Successful Endoscopic Retrograde Appendicitis Therapy Following a Recent ST-Elevation Myocardial Infarction

Acute appendicitis is one of the most common abdominal surgical emergencies. A laparoscopic or open appendectomy has traditionally been the gold standard. Antibiotic therapy has recently been found to be noninferior. The treatment of acute uncomplicated appendicitis remains a challenge, especially in the presence of an appendicolith. We present a case of a 59-year-old man with recent ST-elevation myocardial infarction who underwent successful endoscopic retrograde appendicitis therapy.

Efficacy and Safety of Peroral Endoscopic Myotomy (POEM) in Achalasia: An Updated Meta-analysis

Background: Heller myotomy has been considered the standard surgical treatment for patients with achalasia. Since the initiation of peroral endoscopic myotomy (POEM), it has represented an alternative for treating patients with achalasia. Over the years, numerous prospective and retrospective studies with POEM use for achalasia have been published. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of POEM in patients with achalasia. Methods: Publications investigating the safety and efficacy of POEM in patients with achalasia were searched in Medline, Ovid Journals, Medline non-indexed citations, and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews. Pooling was conducted by both fixed and random effects models. Results: The initial search identified 328 reference articles; of these, 34 relevant articles were selected and reviewed. Data was extracted from 20 studies (n=1753) which met the inclusion criteria. In pooled analysis, the clinical success of POEM at 3 months was 94% (95% CI=93-95). The pooled clinical success of POEM at 12 months was 91% (95% CI=90-92). The pooled rate of gastroesophageal reflux disease (GERD) was 21% (95% CI=19-23), esophagitis was reported in 16% (95% CI=15-18), pneumomediastinum in 4% (95% CI=3-6), cervical emphysema in 12% (95% CI=10-13), pneumoperitoneum in 8% (95% CI=7-10), pneumothorax in 5% (95% CI=4 - 6), pleural effusion in 3% (95% CI=2-3), post-operative bleeding in 4.29% (95% CI=1.91 -7.61) and aspiration pneumonia in 3.08% (95% CI=1.13-5.97) of the patients after POEM. Conclusion: This meta-analysis suggests that POEM is a highly effective and safe endoscopic treatment for patients with achalasia and a reasonable alternative to Heller myotomy.

Learning curve for esophageal peroral endoscopic myotomy: a systematic review and meta-analysis

BACKGROUND AND STUDY AIMS : Peroral endoscopic myotomy (POEM) is a minimally invasive endoscopic procedure for the treatment of achalasia and certain spastic esophageal motility disorders, delivering excellent results in experienced hands. However, this complex and technically challenging procedure requires advanced endoscopic skills. The aim of this study was to conduct a systematic review and meta-analysis of current data to evaluate the learning curve for POEM in new adopters of this technique. METHODS : Electronic databases (PubMed, Embase, and Cochrane Library) from inception to November 2021 were searched for publications addressing the learning curve in POEM. Pooling was conducted by both fixed- and random-effects models. Secondary outcomes reviewed were clinical success defined by Eckardt score ≤ 3 when available and adverse events. RESULTS : Eight studies involving 1904 patients met the inclusion criteria. In the pooled analysis, new adopters of POEM attained proficiency at a mean of 24.67 procedures (95 %CI 23.93 to 25.41). Once proficiency was achieved, the pooled total procedure time plateaued at a mean of 85.38 minutes (95 %CI 81.48 to 89.28), the pooled mean procedure time per centimeter of myotomy was 6.25 minutes (95 %CI 5.69 to 6.82), and the pooled mean length of myotomy was 11.49 cm (95 %CI 10.90 to 12.08). CONCLUSIONS : Our analysis showed that new adopters of POEM with previous advanced endoscopy experience required about 25 procedures to attain proficiency. The average time for each procedure once proficiency was attained was about 85 minutes.

Duodenocaval Fistula from an Inferior Vena Cava Filter Perforation

Background

Case report

Conclusions

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Duodenal perforation from IVC filter strut perforation is a rare complication.

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Patients typically present with abdominal pain and upper gastrointestinal bleeding.

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Both endovascular and open surgical techniques can be used to retrieve a filter

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Endovascular retrieval has the potential for development of peri-operative sepsis.

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Open surgical removal is preferred in patients with significant filter dwell time.

Feasibility and safety of microforceps biopsy in the diagnosis of pancreatic cysts

BACKGROUND AND AIMS

The tissue acquisition and diagnostic yield of cyst fluid cytology is low-to-moderate and rarely provides a specific diagnosis. The aim of this study was to compare the tissue acquisition and diagnostic tissue yield of microforceps biopsy (MFB) with cyst fluid cytology.

METHODS

In this multicenter study, data of 42 patients who had cysts both aspirated by EUS-guided FNA (EUS-FNA) and biopsy specimens were then obtained with an MFB device, were collected. Cytology analysis of cyst fluid and histologic analysis of biopsy specimens were done. Acquisition yield was defined as percentage of patients with tissue present in the aspirate or biopsy. Diagnostic tissue yield was evaluated at 3 levels: the ability of differentiation between mucinous and/or nonmucinous cysts, detection of high risk for malignancy, and specific cyst type diagnosis.

RESULTS

The mean patient age was 69 years. Sixteen pancreatic cysts (38.1%) were located in the head, 17 (40.5%) in the body, and 9 (21.4%) in the tail. The mean cyst size was 28.2 mm (12-60 mm); 25 of 42 (60%) were septated. The EUS-FNA tissue (fluid) acquisition yield was 88.1% (37/42). The MFB tissue acquisition yield was 90.4% (38/42). The diagnostic cytology yield to differentiate between mucinous and/or nonmucinous cysts was 47.6% (20/42), and the MFB histologic yield to differentiate between mucinous and/or nonmucinous cysts was 61.9% (26/42) (P = .188). The percentage of cysts at high risk for malignancy by cytology was 54.7% (23/42), and MFB was 71.5% (30/42) (P = .113). However, the ability of MFB to provide a specific cyst type diagnosis was 35.7% (15/42), and that for cytology was 4.8% (2/42) (P = .001). Surgical histology was concordant with that of MFB in 6 of 7 patients (85%), and with that of cytology in 1 of 7 patients (15%).

CONCLUSION

The cyst tissue acquisition yield for MFBs was 90%. Although cytology of cyst fluid and MFB were comparable in distinguishing mucinous and nonmucinous cysts and detecting cysts at high risk for malignancy, MFB was far superior to cytology for providing a specific cyst diagnosis.

Surgical vs Endoscopic Management of T1 Esophageal Adenocarcinoma: A Modeling Decision Analysis

BACKGROUND & AIMS

Although treatment of T1a esophageal adenocarcinoma (EAC) is shifting from esophagectomy to endoscopic therapy, T1b EACs are considered too high risk to be treated endoscopically. We investigated the effectiveness and cost effectiveness of esophagectomy vs endoscopic therapy for T1a and T1b EACs, and the effects of age and comorbidities, using a decision analytic Markov model.

METHODS

We developed a model to simulate a hypothetical cohort of men 75 years old with Charlson comorbidity index scores of 0 and either T1aN0M0 or T1bN0M0 EAC, as a base case. We used the model to compare the effects of esophagectomy vs serial endoscopic therapy. We performed sensitivity analyses based on age at diagnosis of 60-85 years, comorbidity indices of 0-2, and utilities. Post-procedure cancer-specific mortality was derived from the Surveillance, Epidemiology, and End Results Medicare database.

RESULTS

In the T1a base case, esophagectomy yielded more unadjusted life years than endoscopic therapy (6.97 vs 6.81), but fewer quality-adjusted life years (QALYs, 4.95 for esophagectomy vs 5.22 for endoscopic therapy). In the T1b base case, esophagectomy yielded more unadjusted life years than endoscopic therapy (5.73 vs 5.01) and QALYs (4.07 vs 3.85 for endoscopic therapy), but was not cost effective (incremental cost-effectiveness ratio $156,981). Sensitivity analyses showed endoscopic therapy optimized QALYs for patients more than 80 years old with a comorbidity index of 1 or 2, or if the ratio of post-esophagectomy to post-endoscopic therapy utilities was below 0.875.

CONCLUSION

In a Markov model, we showed that endoscopic therapy of T1a EAC yields more QALYs and is more cost effective than esophagectomy for patients of all ages and comorbidity indices tested. In contrast, selection of therapy for T1b EAC depends on age and comorbidities, due to surgical mortality and the competing risk of non-cancer death.

A meta-analysis and systematic review: Success of endoscopic ultrasound guided biliary stenting in patients with inoperable malignant biliary strictures and a failed ERCP

BACKGROUND

In patients with inoperable malignant biliary strictures, endoscopic retrograde cholangiopancreatography (ERCP) guided biliary stenting fails in 5% to 10% patients due to difficult anatomy/inability to cannulate the papilla. Recently, endoscopic ultrasound guided biliary drainage (EUS-BD) has been described.Primary outcomes were to evaluate the biliary drainage success rates with EUS and compare it to percutaneous transhepatic biliary drainage (PTBD). Secondary outcomes were to evaluate overall procedure related complications.

METHODS

STUDY SELECTION CRITERIA:: Studies evaluating the efficacy of EUS-BD and comparing EUS-BD versus PTBD in inoperable malignant biliary stricture patients with a failed ERCP were included in this analysis.

DATA COLLECTION AND EXTRACTION

Articles were searched in Medline, PubMed, and Ovid journals. Two authors independently searched and extracted data. The study design was written in accordance to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Subgroup analyses of prospective studies and EUS-BD versus PTBD were performed.

STATISTICAL METHOD

Pooled proportions were calculated using fixed and random effects model. I statistic was used to assess heterogeneity among studies.

RESULTS

Initial search identified 846 reference articles, of which 124 were selected and reviewed. Sixteen studies (N = 528) that met the inclusion criteria were included in this analysis. In the pooled patient population, the percentage of patients that had a successful biliary drainage with EUS was 90.91% (95% CI = 88.10-93.38). The proportion of patients that had overall procedure related complications with EUS-PD was 16.46% (95% CI = 13.20-20.01). The pooled odds ratio for successful biliary drainage in EUS-PD versus PTBD group was 3.06 (95% CI = 1.11-8.43). The risk difference for overall procedure related complications in EUS-PD versus PTBD group was -0.21 (95% CI = -0.35 to -0.06). Relative risk for infectious complications and bile leak in EUS-BD versus PTBD was 0.25 (95% CI = 0.07-0.94) and 0.33 (95% CI = 0.12-0.87), respectively.

CONCLUSIONS

In patients with inoperable malignant biliary strictures who failed an ERCP guided biliary stenting, EUS-BD seems to be an excellent management option and superior to PTBD with higher successful biliary drainage rates and relatively fewer complications.

Covered versus uncovered self-expandable metal stents for malignant biliary strictures: A meta-analysis and systematic review

Self-expandable metal stents (SEMS) are used for palliating inoperable malignant biliary strictures. It is unclear if covered metal stents are superior to uncovered metal stents in these patients. We compared clinical outcomes in patients with covered and uncovered stents. Studies using covered and uncovered metallic stents for palliation in patients with malignant biliary stricture were reviewed. Articles were searched in MEDLINE, PubMed, and Ovid journals. Fixed and random effects models were used to calculate the pooled proportions. Initial search identified 1436 reference articles, of which 132 were selected and reviewed. Thirteen studies (n = 2239) for covered and uncovered metallic stents which met the inclusion criteria were included in this analysis. Odds ratio for stent occlusion rates in covered vs. uncovered stents was 0.79 (95 % CI = 0.65 to 0.96). Survival benefit in patients with covered vs. uncovered stents showed the odds ratio to be 1.29 (95 % CI = 0.95 to 1.74). Pooled odds ratio for migration of covered vs. uncovered stents was 9.9 (95 % CI = 4.5 to 22.3). Covered stents seemed to have significantly lesser occlusion rates, increased odds of migration, and increased odds of pancreatitis compared to uncovered stents. There was no statistically significant difference in the survival benefit, overall adverse event rate, and patency period of covered vs. uncovered metal stents in patients with malignant biliary strictures.

EUS-derived criteria for distinguishing benign from malignant metastatic solid hepatic masses

BACKGROUND

Detection of hepatic metastases during EUS is an important component of tumor staging.

OBJECTIVE

To describe our experience with EUS-guided FNA (EUS-FNA) of solid hepatic masses and derive and validate criteria to help distinguish between benign and malignant hepatic masses.

DESIGN

Retrospective study, survey.

SETTING

Single, tertiary-care referral center.

PATIENTS

Medical records were reviewed for all patients undergoing EUS-FNA of solid hepatic masses over a 12-year period.

INTERVENTIONS

EUS-FNA of solid hepatic masses.

MAIN OUTCOME MEASUREMENTS

Masses were deemed benign or malignant according to predetermined criteria. EUS images from 200 patients were used to create derivation and validation cohorts of 100 cases each, matched by cytopathologic diagnosis. Ten expert endosonographers blindly rated 15 initial endosonographic features of each of the 100 images in the derivation cohort. These data were used to derive an EUS scoring system that was then validated by using the validation cohort by the expert endosonographer with the highest diagnostic accuracy.

RESULTS

A total of 332 patients underwent EUS-FNA of a hepatic mass. Interobserver agreement regarding the initial endosonographic features among the expert endosonographers was fair to moderate, with a mean diagnostic accuracy of 73% (standard deviation 5.6). A scoring system incorporating 7 EUS features was developed to distinguish benign from malignant hepatic masses by using the derivation cohort with an area under the receiver operating curve (AUC) of 0.92; when applied to the validation cohort, performance was similar (AUC 0.86). The combined positive predictive value of both cohorts was 88%.

LIMITATIONS

Single center, retrospective, only one expert endosonographer deriving and validating the EUS criteria.

CONCLUSION

An EUS scoring system was developed that helps distinguish benign from malignant hepatic masses. Further study is required to determine the impact of these EUS criteria among endosonographers of all experience.

Interobserver agreement for the detection of Barrett's esophagus with optical frequency domain imaging

BACKGROUND

Optical frequency domain imaging (OFDI) is a second-generation form of optical coherence tomography (OCT) providing comprehensive cross-sectional views of the distal esophagus at a resolution of ~7 μm.

AIM

Using validated OCT criteria for squamous mucosa, gastric cardia mucosa, and Barrett's esophagus (BE), the objective of this study was to determine the inter- and intra-observer agreements by a large number of OFDI readers for differentiating these tissues.

METHODS

OFDI images were obtained from nine subjects undergoing screening and surveillance for BE. Sixty-four OFDI image regions of interest were randomly selected for review. A training set of 19 images was compiled distinguishing squamous mucosa from gastric cardia and BE using previously validated OCT criteria. The ten readers then interpreted images in a test set of 45 different images of squamous mucosa (n = 15), gastric cardia (n = 15), or BE (n = 15). Interobserver agreement differentiating the three tissue types and BE versus non-BE mucosa was determined using multi-rater Fleiss's κ value. The images were later randomized again and four readers repeated the test 3 weeks later to assess intraobserver reliability.

RESULTS

All ten readers showed excellent agreement for the differentiation of BE versus non-BE mucosa (κ = 0.811 p < 0.0001) and for differentiating BE versus gastric cardia versus squamous mucosa (κ = 0.866, p < 0.0001). For the four readers who repeated the test, the median intraobserver agreement (BE vs. non-BE) was high (κ = 0.975, IQR: 0.94, 1.0).

CONCLUSIONS

Trained readers have a high interobserver agreement for differentiating BE, squamous, and gastric cardia mucosa using OFDI.

Diagnostic accuracy of endoscopic ultrasound in pancreatic neuroendocrine tumors: a systematic review and meta analysis

AIM

To detect pancreatic neuroendocrine tumors (PNETs) has been varied. This study is undertaken to evaluate the accuracy of endoscopic ultrasound (EUS) in detecting PNETs.

METHODS

Only EUS studies confirmed by surgery or appropriate follow-up were selected. Articles were searched in Medline, Ovid journals, Medline nonindexed citations, and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews. Pooling was conducted by both fixed and random effects model).

RESULTS

Initial search identified 2610 reference articles, of these 140 relevant articles were selected and reviewed. Data was extracted from 13 studies (n = 456) which met the inclusion criteria. Pooled sensitivity of EUS in detecting a PNETs was 87.2% (95%CI: 82.2-91.2). EUS had a pooled specificity of 98.0% (95%CI: 94.3-99.6). The positive likelihood ratio of EUS was 11.1 (95%CI: 5.34-22.8) and negative likelihood ratio was 0.17 (95%CI: 0.13-0.24). The diagnostic odds ratio, the odds of having anatomic PNETs in positive as compared to negative EUS studies was 94.7 (95%CI: 37.9-236.1). Begg-Mazumdar bias indicator for publication bias gave a Kendall's tau value of 0.31 (P = 0.16), indication no publication bias. The P for χ² heterogeneity for all the pooled accuracy estimates was > 0.10.

CONCLUSION

EUS has excellent sensitivity and specificity to detect PNETs. EUS should be strongly considered for evaluation of PNETs.

Accuracy of EUS in the evaluation of small gastric subepithelial lesions

BACKGROUND

EUS combined with endoluminal resection techniques is increasingly used to provide a definitive diagnosis of small gastric subepithelial lesions seen on standard upper endoscopy.

OBJECTIVE

To evaluate the accuracy of EUS in diagnosing small gastric subepithelial lesions by using histology as the criterion standard.

DESIGN

A retrospective study.

SETTING

Academic tertiary care center.

PATIENTS

A total of 22 patients (15 women, mean age 62.2 years) with an endoscopically resected gastric subepithelial lesion were included in this 3-year retrospective study.

MAIN OUTCOME MEASUREMENTS

The size, echogenicity, the layer of origin, and presumptive diagnosis were determined by EUS. The diagnostic accuracy of EUS was determined by using histology as the criterion standard.

RESULTS

The mean size of the 22 lesions was 13.6 mm (range 8-20 mm). An endoscopic cap band mucosectomy device was used to resect 16 (72.7%) lesions, whereas 6 (27.3%) were resected with a saline solution-assisted and snare technique. Using histology as a criterion standard, we found that the accuracy of the EUS diagnosis was 10 of 22 (45.5%). EUS alone had an accuracy rate of 30.8% and 66.7%, respectively, in the diagnosis of neoplastic and non-neoplastic lesions.

LIMITATIONS

A single-center, retrospective analysis.

CONCLUSION

EUS imaging had a low accuracy rate in the diagnosis of gastric subepithelial lesions, and endoscopic submucosal resection should be performed to provide a histologic diagnosis. Resection of small subepithelial lesions of 20 mm or less can be accomplished en bloc with an endoscopic cap band mucosectomy device.

Protoporphyrin IX fluorescence photobleaching increases with the use of fractionated irradiation in the esophagus

Fluorescence measurements have been used to track the dosimetry of photodynamic therapy (PDT) for many years, and this approach can be especially important for treatments with aminolevulinic-acid-induced protoporphyrin IX (ALA-PpIX). PpIX photobleaches rapidly, and the bleaching is known to be oxygen dependent, and at the same time, fractionation or reduced irradiance treatments have been shown to significantly increase efficacy. Thus, in vivo measurement of either the bleaching rate and/or the total bleaching yield could be used to track the deposited dose in tissue and determine the optimal treatment plans. Fluorescence in rat esophagus and human Barrett's esophagus are measured during PDT in both continuous and fractionated light delivery treatment, and the bleaching is quantified. Reducing the optical irradiance from 50 to 25 mWcm did not significantly alter photobleaching in rat esophagus, but fractionation of the light at 1-min on and off intervals did increase photobleaching up to 10% more (p value=0.02) and up to 25% more in the human Barrett's tissue (p value<0.001). While two different tissues and two different dosimetry systems are used, the data support the overall hypothesis that light fractionation in ALA-PpIX PDT esophageal treatments should have a beneficial effect on the total treatment effect.

Cytokeratins 7 and 20 and mucin core protein expression in esophageal cervical inlet patch

Cervical inlet patch (CIP) is defined by the presence of gastric mucosa within the first few centimeters of the esophagus. Several endoscopic series have demonstrated a frequent association of CIP with Barrett's esophagus (BE) suggesting a pathogenetic link. A histochemical study reporting the presence of acid mucin in CIP, including sulfomucin, supports this hypothesis. We evaluated mucin core protein expression and cytokeratins 7 and 20 (CK7/CK20) pattern in biopsies of CIP, normal antrum, and BE to comment on a possible relationship of CIP with BE. We observed that both lesions have similar cytokeratin patterns with mixed CK7/CK20 reactivity on the surface and pits and lone CK7 positivity in the glands. MUC5AC was strongly expressed on the surface and pits but not in the glands of CIP and antral mucosa. Within BE, MUC5AC positivity was noted not only on the surface and pits but also in the glands. MUC6 similarly decorated the glands of CIP and BE. MUC2 was expressed rarely in CIP with goblet cells but conspicuously on the surface and pits of BE. MUC5B was seen in both CIP and BE and rarely in the antral mucosa. The similarities between CIP and BE but not with normal antral mucosa fits with the hypothesis that both lesions may originate from submucosal esophageal mucous glands. Two pathogenetic pathways can be entertained: focal upper esophageal mucosal misdevelopment in pediatric population and patchy metaplastic replacement of squamous mucosa in adults with gastroesophageal reflux disease.

Genetic susceptibility to breast cancer: HLA DQB*03032 and HLA DRB1*11 may represent protective alleles

Tumors are believed to emerge only when immune surveillance fails. We wished to ascertain whether the failure to inherit putative protective alleles of HLA class II genes is linked to the development of breast cancer. We molecularly typed HLA DPB1, DQB1, DRB1, and DRB3 alleles in 176 Caucasian women diagnosed with early-onset breast cancer and in 215 ethnically matched controls. HLA DQB*03032 was identified in 7% of controls but in no patients with early-onset breast cancer (P = 0.0001). HLA DRB1*11 alleles were also significantly overrepresented (P < 0.0001) in controls (16. 3%) as compared with patients with early-onset breast cancer (3.5%). HLA DQB*03032 and HLA DRB1*11 alleles may have a protective role in human breast cancer.

Analysis of MHC class II DP, DQ and DR alleles in Crohn's disease

BACKGROUND

Although inflammation in Crohn's disease is believed to be mediated by activated T cells, genotyping of all MHC class II alleles in white people with this disease has not been reported.

AIMS

To perform a detailed molecular analysis of HLA DPB, DQB, and DRB genes in white patients with Crohn's disease and controls in order to determine if the inheritance of any class II genes confers susceptibility or resistance to this disease.

METHODS

Complete molecular typing of HLA class II DPB, DQB, and DRB alleles was performed in 58 white patients with Crohn's disease and 93 healthy controls using a polymerase chain reaction-sequence specific oligonucleotide based approach.

RESULTS

No significant association with any DPB or DQB alleles was noted in patients with Crohn's disease. Since our previous studies had shown a strong association of an HLA DRB3*0301/DRB1*1302 haplotype with Crohn's disease, we re-examined this association using more stringent genotyping criteria. This haplotype was present in 20.7% of patients and 5.4% of controls (p = 0.0066; relative risk = 4.59).

CONCLUSIONS

The DRB3*0301/DRB1*1302 haplotype is the only significant MHC class II association noted in white people with Crohn's disease and represents the strongest association of any MHC or non-MHC locus with this disease.