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Prevention and Management of Post-Endoscopic Retrograde Cholangiopancreatography Complications
Michel Kahaleh,Martin Freeman 대한소화기내시경학회 2012 Clinical Endoscopy Vol.45 No.3
Endoscopic retrograde cholangiopancreatography (ERCP) is associated with a spectrum of complications such as pancreatitis, hemorrhage, perforation, and cardiopulmonary events. These complications can range from mild to severe resulting in extended hospitalization, requiring surgical intervention, and leading to permanent disability or even death. Complications of ERCP have been better understood in the past decade, with adoption of standardized consensus-based definitions of complications and introduction of new recommendations to minimize risks of ERCP. Adequate selection of patients undergoing ERCP, skilled operators using novel techniques and prompt identification and treatment are key to successful prevention and management.
Endoscopic Necrosectomy for Walled-Off Pancreatic Necrosis
Michel Kahaleh 대한소화기내시경학회 2012 Clinical Endoscopy Vol.45 No.3
Approximately 20% of patients with acute pancreatitis develop pancreatic necrosis with significant mortality. Surgical debridement is the traditional management of necrotizing pancreatitis, but it is associated with significant morbidity and mortality. Endoscopic necrosectomy using repeats session of debridement and stent insertion has been more frequently used within the last decade and half. This technique continues to evolve as we attempt to optimize the post-procedural outcomes.
The Learning Curve for Peroral Endoscopic Myotomy in Latin America: A Slide to the Right?
Michel Kahaleh,Amy Tyberg,Supriya Suresh,Arnon Lambroza,Fernando Rodriguez Casas,Mario Rey,Jose Nieto,Guadalupe Ma Martínez,Felipe Zamarripa,Vitor Arantes,Maria G Porfilio,Monica Gaidhane,Pietro Fami 대한소화기내시경학회 2021 Clinical Endoscopy Vol.54 No.5
Background/Aims: Peroral endoscopic myotomy (POEM) has been increasingly used for achalasia in Latin America, where Chagasdisease is prevalent, and this makes POEM more challenging. The aim of this study was to determine the learning curve for POEMin Latin America. Methods: Patients undergoing POEM in Latin America with a single operator were included from a prospective registry over 4 years. Non-linear regression and cumulative sum control chart (CUSUM) analyses were conducted for the learning curve. Results: A total of 125 patients were included (52% male; mean age, 59 years), of which 80 had type II achalasia (64%), and 38 hadChagas disease (30%). The average pre-procedure and post-procedure Eckardt scores were 6.79 and 1.87, respectively. Technicalsuccess was achieved in 93.5% of patients, and clinical success was achieved in 88.8%. Adverse events occurred in 27 patients (22%)and included bleeding (4 patients), pneumothorax (4 patients), mucosal perforation (13 patients), mediastinitis (2 patients), andleakage (4 patients). The CUSUM chart showed a median procedure time of 97 min (range, 45-196 min), which was achieved at the 61st procedure. Procedure duration progressively decreased, with the last 10 procedures under 50 min approaching a plateau (p-value <0.01). Conclusions: Mastering POEM in Latin America requires approximately 61 procedures for both POEM efficiency and to accomplishthe procedure within 97 minutes.
Spyglass Direct Visualization System
Michel Kahaleh 대한소화기내시경학회 2012 Clinical Endoscopy Vol.45 No.3
Although endoscopic retrograde cholangiopancreatography is considered the gold standard to manage biliary disorders, it has its own limitations. The single-operator cholangioscopy (SOC) system (Spyglass) may offer an interesting compromise for most advanced biliary endoscopists, in terms of size (10 Fr diameter) and complexity of use. SOC is a great step toward intraductal visualization and therapy but the best is yet to come.
A Review of Probe-Based Confocal Laser Endomicroscopy for Pancreaticobiliary Disease
Kunal Karia,Michel Kahaleh 대한소화기내시경학회 2016 Clinical Endoscopy Vol.49 No.5
Confocal laser endomicroscopy (CLE) is a novel in vivo imaging technique that can provide real-time optical biopsies in the evaluation of pancreaticobiliary strictures and pancreatic cystic lesions (PCLs), both of which are plagued by low sensitivities of routine evaluation techniques. Compared to pathology alone, CLE is associated with a higher sensitivity and accuracy for the evaluation of indeterminate pancreaticobiliary strictures. CLE has the ability to determine the malignant potential of PCLs. As such, CLE can increase the diagnostic yield of endoscopic retrograde cholangiopancreatography and endoscopic ultrasound, reducing the need for repeat procedures. It has been shown to be safe, with an adverse event rate of ≤1%. Published literature regarding its cost-effectiveness is needed.
Safety and Complications of Interventional Endoscopic Ultrasound
Monica Saumoy,Michel Kahaleh 대한소화기내시경학회 2018 Clinical Endoscopy Vol.51 No.3
Endoscopic ultrasound (EUS) has become an essential tool for the diagnostic and therapeutic intervention of gastrointestinal diseases. Beyond the drainage of fluid collections, it enables decompression of inaccessible bile and pancreatic ducts, the gallbladder, and thecreation of anastomosis within the gastrointestinal tract using fully lumen-apposing stents. This review explored the safety and efficacyof these novel procedures and discussed the training pathway that is necessary to perform them efficiently and safely.
Management of Benign and Malignant Pancreatic Duct Strictures
Enad Dawod,Michel Kahaleh 대한소화기내시경학회 2018 Clinical Endoscopy Vol.51 No.2
The diagnosis and management of pancreatic strictures, whether malignant or benign, remain challenging. The last 2 decades haveseen dramatic progress in terms of both advanced imaging and endoscopic therapy. While plastic stents remain the cornerstone of thetreatment of benign strictures, the advent of fully covered metal stents has initiated a new wave of interest in calibrating the pancreaticduct with fewer sessions. In malignant disease, palliation remains the priority and further data are necessary before offering systematicpancreatic stenting.
Tayyaba Mohammad,Michel Kahaleh 대한소화기내시경학회 2022 Clinical Endoscopy Vol.55 No.3
Referral to an endoscopist is often done once curative resection is no longer an option for cholangiocarcinoma management. In suchcases, palliation has become the main objective of the treatment. Photodynamic therapy and radiofrequency ablation can be performedto achieve palliation, with both procedures associated with improved stent patency and survival. Despite the greatly increased cost andassociation with photosensitivity, photodynamic therapy allows transmission to the entire biliary tree. In contrast, radiofrequency ablationis cheaper and faster to apply, but requires intraductal contact. This paper reviews both modalities and compares their efficacy andsafety for bile duct cancer palliation.
Necrotizing Pancreatitis: Current Management and Therapies
Christine Boumitri,Elizabeth Brown,Michel Kahaleh 대한소화기내시경학회 2017 Clinical Endoscopy Vol.50 No.4
Acute necrotizing pancreatitis accounts for 10% of acute pancreatitis (AP) cases and is associated with a higher mortality and morbidity. Necrosis within the first 4 weeks of disease onset is defined as an acute necrotic collection (ANC), while walled off pancreatic necrosis (WOPN) develops after 4 weeks of disease onset. An infected or symptomatic WOPN requires drainage. The management of pancreatic necrosis has shifted away from open necrosectomy, as it is associated with a high morbidity, to less invasive techniques. In this review, we summarize the current management and therapies for acute necrotizing pancreatitis.
Prashant Kedia,Monica Gaidhane,Michel Kahaleh 대한소화기내시경학회 2013 Clinical Endoscopy Vol.46 No.5
Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is one of the least invasive and most effective modality in diagnosing pancreatic adenocarcinoma in solid pancreatic lesions, with a higher diagnostic accuracy than cystic tumors. EUS-FNA has been shown to detect tumors less than 3 mm, due to high spatial resolution allowing the detection of very small lesions and vascular invasion, particularly in the pancreatic head and neck, which may not be detected on transverse computed tomography. Furthermore, this minimally invasive procedure is often ideal in the endoscopic procurement of tissue in patients with unresectable tumors. While EUS-FNA has been increasingly used as a diagnostic tool, most studies have collectively looked at all primary pancreatic solid lesions, including lymphomas and pancreatic neuroendocrine neoplasms, whereas very few studies have examined the diagnostic utility of EUS-FNA of pancreatic ductal carcinoma only. As with any novel and advanced endoscopic procedure that may incorporate several practices and approaches, endoscopists have adopted diverse techniques to improve the tissue procurement practice and increase diagnostic accuracy. In this article, we present a review of literature to date and discuss currently practiced EUS-FNA technique, including indications, technical details, equipment, patient selection, and diagnostic accuracy.