ABSTRACT Accessing the biliary ducts for performing endoscopic retrograde cholangiopancreatography (ERCP) and relevant interventional procedures after gastric bypass surgery is technically difficult and frequently unsuccessful due to anatomical alterations. To overcome such technical challenges, laparoscopic-assisted ERCP (LA-ERCP) is used to approach the biliary ducts via nonperoral reliable access for performing different endoscopic biliary interventions. In this case series, we report a total of three patients with different anatomical alterations who underwent LA-ERCP.

ABSTRACT Introduction Endoscopic retrograde cholangiopancreatography (ERCP) is a relatively new endoscopic procedure combined with fluoroscopy that is performed for multiple diagnostic and therapeutic indications. It carries a known risk of radiation exposure to patients and staff. We aimed to examine radiation administration techniques and to measure the radiation dose delivered by these techniques. Methods This was a retrospective analysis of 437 ERCP procedures performed at a tertiary care hospital between April 2015 and April 2017. Results A total of 437 ERCP procedural charts were reviewed: fluoroscopy administration was endoscopist controlled (EC, n = 187, 42.79%) or technician controlled (TC, n = 250, 57.21%). The mean (and SD) fluoroscopy time (FT) was 2.107 ± 2.0 minutes. The mean (and SD) dose–area product (DAP) was 15,227.371 ± 16,784.738 Gy·cm 2 . The degree of ERCP difficulty was evaluated as recommended by the American Society for Gastrointestinal Endoscopy, and graded 1–4. Level I TC procedures had a mean FT and DAP of 1.600 minutes and 12,644.72 Gy·cm 2 , respectively. The FT and DAP values for level I EC procedures were 1.514 minutes and 12,966.71 Gy·cm 2 , respectively, as compared with level IV TC procedures (mean FT, 2.539 minutes; mean DAP, 19,469.94 Gy·cm 2 ) and level IV EC procedures (mean FT, 4.890 minutes; mean DAP, 37,921.00 Gy·cm 2 ). Conclusion DAP and FT are increased significantly in EC ERCP in American Society for Gastrointestinal Endoscopy 4 procedures. Comparison of the different degrees of difficulty indicated that there is a linear correlation between the degree of difficulty and both FT and DAP.

ABSTRACT Background Pneumonia leading to acute respiratory distress syndrome (ARDS) is one of the devastating consequences of coronavirus disease 2019 (COVID-19). Airway pressure release ventilation (APRV) has been described as beneficial in acute lung injury and ARDS. We hypothesized that utilizing APRV would be advantageous in the COVID-19 ARDS population. Methods Prospective, observational, single-center study. Data were extracted on demographics, vasopressors, sedatives, analgesics, and oxygenation (PaO2/FiO2). A generalized linear mixed models analysis was performed to compare low tidal volume ventilation (LTV) with APRV for patients who required intubation due to ARDS from COVID-19 and who were managed with at least 48 consecutive hours of APRV in our surgical intensive care unit (SICU). Results Twelve patients met criteria; two were on APRV mode from admission to the SICU and were not included in the study. Ten patients were analyzed and were primarily male (70%), average age of 64.5 ± 12.9 years, and 70% were obese (average body mass index of 30.6 ± 8.0 kg/m 2 ). There were no smokers in the sample, but two patients presented with underlying lung pathology. APRV was shown to significantly increase the PaO 2 /FiO 2 ratio by 30% (5% to 61%) ( p = 0.05) and was associated with up to a 12% (−26% to 5%) reduction in the level of F i O 2 and reduction in the use of vasopressor support (−59% [−83% to −2%]), sedatives (−15% [−29% to 2%]), and analgesics (−16% [−38% to 12%]). Conclusions This pilot study showed that APRV was associated with decreases in FiO 2 , vasopressors, sedatives, and analgesic requirements with an increase in PaO 2 /FiO 2 ratio. In the current pandemic, where providers are grappling with ways to manage COVID-19 ARDS, APRV may be the optimal ventilator mode. Prospective randomized studies are required to validate whether use of APRV in the COVID-19 population leads to improved oxygenation and a subsequent decrease of ventilator days and length of stay.

ABSTRACT Three cases from a single institution are presented demonstrating a novel technique of endobronchial blocker insertion under fluoroscopic guidance in patients with massive hemoptysis. This article discusses advantages and limitations compared with bronchoscopic and blind insertion techniques. In all three cases, fluoroscopic guidance demonstrated successful insertion with technically appropriate positioning, allowing for hemodynamic stabilization and more definitive interventional treatment. In one case, endobronchial blocker tamponade, itself, was definitive treatment, without recurrence of hemoptysis during the patient's hospital course. All patients had resolution of their hemoptysis and were eventually discharged from the hospital. Fluoroscopy-guided endobronchial blocker insertion was demonstrated to be both technically feasible and effective in these cases of massive hemoptysis. Moving forward, this can be a valuable tool when emergent endobronchial control of hemoptysis is required in certain instances.