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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

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

Endoscopic ultrasonography guided celiac plexus neurolysis and celiac plexus block in the management of pain due to pancreatic cancer and chronic pancreatitis

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World Journal of Gastroenterology 2007年第26期13卷 3575-3580页

作者： Anthony J Michaels peter v Draganov University of Florida Department of GastroenterologyHepatology and NutritionUnited States

Pain is a common symptom of pancreatic disease and is frequently difficult to manage. Pain relief provided by narcotics is often suboptimal and is associated with significant side effects. An alternative approach to pain management in pancreatic disease is the use of celiac plexus block (CPB) or neurolysis (CPN). Originally performed by anesthesiologists and radiologists via a posterior approach,recent advances in endoscopic ultrasonography (EUS) have made this technique an attractive alternative. EUS guided celiac plexus block/ neurolysis is simple to perform and avoids serious complications such as paraplegia or pneumothorax that are associated with the posterior approach. EUS guided CPN should be considered first line therapy in patients with pain due to pancreatic cancer. It provides superior pain control compared to traditional management with narcotics. A trend for improved survival in pancreatic cancer patients treated with CPN has been reported,but larger studies are needed to confirm this finding. At this time,the use of EUS guided CPB cannot be recommended as routine therapy for pain in chronic pancreatitis since only one-half of the patients experience pain reduction and the beneficial effect tends to be short lived. EUS guided CPB and CPN should be used as part of a multidisciplinary team approach for pain management.

关键词： Celiac plexus Celiac plexus neurolysis Celiacplexus block Endoscopic ultrasound Pain management

Eosinophilic esophagitis

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World Journal of Gastroenterology 2009年第1期15卷 17-24页

作者： Anand R Gupte 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

Eosinophilic esophagitis is increasingly recognized in adults. The diagnosis is based on the presence of both typical symptoms and pathologic findings on esophageal biopsy. Patients usually present with dysphagia, food impaction and/or reflux-like symptoms, and biopsy of the esophagus shows more than 15 eosinophils per high-power fi eld. In addition, it is essential to exclude the presence of known causes of tissue eosinophilia such as gastroesophageal reflux disease, infections, malignancy, collagen vascular diseases, hypersensitivity, and inflammatory bowel disease. There are no standardized protocols for the therapy of eosinophilic esophagitis. A variety of therapeutic approaches including acid suppression, dietary modifications, topical corticosteroids and endoscopic dilation can be used alone or in combination.

关键词： Eosinophilic esophagitis Dysphagia Endoscopic dilation Reflux Gastro esophageal refluxdisease

Colonoscopic polypectomy and associated techniques

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World Journal of Gastroenterology 2010年第29期16卷 3630-3637页

作者： Christopher J Fyock peter v Draganov Division of Gastroenterology Hepatology and NutritionUniversity of Florida

Polypectomy of colonic polyps has been shown to reduce the risk of colon cancer development and is considered a fundamental skill for all endoscopists who perform colonoscopy.A variety of polypectomy techniques and devices are available,and their use can vary greatly based on local availability and *** general,cold forceps and cold snare have been the polypectomy methods of choice for smaller polyps,and hot snare has been the method of choice for larger *** use of hot forceps has mostly fallen out of *** for difficult to remove polyps may require the use of special devices and advanced techniques and has continued to *** a result,the vast majority of polyps today can be removed *** electrocautery is frequently used for polypectomy,endoscopists should be thoroughly familiar with the basic principles of electrosurgery as it pertains to *** of a polypectomy site is an important adjunct to polypectomy and can greatly facilitate future surgery or endoscopic *** two most common post-polypectomy complications are bleeding and *** incidence can be decreased with the use of meticulous polypectomy techniques and the application of some prophylactic *** review will examine the technique of polypectomy and its complications from the perspective of the practicing gastroenterologist.

关键词： Colonic polyp Polypectomy Colonoscopy Polypectomy technique Complications

Evaluation and management of patients with refractory ascites

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World Journal of Gastroenterology 2009年第1期15卷 67-80页

作者： Bahaa Eldeen Senousy peter v Draganov Ain Shams University school of Medicine Abbassia Square 11566 Cairo Egypt University of Florida Gainesville Florida 32610 United States

Some patients with ascites due to liver cirrhosis become no longer responsive to diuretics. Once other causes of ascites such as portal vein thrombosis, malignancy or infection and non-compliance with medications and low sodium diet have been excluded, the diagnosis of refractory ascites can be made based on strict criteria. Patients with refractory ascites have very poor prognosis and therefore referral for consideration for liver transplantation should be initiated. Search for reversible components of the underlying liver pathology should be undertaken and targeted therapy, when available, should be considered. Currently, serial large volume paracentesis （LvP） and transjugular intrahepatic portasystemic stent-shunt （TIPS） are the two mainstay treatment options for refractory ascites. Other treatment options are available but not widely used either because they carry high morlJidity and mortality （most surgical options） rates, or are new interventions that have shown promise but still need further evaluation. In this comprehensive review, we describe the evaluation and management of patients with refractory ascites from the prospective of the practicing physician.

关键词： Refractory ascites Aquaretics Albumininfusion Transjugular intrahepatic portosystemic stentshunt Large volume paracentesis

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

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

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