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Browsing by Author "Watkins, James L."
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Item A comparative study between single-operator pancreatoscopy with intraductal lithotripsy and extracorporeal shock wave lithotripsy for the management of large main pancreatic duct stones(Springer, 2022) Bick, Benjamin L.; Patel, Feenalie; Easler, Jeffrey J.; Tong, Yan; Watkins, James L.; McHenry, Lee; Lehman, Glen; Fogel, Evan L.; Gromski, Mark A.; Sherman, Stuart; Medicine, School of MedicineBackground and aims: Endoscopic management of large main pancreatic ductal (MPD) stones often require treatment with lithotripsy. Extracorporeal shock wave lithotripsy (ESWL) has been the mainstay therapy, and single-operator pancreatoscopy with intraductal (intracorporeal) lithotripsy (SOPIL) is an emerging technique. However, no comparative studies between these techniques exist. We therefore aimed to compare ESWL to SOPIL for the treatment of large MPD stones. Methods: This is a retrospective cohort study comparing patients who were treated with ESWL or SOPIL from September 2013 to September 2019 at a single tertiary center. Logistic regression was performed to identify factors associated with technical success and efficient stone clearance (≤ 2 procedures to clear stones). Results: There were 240 patients who were treated with ESWL and 18 treated with SOPIL. The overall technical success rate of stone clearance was 224/258 (86.8%), which was similar between the ESWL and SOPIL groups (86.7% vs 88.9%, p = 1.000). A SOPIL approach required fewer total procedures (1.6 ± 0.6 vs 3.1 ± 1.5, p < 0.001) and less aggregate procedure time (101.6 ± 68.2 vs 191.8 ± 111.6 min, p = 0.001). Adverse event rates were similar between the groups (6.3% vs 5.6%, p = 1.000). The use of SOPIL was independently associated with greater efficiency compared to ESWL (OR 5.241 [1.348-20.369], p = 0.017). Stone size > 10 mm was associated with less efficient stone clearance (OR 0.484 [0.256-0.912], p = 0.025). Conclusion: Both ESWL and SOPIL are safe and effective endoscopic adjunct modalities for treating large pancreatic duct stones. SOPIL is an emerging alternative to ESWL that is potentially more efficient for lithotripsy and MPD stone clearance.Item Annular pancreas: endoscopic and pancreatographic findings from a tertiary referral ERCP center(Elsevier, 2019-02) Gromski, Mark A.; Lehman, Glen A.; Zyromski, Nicholas J.; Watkins, James L.; El Hajj, Ihab I.; Tan, Damien; McHenry, Lee; Easler, Jeffrey J.; Tirkes, Temel; Sherman, Stuart; Fogel, Evan L.; Medicine, School of MedicineBackground and Aims Annular pancreas is a congenital anomaly whereby pancreatic tissue encircles the duodenum. Current knowledge of endoscopic findings of annular pancreas is limited to small case series. The aim of this study was to describe the endoscopic and pancreatographic findings of patients with annular pancreas at a large tertiary care ERCP center. Methods This is a retrospective observational study. Our Institutional Review Board–approved, prospectively collected ERCP database was queried for cases of annular pancreas. The electronic medical records were searched for patient and procedure-related data. Results From January 1, 1994, to December 31, 2016, 46 patients with annular pancreas underwent ERCP at our institution. Index ERCP was technically successful in 42 patients (91.3%), and technical success was achieved in all 46 patients (100%) after 2 attempts, when required. A duodenal narrowing or ring was found in most patients (n = 39, 84.8%), yet only 2 (4.3%) had retained gastric contents. Pancreas divisum was found in 21 patients (45.7%), 18 of which were complete divisum. Pancreatobiliary neoplasia was the indication for ERCP in 7 patients (15.2%). Pancreatographic findings consistent with chronic pancreatitis were noted in 15 patients (32.6%) at the index ERCP. Conclusion This is the largest series describing the endoscopic and pancreatographic findings of patients with annular pancreas. We found that 45.7% of patients had concurrent pancreas divisum. Endoscopic therapy was successful in most patients at our institution after 1 ERCP, and in all patients after a second ERCP. Nearly one-third of patients had findings consistent with chronic pancreatitis at the time of index ERCP. It is unclear whether this may be a feature of the natural history of annular pancreas.Item Combined Versus Separate Sessions of Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography for the Diagnosis and Management of Pancreatic Ductal Adenocarcinoma with Biliary Obstruction(Springer Nature, 2021) Purnak, Tugrul; El Hajj, Ihab I.; Sherman, Stuart; Fogel, Evan L.; McHenry, Lee; Lehman, Glen; Gromski, Mark A.; Al-Haddad, Mohammad; DeWitt, John; Watkins, James L.; Easler, Jeffrey J.; Medicine, School of MedicineBackground: A single-procedure session combining EUS and ERCP (EUS/ERCP) for tissue diagnosis and biliary decompression for pancreatic duct adenocarcinoma (PDAC) is technically feasible. While EUS/ERCP may offer expedience and convenience over an approach of separate procedures sessions, the technical success and risk for complications of a combined approach is unclear. Aims: Compare the effectiveness and safety of EUS/ERCP versus separate session approaches for PDAC. Methods: Study patients (2010-2015) were identified within our ERCP database. Patients were analyzed in three groups based on approach: Group A: Single-session EUS-FNA and ERCP (EUS/ERCP), Group B: EUS-FNA followed by separate, subsequent ERCP (EUS then ERCP), and Group C: ERCP with/without separate EUS (ERCP ± EUS). Rates of technical success, number of procedures, complications, and time to initiation of PDAC therapies were compared between groups. Results: Two hundred patients met study criteria. EUS/ERCP approach (Group A) had a longer index procedure duration (median 66 min, p = 0.023). No differences were observed between Group A versus sequential procedure approaches (Groups B and C) for complications (p = 0.109) and success of EUS-FNA (p = 0.711) and ERCP (p = 0.109). Subgroup analysis (> 2 months of follow-up, not referred to hospice, n = 126) was performed. No differences were observed for stent failure (p = 0.307) or need for subsequent procedures (p = 0.220). EUS/ERCP (Group A) was associated with a shorter time to initiation of PDAC therapies (mean, 25.2 vs 42.7 days, p = 0.046). Conclusions: EUS/ERCP approach has comparable rates of success and complications compared to separate, sequential approaches. An EUS/ERCP approach equates to shorter time interval to initiation of PDAC therapies.Item Endoscopic papillectomy: risk factors for incomplete resection and recurrence during long-term follow-up(Elsevier, 2014-02) Ridtitid, Wiriyaporn; Tan, Damien; Schmidt, Suzette E.; Fogel, Evan L.; McHenry, Lee; Watkins, James L.; Lehman, Glen A.; Sherman, Stuart; Coté, Gregory A.; Department of Medicine, IU School of MedicineBackground Endoscopic papillectomy is increasingly used as an alternative to surgery for ampullary adenomas and other noninvasive ampullary lesions. Objective To measure short-term safety and efficacy of endoscopic papillectomy, define patient and lesion characteristics associated with incomplete endoscopic resection, and measure adenoma recurrence rates during long-term follow-up. Design Retrospective cohort study. Setting Tertiary-care academic medical center. Patients All patients who underwent endoscopic papillectomy for ampullary lesions between July 1995 and June 2012. Intervention Endoscopic papillectomy. Main Outcome Measurements Patient and lesion characteristics associated with incomplete endoscopic resection and ampullary adenoma-free survival analysis. Results We identified 182 patients who underwent endoscopic papillectomy, 134 (73.6%) having complete resection. Short-term adverse events occurred in 34 (18.7%). Risk factors for incomplete resection were jaundice at presentation (odds ratio [OR] 0.21, 95% confidence interval [CI] 0.07–0.69; P = .009), occult adenocarcinoma (OR 0.06, 95% CI, 0.01–0.36; P = .002), and intraductal involvement (OR 0.29, 95% CI, 0.11–0.75; P = .011). The en bloc resection technique was strongly associated with a higher rate of complete resection (OR 4.05, 95% CI, 1.71–9.59; P = .001). Among patients with ampullary adenoma who had complete resection (n = 107), 16 patients (15%) developed recurrence up to 65 months after resection. Limitations Retrospective analysis. Conclusion Jaundice at presentation, occult adenocarcinoma in the resected specimen, and intraductal involvement are associated with a lower rate of complete resection, whereas en bloc papillectomy increases the odds of complete endoscopic resection. Despite complete resection, recurrence was observed up to 5 years after papillectomy, confirming the need for long-term surveillance.Item Endoscopic retrieval of a proximally migrated biliary stent: digital cholangioscope to the rescue(Elsevier, 2017-09-28) El Hajj, Ihab I.; Lehman, Glen A.; Fogel, Evan L.; Easler, Jeffrey J.; Watkins, James L.; Sherman, Stuart; Medicine, School of MedicineEndoscopic techniques for the retrieval of proximally migrated biliary stents include the following: fluoroscopy-guided grasping of the stent with a rat-tooth forceps, balloon placement parallel to the stent with traction retrieval, cannulation of the stent lumen with a wire (standard technique, or use of the curved plastic tip of a modified Soehendra stent retriever [Cook Medical, Bloomington, Ind]) followed by use of standard or modified Soehendra stent retriever, wire-guided retrieval basket, and snare. The technique used depends on the extent of proximal stent migration, the presence of ductal dilatation or biliary stricture, and the endoscopist’s experience. This report describes the retrieval of a proximally migrated biliary stent within an aberrant right hepatic duct (RHD) using a digital cholangioscope (SpyGlass DS system; Boston Scientific, Natick, Mass)Item Evaluating Adults With Idiopathic Pancreatitis for Genetic Predisposition: Higher Prevalence of Abnormal Results With Use of Complete Gene Sequencing(Wolters Kluwer, 2015-01) Ballard, Darren D.; Flueckiger, Joyce R.; Fogel, Evan L.; McHenry, Lee; Lehman, Glen A.; Watkins, James L.; Sherman, Stuart; Coté, Gregory A.; Department of Medicine, IU School of MedicineOBJECTIVES: In adults with unexplained pancreatitis, the yield of complete gene versus select exosome sequencing on mutation detection and distinguishing clinical characteristics associated with mutations requires clarification. We sought to (1) compare frequency of mutations identified using different techniques and (2) compare clinical characteristics between adults with and without mutations. METHODS: This is a cohort study of adults with unexplained pancreatitis who underwent genetic testing between January 2008 and December 2012. We compare probabilities of having a positive mutation with complete gene sequencing versus alternatives and describe differences in characteristics among patients with and without mutations. RESULTS: Of the 370 patients, 67 (18%) had a genetic mutation; 24 (6%) were of high risk. Mutations were significantly more prevalent with use of complete sequencing (42%) versus other approaches (8%, P < 0.0001). Most (44/67, 66%) with a mutation had no family history. Those with high-risk mutations were more likely to have a family history of chronic pancreatitis (21% vs 4%, P = 0.002). Patients with pancreas divisum were more likely to have mutations (27% vs 14%, P = 0.0007). CONCLUSION: Among individuals with adult-onset pancreatic disease, the probability of finding any mutation, including high risk, is significantly higher using complete gene sequencing. The impact on patients and providers requires further investigation.Item Microbiology of bile aspirates obtained at ERCP in patients with suspected acute cholangitis(Thieme, 2022) Gromski, Mark A.; Gutta, Aditya; Lehman, Glen A.; Tong, Yan; Fogel, Evan L.; Watkins, James L.; Easler, Jeffrey J.; Bick, Benjamin L.; McHenry, Lee; Beeler, Cole; Relich, Ryan F.; Schmitt, Bryan H.; Sherman, Stuart; Medicine, School of MedicineBackground: The cornerstone of treatment for acute cholangitis is source control with biliary drainage and early antibiotics. The primary aim of this study was to describe the microbiology of bile aspirate pathogens obtained at the time of endoscopic retrograde cholangiopancreatography (ERCP) in patients suspected of having acute cholangitis. Methods: In this single-center retrospective study, patients were included if a bile aspirate was collected at ERCP for suspicion of acute cholangitis, from 1 January 2010 to 31 December 2016. Results: There were 721 ERCP procedures for suspected acute cholangitis with bile culture results, with 662 positive bile cultures (91.8 %). Pathogens included: Enterococcus species (spp.) 448 (67.7 %); Klebsiella spp. 295 (44.6 %); Escherichia coli 269 (40.6 %); Pseudomonas spp. 52 (7.9 %); and anaerobes 64 (9.7 %). Susceptibility of Klebsiella pneumoniae and E.coli isolates to ciprofloxacin was 88 % and 64 %, respectively. Extended-spectrum beta-lactamases and carbapenem resistance were found in 7.9 % and 3.6 % of Enterobacteriaceae, respectively. There were 437 concurrent blood cultures, of which 174 were positive (39.8 % of cultures drawn). Prior biliary endoscopic sphincterotomy (ES) was evident in 459 ERCP cases (63.7 %), and was associated with increased frequency of Klebsiella spp., Pseudomonas aeruginosa, Enterobacter spp., and Enterococcus spp. Prior biliary ES significantly increased the probability of vancomycin-resistant Enterococcus (VRE). Conclusions: The vast majority of bile cultures (91.8 %) were positive. The susceptibilities of E.coli and K.pneumoniae to ciprofloxacin are lower than historically noted. A notable portion of cultures contained pathogenic drug-resistant organisms. Prior biliary ES is associated with a higher frequency of certain organisms and higher frequency of VRE.Item Outcomes in Endoscopic and Operative Transgastric Pancreatic Debridement(Wolters Kluwer, 2021) Maatman, Thomas K.; McGuire, Sean P.; Flick, Katelyn F.; Madison, Mackenzie K.; Al-Haddad, Mohammad A.; Bick, Benjamin L.; Ceppa, Eugene P.; DeWitt, John M.; Easler, Jeffrey J.; Fogel, Evan L.; Gromski, Mark A.; House, Michael G.; Lehman, Glen A.; Nakeeb, Attila; Schmidt, C. Max; Sherman, Stuart; Watkins, James L.; Zyromski, Nicholas J.; Surgery, School of MedicineObjectives: Select patients with anatomically favorable walled off pancreatic necrosis may be treated by endoscopic (Endo-TGD) or operative (OR-TGD) transgastric debridement (TGD). We compared our experience with these 2 approaches. Summary background data: Select necrotizing pancreatitis (NP) patients are suitable for TGD which may be accomplished endoscopically or surgically. Limited experience exists contrasting these techniques exists. Methods: Patients undergoing Endo-TGD and OR-TGD at a single, high-volume pancreatic center between 2008 and 2019 were identified from a prospective database. Patient characteristics, procedural details, and outcomes of these 2 groups were compared. Results: Among 498 NP patients undergoing necrosis intervention, 160 (32%) had TGD: 59 Endo-TGD and 101 OR-TGD. The groups were statistically similar in age, comorbidity, pancreatitis etiology, necrosis anatomy, pancreatitis severity, and timing of TGD from pancreatitis insult. OR-TGD required 1.1 ± 0.5 and Endo-TGD 3.0 ± 2.0 debridements/patient. Fewer hospital readmissions and repeat necrosis interventions, and shorter total inpatient length of stay were observed in OR-TGD patients. New-onset organ failure [Endo-TGD (13%); OR-TGD (13%); P = 1.0] was similar between groups. Hospital length of stay after TGD was significantly longer in patients undergoing Endo-TGD (13.8 ± 20.8 days) compared to OR-TGD (9.4 ± 6.1 days; P = 0.047). Mortality was 7% in Endo-TGD and 1% in OR-TGD (P = 0.04). Conclusions: Operative and endoscopic transgastric debridement achieve necrosis resolution with different temporal and procedural profiles. Clear multidisciplinary communication is essential to determine appropriate approach to individual necrotizing pancreatitis patients.Item Performance characteristics of EUS for locoregional evaluation of ampullary lesions(Elsevier, 2015-02) Ridtitid, Wiriyaporn; Schmidt, Suzette E.; Al-Haddad, Mohammad A.; LeBlanc, Julia; DeWitt, John M.; McHenry, Lee; Fogel, Evan L.; Watkins, James L.; Lehman, Glen A.; Sherman, Stuart; Cote, Gregory A.; Medicine, School of MedicineBackground The accuracy of EUS in the locoregional assessment of ampullary lesions is unclear. Objectives To compare EUS with ERCP and surgical pathology for the evaluation of intraductal extension and local staging of ampullary lesions. Design Retrospective cohort study. Setting Tertiary-care referral center. Patients All patients who underwent EUS primarily for the evaluation of an ampullary lesion between 1998 and 2012. Intervention EUS. Main Outcome Measurements Comparison of EUS sensitivity/specificity for intraductal and local extension with ERCP and surgical pathology by using the area under the receiver-operating characteristic (AUROC) curves and outcomes of the subgroup referred for endoscopic papillectomy. Results We identified 119 patients who underwent EUS for an ampullary lesion, of whom 99 (83%) had an adenoma or adenocarcinoma. Compared with ERCP (n = 90), the sensitivity/specificity of EUS for any intraductal extension was 56%/97% (AUROC = 0.77; 95% confidence interval [CI], 0.64-0.89). However, when using surgical pathology as the reference (n = 102), the sensitivity/specificity of EUS (80%/93%; AUROC = 0.87; 95% CI, 0.76-0.97) and ERCP (83%/93%; AUROC = 0.88; 95% CI, 0.77-0.99) were comparable. The overall accuracy of EUS for local staging was 90%. Of 58 patients referred for endoscopic papillectomy, complete resection was achieved in 53 (91%); in those having intraductal extension by EUS or ERCP, complete resection was achieved in 4 of 5 (80%) and 4 of 7 (57%), respectively. Limitation Retrospective design. Conclusions EUS and ERCP perform similarly in evaluating intraductal extension of ampullary adenomas. Additionally, EUS is accurate in T-staging ampullary adenocarcinomas. Future prospective studies should evaluate whether EUS can identify characteristics of ampullary lesions that appropriately direct patients to endoscopic or surgical resection. (Gastrointest Endosc 2015;81:380-8.)Item A rare complication of ERCP: duodenal perforation due to biliary stent migration(Thieme, 2020-11) Gromski, Mark A.; Bick, Benjamin L.; Vega, David; Easler, Jeffrey J.; Watkins, James L.; Sherman, Stuart; Lehman, Glen A.; Fogel, Evan L.; Medicine, School of MedicineBackground and study aims Perforation of the duodenal wall opposing the major papilla due to a migrated pancreatobiliary stent rarely has been described in the literature as a complication of endoscopic retrograde cholangiopancreatography (ERCP). Factors associated with perforation from migrated stents from ERCP are unknown. , Patients and methods This was a retrospective, observational study. Patients were identified from January 1, 1994 to May 31, 2019 in a prospectively maintained ERCP database. , Results Eleven cases of duodenal perforation from migrated pancreatobiliary stents placed at ERCP were identified during the study period. All cases involved biliary stents, placed for biliary stricture management. The perforating stent was plastic in 10 cases (91 %). This complication occurred in one in 2,293 ERCP procedures in which a pancreatobiliary stent was placed. , Conclusion This complication is more common with biliary stents compared to pancreatic stents. This may be related to the angle of exit of biliary stents being more perpendicular to the opposing duodenal wall and the near exclusive use of external pigtail plastic stents in the pancreatic duct. All perforating plastic stents were ≥ 9 cm in length. Longer stents may provide leverage for perforation with a migration event.