title: Endoscopic ultrasound and endoscopic retrograde cholangiopancreatography for obstructing pancreas head masses: combined or separate procedures?
abstract: BACKGROUND
  Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) are complementary procedures in the evaluation of obstructive jaundice.
  
  
  OBJECTIVE
  To determine the feasibility, accuracy, and safety of the combined performance of EUS-guided fine needle aspiration (FNA) and ERCP with biliary stenting in patients with obstructive jaundice.
  
  
  METHODS
  Retrospectively reviewed data from consecutive patients presenting with obstructive jaundice due to a pancreas mass at a tertiary referral hospital between April 2002 and November 2007 who underwent combined (under the same sedation and in the same room) or separate EUS and ERCP. Procedure duration, amount of sedative medication administered, ability to achieve biliary stent placement, and the diagnostic yield of EUS-FNA were evaluated.
  
  
  RESULTS
  A total of 47 patients were evaluated: 29 patients underwent combined EUS and ERCP and 18 had separate procedures (median of 5 d between procedures). Stent placement at ERCP was successful in 72% combined procedures versus 88% separate ERCP. EUS-FNA diagnosis of malignancy was positive in 91.6% combined versus 87.5% separate. The only complication was self-limited melena after a combined procedure in 1 patient. The median time for combined procedures was 75 minutes versus 50 minutes for separate EUS and 50 minutes for ERCP.
  
  
  CONCLUSIONS
  Combined EUS and ERCP can be performed under the same sedation with a median 25 minute greater procedure length and similarly high yields for diagnostic EUS-FNA. A nonsignificant trend toward lower biliary stent placement success rates with combined ERCP procedures merits further study. Benefits of a combined procedure may include expedited patient evaluation and the avoidance of repeated sedation.
authors.affiliation: Department of Internal Medicine, Section of Digestive Diseases †Center for Clinical Investigation, Yale University School of Medicine, New Haven, CT 06510, USA. harry.aslanian@yale.edu
authors.forename: Harry R
authors.initials: HR
authors.lastname: Aslanian
authors.forename: Juan D
authors.initials: JD
authors.lastname: Estrada
authors.forename: Federico
authors.initials: F
authors.lastname: Rossi
authors.forename: James
authors.initials: J
authors.lastname: Dziura
authors.forename: Priya A
authors.initials: PA
authors.lastname: Jamidar
authors.forename: Uzma D
authors.initials: UD
authors.lastname: Siddiqui
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000768:Anesthesia, General; D044963:Biopsy, Fine-Needle; D016009:Chi-Square Distribution; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects / Q000295:instrumentation; D003237:Connecticut; D016292:Procedural Sedation; D004322:Drainage / Q000295:instrumentation; D019160:Endosonography / Q000009:adverse effects; D005240:Feasibility Studies; D006801:Humans; D041781:Jaundice, Obstructive / Q000175:diagnosis* / Q000209:etiology / Q000628:therapy; D008875:Middle Aged; D010190:Pancreatic Neoplasms / Q000150:complications / Q000175:diagnosis*; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome