Endoscopic Insertion Research Articles

What Would You Like to Start With? Choice of Initial Dose of Moderate Sedation and Impact on Time to Endoscope Insertion

Introduction: Midazolam and fentanyl are the most frequently used agents for endoscopy sedation. Guidelines recommend slow incremental dosing to prevent oversedation, however the choice of initial sedative and dose is at the discretion of the endoscopist. We aimed to describe practice patterns in the choice of initial dose and determine whether initial dose is associated with time to endoscope insertion (induction time). Methods: We performed a single-center retrospective cohort study on adults who underwent upper endoscopy and lower endoscopy under moderate sedation from 2008-2016. Multiple procedures on the same day were excluded. The choice of sedative agents, doses, and times of administration were noted. The initial dose was defined as the combination of sedatives given within the first minute of sedation. Induction time was defined as minutes from initiation of sedation to the insertion of the endoscope. Reversal agent use was noted. Patient age, sex and race were recorded and adjusted for. Results: A total of 14,631 upper and 24,281 lower endoscopies were included (Table 1). Midazolam and fentanyl were used in over 95% of cases. A variety of initial sedation combinations were prevalent (Figure 1). The combination of midazolam 2 mg and fentanyl 50 mcg was the most common initial sedation for all age groups. Induction time was lowest for midazolam 2 mg and fentanyl 75 mg across all ages. Induction time for “2 and 50” was consistently longer than for “1 and 75” and for “2 and 75.” Single-agent midazolam 2 mg was associated with the longest induction times of 6 minutes or more. Reversal agents were required in 14 patients who had received “2 and 50” versus 7 patients who had received “2 and 75” (0.08% vs 0.08%, p=0.99). After adjusting for demographics, initial choice of “1 and 75” or “2 and 75” resulted in 1.1 and 1.5 minute decreases respectively in induction time compared to initial use of midazolam 2 mg and fentanyl 50 mcg (p < 0.01, Table 2).Figure: Bars: Initial sedation dose combinations, in order of frequency, stratified by age group. Lines: mean induction time for each initial sedation dose combination.Table: Table. Characteristics of 38,912 Patients Who Underwent Upper and Lower Endoscopy under Moderate SedationTable: Table. Linear Regression Model for Sedative Induction Time in Minutes, with Most Frequent Initial Sedative Doses Combinations, Adjusted for Patient Demographics.Conclusion: There is significant variability in the choice of initial sedative dose, even within age categories. Midazolam appears to have slower onset compared with fentanyl, as evidenced by longer induction times for midazolam-predominant combinations. The initial use of midazolam 2 mg and fentanyl 75 mg was associated with shorter time to endoscope insertion than other combinations, and was not associated with an increased use of reversal agents.

Conservative endoscopic management of a large duodenal defect after cholecystectomy

Reports of duodenal loss of substance after laparoscopic cholecystectomy are rare. We report successful management of a large duodenal defect that occurred after cholecystectomy by endoscopic insertion of a duodenal stent and double pigtail catheters.

How to treat intestinal obstruction due to malignant recurrence after Whipple’s resection for pancreatic head cancer: Description of 2 new endoscopic techniques

The prognosis of pancreatic cancer remains poor, even after initial surgical therapy. Local recurrence after Whipple’s pancreatico-duodenectomy may lead to intestinal obstruction at the level of the afferent limb or the alimentary limb. Endoscopic insertion of a self-expandable metal stent (SEMS) into the intestinal malignant stricture is the preferred method of choice for palliation. We describe two new endoscopic techniques to treat a malignant intestinal obstruction with the insertion of a SEMS into the afferent limb and the alimentary limb. A case of malignant gastric outlet obstruction after a Whipple’s resection was treated by the creation of an endoscopic gastrojejunostomy by the insertion of a lumen apposing HotAxios stent in between the stomach and the alimentary limb under fluoroscopic and endoscopic ultrasound control. Biliary obstruction and jaundice caused by a malignant stricture of the afferent limb after a Roux-en-Y Whipple’s resection was treated by the insertion of a SEMS by means of the single-balloon overtube-assisted technique under fluoroscopic control. Feasibility and advantages of both techniques are discussed.

RIGs – reporting standards, technical outcomes and complications

Background to the audit: Enteral feeding is essential in effective patient management due to a number of reasons including the provision of hydration and nutrition, prevention of oxidative cell injury and modulation of immune responses. Radiologically inserted gastrostomy (RIG) is an often used route for patients due to its high technical success rates and low complication rates. At our institution RIGs are utilised predominantly in patients who are not amenable to endoscopic insertion (for example – in head and neck cancers) or in those who have undergone unsuccessful endoscopic insertion.

Videoendoscopy worsens swallowing function: a videofluoroscopic study. A randomized controlled trial.

Aspiration pneumonia is a cause of mortality in the elderly. Evaluating swallowing function is important. Videofluoroscopy and flexible endoscopic evaluation of swallowing are comparable; however, observing all swallowing dynamics is impossible using the latter approach. We examined the significance of flexible endoscopic evaluation of swallowing using videofluoroscopy. Thirty-seven patients with dysphagia [70.0±8.9 (range 49-84)years] were included. In random order, patients underwent videofluoroscopy with 10cc contrast material, once without, and once with an endoscope inserted. Laryngeal elevation delay time, Penetration-Aspiration Scale score, and Pharyngeal Residue Severity Rating Scale score were evaluated. Laryngeal elevation delay time without or with endoscope insertion was similar (0.35±0.16s vs. 0.36±0.16s, P=0.29). The Penetration-Aspiration Scale (3.59±2.71 vs. 4.41±2.85; P<0.001) and Pharyngeal Residue Severity Rating Scale (0.97±0.93 vs. 1.46±1.10; P<0.001) scores differed significantly. The cases that showed no aspiration without endoscope insertion showed greater aspiration with endoscope insertion, and the cases that did not show aspiration with an endoscope inserted also showed no aspiration without an endoscope. Flexible endoscopic insertion resulted in more severe aspiration and residue than non-insertion, as assessed using videofluoroscopy.

Deep Infiltrating Endometriosis—Urinary Tract Involvement and Predictive Factors for Major Surgery

To evaluate urinary tract involvement by deep infiltrating endometriosis as well as the surgical treatment and existence of predictive factors for major urologic surgery. We conducted a retrospective analysis of 656 women submitted to surgery for endometriosis, of which 28 patients underwent minor or major surgery for deep infiltrating endometriosis involving the urinary tract, with a mean age of 38 ± 6.9 years (27-50) at diagnosis. Clinical data, surgeries performed, and complications were analyzed. Minor surgery was defined by endoscopic surgery or insertion of a percutaneous nephrostomy catheter, and major surgery included open or laparoscopic procedures. Endometriomas affected the ureter in 13 (46.4%), the bladder in 11 (39.3%), and both structures in 4 (14.3%) patients. Twelve (42.9%) patients had decreased renal function, and ureteral involvement was predictive of renal function loss (P = .034). Minor surgeries were performed in most women with isolated bladder involvement and in 12 (42.9%) patients with ureteral infiltration. Patients with ureteric involvement underwent major surgeries more often (n = 12 vs n = 3; P = .025) and had longer hospitalization (8.2 vs 3.1 days, P = .05). After a mean follow-up of 36.3 (1-102) months, there was no bladder involvement recurrence. The most common complication was ureteral stenosis (Clavien-Dindo grade IIIb) in 3 (10.7%) patients. Surgery is highly successful in most cases. Patients with ureteric involvement are more likely to lose kidney function, undergo major surgery, and have longer hospitalization.

Endoscopic biliary stent insertion through specialized duodenal stent for combined malignant biliary and duodenal obstruction facilitated by stent or PTBD guidance

Objectives: Endoscopic stenting for combined malignant biliary and duodenal obstruction is technically demanding. However, this procedure can be facilitated when there is guidance from previously inserted stent or PTBD tube. This study aimed to evaluate the feasibility and clinical success rate of endoscopic placement of biliary self-expandable metal stent (SEMS) through duodenal SEMS in patients with combined biliary and duodenal obstruction due to inoperable or metastatic periampullary malignancy.Materials and methods: A total of 12 patients with combined malignant biliary and duodenal stricture underwent insertion of biliary SEMS through the mesh of specialized duodenal SEMS from July 2012 to October 2016. Technical and clinical success rate, adverse events and survival after completion of SEMS insertion were evaluated.Results: The duodenal strictures were located in the first portion of the duodenum in four patients (Type I), in the second portion in three patients (Type II), and in the third portion in five patients (Type III). Technical success rate of combined metallic stenting was 91.7%. Insertion of biliary SEMS was guided by previously inserted biliary SEMS in nine patients, plastic stent in one patient, and PTBD in two patients. Clinical success rate was 90.9%. There were no early adverse events after the procedure. Mean survival period after combined metallic stenting was 91.9 days (range: 15–245 days).Conclusions: Endoscopic placement of biliary SEMS through duodenal SEMS is feasible with high success rates and relatively easy when there is guidance. This method can be a good alternative for palliation in patients with combined biliary and duodenal obstruction.

Endoscopic metallic stent followed by elective laparoscopic surgery for malignant colorectal obstruction

To investigate the feasibility of endoscopic metallic stent as a bridge to elective laparoscopic surgery in patients with malignant colorectal obstruction. Clinical data of 63 patients with obstructive colorectal cancer who underwent endoscopic metallic stent insertion under radiologic monitoring at the Longyan First Hospital between June 2012 and August 2016 were analyzed retrospectively. After complete remission of the obstruction, all the patients received multi-disciplinary team (MDT) evaluation to make the further treatment strategy. The subsequent surgery included open and laparoscopic procedures, and the short-term efficacy of these two procedures was compared. There were 30 male and 33 female patients with age of 30 to 90 (mean 67) years, including 3 cases of ascending colon cancer, 4 cases of transverse colon cancer, 12 cases of descending colon cancer, 26 cases of sigmoid cancer, and 19 cases of rectal cancer. Only one patient (1.6%) developed sigmoid perforation at 3 hours after stent placement, and underwent emergency laparotomy with Hartmann procedure. The remaining 62 patients had bowel movements. After MDT evaluation, 10 patients (16.1%) were treated with palliative chemotherapy because they were unfit for surgery or for diffuse distant metastases. A total of 52 patients underwent radical surgery after a mean interval from stent insertion of 10 days (7-20 days), including open (n=18, including two cases with conversion to open surgery) and laparoscopy (n=34). The baseline data between open and laparoscopy groups were similar (all P>0.05). Primary anastomosis was successfully performed in all the patients without preventive stoma. Compared to open group, laparoscopy group had faster bowel movement [(2.88±1.06) d vs. (4.05±2.43) d, P=0.022] and shorter postoperative hospital stay [(7.85±0.96) d vs. (9.82±4.41) d, P=0.002]. There were no statistically significant differences in operative time, intraoperative blood loss, number of harvested lymph node, and postoperative complication rate between two groups (all P>0.05). Endoscopic metallic stent placement can effectively remove malignant colorectal obstruction, and thus enables surgeons to perform an elective radical surgery, avoiding emergency surgery with stoma and unnecessary surgery for patients with distant metastasis. In the era of enhanced recovery after surgery, the endoscopic metallic stent placement combined with laparoscopic procedures, as a less invasive alternative, is effective and safe.

Bilateral versus unilateral placement of metal stents for inoperable high-grade malignant hilar biliary strictures: a multicenter, prospective, randomized study (with video)

The efficacy of palliative biliary drainage by using bilateral or unilateral self-expandable metal stents (SEMSs) for a malignant hilar biliary stricture (MHS) remains controversial. This prospective, randomized, multicenter study investigated whether bilateral drainage by using SEMSs is superior to unilateral drainage in patients with inoperable MHSs. Patients with inoperable high-grade MHSs who underwent palliative endoscopic insertion of bilateral or unilateral SEMSs were enrolled. The main outcome measurements were the rate of primary reintervention for malfunction after successful placement of SEMSs, stent patency, technical and clinical success rates, adverse events, and survival duration. A total of 133 pathology-diagnosed patients were randomized to the bilateral group (n= 67) or the unilateral group (n= 66). The primary technical success rates were 95.5% (64/67) and 100% (66/66) in the bilateral and unilateral groups, respectively (P= .244). The clinical success rates were 95.3% (61/64) and 84.9% (56/66), respectively (P= .047). The primary reintervention rates based on the per-protocol analysis were 42.6% (26/61) in the bilateral group and 60.3% (38/63) in the unilateral group (P= .049). The median cumulative stent patency duration was 252 days in the bilateral group and 139 days in the unilateral group. The risk of stent patency failure was significantly higher in the unilateral group (log-rank test; P< .01). In a multivariate Cox proportional hazard model to assess stent patency, bilateral SEMS placement was a favorable factor (adjusted hazard ratio 0.30, 95% confidence interval, 0.172-0.521; P< .001). Survival probability and late adverse events were not different between the 2 groups. Unilateral and bilateral drainage strategies by using SEMSs had similar technical success rates, but bilateral drainage resulted in fewer reinterventions and more durable stent patency in patients with inoperable high-grade MHSs. (Clinical trial registration number: NCT02166970.).

Endoscopic treatment of bile duct post-traumatic and post-operative lesions in children

Background and study aims: The aim of this study was to assess the significance and safety of endoscopic retrograde cholangiopancreatography (ERCP) in diagnosing and treating bile duct injuries in children.Patients and methods: Fourteen pediatric patients, with traumatic or postoperative bile duct injury, in which ERCP was performed, were retrospectively evaluated.Results: We performed 46 ERCP and 12 endoscopic papillotomies in children with suspected bile duct injuries. A bile stent was primarily inserted in 13 patients and there were 20 replacements. Endoscopic treatment of bile leakage without need for bile duct sutures or reconstruction was successful in 85.7%. Post ERCP complications included cholangitis and recurrent bleeding, which occurred only in two patients each.Conclusions: ERCP and endoscopic bile stent insertion is a highly effective, minimally-invasive treatment for bile duct injury and should be included as part of the therapeutic procedures in pediatric patients with suspected bile duct injury.

Editorial: Polyps, Pain, and Propofol: Is Water Exchange the Panacea for All?

Water exchange (WE) is a relatively new method of endoscope insertion during colonoscopy. Although its origin is rooted in the insertion phase of colonoscopy, allowing the procedure to proceed with more ease, less discomfort, and less or no sedation, its most important value may reside in the withdrawal phase. In this issue, a randomized, prospective study from China specifically designed to examine the effect of WE on adenoma detection rate (ADR) confirms previous findings: WE improves ADR. Here we discuss the trial results, the benefits of WE, and the challenges that may preclude or delay widespread WE implementation.

Multiple plastic stents versus covered metal stent for treatment of anastomotic biliary strictures after liver transplantation: a prospective, randomized, multicenter trial

Treatment of anastomotic biliary strictures (ABSs) after orthotopic liver transplantation by endoscopic insertion of multiple plastic stents (MPSs) is well established. The use of covered self-expandable metal stents (cSEMSs) for this indication is less investigated. In an open-label, multicenter, randomized trial, patients with confirmed ABSs were randomly assigned 1:1 to receive either an MPS or a cSEMS. The primary endpoint was the number of endoscopic interventions until ABS resolution. Secondary endpoints were frequency of adverse events, treatment success rates, and time to treatment success and recurrence of ABS during follow-up of at least 1 year. Fifty-eight patients were included between 2012 and 2015, and 48 patients completed follow-up. Patients receiving MPS (n= 24) underwent a median of 4 (range, 3-12) endoscopic retrograde cholangiography examinations, whereas those in the cSEMS group (n= 24) underwent a median of 2 (range, 2-12) sessions until ABS resolution (P< .001). A median of 8 (range, 2-32) stents was used until ABS resolution within the MPS group and 1 (range, 1-24) in the cSEMS group (P< .0001). cSEMS migration occurred in 8 (33.3%) patients. Treatment duration did not differ significantly. Initial treatment success rates were high with 23 (95.8%) in the MPS group and 24 (100%) for cSEMSs (P= 1). Five (20.8%) patients in both groups showed stricture recurrence after a median follow-up of 500 days (range, 48-1317 days). cSEMSs for treatment of ABSs needed less endoscopic interventions to achieve similar efficacy as MPS and might become a new treatment standard. However, the optimal duration of cSEMS therapy and cost-efficacy have to be evaluated. (Clinical trial registration number: NCT01393067.).

Endoscopic-Assisted Burr Hole Reservoir and Ventricle Catheter Placement.

Accurate positioning of a ventricle catheter is of utmost importance. Various techniques to ensure optimal positioning have been described. Commonly, after catheter placement, additional manipulation is necessary to connect a burr hole reservoir or shunt components. This manipulation can lead to accidental catheter dislocation and should be avoided. Here, we present a new technique that allows direct endoscopic insertion of a burr hole reservoir with an already mounted ventricle catheter. Before insertion, the ventricle catheter was slit at the tip, shortened to the correct length, and connected to the special burr hole reservoir. An intracatheter endoscope was then advanced through the reservoir and the connected catheter. This assemblage allowed using the endoscope as a stylet for shielded ventricular puncture. To confirm correct placement of the ventricle catheter, the endoscope was protruded a few millimeters beyond the catheter tip for inspection. The new technique was applied in 12 procedures. The modified burr hole reservoir was inserted for first-time ventriculoperitoneal shunting (n= 1), cerebrospinal fluid withdrawals and drug administration (n= 2), or different stenting procedures (n= 9). Optimal positioning of the catheter was achieved in 11 of 12 cases. No subcutaneous cerebrospinal fluid collection or fluid leakage through the wound occurred. No parenchymal damage or bleeding appeared. The use of the intracatheter endoscope combined with the modified burr hole reservoir provides a sufficient technique for accurate and safe placement. Connecting the ventricle catheter to the reservoir before the insertion reduces later manipulation and accidental dislocation of the catheter.

Study on Endoscopic Insertion of the Enteral Feeding Tube for Patients with Anastomotic Impassability After Gastrectomy

We have investigated about the enteral feeding tube for anastomotic impassability caused by anastomotic inflammation, ulcer, failure after gastrectomy. Subjects: 67 patients who needed enteral feeding because of anastomotic impassability among 1865 patients after gastrectomy from gastric and duodenal ulcer, gastric carcinoma at Pyongyang Medical College Hospital of Kim Il Sung University and other hospitals from February 2007 to August 2015. Method: The aim is to place the enteral feeding tube into the jejunum. At first we inserted the upper gastrointestinal endoscope into the jejunum beyond the anastomotic site and pulled out the it after inserting the guide wire into jejunum through the endoscope. Then we inserted the enteral feeding tube into the jejunum following the guidewire and pulled out it either. Finally we confirmed it by radiography. Results: 71 insertions were applied for 67 patients, among them the number of successes was 67 (94.4%), and required time was 14.4±3.8min, the length of the guidewire inserted into the jejunum was 23.1±2.8cm. The gastric juice output of the patients with anastomotic inflammation and ulcer was 1218±181mL/d before insertion of the tube, but 0 mL/d after insertion. And it was 1218±181mL/d before insertion in anastomotic failure, and it decreased by 5.8±3.0mL/d on the 7 th day after insertion. 2 patients (3.0%) underwent reoperation. Conclusion: This procedure is very high successful and takes a short time, can prevent the pooling of intragastric juice and reoperation.

Association between chronic pancreatitis and pyogenic liver abscess: a nationwide population study

Background: The relationship between chronic pancreatitis (CP) and subsequent pyogenic liver abscess (PLA) is not well understood.Methods: We investigated the risk of PLA in patients with CP using inpatient claims data from the Taiwan National Health Insurance Program for the period 2000–2010. We identified 17,810 patients with chronic pancreatitis (CP group) and 71,240 patients without CP (non-CP group). Both cohorts were followed until a diagnosis of PLA, until they were censored from the study because of loss to follow-up, death, or termination of insurance, or until the study cut-off date of 31 December 2011. Incidence and risk factors for development of PLA, and the effects of comorbidities, were assessed.Results: The incidence of PLA in the CP group was 12.9 times that in the non-CP group (38.3 vs. 2.89 events per 1000 person-years; 95% confidence interval [CI], 10.5–15.8). After adjusting for age, sex, and the comorbidities of hypertension, diabetes, hyperlipidemia, cerebral vascular accident, cirrhosis, heart failure, chronic obstructive pulmonary disease, chronic kidney disease, cancer, alcoholism, other diseases of the pancreas, cholecystitis, and cholelithiasis and other disorders of the biliary tract and endoscopic insertion of stent (tube) into the bile duct, the risk of PLA remained higher among CP patients than among the comparison cohort (adjusted hazard ratio, 6.40; 95% CI, 4.83–8.49). CP patients with five or more comorbidities had a significantly higher risk of PLA (adjusted hazard ratio, 24.9; 95% CI, 18.3–33.8).Conclusion: CP was associated with increased risk of subsequent PLA. The risk of PLA was higher in patients with five or more comorbidities.

Late-onset severe biliary bleeding after endoscopic pigtail plastic stent insertion.

Here, we report our experience with a case of severe biliary bleeding due to a hepatic arterial pseudoaneurysm that had developed 1 year after endoscopic biliary plastic stent insertion. The patient, a 78-year-old woman, presented with hematemesis and obstructive jaundice. Ruptured hepatic arterial pseudoaneurysm was diagnosed, which was suspected to have been caused by long-term placement of an endoscopic retrograde biliary drainage (ERBD) stent. This episode of biliary bleeding was successfully treated by transarterial embolization (TAE). Pseudoaneurysm leading to hemobilia is a rare but potentially fatal complication in patients with long-term placement of ERBD. TAE is a minimally invasive procedure that offers effective treatment for biliary bleeding.

Endoscopic ultrasound-guided fiducial marker insertion to guide radiotherapy in advanced esophageal carcinoma

Background and Objectives:The role of endoscopic ultrasound (EUS)-guided fiducial marker insertion to guide radiotherapy for esophageal cancer is uncertain. The aim of this study is to evaluate the optimal method of performing the technique.Methods:This was a retrospective study of all patients who received EUS-guided fiducial marker insertion between March 2015 and November 2016. Gold fiducial markers of size 5 mm × 0.35 mm (VISICOIL, IBA Dosimetry, USA) were placed under EUS guidance either intratumorally or in the normal submucosa just proximal and distal to the tumor. Outcome parameters included tumor characteristics, migration rates, and tumor response rates.Results:During the study period, 25 patients received the procedure. The mean (standard deviation [S.D.]) age was 59.6 (10.2) years. The mean (S.D.) length and volume of the tumor were 6.7 (4.2) cm and 24.6 (15.8) ml, respectively, and 88% of the patients had Stage 3 disease. Twenty patients had markers inserted by endobronchial ultrasound (EBUS) and 60% in the submucosa. When comparing fiducials that were placed in the submucosa versus intratumorally, significantly, more fiducials had early (42.9% vs. 0%, P = 0.017) and late migration (100% vs. 0%, P < 0.001) in the intratumoral group. There were no differences in the stage of disease (P = 0.657), percentage of patients who completed radiotherapy (P = 0.299), and response rate (P = 0.515).Conclusions:In obstructing esophageal carcinomas, fiducial markers should be placed in the submucosa just proximal and distal to the tumor by EBUS.

Single Center Experience with Gastrostomy Insertion in Pediatric Patients: A 10-Year Review.

PurposeThis study was performed to review the outcomes of gastrostomy insertion in children at our institute during 10 years.MethodsA retrospective chart review was performed on 236 patients who underwent gastrostomy insertion from October 2005 to March 2015. We used our algorithm to select the least invasive method for gastrostomy insertion for each patient. Long-term follow-up was performed to analyze complications related to the method of gastrostomy insertion.ResultsOut of 236 patients, 120 underwent endoscopic gastrostomy, 79 had laparoscopic gastrostomy, and 37 had open gastrostomy procedures. The total major complication rates for endoscopic gastrostomy insertion, laparoscopic gastrostomy insertion, and open gastrostomy were 9.2%, 8.9%, and 8.1%, respectively. The most common major complication was gastroesophageal reflux requiring Nissen fundoplication (3.8%), and other complications included peritonitis (1.3%), hiatal hernia (1.3%), and bowel perforation (0.8%). Gastrostomy removal was successful in 8.6% and 5.0% of patients in the endoscopic and surgical gastrostomy groups, respectively. Gastrocutaneous fistula occurred in 60% of surgically inserted cases, requiring a second operation.ConclusionThis retrospective study was performed to review the outcome of gastrostomy insertion, as well as to introduce an algorithm that can be used for future cases. Further studies should be conducted to make a consensus on choosing the most appropriate method for gastrostomy insertion.

Efficacy of multiple biliary stenting for refractory benign biliary strictures due to chronic calcifying pancreatitis

AIMTo investigate endoscopic therapy efficacy for refractory benign biliary strictures (BBS) with multiple biliary stenting and clarify predictors.METHODSTen consecutive patients with stones in the pancreatic head and BBS due to chronic pancreatitis who underwent endoscopic therapy were evaluated. Endoscopic insertion of a single stent failed in all patients. We used plastic stents (7F, 8.5F, and 10F) and increased stents at intervals of 2 or 3 mo. Stents were removed approximately 1 year after initial stenting. BBS and common bile duct (CBD) diameter were evaluated using cholangiography. Patients were followed for ≥ 6 mo after therapy, interviewed for cholestasis symptoms, and underwent liver function testing every visit. Patients with complete and incomplete stricture dilations were compared.RESULTSEndoscopic therapy was completed in 8 (80%) patients, whereas 2 (20%) patients could not continue therapy because of severe acute cholangitis and abdominal abscess, respectively. The mean number of stents was 4.1 ± 1.2. In two (20%) patients, BBS did not improve; thus, a biliary stent was inserted. BBS improved in six (60%) patients. CBD diameter improved more significantly in the complete group than in the incomplete group (6.1 ± 1.8 mm vs 13.7 ± 2.2 mm, respectively, P = 0.010). Stricture length was significantly associated with complete stricture dilation (complete group; 20.5 ± 3.0 mm, incomplete group; 29.0 ± 5.1 mm, P = 0.011). Acute cholangitis did not recur during the mean follow-up period of 20.6 ± 7.3 mo.CONCLUSIONSequential endoscopic insertion of multiple stents is effective for refractory BBS caused by chronic calcifying pancreatitis. BBS length calculation can improve patient selection procedure for therapy.

Pancreas Cancer: Epidemiological, Clinical, Morphological Aspects, and Therapeutic Modalities: Result of a Moroccan University Centre

Introduction: Cancer of the pancreas is one of the most aggressive solid tumors often discovered at a locally advanced or metastatic. Adenocarcinoma is the most common histological type. The aim of our study was to analyze the profile of pancreatic cancer by the various imaging techniques. Materials and methods: Descriptive retrospective study over a period of 7 years including all patients who were followed for pancreatic cancer. The epidemiological data, clinical, morphological and treatment were collected, all the patients were hospitalized. The therapeutic decision was taken after a multidisciplinary meeting between the different specialists in the Department of Gastroenterology and liver diseases, medicine C, ibn sina hospital, Rabat, Morocco. Results: Over a period of 7 years, 67 patients were collected. These 37 men and 30 women with a sex ratio of 1.23. The average age was 60 years (26-93 ans). 37% of patient’s had a history of diabetes. Clinically 43% of patients had cholestatic jaundice, 28% had abdominal pain. Clinical examination revealed an abdominal mass in 23% of cases. Abdominal ultrasound showed dilatation of the biliary tract in 67% of cases, the abdominal scanner allowed the diagnosis of pancreatic cancer in 88% of cases. The tumor site was cephalic in 67% of cases, corporeal in 7% of cases and caudal in 25% of cases. Magnetic resonance imaging (MRI) was reported in 11% of patients for suspected intra-ductal papillary mucinous neoplasms (IPMNs) or as a complement to the diagnosis. Echoendoscopy was performed in 11% of the patients as part of the locoregional extension. The average size of the tumor was 48 mm. CA19-9 was only dosed in 26 patients. It was positively positive in 65% of patients and normal in 35% of patients. Histologically, 83% had adenocarcinoma, 3% had lymphoma, 3% had neuroendocrine tumors, and 5% had degenerated IPMNs. Cancer was resectable in 9 patients (13%). The main operative contraindications were vascular and lymph node invasion in 6 patients (8%) and pulmonary or peritoneal liver metastases in 53 patients (80%). For patients with non-resectable cancer, palliative treatment was indicated either by surgical biliary drainage in 4% patients or by endoscopic insertion of biliary prosthesis in 14% of cases or by external biliary drainage in 4% of cases. Chemotherapy was indicated in 78% of patients. Therapeutic abstention was indicated in 10 patients. Conclusion: In our study 82% of pancreatic cancers were diagnosed in the metastatic stage and 10% in locally advanced stage. The only curative treatment currently exists is surgery that has been achieved only in 8% of our patients.