1
|
Choi JH, Kozarek RA, Larsen MC, Ross AS, Law JK, Krishnamoorthi R, Irani S. Effectiveness and Safety of Lumen-Apposing Metal Stents in Endoscopic Interventions for Off-Label Indications. Dig Dis Sci 2022; 67:2327-2336. [PMID: 34718905 DOI: 10.1007/s10620-021-07270-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 08/07/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Although released only for drainage of pseudocyst and walled-off necrosis (WON) with ≤ 30% solid debris, the utilization of lumen-apposing metal stent (LAMS) in "real-world" practice has deviated from approved indications. We evaluated the contemporary use of LAMS and associated clinical, procedural outcomes in the setting of a tertiary referral center in the USA. METHODS Data from 303 consecutive patients who underwent LAMS placement were analyzed. Outcomes included technical and clinical success rates and adverse events. RESULTS Of 303 patients, 190 (62.7%) received LAMS for off-label indications. The latter included gallbladder drainage (n = 56, 18.5%), gastroenterostomy (n = 52, 17.2%), treatment of gastrointestinal strictures (n = 37, 12.2%), biliary drainage (n = 20, 6.6%), temporary gastric access for endoscopy (n = 13, 4.3%), symptomatic WON with > 30% solid debris (n = 8, 2.6%), and miscellaneous (n = 4, 1.3%). Technical success rates in the on- and off-label arm were 98.2% and 95.8%, respectively (P = .331; 95% CI 0.08 to 1.96). Clinical success rates in the on- and off-label arm were 89.4% and 83.2%, respectively (P = .137; 95% CI 0.28 to 1.19). The rate of adverse events was 20.5% (n = 39) in the off-label arm and 16.8% (n = 19) in the on-label arm (P = .242; 95% CI 0.69 to 2.34). CONCLUSION Off-label use of LAMS out-numbered on-label use in our practice. The safety profile between the groups was similar and with the exception of refractory stricture treatment, efficacy was comparable.
Collapse
Affiliation(s)
- Jun-Ho Choi
- Department of Gastroenterology, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA.,Department of Gastroenterology, Dankook University Hospital, Dankook University College of Medicine, 201 Manghyang-ro, Dongnam-gu, Cheonan, 31116, Korea
| | - Richard A Kozarek
- Department of Gastroenterology, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA.,Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Ave., Mailstop C3-GAS, Seattle, WA, 98101, USA
| | - Michael C Larsen
- Department of Gastroenterology, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA.,Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Ave., Mailstop C3-GAS, Seattle, WA, 98101, USA
| | - Andrew S Ross
- Department of Gastroenterology, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA.,Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Ave., Mailstop C3-GAS, Seattle, WA, 98101, USA
| | - Joanna K Law
- Department of Gastroenterology, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA.,Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Ave., Mailstop C3-GAS, Seattle, WA, 98101, USA
| | - Rajesh Krishnamoorthi
- Department of Gastroenterology, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA.,Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Ave., Mailstop C3-GAS, Seattle, WA, 98101, USA
| | - Shayan Irani
- Department of Gastroenterology, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA. .,Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, 1100 Ninth Ave., Mailstop C3-GAS, Seattle, WA, 98101, USA.
| |
Collapse
|
2
|
Venu N, Gault C, Kozarek R, Hwang D, Mankaney G. Yet Another Extracolonic Manifestation of Familial Adenomatous Polyposis: Gastric Large-Cell Neuroendocrine Carcinoma. Am J Gastroenterol 2022; 117:837. [PMID: 35175954 DOI: 10.14309/ajg.0000000000001697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/14/2022] [Indexed: 12/11/2022]
|
3
|
Nagra N, Kozarek RA, Burman BE. Therapeutic Advances in Viral Hepatitis A-E. Adv Ther 2022; 39:1524-1552. [PMID: 35220557 DOI: 10.1007/s12325-022-02070-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/31/2022] [Indexed: 11/25/2022]
Abstract
Viral hepatitis remains a significant global health problem. All forms of viral hepatitis A through E (A-E) can lead to acute symptomatic infection, while hepatitis B and C can lead to chronic infection associated with significant morbidity and mortality related to progression to cirrhosis, end-stage-liver disease, and liver cancer. Viral hepatitis occurs worldwide, though certain regions are disproportionately affected. We now, remarkably, have highly effective curative regimens for hepatitis C, and safe and tolerable medications to suppress hepatitis B activity, and to prevent liver damage and slow disease progression. We have effective vaccines for hepatitis A and B which provide long-lasting immunity, while improved sanitation and awareness can curb outbreaks of hepatitis A and E. However, more effective and available preventive and curative strategies are needed to achieve global eradication of viral hepatitis. This review provides an overview of the epidemiology, transmission, diagnosis, and clinical features of each viral hepatitis with a primary focus on current and future therapeutic and curative options.
Collapse
Affiliation(s)
- Navroop Nagra
- Department of Gastroenterology, University of Louisville, Louisville, KY, 40202, USA
| | - Richard A Kozarek
- Center for Digestive Health, Virginia Mason Franciscan Health, 1100 9th Ave., Seattle, WA, 98101, USA
| | - Blaire E Burman
- Center for Digestive Health, Virginia Mason Franciscan Health, 1100 9th Ave., Seattle, WA, 98101, USA.
| |
Collapse
|
4
|
Lee HS, Chiorean MV, Boden E, Lord J, Irani S, Kozarek R, Larsen M, Ross A. Usefulness of Fluoroscopy for Endoscopic Balloon Dilation of Crohn's Disease-Related Strictures. Dig Dis Sci 2022; 67:1295-302. [PMID: 33740171 DOI: 10.1007/s10620-021-06935-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/02/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Fluoroscopy is often used for endoscopic balloon dilation (EBD) of Crohn's disease (CD)-related strictures. However, its benefit remains unclear. AIMS To compare EBD with (EBDF) and without (EBDNF) fluoroscopic guidance in CD patients with strictures. METHODS Single-center, nested, case-control retrospective study of EBD for CD-related strictures. Technical and clinical success and safety outcomes were compared between EBDF and EBDNF. RESULTS A total of 122 strictures in 114 CD patients who underwent EBD from 2010 to 2018 at a single institution were reviewed (44 patients EBDF vs. 70 EBDNF). Esophagogastroduodenoscopy was the approach in 8 strictures, colonoscopy in 86, and deep enteroscopy in 28. There were no significant differences in the rates of technical and clinical success, need for repeat dilation and surgery between the two groups, although the mean maximal endoscopic balloon diameter was larger in the EBDNF group (17.1 ± 1.9 vs. 14.1 ± 2.5; p < 0.001). There was one perforation in EBDF and no serious complications in EBDNF. In multivariate analysis, balloon size < 15 mm (odds ratio [OR] 6.388; 95% CI 1.96-20.79; p = 0.002) and multiple strictures (OR 3.897; 95% CI 1.09-14.01; p = 0.037) were associated with repeat EBD, and age < 50 years (OR 7.178; 95% CI 1.38-37.44; p = 0.019) and small bowel (vs. colon) location (OR 7.525; 95% CI 1.51-37.47; p = 0.014) were associated with the need for surgery after EBD. CONCLUSIONS EBD for CD-related strictures can be performed safely and effectively without fluoroscopic guidance. Balloon size, patient age, stricture location, and multiplicity are associated with clinical success and avoidance of surgery.
Collapse
|
5
|
Larsen M, Kozarek R. Therapeutic endoscopy for the treatment of post-bariatric surgery complications. World J Gastroenterol 2022; 28:199-215. [PMID: 35110945 PMCID: PMC8776527 DOI: 10.3748/wjg.v28.i2.199] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/15/2021] [Accepted: 12/31/2021] [Indexed: 02/06/2023] Open
Abstract
Obesity rates continue to climb worldwide. Obesity often contributes to other comorbidities such as type 2 diabetes, hypertension, heart disease and is a known risk factor for many malignancies. Bariatric surgeries are by far the most invasive treatment options available but are often the most effective and can result in profound, durable weight loss with improvement in or resolution of weight associated comorbidities. Currently performed bariatric surgeries include Roux-en-Y gastric bypass, sleeve gastrectomy, and laparoscopic gastric banding. These surgeries are associated with significant weight loss, but also with significant rates of major complications. The complexity of these patients and surgical anatomies makes management of these complications by a multidisciplinary team critical for optimal outcomes. Minimally invasive treatments for complications are typically preferred because of the high risk associated with repeat operations. Endoscopy plays a large role in both the diagnosis and the management of complications. Endoscopy can provide therapeutic interventions for many bariatric surgical complications including anastomotic strictures, anastomotic leaks, choledocholithiasis, sleeve stenosis, weight regain, and eroded bands. Endoscopists should be familiar with the various surgical anatomies as well as the various therapeutic options available. This review article serves to delineate the current role of endoscopy in the management of complications after bariatric surgery.
Collapse
Affiliation(s)
- Michael Larsen
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
| | - Richard Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
| |
Collapse
|
6
|
Bomman S, Ashat M, Nagra N, Jayaraj M, Chandra S, Kozarek RA, Ross A, Krishnamoorthi R. Contamination Rates in Duodenoscopes Reprocessed Using Enhanced Surveillance and Reprocessing Techniques: A Systematic Review and Meta-Analysis. Clin Endosc 2022; 55:33-40. [PMID: 34974676 PMCID: PMC8831410 DOI: 10.5946/ce.2021.212] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 08/26/2021] [Indexed: 11/28/2022] Open
Abstract
Background/Aims Multiple outbreaks of multidrug-resistant organisms have been reported worldwide due to contaminated duodenoscopes. In 2015, the United States Food and Drug Administration recommended the following supplemental enhanced surveillance and reprocessing techniques (ESRT) to improve duodenoscope disinfection: (1) microbiological culture, (2) ethylene oxide sterilization, (3) liquid chemical sterilant processing system, and (4) double high-level disinfection. A systematic review and meta-analysis was performed to assess the impact of ESRT on the contamination rates. Methods A thorough and systematic search was performed across several databases and conference proceedings from inception until January 2021, and all studies reporting the effectiveness of various ESRTs were identified. The pooled contamination rates of post-ESRT duodenoscopes were estimated using the random effects model.
Results A total of seven studies using various ESRTs were incorporated in the analysis, which included a total of 9,084 post-ESRT duodenoscope cultures. The pooled contamination rate of the post-ESRT duodenoscope was 5% (95% confidence interval [CI]: 2.3%–10.8%, inconsistency index [I2]=97.97%). Pooled contamination rates for high-risk organisms were 0.8% (95% CI: 0.2%–2.7%, I2=94.96).
Conclusions While ESRT may improve the disinfection process, a post-ESRT contamination rate of 5% is not negligible. Ongoing efforts to mitigate the rate of contamination by improving disinfection techniques and innovations in duodenoscope design to improve safety are warranted.
Collapse
Affiliation(s)
- Shivanand Bomman
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Munish Ashat
- Indiana University Health, Indianapolis, IN, USA
| | - Navroop Nagra
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | | | | | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Andrew Ross
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | | |
Collapse
|
7
|
Bomman S, Klair JS, Ashat M, El Abiad R, Gerke H, Keech J, Parekh K, Nau P, Hanada Y, Wong Kee Song LM, Kozarek R, Irani S, Low D, Ross A, Krishnamoorthi R. Outcomes of peroral endoscopic myotomy in patients with achalasia and prior bariatric surgery: A multicenter experience. Dis Esophagus 2021; 34:6310824. [PMID: 34184036 DOI: 10.1093/dote/doab044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 06/02/2021] [Accepted: 06/12/2021] [Indexed: 12/11/2022]
Abstract
Peroral endoscopic myotomy (POEM) in patients with achalasia who are status post bariatric surgery may be technically challenging due to postsurgical scarring and altered anatomy. The aim of the study was to assess the efficacy and safety of POEM for achalasia in patients with prior bariatric surgery. A review of prospectively maintained databases at three tertiary referral centers from January 2015 to January 2021 was performed. The primary outcome of interest was clinical success, defined as a post-treatment Eckardt score ≤ 3 or improvement in Eckardt score by ≥ 1 when the baseline score was <3, and improvement of symptoms. Secondary outcomes were adverse event rates and symptom recurrence. Sixteen patients status post Roux-en-Y gastric bypass (n = 14) and sleeve gastrectomy (n = 2) met inclusion criteria. Indications for POEM were achalasia type I (n = 2), type II (n = 9), and type III (n = 5). POEM was performed either by anterior or posterior approach. The pre-POEM mean integrated relaxation pressure was 26.2 ± 7.6 mm Hg. The mean total myotomy length was 10.2 ± 2.7 cm. The mean length of hospitalization was 1.4 ± 0.7 days. Pre- and postprocedure Eckardt scores were 6.1 ± 2.1 and 1.7 ± 1.8, respectively. The overall clinical success rate was 93.8% (15/16) with mean follow-up duration of 15.5 months. One patient had esophageal leak on postprocedure esophagram and managed endoscopically. Dysphagia recurred in two patients, which was successfully managed with pneumatic dilation with or without botulinum toxin injection. POEM appears to be safe and effective in the management of patients with achalasia who have undergone prior bariatric surgery.
Collapse
Affiliation(s)
- S Bomman
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - J S Klair
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - M Ashat
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - R El Abiad
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - H Gerke
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - J Keech
- Division of Thoracic Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - K Parekh
- Division of Bariatric Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - P Nau
- Division of Thoracic Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Y Hanada
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - L M Wong Kee Song
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - R Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - S Irani
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - D Low
- Division of Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - A Ross
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - R Krishnamoorthi
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| |
Collapse
|
8
|
Slivka A, Ross AS, Sejpal DV, Petersen BT, Bruno MJ, Pleskow DK, Muthusamy VR, Chennat JS, Krishnamoorthi R, Lee C, Martin JA, Poley JW, Cohen JM, Thaker AM, Peetermans JA, Rousseau MJ, Tirrell GP, Kozarek RA. Single-use duodenoscope for ERCP performed by endoscopists with a range of experience in procedures of variable complexity. Gastrointest Endosc 2021; 94:1046-1055. [PMID: 34186052 DOI: 10.1016/j.gie.2021.06.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 06/18/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Expert endoscopists previously reported ERCP outcomes for the first commercialized single-use duodenoscope. We aimed to document usability of this device by endoscopists with different levels of ERCP experience. METHODS Fourteen "expert" (>2000 lifetime ERCPs) and 5 "less-expert" endoscopists performed consecutive ERCPs in patients without altered pancreaticobiliary anatomy. Outcomes included ERCP completion for the intended indication, rate of crossover to another endoscope, device performance ratings, and serious adverse events. RESULTS Two hundred ERCPs including 81 (40.5%) with high complexity (American Society for Gastrointestinal Endoscopy grades 3-4) were performed. Crossover rate (11.3% vs 2.5%, P = .131), ERCP completion rate (regardless of crossovers) (96.3% vs 97.5%, P = .999), median ERCP completion time (25.0 vs 28.5 minutes, P = .130), mean cannulation attempts (2.8 vs 2.8, P = .954), and median overall satisfaction with the single-use duodenoscope (8.0 vs 8.0 [range, 1.0-10.0], P = .840) were similar for expert versus less-expert endoscopists, respectively. The same metrics were similar by procedural complexity except for shorter median completion time for grades 1 to 2 versus grades 3 to 4 (P < .001). Serious adverse events were reported in 13 patients (6.5%). CONCLUSIONS In consecutive ERCPs including high complexity procedures, endoscopists with varying ERCP experience had good procedural success and reported high device performance ratings. (Clinical trial registration number: NCT04223830.).
Collapse
Affiliation(s)
- Adam Slivka
- Department of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Andrew S Ross
- Department of Gastroenterology, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Divyesh V Sejpal
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, New York, USA
| | - Bret T Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands
| | - Douglas K Pleskow
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts, USA
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, University of California, Los Angeles and David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Jennifer S Chennat
- Department of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Rajesh Krishnamoorthi
- Department of Gastroenterology, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Calvin Lee
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, New York, USA
| | - John A Martin
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands
| | - Jonah M Cohen
- Division of Gastroenterology, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Adarsh M Thaker
- Vatche and Tamar Manoukian Division of Digestive Diseases, University of California, Los Angeles and David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Joyce A Peetermans
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts, USA
| | - Matthew J Rousseau
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts, USA
| | - Gregory P Tirrell
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts, USA
| | - Richard A Kozarek
- Department of Gastroenterology, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | | |
Collapse
|
9
|
Bang JY, Rösch T, Kim HM, Thakkar S, Robalino Gonzaga E, Tharian B, Inamdar S, Lee LS, Yachimski P, Jamidar P, Muniraj T, DiMaio C, Kumta N, Sethi A, Draganov P, Yang D, Seoud T, Perisetti A, Bondi G, Kirtane S, Hawes R, Wilcox CM, Kozarek R, Reddy DN, Varadarajulu S. Prospective evaluation of an assessment tool for technical performance of duodenoscopes. Dig Endosc 2021; 33:822-828. [PMID: 33007136 DOI: 10.1111/den.13856] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 09/13/2020] [Accepted: 09/24/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE While single-use and detachable-tip duodenoscopes have been recently developed to overcome risks of infection transmission, there are no reliable tools to objectively assess their technical performance. We evaluated the reliability and validity of a newly developed tool to assess the technical performance of reusable duodenoscopes. METHODS An assessment tool was developed to measure duodenoscope performance based on three distinct criteria: maneuverability, mechanical/imaging characteristics and ability to perform requisite interventions. The assessment tool was tested prospectively on duodenoscopes used in endoscopic retrograde cholangiopancreatography (ERCP) procedures at nine academic medical centers over a 6-month period. The main outcome was reliability of the duodenoscope assessment tool, which was estimated using Cronbach's coefficient alpha (α). The secondary outcome was validity of the assessment tool. RESULTS The assessment tool evaluated technical performance of reusable duodenoscopes in 1080 ERCP procedures. Indications were biliary in 92.8% and pancreatic in 7.2% procedures. The overall Cronbach's coefficient α for maneuverability was 0.81, assessment of mechanical/imaging characteristics was 0.92, and ability to perform requisite interventions was 0.87. On multiple linear regression analysis, prolonged procedure duration, older patient age and pancreatic interventions were significantly positively associated with higher (worse) scores. CONCLUSIONS The newly developed assessment tool appears reliable and valid for evaluating the technical performance of duodenoscopes. Registration: ClinicalTrials.gov Identifier: NCT04004533.
Collapse
Affiliation(s)
- Ji Young Bang
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, Florida, USA
| | - Thomas Rösch
- Division of Gastroenterology & Hepatology, University Medical Center Hamburg - Eppendorf, Hamburg, Germany
| | - Hyungjin Myra Kim
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Shyam Thakkar
- Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | | | - Benjamin Tharian
- Division of Gastroenterology & Hepatology, University of Arkansas, Little Rock, Arkansas, USA
| | - Sumant Inamdar
- Division of Gastroenterology & Hepatology, University of Arkansas, Little Rock, Arkansas, USA
| | - Linda S Lee
- Division of Gastroenterology & Hepatology, Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Patrick Yachimski
- Division of Gastroenterology & Hepatology, Vanderbilt University, Nashville, Tennessee, USA
| | - Priya Jamidar
- Division of Gastroenterology & Hepatology, Yale University, New Haven, Connecticut, USA
| | - Thiruvengadam Muniraj
- Division of Gastroenterology & Hepatology, Yale University, New Haven, Connecticut, USA
| | - Christopher DiMaio
- Division of Gastroenterology & Hepatology, Mount Sinai Medical Center, New York, New York, USA
| | - Nikhil Kumta
- Division of Gastroenterology & Hepatology, Mount Sinai Medical Center, New York, New York, USA
| | - Amrita Sethi
- Division of Gastroenterology & Hepatology, Columbia University, New York, New York, USA
| | - Peter Draganov
- Division of Gastroenterology & Hepatology, University of Florida, Gainesville, Florida, USA
| | - Dennis Yang
- Division of Gastroenterology & Hepatology, University of Florida, Gainesville, Florida, USA
| | - Talal Seoud
- Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Abhilash Perisetti
- Division of Gastroenterology & Hepatology, University of Arkansas, Little Rock, Arkansas, USA
| | - Gayatri Bondi
- Division of Gastroenterology & Hepatology, Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Sachin Kirtane
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, Florida, USA
| | - Robert Hawes
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, Florida, USA
| | - C Mel Wilcox
- Division of Gastroenterology & Hepatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Richard Kozarek
- Division of Gastroenterology & Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | | | - Shyam Varadarajulu
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, Florida, USA
| |
Collapse
|
10
|
Rodrigues-Pinto E, Pereira P, Sousa-Pinto B, Shehab H, Pinho R, Larsen MC, Irani S, Kozarek RA, Capogreco A, Repici A, Shemmeri E, Louie BE, Rogalski P, Baniukiewicz A, Dabrowski A, Correia de Sousa J, Barrias S, Ichkhanian Y, Kumbhari V, Khashab MA, Bowers N, Schulman AR, Macedo G. Retrospective multicenter study on endoscopic treatment of upper GI postsurgical leaks. Gastrointest Endosc 2021; 93:1283-1299.e2. [PMID: 33075368 DOI: 10.1016/j.gie.2020.10.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/09/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Therapeutic endoscopy plays a critical role in the management of upper GI (UGI) postsurgical leaks. Data are scarce regarding clinical success and safety. Our aim was to evaluate the effectiveness of endoscopic therapy for UGI postsurgical leaks and associated adverse events (AEs) and to identify factors associated with successful endoscopic therapy and AE occurrence. METHODS This was a retrospective, multicenter, international study of all patients who underwent endoscopic therapy for UGI postsurgical leaks between 2014 and 2019. RESULTS Two hundred six patients were included. Index surgery most often performed was sleeve gastrectomy (39.3%), followed by gastrectomy (23.8%) and esophagectomy (22.8%). The median time between index surgery and commencement of endoscopic therapy was 16 days. Endoscopic closure was achieved in 80.1% of patients after a median follow-up of 52 days (interquartile range, 33-81.3). Seven hundred seventy-five therapeutic endoscopies were performed. Multimodal therapy was needed in 40.8% of patients. The cumulative success of leak resolution reached a plateau between the third and fourth techniques (approximately 70%-80%); this was achieved after 125 days of endoscopic therapy. Smaller leak initial diameters, hospitalization in a general ward, hemodynamic stability, absence of respiratory failure, previous gastrectomy, fewer numbers of therapeutic endoscopies performed, shorter length of stay, and shorter times to leak closure were associated with better outcomes. Overall, 102 endoscopic therapy-related AEs occurred in 81 patients (39.3%), with most managed conservatively or endoscopically. Leak-related mortality rate was 12.4%. CONCLUSIONS Multimodal therapeutic endoscopy, despite being time-consuming and requiring multiple procedures, allows leak closure in a significant proportion of patients with a low rate of severe AEs.
Collapse
|
11
|
Lin OS, La Selva D, Kozarek RA, Weigel W, Beecher R, Gluck M, Chiorean M, Boden E, Venu N, Krishnamoorthi R, Larsen M, Ross A. Nurse-Administered Propofol Continuous Infusion Sedation: A New Paradigm for Gastrointestinal Procedural Sedation. Am J Gastroenterol 2021; 116:710-6. [PMID: 33982940 DOI: 10.14309/ajg.0000000000000969] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Nurse-Administered Propofol Continuous Infusion Sedation (NAPCIS) is a new nonanesthesia propofol delivery method for gastrointestinal endoscopy. NAPCIS is adopted from the computer-assisted propofol sedation (CAPS) protocol. We evaluated the effectiveness, efficiency, and safety of NAPCIS in low-risk subjects. METHODS Between December 2016 and July 2017, patients who underwent esophagogastroduodenoscopy or colonoscopy with NAPCIS at our center were compared against 2 historical control groups of similar patients who had undergone procedures with CAPS or midazolam and fentanyl (MF) sedation. RESULTS The mean age of the NAPCIS cohort (N = 3,331) was 55.2 years (45.8% male) for 945 esophagogastroduodenoscopies and 57.8 years (48.7% male) for 2,386 colonoscopies. The procedural success rates with NAPCIS were high (99.1%-99.2%) and similar to those seen in 3,603 CAPS (98.8%-99.0%) and 3,809 MF (99.0%-99.3%) controls. NAPCIS recovery times were shorter than both CAPS and MF (24.8 vs 31.7 and 52.4 minutes, respectively; P < 0.001). On arrival at the recovery unit, 86.6% of NAPCIS subjects were recorded as "Awake" compared with 82.8% of CAPS and 40.8% of MF controls (P < 0.001). Validated clinician and patient satisfaction scores were generally higher for NAPCIS compared with CAPS and MF subjects. For NAPCIS, there were only 4 cases of oxygen desaturation requiring transient mask ventilation and no serious sedation-related complications. These low complication rates were similar to those seen with CAPS (8 cases of mask ventilation) and MF (3 cases). DISCUSSION NAPCIS seems to be a safe, effective, and efficient means of providing moderate sedation for upper endoscopy and colonoscopy in low-risk patients.
Collapse
|
12
|
Hyun JJ, Irani SS, Ross AS, Larsen MC, Gluck M, Kozarek RA. Incidence and Significance of Biliary Stricture in Chronic Pancreatitis Patients Undergoing Extracorporeal Shock Wave Lithotripsy for Obstructing Pancreatic Duct Stones. Gut Liver 2021; 15:128-134. [PMID: 32393009 PMCID: PMC7817933 DOI: 10.5009/gnl19380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/04/2020] [Accepted: 01/04/2020] [Indexed: 11/16/2022] Open
Abstract
Background/Aims This study assessed the significance of biliary stricture in symptomatic chronic pancreatitis patients requiring extracorporeal shock wave lithotripsy (ESWL) and endoscopic retrograde cholangiopancreatography (ERCP) to remove obstructing pancreatic calculi. Methods A total of 97 patients underwent ESWL followed by ERCP to remove pancreatic calculi between October 2014 and October 2017 at Virginia Mason Medical Center. Significant biliary stricture (SBS) was defined as a stricture with upstream dilation on computed tomography scan or magnetic resonance cholangiopancreatography scans accompanied by cholestasis and/or cholangitis. SBS was initially managed by either a plastic stent or fully covered self-expandable metallic stent (fcSEMS). If the stricture did not resolve, the stent was replaced with either multiple plastic stents or another fcSEMS. Data were collected by retrospectively reviewing the medical records. Results Biliary strictures were noted in approximately one-third of patients (34/97, 35%) undergoing ESWL for pancreatic calculi. Approximately one-third of the biliary strictures (11/34, 32%) were SBS. Pseudocysts were more frequently found in those with SBS (36% vs 8%, p=0.02), and all pseudocysts in the SBS group were located in the pancreatic head. The initial stricture resolution rates with fcSEMSs and plastic prostheses were 75% and 29%, respectively. The overall success rate for stricture resolution was 73% (8/11), and the recurrence rate after initial stricture resolution was 25% (2/8). Conclusions Although periductal fibrosis is the main mechanism underlying biliary stricture development in chronic pancreatitis, inflammation induced by obstructing pancreatic calculi, including pseudocysts, is an important contributing factor to SBS formation during the acute phase.
Collapse
Affiliation(s)
- Jong Jin Hyun
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea.,Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Shayan S Irani
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Andrew S Ross
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Michael C Larsen
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Michael Gluck
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| |
Collapse
|
13
|
Lee HS, Nagra N, La Selva D, Kozarek RA, Ross A, Weigel W, Beecher R, Chiorean M, Gluck M, Boden E, Venu N, Krishnamoorthi R, Larsen M, Lin OS. Nurse-Administered Propofol Continuous Infusion Sedation for Gastrointestinal Endoscopy in Patients Who Are Difficult to Sedate. Clin Gastroenterol Hepatol 2021; 19:180-188. [PMID: 32931961 DOI: 10.1016/j.cgh.2020.09.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 09/06/2020] [Accepted: 09/09/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients who chronically use alcohol, marijuana, or opioids, or suffer from post-traumatic stress disorder (PTSD), can be difficult to sedate with midazolam and fentanyl, and often are referred for monitored anesthesia care during endoscopy. Nurse-administered propofol continuous infusion sedation (NAPCIS), which confers the benefit of propofol-based sedation without the added expense of anesthesia, is effective and safe for sedation of healthy patients. We investigated whether NAPCIS also is effective for patients who are difficult to sedate. METHODS We performed a retrospective study of patients who underwent upper endoscopy or colonoscopy with NAPCIS at a single center from January 2018 through April 2018. We reviewed records from patients who were heavy users of alcohol (n = 105), daily users of marijuana (n = 267) or opioids (n = 178), had a diagnosis of PTSD (n = 91), or were none of these (controls, n = 786). We compared mean fentanyl and propofol doses (adjusted for body weight), procedure and recovery times, procedure success rates, and adverse events. RESULTS Compared with the controls, the marijuana group required higher mean adjusted sedative doses for colonoscopies (0.6 vs 0.4 mcg/kg fentanyl and 5.0 vs 4.7 mg/kg propofol; P ≤ .025 for both) and upper endoscopies (0.8 vs 0.3 mcg/kg fentanyl and 3.7 vs 3.2 mg/kg propofol; P ≤ .021 for both), the PTSD group required a higher dose of fentanyl for colonoscopies (0.6 vs 0.4 mcg/kg; P = .009), and the alcohol group required a higher dose of fentanyl for upper endoscopies (0.7 vs 0.3 mcg/kg; P < .001). Procedure success rates were high (95.1%-100%) and did not differ significantly between the difficult-to-sedate groups and controls; mean procedure times (7.0-9.0 minutes for upper endoscopies, 21.1-22.9 minutes for colonoscopies) and recovery times (22.5-29.6 minutes) also were similar among groups. Upper endoscopies were associated with lower sedative doses and shorter procedure and recovery times than colonoscopies. Sedation-related adverse events were rare in all groups (only 26 cases total), and there were no serious complications or deaths. CONCLUSIONS NAPCIS seems to be a safe and effective means of providing sedation for endoscopy to patients who may be difficult to sedate owing to alcohol, marijuana, or opioid use, or PTSD.
Collapse
Affiliation(s)
- Hyun Seok Lee
- Digestive Disease Institute; Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea
| | | | | | | | | | - Wade Weigel
- Department of Anesthesia, Virginia Mason Medical Center, Seattle, Washington
| | - Ryan Beecher
- Department of Anesthesia, Virginia Mason Medical Center, Seattle, Washington
| | | | | | | | | | | | | | | |
Collapse
|
14
|
Klair JS, Jayaraj M, Chandrasekar VT, Priyan H, Law J, Murali AR, Singh D, Larsen M, Irani S, Kozarek R, Ross A, Krishnamoorthi R. ERCP with overtube-assisted enteroscopy in patients with Roux-en-Y gastric bypass anatomy: a systematic review and meta-analysis. Endoscopy 2020; 52:824-832. [PMID: 32492751 DOI: 10.1055/a-1178-9741] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y gastric bypass (RYGB) anatomy is challenging. Overtube-assisted enteroscopy (OAE) is usually needed to perform ERCP in these patients. There is significant variation in the reported rates of success and adverse events across published studies. We performed a systematic review and meta-analysis to reliably estimate the pooled rates of success and adverse events. METHODS We performed a systematic search of multiple electronic databases through February 2020 to identify studies reporting outcomes of OAE-ERCP in post-RYGB patients. The pooled rates of enteroscopy success, technical success, and adverse events were estimated for OAE-ERCP. The pooled rates of success and adverse events were also estimated for ERCP using double-balloon enteroscopes (DBE) alone. RESULTS 10 studies reporting a total of 398 procedures were included in the meta-analysis. The pooled rates of enteroscopy and technical success of OAE-ERCP were 75.3 % (95 % confidence interval [CI] 64.5 - 83.6) and 64.8 % (95 %CI 53.1 - 74.9) respectively. The pooled rate of adverse events was 8.0 % (95 %CI 5.2 - 12.2). The pooled rates of enteroscopy and technical success of DBE-ERCP (four studies) were 83.5 % (95 %CI 68.3 - 92.2) and 72.5 % (95 %CI 52.3 - 86.4), respectively. The pooled rate of adverse events with DBE-ERCP was 9.0 % (95 %CI 5.4 - 14.5). Substantial heterogeneity was noted. CONCLUSIONS OAE-ERCP appears to be effective and safe in post-RYGB patients. Among the currently available techniques, OAE-ERCP is the least invasive approach in this challenging group of patients. Future studies comparing the effectiveness and safety of alternative novel techniques, such as endosonography-directed transgastric ERCP, with OAE-ERCP are needed.
Collapse
Affiliation(s)
- Jagpal Singh Klair
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Mahendran Jayaraj
- Division of Gastroenterology and Hepatology, University of Nevada School of Medicine, Las Vegas, Nevada, United States
| | | | - Harshith Priyan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Joanna Law
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Arvind R Murali
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States
| | - Dhruv Singh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Michael Larsen
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Shayan Irani
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Richard Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Andrew Ross
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Rajesh Krishnamoorthi
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, United States
| |
Collapse
|
15
|
La Selva D, Kozarek RA, Dorer RK, Rocha FG, Gluck M. Primary and metastatic melanoma of the GI tract: clinical presentation, endoscopic findings, and patient outcomes. Surg Endosc 2020; 34:4456-4462. [PMID: 31659505 DOI: 10.1007/s00464-019-07225-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 10/04/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND AIMS Melanoma incidence has increased worldwide with a concurrent rise in both primary and metastatic melanomas of the gastrointestinal tract. MATERIALS AND METHODS This retrospective single-center case series includes patients with histopathology-confirmed primary or metastatic melanoma of the GI tract between 1998 and 2018. RESULTS Thirty-four patients were identified for inclusion, of whom 7 were primary and 27 were metastatic cases of gastrointestinal melanoma. For both primary and metastatic cases, the majority of patients presented with frank or occult GI bleeding (57.1% and 70.4%). Primary and metastatic lesions were predominantly diagnosed endoscopically (100% and 63.0%), with 71.4% of primary lesions found at the anorectal junction and 51.9% of metastatic lesions in the small bowel. Endoscopically diagnosed lesions were either polypoid (50%) or a luminal mass (37.5%) in the majority of cases. Common features included: amelanotic (83%), ulcerated (50%), and friable (33.3%). All primary patients were treated with surgical excision or resection. Of the metastatic patients, 56% were resected. The median interval between initial primary and gastrointestinal metastases was 65 months (ranging from 1 month to 24 years). At the time of data analysis, 85.7% of primary and 29.6% of metastatic patients remained alive. CONCLUSIONS The majority of patients in this series were diagnosed endoscopically while investigating a source of gastrointestinal blood loss. Heightened clinical suspicion and recognition of the endoscopic features of gastrointestinal melanoma during evaluation of GI symptoms in a patient with a personal history of primary melanoma are advised.
Collapse
Affiliation(s)
- Danielle La Selva
- Digestive Disease Institute, Virginia Mason Medical Center, C3-GAS, 1100 Ninth Avenue, Seattle, WA, USA
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, C3-GAS, 1100 Ninth Avenue, Seattle, WA, USA
| | - Russell K Dorer
- Digestive Disease Institute, Virginia Mason Medical Center, C3-GAS, 1100 Ninth Avenue, Seattle, WA, USA
| | - Flavio G Rocha
- Digestive Disease Institute, Virginia Mason Medical Center, C3-GAS, 1100 Ninth Avenue, Seattle, WA, USA
| | - Michael Gluck
- Digestive Disease Institute, Virginia Mason Medical Center, C3-GAS, 1100 Ninth Avenue, Seattle, WA, USA.
- Division of Gastroenterology and Hepatology, Digestive Disease Institute, Virginia Mason Medical Center, C3-GAS, 1100 Ninth Avenue, Seattle, WA, 98101, USA.
| |
Collapse
|
16
|
Abstract
PURPOSE OF REVIEW Endoscopic ampullectomy has proven its safety and efficacy in multiple studies, making it the favorable option for the management of endoscopic ampullectomy. In this review, we plan to review the basic steps every endoscopist should be familiar with before undertaking endoscopic ampullectomy. RECENT FINDINGS In this review, we plan to discuss the indications, preresection evaluation process including endoscopic ultrasound, endoscopic ampullectomy techniques with side-viewing endoscope and endoscopist experience/comfort with the management of the endoscopic ampullectomy complications. SUMMARY Things of utmost interest include reviewing all the ampullary biopsy specimens by an expert gastrointestinal pathologist, careful preresection staging, en bloc resection, familiarity with tools and techniques of endoscopic ampullectomy, postresection adverse events & management and postprocedure surveillance.
Collapse
|
17
|
Kozarek R. Are Gastrointestinal Endoscopic Procedures Performed by Anesthesiologists Safer Than When Sedation is Given by the Endoscopist? Clin Gastroenterol Hepatol 2020; 18:1935-1938. [PMID: 31812659 DOI: 10.1016/j.cgh.2019.11.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 11/21/2019] [Indexed: 02/07/2023]
Affiliation(s)
- Richard Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington
| |
Collapse
|
18
|
Muthusamy VR, Bruno MJ, Kozarek RA, Petersen BT, Pleskow DK, Sejpal DV, Slivka A, Peetermans JA, Rousseau MJ, Tirrell GP, Ross AS. Clinical Evaluation of a Single-Use Duodenoscope for Endoscopic Retrograde Cholangiopancreatography. Clin Gastroenterol Hepatol 2020; 18:2108-2117.e3. [PMID: 31706060 DOI: 10.1016/j.cgh.2019.10.052] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 10/11/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Disposable, single-use duodenoscopes might reduce outbreaks of infections associated with endoscope reuse. We tested the feasibility, preliminary safety, and performance of a new single-use duodenoscope in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). METHODS We conducted a case-series study of the outcomes of ERCP with a single-use duodenoscope from April through May 2019 at 6 academic medical centers. We screened consecutive patients (18 years and older) without alterations in pancreaticobiliary anatomy and enrolled 73 patients into the study. Seven expert endoscopists performed roll-in maneuvers (duodenoscope navigation and visualization of duodenal papilla only) in 13 patients and then ERCPs in the 60 other patients. Outcomes analyzed included completion of ERCP for the intended clinical indication, crossover from a single-use duodenoscope to a reusable duodenoscope, endoscopist performance ratings of the device, and serious adverse events (assessed at 72 hours and 7 days). RESULTS Thirteen (100%) roll-in maneuver cases were completed using the single-use duodenoscope. ERCPs were of American Society for Gastrointestinal Endoscopy procedural complexity grade 1 (least complex; 7 patients [11.7%]), grade 2 (26 patients [43.3%]), grade 3 (26 patients [43.3%]), and grade 4 (most complex; 1 patient [1.7%]). Fifty-eight ERCPs (96.7%) were completed using the single-use duodenoscope only and 2 ERCPs (3.3%) were completed using the single-use duodenoscope followed by crossover to a reusable duodenoscope. Median overall satisfaction was 9 out of 10. Three patients developed post-ERCP pancreatitis, 1 patient had post-sphincterotomy bleeding, and 1 patient had worsening of a preexisting infection and required rehospitalization. CONCLUSIONS In a case-series study, we found that expert endoscopists can complete ERCPs of a wide range of complexity using a single-use duodenoscope for nearly all cases. This alternative might decrease ERCP-related risk of infection. Clinicaltrials.gov no: NCT03701958.
Collapse
Affiliation(s)
- V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology; Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands
| | - Richard A Kozarek
- Department of Gastroenterology, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington
| | - Bret T Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Douglas K Pleskow
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Divyesh V Sejpal
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, New York
| | - Adam Slivka
- Department of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Joyce A Peetermans
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts
| | - Matthew J Rousseau
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts
| | - Gregory P Tirrell
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts
| | - Andrew S Ross
- Department of Gastroenterology, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington
| |
Collapse
|
19
|
Vermeulen BD, van der Leeden B, Ali JT, Gudbjartsson T, Hermansson M, Low DE, Adler DG, Botha AJ, D'Journo XB, Eroglu A, Ferri LE, Gubler C, Haveman JW, Kaman L, Kozarek RA, Law S, Loske G, Lindenmann J, Park JH, Richardson JD, Salminen P, Song HY, Søreide JA, Spaander MCW, Tarascio JN, Tsai JA, Vanuytsel T, Rosman C, Siersema PD; Benign Esophageal Perforation Collaborative Group. Early diagnosis is associated with improved clinical outcomes in benign esophageal perforation: an individual patient data meta-analysis. Surg Endosc 2021; 35:3492-505. [PMID: 32681374 DOI: 10.1007/s00464-020-07806-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 06/25/2020] [Indexed: 12/29/2022]
Abstract
Background Time of diagnosis (TOD) of benign esophageal perforation is regarded as an important risk factor for clinical outcome, although convincing evidence is lacking. The aim of this study is to assess whether time between onset of perforation and diagnosis is associated with clinical outcome in patients with iatrogenic esophageal perforation (IEP) and Boerhaave’s syndrome (BS). Methods We searched MEDLINE, Embase and Cochrane library through June 2018 to identify studies. Authors were invited to share individual patient data and a meta-analysis was performed (PROSPERO: CRD42018093473). Patients were subdivided in early (≤ 24 h) and late (> 24 h) TOD and compared with mixed effects multivariable analysis while adjusting age, gender, location of perforation, initial treatment and center. Primary outcome was overall mortality. Secondary outcomes were length of hospital stay, re-interventions and ICU admission. Results Our meta-analysis included IPD of 25 studies including 576 patients with IEP and 384 with BS. In IEP, early TOD was not associated with overall mortality (8% vs. 13%, OR 2.1, 95% CI 0.8–5.1), but was associated with a 23% decrease in ICU admissions (46% vs. 69%, OR 3.0, 95% CI 1.2–7.2), a 22% decrease in re-interventions (23% vs. 45%, OR 2.8, 95% CI 1.2–6.7) and a 36% decrease in length of hospital stay (14 vs. 22 days, p < 0.001), compared with late TOD. In BS, no associations between TOD and outcomes were found. When combining IEP and BS, early TOD was associated with a 6% decrease in overall mortality (10% vs. 16%, OR 2.1, 95% CI 1.1–3.9), a 19% decrease in re-interventions (26% vs. 45%, OR 1.9, 95% CI 1.1–3.2) and a 35% decrease in mean length of hospital stay (16 vs. 22 days, p = 0.001), compared with late TOD. Conclusions This individual patient data meta-analysis confirms the general opinion that an early (≤ 24 h) compared to a late diagnosis (> 24 h) in benign esophageal perforations, particularly in IEP, is associated with improved clinical outcome. Electronic supplementary material The online version of this article (10.1007/s00464-020-07806-y) contains supplementary material, which is available to authorized users.
Collapse
|
20
|
Krishnamoorthi R, Dasari CS, Thoguluva Chandrasekar V, Priyan H, Jayaraj M, Law J, Larsen M, Kozarek R, Ross A, Irani S. Effectiveness and safety of EUS-guided choledochoduodenostomy using lumen-apposing metal stents (LAMS): a systematic review and meta-analysis. Surg Endosc. 2020;34:2866-2877. [PMID: 32140862 DOI: 10.1007/s00464-020-07484-w] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 02/26/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endoscopic ultrasound-guided choledochoduodenostomy (CDD) is emerging as an alternative technique for biliary drainage in patients who fail conventional endoscopic retrograde cholangiopancreatography (ERCP). The lumen-apposing metal stents (LAMS) are being increasingly used for CDD. We performed a systematic review and meta-analysis to evaluate the effectiveness and safety of CDD using LAMS. METHODS We performed a systematic search of multiple databases through May 2019 to identify studies on CDD using covered self-expanding metal stents. Pooled rates of technical success, clinical success, adverse events, and recurrent jaundice associated with CDD using LAMS were estimated. A subgroup analysis was performed based on use of LAMS with electrocautery-enhanced delivery system (EC-LAMS). RESULTS Seven studies on CDD using LAMS (with 284 patients) were included in the meta-analysis. Pooled rates of technical and clinical success (per-protocol analysis) were 95.7% (95% CI 93.2-98.1) and 95.9% (95% CI 92.8-98.9), respectively. Pooled rate of post-procedure adverse events was 5.2% (95% CI 2.6-7.9). Pooled rate of recurrent jaundice was 8.7% (95% CI 4.5-12.8). On subgroup analysis of CDD using EC-LAMS (5 studies with 201 patients), the pooled rates of technical and clinical success (per-protocol analysis) were 93.8% (95% CI 90.4-97.1) and 95.9% (95% CI 91.9-99.9), respectively. Pooled rate of post-procedure adverse events was 5.6% (95% CI 1.7-9.5). Pooled rate of recurrent jaundice was 11.3% (95% CI 6.9-15.7). Heterogeneity (I2) was low to moderate in the analyses. CONCLUSION CDD using LAMS/EC-LAMS is an effective and safe technique for biliary decompression in patients who failed ERCP. Further studies are needed to assess CDD using LAMS as primary treatment modality for biliary obstruction.
Collapse
|
21
|
Krishnamoorthi R, Jayaraj M, Thoguluva Chandrasekar V, Singh D, Law J, Larsen M, Ross A, Kozarek R, Irani S. EUS-guided versus endoscopic transpapillary gallbladder drainage in high-risk surgical patients with acute cholecystitis: a systematic review and meta-analysis. Surg Endosc 2020; 34:1904-13. [PMID: 32048019 DOI: 10.1007/s00464-020-07409-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 01/30/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND In patients with acute cholecystitis who are deemed high risk for cholecystectomy, percutaneous cholecystostomy (PC) was historically performed for gallbladder drainage (GBD). There are several limitations associated with PC. Endoscopic GBD [Endoscopic transpapillary GBD (ET-GBD) and EUS-guided GBD (EUS-GBD)] is an alternative to PC. We performed a systematic review and meta-analysis to compare the effectiveness and safety of EUS-GBD versus ET-GBD. METHODS We performed a systematic search of multiple databases through May 2019 to identify studies that compared outcomes of EUS-GBD versus ET-GBD in the management of acute cholecystitis in high-risk surgical patients. Pooled odds ratios (OR) of technical success, clinical success and adverse events between EUS-GBD and ET-GBD groups were calculated. RESULTS Five studies with a total of 857 patients (EUS-GBD vs ET-GBD: 259 vs 598 patients) were included in the analysis. EUS-GBD was associated with higher technical [pooled OR 5.22 (95% CI 2.03-13.44; p = 0.0006; I2 = 20%)] and clinical success [pooled OR 4.16 (95% CI 2.00-8.66; p = 0.0001; I2 = 19%)] compared to ET-GBD. There was no statistically significant difference in the rate of overall adverse events [pooled OR 1.30 (95% CI 0.77-2.22; p = 0.33, I2 = 0%)]. EUS-GBD was associated with lower rate of recurrent cholecystitis [pooled OR 0.33 (95% CI 0.14-0.79; p = 0.01; I2 = 0%)]. There was low heterogeneity in the analyses. CONCLUSION EUS-GBD has higher rate of technical and clinical success compared to ET-GBD. While the rates of overall adverse events are statistically similar, EUS-GBD has lower rate of recurrent cholecystitis. Hence, EUS-GBD is preferable to ET-GBD for endoscopic management of acute cholecystitis in select high-risk surgical patients.
Collapse
|
22
|
Ross AS, Bruno MJ, Kozarek RA, Petersen BT, Pleskow DK, Sejpal DV, Slivka A, Moore D, Panduro K, Peetermans JA, Insull J, Rousseau MJ, Tirrell GP, Muthusamy VR. Novel single-use duodenoscope compared with 3 models of reusable duodenoscopes for ERCP: a randomized bench-model comparison. Gastrointest Endosc 2020; 91:396-403. [PMID: 31679738 DOI: 10.1016/j.gie.2019.08.032] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 08/19/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Multidrug-resistant infectious outbreaks associated with duodenoscope reuse have been documented internationally. A single-use endoscope could eliminate exogenous patient-to-patient infection associated with ERCP. METHODS We conducted a comparative bench simulation study of a new single-use and 3 models of reusable duodenoscopes on a synthetic anatomic bench model. Four ERCP tasks were performed: guidewire locking (single-use and 1 reusable duodenoscope only), plastic stent placement and removal, metal stent placement and removal, and basket sweeping. The study schedule included block randomization by 4 duodenoscopes, 4 tasks, and 2 anatomic model ERCP stations. Ability to complete tasks, task completion times, and subjective ratings of overall performance, navigation/pushability, tip control, and image quality on a scale of 1 (worst) to 10 (best) were compared among duodenoscopes. RESULTS All 4 ERCP tasks (total 14 subtasks) were completed by 6 expert endoscopists using all 4 duodenoscopes, with similar task completion times (median, 1.5-8.0 minutes per task) and overall performance ratings by task (median, 8.0-10.0). Navigation/pushability ratings were lower for the single-use duodenoscope than for the 3 reusable duodenoscopes (median, 8.0, 10.0, 9.0, and 9.0, respectively; P < .01). Tip control ratings were similar among all the duodenoscopes (median, 9.0-10.0; P = .77). Image quality ratings were lower for 1 reusable duodenoscope compared with the single-use and other 2 reusable duodenoscopes (median, 8.0, 9.0, 9.0, and 9.0, respectively; P < .01). CONCLUSIONS A new single-use duodenoscope was used to simulate 4 ERCP tasks in an anatomic model, with performance ratings and completion times comparable with 3 models of reusable duodenoscopes.
Collapse
Affiliation(s)
- Andrew S Ross
- Department of Gastroenterology, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands
| | - Richard A Kozarek
- Department of Gastroenterology, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Bret T Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Douglas K Pleskow
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Divyesh V Sejpal
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, New York, USA
| | - Adam Slivka
- Department of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Dale Moore
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, New York, USA
| | - Karina Panduro
- Vatche and Tamar Manoukian Division of Digestive Diseases, University of California, Los Angeles and David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Joyce A Peetermans
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts, USA
| | - Jeffrey Insull
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts, USA
| | - Matthew J Rousseau
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts, USA
| | - Gregory P Tirrell
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts, USA
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, University of California, Los Angeles and David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| |
Collapse
|
23
|
Affiliation(s)
- Richard Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| |
Collapse
|
24
|
Sahar N, Krishnamoorthi R, Kozarek RA, Gluck M, Larsen M, Ross AS, Irani S. Long-Term Outcomes of Endoscopic Papillectomy for Ampullary Adenomas. Dig Dis Sci 2020; 65:260-8. [PMID: 31463668 DOI: 10.1007/s10620-019-05812-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 08/20/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoscopic papillectomy is a safe and effective treatment for ampullary adenomas and has mostly replaced surgical local resection. Recent data have discussed the role of endoscopic removal of laterally spreading adenomas associated with ampullary adenomas. We evaluated our long-term results of endoscopic papillectomy for ampullary adenomas. METHODS We retrospectively analyzed patients who underwent endoscopic papillectomy of biopsy-proven adenomas at our tertiary center between 1994 and 2017. Clinical success was defined as complete excision of an adenoma with no evidence of recurrence during follow-up, no evidence of cancer, and without the need for surgery. RESULTS A total of 161 patients (73M/88F) with a mean age of 61 (range 19-93) were included. Mean adenoma size was 20 mm (range 5-70). In total, 114/161 patients continued endoscopic surveillance for a minimum of 6 months with a median follow-up of 30 months (range 6-283). Recurrent adenomas were diagnosed in 8 patients (7%) after a median of 36 months (range 12-138). Clinical success was 83%; 35 laterally spreading adenomas were treated, which were larger than adenomas confined to the papilla (mean size 38 mm vs 15 mm, P < 0.05) and required more piecemeal resections (77% vs 15%, P < 0.05). However, no difference was found in recurrence rates between the two groups (8% vs 4%, P = 0.26); 24/161 (15%) of patients had adverse events including bleeding (6%) and pancreatitis (7%). CONCLUSIONS Endoscopic papillectomy is a safe and effective treatment for ampullary adenomas, including laterally spreading ones. Long-term surveillance demonstrates low recurrence rates at expert centers.
Collapse
|
25
|
Lin OS, La Selva D, Kozarek RA, Tombs D, Weigel W, Beecher R, Koch J, McCormick S, Chiorean M, Drennan F, Gluck M, Venu N, Larsen M, Ross A. Computer-Assisted Propofol Sedation for Esophagogastroduodenoscopy Is Effective, Efficient, and Safe. Dig Dis Sci 2019; 64:3549-56. [PMID: 31165379 DOI: 10.1007/s10620-019-05685-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 05/25/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS Computer-assisted propofol sedation (CAPS) allows non-anesthesiologists to administer propofol for gastrointestinal procedures in relatively healthy patients. As the first US medical center to adopt CAPS technology for routine clinical use, we report our 1-year experience with CAPS for esophagogastroduodenoscopy (EGD). METHODS Between September 2014 and August 2015, 926 outpatients underwent elective EGDs with CAPS at our center. All EGDs were performed by 1 of 17 gastroenterologists certified in the use of CAPS. Procedural success rates, procedure times, and recovery times were compared against corresponding historical controls done with midazolam and fentanyl sedation from September 2013 to August 2014. Adverse events in CAPS patients were recorded. RESULTS The mean age of the CAPS cohort was 56.7 years (45% male); 16.2% of the EGDs were for variceal screening or Barrett's surveillance and 83.8% for symptoms. The procedural success rates were similar to that of historical controls (99.0% vs. 99.3%; p = 0.532); procedure times were also similar (6.6 vs. 7.4 min; p = 0.280), but recovery time was markedly shorter (31.7 vs. 52.4 min; p < 0.001). There were 11 (1.2%) cases of mild transient oxygen desaturation (< 90%), 15 (1.6%) cases of marked agitation due to undersedation, and 1 case of asymptomatic hypotension. In addition, there were six (0.6%) patients with more pronounced desaturation episodes that required brief (< 1 min) mask ventilation. There were no other serious adverse events. CONCLUSIONS CAPS appears to be a safe, effective, and efficient means of providing sedation for EGD in healthy patients. Recovery times were much shorter than historical controls.
Collapse
|
26
|
Kim KO, Kozarek R, Gluck M, Ross A, Lin OS. Changes in Lower Gastrointestinal Bleeding Presentation, Management, and Outcomes Over a 10-Year Span. J Clin Gastroenterol 2019; 53:e463-7. [PMID: 31593973 DOI: 10.1097/MCG.0000000000001223] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND There are only limited data available on changes in the etiology, management, and clinical outcomes in patients with lower gastrointestinal bleeding over the past decade. STUDY We compared 2 groups of consecutive patients hospitalized with lower gastrointestinal bleeding during 2 time periods: 2005 to 2007 (301 patients) and 2015 to 2017 (249 patients). RESULTS Compared with the 2005 to 2007 group, the mean Charlson comorbidity index in the 2015 to 2017 group was higher (5.0±2.6 vs. 6.0±3.0, P=0.028), whereas the use of computerized tomographic angiography and small bowel capsule endoscopy was more common (12.9% vs. 58.1%, P<0.001, and 28.8% vs. 69.0%, P=0.031, respectively). In 2005 to 2007, ischemic colitis (12.0%) was the most common confirmed etiology of bleeding and diverticular bleeding the second most common (8.6%), whereas in 2015 to 2017, diverticular bleeding was the most common etiology (10.4%), followed by angiodysplasia (8.4%). Small bowel bleeding sources were confirmed more often in the 2015 to 2017 group (P=0.017). Endoscopic treatment was attempted in 16.6% of patients in 2005 to 2007 versus 25.3% in 2015 to 2017 (P=0.015). Higher rebleeding rates, longer hospitalization durations (4.6±4.3 vs. 5.5±3.4 d, P=0.019), and a higher proportion of patients needing a transfusion (62.0% vs. 78.4%, P=0.016) were noted in 2015 to 2017. CONCLUSIONS Over a 10-year span, there were several notable changes: (1) more comorbidities in patients hospitalized for lower gastrointestinal bleeding; (2) marked increase in the use of computerized tomographic angiography and capsule endoscopy for diagnostic evaluation; and (3) longer hospitalization durations and greater need for blood transfusion, possibly reflecting the selection of sicker patients for in-patient management in 2015 to 2017.
Collapse
|
27
|
Seo DW, Sherman S, Dua KS, Slivka A, Roy A, Costamagna G, Deviere J, Peetermans J, Rousseau M, Nakai Y, Isayama H, Kozarek R. Covered and uncovered biliary metal stents provide similar relief of biliary obstruction during neoadjuvant therapy in pancreatic cancer: a randomized trial. Gastrointest Endosc 2019; 90:602-612.e4. [PMID: 31276674 DOI: 10.1016/j.gie.2019.06.032] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 06/15/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Preoperative biliary drainage with self-expanding metal stents (SEMSs) brings liver function within an acceptable range in preparation for neoadjuvant therapy (NATx) and provides relief of obstructive symptoms in patients with pancreatic cancer. We compared fully-covered SEMSs (FCSEMSs) and uncovered SEMSs (UCSEMSs) for sustained biliary drainage before and during NATx. METHODS Patients with pancreatic cancer and planned NATx who need treatment of jaundice and/or cholestasis before pancreaticoduodenectomy were randomized to FCSEMSs versus UCSEMSs. The primary endpoint was sustained biliary drainage, defined as the absence of reinterventions for biliary obstructive symptoms, and was assessed from SEMS placement until curative intent surgery or at 1 year. RESULTS The intention-to-treat population included 119 patients (59 FCSEMSs, 60 UCSEMSs). Sustained biliary drainage was equally successful with FCSEMSs and UCSEMSs (72.2% vs 72.9%, noninferiority P = .01). Reasons for FCSEMS and UCSEMS failure differed significantly between the groups and included tumor ingrowth in 0% versus 16.7% (P < .01), and stent migration in 6.8% versus 0% (P = .03), respectively. Serious adverse event rates related to stent placement were not significantly different in both groups (23.7% [14/59] vs 20.0% [12/60], P = .66), as were acute cholecystitis rates when the gallbladder was in situ (9.3% [4/43] vs 4.8% [2/42], P = .68) for FCSEMSs and UCSEMSs, respectively. In our study, independent of stent type, predictors of reinterventions were 4-cm stent length and presence of the gallbladder. CONCLUSION FCSEMSs and UCSEMSs provide similar preoperative management of biliary obstruction in patients with pancreatic cancer receiving NATx, but mechanisms of stent dysfunction depend on stent type, stent length, and presence of the gallbladder. (Clinical trial registration number: NCT02238847.).
Collapse
Affiliation(s)
- Dong Wan Seo
- Internal Medicine, Asan Medical Center University of Ulsan, Seoul, South Korea
| | - Stuart Sherman
- Division of Gastroenterology and Hepatology Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kulwinder S Dua
- Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Adam Slivka
- Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Andre Roy
- Surgery, Centre hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Guido Costamagna
- Fondazione Policlinico A. Gemelli - IRCCS, Digestive Endoscopy Unit; Università Cattolica del S. Cuore, Rome, Italy
| | - Jacques Deviere
- Gastro-Entérologie et d'Hépato-Pancréatologie, Université Libre de Bruxelles Hôpital Erasme, Brussels, Belgium
| | | | | | | | | | - Richard Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | | |
Collapse
|
28
|
Higa JT, Sahar N, Kozarek RA, La Selva D, Larsen MC, Gan SI, Ross AS, Irani SS. EUS-guided gallbladder drainage with a lumen-apposing metal stent versus endoscopic transpapillary gallbladder drainage for the treatment of acute cholecystitis (with videos). Gastrointest Endosc 2019; 90:483-492. [PMID: 31054909 DOI: 10.1016/j.gie.2019.04.238] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 04/21/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS There is an evolving role for EUS-guided transmural gallbladder (GB) drainage. Endoscopic transpapillary GB drainage is a well-established, nonoperative treatment for acute cholecystitis. We compared the outcomes of 78 cases of EUS-guided versus transpapillary GB drainage at a single, U.S.-based, high-volume endoscopy center. METHODS This was a retrospective analysis performed from May 2013 to January 2018, identified from a database of nonoperative patients with acute cholecystitis. Both electrocautery-enhanced and nonelectrocautery-enhanced lumen-apposing metal stents were used. For transpapillary drainage, guidewire access was obtained and then a transpapillary 7F × 15-cm double-pigtail plastic stent was placed. RESULTS In patients who had successful transpapillary or transmural drainage, demographics data were similar. Technical success was observed in 39 of 40 patients (97.5%) who underwent first attempt at EUS-guided drainage versus 32 of 38 patients (84.2%) for first-attempt transpapillary drainage (adjusted odds ratio, 9.83; 95% confidence interval, .93-103.86). Clinical success was significantly higher with EUS drainage in 38 of 40 patients (95.0%) versus transpapillary drainage in 29 of 38 patients (76.3%) (adjusted odds ratio, 7.14; 95% confidence interval, 1.32-38.52). Recurrent cholecystitis was lower in the EUS-guided drainage group (2.6% vs 18.8%, respectively; P = .023) on univariate analysis but only trended to significance in a multiple regression model. Duration of follow-up, reintervention rates, hospital length of stay, and overall adverse event rates were similar between groups. CONCLUSIONS EUS-guided GB drainage results in a higher clinical success rate compared with transpapillary drainage and may be associated with a lower recurrence rate of cholecystitis. However, transpapillary drainage should be considered as the first-line treatment for patients who are surgical candidates but require temporizing measures or require an ERCP for alternative reasons.
Collapse
Affiliation(s)
- Jennifer T Higa
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Nadav Sahar
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Richard A Kozarek
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Danielle La Selva
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Michael C Larsen
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Seng-Ian Gan
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Andrew S Ross
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Shayan S Irani
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| |
Collapse
|
29
|
Hyun JJ, Sahar N, Singla A, Ross AS, Irani SS, Gan SI, Larsen MC, Kozarek RA, Gluck M. Outcomes of Infected versus Symptomatic Sterile Walled-Off Pancreatic Necrosis Treated with a Minimally Invasive Therapy. Gut Liver 2019; 13:215-222. [PMID: 30602076 PMCID: PMC6430426 DOI: 10.5009/gnl18234] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 08/23/2018] [Accepted: 08/24/2018] [Indexed: 12/11/2022] Open
Abstract
Background/Aims Acute pancreatitis complicated by walled-off necrosis (WON) is associated with high morbidity and mortality, and if infected, typically necessitates intervention. Clinical outcomes of infected WON have been described as poorer than those of symptomatic sterile WON. With the evolution of minimally invasive therapy, we sought to compare outcomes of infected to symptomatic sterile WON. Methods We performed a retrospective cohort study examining patients who were undergoing dual-modality drainage as minimally invasive therapy for WON at a high-volume tertiary pancreatic center. The main outcome measures included mortality with a drain in place, length of hospital stay, admission to intensive care unit, and development of pancreatic fistulae. Results Of the 211 patients in our analysis, 98 had infected WON. The overall mortality rate was 2.4%. Patients with infected WON trended toward higher mortality although not statistically significant (4.1% vs 0.9%, p=0.19). Patients with infected WON had longer length of hospitalization (29.8 days vs 17.3 days, p<0.01), and developed more spontaneous pancreatic fistulae (23.5% vs 7.8%, p<0.01). Multivariate analysis showed that infected WON was associated with higher odds of spontaneous pancreatic fistula formation (odds ratio, 2.65; 95% confidence interval, 1.20 to 5.85). Conclusions This study confirms that infected WON has worse outcomes than sterile WON but also demonstrates that WON, once considered a significant cause of death, can be treated with good outcomes using minimally invasive therapy.
Collapse
Affiliation(s)
- Jong Jin Hyun
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA.,Division of Gastroenterology and Hepatology, Korea University College of Medicine, Seoul, Korea
| | - Nadav Sahar
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Anand Singla
- Division of Gastroenterology, Northwestern University, Chicago, IL, USA
| | - Andrew S Ross
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Shayan S Irani
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - S Ian Gan
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Michael C Larsen
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Michael Gluck
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| |
Collapse
|
30
|
Bushyhead D, Lin OST, Kozarek RA. A Review of the Management of Sporadic Colorectal Adenomas in Young People: Is Surveillance Wasted on the Young? Dig Dis Sci 2019; 64:2107-12. [PMID: 30788685 DOI: 10.1007/s10620-019-05521-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 02/05/2019] [Indexed: 12/25/2022]
Abstract
The national incidence of colorectal cancer is increasing in people younger than 50 years old. Although diagnostic colonoscopy is detecting more sporadic adenomas in young adults, there are no guidelines for post-polypectomy surveillance. The aim of this review was to survey the medical literature on the prevalence of sporadic adenomas in young adults, subsequent risk of metachronous neoplasia, and lastly to provide several concluding recommendations for clinical practice. We found that the prevalence of sporadic adenomas in young adults is greater than initially estimated and dependent upon factors such as colonoscopy indication and age. The incidence of metachronous colorectal neoplasia following polypectomy is unclear but does not appear to be greater than that of older adults. Risk factors for metachronous neoplasia include findings on index colonoscopy, male gender, smoking status, and certain medical comorbidities. Upon finding a colorectal adenoma in a young person, we suggest that a detailed family history be obtained to confirm that it is truly sporadic. Testing adenomas for evidence of Lynch syndrome is low yield. Strategies to inform surveillance intervals may include an assessment of risk factors for metachronous neoplasia, although surveillance intervals shorter than those recommended in current guidelines are not warranted. Future research should focus on obtaining long-term, prospective data on the incidence of metachronous neoplasia in diverse patient populations.
Collapse
|
31
|
Baison GN, Bonds MM, Helton WS, Kozarek RA. Choledochal cysts: Similarities and differences between Asian and Western countries. World J Gastroenterol 2019; 25:3334-3343. [PMID: 31341359 PMCID: PMC6639560 DOI: 10.3748/wjg.v25.i26.3334] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 05/05/2019] [Accepted: 06/01/2019] [Indexed: 02/06/2023] Open
Abstract
Choledochal cysts (CCs) are rare bile duct dilatations, intra-and/or extrahepatic, and have higher prevalence in the Asian population compared to Western populations. Most of the current literature on CC disease originates from Asia where these entities are most prevalent. They are thought to arise from an anomalous pancreaticobiliary junction, which are congenital anomalies between pancreatic and bile ducts. Some similarities in presentation between Eastern and Western patients exist such as female predominance, however, contemporary studies suggest that Asian patients may be more symptomatic on presentation. Even though CC disease presents with an increased malignant risk reported to be more than 10% after the second decade of life in Asian patients, this risk may be overstated in Western populations. Despite this difference in cancer risk, management guidelines for all patients with CC are based predominantly on observations reported from Asia where it is recommended that all CCs should be excised out of concern for the presence or development of biliary tract cancer.
Collapse
Affiliation(s)
- George N Baison
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
| | - Morgan M Bonds
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
| | - William S Helton
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
| |
Collapse
|
32
|
Bushyhead D, Rocha FG, Kozarek RA. Small Bowel Necrosis After Colonoscopy. Gastroenterology 2019; 156:e12-e13. [PMID: 30716323 DOI: 10.1053/j.gastro.2019.01.257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 01/16/2019] [Accepted: 01/18/2019] [Indexed: 12/02/2022]
Affiliation(s)
- Daniel Bushyhead
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Flavio G Rocha
- Section of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington
| |
Collapse
|
33
|
Hyun JJ, Rose JB, Alseidi AA, Biehl TR, Helton S, Coy DL, Kozarek RA, Rocha FG. Significance of radiographic splenic vessel involvement in the pancreatic ductal adenocarcinoma of the body and tail of the gland. J Surg Oncol 2019; 120:262-269. [PMID: 31093997 DOI: 10.1002/jso.25498] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 04/01/2019] [Accepted: 04/25/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Unlike pancreatic head tumors, little is known about the biological significance of radiographic vessel involvement with pancreatic body/tail adenocarcinoma. We hypothesized radiographic splenic vessel involvement may be an adverse prognostic factor. METHODS All distal pancreatectomies performed for resectable pancreatic adenocarcinoma between 2000 and 2016 were reviewed and clinicopatholgic data were collected, retrospectively. Preoperative computed tomography imaging was re-reviewed and splenic vessel involvement was graded as none, abutment, encasement, or occlusion. RESULTS Among a total of 71 patients, splenic artery or vein encasement/occlusion was present in 41% (29 of 71) of patients, each. There were no significant differences in tumor size or grade, margin positivity, and perineural or lymphovascular invasion. However, splenic artery encasement/occlusion (P = 0.001) and splenic vein encasement/occlusion (P = 0.038) both correlated with lymph node positivity. Splenic artery encasement was associated with a reduced median overall survival (20 vs 30 months, P = 0.033). Multivariate analysis also showed that splenic artery encasement was an independent risk factor of worse survival (hazard ratio, 2.246; 95% confidence interval, 1.118-4.513; P = 0.023). CONCLUSION Patients with cancer of the body or tail of the pancreas presenting with radiographic encasement of the splenic artery, but not the splenic vein, have a poorer prognosis and perhaps should be considered for neoadjuvant therapy before an attempt at curative resection.
Collapse
Affiliation(s)
- Jong Jin Hyun
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea.,Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington
| | - J Bart Rose
- Division of Surgical Oncology, University of Alabama, Birmingham, Alabama
| | - Adnan A Alseidi
- Section of General, Vascular, and Thoracic Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - Thomas R Biehl
- Section of General, Vascular, and Thoracic Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - Scott Helton
- Section of General, Vascular, and Thoracic Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - David L Coy
- Section of Radiology, Virginia Mason Medical Center, Seattle, Washington
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington
| | - Flavio G Rocha
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington.,Section of General, Vascular, and Thoracic Surgery, Virginia Mason Medical Center, Seattle, Washington
| |
Collapse
|
34
|
Crown A, Kennecke H, Kozarek R, Lopez-Aguiar AG, Dillhoff M, Beal EW, Poultsides GA, Makris E, Idrees K, Smith PM, Nathan H, Beems M, Abbott D, Fisher AV, Fields RC, Davidson J, Maithel SK, Rocha FG. Gastric carcinoids: Does type of surgery or tumor affect survival? Am J Surg 2019; 217:937-942. [PMID: 30686481 DOI: 10.1016/j.amjsurg.2018.12.057] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 12/10/2018] [Accepted: 12/27/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Gastric carcinoids are rare neuroendocrine tumors of the gastrointestinal tract. They are typically managed according to their etiology. However, there is little known about the impact of surgical strategy on the long-term outcomes of these patients. METHODS All patients who underwent resection of gastric carcinoids at 8 institutions from 2000 to 2016 were analyzed retrospectively. Tumors were stratified according to subtype (I, II, III, IV) and resection type (local resection, LR or formal gastrectomy, FG). Clinicopathological parameters, recurrence-free (RFS) and overall survival (OS) were compared between groups. RESULTS Of 79 patients identified with gastric carcinoids, 34 had type I lesions associated with atrophic gastritis, 4 had type II lesions associated with a gastrinoma, 37 had type III sporadic lesions, and 4 had type IV poorly-differentiated lesions. The mean age of presentation was 56 years in predominantly Caucasian (77%) and female (63%) patients. Mean tumor size was 2.4 cm and multifocal tumors were found in 24 (30%) of patients with the majority occurring in those with type I tumors. Lymph node positive tumors were seen in 15 (19%) patients and 7 (8%) had M1 disease; both most often in type IV followed by type III tumors. R0 resection was achieved in 56 (71%) patients while 15 (19%) had R1 resections and 6 (8%) R2 resections. Patients with type I and III tumors were equally likely to have a LR (50% and 43% respectively) compared to FG while those with type II and IV all had FG with one exception. Type IV tumors had the poorest RFS and OS while Type II tumors had the most favorable RFS and OS (p < 0.04 and p < 0.0004, respectively). While there was no difference in RFS in those patients undergoing FG versus LR, OS was worse in the FG group (p < 0.017). This trend persisted when type II and type IV groups were excluded (p < 0.045). CONCLUSION Gastric carcinoid treatment should be tailored to tumor type, as biologic behavior rather than resection technique is the more important factor contributing to long-term outcomes.
Collapse
|
35
|
Sahar N, Ross A, Lakhtakia S, Coté GA, Neuhaus H, Bruno MJ, Haluszka O, Kozarek R, Ramchandani M, Beyna T, Poley JW, Maranki J, Freeman M, Kedia P, Tarnasky P. Reducing the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis using 4-Fr pancreatic plastic stents placed with common-type guidewires: Results from a prospective multinational registry. Dig Endosc 2019; 31:299-306. [PMID: 30506606 DOI: 10.1111/den.13311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 11/26/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIM Pancreatic plastic stents (PPS) can reduce the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). Prospective multicenter documentation of PEP rate after PPS placement is scarce. A new 4-Fr stent designed to be deployed over a 0.035-inch guidewire was used to assess the effectiveness of PEP prophylaxis. METHODS High-PEP-risk patients received a 4-Fr PPS for primary or secondary prophylaxis at seven centers in four countries. Patients were followed until spontaneous PPS migration, endoscopic stent removal, or for 4 months, whichever came first. Main outcome was PEP rate. RESULTS One hundred six (106) patients received PPS for PEP prophylaxis [61 (58%) primary, 45 (42%) secondary prophylaxis]. Median age was 54 years. Eighty-one (76%) PPS were placed using a 0.035-inch guidewire. By investigator choice 99 (93%) stents were single pigtail. Median stent length was 8 cm (range 3-12 cm). Technical success achieved in 100% of cases. Two patients in the primary prophylaxis group (3%, 95% CI 0.4-11%) experienced mild/moderate PEP. Seventy-eight PPS available for analysis underwent spontaneous migration after a median of 29 days. There were no reports of stent-induced ductal trauma. Post-hoc analysis of migration rate by PPS length showed no statistically significant trend. CONCLUSIONS Among high-risk patients in the primary prophylaxis group, observed rates of PEP are low (3%, 95% CI 0.4-11%) with the use of prophylactic 4-Fr pancreatic duct stents compatible with a 0.035-inch guidewire. This low rate is not unequivocally due to the prophylactic stent.
Collapse
Affiliation(s)
| | | | | | | | - Horst Neuhaus
- Evangelical Hospital Dusseldorf, Dusseldorf, Germany
| | - Marco J Bruno
- Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Oleh Haluszka
- Temple University Health System, Philadelphia.,Southern Arizona VA Health Care System, Tucson
| | | | | | - Torsten Beyna
- Evangelical Hospital Dusseldorf, Dusseldorf, Germany
| | - Jan W Poley
- Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Jennifer Maranki
- Temple University Health System, Philadelphia.,Penn State Milton S. Hershey Medical Center, Hershey
| | | | | | | | | |
Collapse
|
36
|
Cha JM, La Selva D, Kozarek RA, Gluck M, Ross A, Lin OS. Young patients with sporadic colorectal adenomas: current endoscopic surveillance practices and outcomes. Gastrointest Endosc 2018; 88:818-825.e1. [PMID: 29908175 DOI: 10.1016/j.gie.2018.06.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 06/05/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS For young individuals (age <40 years) without strong family histories that would put them at risk for genetic colorectal cancer syndromes, it is unclear if national Multi-Society Task Force surveillance recommendations apply or if endoscopists follow these guideline recommendations when such patients are incidentally found to have adenoma(s) on colonoscopy. METHODS We reviewed records on young (age <40 years) patients, with either no family history or only a moderate family history (1 first-degree family member with colorectal cancer at age ≥50), who were found to have neoplastic polyp(s) on their index colonoscopy. We assessed the pattern of endoscopist surveillance recommendations, whether endoscopist recommendations complied with national guidelines, and compliance with surveillance recommendations. RESULTS One hundred forty-one subjects were included, of whom 19 (13.5%) had a moderate family history of colorectal cancer. For patients with non-high-risk findings, 27.7% were asked to repeat their colonoscopy in ≤3 years and 99.0% within 5 years. Endoscopist surveillance recommendation compliance rates with national guidelines were >65.0% for low-risk neoplasia but lower for high-risk (40.0%), nonpolypoid (44.2%), and serrated neoplasia (54.2%, P < .001 for all). Subjects whose endoscopist recommendations were noncompliant with guidelines were usually recalled too early (96%). Only 24.7% of subjects were actually compliant with endoscopist surveillance recommendations. CONCLUSIONS For young patients with neoplastic polyp(s) but no strong family history, most endoscopists complied with national guidelines and recommended repeat colonoscopy in 3 to 5 years. However, relatively few patients were compliant with repeat colonoscopy recommendations. For most cases that were noncompliant with guidelines, patients were recalled too early as opposed to too late.
Collapse
Affiliation(s)
- Jae Myung Cha
- Gastroenterology Division, Kyung Hee University Hospital at Gang Dong, Kyung Hee University School of Medicine, Seoul, South Korea; Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Danielle La Selva
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Michael Gluck
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Andrew Ross
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Otto S Lin
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| |
Collapse
|
37
|
Clanton J, Oh S, Kaplan SJ, Johnson E, Ross A, Kozarek R, Alseidi A, Biehl T, Picozzi VJ, Helton WS, Coy D, Dorer R, Rocha FG. Does mesenteric venous imaging assessment accurately predict pathologic invasion in localized pancreatic ductal adenocarcinoma? HPB (Oxford) 2018; 20:925-931. [PMID: 29753633 DOI: 10.1016/j.hpb.2018.03.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 02/28/2018] [Accepted: 03/31/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Accurate prediction of mesenteric venous involvement in pancreatic ductal adenocarcinoma (PDAC) is necessary for adequate staging and treatment. METHODS A retrospective cohort study was conducted in PDAC patients at a single institution. All patients with resected PDAC and staging CT and EUS between 2003 and 2014 were included and sub-divided into "upfront resected" and "neoadjuvant chemotherapy (NAC)" groups. Independent imaging re-review was correlated to venous resection and venous invasion. Sensitivity, specificity, positive and negative predictive values were then calculated. RESULTS A total of 109 patients underwent analysis, 60 received upfront resection, and 49 NAC. Venous resection (30%) and vein invasion (13%) was less common in patients resected upfront than those who received NAC (53% and 16%, respectively). Both CT and EUS had poor sensitivity (14-44%) but high specificity (75-95%) for detecting venous resection and vein invasion in patients resected upfront, whereas sensitivity was high (84-100%) and specificity was low (27-44%) after NAC. CONCLUSIONS Preoperative CT and EUS in PDAC have similar efficacy but different predictive capacity in assessing mesenteric venous involvement depending on whether patients are resected upfront or received NAC. Both modalities appear to significantly overestimate true vascular involvement and should be interpreted in the appropriate clinical context.
Collapse
Affiliation(s)
- Jesse Clanton
- Sections of General, Thoracic and Vascular Surgery, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Stephen Oh
- Hematology and Oncology, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Stephen J Kaplan
- Sections of General, Thoracic and Vascular Surgery, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Emily Johnson
- Radiology, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Andrew Ross
- Gastroenterology, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Richard Kozarek
- Gastroenterology, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Adnan Alseidi
- Sections of General, Thoracic and Vascular Surgery, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Thomas Biehl
- Sections of General, Thoracic and Vascular Surgery, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Vincent J Picozzi
- Hematology and Oncology, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - William S Helton
- Sections of General, Thoracic and Vascular Surgery, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - David Coy
- Radiology, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Russell Dorer
- Pathology, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Flavio G Rocha
- Sections of General, Thoracic and Vascular Surgery, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA.
| |
Collapse
|
38
|
Hyun JJ, Kozarek RA. Similar in Size But Different in Detail. Gastroenterology 2018; 155:613-615. [PMID: 29410042 DOI: 10.1053/j.gastro.2018.01.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 01/02/2018] [Indexed: 12/02/2022]
Affiliation(s)
- Jong Jin Hyun
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington; Korea University College of Medicine, Seoul, Korea
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington
| |
Collapse
|
39
|
Abstract
PURPOSE OF REVIEW To review important manuscripts published over the previous 2 years relative to sphincter of Oddi dysfunction (SOD). RECENT FINDINGS The long-term outcomes of the Evaluating Predictors and Interventions of SOD (EPISOD) trial further substantiated results from the initial EPISOD study, reinforcing that neither endoscopic retrograde cholangiopancreatography-manometry nor endoscopic sphincterotomy are appropriate for SOD type III. Pain management in the latter patients has reverted to neuromodulating agents, and recent studies have suggested a role for duloxetine and potentially acupuncture. The functional role of the sphincter of Oddi has been reiterated with a report demonstrating a higher clinically significant pancreatic fistula rate in distal pancreatectomy patients treated with higher doses of postoperative narcotics. Moreover, the injection of periampullary botulinum toxin preoperatively has been shown to decrease these fistulas in a pilot trial. Additional studies have reinforced that eluxadoline can cause sphincter of Oddi spasm and pancreatitis. In contrast to approaching patients with acute relapsing pancreatitis using endoscopic retrograde cholangiopancreatography and manometry, previous and current studies suggest that endoscopic ultrasound should be done first and the role of SOD in idiopathic acute relapsing pancreatitis remains controversial. Finally, there remain widespread disparities in practice patterns in the approach to patients currently classified as SOD type II. SUMMARY In contrast to historical manuscripts which stress the classical definitions of three types of SOD and their consequences, more recent manuscripts on this topic have focused on improving surgical outcomes based on the physiologic role of sphincter of Oddi, as well as the pharmacologic causes and treatments of SOD. The simplistic view that SOD, however it has been diagnosed, requires biliary or dual sphincterotomy is just that, simplistic and potentially misguided.
Collapse
|
40
|
Brewer Gutierrez OI, Irani SS, Ngamruengphong S, Aridi HD, Kunda R, Siddiqui A, Dollhopf M, Nieto J, Chen YI, Sahar N, Bukhari MA, Sanaei O, Canto MI, Singh VK, Kozarek R, Khashab MA. Endoscopic ultrasound-guided entero-enterostomy for the treatment of afferent loop syndrome: a multicenter experience. Endoscopy 2018; 50:891-895. [PMID: 29499577 DOI: 10.1055/s-0044-102254] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Afferent loop syndrome (ALS) is traditionally managed surgically and, more recently, endoscopically. The role of endoscopic ultrasound-guided entero-enterostomy (EUS-EE) has not been well described. The aim of this study was to assess the technical and clinical success and safety of EUS-EE. METHODS This was a multicenter, retrospective series at six centers in patients with ALS treated by EUS-EE. Data on patients treated with enteroscopy-assisted luminal stenting (EALS) at a single center were also collected. RESULTS 18 patients (mean age 64.2 years, 72 % post-pancreaticoduodenectomy, 10 female) underwent EUS-EE. The most common symptoms were vomiting (27.8 %) and jaundice (33.3 %). Clinical success included resolution of symptoms in 88.9 % and improvement to allow hospital discharge in 11.1 %. Technical success was achieved in 100 % of cases, with a mean procedure time of 29.7 minutes. The most common procedure was a gastro-jejunostomy (72.2 %). Three adverse events (16.7 %) occurred (two mild, one moderate). When compared with data on EALS, patients treated with EUS-EE needed fewer re-interventions (16.6 % vs. 76.5 %; P < 0.001). CONCLUSION EUS-EE seems to be safe and effective in the treatment of ALS. Indirect comparison with EALS suggested that EUS-EE is associated with a reduced need for re-intervention.
Collapse
Affiliation(s)
- Olaya I Brewer Gutierrez
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Shayan S Irani
- Division of Gastroenterology and Hepatology, Virginia Mason, Seattle, Washington, United States
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Hanaa D Aridi
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Rastislav Kunda
- Department of Surgical Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Ali Siddiqui
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Markus Dollhopf
- Division of Gastroenterology and Hepatology, Leitender Oberarzt der Klinik, Munchen, Germany
| | - Jose Nieto
- Division of Gastroenterology and Hepatology, Borland Groover Clinic, Jacksonville, Florida, United States
| | - Yen-I Chen
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Nadav Sahar
- Division of Gastroenterology and Hepatology, Virginia Mason, Seattle, Washington, United States
| | - Majidah A Bukhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Omid Sanaei
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Marcia I Canto
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Vikesh K Singh
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Richard Kozarek
- Division of Gastroenterology and Hepatology, Virginia Mason, Seattle, Washington, United States
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| |
Collapse
|
41
|
Sahar N, Kozarek RA, Kanji ZS, Chihara S, Gan SI, Gluck M, Larsen M, Ross AS, Irani S. Duration of antibiotic treatment after endoscopic ultrasound-guided drainage of walled-off pancreatic necrosis not affecting outcomes. J Gastroenterol Hepatol 2018; 33:1548-1552. [PMID: 29392766 DOI: 10.1111/jgh.14111] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 01/18/2018] [Accepted: 01/22/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND AIM Although society guidelines recommend a short course of antibiotics after drainage of walled-off necrosis (WON), the exact duration is unclear. METHODS This is a retrospective review of patients with no prior antibiotic exposure who underwent dual-modality drainage (DMD) for sterile WON from 2008 to 2017. Patients were grouped into short duration (SD, ≤5 days) versus long duration (LD, >5 days). The main outcome was the frequency of recurrent infections. RESULTS Sixty-one patients (25 in the SD group and 36 in the LD group) were included. Patients in the two groups had comparable age, comorbidities, and severity of disease (P = 0.89). Patients in the SD group were treated with antibiotics for a median of 3 days compared with 8.5 days in the LD group. There were no differences in recurrent febrile episodes within 30 days of procedure-44% of SD group versus 39% of LD (P = 0.69). There was also no difference in time to resolution of WON (64 days for both groups, P = 0.72) or duration of hospitalization post-DMD (SD 7.7 days versus LD 7.5 days, P = 0.42). Three cases of Clostridium difficile colitis were observed in the LD group. CONCLUSIONS Longer course of antibiotics seems to have similar outcomes compared with shorter courses in patients with WON treated with DMD. Prolonged-course therapy may predispose to secondary infections like C. difficile colitis. A randomized controlled trial is needed to evaluate the role and duration of peri-procedural antibiotics after drainage of sterile WON.
Collapse
Affiliation(s)
- Nadav Sahar
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Zaheer S Kanji
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Shingo Chihara
- Section of Infectious Diseases, Department of Internal Medicine, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Seng Ian Gan
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Michael Gluck
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Michael Larsen
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Andrew S Ross
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Shayan Irani
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| |
Collapse
|
42
|
Affiliation(s)
- Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, and University of Washington, Seattle, Washington
| |
Collapse
|
43
|
Sahar N, La Selva D, Gluck M, Gan SI, Irani S, Larsen M, Ross AS, Kozarek RA. The ASGE grading system for ERCP can predict success and complication rates in a tertiary referral hospital. Surg Endosc 2018; 33:448-453. [PMID: 29987568 DOI: 10.1007/s00464-018-6317-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 06/29/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The utility of the American Society for Gastrointestinal Endoscopy (ASGE) grading scale assessing complexity of endoscopic retrograde cholangiopancreatography (ERCP) has not been evaluated in clinical practice. METHODS Patients that underwent ERCP between January 2015 and December 2015 were included. Procedural difficulty was graded according to the grading system proposed by the ASGE workshop. Technical success rates and complications were recorded. RESULTS A total of 1355 ERCPs were performed on 934 patients. Patients were equally divided with respect to gender and had a mean age of 58 years (range 29-86). 391 cases were grade 1, 2 (29%), 695 were grade 3 (51%), and 269 were grade 4 (20%). Altered anatomy was observed in 88% of grade 4 patients. Cannulation was achieved in 98% of cases graded 1-3 and in 88% of cases graded 4 (p < 0.05). Complications were recorded in 10% of all cases with post-ERCP pancreatitis (5.4%) and procedure-related bleeding (1.5%) being the more common ones. No statistically significant difference was noted between the groups with regard to complications. Three perforations were seen in grade 1-3 cases (0.3%) compared to 4 cases in grade 4 cases (1.5%), (p = 0.01). CONCLUSION The grading system proposed by the ASGE workshop can aid in predicting cannulation success and perforation rates in ERCP. Based on this retrospective study, the most complex ERCP procedures can be achieved with encouraging rates of success. There is a need to validate our study with prospective ones performed in other high-volume centers.
Collapse
Affiliation(s)
- Nadav Sahar
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Avenue, C3-GAS, Seattle, WA, 98101, USA.
| | - Danielle La Selva
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Avenue, C3-GAS, Seattle, WA, 98101, USA
| | - Michael Gluck
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Avenue, C3-GAS, Seattle, WA, 98101, USA
| | - S Ian Gan
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Avenue, C3-GAS, Seattle, WA, 98101, USA
| | - Shayan Irani
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Avenue, C3-GAS, Seattle, WA, 98101, USA
| | - Michael Larsen
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Avenue, C3-GAS, Seattle, WA, 98101, USA
| | - Andrew S Ross
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Avenue, C3-GAS, Seattle, WA, 98101, USA
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Avenue, C3-GAS, Seattle, WA, 98101, USA
| |
Collapse
|
44
|
Affiliation(s)
- Jong Jin Hyun
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA.,Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Shayan S Irani
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| |
Collapse
|
45
|
Shin HP, Burman B, Kozarek RA, Zeigler A, Wang C, Lee H, Zehr T, Edwards AM, Siddique A. Real-World Single-Center Experience with Sofosbuvir-Based Regimens for the Treatment of Chronic Hepatitis C Genotype 1 Patients. Gut Liver 2018. [PMID: 28651301 PMCID: PMC5593334 DOI: 10.5009/gnl16447] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Background/Aims The approval of sofosbuvir (SOF), a direct-acting antiviral, has revolutionized the treatment of chronic hepatitis C virus (HCV). Methods We assessed the sustained virological response (SVR) of SOF-based regimens in a real-world single-center setting for the treatment of chronic HCV genotype 1 (G1) patients. This was a retrospective review of chronic HCV G1 adult patients treated with a SOF-based regimen at Virginia Mason Medical Center between December 2013 and August 2015. Results The cohort comprised 343 patients. Patients received SOF+ledipasvir (LDV) (n=155), SOF+simeprevir (SIM) (n=154), or SOF+peginterferon (PEG)+ribavirin (RBV) (n=34). Of the patients, 50.1% (n=172) had cirrhosis. The SVR rate was 92.2% for SOF/LDV, 87.0% for SOF/SIM, and 82.4% for SOF/PEG/RBV. Compared with the cirrhotic patients, the patients without cirrhosis had a higher SVR (96.8% vs 85.5%, p=0.01, SOF/LDV; 98.2% vs 80.6%, p=0.002, SOF/SIM; 86.4% vs 75.0%, p=0.41, SOF/PEG/RBV). In this study, prior treatment experience adversely affected the response rate in subjects treated with SOF/PEG/RBV. Conclusions In this single-center, real-world setting, the treatment of chronic HCV G1 resulted in a high rate of SVR, especially in patients without cirrhosis.
Collapse
Affiliation(s)
- Hyun Phil Shin
- Hepatology Division, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Blaire Burman
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Amy Zeigler
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Chia Wang
- Department of Infectious Disease, Virginia Mason Medical Center, Seattle, WA, USA
| | - Houghton Lee
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Troy Zehr
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Alicia M Edwards
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Asma Siddique
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| |
Collapse
|
46
|
Abstract
INTRODUCTION Biliary atresia is a progressive inflammatory disease of the bile duct that eventually results in biliary cirrhosis. It is a rare neonatal disease that mandates treatment within the first 2 years of life in order for the infant to survive. Patients usually undergo palliative Kasai portoenterostomy. Even when Kasai portoenterostomy has been performed in a timely manner, progression is still inevitable. In fact, the majority of patients require curative liver transplantation at a later stage before reaching adulthood. METHODS Two jaundiced biliary atresia patients who have lived well beyond 20 years with their native liver after undergoing Kasai portoenterostomy and underwent endoscopic retrograde cholangiopancreatography (ERCP) were identified. The data on patients' clinical information, procedures performed, and outcomes were retrospectively collected by chart review. RESULTS Presence of a long Roux limb and acute angulation from external adhesions along with ductal anomaly from disease itself rendered ERCP challenging, and intraoperative ERCP had to be performed in 1 patient. As enteroscopes had to be used, availability of accessory devices was limited. CONCLUSION Management of adult biliary atresia patients with biliary obstruction with ERCP is feasible, at times, through multidisciplinary means.
Collapse
Affiliation(s)
- Jong Jin Hyun
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | | | | |
Collapse
|
47
|
Sahar N, Kozarek RA, Kanji ZS, Chihara S, Gan SI, Irani S, Larsen M, Ross AS, Gluck M. The microbiology of infected pancreatic necrosis in the era of minimally invasive therapy. Eur J Clin Microbiol Infect Dis 2018; 37:1353-1359. [PMID: 29675786 DOI: 10.1007/s10096-018-3259-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 04/10/2018] [Indexed: 12/21/2022]
Abstract
We aimed to determine the microbiology of infected walled-off pancreatic necrosis (WON) in an era of minimally invasive treatment, since current knowledge is based on surgical specimens performed over two decades ago. We retrospectively analyzed a prospectively maintained database of patients who were treated for symptomatic WON using combined endoscopic and percutaneous drainage between 2008 and 2017. Aspirates from WON at initial treatment were evaluated. One hundred eighty-two patients were included with a mean age of 56 of whom 67% were male. Culture results were obtained at a median of 45 days from onset of acute pancreatitis of which 41% were infected. Candida spp. accounted for 27%; yet, multidrug-resistant organisms were found in only five patients. Approximately 64% were transferred to our institution for continuation of care. Of those, 55% were infected, most frequently with Candida spp., Enterococcus spp., and coagulase-negative Staphylococcus. Patients seen and admitted initially at our institution had milder forms of pancreatitis, fewer comorbidities, and 85% had symptomatic sterile WON. Empiric antibiotic use successfully predicted infection 70% of the time. Multivariate analysis demonstrated that elderly age, severity of pancreatitis, and prior use of antibiotics were indicators of infection. Necrotic pancreatic tissue remains sterile in the majority of cases treated with minimally invasive therapy, enabling judicious selection of antibiotics. Candida and Enterococcus spp. were common. Patients at highest risk for infection were previously treated with antibiotics and those transferred from outside institutions.
Collapse
Affiliation(s)
- Nadav Sahar
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 9th Avenue, C3-GAS, Seattle, WA, 98101, USA
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 9th Avenue, C3-GAS, Seattle, WA, 98101, USA
| | - Zaheer S Kanji
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 9th Avenue, C3-GAS, Seattle, WA, 98101, USA
| | - Shingo Chihara
- Section of Infectious Diseases, Department of Internal Medicine, Virginia Mason Medical Center, Seattle, USA
| | - S Ian Gan
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 9th Avenue, C3-GAS, Seattle, WA, 98101, USA
| | - Shayan Irani
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 9th Avenue, C3-GAS, Seattle, WA, 98101, USA
| | - Michael Larsen
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 9th Avenue, C3-GAS, Seattle, WA, 98101, USA
| | - Andrew S Ross
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 9th Avenue, C3-GAS, Seattle, WA, 98101, USA
| | - Michael Gluck
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 9th Avenue, C3-GAS, Seattle, WA, 98101, USA.
| |
Collapse
|
48
|
Kanji ZS, Edwards AM, Mandelson MT, Sahar N, Lin BS, Badiozamani K, Song G, Alseidi A, Biehl TR, Kozarek RA, Helton WS, Picozzi VJ, Rocha FG. Gemcitabine and Taxane Adjuvant Therapy with Chemoradiation in Resected Pancreatic Cancer: A Novel Strategy for Improved Survival? Ann Surg Oncol 2018; 25:1052-1060. [PMID: 29344878 DOI: 10.1245/s10434-018-6334-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Indexed: 01/05/2023]
Abstract
BACKGROUND Gemcitabine-taxane combination chemotherapy has demonstrated a survival benefit clinically in metastatic pancreatic cancer (PC). The authors present their experience with gemcitabine and docetaxel (gem/tax)-based adjuvant treatment (Rx) after surgery with curative intent. METHODS Patients with de novo resectable PC from January 2010 to December 2015 were identified from the authors' institutional database and registry. The study included only patients who received gem/tax as their initial Rx administered exclusively at the authors' institution with or without chemoradiation (CRTx). Survival analysis was performed using Kaplan-Meier methods, and prognostic factors were investigated by Cox proportional hazard modeling. RESULTS Of 102 patients identified, 58 met the study criteria. The median age at diagnosis was 65 years, with 55% of the patients undergoing an R1 resection (margin ≤ 1 mm). Tumor characteristics included a median tumor size of 28 mm, a poor differentiation rate of 54%, and a lymph node positivity of 67%. Most of the patients (90%, 52/58) completed 80% or more of the 24 week Rx. Of these patients, 71% received post-gem/tax CRTx Rx. Grade 3 or 4 toxicity was observed in 52% of the patients. The median follow-up period was 51.2 months, and the observed median overall survival (OS) was 52 months [95% confidence interval (CI) 27.4-not reached]. The actuarial 5-year OS was 49% (95% CI 33.7-63.4%). In the multivariate analysis, an R1 resection and American Joint Committee on Cancer (AJCC) stage 2 versus stage 1 disease were negatively associated with OS, whereas administration of CRTx was positively associated with OS. CONCLUSIONS Adjuvant gem/tax with or without CRTx is feasible, with a favorable OS. Future prospective studies of gem/taxane-based adjuvant Rx for PC are warranted.
Collapse
Affiliation(s)
- Zaheer S Kanji
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA.,Section of General Thoracic, and Vascular Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Alicia M Edwards
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | | | - Nadav Sahar
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Bruce S Lin
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA.,Cancer Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Kasra Badiozamani
- Section of Radiation Oncology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Guobin Song
- Section of Radiation Oncology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Adnan Alseidi
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA.,Cancer Institute, Virginia Mason Medical Center, Seattle, WA, USA.,Section of General Thoracic, and Vascular Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Thomas R Biehl
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA.,Cancer Institute, Virginia Mason Medical Center, Seattle, WA, USA.,Section of General Thoracic, and Vascular Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - William S Helton
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA.,Cancer Institute, Virginia Mason Medical Center, Seattle, WA, USA.,Section of General Thoracic, and Vascular Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Vincent J Picozzi
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA.,Cancer Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Flavio G Rocha
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA. .,Cancer Institute, Virginia Mason Medical Center, Seattle, WA, USA. .,Section of General Thoracic, and Vascular Surgery, Virginia Mason Medical Center, Seattle, WA, USA.
| |
Collapse
|
49
|
Affiliation(s)
- Todd H. Baron
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill
| | - Richard A. Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington
| |
Collapse
|
50
|
Sahar N, Razzak A, Kanji ZS, Coy DL, Kozarek R, Ross AS, Gluck M, Larsen M, Irani S, Gan SI. New guidelines for use of endoscopic ultrasound for evaluation and risk stratification of pancreatic cystic lesions may be too conservative. Surg Endosc 2018; 32:2420-6. [PMID: 29288277 DOI: 10.1007/s00464-017-5941-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 10/17/2017] [Indexed: 12/11/2022]
|