Carbon dioxide insufflation during endoscopic retrograde cholangiopancreatography reduces bowel gas volume but does not affect visual analogue scale scores of suffering: a prospective, double-blind, randomized, controlled trial

Background: Endoscopic retrograde cholangiopancreatography (ERCP) and related procedures can cause abdominal pain and discomfort. Two clinical trials have indicated, using the visual analogue scale (VAS) score, that CO2 insufflation during ERCP ameliorates the suffering of patients without complications, as compared with air insufflation. However, differences in patient suffering between CO2 and air insufflation after ERCP under deep conscious sedation have not been reported. We focused on the gas volume score (GVS) as an objective indicator of gas volume, and designed a multicenter, prospective, double-blind randomized controlled study with CO2 and air insufflation during ERCP. Methods: Between March 2010 and August 2010, 80 patients who required ERCP were enrolled and evenly randomized to receive CO2 insufflation (CO2 group) or air insufflation (air group). ERCP and related procedures were performed under deep conscious sedation with fentanyl citrate or pethidine and midazolam or diazepam. The GVS was evaluated as the primary endpoint in addition to the VAS score as the secondary endpoint. Results: The GVS after ERCP and related procedures in the CO2 group was significantly lower than that in the air group (0.14 ± 0.06 vs. 0.31 ± 0.11, P < 0.01), as well as the increase in the rate of GVS ([GVS after - GVS before] / [GVS before ERCP and related procedures] x 100) (3.8 ± 5.9 vs. 21.0 ± 11.1%, P < 0.01). VAS scores 3 and 24 hours after ERCP and related procedures were comparable between the CO2 and air groups for abdominal pain, abdominal distension, and nausea. Additionally, VAS scores were not correlated with the GVS. Conclusions: CO2 insufflation during ERCP reduces GVS (bowel gas volume), but not the VAS score of suffering, as compared with air insufflation. Deep and sufficient sedation during ERCP and related procedures is important for the palliation of patients' pain and discomfort

Detectability on Plain CT Is an Effective Discriminator between Carcinoma and Benign Disorder for a Polyp &gt;10 mm in the Gallbladder

An appropriate diagnosis is required to avoid unnecessary surgery for gallbladder cholesterol polyps (GChPs) and to appropriately treat pedunculated gallbladder carcinomas (GCs). Generally, polyps &gt;10 mm are regarded as surgical candidates. We retrospectively evaluated plain and contrast-enhanced (CE) computed tomography (CT) findings and histopathological features of 11 early GCs and 10 GChPs sized 10–30 mm to differentiate between GC and GChP &gt;10 mm and determine their histopathological background. Patient characteristics, including polyp size, did not significantly differ between groups. All GCs and GChPs were detected on CE-CT; GCs were detected more often than GChPs on plain CT (73% vs. 9%; p &lt; 0.01). Sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy for GCs were 73%, 90%, 89%, 75%, and 81%, respectively. On multivariate analysis, lesion detectability on plain CT was independently associated with GCs (odds ratio, 27.1; p = 0.044). Histopathologically, GChPs consisted of adipose tissue. Although larger vessel areas in GCs than in GChPs was not significant (52,737 μm2 vs. 31,906 μm2; p = 0.51), cell densities were significantly greater in GCs (0.015/μm2 vs. 0.0080/μm2; p &lt; 0.01). Among GPs larger than 10 mm, plain CT could contribute to differentiating GCs from GChPs

High and low negative pressure suction techniques in EUS- guided fine- needle tissue acquisition by using 25-gauge needles: a multicenter, prospective, randomized, controlled trial

Background: EUS-guided FNA (EUS-FNA) has a high diagnostic accuracy for pancreatic diseases. However, although most reports have typically focused on cytology, histological tissue quality has rarely been investigated. The effectiveness of EUS-FNA combined with high negative pressure (HNP) suction was recently indicated for tissue acquisition, but has not thus far been tested in a prospective, randomized clinical trial. Objective: To evaluate the adequacy of EUS-FNA with HNP for the histological diagnosis of pancreatic lesions by using 25-gauge needles. Design: Prospective, single-blind, randomized, controlled crossover trial. Setting: Seven tertiary referral centers. Patients: Patients referred for EUS-FNA of pancreatic solid lesions. From July 2011 to April 2012, 90 patients underwent EUS-FNA of pancreatic solid masses by using normal negative pressure (NNP) and HNP with 2 respective passes. The order of the passes was randomized, and the sample adequacy, quality, and histology were evaluated by a single expert pathologist. Intervention: EUS-FNA by using NNP and HNP. Main Outcome Measurements: The adequacy of tissue acquisition and the accuracy of histological diagnoses made by using the EUS-FNA technique with HNP. Results: We found that 72.2% (65/90) and 90% (81/90) of the specimens obtained using NNP and HNP, respectively, were adequate for histological diagnosis (P = .0003, McNemar test). For 73.3% (66/90) and 82.2% (74/90) of the specimens obtained by using NNP and HNP, respectively, an accurate diagnosis was achieved (P = .06, McNemar test). Pancreatitis developed in 1 patient after this procedure, which subsided with conservative therapy. Limitations: This was a single-blinded, crossover study. Conclusion: Biopsy procedures that combine the EUS-FNA with HNP techniques are superior to EUS-FNA with NNP procedures for tissue acquisition