Endoscopic retrograde cholangiopancreatography in elderly patients: Difficult cannulation and adverse events

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is a valuable therapeutic technique for pancreatobiliary diseases, and its application in the elderly is no longer limited. However, a higher incidence of procedure difficulty and periprocedural adverse events might be expected in elderly patients due to the presence of other medical disorders and the poor general condition of this population.

AIM

To evaluate the incidence, causes, and management of difficult biliary cannulation during ERCP in elderly patients and the role of difficult cannulation as a risk factor for adverse events.

METHODS

A total of 614 patients who underwent ERCP during the study period were prospectively studied and divided into two groups based on their age. One hundred and forty-six patients were aged 80 years or older and 468 patients were aged less than 80 years. The primary outcome measurements were cannulation difficulty, cannulation success rate, ERCP procedure time, and related adverse events.

RESULTS

There was no difference in the incidence of difficult cannulation among the two groups (32.9% vs 34.4%, P = 0.765), as well as in the cannulation success rate (96.6% vs 96.8%, P = 0.54). The cannulation techniques were shown to be safe and efficient in achieving successful cannulation. Logistic regression analysis showed that patients aged 80 years or older were not associated with increased adverse events; however, difficult cannulation cases [adjusted odds ratio (AOR) = 3.478; 95% confidence interval (CI): 1.877-6.442; P < 0.001] and patients with Charlson Comorbidity Index ≥ 2 (AOR = 1.824; 95%CI: 0.993-3.349; P = 0.045) were more likely to develop adverse events. In contrast, other factors including age ≤ 65 (AOR = 3.460; 95%CI: 1.511-7.922; P = 0.003), female gender (AOR = 2.362; 95%CI=1.089-5.124; P = 0.030), difficult cannulation (AOR = 4.527; 95%CI: 2.078-9.860; P < 0.001), and patients with cholangitis (AOR = 3.261; 95%CI: 1.204-8.832; P = 0.020) were strongly associated with a higher rate of post-ERCP pancreatitis.

CONCLUSION

Advanced age has not been proved to be a risk factor for difficult cannulation, and secondary cannulation techniques can be safely and efficaciously utilized in this group. Patients with a Charlson Comorbidity Index ≥ 2 and difficult cannulation are associated with an increased overall adverse events rate, while age ≥ 80 years is not.

SP/NK-1R promotes gallbladder cancer cell proliferation and migration

Aberrant substance P/neurokinin‐1 receptor (SP/NK‐1R) system activation plays a critical role in various disorders, however, little is known about the expression and the detailed molecular mechanism of the SP and NK‐1R in gallbladder cancer (GBC). In this study, we firstly analyzed the expression and clinical significance of them in patients with GBC. Then, cellular assays were performed to clarify their biological role in GBC cells. Moreover, we investigated the molecular mechanisms regulated by SP/NK‐1R. Meanwhile, mice xenografted with human GBC cells were analyzed regarding the effects of SP/NK1R complex in vivo. Finally, patient samples were utilized to investigate the effect of SP/NK‐1R. The results showed that SP and NK‐1R were highly expressed in GBC. We found that SP strongly induced GBC cell proliferation, clone formation, migration and invasion, whereas antagonizing NK‐1R resulted in the opposite effects. Moreover, SP significantly enhanced the expression of NF‐κB p65 and the tumor‐associated cytokines, while, Akt inhibitor could reverse these effects. Further studies indicated that decreasing activation of NF‐κB or Akt diminished GBC cell proliferation and migration. In consistent with results, immunohistochemical staining showed high levels of Akt, NF‐κB and cytokines in tumor tissues. Most importantly, the similar conclusion was obtained in xenograft mouse model. Our findings demonstrate that NK‐1R, after binding with the endogenous agonist SP, could induce GBC cell migration and spreading via modulation of Akt/NF‐κB pathway.

Direct precision frequency measurement and correction technology with double ADC

A new method of direct precision frequency measurement is proposed in this paper, which uses the clock cursor effect between the sampling clock signal and input signal and ADC (analog to digital converter) quantization error suppression technique in the background of digital measurement with double ADC. On this basis, a precision frequency corrector is designed. Compared with the traditional frequency synthesizer, this device takes the non-standard frequency signal of the crystal oscillator as the reference to realize the standard frequency signal output through the frequency correction function. Meanwhile, the output signal is obviously narrower in range, from 0.0001 Hz to 0.1 Hz. The frequency corrector can also realize the second stability of less than 3 × 10^-12 and a small frequency correction of 10^-11 orders of magnitude.

Endoscopic transpancreatic septotomy as a precutting technique for difficult bile duct cannulation

AIM: To evaluate the technique of transpancreatic septotomy (TS) for cannulating inaccessible common bile ducts in endoscopic retrograde cholangiopancreatography (ERCP).

METHODS: Between May 2012 and April 2013, 1074 patients were referred to our department for ERCP. We excluded 15 patients with previous Billroth II gastrectomy, Roux-en-Y anastomosis, duodenal stenosis, or duodenal papilla tumor. Among 1059 patients who underwent ERCP, there were 163 patients with difficult bile duct cannulation. Pancreatic guidewire or pancreatic duct plastic stent assistance allowed for successful ERCP completion in 94 patients. We retrospectively analyzed clinical data from 69 failed patients (36 transpancreatic septotomies and 33 needle-knife sphincterotomies).

RESULTS: Of the 69 patients who underwent precut papillotomy, common bile duct cannulation was successfully achieved in 67. The success rates in the TS and needle knife sphincterotomy (NKS) groups were 97.2% (35/36) and 96.9% (32/33), respectively, which were not significantly different (P > 0.05). Complications occurred in 11 cases, including acute pancreatitis (n = 6), bleeding (n = 2), and cholangitis (n = 3). The total frequency of complications in the TS group was lower than that in the NKS group (8.3% vs 24.2%, P < 0.05).

CONCLUSION: Pancreatic guidewire or pancreatic duct plastic stent assistance improves the success rate of selective bile duct cannulation in ERCP. TS and NKS markedly improve the success rate of selective bile duct cannulation in ERCP. TS precut is safer as compared with NKS.

Gastrotracheal fistula: Treatment with a covered elf-expanding Y-shaped metallic stent

A 67-year-old man had a sev-ere cough and pulmonary infection for 1 wk before seeking evaluation at our hospital. He had undergone esophagectomy with gastric pull-up and radiotherapy for esophageal cancer 3 years previously. After admission to our hospital, gastroscopy and bronchoscopy revealed a fistulous communication between the posterior tracheal wall near the carina and the upper residual stomach. We measured the diameter of the trachea and bronchus and determined the site and size of the fistula using multislice computed tomography and gastroscopy. A covered self-expanding Y-shaped metallic stent was implanted into the trachea and bronchus. Subsequently, the fistula was closed completely. The patient tolerated the stent well and had good palliation of his symptoms.

Two-year follow-up for 45 patients with achalasia who underwent peroral endoscopic myotomy

OBJECTIVES

Achalasia is an oesophageal disorder characterized by abnormalities of peristalsis and impaired swallowing-induced relaxation. The therapeutic approach at present remains palliative. Peroral endoscopic myotomy (POEM) is thought to be less invasive and to maintain the function of the lower oesophageal sphincter postoperatively. However, the effects of POEM still need to be evaluated and understood.

METHODS

We analysed the outcome for 45 achalasia patients who underwent POEM in our centre, described the details of surgery and evaluated the effects by 4 s integrated relaxation pressure (4s-IRP). All patients were followed up for at least 2 years and were assessed by the dysphagia score, the Eckardt score, oesophageal manometry and the gastro-oesophageal reflux disease (GERD) Q-questionnaire. According to the new Chicago classification of oesophageal motility using high-resolution manometry, the patients were diagnosed and classified into types I, II and III.

RESULTS

The average age of the patients was 46.32 ± 19.04 years (range 26-72 years), and the ratio of women to men was 1.81. All patients were suffering from dysphagia; more than half of them experienced regurgitation. The data revealed that POEM considerably reduced the 4s-IRP, dysphagia score and Eckardt score postoperatively (all P < 0.05). The patients with type III achalasia had higher values of 4s-IRP than the others (type I, P = 0.025; type II, P = 0.022) before treatment and at 3 months after treatment (type I, P = 0.028; type II, P = 0.047). In type I patients, GERD symptoms were more likely to appear at 24 months after POEM than in type II and III patients (P = 0.001 and P < 0.001, respectively).

CONCLUSIONS

Peroral endoscopic myotomy provides definite relief of symptoms in these patients with achalasia and offers them long-term therapeutic benefit. Considering the risks of surgery, we believe that POEM is a better choice than surgery for achalasia patients and carries lower risk. However, our study is a preliminary exploration; therefore, larger-scale studies are needed for further research on POEM.

Endoscopic retrieval of 28 foreign bodies in a 100-year-old female after attempted suicide

Foreign body ingestion is a common emergency situation in children with one or a few objects having been ingested. Here we report our experience using endoscopic retrieval in a female centenarian with dyspnea and foreign bodies in the esophagus. She attempted suicide by swallowing 26 coins and two other foreign bodies. A gastroscope was used to remove all foreign bodies in the lower esophagus. In total, 26 coins, one ferrous ring and one cylindrical plastic object were retrieved. To our knowledge, this is the first clinical report on retrieval of so many foreign bodies in a single case.

Response of cochlear potentials to presumed alterations of ionic conductance: endolymphatic perfusion of barium, valinomycin and nystatin

Two models ('single-pump' and 'two-pump') of transepithelial potassium movement by the marginal cells of the stria vascularis have been proposed in the literature. Their validity was considered by exposing the endolymphatic (luminal) surface to agents (barium, valinomycin and nystatin) which are known to alter specific cellular membrane conductances in other tissues. This was accomplished by the use either of injections or of a relatively satisfactory technique for perfusion of scala media, which is described. Injection of barium caused the endocochlear potential (EP) to increase in normal animals and had no effect on the EP of deaf, Waltzing guinea pigs. Perfusion of the ionophores caused a decline in the EP in both normal and Waltzing guinea pigs. Only the 'two-pump' model (Na/K-ATPase-mediated cation pump on the basolateral membrane and rheogenic K transporter at the luminal membrane) is consistent with the results. The cellular heterogeneity of the cochlear duct, however, introduces a measure of uncertainty into this interpretation.

The pathophysiology of compression injuries of the peripheral facial nerve

The buccolabial branches of guniea pig facial nerves were crushed to produce axonotmesis, Wallerian degeneration, and demyelination. The lesions were followed from 1 to 8 weeks by transmission electron microscopy, electrophysiological tests, and cytochemical staining methods for Na+ channels. The first week demonstrated the classic degenerative neural changes. At 2 weeks the axoplasmic side of the demyelinated axolemma demonstrated diffuse staining for Na+ channels at a distance of 1 micrometer. At 4 weeks multiple condensed areas of dense staining were noted along the demyelinated axolemma. These staining areas resemble in character and length a normal node of Ranvier and denote new Na+ channels. The internodal distance is shorter than for the normal facial nerve. At 6 weeks a thin layer of myelin covered the nerve fibers. At 8 weeks half of the nerves were normal sized and the myelin sheath was normal in width. Following nerve crushing, electrical activity is present for 24-48 hours in the axonotmetic distal stump. Then the axon becomes unresponsive to electrical stimulation. There is gradual resumption of electrical activity between 5 and 14 days. Normal conduction resumes by 8 weeks. This study provides ultrastructural and cytochemical evidence for nerve fiber reorganization, axolemmal plasticity and sodium channel production and redistribution following Wallerian degeneration and demyelination in axonotmesis. Resumption of electrical neural excitability is achieved by an increase in the density of sodium channels and reduction in the internodal distance as a means for impedence matching. Reduction of the cross sectional diameter of the regenerating axon facilitates electrical conduction.

Comparison of the non-adrenergic action of phentolamine with that of vanadate on cochlear function

Two drugs, which upon superficial examination appeared to be acting on common processes, have been found upon closer investigation to act by quite different means. Both act primarily at the organ of Corti, causing a pronounced increase of the endocochlear potential and a depression of the cochlear microphonic (CM). These effects are accompanied by the elimination of a negative component of the EP; however, it was found that these three effects are produced by phentolamine in scala media (or, more slowly, in scala tympani) but by vanadate only in scala tympani. This difference in locus of action isd manifested further by different changes of the summating potential (SP): phentolamine has little effect on the magnitude of SP-, while vanadate leads to an elevated SP-. In spite of this difference in the 'zeroth order harmonic', the second harmonic of the CM is depressed by both agents. It is argued that phentolamine may act either by blocking the acoustically-modulated ion channels in the luminal membranes of the hair cells or by inducing a large, non-selective, paracellular conductance in the organ of Corti. The present results, in conjunction with our previous results (Marcus, D.C., DeMott, J.E., Kobayashi, T., Ge, X.-X. and Thalmann, R. (1981): Hearing Res. 5, 231-243), are further interpreted as suggesting that vanadate may initially act by depolarizing the hair cells.

Development of the hypotympanum in the human fetus and neonate

The human hypotympanum develops over a 10-week period in utero (22-32 weeks) as a triphasic osseous mosaic. The tympanic bone ossifies as a membranous bone (8-36 weeks in utero). The canalicular otic capsule ossifies in cartilage by 26 weeks in utero. A petrosal ledge of bone ossifies as periosteal bone at 24-29 weeks in utero. The fusion of these three bony structures closes the hypotympanum and forms two persistent hypotympanic fissures. The medial hypotympanic fissure forms between the canalicular otic capsule and petrosa at 24 weeks in utero. It transmits the medial hypotympanic artery and vein (from the posterior CNS circulation) and Jacobson's nerve (from the ninth nerve). The lateral hypotympanum fissure forms between the tympanic bone and the petrosa at 29 weeks in utero. It transmits the lateral hypotympanic artery and vein from the external carotid circulation. The two vascular supplies form a rich hypotympanic plexus on the floor of the middle ear. The fibrous annulus and middle layer of the tympanic membrane form an avascular plane.

Specificity of action of vanadate to the organ of corti

Although vanadate strongly inhibits Na/K-ATPase activity of the stria vascularis in vitro, it initially causes no depression of the ouabain-sensitive endocochlear potential (EP) when perfused perilymphatically or via the vasculature. However, when the perilymph of scala tympani is replaced with artificial media containing 0.1 to 1 mM vanadate, there is a large (about 17 mV) increase in the EP of the second cochlear turn. Further experiments showed that the cochlear microphonics declined during the time in which the EP increased, and that the response of these two potentials to vanadate is greater in the second turn than in the first. Injection of 50 n1 of 1 mM vanadate (in artificial endolymph) into the endolymphatic space of the second turn caused no increase in the EP. These results support the notion that the early effects of vanadate are on the contra-luminal membranes of cells of the organ of Corti rather than on the stria vascularis. By superimposing anoxia or furosemide (i.v.) upon vanadate intoxication, we determined that the initial increase of the compound EP due to vanadate alone was due to a reduction in magnitude of the negative component of the EP. It is argued that of the three prevalent theories concerning the generation of the negative EP, the data tend to support the hypothesis that the intracellular potential of the hair cells gives rise to the negative EP.

Labyrinthine segment and geniculate ganglion of facial nerve in fetal and adult human temporal bones

The later stages of development (15-40 weeks in utero) of the geniculate ganglion and labyrinthine segment of the facial nerve in the human fetus demonstrate minimal neuronal growth. The vascular supply is well established. The major changes occur in the perineural ossification pattern. The canal of the labyrinthine facial nerve segment ossifies first via the petrous apex and periotic capsule. The narrowest portion of the canal is at the geniculate ganglion in the earlier stages and at the fundus of the internal auditory canal at term. The geniculate ganglion area ossifies by means of two bony plates. The medial plate is a derivate of the periosteal growth of the petrous apex and the lateral plate is an extension of membranous bone from the squama. The major relationships to the middle ear do not change. The hiatus of the facial canal diminishes in size during gestation, but remains patent at birth.