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ERCP wire systems: The long and the short of it

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World Journal of Gastroenterology 2009年第1期15卷 55-60页

作者： Shilpa Chandrupatla Reddy peter v draganov Department of Medicine University of Florida College of MedicineJacksonville Florida 32610 United States Department of Gastroenterology Hepatology and Nutrition University of Florida1600 SW Archer Rd Room HD 602 PO Box 100214 Gainesville Florida 32610 United States

Guidewires are routinely used at the time of endoscopic retrograde cholangiopancreatography (ERCP) to gain and maintain access to the desired duct and aid in the advancement of various devices. Limitations of the traditional long-wire systems have led to the introduction of three proprietary short-wire systems. These systems differ in many respects but share two main principles: They lock a shorter wire in position to allow advancement or removal of various devices without displacement of the wire and they all allow for physician control of the wire. In this comprehensive review, we describe the key features of the three currently available short-wire systems: RX, Fusion and v systems. We also focus on the potential benef its and drawbacks that accompany the short-wire concept as a whole and each specif ic system in particular. Although the available data are limited, it appears that the use of the short-wire systems lead to reduced procedure, fluoroscopy and device exchange times, decreased sedation requirements, improved wire stability and increased endoscopist control of the wire. Furthermore, the physician-controlled wire-guided cannulation has the potential to decrease ampullary trauma and the rate of post-ERCP pancreatitis. The short guidewire systems appear to be an improvement over the traditional long-wire systems but further studies directly comparing the two approaches are needed.

关键词： Endoscopic retrograde cholangiopancreatography Guidewires v-system RX system Fusion system

Recent advances and remaining gaps in our knowledge of associations between gut microbiota and human health

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World Journal of Gastroenterology 2009年第1期15卷 81-85页

作者： volker Mai peter v draganov Department of Gastroenterology Hepatology and Nutrition University of Florida1600 SW Archer Rd Room HD 602 PO Box 100214 Gainesville Florida 32610 United States

The complex gut microbial flora harbored by individuals(microbiota) has long been proposed to contribute tointestinal health as well as disease. Pre-and probioticproducts aimed at improving health by modifyingmicrobiota composition have already become widelyavailable and acceptance of these products appearsto be on the rise. However, although required forthe development of effective microbiota basedinterventions, our basic understanding of microbiotavariation on a population level and its dynamics withinindividuals is still rudimentary. Powerful new parallelsequence technologies combined with other efficientmolecular microbiota analysis methods now allow forcomprehensive analysis of microbiota composition inlarge human populations. Recent fi ndings in the fi eldstrongly suggest that microbiota contributes to thedevelopment of obesity, atopic diseases, inflammatorybowel diseases and intestinal cancers. Through theongoing National Institutes of Health Roadmap 'HumanMicrobiome Project' and similar projects in other partsof the world, a large coordinated effort is currentlyunderway to study how microbiota can impact humanhealth. Translating findings from these studies intoeffective interventions that can improve health,possibly personalized based on an individuals existingmicrobiota, will be the task for the next decade(s).

关键词： Microbiota Intestinal microbial flora Probiotic Gut Intestine

Endoscopic management of biliary strictures after liver transplantation

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World Journal of Gastroenterology 2009年第30期15卷 3725-3733页

作者： Emmanuelle D Williams peter v draganov Division of Gastroenterology University of FloridaGainesvilleFL 32610-0214United States

Bile duct strictures remain a major source of morbidity after orthotopic liver transplantation (OLT). Biliary strictures are classifi ed as anastomotic or non-anastomotic strictures according to location and are defi ned by distinct clinical behaviors. Anastomotic strictures are localized and short. The outcome of endoscopic treatment for anastomotic strictures is excellent. Nonanastomotic strictures often result from ischemic and immunological events, occur earlier and are usually multiple and longer. They are characterized by a far less favorable response to endoscopic management, higher recurrence rates, graft loss and need for retransplantation. Living donor OLT patients present a unique set of challenges arising from technical factors, and stricture risk for both recipients and donors. Endoscopic treatment of living donor OLT patients is less promising. Current endoscopic strategies for biliary strictures after OLT include repeated balloon dilations and placement of multiple side-by-side plastic stents. Lifelong surveillance is required in all types of strictures. Despite improvements in incidence and long term outcomes with endoscopic management, and a reduced need for surgical treatment, the impact of strictures on patients after OLT is signifi cant. Future considerations include new endoscopic technologies and improved stents, which could potentially allow for a decreased number of interventions, increased intervals before retreatment, and decreased reliance on percutaneous and surgical modalities. This review focuses on the role of endoscopy in biliary strictures, one of the most common biliary complications after OLT.

关键词： Anastomotic strictures Bile duct diseases Endoscopic retrograde cholangiopancreatography Orthotopic liver transplantation Surgical anastomosis

Treatment of malignant gastric outlet obstruction with endoscopically placed self-expandable metal stents

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World Journal of Gastroenterology 2009年第35期15卷 4365-4371页

作者： Jill KJ Gaidos peter v draganov Department of Gastroenterology Hepatologyand NutritionUniversity of Florida

Malignant gastroduodenal obstruction can occur in up to 20%of patients with primary pancreatic,gastric or duodenal *** symptoms include nausea,vomiting,abdominal distention,pain and decreased oral intake which can lead to dehydration, malnutrition,and poor quality of *** stent placement has become the primary therapeutic modality because it is safe,minimally invasive,and a cost-effective option for *** can be successfully deployed in the majority of patients. Stent placement appears to lead to a shorter time to symptomatic improvement,shorter time to resumption of an oral diet,and shorter hospital stays as compared with surgical *** of the obstructive symptoms resulting from stent occlusion,due to tumor ingrowth or overgrowth,can be successfully treated with repeat endoscopic stent placement in the majority of the *** endoscopic stenting and surgical bypass are considered palliative treatments and,to date,no improvement in survival with either modality has been demonstrated.A tailored therapeutic approach,taking into consideration patient preferences and involving a multidisciplinary team including the therapeutic endoscopist,surgeon,medical oncologist, radiation therapist,and interventional radiologist, should be considered in all cases.

关键词： Malignant gastric outlet obstruction Endoscopic self-expandable metal stent Palliativetreatment Endoscopy

Intraductal biliary and pancreatic endoscopy: An expanding scope of possibility

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World Journal of Gastroenterology 2008年第20期14卷 3129-3136页

作者： Joel R Judah peter v draganov Division of Gastroenterology Hepatology and Nutrition University of Florida Gainesville

Intraductal endoscopy describes the use of an endoscope to directly visualize the biliary and pancreatic ducts. For many years, technological challenges have made performing these procedures difficult. The "mother-baby" system and other various miniscopes have been developed, but routine use has been hampered due to complex setup, scope fragility and the time consuming, technically demanding nature of the procedure. Recently, the SpyGlass peroral cholangiopancreatoscopy system has shown early success at providing diagnostic information and therapeutic options. The clinical utility of intraductal endoscopy is broad. It allows better differentiation between benign and malignant processes by allowing direct visualization and targeted sampling of tissue. Therapeutic interventions, such as electrohydraulic lithotripsy (EHL), laser lithotripsy, photodynamic therapy, and argon plasma coagulation (APC), may also be performed as part of intraductal endoscopy. Intraductal endoscopy significantly increases the diagnostic and therapeutic yield of standard endoscopic retrograde cholangiography (ERCP), and as technology progresses, it is likely that its utilization will only increase. In this review of intraductal endoscopy, we describe in detail the various endoscopic platforms and their diagnostic and clinical applications.

关键词： Intraductal endoscopy Choledochoscopy Cholangioscopy Pancreatoscopy Biliary endoscopy Duodenoscope-assisted cholangiopancreatoscopy Miniscope Percutaneous choledochoscopy Laparoscopiccholedochoscopy Lithotripsy

Colorectal cancer surveillance in inflammatory bowel disease: The search continues

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World Journal of Gastroenterology 2009年第1期15卷 61-66页

作者： Anis Ahmadi Steven Polyak peter v draganov Department of Gastroenterology Hepatology and Nutrition University of Florida1600 SW Archer Rd Room HD 602 PO Box 100214 Gainesville Florida 32610 United States

Patients with infl ammatory bowel disease (IBD) are at increased risk for colorectal cancer (CRC). Risk factors for the development of CRC in the setting of IBD include disease duration, anatomic extent of disease, age at time of diagnosis, severity of inflammation, family history of colon cancer, and concomitant primary sclerosing cholangitis. The current surveillance strategy of surveillance colonoscopy with multiple random biopsies most likely reduces morbidity and mortality associated with IBD-related CRC. Unfortunately, surveillance colonoscopy also has severe limitations including high cost, sampling error at time of biopsy, and interobserver disagreement in histologically grading dysplasia. Furthermore, once dysplasia is detected there is disagreement about its management. Advances in endoscopic imaging techniques are already underway, and may potentially aid in dysplasia detection and improve overall surveillance outcomes. Management of dysplasia depends predominantly on the degree and focality of dysplasia, with the mainstay of management involving either proctocolectomy or continued colonoscopic surveillance. Lastly, continued research into additional chemopreventive agents may increase our arsenal in attempting to reduce the incidence of IBD-associated CRC.

关键词： Colorectal cancer Crohn's disease Inflammatory bowel disease Surveillance colonoscopy Ulcerative colitis

Gastroparesis: Current diagnostic challenges and management considerations

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World Journal of Gastroenterology 2009年第1期15卷 25-37页

作者： Shamaila Waseem Baharak Moshiree peter v draganov Department of Pediatric Gastroenterology Hepatology and Nutrition University of FloridaGainesville Florida 32610 United States Department of Gastroenterology Hepatology and Nutrition University of FloridaGainesville Florida 32610 United States

Gastroparesis refers to abnormal gastric motility characterized by delayed gastric emptying in the absence of mechanical obstruction. The most common etiologies include diabetes, post-surgical and idiopathic. The most common symptoms are nausea, vomiting and epigastric pain. Gastroparesis is estimated to affect 4% of the population and symptomatology may range from little effect on daily activity to severe disability and frequent hospitalizations. The gold standard of diagnosis is solid meal gastric scintigraphy. Treatment is multimodal and includes dietary modification, prokinetic and anti-emetic medications, and surgical interventions. New advances in drug therapy, and gastric electrical stimulation techniques have been introduced and might provide new hope to patients with refractory gastroparesis. In this comprehensive review, we discuss gastroparesis with emphasis on the latest developments; from the perspective of the practicing clinician.

关键词： Gastroparesis, Nausea vomiting Prokinetic Therapy

Pancreatic function testing: Here to stay for the 21st century

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World Journal of Gastroenterology 2008年第20期14卷 3149-3158页

作者： John G Lieb II peter v draganov University of Florida

The diagnosis of Chronic Pancreatitis （CP） is based on the detection of abnormal structure or function of the diseased pancreas. The pancreatic function tests more accurately determine the presence of CP than tests of structure, especially for early stage disease. The function tests can be divided into two categories： non- invasive and invasive. The invasive ＂tube＂ tests can reliably detect mild, early CP, but are only available at a few referral centers and tend to be poorly tolerated by patients. The non-invasive tests are easy to obtain, but tend to perform poorly in patients with early, mild disease. Therefore, no one test is useful in all clinical situations, and a detailed understanding of the rational, pathophysiologic basis, strengths, and limitations of various tests is needed. This review highlights the role of various pancreatic function tests in the diagnosis of CP including fecal fat analysis, fecal elastase, fecal chymotrypsin, serum trypsin, the secretin stimulation test, the cholecystokinin （CCK） stimulation test, the combined secretin-CCK stimulation test, the intraductal and endoscopic secretin stimulation tests, and the functional magnetic resonance imaging of the pancreas after secretin stimulation.

关键词： Pancreatic function testing Secretinstimulation test CCK stimulation test Fecal elastase Endsocopic secretin stimulation test Chronic pancreatitis

Early successes and late failures in the prevention of post endoscopic retrograde cholangiopancreatography

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World Journal of Gastroenterology 2007年第26期13卷 3567-3574页

作者： John G Lieb II peter v draganov Gastroenterology Fellow Division of GastroenterologyDepartment of Internal MedicineUniversity of Florida FL 32610-0214United States Associate Professor of Medicine Division of GastroenterologyUniversity of Florida FL 32610-0214United States

Acute pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). The only way to prevent this complication is to avoid an ERCP all together. Because of the risks involved, a careful consideration should be given to the indication for ERCP and the potential risk/benefit ratio of the test. Once a decision to perform an ERCP is made, the procedure should be carried out with meticulous care by an experienced endoscopist, and with a minimum of pancreatic duct opacification. Several pharmacologic agents have been tested, but to date the most important method of reducing post ERCP pancreatitis is the placement of pancreatic stent. Pancreatic stents should be placed in all patients at high risk of this complication such as those undergoing pancreatic sphincterotomy, pancreatic duct manipulation and intervention, and patients with suspected sphincter of Oddi dysfunction. Pancreatic stents should be also considered in patients requiring precut sphincterotomy to gain biliary access.

关键词： Post endoscopic retrograde cholangiopancre-atography pancreatitits Somatostatin Gabexate IL-10 Pancreatic stents Aspirating catheter Sphincter of Oddidysfunction