Management of occluded biliary Wallstents

BACKGROUND

Wallstents (Schneider Stent, Inc., USA) used for the palliation of malignant biliary strictures, although associated with prolonged patency, can occlude. There is no consensus regarding the optimal management of Wallstent occlusion.

AIMS

To evaluate the efficacy of different endoscopic methods for managing biliary Wallstent occlusion.

METHODS

A multicentre retrospective study of patients managed for a biliary Wallstent occlusion.

RESULTS

Data were available for 38 patients with 44 Wallstent occlusions, all of which had initial endoscopic management. Twenty four patients had died and 14 were alive after a median follow up of 231 (30-1095) days following Wallstent occlusion. Occlusions were managed by insertion of another Wallstent in 19, insertion of a plastic stent in 20, and mechanical cleaning in five. Endoscopic management was successful in 43 (98%). Following management of the occlusion, bilirubin decreased from 6.0 (0.5-34.3) to 2.1 (0.2-27.7) mg/100 ml (p < 0.05). No complications occurred. The median duration of second stent patency was 75 days (95% confidence interval 43 to 107) after insertion of another Wallstent, 90 days (71 to 109) after insertion of a plastic stent, and 34 days (30 to 38) after mechanical cleaning (NS). The respective median survivals were 70 days (22-118), 98 days (54-142), and 34 days (30-380) (NS). Incremental cost effective analysis showed that plastic stent insertion is the most cost effective option.

CONCLUSION

Although all three methods are equally effective in managing an occluded Wallstent, the most cost effective method appears to be plastic stent insertion.

Role of endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis in patients undergoing laparoscopic cholecystectomy

BACKGROUND

We report our experience of selective cholangiography in a series of laparoscopic cholecystectomies and evaluate the strategy of using "stricter criteria" to select preoperative endoscopic retrograde cholangiopancreatography (ERCPs).

METHODS

A total of 1847 consecutive laparoscopic cholecystectomies were analyzed for use of cholangiography. A high risk of common bile duct stones (bilirubin level more than 2 mg/dL, jaundice, alkaline phosphatase level more than 150 U/L, pancreatitis, or dilated bile duct and/or stone on ultrasound or CT) was an indication for preoperative ERCP. Selective intraoperative cholangiography was performed for intermediate risk of bile duct stones. The strategy of using "stricter criteria" (jaundice and/or demonstrated bile duct stones on ultrasound or CT) for selecting preoperative ERCP was evaluated retrospectively.

RESULTS

Preoperative ERCP was performed in 135 patients (7.3%) and demonstrated bile duct stones in 43 (32%). Of 36 patients with mild gallstone pancreatitis alone, stones were found only in 6 patients (17%). Selective intraoperative cholangiography was performed in 87 (5%), and stones were found in 2 (2%); 67 (3.6%) postoperative ERCPs were performed for suspected choledocholithiasis, and stones were found in 21 (32%). Applying "stricter criteria" to select preoperative ERCP would predict ductal stones in 56%, whereas 3% of patients with stones would be missed, resulting in a 50% reduction in preoperative ERCPs.

CONCLUSIONS

Even in selected patients considered likely to have choledocholithiasis, the diagnostic yield of preoperative ERCP is low. Using "stricter criteria" to select patients for preoperative ERCP can avoid unnecessary ERCPs.

Therapeutic ERCP in outpatients

BACKGROUND

We evaluated the safety of outpatient therapeutic ERCP since most complications are apparent within a few hours.

METHODS

We reviewed 190 patients undergoing planned outpatient therapeutic ERCP from a cohort of 409 consecutive therapeutic ERCP procedures. Patients were selected for outpatient therapeutic ERCP based on relative good health and overnight accommodation near our institution.

RESULTS

Outpatient therapeutic ERCPs included plastic biliary stent insertion (n = 71), biliary sphincterotomy (45), pancreatic stent insertion (28), Wallstent insertion (19), biliary balloon or catheter dilation (10), pancreatic balloon or catheter dilation (8), biliary stone extraction with prior sphincterotomy (7), pancreatic sphincterotomy (5), and duodenal ampullectomy (1). Admission was necessary in 31 (16%) because of complications in 22 (11.6%) and observation of post-ERCP symptoms in 9. Twenty-six (13%) of these patients were admitted directly from the endoscopy unit recovery room and 5 (3%) from home after a median interval of 24 hours following discharge (range 5 to 48 hours). Reasons for admission were pancreatitis in 17, hemorrhage in 3, cholangitis in 3, endoscopic but not clinical hemorrhage in 4, pain in 4, and vomiting in 1. Of the patients who were admitted from home, 3 had pancreatitis (following sphincterotomy in 1, pancreatic stenting in 1, pancreatic balloon dilation in 1) and 2 had hemorrhage (postsphincterotomy in 1 and ampullectomy in 1). In comparison, of the 219 consecutive inpatients undergoing therapeutic ERCP, 28 (13%) developed complications with 1 (0.4%) death.

CONCLUSIONS

A policy of selective outpatient therapeutic ERCP, with admission reserved for those with established or suspected complication, appears to be safe and reduces health care costs.

Possible role of Helicobacter pylori serology in reducing endoscopy workload

We validated a commercial enzyme-linked immunosorbent assay (ELISA), Helico-G, in diagnosing H. pylori in 129 patients (mean age 50 years, range 15-86). We analysed the results of endoscopy against serology to see whether there was a possibility of adopting the strategy of not endoscoping dyspeptic subjects under the age of 45. H. pylori infection was considered present if either histology and/or culture were positive. The ELISA had a sensitivity of 88%, specificity of 72%, positive predictive value of 85%, negative predictive value of 77% and accuracy of 82% in detecting H. pylori. In a subgroup of 52 subjects aged 45 or less (mean age 35 years, range 15-45), 17 out of 25 patients with positive endoscopic findings were H. pylori seropositive while 16 out of 27 patients had normal endoscopic findings. Eighteen out of the 52 patients (35%) were H. pylori seronegative and normal endoscopically except for five patients (10%) who had mild to moderate oesophagitis and two who had non-erosive gastritis (4%). All patients with duodenal ulcer disease (7) were seropositive giving predictive values of positive and negative serology for a diagnosis of duodenal ulcer disease as 28% and 100%, respectively. Therefore adopting a strategy of endoscoping subjects under the age of 45 only if they were H. pylori seropositive would have saved 35% of endoscopies in this age group but missed oesophagitis in 10%. Negative serology would tend to exclude duodenal ulcer disease while positive serology discriminates poorly for it. Serology may be a useful adjunct in screening to reduce endoscopy workload provided that patients with gastro-oesophageal reflux symptoms are excluded.

Effect of Helicobacter pylori eradication on antral somatostatin cell density in humans

OBJECTIVE

As Helicobacter pylori infection is associated with an elevation in plasma gastrin with normal antral gastrin cell counts, an abnormality in antral somatostatin cells may be associated with the infection. We evaluated the effect of eradication of H. pylori on antral somatostatin cell density in the light of antral gastrin cell density and plasma gastrin levels.

DESIGN

Prospective study.

METHODS

Of 25 dyspeptic patients with H. pylori infection, nine had H. pylori successfully eradicated and the rest remained infected. Antral biopsies were immunostained for somatostatin cells and plasma gastrin measured before and 4 weeks after H. pylori eradication therapy. Ten other dyspeptic patients without H. pylori infection had their somatostatin cell density evaluated as controls.

RESULTS

Somatostatin cell density in the patients without H. pylori infection at the outset was significantly higher than that in the patients with H. pylori infection at the outset (median 57 [18-83] vs. 37 [6-80] cells/mm) respectively (P <0.05). Somatostatin cell density increased after H. pylori eradication (before treatment, median 50 [15-72]; after treatment 71 [39-107] cells/mm) (P < 0.05) but was unchanged with persistent H. pylori infection. Plasma gastrin decreased after H. pylori eradication (before treatment, median 70 [45-100]; after treatment 30 [10-100] ng/l) (P < 0.05) but was unchanged with persistent H. pylori infection.

CONCLUSIONS

Following eradication of H. pylori, there is an increase in somatostatin cell density with a fall in plasma gastrin. This supports the theory that H. pylori infection results in a decrease in somatostatin cell density and, as the latter is an inhibitor of gastrin cells, this results in an increased plasma gastrin.

Evaluation of feedback given to trainees in medical specialties

The aim of this study was to evaluate the quality of feedback provided to specialty trainees (ST3 or higher) in medical specialties during their workplace-based assessments (WBAs). The feedback given in WBAs was examined in detail in a group of 50 ST3 or higher trainees randomly selected from those taking part in a pilot study of changes to the WBA system conducted by the Joint Royal Colleges of Physicians Training Board. They were based in Health Education Northeast (Northern Deanery) and Health Education East of England (Eastern Deanery). Thematic analysis was used to identify commonly occurring themes. Feedback was mainly positive but there were differences in quality between specialties. Problems with feedback included insufficient detail, such that it was not possible to map the progression of the trainee, insufficient action plans made and the timing of feedback not being contemporaneous (feedback not being given at the time of assessment). Recommendations included feedback should be more specific; there need to be more options in the feedback forms for the supervisor to compare the trainee's performance to what is expected and action plans need to be made.

Diagnosis of common bile duct stones by intravenous cholangiography: prediction by ultrasound and liver function tests compared with endoscopic retrograde cholangiography

BACKGROUND

Routine intravenous cholangiography using the safer contrast medium, meglumine iotroxate, may be a useful investigation prior to laparoscopic cholecystectomy for the detection of suspected common bile duct stones. We compared this with endoscopic cholangiography.

METHODS

Eighty-one consecutive nonjaundiced patients (mean age 62 years; range 20 to 90) with suspected common bile duct stones referred for endoscopic cholangiography to one center underwent intravenous cholangiography that was considered positive if it detected ductal stones. The ability of ultrasound scans and liver function tests to predict ductal stones was also assessed.

RESULTS

Sixty patients had both endoscopic and intravenous cholangiograms performed. Thirteen out of 27 patients with ductal stones confirmed by endoscopic cholangiography had positive intravenous cholangiograms, and 29 out of 30 with no stones had negative intravenous cholangiograms. The sensitivity for intravenous cholangiography was 48%, specificity 97%, positive predictive value 93%, negative predictive value 67%, and accuracy 73%. For ultrasound scans the positive predictive value was 69%; negative predictive value was 78%. For liver function tests the positive predictive value was 68%; negative predictive value was 93%.

CONCLUSIONS

Intravenous cholangiography cannot be recommended instead of endoscopic cholangiography except in situations where the latter is not readily available. Ultrasound and liver function tests are useful in predicting ductal stones.

Circadian variation of alpha 1-adrenoceptor-mediated pressor response to phenylephrine in man

The variability in the pressor effects of the alpha 1-adrenoceptor agonist phenylephrine was observed under placebo conditions in ten healthy subjects in a double blind randomized study. Phenylephrine infusions were administered before administration of placebo (baseline) and 2, 4, 8, 12, 24 and 48 h later. The doses of phenylephrine required to increase systolic blood pressure by 20 mmHg after 8 and 12 h (5.30 and 9.30 pm, 81.4 +/- 15.3 and 71.1 +/- 16.0 micrograms min-1, respectively) were significantly (P < 0.01) less than the baseline values (8.30 am, 108.0 +/- 27.6 g min-1). These results might indicate a circadian variation in the phenylephrine-induced alpha-adrenoceptor-mediated vascular response in healthy subjects. These observations lend further insight into circadian variations of vascular tone that might contribute to circadian rhythms in cardiovascular disease.

Long-term semi-quantitative follow-up of Helicobacter pylori associated gastritis

Helicobacter pylori infection has been implicated with the development of gastric carcinoma and lymphoma. We studied the long-term effects of H. pylori infection on gastric mucosa. Ten patients with Helicobacter pylori infection underwent repeat endoscopy and antral biopsies 8 years later. Gastric mucosal features (polymorphs, monocytes, intestinal metaplasia, atrophy and lymphoid aggregates) were graded from mild to severe (0 to 3) based on the Sydney system of gastritis classification. At repeat biopsy, 1 patient was negative for H. pylori after eradication therapy. Two patients (20 per cent) had spontaneous disappearance of H. pylori. One of these had intestinal metaplasia which progressed to low grade dysplasia. Polymorphs decreased with eradication of H. pylori (P < 0.05). Lymphoid aggregates increased with continued H. pylori infection but decreased with eradication of H. pylori (P < 0.05). Monocytes, intestinal metaplasia and atrophy remained unchanged. Persistent H. pylori infection appears to increase lymphoid aggregates and may promote its evolution into gastric lymphoma while eradication of H. pylori may result in a reduction of polymorphs and lymphoid aggregates.

Randomised controlled trial of ranitidine versus omeprazole in combination with antibiotics for eradication of Helicobacter pylori

This study compared high dose ranitidine versus low dose omeprazole with antibiotics for the eradication of H pylori. 80 patients (mean age 48 years, range 18-75) who had H pylori infection were randomised in an investigator-blind manner to either a two-week regime of omeprazole 20 mg daily, amoxycillin 500 mg tid and metronidazole 400 mg tid (OAM), or ranitidine 600 mg bd, amoxycillin 500 mg tid and metronidazole 400 mg tid (RAM), or omeprazole 20 mg daily and clarithromycin 500 mg tid (OC), or omeprazole 20 mg daily and placebo (OP). H pylori was eradicated in 6 of 19 patients in the OAM group (32%); 8 of 18 in the RAM group (44%), 4 of 15 in the OC group (27%); none of 18 in the OP group (0%). [< P0.005 for OAM, RAM, OC vs OP; P = N.S. between OAM, RAM, OC]. Overall metronidazole resistance was unexpectedly high at 58%. Eradication rates in metronidazole sensitive patients were 71% (5/7) and 100% (3/3) for OAM and RAM respectively. In conclusion, H pylori eradication rates using high dose ranitidine plus amoxycillin and metronidazole may be similar to that of low dose omeprazole in combination with the same antibiotics for omeprazole with clarithromycin. Overall eradication rates were low due to a high incidence of metronidazole resistance but were higher in metronidazole-sensitive patients. Even high dose ranitidine with two antibiotics achieves a relatively low eradication rate. These metronidazole-based regimens cannot be recommended in areas with a high incidence of metronidazole resistance.