Magnetic resonance image-guided salvage brachytherapy after radiation in select men who initially presented with favorable-risk prostate cancer

BACKGROUND

The authors prospectively evaluated the late gastrointestinal (GI) and genitourinary (GU) toxicity and prostate-specific antigen (PSA) control of magnetic resonance imaging (MRI)-guided brachytherapy used as salvage for radiation therapy (RT) failure.

METHODS

From October 2000 to October 2005, 25 men with a rising PSA level and biopsy-proven, intraprostatic cancer at least 2 years after initial RT (external beam in 13 men and brachytherapy in 12 men) who had favorable clinical features (Gleason score < or =7, PSA < 10 ng/mL, negative pelvic and bone imaging studies), received MRI-guided salvage brachytherapy to a minimum peripheral dose of 137 gray on a phase 1/2 protocol. Estimates of toxicity and cancer control were calculated using the Kaplan-Meier method.

RESULTS

The median follow-up was 47 months. The 4-year estimate of grade 3 or 4 GI or GU toxicity was 30%, and 13% of patients required a colostomy and/or urostomy to repair a fistula. An interval < 4.5 years between RT courses was associated with both outcomes with a hazard ratio of 12 (95% confidence interval [95% CI], 1.4-100; P = .02) for grade 3 or 4 toxicity and 25 (95% CI, 1.1-529; P = .04) for colostomy and/or urostomy. PSA control (nadir +2 definition) was 70% at 4 years.

CONCLUSIONS

The current results indicated that MRI-guided salvage brachytherapy in men who are selected based on presenting characteristics and post-failure PSA kinetics can achieve high PSA control rates, although complications requiring surgical intervention may occur in 10% to 15% of patients. Prospective randomized studies are needed to characterize the relative cancer control and toxicity after all forms of salvage local therapy.

Treatment of a radiation-induced rectal ulcer with hyperbaric oxygen therapy in a man with prostate cancer

Late radiation proctopathy is a painful and vexing complication of prostate radiation. We report a case of a 55-year-old man with prostate cancer, and complaints of tenesmus and severe rectal pain after radiation therapy. The patient was diagnosed with a locally advanced Gleason score 8 prostate cancer and an increased prostate-specific antigen of 42.3 ng/ml. His past medical history was notable for a history of bilateral lymph node dissection complicated by Clostridium difficile colitis. He subsequently received 3-dimensional conformal radiation therapy. Seven months after completing therapy, minor rectal bleeding and significant pain developed, requiring increasing doses of opioid analgesics. Fourteen months after 3-dimensional conformal radiation therapy, sigmoidoscopy revealed a single chronic deep ulcer at the anorectal junction. As an alternative to diverting colostomy, the patient underwent a course of hyperbaric oxygen. Within 1 month of completing hyperbaric oxygen treatment, his symptoms completely resolved. Nine months from completion of hyperbaric oxygen therapy, he has had no recurrence of symptoms. Hyperbaric oxygen therapy can be considered a treatment option after failure of standard treatments in patients with severe radiation proctopathy.

Endoscopic treatment for atypical manifestations of gastroesophageal reflux disease

OBJECTIVES

Atypical manifestations are common in patients with gastroesophageal reflux disease (GERD). The aim of this study was to evaluate the response of atypical manifestations of GERD to endoscopic antireflux treatment.

METHODS

Patients with atypical manifestations of GERD including hoarseness, cough, wheezing, and non-cardiac chest pain were studied. Endoscopic antireflux treatment consisted of placement of sutures below the squamo-columnar junction. Clinical response was defined as complete resolution of the atypical symptom. Patients were followed clinically for up to 3 yr after the procedure. Short-term response was evaluated within 6 months of the procedure, and long-term follow-up was determined 1-3 yr after the procedure.

RESULTS

Forty-three patients met the inclusion criteria; four patients underwent repeat procedures during the study period and were excluded from the analysis. Long-term follow-up was available in all 39 patients. Short-term response counts were: hoarseness, 12 of 19 patients, cough, 17 of 19; wheezing, 8 of 9; and chest pain, 13 of 18. Long-term follow-up of patients (mean of 18 months) for these symptoms was not significantly different compared to short-term response.

CONCLUSIONS

Endoscopic suturing of the gastroesophageal junction appears to be a possible treatment option for atypical manifestations of GERD and future studies are needed to determine its role in management.

Endoscopic treatment of gastroesophageal reflux disease: effect of gender on clinical outcome

OBJECTIVE

Gender differences in gastroesophageal reflux disease have been reported. Higher frequency and severity of symptoms, lower esophageal acid exposure and lower incidence of reflux-related complications have been observed in women. The aim of this study was to determine whether there are any gender differences in clinical presentation, diagnostic evaluations and response to endoscopic therapy in patients with gastroesophageal reflux disease.

MATERIAL METHODS

Patients with gastroesophageal reflux disease referred for endoscopic therapy were scored for typical (heartburn and regurgitation) and atypical (chest pain, cough, wheezing, and hoarseness) symptoms at baseline. Upper endoscopy, manometry and pH studies were performed for all patients. Endoscopic treatment consisted of placement of two to three sutures within 2 cm of the squamocolumnar junction. Reflux symptoms were re-scored after endoscopic treatment.

RESULTS

Ninety-five patients (37 M, 58 F, mean age 51 years) were included in the analysis. Male and female patients at baseline reported similar severity of typical reflux symptoms as well as comparable prevalence of atypical symptoms. Manometric findings were also comparable between the genders. Endoscopic and ambulatory pH studies revealed a higher incidence of erosive esophagitis and a trend towards higher acid exposures in male patients. The response to endoscopic therapy was similar for men and women.

CONCLUSIONS

Apart from a higher incidence of erosive esophagitis in male patients, no major differences were found in endoscopic, manometric, esophageal acid exposure studies and clinical response to endoscopic therapy between the genders.

Prospective trial of endoscopic clips versus combination therapy in upper GI bleeding (PROTECCT--UGI bleeding)

BACKGROUND

It is not known if combination therapy of epinephrine injection and multipolar electrocoagulation or hemoclips are a more efficient or effective treatment for patients with acute nonvariceal upper gastrointestinal (GI) bleeding.

METHODS

Adult patients with active nonvariceal upper GI bleeding, a nonbleeding visible vessel, or after removal of an adherent clot findings of active bleeding or a visible vessel were studied. Patients were randomized to either therapy and the outcomes were assessed at 30 days.

RESULTS

Forty-seven patients were studied: 26 patients randomized to hemoclips and 21 to combination therapy. There were 22 patients with active bleeding, 13 with a nonbleeding visible vessel, and 12 with an adherent clot. The median duration of endoscopic therapy was 17 min in the hemoclip group versus 20 min for the combination therapy, p= 0.29. Primary hemostasis with successful initial control of bleeding occurred in 26 (100%) of 26 hemoclip patients and 20 (95.2%) of 21 combination therapy patients, p= 0.45. The rebleeding rates were: 4 (15.4%) of 26 hemoclip patients versus 5 (23.8%) of 21 combination therapy patients, p= 0.49. Overall, the length of hospital stay, units of blood transfused, surgery rates, and mortality were not different.

CONCLUSIONS

In this prospective, randomized controlled trial of endoscopic hemoclips versus combination therapy in the nonvariceal upper GI bleeding, the efficiency, efficacy, and complications of the two treatment modalities were not significantly different.

Chronic diarrhea due to metastatic breast cancer

We report the case of a patient with chronic diarrhea due to infiltrative cancer to the colon from the breast. A 49-year-old woman with a history of metastatic breast cancer to the bones was admitted to hospital with 4 weeks of watery diarrhea. Computed tomography (CT) scan of the abdomen showed pancolitis. Colonoscopy showed patchy subepithelial hemorrhages, most prominently in the ascending colon and sigmoid colon, but no mass lesion. Random biopsies taken throughout the colon showed infiltrative adenocarcinoma of breast origin in multiple specimens. Infectious work-up was negative.

Long-term outcomes of endoluminal gastroplication: a U.S. multicenter trial

BACKGROUND

Endoluminal gastroplication has shown promise for the treatment of GERD in short-term studies. Until now, long-term outcome data have been lacking.

METHODS

A prospective, multicenter trial enrolled 85 patients with GERD to be treated with endoluminal gastroplication. Inclusion criteria were 3 or more heartburn or regurgitation episodes per week, >4.2% time in 24 hours with esophageal pH < 4, and dependency on antisecretory medications. Exclusion criteria were the presence of varices, achalasia, aperistalsis, or previous gastric resection. Patients underwent manometry, 24-hour pH monitoring, and symptom severity scoring before and after the procedure. Patient diaries were used to assess medication use and to estimate annual medication cost.

RESULTS

At 1- and 2-year follow-up, patients had significant reductions in median heartburn symptom scores (72 at baseline [interquartile range (IQR) 90-48] vs. 4 at 12 months [IQR 43-0] and 16 at 24 months [IQR 53-3.5]; p < 0.0001 vs. baseline) and median regurgitation symptoms (2 at baseline [IQR 3-1] vs. 0 at 12 months (IQR 1-0) and 1 at 24 months [IQR 1-0]; p < 0.0001 vs. baseline). Of all patients, 59% and 52% showed heartburn symptom resolution at 12 and 24 months, respectively ( p < 0.0001 vs. baseline). Also, 83% and 77% had regurgitation symptom resolution at 12 and 24 months, respectively (p < 0.0001 vs. baseline). Proton pump inhibitor use also was significantly reduced at 12 and 24 months after the procedure. At 2-year follow-up, median annualized medication costs were reduced by 88% (1381 US dollars) (p < 0.0001). Endoluminal gastroplication significantly reduced the duration and the number of episodes of esophageal acid exposure (p < 0.0001 vs. baseline). Only 7 patients experienced adverse events.

CONCLUSIONS

Endoscopic gastroplication is safe and effective, and is associated with symptom reductions in patients with GERD for at least 24 months.

Randomized trial of a video headset vs. a conventional video monitor during colonoscopy

BACKGROUND

Head-mounted video displays recently became available for endoscopy. This study compared a video headset with a conventional monitor during colonoscopy.

METHODS

Five endoscopists were randomized to headset or to monitor use during colonoscopy. They completed a questionnaire that assessed image quality, procedure characteristics, and comfort. Medication use and length of procedure were recorded.

RESULTS

A total of 96 colonoscopies were performed. Image quality and comfort were rated as poorer during headset use (p < 0.05). However, neck strain was significantly reduced with the headset. Medication use and total procedure time were similar. There was a trend toward increased time to cecum with the headset (9.8 vs. 8.0 minutes, p = 0.055).

CONCLUSIONS

In this randomized study, comparing a video headset and a conventional monitor for colonoscopy, image quality and comfort were inferior with the headset, although neck strain was improved. Further improvements in technology are needed before headsets can be considered an acceptable alternative to the conventional video monitor for GI endoscopy.

Palliation of patients with malignant gastric outlet obstruction with the enteral Wallstent: outcomes from a multicenter study

BACKGROUND

Endoscopic placement of self-expandable metallic stents for palliation of patients with malignant gastric outlet obstruction is safe and feasible.

METHODS

Patients with malignant gastric outlet obstruction undergoing enteral stent insertion were identified from endoscopy databases. Duration of oral intake after stent insertion was calculated by using the log-rank test. Factors associated with duration of oral intake were assessed by using Cox multivariable regression analysis.

RESULTS

A total of 176 patients (mean age 65 [14] years) treated at 4 centers from 1996 to 2003 were identified. Obstruction was caused by cancer of the pancreas in 84, the stomach in 20, the bile duct in 15, the major duodenal papilla in 8, another primary site in 16, and metastases in 33. The site of obstruction was the duodenum in 125, the distal stomach in 17, the stomach and the duodenum in 18, and surgical anastomosis in 16 patients. Stent deployment was technically successful in 173. Complications occurred in 14 patients. Seventeen patients were lost to follow-up. Of the remaining 159 patients, 133 resumed oral intake for a median time of 146 days: 95% CI [65, 202]. On regression analysis, chemotherapy after stent placement was associated with prolonged duration of oral intake (hazard ratio 0.41: 95% CI [0.23, 0.72]).

CONCLUSIONS

After enteral stent insertion for malignant gastric outlet obstruction, 84% of patients resumed oral intake for a median time of 146 days. Chemotherapy after enteral stent insertion was independently associated with prolongation of oral intake.

Endoscopic balloon dilation compared with sphincterotomy for extraction of bile duct stones

BACKGROUND AND AIMS

Endoscopic retrograde cholangiopancreatography is commonly performed to remove bile duct stones. The aim of this study was to determine short-term outcomes of endoscopic balloon dilation of the sphincter of Oddi compared with sphincterotomy for stone extraction.

METHODS

A randomized, controlled multicenter study of 117 patients assigned to dilation and 120 to sphincterotomy was performed in a spectrum of clinical and academic practices.

RESULTS

Characteristics of the patients, procedures, and endoscopists were similar except that dilation patients were younger. Procedures were successful in 97.4% and 92.5% of the dilation and sphincterotomy patients, respectively. Overall morbidity occurred in 17.9% and 3.3% ( P < .001; difference, 14.6; 95% confidence interval, 7-22.3) and severe morbidity, including 2 deaths, in 6.8% and 0%( P < .004; difference, 6.8; 95% confidence interval, 2.3-11.4) for dilation and sphincterotomy, respectively. Complications for dilation and sphincterotomy, respectively, included: pancreatitis, 15.4% and .8% ( P < .001; difference, 14.6; 95% confidence interval, 7.8-21.3); cystic duct fistula, 1.7% and 0%; cholangitis, .9% and .8%; perforation, 0% and .8%; and cholecystitis, 0% and .8%. There were 2 deaths (1.7%) due to pancreatitis following dilation and none with sphincterotomy. The study was terminated at the first interim analysis. Dilation patients required significantly more invasive procedures, longer hospital stays, and longer time off from normal activities.

CONCLUSIONS

In a broad spectrum of patients and practices, endoscopic balloon dilation compared with sphincterotomy for biliary stone extraction is associated with increased short-term morbidity rates and death due to pancreatitis. Balloon dilation of the sphincter of Oddi for stone extraction should be avoided in routine practice.

Gastroesophageal junction smooth muscle remodeling after endoluminal gastroplication

OBJECTIVES

Endoluminal gastroplication (ELGP) is an endoscopic mucosal suturing procedure for the treatment of gastroesophageal reflux disease. The antireflux mechanism of the mucosal suture remains poorly understood. The aim of this study is to investigate any morphologic changes in the smooth muscle layer induced by the mucosal sutures placed at the gastroesophageal junction.

METHODS

ELGPs were performed using endoscopic suturing devices with placement of two or three circumferential sutures within 2 cm of the squamocolumnar junction. Eight patients with subsequent symptom resolution underwent endoscopic ultrasound (EUS) to evaluate the muscularis propria layer at the gastroesophageal junction. A swine model was used for EUS and histopathologic correlation study. Six control and 15 ELGP pigs were evaluated with EUS and histological examination of the gastroesophageal junction smooth muscle layer.

RESULTS

Focal thickening of the muscularis propria layer near the suture region (2.3 +/- 0.4 mm vs 1.4 +/- 0.3 mm, p < 0.01) was found in eight patients with symptomatic resolution. In ELGP pigs, the smooth muscle layer thickness increased by 2.6 mm near the suture site by EUS. By histology, the total and circular smooth muscle layer thickness increased by 2.1 mm and 1.9 mm, respectively.

CONCLUSIONS

Focal thickening of smooth muscle layer occurs at the gastroesophageal junction after ELGP in patients with gastroesophageal reflux disease. This finding was reproduced in a swine model and localized hypertrophy was found to be entirely due to an increase in the circular smooth muscle layer.

Life-threatening acute airway obstruction in achalasia

Acute airway obstruction from mega-esophagus is an extremely rare presentation of achalasia. We present the case of an 82-year-old woman without previously diagnosed achalasia who presented with shortness of breath. Her respiratory status deteriorated rapidly, with development of stridor. Prompt nasogastric tube placement decompressed the dilated esophagus and relieved airway obstruction. This case illustrates an unusual presentation of achalasia and underscores the need for emergent life-saving esophageal decompression. Hypotheses regarding the mechanism of airway compromise as well as treatment options are reviewed.

Analysis of cystic fibrosis gener product (CFTR) function in patients with pancreas divisum and recurrent acute pancreatitis

BACKGROUND

The mechanism by which pancreas divisum may lead to recurrent episodes of acute pancreatitis in a subset of individuals is unknown. Abnormalities of the cystic fibrosis gene product (CFTR) have been implicated in the genesis of idiopathic chronic pancreatitis. The aim of this study was to determine if CFTR function is abnormal in patients with pancreas divisum and recurrent acute pancreatitis (PD/RAP).

METHODS

A total of 69 healthy control subjects, 12 patients with PD/RAP, 16 obligate heterozygotes with a single CFTR mutation, and 95 patients with cystic fibrosis were enrolled. CFTR function was analyzed by nasal transepithelial potential difference testing in vivo. The outcomes of the PD/RAP patients following endoscopic and surgical treatments were concomitantly analyzed.

FINDINGS

Direct measurement of CFTR function in nasal epithelium in response to isoproterenol demonstrated that the values for PD/RAP were intermediate between those observed for healthy controls and cystic fibrosis patients. The median value was 13 mV for PD/RAP subjects, which was statistically different from healthy controls (22 mV, p= 0.001) and cystic fibrosis pancreatic sufficient (-1 mV, p < 0.0001) and pancreatic insufficient (-3 mV, p < 0.0001) patients.

INTERPRETATIONS

These results suggest a link between CFTR dysfunction and recurrent acute pancreatitis in patients with pancreas divisum and may explain why a subset of patients with pancreas divisum develops recurrent acute pancreatitis.

Endoluminal gastroplication for treatment of patients with classic gastroesophageal reflux symptoms and borderline 24-h pH studies

BACKGROUND

Patients with classic gastroesophageal reflux disease (GERD) symptoms and borderline 24-h pH studies are not considered to be good candidates for surgical fundoplication. Endoluminal gastroplication (ELGP) is a new endoscopic treatment for patients with GERD. The aim of this study was to evaluate the efficacy of ELGP in these patients.

METHODS

Patients with heartburn, regurgitation symptoms and a DeMeester score of less than 30 were studied. ELGP involved placement of two or three plications within 2 cm of the gastroesophageal junction. Clinical outcomes measured were heartburn symptom score (HSS), regurgitation frequency score (RFS) and medication use.

RESULTS

Twenty-five patients (11 M, 14 F, mean age of 51 years) had a medication use of 11.5 doses of proton-pump inhibitors per week prior to ELGP. Average lower esophageal sphincter pressure measured 15 +/- 8 mmHg, and average DeMeester score was 18 +/- 8. Nine patients had hiatal hernias and 11 had esophagitis. Twenty-four patients were available for a mean follow-up of 12 months. HSS significantly decreased from 48 to 17 (P < 0.01) and RFS was reduced from 1.8 to 0.7 (P < 0.01). Proton-pump inhibitor use was 5.3 doses per week (P < 0.01) post-ELGP; 12 patients (50%) were off medications, 3 (13%) had a 50% reduction in medication use, and in 9 (37%) there was no change. Complications were bleeding in one patient and aspiration pneumonia in another patient.

CONCLUSIONS

Endoluminal gastroplication provides symptomatic relief for patients with classic GERD symptoms despite medical therapy and borderline 24-h pH studies.

Granulomatous tracheo-bronchitis associated with Crohn's disease

We report a rare case of diffuse tracheo-bronchitis as a complication of Crohn's disease. A young man with a long-standing history of Crohn's enterocolitis initially presented with epigastric pain and melena. Upper endoscopy revealed erythematous, edematous, and friable mucosa with erosions, particularly in the pyloric channel, causing gastric outlet obstruction, and a nonbleeding ulcer in the corpus of stomach. Biopsy of these lesions showed chronic gastritis and a noncaseating epithelioid granuloma, consistent with active Crohn's disease. The patient was treated with a course of corticosteroids and the gastric symptoms resolved. A few months later, he developed fever, cough, hemoptysis, and rash. Bronchoscopy demonstrated a markedly thickened and very inflamed trachea with extensive friable, whitish lesions and ulcerations. Histology showed severe noncaseating granulomatous inflammation. The patient improved with a 6-week oral, followed by an additional 4-week inhaled, corticosteroid treatment. Since then, he has been doing well without relapse of pulmonary symptoms for 2 years.

Biliary Access During Endoscopic Retrograde Cholangiopancreatography

Several techniques have been developed to facilitate cannulation of the papilla during endoscopic retrograde cholangiopancreatography (ERCP). The position of the endoscope should generally provide a 'straight' route to the papilla, and the efforts should be directed at shortening the intraduodenal portion of the bile duct. If a guidewire is used, one should be chosen that possesses suitable tip and shaft characteristics, including flexibility, strength, low friction and trackability, but no one device is likely to be suitable for all purposes. The development of guidewires composed of nitinol has revolutionized endoscopic practice. Access papillotomy ('pre-cut') can be employed as an alternative to (or in addition to) insertion of a guidewire when cannulation of the major papilla has been unsuccessful. The same techniques may be used to allow deep cannulation of the bile or pancreatic duct after ductography, when fluoroscopy can also be used. The 'needle-knife', which must be used carefully because it cuts with even slight tissue contact, is moved in the expected direction of the intramural bile (or pancreatic) duct to gain direct access into the duct. Access papillotomy is a valuable procedure in difficult cases, but is associated with greater risks than standard ERCP techniques (except perhaps for a reduced likelihood of pancreatitis), and is best employed by personnel who have extensive experience with therapeutic endoscopy. Technical details for a variety of clinical situations are described. Success requires application of 'the four Ps': position, practice, patience and perseverance.

Late genitourinary and gastrointestinal toxicity after magnetic resonance image-guided prostate brachytherapy with or without neoadjuvant external beam radiation therapy

BACKGROUND

This study was designed to estimate the rates of late genitourinary (GU) and rectal toxicity after magnetic resonance image (MRI)-guided prostate brachytherapy exclusively or in conjunction with external beam radiation therapy (EBRT).

METHODS

Between November 1997 and April 2002, 201 patients with category T1C prostate carcinoma (according to the 2002 American Joint Committee on Cancer staging criteria), prostate specific antigen levels < 10 ng/mL, and biopsy Gleason score 3 + 4 disease were treated with MRI-guided brachytherapy exclusively or in conjunction with EBRT. The MRI-guided technique was designed to spare the urethra based on delivery of the prescription dose to the peripheral zone exclusively. The Kaplan-Meier method was used to estimate rates of freedom from late GU and rectal toxicity. Comparisons were made using a log-rank test.

RESULTS

At a median follow-up of 2.8 years (range, 0.5-5.0 years), the 4-year estimates of rectal bleeding requiring coagulation for patients who underwent implantation therapy, compared with patients who received combined-modality therapy, were 8% versus 30%, respectively (log-rank P value = 0.0001). Although erectile dysfunction was common (range, 82-93%), with the use of sildenafil citrate (Viagra), it was estimated that at least two-thirds of patients had erectile function comparable to or superior to baseline function, independent of whether they received monotherapy or combined-modality therapy (P = 0.46). The 4-year estimate of freedom from radiation cystitis was 100% versus 95% (P = 0.01) for patients who received monotherapy and patients who received combined-modality therapy, respectively. No urethral strictures were observed, and no patients underwent postimplantation transurethral resection of the prostate.

CONCLUSIONS

In the current study, rectal bleeding after MRI-guided prostate brachymonotherapy was infrequent, and urethral and bladder toxicity is reported to be rare and may be attributed to the urethral-sparing technique of the MRI-guided approach.

Anti-Yo antibody-mediated paraneoplastic cerebellar degeneration in a man with esophageal adenocarcinoma

We report a case of paraneoplastic cerebellar degeneration (PCD) associated with adenocarcinoma of the esophagus and anti-Yo antibodies in a male patient. The patient presented with progressive ataxia, dysarthria, and significant weight loss. Extensive work-up suggested paraneoplastic neurologic syndrome. A wide search for a cancer was undertaken and a small mass was identified in the distal esophagus on upper endoscopy. Biopsies of this lesion revealed well-differentiated invasive adenocarcinoma of the esophagus. The endoscopic ultrasound staged the tumor as T3N1M0. Despite trials of multiple therapeutic modalities, the patient's cerebellar dysfunction progressed. This is only the second report of PCD caused by esophageal adenocarcinoma and the fourth report of anti-Yo antibodies occurring in a male patient.

Benign nonampullary duodenal neoplasms

Benign duodenal neoplasms (BDNs) are uncommon, and their optimal management remains undefined. We analyzed all cases of BDN treated at our institution during a 10-year period (January 1990 through January 2000). Data are expressed as median (range). Sixty-two patients were treated for BDNs. The results of histologic examination of their lesions were as follows: 36 adenomas, eight Brunner's gland tumors, 10 inflammatory polyps, two hamartomas, and six others. Forty-seven patients were treated nonoperatively, and 15 patients underwent surgery. Lesion characteristics leading to surgical intervention included large polyp diameter and submucosal penetration detected on endoscopic ultrasound imaging. There were no treatment-related deaths. Major morbidity occurred in 2% of patients who underwent endoscopic resection and in 33% of patients who underwent surgery (P = 0.002). Among patients treated for adenomas, seven (19.4%) had a recurrence at a median of 12 (4 to 48) months. Most BDNs can be managed with minimal morbidity using endoscopic techniques. Systematic follow-up of patients treated for adenomas is required.

Biliary pancreatitis

Gallstone-induced acute pancreatitis is a prevalent condition that is associated with an unacceptably high mortality rate. Early endoscopic intervention, including endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy within 24 to 72 h of hospital admission, can be used to remove stones in the common bile duct (CBD) and establish biliary drainage. Anecdotal evidence of its effectiveness led to formal testing in randomized clinical trials. Although the design and results of the four published studies have varied, the overall conclusion is that early endoscopic therapy reduces morbidity and mortality in patients with acute biliary pancreatitis. Benefits are especially apparent in patients who satisfy generally accepted criteria for severe pancreatitis. The author's practice is to undertake endoscopic retrograde cholangiopancreatography in patients with severe or worsening pancreatitis, or in patients with jaundice, cholangitis or dilation of the CBD. Endoscopic sphincterotomy is performed in patients with CBD stones or in patients with biliary pancreatitis and cholelithiasis who are not candidates for cholecystectomy. The roles of newer diagnostic modalities, including magnetic resonance cholangiopancreatography and endoscopic ultrasonography, are not yet clear.

Safety of ERCP during pregnancy

OBJECTIVES

There are few data in the literature regarding the indications, therapy, and safety of endoscopic management of pancreatico-biliary disorders during pregnancy. We report the largest single center experience with ERCP in pregnancy.

METHODS

We reviewed 15 patients that underwent ERCP during pregnancy. In all patients, the pelvis was lead-shielded and the fetus was monitored by an obstetrician. Fluoroscopy was minimized and hard copy radiographs taken only when essential.

RESULTS

The mean patient age was 28.9 yr (15-36 yr). The mean duration of gestation was 25 wk (12-33 wk); one patient was in the first, five in the second, and nine in the third trimester. The indications were gallstone pancreatitis (n = 6), choledocholithiasis on ultrasound (n = 5), elevated liver enzymes and a dilated bile duct on ultrasound (n = 2), abdominal pain and gallstones (n = 1), and chronic pancreatitis (n = 1). ERCP findings were bile duct stones (n = 6), patulous papilla (n = 1), bile duct debris (n = 1), normal bile duct and gallstones or gallbladder sludge (n = 3), dilated bile duct and gallstones (n = 1), normal bile duct and no gallstones (n = 2), and chronic pancreatitis (n = 1). Six patients underwent sphincterotomies and one a biliary stent insertion. One sphincterotomy was complicated by mild pancreatitis. All infants delivered to date have had Apgar-scores >8, and continuing pregnancies are uneventful. Mean fluorosocopy time was 3.2 min (SD +/- 1.8). An estimated fetal radiation exposure was 310 mrad (SD +/- 164) which is substantially below the accepted teratogenic dose.

CONCLUSIONS

ERCP in pregnancy seems to be safe for both mother and fetus; however, it should be restricted to therapeutic indications with additional intraprocedure safety measures.

Virtual colonoscopy for the detection of colorectal polyps and cancers in a Chinese population

AIM

The aim of this study is to assess the sensitivity of virtual colonoscopy in detecting colorectal polyps and cancers in a Chinese population.

METHODS

Seventy-one consecutive Chinese patients (38 men and 33 women) referred for diagnostic colonoscopy were recruited. Patients received a routine bowel preparation in the morning followed by a helical abdominal computed tomography (CT) scan with air insufflation of the colon. The CT images were then processed by using surface-rendered software and interpreted by a single radiologist who was blinded to the clinical information. Colonoscopy was performed in the same afternoon without knowledge of the radiology results. All polyps and cancers were proven histologically.

RESULTS

Five colorectal cancers were diagnosed and all were detected by virtual colonoscopy. The sensitivity and specificity of virtual colonoscopy for the detection of patients with polyps of all sizes, and patients with polyps >/=10 mm were 59, 92, 88 and 100%, respectively. The procedure was well tolerated by all patients.

CONCLUSIONS

This study was carried out in a real clinical setting without a preselection of cases. Virtual colonoscopy was satisfactory for the detection of polyps greater than 10 mm, and for the diagnosis of cancer, and it is also a promising imaging modality for colorectal neoplasm detection in a Chinese population.

Risk factors for complications after performance of ERCP

BACKGROUND

ERCP has become widely available for the diagnosis and treatment of benign and malignant pancreaticobiliary diseases. In this prospective study, the overall complication rate and risk factors for diagnostic and therapeutic ERCP were identified.

METHODS

Data were collected prospectively on patient characteristics and endoscopic techniques from 1223 ERCPs performed at a single referral center and entered into a database. Univariate and multivariate analyses were used to identify risk factors for ERCP-associated complications.

RESULTS

Of 1223 ERCPs performed, 554 (45.3%) were diagnostic and 667 (54.7%) therapeutic. The overall complication rate was 11.2%. Post-ERCP pancreatitis was the most common (7.2%) and in 93% of cases was self-limiting, requiring only conservative treatment. Bleeding occurred in 10 patients (0.8%) and was related to a therapeutic procedure in all cases. Nine patients had cholangitis develop, most cases being secondary to incomplete drainage. There was one perforation (0.08%). All other complications totaled 1.5%. Variables derived from cannulation technique associated with an increased risk for post-ERCP pancreatitis were precut access papillotomy (20%), multiple cannulation attempts (14.9%), sphincterotome use to achieve cannulation (13.1%), pancreatic duct manipulation (13%), multiple pancreatic injections (12.3%), guidewire use to achieve cannulation (10.2%), and the extent of pancreatic duct opacification (10%). Patient characteristics associated with an increased risk of pancreatitis were sphincter of Oddi dysfunction (21.7%) documented by manometry, previous ERCP-related pancreatitis (19%), and recurrent pancreatitis (16.2%). Pain during the procedure was an important indicator of an increased risk of post-ERCP pancreatitis (27%). Independent risk factors for post-ERCP pancreatitis were identified as a history of recurrent pancreatitis, previous ERCP-related pancreatitis, multiple cannulation attempts, pancreatic brush cytology, and pain during the procedure.

CONCLUSIONS

The most frequent ERCP-related complication was pancreatitis, which was mild in the majority of patients. The frequency of post-ERCP pancreatitis was similar for both diagnostic and therapeutic procedures. Bleeding was rare and mostly associated with sphincterotomy. Other complications such as cholangitis and perforation were rare. Specific patient- and technique-related characteristics that can increase the risk of post-ERCP complications were identified.

Risk factors for complications after performance of ERCP

BACKGROUND

ERCP has become widely available for the diagnosis and treatment of benign and malignant pancreaticobiliary diseases. In this prospective study, the overall complication rate and risk factors for diagnostic and therapeutic ERCP were identified.

METHODS

Data were collected prospectively on patient characteristics and endoscopic techniques from 1223 ERCPs performed at a single referral center and entered into a database. Univariate and multivariate analyses were used to identify risk factors for ERCP-associated complications.

RESULTS

Of 1223 ERCPs performed, 554 (45.3%) were diagnostic and 667 (54.7%) therapeutic. The overall complication rate was 11.2%. Post-ERCP pancreatitis was the most common (7.2%) and in 93% of cases was self-limiting, requiring only conservative treatment. Bleeding occurred in 10 patients (0.8%) and was related to a therapeutic procedure in all cases. Nine patients had cholangitis develop, most cases being secondary to incomplete drainage. There was one perforation (0.08%). All other complications totaled 1.5%. Variables derived from cannulation technique associated with an increased risk for post-ERCP pancreatitis were precut access papillotomy (20%), multiple cannulation attempts (14.9%), sphincterotome use to achieve cannulation (13.1%), pancreatic duct manipulation (13%), multiple pancreatic injections (12.3%), guidewire use to achieve cannulation (10.2%), and the extent of pancreatic duct opacification (10%). Patient characteristics associated with an increased risk of pancreatitis were sphincter of Oddi dysfunction (21.7%) documented by manometry, previous ERCP-related pancreatitis (19%), and recurrent pancreatitis (16.2%). Pain during the procedure was an important indicator of an increased risk of post-ERCP pancreatitis (27%). Independent risk factors for post-ERCP pancreatitis were identified as a history of recurrent pancreatitis, previous ERCP-related pancreatitis, multiple cannulation attempts, pancreatic brush cytology, and pain during the procedure.

CONCLUSIONS

The most frequent ERCP-related complication was pancreatitis, which was mild in the majority of patients. The frequency of post-ERCP pancreatitis was similar for both diagnostic and therapeutic procedures. Bleeding was rare and mostly associated with sphincterotomy. Other complications such as cholangitis and perforation were rare. Specific patient- and technique-related characteristics that can increase the risk of post-ERCP complications were identified.

The role of ERCP and pancreatoscopy in cystic and intraductal tumors

ERCP and pancreatoscopy may establish a diagnosis of IPMT and differentiate it from a pseudocyst or cystic neoplasm of the pancreas. These techniques may also assess risk of malignancy, extent of disease, allow tissue sampling, and provide therapeutic intervention.

Pancreatic stent placement for duct disruption

BACKGROUND

The aim of this study was to identify predictors of outcome after pancreatic duct stent placement for duct disruption.

METHODS

Patients were identified from endoscopy databases. Disruption was defined by extravasation of contrast from the pancreatic duct during endoscopic retrograde pancreatography. Data collected included demographic information, imaging studies, management before and outcome after stent placement. Success was defined as resolution of the disruption clinically, on radiologic imaging, and/or at endoscopic retrograde pancreatography.

RESULTS

Forty-three patients (23 women, 20 men; mean age 57 years, [SD] 15.2 years) were studied. The etiology of pancreatic duct disruption was acute pancreatitis in 24, chronic pancreatitis in 9, operative injury in 7, and trauma in 3 patients. In 25 patients there was resolution of the disruption, whereas stent therapy was unsuccessful in 16 and the outcome was indeterminate in 2 patients. On univariate analysis, stent positioned to bridge the disruption (p = 0.04) and longer duration of stent therapy (p = 0.002) were associated with a successful outcome. Female gender (p = 0.05) and acute pancreatitis (p = 0.05) were associated with a lack of success. On multivariate analysis, only the bridging stent position remained correlated to outcome. Complications occurred in 4 patients.

CONCLUSIONS

A bridging stent is associated with a successful outcome after pancreatic duct stent placement for duct disruption.

Bedside scoring system to predict the risk of developing pancreatitis following ERCP

BACKGROUND AND STUDY AIMS

Pancreatitis is the most common significant complication of endoscopic retrograde cholangiopancreatography (ERCP). The aim of the present study was to develop a simple scoring system that clinicians can use to predict the risk of post-ERCP pancreatitis.

PATIENTS AND METHODS

We analyzed a prospectively assembled database of 1835 ERCP procedures at a single referral hospital. Multivariate logistic regression analysis was performed to identify risk factors for pancreatitis and determine their relative contributions. From these results, a scoring system was constructed. The performance of the scoring system was assessed on the entire procedure database and in selected subgroups.

RESULTS

Multivariate analysis yielded four risk factors: pain during the procedure, cannulation of the pancreatic duct (PD), previous post-ERCP pancreatitis, and number of cannulation attempts. Based on the regression model, the scoring system was: 4 points for pain, 3 points for PD cannulation, 2 points for a history of post-ERCP pancreatitis, and 1 - 4 points depending on the number of cannulation attempts. A total score of 1 - 4 points was associated with a low risk of pancreatitis (< 2 %), while a score of 5 - 8 points had an intermediate risk (7 %), and a score of 9 or above had a high risk (28 %).

CONCLUSIONS

This simple scoring system may enable clinicians to stratify patients into low-risk, medium-risk, and high-risk groups for the development of post-ERCP pancreatitis. In addition, when patients with suspected sphincter of Oddi dysfunction and patients who underwent minor papilla cannulation were analyzed separately, the scoring system was able to predict accurately the pancreatitis risk of these patients as well.

High-resolution chromoendoscopy for classifying colonic polyps: a multicenter study

BACKGROUND

Chromoendoscopy may reliably separate adenomatous from nonadenomatous polyps. The aim of this multicenter trial was to determine the accuracy of high-resolution chromoendoscopy for the determination of colonic polyp histology.

METHODS

This multicenter trial included 4 academic centers and a primary care practice. In 299 patients referred for routine colonoscopy or sigmoidoscopy, 520 polyps 10 mm in size were sprayed with indigo carmine dye. Using a high-resolution endoscope, the endoscopist predicted the histology of each polyp based on its surface characteristics. Hyperplastic polyps had a "pitted" surface pattern of orderly arranged "dots" that resembled surrounding normal mucosa. Adenomatous polyps had at least one surface "groove" or "sulcus." Each polyp was subsequently resected for histopathologic evaluation.

RESULTS

The resected polyps were comprised by 193 adenomas (37%), 225 hyperplastic polyps (43%), and 102 "other" types (20%). Forty polyps (7.7%) could not be classified by high resolution chromoendoscopy with indigo carmine dye. For the remaining polyps, the sensitivity, specificity, and negative predictive value of indigo carmine dye staining for adenomatous polyps were, respectively, 82%, 82%, and 88%. The results were consistent among the academic centers and the primary care practice.

CONCLUSIONS

High-resolution chromoendoscopy with indigo carmine dye demonstrates morphologic detail of diminutive colorectal polyps that can reliably be used to separate adenomatous from nonadenomatous polyps.

"Tannenbaum" Teflon stents versus traditional polyethylene stents for treatment of malignant biliary stricture

BACKGROUND

Premature stent clogging is the major limitation with plastic stents used in the treatment of malignant biliary structures. A pilot study suggested improved duration of patency of the Tannenbaum stent compared with polyethylene stents. The aim of this prospective, multicenter randomized trial was to compare the Tannenbaum Teflon stent with a conventional polyethylene endoprosthesis (Cotton-Leung biliary stent set) for the treatment of malignant biliary strictures.

METHODS

Patients over age 18 years with symptoms caused by nonhilar malignant biliary strictures were enrolled. Patients were randomized to receive a 10F Tannenbaum or polyethylene stent after a guidewire was passed beyond the stricture. One hundred six patients (mean age 72 years and 71 years, respectively) were enrolled (54 Tannenbaum, mean age 72 years; 52 polyethylene, mean age 71 years).

RESULTS

Tannenbaum and polyethylene stent placement was successful in, respectively, 100% and 96% of procedures without complications. The mean (SD) 90-day stent patency of the Tannenbaum stent was 67% (7%) compared with 73% (7%) for the polyethylene stents.

CONCLUSIONS

The present study demonstrated no difference in ease of implantation or stent patency between Tannenbaum and polyethylene stents.

NAD(P)H and collagen as in vivo quantitative fluorescent biomarkers of epithelial precancerous changes

During the development of neoplasia, epithelial tissues undergo biochemical and structural changes that can manifest in tissue fluorescence. There have been several reports on different in vivo fluorescence characteristics between normal and precancerous (dysplastic) tissues. However, it has been difficult to identify and quantify the origins of these changes, mainly because of distortions introduced in measured tissue fluorescence spectra by tissue scattering and absorption. Such distortions can be removed by combining information in simultaneously measured fluorescence and reflectance spectra. Thus, we can recover the intrinsic (undistorted) tissue fluorescence. In this report, we show that extraction of the intrinsic fluorescence allows us: (a) to determine the fluorescence spectra of NAD(P)H and collagen in an in vivo environment, and (b) to use these NAD(P)H and collagen spectra to describe, quantitatively, diagnostically significant biochemical changes between normal and dysplastic tissues. Specifically, by analyzing intrinsic fluorescence of human epithelial tissue as it becomes deoxygenated in vivo, we can resolve the fluorescence spectra of NAD(P)H and collagen, two of the major tissue fluorophores. This is important because fluorescence depends on the local environment of the chromophore. Then, we extract the intrinsic fluorescence spectra of sites from 35 patients with suspected cervical lesions and 7 patients with Barrett's esophagus and describe them accurately as a linear combination of NAD(P)H and collagen contributions. In both tissue cases, we find that low collagen and high NAD(P)H fluorescence characterizes the high-grade dysplastic lesions when compared with nondysplastic tissues. These data present evidence for the presence of detectable levels of NAD(P)H fluorescence in human epithelial tissues in an in vivo setting and demonstrate that NAD(P)H and collagen may be used as quantitative fluorescence biomarkers for in vivo detection of dysplasia in the cervix and the esophagus.

Endoscopic treatment of massive rectal bleeding following prostate needle biopsy

We describe two cases of massive rectal bleeding following needle biopsy of the prostate. In each case, colonoscopic evaluation revealed bleeding from the biopsy site. Bleeding was controlled with the placement of a single band in one case, and with epinephrine injection in the other. Endoscopic evaluation of patients presenting with severe rectal bleeding following needle biopsy of the prostate may allow immediate therapy.