Endoscopic ultrasound-guided gastrojejunostomy versus robotic gastrojejunostomy for unresectable malignant gastric outlet obstruction

Objectives

Malignant gastric outlet obstruction (GOO) has traditionally been managed with enteral stenting and surgical gastrojejunostomy. Our study aimed to compare outcomes between endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) using a lumen-apposing metal stent and robotic GJ (R-GJ) for unresectable malignant GOO.

Methods

Patients undergoing EUS-GJ or R-GJ for unresectable malignant GOO were retrospectively analyzed. The primary outcome was clinical success defined by the ability to tolerate oral intake at the time of discharge. Secondary outcomes included technical success, procedure duration, adverse events, and post-procedure length of stay (LOS).

Results

A total of 44 patients met the inclusion criteria. Of the 44, 29 underwent EUS-GJ and 15 underwent R-GJ. Age, gender, malignant etiology, and presence of ascites were similar between the two groups. Patients treated with EUS-GJ had a higher mean Charlson comorbidity index (10.3 vs. 7.0; p ≤ 0.0001) and a lower preoperative body mass index (22.3 vs. 27.2; p = 0.007). Technical and clinical success was achieved in 100% of patients in both groups (p > 0.99). EUS-GJ was associated with shorter procedure duration (57.5 vs. 146.3 min; p < 0.0001), hospital LOS (4.3 vs. 8.2 days, p = 0.0009), and time to oral intake (1.0 vs. 5.8 days; p < 0.0001) when compared to R-GJ. Adverse events occurred in 5 of the R-GJ patients and none of the EUS-GJ patients (p = 0.003).

Conclusions

EUS-GJ has similar efficacy and superior clinical outcomes compared to R-GJ in the management of malignant GOO. Prospective studies with longer follow-up duration are needed to validate these findings.

EUS-guided hepaticogastrostomy versus percutaneous transhepatic biliary drainage after failed ERCP: A propensity score-matched analysis

Background and study aims Percutaneous transhepatic biliary drainage (PTBD) is the traditional second-line option after unsuccessful endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HG) is a viable alternative to PTBD. Our study aimed to compare outcomes of EUS-HG and PTBD for benign and malignant biliary diseases following failed ERCP. Patients and methods This single-center study retrospectively analyzed patients undergoing EUS-HG and PTBD for benign and malignant biliary disorders. A propensity score-matched analysis was performed using age, sex, and Charlson Comorbidity Index. The primary outcome was clinical success, which we defined as a decrease in total bilirubin by ≥ 50% at 2 weeks for malignant disease and resolution of the biliary disorder for benign disease. Results In total, 41 patients underwent EUS-HG and 138 patients underwent PTBD. After propensity score matching in a 1:2 ratio, 32 EUS-HG patients were matched with 64 PTBD. Technical success was achieved in 29 of 32 (91%) for EUS-HG and 63 of 64 (98%) for PTBD ( P =0.11). Clinical success was 100% for EUS-HG and 75% for PTBD ( P =0.0021). EUS-HG was associated with a lower adverse event rate (EUS-HG 13% vs. PTBD 58%, P <0.0001), shorter procedure duration (median 60 vs. 115 minutes, P <0.0001), shorter post-procedure length of stay (median 2 vs. 4 days, P <0.0001), and fewer reinterventions (median 1 vs. 3, P <0.0001). Conclusions Our results suggest that EUS-HG is superior to PTBD in the treatment of benign and malignant biliary disorders after failed ERCP.

Endoscopic Ultrasound-Guided Gallbladder Drainage: Beyond Cholecystitis

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is an alternative to surgery for acute cholecystitis (AC) in poor operative candidates. However, the role of EUS-GBD in non-cholecystitis (NC) indications has not been well studied. We compared the clinical outcomes of EUS-GBD for AC and NC indications. Consecutive patients undergoing EUS-GBD for all indications at a single center were retrospectively analyzed. Fifty-one patients underwent EUS-GBD during the study period. Thirty-nine (76%) patients had AC while 12 (24%) had NC indications. NC indications included malignant biliary obstruction (n = 8), symptomatic cholelithiasis (n = 1), gallstone pancreatitis (n = 1), choledocholithiasis (n = 1), and Mirizzi's syndrome (n = 1). Technical success was noted in 92% (36/39) for AC and 92% (11/12) for NC (p > 0.99). The clinical success rate was 94% and 100%, respectively (p > 0.99). There were four adverse events in the AC group and 3 in the NC group (p = 0.33). Procedure duration (median 43 vs. 45 min, p = 0.37), post-procedure length of stay (median 3 vs. 3 days, p = 0.97), and total gallbladder-related procedures (median 2 vs. 2, p = 0.59) were similar. EUS-GBD for NC indications is similarly safe and effective as EUS-GBD in AC.

Cholecystocolonic fistula following endoscopic ultrasound-guided gallbladder drainage for stump cholecystitis

Cholecystocolonic fistulas are a rare sequela of gallstone disease. Presenting symptoms are variable but a triad of chronic diarrhea, vitamin K malabsorption, and pneumobilia has been proposed. If untreated, recurrent biliary sepsis can occur with substantial morbidity and mortality. Definitive management is surgical although endoscopic treatment has been described in nonsurgical patients. We present a case of a cholecystocolonic fistula following transgastric endoscopic ultrasound-guided gallbladder drainage with a lumen-apposing metal stent for stump cholecystitis. The patient's presenting symptom was diarrhea. Upper endoscopy and cholecystoscopy 4 weeks following gallbladder drainage revealed a cholecystocolonic fistula. The cholecystogastric tract was closed through the scope clips. The patient had no episodes of cholangitis and had a patent biliary tree with a prior biliary sphincterotomy so clinical observation was chosen. Colonoscopy 1 month later confirmed the closure of the fistula and the patient had a resolution of diarrhea. Our case highlights a novel adverse event of endoscopic ultrasound-guided gallbladder drainage caused by direct pressure of the lumen apposing metal and double pigtail stents on an already inflamed gallbladder wall. Endoscopic therapies that aid in transcapillary biliary drainage are viable alternatives to surgery and can result in fistula closure.

Preoperative Endoscopic Ultrasound-Guided Hepaticogastrostomy Facilitates Decompression and Diagnosis in Patients With Suspected Malignant Biliary Obstruction: A Case Series

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HG) is increasingly being used as an alternative to percutaneous transhepatic biliary drainage (PTBD) after unsuccessful endoscopic retrograde pancreatography (ERCP). This technique has also been utilized for diagnosis of malignant biliary obstruction by providing biliary access for antegrade cholangioscopy with biopsies and brushings for cytology and fluorescent in situ hybridization (FISH). However, the potential impact of EUS-HG on surgical candidacy in cases with resectable disease remains unknown. We present three patients who underwent pancreaticoduodenectomy (Whipple procedure) for suspected distal malignant biliary obstruction following EUS-HG. Biliary drainage was achieved in all three patients preoperatively and a diagnosis of malignancy could be established in two of the three cases using this technique. There were no procedure-related complications. The HG metal stent was removed eight weeks post-operatively with cholangiogram showing a patent hepaticojejunostomy in all three patients. Mean length of follow-up after EUS-HG was 298 +/- 96 days. Our case series demonstrates that EUS-HG is an effective method to achieve biliary decompression in patients with an inaccessible papilla. The mature HG tract can subsequently be used to obtain a tissue diagnosis. Lastly, EUS-HG does not preclude patients from undergoing a curative Whipple procedure.

Rectal indomethacin reduces the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis in low-risk patients

Background:

Evidence shows that rectal indomethacin (RI) reduces the risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in high-risk patients. The prophylactic role of RI in low-risk patients has not yet been identified. The objective of our study was to evaluate the impact of RI in preventing PEP in low-risk patients.

Methods:

A retrospective cohort study was conducted to evaluate the impact of RI in preventing PEP. RI was available starting November 2012. Patient characteristics and procedure details were collected.

Results:

The study population included 2238 patients who underwent ERCP (1055 in the RI group and 1183 in the control group). PEP was diagnosed in 107 patients (4.8%). In a multivariate model of consecutive patients, RI reduced the incidence of PEP by 55% (odds ratio [OR] 0.45, 95% confidence interval [CI] 0.36-0.94; P=0.03). In a multivariate model that included 1874 (84%) low-risk patients, RI reduced the incidence of PEP by 62% (OR 0.38, 95%CI 0.19-0.74; P=0.004). Propensity-matched group analysis was performed for low-risk native papilla patients. RI reduced the incidence of PEP by 61% (OR 0.39, 95%CI 0.18-0.8; P=0.009).

Conclusion:

RI reduced PEP in consecutive as well as low-risk patients. RI should be administrated in consecutive patients unless contraindicated. Larger prospective studies are needed to confirm our results.

Impact of body mass index on the incidence and severity of post-endoscopic retrograde cholangiopancreatography pancreatitis

Background

Pancreatitis is a potential major complication after endoscopic retrograde cholangiopancreatography (post-ERCP pancreatitis; PEP). Obesity has been associated with increased severity of acute pancreatitis. However, the correlation between obesity and PEP is controversial. Therefore, our study aimed to clarify the relationship between body mass index (BMI) and the incidence and severity of PEP.

Methods

A retrospective cohort study was conducted to elucidate the relationship between BMI and PEP in all patients who underwent ERCP in a tertiary referral center between January 2009 and October 2016. Patient characteristics and procedure details were collected. PEP was defined by consensus criteria. Multivariate logistic regression was used to determine the association between BMI and PEP.

Results

The analysis included 2236 patients whose BMI was recorded and had adequate follow up (921 with BMI≥30 kg/m², 1315 with BMI<30 kg/m²). PEP was diagnosed in 107 (4.8%) patients. PEP was seen in 49 obese patients (5.3%) and 58 non-obese patients (4.4%). In the univariate and multivariate analysis BMI≥30 kg/m² was not associated with PEP (odds ratio 1.2, 95%CI 0.8-1.8; P=0.32). A subgroup analysis of different BMI subcategories found that BMI was not associated with the incidence or severity of PEP.

Conclusion

In the largest study to date, neither obesity nor low body weight increased the incidence or severity of PEP.

The diagnostic and cellularity yield of reverse bevel versus fork-tip fine needle biopsy

INTRODUCTION

Two new systems with a novel tip (Procore™ and SharkCore™) have been introduced for ultrasound-guided fine needle biopsy (US-FNB). Direct comparison of the diagnostic yield of these needles in the evaluation of pancreatic lesions is currently under investigation. This study aims to compare the diagnostic and cellular yields of the two needle systems.

METHODS

Consecutive patients with upper gastrointestinal lesions undergoing EUS-FNB using 22 gauge Procore™ (reverse bevel) or SharkCore™ (fork-tip) needles were included in the study. Cytological rapid on-site evaluation (ROSE) slides were scored on a numerical scale of diagnostic yield relative to the number of passes. Similarly, histology of biopsy material was assessed on diagnostic quality using a numeric score. The final diagnosis was based on resection specimens and/or follow-up of clinical and imaging data of the subject.

RESULTS

The diagnostic yield was similar between the fork-tip and reverse bevel needles (125/163; 77% vs 103/139;74% with P = .60). Sub-analysis for solid pancreatic masses demonstrated similar results (69/88; 78% vs. 83/107; 78% with P = .88). The fork-tip needle had a lower mean number of passes (2.5 vs 3.1; P = .04) and ROSE was utilized in significantly less cases than in the reverse bevel needle group (77% versus 98.3%).

CONCLUSIONS

Although we observed no difference in the diagnostic yield using either the fork-tip or the reverse bevel needle, the fork-tip needle had significantly better performance with regards to achieving more adequate cytologic specimen in fewer number of passes while at the same time requiring fewer episodes of ROSE.

Localized high-grade gastroenteropancreatic neuroendocrine tumors: Defining prognostic and therapeutic factors for a disease of increasing clinical significance

BACKGROUND

Due to the limited sample size in the existing series, the natural history and management of high-grade gastroenteropancreatic neuroendocrine tumors (GEP-NET) is poorly understood. In order to better understand high-grade GEP-NET, a large cohort study was undertaken.

OBJECTIVE

To determine the prognostic factors associated with high-grade GEP-NET.

METHODS

Patients diagnosed with non-metastatic high-grade GEP-NET from 1988 to 2010 were identified in SEER.

RESULTS

Incidence of high-grade GEP-NETs increased from 0.03 to 0.19/100,000 over the study period. The median age was 65 years, and the majority of the patients were white and females. The most common primary site was colorectal, and the most frequent T classification was T3. Surgical resection was performed in 89% of patients that varied by site (p < 0.0001). Nodal involvement was frequent and varied by site (p = 0.0002). The 5-year disease-specific survival was 63.3% and was the greatest for small bowel (p = 0.0003). Survival was associated with age, node status and surgery (p < 0.05). On multivariate analysis, the node status, surgery, and site continued to be associated with survival (p < 0.05); however, age (p = 0.08) no longer influenced the patient's survival.

CONCLUSION

High-grade GEP-NETs are neoplasms with exponentially increasing in incidence. Tumor location and nodal status are predictors of survival. Surgery is associated with a survival advantage and could be considered for localized disease.

A Single Surgeons Experience with Enhanced Recovery after Surgery: An Army of One

The benefits of enhanced recovery after surgery (ERAS) have been demonstrated for multiple surgical procedures in high-volume programs. However, resources required for its implementation may be daunting to individual surgeons. Patients undergoing elective abdominal procedures from June 2013 to April 2015 by a surgical oncologist before and after the implementation of an ERAS protocol were reviewed. A total of 179 patients were included. The mean age of the patients was 63 years, and a majority of them were females (53.6%), white (61.5%), had a Charlson score of 0 to 2 (45.8%), and a Clavien complication grade of 0 to I (60.1%). The univariate analysis revealed that the ERAS protocol was associated with shorter length of stay (LOS) (6.2 vs 9.6 days), lower cost ($21,674 vs $30,380), and lower mortality (0 vs 3.3%); P < 0.05. Differences were noted in LOS and costs for all procedures, the differences were the greatest for hepatic resection (3.8 vs 8.4 days and $16,770 vs $28,589), intestinal resection/stoma closure (4.8 vs 7.6 days and $18,391 vs $22,239), and other abdominal procedures (5.0 vs 10.8 and $17,713 vs $30,900); P < 0.05. The differences were less for patients undergoing procedures for which postoperative pathways were already in place such as pancreatic (9 vs 10.8 days and $30,524 vs $34,291) and colorectal (5.3 vs 6.5 days and $20,733 vs $25,150) surgeries. P > 0.05. An ERAS program can be instituted by an individual surgeon with the benefits of decreased LOS, cost, and mortality.

A Single Surgeon's Experience with Enhanced Recovery after Surgery: An Army of One

The benefits of enhanced recovery after surgery (ERAS) have been demonstrated for multiple surgical procedures in high-volume programs. However, resources required for its implementation may be daunting to individual surgeons. Patients undergoing elective abdominal procedures from June 2013 to April 2015 by a surgical oncologist before and after the implementation of an ERAS protocol were reviewed. A total of 179 patients were included. The mean age of the patients was 63 years, and a majority of them were females (53.6%), white (61.5%), had a Charlson score of 0 to 2 (45.8%), and a Clavien complication grade of 0 to I (60.1%). The univariate analysis revealed that the ERAS protocol was associated with shorter length of stay (LOS) (6.2 vs 9.6 days), lower cost ($21,674 vs $30,380), and lower mortality (0 vs 3.3%); P < 0.05. Differences were noted in LOS and costs for all procedures, the differences were the greatest for hepatic resection (3.8 vs 8.4 days and $16,770 vs $28,589), intestinal resection/stoma closure (4.8 vs 7.6 days and $18,391 vs $22,239), and other abdominal procedures (5.0 vs 10.8 and $17,713 vs $30,900); P < 0.05. The differences were less for patients undergoing procedures for which postoperative pathways were already in place such as pancreatic (9 vs 10.8 days and $30,524 vs $34,291) and colorectal (5.3 vs 6.5 days and $20,733 vs $25,150) surgeries. P > 0.05. An ERAS program can be instituted by an individual surgeon with the benefits of decreased LOS, cost, and mortality.