Combination of diclofenac plus somatostatin in the prevention of post-ERCP pancreatitis: a randomized, double-blind, placebo-controlled trial

BACKGROUND AND STUDY AIMS

Pancreatitis is the most common complication of therapeutic endoscopic retrograde cholangiopancreatography (ERCP), and many pharmacoprophylactic approaches have been suggested, though not without controversy. The aim was to investigate the impact of combined therapy with diclofenac plus somatostatin on reducing the frequency and severity of post-ERCP pancreatitis (PEP).

PATIENTS AND METHODS

A prospective, double-blind, placebo-controlled trial was conducted in two tertiary referral centers, with 540 eligible patients randomized to receive either combined therapy with diclofenac 100 mg rectally 30 to 60 minutes before ERCP plus somatostatin 0.25 mg/h for 6 hours (group A), or a placebo suppository identical in appearance to the diclofenac along with saline solution (group B). Patients were clinically evaluated and serum amylase levels were determined before ERCP and at 6 and 24 hours post-procedure. Standardized criteria were used to diagnose and grade the severity of PEP. Adverse events were recorded prospectively.

RESULTS

There were no statistical differences between the groups regarding demographic data, ERCP findings, and procedure risk factors for PEP. The overall incidence of acute pancreatitis was 7.2 %. The PEP rate was significantly lower in the patients who received the combination therapy than in controls (4.7 % vs. 10.4 %, P = 0.015). Previous history of acute pancreatitis (P = 0.001), pancreatic opacification of first-class branches and beyond (P = 0.008), and absence of pharmacoprophylaxis (P = 0.023) were identified as independent risk factors for PEP in multivariate analysis.

CONCLUSION

Although combined prophylactic therapy with diclofenac plus somatostatin was promising in reducing frequency of PEP, further comparative large-scale studies are needed to confirm our findings before definitive conclusions can be drawn.

Outpatient therapeutic endoscopic retrograde cholangiopancreatography is safe in patients aged 80 years and older

BACKGROUND AND STUDY AIM

The aim of this observational prospective study was to evaluate the safety of outpatient therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in a very elderly cohort.

PATIENTS AND METHODS

A total of 600 patients were included in the study between June 2006 and June 2009. All underwent first therapeutic ERCP and were scheduled to be discharged on the same day following a postprocedure observation period of 6 hours. Of the 600 patients, 123 patients (group A) were re-admitted due to postprocedure complications that presented during the observation period, and 477 patients (group B) were discharged on the same day. Concomitant diseases, details of ERCP procedures, complications, and outcomes were all evaluated. The accuracy of the 6-hour postprocedure observation period, clinical criteria in predicting those patients aged 80 years and older in whom all therapeutic ERCP can be performed on an outpatient basis, and costs saved were all assessed.

RESULTS

There was a statistical difference in incidence of concomitant diseases between groups A and B (group A 84.5 % vs. group B 74.6 %; P = 0.020). However, there was no difference between the groups with regard to indication for ERCP and type of intervention. There was no difference in postprocedure complication rate between very elderly patients and younger patients (< 80 years), except for prolonged sedation or hypotension, which occurred more frequently in older (≥ 80 years) than in younger (< 80 years) patients (7.6 % vs. 3.2 %; P = 0.037). In group B, complications necessitating re-admission after the 6-hour observation period occurred in 10 patients (2.09 %) (patients ≥ 80 years 0.8 % and patients < 80 years 2.5 %). The costs saved by performing the procedure on an outpatient basis was calculated as 150 € per patient.

CONCLUSION

Outpatient therapeutic ERCP with postprocedure observation of 6 hours is a safe and cost-effective procedure in a significant proportion of very elderly patients.

Diagnostic yield and clinical impact of wireless capsule endoscopy in patients with chronic abdominal pain with or without diarrhea: a Greek multicenter study

BACKGROUND

Wireless capsule endoscopy has become the gold standard for the examination of small bowel. However, its role in the evaluation of patients suffering from chronic abdominal pain is not yet clearly defined. We conducted an open-label prospective multi-center study to evaluate the yield and clinical outcome of capsule endoscopy in patients with chronic abdominal pain with/without diarrhea.

METHODS

Seventy-two patients with chronic (>3months) abdominal pain with/without diarrhea in whom the underlying pathology could not be diagnosed by conventional modalities, underwent capsule endoscopy in either of the 6 participating centers. Patients were then followed up for clinical outcomes.

RESULTS

The overall diagnostic yield of capsule endoscopy was 44.4%. More specifically, its diagnostic yield was 21.4% in patients with abdominal pain and negative inflammatory markers (C-reactive protein and erythrocyte sedimentation rate), 66.7% in patients with abdominal pain and positive inflammatory markers, 0% in patients with abdominal pain, diarrhea and negative inflammatory markers, and 90.1% in patients with abdominal pain, diarrhea and positive inflammatory markers. Both univariate and multivariate regression analyses showed that abnormal C-reactive protein and erythrocyte sedimentation rate were significant factors related with positive capsule endoscopy findings.

CONCLUSIONS

Chronic abdominal pain with/without diarrhea should be accompanied by elevated inflammatory markers to be regarded as a valid indication for capsule endoscopy. The yield of capsule endoscopy in such patients is reasonably high and clinical outcomes of patients treated with capsule endoscopy findings as a guide are significant.

The role of capsule endoscopy in the evaluation and treatment of obscure-overt gastrointestinal bleeding during daily clinical practice: a prospective multicenter study

OBJECTIVE

Capsule endoscopy (CE) is most commonly performed to evaluate obscure gastrointestinal bleeding (GIB). However, at present the role of CE in patients with obscure-overt GIB especially during daily clinical practice is unknown. The aim of the present study was to investigate the diagnostic yield and the impact of CE on the management of patients with obscure-overt GIB.

MATERIAL AND METHODS

Between January 2007 and December 2011 we prospectively included all patients with obscure-overt GIB who underwent CE after negative bidirectional endoscopy. CE findings revealing the cause of bleeding, type of therapeutic intervention and clinical variables associated with positive CE and recurrence of GIB were evaluated.

RESULTS

One hundred and eighteen patients with a median age of 66 years (range 8-89 years) were enrolled in the final analysis. The overall diagnostic yield of the CE was 66.9%. The most common findings were angiodysplasias (33.1%), followed by ulcer (23.7%), and tumors (6.8%). Age (p = 0.001) and cardiovascular disease (p = 0.007) were significant clinical variables predicting the higher incidence of angiodysplasias. Specific therapeutic interventions were undertaken in 54 patients with positive CE (68.4%). Recurrence of GIB was observed in one patient with negative CE (2.6%) and 16 patients with positive CE (20.3%). Univariate and multivariate analysis showed high age and no therapeutic intervention as significant factors associated with recurrent bleeding.

CONCLUSIONS

CE represents a promising diagnostic method in the investigation of obscure-overt GIB, with significant impact on its clinical management in daily clinical practice.

Diagnostic yield and clinical impact of capsule endoscopy in obscure gastrointestinal bleeding during routine clinical practice: a single-center experience

OBJECTIVE

This study assessed the diagnostic yield of capsule endoscopy (CE) and its impact on patients with obscure gastrointestinal bleeding (OGIB).

SUBJECTS AND METHODS

Between May 2007 and May 2009, 63 patients with OGIB (overt bleeding: 25, and occult blood loss with chronic ferropenic anemia: 38) and normal upper and lower endoscopy were studied by CE. Demographic characteristics, prior diagnostic tests, CE findings, therapeutic interventions, medical treatment and clinical outcomes following CE were evaluated.

RESULTS

The overall diagnostic yield was 44.44% of patients and included findings of angiectasia in 11 (17.46%) patients, nonsteroidal anti-inflammatory drugs enteropathy in 6 (9.52%) patients, celiac disease in 3 (4.76%) patients, tumors in 2 (3.17%) patients, and a variety of other diagnoses ranging from varices to ulcers (due to congenital afibrinogenemia and amyloidosis). The diagnostic yield was notably higher in overt bleeders (15/25, 60%) compared to occult bleeders (13/38, 34.21%; p = 0.044), and in patients with overt bleeding who had CE within the first 10 days (14/16, 87.5%) after the bleeding episode in comparison to overt bleeders who underwent CE >10 days after the bleeding episode (2/16, 11.1%; p < 0.0001). During follow-up (11.8 ± 7 months), CE findings led to specific therapy that resolved the underlying disease or improved the clinical condition in 45 of 63 patients, thus having a positive clinical impact of 71.43%.

CONCLUSION

CE has a high diagnostic yield and a positive influence on clinical management in a significant proportion of patients with OGIB. These data further support the role of CE in routine clinical practice.

Impact of periampullary diverticula on the outcome and fluoroscopy time in endoscopic retrograde cholangiopancreatography

BACKGROUND

It is unclear whether the presence of periampullary diverticula (PAD) affects technical success and complication rates during endoscopic retrograde cholangiopancreatography (ERCP). Moreover, the impact of PAD on fluoroscopy duration is still unknown. The present study aimed to investigate the success rate and difficulty of common bile duct (CBD) cannulation, post-procedure complications and fluoroscopy duration in patients with and without PAD.

METHODS

Patients from January 2008 to December 2010 with PAD (group A) and without PAD (group B) and similar indications for therapeutic ERCP were prospectively compared. The comparison included patient characteristics, findings of ERCP, and details of procedure and fluoroscopy time. The influence of papilla's location with respect to the diverticulum on procedure was also investigated.

RESULTS

A total of 428 consecutive patients who had undergone therapeutic ERCP for similar indications were divided in two groups according to the presence (group A, 107 patients) or absence (group B, 321 patients) of PAD. The mean age and ASA score of the patients with PAD were significantly higher than those patients without PAD. The main indication was choledocholithiasis. Successful final CBD cannulation was achieved in 97.20% of the patients in group A vs 99.69% in group B (P=0.05). CBD diameter, number of stones and the largest stone size were significantly higher in group A than group B (P<0.001). Complete clearance of the CBD after the first attempt was achieved in 85.86% and 94.75% of the patients in groups A and B, respectively (P=0.03). In both groups, the time needed to complete the procedure and fluoroscopy time was significantly longer in patients with PAD (22.87 vs 18.99 minutes, P<0.001; 76.51 vs 47.42 seconds, P<0.001). There was no significant difference between the two groups in the complication rate. The type of papilla's location with respect to the diverticulum did not influence the total cannulation rate and post-procedure complications.

CONCLUSION

The presence of a PAD does not affect the success rate and complications of therapeutic ERCP in expert hands; however, the fluoroscopy time is significantly longer in patients with PAD.

Can capsule endoscopy be used as a diagnostic tool in the evaluation of nonbleeding indications in daily clinical practice? A prospective study

OBJECTIVE

To evaluate the diagnostic yield of capsule endoscopy (CE) and its impact on treatment and outcome in patients without bleeding indications.

SUBJECTS AND METHODS

One hundred and sixty-five nonbleeding patients were enrolled in the study. The most common indications for CE were chronic abdominal pain alone (33 patients) or combined with chronic diarrhea (31 patients) and chronic diarrhea alone (30 patients). Among the 165 patients, 129 underwent CE for evaluation of gastrointestinal symptoms and 36 for surveillance or disease staging.

RESULTS

CE findings were positive, suspicious and negative in 73 (44.2%), 13 (7.9%) and 79 (47.9%) of cases, respectively. The diagnostic yield was highest in patients with refractory celiac disease (10/10, 100%) and suspected Crohn's disease (5/6, 83.3%), followed by patients with chronic abdominal pain and chronic diarrhea (13/31, 41.9%), established Crohn's disease (2/6, 33.3%), chronic diarrhea alone (8/30, 26.7%), chronic abdominal pain alone (8/33, 24.2%) and other indications (3/13, 23.1%) (p < 0.005). The CE findings led to a change of medication in 74 (47.7%) patients, surgery in 15 (9.7%), administration of a strict gluten-free or other special diet in 13 (8.4%) and had other consequences in 11 (6.7%). Management was not modified in 42 (27.1%) patients. Among symptomatic patients (n = 129), 29 (22.5%) were lost to follow-up. The remaining 100 patients were followed up for 8.7 ± 4.0 months (range 2-19). Among the latter, resolution or improvement of symptoms was observed in 86 (86%) patients, no change in 11 (11%) and 3 (3%) died. All 86 patients who experienced resolution or improvement of their symptoms had a modification of their management after CE; only 7/11 patients whose symptoms did not change (63.6%) and 2/3 patients who died (66.7%) had a modification of management (p < 0.001).

CONCLUSIONS

CE appears to be a useful tool in the evaluation of patients with nonbleeding indications. The outcome of most patients with negative findings was excellent.

Endoscopic management of occluded biliary uncovered metal stents: A multicenter experience

AIM: To compare diverse endoscopic interventions in the management of occluded uncovered self-expanding metal stents (SEMSs) that had been placed for palliative treatment of unresectable malignant biliary obstruction.

METHODS: A retrospective review was undertaken in 4 tertiary endoscopic centers to determine optimal management of different types of occluded SEMSs. The technical success of performed treatment in occluded SEMSs, the patency of the stent, the need for re-intervention and the financial costs of each treatment were analyzed.

RESULTS: Fifty four patients were included in the analysis; 21 received Hanaro, 19 Wallstent and 14 Flexus. For the relief of obstruction, a plastic stent was inserted in 24 patients, a second SEMS in 25 and mechanical cleaning was performed in 5 patients. The overall median second patency rates between second SEMSs and plastic stents did not differ (133 d for SEMSs vs 106 d for plastic stents; P = 0.856). Similarly, no difference was found between the overall survival of SEMS and plastic stent groups, and no procedure-related complications occurred. Incremental cost analysis showed that successive plastic stenting was a cost-saving strategy at least in Greece.

CONCLUSION: Insertion of uncovered SEMSs or plastic stents is a safe and effective treatment for occluded uncovered SEMSs; insertion of plastic stents appears to be the most cost-effective strategy.

Double major papilla of Vater--a rare endoscopic finding during endoscopic retrograde cholangiopancreatography: a case report

BACKGROUND

A double major papilla of Vater is a rare congenital anomaly with only three documented cases described in the literature.

CASE REPORT

We report the case of a 19-year-old man, with chronic ulcerative pancolitis and congenital sphrerocytosis, who underwent endoscopic retrograde cholangiopancreatography because he had persistent elevation of liver enzymes and normal MRI cholangiography. During endoscopic retrograde cholangiopancreatography, a double papilla of Vater with separate drainage for the bile duct and the pancreatic duct was observed.

CONCLUSION

Endoscopic retrograde cholangiopancreatography showed normal pancreatogram and findings compatible with sclerosing cholangitis.

Partially covered vs uncovered sphincterotome and post-endoscopic sphincterotomy bleeding

AIM: To prospectively compare partially covered vs uncovered sphincterotome use on post-endoscopic biliary sphincterotomy (ES) hemorrhage and other complications.

METHODS: All patients referred for therapeutic endoscopic retrograde cholangiopancreatography (ERCP) were randomly assigned to undergo ES either with a partially covered or an uncovered sphincterotome. Both patient and technical risk factors contributing to the development of post-ES bleeding were recorded and analyzed. The characteristics of bleeding was recorded during and after ES. Other complications were also compared.

RESULTS: Three-hundred and eighty-seven patients were recruited in this study; 194 patients underwent ES with a partially covered sphincterotome and 193 with conventional uncovered sphincterotome. No statistical difference was noted in the baseline characteristics and risk factors for post-ES induced hemorrhage between the 2 groups. No significant difference in the incidence and pattern of visible bleeding rates was found between the 2 groups (immediate bleeding in 24 patients with the partially covered sphincterotome vs 19 patients with the uncovered sphincterotome, P = 0.418). Delayed bleeding was observed in 2 patients with a partially covered sphincterotome and in 1 patient with an uncovered sphincterotome (P = 0.62). No statistical difference was noted in the rate of other complications.

CONCLUSION: The partially covered sphincterotome was not associated with a lower frequency of bleeding. Also, there was no difference in the incidence of other significant complications between the 2 types of sphincterotome.

Building Strong Primary Healthcare Systems in Greece

The healthcare system in Greece has undergone significant changes over the past 10 years. While there have been some positive developments, such as improvements in primary care and public health, there are still many challenges that need to be addressed. One of the major changes in the Greek healthcare system over the past decade has been the impact of the country's economic crisis. The government has had to implement a series of austerity measures, including significant cuts to healthcare funding. This has had a negative impact on the availability and quality of care, particularly for those on low incomes or living in rural areas.

Diagnostic yield and clinical management after capsule endoscopy in daily clinical practice: A single-center experience

BACKGROUND

Capsule endoscopy is an effective method of examining the small bowel in patients with obscure gastrointestinal bleeding, suspected inflammatory mucosal diseases and neoplasms. We herein evaluate the diagnostic yield of capsule endoscopy and its effect on clinical management in daily clinical practice.

PATIENTS AND METHODS

One hundred and one capsule endoscopies performed at the Department of Endoscopy and Motility Unit of G. Gennimatas General Hospital of Thessaloniki from May 2007 to February 2009 were retrospectively reviewed. Clinical management following capsule endoscopy findings was evaluated. The most frequent indication was obscure gastrointestinal bleeding (n=56, overt=20).

RESULTS

The overall diagnostic yield was 47.5%. The diagnostic yield was 88.9% in patients with overt bleeding who underwent early capsule endoscopy (within 5 days), versus 36.4% in patients who underwent late capsule endoscopy (p=0.028). Moreover, it reached 81.8% in patients with abdominal pain, with/without diarrhea and abnormal biological markers, versus 8.3% in patients with normal biological markers (p<0.0001). Capsule endoscopy was diagnostic in all patients with symptomatic celiac disease. Adenomas were found in 9 of 14 familial adenomatous polyposis patients. Capsule retention (>72 hours) occurred in two patients. Forty-three of 48 (89.6%) patients with positive capsule endoscopy findings that received intervention or medical treatment had positive clinical outcomes.

CONCLUSIONS

Capsule endoscopy has an important diagnostic role and contribution in the clinical management during routine clinical practice; however, it remains to be determined which patients are more likely to benefit from this expensive examination.

Factors predicting a positive capsule endoscopy in past overt obscure gastrointestinal bleeding: a multicenter retrospective study

OBJECTIVES

Capsule endoscopy (CE) remains the examination of choice for the investigation of obscure gastrointestinal bleeding. Although the factors predicting positive CE findings in the overall obscure gastrointestinal bleeding have been investigated, the clinical characteristics that predict a positive CE in patients with past overt obscure gastrointestinal bleeding (OOGIB) have not been systematically studied.

METHODS

Between September 2004 and December 2013, 262 patients underwent CE for evaluation of past OOGIB after negative upper and lower endoscopy, and other diagnostic modalities. Patients' records were retrospectively reviewed to assess the factors that could possibly predict positive CE findings.

RESULTS

Two hundred and twenty four patients with a median age of 70 years (range: 17-87) were enrolled in the final analysis and were divided into two groups; those who had positive (group A: 118 patients) and those who had negative CE findings (group B: 106 patients). The overall diagnostic yield of CE was 52.68 %. Multivariate analysis demonstrated that age >65 years, anticoagulant use, antiplatelet use, and non-steroidal anti-inflammatory drugs use were independent predictive factors for positive findings on CE. Of the 118 patients with positive CE, therapeutic interventions were performed in 56 patients (47.46 %). Recurrence of bleeding presented in nine patients of group B compared with 39 patients of group A (p <0.001).

CONCLUSIONS

Certain clinical characteristics predict a positive CE in patients with past OOGIB. Patients with OOGIB and negative CE had a considerably lower rebleeding rate, and further invasive investigational procedures may be adjourned or may not be required, though such recommendation warrants further validation. Hippokratia 2016, 20(2): 127-132.

The impact of age on the incidence and severity of post-endoscopic retrograde cholangiopancreatography pancreatitis

Background:

With advancing age there is progressive pancreatic atrophy and fibrosis, leading to tissue destruction and chronic pancreatitis that has been found to be protective against post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, there are no reports regarding the potential effect of the aging pancreatic changes on the incidence and severity of PEP. Therefore, the aim of the present study was to investigate the impact of senile changes in the pancreas on the incidence and severity of PEP.

Methods:

A total of 2688 patients who underwent the first therapeutic ERCP at a single center were included in the final analysis of the study. Patients were classified into two groups: 1644 patients aged ≤75 years (mean age 61.56+1.26 years), group A; and 1044 patients aged >75 years (mean age 81.97+4.29 years), group B. Patients’ files were identified using a retrospective database linked to the endoscopy reporting system. Patients’ characteristic, endoscopic findings, details of intervention and rate and severity of PEP were evaluated.

Results:

No significant differences between the two groups were observed with regard to ERCP indication, patient- and technique-related risk factors for PEP, presence of periampullary diverticulum, and type of therapeutic intervention. The incidence of PEP was 5.2% in group A and 4% in group B (P=NS) with comparable grades of severity. All episodes of pancreatitis had full recovery with conventional treatment. One death occurred from respiratory arrest in each group of patients.

Conclusion:

This study shows that the pancreatic changes associated with aging do not influence the incidence and severity of PEP.

Risk factors for therapeutic ERCP-related complications: an analysis of 2,715 cases performed by a single endoscopist

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is now the exclusive endoscopic therapeutic modality for biliary as well as pancreatic diseases. The aim of the present study was to investigate patient- and procedure-related risk factors for post-ERCP complications in a large-scale study of procedures performed by a single experienced endoscopist.

METHODS

This is a retrospective cohort study which included a total of 2,715 therapeutic ERCPs enrolled in the final analysis. Potential important patient- and procedure-related risk factors for overall post-ERCP complications, pancreatitis and post-endoscopic sphincterotomy (ES) bleeding were investigated by univariate and multivariate analyses.

RESULTS

Following the first therapeutic ERCP, 327 patients suffered complications; pancreatitis was observed in 132 (4.9%) patients, hemorrhage in 122 (4.5%) patients, cholangitis in 63 (2.3%) patients, perforation in 3 (0.11%) patients, and basket impaction in 7 (0.26%) patients. History of acute pancreatitis was more common in patients with post-ERCP complications (P<0.001). Female gender, young age (<40 years), periampullary diverticulum, suspected sphincter of Oddi dysfunction, metal stent placement, opacification of main pancreatic duct and suprapapillary fistulotomy were not found to be risk factors for overall post-ERCP complications and post-ERCP pancreatitis (PEP). Multivariate analysis showed a history of acute pancreatitis, difficult cannulation, needle-knife papillotomy, transpancreatic sphincterotomy, opacification of first and second class pancreatic ductules and acinarization as independent risk factors for overall complications and PEP, whereas antiplatelet and anticoagulation drug use were not found to be independent risk factors for post-ES bleeding.

CONCLUSIONS

The results of this study demonstrate that the endoscopist's experience reduces patient- and procedure-related risk factors for post-ERCP complications.

A prospective analysis of factors influencing fluoroscopy time during therapeutic ERCP

BACKGROUND

Fluoroscopy time (FT) in endoscopic retrograde cholangiopancreatography (ERCP) has a linear relationship with radiation exposure to endoscopist, personnel and patients. The aim of this prospective study was to investigate the factors influencing the FT during ERCP.

PATIENTS AND METHODS

Between January 2010 and August 2011, patients with naïve papilla undergoing therapeutic ERCP were included in the study. Patient and procedural factors affecting fluoroscopy duration were investigated.

RESULTS

During the study period 549 ERCP records were included in the final analysis. The mean procedural time and FT were 19.53±7.61 min and 48.82±26.43 sec, respectively. There was no effect of age or gender on FT. Univariate analysis showed choledocholithiasis (+17.92 sec; 95%CI: 12.73-23.11, p<0.001), multiple stones (+21.21 sec; 95%CI: 14.31-30.35, p<0.001), stone size >10 mm (+27.514 sec; 95%CI: 16.62-35.71; p<0.001), precut technique (+12.46 sec; 95%CI: 6.32-18.60; p<0.001), periampullary diverticulum (+33.36 sec; 95%CI: 28.49-38.23; p<0.001), mechanical lithotripsy (+31.14 sec; 95%CI: 24.67-37.61; p<0.001) and mechanical lithotripsy plus stent placement (+42.41 sec; 95%CI: 31.93-52.89; p<0.001) to be associated with longer FT. Multivariate analysis identified choledocholithiasis (+13.24 sec; 95%CI: 4.44-22.04; p=0.003), multiple stones (+19.51 sec; 95%CI: 11.72-26.78; p<0.001), stone size >10 mm (+23.95 sec; 95%CI: 14.35-29.45; p<0.001), needle-knife papillotomy (+17.26 sec; 95%CI: 7.77-26.75; p<0.001), periampullary diverticulum (+21.99 sec; 95%CI: 17.81-26.16; p<0.001) and mechanical lithotripsy plus stent placement (+20.39 sec; 95%CI: 7.38-33.40; p=0.002) to prolong FT.

CONCLUSIONS

The identified factors influencing the FT may help endoscopists take appropriate precautions during ERCP to significantly decrease FTs.

Prospective randomized study comparing double layer and Tannenbaum stents in distal malignant biliary stenosis

BACKGROUND AND STUDY AIMS

This prospective randomized study compared the patency and effective drainage rate of two stents with different materials but similar design, in the palliation of inoperable malignant biliary obstruction.

PATIENTS AND METHODS

A total of 49 patients (26 women, mean age 72.55 +/- 10.75 years, range: 48-91 years) with obstructive jaundice due to inoperable malignant stricture of the distal common bile duct without previous drainage procedure, were randomly assigned to receive 10F Double Layer (DLS) (n = 24) or 10F Tannenbaum (TAN) (n = 25) biliary plastic stent. The diagnosis included pancreatic cancer (n = 33), cholangiocarcinoma (n = 8), ampullary cancer (n = 7) and metastatic lymphadenopathy (n = 1). The duration of stent patency, the effective drainage, and the adverse events were analyzed.

RESULTS

Stent placement was successful in all patients with minor complications. The overall median patency rates between the two groups did not differ (107.5 days for DLS group vs. 101 days for TAN group ; p = 0.066). Effective drainage rate at the end of second week was 95.8% for DLS group and 96% for TAN group, (p = 1.00). Proximal stent migration occurred in one patient with TAN stent.

CONCLUSIONS

The present study demonstrated that both DLS and TAN stents are comparable in terms of placement, overall stent patency, and complications.

Secondary rectal linitis plastica as first manifestation of urinary bladder carcinoma

Secondary rectal linitis plastica is a very rare malignancy with poor prognosis. Diagnosis is difficult because of nonspecific clinical and endoscopic findings and negative biopsies in most cases owing to the fact that the mucosa is frequently unaffected. We herein describe a 68-year-old man who presented with a six-month history of tenesmus and constipation. Endoscopy revealed a narrow distal rectum with an indurated, cobblestone appearance of mucosa. Multiple biopsies and fine-needle aspiration were negative for malignancy. Abdominal MRI and transrectal ultrasonography showed findings compatible with rectal linitis plastica. He underwent rectal extirpation with total cystectomy and lymph nodes dissection. Histology demonstrated secondary rectal linitis plastica due to a poorly differentiated urinary bladder carcinoma. We emphasize the endoscopic and endosonographic features and the difficulty to establish a preoperative diagnosis of secondary rectal linitis plastica.

Prevalence of Barrett's esophagus in Northern Greece: A Prospective Study (Barrett's esophagus)

BACKGROUND

Barrett's esophagus(BE) is a premalignant condition associated with chronic gastro-esophageal reflux disease (GERD). As only a small proportion of BE progresses to malignancy, it is important to study BE prevalence to prevent adenocarcinoma.

MATERIALS AND METHODS

Between January 2007 and December 2010, all consecutive individuals who underwent routine upper endoscopy were prospectively recruited. Patients referred for GERD were excluded from the study. Clinical and endoscopic data were collected.

RESULTS

A total of 1,990 patients (mean age 47.48±13.4 years; 52.8% males) were included. Of them, 496 (24.9%) reported GERD. Erosive esophagitis (EE) was found in 221 participants (11.1%, 193 patients with LA grade A and 28 patients with LA grade B). Overall 31 of 1494 participants not reporting reflux symptoms (2.07%) suffered from silent GERD. BE was diagnosed in 75 participants (3.77%), four (5.3%) with long-segment BE and 71 (94.7%) with short-segment BE. Low-grade dysplasia was noticed in 1 patient with long-segment BE. Hiatal hernia (HH) was found in 196 patients (9.8%), and mean HH length was 3.22 ± 0.2 cm. BE was correlated to EE, GERD and the presence of HH (p= 0.0167, <0.001 and 0.017, respectively) whereas it was not associated with age, alcohol consumption and smoking (p= 0.057, 0.099 and 0.06, respectively). BE was not correlated with Helicobacter pylori infection (p=0.542).

CONCLUSION

The prevalence of BE was 3.77% in a Greek population undergoing upper endoscopy not referred for GERD. Long-segment BE was very uncommon (0.2%) whereas 2.07% of patients not reporting symptoms suffered from silent GERD.