Background Guidewire (GW) cannulation can reduce the risk of post-ERCP pancreatitis (PEP) by avoiding the opacification of the main pancreatic duct. Objective To compare the effects of conventional ...contrast ERCP and GW cannulation of the common bile duct on the rate of PEP in low- and high-risk patients. Design Prospective, comparative-intervention single-center study. Setting Tertiary referral center. Patients Patients with biliary disease with an intact papilla were prospectively examined by ERCP. Interventions Biliary cannulation using a sphincterotome with contrast injection (ConI) or a hydrophilic GW without contrast injection. Main Outcome Measurements Pancreatitis rate in the GW group and the contrast injection (ConI) group. Results PEP occurred in 60 of 1249 patients (4.8%), 35 of 678 (5.2%) in the GW group and 25 of 571 (4.4%) in the ConI group (not significant). The overall rate of PEP was significantly higher in high-risk patients (12.2%) than in low-risk patients (3.5%) ( P < .001), but was similar for the 2 techniques within each of these 2 groups. In patients with unintended main pancreatic duct (MPD) cannulation or opacification, the rate of PEP was not significantly different with the GW (15.2%) and ConI (8.4%) techniques but was associated with a significantly higher rate of pancreatitis (11.9%) than in patients in whom the contrast medium or GW did not enter the MPD (3.5%) ( P < .001). Multivariate analysis indicated that more than 10 papillary cannulation attempts, MPD cannulation or opacification, suspected sphincter of Oddi dysfunction, and precut methods were significant risk factors independently associated with PEP. Limitations Lack of randomization. Conclusions For selective cannulation of the CBD, the risk of inducing PEP is similar with the ConI and GW techniques in high-risk and low-risk patients. Any manipulation of the MPD must be considered a high-risk factor for PEP, such as multiple attempts on the papilla or use of the precut method.
Background Celiac disease (CD) is a gluten-dependent enteropathy. The current standard for diagnosing CD involves obtaining 4 biopsy samples from the descending duodenum. It has been suggested that ...duodenal bulb biopsies may also be useful. Objective To assess the utility of bulbar biopsies for the diagnosis of CD in pediatric patients. Design Prospective study. Setting Single center. Patients Forty-seven consecutively enrolled pediatric patients with celiac serologies and a clinical suspicion of CD. Interventions All patients underwent EGD, and 4 biopsy samples were obtained from the duodenal bulb and 4 from the descending duodenum of each child. Main Outcome Measurements The pathologist blindly reported the Marsh histological grade for the diagnosis of CD of the bulb and descending duodenum. Results The diagnosis of CD was histologically confirmed in 89.4% (42/47) of the cases of biopsy samples obtained from the descending duodenum and in all 47 obtained from the bulb. In 35 patients (74.5%), histology was the same in the bulb and duodenum; in 11 (23.4%) cases, the grade of atrophy was higher in the bulb than in the descending duodenum, and 5 (10.6%) had bulb histology positive for CD but negative duodenal findings. One child (2.1%) had a higher histological grade in the duodenum than in the bulb. The diagnostic gain with bulbar biopsies was 10.6%. Limitations Small sample and absence of a comparison group (asymptomatic children with normal CD antibodies). Conclusions We suggest examining 4 biopsy samples from the duodenal bulb and 4 from the descending duodenum to improve diagnostic accuracy of CD.
Background In patients with recurrent pancreatitis of unknown etiology and nondilated ducts, accurate morphofunctional evaluation of the pancreaticobiliary ductal system and sphincter of Oddi ...function is important in the diagnostic workup. However, ERCP and sphincter of Oddi manometry may be nondiagnostic and postprocedure complications may be frequent. Objective Our purpose was to assess the diagnostic accuracy of the magnetic resonance cholangiopancreatography with secretin test (MRCP-S) in patients with recurrent acute pancreatitis of unknown etiology. Accuracy was established on the basis of ERCP findings and a minimum of 24 months' clinical follow-up. Design Thirty-seven consecutive patients with intact gallbladder and a nondilated pancreaticobiliary ductal system with nonpathologic EUS findings entered a prospective MRCP-S–guided and ERCP-guided diagnostic and therapeutic study protocol. Results Patients were followed up for a mean of 31.3 months (range 26-38 months). MRCP-S identified some pancreatic outflow impairment, suggesting morphofunctional dysfunction of either the major or minor papilla, in 12 of 37 patients (32.4%). The addition of ERCP to MRCP-S did not substantially improve the diagnostic yield for the etiology of recurrent pancreatitis, and 13.6% of cases had mild postprocedure pancreatitis. The S-test was abnormal in 12 of 20 cases (60%) in whom some dysfunction of the sphincter of Oddi or minor papilla was assumed on the basis of follow-up findings. The outcome was successful after biliary or pancreatic sphincterotomy in all patients with an abnormal S-test result. Sensitivity, specificity, and positive and negative predictive values of the S-test for the diagnosis of pancreatic outflow impairment at the major or minor papilla were, respectively, 57.1%, 100%, 100%, and 64%. When the test showed an abnormal result, we were unable to distinguish between biliary and pancreatic segment dysfunction of the sphincter of Oddi. Conclusions In idiopathic recurrent pancreatitis with nondilated ducts, the MRCP-S–guided approach gave diagnostic accuracy comparable to ERCP with regard to morphologic lesions, and it can be used as an alternative, avoiding ERCP-related complications in the diagnostic phase. An abnormal S-test result showed an excellent positive predictive value and somewhat disappointing negative predictive value for sphincter of Oddi or minor papilla dysfunction and for clinical success of therapeutic endoscopic approach.
This single-center study analyzed the occurrence of severe thrombocytopenia and its clinical effect after concomitant and isolated aortic valve replacement (AVR) with the stentless Freedom Solo (FS) ...prosthetic valve (Sorin Group, Saluggia, Italy).
Between October 2009 and February 2012, 151 consecutive patients underwent AVR with a FS, either isolated (lone-FS group) or concomitant with another procedure (all-FS group). These groups were compared with 152 consecutive patients implanted with a stented Edwards Lifesciences Perimount (EP) bioprosthesis (Edwards Lifesciences, Irvine, CA). Primary end point was the incidence of severe thrombocytopenia (platelet count < 50 × 10(9)/L). Secondary end points were clinical outcomes, administered transfusions (red blood cells, thrombocytes, frozen plasma), and adverse events. Rinsing the FS before implantation with saline solution was also evaluated.
Platelet counts were significantly lower in the all-FS and lone-FS groups than in the EP group during the first 5 days (p < 0.001). Average nadir was 102 ± 50 in lone-FS group and 130 ± 35 in lone-EP group (p < 0.001). Independent predictors for severe thrombocytopenia were FS, body surface area, and preoperative platelet count. No significant difference was found in transfusions or adverse events. Intensive care unit stay was slightly increased in the lone-FS group (p = 0.04). Rinsing the FS did not prevent thrombocytopenia.
AVR with FS was associated with severe thrombocytopenia during the first postoperative days. Besides a slightly longer hospitalization in the intensive care unit in the FS group, the clinical outcome did not differ significantly, indicating thrombocytopenia was a transient and self-recovering phenomenon, not affecting clinical outcome. Rinsing the FS did not prevent thrombocytopenia.
Patients on extracorporeal support for severe acute respiratory distress syndrome may require a prolonged period of deep sedation. In these patients, volatile sedation may represent a valid ...alternative to IV drugs. The aim of our study was to describe the feasibility of volatile sedation in a large cohort of acute respiratory distress syndrome patients undergoing venovenous extracorporeal membrane oxygenation and ultraprotective ventilation.
Retrospective monocentric study.
Adult ICU, ASST Monza, Italy.
Adult patients who underwent volatile sedation with isoflurane during venovenous extracorporeal membrane oxygenation between 2009 and 2019.
Isoflurane was delivered via the AnaConDa system. The sedation level, hemodynamics, and laboratory tests were compared between the volatile sedation phase and the IV sedation phases before and after the isoflurane sedation period.
About 74 patients (50 yr 43-56 yr) were included. Median duration of venovenous extracorporeal membrane oxygenation support was 22 days (14-51 d). Volatile sedation started on day 3 (2-6) of extracorporeal membrane oxygenation support, and its median duration was 7 days (4-13 d), ranging from 1 to 38 days. A total of 970 venovenous extracorporeal membrane oxygenation days were analyzed. During the volatile phase, the sedation level was slightly deeper (bispectral index 39 ± 6) compared with the IV phase before and after isoflurane (42 ± 8 and 43 ± 9, respectively,
< 0.001). Requirements of fentanyl and remifentanyl were reduced during the volatile phase. Minor differences in hemodynamics were observed during volatile sedation: mean arterial pressure was lower (75 ± 13 vs 79 ± 14 and 80 ± 15;
< 0.001), whereas cardiac output was higher (8.5 ± 1.9 vs 7.9 ± 1.8 and 8.0 ± 1.8;
= 0.003). Aspartate aminotransferase levels were lower during the volatile sedation phases (
< 0.001), whereas alanine aminotransferase, triglycerides, and creatine phosphokinase were more altered during the IV sedation phase before isoflurane (
< 0.001).
Volatile sedation represents an alternative to IV agents to achieve long-term deep sedation in critically ill patients on extracorporeal membrane oxygenation undergoing ultraprotective ventilation.
The aim of this study was to determine whether early myocardial structural and functional systolic and diastolic alterations in asymptomatic and uncomplicated patients with type 1 diabetes mellitus ...(DM) could be detected using the new highly sensitive echocardiographic techniques of integrated backscatter and color Doppler myocardial imaging. Forty asymptomatic and uncomplicated patients with type 1 DM and 40 gender- and age-matched normal controls were studied. All patients were analyzed by conventional and new echocardiographic techniques (integrated backscatter and color Doppler myocardial imaging). Patients with DM showed reduced systolic function compared with controls, evidenced by significantly lower peak strain, strain rates, and cyclic variation indexes at the septum (p <0.0001, <0.01, and <0.001, respectively) and at the posterior wall level (p <0.0001, <0.0001, and <0.001, respectively). On receiver-operating characteristic curve analysis, systolic strain and the cyclic variation index showed the highest discriminating power for separating patients with DM and control subjects. Neither structural or ultrastructural nor diastolic functional abnormalities were detected. On univariate regression analysis, a significant inverse correlation was found for DM duration with conventional (E/A ratio) and unconventional (tissue Doppler imaging E/A ratio) indexes of diastolic function, in the absence of any correlation for systolic function. In conclusion, highly sensitive ultrasonic techniques demonstrate evidence of left ventricular systolic dysfunction in the early stage of type 1 DM, in the absence of ultrastructural and left ventricular diastolic functional abnormalities.
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