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1.  Increased fat in pancreas not associated with risk of pancreatitis post-endoscopic retrograde cholangiopancreatography 
A preliminary study has shown increased pancreatic fat in patients with idiopathic pancreatitis and sphincter of Oddi dysfunction. In this study, we aimed to determine if an increased quantity of pancreatic fat is an independent risk factor for pancreatitis post-endoscopic retrograde cholangiopancreatography (ERCP).
In this case control study, we retrospectively reviewed a local radiological and ERCP database to identify patients who had had abdominal magnetic resonance imaging (MRI) followed by ERCP no more than 60 days later between September 2003 and January 2011. Percentage of fat was determined by recording signal intensity in the in-phase (Sin) and out-of-phase (Sout) T1-weighted gradient sequences, and calculation of the fat fraction as (Sin − Sout)/(Sin) × 2 by an abdominal radiologist blinded to clinical history. Controls matched for age, gender, and other pancreatobiliary disease were selected from a group with no post-ERCP pancreatitis (before fat content of the pancreas was analyzed).
Forty-seven patients were enrolled. Compared with controls, subjects with post-ERCP pancreatitis were similar in terms of age (41.4 years versus 41.1 years), gender (21.2% versus 20.2% males), pancreatobiliary disease characteristics, and most ERCP techniques. Measurements of pancreatic head, body, and tail fat and body mass index were similar in patients and controls.
Increased pancreatic fat on MRI criteria is not an independent predictor of post-ERCP pancreatitis.
PMCID: PMC4061141  PMID: 24959090
magnetic resonance imaging; obesity; pancreatic fat; post-ERCP pancreatitis; sphincter of Oddi dysfunction
2.  Rescue Endoscopic Ultrasound (EUS)-Guided Trucut Biopsy Following Suboptimal EUS-Guided Fine Needle Aspiration for Mediastinal Lesions 
Gut and Liver  2013;7(2):150-156.
Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and Trucut biopsy (TCB) are sensitive techniques for diagnosing mediastinal lesions, but it is unclear how either one or both should be used to obtain a pathologic diagnosis. The objective of our study was to evaluate whether EUS-TCB impacts the diagnosis of mediastinal lesions after the initial on-site review of EUS-FNA specimen suggests a suboptimal result.
We enrolled consecutive patients with mediastinal lesions who underwent EUS-TCB during the same procedure if the initial EUS-FNA demonstrated an inadequate FNA sample or suggested that histopathology was required for diagnosis. Diagnostic accuracies between procedures were compared as the main outcome.
Twenty-seven patients (14 men; median age, 56 years; range, 19 to 82 years) underwent EUS-FNA and EUS-TCB to evaluate a mediastinal lymphadenopathy or mass (n=17), to determine the cancer stage (n=3) or to exclude tumor recurrence or metastasis (n=7). The overall diagnostic accuracies of EUS-FNA and EUS-TCB were 78% and 67%, respectively (p=0.375). The combined diagnostic accuracy of EUS-FNA plus EUS-TCB was 82%. In six patients with nondiagnostic EUS-FNA, EUS-TCB provided a final diagnosis in one patient (17%).
In the current series of patients with mediastinal masses or adenopathy, the administration of EUS-TCB following suboptimal results for the on-site cytology review did not increase the diagnostic yield.
PMCID: PMC3607767  PMID: 23560149
Endoscopic ultrasound; Endoscopic ultrasound-guided fine needle aspiration; Endoscopic ultrasound-guided Trucut biopsy; Mediastinum
3.  Endoscopic Ultrasound-Guided Celiac Plexus Neurolysis in Pancreatic Cancer: A Prospective Pilot Study of Safety Using 10 mL versus 20 mL Alcohol 
Background. The dose of alcohol used in EUS-CPN is not standardized. The objective was to compare the safety of 20 mL alcohol versus 10 mL alcohol during EUS-CPN for patients with pancreatic cancer-related pain. Methods. 20 patients were selected to receive 10 mL or 20 mL of alcohol during EUS-CPN. Followup was done at baseline, 24 hours, and weekly. Health-related quality of life (HRQoL) was assessed at baseline, week 2, week 4, and every 4 weeks thereafter until pain returned. Results. There were no major complications in both groups. Minor self-limited adverse effects were seen in 6 (30%) subjects and included lightheadedness in 1 (5%), transient diarrhea in 2 (10%), and transient nausea and vomiting in 3. Pain relief was similar in both groups: 80% in the 10 mL group and 100% in the 20 mL group (P = 0.21). The mean (± SD) duration of pain relief in the 10 mL and 20 mL groups was 7.9 ± 10.8 and 8.4 ± 9.2 weeks, respectively. 30% of patients in each group had complete pain relief. Conclusions. EUS-CPN using 20 mL of alcohol is safe. Similar clinical outcomes were seen in both groups. Further investigations to confirm these findings are warranted.
PMCID: PMC3556397  PMID: 23365492
4.  A Randomized Trial of Rectal Indomethacin to Prevent Post-ERCP Pancreatitis 
The New England Journal of Medicine  2012;366(15):1414-1422.
Preliminary research suggests that rectally administered nonsteroidal antiinflammatory drugs may reduce the incidence of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP).
In this multicenter, randomized, placebo-controlled, double-blind clinical trial, we assigned patients at elevated risk for post-ERCP pancreatitis to receive a single dose of rectal indomethacin or placebo immediately after ERCP. Patients were determined to be at high risk on the basis of validated patient- and procedure-related risk factors. The primary outcome was post-ERCP pancreatitis, which was defined as new upper abdominal pain, an elevation in pancreatic enzymes to at least three times the upper limit of the normal range 24 hours after the procedure, and hospitalization for at least 2 nights.
A total of 602 patients were enrolled and completed follow-up. The majority of patients (82%) had a clinical suspicion of sphincter of Oddi dysfunction. Post-ERCP pancreatitis developed in 27 of 295 patients (9.2%) in the indomethacin group and in 52 of 307 patients (16.9%) in the placebo group (P = 0.005). Moderate-to-severe pancreatitis developed in 13 patients (4.4%) in the indomethacin group and in 27 patients (8.8%) in the placebo group (P = 0.03).
Among patients at high risk for post-ERCP pancreatitis, rectal indomethacin significantly reduced the incidence of the condition. (Funded by the National Institutes of Health; number, NCT00820612.)
PMCID: PMC3339271  PMID: 22494121
5.  Fluid analysis prior to surgical resection of suspected mucinous pancreatic cysts. A single centre experience 
EUS-FNA cytology and fluid analysis are frequently utilized to evaluate pancreatic cysts. Elevated cyst fluid CEA is usually indicative of a mucinous pancreatic cyst but whether CEA or amylase values can subclassify various mucinous cysts is unknown. The purpose of this study is to determine whether cyst fluid CEA and amylase obtained by EUS-FNA can differentiate between mucinous cystic neoplasms (MCNs) and intraductal papillary mucinous neoplasms (IPMNs).
Using our prospective hospital EUS and surgical databases, we identified all patients who underwent EUS of a pancreatic cyst prior to surgical resection, in the last 10 years. Cysts were pathologically sub-classified as MCNs or IPMNs; all other cysts were considered non-mucinous. Values of cyst fluid CEA and amylase were correlated to corresponding surgical histopathology and compared between the two groups.
134 patients underwent surgery for pancreatic cysts including 82 (63%) that also had preoperative EUS. EUS-FNA was performed in 61/82 (74%) and cyst fluid analysis in 35/61 (57%) including CEA and amylase in 35 and 33 patients, respectively. Histopathology in these 35 cysts demonstrated nonmucinous cysts in 10 and mucinous cysts in 25 including: MCNs (n=9) and IPMNs (n=16). Cyst fluid CEA (p=0.19) and amylase (p=0.64) between all IPMNs and MCNs were similar. Between branched duct IPMNs and MCNs alone, cyst fluid CEA (p=0.34) and amylase (p=0.92) were also similar.
In this single center study, pancreatic cyst fluid amylase and CEA levels appeared to be of limited value to influence the differential of mucinous pancreatic cysts. Larger studies are recommended to evaluate this role further.
PMCID: PMC3397629  PMID: 22811854
pancreatic cysts; EUS; FNA; amylase; CEA
6.  Bedside Endoscopic Ultrasound in Critically Ill patients 
Background. The aim of this study was to evaluate the role and impact of EUS in the management of critically ill patients. Methods. We retrospectively identified all patients at our institution over a 68-month period in whom bedside inpatient EUS was performed. EUS was considered to have a significant impact if a new diagnosis was established and/or the findings altered subsequent clinical management. Results. Fifteen patients (9 male; mean age 58 ± 15 years) underwent bedside EUS without complications. EUS-FNA (median 4 passes; range 2–7) performed in 12 (80%) demonstrated a malignant mediastinal mass/lymph node (5), pancreatic abscess (1), excluded a pelvic abscess (1), established enlarged gastric folds as benign (1) and excluded malignancy in enlarged mediastinal (1) and porta hepatis adenopathy (1). In two patients, EUS-FNA failed to diagnose mediastinal histoplasmosis (1) and a hemorrhagic pancreatic pseudocyst (1). In three diagnostic exams without FNA, EUS correctly excluded choledocholithaisis (n = 1) and cholangiocarcinoma (1), and found gastric varices successfully thrombosed after previous cyanoacrylate injection (1). EUS was considered to have an impact in 13/15 (87%) patients. Conclusions. In this series, bedside EUS in critically ill patients was technically feasible, safe and had a major impact on the majority of patients.
PMCID: PMC3123909  PMID: 21747653
7.  The effect of biliary sphincterotomy on serum cholesterol levels in postcholecystectomy patients: A pilot study 
Cholesterol, in the form of bile salts, is reabsorbed from the small intestine via the enterohepatic circulation. Biliary sphincterotomy increases the delivery of bile to the terminal ileum. If the absorptive capacity is exceeded, cholesterol excretion may increase, resulting in a decrease in serum cholesterol levels and improvement in serum lipid profiles.
To determine the effect of biliary sphincterotomy on serum cholesterol levels in patients without biliary obstruction.
Postcholecystectomy patients with type III biliary sphincter of Oddi dysfunction (disabling pancreatobiliary-type pain with normal liver function tests and bile duct diameter) who underwent biliary sphincterotomy were identified retrospectively from the endoscopic retrograde cholangiopancreatography database. Baseline (pre-endoscopic retrograde cholangiopancreatography) laboratory investigations (including cholesterol) were obtained for all patients. The effect of sphincterotomy on total cholesterol levels was noted in all patients who returned for subsequent procedures (temporary pancreatic stent removal or evaluation of recurrent symptoms), and also in the subgroup of patients with baseline hypercholesterolemia (higher than 5.18 mmol/L).
In the present pilot study, the performance of biliary sphincterotomy was associated with a reduction in total serum cholesterol levels in postcholecystectomy patients without biliary obstruction. This was statistically significant in patients with a baseline cholesterol level higher than 5.18 mmol/L. A possible effect on low-and high-density lipoprotein concentrations was not evaluated. The influence of dietary changes and exercise were not accounted for.
A prospective, controlled study involving a larger series of patients is required to determine whether biliary sphincterotomy lowers cholesterol levels and improves lipid profiles.
PMCID: PMC2657665  PMID: 17299610
Biliary sphincterotomy; Cholesterol levels; Postcholecystectomy

Results 1-7 (7)