Endoscopic Ultrasound-Guided Rendezvous Technique Versus Precut Sphincterotomy as Salvage Technique in Patients With Benign Biliary Disease and Difficult Biliary Cannulation : A Randomized Controlled Trial

BACKGROUND

The standard salvage technique used for difficult bile duct cannulation is precut sphincterotomy, whereas endoscopic ultrasound-guided rendezvous technique (EUS-RV) is a relatively newer method. Prospective comparative data between these 2 techniques as salvage for biliary access in patients with benign biliary disease and difficult bile duct cannulation is lacking.

OBJECTIVE

To compare EUS-RV and precut sphincterotomy as salvage technique for difficult bile duct cannulation in benign biliary obstruction.

DESIGN

Participant-masked, parallel-group, superiority, randomized controlled trial. (Clinical Trials Registry of India: CTRI/2020/07/026613).

SETTING

Tertiary care academic institute from July 2020 to May 2021.

PARTICIPANTS

All patients with benign biliary disease and difficult bile duct cannulation requiring salvage strategy.

INTERVENTION

Patients were randomly assigned by computer-generated randomized blocks sequence in 1:1 fashion to either EUS-RV or precut sphincterotomy. Patients with failure in EUS-RV were crossed over to precut sphincterotomy and vice versa.

MEASUREMENTS

The primary outcome measure was technical success. The other outcome measures included procedure time, radiation dose, and adverse events.

RESULTS

In total, 100 patients were randomly assigned to EUS-RV (n = 50) and precut sphincterotomy (n = 50). The technical success rate (92% vs. 90%; P = 1.00; relative risk, 1.02 [95% CI, 0.90 to 1.16]), median procedure time (10.1 vs. 9.75 minutes), and overall complication rate (12% vs. 10%; relative risk, 1.20 [CI, 0.39 to 3.68]) were similar between the 2 groups. Five patients (10%) in the EUS-RV group and 5 patients (10%) in the precut sphincterotomy group had developed post-endoscopic retrograde cholangiopancreatography pancreatitis. All failed cases in either salvage group could be successfully cannulated when crossed over to the other group.

LIMITATION

Single center study done by experts.

CONCLUSION

Endoscopic ultrasound-guided rendezvous technique and precut sphincterotomy have similar success rates as salvage techniques in the technically challenging cohort of difficult bile duct cannulation for benign biliary disease, with acceptable complications rates.

PRIMARY FUNDING SOURCE

None.

OUTCOME OF PER ORAL ENDOSCOPIC MYOTOMY (POEM) IN SIGMOID ACHALASIA AT A MEDIAN FOLLOW UP OF 17 MONTHS

BACKGROUND

Advanced achalasia cardia (AC) represents the end stage in the natural history of AC. Role of per oral endoscopic myotomy (POEM) in this technically difficult subset is emerging.

METHODS

Retrospective review of the patients who had undergone POEM for advanced AC with sigmoid esophagus. We assessed the technical success, clinical success and adverse event rate. Pre and post POEM Eckardt score (ES), integrated relaxation pressure-4sec (IRP-4), lower oesophageal sphincter pressure (LESP) and height and width of barium column at 5 minutes were noted.

RESULTS

Of the 85 patients who underwent POEM for AC, 10 patients had advanced AC with sigmoid esophagus of which eight were sigmoid and two were advanced sigmoid. The clinical and technical success was 100% with significant reduction of ES, IRP-4, LESP and height and width of barium column at 5 minutes. One patient had a minor adverse event in the form of mucosal injury that was closed with hemoclips. At a median follow up of 17 months there was no recurrence.

CONCLUSION

Our study demonstrates POEM to be a safe and effective modality of treatment in this technically difficult subset of AC with sigmoid morphology.

Role of Novel Motorized Enteroscopy in the Evaluation of Small Bowel Diseases: A Systematic Review and Meta-analysis

BACKGROUND AND AIM

Motorized spiral enteroscopy (MSE) has recently been introduced for small bowel evaluation. In this systematic review and meta-analysis, we aim to evaluate the safety and efficacy of MSE for evaluation of small bowel diseases.

METHODS

A literature search was performed in Embase, PubMed, Medline databases for studies evaluating MSE between January -2010 and October-2022. The primary outcome of the study was diagnostic yield with MSE. Secondary outcomes included technical success, procedure duration, depth of maximum insertion (DMI), rate of pan-enteroscopy and adverse events.

RESULTS

10 studies with 961 patients [581 (60.5%) males] were included in the analysis. 1068 MSE procedures were performed by antegrade route in 698, retrograde route in 215 and bidirectional in 155 patients. Technical success was achieved in 94.9% (95% CI 92.9% to 96.4%) procedures. The pooled diagnostic yield of MSE was 73.7% (95% CI 70.7% to 76.4%). Pooled rate of pan-enteroscopy by antegrade route was 21.9% (95% CI 18.1% to 26.1%), retrograde route was 6.9% (95% CI 2.4% to 18.3%) and combined route was 61.2% (95% CI 52.4% to 69.3%). Pooled rate of major adverse events was 1.9% (95% CI 1.2% to 3.2%).

CONCLUSIONS

MSE is a safe and effective tool for evaluating small bowel disorders. High diagnostic yield and low rate of adverse events make it a potential alternative to balloon enteroscopy. However, comparative trials are required in the future.

Outcomes of Self-expandable Metal Stents in Patients With Unresectable Gallbladder Cancer Undergoing Percutaneous Biliary Drainage

Background

Biliary obstruction in gallbladder cancer (GBC) is associated with worse prognosis and needs drainage. In patients with biliary confluence involvement, percutaneous biliary drainage (PBD) is preferred over endoscopic drainage. However, PBD catheters are associated with higher complications compared to endoscopic drainage. PBD with self-expandable metal stents (SEMS) is desirable for palliation. However, the data in patients with unresectable GBC is lacking.

Materials and methods

This retrospective study comprised consecutive patients with proven GBC who underwent PBD-SEMS insertion between January 2021 and December 2022. Technical success, post-procedural complications, clinical success, duration of stent patency, and biliary reinterventions were recorded. Clinical follow-up data was analysed at 30 days and 180 days of SEMS insertion and mortality was recorded.

Results

Of the 416 patients with unresectable GBC, who underwent PBD, 28 (median age, 50 years; 16 females) with PBD-SEMS insertion were included. All SEMS placement procedures were technically successful. There were no immediate/early post-procedural complications/deaths. The procedures were clinically successful in 63.6% of the patients with hyperbilirubinemia (n = 11). Biliary re-interventions were done in 6 (21.4%). The survival rate was 89.3 % (25/28) at 30 days and 50% at 180 days. The median follow-up duration was 80 days (range, 8-438 days).

Conclusion

PBD-SEMS has moderate clinical success and 6-months patency in almost half of the patients with metastatic GBC and must be considered for palliation.

Diagnostic work-up of bile duct strictures: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

1: ESGE recommends the combination of endoscopic ultrasound-guided tissue acquisition (EUS-TA) and endoscopic retrograde cholangiopancreatography (ERCP)-based tissue acquisition as the preferred diagnostic approach for tissue acquisition in patients with jaundice and distal extrahepatic biliary stricture in the absence of a pancreatic mass. 2: ESGE suggests that brushing cytology should be completed along with fluoroscopy-guided biopsies, wherever technically feasible, in patients with perihilar biliary strictures. 3: ESGE suggests EUS-TA for perihilar strictures when ERCP-based modalities yield insufficient results, provided that curative resection is not feasible and/or when cross-sectional imaging has shown accessible extraluminal disease. 4: ESGE suggests using standard ERCP diagnostic modalities at index ERCP. In the case of indeterminate biliary strictures, ESGE suggests cholangioscopy-guided biopsies, in addition to standard ERCP diagnostic modalities. Additional intraductal biliary imaging modalities can be selectively used, based on clinical context, local expertise, and resource availability.

Application of deep learning models for accurate classification of fluid collections in acute necrotizing pancreatitis on computed tomography: a multicenter study

PURPOSE

To apply CT-based deep learning (DL) models for accurate solid debris-based classification of pancreatic fluid collections (PFC) in acute pancreatitis (AP).

MATERIAL AND METHODS

This retrospective study comprised four tertiary care hospitals. Consecutive patients with AP and PFCs who had computed tomography (CT) prior to drainage were screened. Those who had magnetic resonance imaging (MRI) or endoscopic ultrasound (EUS) within 20 days of CT were considered for inclusion. Axial CT images were utilized for model training. Images were labelled as those with≤30% solid debris and >30% solid debris based on MRI or EUS. Single center data was used for model training and validation. Data from other three centers comprised the held out external test cohort. We experimented with ResNet 50, Vision transformer (ViT), and MedViT architectures.

RESULTS

Overall, we recruited 152 patients (129 training/validation and 23 testing). There were 1334, 334 and 512 images in the training, validation, and test cohorts, respectively. In the overall training and validation cohorts, ViT and MedVit models had high diagnostic performance (sensitivity 92.4-98.7%, specificity 89.7-98.4%, and AUC 0.908-0.980). The sensitivity (85.3-98.6%), specificity (69.4-99.4%), and AUC (0.779-0.984) of all the models was high in all the subgroups in the training and validation cohorts. In the overall external test cohort, MedViT had the best diagnostic performance (sensitivity 75.2%, specificity 75.3%, and AUC 0.753). MedVit had sensitivity, specificity, and AUC of 75.2%, 74.3%, and 0.748, in walled off necrosis and 79%, 74.2%, 75.3%, and 0.767 for collections >5 cm.

CONCLUSION

DL-models have moderate diagnostic performance for solid-debris based classification of WON and collections greater than 5 cm on CT.

No definite associations between opioid doses and severity of acute pancreatitis - Results from a multicentre international prospective study

BACKGROUND

Abdominal pain is the cardinal symptom of acute pancreatitis (AP), often requiring opioid therapy. This study aimed to investigate the dose-dependent relationship between opioid therapy and moderately severe or severe AP.

METHODS

This was a post-hoc analysis of the prospective PAINAP database, which recruited patients with first-time AP from 118 centres across 27 countries between April-June 30, 2022. Baseline demographic details, opioid treatment dose, and AP outcome characteristics were extracted. The intravenous morphine-equivalent doses (MEDs) of each opioid administered were calculated based on daily doses and duration. They were subsequently summarised into cumulative MEDs. Furthermore, mean daily intravenous MEDs were registered. Using multivariable regression analysis, associations between opioid doses and the severity of AP were explored.

RESULTS

The final cohort consisted of 1,043 patients receiving various doses of opioids (51 % male; median age 54 years). Most (79 %) patients had mild, 14 % moderately severe, and 7 % severe AP. Median cumulative MED was 20 mg (IQR, 8-48), whereas median daily MED was 6 (IQR, 3-11), and median duration was 3 days (IQR, 2-5). There was a significant association between moderately severe or severe AP and cumulative intravenous MEDs per 10 mg (OR 1.02 (IQR 1.00-1.03), P = 0.01). When considering daily intravenous MEDs, this association was non-significant (P = 0.15).

CONCLUSIONS

The association between opioid doses and AP severity was dose-dependent with cumulative opioid doses but not with daily doses. In the absence of adequate evidence and potential reverse causation bias, future studies are warranted to assess the safety of opioids in AP.

Impact of contrast-enhanced versus non-contrast computed tomography on acute kidney injury in acute necrotizing pancreatitis: A randomized controlled trial

BACKGROUND

The data evaluating contrast-induced-acute kidney injury (AKI) in patients with acute pancreatitis is scarce. This study aimed to compare the frequency of AKI in patients with acute necrotizing pancreatitis undergoing non-contrast computed tomography (NCCT) with those undergoing contrast-enhanced computed tomography (CECT) during hospitalization.

METHODS

This prospective randomized controlled trial (CTRI/2019/12/022206) screened consecutive patients with acute pancreatitis for eligibility and randomly allocated patients with acute necrotizing pancreatitis (based on CECT in the first week of illness) and normal renal functions to receive either NCCT or CECT during hospitalization. The incidence of development of new AKI and clinical outcomes was compared between the two groups. Post-hoc analysis was done to adjust for disease severity.

RESULTS

As many as 105 patients completed the study as per protocol (NCCT = 45 and CECT = 60). AKI occurred in 36 (34.3%) patients, nine (20%) in the NCCT and 27 (45%) in the CECT group. Contrast induced-AKI occurred in 11 (18.3%) patients, while 25 had AKI secondary to acute pancreatitis. The relative risk (RR) of AKI in the CECT group was 2.25 (95% CI 1.17-4.30, p = .0142). The frequency of intensive care unit (ICU) admission (RR = 2.1, 95% CI 1.34-3.27, p = .0001) and need for drainage of collections (RR = 1.39, 95% CI 1.1-1.7, p = .005) was significantly higher and the length of hospitalization (p = .001) and ICU admission (p = 0.001) were significantly longer in the CECT group. However, when adjusted for the severity of acute pancreatitis, there was no difference in AKI and clinical outcomes between the NCCT and CECT groups. The duration of AKI was significantly longer and the need for dialysis was significantly higher in patients who had AKI secondary to acute pancreatitis compared to those with contrast induced-AKI (p = .003).

CONCLUSION

CECT is not significantly associated with AKI in acute necrotizing pancreatitis.

The role of endoscopy in malignant hilar obstruction

Malignant hilar biliary obstruction (MHO) is a medical challenge as regards both forming a correct diagnosis and its adequate management, in terms of treatment alternatives and palliative options. Surgical resection is the only curative treatment for the underlying disease, but the majority of patients are not suitable candidates because of an unresectable tumor or poor performance status. Biliary drainage (BD) can be achieved through the percutaneous transhepatic route or endoscopically, and the choice depends on a host of factors, including biliary anatomy and comorbidity of the patient. Though there is no consensus, the endoscopic approach is usually preferred over the former. Endoscopy can aid in both diagnosis (collection of histological as well as cytological samples, direct visualization of suspected malignant pathology, or use of endoscopic ultrasound [EUS] for evaluation and locoregional staging), and in achieving internal BD. Advances in the development of various stents, accessories and, more recently, the use of EUS have in fact further expanded its application in MHO management. The choice of stents to be used (type, make, and number), palliation methods, deployment techniques and the use of local ablative strategy are still evolving and require more data. The complexity of management of MHO mandates that each patient should receive a "personalized approach", all the way from establishing a diagnosis until final treatment, with the help of a multidisciplinary team effort. Herein, we provide a comprehensive literature review of the current role of endoscopy for MHO, according to its applications in various clinical settings.

Endoscopic ultrasound-guided pancreatic duct drainage: a comprehensive state of the art review

INTRODUCTION

Endoscopic retrograde pancreatography (ERP) has traditionally been the standard modality for pancreatic endotherapy. However, in certain situations, failure of retrograde ductal access may warrant an alternative modality of drainage. This can occur in various settings like difficult and/or surgically altered anatomy or duodenal obstruction. Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD) is a relatively newer addition to the armamentarium for endoscopic access to the PD.

AREAS COVERED

This comprehensive state-of-art review aims to give an overview of the indications, technical details, different approaches, and outcomes of EUS-PDD, with the latest evidence available in scientific literature.

EXPERT OPINION

Akin to its biliary drainage counterpart, EUS-PDD enables an EUS-assisted-ERP using rendezvous technique or EUS-guided drainage through transmural stenting. The technique has evolved over the ensuing years with multitude of accessories, approaches, and devices to optimize the outcomes. However, the technical success and adverse events rates need to be further improved. Additionally, it has a steep learning curve with requirements of advanced technical skill and optimum infrastructure back-up. Meticulous patient selection, precise knowledge of ductal anatomy, appropriate approach, and carefully chosen accessories can improve its clinical outcomes.

Variability of contrast enhancement of pancreas on computed tomography in patients with acute pancreatitis and isolated extrapancreatic necrosis

BACKGROUND AND STUDY AIM

To evaluate the variability in the enhancement of pancreas on computed tomography (CT) in patients with acute pancreatitis (AP) and isolated extrapancreatic necrosis (EPN) and to investigate whether it affects the extrapancreatic findings and patient outcomes.

PATIENTS AND METHODS

This retrospective study comprised of consecutive patients with isolated EPN evaluated between April 2017 and April 2019. A radiologist measured the pancreatic attenuation values (PAV) of head, body, and tail on a contrast enhanced CT. Using a cut-off PAV of 100HU, patients were divided into two groups. The extrapancreatic CT findings and outcome parameters were compared between the two groups.

RESULTS

Thirty patients (mean age, 42.13 years, 17 males) with isolated EPN were evaluated. The mean PAV in the head, body, and tail was 83.13 HU (range, 59-161), 84.17 HU (range, 60-160), and 82.23 HU (range, 53-137). The overall mean PAV was 83.12 HU (range, 58-152). There were six patients with overall mean PAV≥100 HU. The group with PAV≥100 HU had a higher number of patients with infected necrosis (66.6% vs. 14.2%, P=0.018). PAV had a significant association with length of hospitalization (P=0.045).

CONCLUSION

There is significant variability in the pancreatic enhancement on CT among patients with AP and isolated EPN. Patients with PAV≥100 HU had a significantly longer hospital stay. This, however, may be related to a greater number of patients with infected necrosis in this group.

Same versus separate sessions of endoscopic ultrasound-guided fine-needle biopsy and endoscopic retrograde cholangiopancreatography for distal malignant biliary obstruction: a propensity score-matched study

BACKGROUND

Same-session endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) is an attractive policy for patients with distal malignant biliary obstruction (DMBO) requiring fine-needle biopsy (FNB) and biliary drainage. However, scanty and conflicting data exists regarding safety and efficacy when comparing these two procedures performed in same versus separate sessions.

METHODS

Single-center, retrospective, propensity score-matched study including patients with DMBO who underwent EUS-FNB followed by ERCP during the same or separate sessions. The primary outcome was the safety of the procedure [number of patients experiencing adverse events (AEs), overall AEs, its severity, post-ERCP pancreatitis (PEP)]. Secondary outcomes were successful ERCP, use of advanced cannulation techniques, EUS-FNB adequacy, length of hospital stay, overall procedure time, and time to recurrent biliary obstruction.

RESULTS

After propensity matching, 87 patients were allocated to each group. AEs developed in 23 (26.4%) vs. 17 (19.5%) patients in the same and separate sessions group, respectively (p = 0.280). The overall number, the severity of AEs, and the rate of PEP were similar in the two groups. Secondary outcome parameters were also comparable in the 2 groups.

CONCLUSIONS

Same-session EUS-FNB followed by ERCP with biliary drainage is safe and does not impair technical outcomes of tissue adequacy and biliary cannulation.

Retroperitoneal versus transperitoneal percutaneous catheter drainage of necrotic pancreatic collections: a comparative analysis

PURPOSE

To compare the success rate, clinical outcomes, and complications of retroperitoneal (RP) versus transperitoneal (TP) percutaneous catheter drainage (PCD) of the necrotic pancreatic fluid collections.

MATERIALS AND METHODS

This retrospective study comprised consecutive patients with acute pancreatitis who underwent PCD of lesser sac collections amenable to drainage via both TP and RP routes. The patients were divided into two groups based on the route of drainage (group I, RP, and group II, TP). The technical success, clinical success, complications, and clinical outcomes were compared between the groups. Subgroup analysis was performed based on the timing of drainage (acute necrotic collections, ANC vs. walled-off necrosis, WON) and organ failure (OF).

RESULTS

Seventy-nine patients [mean age, 38.7 ± 12.3 years, 54 males] were included in the study. Group I and II comprised 22 (27.8%) and 57 (72.2%) patients, respectively. The procedures were technically successful in all the patients. There was no significant difference in the complication rate between the two groups. The clinical success was higher in group II (75.4%) as compared to group I (54.5%). However, the difference was not statistically significant (p = 0.070). There was no significant difference in the hospital stay (p = 0.298), intensive care unit stay (p = 0.401), need for surgical necrosectomy (p = 0.243), and mortality (p = 0.112) between the two groups. The outcomes in patients with OF and ANC were not affected by the route of PCD. Clinical success rate was significantly higher in WON undergoing TP drainage (p = 0.009).

CONCLUSION

Both RP and TP routes of PCD are safe and effective. Clinical success rate was significantly higher in WON undergoing TP drainage.

Impact of Hepatic Steatosis, Psoas Muscle Mass, and Density on Outcomes in Patients with Moderately Severe and Severe Acute Pancreatitis: A Serial Computed Tomography-Based Retrospective Study

Background and Objective There is limited literature on the association of fatty liver and muscle mass with outcomes of acute pancreatitis (AP) in Indian patients. We aim to investigate the impact of these parameters on clinical outcomes in AP patients based on serial computed tomography (CT) scans.

Materials and Methods Consecutive patients of AP who had a baseline CT scan within 2 weeks of pain onset and a follow-up CT scan within 2 months of initial CT scan were included. Fatty liver, spleen to liver attenuation difference (AD), psoas muscle area (PMA), and psoas muscle attenuation (PMAt) were assessed on baseline and follow-up portal venous CT scans. Their association with the length of hospitalization, intensive care unit (ICU) admission, length of ICU stay, surgery, and mortality were assessed using univariate and multivariate analysis.

Results One hundred and ninety-eight patients (143 [72.2%] males, mean age 37.9 [ ± 12.4] years) were included. The mean interval between the two CT scans was 30 days (± 13.5 days). Twenty-four (12.1%) patients had fatty liver at baseline CT and 58 (29.3%) patients had fatty liver on follow-up CT (p < 0.001). The mean AD at the baseline scan was –10.2 (± 12.3) Hounsfield units (HU) and on follow up was –18.8 (± 21.7) HU (p < 0.001). PMA in baseline CT was 13.9 (± 5.5) mm2 and on follow-up was 11.2 (± 4.6) mm2 (p < 0.001). PMAt on baseline CT was 49.2 (± 8.2) HU and on follow-up was 47.1 (± 12.1) HU (p < 0.001). In multivariate analysis, the PMA and PMAt were significantly associated with the clinical outcomes. There was no association of fatty liver with clinical outcomes. The parameter with the highest area under the curve for predicting clinical outcomes was PMAt at follow-up CT.

Conclusion Psoas muscle-based assessment is associated with clinical outcomes in patients with AP.

The Use of a New Dedicated Electrocautery Lumen-Apposing Metal Stent for Gallbladder Drainage in Patients with Acute Cholecystitis

Aims: Lumen-apposing metal stents (LAMSs) in ultrasonography-guided gallbladder drainage (EUS-GBD) have become increasingly important for high-risk surgical patients. Our study aims to evaluate the technical and clinical success, safety, and feasibility of endoscopic ultrasonography-guided gallbladder drainage using a new dedicated LAMS. Methods: This is a retrospective multicenter study that included all consecutive patients not suitable for surgery who were referred to a tertiary center for EUS-GBD using a new dedicated electrocautery LAMS for acute cholecystitis at eight different centers. Results: Our study included 54 patients with a mean age of 76.48 years (standard deviation: 12.6 years). Out of the 54 endoscopic gallbladder drainages performed, 24 (44.4%) were cholecysto-gastrostomy, and 30 (55.4%) were cholecysto-duodenostomy. The technical success of LAMS placement was 100%, and clinical success was achieved in 23 out of 30 patients (76.67%). Adverse events were observed in two patients (5.6%). Patients were discharged after a median of 5 days post-stenting. Conclusions: EUS-GBD represents a valuable option for high-surgical-risk patients with acute cholecystitis. This new dedicated LAMS has demonstrated a high rate of technical and clinical success, along with a high level of safety.