Yan Bakman

Significant clinical implications of prophylactic pancreatic stent placement in previously normal pancreatic ducts

Pancreatic duct stent placement is increasingly performed for the prevention of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP); however stents can result in injury especially in normal ducts. The clinical significance and outcomes of subsequent endoscopic therapy are unknown. This study was a retrospective review of the management of symptomatic stent-induced pancreatic duct injury following stent placement for prevention of post-ERCP pancreatitis in eight patients with previously normal pancreatic ducts. Subsequent treatment included pancreatic sphincterotomy, balloon dilation of stricture, and placement of multiple 3 - 5-Fr soft polymer pancreatic stents. All patients showed improvement or resolution of pancreatic strictures. Five patients had resolution or substantial improvement of pain, one patient showed a fair response with repeated ERCPs, and two patients failed to respond and underwent total pancreatectomy with islet autotransplantation. Pancreatic duct stent-induced ductal injury with significant clinical consequences can occur with conventional polyethylene stents. Endoscopic therapy is moderately effective but some patients develop irreversible damage. Caution should be used when placing standard polyethylene stents in normal ducts. Further research is required to identify safer materials and configurations of pancreatic stents.

Urgent ERCP with pancreatic stent placement or replacement for salvage of post-ERCP pancreatitis

BACKGROUND AND STUDY AIMS Urgent placement or replacement of pancreatic stents shortly after endoscopic retrograde cholangiopancreatography (ERCP) might attenuate the course of evolving post-ERCP pancreatitis (PEP). PATIENTS AND METHODS Salvage ERCP with de novo pancreatic stent placement or replacement of outwardly migrated stents was performed within 2 - 48 hours in patients with evolving PEP accompanied by severe pain, systemic inflammatory response syndrome (SIRS), and major elevations in serum amylase and lipase. Serial pain scores, amylase and lipase levels, and hospital course were studied. RESULTS PEP according to Cotton consensus criteria developed after 64 (2 %) of 3216 ERCPs over 3 years. Of the 64 patients with PEP, 14 underwent salvage ERCP (5 without and 9 with prior pancreatic stents, 7 of which had migrated outwards prematurely). All patients had SIRS and a high score (≥ 3) for the bedside index for severity in acute pancreatitis. Median clinical onset of PEP was at 5 hours (range 0 - 68 hours) in patients with prophylactic pancreatic stents vs. 2 hours (range 0.5 - 2.5 hours) in patients without prophylactic pancreatic stents (P < 0.05). Salvage ERCP was performed at a median of 10 hours (interquartile range [IQR] 2.4 - 22.7 hours). Improvement in pain, amylase, lipase, and resolution of SIRS were statistically significant at 24 hours after salvage ERCP (P = 0.003). Median length of hospital stay was 2 days (IQR 1 - 4.75). No necrotizing pancreatitis or late complications occurred. CONCLUSION Urgent salvage ERCP with de novo pancreatic stent placement or replacement of a migrated stent is a novel approach in the setting of early PEP, and was associated with rapid resolution of clinical pancreatitis and reduction in levels of amylase and lipase.

Difficult biliary access at ERCP.

Endoscopic retrograde cholangiopancreatography allows intervention for a variety of diseases of the biliary tract. Cannulation of the bile duct is the prerequisite step for biliary intervention. Although obtaining biliary access is straightforward in many cases, it can occasionally be challenging. Multiple devices, all with additional wire-guided techniques, have been developed to aid cannulation. More advanced techniques have also been developed to aid biliary access if it is unsuccessful with standard devices. Multimodality techniques can be used if other approaches fail. This article provides an evidence-based discussion of these approaches, and provides insight into their appropriate application.

Update on biliary and pancreatic sphincterotomy.

Purpose of review To summarize the indications, success rates and complications associated with endoscopic sphincterotomy and endoscopic balloon dilation (EBD). Recent findings Pancreatic and/or biliary sphincterotomies are essential components of most current therapeutic endoscopic retrograde cholangiopancreatography (ERCP). A current large body of evidence has established biliary sphincterotomy as effective in extraction of bile duct stones. The most common complications of biliary sphincterotomy are post-ERCP pancreatitis, as well as acute or delayed hemorrhage, the risks for which can be stratified according to well described patient and procedure related factors. Evidence is accumulating that pancreatic sphincterotomy is useful in at least some settings for treatment of sphincter of Oddi dysfunction, chronic pancreatitis, and pancreas divisum. EBD provides an adjunct or an alternative to biliary sphincterotomy for extraction of stones from the bile duct when routine biliary sphincterotomy is inadequate or risk excessive. Summary Sphincterotomy and EBD are useful in managing a variety of pancreatobiliary conditions. Attention to risks of these procedures is essential for their efficacy and safety.

Clinical Significance of Isolated Peri-Appendiceal Lesions in Patients With Left Sided Ulcerative Colitis.

Background Ulcerative colitis is classically described as a condition originating in the rectum and extending proximally towards the cecum. In recent years, a discontinuous peri-appendiceal lesion has been described. Our aim was to evaluate the risk of progression to pancolitis in patients presenting with an isolated peri-appendiceal lesion on ileocolonoscopy. Methods Endoscopy databases at three tertiary care centers were searched for patients undergoing ileocolonoscopy for diagnosis or surveillance of ulcerative colitis. Patients with isolated periappendiceal lesions as well as histologically confirmed left sided colitis were enrolled. Controls were defined as patients with left-sided ulcerative colitis without evidence of peri-appendiceal inflammation. The main outcome was the need for escalation of therapy to systemic corticosteroids, immunomodulators or biologic agents. Secondary outcomes were progression to pancolitis or requirement for colectomy. A secondary analysis of other risk factors for proximal extension/progression of colitis was also performed. Results We identified 228 patients with ulcerative colitis, 123 were included in the analysis. Four point eight percent of patients had isolated peri-appendiceal lesions. In the group with peri-appendiceal lesions, 47.4% required escalation of therapy vs. 70% in the control group (P = 0.53). There was no difference in progression to pan-colitis or colectomy rates between the two groups. Progression was not predicted by inflammatory markers, age, gender, initial Mayo UC score or IBD therapy utilization. Conclusions The presence of isolated peri-appendiceal lesions is not a risk factor for future escalation of therapy for ulcerative colitis and is not correlated with proximal extension of disease.

Novel Use of Long, Large-Caliber, Fenestrated Stents for Endoscopic Transpapillary Gallbladder Stenting for Therapy of Symptomatic Gallbladder Disease

Symptomatic gallbladder disease (SGBD) has a high prevalence in the general population, and early cholecystectomy is considered definitive therapy for patients with symptomatic cholelithiasis [1, 2]. Conservative therapy is recommended for those patients in whom surgery is contraindicated or considered high risk [3–5]. Nonsurgical gallbladder drainage methods include percutaneous and endoscopic drainage techniques [5]. While percutaneous transhepatic gallbladder catheter drainage (PCD) is efficacious, it has risks of puncture-related adverse events and tube dislodgement and results in significant patient discomfort [5, 6]. PCD is usually a temporary step until the patient is fit for surgery, symptoms resolve or drainage can be internalized by endoscopic transpapillary gallbladder stenting (ETGS) which involves placement of an internal transpapillary stent. ETGS has technical and clinical success rates comparable to PCD with the advantage of internal drainage; however, its limitations include the potential for stent migration or occlusion requiring stent exchange, cystic duct or gallbladder perforation, and recurrence of symptomatic biliary disease [5–10]. ETGS has been previously described mainly using rigid, double-pigtail polyethylene plastic stents of diameter 5–7 Fr and length 10–15 cm, with inherent limitations in drainage, flexibility, and patency [5–10]. Johlin pancreatic wedge stents (JS) (Wilson-Cook Medical, Winston-Salem, NC, USA) are made of Sof-Flex material, which is a softer polyurethane and polyethylene blend. They are fenestrated with large, multi-side holes along the length of the stent and are available in 8.5 and 10 Fr diameters and variable lengths up to 22 cm (Fig. 1). JS for ETGS have theoretical advantages over conventional stents, including soft material with conformability to tortuous cystic ducts, the presence of side holes, and large caliber allowing potentially longer patency. We report our initial experience using JS for ETGS.

Endoscopic Drainage of >50% of Liver in Malignant Hilar Biliary Obstruction Using Metallic or Fenestrated Plastic Stents

Objectives:Endoscopic drainage of complex hilar tumors has generally resulted in poor outcomes. Drainage of >50% of liver volume has been proposed as optimal, but not evaluated using long multifenestrated plastic stents (MFPS) or self-expanding metal stents (SEMS). We evaluated outcomes of endoscopic drainage of malignant hilar strictures using optimal strategy and stents, and determined factors associated with stent patency, survival, and complications.Methods:Cross-sectional study was conducted at an academic center over 5 years. MFPS (10 French or 8.5 French) or open-cell SEMS were used for palliation of unresectable malignant hilar strictures, with imaging-targeted drainage of as many sectors as needed to drain >50% of viable liver volume. Risk factors were evaluated using regression analysis. The cumulative risk was assessed using Kaplan–Meier analysis.Results:77 patients with malignant hilar biliary strictures (median Bismuth IV) underwent targeted stenting (41 MFPS and 36 SEMS). Comparing MFPS vs. SEMS, technical success (95.1 vs. 97.2%, P=0.64), clinical success (75.6 vs. 83.3%, P=0.40), frequency of multiple stents (23/41 vs. 25/36, P=0.19), survival and adverse events were similar, but stent patency was significantly shorter (P<0.0001). Factors associated with survival were Karnofsky score and serum bilirubin level at presentation. Outcomes were independent of Bismuth class with acceptable results in Bismuth III and IV.Conclusions:Endoscopic biliary drainage with MFPS or open-cell SEMS targeting >50% of viable liver resulted in effective palliation in patients with complex malignant hilar biliary strictures. Patency was shorter in the MFPS group, but similar survival and complications were found when comparing MFPS and SEMS group.

Proliferating Pilar Tumor of Scalp Metastasizing to Pancreas: Diagnosis With Endoscopic Ultrasound-guided Fine-needle Aspiration

65-year-old man with history of diabetes and Ahypertension was evaluated for rapid enlargement of 2 scalp masses that had been present for 40 years, concerning for malignant transformation. Physical examination revealed 2 very large, flesh-colored, pedunculated masses in the occipital region and a 4-cm enlarged right supraclavicular lymphnode. He underwentwide local excision of the scalp lesions. Pathology showed a high-grade proliferating pilar tumor (PPT) of the scalp with negative resectionmargins (Figures A and B, arrows). A neck dissection with excision of the right supraclavicular node confirmed the locoregional metastases of the pilar tumor. Positron emission tomography (PET)–computed tomography (CT) performed 15 months later showed mildly PET avid pulmonary nodules and mediastinal lymph nodes in the anteroposterior window. Endoscopic ultrasound (EUS) was performed to evaluate for metastatic disease in the mediastinal lymph node. A hypoechoic