoscopic surgery (NOTES) access points.12-14 Subsequent case reports and small case series in humans have shown great promise of the device for the treatment of arterial bleeding and for the closure of endoscopic perforations and fistulae.15,16 The largest series published to date comrises 50 patients.17 All of these studies have emanated

Papillectomy for ampullary neoplasm: results of a single referral center over a 10-year period

BACKGROUND Severe acute pancreatitis is often complicated by organized necrosis, which can lead to abscess formation and clinical deterioration. We sought to devise a combined endoscopic and percutaneous approach to drainage of organized pancreatic necrosis, with the primary goal of preventing the formation of chronic pancreaticocutaneous fistulae, and secondary goals of avoiding the need for surgical necrosectomy and reducing endoscopic resource utilization. DESIGN Retrospective review of an institutional review board-approved database. SETTING Single North American tertiary referral center. PATIENTS Patients with severe acute pancreatitis complicated by organized necrosis requiring drainage. INTERVENTIONS CT-guided percutaneous drain, followed immediately by endoscopic transenteric drainage. MAIN OUTCOME MEASUREMENTS Development of chronic pancreaticocutaneous fistulae, number of endoscopic procedures requiring follow-up drainage, need for surgical necrosectomy, procedure-related morbidity, and mortality. RESULTS Fifteen patients (12 males, 3 females; mean age, 58 years) underwent combined modality drainage. All procedures were technically successful. Immediate complications included fever and hypotension (n = 2); late complications included parenchymal infection after drain removal (n = 1). Twenty-five total endoscopies (4 for drain manipulation) were performed in the cohort subsequent to the initial drainage. After a median duration of follow-up of 189 days, percutaneous drains were removed in all 13 patients in whom this was attempted; no patients had development of chronic pancreaticocutaneous fistulae. There were no deaths, and no patients required surgery. LIMITATIONS Highly selected patient population, lack of comparison group, single-center experience. CONCLUSIONS In some highly selected patients with infected or symptomatic organized pancreatic necrosis, combined modality drainage results in favorable clinical outcomes with low associated, procedure-related morbidity. Pancreaticocutaneous fistulae and surgical necrosectomy were avoided with minimal endoscopic resource utilization.

Endoscopic and Percutaneous Drainage of Symptomatic Walled-Off Pancreatic Necrosis Reduces Hospital Stay and Radiographic Resources

BACKGROUND Tumors arising from the duodenal papilla account for approximately 5% of GI neoplasms, but are increasingly identified. OBJECTIVE To describe the clinical characteristics and outcomes in a large single-center experience with patients referred for ampullary lesions. DESIGN A retrospective review of the Virginia Mason Medical Center endoscopy and hospital service database. SETTING Tertiary referral center. PATIENTS One hundred ninety-three patients referred for ampullary lesions from 1997 to 2007. INTERVENTIONS Endoscopic management of ampullary lesions. MAIN OUTCOME MEASUREMENTS The relationship of demographic and clinical data with endoscopic treatment and clinical outcomes in these patients. RESULTS One hundred ninety-three patients underwent endoscopy for ampullary lesions. Fifteen juxta-ampullary lesions and 10 normal variants were excluded. Among 168 patients, there were 112 (67%) adenomas, 38 (23%) adenocarcinomas, and 18 (10%) nonadenomatous lesions. There were 88 men and 80 women, with a mean age of 64 years. Clinical presentation included cholestasis/cholangitis (72 patients), abdominal pain (54 patients), incidental/asymptomatic (51 patients), pancreatitis (9 patients), and bleeding (7 patients). Of the 57 patients referred to surgery, 42 were sent directly without papillectomy, and 16 were sent after papillectomy. Papillectomies were performed in 102 patients with adenomatous lesions. The mean tumor size was 2.4 cm (range 0.5-6 cm). The papillectomy complication rate was 21%: mild pancreatitis in 10 (10%) patients, cholangitis in 1, retroperitoneal perforation in 1 (adenocarcinoma), intraperitoneal perforation in 1 (lateral extension), bleeding in 5 (lateral extension in 2 of these 5), and delayed papillary stenosis in 3. Recurrences were seen in 8%. The endoscopic success rate was 84%. Factors affecting success were a smaller adenoma size and the absence of dilated ducts. CONCLUSIONS Most ampullary adenomas are amenable to endoscopy. Underlying malignancy and lateral extension may be risk factors for bleeding and perforation. Smaller lesion size and the absence of dilated ducts are factors favorably affecting success.

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

BACKGROUND & AIMS Walled-off pancreatic necrosis (WOPN), a complication of severe acute pancreatitis (SAP), can become infected, obstruct adjacent structures, and result in clinical deterioration of patients. Patients with WOPN have prolonged hospitalizations, needing multiple radiologic and medical interventions. We compared an established treatment of WOPN, standard percutaneous drainage (SPD), with combined modality therapy (CMT), in which endoscopic transenteric stents were added to a regimen of percutaneous drains. METHODS Symptomatic patients with WOPN between January 2006 and August 2009 were treated with SPD (n = 43, 28 male) or CMT (n = 23, 17 male) and compared by disease severity, length of hospitalization, duration of drainage, complications, and number of radiologic and endoscopic procedures. RESULTS Patient age (59 vs 54 years), sex (77% vs 58% male), computed tomography severity index (8.0 vs 7.2), number of endoscopic retrograde cholangiopancreatographies (2.0 vs 2.6), and percentage with disconnected pancreatic ducts (50% vs 46%) were equivalent in the CMT and SPD arms, respectively. Patients undergoing CMT had significantly decreased length of hospitalization (26 vs 55 days, P < .0026), duration of external drainage (83.9 vs 189 days, P < .002), number of computed tomography scans (8.95 vs 14.3, P < .002), and drain studies (6.5 vs 13, P < .0001). Patients in the SPD arm had more complications. CONCLUSIONS For patients with symptomatic WOPN, CMT provided a more effective and safer management technique, resulting in shorter hospitalizations and fewer radiologic procedures than SPD.

Gastric Varices: An Updated Review of Management

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.

Good stents gone bad: endoscopic treatment of proximally migrated pancreatic duct stents

Gastric varices are less prevalent than esophageal varices, but are associated with an increased mortality with each bleeding episode. This review describes the portal hemodynamics, classification, and management of gastric varices. Management options are outlined based on the most recent literature and according to the clinical presentation of acutely bleeding gastric varices, secondary prophylaxis after bleeding, and primary prophylaxis against an initial bleed. The optimal treatment remains controversial because of the lack of data from large controlled trials. We suggest an algorithm for the management based on the etiology of the gastric varices, severity of the underlying liver disease, and local availability and expertise.

Afferent limb syndrome and delayed GI problems after pancreaticoduodenectomy for pancreatic cancer: single-center, 14-year experience

BACKGROUND Pancreatic duct stents are used for a variety of endoscopic pancreatic manipulations, and small surgical stents are used prophylactically to bridge pancreatic-enteric anastomoses. With increasing use of pancreatic stents, many complications have been recognized. OBJECTIVE To determine the complications and outcomes of pancreatic stent migration. DESIGN Case series from a retrospective review of all cases of upstream or proximally migrated pancreatic duct stents, placed either endoscopically or surgically, identified between 2000 and 2007. SETTING Tertiary referral center. PATIENTS This study involved 33 patients; 23 postendoscopic and 10 postsurgical stents. MAIN OUTCOME MEASUREMENTS Retrieval rates, minor/major complications. RESULTS Endoscopic stents had a successful retrieval rate of 78%. Most patients were asymptomatic. The most common procedure was balloon extraction (8 of 18; 44%). Nine patients required multiple procedures (3 patients, 2 attempts; 5 patients, 3 attempts; 1 patient, 4 attempts). Five stents could not be retrieved. Of these, 4 were associated with downstream stenosis. Four patients underwent surgery, and 1 patient was treated with observation. Complications included pancreatic duct disruption (1 of 23), stent fragmentation (1 of 23), and postprocedure pancreatitis (1 of 23). Surgically placed stents had a successful retrieval rate of 80%. Most surgical stents had migrated into the biliary tree (8 of 10). All of these patients were symptomatic with pain or fever. Two stents could not be retrieved; 1 of those patients underwent surgery. LIMITATION Retrospective study. CONCLUSION The majority of upstream-migrated stents can be endoscopically removed. Despite manipulation of the pancreatic duct, pancreatitis was infrequent. Surgically placed pancreatic stents migrate downstream and into the open biliary anastomosis and are associated with pain, cholangitis, or liver abscesses.

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

BACKGROUND There are limited data on the incidence of afferent limb syndrome and other delayed GI problems in pancreatic cancer (PaC) patients, especially among long-term survivors (>2 years). OBJECTIVE To evaluate the incidence of afferent limb syndrome (chronic afferent limb obstruction resulting in pancreatobiliary obstruction) and delayed GI problems in PaC patients after pancreaticoduodenectomy (PD). DESIGN Retrospective case series. SETTING Tertiary referral center. PATIENTS PaC patients treated with PD (N = 186) over a 14-year period (January 1995-October 2009). INTERVENTIONS Endoscopic balloon dilation and stent placement, percutaneous biliary drainage. MAIN OUTCOME MEASUREMENTS Incidence of afferent limb syndrome and delayed GI complications (marginal ulcers, radiation enteropathy, anastomotic strictures). RESULTS Mean age was 63 ± 10 years; 55% of patients were male. Afferent limb syndrome was noted in 24 patients (13%). Median time to diagnosis was 1.2 years (range 0.03-12.3 years); obstruction was primarily caused by recurrent PaC (8 patients, 33%) and radiation enteropathy (9 patients, 38%). Afferent limb syndrome was more likely to develop in patients with 2 years or longer of follow-up (n = 71, [38%]) compared with patients with 2 years or less of follow-up, after controlling for age, sex, surgery type, and adjuvant treatment (adjusted odds ratio, 4.5; 95% CI, 1.8-11.7). Other delayed GI problems included radiation enteropathy (6%), marginal ulcers (5%), anastomotic strictures (4%), cholangitis/liver abscesses (5%), and GI bleeding (6%). LIMITATIONS Retrospective, single-center study. CONCLUSIONS GI problems, including afferent limb syndrome, are relatively common in PaC patients after surgery and adjuvant therapy. Clinicians should recognize and effectively treat these delayed GI problems, especially in long-term survivors.