A pilot randomized trial to study the success rate of early precut fistulotomy and its effect on radiation dose in patients with difficult biliary cannulation

Background: Role of precut fistulotomy in reducing fluoroscopy time and the radiation dose in difficult selective biliary cannulation is unknown. Methods: We performed a randomized trial where patients with difficult biliary cannulation were randomized into 2 groups: early precut fistulotomy (precut five minutes after failed standard biliary cannulation) or late precut fistulotomy (precut fifteen minutes after failed standard biliary cannulation). We compared the success rates of selective biliary cannulation, fluoroscopy time, radiation dose, complication rates, need for repeat endoscopic retrograde cholangiography (ERC) and need for other interventions Results: Of the 130 eligible patients screened, 40 patients were randomized. The technical success was comparable between early and late group. The fluoroscopy time and radiation dose were significantly less in the early group [4 minutes (3, 6) vs 15 minutes (8, 28), p=0.001] and [1.35 mGy (0.90, 1.63) vs 2.40 mGy (1.58, 3.25), p=0.010] respectively. In the late group, 60% required need for rescue precut fistulotomy. One patient from late group developed post ERC pancreatitis while 1 from early group developed perforation. Three needed other interventions due to failed second attempt. Conclusion: Early precut fistulotomy has comparable technical success and reduces the radiation dose as compared to late precut fistulotomy for difficult biliary cannulation.

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The First 150 Endovascular AAA Repairs at a Single Institution: How Steep is the Learning Curve?

Journal of Endovascular Therapy ◽

10.1177/152660280200900303 ◽

2002 ◽

Vol 9 (3) ◽

pp. 269-276 ◽

Cited By ~ 18

Author(s):

W. Anthony Lee ◽

Yehuda G. Wolf ◽

Bradley B. Hill ◽

Paul Cipriano ◽

Thomas J. Fogarty ◽

...

Keyword(s):

Learning Curve ◽

Medical Center ◽

Primary Repair ◽

Fluoroscopy Time ◽

Early Group ◽

Technical Success ◽

Single Institution ◽

Proximal Neck ◽

Frequent Use ◽

Late Group

Purpose: To determine whether increasing experience with endovascular abdominal aortic aneurysm (AAA) repair in a single institution will result in improved outcome. Methods: A retrospective review was undertaken of 150 consecutive cases of endovascular AAA repairs performed using the AneuRx device between October 1996 and April 2000 in a university-based medical center. The population was divided into early and late groups of 75 patients each. Endpoints included technical success; complications; early (≤30-day) morbidity, mortality and rupture; endoleak at discharge and at 1 month; early secondary intervention; proximal neck and iliac tortuosity; extender cuff placement; femoral reconstructions beyond primary repair; total fluoroscopy time; and contrast load. Results: Baseline patient and aneurysm characteristics were similar between the 2 groups. Technical success was 98.7%; 2 cases were converted intraprocedurally owing to difficult iliac access (early group) and a severely angulated proximal neck (late group). There was a tendency toward more frequent use of intraoperative proximal extender cuffs in the early group (12% versus 4% in the late group, p=0.13). Femoral reconstructions were more frequent in the early group (36% versus 19%, p<0.025). While total contrast volume was similar (111 ± 56 versus 105 ± 45 mL, p=NS), total fluoroscopy time was significantly reduced (p<0.05) between the early and late groups. Conclusions: With attention to detail and careful patient selection, successful endovascular AAA repair can be achieved with very few conversions and low perioperative mortality even during the center's early experience. Evidence indicates, however, that a learning curve definitely exists, as shown by fewer access site problems, more accurate device deployments, and decreased fluoroscopy times as proficiency is attained.

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Distal Radial Artery Access for Superficial Femoral Artery Interventions

Journal of Endovascular Therapy ◽

10.1177/1526602820963022 ◽

2020 ◽

pp. 152660282096302

Author(s):

Zoltán Ruzsa ◽

Ádám Csavajda ◽

Balázs Nemes ◽

Mónika Deák ◽

Péter Sótonyi ◽

...

Keyword(s):

Radiation Dose ◽

Femoral Artery ◽

Superficial Femoral Artery ◽

Fluoroscopy Time ◽

Complication Rates ◽

Procedure Time ◽

Technical Success ◽

Access Site ◽

Femoral Access ◽

Crossover Rate

Purpose: To compare the acute success and complication rates of distal radial (DR) vs proximal radial (PR) artery access for superficial femoral artery (SFA) interventions. Materials and Methods: Between 2016 and 2019, 195 consecutive patients with symptomatic SFA stenosis were treated via DR (n=38) or PR (n=157) access using a sheathless guide. Secondary access was achieved through the pedal artery when necessary. The main outcomes were technical success, major adverse events (MAEs), and access site complications. Secondary outcomes were treatment success, fluoroscopy time, radiation dose, procedure time, and crossover rate to another puncture site. Results: Overall technical success was achieved in 188 patients (96.4%): 37 of 38 patients (97.3%) in the DR group and 151 of 157 patients (96.2%) in the PR group (p=0.9). Dual (transradial and transpedal) access was used in 14 patients (36.8%) in the DR group and 28 patients (18.9%) in the PR group (p<0.01). Chronic total occlusions were recanalized in 25 of 26 DR patients (96.1%) and in 79 of 81 PR patients (92.6%) (p=0.57). The crossover rate to femoral access was 0% in the DR group vs 3.2% in the PR group (p=0.59). Stents were implanted in the SFA in 15 DR patients (39.4%) and in 39 patients (24.8%) in the PR group (p=0.1). The contrast volume, fluoroscopy time, radiation dose, and procedure time were not statistically different between the DR and PR groups, nor were the rates of access site complications (2.6% and 7.0%, respectively). The cumulative incidences of MAE at 6 months in the DR and PR groups were 15.7% vs 14.6%, respectively (p=0.8). Conclusion: SFA interventions can be safely and effectively performed using PR or DR access with acceptable morbidity and a high technical success rate. DR access is associated with few access site complications.

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EUS-directed transgastric endoscopic retrograde cholangiopancreatography versus laparoscopic-assisted ERCP versus deep enteroscopy-assisted ERCP for patients with RYGB

Endoscopy International Open ◽

10.1055/a-1164-6282 ◽

2020 ◽

Vol 08 (07) ◽

pp. E877-E882 ◽

Cited By ~ 1

Author(s):

Gursimran S. Kochhar ◽

Nabeeha Mohy-ud-din ◽

Abhinav Grover ◽

Neil Carleton ◽

Abhijit Kulkarni ◽

...

Keyword(s):

Endoscopic Retrograde Cholangiopancreatography ◽

Retrospective Chart Review ◽

Complication Rates ◽

Success Rates ◽

Technical Success ◽

Endoscopic Retrograde ◽

Technical Success Rate ◽

Edge Group ◽

History Of ◽

Laparoscopic Assisted

Abstract Background and study aims Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP) (EDGE) is a novel technique for managing pancreaticobiliary diseases in patients with a history of Roux-en-Y Gastric Bypass (RYGB). It has shown to have high technical success rates and fewer adverse events as compared to laparoscopic-assisted ERCP (LA-ERCP). We compared the technical success and clinical outcomes of EDGE vs. LA-ERCP vs. E-ERCP. Patients and methods A retrospective chart review was performed for 56 patients, of whom 18 underwent LA-ERCP, 12 underwent E-ERCP, and 26 had EDGE, and a comparison of technical success and complication rates was done. Results Baseline demographic characteristics of patients undergoing these procedures, including age and gender, were comparable. The technical success rate for patients in the EDGE group were 100 % (n = 26), compared with 94 % (n = 17) and 75 % (n = 9) in the LA-ERCP and E-ERCP groups (P = 0.02). In the EDGE group, 8 % of patients (n = 2) had bleeding, and 4 % of patients (n = 1) had lumen-apposing metal stent migration occur during the procedure. In the LA-ERCP group 6 % (n = 1) of patient had bleeding, 6 % (n = 1) post-ERCP pancreatitis and 6 % (n = 1) were diagnosed with an intra-abdominal infection post-procedure. Time to complete the EDGE procedure was significantly shorter at 79 ± 31 mins, compared with 158 ± 50 mins for LA-ERCP and 102 ± 43 mins for E-ERCP (P < 0.001). Conclusion EDGE is a novel procedure with short procedure times and an effective alternative to LA-ERCP and E-ERCP in management of pancreaticobiliary diseases in patients with a history of RYGB.

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Outcomes of precut sphincterotomy techniques in cases of difficult biliary access

Frontline Gastroenterology ◽

10.1136/flgastro-2019-101380 ◽

2020 ◽

pp. flgastro-2019-101380

Author(s):

Jared Rejeski ◽

Marc Hines ◽

Jason Jones ◽

Jason Conway ◽

Girish Mishra ◽

...

Keyword(s):

High Volume ◽

Complication Rates ◽

Success Rates ◽

Biliary Cannulation ◽

Pancreatic Duct Stenting ◽

Significant Difference ◽

Effective Option ◽

Needle Knife ◽

Precut Sphincterotomy ◽

Rectal Indomethacin

GoalsOur study aims to define success and complication rates of precut sphincterotomy with the needle-knife and transpancreatic papillary septotomy (TPS) techniques as experienced at a single, high-volume endoscopy centre.BackgroundComplication rates rise with increasing number of failed attempts at biliary cannulation; therefore, early precut sphincterotomy (PS) has been recommended. Selecting the ideal method for PS can be challenging and there is a paucity of data to help guide this decision.StudyWe performed a retrospective analysis over 37 months of endoscopic retrograde cholangiopancreatography (ERCP) experience at a single institution. We identified all ERCPs performed and stratified based on the presence of PS; if PS occurred, a thorough chart review was performed to identify success and complication rates. Patients received guideline-driven management for post-ERCP pancreatitis including rectal indomethacin and pancreatic duct stenting when appropriate.ResultsWe identified 1808 ERCP procedures performed during this time. Successful biliary cannulation was achieved in 1748 cases, yielding a success rate of 96.7% (Grades I–IV ERCP difficulty/complexity). PS was required in 232 cases (12.8%); we identified 88 TPS cases and 114 needle-knife precut sphincterotomy (NKPS) cases. Complications following PS procedures occurred in 9.1% of TPS patients and 11.4% of NKPS patients. Success rates for TPS and NKPS were 97.7% and 81.6%, respectively—a statistically significant difference (p<0.001).ConclusionThis data supports TPS as a safe and effective option for biliary access in difficult cannulation settings when performed by experienced advanced endoscopists.

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Use of the Magellan Robotic System for Conventional Transarterial Chemoembolization (cTACE): A 6-Patient Case Series Showing Safety and Technical Success

Journal of Clinical Interventional Radiology ISVIR ◽

10.1055/s-0039-1694093 ◽

2019 ◽

Vol 03 (02) ◽

pp. 142-146 ◽

Cited By ~ 1

Author(s):

Warren Clements ◽

Madeleine Scicchitano ◽

Jim Koukounaras ◽

Tim Joseph ◽

Gerard S. Goh

Keyword(s):

Radiation Dose ◽

Adverse Events ◽

Transarterial Chemoembolization ◽

First Generation ◽

Case Series ◽

Fluoroscopy Time ◽

Technical Success ◽

Catheter Tip ◽

Further Development ◽

Generation Technology

AbstractRobotic endovascular technology is an emerging concept, and is being developed to allow more precise navigation of anatomy in challenging endovascular cases. The Magellan Endovascular System allows either direct or remote steerability of a 2-point articulating robotic platform with the ability to place a conventional microcatheter through the catheter tip. Such flexibility may help to reach an otherwise difficult anatomic location, especially in variant anatomy. To date, this platform has been shown to be technically successful in a small number of different settings. This case series shows another potential platform for such technology and explores the technical use and overall safety in conventional transarterial chemoembolization (cTACE). The study retrospectively assessed 6 patients undergoing selective cTACE. Treatments were performed in a single center by two experienced interventional radiologists. Fluoroscopy time, radiation dose, anatomic target, and adverse events were logged. In spite of a longer than expected average fluoroscopy time, which can be expected for a first-generation technology, the average radiation dose was comparable to literature and technical success was able to be shown in all 6 patients with no adverse events. This technology has wide scope for future use and once overcoming a learning curve, may allow us to avoid repeat procedure attempts thus reducing fluoroscopy time and leading to earlier successful treatment. Providing a platform of interest and usability in the interventional radiology world may also lead to further development of smaller, cheaper, and more widely-accessible devices.

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Pull-Type Radiologically Inserted Gastrostomy: An Improvised Technique Using a Frugal Innovation

Journal of Clinical Interventional Radiology ISVIR ◽

10.1055/s-0039-1681124 ◽

2019 ◽

Vol 03 (01) ◽

pp. 007-011

Author(s):

Anurag Chahal ◽

Sundeep Malla ◽

Chinmaya Dash ◽

Deepak Gupta ◽

Shivanand Gamanagatti

Keyword(s):

Radiation Dose ◽

Safety Profile ◽

Conventional Technique ◽

New Technique ◽

Fluoroscopy Time ◽

P Value ◽

Complication Rates ◽

Nasogastric Feeding ◽

Group A ◽

Group B

Abstract Purpose To describe a new technique for “pull type” radiologically inserted gastrostomy (RIG) and prospectively compare it with conventional (described) technique in terms of technical ease (fluoroscopy time, radiation dose) and safety profile. Materials and Methods Adult patients with head injury with Glasgow coma scale (GCS) (M score) < 5, one week after decompression or those requiring nutritional support for > 4 weeks, or patients with recurrent aspiration pneumonitis on nasogastric feeding were included. Hemodynamically unstable patients or those with uncorrectable coagulopathy were excluded. Patients underwent pull-type RIG with alternate patient getting allocated to groups A (conventional technique) and B (new technique). The authors compared the technical success, complication rate, fluoroscopy time, radiation dose, and cost of hardware in these two groups. Results The average fluoroscopy time for group A (9 patients) was 498.7 ± 145.3 seconds, whereas for group B (16 patients), it was 302.8 ± 54.1 seconds with p-value = 0.06. The mean radiation dose of group A was 74.7 ± 15.7 mGy, whereas for group B, it was 56.7 ± 14.1 mGy (p-value = 0.004). The minor complication rates were 11.1% in both the groups. Conclusion The authors’ innovative technique using a customized snare has the potential to increase the technical ease of pull-type RIG with reduced fluoroscopy time, radiation dose, and cost with a similar safety profile.

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P.007 Autoimmune Encephalitis Timing and Incidence: the Manitoba Experience

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2021.290 ◽

2021 ◽

Vol 48 (s3) ◽

pp. S22-S22

Author(s):

DH Nguyen ◽

C Xu ◽

M Ng

Keyword(s):

Chart Review ◽

Autoimmune Encephalitis ◽

Retrospective Chart Review ◽

Mortality Rates ◽

Secondary Outcome ◽

Complication Rates ◽

Early Group ◽

Intensive Care Admission ◽

Receive Treatment ◽

Late Group

Background: Early treatment of autoimmune encephalitis (AE) can improve outcomes. Despite expert recommendation, it remains unclear if suspected AE patients consistently receive empiric treatments prior to availability of antibody results. Methods: Retrospective chart review of patients referred for AE testing in Manitoba. Primary outcomes were the proportion of patients treated empirically prior to the availability of antibody results. Incidence, clinical presentation, investigations, complications, mortality rates, and hospital course were secondary outcome measures. Results: We identified 151 patients from 2012-2018. 43 patients met inclusion criteria. The annual incidence of AE in Manitoba was 0.37/100,000. 28/43 (65%) patients were treated prior to availability of antibody results (“Early group”). 15/43 (35%) patients did not receive treatment (“Late group”). Significantly more Early group patients had repeat immunotherapy (p=0.001), abnormal MRI (p=0.027), and investigations for malignancy (p=0.015). Durations of hospital and intensive care admission, complication rates, and mortality rates were not different between the two groups. Conclusions: This is the first-ever AE incidence, timing, and management study of a comprehensive Canadian geopolitical and medical catchment area. Just over 1/3 of suspected AE over seven years were not treated prior to antibody results becoming available. Patients treated earlier did not experience greater complication rates.

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Hip Arthroscopic Surgery for Femoroacetabular Impingement: A Prospective Analysis of the Relationship Between Surgeon Experience and Patient Outcomes

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967118755048 ◽

2018 ◽

Vol 6 (2) ◽

pp. 232596711875504 ◽

Cited By ~ 7

Author(s):

Sergio E. Flores ◽

Kristina R. Borak ◽

Alan L. Zhang

Keyword(s):

Patient Outcomes ◽

Femoroacetabular Impingement ◽

Arthroscopic Surgery ◽

Harris Hip Score ◽

Complication Rates ◽

Early Group ◽

Procedure Time ◽

Surgeon Experience ◽

The Relationship ◽

Late Group

Background: Hip arthroscopic surgery is a rapidly growing procedure, but it may be associated with a steep learning curve. Few studies have used patient-reported outcome (PRO) surveys to investigate the relationship between surgeon experience and patient outcomes after the arthroscopic treatment of femoroacetabular impingement (FAI). Hypothesis: Patients undergoing hip arthroscopic surgery for the treatment of FAI in the early stages of a surgeon’s career will have significantly worse outcomes and longer procedure times compared with patients treated after the surgeon has gained experience. Study Design: Cohort study; Level of evidence, 2. Methods: Patients undergoing hip arthroscopic surgery for FAI and labral injuries were prospectively enrolled during a sports medicine fellowship–trained surgeon’s first 15 months of practice. Patients were stratified into an early group, consisting of the first 30 consecutive cases performed by the surgeon, and a late group, consisting of the second 30 consecutive cases. Radiographic and physical examinations were performed preoperatively and postoperatively. PRO surveys, including the 12-item Short Form Health Survey (SF-12), the modified Harris Hip Score (mHHS), and the Hip disability and Osteoarthritis Outcome Score (HOOS), were administered preoperatively and at a minimum of 1 year postoperatively. Results: There was no difference between the early and late groups for patient age (37.2 ± 11.5 vs 35.3 ± 10.8 years, respectively; P = .489), body mass index (25.6 ± 4.0 vs 25.1 ± 4.5 kg/m2, respectively; P = .615), or sex ( P = .465). There was a significantly increased procedure time (119.3 ± 21.0 vs 99.0 ± 28.6 minutes, respectively; P = .002) and traction time (72.7 ± 21.4 vs 59.0 ± 16.7 minutes, respectively; P = .007) in the early group compared with the late group. Mean postoperative PRO scores significantly improved in both groups compared with preoperative values for all surveys except for the SF-12 mental component summary. No differences were found in PRO score improvements or complication rates between the early and late groups. Conclusion: The total procedure time and traction time decrease after a surgeon’s first 30 hip arthroscopic surgery cases for FAI and labral tears, but patient outcomes can similarly improve regardless of surgeon experience in the early part of his or her career.

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Precut Papillotomy Versus Persistence in Difficult Biliary Cannulation: A Prospective Randomized Trial

Endoscopy ◽

10.1055/s-2004-826077 ◽

2005 ◽

Vol 37 (1) ◽

pp. 58-65 ◽

Cited By ~ 71

Author(s):

S.-J. Tang ◽

G. B. Haber ◽

P. Kortan ◽

S. Zanati ◽

M. Cirocco ◽

...

Keyword(s):

Randomized Trial ◽

Prospective Randomized Trial ◽

Biliary Cannulation ◽

Difficult Biliary Cannulation

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Initial experience with a homemade “hybrid-tome” for needle-knife precut in patients with difficult biliary cannulation

Endoscopy International Open ◽

10.1055/a-1552-3202 ◽

2021 ◽

Vol 09 (11) ◽

pp. E1611-E1616

Author(s):

Emilio J. De la Morena Madrigal ◽

Isabel Rodríguez García ◽

Ana Belén Galera Ródenas ◽

Elena Pérez Arellano

Keyword(s):

Clinical Success ◽

Clinical Success Rate ◽

Objective Data ◽

Efficacy And Safety ◽

Duodenal Papilla ◽

Technical Success ◽

Biliary Cannulation ◽

Improve Compliance ◽

Difficult Biliary Cannulation ◽

Needle Knife

Abstract Background and study aims Current clinical guidelines recommend needle-knife precut (NKP) as the primary and best method for performing a biliary cannulation (BC) when simple techniques fail and the criteria are met for difficult BC (DBC). However, many endoscopists avoid or defer early NKP in favor of alternative, simpler techniques that have not been shown to be either safer or more effective. Our goal is to test a device that provides the needle-knife papillotome (NKPT) with traction capability and which can facilitate the learning and execution of NKP. Patients and methods This was a descriptive bicentric observational study of a personal cohort of patients undergoing early NKP to analyse the efficacy and safety of the technique with a “hybrid-tome” (HT) built using the isolated core of a NKPT and a conventional canulotome. Results Over a 4-year period, we performed 43 NKPs with the HT, achieving BC in one or two steps in all cases. The 100 % technical success was matched by a 95 % clinical success rate. We recorded 11 adverse events (23 %): five hemorrhages, four pancreatitis, and two cholangitis. In addition to the objective data, we confirmed that HT facilitates alignment with the duodenal papilla and the execution of pre-cutting, especially if the papilla is intradiverticular or hidden by folds. Conclusions The HT tested seems to help trained endoscopists to perform NKP, especially in some anatomic situations, which can improve compliance with the guidelines recommended for early NKP in patients with DBC.

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