Endoscopic Success Research Articles

Neoplastic severe central airways obstruction, interventional bronchoscopy: A decision-making analysis

Cancer can involve the airways, causing various degrees of obstruction. Usually, after days or months of mild to moderate undervalued symptoms, severe dyspnea arises abruptly, imposing an immediate attempt to restore the airflow regardless of the etiology. This study focuses on the development of a predictive preintervention model that is useful when deciding whether to perform therapeutic interventional bronchoscopy in patients with severe central airway obstruction. A total of 804 patients who underwent rigid bronchoscopy under general anesthesia to treat severe neoplastic central airway obstruction from 1990 to 2009 were studied. Electronic records for patients who underwent bronchoscopy were analyzed. The patients were primarily male (n = 618, 76.9%) and the median age was 62 years. Lung cancer was the most frequent cause of neoplastic airway obstruction (n = 645, 81.65%). An estimate of the probability of individual endoscopic success was made. Of the 804 patients with severe neoplastic airway obstruction, 681 (84.7%) achieved luminal clearance, and the procedure was considered an endoscopic success. Tracheal involvement (rate ratio, 1.21; range, 1.16-1.27) endoluminal mass (rate ratio, 1.13; range, 1.06-1.12), and extrinsic compression (rate ratio, 1.17; 1.11-1.17) were associated significantly with a favorable endoscopic outcome. Tumor location and any kind of mucosal infiltration were the main determinants of the predictive preoperative model of intervention success. Endoscopic characteristics and location of the neoplastic lesions are the major determinants of patients' endoscopic outcome. The preintervention model adds to the clinical evaluation an important contribution to the decision-making process on performing therapeutic interventional bronchoscopy in a critical setting.

PWE-196 Endoscopic mucosal resection of flat and sessile polyps in the colon: safety, efficacy and clinical outcomes from a large data base in the UK tertiary referral centre

IntroductionEndoscopic Mucosal Resection (EMR) is now well established as the procedure of choice for removing flat and sessile polyps in the colon. It stems from large scale studies in Japan...

PTU-126 MR assessment of Crohn's related strictures correlates well with endoscopic findings facilitating safe and effective fluoroscopic dilatation

IntroductionIntestinal strictures are a known complication of Crohn's disease (CD) and may be inflammatory (in part), fibrostenotic or post-operative (anastomotic). Treatment options include a combination of medical, endoscopic or surgical...

PTU-076 Factors at first ERCP which influence the decision to proceed to subsequent surgery or repeat ERCP for complex biliary problems

IntroductionERCP is a safe and highly effective solution to many pancreaticobiliary problems. However, surgical options also exist. After a challenging first ERCP, it can be unclear whether surgery or repeat...

Treatment Outcomes of Endoscopic Repairs of Sinonasal Cerebrospinal Fluid Leaks

The objectives of the study were to evaluate the clinical characteristics of cerebrospinal fluid (CSF) leaks and determine the clinical parameters affecting endoscopic repair of CSF leaks of the anterior and central skull base. A retrospective study was undertaken to analyze the clinical characteristics of 28 patients who underwent endoscopic treatment of sinonasal CSF leaks between 2002 and 2009. The causes of sinonasal CSF leaks were traumatic (n = 27) and spontaneous (n = 1). The sites of CSF leaks included the frontal sinus and frontal recess (n = 9), ethmoid sinus (n = 9), sella and clivus (n = 6), and sphenoid sinus (n = 4). The success rate at first-attempt endoscopic repair was 86% (24/28). Cerebrospinal fluid leaks from the frontal sinus/recess had a high failure rate (44% [4/9]). Recurrent frontal CSF leaks were successfully salvaged by an open-endoscopic approach. The final success rate at second attempt was 93% (26/28). Among the variables affecting initial endoscopic success, the location of CSF leak and direct visualization were significant factors (P = 0.008 and 0.018, respectively [Fisher exact test]). No postoperative complications were noted. Our results showed that endoscopic repair of sinonasal CSF leaks is an effective treatment with a success rate of 93%. Open-endoscopic repair of frontal CSF leaks is feasible in treating endoscopic failures of frontal CSF leaks.

Endoscopic Excision of Large Colorectal Polyps as a Viable Alternative to Surgical Resection

To determine the outcome of endoscopic excision of large colorectal polyps. Retrospective medical record review. Kaiser Permanente, a large health care maintenance organization. One hundred four consecutive patients with large colorectal lesions deemed not amenable to endoscopic resection at initial colonoscopy and referred for surgical resection. Endoscopic excision under intravenous sedation by 2 interventional endoscopists. Endoscopic success (the ability to completely eradicate the original or recurrent lesion endoscopically at the index procedure or at reintervention), procedure-related complications, disease recurrence, endoscopic reintervention, and surgical intervention. We included 48 men (46%) and 56 women (54%) with a mean age of 67 (range, 29-92) years for analysis. Anatomic distribution of the lesions included the colon (68%) and rectum (32%). Thirty-nine patients (37%) had carcinoma. The median size of the lesions was 3.0 (range, 1-9) cm. The endoscopic success rate was 83% and was highest in patients with noncarcinoma histologic findings compared with carcinoma (P < .001). The morbidity rate was 7%, and all complications occurred in the ascending colon (P = .06). Endoscopic reintervention occurred in 25 of 92 patients (27%). Surgical intervention was undertaken in 14% of all patients. During a mean follow-up of 14 (median, 12) months, recurrent disease was noted in 10 of 86 patients (12%) and occurred more frequently in rectal lesions (P = .002). All recurrences were eradicated endoscopically. Endoscopic excision of large colorectal polyps is a viable alternative to surgical resection in a select group of patients and can be performed safely with a good success rate.

Endoscopic Balloon Dilatation of Anastomotic Strictures in Patients With Crohn's Disease: Effect of Immediate Endoscopic Success and Biological Therapy

Endoscopic Balloon Dilatation of Anastomotic Strictures in Patients With Crohn's Disease: Effect of Immediate Endoscopic Success and Biological Therapy

171 The Incidence and Endoscopic Management of Recurrent Post-Orthotopic Liver Transplantation (OLT) Biliary Strictures After Initial Successful Endoscopic Management

The Incidence and Endoscopic Management of Recurrent PostOrthotopic Liver Transplantation (OLT) Biliary Strictures After Initial Successful Endoscopic Management Mehul M. Patel, Aaron B. Trimble, Isaac Galandauer, Jason Broker, Shireen A. Pais, Patricia Sheiner, Edward Lebovics Division of Gastroenterology and Hepatobiliary Diseases, Westchester Medical Center, Valhalla, NY; Division of Liver Transplant and Hepatobiliary Surgery, Westchester Medical Center, Valhalla, NY Background: Successful endoscopic management of post-OLT strictures with multiple parallel stents has been reported. Few data on the incidence and management of recurrent strictures. Methods: We conducted a retrospective study of post-OLT pts who had prior successful endoscopic therapy of a biliary stricture and developed recurrent stricture. Primary management of strictures was initially by single stent placement. If the stricture persisted at the time of stent removal, parallel stents were placed. The number of parallel stents was increased every 4-8 weeks until the maximum number felt to safely accommodate the duct was reached. Endoscopic success was defined by radiologic improvement, improved liver enzymes, and ability to pass a balloon 12mm across the stricture with minimal resistance. Biliary reconstruction was undertaken for endoscopic failures or progressive liver dysfunction. Pts in which recurrent strictures developed after initial successful endoscopic management were considered for retreatment. Pts currently undergoing primary endoscopic therapy who have not yet reached an endpoint were excluded. Outcomes of stent therapy were examined based on stricture location. Results: From 3/01 to 6/10, OLT was performed in 495 pts of whom 128 (26%) underwent 397 ERCPs (mean 3.1 ERCP per pt). Biliary strictures were seen in 86 (17.4%) pts of whom 69 (80%) had only anastomotic strictures (AS), 13 (15%) had both AS and non-anastomotic strictures (NAS) and 4 (5%) had only NAS. Of 62 pts with AS who reached an endpoint, 50 (80.6%) were treated successfully, 12 (19.3%) failed treatment and required surgical intervention. Of the 50 pts with successful AS treatment, 10 (20%) had recurrent strictures; 8 (80%) successfully retreated, 2 (20%) failed re-treatment. AS pts with or without recurrence did not significantly differ in the number of ERCPs until initial success, maximum number of parallel stents, or duration of initial stent therapy. Of 13 pts with both AS and NAS, 10 pts reached an end point; 6 (60%) were treated successfully, 4 (40%) failed treatment. 1 of 6 pts that were treated successfully developed a recurrent stricture, failed a second treatment, and ultimately required re-transplant. The 4 pts with NAS all failed endoscopic treatment and required surgical intervention. The mean time from primary stricture resolution to recurrence was 107 57 days. Overall 23 of 86 (26.7%) pts required biliary reconstruction. All 9 pts with intra-hepatic strictures required repeat OLT. Conclusions: 1. Successful endoscopic therapy of post-OLT AS carries a high recurrence rate of 20% requiring vigilant monitoring; 2. Repeat endoscopic therapy of recurrent AS has a similar success rate (80%) as primary therapy resulting in 20% of prior responders proceeding to surgical biliary reconstruction; 3. NAS do not respond well to endoscopic therapy.

Su1452 Endoscopic Ampullectomy of Adenoma of the Major Duodenal Papilla (MPD): Long-Term Outcome

Endoscopic Ampullectomy of Adenoma of the Major Duodenal Papilla (MPD): Long-Term Outcome Marc F. Catalano, Naeem Aslam, Robbie Taha, Nalini M. Guda, Joseph E. Geenen Wisconsin Center for Advanced Research, GI Associates, LLC, Milwaukee, WI; Pancreatobiliary, St. Luke’s Medical Center, Milwaukee, WI Adenoma of MPD is more likely to undergo malignant transformation than adenoma elsewhere in duodenum. Pts w/ FAP have increased likelihood of papillary neoplasm. Treatment of ampullary adenomas is surgical excision. Endoscopic ampullectomy is a relatively new treatment option. Aim: Determine efficacy of endoscopic resection of ampullary adenoma. Methods: Consecutive pts w/ ampullary adenomas over 10yr were reviewed. Criteria for ampullectomy included: previously untreated, endoscopically accessible lesions w/ benign features. Pts w/ biliary or pancreatic extension of lesion were excluded. Imaging suggesting advanced disease (EUS, CT) was an exclusion criteria whereas presence of dysplasia w/o frank carcinoma was not. Ampullectomy technique: Standard polypectomy snare; blended current; dual sphincterotomy (pancreatic & biliary). Pancreatic duct (PD) stent placement was performed to prevent ampullary stenosis. Endoscopic success determined as complete excision & absence of recurrence during 2yr F/U. Endoscopic failure defined as inability to completely remove lesion, recurrence treated surgically, discovery of carcinoma beyond mucosal layer. Ampullectomy complications; early (pancreatitis, bleeding, perforation) & late (post-ampullectomy stenosis). Results: 58 pts; 31W; age 20-72 met inclusion criteria. 41 had sporadic adenomas & 17 had FAP. Presenting Sx: jaundice/cholangitis/pain (n 22); acute pancreatitis (AP) (n 11), bleeding (n 6); no Sx (n 19). Mean F/U was 38 mos (24-78). 49 pts (85%) had long-term success & 9 (15%) unsuccessful (initial failure, recurrent adenoma) including 6 initial failures, & 3 recurrences. High grade dysplasia present in 8; 3 had focal adeno CA. Lesions size was 10-40mm. Pts w/ successful ampullectomy had significantly smaller lesions (18.5vs28.3). FAP pts were significantly younger compared to sporadic (32.6vs58.4). FAP pts had significantly smaller lesions compared to sporadic (18.7vs25.2). Success rate in pts w/ FAP (n 17) was 94% (16/17) vs 80% (33/41) for sporadic. Adjunctive thermal ablation was used in 18/ 58 pts in (14 APC, 4 multipolar). Success was similar among pts who had ablation (15/18) vs w/o (34/40). Predictors of success included age 45 &, size of 24 mm. PD stent (5-7 Fr) was placed in all but 2 pts w/ accessible ducts. All but 14 pts underwent biliary stents based on clinically. All stents were removed w/in 8wks. There were 4 procedural complications in 58pts: AP (n 2), bleeding (n 1) & late papillary stenosis (n 1). AP occurred only in pts w/o PD stents. Papillary stenosis occurred more frequently in pts w/o PD stents (50%vs2%). Conclusion: Endoscopic treatment of ampullary adenomas in selective pts is highly successful & safe. Dual sphincterotomy/stenting may prevent postprocedural complications. Adjunctive thermoablation may prevent postampullectomy recurrence.

The role of endoscopic retrograde cholangiography for biliary stricture after adult living donor liver transplantation: Technical aspect and outcome

Objective. Biliary strictures, occurring after living donor liver transplantation (LDLT) with duct-to-duct biliary reconstruction, are usually treated by endoscopic retrograde cholangiography (ERC); nevertheless, its therapeutic value is still under evaluation. The aim of this study was to describe technical aspects of ERC in treating biliary strictures and evaluate their outcomes. Material and methods. A total of 147 patients who underwent ERC for biliary strictures distal to left and right main hepatic ducts occurring after LDLT performed between January 2004 and March 2007 were retrospectively analyzed. Biliary strictures were treated by both balloon dilation and stenting in consecutive ERC sessions. Then, we evaluated immediate and final endoscopic success rates. Results. Immediate endoscopic success was achieved in 82/147 (55.8%) patients and final endoscopic success in 52/141 (36.9%). An average of 6.3 endoscopic sessions and 12.7 months were required to achieve final endoscopic success. ERC-related complications including death in one patient occurred in about 7.2%. Mean recurrence-free period after final endoscopic success was 21.5 months, with six (11.5%) patients having a relapse of biliary strictures. Final endoscopic success group compared with failure group showed significantly later occurrence of biliary strictures after LDLT. Conclusions. Achieving final endoscopic success using ERC alone for treating post-LDLT biliary strictures distal to left and right main hepatic ducts is rather difficult, although outcomes are improving with time. Strategies are thought to be needed to improve outcomes such as technical/instrumental improvement.

Pseudocyst Management Revisited: Failed Surgery Yields Endoscopic Success

Purpose: A 14yo male presented with severe abdominal pain associated with nausea and vomiting after sustaining blunt abdominal trauma while playing football. Physical examination revealed generalized abdominal tenderness on deep palpation. Serologic tests noted a lipase of 7774 IU/L, amylase of 1307 IU/L and WBC of 18,000/uL; a computed tomography (CT) scan of the abdomen revealed hemoperitoneum and a pancreatic body laceration. The patient was started on antibiotic therapy and admitted to the Pediatric ICU for observation. He was evaluated by surgery and conservative management was recommended. The patient responded well clinically with resolution of pancreatitis over the course of one week. An abdominal ultrasound (US) completed on the day of discharge eight days later revealed a 5.8 × 3.0 × 6.3 cm pancreatic cyst. Upon evaluation one month after discharge, the patient complained of significant reflux with abdominal discomfort. On physical exam, he was noted to have a large palpable mass in the epigastrium. A follow-up CT of the abdomen revealed a progressively enlarging well-circumscribed pancreatic fluid collection which had doubled in size. Given the enlarging symptomatic pseudocyst, a transgastric cystgastrostomy was performed surgically and complete evacuation of the pancreatic fluid collection was achieved; pathologic specimens confirmed a pseudocyst. A post surgical abdominal US completed one month later revealed a large recurring pancreatic cystic lesion. The patient complained of early satiety and physical exam was notable for recurrence of the large palpable abdominal fluid collection; he was then referred to GI for further management. Endoscopic transgastric pseudocyst drainage with transmural stenting was successfully performed with complete resolution of the pancreatic pseudocyst. Subsequent imaging three months after endoscopic drainage confirmed complete resolution with no recurrence of the pseudocyst. Despite current literature suggesting surgical management of pancreatic pseudocysts as the “gold standard,” endoscopic therapy via endoscopic ultrasound guided transmural pseudocyst drainage is emerging as the method of choice due to its minimally invasive approach and safety and success profile when compared to surgery; pseudocyst resolution rates range from 65-89% with no mortality reported to date. Also, endoscopic management allows for transpapillary stenting which may be needed if pancreatic duct disruption is a suspected etiology of pseudocyst formation. Surgical management of pancreatic pseudocysts is invasive and carries substantial morbidity; therefore, we suggest that surgical management be reserved for cases which are not amenable to endoscopic drainage.

Management of Benign Ureteral Strictures in the Endoscopic Era

During the past decade, endoscopic management has emerged as the first-line treatment of benign ureteral strictures. We reviewed our experience with the management of benign ureteral strictures to determine the success rate of endoscopic surgery in a contemporary series and assessed the viability of surgical reimplantation in the modern era. We identified 75 patients with a diagnosis of ureteral stricture between 2000 and 2005 via electronic medical records search and excluded those with completely obliterated, external compressive, malignant, or ureteroenteric strictures, ureteropelvic junction obstruction, and those with follow-up less than 2 months. Thirty-four patients who were treated endoscopically (balloon dilation and/or holmium laser endoureterotomy) were identified. Mean stricture length in each patient was 1.6 +/- 1 cm (range 0.5-4 cm), and the mean number of procedures per patient was 1.7 +/- 0.8. Endoscopic success was achieved in 29 (85%), while 5 (15%) patients experienced endoscopic management failure and ultimately needed ureteral reimplantation. When comparing the endoscopically treated and reimplant groups, there was no significant difference in mean stricture length (1.38 +/- 1.13 vs 2 +/- 1.1 cm, P = 0.14), yet mean number of procedures performed (1.41 +/- 0.85 vs 3.6 +/- 1.5; P = 0.002) reached statistical significance. There were no clinical or radiographic signs of obstruction in 100% of patients who received endoscopic therapy only and 100% of patients who needed open surgical management at a mean follow-up of 25.2 +/- 19.3 and 7.7 +/- 3.2 months, respectively. Endoscopic surgery is clearly a successful primary treatment modality in the management of benign ureteral strictures with minimal morbidity. In the modern era of endoscopic surgery, however, ureteral reimplantation remains a viable option in treating the small subset of patients with benign ureteral strictures for whom endoscopic management fails.

Therapeutic pancreatic endoscopy after Whipple resection requires rendezvous access

Chronic pancreatic complications after pancreaticoduodenectomy, including strictured pancreaticojejunostomy and pancreatic fistulas, may be amenable to endoscopic therapy. To date there is no published series focusing on pancreatic endotherapy in this group of patients. We report our experience performing pancreatic therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in 10 patients after pancreaticoduodenectomy. All patients had evidence of pancreatic anastomotic obstruction by endoscopic ultrasound (EUS) or secretin-enhanced magnetic resonance cholangiopancreatography. Technical endoscopic success and clinical outcomes were measured. Technically successful endoscopic access and therapy was ultimately achieved by ERCP in eight of the 10 patients. Although a duodenoscope or pediatric colonoscope could be advanced up the afferent limb in all patients, initial unassisted pancreatic cannulation and therapy was successful in only one patient. Rendezvous techniques, either percutaneous or EUS-guided, were required for endoscopic access in the other 9 patients. Complications included moderate pancreatitis with retroperitoneal air after percutaneous rendezvous access in 1 patient, and fever in 1 patient. Therapeutic pancreatic ERCP for chronic complications after Whipple pancreaticoduodenectomy is feasible but quite challenging. Endoscopic access through a stenotic pancreaticojejunal anastomosi generally requires either EUS or percutaneous rendezvous assistance.

Endobronchial tumor debulking with a flexible cryoprobe for immediate treatment of malignant stenosis

In addition to use of a laser, argon plasma coagulation, electrocautery, or coring with a rigid bronchoscope, tumor debulking with a flexible cryoprobe is used for therapeutic bronchoscopy with an immediate effect for endobronchial pathologies. We performed this analysis to determine the usefulness, efficacy, and safety of the flexible cryorecanalization in a large population under routine conditions. We identified 225 bronchoscopic interventions that were done as cryorecanalization with a flexible cryoprobe. All patients had symptomatic airway stenosis. We determined the endoscopic success rate and safety (bleeding and perforation) of the procedure. Successful cryorecanalization was achieved in 205 (91.1%) of 225 patients. The flexible cryoprobe was used with all patients, in most patients in combination with flexible bronchoscopy and only in a minority (n = 31, 13.8%) in combination with a rigid bronchoscope. Additional interventional techniques used were endobronchial stents (n = 11, 4.9%) and argon plasma coagulation (n = 37, 16.4%). Mild bleeding (if ice-cold NaCl or epinephrine solution was necessary) occurred in 9 (4.0%) patients, moderate bleeding (if argon plasma coagulation or a bronchus blocker was required) occurred in 18 (8.0%) patients, and severe bleeding (events with hemodynamic instability) never occurred. Cryorecanalization with the flexible cryoprobe for treatment of symptomatic endobronchial tumor stenosis is a safe technique with a high success rate and immediate treatment effect.

Papillectomy for ampullary neoplasm: results of a single referral center over a 10-year period

Tumors arising from the duodenal papilla account for approximately 5% of GI neoplasms, but are increasingly identified. To describe the clinical characteristics and outcomes in a large single-center experience with patients referred for ampullary lesions. A retrospective review of the Virginia Mason Medical Center endoscopy and hospital service database. Tertiary referral center. One hundred ninety-three patients referred for ampullary lesions from 1997 to 2007. Endoscopic management of ampullary lesions. The relationship of demographic and clinical data with endoscopic treatment and clinical outcomes in these patients. One hundred ninety-three patients underwent endoscopy for ampullary lesions. Fifteen juxta-ampullary lesions and 10 normal variants were excluded. Among 168 patients, there were 112 (67%) adenomas, 38 (23%) adenocarcinomas, and 18 (10%) nonadenomatous lesions. There were 88 men and 80 women, with a mean age of 64 years. Clinical presentation included cholestasis/cholangitis (72 patients), abdominal pain (54 patients), incidental/asymptomatic (51 patients), pancreatitis (9 patients), and bleeding (7 patients). Of the 57 patients referred to surgery, 42 were sent directly without papillectomy, and 16 were sent after papillectomy. Papillectomies were performed in 102 patients with adenomatous lesions. The mean tumor size was 2.4 cm (range 0.5-6 cm). The papillectomy complication rate was 21%: mild pancreatitis in 10 (10%) patients, cholangitis in 1, retroperitoneal perforation in 1 (adenocarcinoma), intraperitoneal perforation in 1 (lateral extension), bleeding in 5 (lateral extension in 2 of these 5), and delayed papillary stenosis in 3. Recurrences were seen in 8%. The endoscopic success rate was 84%. Factors affecting success were a smaller adenoma size and the absence of dilated ducts. Most ampullary adenomas are amenable to endoscopy. Underlying malignancy and lateral extension may be risk factors for bleeding and perforation. Smaller lesion size and the absence of dilated ducts are factors favorably affecting success.

Endoscopic Snare Papillectomy: Outcomes of a Large Consecutive Series of Patients

Background: The role of endoscopic snare papillectomy (ESP) for the management of tumors of the duodenal papilla is debated. The aim of the study is to evaluate the outcomes of ESP in a large consecutive series of patients with tumors of the duodenal papilla. Patients and Methods: The study included 58 patients (25 men, mean age 58 years, range 26-83 years, ten affected by Familial Adenomatous Polyposis [FAP]) with a neoplasm of the duodenal papilla without any endoscopic and histological feature of malignancy, who underwent ESP between 1999 and September 2007. Medical, endoscopic, surgical and histological reports were reviewed to evaluate the complication rate, and the outcomes of ESP at the mid-term follow-up. Endoscopic success was defined as complete excision of the lesion regardless to the number of resections required (including patients with small recurrences that were easily treated endoscopically). Results: ESP was performed en-bloc in 47 patients (81%). After resection, 45 patients (77.6%) were diagnosed with an adenoma (23 with high grade dysplasia/in-situ carcinoma), 11 (18.9%) with an adenocarcinoma (AdCa), 2 (3.4%) with a neuroendocrine tumor. Eight patients with AdCa underwent pancreatico-duodenectomy; three patients were not operated because of comorbidities. Two patients with a neuroendocrine tumor did not experience recurrence during a 33.5 months follow up. All the patients with a papillary adenoma (n=45) were successfully treated by ESP alone: during a 18.9 months follow up, 36 patients did not experience any recurrence; 9 (20%) were diagnosed with a recurrent adenoma but were successfully re-treated by endoscopy. Five out of 9 recurrences occurred in FAP patients; three recurrences occurred after piece-meal resections. Frequency of recurrence did not differ for adenoma with low- (22.7%) or high- (17.4%) grade dysplasia (p=NS). Early complication rate was 12% (including 4 severe bleedings, 2 perforations, 1 mild pancreatitis). Late complications occurred in two patients who experienced a stricture of the biliary and pancreatic duct. The patients were treated by endoscopy. Overall, eight complications were managed conservatively. One patient with a perforation underwent surgery. Conclusions: The present series confirms that ESP is an effective procedure for the management of tumors of the duodenal papilla. ESP is associated with an acceptable complication rate and no mortality. A relatively high frequency of recurrence was reported in this series (20%). However all the patients with recurrences were successfully treated by endoscopy. ESP should be considered as a first-line therapy for benign lesions of the duodenal papilla.

ERCP in the Very Elderly: Outcomes Among Patients Older than Eighty

Life expectancy is rising, which is increasing the demand for endoscopic retrograde cholangiopancreatography (ERCP) in the elderly. Little data, particularly on complex procedures, has been reported. In this study, we compare the differences in the success and complications in ERCP between patients older and younger than 80 years old. We used a large endoscopic database reviewing the ERCPs performed and 30-day complications addressing age, degree of difficulty of procedures, and complications. A total of 2,606 patients underwent 3,924 ERCPs. Six hundred and twenty-eight were octogenarians undergoing 728 procedures. Mean age was 83.5 years in the octogenarian group and 59.0 years in the younger group. The endoscopic success rate was lower in octogenarians (96.9 vs. 98.3%, P = 0.004). Overall, complication rates between both groups was significantly less in older compared to younger patients (1.64 vs. 3.50%, P = 0.006). Complication and failure rates were higher as procedure complexity increased in all patients. ERCP in the elderly carries a high degree of success with low complication rates. Elderly patients carry similar risks of bleeding and perforation and a lower risk of pancreatitis.

A Phase 2, Open-Label Study of the Safety and Efficacy of Intravenous Anidulafungin as a Treatment for Azole-Refractory Mucosal Candidiasis

Azole-refractory mucosal candidiasis is a debilitating disease frequently seen in patients who are immunosuppressed as a result of HIV, malignancy, posttransplant immunosuppressive therapy, persistent neutropenia, steroid use, or diabetes. Anidulafungin has potent activity against a broad spectrum of Candida species, including strains resistant to azoles and amphotericin B. We performed an open-label, noncomparative study to examine efficacy and safety of anidulafungin in patients with azole-refractory oropharyngeal and esophageal candidiasis. Patients enrolled met diagnostic criteria for azole-refractory mucosal candidiasis. They received intravenous anidulafungin 100 mg on day 1 followed by daily 50-mg doses on day 2 through day 14 or for a maximum of 21 days. Primary efficacy variables were clinical response (for oropharyngeal candidiasis) and endoscopic and clinical response (for esophageal candidiasis) at the end of therapy. Nineteen patients were enrolled; 89% had advanced HIV infection. Clinical success was observed in 95% of patients at end of therapy, and endoscopic success was observed in 92% of patients with esophageal candidiasis. At follow-up, clinical success was maintained in 47% of patients. The most common adverse event, experienced by 4 patients, was nausea and/or vomiting. Anidulafungin was well tolerated and efficacious in the treatment of patients with azole-refractory esophageal and oropharyngeal candidiasis.

Endoscopic resection of ampullary tumors: 12-year review of 21 cases

Endoscopic snare papillectomy is increasingly performed with curative intent for benign papillary tumors. This study aimed to evaluate the outcome of endoscopic resection for ampullary tumors at a single center. All ampullary tumors without macroscopic features of malignancy identified by the endoscopic retrograde cholangiopancreatography (ERCP) from January 1995 to February 2007 were included in the study. Papillectomy was performed by snare resection using electrocautery. Argon plasma coagulation was effective for fulguration of small tissue remnants not amenable to snare resection. Of the 21 patients (9 men and 12 women; mean age, 67.2 +/- 14.3 years) evaluated, 11 had adenoma (7 had low-grade dysplasia [LGD] and 4 had high-grade dysplasia [HGD]), and 10 had carcinoma. All the patients underwent papillectomy. Of the 21 patients, 18 had extraductal growth or minimal intraductal growth, and 3 had extensive intraductal growth. The endoscopic complications (23.8%) included one case of mild bleeding, two cases of mild pancreatitis, and two cases of moderate pancreatitis. After papillectomy, 15 patients underwent Whipple procedures (endoscopic failure, 74.1%), including 3 patients with extensive intraductal growth (complete removal of the lesion impossible), 9 patients with carcinoma beyond the mucosal layer, and 3 patients with recurrence treated surgically. Endoscopic success (28.5%) was obtained for the remaining six patients (4 with LGD and 2 with HGD). Papillectomy was determined to be curative after a mean follow-up period of 15.9 +/- 14.9 months. In the hands of an experienced endoscopist, endoscopic papillectomy is a clinically effective treatment for ampullary tumors without invasive neoplasia. Evaluation of a prepapillectomy tumor extension is an important criterion for assessment of endoscopic success.

Gastric Antral Vascular Ectasia: Does APC Cautery Really Decrease Bleeding?

Watermelon stomach (gastric antral vascular ectasia), is an uncommon condition affecting the antrum which often presents with anemia presumed to be secondary to bleeding. Treatment has ranged from supportive (iron supplementation, transfusions) to surgical intervention to medical therapy (i.e. estrogens) to endoscopic treatment. Endoscopic therapy includes cautery, which can be either contact (bipolar) or non contact (argon plasma coagulation-APC). Several studies with APC have concluded that it is a safe and effective way of treating GAVE. We have noticed that despite adequate non-contact cautery, a number of our patients with GAVE continue to have transfusion requirements. Objective: To determine the benefit of multiple APC treatments on transfusion requirements in patients with transfusion requirements documented through a provincial blood bank database. Methods/Results: We have prospectively collected data on 35 consecutive GAVE patients in an effort to determine clinical outcomes. Of these, 22 patients (15 female) treated between 2002-2004 had complete provincial blood bank data for one year prior and one year post-therapy available. Over the treatment period (0 to 2.2 years, mean 7 months), the mean blood transfusion requirement was 7.8 units of PRBC (range 0 to 55 units) with a mean number of APC treatments at 3.5 (range 1 to 8). We compared the transfusions requirements (0 to 59 units, mean 11.09) 1 year prior to the first APC treatment to the transfusion requirements (0 to 50 units, mean 5.73) in the year following the last APC treatment and found that APC treatments did not statistically reduce the transfusion requirements of our patients (mean of the difference 5.4, SD 18.1, p-value > 0.17 with or without adjusting other clinical factors like age, and gender. Even when excluding two patients who ‘skewed’ the data, the differences in transfusion requirements was still not significant. Conclusion: Although in selected patients cautery of GAVE appears to have impressive endoscopic results, in patients with transfusion requirements and GAVE, our data suggests that APC has not significantly decreased transfusion requirements, despite apparent endoscopic success. Factors responsible for this treatment inefficiency are being explored however, it appears that at least some of the patients have other sources (i.e. small intestinal) of bleeding.