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Biomedical subjects

M S Branch

Publications and source records attributed to M S Branch.

At least 19 recordsLinked to original sources
PubMed2003

The importance of indication in the diagnostic value of push enteroscopy.

BACKGROUND AND STUDY AIMS: Small-bowel enteroscopy (SBE) is frequently used to examine patients suspected of small-bowel disease. Unfortunately, the diagnostic yield varies widely, from 13 % to 78 % of cases. This disparity may be in part attributable to the vast array of indications for the use of the procedure. The purpose of this study was to examine the diagnostic yield of small-bowel enteroscopy for various indications. PATIENTS AND METHODS: This is a retrospective cohort study of all patients who underwent SBE over a 5-year period, from 1995 to 1999. RESULTS: The indications were grouped into in-patient gastrointestinal blood loss (46% of the patient population), outpatient gastrointestinal blood loss (33 %), abnormal radiographic study (7%), iron-deficiency anemia (5%), and others (9%, defined as anemia not otherwise specified, abdominal pain, nausea and vomiting, diarrhea, and weight loss). The overall diagnostic yield was 42 %. Gastrointestinal bleeding had the highest yield, at 44% (in-patient gastrointestinal blood loss 51%, outpatient gastrointestinal blood loss 40%; P=0.1314). Patients with iron-deficiency anemia had a yield of 42%, and patients with a previous abnormal radiograph had a yield of 41%. The combined diagnostic yield for the indications in the "other" category was 21% --significantly lower than in patients with gastrointestinal bleeding, abnormal radiographs, and iron deficiency (P=0.049). CONCLUSIONS: SBE is safe and useful in the evaluation of small-bowel disease. Although the overall yield is highly dependent on the specific indication, it is effective for patients with in-patient or outpatient gastrointestinal blood loss, patients with abnormal radiographs that demonstrate small-bowel pathology considered to be within reach of the enteroscope, and iron-deficiency anemia. There are insufficient data to support the use of enteroscopy for other indications such as anemia not otherwise specified, abdominal pain, nausea and vomiting, and chronic diarrhea, and in these cases it is unlikely to be useful.

Adolescent↗
PubMed2003

Predictors of successful clinical and laboratory outcomes in patients with primary sclerosing cholangitis undergoing endoscopic retrograde cholangiopancreatography.

UNLABELLED: Endoscopic retrograde cholangiopancreatography (ERCP) in patients with primary sclerosing cholangitis (PSC) can be a challenging and sometimes gratifying opportunity for therapeutic intervention. Although there often appears to be initial radiological improvement after ERCP, the benefit as measured by serial estimations of subsequent liver enzymes is questionable. The fluctuating course of the inflammatory process makes the interpretation of serology even more difficult. OBJECTIVES: To document and compare the liver profile and clinical status of patients before and after diagnostic and therapeutic ERCP; to determine predictors of clinical and laboratory success in patients with PSC; and to assess the complication rate of diagnostic and therapeutic ERCP in these patients. METHODS: All patients with PSC who underwent ERCP at the authors' medical centres between January 6, 1987 and January 12, 1998 were identified using a computerized database. Presenting symptoms, liver enzymes (aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase) and bilirubin were recorded before ERCP. Clinical success was defined as resolution of the presenting symptoms. Laboratory success was defined as improvement in two of three liver enzymes by at least 50%, or resolution of jaundice. RESULTS: One hundred four patients underwent 204 ERCPs of which 56 ERCPs were diagnostic. Clinical improvement was seen in 35% of the patients after diagnostic ERCP and in 70% after therapeutic procedures (chi 2=18.4, P=0.001). Laboratory improvement was seen in 35% of patients undergoing diagnostic ERCP and in 52% of the patients undergoing therapeutic ERCP (P=0.04). The reductions in liver enzymes were significant in both the diagnostic and therapeutic groups. Serum bilirubin level decreased significantly in the therapeutic ERCP group only. In a univariate analysis, patients with common bile duct strictures, any dominant stricture and those who underwent a therapeutic procedure were most likely to have clinical and laboratory improvement. In multivariable logistic regression, the presence of a dominant stricture, endoscopic therapy and high serum bilirubin were all independent predictors of a successful clinical outcome. There was no difference in total complication rates (18% versus 14%) when comparing the diagnostic and therapeutic ERCP groups. However, all seven severe complications occurred in the therapeutic ERCP group. CONCLUSIONS: First, in PSC, clinical and laboratory improvement is more common in patients undergoing therapeutic ERCP than diagnostic ERCP. Second, aspartate aminotransferase, alanine aminotransferase and alkaline phosphatase improve following both diagnostic and therapeutic ERCP, and should therefore not be relied upon to determine the success of the procedure. Third, bilirubin levels decreased in the therapeutic group but remained unchanged in the diagnostic group, suggesting that the serum bilirubin level may be a more sensitive indicator of successful therapeutic intervention than transaminases. Fourth, common bile duct strictures, dominant strictures and bilirubin levels are important variables in determining the success of an ERCP in PSC. Finally, complication rates after therapeutic ERCP are similar to those after diagnostic ERCP in PSC patients. However, severe complications occur more commonly in the therapeutic group.

Adult↗
PubMed2002

ERCP-related perforations: risk factors and management.

BACKGROUND AND STUDY AIMS: Perforations during endoscopic retrograde cholangiopancreatography (ERCP) are rare, and the management of these perforations is variable, with some patients requiring immediate surgery and others only conservative management. We reviewed all ERCP-related perforations at our institution to determine: a) their incidence; b) clinical outcomes; c) which management approaches gave the best results; and d) which factors predict a perforation. PATIENTS AND METHODS: All patients who underwent ERCP and suffered perforation were reviewed. To compare the length of hospital stay of the perforation group with that of patients suffering a different complication, patients who developed post-ERCP pancreatitis were also reviewed. To evaluate predictors of ERCP-related perforations, three groups were compared: group 1 (n = 49), normal ERCP/no complications; group 2 (n = 52), ERCP complicated by pancreatitis; and group 3 (n = 33), ERCP with perforation. RESULTS: Of 33 patients with confirmed ERCP-related perforations, only seven patients required surgical intervention. The overall length of hospital stay (6.5 +/- 3.5 days) was significantly longer (P = 0.003) than that of a random group of patients with the complication of post-ERCP pancreatitis (4.7 +/- 2.6 days). According to univariate analysis, risk factors included: sphincterotomy (odds ratio [OR] 9.0, 95 % confidence interval [CI] 3.2 - 28.1); sphincter of Oddi dysfunction (OR 3.8, 95 % CI 1.4 - 11.0); and dilated common bile duct (OR 4.07, 95 % CI 1.63 - 10.18, P = 0.003). In the multivariate logistic regression analysis, additional predictive factors included the duration of procedure (OR 1.021, 95 % CI 1.006 - 1.036), and biliary stricture dilation (OR 7.2, 95 % CI 1.84 - 28.11). CONCLUSIONS: (i) The incidence of ERCP-related perforations is very low (0.35 %). (ii) Esophageal, gastric and duodenal perforations usually require surgery, but sphincterotomy- and guide wire-related perforations rarely do so. (iii) Factors which carry increased risk of an ERCP-related perforation include suspected sphincter of Oddi dysfunction, greater age, a dilated bile duct, sphincterotomy, and longer duration of the procedure.

Adult↗
PubMed2001

Neoadjuvant chemoradiation for localized adenocarcinoma of the pancreas.

BACKGROUND: The use of neoadjuvant (preoperative) chemoradiotherapy (CRT) for pancreatic cancer has been advocated for its potential ability to optimize patient selection for surgical resection and to downstage locally advanced tumors. This article reports our experience with neoadjuvant CRT for localized pancreatic cancer. METHODS: Since 1995, 111 patients with radiographically localized, pathologically confirmed pancreatic adenocarcinoma have received neoadjuvant external beam radiation therapy (EBRT; median, 4500 cGy) with 5-flourouracil-based chemotherapy. Tumors were defined as potentially resectable (PR, n = 53) in the absence of arterial involvement and venous occlusion and locally advanced (LA, n = 58) with arterial involvement or venous occlusion by CT. RESULTS: Five patients (4.5%) were not restaged due to death (n = 3) or intolerance of therapy (n = 2). Twenty-one patients (19%) manifested distant metastatic disease on restaging CT. Twenty-eight patients with initially PR tumors (53%) and 11 patients with initially LA tumors (19%) were resected after CRT. Histologic examination revealed significant fibrosis in all resected specimens and two complete responses. Surgical margins were negative in 72%, and lymph nodes were negative in 70% of resected patients. Median survival in resected patients has not been reached at a median follow-up of 16 months. CONCLUSIONS: Neoadjuvant CRT provided an opportunity for patients with occult metastatic disease to avoid the morbidity of resection and resulted in tumor downstaging in a minority of patients with LA tumors. Survival after neoadjuvant CRT and resection appears to be at least comparable to survival after resection and adjuvant (postoperative) CRT.

Adenocarcinoma↗
PubMed2000

A double-blind, randomized, dose response study testing the pharmacological efficacy of synthetic porcine secretin.

BACKGROUND: Biologically derived porcine secretin has been used as a diagnostic agent in clinical gastrointestinal practice for many years. Pure synthetic porcine secretin is now available for investigational clinical use. AIM: To compare the pharmacology of synthetic porcine secretin and biologically derived porcine secretin in healthy volunteers. METHODS: Secretin stimulation tests were performed in 12 volunteer subjects in a double-blind, randomized, Latin square crossover design study comparing three doses of synthetic porcine secretin (0.05, 0.2, and 0.4 microgram/kg) with a standard dose of biologically derived porcine secretin (1 CU/kg). Duodenal aspirates were analysed for total volume and for bicarbonate concentration. Total bicarbonate output was calculated. RESULTS: Twelve subjects completed four dosing regimens. A multiple comparison test was used to compare dosing regimens. The 0.2 and 0.4 microgram/kg doses of synthetic porcine secretin were not different from the 1 CU/kg dose of biologically derived porcine secretin for volume, bicarbonate concentration and total output from 0 to 60 min. Only one patient had an adverse event, which was mild, transient flushing after the 0.2 and 0.4 microgram/kg doses of synthetic porcine secretin and after the 1 CU/kg dose of biologically derived porcine secretin. CONCLUSIONS: Synthetic porcine secretin has identical pharmacologic effects to biologically derived porcine secretin in normal subjects. Both drugs were safe and well-tolerated. This study validates synthetic porcine secretin as a substitute for biologically derived porcine secretin.

Adult↗
PubMed2000

Helical CT cholangiography with three-dimensional volume rendering using an oral biliary contrast agent: feasibility of a novel technique.

OBJECTIVE: We evaluated the feasibility and image quality of a new noninvasive biliary imaging technique: helical CT cholangiography with three-dimensional volume rendering using an oral biliary contrast agent. SUBJECTS AND METHODS: Nineteen subjects including five healthy volunteers and 14 patients underwent helical CT cholangiography. Subjects ingested 6.0 g of iopanoic acid 6-10 hr before undergoing imaging. Axial data were used to construct three-dimensional volume-rendered cholangiograms. Two radiologists, an endoscopist, and a laparoscopic surgeon reviewed the images and evaluated overall image quality. In the 14 patients, findings from CT cholangiography were compared with those from ERCP, surgery, and intraoperative cholangiography. RESULTS: All segments of the biliary tree were opacified in all volunteers except one, in whom the intrahepatic ducts were not opacified. Image quality was good to excellent in all volunteers. Anomalous cystic duct insertions were seen in two volunteers. Opacification of the biliary tree was rated as acceptable to excellent in nine patients and suboptimal in five. In five patients with good or excellent opacification, the biliary anatomy correlated with findings on intraoperative cholangiography or ERCP. CT cholangiography revealed additional conditions (gallbladder varices and acute pancreatitis) and variant anatomy in three patients. CONCLUSION: Results of this pilot project suggest that obtaining CT cholangiograms using an oral biliary contrast agent is a feasible, noninvasive method for revealing biliary anatomy. However, visualization of the biliary tree was suboptimal in 36% of the patients, which represents a limitation of this technique.

Administration, Oral↗
PubMed1999

The role of ERCP in diagnosis and management of accessory bile duct leaks after cholecystectomy.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) plays an important role in the management of bile leaks after cholecystectomy. Although most leaks occur from the cystic duct stump, clinically significant leakage from accessory bile ducts is less common and has not been investigated systematically. We report our experience with endoscopic diagnosis and treatment of accessory bile duct leaks after cholecystectomy. METHODS: Patients with accessory bile duct leaks were identified from a computerized database. Hospital charts and cholangiograms were reviewed to determine the outcome of diagnostic and therapeutic interventions. RESULTS: Of 86 patients with postcholecystectomy leaks, 15 (17%) were diagnosed with accessory bile duct leaks. ERCP established the diagnosis of accessory bile duct leaks in 11 of 15 patients (73%); percutaneous fistulography (2) and percutaneous transhepatic cholangiography (2) were diagnostic in 4 patients. Endoscopic therapy led to resolution of the leak in 12 patients. One patient underwent successful percutaneous biliary drainage, and two patients required surgical repair. CONCLUSIONS: Accessory bile ducts are rare sites of significant bile leakage after cholecystectomy. ERCP identifies the leak in the majority of patients; percutaneous fistulography or percutaneous transhepatic cholangiography may help clarify the diagnosis if ERCP is nondiagnostic. Most patients can be successfully treated with endoscopic stenting. If endoscopic therapy fails, percutaneous drainage or surgical repair needs to be considered.

Adult↗
PubMed1999

Endoscopic nasobiliary drain placement facilitates subsequent percutaneous transhepatic cholangiography.

BACKGROUND: Percutaneous biliary drainage is an established alternative to ERCP for managing bile duct obstruction. Although generally safe and effective, percutaneous drainage has its risks and is technically more difficult in patients with nondilated bile ducts. We report the use of nasobiliary drains and subsequent nasobiliary drain cholangiography to facilitate percutaneous biliary drainage by providing a target for accessing intrahepatic bile ducts. METHODS/RESULTS: Nine patients who were identified as requiring percutaneous biliary drainage underwent nasobiliary tube placement at completion of ERCP. Five of 9 patients had generalized intrahepatic ductal dilatation; in 4 patients, dilatation was focal or absent. Following nasobiliary drain cholangiography, percutaneous needle puncture of a bile duct was successful in all patients, in most cases with only a single puncture of the liver capsule. No procedural complications were encountered. CONCLUSION: Nasobiliary drain placement with subsequent nasobiliary drain cholangiography facilitates percutaneous biliary drainage and may be especially helpful in patients with nondilated intrahepatic bile ducts.

Catheterization↗
PubMed1999

A stone in a grossly dilated cystic duct stump: a rare cause of postcholecystectomy pain.

We describe the unusual case of a patient who developed recurrent right upper quadrant pain 25 yr after cholecystectomy. A cystic lesion containing a calculus was identified on transabdominal ultrasound, initially suggesting the possibility of gallbladder duplication. Endoscopic retrograde cholangiography identified this lesion as a massively dilated cystic duct stump. Surgical resection led to complete resolution of symptoms. Recurrent cholelithiasis involving the cystic duct stump may lead to massive dilatation, and must be considered in the differential diagnosis of postcholecystectomy syndrome.

Cholecystectomy↗
PubMed1998

Pseudo-Mirizzi syndrome in acute cholecystitis.

Common hepatic duct obstruction secondary to an impacted cystic duct stone is commonly referred to as the Mirizzi syndrome. Mirizzi syndrome is an uncommon cause of obstructive jaundice and can be mimicked by several other rare conditions. We describe a patient with a massively distended gallbladder due to acute cholecystitis who presented with clinical and cholangiographic findings simulating the Mirizzi syndrome. Endoscopists should be aware of acute cholecystitis as a possible etiology of common hepatic duct obstruction.

Aged↗
PubMed1998

Diagnosis of pancreatic carcinoma: role of FDG PET.

OBJECTIVE: The purpose of this study was to investigate the role of positron emission tomography (PET) with 18F-fluorodeoxyglucose (FDG) in differentiating benign from malignant disease in patients with possible pancreatic malignancy. SUBJECTS AND METHODS: All patients with a possible diagnosis of pancreatic carcinoma based on CT or ERCP findings were eligible for inclusion in this prospective study. PET imaging of the abdomen was performed in 37 patients and was interpreted as positive if FDG activity in the pancreas exceeded background activity and as negative if activity was less than or equal to background activity. Semiquantitative analysis was performed by calculating a standardized uptake ratio. Studies were reviewed independently by two radiologists, and results were correlated with biopsy results and with CT and ERCP findings. Sensitivity and specificity of FDG PET for revealing pancreatic malignancy was determined. RESULTS: FDG activity in the pancreas was increased in 24 patients, and adenocarcinoma was diagnosed in 22 of these patients (92%). Two patients (8%) with increased activity had benign disease, including one patient with chronic pancreatitis who showed no evidence of tumor at laparotomy and one patient with a mucinous cystic tumor who showed no malignant features at laparotomy. FDG uptake was low or normal in 13 patients, 10 of whom (77%) had benign disease. FDG uptake was also low in three patients with adenocarcinoma, whose tumor size ranged from 2 to 4 cm in diameter. The mean standardized uptake ratio value for malignant disease was 5.1 (range, 1.0-10.1) and for benign disease was 1.9 (range, 0.0-5.8) (p < .001). The sensitivity of FDG PET for revealing malignant disease in the pancreas was 88% and the specificity was 83%. CONCLUSION: FDG PET is a sensitive and specific noninvasive technique for the diagnosis of pancreatic malignancy.

Adenocarcinoma↗
PubMed1996

Quantitative assessment of procedural competence. A prospective study of training in endoscopic retrograde cholangiopancreatography.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a technically demanding procedure that can cause substantial complications. Competence in performing ERCP and the learning curve for achieving competence are poorly understood. OBJECTIVE: To evaluate the number of supervised ERCPs that physicians must do to achieve procedural competence. Competence was defined as a 0.8 probability of successfully completing specific technical components of ERCP and an overall grading of competence as judged by the attending physician. DESIGN: Prospective study. SETTING: University training program for gastroenterologists. PARTICIPANTS: 17 gastroenterology fellows at various stages of training. MEASURES: Experienced therapeutic endoscopists prospectively graded gastroenterology fellows during 1796 consecutive ERCPs. Fellows were graded on their overall level of competence for the procedure and on specific technical components of ERCP. RESULTS: Grading data were available for 1450 ERCPs (81%). The number of ERCPs done before adequate skill was achieved was 160 for cholangiography, 140 for pancreatography, 160 for deep cannulation of the pancreatic duct, 120 for stone extraction, and 60 for stent insertion. Fellows achieved overall competence after completing 180 to 200 ERCPs. The predicted probability of overall competence was 0.8 after 137 ERCPs and 0.9 after 185 ERCPs. CONCLUSIONS: At least 180 ERCPs were required before these gastroenterology fellows could be considered competent in ERCP. This number is much greater than that previously recommended, and these findings have substantial implications for training guidelines and issues of competence and certification in ERCP. The methods used to define and evaluate competence in ERCP could also be used to assess competence in other medical procedures.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1996

Prospective multicenter trial of esophageal Z-stent placement for malignant dysphagia and tracheoesophageal fistula.

BACKGROUND: Conventional esophageal prosthesis placement has been associated with a 6% to 8% perforation rate and numerous postplacement complications. Expandable esophageal stents have been developed to preclude the above but there are few studies that have prospectively defined clinical results and subsequent stent-related complications. METHODS: All patients who underwent esophageal Z-stent placement at nine university or referral hospitals were prospectively assessed. Data collected included patient demographics, acute and subacute placement problems, the ability to occlude airway fistulas, prestent and poststent dysphagia scores, and patient survival. RESULTS: Fifty-four of 56 patients (96%) with refractory dysphagia or malignant esophagoairway fistulae had 73 Z-stents successfully inserted. Initial distal deployment occurred in 13% of the patients and an additional 17% required balloon dilation to achieve maximal diameter. Acute placement complications occurred in 11% of patients and included severe pain (3), bleeding from necrotic tumor (2), and hiatal hernia intussusception (1). No perforations occurred. Eight of 11 patients (73%) had complete tracheoesophageal fistula occlusion and mean dysphagia score (+/- SD) improved from 2.6 (0.7) to 1.1 (1.2) (p < 0.01). Fifteen stents (27%) had delayed migration at a mean of 1 month and 3 required surgery for retrieval. Three patients had ultimate stent erosion resulting in bleeding in 2 (exsanguination 1) or fistula (treated with a conventional stent). CONCLUSIONS: The authors conclude that esophageal Z-stents can be placed safely and successfully in the majority of patients. The tendency of distal deployment during placement and subsequent migration problems at a time distant from placement in a patient subset deserve attention and are currently being addressed.

Adult↗