Clinical outcomes: endoscopic resection of duodenal ampullary lesions

Background

Ampullary adenomas are lesions at the duodenum's major papilla commonly associated with familial adenomatous polyposis (FAP) but may also occur sporadically. Historically, ampullary adenomas were removed surgically, however endoscopic resection has become the preferred method of resection. Most of the literature on management of ampullary adenomas are small single-center retrospective reviews. The objective of this study is to describe endoscopic papillectomy outcomes to further refine management guidelines.

Methods

This is a retrospective study of patients who underwent endoscopic papillectomy. Demographic data were included. Details regarding lesions and procedures were also collected, including endoscopic impression, size, resection method and adjunctive therapies. Chi-square, Kruskal-Wallis rank-sum, and t-tests were performed.

Results

A total of 90 patients were included. 60% patients (54 of 90) had pathology-proven adenomas. 14.4% of all lesions (13 of 90) and 18.5% of adenomas (10 of 54) were treated with APC. Among APC-treated lesions, 36.4% developed recurrence (4 of 11) vs. 7.1% developed residual lesion (1 of 14) (P=0.019). 15.6% of all lesions (14 of 90) and 18.5% of adenomas (10 of 54) reported complications, and the most common was pancreatitis (11.1% and 5.6%). Median follow-up time was 8 months for all lesions and 14 months (range, 1-177 months) for adenomas, with time to recurrence 30 and 31 months (range, 1-137 months), respectively. Recurrence was observed in 16.7% of all lesions (15 of 90) and 20.4% of adenomas (11 of 54). Endoscopic success was observed in 69.2% of all lesions (54 of 78) and 71.4% of adenomas (35 of 49) after removing patients lost to follow-up.

Conclusions

Endoscopic papillectomy is an effective method for managing duodenal adenomas. Pathology-proven adenoma should undergo surveillance for at least 31 months. Lesions treated with APC may require closer follow-up and for a prolonged period.

Gastrointestinal hemorrhage in the setting of gastrointestinal cancer: Anatomical prevalence, predictors, and interventions

BACKGROUND

Gastrointestinal hemorrhage (GIH) is a common complication with gastrointestinal cancers (GIC). There is no comprehensive research that examines GIH in different types of GIC.

AIM

To study the prevalence, predictors, and interventions of GIH based on the anatomical location of GIC.

METHODS

This is a retrospective analysis of the 2016-2018 National Inpatient Sample database, the largest inpatient care database in the United States. All adult inpatients (≥ 18-year-old) were included. ICD-10-CM codes were used to identify patients with GIH and GIC. Prevalence of GIH was obtained based on the anatomical location of GIC. Predictors of GIH in the GIC population were studied using multivariate analysis. Interventions including endoscopy were compared to the non-intervention group to determine the differences in inpatient mortality.

RESULTS

Out of a total of 18173885 inpatients, 321622 (1.77%) cases had a diagnosis of GIC. Within GIC patients, 30507 (9.5%) inpatients had GIH, which was significantly (P < 0.001) more than the prevalence of GIH in patients without GIC (3.4%). The highest to lowest GIH rates are listed in the following order: Stomach cancer (15.7%), liver cancer (13.0%), small bowel cancer (12.7%), esophageal cancer (9.1%), colorectal cancer (9.1%), pancreatic cancer (7.2%), bile duct cancer (6.0%), and gallbladder cancer (5.1%). Within gastric cancer, the GIH rate ranged from 14.8% in cardia cancer to 25.5% in fundus cancer. Within small bowel cancers, duodenal cancers had a higher GIH rate (15.6%) than jejunal (11.1%) and ileal cancers (5.7%). Within esophageal cancers, lower third cancers had higher GIH (10.7%) than the middle third (8.0%) or upper third cancers (6.2%). When studying the predictors of GIH in GIC, socioeconomic factors such as minority race and less favorable insurances (Medicaid and self-pay) were associated with significantly higher GIH on multivariate analysis (P < 0.01). Chemotherapy and immunotherapy were also identified to have a lower risk for GIH [odds ratios (OR) = 0.74 (0.72-0.77), P < 0.001]. Out of 30507 GIC inpatients who also had GIH, 16267 (53.3%) underwent an endoscopic procedure, i.e., upper endoscopy or colonoscopy. Inpatient mortality was significantly lower in patients who underwent endoscopy compared to no endoscopy [5.5% vs 14.9%, OR = 0.42 (0.38-0.46), P < 0.001].

CONCLUSION

The prevalence of GIH in patients with GIC varies significantly based on the tumor’s anatomical location. Endoscopy, which appears to be associated with a substantial reduction in inpatient mortality, should be offered to GIC patients with GIH. Nevertheless, the decision on intervention in the GIC population should be tailored to individual patient's goals of care, the benefit on overall care, and long-term survival.

Role of colonoscopy in diagnosis of capecitabine associated ileitis: Two case reports

BACKGROUND

Capecitabine is considered a first line agent in adjuvant therapy for breast and colorectal cancer. However, cases of severe diarrhea have been reported with increasing frequency in recent years. When diarrhea is severe and prolonged, capecitabine associated ileitis should be considered as a possible etiology.

CASE SUMMARY

Herein, we present two cases of capecitabine ileitis, specifically involving the terminal ileum and ascending colon. We will demonstrate the disease course and treatment modalities applied to alleviate this condition, as well as discuss the merits of using colonoscopy to aid in diagnosis.

CONCLUSION

Ultimately our cases demonstrate that symptomatic management with traditional anti-diarrheal medications is largely ineffective. Prompt recognition and discontinuation of capecitabine is an imperative step in proper management of this condition and colonoscopy with biopsy can be helpful when the diagnosis is unclear.

Hepatotoxicity induced by immune checkpoint inhibitors: a comprehensive review including current and alternative management strategies

INTRODUCTION

Immune checkpoint inhibitors (ICIs) block cytotoxic T lymphocyte antigen 4 (CTLA-4) and programmed cell death protein 1 (PD-1)/PD ligand 1 (PD-L1) receptors that control antitumor activities of lymphocytes. While highly efficacious, these drugs have been associated with several immune-related adverse events (irAEs) due to the disruption of self-tolerance. Immune-mediated hepatitis (IMH) usually presents as mild elevations of liver enzymes though it can rarely be associated with life-threatening hepatic injury. Areas covered: A comprehensive review was performed to define the clinicopathologic forms of liver injury associated with ICIs, comparing the various ICI classes as well as comparing this form of IMH with idiopathic autoimmune hepatitis and drug-induced autoimmune hepatitis. Liver biopsy has proven very useful in selected patients. A specific form of fibrin ring granulomatous hepatitis appears to be associated with IMH. The current societal treatment algorithms and emerging data were reviewed to determine when to utilize corticosteroids. Expert opinion: Monitoring for severe ICI-IMH is recommended although acute liver failure remains rare. Most patients with grade 3-4 hepatotoxicity respond to corticosteroids, but a subset of patients with mild hepatitis on liver biopsy resolve without steroids and need to be carefully selected in concert with the consultation of a hepatologist.

Treatment of hypocalcemia in hungry bone syndrome: A case report

INTRODUCTION

Hungry bone syndrome (HBS) is rapid, intense and prolonged hypocalcemia that follows parathyroidectomy. The focus of this paper is HBS in patients with secondary hyperparathyroidism (SHPT) due to end stage renal disease (ESRD). Various risk factors are correlated with developing HBS post-parathyroidectomy due to SHPT which include: old age (>60 years); the preoperative level of parathyroid hormone (PTH); increased osteoclasts; and evidence of bone disease before surgery.

PRESENTATION OF CASE

A 25-year-old woman, who underwent parathyroidectomy of all four parathyroid glands due to SHPT caused by ESRD. Her calcium deficit was prolonged, as expected in patients who undergo parathyroidectomy, however her calcium levels remained low despite unprecedented supplementation of elemental calcium and calcitriol.

DISCUSSION

Unfortunately, there is not enough data-based evidence to help prevent or minimize severe complications of hypocalcemia prior to parathyroidectomy. The main goal of treatment is replenishing the calcium deficiency through supplementation with calcium salts, high doses of active metabolites of vitamin D, and electrolytes.

CONCLUSION

The ultimate goal of reviewing and analyzing this particular case is to obtain a better understanding for the treatment of Hungry bone syndrome. Although, there are very few cases as severe as this patient, hopefully this case study will result in greater insight and lead to improvement in the overall treatment of hypocalcemia.

Liver transplantation for hepatocellular carcinoma in Puerto Ricans: underutilization of a curative therapy

OBJECTIVE

Hepatocellular carcinoma (HCC), the most common type of liver cancer, is becoming a healthcare burden for Puerto Rico and, in particular, for those clinics that specialize in liver disease. It is our hypothesis that liver transplantation, the most effective curative option for unresectable tumors, is underutilized. We describe in detail the outcomes of liver transplants for HCC in Puerto Ricans referred to a major liver transplant center in the USA.

METHODS

Thirty-two Puerto Rican HCC patients receiving transplants (from January 1, 1997, through July of 2012) at Tampa General Hospital are described. Recurrence rates were calculated, and the Kaplan-Meier estimator was used for survival analysis.

RESULTS

The proportion of transplants performed for HCC in our Puerto Rican patients was only 12% (p = 0.05). Disease-free survival at 1, 3, and 5 years was 93.7%, 83%, and 78.8%, respectively. Patient survival at 1, 3, and 5 years was 96.7%, 75%, and 67%, respectively. Sixty-nine percent of the 32 patients were alive at the mean follow-up of 56 months. The recurrence rate from 2002 to the present is 14%.

CONCLUSION

This study provides the most comprehensive report detailing the relative benefits of utilizing liver transplantation as a curative option for Puerto Ricans with hepatocellular carcinoma. It also incorporates the first comprehensive review of the available literature of liver cancer in Puerto Rico. Survival and recurrence rates were comparable to published results. In Puerto Rico, liver transplantation for HCC patients has been underutilized. In order to improve outcomes over the next 2 decades, it is imperative that the healthcare system in Puerto Rico handle the burden of this disease using liver transplantation, locoregional therapies, and newer treatments for hepatitis C and HCC.