One-stage percutaneous triple procedure for treatment of endoscopically unmanageable patients with malignant biliary obstruction and marked ascites

Background and study aimsTo assess the feasibility, safety and efficacy of one-stage percutaneous triple procedure including; ascites drainage, primary metallic biliary stenting, and tract embolisation with N-butyl 2-cyanoacrylate (NBCA), in treatment of patients with malignant biliary obstruction and marked ascites.Patients and methodsThis study involved 25 patients with malignant biliary obstruction and marked ascites (age range, 46–78 y; mean age ± SD, 65 y ± 5) for whom endoscopic treatment failed or was unsuitable. Ascites drainage, percutaneous primary metallic biliary stenting, and tract embolisation with lipiodol/NBCA mixture were performed in a one-stage procedure. The mean ± SD follow up period was 26 ± 2 weeks.ResultsThe technical and clinical success rates were 96% and 88% respectively. No procedure related deaths or major complications were observed. The reported minor complications included; moderate pain and vomiting during and after balloon dilation, postprocedural cholangitis, and bile leakage in 44%, 16%, and 8% of the patients respectively. Primary stent patency was achieved in 96%. The 30-days mortality was 8%. The stent obstruction occurred in 3 (13%) of the 23 patients who survived more than 30-days.ConclusionsPercutaneous drainage of ascites followed immediately by primary biliary stenting, together with tract embolisation with NBCA is technically feasible, safe, and effective alternative palliative treatment for endoscopically unmanageable patients with malignant biliary obstruction and marked ascites.     

Changes in liver stiffness using acoustic radiation force impulse imaging in patients with obstructive cholestasis and cholangitis

BackgroundAcoustic radiation force impulse imaging is used to assess stages of liver fibrosis. The aim of our study was to evaluate liver stiffness changes in patients with biliary obstruction with or without sclerosing cholangitis after biliary drainage.MethodsA total of 71 patients were enrolled in this prospective study (cohort N = 51, control group N = 20); 51 patients with obstructive cholestasis, indicated for endoscopic retrograde cholangiography, received stiffness measurement by acoustic radiation force impulse imaging before and 1–2 days after endoscopic retrograde cholangiography. Seventeen patients with obstructive cholestasis had primary or secondary sclerosing cholangitis. Forty one patients had a follow-up acoustic radiation force impulse imaging measurement after 3.0 ± 9.31 weeks.ResultsIn all patients with obstructive cholestasis, stiffness decreased significantly after biliary drainage (p < 0.001). The main decrease was observed within 2 days after endoscopic retrograde cholangiography (1.92–1.57 m/s, p < 0.001) and correlated with the decrease of bilirubin and alkaline phosphatase (p = 0.04 and p = 0.002, respectively). In patients with sclerosing cholangitis, the initial decrease of stiffness after biliary drainage was weaker than in those without (2.1–1.85 m/s vs. 1.81–1.43 m/s, p = 0.016).ConclusionAcoustic radiation force impulse imaging elastography shows that liver stiffness is increased by biliary obstruction, and decreases after endoscopic retrograde cholangiography irrespective of the aetiology. In patients with sclerosing cholangitis the reduction in stiffness after biliary drainage is impaired.     

Clinical outcome after biliary drainage for metastatic colorectal cancer: Survival analysis and prognostic factors

IntroductionBiliary obstruction secondary to colorectal cancer liver metastases is associated with a poor prognosis especially when chemotherapy cannot be re-started. The aim of this study was to determine the survival after biliary drainage and the associated prognostic factors.MethodsPatients from two French centers were included retrospectively after first biliary endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography drainage for biliary obstruction secondary to liver metastases of colorectal cancer, occurring during chemotherapy.ResultsThe final analysis included 69 patients. Overall median survival was 115 days. In univariate analysis, a previous liver surgery, technical and functional success of drainage and restarted chemotherapy were significantly associated with an improved survival. Chemotherapy was restarted after a median of 27 days. When drainage was efficient, survival improved from 33 to 262 days (p < 0.001). In multivariate analysis, significant protective factors for survival included previous a hepatectomy (HR 0.41) and functional success of the drainage (HR 0.29). Predictive factors for death included increased lines of chemotherapy (HR 1.68) and fever before drainage (HR 2.97).ConclusionsThis is the first study concerning the benefits of biliary drainage for malignant biliary obstruction during the course of chemotherapy for colorectal cancer. A successful biliary drainage leads to improved survival and allows achievement of chemotherapy for 70% of patients.     

Primary tumour resection in metastatic nonfunctioning pancreatic endocrine carcinomas

BackgroundThe role of debulking surgery in metastatic nonfunctioning pancreatic endocrine carcinomas (M-NF-PECs) with resectable primary tumour and unresectable liver metastases is debated.AimAim of the study is to evaluate whether the resection of the primary tumour in metastatic nonfunctioning pancreatic endocrine carcinoma improves survival.Patients and methodsFifty-one metastatic nonfunctioning pancreatic endocrine carcinoma patients with unresectable liver metastases were enrolled from 1990 to 2004 at the time of diagnosis. Nineteen patients underwent complete resection of the primary tumour whilst 32 were judged unresectable. All cases were classified according to the WHO 2000 classification. All clinico-pathological parameters, including grade of differentiation and the Ki-67 proliferation index were considered in univariate and multivariate models.ResultsOf the 19 resected patients, 14 (73.7%) underwent left-pancreatectomy and 5 (26.3%) pancreaticoduodenectomy. In the unresected group of 32 patients, 9 (28.1%) underwent surgical biliary and/or gastric by-pass. There was no postoperative mortality and the median survival was 54.3 months (95% CI: 25.7–82.9). No difference in survival was observed between the two groups [resected: median 54.3 months (95% CI: 25–83.6), unresected: median 39.5 months (95% CI: 5.4–73.6); p = 0.74]. Upon multivariate analysis poor differentiation (HR 3.01; 95% CI 1.08–8.4; p = 0.035) and a Ki-67 index ≥10% (HR 4.4; 95% CI 1.2–16.1; p = 0.023) were significant predictors of survival.ConclusionsResection of the primary pancreatic tumour in metastatic nonfunctioning pancreatic endocrine carcinoma patients with unresectable liver metastases does not significantly improve survival. Resection can be considered as symptomatic palliative therapy in patients with well-differentiated endocrine carcinomas and a proliferative index lower than 10%.     

Single-session endosonography and endoscopic retrograde cholangiopancreatography for biliopancreatic diseases is feasible,effective and cost beneficial

BackgroundEndoscopic ultrasonography (EUS) and Endoscopic Retrograde Cholangiopancreatography (ERCP) are often required in patients with pancreaticobiliary disorders.AimsTo assess the clinical impact and costs savings of a single session EUS-ERCP.MethodsPatient and intervention data from April 2009 to March 2012 were prospectively recruited and retrospectively analyzed from a database at a tertiary hospital. Indications, diagnostic yield, procedure details, complications and costs were evaluated.ResultsFifty-five scheduled combined procedures were done in 53 patients. The accuracy of EUS–fine needle aspiration for malignancy was 90%. The main clinical indication was a malignant obstructing lesion (66%). The ERCP cannulation was successful in 67%, and in 11/15 failed ERCP (73%), drainage was completed thanks to an EUS-guided biliary drainage: 6 transmurals, 5 rendezvous. Eight patients (14%) had related complications: bacteremia (n = 3), pancreatitis (n = 2), bleeding (n = 2) and perforation (n = 1). The mean duration was 65 ± 22.2 min.The mean estimated cost for a single session was €3437, and €4095 for two separate sessions. The estimated cost savings using a single-session strategy was €658 per patient, representing a total savings of €36,189.ConclusionCombined EUS and ERCP is safe, technically feasible and cost beneficial. Furthermore, in failed ERCP cases, the endoscopic biliary drainage can be completed with EUS-guided biliary access in the same procedure.     

Prospective evaluation of the partially covered nitinol “ComVi” stent for malignant non hilar biliary obstruction

BackgroundBiliary partially covered self-expandable metal stents (PC-SEMS) offer prolonged relief of symptoms of biliary obstruction but may induce complications including pancreatitis, cholecystitis and migration.AimsTo assess efficacy and safety of the ComVi partially covered self-expandable metal stents as primary palliative treatment of distal malignant biliary obstruction.MethodsSeventy patients (mean age 69.2 years) with distal malignant biliary strictures were prospectively included and underwent endoscopic retrograde cholangio-pancreatography and partially covered self-expandable metal stents placement. Follow-up was done for 12 months. self-expandable metal stents patency, survival and complication-rate after partially covered self-expandable metal stents placement were evaluated.ResultsOverall median survival time was 190 days (30–856). Forty-four patients (62.8%) died after median 175.5 days (30–614) without signs of stent dysfunction; 37 patients (52.8%) were alive after 6 months without signs of self-expandable metal stents occlusion. Survival rapidly dropped between 8 and 12 months after treatment. Survival was not influenced by sex (P = 0.1) or type of neoplasia (P = 0.178). Median survival was longer (254 days [44–836]) in patients who underwent chemotherapy (P < 0.0001). Partially covered self-expandable metal stents occlusion had 24 (35.7%) patients 154 days (35–485) after treatment. Median survival after re-treatment was 66 days (13–597). Cholecystitis occurred in one patient (1.7%).ConclusionsThe ComVi partially covered self-expandable metal stents is effective for palliation of biliary obstruction secondary to distal malignant biliary strictures. Self-expandable metal stents patency during follow-up is satisfactory without significant complications.     

Staging laparoscopy for proximal pancreatic cancer in a magnetic resonance imaging-driven practice: what's it worth?

BackgroundPreoperative imaging is often inadequate in excluding unresectable pancreatic cancer. Accordingly, many groups employ staging laparoscopy (SL), although none have evaluated SL after preoperative magnetic resonance imaging (MRI). We performed a retrospective, indirect cost-effectiveness analysis of SL after MRI for pancreatic head lesions.MethodsAll MRI scans administered for proximal pancreatic cancer between 2004 and 2008 were reviewed and the clinical course of each patient determined. We queried our billing database to render average total costs for all inpatients with proximal pancreatic cancer who underwent pancreaticoduodenectomy, palliative bypass or an endoscopic stenting procedure. We then performed an indirect evaluation of the cost of routine SL.ResultsThe average costs of hospitalization for patients undergoing pancreaticoduodenectomy, open palliative bypass and endoscopic palliation were: US$26 122.43, US$21 957.18 and US$11 304.00, respectively. The calculated cost of SL without laparotomy was US$2966.25 or US$1538.61 prior to laparotomy. The calculated cost of treating unresectable disease by outpatient laparoscopy followed by endoscopy was US$5943.17. Routine SL would increase our costs by US$76 967.46 (3.6%).ConclusionsStaging laparoscopy becomes cost-effective by diverting unresectable patients from operative to endoscopic palliation. Given the paucity of missed metastases on MRI, the yield of SL is marginal and its cost-effectiveness is poor. Future studies should address the utility of SL by both examining this issue prospectively and investigating the cost-effectiveness of endoscopic vs. surgical palliation in a manner that takes account of survival and quality of life data.     

ERCP and short-term stent-trial in patients with anastomotic biliary stricture following liver transplantation

BackgroundAnastomotic biliary stricture represents one of the possible factors leading to liver dysfunction after transplantation.PurposeOur aims were to evaluate the role of endoscopic retrograde cholangio-pancreatography and a short-term stenting (stent-trial) in assessment of the clinical relevance of the biliary stricture.Materials and methodsThirty transplanted patients for HCV (n = 17) or non-HCV (n = 13)-related cirrhosis (27 M, median age 53 yr, range 24–67 yr) who developed persistently abnormal liver function tests and presented with an anastomotic biliary stricture suggested by non-invasive cholangiography, underwent endoscopic retrograde cholangio-pancreatography. If the stricture was confirmed, dilation was performed and a plastic stent was placed. Clinical and biochemical evaluation was done one and two months later. Resolution of symptoms and normalization or > 50% reduction of at least one liver function test were needed to consider the stricture as clinically relevant. Patients were followed up for a median of 19 months.ResultsEndoscopic retrograde cholangio-pancreatography was successful in 29 patients and confirmed the anastomotic biliary stricture in 19 (66%); 14 patients underwent endoscopic dilation and stenting and five patients underwent surgery. The stent-trial suggested the stricture to be clinically relevant in 7 of 14 patients, confirmed by prolonged stenting and follow-up. A trend towards a higher likelihood of a clinically relevant stricture was observed in HCV-negative compared to HCV-positive patients (5 of 7, 71% vs 2 of 7, 29% , respectively; p = 0.1).ConclusionsOur data suggest that endoscopic retrograde cholangio-pancreatography is a valuable tool to evaluate the clinical relevance of an anastomotic stricture, when coupled with a short-term stent-trial.     

Manometric assessment of esophageal motor function in patients with primary biliary cirrhosis

Introduction/aimPrimary biliary cirrhosis is associated with other autoimmune diseases including Sjögren's syndrome, and scleroderma. Esophageal dysmotility is well known in scleroderma, and Sjögren's syndrome. The aim of this study is to investigate whether any esophageal motor dysfunction exists in patients with primary biliary cirrhosis.MethodThe study was performed in 37 patients (36 women, mean age: 56.29 ± 10.01 years) who met diagnostic criteria for primary biliary cirrhosis. Thirty-seven functional dyspepsia patients, were also included as a control group. Patients entering the study were asked to complete a symptom questionnaire. Distal esophageal contraction amplitude, and lower esophageal sphincter resting pressure were assessed.ResultsManometric findings in primary biliary cirrhosis patients vs. controls were as follows: Median lower esophageal sphincter resting pressure (mm Hg): (24 vs 20, p = 0.033); median esophageal contraction amplitude (mm Hg): (71 vs 56, p = 0.050); mean lower esophageal sphincter relaxation duration (sc, x ± SD): (6.10 ± 1.18 vs 8.29 ± 1.92, p < 0.001); and median lower esophageal sphincter relaxation (%) (96 vs 98, p = 0.019); respectively. No significant differences were evident in median peak velocity (sc) (3.20 vs 3.02, p = 0.778) between patients with primary biliary cirrhosis and the functional dyspepsia patients. Esophageal dysmotility was found in 17 (45.9%) primary biliary cirrhosis patients (non-specific esophageal motor disorder in ten patients, hypomotility of esophagus in five patients, nutcracker esophagus in one patient and hypertensive lower esophageal sphincter in one patient).ConclusionEsophageal dysmotility was detected in 45.9% of patients. The study suggests that subclinic esophageal dysmotility is frequent in patients with primary biliary cirrhosis.     

Blood B-type natriuretic peptide level increases in patients who complain shortness of breath and chest pain in the course of panic attack

ObjectiveBlood pro-B-type natriuretic peptide (pro-BNP) level increases in case of myocardial ischemia and myocardial volume or pressure overload. The aim of this study is to measure changes in blood pro-BNP level during the course of panic attack with symptoms of chest pain and/or dyspnea.MethodsPatients who were admitted to the emergency room with panic attack have been regarded as the study group. Blood pro-BNP level has been measured during follow-up of the patients upon admission and 2h later.ResultsSystolic and diastolic blood pressure and pulse rate were significantly decreased (p < 0.0001) during follow-up of the patients (ages between 18 and 43 years; mean 26 ± 6.13 years). Paradoxically, blood pro-BNP level of patients was significantly increased during the same period (52.86 ± 59.73 versus 50.97 ± 57.42 U/L; p < 0.0001).ConclusionBlood pro-BNP level has increased among patients who have complained chest pain and/or dyspnea as symptoms of panic attack. It is thought that chest pain and dyspnea in the course of panic attack may not be purely psychological.     

Predictive factors of transarterial chemoembolisation toxicity in unresectable hepatocellular carcinoma

BackgroundTransarterial chemoembolisation (TACE) is an effective treatment for unresectable hepatocellular carcinoma (HCC), but can cause severe toxicity.AimTo identify predictive factors of severe TACE-related toxicity in patients with unresectable HCC.MethodsAll HCC patients who underwent TACE at the Dijon University Hospital between 2008 and 2011 were included in this retrospective study. Severe TACE-related toxicity was defined as the occurrence of any adverse event grade ≥4, or any adverse event that caused a prolongation of hospitalisation of >8 days, or any additional hospitalisation within 1 month after TACE. Factors predicting toxicity were identified using a logistic regression model. The robustness of the final model was confirmed using bootstrapping (500 replications).Results124 patients were included, median age was 67 years and 90% were male; 22 patients (18%) experienced severe TACE-related toxicity. Factors that independently predicted severe TACE-related toxicity in multivariate analysis were total tumour size (OR, 1.15 cm⁻¹; 95%CI, 1.04–1.26; p = 0.01), and high serum AST levels (OR, 1.10 per 10 IU/l; 95%CI, 1.01–1.21; p = 0.04). The results were confirmed by bootstrapping.ConclusionsTotal tumour size and high serum AST levels were predictive factors of severe TACE-related toxicity in this hospital-based series of patients with unresectable HCC.     

A prediction model for liver abscess developing after transarterial chemoembolization in patients with hepatocellular carcinoma

BackgroundLiver abscess is a rare but potentially fatal complication of transarterial chemoembolization. Other than for biliary abnormalities, risk factors for liver abscess formation after transarterial chemoembolization have rarely been discussed.AimsTo identify other risk factors of liver abscess after transarterial chemoembolization in patients with hepatocellular carcinoma.MethodsData for 5299 patients with hepatocellular carcinoma who underwent transarterial chemoembolization from July 1999 to December 2009 were retrospectively reviewed. 72 patients who experienced liver abscess after transarterial chemoembolization were enrolled as a case group, which was compared with a randomly selected control group (n = 1009) of patients who did not develop liver abscess after transarterial chemoembolization.ResultsPneumobilia, type 2 biliary abnormality, type 1 biliary abnormality, diabetes mellitus, tumour number (≥3), tumour size (≥3 cm), and tumour necrosis on the pre-transarterial chemoembolization computed tomography, and gelfoam embolization and vessel injury during transarterial chemoembolization were all significant predisposing factors for liver abscess after transarterial chemoembolization. A prediction model for postembolization liver abscess was developed from these risk factors.ConclusionThe group of patients with risk scores greater than 71 showed a significantly increased risk of liver abscess after transarterial chemoembolization. These high-risk patients should be monitored carefully after transarterial chemoembolization.     

Telomere dysfunction in peripheral blood mononuclear cells from patients with primary biliary cirrhosis

BackgroundChromosomal instability in peripheral blood mononuclear cells has a role in the onset of primary biliary cirrhosis. We hypothesized that patients with primary biliary cirrhosis may harbour telomere dysfunction, with consequent chromosomal instability and cellular senescence.AimTo evaluate the clinical significance of telomerase activity and telomere length in peripheral blood mononuclear cells from patients with primary biliary cirrhosis.Study designIn this population-based case control study, 48 women with primary biliary cirrhosis (25 with cirrhosis), 12 with chronic hepatitis C matched by age and severity of disease, and 55 age-matched healthy women were identified. Mononuclear cells from the peripheral blood of patients and controls were isolated. Telomere length and telomerase activity were measured.ResultsTelomere length and telomerase activity did not differ between cases (5.9 ± 1.5 kb) and controls (6.2 ± 1.4 kb, p_c = 0.164). Telomere shortening and advanced-stage disease strongly correlated with telomerase activity. Patients with advanced disease retained significantly less telomerase activity than those with early-stage disease (0.6 ± 0.9 OD vs. 1.5 ± 3.7 OD, p = 0.03). Telomere loss correlated with age, suggesting premature cellular ageing in patients with primary biliary cirrhosis.ConclusionOur data strongly support the telomere hypothesis of human cirrhosis, indicating that telomere shortening and telomerase activity represent a molecular mechanism in the evolution of human cirrhosis in a selected population of patients.     

Intensity of bronchial hyperresponsiveness and asthma relapse risk in the young adult

BackgroundThe evolution of asthma starting in childhood varies and depends on a series of factors (atopy, allergens, and environmental irritants, etc). Treatment may influence the evolution of the disease and even cause the symptoms to disappear. However, there remains a risk of relapse years later.ObjectivesTo assess the role of bronchial hyperresponsiveness in asthma relapse in young adulthood in patients with symptoms that disappeared after treatment prescribed in childhood.Material and methodsTo determine the evolution of asthma and patients’ personal opinions, 78 patients were sent a questionnaire several years after having been discharged without symptoms in the previous 2 years, and without the need for medication. The methacholine test was used to evaluate bronchial hyperresponsiveness at discharge. The 40 patients who correctly completed the questionnaire were divided into three groups according to the methacholine dose required to obtain a 20 % decrease in forced expiratory volume in 1 second (PD20): group 1 (15 patients), < 1000 μg; group 2 (10 patients) between 1001 and 2000 μg; and group 3 (15 patients) > 2100 μg. The mean age at discharge was 16 years (range 13-25 years) versus 26 years at the time of response (range 18-33 years), with a similar distribution in all three groups. Age at disease onset, with estimation of severity, age at the first visit and at the start of treatment, and respiratory function were evaluated.ResultsThirty of the interviewed patients considered themselves to be cured. Seven of the patients (three in group 1, one in group 2, and three in group 3) did not consider themselves to be cured, although their symptoms were minimal and they rarely used medication. Health status was described as “regular” with sporadic symptoms by one patient in each group. No correlation with methacholine response was observed.ConclusionNo relationship was found between the degree of bronchial hyperresponsiveness and the risk of relapse in young adults who suffered asthma in childhood.     

Intrahepatic biliary cystadenoma and cystadenocarcinoma: an experience of 30 cases

Background and objectivesIntrahepatic biliary cystadenoma and biliary cystadenocarcinoma are extremely rare neoplasms of the liver. They share similar radiological characteristics, and the clinicopathological features are poorly defined. We aim to provide an algorithm for preoperative differentiation of the two diseases.MethodsPatients who underwent liver resection between May 2001 and May 2011 at Peking Union Medical College Hospital with biliary cystadenoma (20 cases) and biliary cystadenocarcinoma (10 cases) were reviewed.ResultsSignificant differences were shown in age (P = 0.030), gender (P = 0.002) and symptom duration (P = 0.012). Most biliary cystadenomas occurred in women ≤60 years old (85%), whilst most biliary cystadenocarcinomas occurred in older males (50%). Shorter symptom duration indicated a higher risk of biliary cystadenocarcinoma. Arterial blood flow and wall/nodule enhancement tended to be more common in biliary cystadenocarcinoma, but the difference was not significant (P = 0.348). A score system was developed. The case-by-case validation and leave-one-out cross-validation showed an accuracy of 95.5% and 90.9%, respectively. The discriminative accuracy for cases from another hospital during the same period was 90.9%.ConclusionsOlder age, male gender, and shorter symptom duration are associated with higher possibility of biliary cystadenocarcinoma. Location and blood supply by radiology might be instrumental but still need further verification.     

A comparison of uncovered metal stents for the palliation of patients with malignant biliary obstruction: nitinol vs. stainless steel

BackgroundVarious types of self-expandable metal stents have been introduced for the palliation of malignant biliary obstruction.AimsTo compare the outcomes of WallFlex™ and Wallstent™ uncovered biliary self-expandable metal stents (SEMSs) for the palliation of patients with malignant biliary obstruction.MethodsBetween October 2008 and December 2009, all SEMSs placed for malignant biliary obstruction were WallFlex™: all patients palliated were included in the study. Before October 2008, all the SEMSs placed for malignant biliary obstruction were Wallstent™, and the patients palliated from July 2007 to September 2008 were the comparative group.ResultsA total of 58 WallFlex™ and 54 Wallstent™ SEMSs were placed, and efficacious biliary decompression was achieved in all patients. Early complications occurred in 5 patients in the WallFlex™ group and in 3 in the Wallstent™ group (p = ns). Late complications occurred in 6 patients in the WallFlex™ group and in 16 in the Wallstent™ group (p < 0.01). The overall patency of the self-expandable metal stent in the WallFlex™ and the Wallstent™ groups was similar (227 days vs. 215 days, p = ns). Mean patient survival was 242 days in the WallFlex™ group and 257 days in the Wallstent™ group (p = ns).ConclusionsWe found no difference in terms of overall patency between the two types of SEMSs, but there was an increased rate of late adverse events in the Wallstent™ group.     

Markers for Step-Down of Inhaled Corticosteroid Therapy in Adult Asthmatics

BackgroundTreatment guidelines recommend the use of inhaled corticosteroids (ICS) as first-line therapy for all stages of persistent asthma. However, it is unknown whether ICS dose reduction in adult asthmatics is compatible with maintaining asthma control. Moreover, there are no predictors of efficacy in maintaining asthma control upon ICS reduction.MethodsWe recruited 90 adult patients with moderate or severe asthma but no clinical symptoms of asthma for at least 6 months. All patients reduced their ICS doses by half but continued taking other asthma-related medications. As a primary outcome, we measured asthma exacerbations during the 12 months following ICS reduction. We also further monitored patients from the above study who had maintained total asthma control for 12 months after ICS reduction and who had continued on their reduced doses of ICS or had further reduced, or stopped, their ICS.ResultsForty of ninety patients (44.4%) experienced exacerbations after ICS reduction (time to first exacerbation: 6.4 ± 3.6 months). Multivariate logistic regression modeling revealed a rank order of predictors of success in ICS reduction while retaining asthma control: acetylcholine (ACh) PC20 (p < 0.01); length of time with no clinical symptoms before ICS reduction (p < 0.01); FeNO (p = 0.028); and forced expiratory volume in 1 s (FEV1; % predicted) (p = 0.03). Finally thirty-nine of 50 patients maintained total asthma control for at least 2 years after the initial ICS reduction.ConclusionsIn asthma patients with normalized AChPC₂₀ of 20 mg/mL or 10 mg/mL and no clinical symptoms for at least 12 or 24 months it may be possible to successfully reduce ICS without increasing exacerbations for long time.     

Usefulness of endoscopic ultrasound in patients with minilithiasis and/or biliary sludge as a cause of symptoms of probable biliary origin after cholecystectomy

IntroductionEndoscopic ultrasound (EUS) is a more sensitive technique than transabdominal ultrasound for the diagnosis of gallstones. This greater sensitivity, especially in the diagnosis of microlithiasis/biliary sludge, facilitates the indication of cholecystectomy in patients with symptoms of probable biliary origin but may result in over-indication of this surgery.ObjectivesEvaluate the role of EUS in the diagnosis of minilithiasis/biliary sludge in patients with digestive symptoms of probable biliary origin by resolving the symptoms after cholecystectomy. Analyse factors related to the remission of symptoms following cholecystectomy.Patients and methodsRetrospective, longitudinal, single-centre study based on a prospective database of 1.121 patients undergoing EUS. Seventy-four patients were identified as meeting inclusion-exclusion criteria (diagnosed with minilithiasis/sludge by EUS after presenting digestive symptoms of probable biliary origin without a history of complicated cholelithiasis). A telephone questionnaire for symptoms was conducted with cholecystectomized patients. Factors related to a good response were analysed with logistic regression analysis.ResultsOf the 74 patients, 50 were cholecystectomized (67.5%), mean age 49 years (SEM 2.26) (41 women). Seventy percent of patients (35/50) presented remission of symptoms with median follow-up 353.5 days (95% CI, 270–632.2). The only variable associated with remission of symptoms was the presence of typical biliary colic with an OR of 7.8 (95% CI, 1.8–34; p = 0.006). No complications associated with EUS were recorded. One patient (2%) suffered haemoperitoneum and 18% (9/50) suffered diarrhoea following cholecystectomy.ConclusionsEUS is a very useful technique for the indication of cholecystectomy in patients with minilithiasis/sludge and typical symptoms of biliary colic.