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Background: The accuracy of EUS in the locoregional assessment of ampullary lesions is unclear., Objectives: To compare EUS with ERCP and surgical pathology for the evaluation of intraductal extension and local staging of ampullary lesions., Design: Retrospective cohort study., Setting: Tertiary-care referral center., Patients: All patients who underwent EUS primarily for the evaluation of an ampullary lesion between 1998 and 2012., Intervention: EUS., Main Outcome Measurements: Comparison of EUS sensitivity/specificity for intraductal and local extension with ERCP and surgical pathology by using the area under the receiver-operating characteristic (AUROC) curves and outcomes of the subgroup referred for endoscopic papillectomy., Results: We identified 119 patients who underwent EUS for an ampullary lesion, of whom 99 (83%) had an adenoma or adenocarcinoma. Compared with ERCP (n = 90), the sensitivity/specificity of EUS for any intraductal extension was 56%/97% (AUROC = 0.77; 95% confidence interval [CI], 0.64-0.89). However, when using surgical pathology as the reference (n = 102), the sensitivity/specificity of EUS (80%/93%; AUROC = 0.87; 95% CI, 0.76-0.97) and ERCP (83%/93%; AUROC = 0.88; 95% CI, 0.77-0.99) were comparable. The overall accuracy of EUS for local staging was 90%. Of 58 patients referred for endoscopic papillectomy, complete resection was achieved in 53 (91%); in those having intraductal extension by EUS or ERCP, complete resection was achieved in 4 of 5 (80%) and 4 of 7 (57%), respectively., Limitation: Retrospective design., Conclusions: EUS and ERCP perform similarly in evaluating intraductal extension of ampullary adenomas. Additionally, EUS is accurate in T-staging ampullary adenocarcinomas. Future prospective studies should evaluate whether EUS can identify characteristics of ampullary lesions that appropriately direct patients to endoscopic or surgical resection., (Copyright © 2015 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background: It is believed, based on limited observational data, that an unsuccessful attempt to place a prophylactic pancreatic stent substantially increases the risk of post-ERCP pancreatitis (PEP)., Objective: To better understand the risk of PEP in patients with failed pancreatic stent placement (FPS) and the impact of rectal indomethacin on this risk., Design: Secondary analysis of randomized, controlled trial data., Setting: University of Michigan and Indiana University., Patients: A total of 577 clinical trial participants at elevated risk for PEP., Interventions: Pancreatic stent placement., Main Outcome Measurements: Within the placebo group, we compared PEP rates in patients with FPS, patients who underwent successful stent placement, and in those without a stent attempt. We also performed a regression analysis evaluating the association between FPS and PEP. To define the protective effect of indomethacin, we repeated these analyses in the indomethacin group and in the full study cohort., Results: The incidence of PEP among patients in the placebo group who experienced FPS was 34.7%, significantly exceeding rates in patients who underwent successful stent placement (16.4%) and in those without a stent attempt (12.1%). After we adjusted for known PEP risk factors, FPS was found to be independently associated with PEP. Among the indomethacin group and in the full cohort, FPS was not associated with a higher risk of PEP., Limitations: Low event rate, FPS not prospectively captured., Conclusion: FPS appears to confer an increased risk of PEP, which is attenuated by rectal indomethacin administration. These findings highlight the importance of adequate training and proficiency before endoscopists attempt pancreatic stent placement and the routine use of rectal indomethacin in high-risk ERCP cases., (Copyright © 2015 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background: Endoscopic papillectomy is increasingly used as an alternative to surgery for ampullary adenomas and other noninvasive ampullary lesions., Objective: To measure short-term safety and efficacy of endoscopic papillectomy, define patient and lesion characteristics associated with incomplete endoscopic resection, and measure adenoma recurrence rates during long-term follow-up., Design: Retrospective cohort study., Setting: Tertiary-care academic medical center., Patients: All patients who underwent endoscopic papillectomy for ampullary lesions between July 1995 and June 2012., Intervention: Endoscopic papillectomy., Main Outcome Measurements: Patient and lesion characteristics associated with incomplete endoscopic resection and ampullary adenoma-free survival analysis., Results: We identified 182 patients who underwent endoscopic papillectomy, 134 (73.6%) having complete resection. Short-term adverse events occurred in 34 (18.7%). Risk factors for incomplete resection were jaundice at presentation (odds ratio [OR] 0.21; 95% confidence interval [CI] 0.07-0.69; P = .009), occult adenocarcinoma (OR 0.06; 95% CI, 0.01-0.36; P = .002), and intraductal involvement (OR 0.29; 95% CI, 0.11-0.75; P = .011). The en bloc resection technique was strongly associated with a higher rate of complete resection (OR 4.05; 95% CI, 1.71-9.59; P = .001). Among patients with ampullary adenoma who had complete resection (n = 107), 16 patients (15%) developed recurrence up to 65 months after resection., Limitations: Retrospective analysis., Conclusion: Jaundice at presentation, occult adenocarcinoma in the resected specimen, and intraductal involvement are associated with a lower rate of complete resection, whereas en bloc papillectomy increases the odds of complete endoscopic resection. Despite complete resection, recurrence was observed up to 5 years after papillectomy, confirming the need for long-term surveillance., (Copyright © 2014 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: A fatty meal before ERCP relaxes the sphincter of Oddi and may facilitate biliary cannulation., Objective: To assess the effect of an oral fatty meal before ERCP on time to and success rate of biliary cannulation., Design: Human clinical study., Setting: Tertiary ERCP center., Patients: Adult patients with intact papilla undergoing ERCP for presumed biliary pathology., Interventions: Patients arriving more than 1 hour before the procedure were given oil by mouth. Patients not receiving oil served as controls. The need for a precut sphincterotomy was considered a failure of initial cannulation., Main Outcome Measurements: Appearance of the papillary orifice, bile flow, cannulation success rate, cannulation and fluoroscopy times., Results: A total of 86 patients received oil (mean age 52.8 years; 40% male), and 103 patients served as controls (mean age 53.3 years; 49% male). The papillary orifice was open in 52 of 86 (61%) and 38 of 103 (37%) patients in the oil and control groups, respectively (P = .002). Bile flow was seen in 59 of 86 (68%) and 50 of 103 (49%) patients, respectively (P = .009). The overall initial biliary cannulation success rate was 80 of 86 (93%) and 97 of 103 (94%), respectively (P = .77). There was no difference in cannulation success rates, cannulation, and fluoroscopy times for fellows or faculty endoscopists in each group. No pulmonary aspiration was seen in either group., Limitations: Unblinded study., Conclusions: The biliary orifice appeared more open and bile flow was seen in more patients receiving oil, but there was no difference in successful biliary cannulation rates and cannulation and fluoroscopy times in the 2 groups., (Copyright © 2013 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)