Faculty Bibliography

BACKGROUND:Cholecystectomy remains the gold standard treatment of cholecystitis. Endoscopic treatment of cholecystitis includes transpapillary gallbladder drainage. Recently, endoscopic ultrasound-guided transmural drainage of the gallbladder (EUS-GBD) has been reported. This study reports the cumulative experience of an international group performing EUS-GBD. METHODS:Cases of EUS-GBD from January 2012 to November 2013 from 3 tertiary-care institutions were captured in a registry. Patient demographics, disease characteristics, procedural and clinical outcomes were recorded. RESULTS:35 patients (15 malignant, 20 benign) were included. Median age was 81 years (SD=13.76 years), sixteen (46%) were males. Median follow-up was 91.5 days (SD=157 days). Transmural access was obtained from the stomach (n=17) or duodenum (n=18). Stents placed included plastic (n=6), metal (n=20), or combination (n=7). Technical success was achieved in 91.4% (n=32). Immediate adverse events (14%) included: bleeding, stent migration, cholecystitis and hemoperitoneum. Delayed adverse events (11%) included abscess formation and recurrence of cholecystitis. Long-term clinical success rate was 89%. Stent type and puncture site were not associated with immediate (p=0.88, p=0.62), or long-term (p=0.47, p=0.27) success. CONCLUSIONS:EUS-GBD appears to be feasible, safe, and effective. Prospective studies are needed to confirm these findings and identify the best technique to use. CLINICAL TRIAL REGISTRATION/BACKGROUND:NCT01522573.

PURPOSE OF REVIEW/OBJECTIVE:Radiofrequency ablation (RFA) has been recognized for its potential in palliative treatment for pancreatic cancer as well as malignant biliary strictures. The purpose of this review is to describe the technology, endoscopic technique, and reported outcomes of endoscopic RFA in the management of malignant biliary strictures and unresectable pancreatic cancer. RECENT FINDINGS/RESULTS:Intraductal biliary RFA is safe and feasible and appears to confer a survival advantage. Pancreatic endoscopic ultrasound-guided RFA is a promising new technique and may result in either resolution of tumor or reduction in size. SUMMARY/CONCLUSIONS:Intraductal biliary RFA and pancreatic endoscopic ultrasound-guided RFA are important modalities in malignant biliary obstruction and unresectable pancreatic cancer. Intraductal biliary RFA should be used as an adjunct to biliary stenting. Further trials are needed to determine if RFA leads to a benefit in pancreatic cancer treatment. Two prospective trials are currently underway to determine if intraductal biliary RFA indeed confers a survival advantage in malignant obstruction.

GOALS: To describe a multicenter experience using an endoscopic suturing device for management of gastrointestinal (GI) defects and stent anchorage. BACKGROUND: Endoscopic closure of GI defects including perforations, fistulas, and anastomotic leaks as well as stent anchorage has improved with technological advances. An endoscopic suturing device (OverStitch; Apollo Endosurgery Inc.) has been used. STUDY: Retrospective study of consecutive patients who underwent endoscopic suturing for management of GI defects and/or stent anchorage were enrolled between March 2012 and January 2014 at multiple academic medical centers. Data regarding demographic information and outcomes including long-term success were collected. RESULTS: One hundred and twenty-two patients (mean age, 52.6 y; 64.2% females) underwent endoscopic suturing at 8 centers for stent anchorage (n=47; 38.5%), fistulas (n=40; 32.7%), leaks (n=15; 12.3%), and perforations (n=20; 16.4%). A total of 44.2% underwent prior therapy and 97.5% achieved technical success. Immediate clinical success was achieved in 79.5%. Long-term clinical success was noted in 78.8% with mean follow-up of 68 days. Clinical success was 91.4% in stent anchorage, 93% in perforations, 80% in fistulas, but only 27% in anastomotic leak closure. CONCLUSIONS: Endoscopic suturing for management of GI defects and stent anchoring is safe and efficacious. Stent migration after stent anchoring was reduced compared with published data. Long-term success without further intervention was achieved in the majority of patients. The role of endoscopic suturing for repair of anastomotic leaks remains unclear given limited success in this retrospective study.

BACKGROUND:High-risk patients with cholecystitis have conventionally been offered percutaneous gallbladder drainage (PGBD) for treatment. A growing experience of endoscopic gallbladder drainage (EGBD) has been reported to be effective and safe. OBJECTIVE:To compare the short- and long-term outcomes of EGBD and PGBD. DESIGN/METHODS:A retrospective review. SETTING/METHODS:Single academic tertiary care center. PATIENTS/METHODS:Inpatients diagnosed with cholecystitis. INTERVENTIONS/METHODS:Any patient deemed a nonsurgical candidate and who has undergone either PGBD or EGBD was included in the analysis. MAIN OUTCOME MEASUREMENTS/METHODS:Patient demographics along with procedural and clinical outcomes were recorded for each group. RESULTS:Forty-three patients underwent PGBD and 30 underwent EGBD (24 transpapillary, 6 transmural). Technical (97.6% vs 100%) and clinical (97.6% vs 86.7%) success rates of PGBD and EGBD were similar. However, postprocedure hospital length of stay (16.3 vs 7.6 days), time to clinical resolution (4.6 vs 3.0 days), adverse event rate (39.5% vs 13.3%), number of sessions (2.0 vs 1.0), number of repeat interventions (53.4% vs 13.3%), and postprocedure pain scores (3.8 vs 2.1) were significantly higher for PGBD than EGBD. LIMITATIONS/CONCLUSIONS:Retrospective analysis. CONCLUSION/CONCLUSIONS:Although EGBD has similar technical and clinical success compared with PGBD, it uses fewer hospital resources and results in fewer adverse events, improved pain scores, and decreased need for repeat gallbladder drainage. EGBD may provide a less-invasive, safer, cost-effective option for gallbladder drainage than PGBD with improved clinical outcomes.