Vanessa M. Shami

Temporary placement of covered self-expandable metal stents in benign biliary strictures: a new paradigm? (with video)

BACKGROUND Benign biliary strictures (BBS) are usually managed with plastic stents, whereas placement of uncovered metallic stents has been associated with failure related to mucosal hyperplasia. OBJECTIVE We analyzed the efficacy and safety of temporary placement of a covered self-expanding metal stent (CSEMS) in BBS. DESIGN Patients with BBS received temporary placement of CSEMSs until adequate drainage was achieved; confirmed by resolution of symptoms, normalization of liver function tests, and imaging. SETTING Tertiary-care center with long-standing experience with CSEMSs. PATIENTS Seventy-nine patients with BBS secondary to chronic pancreatitis (32), calculi (24), liver transplant (16), postoperative biliary repair (3), autoimmune pancreatitis (3), and primary sclerosing cholangitis (1). INTERVENTION ERCP with temporary CSEMS placement. Removal of CSEMSs was performed with a snare or a rat-tooth forceps. MAIN OUTCOME MEASUREMENTS End points were efficacy, morbidity, and clinical response. RESULTS CSEMSs were removed from 65 patients. Resolution of the BBS was confirmed in 59 of 65 patients (90%) after a median follow-up of 12 months after removal (range 3-26 months). If patients who were lost to follow-up, developed cancer, or expired were considered failures, then an intent-to-treat global success rate of 59 of 79 (75%) was obtained. Complications associated with placement included 3 post-ERCP pancreatitis (4%), 1 postsphincterotomy bleed (1%), and 2 pain that required CSEMS removal (2%). In 11 patients (14%), the CSEMS migrated. In 1 patient, CSEMS removal was complicated by a bile leak that was successfully managed with plastic stents. LIMITATION Pilot study from a single center. CONCLUSIONS Temporary CSEMS placement in patients with BBS offers a potential alternative to surgery.

Temporary placement of fully covered self-expandable metal stents in benign biliary strictures: midterm evaluation (with video)

BACKGROUND Benign biliary strictures (BBS) have been endoscopically managed with placement of multiple plastic stents. Uncovered metal stents have been associated with mucosal hyperplasia and partially covered self-expandable metal stents with migration. Recently, fully covered self-expandable metal stents (CSEMSs) with anchoring fins have become available. OBJECTIVE Our purpose was to analyze the efficacy and complication rates of CSEMSs in the treatment of BBS. DESIGN CSEMSs (10-mm diameter) were placed in 44 patients with BBS. CSEMSs were left in place until adequate biliary drainage was achieved, confirmed by resolution of symptoms, normalization of liver function tests, and imaging. SETTING Tertiary care center with long-standing experience with metal stents. PATIENTS A total of 44 patients with BBS (28 men, median age 53.5 years) were included. The preprocedure diagnoses included chronic pancreatitis (n = 19), gallstone-related strictures (n = 14), post liver transplant (n = 9), autoimmune pancreatitis (n = 1), and primary sclerosing cholangitis (n = 1). INTERVENTION ERCP with temporary CSEMS placement. Removal of CSEMSs was performed with a snare or rat tooth. MAIN OUTCOME MEASUREMENTS Stricture resolution and morbidity. RESULTS The median time of CSEMS placement was 3.3 months (interquartile range 3.0-4.8). Resolution of the BBS was confirmed in 34 of 41 patients (83%) after a median postremoval follow-up time of 3.8 months (interquartile range 1.2-7.7). Complications were observed in 6 (14%) patients after CSEMS placement and in 4 (9%) after CSEMS removal. LIMITATION Pilot study from a single center. CONCLUSION Temporary placement of CSEMSs for BBS may offer an alternative to plastic stenting. Further investigation is required to further assess safety and long-term efficacy.

Transenteric drainage of pancreatic-fluid collections with fully covered self-expanding metallic stents (with video)

BACKGROUND Drainage of pancreatic-fluid collections (PFCs) by using fully covered self-expanding metallic stents (CSEMSs) offers the option of providing a larger-diameter access fistula for drainage when compared with plastic stents. OBJECTIVE To evaluate the efficacy and safety of transenteric drainage of PFCs by using CSEMSs. DESIGN A prospective case series. SETTING A tertiary-referral center. PATIENTS Between January 2007 and September 2007, 18 patients underwent drainage of PFCs by using CSEMSs. Follow-up and final results were prospectively recorded until May 2008. INTERVENTIONS Placement of CSEMSs with a double-pigtail stent placed alongside (4 cases) or into the CSEMS (14 cases) to prevent migration. MAIN OUTCOME MEASUREMENTS The number of sessions and time to resolution of the PFCs. RESULTS A median of 1 session was required to achieve drainage (range 1-4) when using CSEMSs. Complications included superinfection (5), bleeding (2), and inner migration (1). A total of 17 of 18 patients (95%) responded successfully, with 14 patients (78%) achieving complete resolution of their PFC. The mean (+/- SD) time of follow-up until final resolution was 77 +/- 80 days (range 15-310 days). CONCLUSIONS Placement of CSEMSs seems to offer an effective and safe alternative for the drainage of PFCs. A randomized controlled trial should be performed to compare this technique with plastic-stent drainage.

Unresectable Cholangiocarcinoma: Comparison of Survival in Biliary Stenting Alone Versus Stenting With Photodynamic Therapy

BACKGROUND & AIMS Photodynamic therapy (PDT) for unresectable cholangiocarcinoma is associated with improvement in cholestasis, quality of life, and potentially survival. We compared survival in patients with unresectable cholangiocarcinoma undergoing endoscopic retrograde cholangiopancreatography (ERCP) with PDT and stent placement with a group undergoing ERCP with stent placement alone. METHODS Forty-eight patients were palliated for unresectable cholangiocarcinoma during a 5-year period. Nineteen were treated with PDT and stents; 29 patients treated with biliary stents alone served as a control group. Multivariate analysis was performed by using Model for End-Stage Liver Disease score, age, treatment by chemotherapy or radiation, and number of ERCP procedures and PDT sessions to detect predictors of survival. RESULTS Kaplan-Meier analysis demonstrated improved survival in the PDT group compared with the stent only group (16.2 vs 7.4 months, P<.004). Mortality in the PDT group at 3, 6, and 12 months was 0%, 16%, and 56%, respectively. The corresponding mortality in the stent group was 28%, 52%, and 82%, respectively. The difference between the 2 groups was significant at 3 months and 6 months but not at 12 months. Only the number of ERCP procedures and number of PDT sessions were significant on multivariate analysis. Adverse events specific to PDT included 3 patients with skin phototoxicity requiring topical therapy only. CONCLUSIONS ERCP with PDT seems to increase survival in patients with unresectable cholangiocarcinoma when compared with ERCP alone. It remains to be proved whether this effect is attributable to PDT or the number of ERCP sessions. A prospective randomized multicenter study is required to confirm these data.

Acute pancreatitis after EUS-guided FNA of solid pancreatic masses: a pooled analysis from EUS centers in the United States

BACKGROUND The aim of this study was to determine the frequency and the severity of pancreatitis after EUS-guided FNA of solid pancreatic masses. A survey of centers that offer training in EUS in the United States was conducted. METHODS A list of centers in which training in EUS is offered was obtained from the Web site of the American Society for Gastrointestinal Endoscopy. Designated program directors were contacted via e-mail. The information requested included the number of EUS-guided FNA procedures performed for solid pancreatic masses, the number of cases of post-procedure pancreatitis, and the method for tracking complications. For each episode of pancreatitis, technical details were obtained about the procedure, including the location of the mass, the type of fine needle used, the number of needle passes, and the nature of the lesion. RESULTS Nineteen of the 27 programs contacted returned the questionnaire (70%). In total, 4909 EUS-guided FNAs of solid pancreatic masses were performed in these 19 centers over a mean of 4 years (range 11 months to 9 years). Pancreatitis occurred after 14 (0.29%): 95% CI[0.16, 0.48] procedures. At two centers in which data on complications were prospectively collected, the frequency of acute pancreatitis was 0.64%, suggesting that the frequency of pancreatitis in the retrospective cohort (0.26%) was under-reported (p=0.22). The odds that cases of pancreatitis would be reported were 2.45 greater for the prospective compared with the retrospective cohort (95% CI[0.55, 10.98]). The median duration of hospitalization for treatment of pancreatitis was 3 days (range 1-21 days). The pancreatitis was classified as mild in 10 cases, moderate in 3, and severe in one; one death (proximate cause, pulmonary embolism) occurred after the development of pancreatitis in a patient with multiple comorbid conditions. CONCLUSIONS EUS-guided FNA of solid pancreatic masses is infrequently associated with acute pancreatitis. The procedure appears to be safe when performed by experienced endosonographers. The frequency of post EUS-guided FNA pancreatitis may be underestimated by retrospective analysis.

Interventional endoscopic ultrasound-guided cholangiography: long-term experience of an emerging alternative to percutaneous transhepatic cholangiography.

BACKGROUND AND STUDY AIMS Endoscopic retrograde cholangiography (ERC) with stenting is the procedure of choice for biliary decompression in patients with obstructive jaundice. In cases where biliary access cannot be achieved, interventional endoscopic ultrasound-guided cholangiography (IEUC) has become an alternative to percutaneous transhepatic cholangiography (PTC). PATIENTS AND METHODS We report on 5 years of experience in patients who underwent IEUC after failed endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic ultrasound-guided access to the targeted biliary duct was attempted with one of two approaches: transgastric-transhepatic (intrahepatic) or transenteric-transcholedochal (extrahepatic). A stent was then advanced over the wire and into the biliary tree. RESULTS A total of 49 patients underwent IEUC: 35 had biliary obstruction due to malignancy and 14 had a benign etiology. The overall success rate of IEUC was 84% (41/49), with an overall complication rate of 16%. Of the 35 patients who underwent the intrahepatic approach, 23 had a stent placed across the major papilla, one had a stent placed intraductally in the common bile duct, and three patients underwent placement of a gastrohepatic stent. Resolution of obstruction was achieved in 29 patients, with a success rate of 83%. In all, 14 patients underwent an extrahepatic approach. In 8/14 (57%), stent placement across the major papilla was achieved. A transenteric stent was placed in four patients. Biliary decompression was achieved in 12/14 cases (86%). Based on intention-to-treat analysis, the intrahepatic approach achieved success in 29 of 40 cases (73%), and the extrahepatic approach was successful in seven of nine cases (78%). There were no procedure-related deaths. CONCLUSION IEUC offers a feasible alternative to PTC in patients with obstructive jaundice in whom ERC has failed.

Single-balloon enteroscopy effectively enables diagnostic and therapeutic retrograde cholangiography in patients with surgically altered anatomy

BACKGROUND In patients with surgically altered anatomy, ERCP is often unsuccessful. Single-balloon enteroscopy (SBE) enables deep intubation of the small bowel, permitting diagnostic and therapeutic ERCP in this subset of patients. OBJECTIVE To determine the effectiveness of SBE in performing endoscopic retrograde cholangiography (ERC) in patients with surgically altered anatomy. DESIGN Case series. SETTING Large quaternary-care center. PATIENTS Thirteen patients (11 women) underwent 16 SBE procedures with ERCP. Patient anatomy consisted of Whipple (n = 3), hepaticojejunostomy (n = 3), Billroth II (n = 1), and Roux-en-Y (n = 9). INTERVENTIONS Patients with surgically altered anatomy in whom standard ERCP techniques had failed or were not possible underwent ERC by using SBE with initial therapeutic intent. MAIN OUTCOME MEASUREMENTS Success rates of diagnostic ERC and therapeutic ERC in those patients who required biliary intervention. Procedure-related complications were also assessed. RESULTS Diagnostic ERC was successful 12 (92.3%) of 13 patients and in 13 (81.3%) of 16 cases. Therapeutic ERC was required in 10 patients in whom diagnostic ERC was first accomplished, and therapeutic ERC was successful in 9 (90%) of 10 patients. Biliary interventions included balloon dilation (n = 4), stone extraction (n = 2), sphincterotomy (n = 4), removal of a surgically placed stent (n = 3), and stenting (n = 2). Two patients developed pancreatitis after therapeutic ERC. Median follow-up was 53 days (range 22-522 days). Overall procedural success in an intent-to-treat analysis by case was 75%. LIMITATION Single-center experience. CONCLUSION SBE enables diagnostic and therapeutic ERC in most patients with altered anatomy. SBE-assisted therapeutic ERC may be associated with an increased risk of pancreatitis. Improvement of the available equipment is necessary to perform more efficient and effective biliary interventions.

EUS-guided transhepatic cholangiography: report of 6 cases

BACKGROUND This report describes a novel application of EUS-guided cholangiography in which a transhepatic approach was used to alleviate perihilar and distal biliary obstructions when this could not be accomplished at ERCP. METHODS EUS-guided transhepatic cholangiography was used to alleviate symptoms of biliary obstruction in 6 patients. In 4 cases, after transgastric puncture of an intrahepatic branch of the obstructed bile duct with a 19- or a 22-gauge EUS needle, a guidewire was advanced antegrade across both the biliary stricture and the papilla. Subsequently, a rendezvous procedure was performed, allowing ERCP and stent placement. OBSERVATIONS EUS-guided transhepatic cholangiography was performed in 6 patients, with successful rendezvous ERCP and stent placement in 4, and transduodenal stent placement in another patient. Stent placement was unsuccessful in one patient, because of the inability to advance a guidewire into the common hepatic duct. There was no immediate complication of the procedures. CONCLUSIONS EUS-guided transhepatic cholangiography can be used to access and to drain bile ducts that are obstructed by proximal, as well as distal lesions when ERCP is unsuccessful.

Clinical Impact of Endoscopic Ultrasound and Endoscopic Ultrasound-Guided Fine-Needle Aspiration in the Management of Rectal Carcinoma

PURPOSE: There is scant data about the clinical impact of endoscopic ultrasound-guided fine-needle aspiration in rectal carcinoma. This study was designed to determine the impact of endoscopic ultrasound-guided fine-needle aspiration on the staging and management of rectal carcinoma and to compare the staging accuracy of computed tomography scan, endoscopic ultrasound, and endoscopic ultrasound-guided fine-needle aspiration. METHODS: The records of 60 consecutive patients diagnosed with rectal carcinoma referred for endoscopic ultrasound staging were reviewed. Computed tomography scans, endoscopic ultrasound imaging, endoscopic ultrasound-guided fine-needle aspiration staging, surgical pathology, and subsequent treatment were compared. RESULTS: Of 48 patients who underwent computed tomography scan imaging, the additional information provided by endoscopic ultrasound changed management in 38 percent of patients. Sixteen patients identified as having nonjuxtatumoral lymph nodes underwent fine-needle aspiration and the additional information obtained changed therapy in three (19 percent) of these patients. All five cases of recurrent rectal carcinoma were correctly diagnosed by fine-needle aspiration. Tumor staging accuracy was 45 percent (computed tomography) and 89 percent (endoscopic ultrasound; P < 0.0001); nodal staging accuracy was 68 percent (computed tomography), 85 percent (endoscopic ultrasound), and 92 percent (endoscopic ultrasound-guided fine-needle aspiration; P = not significant). CONCLUSIONS: Endoscopic ultrasound imaging was better than computed tomography scanning at overall tumor staging, whereas endoscopic ultrasound-guided fine-needle aspiration demonstrated a trend toward more accurate nodal staging. Preoperative staging with endoscopic ultrasound resulted in a change of management in 38 percent of patients. The addition of fine-needle aspiration changed the management in 19 percent of those who underwent nonjuxtatumoral lymph node sampling. Endoscopic ultrasound-guided fine-needle aspiration accurately diagnosed 100 percent of those with recurrent rectal carcinoma. Clearly, endoscopic ultrasound and endoscopic ultrasound-guided fine-needle aspiration are important for the staging and management of rectal carcinoma and for detecting disease recurrence.

Factors predictive of malignancy and Endoscopic resectability in ampullary neoplasia

OBJECTIVE:Endoscopic treatment of ampullary lesions has been well described, though it remains uncertain if specific features predict malignancy, and whether identifiable factors are associated with successful endoscopic resection of benign lesions.METHODS:Fifty-six consecutive patients undergoing endoscopic evaluation of ampullary neoplasia between March 2000 and May 2004 were included in the study. Clinical presentation, underlying medical conditions, endoscopic treatment, endoscopic ultrasound (EUS) to define extent of local involvement, pathology results, and outcome were documented. Data elements for analysis included EUS findings, lesion lifting with submucosal injection, age, gender, tumor size, and endoscopic intervention. Analyses were performed to determine the ability to predict malignancy and the ability to extirpate benign lesions.RESULTS:Thirty-one males and 25 females were included; mean age was 62 yr. Final diagnoses included 29 adenomas, 20 adenocarcinomas, 4 adenomyomas, 2 paragangliomas, and 1 neuroendocrine tumor. Thirty of 35 patients with benign lesions had extirpation with a mean of two endoscopic procedures. Complications of endoscopic resection included cholangitis (1), bleeding (2), and pancreatitis (4). The presence of malignancy was associated by multivariate analysis with the inability to obtain a cleavage plane with saline injection. Univariate analysis also identified EUS T stage as a predictor of malignancy. In benign lesions, none of the analyzed variables predicted successful endoscopic resection.CONCLUSION:In ampullary lesions, failure to achieve a cleavage plane with submucosal injection is the strongest predictor of malignancy followed by EUS T stage. Endoscopic treatment of benign ampullary neoplasia is effective; no factor was predictive of successful extirpation.