Jorma Halttunen

There is a lack of studies about procedural sedation of alcoholics. Dexmedetomidine is recommended for procedural sedation and reported effective for alcohol withdrawal. We evaluated the suitability of dexmedetomidine for sedation of alcoholics during endoscopic retrograde cholangiopancreatography (ERCP). Fifty patients with chronic alcoholism scheduled for elective ERCP were randomized 1:1 to receive dexmedetomidine (Dex group) (loading dose 1 μg kg⁻¹ over 10 min, followed by constant intravenous infusion 0.7 μg kg⁻¹ h⁻¹) or saline placebo (P group). Patient-controlled sedation with propofol–alfentanil was used by patients as a rescue method. Sedation was considered as successful if no intervention of an anesthesiologist was needed. Consumption of sedatives was registered, and sedation levels and vital signs were monitored. Dexmedetomidine alone was insufficient in all patients. The mean ± SD consumption of propofol was 159 ± 72 mg in the P group, and 116 ± 61 mg in the Dex group (p = 0.028). Sedation was successful in 19 of 25 (76 %) patients in the Dex group and in all patients in the P group (p = 0.022). The incidence of sedation adverse events did not differ between the groups. Dexmedetomidine was associated with delayed recovery. Patient-controlled sedation with propofol and alfentanil but not dexmedetomidine can be recommended for sedation of alcoholics during ERCP.

Endoscopic retrograde cholangiopancreatography (ERCP) is a valuable tool in the diagnosis and management of various pancreatobiliary disorders. Our aim was to evaluate whether the combination of a thin guide wire and a thin sphincterotome would facilitate selective cannulation of the bile duct and reduce the incidence of post-ERCP pancreatitis (PEP) by reducing papillary trauma when compared with a regular-sized hydrophilic guide wire. Between June 2011 and February 2012, we performed 100 biliary cannulations for a native papilla in a randomized controlled trial. Having given their written informed consent, patients were randomly assigned to a 0.025-inch guide wire and sphincterotome group (n = 50) or to a 0.035-inch guide wire and sphincterotome group (n = 50). Number of cannulation attempts, number of accidental guide wire passages into the pancreatic duct, secondary cannulation techniques after failed primary cannulation, time to change the technique, and time for successful cannulation were collected in a database. Patients were followed up after ERCP, and all post-ERCP complications were recorded. Primary cannulation was successful in 80 %. With accessory techniques, cannulation of the biliary duct was achieved in every case except one. There was no difference in primary cannulation rate between the 0.025-inch and 0.035-inch wire groups (n = 40 in each group). PEP was diagnosed in two patients (2.0 %), one in each study group. Postsphincterotomy bleeding occurred in one patient (1.0 %). The thickness of the hydrophilic guide wire does not appear to affect either the success rate of primary cannulation or the risk of complications.

Malignant gastric outlet obstruction (GOO) leads to malnutrition and limits quality of life. Gastrojejunostomy has been the traditional treatment for GOO. Recently, the results of releasing duodenal obstruction with self-expandable metal stents (SEMS) have been encouraging. After the exclusion of 13 patients with gastrojejunal or jejunal strictures and 1 patient with intraabdominal lymphoma, the authors palliated the malignant GOO in 104 patients with 130 SEMS at a single center during the years 1999–2007. The GOO was caused by pancreatic (n = 51), gastric (n = 24), duodenal (n = 7), biliary (n = 5), and other (n = 17) malignancies. Of the 104 patients, 76 (73%) did well with only one enteral stent placement, 21 (20.2%) required two stent placements, 4 (3.8%) required three stent placements, and 1 required four stent placements. The median dysphagia score was 0 before stenting and 2 after treatment (p < 0.001). Immediate failure occurred after 10 procedures (7.7%). Among the 104 patients, 6 (5.8%) died of stent placement-related reasons. Complications occurred for 13 patients (12.5%). The median hospital stay was 3 days, and the overall survival time was 62 days (range, 1–933 days). Of 11 patients with concomitant biliary obstruction and GOO, 10 (91%) underwent successful enteral and biliary stent placement within the same session. Of 15 patients experiencing jaundice after enteral stent placement, 6 (40%) underwent endoscopic biliary drainage successfully. Enteral stenting is a safe and effective way to treat GOO. Gastrojejunostomy should be preserved for cases in which endoscopic stenting is not successful or possible.

In endoscopic retrograde cholangiopancreaticography (ERCP) difficult cannulation is an independent risk factor for complications. Altogether 6,209 ERCPs were performed in Helsinki University Central Hospital in the period 1996–2006. In 558 cases (9%) without a previous sphincterotomy, direct access into the biliary duct could not be achieved. In this group access was attempted by first performing a pancreatic sphincterotomy in 351 difficult cannulation cases (63%). A needle knife precut without a pancreatic sphincterotomy was performed in 178 cases (32%). All the necessary clinical and laboratory information was available for 262 of the 351 patients who had undergone a pancreatic sphincterotomy and for 157 of the 178 patients who had been subjected to needle knife precutting, and these data were further evaluated in this study. The pancreatic sphincterotomy technique was successful in 255 cases (97.3%). Post-ERCP pancreatitis developed in 8.8% of the pancreatic sphincterotomy group. In 147 patients, biliary cannulation was successful following a pancreatic sphincterotomy, and the post-ERCP pancreatitis rate for those patients was 9.3%. In 108 patients, a needle knife papillotomy, in addition to a pancreatic sphincterotomy, was necessary and resulted in a post-ERCP pancreatitis rate of 8.2%. In the needle knife precut group only, post-ERCP pancreatitis developed in 5.1% of cases. Biliary cannulation succeeded less frequently following needle knife precutting than following the pancreatic sphincterotomy technique (71.3% versus 97.3%, p < 0.001). There was no significant difference in the post-ERCP pancreatitis rate between the precut and pancreatic sphincterotomy techniques (p = 0.16). In difficult cannulation, a pancreatic sphincterotomy to achieve deep biliary duct cannulation can be performed with a high success rate (failure rate less than 3%). The corresponding success rate using the needle knife precut technique is 71%. In both methods the risk for post-ERCP pancreatitis is comparable to that of a standard biliary sphincterotomy.

This study aimed to assess the effectiveness of therapeutic endoscopy in the treatment of pancreatic pseudocysts, and to define factors limiting endoscopic therapy. The results of therapeutic endoscopy were evaluated for 170 patients with pancreatic pseudocysts treated at the Department of Surgery, Helsinki University Central Hospital, during the 6-year period from 1998 to 2003. The therapeutic endoscopy success rate was 86.1%, with 23 (13.9%) patients requiring operative treatment because therapeutic endoscopy was unsuccessful or technically impossible. There was little morbidity and no procedure-related mortality. The majority of the 38 complications, which arose from 380 procedures, could be treated conservatively. Endoscopic methods are safe and effective for the treatment of pancreatic pseudocysts. The indications for surgery include inaccessible pancreatic duct, location, or content of the pseudocyst rendering the problem not amenable to endoscopic therapy, as well as complications of the endoscopic treatment.

Interest in the use of therapeutic endoscopy for the treatment of pancreatic diseases has been on the increase for several years. Our aim was to assess the efficacy of endoscopic retrograde cholangiopancreaticography (ERCP) in the treatment of pancreatic fistulas. We evaluated the results of therapeutic ERCP in 50 patients with pancreatic fistula treated at the Helsinki University Central Hospital from 1998 to 2003. The success rate of fistula closure after therapeutic ERCP was 82%. Five patients required operative treatment when ERCP was unsuccessful. There was little morbidity and no procedure-related mortality. Four patients died because severe illnesses made them unfit for any further procedures. ERCP is a safe and effective modality and should be considered as first-line therapy in the management of pancreatic fistula.

Background: The management of gastrointestinal-cutaneous fistulas may be complicated by the difficulty in obtaining adequate control of the fistula tract. This study describes a new method to obtain better fistula control utilizing a semi-rigid stent in the form of a gastrostomy tube. Methods: Consecutive patients with intestinal-cutaneous fistulas of at least 3 weeks duration and treated by the new technique were analyzed. The technique involved the insertion of a guide wire into the fistula tract from the luminal side using an endoscope, snaring the wire with a Dormia basket inserted into the fistula tract from the cutaneous side and then exteriorized. The gastrostomy tube was then pulled with the guide wire from the lumen along the fistula tract and out through the skin. Results: Five patients had had fistulas for a median duration of 42 (range 26–140) days before insertion of the gastrostomy tube. The gastrostomy tube was replaced with a smaller diameter tube in 4 of the patients (range 1–3 changes). The patients were discharged from the hospital at a median of 14 (range 12–23) days after the tube insertion but with the tube in situ. The median time from the insertion of the tube to its removal was 42 (range 32–108) days. Conclusions: Gastrostomy tube insertion using minimally invasive techniques may improve fistula control enabling patients to be discharged home sooner than otherwise and improve the rate of healing.