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Teoh AYB, Napoleon B, Kunda R, Arcidiacono PG, Kongkam P, Larghi A, Van der Merwe S, Jacques J, Legros R, Thawee RE, Saxena P, Aerts M, Archibugi L, Chan SM, Fumex F, Kaffes AJ, Ma MTW, Messaoudi N, Rizzatti G, Ng KKC, Ng EKW, Chiu PWY. EUS-Guided Choledocho-duodenostomy Using Lumen Apposing Stent Versus ERCP With Covered Metallic Stents in Patients With Unresectable Malignant Distal Biliary Obstruction: A Multicenter Randomized Controlled Trial (DRA-MBO Trial). Gastroenterology 2023; 165:473-482.e2. [PMID: 37121331 DOI: 10.1053/j.gastro.2023.04.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 03/29/2023] [Accepted: 04/11/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND & AIMS Several studies have compared primary endoscopic ultrasound (EUS)-guided biliary drainage to endoscopic retrograde cholangiopancreatography (ERCP) with insertion of metal stents in unresectable malignant distal biliary obstruction (MDBO) and the results were conflicting. The aim of the current study was to compare the outcomes of the procedures in a large-scale study. METHODS This was a multicenter international randomized controlled study. Consecutive patients admitted for obstructive jaundice due to unresectable MDBO were recruited. Patients were randomly allocated to receive EUS-guided choledocho-duodenostomy (ECDS) or ERCP for drainage. The primary outcome was the 1-year stent patency rate. Other outcomes included technical success, clinical success, adverse events, time to stent dysfunction, reintervention rates, and overall survival. RESULTS Between January 2017 and February 2021, 155 patients were recruited (ECDS 79, ERCP 76). There were no significant differences in 1-year stent patency rates (ECDS 91.1% vs ERCP 88.1%, P = .52). The ECDS group had significantly higher technical success (ECDS 96.2% vs ERCP 76.3%, P < .001), whereas clinical success was similar (ECDS 93.7% vs ERCP 90.8%, P = .559). The median (interquartile range) procedural time was significantly shorter in the ECDS group (ECDS 10 [5.75-18] vs ERCP 25 [14-40] minutes, P < .001). The rate of 30-day adverse events (P = 1) and 30-day mortality (P = .53) were similar. CONCLUSION Both procedures could be options for primary biliary drainage in unresectable MDBO. ECDS was associated with higher technical success and shorter procedural time then ERCP. Primary ECDS may be preferred when difficult ERCPs are anticipated. This study was registered to Clinicaltrials.gov NCT03000855.
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Affiliation(s)
- Anthony Yuen Bun Teoh
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China.
| | | | - Rastislav Kunda
- Department of Surgery, Department of Gastroenterology-Hepatology, Department of Advanced Interventional Endoscopy, Universitair Ziekenhuis Brussel UZB, Vrije Universiteit Brussel VUB, Brussels, Belgium; Department of Surgical Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Paolo Giorgio Arcidiacono
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita Salute San Raffaele University, Milan, Italy
| | - Pradermchai Kongkam
- Division of Hospital and Ambulatory Medicine and Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Schalk Van der Merwe
- Department of Gastroenterology and Hepatology, The University of Leuven, Leuven, Belgium
| | - Jeremies Jacques
- Gastroenterology Department, Dupuytren University Hospital, Limoges, France
| | - Romain Legros
- Gastroenterology Department, Dupuytren University Hospital, Limoges, France
| | | | - Payal Saxena
- Department of Gastroenterology, Royal Prince Alfred Hospital, Sidney, Australia
| | - Maridi Aerts
- Department of Gastroenterology-Hepatology, Universitair Ziekenhuis Brussel UZB, Vrije Universiteit Brussel VUB, Brussels, Belgium
| | - Livia Archibugi
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita Salute San Raffaele University, Milan, Italy
| | - Shannon Melissa Chan
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Fabien Fumex
- Hopital Privé Jean Mermoz, Ramsay Santé, Lyon Cedex 08, France
| | - Arthur J Kaffes
- Department of Gastroenterology, Royal Prince Alfred Hospital, Sidney, Australia
| | - Mark Tsz Wah Ma
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Nouredin Messaoudi
- Department of Surgery, Universitair Ziekenhuis Brussel UZB, Vrije Universiteit Brussel VUB, Brussels, Belgium
| | - Gianenrico Rizzatti
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Kelvin Kwok Chai Ng
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Enders Kwok Wai Ng
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Philip Wai Yan Chiu
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
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Staudenmann DA, Sui Z, Saxena P, Kaffes AJ, Marinos G, Kumbhari V, Aepli P, Sartoretto A. Endoscopic bariatric therapies for obesity: a review. Med J Aust 2021; 215:183-188. [PMID: 34333788 DOI: 10.5694/mja2.51179] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
▪ Obesity is reaching pandemic proportions globally, with overweight or obesity affecting at least two-thirds of Australian adults. ▪ Bariatric surgery is an effective weight loss strategy but is constrained by high resource requirements and low patient acceptance. ▪ Multiple endoscopic bariatric therapies have matured, with well established and favourable safety and efficacy profiles in multiple randomised controlled trials (RCTs), and are best used within a multidisciplinary setting as an adjuvant to lifestyle intervention. ▪ Three types of intragastric balloon are currently in use in Australia offering average total weight loss ranging from 10% to 18%, with others available internationally. ▪ Endoscopic sleeve gastroplasty produces average total weight loss of 15-20% with low rates of severe complications, with RCT data anticipated in December 2021. ▪Bariatric and metabolic endoscopy is rapidly evolving, with many novel, promising therapies currently under investigation.
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Affiliation(s)
- Dominic A Staudenmann
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW.,Praxis Balsiger Seibold und Partner, Bern, Switzerland.,Université de Fribourg, Fribourg, Switzerland
| | | | | | - Arthur J Kaffes
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW
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3
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Staudenmann D, Kaffes AJ, Saxena P. Plastic bezoar causing acute pancreatitis in an adolescent: A case report. JPGN Rep 2021; 2:e026. [PMID: 37206927 PMCID: PMC10191470 DOI: 10.1097/pg9.0000000000000026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/15/2020] [Indexed: 05/21/2023]
Affiliation(s)
- Dominic Staudenmann
- From the AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Arthur J Kaffes
- From the AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- The University of Sydney, Sydney, Australia
| | - Payal Saxena
- From the AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- The University of Sydney, Sydney, Australia
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4
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Staudenmann DA, Kaffes AJ, Saxena P. Endoscopic Ultrasound-Guided Vascular Procedures: A Review. Clin Endosc 2020; 53:519-524. [PMID: 33027582 PMCID: PMC7548160 DOI: 10.5946/ce.2020.222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 09/03/2020] [Indexed: 12/02/2022] Open
Abstract
Since the 1980s, endoscopic ultrasound has advanced from being purely diagnostic to an interventional modality. The gastrointestinal tract offers an exceptional window for assessing the vascular structures in the mediastinum and in the abdomen. This has led to a rapidly growing interest in endoscopic ultrasound-controlled vascular interventions as a minimally invasive alternative to surgical and radiological procedures.
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Affiliation(s)
- Dominic A Staudenmann
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
| | - Arthur J Kaffes
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia.,The University of Sydney, Sydney, Australia
| | - Payal Saxena
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia.,The University of Sydney, Sydney, Australia
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5
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Almadi MA, Itoi T, Moon JH, Goenka MK, Seo DW, Rerknimitr R, Lau JY, Maydeo AP, Lee JK, Nguyen NQ, Niaz SK, Sud R, Ang TL, Aljebreen A, Devereaux BM, Kochhar R, Reichenberger J, Yasuda I, Kaffes AJ, Kitano M, Peetermans J, Goswamy PG, Rousseau MJ, Reddy DN, Lakhtakia S, Lee YN, Rai VK, Kamada K, Tanaka R, Tonozuka R, Tsuchida A, Song TJ, Ramchandani MK. Using single-operator cholangioscopy for endoscopic evaluation of indeterminate biliary strictures: results from a large multinational registry. Endoscopy 2020; 52:574-582. [PMID: 32289852 DOI: 10.1055/a-1135-8980] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Peroral cholangioscopy (POCS) of indeterminate biliary strictures aims to achieve a diagnosis through visual examination and/or by obtaining targeted biopsies under direct visualization. In this large, prospective, multinational, real-life experience of POCS-guided evaluation of indeterminate biliary strictures, we evaluated the performance of POCS in this difficult-to-manage patient population. METHODS This prospective registry enrolled patients, with indeterminate biliary strictures across 20 centers in Asia, the Middle East, and Africa. The primary end points were the ability to visualize the lesion, obtain histological sampling when intended, and an assessment of the diagnostic accuracy of POCS for malignant strictures. Patients were followed for 6 months after POCS or until a definitive malignant diagnosis was made, whichever occurred first. RESULTS 289 patients underwent 290 POCS procedures with intent to biopsy in 182 cases. The stricture/filling defect was successfully visualized in 286/290 (98.6 %), providing a visual diagnostic impression in 253/290 (87.2 %) and obtaining adequate biopsies in 169/182 (92.9 %). Procedure-related adverse events occurred in 5/289 patients (1.7 %). POCS influenced patient management principally by elucidating filling defects or the causes of bile duct stricture or dilation. The visual impression of malignancy showed 86.7 % sensitivity, 71.2 % specificity, 65.8 % positive and 89.4 % negative predictive value, and 77.2 % overall accuracy compared with final diagnosis. Histological POCS-guided samples showed 75.3 % sensitivity, 100 % specificity, 100 % positive and 77.1 % negative predictive value, and 86.5 % overall accuracy. CONCLUSION In this large, real-life, prospective series, POCS was demonstrated to be an effective and safe intervention guiding the management of patients with indeterminate biliary strictures.
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Affiliation(s)
- Majid A Almadi
- King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | | | - Jong Ho Moon
- Soon Chun Hyang University Hospital, Seoul, Republic of Korea
| | | | | | | | | | - Amit P Maydeo
- Baldota Institute of Digestive Sciences, Mumbai, Maharashtra, India
| | | | | | | | | | | | | | | | - Rakesh Kochhar
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Ichiro Yasuda
- Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | | | | | | | - Pooja G Goswamy
- Boston Scientific Corporation, Marlborough, Massachusetts, USA
| | | | | | | | - Yun Nah Lee
- Soon Chun Hyang University Hospital, Seoul, Republic of Korea
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6
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Wong MY, Saxena P, Kaffes AJ. Benign Biliary Strictures: A Systematic Review on Endoscopic Treatment Options. Diagnostics (Basel) 2020; 10:diagnostics10040221. [PMID: 32326542 PMCID: PMC7235774 DOI: 10.3390/diagnostics10040221] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/02/2020] [Accepted: 04/14/2020] [Indexed: 01/18/2023] Open
Abstract
Benign biliary strictures can be difficult to manage. Untreated biliary strictures can lead to complications, such as chronic cholestasis, jaundice, recurrent sepsis, and secondary biliary cirrhosis, which can have severe ramifications. The management landscape is constantly evolving, with the development of modifiable self-expandable metal stents and biodegradable stents. This review critically appraises current endoscopic treatment strategies, in particular focusing on the shortfalls, such as stent migration and stricture recurrence. It also proposes a treatment algorithm based on aetiologias and the location of the strictures.
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Affiliation(s)
- May Y.W. Wong
- Interventional Endoscopy, Chris O Brien Lifehouse, Missenden Road, Camperdown 2050, Australia; (M.Y.W.W.); (P.S.)
| | - Payal Saxena
- Interventional Endoscopy, Chris O Brien Lifehouse, Missenden Road, Camperdown 2050, Australia; (M.Y.W.W.); (P.S.)
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Missenden Road, Camperdown 2050, Australia
- Department of Medicine, University of Sydney, Camperdown 2050, Australia
| | - Arthur J. Kaffes
- Interventional Endoscopy, Chris O Brien Lifehouse, Missenden Road, Camperdown 2050, Australia; (M.Y.W.W.); (P.S.)
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Missenden Road, Camperdown 2050, Australia
- Department of Medicine, University of Sydney, Camperdown 2050, Australia
- Correspondence:
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7
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Baars JE, Keegan M, Bonnichsen MH, Aepli P, Theyventhiran R, Farrell E, Kench JG, Saxena P, Kaffes AJ. The ideal technique for processing SpyBite tissue specimens: a prospective, single-blinded, pilot-study of histology and cytology techniques. Endosc Int Open 2019; 7:E1241-E1247. [PMID: 31579705 PMCID: PMC6773591 DOI: 10.1055/a-0950-9554] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 10/08/2018] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Diagnostic sensitivity for indeterminate biliary lesions remains suboptimal. Cytology techniques may mitigate the impediment of small cholangioscopic specimens. Our primary aim was to compare cell block cytology (CB) with standard histology for foregut SpyBite (SB) specimens. Our secondary aim was to assess CB in biliary SB biopsies. Patients and methods This was a two-phase prospective pilot study. In phase one, a prospective pilot study, foregut SB specimens from three sites (4 per site per patient per processing technique) were allocated to CB or histology, and assessed by a single, blinded pathologist. The gold standard comprised two standard forceps (CFB) histological specimens per site per patient. Specimen ease of processing, size and number, adequacy for diagnosis and artefact were evaluated. In phase two, CB was used for consecutive patients with indeterminate biliary lesions, and compared with phase one CB results. Results In phase one, 240 SB foregut biopsies were performed in 10 patients, 227 specimens recorded by pathologist. Specimen origin was identified in 100 % and 97 % of histology and CB batches respectively. Specimens were significantly larger in the histology group (2.02 mm vs 1.49 mm, P < 0.05). There was a trend to less crush artifact with CB, and no difference in processing difficulty. In phase two, 11 patients (63.0 ±12.7 years, 91 % female) underwent SpyGlass (SG) assessment of suspected indeterminate stricture (n = 8) or mass (n = 3), and six underwent SB. All CB specimens were adequate for diagnosis. Specimen parameters were not significantly different from luminal CB outcomes. Conclusions In this pilot study, cell block cytology showed similar results as histological analysis of SpyBite specimens in the analysis of biliary stricture.
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Affiliation(s)
- Judith E. Baars
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
| | - Mathew Keegan
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
| | - Mark H. Bonnichsen
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
| | - Patrick Aepli
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
| | - Ruben Theyventhiran
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
| | - Elizabeth Farrell
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
| | - James G. Kench
- Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Payal Saxena
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
| | - Arthur J. Kaffes
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia,Corresponding author Dr. Arthur Kaffes Suite G10, RPA Medical Centre100 Carillon Ave, NewtownNSW 2042Australia+61295160778
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8
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Abstract
PURPOSE OF REVIEW Strictures of the small bowel are an underdiagnosed entity with significant morbidity because of obstruction and risk of perforation and penetrating disease. RECENT FINDINGS Recent advances in imaging, enteroscopy, and therapeutic advances particularly in Crohn's disease have enabled gastroenterologists to target and individualize management of small bowel strictures, preventing untimely surgery and complications. SUMMARY All patients with obstructive symptoms, suspected small bowel disease, and negative panendoscopy should be evaluated for small intestinal strictures with cross-sectional imaging and considered for capsule endoscopy. Furthermore, the role of device-assisted enteroscopy, initially employed as a diagnostic tool, has evolved into triaging and delivering further medical and interventional treatments.
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Affiliation(s)
- Deniz Durmush
- Prince of Wales Clinical School, UNSW Medicine, Gastrointestinal and Liver Unit, Prince of Wales Hospital, Randwick
| | - Arthur J Kaffes
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, RPA Medical Centre, Camperdown, Sydney, New South Wales, Australia
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9
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Baars JE, Aslam P, Kaffes AJ, Saxena P. Spot diagnosis of intermittent gastrointestinal bleeding. Endosc Int Open 2018; 6:E1276-E1277. [PMID: 30302386 PMCID: PMC6175679 DOI: 10.1055/a-0629-8109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 02/20/2018] [Indexed: 11/08/2022] Open
Abstract
Background and study aims In this case report with video, we present a unique image of a rare, but important cause of gastrointestinal bleeding which often is missed due to its intermittent nature.
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Affiliation(s)
| | - Perveen Aslam
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | | | - Payal Saxena
- Royal Prince Alfred Hospital, Sydney, NSW, Australia,Corresponding author Dr. Payal Saxena Suite G10, RPA Medical Centre100 Carillon Ave, NewtownNSW 2042Australia+61 2 95160778
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Baars JE, Strasser SI, Kaffes AJ, Saxena P. Gastrointestinal: Knot the intent. J Gastroenterol Hepatol 2018; 33:1431. [PMID: 29573478 DOI: 10.1111/jgh.14125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- J E Baars
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - S I Strasser
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - A J Kaffes
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - P Saxena
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Baars JE, Kaffes AJ, Saxena P. Adverse events of pancreatic fluid collections. VideoGIE 2018; 3:68-72. [PMID: 29905192 PMCID: PMC5968021 DOI: 10.1016/j.vgie.2017.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Judith E Baars
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Arthur J Kaffes
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Payal Saxena
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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12
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Abstract
EUS-guided biliary drainage (EUS-BD) has emerged as a technique for gaining biliary access when ERCP fails. This article gives a comprehensive review on the role and technique of EUS-BD. Moreover, we propose an algorithm guiding the clinician when to consider EUS-BD after failed ERCP or in anticipated difficult cannulations.
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Affiliation(s)
- Judith E Baars
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Arthur J Kaffes
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Payal Saxena
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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13
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Affiliation(s)
- Judith E Baars
- Department of Gastroenterology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Fei Chen
- Department of Gastroenterology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Charbel Sandroussi
- Department of Hepatobiliary and Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Arthur J Kaffes
- Department of Gastroenterology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Payal Saxena
- Department of Gastroenterology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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14
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Liu K, Joshi V, van Camp L, Yang QW, Baars JE, Strasser SI, McCaughan GW, Majumdar A, Saxena P, Kaffes AJ. Prevalence and outcomes of pancreatic cystic neoplasms in liver transplant recipients. World J Gastroenterol 2017; 23:8526-8532. [PMID: 29358860 PMCID: PMC5752712 DOI: 10.3748/wjg.v23.i48.8526] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Revised: 11/30/2017] [Accepted: 12/12/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To determine the prevalence, characteristics and clinical course of pancreatic cystic neoplasms (PCNs) in liver transplantation (LT) recipients.
METHODS We retrospectively studied consecutive patients who underwent LT between January 1998 to April 2016. Clinical and laboratory data were obtained from patient medical records. Imaging findings on computed tomography and magnetic resonance cholangiopancreatography were reviewed by two radiologists.
RESULTS During the study period, 872 patients underwent cadaveric LT. Pancreatic cysts were identified in 53/872 (6.1%) and 31/53 (58.5%) were PCNs [28 intraductal papillary mucinous neoplasm (IPMN), 2 mucinous cystic neoplasm (MCN), 1 serous cystadenoma]. Patients with PCNs exhibited less male predominance (55% vs 73%, P = 0.03) compared to patients without pancreatic cysts. Thirteen patients (42%) were diagnosed with PCN pre-LT while 18 patients (58%) developed PCN post-LT. The median size of PCNs was 13mm [interquartile range (IQR) 10-20 mm]. All IPMNs were side-branch type. Most PCNs were found in the head and body of pancreas (37% each), followed by the tail (25%). Five patients underwent further evaluation with endoscopic ultrasound. Progress imaging was performed on 81% of patients. PCNs remained stable in size and number in all but 2 patients. During a median follow up of 39 mo (IQR 26-58 mo), the 2 (6%) patients with MCN underwent pancreatectomy. No PCN patient developed pancreatic adenocarcinoma, while 5 died from illnesses unrelated to the PCN. Among patients without PCN, 1/841 (0.1%) developed pancreatic adenocarcinoma.
CONCLUSION The prevalence of PCNs in LT recipients was similar to the general population (3.6%, 31/872). Side-branch IPMNs do not appear to have accelerated malignant potential in post-LT patients, indicating the current surveillance guidelines are applicable to this group.
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Affiliation(s)
- Ken Liu
- Arthur Kaffes, Sydney Medical School, The University of Sydney, NSW 2006, Australia
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia
| | - Vikram Joshi
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia
| | - Louise van Camp
- Department of Radiology, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia
| | - Qi-Wei Yang
- Arthur Kaffes, Sydney Medical School, The University of Sydney, NSW 2006, Australia
| | - Judith E Baars
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia
| | - Simone I Strasser
- Arthur Kaffes, Sydney Medical School, The University of Sydney, NSW 2006, Australia
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia
| | - Geoffrey W McCaughan
- Arthur Kaffes, Sydney Medical School, The University of Sydney, NSW 2006, Australia
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia
| | - Avik Majumdar
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia
| | - Payal Saxena
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia
| | - Arthur J Kaffes
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia
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Baars JE, Theyventhiran R, Aepli P, Saxena P, Kaffes AJ. Double-balloon enteroscopy-assisted dilatation avoids surgery for small bowel strictures: A systematic review. World J Gastroenterol 2017; 23:8073-8081. [PMID: 29259383 PMCID: PMC5725302 DOI: 10.3748/wjg.v23.i45.8073] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 09/17/2017] [Accepted: 10/17/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the therapeutic role of double-balloon enteroscopy (DBE) in small bowel strictures and to propose a standard approach to small bowel strictures.
METHODS Systematic review of studies involving DBE in patients with small bowel strictures. Only studies limited to small bowel strictures were included and those with ileo-colonic strictures were excluded.
RESULTS In total 13 studies were included, in which 310 patients were dilated. The average follow-up time was 31.8 mo per patient. The complication rate was 4.8% per patient and 2.6% per dilatation. Surgery was avoided in 80% of patients. After the first dilatation, 46% were treated with re-dilatation and only 17% required surgery.
CONCLUSION DBE-assisted dilatation avoids surgery in 80% of patients with small bowel strictures and is safe and effective. We propose a standardized approach to small bowel strictures.
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Affiliation(s)
- Judith E Baars
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Camperdown, Sydney NSW 2050, Australia
| | - Ruben Theyventhiran
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Camperdown, Sydney NSW 2050, Australia
| | - Patrick Aepli
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Camperdown, Sydney NSW 2050, Australia
| | - Payal Saxena
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Camperdown, Sydney NSW 2050, Australia
| | - Arthur J Kaffes
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Camperdown, Sydney NSW 2050, Australia
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Liu K, Joshi V, Saxena P, Kaffes AJ. Predictors of success for double balloon-assisted endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y anastomosis. Dig Endosc 2017; 29:190-197. [PMID: 27637997 DOI: 10.1111/den.12739] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 09/14/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Endoscopic retrograde cholangiopancreatography (ERCP) in patients with roux-en-Y anastomosis (REYA) is challenging. Use of double balloon enteroscope-assisted ERCP (DBE-ERCP) has been successful. We aim to determine predictors of successful biliary cannulation with DBE-ERCP in patients with REYA. METHODS We retrospectively studied patients with REYA who had DBE-ERCP between 2009 and 2015. RESULTS 86 DBE-ERCP were done on 52 patients. Patients had REYA for liver transplant (n = 26), gastrojejunostomy (n = 9), previous bile duct injury (n = 9), biliary atresia (n = 2) and other (n = 6). The biliary-enteric anastomosis was reached in 76% and cholangiogram was successful in 70%. Highest success rates were in patients with previous bile duct injury (94%) or gastrojejunostomy (89%). Post-transplant patients had intermediate success (64%). Patients with redo surgery (46%) and childhood surgery (38%), especially Kasai procedure (20%), had low success. Patients with previous bile duct injury were more likely to succeed (94% vs 63%, P = 0.010). Those more likely to fail were patients with childhood surgery (38% vs 73%, P = 0.037), biliary atresia (20% vs 73%, P = 0.013) and second operation post-transplant (25% vs 70%, P = 0.046). CONCLUSION Indication for REYA impacts on successful biliary cannulation in patients undergoing DBE-ERCP. The procedure is most successful in non-liver transplant adult surgery and post-transplant patients without a second operation. It is least successful in patients with surgically corrected biliary atresia and post-transplant patients with second operation. Alternative methods of biliary access should be considered in these patients.
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Affiliation(s)
- Ken Liu
- Faculty of Medicine, University of Sydney, Sydney, Australia.,AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
| | - Vikram Joshi
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
| | - Payal Saxena
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
| | - Arthur J Kaffes
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
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Kuruvilla N, Paramsothy R, Gill R, Selby WS, Remedios ML, Kaffes AJ. A prospective dual-center proof-of-principle study evaluating the incremental benefit of narrow-band imaging with a fixed zoom function in real-time prediction of polyp histology. Can we resect and discard? Gastrointest Endosc 2015; 82:362-9. [PMID: 25841577 DOI: 10.1016/j.gie.2015.01.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Accepted: 01/04/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Advancements in endoscopic technology have increased the ability to distinguish neoplastic polyps during colonoscopy. If a minimum accuracy can be achieved, then a resect-and-discard model can be implemented, although studies to date have demonstrated limited success, especially in the assessment of serrated polyps. OBJECTIVE To perform a proof-of-principle study assessing the accuracy of narrow-band imaging with near focus in predicting polyp histology including serrated polyps and to determine whether the minimum requirements can be achieved for a resect-and-discard policy. DESIGN Dual-center, prospective case series. SETTING Two tertiary-care referral endoscopic centers in Australia. PATIENTS Two hundred consecutive patients undergoing colonoscopy for routine indications were recruited. INTERVENTIONS Any polyps identified were assessed by using standard white light followed by narrow-band imaging with near focus for Kudo pit patterns and modified Sano capillary patterns. Based on this assessment and the macroscopic appearance, the polyp histology was predicted and subsequently compared with histopathology results. MAIN OUTCOME MEASUREMENTS Correlation in postpolypectomy surveillance intervals between endoscopic and pathologic assessments as well as negative predictive value for rectosigmoid hyperplastic polyps. RESULTS There was a 96% agreement for surveillance intervals between endoscopic assessment and histology by using the American Society for Gastrointestinal Endoscopy guidelines. There was a 96% negative predictive value in assessing rectosigmoid hyperplastic polyps. LIMITATIONS Because this was a proof-of-principle study, there was no control arm, and there were small numbers, especially in assessing subgroups. The results have limited generalizability with the training requirements for polyp recognition, with confidence to be determined. CONCLUSION Narrow-band imaging with near focus can predict polyp histology (including serrated polyps) accurately in the hands of trained endoscopists. Further studies with larger numbers are required to further validate this practice.
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Kaffes AJ. Management of benign biliary strictures: current status and perspective. J Hepatobiliary Pancreat Sci 2015; 22:657-63. [DOI: 10.1002/jhbp.272] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 05/27/2015] [Indexed: 02/06/2023]
Affiliation(s)
- Arthur J. Kaffes
- AW Morrow Gastroenterology and Liver Centre; Royal Prince Alfred Hospital; Camperdown Sydney NSW Australia
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Abstract
BACKGROUND There is little data on the role of balloon enteroscopy and small bowel strictures. We aim to characterize the diagnostic role of double balloon enteroscopy (DBE) in small bowel strictures and document the outcomes of dilatation. METHODS This is a retrospective review from a single tertiary referral centre DBE database from July 2004 to September 2012. All patients with suspected strictures in the small bowel undergoing DBE were included. The position of the small bowel strictures considered for dilatation was determined by diagnostic imaging, i.e. CT enterography, MR enterography or capsule endoscopy in the workup before DBE. Endpoints included stricture description, dilatation parameters and response to treatment. Main outcome measurements were the safety and efficacy of DBE and dilatation. RESULTS From our DBE database of 594 patients, a total of 32 patients underwent 44 DBE procedures for suspected or known strictures. Stricture aetiology included Crohn's disease (CD), nonsteroidal anti-inflammatory drugs (NSAIDs), surgical, Beçhets disease and one unknown. A total of 17 patients did not undergo dilatation as the strictures were ulcerated, nonobstructing or of uncertain aetiology. From the total of 25 dilatations in 15 patients that were attempted, 8/15 (53%) patients had 1 dilatation, 5 patients had 2 dilatations, 1 had 3 dilatations and 1 had 4 dilatations. The mean dilatation diameter was 14 mm. Three patients underwent surgery post-dilatation (2 for perforation). Mean follow up was 16 months. CONCLUSION DBE is a useful method in determining the need for dilatation by assessing for active ulceration. Dilatation is effective in the 10-18 mm range, however perforation does occur.
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Affiliation(s)
- Raghubinder S Gill
- A.W. Morrow Gastroenterology and Liver Centre, Royal Prince Hospital, Sydney, NSW, Australia
| | - Arthur J Kaffes
- Gastroenterology Consultant, A.W. Morrow Gastroenterology and Liver Centre, Royal Prince Hospital, Camperdown, Sydney, NSW 2050, Australia
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Fuller NR, Pearson S, Lau NS, Wlodarczyk J, Halstead MB, Tee HP, Chettiar R, Kaffes AJ. An intragastric balloon in the treatment of obese individuals with metabolic syndrome: a randomized controlled study. Obesity (Silver Spring) 2013; 21:1561-70. [PMID: 23512773 DOI: 10.1002/oby.20414] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Accepted: 11/25/2012] [Indexed: 02/06/2023]
Abstract
OBJECTIVE There are limited controlled data for intragastric balloons (IGB) in obesity treatment. This randomized, controlled study evaluated the efficacy and safety of an IGB in obese individuals with metabolic syndrome (MS). DESIGN AND METHODS Sixty-six adults (BMI: 30-40 kg/m(2)) were randomized to IGB for 6 months, with a 12 month behavioral modification (IGB Group; "IGBG"), or 12 month behavioral modification alone (Control Group; "CG"). The primary outcome was percentage change in body weight. RESULTS Thirty-one subjects (female: 68%; mean age: 43; mean BMI: 36.0) were randomized to IGBG and 35 (66%; 48; 36.7) to CG. At 6 months, there was a significantly greater weight loss in the IGBG: -14.2 vs. -4.8; P < 0.0001. This was associated with a significantly greater reduction in waist circumference, and an improvement in quality of life, with a trend for a larger %MS remission (50% vs. 30%; n.s.). At month 12, the differences in weight loss were enduring: -9.2 vs. -5.2; P = 0.007. Gastrointestinal-related adverse events were common in the IGBG, resolving predominantly within two weeks. The IGB was removed prematurely in three subjects (one for refractory gastrointestinal symptoms). CONCLUSIONS Statistically significant and clinically relevant improvements in weight loss and health outcomes were observed with the IGBG at 6 months versus behavioral modification alone. The differential weight loss was still evident 6 months after IGB removal.
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Kaffes AJ, Liu K. Fully covered self-expandable metal stents for treatment of benign biliary strictures. Gastrointest Endosc 2013; 78:13-21. [PMID: 23548962 DOI: 10.1016/j.gie.2013.02.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Accepted: 02/13/2013] [Indexed: 12/21/2022]
Affiliation(s)
- Arthur J Kaffes
- A.W. Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Kaffes AJ, Chen RY, Tam W, Norton I, Cho S, Devereaux B, Vaughan R. A prospective multicenter evaluation of a new side-port endoscopic ultrasound-fine-needle aspiration in solid upper gastrointestinal lesions. Dig Endosc 2012; 24:448-51. [PMID: 23078438 DOI: 10.1111/j.1443-1661.2012.01302.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND STUDY AIMS Diagnostic yield of endoscopic ultrasound (EUS)-fine-needle aspiration (FNA) varies depending on the equipment used and the site targeted. Multiple needle passes are usually required to obtain a diagnosis. A new needle incorporating a side-port carries a theoretical advantage regarding acquisition of cytological material. The aim of the study was to demonstrate the safety and efficacy of the Olympus side-port needle in solid upper gastrointestinal indications. PATIENTS AND METHODS A prospective multicenter evaluation of patients referred for EUS-FNA for solid lesions was performed across six tertiary gastroenterology referral centers in four capital cities in Australia. The main outcome measures include cytological diagnosis, number of needle passes required for diagnosis and complication rates. RESULTS Thirty patients (17 men; 13 women) with a mean age of 67.5 years were studied. Indications included pancreatic or biliary mass in 24 patients, retroperitoneal or periduodenal mass in 2, enlarged lymph node in 2, a gastric submucosal tumor in 1 and a subcarinal mass in 1. The mean size of the lesions was 3.47 cm (range, 0.5-8 cm). All but one case had a diagnosis made (96.7%). The mean number of passes required to reach a diagnosis was 1.7. In neoplastic lesions the diagnosis was made with a mean of 1.6 passes. No complications were encountered. CONCLUSIONS The new EUS-FNA needle with side port appears effective and safe in solid upper gastrointestinal EUS-FNA indications.
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Affiliation(s)
- Arthur J Kaffes
- Royal Prince Alfred Hospital Royal North Shore Hospital, Sydney, Australia.
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Tee HP, How SH, Kaffes AJ. Learning curve for double-balloon enteroscopy: Findings from an analysis of 282 procedures. World J Gastrointest Endosc 2012; 4:368-72. [PMID: 22912911 PMCID: PMC3423518 DOI: 10.4253/wjge.v4.i8.368] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2011] [Revised: 07/16/2012] [Accepted: 08/08/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the learning curves for antegrade double-balloon enteroscopy (aDBE) and retrograde DBE (rDBE) by analyzing the technical success rates.
METHODS: A retrospective analysis in a tertiary referral center. This study reviewed all cases from June 2006 to April 2011 with a target lesion in the small-bowel identified by either capsule endoscopy or computed tomography scan posted for DBE examinations. Main outcome measurements were: (1) Technical success of aDBE defined by finding or excluding a target lesion after achieving sufficient length of small bowel intubation; and (2) Technical success for rDBE was defined by either finding the target lesion or achieving stable overtube placement in the ileum.
RESULTS: Two hundred and eighty two procedures fulfilled the inclusion criteria and were analyzed. These procedures were analyzed by blocks of 30 cases. There was no distinct learning curve for aDBE. Technical success rates for rDBE continued to rise over time, although on logistic regression analysis testing for trend, there was no significance (P = 0.09). The odds of success increased by a factor of 1.73 (95% CI: 0.93-3.22) for rDBE. For these data, it was estimated that at least 30-35 cases of rDBE under supervision were needed to achieve a good technical success of more than 75%.
CONCLUSION: There was no learning curve for aDBE. Technical success continued to increase over time for rDBE, although a learning curve could not be proven statistically. Approximately 30-35 cases of rDBE will be required for stable overtube intubation in ileum.
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Affiliation(s)
- Hoi-Poh Tee
- Hoi-Poh Tee, Arthur J Kaffes, A W Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Camperdown, Sydney, NSW 2050, Australia
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Abstract
BACKGROUND Obscure gastrointestinal bleeding (OGIB) is a commonly encountered clinical problem in gastroenterology and is associated with significant morbidity and mortality. The investigation and management of OGIB has changed dramatically over the past decade with the advent of newer gastroenterological and radiological technologies. AIM To review the current evidence on the diagnosis and investigation of OGIB. METHODS We searched the PubMed database (1985-2010) for full original articles in English-language journals relevant to the investigation of OGIB. The search terms we used were 'gastrointestinal bleeding' or 'gastrointestinal hemorrhage' or 'small bowel bleeding' each in combination with 'obscure', or 'capsule endoscopy', or 'enteroscopy' or 'enterography' or 'enteroclysis'. RESULTS Capsule endoscopy (CE) or double balloon enteroscopy (DBE) should be first line investigations. They are complimentary procedures with comparable high diagnostic yields. DBE is also able to provide therapeutic intervention. Newer technologies such as single balloon and spiral enteroscopy are currently being evaluated. Radiological and nuclear medicine investigations, such as CT enterography and CT enteroclysis, are alternative diagnostic tools when CE or DBE are contraindicated. Repeating the gastroscopy and/or colonoscopy may be considered in selective situations. An algorithm for investigation of obscure bleeding is proposed. CONCLUSIONS The development of capsule endoscopy and double balloon enteroscopy has transformed the approach to the evaluation and management of obscure gastrointestinal bleeding over the past decade. Older diagnostic modalities still play a complementary, but increasingly selective role.
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Affiliation(s)
- K Liu
- Faculty of Medicine, University of Sydney, Sydney, NSW, Australia.
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Tee HP, Corte C, Al-Ghamdi H, Prakoso E, Darke J, Chettiar R, Rahman W, Davison S, Griffin SP, Selby WS, Kaffes AJ. Prospective randomized controlled trial evaluating cap-assisted colonoscopy vs standard colonoscopy. World J Gastroenterol 2010; 16:3905-10. [PMID: 20712051 PMCID: PMC2923764 DOI: 10.3748/wjg.v16.i31.3905] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To study the significance of cap-fitted colonoscopy in improving cecal intubation time and polyp detection rate.
METHODS: This study was a prospective randomized controlled trial conducted from March 2008 to February 2009 in a tertiary referral hospital at Sydney. The primary end point was cecal intubation time and the secondary endpoint was polyp detection rate. Consecutive cases of total colonoscopy over a 1-year period were recruited. Randomization into either standard colonoscopy (SC) or cap-assisted colonoscopy (CAC) was performed after consent was obtained. For cases randomized to CAC, one of the three sizes of cap was used: D-201-15004 (with a diameter of 15.3 mm), D-201-14304 (14.6 mm) and D-201-12704 (13.0 mm). All of these caps were produced by Olympus Medical Systems, Japan. Independent predictors for faster cecal time and better polyp detection rate were also determined from this study.
RESULTS: There were 200 cases in each group. There was no significant difference in terms of demographic characteristics between the two groups. CAC, when compared to the SC group, had no significant difference in terms of cecal intubation rate (96.0% vs 97.0%, P = 0.40) and time (9.94 ± 7.05 min vs 10.34 ± 6.82 min, P = 0.21), or polyp detection rate (32.8% vs 31.3%, P = 0.75). On the subgroup analysis, there was no significant difference in terms of cecal intubation time by trainees (88.1% vs 84.8%, P = 0.40), ileal intubation rate (82.5% vs 79.0%, P = 0.38) or total colonoscopy time (23.24 ± 13.95 min vs 22.56 ± 9.94 min, P = 0.88). On multivariate analysis, the independent determinants of faster cecal time were consultant-performed procedures (P < 0.001), male patients (P < 0.001), non-usage of hyoscine (P < 0.001) and better bowel preparation (P = 0.01). The determinants of better polyp detection rate were older age (P < 0.001), no history of previous abdominal surgery (P = 0.04), patients not having esophagogastroduodenoscopy in the same setting (P = 0.003), trainee-performed procedures (P = 0.01), usage of hyoscine (P = 0.01) and procedures performed for polyp follow-up (P = 0.01). The limitations of the study were that it was a single-center experience, no blinding was possible, and there were a large number of endoscopists.
CONCLUSION: CAC did not significantly different from SC in term of cecal intubation time and polyp detection rate.
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Abstract
Postoperative biliary strictures are the most common cause of benign biliary stricture in Western countries, secondary to either operative injury or bile duct anastomotic stricture following orthotopic liver transplantation (OLT). Surgery or endoscopic interventions are the mainstay of treatment for benign biliary strictures. We aim to report the outcome of 2 patients with refractory anastomotic biliary stricture post-OLT, who had successful temporary placement of a prototype removable covered self-expandable metal stent (RCSEMS). These 2 patients (both men, aged 44 and 53 years) were given temporary placement of a prototype RCSEMS (8.5 Fr gauge delivery system, 8 mm × 40 mm stent dimensions) in the common bile duct across the biliary stricture. There was no morbidity associated with stent placement and removal in these 2 cases. Clinical parameters improved after the RCSEMS placement. Long-term biliary patency was achieved in both the patients. No further biliary intervention was required within 14 and 18 mo follow-up after stent removal.
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Abstract
AIM: To report the incidence of non-small-bowel bleeding pathologies encountered during double-balloon enteroscopy (DBE) procedures and to analyse their significance.
METHODS: A retrospective study of a prospective DBE database conducted in a tertiary-referral center was conducted. A total of 179 patients with obscure gastrointestinal bleeding (OGIB) referred for DBE from June 2004 to November 2008 were analysed looking for the incidence of non-small-bowel lesions (NSBLs; all and newly diagnosed) encountered during DBE.
RESULTS: There were 228 (150 antegrade and 78 retrograde) DBE procedures performed in 179 patients. The mean number of DBE procedures was 1.27 per patient. The mean age (SD) of the patients was 62 ± 16 years old. There were 94 females (52.5%). The positive yield for a bleeding lesion was 65.9%. Of the 179 patients, 44 (24.6%) had NSBLs (19 of them had dual pathology with small-bowel lesions and NSBLs); 27 (15.1%) had lesions not detected by previous endoscopies. The most common type of missed lesions were vascular lesions.
CONCLUSION: A significant proportion of patients (24.6%) had lesions within reach of conventional endoscopy. Careful repeat examination with gastroscopy and colonoscopy might be required.
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Bailey AA, Bourke MJ, Kaffes AJ, Byth K, Lee EY, Williams SJ. Needle-knife sphincterotomy: factors predicting its use and the relationship with post-ERCP pancreatitis (with video). Gastrointest Endosc 2010; 71:266-71. [PMID: 20003969 DOI: 10.1016/j.gie.2009.09.024] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2009] [Accepted: 09/25/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND In the absence of precut needle-knife sphincterotomy (NKS), failure of biliary cannulation may occur in up to 10% of cases. There are few prospective evaluations of the safety and efficacy of NKS, and studies of its early use in difficult cannulation have been inconclusive. Whether precut NKS after failure of primary biliary cannulation is independently associated with post-ERCP pancreatitis (PEP) remains controversial. OBJECTIVE To examine the relationship between NKS and PEP. DESIGN Analysis of prospectively collected data from two randomized trials of ERCP techniques, with PEP as the primary endpoint measure. SETTING Tertiary-care academic medical center. PATIENTS This study involved 732 patients from two successive, prospective, randomized trials of naïve papilla cannulation between November 2001 and April 2006. Patients with pancreatic or ampullary cancer were excluded. INTERVENTION Naïve papilla cannulation, NKS, primary guidewire versus contrast-assisted cannulation, and glyceryl trinitrate patch versus placebo. MAIN OUTCOME MEASUREMENTS PEP and procedure-related complications. RESULTS NKS was performed in 94 of 732 patients (12.8%) and was successful in achieving bile duct access in 80 of 94 patients (85%). Cannulation success in the entire group was 717 of 732 patients (97.7%). The overall frequency of PEP following NKS was 14.9% (14 of 94 patients) compared with 6.1% (39 of 638 patients) without NKS (P < .001). The incidence of PEP increased with an increasing number of attempts at cannulating the papilla. Pancreatic stents were inserted in 22 patients, 5 of whom developed pancreatitis. In multivariate analysis, independent predictors of PEP were as follow: female sex (odds ratio [OR] = 3.5, P = .028), suspected sphincter of Oddi dysfunction (SOD) (OR = 9.7, P < .001), partial pancreatic drainage (OR = 4.8, P = .011), 10 to 14 attempts at papilla cannulation (OR = 4.4, P = .031), and >/=15 attempts at papilla cannulation (OR = 9.4, P = .013). NKS was not an independent predictor of PEP. There were no perforations, no major bleeding, and no cases of severe pancreatitis in the NKS group. LIMITATIONS Nonrandomized for NKS intervention. CONCLUSIONS The number of attempts at cannulating the papilla is independently associated with PEP, and the risk increases with an increasing number of attempts. NKS is not an independent predictor of PEP.
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Affiliation(s)
- Adam A Bailey
- Department of Gastroenterology, Westmead Hospital, Westmead Millennium Institute, Sydney, Australia.
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Kaffes AJ, Siah C, Koo JH. Clinical outcomes after double-balloon enteroscopy in patients with obscure GI bleeding and a positive capsule endoscopy. Gastrointest Endosc 2007; 66:304-9. [PMID: 17643704 DOI: 10.1016/j.gie.2007.02.044] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2006] [Accepted: 02/14/2007] [Indexed: 12/13/2022]
Abstract
BACKGROUND Obscure GI bleeding (OGIB) accounts for about 5% of all patients with GI bleeding. There are limited data on double-balloon enteroscopy (DBE) after a positive finding on capsule endoscopy (CE) in this setting. OBJECTIVE To determine the clinical outcomes after DBE therapy. DESIGN Prospective single-center cohort study. SETTING Tertiary referral university hospital. MAIN OUTCOME MEASUREMENTS Recurrent bleeding and blood transfusion requirements. PATIENTS AND METHODS This prospective study of 60 consecutive patients with OGIB was conducted between July 2004 and March 2006. Patients underwent CE before DBE to target the lesion for either further diagnostic evaluation or therapeutic intervention. The mean (standard deviation [SD]) duration of follow-up was 10.0 +/- 5.2 months. RESULTS The mean (SD) age was 62 +/- 18 years, with 31 men. A total of 74 DBE procedures were performed. An abnormality was seen by DBE in 45 patients (75%). In 12 patients (20%), a diagnosis was clarified or a new diagnosis was made. Therapy at DBE was performed in 34 patients (57%): 30 diathermies and 4 polypectomies. Endoscopic tattooing for targeted surgical removal was made in 3 additional patients. Multiple logistic regression analysis identified previous blood transfusion (odds ratio 10.5, 95% confidence interval 3.1-35; P < .001) to be the only independent predictor that required endoscopic therapy at DBE. Forty-eight patients (80%) had no further bleeding, and 46 patients (77%) had a normal Hb. Blood transfusion requirements fell from 34 patients to 10, P < .001. One patient had a perforation after therapeutic diathermy. LIMITATIONS Nonrandomized study. CONCLUSIONS In patients with OGIB and a positive finding on CE, DBE provided a safe and ambulatory method to achieve an excellent clinical outcome with significant reductions in recurrent bleeding and blood-transfusion requirements.
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Affiliation(s)
- Arthur J Kaffes
- AW Morrow Department of Gastroenterology and Hepatology, Royal Prince Alfred Hospital Camperdown, Pert, Australia
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Mensink PBF, Haringsma J, Kucharzik T, Cellier C, Pérez-Cuadrado E, Mönkemüller K, Gasbarrini A, Kaffes AJ, Nakamura K, Yen HH, Yamamoto H. Complications of double balloon enteroscopy: a multicenter survey. Endoscopy 2007; 39:613-5. [PMID: 17516287 DOI: 10.1055/s-2007-966444] [Citation(s) in RCA: 273] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND STUDY AIMS Double balloon enteroscopy (DBE) is a new technique for the visualization of the small bowel. Although the technique is widely used, little is known about the complications. A few complications have been reported in the literature, mainly in case reports. The aim of this study was to establish the complication rate of both diagnostic and therapeutic DBE. PATIENTS AND METHODS A total of 10 centers (nine academic centers and one teaching hospital) across four continents participated in the study. Complications were defined according to the literature. A therapeutic DBE was defined as a DBE with use of argon plasma coagulation, a polypectomy snare, injection of fluids (other than ink for marking), removal of foreign body, or balloon dilation. RESULTS A total 85 adverse events were reported in 2362 DBE procedures. In all, 40 events fulfilled the definition of a complication, 13 in 1728 diagnostic DBE (0.8 %) and 27 during 634 therapeutic procedures (4.3 %). The complications were rated minor in 21 (0.9 %), moderate in 6 (0.3 %) and severe in 13 procedures (0.6 %). No fatal complications were reported. Seven cases of pancreatitis were reported, six after diagnostic (0.3 %) and one after therapeutic (0.2 %) DBE. CONCLUSIONS Diagnostic DBE is safe with a low complication rate. The complication rate of therapeutic DBE is high compared with therapeutic colonoscopy. The reason for this is unclear. The incidence of pancreatitis after DBE is low (0.3 %), but has to be considered in patients with persistent abdominal complaints after a DBE procedure.
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Affiliation(s)
- P B F Mensink
- Department of Gastroenterology and Hepatology, Erasmus MC - University Medical Center, Rotterdam, The Netherlands.
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Kaffes AJ, Koo JH, Meredith C. Double-balloon enteroscopy in the diagnosis and the management of small-bowel diseases: an initial experience in 40 patients. Gastrointest Endosc 2006; 63:81-6. [PMID: 16377321 DOI: 10.1016/j.gie.2005.09.017] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2005] [Accepted: 09/01/2005] [Indexed: 12/24/2022]
Abstract
BACKGROUND Double-balloon enteroscopy (DBE) is a new technique, recently described by its innovator, and it is seen to be beneficial in the diagnosis and management of small-bowel disease. OBJECTIVE To evaluate this new technique in consecutive patients with suspected small-bowel disease. DESIGN Single-center prospective study. SETTING Tertiary referral hospital, conducted from July to December 2004. PATIENTS Forty consecutive patients with suspected small-bowel disease referred for DBE, mean age of 58 years (range, 14-89 years), 17 men. INTERVENTIONS Endoscopic biopsies or therapy was performed as clinically indicated. MAIN OUTCOME MEASUREMENTS Significant diagnostic input and therapeutic intervention based on clinical outcomes. RESULTS Indications included obscure GI bleeding (18), iron deficiency anemia (6), anemia of chronic disease (4), acute obscure GI bleeding (4), abdominal pain with other symptoms (4), Crohn's disease (3), and abdominal pain alone (1). Nineteen patients (47.5%) had a small-bowel finding, with 30 of 40 (75%) of the patients having a significant diagnostic input. Intervention was performed in 13 (32.5%) patients with success in 10 (77%). The only variable significantly associated with therapeutic success was a previous history of blood transfusions (p < 0.01). This was the only independent predictor identified by multiple logistic regression analysis (Odds ratio 13.5: 95% confidence interval [1.5, 120]). One perforation from contact diathermy occurred. In 10 attempts at total enteroscopy, none were successful. LIMITATIONS Nonblinded nonrandomized study. CONCLUSIONS These early data suggest DBE to be effective in the diagnosis and the therapy of small-bowel disease, particularly those patients with a history of blood transfusion.
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Affiliation(s)
- Arthur J Kaffes
- Department of Gastroenterology and Hepatology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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Kwan V, Bourke MJ, Williams SJ, Gillespie PE, Murray MA, Kaffes AJ, Henriquez MS, Chan RO. Argon plasma coagulation in the management of symptomatic gastrointestinal vascular lesions: experience in 100 consecutive patients with long-term follow-up. Am J Gastroenterol 2006; 101:58-63. [PMID: 16405534 DOI: 10.1111/j.1572-0241.2006.00370.x] [Citation(s) in RCA: 129] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The long-term efficacy of argon plasma coagulation (APC) in the management of gastrointestinal vascular lesions has not been evaluated in a large and well-defined series. The impact of APC on transfusion requirements and hemoglobin, and technical parameters including complications and number of treatment sessions, is assessed in this series. METHODS Patients who underwent APC for bleeding gastrointestinal vascular lesions were identified via interrogation of an established endoscopic database, excluding patients with radiation proctitis, tumors, residual polypectomy tissue and acute ulcer bleeding. Follow-up data were collected via interview with patients and referring doctors, review of medical records, and follow-up blood tests. RESULTS One hundred patients were enrolled, males = 46, median age = 74 yr (range: 19-99 yr). Median follow-up time was 16 months (range: 4-47 months). Lesions treated were arteriovenous malformations (n = 74) and gastric antral vascular ectasia (n = 26). Fifty-three patients required transfusion. In this group, median hemoglobin improved from 66 g/L (range: 35-114) to 111 g/L (range: 55-155, p < 0.001). Median transfusion velocity fell from 2 units/month (range: 0.1-6) to 0 units/month (range: 0-4, p < 0.001). Transfusion requirement was abolished in 77%. In non-transfusion-requiring patients, median hemoglobin improved from 105 g/L (range: 58-143) to 123 g/L (range: 79-158, p < 0.001). No complications occurred. CONCLUSIONS APC is effective and safe in the management of gastrointestinal vascular lesions.
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Affiliation(s)
- V Kwan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
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Kaffes AJ, Sriram PVJ, Rao GV, Santosh D, Reddy DN. Early institution of pre-cutting for difficult biliary cannulation: a prospective study comparing conventional vs. a modified technique. Gastrointest Endosc 2005; 62:669-74. [PMID: 16246677 DOI: 10.1016/j.gie.2005.05.022] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2005] [Accepted: 05/12/2005] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pre-cutting techniques have been used to gain biliary access at the expense of an increased complication rate. This may be because of the multiple attempts to achieve cannulation by using standard methods before pre-cutting and causing excess edema and papillary trauma. There are limited data on the early use of pre-cutting techniques. METHODS We performed a prospective study of the early introduction of needle-knife techniques in patients with difficult biliary cannulation. Standard biliary cannulation was attempted with a sphincterotome and a guidewire. If this failed within 10 minutes or if there were more than 5 pancreatic cannulations, the needle-knife technique was used. Either a standard method of pre-cutting (below-upward) from the papillary orifice or the modified technique of pre-cutting (above-downward), stopping short of the papillary orifice, was adopted, as per the discretion of the endoscopist. If pre-cutting failed, the cannulation was reattempted 24 to 48 hours later. RESULTS A total of 346 therapeutic biliary ERCP procedures were performed between April and August 2003. Of these, 70 patients (20%) (mean age, 54 years; 38 men) underwent needle-knife pre-cut sphincterotomy (16 with the standard technique). In 58 patients (83%), the procedure was successful with the initial pre-cutting, making the total success at initial ERCP 334/346 (96.5%). Nine patients in whom pre-cut failed, returned for a second-attempt ERCP, with 7 completed successfully. The total success rate of pre-cutting was 65/70 (93%). The overall success rate of biliary cannulation, after two ERCP attempts, was 341/346 (98.5%). Six patients had mild bleeding, and one had mild pancreatitis. There was no difference in these complications between the two types of pre-cut techniques. CONCLUSIONS The early use of needle knife for difficult biliary cannulation is safe and effective, irrespective of the technique used.
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Affiliation(s)
- Arthur J Kaffes
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
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Sriram PV, Kaffes AJ, Rao GV, Reddy DN. Endoscopic ultrasound-guided drainage of pancreatic pseudocysts complicated by portal hypertension or by intervening vessels. Endoscopy 2005; 37:231-5. [PMID: 15731938 DOI: 10.1055/s-2005-860997] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND STUDY AIMS Portal hypertension often coexists with pancreatic pseudocysts and is potentially dangerous if a collateral vessel is in the vicinity of the needle puncture pathway. Hitherto, there have been no reports of pseudocyst drainage in this setting. PATIENTS AND METHODS Patients who underwent endoscopic ultrasound (EUS)-guided pancreatic pseudocyst drainage complicated by intervening vessels were assessed for success and outcomes. An Olympus mechanical linear-array video echo endoscope GF-UM 140D was used for the drainage procedure in all patients. Either a "hot" diathermy technique was employed or a "cold" technique using direct aspiration with a 19-G needle, followed by deployment of a nasocystic catheter. RESULTS Eight patients with a symptomatic pseudocyst and intervening vessels underwent drainage that was guided (n = 6) or assisted (n = 2) by EUS. All were found to have successful resolution of the cyst at follow-up 6 weeks later, while segmental portal hypertension had disappeared in one patient. There were no major complications. One patient had transient hemorrhagic drainage that resolved by itself. CONCLUSIONS Pseudocysts complicated by portal hypertension or by intervening vessels can be safely drained under EUS guidance, even in the absence of color Doppler imaging.
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Affiliation(s)
- P V Sriram
- Department of Gastroenterology, Asian Institute of Gastroenterology, 500-082 Hyderabad, India.
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Abstract
BACKGROUND Endoscopic ultrasound (EUS) is a relatively new method used in the investigation and staging of upper gastrointestinal tract (UGIT) disease. AIMS To review practice and outcomes of EUS in an Australian university teaching hospital. METHODS The first part of the study was a retrospective review of indications, safety, referral patterns and technical difficulties of all EUS procedures performed at Concord Hospital, New South Wales, Australia, over a 10-year period from 1990 to 2000. The second part of the study examined the impact of EUS on the management of 225 consecutive cases, as determined by a questionnaire completed by each of the referring doctors. RESULTS A total of 537 EUS examinations was performed over the 10-year period. Indications for EUS included: (i) assessment of oesophageal lesions (241), (ii) assessment of gastric lesions (184) and (iii) assessment of pancreaticobiliary (112) disease. Cancer staging was performed in 46.7% of oesophageal and 31.4% of gastric cases. Sedation was achieved using intravenous midazolam (5.3+/-1.3 mg; mean +/- SD) and 52% of cases required additional intravenous pethidine (48.5+/-10.0 mg; mean +/- SD). Technical difficulties were encountered in 11% of cases and these were mainly related to nontraversable luminal stricturing. Of the 537 referrals, 48.2% were from within Central Sydney Area Health Services, and the remainder were from other Sydney hospitals, New South Wales regional centres and interstate. Of 225 questionnaires sent to referring doctors, 146 questionnaires were completed and returned for analysis. EUS aided staging of malignant disease, and confirmed or established a diagnosis in 86% of cases. The diagnostic accuracy of EUS was 76% when confirmed histologically. EUS avoided further diagnostic investigations in the majority of cases and in 25% of cases surgery was avoided. Fine-needle aspiration biopsy (FNAB) during EUS would have been useful in 30% of cases. Overall, clinical decision-making and management were changed in one-third of cases. CONCLUSIONS Endoscopic ultrasound is an accurate, safe and useful imaging method in UGIT disease. The increasing demand for EUS and EUS-guided FNAB suggests an expanding future for EUS in Australia.
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Affiliation(s)
- A J Kaffes
- Cardiothoracic Care Centre, St Vincent's Hospital, Melbourne, Victoria, Australia
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