Randomized study of digital single-operator cholangioscope compared to fiberoptic single-operator cholangioscope in a novel cholangioscopy bench model

BACKGROUND AND STUDY AIMS

 Cholangiopancreatoscopy is utilized for diagnosis and therapy of pancreaticobiliary disorders. a fully-disposable, digital, single-operator cholangioscope (DSOC) was developed with high image resolution and wide field-of-view. This bench study compared the new DSOC to the previous semi-disposable, fiber-optic cholangioscope (FSOC) prior to the clinical availability of the DSOC system.

METHODS

Five experts performed one practice run followed by randomized runs comparing DSOC to FSOC in a biliary tract model consisting of three fixed left-intrahepatic tracts (LIHD), and variable common bile duct (CBD) and right-intrahepatic tracts (RIHD) with seven total lesions in multiple configurations. Timed runs aimed to visualize and target each lesion using miniature biopsy forceps. Definitions: visual success, visualizing targets; targeting success, touching target with forceps; complete run, touching seven targets within 20 minutes. Image quality, ease-of-use, and time to completion were recorded.

RESULTS

Thirty-seven evaluable runs (20 DSOC, 17 FSOC) were completed. DSOC was superior to FSOC in Visual (99 % vs. 67 %, P  < 0.001) and targeting success (6.6 vs. 4.5, P  = 0.009), proportion of complete runs (13 /20 vs. 0 /17, P  < 0.001) and time of run (10.1 min vs. 15.4 min, P  < 0.001). For fixed LIHD, DSOC achieved higher targeting success compared to FSOC (2.6 vs. 1.1, P  < 0.001) with no difference in RIHD and CBD targets (4.0 vs. 3.4, P  = 0.39). Investigators reported superior image quality and ease-of-use with DSOC.

CONCLUSIONS

In this model, DSOC performed superiorly to FSOC in image quality, visualization, and maneuverability. The model could potentially be utilized for training endoscopists less experienced with cholangiopancreatoscopy.

Association of covered metallic stents with cholecystitis and stent migration in malignant biliary stricture

BACKGROUND AND AIMS

ERCP with self-expandable metallic stent (SEMS) placement provides reliable and durable relief of malignant biliary obstruction. Our objective was to compare efficacy and adverse outcomes between uncovered SEMSs (USEMSs) and covered SEMSs (CSEMSs).

METHODS

A retrospective cohort study was performed of all consecutive patients who underwent ERCP with SEMS placement for the management of a malignant bile duct stricture. Comparative analyses on clinical success, patency duration, stent dysfunction, and adverse outcomes were performed. Univariate and multivariable analyses were performed to identify factors associated with stent dysfunction.

RESULTS

Six hundred forty-five patients underwent SEMS placement for the management of malignant bile duct stricture from 2008 to 2016. CSEMSs and USEMSs had similar rates of clinical success in relief of bile duct obstruction (93.0% vs 92.1%, respectively; P = .69) and patency duration (546.7 vs 557.9 days, P = .14). Among those with an intact gallbladder, the incidence of acute cholecystitis was higher in the CSEMS group compared with the USEMS group (7.8% vs 1.2%; P < .001). In the multivariable analysis, CSEMS use was associated with increased risk of stent migration (hazard ratio, 10.7; 95% confidence interval, 4.1-27.7).

CONCLUSIONS

CSEMSs and USEMSs have similar clinical success rates and patency durations in management of malignant bile duct stricture. CSEMSs, however, are associated with increased rates of migration and cholecystitis. Comparable efficacy and superior safety profile of USEMSs render a compelling argument for its place as the preferred choice of SEMSs in the management of malignant biliary stricture.

Endoscopic pancreatic function test using combined secretin and cholecystokinin stimulation for the evaluation of chronic pancreatitis

BACKGROUND

Current endoscopic pancreatic function test (ePFT) methods use either secretin or cholecystokinin (CCK) to measure pancreatic function.

OBJECTIVE

To evaluate a novel ePFT protocol that includes both secretin and CCK stimulation and to assess which fluid parameters best discriminate patients with chronic pancreatitis (CP).

DESIGN

Prospective, cross-sectional diagnostic study.

SETTING

Single, tertiary-care institution.

PATIENTS

Healthy volunteers and patients evaluated for CP were included.

INTERVENTIONS

All patients underwent a combined secretin-CCK ePFT. Patients evaluated for CP also underwent EUS during the same endoscopic session.

MAIN OUTCOME MEASUREMENTS

Duodenal fluid bicarbonate, lipase, and amylase concentrations were measured after CCK and secretin stimulation. Results were compared based on the presence of CP detected by EUS (≥5 features).

RESULTS

Twenty healthy volunteers and 69 patients evaluated for CP completed the secretin and CCK ePFT. Patients with an EUS score of 5 or higher had significantly decreased peak bicarbonate concentrations (72 mmol) compared with patients with an EUS score lower than 5 (90 mmol) and healthy subjects (108 mmol) (P < .001). Peak concentrations of amylase and lipase and total fluid volume were not significantly different between patients with CP and controls. Receiver-operating characteristic analysis revealed that peak bicarbonate concentration had superior discrimination for CP (area under the curve [AUC] 0.738) compared with peak amylase (AUC 0.677) and peak lipase (AUC 0.627). The addition of enzyme concentration measurement did not improve discrimination compared with peak bicarbonate alone.

LIMITATIONS

Secretin and cholecystokinin endoscopic pancreatic function test (SC ePFT) results were not compared with those of single hormone ePFTs.

CONCLUSIONS

The addition of CCK infusion and enzyme concentration measurement to a standard secretin ePFT does not enhance the diagnosis of CP.

Cigarette smoking is independently associated with chronic pancreatitis

BACKGROUND AND AIMS

It is not completely understood whether smoking contributes to chronic pancreatitis (CP). Past studies have included mostly patients with alcohol-related and severe CP. Our aim was to assess the relationship of smoking and CP adjusting for alcohol and other clinical risk factors.

METHODS

A cross-sectional study was performed of patients referred to the pancreatic disease clinic in the past 2 years with abdominal pain and suspected CP. Patients were questioned on their smoking and alcohol habits. Patients underwent an etiological workup and diagnostic evaluation for early and late CP comprised of computed tomography scan and combined endoscopic ultrasound and secretin endoscopic pancreatic function test if indicated. Logistic regression was used to determine the association of current smoking with CP adjusting for other risk factors.

RESULTS

The adjusted odds ratio (OR) for current smoking was 1.99 (95% CI 1.01, 3.91). Other significant predictors included consumption of > or =10 alcohol drinks/week, advancing age, history of acute pancreatitis, and the presence of another etiological factor. Smoking was also independently associated with exocrine insufficiency (OR 2.00, 95% CI 1.07, 3.75) and calcifications (OR 2.68, 95% CI 1.03, 6.94).

CONCLUSION

Active cigarette smoking is associated with CP adjusting for alcohol and other risk factors. and IAP.

Virulence-related DNA sequences and adherence patterns in strains of enteropathogenic Escherichia coli

The presence of the genes for Escherichia coli adherence factor (EAF), attaching and effacing lesion (eae) and bundle-forming pili (bfp) in 72 strains identified as enteropathogenic E. coli (EPEC) by slide agglutination was evaluated using hybridization and PCR. The adherence property of these strains was assayed using 3h HeLa cells adherence assay. The results obtained indicated that virulence-associated genes were present in 65% of the strains but only ten (13.9%) isolates were positive for all the three markers (typical EPEC), 37 (51.4%) isolates carried either one or two of these determinants (atypical EPEC) and the remaining 25 (34.7%) were negative for all these genes. In vitro adherence assay showed that 44 (61.1%) strains adhered to HeLa cells with a defined pattern, 13 (18.1%) isolates adhered loosely with no definite pattern and the remaining 15 (20.8%) were non-adherent. Analysis of the results showed a statistically significant association between the presence of the virulence-related genes with adherence of the strains with a defined pattern (P</=0.0001). These results indicated that since over 60% of the strains identified by serogrouping carried at least one of the putative virulence markers, it therefore seems that this simple test is still of value in our setting although the need for a confirmatory test is also indicated.

Premarital sexual, child rearing, and family attitudes of Iranian men and women in the United States and in Iran

Sexual, child rearing, and family attitudes of 160 Iranian immigrants in the United States (61 men, 99 women) and 97 Iranians (55 men, 42 women) in Iran were compared. Iranians in the United States in general, and women in particular, compared with their counterparts in Iran, expressed more permissive attitudes toward premarital sex and sex education, more tolerance toward homosexuality, and a greater acceptance of marital dissolution. Iranians in both countries assigned a high value to the maternal role and to family loyalty but did not endorse unrestricted freedom for youngsters. Influences of attitudinal disparity on interpersonal and family relationships are discussed, and implications for marriage counseling and family therapy are suggested.

Adherence of non-enteropathogenic Escherichia coli to HeLa cells

Three hundred and nine strains of Escherichia coli isolated from infants and children with diarrhoea but not belonging to any recognised classes of diarrhoeagenic E. coli were investigated for their ability to adhere to HeLa cells in the presence of D-mannose. An enteroadherent-aggregative pattern (EAgg) was observed in 32.03%, localised adherence (LA) in 4.5%, diffuse adherence (DA) in 5.8%, and LA/DA and EAgg/LA in 1.9% and 1.2% of the isolates respectively. The results obtained with 100 control isolates were: EAgg 17%, LA 2%, DA 2%, LA/DA 2%, EAgg/LA 6% and DA/EAgg 1%. No adherence was manifested by 168 (54.36%) of 309 diarrhoeal isolates and 70% of the 100 control isolates. The results of this study showed that amongst non-enteropathogenic E. coli, strains exhibiting the EAgg pattern are significantly associated with diarrhoea (p < 0.005). Most of these strains showed a pattern of multiple drug resistance.

In vitro adhesion and invasion of Salmonella enterica serovar Havana

A total of 132 isolates of the Havana serovar of Salmonela enterica were studied for their adhesion to and invasion of Hela cells in the presence of D-mannose. A total of 124 (93.9%) isolates were adherent, and 51% of these were invasive. Of these 124 strains 82 (66%) adhered to HeLa cells with a pattern typical for enteroaggregative (EAgg) Escherichia coli whereas the remaining 34% adhered in a non-aggregative (non-EAgg) pattern. Of the 82 strains showing the EAgg pattern 60% were invasive whereas only 33% of the 49 non-EAgg isolates invaded HeLa cells (P < 0.01). The action of mannose-sensitive type 1 pili was inhibited by the addition of D-mannose. Therefore we conclude that type 1 pili are not important in adhesion and invasion of Havana.

Antimicrobial drug resistance and resistance factor transfer among clinical isolates of salmonellae in Iran

508 salmonella strains isolated during 1983-1986 in Tehran, Iran from cases of diarrhoea in children less than 5 were tested for sensitivity to 10 antimicrobial drugs and their ability to transfer the resistance determinants. Salmonella typhimurium and S. havana were most common (45.7% and 30.9%, respectively) followed by S. typhi (2.9%) and S. larochelle (2.4%). The antimicrobial agents used were chloramphenicol (C), gentamicin (G), tetracycline (T), ampicillin (A), cephalothin (Cf), trimethoprim-sulfamethoxazole (SXT), kanamycin (K), nalidixic acid (Na), streptomycin (S), and furoxone (F). 91% of the salmonellae isolates contained resistance determinants, of which 89.6% were resistant to more than one agent. Strains resistant to 4-7 drugs comprised 85.6% of the total isolates. Ampicillin resistance was found in 85.4% and nalidixic acid in 2.7%. 58 different patterns of resistance to the antimicrobial agents used were observed, of which C/T/A/SXT/K/S and C/T/A/SXT/K/S/Cf were the most frequently encountered. 71.9% of the resistant strains contained transferable resistance factors and S. typhimurium had the highest rate of transfer (80.8%). Resistance to chloramphenicol had the highest rate of transfer among the agents used (77.4%) and streptomycin the lowest (20.0%). The pattern most frequently transferred was C/T/A/SXT/K (41.9%).

Histiocytic lymphoma presenting with portal hypertension and bleeding esophageal varices: a case report

An unusual case of histiocytic lymphoma presenting with portal hypertension and bleeding esophageal varices is reported. Laparotomy revealed bulky nodal disease in the portahepatis compressing the portal vein, common bile duct, hepatic artery, and cystic duct. Liver was free of tumor, and there was no evidence of extra-abdominal disease. Radiation therapy to the right upper quadrant of the abdomen produced a transient remission for one month, followed by relapse in mediastinum and both lung hilae.