Patients With Esophageal Adenocarcinoma With Prior Gastroesophageal Reflux Disease Symptoms Are Similar to Those Without Gastroesophageal Reflux Disease: A Cross-Sectional Study

INTRODUCTION

A substantial proportion of patients with esophageal adenocarcinoma (EAC) do not report gastroesophageal reflux disease (GERD) symptoms. This study aimed to compare the risk factor profiles and cancer stage at presentation of patients with EAC with and without prior GERD.

METHODS

In this retrospective cross-sectional study, patients with EAC were divided into 2 cohorts: (i) EAC with prior GERD: patients who reported typical GERD symptoms (heartburn or regurgitation) ≥1 year before cancer diagnosis and (ii) EAC without prior GERD: patients who did not report prior GERD symptoms or reported symptoms within 1 year of their cancer diagnosis. Baseline demographics, risk factors, and cancer stage at presentation were compared between the 2 cohorts. In addition, the distribution of patients based on numbers of BE/EAC-associated risk factors (1, 2, 3, 4, and 5 or more) was examined in the symptomatic and asymptomatic cohorts.

RESULTS

Over 13 years, 388 patients with EAC with prior GERD and 245 patients with EAC without prior GERD were recruited. Both groups had similar baseline demographics and risk factors, but patients with EAC with prior GERD were more likely to have a history of BE. Asymptomatic patients had more advanced disease. Patients with 3 or more BE/EAC-related risk factors formed the largest proportion of patients in both the symptomatic and asymptomatic cohorts.

DISCUSSION

Patients with EAC with and without prior GERD symptoms are phenotypically similar, suggesting that BE screening efforts to prevent or detect early EAC should not be restricted to just those with GERD.

MULTICENTER, PROSPECTIVE TRIAL OF NON-ENDOSCOPIC BIOMARKER-DRIVEN DETECTION OF BARRETT'S ESOPHAGUS AND ESOPHAGEAL ADENOCARCINOMA

BACKGROUND

Preliminary data suggest that an encapsulated balloon (EsoCheckTM), coupled with a two methylated DNA biomarker panel (EsoGuardTM), detects Barrett's esophagus (BE) and esophageal adenocarcinoma (EAC) with high accuracy. The initial assay required sample freezing upon collection.

AIM

Assess a next-generation EsoCheck sampling device and EsoGuard assay in a much-enlarged multicenter study clinically enhanced by utilizing a CLIA-compliant assay and samples maintained at room temperature.

METHODS

Cases with nondysplastic BE (NDBE), dysplastic BE (indefinite=IND, low grade dysplasia = LGD, high grade dysplasia = HGD), EAC, junctional adenocarcinoma (JAC), plus endoscopy controls without esophageal intestinal metaplasia, were prospectively enrolled. Medical assistants at six institutions delivered the encapsulated balloon per orally, with inflation in the stomach. The inflated balloon sampled the distal 5 cm of the esophagus, then was deflated and retracted into the capsule, preventing sample contamination. EsoGuard bisulfite sequencing assayed levels of methylated Vimentin (mVIM) and methylated Cyclin A1 (mCCNA1).

RESULTS

A total of 243 evaluable patients - 88 cases (median age 68, 78% men, 92% white) and 155 controls (median age 57, 41% men, 88% white) - underwent adequate EsoCheck sampling. Mean procedural time was approximately 3 minutes. Cases included 31 NDBE, 16 IND/LGD, 23 HGD, and 18 EAC/JAC. Thirty-seven (53%) non-dysplastic and dysplastic BE cases were short segment BE (SSBE; < 3 cm). Overall sensitivity was 85% (95% CI= 0.78-0.93), and specificity was 85% (95% CI=0.79-0.90). Sensitivity for NDBE was 84%. EsoCheck/EsoGuard detected 100% of cancers (n=18).

CONCLUSION

EsoCheck/EsoGuard demonstrated high sensitivity and specificity in detecting BE and BE-related neoplasia.

LIQUID NITROGEN SPRAY CRYOTHERAPY FOR ERADICATION OF DYSPLASTIC BARRETT'S ESOPHAGUS: RESULTS FROM A MULTICENTER PROSPECTIVE REGISTRY

BACKGROUND AND AIMS

Liquid nitrogen spray cryotherapy (SCT) is an alternative to radiofrequency ablation (RFA) for eradication of dysplastic Barrett's esophagus (BE). We aimed to assess the safety, efficacy, and durability of SCT in a multicenter U.S. registry.

METHODS

This is a multicenter prospective registry of adults with BE treated with truFreeze Spray Cryotherapy (4 community and 11 academic sites, 2013-2022). Complete eradication of intestinal metaplasia (CEIM) and dysplasia (CED) were assessed in BE with dysplasia or intramucosal adenocarcinoma (IMC). Kaplan-Meier analysis of CEIM and CED was performed. Hazard ratios for CEIM stratified by baseline risk factors were calculated.

RESULTS

Among 138 subjects, with LGD (24%), HGD (49%) and IMC (27%), 34% received prior RFA therapy. Subjects received a median of 2 SCT sessions. Adverse events were uncommon, with 5.5% reporting strictures and 0.7% a perforation. Rates of CEIM and CED, respectively, were 66% and 84% after two years, and 67% and 92% after three years. In RFA-naive patients, CEIM was 77% and CED was 96% at 3 years. Increasing BE length (adjusted hazard ratio [95% CI]:0.90 [0.83-0.96] per cm) and prior treatment with RFA (0.39 [0.22-0.69]) were associated with a lower rate of CEIM. Recurrence occurred in 8.8% (n=6) at a mean follow-up of 2.5 years after CEIM.

CONCLUSION

In this largest reported prospective cohort, liquid nitrogen SCT was safe and effective for treatment of dysplastic and neoplastic BE. Response was lower in those with prior failed RFA; in that cohort approximately 50% attained CEIM at 3 years.

Effect of Delayed Endoscopy Protocol on Timing and Safety of Endoscopy for Foreign Body Ingestion and Esophageal Food Impaction

BACKGROUND AND AIMS

Endoscopic procedures for foreign body ingestion (FBI) and esophageal food impactions (EFI) performed during on-call hours are associated with increased stress, risk, and cost. We implemented a Foreign Body Algorithm (FBA) designed to delay all but the most urgent endoscopy for EFI and FBI until regular working hours.

METHODS

Using endoscopy records from multiple academic and community hospitals within a large integrated health system in the United states, we identified esophagogastroduodenoscopy (EGD) performed for food impactions and foreign body ingestions occurring between May 2011 and February 2021.

RESULTS

We identified 479 EGDs performed for FBI and EFI. The introduction of the FBA was associated with a shorter length of stay (LOS) for overall cases (0.35 vs. 0.8 d P <0.001), day cases (0.16 vs. 1.0 d P <0.001), and night cases (0.40 vs. 0.6 d P =0.03). The introduction of the FBA did not change the rate of overall adverse events (AE) or night AE. AE from the entire cohort was rare (3%; 16 total). Of the AE, most were sedation related. The introduction of the FBA did not affect the overall rate of night cases or AE, but the rate of after-hours endoscopy for intentional ingestions decreased from 17.2% to 3.1% ( P =0.01).

CONCLUSION

This is one of the largest studies of esophageal impactions and foreign bodies in adults in the United States, and the first to examine the effects of a protocol designed to avoid after-hours endoscopy. These results suggest that postponing after-hours EGD until the daytime is not associated with adverse safety outcomes or increased LOS.

NON-ENDOSCOPIC ESOPHAGEAL SAMPLING DEVICE AND BIOMARKER PANEL FOR DETECTION OF BARRETT'S ESOPHAGUS (BE) AND ESOPHAGEAL ADENOCARCINOMA (EAC)

BACKGROUND

We previously reported an encapsulated balloon (EsoCheck TM , EC), which selectively samples the distal esophagus, that coupled with a two methylated DNA biomarker panel (EsoGuard TM , EG), detected Barrett's esophagus (BE) and esophageal adenocarcinoma (EAC), with a sensitivity and specificity of 90.3% and 91.7%, respectively. This previous study utilized frozen EC samples.

AIM

To assess a next generation EC sampling device and EG assay that utilizes a room temperature sample preservative to enable office-based testing.

METHODS

Cases with nondysplastic (ND) and dysplastic (indefinite=IND, low grade dysplasia = LGD, high grade dysplasia = HGD) BE, EAC, junctional adenocarcinoma (JAC) and controls with no intestinal metaplasia (IM) were included. Nurses or physician assistants at six institutions, who were trained in EC administration, delivered the encapsulated balloon per orally and inflated it in the stomach. The inflated balloon was pulled back to sample 5 cm of the distal esophagus, then deflated and retracted into the EC capsule to prevent sample contamination from proximal esophagus. Nextgen EG sequencing assays performed on bisulfite-treated DNA extracted from EC samples determined levels of methylated Vimentin (mVIM) and methylated Cyclin A1 (mCCNA1) in a CLIA-certified laboratory, blinded to patients' phenotypes.

RESULTS

A total of 243 evaluable patients - 88 cases (median age 68 years, 78% men, 92% white) and 155 controls (median age 57 years, 41% men, 88% white) - underwent adequate EC sampling. Mean time for EC sampling was just over 3 minutes. The cases included 31 NDBE, 16 IND/LGD, 23 HGD, and 18 EAC/JAC. Thirty-seven (53%) of the non-dysplastic and dysplastic BE cases were short-segment BE (SSBE; < 3 cm). Overall sensitivity for detecting all cases was 85% (95% CI= 0.78-0.93) and specificity was 85% (95% CI=0.79-0.90). Sensitivity for NDBE was 84% (n=37). The EC/EG test detected 100% of cancers.

CONCLUSION

The next-generation EC/EG technology has been both successfully updated to incorporate a room temperature sample collection preservative and successfully implemented in a CLIA certified laboratory. When performed by trained personnel, EC/EG detects non-dysplastic BE, dysplastic BE, and cancer with high sensitivity and specificity, replicating the operating characteristics of the initial pilot study of this technology. Future applications utilizing EC/EG to screen broader populations at risk for developing cancer are proposed.

SIGNIFICANCE

This multi-center study demonstrates the successful performance of a commercially available clinically implementable non-endoscopic screening test for BE in the U.S., as recommended in the most recent ACG Guideline and AGA Clinical Update. It transitions and validates a prior academic laboratory-based study of frozen research samples over to a CLIA laboratory, one that also integrates a clinically practical room temperature method for sample acquisition and storage, enabling office-based screening.

Outcomes for endoscopic submucosal dissection of pathologically staged T1b esophageal cancer: a multicenter study

BACKGROUND AND AIMS

The outcomes of endoscopic submucosal dissection (ESD) for T1b esophageal cancer (EC) and its recurrence rates remain unclear in the West. Using a multicenter cohort, we evaluated technical outcomes and recurrence rates of ESD in the treatment of pathologically staged T1b EC.

METHODS

We included patients who underwent ESD of T1b EC at 7 academic tertiary referral centers in the United States (n = 6) and Brazil (n = 1). We analyzed demographic, procedural, and histopathologic characteristics and follow-up data. Time-to-event analysis was performed to evaluate recurrence rates.

RESULTS

Sixty-six patients with pathologically staged T1b EC after ESD were included in the study. A preprocedure staging EUS was available in 54 patients and was Tis/T1a in 27 patients (50%) and T1b in 27 patients (50%). En-bloc resection rate was 92.4% (61/66) and R0 resection rate was 54.5% (36/66). Forty-nine of 66 patients (74.2%) did not undergo surgery immediately after resection and went on to surveillance. Ten patients had ESD resection within the curative criteria, and no recurrences were seen in a 13-month (range, 3-18.5) follow-up period in these patients. Ten of 39 patients (25.6%) with noncurative resections had residual/recurrent disease. Of the 10 patients with noncurative resection, local recurrence alone was seen in 5 patients (12.8%) and metastatic recurrence in 5 patients (12.8%). On univariate analysis, R1 resection had a higher risk of recurrent disease (hazard ratio, 6.25; 95% confidence interval, 1.29-30.36; P = .023).

CONCLUSIONS

EUS staging of T1b EC has poor accuracy, and a staging ESD should be considered in these patients. ESD R0 resection rates were low in T1b EC, and R1 resection was associated with recurrent disease. Patients with noncurative ESD resection of T1b EC who cannot undergo surgery should be surveyed closely, because recurrent disease was seen in 25% of these patients.

A nationwide analysis of pancreatic cancer trial enrollment reveals disparities and participation problems

BACKGROUND

Our research group recently surveyed the clinical trial landscape in pancreatic adenocarcinoma and identified 430 active trials. These represent an opportunity to expand treatment options for patients with pancreatic adenocarcinoma. Our primary objective was to detail clinical trial participation among patients with pancreatic adenocarcinoma. Our secondary objective was to evaluate survival.

METHODS

We queried the National Cancer Database (2004-2016) for patients with pancreatic adenocarcinoma. Patients were stratified by trial participation: clinical trial or non-trial. Multivariable logistic regression was used to identify variables associated with trial participation. The Kaplan-Meier method and multivariable Cox hazards regression were used to analyze survival.

RESULTS

In total, 261,483 patients were included: 1,110 (0.4%) were enrolled in a clinical trial. A total of 57 Black patients participated in a clinical trial (0.19% of Black patients). This was lower compared to White patients (n = 955, 0.49% of White patients, P < .001). After adjusting for demographic and clinical factors, Black patients were less likely to be enrolled in a clinical trial (odds ratio = 0.387, P < .001). Patients treated at nonacademic medical centers were less likely to be in a clinical trial. Trial participation was associated with an increased median survival relative to non-trial patients (stage IV: 9.0 vs 3.8 months, P < .001), and this association remained on multivariable regression (hazard ratio = 0.779, P < .001).

CONCLUSION

Fewer than 1% of patients with pancreatic adenocarcinoma participated in a clinical trial. There are racial and sociodemographic disparities in clinical trial enrollment. An association was observed between clinical trial participants and prolonged survival.

Endoscopic submucosal dissection vs. endoscopic mucosal resection for early Barrett's neoplasia in the West: a retrospective study

BACKGROUND

The difference in clinical outcomes after endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) for early Barrett's esophagus (BE) neoplasia remains unclear. We compared the recurrence/residual tissue rates, resection outcomes, and adverse events after ESD and EMR for early BE neoplasia.

METHODS

We included patients who underwent EMR or ESD for BE-associated high grade dysplasia (HGD) or T1a esophageal adenocarcinoma (EAC) at eight academic hospitals. We compared demographic, procedural, and histologic characteristics, and follow-up data. A time-to-event analysis was performed to evaluate recurrence/residual disease and a Kaplan-Meier curve was used to compare the groups.

RESULTS

243 patients (150 EMR; 93 ESD) were included. EMR had lower en bloc (43 % vs. 89 %; P < 0.001) and R0 (56 % vs. 73 %; P = 0.01) rates than ESD. There was no difference in the rates of perforation (0.7 % vs. 0; P > 0.99), early bleeding (0.7 % vs. 1 %; P > 0.99), delayed bleeding (3.3 % vs. 2.1 %; P = 0.71), and stricture (10 % vs. 16 %; P = 0.16) between EMR and ESD. Patients with non-curative resections who underwent further therapy were excluded from the recurrence analysis. Recurrent/residual disease was 31.4 % [44/140] for EMR and 3.5 % [3/85] for ESD during a median (interquartile range) follow-up of 15.5 (6.75-30) and 8 (2-18) months, respectively. Recurrence-/residual disease-free survival was significantly higher in the ESD group. More patients required additional endoscopic resection procedures to treat recurrent/residual disease after EMR (EMR 24.2 % vs. ESD 3.5 %; P < 0.001).

CONCLUSIONS

ESD is safe and results in more definitive treatment of early BE neoplasia, with significantly lower recurrence/residual disease rates and less need for repeat endoscopic treatments than with EMR.

Biosimilar strategic implementation at a large health system

DISCLAIMER

In an effort to expedite the publication of articles , AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

This article highlights one health system's response to the market influx of biosimilars with the establishment of a process for formulary review and selection of preferred agents and support for therapeutic interchanges.

SUMMARY

Through assessment of available literature, insurance payor coverage, and manufacturer-anticipated approvals of biosimilars, a strategic stance was developed to guide biosimilar order preparation, review, adoption, and implementation. The electronic medical record (EMR) is prepared for biosimilar implementation at least 6 to 12 months ahead of anticipated formulary review. The review includes assessment of a class (reference product and available biosimilars) after at least 2 biosimilars become available. Key health-system departments and clinicians are enlisted to support review of clinical, safety, and economic implications. Implementation of a preferred product relies on standard education, formulary availability, and staff awareness to address any perceived patient safety concerns and gather provider support. The standard steps developed now apply to all future biosimilar reviews, adoption plans, and ongoing monitoring. Barriers evaluated include changes in payor coverage and challenges in preparation of the EMR for future biosimilars, meeting precertification team education needs, and providing operational support for pharmacy inventory.

CONCLUSION

To date, use of 5 preferred biosimilar products has led to significant cost savings to the institution, and the process has been endorsed by providers. The institution's successes can be attributed to clear communication with stakeholders and the development of a deliberate process, led by a multidisciplinary leadership team, for managing formulary, safety, and operational barriers in a thoughtful and systematic manner.

A survey of physician training and credentialing in endoscopic submucosal dissection in the United States

BACKGROUND

Endoscopic submucosal dissection (ESD) is technically challenging, has a longer learning curve and a greater complication rate than most new endoscopic procedures. Formal training and credentialing guidelines for ESD are currently lacking in the United States (US).

AIM

To survey ESD experts across the US to determine their learning process and obtain their opinion on how training and credentialing for ESD should develop.

DESIGN

Anonymous electronic survey.

SUBJECTS

ASGE members who are practicing US endoscopists.

METHODS

The survey was developed by iterative revisions of questions administered to three investigators who have been performing ESD for > 5 years. The final survey was distributed electronically to US endoscopists who had previously attended ESD expert conferences.

RESULTS

Thirty-five (58.3%) of 60 practicing ESD experts responded to the survey. A majority (91%) were in university-based, community, or tertiary care hospitals. All practitioners practiced on porcine explants and observed live ESD procedures as part of the training. Out of the participants, 75.8% received formal supervised hands-on training on porcine explants and/or humans before performing ESD independently. Fifty percent indicated that their facility had written guidelines specifically for ESD credentialing. Four out of 5 felt that credentialing requirements should include attending weekend ESD courses, observing live procedures, practicing on explants, and advanced endoscopic training in interventional endoscopy such as an additional year of fellowship.

LIMITATIONS

Survey completion rate of 58.3%.

CONCLUSION

ESD training should include practicing on explants, observation of live procedures, training in interventional endoscopy, and attending educational courses. Credentialing guidelines for ESD based on expert opinion need to be developed in the US.

High grade dysplasia or esophageal adenocarcinoma in patients with a history of Roux-en-Y gastric bypass surgery: a case series

BACKGROUND

 Roux-en-Y gastric bypass (RYGB) is the favored bariatric option in patients with gastroesophageal reflux and Barrett's esophagus because it prevents reflux. Weight loss and decreased reflux following RYGB could theoretically minimize the risk of progression to cancer. We aimed to demonstrate the management of high grade dysplasia (HGD) and esophageal adenocarcinoma (EAC) developing in patients after RYGB.

METHODS

 A prospectively maintained database was searched to identify cases of HGD and cancer in RYGB patients. Charts were reviewed for past history, endoscopic findings, endoscopic therapy, and pathology findings.

RESULTS

 There were five cases where HGD/EAC developed several years after RYGB. The prior bariatric surgery precluded curative esophagectomy, illustrating the management challenges. All but one of the patients were uniquely and successfully managed with endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD).

CONCLUSIONS

 RYGB patients are still at risk of developing esophageal cancer. Patients at risk should be screened prior to RYGB and those with Barret's esophagus need to undergo rigorous endoscopic surveillance following surgery. If detected early, EMR and ESD are invaluable in managing those who progress.

Multifocal Cryoballoon Ablation for Eradication of Barrett's Esophagus-Related Neoplasia: A Prospective Multicenter Clinical Trial

INTRODUCTION

Ablation of Barrett's esophagus (BE) is the preferred approach for the treatment of neoplasia without visible lesions. Limited data on cryoballoon ablation (CBA) suggest its potential clinical utility. We evaluated the safety and efficacy of CBA in a multicenter study of patients with neoplastic BE.

METHODS

In a prospective clinical trial, 11 academic and community centers recruited consecutive patients with BE of 1-6 cm length and low-grade dysplasia, high-grade dysplasia (HGD), or intramucosal adenocarcinoma (ImCA) confirmed by central pathology. Patients with symptomatic pre-existing strictures or visible BE lesions had dilation or endoscopic mucosal resection (EMR), respectively, before enrollment. A nitrous oxide cryoballoon focal ablation system was used to treat all visible columnar mucosa in up to 5 sessions. Study end points included complete eradication of all dysplasia (CE-D) and intestinal metaplasia (CE-IM) at 1 year.

RESULTS

One hundred twenty patients with BE with ImCA (20%), HGD (56%), or low-grade dysplasia (23%) were enrolled. In the intention-to-treat analysis, the CE-D and CE-IM rates were 76% and 72%, respectively. In the per-protocol analysis (94 patients), the CE-D and CE-IM rates were 97% and 91%, respectively. Postablation pain was mild and short lived. Fifteen subjects (12.5%) developed strictures requiring dilation. One patient (0.8%) with HGD progressed to ImCA, which was successfully treated with EMR. Another patient (0.8%) developed gastrointestinal bleeding associated with clopidogrel use. One patient (0.8%) had buried BE with HGD in 1 biopsy, not confirmed by subsequent EMR.

DISCUSSION

In patients with neoplastic BE, CBA was safe and effective. Head-to-head comparisons between CBA and other ablation modalities are warranted (clinicaltrials.gov registration NCT02514525).

Identifying DNA methylation biomarkers for non-endoscopic detection of Barrett's esophagus

We report a biomarker-based non-endoscopic method for detecting Barrett's esophagus (BE) based on detecting methylated DNAs retrieved via a swallowable balloon-based esophageal sampling device. BE is the precursor of, and a major recognized risk factor for, developing esophageal adenocarcinoma. Endoscopy, the current standard for BE detection, is not cost-effective for population screening. We performed genome-wide screening to ascertain regions targeted for recurrent aberrant cytosine methylation in BE, identifying high-frequency methylation within the CCNA1 locus. We tested CCNA1 DNA methylation as a BE biomarker in cytology brushings of the distal esophagus from 173 individuals with or without BE. CCNA1 DNA methylation demonstrated an area under the curve of 0.95 for discriminating BE-related metaplasia and neoplasia cases versus normal individuals, performing identically to methylation of VIM DNA, an established BE biomarker. When combined, the resulting two biomarker panel was 95% sensitive and 91% specific. These results were replicated in an independent validation cohort of 149 individuals who were assayed using the same cutoff values for test positivity established in the training population. To progress toward non-endoscopic esophageal screening, we engineered a well-tolerated, swallowable, encapsulated balloon device able to selectively sample the distal esophagus within 5 min. In balloon samples from 86 individuals, tests of CCNA1 plus VIM DNA methylation detected BE metaplasia with 90.3% sensitivity and 91.7% specificity. Combining the balloon sampling device with molecular assays of CCNA1 plus VIM DNA methylation enables an efficient, well-tolerated, sensitive, and specific method of screening at-risk populations for BE.

Association of covered metallic stents with cholecystitis and stent migration in malignant biliary stricture

BACKGROUND AND AIMS

ERCP with self-expandable metallic stent (SEMS) placement provides reliable and durable relief of malignant biliary obstruction. Our objective was to compare efficacy and adverse outcomes between uncovered SEMSs (USEMSs) and covered SEMSs (CSEMSs).

METHODS

A retrospective cohort study was performed of all consecutive patients who underwent ERCP with SEMS placement for the management of a malignant bile duct stricture. Comparative analyses on clinical success, patency duration, stent dysfunction, and adverse outcomes were performed. Univariate and multivariable analyses were performed to identify factors associated with stent dysfunction.

RESULTS

Six hundred forty-five patients underwent SEMS placement for the management of malignant bile duct stricture from 2008 to 2016. CSEMSs and USEMSs had similar rates of clinical success in relief of bile duct obstruction (93.0% vs 92.1%, respectively; P = .69) and patency duration (546.7 vs 557.9 days, P = .14). Among those with an intact gallbladder, the incidence of acute cholecystitis was higher in the CSEMS group compared with the USEMS group (7.8% vs 1.2%; P < .001). In the multivariable analysis, CSEMS use was associated with increased risk of stent migration (hazard ratio, 10.7; 95% confidence interval, 4.1-27.7).

CONCLUSIONS

CSEMSs and USEMSs have similar clinical success rates and patency durations in management of malignant bile duct stricture. CSEMSs, however, are associated with increased rates of migration and cholecystitis. Comparable efficacy and superior safety profile of USEMSs render a compelling argument for its place as the preferred choice of SEMSs in the management of malignant biliary stricture.

A nonrandomized trial of vitamin D supplementation for Barrett's esophagus

Background

Vitamin D deficiency may increase esophageal cancer risk. Vitamin D affects genes regulating proliferation, apoptosis, and differentiation and induces the tumor suppressor 15-hydroxyprostaglandin dehydrogenase (PGDH) in other cancers. This nonrandomized interventional study assessed effects of vitamin D supplementation in Barrett’s esophagus (BE). We hypothesized that vitamin D supplementation may have beneficial effects on gene expression including 15-PGDH in BE.

Methods

BE subjects with low grade or no dysplasia received vitamin D₃ (cholecalciferol) 50,000 international units weekly plus a proton pump inhibitor for 12 weeks. Esophageal biopsies from normal plus metaplastic BE epithelium and blood samples were obtained before and after vitamin D supplementation. Serum 25-hydroxyvitamin D was measured to characterize vitamin D status. Esophageal gene expression was assessed using microarrays.

Results

18 study subjects were evaluated. The baseline mean serum 25-hydroxyvitamin D level was 27 ng/mL (normal ≥30 ng/mL). After vitamin D supplementation, 25-hydroxyvitamin D levels rose significantly (median increase of 31.6 ng/mL, p<0.001). There were no significant changes in gene expression from esophageal squamous or Barrett’s epithelium including 15-PGDH after supplementation.

Conclusion

BE subjects were vitamin D insufficient. Despite improved vitamin D status with supplementation, no significant alterations in gene expression profiles were noted. If vitamin D supplementation benefits BE, a longer duration or higher dose of supplementation may be needed.

Starting a High-Quality Pancreatic Surgery Program at a Community Hospital

BACKGROUND

Most literature suggests that pancreatic resections should be done by high-volume surgeons at high-volume hospitals to optimize patient outcomes. However, patient preference and insurance requirements may restrict hospital location. After careful planning, a high-volume pancreatic surgeon started performing pancreatectomies at a community hospital.

METHODS

Sixty pancreatectomies were performed at an academic medical center and 28 at a 144-bed community, non-teaching hospital. Sixty-day outcomes were recorded.

RESULTS

There were no statistically significant differences between the academic medical center and community hospital with regard to the median age of the patients (66 vs. 61 years), the gender distribution (57 vs. 64 % female), or the median BMI (28 vs. 26 kg/m(2)). There was a significant difference in the American Society of Anesthesiologists class distribution between the academic medical center and community hospital (1; 0 vs. 4 %, 2; 7 vs. 21 %, 3; 88 vs. 75 %, 4; 5 vs. 0 %, p = 0.006). The median length of stay (LOS) for 17 pancreaticoduodenectomy/total pancreatectomy patients at the community hospital was significantly less than for 39 patients at the academic medical center (5 vs. 7 days, p = 0.006). Eleven distal pancreatectomy/splenectomy patients at the community hospital tended to have a shorter median LOS than 21 patients at the academic medical center (4 vs. 5 days, p = 0.25). Accordion ≥ 3 complications (7 vs. 27 %) and readmissions (11 vs. 22 %) tended to be lower at the community hospital than the academic medical center. Greater than 80 % of patients with adenocarcinoma at both hospital settings who were recommended to receive adjuvant therapy started their treatment within 60 days of surgery.

CONCLUSIONS

With appropriate planning and careful patient selection, high-quality pancreatic surgery can be performed at a community hospital by a high-volume pancreatic surgeon.

Esophageal squamous cell carcinoma arising after endoscopic ablation therapy of Barrett's esophagus with high-grade dysplasia. Report of a case

Patients with Barrett's esophagus are at risk for dysplasia and esophageal adenocarcinoma. Although surgery was the mainstay treatment for Barrett's dysplasia and cancer, patients with high-grade dysplasia and early cancers now have several nonsurgical treatment options. Most of the endoscopic therapies are relatively safe but do carry a risk for complications. Treatment failure with progression of the disease is the most severe complication, especially among patients with low surgical risk. Cryoablation has been used with promising results in both high-grade dysplasia and early esophageal cancer. A patient with a well-documented history of Barrett's esophagus with high-grade dysplasia that underwent multiple sessions of photodynamic therapy and salvage cryoablation for residual high-grade dysplasia was presented. The patient was diagnosed with squamous cell carcinoma of the distal esophagus approximately 1 year after cryoablation. This is the first complete report of squamous cell carcinoma occurring after endoscopic ablation for Barrett's neoplasia. Careful follow up is necessary in any endoscopic ablation program due to the risk of recurrent neoplasia.

Natural history of indeterminate pancreatic cysts

BACKGROUND

The optimal treatment for incidental asymptomatic pancreatic cysts is not known. The purpose of this study was to determine whether nonmucinous cysts by cyst-aspiration analysis can be observed safely.

METHODS

A prospective protocol was initiated in September of 1999 for all suspected cystic neoplasms. Asymptomatic patients with negative cyst aspirates (no extracellular mucin, and concentration of carcinoembryonic antigen in the cyst fluid <200 ng/mL) were followed-up clinically and radiographically.

RESULTS

Through December 2004, 221 patients have been evaluated, and 80 (36%) initially were operated. There were 141 (64%) patients with indeterminate cysts, 98 have been followed-up for more than 12 months. Compared with resected patients, observed patients were older (62 vs 56 y, P < .006), and had smaller cysts (2.4 vs 4.0, P = .001). At a mean follow-up period of 24 months, 4 patients (4%) were resected. The indication, time to resection, and pathology were as follows: 2 patients for symptoms (abdominal pain and obstructive jaundice) at 24 and 72 months, respectively: mucinous and serous cystadenomas; 1 patient for an increase in size (6.6 to 7.8 cm) at 18 months: lymphoepithelial cyst; and 1 patient for abdominal pain and increase in size (2.0 to 3.7 cm) at 41 months: pseudocyst. The only patient resected for a mucinous neoplasm had a cyst fluid carcinoembryonic antigen level of 896 ng/mL. In the remaining observed patients, 20 (23%) showed a decrease in cyst size, and 16 (19%) showed an increase in size (mean diameter change, 21%).

CONCLUSIONS

Initial follow-up evaluation indicates that asymptomatic patients without evidence of a mucinous neoplasm by cyst aspiration can be followed clinically and with interval imaging.

The effect of moderate sedation on exocrine pancreas function in normal healthy subjects: a prospective, randomized, cross-over trial using the synthetic porcine secretin stimulated Endoscopic Pancreatic Function Test (ePFT)

BACKGROUND

We have developed a purely endoscopic collection method for the assessment of pancreatic secretory function (ePFT). The pancreatic secretory effects of sedation medications utilized during endoscopic procedures are not completely known.

AIMS

To study the effect of moderate sedation on the exocrine pancreas gland in a prospective, randomized trial.

METHODS

Healthy volunteers were randomized by computers to one of two treatments (A-no sedation, B-sedation) in period 1 and crossed-over to the other treatment in period 2 with a minimal washout interval of 7 days. Sedation dosage was standardized for each patient based on age, gender and weight from a previously published dosing nomogram. Synthetic porcine secretin (ChiRhoClin, Inc., Burtonsville, Maryland) was used as the pancreatic stimulant. Duodenal fluid samples were aspirated via the endoscope every 5 min for 1 h and sent on ice to our hospital laboratory for the measurement of pancreatic secretory electrolyte concentrations by autoanalyzer.

RESULTS

A total of 17 healthy volunteers were enrolled. Sixteen subjects (8 males and 8 females) completed the randomized prospective trial. Median intravenous meperidine and midazolam sedation dose was 62.5 mg and 2.5 mg, respectively. Maximum pancreatic juice flow occurred during the early phase of secretion and maximum bicarbonate concentration occurred during the late phase of secretion. Analysis of the electrolyte composition of the endoscopically collected duodenal drainage fluid revealed a constant cation concentration for both sodium and potassium over the 1 h collection period. The anions, chloride and bicarbonate, exhibited a reciprocal relationship identical to that seen in traditional gastroduodenal tube collection studies. There was no statistical difference observed between the sedation and no sedation groups. The estimated total bicarbonate output (area under curve, AUC) for the sedated and non-sedated groups were 5,017 meq + 724 (range 3,663-6,173) and 5,364 meq +/- 583 (range 4,323-6563) respectively (p= 0.0656). The mean peak bicarbonate concentrations for sedated (n = 8) versus non-sedated (n = 8) groups were 103 +/- 11 meq/L (range 78-125) and 106 +/- 11 meq/L (range 87-138), respectively (p= 0.1346). There was excellent correlation of peak bicarbonate concentrations when sedation and no sedation groups were compared (r= 0.744, p < 0.05; Spearman rank correlation). There were no episodes of pancreatitis.

CONCLUSIONS

(a) Moderate sedation used for upper endoscopy does not effect the clinical diagnostic parameters (peak bicarbonate concentration or total bicarbonate output) utilized to diagnose pancreatic insufficiency. (b) Analysis of duodenal drainage fluid collected endoscopically after synthetic secretin stimulation produces an identical pancreatic secretory curve described with traditional gastroduodenal tube collection methods.

Retained gallbladder/cystic duct remnant calculi as a cause of postcholecystectomy pain

BACKGROUND

Pain following cholecystectomy can pose a diagnostic and therapeutic dilemma. We reviewed our experience with calculi retained in gallbladder and cystic duct remnants that present with recurrent biliary symptoms.

METHODS

Over the last 6 years, seven patients were referred to us for the evaluation of recurrent biliary colic or jaundice. There were four men and three women ranging in age from 35 to 70 years. All seven had biliary pain similar to the symptoms that precede cholecystectomy; two of them also had also associated jaundice and one had pancreatitis. The time from cholecystectomy to onset of symptoms ranged from 14 months to 20 years (median, 8.5 Years). Four had undergone laparoscopic cholecystectomy and three had had an open cholecystectomy; none had an operative cholangiogram.

RESULTS

Five of seven underwent diagnostic endoscopic retrograde cholangiography (ERC), which revealed obvious filling defects in the cystic duct or gallbladder remnant. The final patient was diagnosed by laparoscopic ultrasound after eight negative radiographic studies. Four patients underwent laparotomy and resection of a retained gallbladder and/or cystic duct. Two patients were treated with extracorporeal shock-wave lithotripsy (ESWL); one of them also required endoscopic biliary holmium laser lithotripsy. One patient underwent successful repeat laparoscopic cholecystectomy. There were no treatment-related complications. At a median follow-up of 11.5 months, all have achieved complete stone clearance and are asymptomatic.

CONCLUSION

Retained gallbladder and cystic duct calculi can be a source of recurrent biliary pain, and a heightened suspicion may be required to make the diagnosis. This entity can be prevented by accurate identification of the gallbladder-cystic duct junction at cholecystectomy and by routine use of cholangiography. A variety of therapeutic options can be employed to obtain a successful outcome.

Optical coherence tomography of the esophagus and proximal stomach in health and disease

OBJECTIVE

Surveillance of Barrett's esophagus is problematic, as high-grade dysplasia cannot be recognized endoscopically. Endoscopic ultrasound lacks the resolution to detect high-grade dysplasia. Optical coherence tomography (OCT) employs infrared light reflectance to provide in vivo tissue images at resolution far superior to endoscopic ultrasound, nearly at the level of histology. We have developed a catheter-based system well suited for study of the GI tract. The purpose of this study was to test this catheter-based OCT system and characterize the OCT appearance of normal squamous mucosa, gastric cardia, Barrett's esophagus, and carcinoma.

METHODS

The OCT catheter was passed through the operating channel of the endoscope and placed in contact with the esophageal mucosa. Image acquisition occurred in approximately 3 s. OCT images were correlated with biopsy and/or resection specimens.

RESULTS

OCT was used to construct 477 images of the esophagus and stomach in 69 patients. There were unique, distinct OCT appearances of squamous mucosa, gastric cardia, Barrett's esophagus, and carcinoma. Further, these OCT images were accurately recognized by observers unaware of their site of origin.

CONCLUSIONS

OCT provides a highly detailed view of the GI wall, with clear delineation of a multiple layered structure. It is able to distinguish squamous mucosa, gastric cardia, Barrett's esophagus, and cancer. This technique holds great potential as an adjunct to the surveillance of patients with Barrett's esophagus, ulcerative pancolitis, and other premalignant conditions.