The Increase in Balloon Size to Over 15 mm Does Not Affect the Development of Pancreatitis After Endoscopic Papillary Large Balloon Dilatation for Bile Duct Stone Removal

BACKGROUND: Endoscopic papillary large balloon dilatation (EPLBD) after endoscopic sphincterotomy (EST) has recently become widely used for common bile duct (CBD) stone removal, but many clinicians remain concerned about post-procedural pancreatitis with increasing the balloon size to over 15 mm. AIMS: We aimed to evaluate the safety and efficacy of EPLBD with a relatively large balloon (15-20 mm) after EST and to evaluate the factors related to post-EPLBD pancreatitis. METHODS: A retrospective review was undertaken of the endoscopic database of 101 patients with CBD stones who underwent EPLBD using a larger balloon size of over 15 mm (15-20 mm). Clinical parameters, endoscopic data, and outcomes were analyzed. RESULTS: The mean age of the subjects was 69 years. All patients had a dilated CBD of over 11 mm (mean = 22.6 mm). The mean size of balloon used in EPLBD was 17.1 ± 1.9 mm (range 15-20 mm). Mechanical lithotripsy was required in seven patients (6.9%). The rate of complete stone removal in the first session was 92.1%. Post-procedural pancreatitis developed in five cases (5.4%), but none were graded as severe. The smaller dilatation of the CBD, longer cannulation time, and longer time for stone removal were associated with post-procedural pancreatitis, but larger size of balloon did not affect the development of post-EPLBD pancreatitis. CONCLUSIONS: EPLBD with a large balloon of over 15 mm with EST is an effective and safe procedure with a very low probability of severe post-procedural pancreatitis. Post-EPLBD pancreatitis was not associated with larger balloon size, but was associated with longer procedure time and smaller dilatation of the CBD.ope

Update on Endoscopic Treatment of Chronic Pancreatitis

Endoscopic therapy has been increasingly recognized as the effective therapy in selected patients with chronic pancreatitis. Utility of endotherapy in various conditions occurring in chronic pancreatitis is discussed. Its efficacy, limitations, and alternatives are addressed. For the best management of these complex entities, a multidisciplinary approach involving expertise in all pancreatic specialties is essential to achieve the goal

Update on Endoscopic Management of Main Pancreatic Duct Stones in Chronic Calcific Pancreatitis

Pancreatic duct stones are a common complication during the natural course of chronic pancreatitis and often contribute to additional pain and pancreatitis. Abdominal pain, one of the major symptoms of chronic pancreatitis, is believed to be caused in part by obstruction of the pancreatic duct system (by stones or strictures) resulting in increasing intraductal pressure and parenchymal ischemia. Pancreatic stones can be managed by surgery, endoscopy, or extracorporeal shock wave lithotripsy. In this review, updated management of pancreatic duct stones is discussed

Performance evaluation of TLB consistency solutions in large-scale shared-memory multiprocessors with consistent caches

Three methods to maintain translation lookaside buffer (TLB) consistency in highly-parallel, shared-memory multiprocessors (HPSMMs) without consistent caches, Read-locked TLBs, Validation, and Memory-based TLBs, were suggested by Teller. The state-of-the-art of microprocessors and shared-memory multiprocessors has changed significantly since the time when these solutions were first introduced, thus, they may not be suitable for state-of-the-art, cache-consistent HPSMMs. Accordingly, we examine these solutions and modify them as is necessary to implement them in cache-consistent HPSMMs. In addition, we study the performance of two solutions, revised-Validation and Memory-based TLBs, in today\u27s cache-consistent HPSMMs via an augmented version of the execution-driven simulator, Rice Simulator for ILP Multiprocessors (RSIM+), which models wormhole-routed networks interconnecting N processors and N memory modules and is capable of simulating a range of multiprocessor architectures. The simulations are driven by Stanford ParalleL Applications for SHared memory (SPLASH-2) application programs (FFT, LU, RADIX, and WATER). For the systems and workloads studied, the results of the simulations show that Memory-based TLBs outperforms revised-Validation as the TLB size or the number of paging arenas increases

Endoscopic Obliteration of Fundal Varices

In cases of portal hypertension, the fundus of the stomach is second to the esophagus as the most likely area for varices, at a frequency of about 10%, in all patients having esophageal varices. It is relatively rare, probably due to the individual vascular anatomy rather than the level of portal pressure. The authors' experience shows that fundal varices appear more frequently with prehepatic block than intrahepatic

Novel ex vivo model for hands-on teaching of and training in EUS-guided biliary drainage: creation of "Mumbai EUS" stereolithography/3D printing bile duct prototype (with videos)

Background: EUS-guided biliary drainage (EUS-BD) has emerged as an alternative rescue method in patients with failed ERCP. Opportunities for teaching and training are limited because of a low case volume at most centers. Objective: To evaluate a stereolithography/3-dimensional (3D) printing bile duct prototype for teaching and training in EUS-BD. Design: Prospective observational feasibility study. Setting: Tertiary referral center. Subjects: Twenty endosonographers attending an interventional EUS workshop. Intervention: A prototype of a dilated biliary system was prepared by computer-aided design and 3D printing. The study participants performed guidewire manipulation and EUS-BD procedures (antegrade procedure and/or choledochoduodenostomy) on the prototype. Participants were scored with the device on a scale of 1 to 5 via a questionnaire. Participants' success rate for various steps of the EUS-BD procedure was noted. Main Outcome Measurements: Subjective and objective evaluation of the prototype regarding its overall applicability, quality of radiographic and EUS images, and 4 steps of EUS-BD procedure (needle puncture, guidewire manipulation, tract dilation, stent placement). Results: Fifteen participants returned the questionnaire, and 10 completed all 4 steps of EUS-BD. The median score for overall utility was 4, whereas that for EUS and US views was 5. Participants with experience in performing more than 20 EUS-BD procedures scored the prototype significantly lower for stent placement (P = .013) and equivalent for needle puncture, tract dilation, and wire manipulation. The success rate of various steps was 100% for needle puncture and tract dilation, 82.35% for wire manipulation, and 80% for stent placement. The mean overall procedure time was 18 minutes. Limitations: Small number of participants. Conclusion: The 3D printing bile duct prototype appears suitable for teaching of and training in the various steps of EUS-BD. Further studies are required to elucidate its rol