- Email: [email protected]
CME Activity: Continuing Medical Education Exam: October 2009
CME ACTIVITY
Continuing Medical Education Exam: October 2009 Raquel E. Davila, MD, Jeffrey H. Lee, MD, William Ross, MD, Shou-Jiang Tang, MD Co-Editors, CME Section G. S. Raju, MD, Editor, CME Section George Triadafilopoulos, MD, Editor-in-Chief, Gastrointestinal Endoscopy
Instructions:
The GIE: Gastrointestinal Endoscopy CME Activity can now be completed entirely on-line. To complete this CME activity, you will need to do the following: 1. Read the following articles that have been designated for CME in this issue: Dunbar K, Okolo P, Montgomery E, et al. Confocal laser endomicroscopy in Barrett’s esophagus and endoscopically inapparent Barrett’s neoplasia: a prospective randomized, double-blind, controlled, crossover trial. Gastrointest Endosc 2009;70:645-54. Ravipati M, Katragadda S, Swaminathan PD, et al. Pharmacotherapy plus endoscopic intervention is more effective than pharmacotherapy or endoscopy alone in the secondary prevention of esophageal variceal bleeding: a meta-analysis of randomized, controlled trials. Gastrointest Endosc 2009;70:658-64. Tejada AH, Calleja JL, Díaz G, et al. Double-guidewire technique for difficult bile duct cannulation: a multicenter, randomized, controlled trial. Gastrointest Endosc 2009;70:700-9. DeWitt J, McGreevy K, Schmidt, CM, et al. EUS-guided ethanol versus saline solution lavage for pancreatic cysts: a randomized, doubleblind study. Gastrointest Endosc 2009;70:710-23. 2. Log-in on-line to complete a single exam with multiple choice questions followed by a brief post-test evaluation. Visit the Journal’s Web site at www.asge.org (members) or www.giejournal.org (nonmembers). 3. Persons scoring greater than or equal to 75% pass the exam and can print a CME certificate. Persons scoring less than 75% cannot print a CME certificate; however, they can retake the exam. Exams can be saved to be accessed at a later date. You may create a free personal account to save and return to your work in progress, as well as save and track your completed activities so that you may print a certificate at any time. The complete articles, detailed instructions for completion, as well as past Journal CME activities can also be found at this site.
Target Audience
This activity is designed for physicians who are involved with providing patient care and who wish to advance their current knowledge of clinical medicine.
Learning Objectives
As a result of completing this activity, participating physicians will be able to: 1. Identify the advantages of confocal laser endomicroscopy in the evaluation and detection of Barrett’s esophagus-associated neoplasia. 2. Assess the differences in outcomes among the various therapies for variceal rebleeding. 3. Examine different biliary cannulation techniques. 4. Assess the outcomes of EUS-guided ethanol lavage in the treatment of pancreatic cysts.
Continuing Medical Education
The American Society for Gastrointestinal Endoscopy (ASGE) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The ASGE designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Activity Start Date: October 1, 2009 Activity Expiration Date: October 31, 2011
Disclosures
Disclosure information for authors of the articles can be found with the article in the abstract section. All disclosure information for GIE editors can be found online at http://www.giejournal.org/content/conflictofinterest. CME editors, and their disclosures, are as follows: G. S. Raju, MD, FASGE (Associate Editor for Journal CME): Jeffrey H. Lee, MD (CME Editor): Consultant, Research Support: InScope Consulting/Advisory/Speaking: Wyeth, Olympus Speaking honorarium, Research Support: Boston Scientific Research Support: ConMed Research Support: Pentax William Ross, MD (CME Editor): Raquel E. Davila, MD (CME Editor): Consulting/Advisory/Speaking: Boston Scientific, Disclosed no relevant financial relationships Olympus All CME activities, including their associated articles Shou-Jiang Tang, MD (CME Editor): are copyrighted by the ASGE. Consulting/Advisory/Speaking: Olympus America Minimum Online System Requirements: Other Financial: Ethicon Endo-Surgery, licensing 486 Pentium 1 level computer (PC or Macintosh) agreement for magnetic anchoring and guidance Windows 95, 98 2000, NT or Mac OS system; Patents pending for magnetic anchoring Netscape 4.X or Microsoft Internet Explorer 4.X and above and guidance system 16 MB RAM 56.6K modem www.giejournal.org
Volume 70, No. 4 : 2009 GASTROINTESTINAL ENDOSCOPY 748
CME ACTIVITY
Continuing Medical Education Questions: October 2009 QUESTION 1 OBJECTIVE: Identify the advantages of confocal laser endomicroscopy in the evaluation and detection of Barrett’s esophagus-associated neoplasia.
How good is confocal laser endomicroscopy for Barrett’s esophagus? Question 1:
Possible answers (A-D)
A 68-year-old male veteran with a long segment of Barrett’s esophagus and high-grade dysplasia at 36 cm and 34 cm from the incisors, but without endoscopically visible mucosal abnormalities, is referred to you for further management. You decide to perform confocal laser endomicroscopy. What are the advantages of confocal laser endomicroscopy compared with standard white light endoscopy in this patient?
A. Significantly higher detection rate of neoplasia B. Fewer number of biopsies required C. Longer total procedure time D. Higher risk of cardiopulmonary events
Look-up: Dunbar K, Okolo P, Montgomery E, et al. Confocal laser endomicroscopy in Barrett’s esophagus and endoscopically inapparent Barrett’s neoplasia: a prospective, randomized, double-blind, controlled crossover trial. Gastrointest Endosc 2009;70:645-54.
QUESTION 2 OBJECTIVE: Assess the differences in outcomes among the various therapies for variceal rebleeding.
How good are the different options for preventing variceal re-bleeding? Question 2:
Possible answers (A-D)
After having undergone endoscopic band ligation of bleeding esophageal varices, a 56-year-old man with alcoholic cirrhosis but without ascites is scheduled for repeat endoscopic therapy in 1 week. In addition, propranolol is being considered. What additional benefits can be anticipated from the addition of a beta-blocker to endoscopic therapy?
A. Reduction in overall all-cause mortality B. Reduction in mortality from GI bleeding C. Reduction in variceal re-bleeding D. Reduction in spontaneous bacterial peritonitis
Look-up: Ravipati M, Katragadda S, Swaminathan PD, et al. Pharmacotherapy plus endoscopic intervention is more effective than pharmacotherapy or endoscopy alone in the secondary prevention of esophageal variceal bleeding: a meta-analysis of randomized, controlled trials. Gastrointest Endosc 2009;70:658-64.
748.e1 GASTROINTESTINAL ENDOSCOPY Volume 70, No. 4 : 2009
www.giejournal.org
CME Exam
QUESTION 3 OBJECTIVE: Examine different biliary cannulation techniques.
Dealing with a difficult bile duct cannulation. Question 3:
Possible answers (A-D)
During ERCP, you start with a sphincterotome and a wire to achieve biliary cannulation, but you fail after more than 5 cannulation attempts. Which of the options listed below would be your next choice?
A. Use a different sphincterotome with wire B. Use a standard cannula C. Double-wire technique D. Pre-cutting with pancreatic stent placement
Look-up: Tejada AH, Calleja JL, Díaz G, et al. Double-guidewire technique for difficult bile duct cannulation: a multicenter randomized, controlled trial. Gastrointest Endosc 2009;70:700-9.
QUESTION 4 OBJECTIVE: Assess the outcomes of EUS-guided ethanol lavage in the treatment of pancreatic cysts.
Is alcohol a friend of the pancreas? Question 4:
Possible answers (A-D)
A 65-year-old female with heart failure is referred to you for management of a pancreatic cyst found incidentally on CT scan. EUS examination confirms a 3-cm cyst in the body of the pancreas, without thickened wall, septations, intracystic growth, or communication with the pancreatic duct. EUS-guided FNA shows moderately viscous clear fluid with carcinoembryotic antigen (CEA) level of 330 ng/mL. After counseling her about various management options, including EUS-guided ethanol injection of the cyst, she decides to opt for endoscopic therapy. What is the benefit of ethanol lavage of the pancreatic cyst in this patient?
A. Provides approximately 33% chance of cyst resolution B. Is technically feasible in all cases C. Carries no risk for procedure-related pancreatitis D. Improves survival
Look-up: DeWitt J, McGreevy K, Schmidt, CM, et al. EUS-guided ethanol versus saline solution lavage for pancreatic cysts: a randomized, double-blind study. Gastrointest Endosc 2009;70:710-23.
www.giejournal.org
Volume 70, No. 4 : 2009 GASTROINTESTINAL ENDOSCOPY 748.e2
CME ACTIVITY
Continuing Medical Education Answers: October 2009 QUESTION 1: CORRECT RESPONSE: B Rationale for correct response: Confocal laser endomicroscopy (CLE) is a form of virtual histology in which in vivo microscopic, high-resolution images of the GI mucosa can be obtained to predict tissue histology.1 In a prospective, randomized, double-blind, crossover, single-center study,2 39 patients with Barrett’s esophagus underwent both standard endoscopy with random 4-quadrant biopsies and CLE with targeted biopsies of sites suspicious for neoplasia. • CLE resulted in a significantly lower number of biopsy specimens obtained during the endoscopic examination. • There was no significant difference in the neoplasia detection rate between the two endoscopic techniques. Both CLE and standard endoscopy detected 11 cases of high-grade dysplasia in 16 patients recruited with suspected neoplasia. The study did not evaluate total procedure time as an endpoint; however, comparison of the median time spent acquiring mucosal biopsies was significantly shorter during CLE in patients with long-segment Barrett’s esophagus. There was no significant difference in complication rates, and there was only one report of a postprocedure pneumonia after CLE that required a 2-day hospitalization and antibiotics. Take-home message: Confocal laser endomicroscopy is feasible and safe, and allows the performance of limited, targeted biopsies for the detection of Barrett’s esophagus-associated neoplasia. This in turn, results in a marked reduction in the number of biopsies required during endoscopy, and may completely eliminate the need for biopsies in patients who have no endoscopic evidence of mucosal abnormalities. REFERENCES: 1. Kiesslich R, Canto MI. Confocal laser endomicroscopy. Gastrointest Endosc Clin N Am 2009;19:261-72. 2. Dunbar K, Okolo P, Montgomery E, et al. Confocal laser endomicroscopy in Barrett’s esophagus and endoscopically inapparent Barrett’s neoplasia: a prospective, randomized, double-blind, controlled crossover trial. Gastrointest Endosc 2009;70:645-54.
QUESTION 2: CORRECT RESPONSE: B Rationale for correct response: Esophageal variceal bleeding signals a serious turn in the life of a patient with cirrhosis of liver—two-thirds of them re-bleed, and a third of them succumb to it. Over the past 3 decades, both endoscopic therapy to ablate varices and pharmacologic therapy to reduce portal hypertension have been extensively used. A meta-analysis of the studies investigating the outcome of endoscopic and pharmacologic therapies could be summarized as follows: • Pharmacotherapy is as effective as endoscopic therapy in preventing re-bleeding, variceal re-bleeding, all cause mortality, and mortality from re-bleeding. • Pharmacotherapy combined with endoscopic therapy does not reduce all-cause mortality or mortality due to re-bleeding when compared with endoscopic therapy; however, combination of endoscopic and pharmacotherapy significantly reduces the incidence of all re-bleeding and variceal re-bleeding. Take-home message: Consider adding pharmacotherapy to endoscopic therapy to reduce re-bleeding in patients with cirrhosis. REFERENCE: 1. Ravipati M, Katragadda S, Swaminathan PD, et al. Pharmacotherapy plus endoscopic intervention is more effective than pharmacotherapy or endoscopy alone in secondary prevention of esophageal variceal bleeding: a meta-analysis of randomized, controlled trials. Gastrointest Endosc 2009;70:658-64.
748.e3 GASTROINTESTINAL ENDOSCOPY Volume 70, No. 4 : 2009
www.giejournal.org
CME Answers
QUESTION 3: CORRECT RESPONSE: D Rationale for correct response: Biliary cannulation is one of the most challenging and exciting parts of ERCP because it can be difficult in 35% to 60% of cases and may precipitate post-ERCP pancreatitis. A number of techniques can be used after initial failure to cannulate the bile duct. The double-guidewire technique involves biliary cannulation by using a second guidewire through a standard cannulation device after initial insertion of a guidewire into the pancreatic duct (PD).1,2 The perceived advantages of this technique include the following: the pancreatic guidewire can potentially straighten both pancreatic and bile ducts; the presence of pancreatic wire within the papillary structure can potentially facilitate biliary cannulation; the direction of the pancreatic guidewire can guide biliary cannulation; and the ampulla can be anchored by the pancreatic guidewire. In a multicenter randomized clinical trial, Tejada et al2 randomized 188 patients with difficult biliary cannulation defined by failed cannulation after 5 attempts with initial wire-guided approach. After 10 additional attempts, successful biliary cannulation was achieved in 46 of 97 patients (47%) in the double-guidewire arm and 51 of 91 patients (56%) in the standard cannulation or persistence arm (OR = 0.85; 95% CI 0.64 – 1.12). Analysis per protocol showed a statistically significant lower success rate for double-guidewire arm (OR = 0.66; 95% CI 0.46 – 0.94). In those patients with successful biliary cannulation, the median time of cannulation was longer in the double-guidewire arm: 16 minutes versus 11 minutes (P = .287). In addition, the incidence of post-ERCP pancreatitis was higher in the double-guidewire arm: 17% versus 8% (OR = 1.87; 95% CI 0.79 – 4.42). In this study, for patients who failed cannulation in both randomized arms, pre-cutting was the most-used backup technique, and it was the most successful in achieving biliary cannulation. It is possible that the prolonged manipulation of PD by the pancreatic wire during the double-guidewire technique increased the pancreatitis risk in this study. Other randomized trials have shown that persistence in cannulation with the standard technique and pre-cutting are both safe and effective in achieving biliary cannulation.3,4 Take-home message: In patients with difficult biliary cannulation, double-guidewire technique is not superior to standard single-wire technique or persistence in achieving cannulation. In addition, in this multicenter randomized clinical trial, double-wire technique was associated with a longer cannulation time and higher risk of post-ERCP pancreatitis. REFERENCES: 1. Dumonceau JM, Deviere J, Cremer M. A new method of achieving deep cannulation of the common bile duct during endoscopic retrograde cholangiopancreatography. Endoscopy 1998;30:S80. 2. Tejada AH, Calleja JL, Díaz G, et al. Double-guidewire technique for difficult bile duct cannulation: a multicenter, randomized, controlled trial. Gastrointest Endosc 2009;70:700-9. 3. Tang SJ, Haber GB, Kortan P, et al. Precut papillotomy versus persistence in difficult biliary cannulation: a prospective, randomized trial. Endoscopy 2005;37:58-65. 4. Cennamo V, Fuccio L, Repici A, et al. Timing of precut procedure does not influence success rate and complications of ERCP procedure: a prospective, randomized, comparative study. Gastrointest Endosc 2009;69:473-9.
www.giejournal.org
Volume 70, No. 4 : 2009 GASTROINTESTINAL ENDOSCOPY 748.e4
CME Answers
QUESTION 4: CORRECT RESPONSE: A Rationale for correct response: Pancreatic EUS has certainly evolved over the last 2 decades from an imaging modality to one that can acquire tissue to confirm the diagnosis. Recently, the therapeutic potential of EUS has been explored in the management of pancreatic neoplasms. Progress in this field is summarized below: A. Imaging: Radial EUS helps us identify both small and large pancreatic cysts and define the structure of the cyst and its contents better than any other currently available imaging modalities. A thick cyst wall and an intracystic growth suggest premalignant cysts (mucinous cystadenoma [MCN] and intraductal papillary mucinous neoplasms [IPMN]) or malignant cysts (mucinous cystadenocarcinoma).1 B. Diagnosis: EUS-guided FNA technology provides us with the ability to diagnose the lesions with greater confidence. Cyst fluid analysis (“string sign” and elevated cyst fluid CEA) suggests premalignant (MCN and IPMN) or malignant cysts (mucinous cystadenocarcinoma).1 C. Therapy: For MCN and IPMN, a conservative approach of observation may have a role. Leung et al1 reported that, in the absence of worrisome features on EUS or symptoms, these cysts may not require immediate resection, and conservative management with serial EUS imaging may be a consideration in appropriate clinical settings. However, careful surveillance for malignant transformation should be undertaken.1 Recently, EUS-guided alcohol ablation of pancreatic cysts is being explored as a therapeutic option. In a randomized controlled trial and compared with saline solution lavage, EUS-guided ethanol lavage of pancreatic cysts resulted in a decrease in cyst surface area, 50% to 100% epithelial ablation, and resolution of the cysts in 33.3% of cases. Complications included abdominal pain (20%), acute pancreatitis (4%), and intracystic hemorrhage (4%). 2 Take-home message: EUS-guided ethanol lavage of pancreatic cysts is a novel option worthy of further investigation, and it should be presented to patients as an important therapeutic option. 2 REFERENCES: 1. Leung KK, Ross WA, Evans D, et al. Pancreatic cystic neoplasm: the role of cyst morphology, cyst fluid analysis, and expectant management. Ann Surg Oncol. 2009 Jun 18 [Epub ahead of print]. 2. DeWit J, McGreevy K, Schmidt, CM, et al. EUS-guided ethanol versus saline solution lavage for pancreatic cysts: a randomized, double-blinded study. Gastrointest Endosc 2009;70:710-23.
748.e5 GASTROINTESTINAL ENDOSCOPY Volume 70, No. 4 : 2009
www.giejournal.org
CME Answers
EVALUATION PAGE, GIE Please complete the following questions in order to complete the process for earning your CME. Assessment of change in knowledge, skills and/or practice In general, this activity (check all that apply): Reinforced my existing knowledge and/or skills. Increased my knowledge. Will positively impact my practice.
Yes Yes Yes
No No No
Please specify any changes you plan to implement in your practice as a result of this activity:
Overall Evaluation of Activity
Strongly agree Agree
1. The overall educational value of this activity is excellent. 2. I would recommend this activity to a colleague. 3. I am interested in participating in future journal CME activities. Did you perceive commercial bias in this activity?
www.giejournal.org
Disagree
Yes
No
Volume 70, No. 4 : 2009 GASTROINTESTINAL ENDOSCOPY 748.e6
Continuing Medical Education Exam: October 2009 Raquel E. Davila, MD, Jeffrey H. Lee, MD, William Ross, MD, Shou-Jiang Tang, MD Co-Editors, CME Section G. S. Raju, MD, Editor, CME Section George Triadafilopoulos, MD, Editor-in-Chief, Gastrointestinal Endoscopy
Instructions:
The GIE: Gastrointestinal Endoscopy CME Activity can now be completed entirely on-line. To complete this CME activity, you will need to do the following: 1. Read the following articles that have been designated for CME in this issue: Dunbar K, Okolo P, Montgomery E, et al. Confocal laser endomicroscopy in Barrett’s esophagus and endoscopically inapparent Barrett’s neoplasia: a prospective randomized, double-blind, controlled, crossover trial. Gastrointest Endosc 2009;70:645-54. Ravipati M, Katragadda S, Swaminathan PD, et al. Pharmacotherapy plus endoscopic intervention is more effective than pharmacotherapy or endoscopy alone in the secondary prevention of esophageal variceal bleeding: a meta-analysis of randomized, controlled trials. Gastrointest Endosc 2009;70:658-64. Tejada AH, Calleja JL, Díaz G, et al. Double-guidewire technique for difficult bile duct cannulation: a multicenter, randomized, controlled trial. Gastrointest Endosc 2009;70:700-9. DeWitt J, McGreevy K, Schmidt, CM, et al. EUS-guided ethanol versus saline solution lavage for pancreatic cysts: a randomized, doubleblind study. Gastrointest Endosc 2009;70:710-23. 2. Log-in on-line to complete a single exam with multiple choice questions followed by a brief post-test evaluation. Visit the Journal’s Web site at www.asge.org (members) or www.giejournal.org (nonmembers). 3. Persons scoring greater than or equal to 75% pass the exam and can print a CME certificate. Persons scoring less than 75% cannot print a CME certificate; however, they can retake the exam. Exams can be saved to be accessed at a later date. You may create a free personal account to save and return to your work in progress, as well as save and track your completed activities so that you may print a certificate at any time. The complete articles, detailed instructions for completion, as well as past Journal CME activities can also be found at this site.
Target Audience
This activity is designed for physicians who are involved with providing patient care and who wish to advance their current knowledge of clinical medicine.
Learning Objectives
As a result of completing this activity, participating physicians will be able to: 1. Identify the advantages of confocal laser endomicroscopy in the evaluation and detection of Barrett’s esophagus-associated neoplasia. 2. Assess the differences in outcomes among the various therapies for variceal rebleeding. 3. Examine different biliary cannulation techniques. 4. Assess the outcomes of EUS-guided ethanol lavage in the treatment of pancreatic cysts.
Continuing Medical Education
The American Society for Gastrointestinal Endoscopy (ASGE) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The ASGE designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Activity Start Date: October 1, 2009 Activity Expiration Date: October 31, 2011
Disclosures
Disclosure information for authors of the articles can be found with the article in the abstract section. All disclosure information for GIE editors can be found online at http://www.giejournal.org/content/conflictofinterest. CME editors, and their disclosures, are as follows: G. S. Raju, MD, FASGE (Associate Editor for Journal CME): Jeffrey H. Lee, MD (CME Editor): Consultant, Research Support: InScope Consulting/Advisory/Speaking: Wyeth, Olympus Speaking honorarium, Research Support: Boston Scientific Research Support: ConMed Research Support: Pentax William Ross, MD (CME Editor): Raquel E. Davila, MD (CME Editor): Consulting/Advisory/Speaking: Boston Scientific, Disclosed no relevant financial relationships Olympus All CME activities, including their associated articles Shou-Jiang Tang, MD (CME Editor): are copyrighted by the ASGE. Consulting/Advisory/Speaking: Olympus America Minimum Online System Requirements: Other Financial: Ethicon Endo-Surgery, licensing 486 Pentium 1 level computer (PC or Macintosh) agreement for magnetic anchoring and guidance Windows 95, 98 2000, NT or Mac OS system; Patents pending for magnetic anchoring Netscape 4.X or Microsoft Internet Explorer 4.X and above and guidance system 16 MB RAM 56.6K modem www.giejournal.org
Volume 70, No. 4 : 2009 GASTROINTESTINAL ENDOSCOPY 748
CME ACTIVITY
Continuing Medical Education Questions: October 2009 QUESTION 1 OBJECTIVE: Identify the advantages of confocal laser endomicroscopy in the evaluation and detection of Barrett’s esophagus-associated neoplasia.
How good is confocal laser endomicroscopy for Barrett’s esophagus? Question 1:
Possible answers (A-D)
A 68-year-old male veteran with a long segment of Barrett’s esophagus and high-grade dysplasia at 36 cm and 34 cm from the incisors, but without endoscopically visible mucosal abnormalities, is referred to you for further management. You decide to perform confocal laser endomicroscopy. What are the advantages of confocal laser endomicroscopy compared with standard white light endoscopy in this patient?
A. Significantly higher detection rate of neoplasia B. Fewer number of biopsies required C. Longer total procedure time D. Higher risk of cardiopulmonary events
Look-up: Dunbar K, Okolo P, Montgomery E, et al. Confocal laser endomicroscopy in Barrett’s esophagus and endoscopically inapparent Barrett’s neoplasia: a prospective, randomized, double-blind, controlled crossover trial. Gastrointest Endosc 2009;70:645-54.
QUESTION 2 OBJECTIVE: Assess the differences in outcomes among the various therapies for variceal rebleeding.
How good are the different options for preventing variceal re-bleeding? Question 2:
Possible answers (A-D)
After having undergone endoscopic band ligation of bleeding esophageal varices, a 56-year-old man with alcoholic cirrhosis but without ascites is scheduled for repeat endoscopic therapy in 1 week. In addition, propranolol is being considered. What additional benefits can be anticipated from the addition of a beta-blocker to endoscopic therapy?
A. Reduction in overall all-cause mortality B. Reduction in mortality from GI bleeding C. Reduction in variceal re-bleeding D. Reduction in spontaneous bacterial peritonitis
Look-up: Ravipati M, Katragadda S, Swaminathan PD, et al. Pharmacotherapy plus endoscopic intervention is more effective than pharmacotherapy or endoscopy alone in the secondary prevention of esophageal variceal bleeding: a meta-analysis of randomized, controlled trials. Gastrointest Endosc 2009;70:658-64.
748.e1 GASTROINTESTINAL ENDOSCOPY Volume 70, No. 4 : 2009
www.giejournal.org
CME Exam
QUESTION 3 OBJECTIVE: Examine different biliary cannulation techniques.
Dealing with a difficult bile duct cannulation. Question 3:
Possible answers (A-D)
During ERCP, you start with a sphincterotome and a wire to achieve biliary cannulation, but you fail after more than 5 cannulation attempts. Which of the options listed below would be your next choice?
A. Use a different sphincterotome with wire B. Use a standard cannula C. Double-wire technique D. Pre-cutting with pancreatic stent placement
Look-up: Tejada AH, Calleja JL, Díaz G, et al. Double-guidewire technique for difficult bile duct cannulation: a multicenter randomized, controlled trial. Gastrointest Endosc 2009;70:700-9.
QUESTION 4 OBJECTIVE: Assess the outcomes of EUS-guided ethanol lavage in the treatment of pancreatic cysts.
Is alcohol a friend of the pancreas? Question 4:
Possible answers (A-D)
A 65-year-old female with heart failure is referred to you for management of a pancreatic cyst found incidentally on CT scan. EUS examination confirms a 3-cm cyst in the body of the pancreas, without thickened wall, septations, intracystic growth, or communication with the pancreatic duct. EUS-guided FNA shows moderately viscous clear fluid with carcinoembryotic antigen (CEA) level of 330 ng/mL. After counseling her about various management options, including EUS-guided ethanol injection of the cyst, she decides to opt for endoscopic therapy. What is the benefit of ethanol lavage of the pancreatic cyst in this patient?
A. Provides approximately 33% chance of cyst resolution B. Is technically feasible in all cases C. Carries no risk for procedure-related pancreatitis D. Improves survival
Look-up: DeWitt J, McGreevy K, Schmidt, CM, et al. EUS-guided ethanol versus saline solution lavage for pancreatic cysts: a randomized, double-blind study. Gastrointest Endosc 2009;70:710-23.
www.giejournal.org
Volume 70, No. 4 : 2009 GASTROINTESTINAL ENDOSCOPY 748.e2
CME ACTIVITY
Continuing Medical Education Answers: October 2009 QUESTION 1: CORRECT RESPONSE: B Rationale for correct response: Confocal laser endomicroscopy (CLE) is a form of virtual histology in which in vivo microscopic, high-resolution images of the GI mucosa can be obtained to predict tissue histology.1 In a prospective, randomized, double-blind, crossover, single-center study,2 39 patients with Barrett’s esophagus underwent both standard endoscopy with random 4-quadrant biopsies and CLE with targeted biopsies of sites suspicious for neoplasia. • CLE resulted in a significantly lower number of biopsy specimens obtained during the endoscopic examination. • There was no significant difference in the neoplasia detection rate between the two endoscopic techniques. Both CLE and standard endoscopy detected 11 cases of high-grade dysplasia in 16 patients recruited with suspected neoplasia. The study did not evaluate total procedure time as an endpoint; however, comparison of the median time spent acquiring mucosal biopsies was significantly shorter during CLE in patients with long-segment Barrett’s esophagus. There was no significant difference in complication rates, and there was only one report of a postprocedure pneumonia after CLE that required a 2-day hospitalization and antibiotics. Take-home message: Confocal laser endomicroscopy is feasible and safe, and allows the performance of limited, targeted biopsies for the detection of Barrett’s esophagus-associated neoplasia. This in turn, results in a marked reduction in the number of biopsies required during endoscopy, and may completely eliminate the need for biopsies in patients who have no endoscopic evidence of mucosal abnormalities. REFERENCES: 1. Kiesslich R, Canto MI. Confocal laser endomicroscopy. Gastrointest Endosc Clin N Am 2009;19:261-72. 2. Dunbar K, Okolo P, Montgomery E, et al. Confocal laser endomicroscopy in Barrett’s esophagus and endoscopically inapparent Barrett’s neoplasia: a prospective, randomized, double-blind, controlled crossover trial. Gastrointest Endosc 2009;70:645-54.
QUESTION 2: CORRECT RESPONSE: B Rationale for correct response: Esophageal variceal bleeding signals a serious turn in the life of a patient with cirrhosis of liver—two-thirds of them re-bleed, and a third of them succumb to it. Over the past 3 decades, both endoscopic therapy to ablate varices and pharmacologic therapy to reduce portal hypertension have been extensively used. A meta-analysis of the studies investigating the outcome of endoscopic and pharmacologic therapies could be summarized as follows: • Pharmacotherapy is as effective as endoscopic therapy in preventing re-bleeding, variceal re-bleeding, all cause mortality, and mortality from re-bleeding. • Pharmacotherapy combined with endoscopic therapy does not reduce all-cause mortality or mortality due to re-bleeding when compared with endoscopic therapy; however, combination of endoscopic and pharmacotherapy significantly reduces the incidence of all re-bleeding and variceal re-bleeding. Take-home message: Consider adding pharmacotherapy to endoscopic therapy to reduce re-bleeding in patients with cirrhosis. REFERENCE: 1. Ravipati M, Katragadda S, Swaminathan PD, et al. Pharmacotherapy plus endoscopic intervention is more effective than pharmacotherapy or endoscopy alone in secondary prevention of esophageal variceal bleeding: a meta-analysis of randomized, controlled trials. Gastrointest Endosc 2009;70:658-64.
748.e3 GASTROINTESTINAL ENDOSCOPY Volume 70, No. 4 : 2009
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CME Answers
QUESTION 3: CORRECT RESPONSE: D Rationale for correct response: Biliary cannulation is one of the most challenging and exciting parts of ERCP because it can be difficult in 35% to 60% of cases and may precipitate post-ERCP pancreatitis. A number of techniques can be used after initial failure to cannulate the bile duct. The double-guidewire technique involves biliary cannulation by using a second guidewire through a standard cannulation device after initial insertion of a guidewire into the pancreatic duct (PD).1,2 The perceived advantages of this technique include the following: the pancreatic guidewire can potentially straighten both pancreatic and bile ducts; the presence of pancreatic wire within the papillary structure can potentially facilitate biliary cannulation; the direction of the pancreatic guidewire can guide biliary cannulation; and the ampulla can be anchored by the pancreatic guidewire. In a multicenter randomized clinical trial, Tejada et al2 randomized 188 patients with difficult biliary cannulation defined by failed cannulation after 5 attempts with initial wire-guided approach. After 10 additional attempts, successful biliary cannulation was achieved in 46 of 97 patients (47%) in the double-guidewire arm and 51 of 91 patients (56%) in the standard cannulation or persistence arm (OR = 0.85; 95% CI 0.64 – 1.12). Analysis per protocol showed a statistically significant lower success rate for double-guidewire arm (OR = 0.66; 95% CI 0.46 – 0.94). In those patients with successful biliary cannulation, the median time of cannulation was longer in the double-guidewire arm: 16 minutes versus 11 minutes (P = .287). In addition, the incidence of post-ERCP pancreatitis was higher in the double-guidewire arm: 17% versus 8% (OR = 1.87; 95% CI 0.79 – 4.42). In this study, for patients who failed cannulation in both randomized arms, pre-cutting was the most-used backup technique, and it was the most successful in achieving biliary cannulation. It is possible that the prolonged manipulation of PD by the pancreatic wire during the double-guidewire technique increased the pancreatitis risk in this study. Other randomized trials have shown that persistence in cannulation with the standard technique and pre-cutting are both safe and effective in achieving biliary cannulation.3,4 Take-home message: In patients with difficult biliary cannulation, double-guidewire technique is not superior to standard single-wire technique or persistence in achieving cannulation. In addition, in this multicenter randomized clinical trial, double-wire technique was associated with a longer cannulation time and higher risk of post-ERCP pancreatitis. REFERENCES: 1. Dumonceau JM, Deviere J, Cremer M. A new method of achieving deep cannulation of the common bile duct during endoscopic retrograde cholangiopancreatography. Endoscopy 1998;30:S80. 2. Tejada AH, Calleja JL, Díaz G, et al. Double-guidewire technique for difficult bile duct cannulation: a multicenter, randomized, controlled trial. Gastrointest Endosc 2009;70:700-9. 3. Tang SJ, Haber GB, Kortan P, et al. Precut papillotomy versus persistence in difficult biliary cannulation: a prospective, randomized trial. Endoscopy 2005;37:58-65. 4. Cennamo V, Fuccio L, Repici A, et al. Timing of precut procedure does not influence success rate and complications of ERCP procedure: a prospective, randomized, comparative study. Gastrointest Endosc 2009;69:473-9.
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QUESTION 4: CORRECT RESPONSE: A Rationale for correct response: Pancreatic EUS has certainly evolved over the last 2 decades from an imaging modality to one that can acquire tissue to confirm the diagnosis. Recently, the therapeutic potential of EUS has been explored in the management of pancreatic neoplasms. Progress in this field is summarized below: A. Imaging: Radial EUS helps us identify both small and large pancreatic cysts and define the structure of the cyst and its contents better than any other currently available imaging modalities. A thick cyst wall and an intracystic growth suggest premalignant cysts (mucinous cystadenoma [MCN] and intraductal papillary mucinous neoplasms [IPMN]) or malignant cysts (mucinous cystadenocarcinoma).1 B. Diagnosis: EUS-guided FNA technology provides us with the ability to diagnose the lesions with greater confidence. Cyst fluid analysis (“string sign” and elevated cyst fluid CEA) suggests premalignant (MCN and IPMN) or malignant cysts (mucinous cystadenocarcinoma).1 C. Therapy: For MCN and IPMN, a conservative approach of observation may have a role. Leung et al1 reported that, in the absence of worrisome features on EUS or symptoms, these cysts may not require immediate resection, and conservative management with serial EUS imaging may be a consideration in appropriate clinical settings. However, careful surveillance for malignant transformation should be undertaken.1 Recently, EUS-guided alcohol ablation of pancreatic cysts is being explored as a therapeutic option. In a randomized controlled trial and compared with saline solution lavage, EUS-guided ethanol lavage of pancreatic cysts resulted in a decrease in cyst surface area, 50% to 100% epithelial ablation, and resolution of the cysts in 33.3% of cases. Complications included abdominal pain (20%), acute pancreatitis (4%), and intracystic hemorrhage (4%). 2 Take-home message: EUS-guided ethanol lavage of pancreatic cysts is a novel option worthy of further investigation, and it should be presented to patients as an important therapeutic option. 2 REFERENCES: 1. Leung KK, Ross WA, Evans D, et al. Pancreatic cystic neoplasm: the role of cyst morphology, cyst fluid analysis, and expectant management. Ann Surg Oncol. 2009 Jun 18 [Epub ahead of print]. 2. DeWit J, McGreevy K, Schmidt, CM, et al. EUS-guided ethanol versus saline solution lavage for pancreatic cysts: a randomized, double-blinded study. Gastrointest Endosc 2009;70:710-23.
748.e5 GASTROINTESTINAL ENDOSCOPY Volume 70, No. 4 : 2009
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EVALUATION PAGE, GIE Please complete the following questions in order to complete the process for earning your CME. Assessment of change in knowledge, skills and/or practice In general, this activity (check all that apply): Reinforced my existing knowledge and/or skills. Increased my knowledge. Will positively impact my practice.
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