1
|
Barakat MT, Thosani NC, Huang RJ, Choudhary A, Kochar R, Kothari S, Banerjee S. Effects of a Brief Educational Program on Optimization of Fluoroscopy to Minimize Radiation Exposure During Endoscopic Retrograde Cholangiopancreatography. Clin Gastroenterol Hepatol 2018; 16:550-557. [PMID: 28804031 PMCID: PMC5809234 DOI: 10.1016/j.cgh.2017.08.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [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: 03/06/2017] [Revised: 08/02/2017] [Accepted: 08/04/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Fluoroscopy during endoscopic retrograde cholangiopancreatography (ERCP) is increasingly performed by therapeutic endoscopists, many of whom have not received formal training in modulating fluoroscopy use to minimize radiation exposure. Exposure to ionizing radiation has significant health consequences for patients and endoscopists. We aimed to evaluate whether a 20-minute educational intervention for endoscopists would improve use of fluoroscopy and decrease ERCP-associated exposure to radiation for patients. METHODS We collected data from 583 ERCPs, performed in California from June 2010 through November 2012; 331 were performed at baseline and 252 following endoscopist education. The educational intervention comprised a 20-minute video explaining best practices for fluoroscopy, coupled with implementation of a formal fluoroscopy time-out protocol before the ERCP was performed. Our primary outcome was the effect of the educational intervention on direct and surrogate markers of patient radiation exposure associated with ERCPs performed by high-volume endoscopists (HVEs) (200 or more ERCPs/year) vs low-volume endoscopists (LVEs) (fewer than 200 ERCPs/year). RESULTS At baseline, total radiation dose and dose area product were significantly higher for LVEs, but there was no significant difference between HVEs and LVEs following education. Education was associated with significant reductions in median fluoroscopy time (48% reduction for HVEs vs 30% reduction for LVEs), total radiation dose (28% reduction for HVEs vs 52% for LVEs) and dose area product (35% reduction for HVEs vs 48% reduction for LVEs). All endoscopists significantly increased their use of low magnification and collimation following education. CONCLUSIONS A 20-minute educational program with emphasis on ideal use of modifiable fluoroscopy machine settings results in an immediate and significant reduction in ERCP-associated patient radiation exposure for low-volume and high-volume endoscopists. Training programs should consider radiation education for advanced endoscopy fellows.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Subhas Banerjee
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, California.
| |
Collapse
|
2
|
Kumar S, Thosani N, Ladabaum U, Friedland S, Chen AM, Kochar R, Banerjee S. Adenoma miss rates associated with a 3-minute versus 6-minute colonoscopy withdrawal time: a prospective, randomized trial. Gastrointest Endosc 2017; 85:1273-1280. [PMID: 27931951 DOI: 10.1016/j.gie.2016.11.030] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [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: 09/09/2016] [Accepted: 11/21/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The 6-minute withdrawal time for colonoscopy, widely considered the standard of care, is controversial. The skill and technique of endoscopists may be as important as, or more important than, withdrawal time for adenoma detection. It is unclear whether a shorter withdrawal time with good technique yields an acceptable lesion detection rate. Our objective was to evaluate a 3-minute versus a 6-minute withdrawal time by using segmental tandem colonoscopy. METHODS We performed a prospective, randomized trial by using 4 expert endoscopists. Patients were randomized to a 3-minute or a 6-minute initial withdrawal, each followed by a tandem second 6-minute withdrawal. All polyps were removed. The primary outcomes were adenoma miss rates (AMRs), adenomas per colonoscopy (APC) rates, and adenoma detection rates (ADRs). RESULTS A total of 99 and 101 patients were enrolled in the 3-minute and 6-minute withdrawal groups, respectively. The AMR was significantly higher in the 3-minute withdrawal group (48.0% vs 22.9%; P = .0001). After controlling for endoscopist, patient age and/or sex, Boston Bowel Preparation Scale score, and size and/or location and/or morphology of adenoma, the AMR remained significantly higher in the 3-minute withdrawal group (odds ratio, 2.78; 95% confidence interval, 1.35-5.15; P = .0001). The ADR was similar between both groups (39.2% vs 40.6%; P = .84). However, the mean APC rate was significantly lower in the 3-minute withdrawal group (0.55 vs 0.80; P = .0001). CONCLUSIONS The AMR was significantly higher, and the APC rate was significantly lower in the 3-minute withdrawal group versus the 6-minute withdrawal group. Despite expert technique, a shorter withdrawal time is associated with an unacceptably high AMR and low APC rate. (Clinical trial registration number: NCT01802008.).
Collapse
Affiliation(s)
- Sheila Kumar
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Nirav Thosani
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Uri Ladabaum
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Shai Friedland
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Ann M Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Rajan Kochar
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Subhas Banerjee
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| |
Collapse
|
3
|
Thosani N, Zubarik RS, Kochar R, Kothari S, Sardana N, Nguyen T, Banerjee S. Prospective evaluation of bacteremia rates and infectious complications among patients undergoing single-operator choledochoscopy during ERCP. Endoscopy 2016; 48:424-31. [PMID: 26919263 DOI: 10.1055/s-0042-101407] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [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] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND STUDY AIMS Choledochoscopy is increasingly performed during endoscopic retrograde cholangiopancreatography (ERCP) for direct bile duct visualization. Choledochoscopy necessitates irrigation of the bile duct with water or saline, which may increase intrabiliary pressure and consequently the risks of bacteremia and cholangitis. The aim of this study was to prospectively evaluate the risk of bacteremia and infectious complications in patients undergoing single-operator choledochoscopy (SOC). PATIENTS AND METHODS Patients requiring ERCP with SOC at two tertiary care centers were enrolled prospectively. Blood cultures were obtained immediately before the ERCP, after completion of the ERCP portion of the procedure (to determine ERCP-related bacteremia), and 15 minutes after completion of SOC. RESULTS A total of 72 patients (mean age 64 years; 51.4 % male) underwent ERCP with SOC. True positive blood cultures were noted in 20 patients (27.8 %; 95 % confidence interval [CI] 17.86 % - 39.59 %), of whom 6 patients (8.3 %; 95 %CI 3.12 % - 17.26 %) had transient bacteremia following ERCP. Of 14 patients (19.4 %; 95 %CI 11.05 % - 30.46 %) with sustained bacteremia following ERCP or SOC, 10 patients (13.9 %; 95 %CI 6.86 % - 24.06 %) had sustained bacteremia related to SOC. Despite the use of post-procedure intravenous antibiotic administration, seven patients (9.7 %; 95 %CI 3.99 - 19.01 %) required further antibiotic treatment for infectious complications, three of whom (4.2 %; 95 %CI 0.86 % - 11.69 %) were hospitalized in order to receive intravenous antibiotic therapy. CONCLUSION The bacteremia associated with ERCP with SOC and the subsequent risk of hospitalization for infectious complications suggest that preprocedure antibiotic prophylaxis should be considered for patients undergoing SOC, particularly in older patients and those with prior stent placement or undergoing intraductal stone lithotripsy. TRIAL REGISTRATION clinical trials.gov (NCT01414400).
Collapse
Affiliation(s)
- Nirav Thosani
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, California, United States
| | - Richard S Zubarik
- Gastroenterology and Hepatology, University of Vermont Hospitals, Burlington, Vermont, United States
| | - Rajan Kochar
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, California, United States
| | - Shivangi Kothari
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, California, United States
| | - Neeraj Sardana
- Gastroenterology and Hepatology, University of Vermont Hospitals, Burlington, Vermont, United States
| | - Tu Nguyen
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, California, United States
| | - Subhas Banerjee
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, California, United States
| |
Collapse
|
4
|
Abstract
Because of significant advances in endoscopic techniques and the development of high-quality stents, endoscopic enteral stent placement is increasingly being performed for the management of malignant GI obstruction. Palliative stenting is now routinely performed for malignant esophageal, gastric, duodenal, and colon obstruction. In addition to palliative indications, preoperative stenting in the colon may be performed as a bridge to surgery to achieve immediate decompression and convert an emergent surgery into an elective, 1-stage procedure.The realm of enteral stenting has recently expanded to include management of benign conditions such as leaks, fistulas, and benign strictures in the GI tract. Further research is required to study the use of enteral stents in benign conditions and to adequately compare endoscopic stent placement with surgical intervention. Promising new technologies such as biodegradable stents and drug-eluting stents also require further investigation. With continued innovation in endoscopic techniques and stenting devices, the field of enteral stenting is likely to expand further, with an increase in indications and improvement in outcomes.
Collapse
Affiliation(s)
- Rajan Kochar
- Clinical Instructor, Advanced Endoscopy, Division of Gastroenterology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Nimeesh Shah
- Associate Chief, Division of Gastroenterology, Santa Clara Valley Medical Center, San Jose, California, USA; Clinical Instructor of Medicine, Division of Gastroenterology, Stanford University School of Medicine, Palo Alto, California, USA
| |
Collapse
|
5
|
Kochar R, Atiq M, Lee JH, Landon G, Mansfield PF, Bhutani MS. Giant hepatic hemangioma masquerading as a gastric subepithelial tumor. Gastroenterol Hepatol (N Y) 2013; 9:396-398. [PMID: 23935548 PMCID: PMC3736798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Rajan Kochar
- Department of Gastroenterology, Hematology, and Nutrition
| | - Muslim Atiq
- Department of Gastroenterology, Hematology, and Nutrition
| | - Jeffrey H. Lee
- Department of Gastroenterology, Hematology, and Nutrition
| | | | - Paul F. Mansfield
- Department of Surgical Oncology, MD Anderson Cancer Center, Houston, Texas
| | | |
Collapse
|
6
|
Pandey R, Kochar R, Kemp S, Rotaru D, Shah SV. Ehrlichiosis presenting with toxic shock-like syndrome and secondary hemophagocytic lymphohistiocytosis. J Ark Med Soc 2013; 109:280-282. [PMID: 23808094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Human monocytotropic ehrlichios is a tick borne illness caused by Ehrlichia chaffeensis. Ehrlichiosis presenting with septic shock and severe azotemia is rare, and may be seen in immunocompromised individuals. We present a case of ehrlichia induced toxic shock like syndrome in a patient with rheumatoid arthritis on disease modifying agents. He also had oliguric renal failure requiring dialysis on presentation and later found to have Hemophagocytic Lymphohistiocytosis secondary to severe ehrlichia sepsis.
Collapse
Affiliation(s)
- Richa Pandey
- Department of Internal Medicine, University of Arkansas for Medical Sciences Little Rock, AR, USA
| | | | | | | | | |
Collapse
|
7
|
Abstract
Infection of the biliary tract, or cholangitis, is a potentially life-threatening condition. Bile duct stones are the most common cause of biliary obstruction predisposing to cholangitis. The key components in the pathogenesis of cholangitis are biliary obstruction and biliary infection. Several underlying mechanisms of bactibilia have been proposed. Characteristic clinical features of cholangitis include abdominal pain, fever, and jaundice. A combination of clinical features with laboratory tests and imaging studies are frequently used to diagnose cholangitis. Endoscopic retrograde cholangiopancreatography is the best diagnostic test. Less invasive imaging tests may be performed initially in clinically stable patients with uncertain diagnoses.
Collapse
Affiliation(s)
- Rajan Kochar
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | | |
Collapse
|
8
|
Kochar R, Pandey R, Mileski W, Lick SD, Schreiber MH, Parupudi SVJ. Endoscopic retrograde cholangiopancreatography (ERCP)-related esophageal perforation in osteogenesis imperfecta. Endoscopy 2012; 44 Suppl 2 UCTN:238-9. [PMID: 22715007 DOI: 10.1055/s-0032-1308930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 12/10/2022]
Affiliation(s)
- R Kochar
- Division of Gastroenterology and Hepatology, The University of Texas Medical Branch, Galveston, Texas 77555, USA.
| | | | | | | | | | | |
Collapse
|
9
|
Abstract
BACKGROUND/AIM The natural history of hepatopulmonary syndrome (HPS) is poorly characterized and how hypoxemia develops and progresses over time is unclear. We evaluated oxygenation over time in advanced liver disease patients with and without HPS using serial pulse oximetry. METHODS Data from a prospective cohort of patients evaluated for liver transplantation were analyzed. All patients with significant cardiopulmonary disease were excluded and patients with and without HPS were compared. Arterial oxygen saturation measurements with pulse oximetry (SpO(2)) were recorded serially from initial evaluation until transplantation or last clinic visit on record. Patients with SpO(2) measurements at ≥ 2 visits were included. RESULTS A total of 22 HPS patients were compared to 32 non-HPS patients (18 with intrapulmonary vasodilation on contrast echocardiography, CE) over a mean duration of 20 months and 4 SpO(2) measurements. HPS patients had lower SpO(2) at baseline (96.8 vs. 98.4%, P = 0.02) and at end of follow-up (95.8 vs. 98.2%, P = 0.02), and were more likely to have a ≥ 2% reduction (P = 0.04) and faster decline in SpO(2) as compared to non-HPS patients (F = 2.2, P = 0.04). HPS patients with lower SpO(2) and/or PO(2) at baseline appeared more likely to worsen over time. There was no difference in SpO(2) over time between the 2 non-HPS subgroups (- or +CE). CONCLUSIONS HPS patients have a significant decline in SpO(2) over time compared to non-HPS patients, and therefore, pulse oximetry may be useful for monitoring cirrhotics for development or worsening of HPS. Presence of intrapulmonary vasodilation in the absence of hypoxemia does not appear to affect SpO(2) over time.
Collapse
Affiliation(s)
- Rajan Kochar
- Division of Gastroenterology, Hepatology and Nutrition, The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.234, Houston, TX 77030, USA.
| | | | | |
Collapse
|
10
|
Abstract
Pulmonary vascular complications of liver disease comprise two distinct clinical entities: hepatopulmonary syndrome (HPS-microvascular dilatation and angiogenesis) and portopulmonary hypertension (POPH-vasoconstriction and remodeling in resistance vessels). These complications occur in similar pathophysiologic environments and may share pathogenic mechanisms. HPS is found in 15% to 30% of patients with cirrhosis and its presence increases mortality and the risks of liver transplantation, particularly when hypoxemia is present. Contrast echocardiography and arterial blood gas analysis are required to establish the diagnosis. No medical therapies are available, although liver transplantation is effective in reversing the syndrome. POPH is found in 4% to 8% of patients undergoing liver transplantation evaluation, and the presence of moderate to severe disease significantly increases perioperative transplant mortality. Transthoracic echocardiography is recommended for screening and right-heart catheterization is required to establish the diagnosis. Medical therapies are increasingly effective in improving pulmonary vascular hemodynamics in POPH and may result in better perioperative outcomes.
Collapse
Affiliation(s)
- Rajan Kochar
- The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | | | | |
Collapse
|
11
|
Abstract
Chronic liver disease is associated with many pulmonary complications. Several, including hepatopulmonary syndrome, portopulmonary hypertension, and hepatic hydrothorax have been extensively reviewed. However, hepatobiliary manifestations of primary pulmonary diseases have received less attention. This review focuses on hepatobiliary complications of respiratory failure, cystic fibrosis, α-1 antitrypsin deficiency, sarcoidosis, and tuberculosis.
Collapse
Affiliation(s)
- Rajan Kochar
- Division of Gastroenterology, Hepatology and Nutrition, The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.234, Houston, TX 77030, USA
| | | |
Collapse
|
12
|
Kochar R, Nevah MI, Lukens FJ, Fallon MB, Machicao VI. Vanishing bile duct syndrome in human immunodeficiency virus: Nevirapine hepatotoxicity revisited. World J Gastroenterol 2010; 16:3335-8. [PMID: 20614492 PMCID: PMC2900728 DOI: 10.3748/wjg.v16.i26.3335] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [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
Vanishing bile duct syndrome (VBDS) refers to a group of disorders characterized by prolonged cholestasis as a result of destruction and disappearance of intrahepatic bile ducts. Multiple etiologies have been indentified including infections, neoplastic disorders, autoimmune conditions and drugs. The natural history of this condition is variable and may involve resolution of cholestasis or progression with irreversible damage. VBDS is extremely rare in human immunodeficiency virus (HIV)-infected patients and anti-retroviral therapy has never been implicated as a cause. We encountered a young pregnant female with HIV and VBDS secondary to anti-retroviral therapy. Here, we report her clinical course and outcome.
Collapse
|
13
|
Abstract
Gastric variceal bleeding is a common problem in patients with cirrhosis and is associated with increased morbidity and mortality. Management is complex and includes pharmacotherapy, endoscopic therapy, and shunt placement. Recent studies indicate that endoscopic therapy with tissue adhesives has similar hemostasis rates and outcomes in terms of mortality as shunt placement but has a lower complication rate and therefore could be considered the first line therapy for acute bleeding and secondary prophylaxis of gastric varices.
Collapse
Affiliation(s)
- Rajan Kochar
- Division of Gastroenterology, Hepatology & Nutrition, The University of Texas Health Science Center at Houston 6431 Fannin Street, MSB 4.234, Houston, TX 77030 USA
| | | |
Collapse
|
14
|
|
15
|
|
16
|
Abstract
The risk for colorectal carcinoma in acromegaly remains controversial. In our earlier study, we have demonstrated that the risk of colorectal carcinoma in Asian Indians with acromegaly is not increased and after this report, routine colonoscopy in our patients with acromegaly was abandoned. Subsequently, two consecutive young men aged 30 and 35, one 6 years after and other at the time of diagnosis of acromegaly had colorectal carcinoma respectively. None of them had family history of colonic neoplasm. These two younger patients with no other predisposition for colorectal neoplasm suggests that colonoscopy should be done in all patients with acromegaly at diagnosis and they should remain under surveillance.
Collapse
Affiliation(s)
- Anil Bhansali
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
| | | | | | | | | | | |
Collapse
|
17
|
Abstract
OBJECTIVE To evaluate the utility of stool water analysis in the management of patients with chronic diarrhea. DESIGN Retrospective analysis of 6 years of experience. SETTING A specialized laboratory in a major referral center. PATIENTS 325 patients with diarrhea who were referred for stool chemistry analysis. Fecal analysis was requested by many internists and gastroenterologists. Patient records were reviewed to establish the final and most likely cause of diarrhea. RESULTS One third of patients provided samples that were inappropriate for analysis, but data from 202 persons were available. The usefulness of the general separation of cases of chronic diarrhea into those in which patients had predominantly osmotic pathophysiologies and those in which patients had predominantly secretory pathophysiologies was confirmed, but overlap and intra-individual variability limited the usefulness of this approach in individual patients. Thirty-five patients (17%) had a diagnosis of factitial diarrhea (30 because of laxative use and 5 because of fluid added to stools). CONCLUSIONS Among selected subpopulations, the chemical analysis of fresh stools has a role in the evaluation of obscure examples of chronic diarrhea. It is especially useful in identifying factitial diarrhea.
Collapse
|
18
|
Singh T, Kochar R, Gaiha M. Estimation of marrow iron stores, biopsy vs. aspirate. J Assoc Physicians India 1989; 37:705-6. [PMID: 2632536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
|