Sotiris Terzoudis

Combination of diclofenac plus somatostatin in the prevention of post-ERCP pancreatitis: a randomized, double-blind, placebo-controlled trial

BACKGROUND AND STUDY AIMS Pancreatitis is the most common complication of therapeutic endoscopic retrograde cholangiopancreatography (ERCP), and many pharmacoprophylactic approaches have been suggested, though not without controversy. The aim was to investigate the impact of combined therapy with diclofenac plus somatostatin on reducing the frequency and severity of post-ERCP pancreatitis (PEP). PATIENTS AND METHODS A prospective, double-blind, placebo-controlled trial was conducted in two tertiary referral centers, with 540 eligible patients randomized to receive either combined therapy with diclofenac 100 mg rectally 30 to 60 minutes before ERCP plus somatostatin 0.25 mg/h for 6 hours (group A), or a placebo suppository identical in appearance to the diclofenac along with saline solution (group B). Patients were clinically evaluated and serum amylase levels were determined before ERCP and at 6 and 24 hours post-procedure. Standardized criteria were used to diagnose and grade the severity of PEP. Adverse events were recorded prospectively. RESULTS There were no statistical differences between the groups regarding demographic data, ERCP findings, and procedure risk factors for PEP. The overall incidence of acute pancreatitis was 7.2 %. The PEP rate was significantly lower in the patients who received the combination therapy than in controls (4.7 % vs. 10.4 %, P = 0.015). Previous history of acute pancreatitis (P = 0.001), pancreatic opacification of first-class branches and beyond (P = 0.008), and absence of pharmacoprophylaxis (P = 0.023) were identified as independent risk factors for PEP in multivariate analysis. CONCLUSION Although combined prophylactic therapy with diclofenac plus somatostatin was promising in reducing frequency of PEP, further comparative large-scale studies are needed to confirm our findings before definitive conclusions can be drawn.

Outpatient therapeutic endoscopic retrograde cholangiopancreatography is safe in patients aged 80 years and older.

BACKGROUND AND STUDY AIM The aim of this observational prospective study was to evaluate the safety of outpatient therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in a very elderly cohort. PATIENTS AND METHODS A total of 600 patients were included in the study between June 2006 and June 2009. All underwent first therapeutic ERCP and were scheduled to be discharged on the same day following a postprocedure observation period of 6 hours. Of the 600 patients, 123 patients (group A) were re-admitted due to postprocedure complications that presented during the observation period, and 477 patients (group B) were discharged on the same day. Concomitant diseases, details of ERCP procedures, complications, and outcomes were all evaluated. The accuracy of the 6-hour postprocedure observation period, clinical criteria in predicting those patients aged 80 years and older in whom all therapeutic ERCP can be performed on an outpatient basis, and costs saved were all assessed. RESULTS There was a statistical difference in incidence of concomitant diseases between groups A and B (group A 84.5 % vs. group B 74.6 %; P = 0.020). However, there was no difference between the groups with regard to indication for ERCP and type of intervention. There was no difference in postprocedure complication rate between very elderly patients and younger patients (< 80 years), except for prolonged sedation or hypotension, which occurred more frequently in older (≥ 80 years) than in younger (< 80 years) patients (7.6 % vs. 3.2 %; P = 0.037). In group B, complications necessitating re-admission after the 6-hour observation period occurred in 10 patients (2.09 %) (patients ≥ 80 years 0.8 % and patients < 80 years 2.5 %). The costs saved by performing the procedure on an outpatient basis was calculated as 150 € per patient. CONCLUSION Outpatient therapeutic ERCP with postprocedure observation of 6 hours is a safe and cost-effective procedure in a significant proportion of very elderly patients.

Diagnostic yield and clinical impact of wireless capsule endoscopy in patients with chronic abdominal pain with or without diarrhea: a Greek multicenter study.

BACKGROUND Wireless capsule endoscopy has become the gold standard for the examination of small bowel. However, its role in the evaluation of patients suffering from chronic abdominal pain is not yet clearly defined. We conducted an open-label prospective multi-center study to evaluate the yield and clinical outcome of capsule endoscopy in patients with chronic abdominal pain with/without diarrhea. METHODS Seventy-two patients with chronic (>3months) abdominal pain with/without diarrhea in whom the underlying pathology could not be diagnosed by conventional modalities, underwent capsule endoscopy in either of the 6 participating centers. Patients were then followed up for clinical outcomes. RESULTS The overall diagnostic yield of capsule endoscopy was 44.4%. More specifically, its diagnostic yield was 21.4% in patients with abdominal pain and negative inflammatory markers (C-reactive protein and erythrocyte sedimentation rate), 66.7% in patients with abdominal pain and positive inflammatory markers, 0% in patients with abdominal pain, diarrhea and negative inflammatory markers, and 90.1% in patients with abdominal pain, diarrhea and positive inflammatory markers. Both univariate and multivariate regression analyses showed that abnormal C-reactive protein and erythrocyte sedimentation rate were significant factors related with positive capsule endoscopy findings. CONCLUSIONS Chronic abdominal pain with/without diarrhea should be accompanied by elevated inflammatory markers to be regarded as a valid indication for capsule endoscopy. The yield of capsule endoscopy in such patients is reasonably high and clinical outcomes of patients treated with capsule endoscopy findings as a guide are significant.

Diagnostic yield and clinical impact of capsule endoscopy in obscure gastrointestinal bleeding during routine clinical practice: a single-center experience.

Objective: This study assessed the diagnostic yield of capsule endoscopy (CE) and its impact on patients with obscure gastrointestinal bleeding (OGIB). Subjects and Methods: Between May 2007 and May 2009, 63 patients with OGIB (overt bleeding: 25, and occult blood loss with chronic ferropenic anemia: 38) and normal upper and lower endoscopy were studied by CE. Demographic characteristics, prior diagnostic tests, CE findings, therapeutic interventions, medical treatment and clinical outcomes following CE were evaluated. Results: The overall diagnostic yield was 44.44% of patients and included findings of angiectasia in 11 (17.46%) patients, nonsteroidal anti-inflammatory drugs enteropathy in 6 (9.52%) patients, celiac disease in 3 (4.76%) patients, tumors in 2 (3.17%) patients, and a variety of other diagnoses ranging from varices to ulcers (due to congenital afibrinogenemia and amyloidosis). The diagnostic yield was notably higher in overt bleeders (15/25, 60%) compared to occult bleeders (13/38, 34.21%; p = 0.044), and in patients with overt bleeding who had CE within the first 10 days (14/16, 87.5%) after the bleeding episode in comparison to overt bleeders who underwent CE >10 days after the bleeding episode (2/16, 11.1%; p < 0.0001). During follow-up (11.8 ± 7 months), CE findings led to specific therapy that resolved the underlying disease or improved the clinical condition in 45 of 63 patients, thus having a positive clinical impact of 71.43%. Conclusion: CE has a high diagnostic yield and a positive influence on clinical management in a significant proportion of patients with OGIB. These data further support the role of CE in routine clinical practice.

Prophylactic clip application before endoscopic resection of large pedunculated colorectal polyps in patients receiving anticoagulation or antiplatelet medications.

Background: The aim of the present study was to evaluate the safety of prophylactic endoclipping before resection of large pedunculated colorectal polyps in patients with uninterrupted anticoagulation or antiplatelet therapy. Patients and Methods: In a single tertiary referral center, patients with normal coagulation parameters and those with uninterrupted anticoagulation or antiplatelet medications, who underwent prophylactic endoclipping before resection of large pedunculated colorectal polyps (polyp’s head diameter >10 mm), were evaluated retrospectively. Demographic, clinical, and laboratory parameters, polyp characteristics, number of clips used for endoclipping, histology of resected polyps, the polypectomy technique, and postpolypectomy complications were recorded and compared. Results: In 64 patients with large pedunculated colorectal polyps, successful endoclipping before resection was achieved. Eleven patients (17.2%) had uninterrupted anticoagulation (n=4) or antiplatelet (n=7) medications. Statistical analysis showed no significant differences in age, sex, indications for colonoscopy, location of polyps, size of polyp head or stalk, coexisting small polyps, histology of resected polyps, and polypectomy techniques among patients with normal coagulation parameters (group A) and patients on uninterrupted anticoagulant or antiplatelet treatment (group B). Coronary artery disease, hypertension, and atrial fibrillation were significantly more prevalent in group B. No immediate or delayed postpolypectomy hemorrhage occurred in either group. One patient (1.9%) in group A developed postpolypectomy coagulation syndrome and was successfully treated conservatively. Follow-up evaluation demonstrated no recurrence of polyps or cancer development. Conclusions: According to our experience, uncomplicated polypectomy of large pedunculated colorectal polyps can be performed by prophylactic endoclipping in patients receiving anticoagulation or antiplatelet medications.

Large-balloon dilation of the biliary orifice for the management of basket impaction: a case series of 6 patients

ERCP with endoscopic sphincterotomy (ES) and stone extraction remains the treatment of choice for bile duct stones 1,2 ; 85% to 90% of all CBD stones can be effectively treated by ES and stone extraction by using balloon catheters or baskets. 3 Regarding the latter devices, impaction of a Dormia basket or fracture of the basket’s traction wires during endoscopic mechanical lithotripsy with an entrapped stone in the distal CBD is an uncommon but well-known complication, 4-6 presenting a challenge to most endoscopists. Reported management strategies include the use of a mechanical lithotriptor to capture the impacted basket and crush the stone, extracorporeal shock-wave lithotripsy, endoscopic laser lithotripsy, or other sophisticated methods. 7-12 This case series describes, for the first time, the safe and effective use of large-diameter balloon dilation of the biliary orifice in the management of impacted baskets in the distal CBD.

Endoscopic management of occluded biliary uncovered metal stents：A multicenter experience

AIM To compare diverse endoscopic interventions in the management of occluded uncovered self-expanding metal stents (SEMSs) that had been placed for palliative treatment of unresectable malignant biliary obstruction. METHODS A retrospective review was undertaken in 4 tertiary endoscopic centers to determine optimal management of different types of occluded SEMSs. The technical success of performed treatment in occluded SEMSs, the patency of the stent, the need for re-intervention and the financial costs of each treatment were analyzed. RESULTS Fifty four patients were included in the analysis; 21 received Hanaro, 19 Wallstent and 14 Flexus. For the relief of obstruction, a plastic stent was inserted in 24 patients, a second SEMS in 25 and mechanical cleaning was performed in 5 patients. The overall median second patency rates between second SEMSs and plastic stents did not differ (133 d for SEMSs vs 106 d for plastic stents; P=0.856). Similarly, no difference was found between the overall survival of SEMS and plastic stent groups, and no procedure-related complications occurred. Incremental cost analysis showed that successive plastic stenting was a cost-saving strategy at least in Greece. CONCLUSION Insertion of uncovered SEMSs or plastic stents is a safe and effective treatment for occluded uncovered SEMSs; insertion of plastic stents appears to be the most cost-effective strategy.

The role of capsule endoscopy in the evaluation and treatment of obscure-overt gastrointestinal bleeding during daily clinical practice: a prospective multicenter study

Abstract Objective. Capsule endoscopy (CE) is most commonly performed to evaluate obscure gastrointestinal bleeding (GIB). However, at present the role of CE in patients with obscure-overt GIB especially during daily clinical practice is unknown. The aim of the present study was to investigate the diagnostic yield and the impact of CE on the management of patients with obscure-overt GIB. Material and methods. Between January 2007 and December 2011 we prospectively included all patients with obscure-overt GIB who underwent CE after negative bidirectional endoscopy. CE findings revealing the cause of bleeding, type of therapeutic intervention and clinical variables associated with positive CE and recurrence of GIB were evaluated. Results. One hundred and eighteen patients with a median age of 66 years (range 8–89 years) were enrolled in the final analysis. The overall diagnostic yield of the CE was 66.9%. The most common findings were angiodysplasias (33.1%), followed by ulcer (23.7%), and tumors (6.8%). Age (p = 0.001) and cardiovascular disease (p = 0.007) were significant clinical variables predicting the higher incidence of angiodysplasias. Specific therapeutic interventions were undertaken in 54 patients with positive CE (68.4%). Recurrence of GIB was observed in one patient with negative CE (2.6%) and 16 patients with positive CE (20.3%). Univariate and multivariate analysis showed high age and no therapeutic intervention as significant factors associated with recurrent bleeding. Conclusions. CE represents a promising diagnostic method in the investigation of obscure-overt GIB, with significant impact on its clinical management in daily clinical practice.

Can Capsule Endoscopy Be Used as a Diagnostic Tool in the Evaluation of Nonbleeding Indications in Daily Clinical Practice? A Prospective Study

Objective: To evaluate the diagnostic yield of capsule endoscopy (CE) and its impact on treatment and outcome in patients without bleeding indications. Subjects and Methods: One hundred and sixty-five nonbleeding patients were enrolled in the study. The most common indications for CE were chronic abdominal pain alone (33 patients) or combined with chronic diarrhea (31 patients) and chronic diarrhea alone (30 patients). Among the 165 patients, 129 underwent CE for evaluation of gastrointestinal symptoms and 36 for surveillance or disease staging. Results: CE findings were positive, suspicious and negative in 73 (44.2%), 13 (7.9%) and 79 (47.9%) of cases, respectively. The diagnostic yield was highest in patients with refractory celiac disease (10/10, 100%) and suspected Crohn’s disease (5/6, 83.3%), followed by patients with chronic abdominal pain and chronic diarrhea (13/31, 41.9%), established Crohn’s disease (2/6, 33.3%), chronic diarrhea alone (8/30, 26.7%), chronic abdominal pain alone (8/33, 24.2%) and other indications (3/13, 23.1%) (p < 0.005). The CE findings led to a change of medication in 74 (47.7%) patients, surgery in 15 (9.7%), administration of a strict gluten-free or other special diet in 13 (8.4%) and had other consequences in 11 (6.7%). Management was not modified in 42 (27.1%) patients. Among symptomatic patients (n = 129), 29 (22.5%) were lost to follow-up. The remaining 100 patients were followed up for 8.7 ± 4.0 months (range 2–19). Among the latter, resolution or improvement of symptoms was observed in 86 (86%) patients, no change in 11 (11%) and 3 (3%) died. All 86 patients who experienced resolution or improvement of their symptoms had a modification of their management after CE; only 7/11 patients whose symptoms did not change (63.6%) and 2/3 patients who died (66.7%) had a modification of management (p < 0.001). Conclusions: CE appears to be a useful tool in the evaluation of patients with nonbleeding indications. The outcome of most patients with negative findings was excellent.

Acute pancreatitis caused by impaction of hydatid membranes in the papilla of Vater: a case report

Acute pancreatitis is a rare complication of hydatidosis and the successful use of endoscopic sphincterotomy associated with extraction of hydatid membranes has been rarely reported. We describe a young man who developed acute pancreatitis after rupture of an echinococcus cyst, located at the left hepatic lobe, into the biliary tract. The cause of pancreatitis was confirmed by endoscopic retrograde cholangiopancreatography, which revealed the presence of a daughter cyst impacted in the major papilla. After sphincterotomy and removal of hydatid membranes from the biliary tract, the patient presented rapid resolution of pancreatitis and made an uneventful recovery.