Doing “LESS” is Beneficial -Combining ERCP and Cholecystectomy

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A recent retrospective study (DS Fishman et al. JPGN 2020; 71: 203-207) identified 25 patients who underwent combined Laparascopic cholecystectomy/ERCP in Same Session (=LESS) to more conventional ERCP followed by laparoscopic cholecystectomy (n=42).  The center utilized prospectively-collected data from 13 centers and 67 consecutive ERCPs.

Key findings:

  • Median hospital stay was shorter for LESS patients, 3 days vs. 4 days (P=.32)
  • Total procedure time was similar, though a decrease in total anesthesia time was reported for LESS patients: mean 177 minutes compared to 205 minutes (P=.04)
  • No significant adverse events were reported in either group, though both groups had two patients who required repeat care due to suspected retained stones
  • The authors note that concerns about gaseous distention following ERCP “is likely unfounded as all cholecystectomies were completed.”
  • No local or systemic infections were reported.  The authors recommend antibiotic prophylaxis with the LESS approach

My take: Given the recommendation that cholecystectomy should take place during the same hospitalization for patients with choledocholithiasis, this combined approach makes a lot sense and is supported by this study.

Related posts:

Isle of Palms, SC

Liver Shorts -August 2020

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V Cardenas et al. JPGN 2020; 71: 197-202.  Incidence and Sequelae of Liver Injury Among Children Treated for Solid Tumors: Analysis of a Large Single-Center Prospective Cohort

  • Of 1136 solid tumor patients, 160 (14%) experienced liver injury, and the overall frequency of DILI was 4%.
  • DILI was the leading identified cause of liver injury (31%), followed by infection (17%), metastatic/malignant biliary disease (13%), and perioperative liver injury (13%).
  • Most DILI cases (>90%) were mild acute hepatocellular injury episodes that did not result in modification to the chemotherapy plan, and all DILI eventually resolved.

N Kapila et al. Hepatology 2020; 72: 32-41. Full Text Link: Hepatitis C Virus NAT‐Positive Solid Organ Allografts Transplanted Into Hepatitis C Virus–Negative Recipients: A Real‐World Experience

Background: As of April 1, 2019, an estimated 103,000 kidney, 13,500 liver, and 3,800 heart transplant (HT) candidates are awaiting transplantation

Key findings:

  • Seventy‐seven patients who were HCV negative underwent solid organ transplantation from a donor who was HCV viremic. Only one has been a HCV-treatment nonresponder (though several have not completed SVR12).
  • “Our study is the largest to describe a real‐world experience of the transplantation of HCV‐viremic organs into recipients who are aviremic. In carefully selected patients, the use of HCV‐viremic grafts in the DAA era appears to be efficacious and well tolerated.”

M Martinello et al. Hepatology 2020; 72: 7-18. Short‐Duration Pan‐Genotypic Therapy With Glecaprevir/Pibrentasvir for 6 Weeks Among People With Recent Hepatitis C Viral Infection

  • This was an  open‐label, single‐arm, multicenter, international pilot study; adults with recent HCV (duration of infection < 12 months) received glecaprevir/pibrentasvir 300/120 mg daily for 6 weeks.
  • At baseline, median estimated duration of infection was 29 weeks (range 13, 52) and median HCV RNA was 6.2 log10 IU/mL (range 0.9, 7.7). SVR12 in the intention‐to‐treat and per‐protocol populations was achieved in 90% (27/30) and 96% (27/28), respectively.

H Verkade et al. JPGN 2020; 71: 176-83. Systematic Review and Meta-analysis: Partial External Biliary Diversion in Progressive Familial Intrahepatic Cholestasis

  • With regard to  pruritus improvement, 104/155 (67%) were responders, 14/155 (9%) had partial response, and 37/155 (24%) were nonresponders.

K Patel et al. Hepatology 2020; 72: 58-71. Cilofexor, a Nonsteroidal FXR Agonist, in Patients With Noncirrhotic NASH: A Phase 2 Randomized Controlled Trial

  • “Cilofexor for 24 weeks was well‐tolerated and provided significant reductions in hepatic steatosis, liver biochemistry, and serum bile acids in patients with NASH.”

Building a Bigger (Better?) Brain in Premature Infants

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A recent retrospective study (PE van Beek et al. J Pediatr 2020; 223: 57-63. Increase in Brain Volumes after Implementation of a Nutrition Regimen in Infants Born Extremely Preterm) with 178 infants (median gestational age 26.6 weeks) found that a modification in the nutritional regimen resulted in improved brain volumes.

Key findings:

  • In cohort B (new regimen), mean protein and caloric intake were 3.4 g/kg/d & 109 kcal/kg/day which were significantly  increased compared to Cohort A: 2.7 g/kg/d and 104 kcal/kg/d for first 28 days of life.
  • At 30 weeks gestational age, 22 brain regions were significantly large in cohort B compared with cohort A, though at term age equivalence, only the caudate nucleus remained significantly larger.
  • key limitation: brain MRI can only be performed in relatively stable neonates; thus, sicker infants may be underrepresented.

My view: Optimizing nutrition as early as possible is likely to help improve cognitive outcomes.

Related blog posts:

Other nutrition-related articles in this issue:

DL Harris et al. J Pediatr 2020; 223: 34-41. Glucose Profiles in Healthy Term Infants in the First 5 Days: The Glucose in Well Babies (GLOW) Study

  • In term infants, plasma glucose concentrations of 47 mg/dL (2.6 mmol/L) approximated the 10th percentile in the first 48 hours, and 39% of infants had ≥1 episode below this threshold.
  •  The mean glucose concentrations increased over the first 18 hours, remained stable to 48 hours (59 ± 11 mg/dL; 3.3 ± 0.6 mmol/L)] before increasing to a new plateau by the fourth day (89 ± 13 mg/dL; 4.6 ± 0.7 mmol/L).

WG Sharp et al. J Pediatr 2020; 223: 73-80. Intensive Multidisciplinary Intervention for Young Children with Feeding Tube Dependence and Chronic Food Refusal: An Electronic Health Record Review  Congratulations to my colleagues at the Marcus Center for this work, particularly Valerie Volkert who has worked with so many of our kids and Barbara McElhanon who has been so helpful.  83 patients with complex medical-behavioral-developmental problems met study criteria.  Key finding:  58 patients (72%) weaned from tube feeding at follow-up.

From Pitt Street Bridge Park, Mount Pleasant, SC

 

Briefly Noted: How to Approach Crohn’s Disease Complicated by an Intra-abdominal Abscess

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A recent review (T Qazi, M Regueiro. Practical Gastroenterology 2020: June Issue, 10-18. Full PDF Link: Crohn’s Disease Complicated by an Intra-abdominal Abscess: Poke, Prod, or Cut?)

The article is a good review & the algorithm below provides some good guidance -if difficult to visualize, then it may be worthwhile to look at source article.

The authors propose initial management with antibiotics, minimization of steroids, nutritional support and drainage.

Medical treatment is favored after initial management:

  • Newly diagnosed Crohn’s disease
  • Extensive disease
  • No fibrostenoting disease
  • Active perianal disease

Surgical treatment is favored after initial management:

  • Long-standing disease
  • Stricture with dilatation
  • Abscess >6 cm in size
  • Prior surgical intervention

The authors note that “recent studies have suggested that roughly 30% of patients
treated with PD are able to avoid future surgical resection.”

Related blog posts:

 

AASLD: Advice for Patients with Liver Diseases and Liver Transplants During COVID-19

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AASLD: OK Fix et al. Hepatology 2020; 72: 287-304. Full Article Link: Clinical Best Practice Advice for Hepatology and Liver Transplant Providers During the COVID‐19 Pandemic: AASLD Expert Panel Consensus Statement

This is a lengthy article with extensive recommendations –here are a few:

  • Consider etiologies unrelated to COVID‐19, including other viruses such as hepatitis A, B and C, when assessing patients with COVID‐19 and elevated liver biochemistries.
  • Consider other causes of elevated liver biochemistries, including myositis (particularly when AST>ALT), cardiac injury, ischemia, and cytokine release syndrome.
  • Generally, this article supports continuation of ongoing treatments in those with liver disease who are without active infection.  “Do not reduce immunosuppression or stop mycophenolate for asymptomatic posttransplant patients without known COVID‐19”
  •  “As we learn more about how the COVID‐19 pandemic impacts the care of patients with liver disease, we will update the online document available at https://www.aasld.org/about-aasld/covid-19-and-liver.”

Nutrition ‘Mythbuster’ Webinar

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A recent Children’s Healthcare Webinar by Hillary Bashaw reviewed several nutrition topics.  I took some notes and some screenshots.  Some errors of omission and transcription may have occurred.

Key points from talk:

  • Cow’s milk overall is a healthy beverage for children, though there are several plant-based alternatives that can be effective substitutes.  Soy milk and pea-protein milk are often the best alternatives.
  • Fiber from foods is the best way to get fiber.  Gummy fiber products are not recommended.
  • Eating breakfast likely helps with school performance; however, this does not mean it is the ‘most important’ meal of the day.

Related article: RJ Merritt et al. JPGN 2020; 71: 276–81. Full text link: NASPGHAN Position Paper: Plant-based Milks

  • One of the slides from this talk modifies the Table 1 (adds skim milk) from this article.
  • “Milk‘s contribution to the protein intake of young children is especially important. For almond or rice milk, an 8 oz serving provides only about 2% or 8%, respectively, of the protein equivalent found in a serving of CM.”
  • “As presently constituted, almond, rice, coconut, hemp, flax seed, and cashew “milks” are inappropriate replacements for CM in toddlers and young children for whom milk remains an important part of the diet.”

Milk–related blog posts:

Fiber:

Fiber–related blog posts:

Breakfast:

Breakfast-related blog posts:

 

Trichobezoar: Don’t Do What They Did

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A recent review and case report (AF Nita et al JPGN 2020; 71: 163-70) describe an anguishing outcome after an endoscopy.  This publication is a useful, cautionary tale. In my view, the associated editorial (“MacGyver and Rapunzel in the Pediatric Endoscopy Suite” by JR Lightdale, pg 147-8) tiptoes on the issue of safety concerns of the endoscopic approach described in the review.

Case report: The authors describe a 9 year old with trichobezoar/Rapunzel syndrome who underwent a 3 hour endoscopic procedure with APC to remove the trichobezoar which was found to be composed of both human hair and doll’s hair (the latter may have contributed to complications).  In addition, the child had undiagnosed celiac disease.  Subsequent to the procedure, the child required a laparotomy; she had 18 small intestinal perforations and a gastric perforation.  The child went on to need an extensive small bowel resection (107 cm) and a 3 month hospitalization.

The authors state that a previous review had indicated only a 5% success rate for trichobezoar endoscopic removal (RR Gorter et al. Pediatr Surg Int 2010; 26: 457-63). However, they claim increased success more recently by identifying 16 of 52 (30.7%) removal rate from recent case reports.  Interestingly, one of the successful endoscopic removals cited by the authors had a respiratory arrest during the procedure (Esmali et al).

Bad advice from this article:

  • #1 The authors repeatedly suggest now that there is a >30% endoscopic success rate for endoscopic removal and thus they suggest that “it remains reasonable to attempt endoscopic retrieval” as long as a gastric trichobezoar occupies less than two-thirds of the stomach and has limited to no extension into the small bowel.
  • #2 The authors believe that “the skill mix of the endoscopist” is an important issue.

My take on their ‘learning points’:

  1. This 30% success rate should not be taken seriously due to publication bias (many unsuccessful cases are not reported) and due to treatment bias.  Many clinicians would never attempt to remove a very large trichobezoar.  Thus, the 30% success rate likely includes bezoars that may be more amenable to removal and by centers with more advanced endoscopists.
  2. The second claim about endoscopist skill is also bad advice.  First of all, some of the authors of this study have extensive endoscopic experience and yet this did not preclude a bad outcome for this child.  Secondly, in my experience, ~85% of individuals (including GI doctors) consider themselves above average; thus, it may be difficult to know if the ‘skill mix’ of the endoscopist is suitable.  Large trichobezoars are rare and no individuals will have enough experience to be considered experts.
  3. My advice: Don’t try to be MacGyver in the endoscopy suite.  Most trichobezoar cases are more suitable for surgical removal.  The most important skill of a good endoscopist is good judgement and the ability to identify cases in which an endoscopy is ill-advised.

Isle of Palms, SC

MIT Technology Review: How to Talk to Conspiracy Theorists

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From Bryan Vartabedian’s 33email –this link: MIT Technology Review: How to Talk to Conspiracy Theorists

An excerpt:

  • Always, always speak respectfully. Every single person I spoke to said that without respect, compassion, and empathy, no one will open their mind or heart to you. No one will listen.
  • Go private…
  • Test the waters first. That way you save yourself time and energy. “You can ask what it would take to change their mind, and if they say they will never change their mind, then you should take them at their word and not bother engaging,”
  • Agree…[with some parts] Conspiracy theories often feature elements that everyone can agree on
  • Try the “truth sandwich. Use the fact-fallacy-fact approach…
  • Or use the Socratic method. In other words, use questions to help others probe their own argument and see if it stands up. ..The best way to change someone’s view is to make them feel like they’ve uncovered it themselves,” he says. That means engaging in back-and-forth questions and answers until you hit a dead end, gently pointing out inconsistencies.
  • Be very careful with loved ones.
  • Realize that some people don’t want to change, no matter the facts.
  • If it gets bad, stop. … “If I am not enjoying the discussion and getting angry, then I simply stop.”
  • Every little bit helps. One conversation will probably not change a person’s mind, and that’s okay

Related blog posts: