Self-expanding metal stents (SEMS) for preoperative biliary decompression in patients with resectable and borderline-resectable pancreatic cancer: outcomes in 241 patients

BACKGROUND AND AIM

Obstructive jaundice caused by distal biliary obstruction can present in up to 70 % of patients with localized cancer of the head of the pancreas. The aim of this study was to report our experience in using self-expanding metal stents (SEMS) for preoperative biliary decompression in patients with resectable and borderline resectable carcinoma of the pancreatic head.

METHODS

We performed a retrospective study evaluating patients from two tertiary referral centers. Two-hundred and forty-one patients with resectable and borderline resectable pancreatic carcinoma underwent ERCP with metal biliary stent placement between September 2006 and August 2011. We assessed the effectiveness of SEMS to adequately decompress the biliary tree, procedural success, patient survival, stent patency, and stent-related complications.

RESULTS

Two-hundred and forty-one patients were evaluated [123 male, mean age (± SD) 67.4 ± 9.8 years; resectable 174, borderline resectable 67]. Patients with borderline-resectable cancer underwent neoadjuvant therapy and restaging before possible curative surgery. Successful placement of a metal biliary stent was achieved in all patients and improved jaundice. Patients were followed for mean duration of 6.3 months. The overall survival was 49 % at 27 months. Fourteen (5.8 %) patients experienced stent occlusion; the mean time to stent occlusion was 6.6 (range 1-20) months. Immediate complications included: post-ERCP pancreatitis (n = 14), stent migration (n = 3), and duodenal perforation (n = 3). Long-term complications included stent migration (n = 9) and hepatic abscess (n = 1). A total of 144/174 patients deemed to have resectable cancer at time of diagnosis underwent curative surgery. Due to disease progression or the discovery of metastasis after neoadjuvant therapy, only 22/67 patients with borderline-resectable cancer underwent curative surgery.

CONCLUSIONS

SEMS should be considered for patients with obstructive jaundice and resectable or borderline resectable pancreatic cancer, especially if surgery is not planned immediately as a result of preoperative chemoradiation. These stents appear to be safe and effective.

A comparative needle study: EUS-FNA procedures using the HD ProCore(™) and EchoTip(®) 22-gauge needle types

The specific needle sizes/types used in performing endoscopic ultrasound-guided fine needle aspirations (EUS-FNA) vary. The HD ProCore(™) is a 22-gauge beveled needle allowing for core biopsy along with aspiration material. In this study we compare this needle with a standard 22-gauge needle. Between April 1, 2011 and November 15, 2011, 18 patients undergoing EUS-FNA using the HD ProCore(™) needle were compared to a control group of 18 cases using the standard 22-gauge needle. Smears were assessed for: three-dimensional clusters, thick obscuring clusters, monolayer sheets, cellularity, crowded obscuring single cells, blood, and nuclear staining. Cell blocks were assessed for cellularity and presence of diagnostic material. Records were reviewed for the overall adequacy, number of FNA passes, and patient follow-up. Overall, the two needle groups demonstrated similar results for the cytology parameters, amount of diagnostic cell block material, adequacy, and accuracy. The mean number of passes to achieve adequacy varied between the groups [2.94 for the standard 22-gauge needle group versus 2.11 for the beveled needle group (P=0.03)] with no meaningful difference in case duration between needle groups. No complications were reported. The beveled EUS needle affords similar cytologic interpretability, adequacy, diagnostic accuracy, and amount of cell block material as a standard needle. There was a statistically significant trend toward fewer passes to achieve adequacy with the beveled EUS-FNA needle. Therefore, the EUS-FNA needle with a lateral bevel is a diagnostically similar alternative to standard endoscopy needles, the possibility that this beveled needle may improve per pass adequacy requires further verification.

Placement of fully covered self-expandable metal stents in patients with locally advanced esophageal cancer before neoadjuvant therapy

BACKGROUND

Most patients with locally advanced esophageal cancer requiring neoadjuvant therapy have significant dysphagia.

OBJECTIVE

To report our experience in using a fully covered self-expandable metal stent (FCSEMS) to treat malignant dysphagia and for maintenance of nutritional support during neoadjuvant therapy.

DESIGN

Retrospective study.

SETTING

Two tertiary-care referral centers.

PATIENTS

This study involved 55 patients with locally advanced esophageal cancer (50 adenocarcinoma, 5 squamous cell carcinoma). Forty-three patients were men, and the mean age was 65.8 years.

INTERVENTION

EUS followed by FCSEMS placement.

MAIN OUTCOME MEASUREMENTS

Procedural success, dysphagia scores, patient weights, stent migration, and stent-related complications.

RESULTS

All stents were successfully placed. Tumors were located in the middle esophagus (n = 10) and distal esophagus (n = 45). The mean dysphagia score obtained at 1 week after stent placement had improved significantly from baseline (2.4 and 1, respectively; P < .001). Patients maintained their weights at 1 month follow-up when compared with baseline (153 and 149 pounds, respectively; P = .58). Immediate complications included chest discomfort in 13 patients; 2 patients required stent removal because of intractable pain. One patient had stent removal because of significant acid reflux. Stent migration occurred at some point in 17 of 55 patients (31%). There was a delayed perforation in 1 patient. Because of disease progression or the discovery of metastasis after neoadjuvant therapy, only 8 of 55 patients underwent curative surgery.

LIMITATIONS

Retrospective study.

CONCLUSION

Placement of FCSEMSs in patients with locally advanced esophageal cancer significantly improves dysphagia and allows for oral nutrition during neoadjuvant therapy. FCSEMSs appear to be effective for palliating dysphagia. Migration was not associated with injury or harm to the patient and usually represented a positive response to neoadjuvant therapy. Few patients undergoing stenting in this situation ultimately undergo surgery because of disease progression or poor operative candidacy.

A retrospective correlation of percutaneous feeding tube stoma length in sitting and supine positions compared with body mass index

BACKGROUND

Accurate knowledge of stoma tract length is important to prevent gastric ulcer formation, buried bumper syndrome, and peristomal leakage/infection. Current guidelines suggest 0.5-1.0 cm of play between the skin and external bolster. The aim of this study was to determine if stoma tract length changes from supine and sitting position and if this change is related to BMI.

METHODS

Patients undergoing percutaneous feeding tube change from November 2006 to September 2009 were enrolled. Correlations were made between BMI and stoma tract length in both sitting and supine positions.

RESULTS

Twenty-eight patients (24 percutaneous endoscopic gastrostomy [PEG], 4 direct percutaneous jejunal feeding tube) were included; 19 (68%) were female. The mean ± SD stoma length was 3.6 ± 0.9 cm in the supine position and 4.9 ± 1.4 cm in the sitting position. The mean ± SD stoma length change from supine to sitting position was 1.53 ± 0.9 cm. Mean ± SD BMI was 21.2 ± 4.5 (range, 14.9-33.8). Stoma length in the supine position (r = 0.65, P = .0002) and sitting position (r = 0.6, P = .0009) was strongly correlated with BMI. Change in stoma tract length was correlated with BMI (r = 0.43, P = .02).

CONCLUSION

Stoma tract length is strongly correlated with BMI in both the sitting and supine positions. PEG stoma tract length changes significantly from the supine and sitting position. To prevent complications, most patients should have a longer distance set between internal and external bolsters than is recommended.

Comorbidities, sphincterotomy, and balloon dilation predict post-ERCP adverse events in PSC patients: operator experience is protective

BACKGROUND

Primary sclerosing cholangitis (PSC) is a chronic cholestatic disease. Interventional ERCP improves survival in PSC patients.

AIMS

To describe the frequency and risk factors for post-ERCP adverse events in patients with PSC via multivariate analysis.

METHODS

Retrospective cohort study included patients with a diagnosis of PSC who underwent ERCP at academic institutions between February 2000 and October 2009. Demographis, co-morbid conditions, antibiotic use, cannulation method, ERCP maneuvers and 30-day post-ERCP adverse events were collected. Multivariate analysis was performed using logistic regression.

RESULTS

A total of 185 procedures were performed on 75 PSC patients (58 M,17 F). Seven endoscopists performed ERCPs. Comorbidies included ulcerative colitis (44%, n = 33), Crohn's disease (12%, n = 9 patients), Cirrhosis (8%, n = 6 patients) and autoimmune hepatitis (2.7%, n = 2). Cannulation was achieved using dye-free guidewire cannulation techniques in 139/185 procedures (76%) and with contrast-based techniques in 46/185 procedures (24%). Thirty-day post-ERCP adverse events included post-ERCP pancreatitis (5%, n = 9, cholangitis (1%, n = 2), acute cholecystitis (0.5%, n = 1), stent occlusion (0.5%, n = 1), stent migration (0.5%, n = 1), and bile leak (0.5%, n = 1). In the multivariate analysis, associations with specific endoscopists who performed the procedure (P = 0.01), biliary dilation (P = 0.02), sphincterotomy (P = 0.03), presence of cirrhosis (P = 0.05), Crohn's disease (P < 0.001), and autoimmune hepatitis (P < 0.001) significantly predicted a complication following ERCP. Gender, stenting during procedure, presence of a dominant stricture, and cholangitis were not predictive for post-ERCP adverse events.

CONCLUSIONS

Factors predicting 30-day post-ERCP adverse events included certain co-morbid conditions, the endoscopist ERCP volume, maneuvers during ERCP including dilation and sphincterotomy. Stenting was not associated with adverse events.

Nurse-administered propofol sedation is safe for patients with obstructive sleep apnea undergoing routine endoscopy: a pilot study

BACKGROUND

Nurse-administered propofol sedation (NAPS) is now in widespread use. The safety profile of NAPS for routine endoscopic procedures in patients with obstructive sleep apnea (OSA) is unknown.

AIMS

To compare outcomes of patients with and without OSA undergoing routine endoscopic procedures with NAPS and standard conscious sedation (CS) with benzodiazepines and narcotics.

METHODS

Retrospective cohort study.

RESULTS

A total of 215 patients were placed in one of four groups: OSA patients undergoing endoscopy with NAPS, OSA patients undergoing endoscopy with standard CS, non-OSA patients undergoing endoscopy with NAPS, and non-OSA patients undergoing endoscopy with standard CS. Procedures were generally accomplished faster with NAPS. There was no statistically significant difference in complication rates or overall outcomes in patients with OSA when compared to non-OSA patients when either NAPS or CS was utilized.

CONCLUSIONS

Routine endoscopic procedures using NAPS are safe in patients with documented OSA, with complication rates comparable to when using CS. NAPS helped to decrease procedure times in general.

Evaluation of gastropexy and stoma tract maturation using a novel introducer kit for percutaneous gastrostomy in a porcine model

BACKGROUND

Fluoroscopic placement of percutaneous gastrostomy (PG) requires the use of T-bar fasteners to affix the stomach to the anterior abdominal wall; the effect of T-fasteners on stoma tract maturation is unknown. The authors studied PG stoma tract maturation, comparing PG + gastropexy with standard percutaneous endoscopic gastrostomy (PEG).

METHODS

Sixteen pigs underwent PG placement using a novel introducer kit. Three absorbable suture T-fasteners were placed around the stoma site, and PG was placed using the Russell method. A standard PEG was then placed using the Ponsky pull method, allowing each animal to serve as its own control. Gross and histopathological integrity of stoma tract formation was assessed at 1-3 weeks.

RESULTS

At sacrifice, all PGs were intact with no evidence of infection, disruption, or significant leakage. Stoma tracts of all test and control sites were robust and histologically mature at all time points. Stoma tract diameters were also similar between test and control PGs (mean ± SEM: control 13.1 ± 0.7 mm, test 12.1 ± 0.4 mm; P = .2, n = 15). Histopathological evaluation demonstrated a generally comparable tissue response between test and control PGs, with slight decreases in fibrosis noted in test compared to control sites (P = .02, n = 15).

CONCLUSIONS

Stoma tract maturation of PG with gastropexy provides similar results to standard PEG. Stoma tracts were mature at 1 week regardless of placement method. Placement and performance of PG using the new introducer kit with novel T-fasteners and absorbable suture yields effective gastric anchoring and has similar ease of use as standard PEG placement.

Endoscopic findings in patients presenting with dysphagia: analysis of a national endoscopy database

Dysphagia is a common problem and an indication for upper endoscopy. There is no data on the frequency of the different endoscopic findings and whether they change according to demographics or by single versus repeat endoscopy. To determine the prevalence of endoscopic findings in patients with dysphagia and whether findings differ in regard to age, gender, ethnicity, and repeat procedure. This was a retrospective study using a national endoscopic database (CORI). A total of 30,377 patients underwent esophagogastroduodenoscopy (EGD) for dysphagia of which 4,202 patients were repeat endoscopies. Overall frequency of endoscopic findings was determined by gender, age, ethnicity, and single vs. repeat procedures. Esophageal stricture was the most common finding followed by normal, esophagitis/ulcer (EU), Schatzki ring (SR), esophageal food impaction (EFI), and suspected malignancy. Males were more likely to undergo repeat endoscopies and more likely to have stricture, EU, EFI, and suspected malignancy (P = 0.001). Patients 60 years or older had a higher prevalence of stricture, EU, SR, and suspected malignancy (P < 0.0001). Esophageal stricture was most common in white non-Hispanic patients compared to other ethnic groups. In patients undergoing repeat EGD, stricture, SR, EFI, and suspected malignancy were more common (P < 0.0001). The prevalence of endoscopic findings differs significantly by gender, age, and repeat procedure. The most common findings in descending order were stricture, normal, EU, SR, EFI, and suspected malignancy. For patients undergoing a repeat procedure, normal and EU were less common and all other abnormal findings were significantly more common.

Endoscopic retrograde cholangiopancreatography for non-gastroenterologists: what you need to know

Endoscopic retrograde cholangiopancreatography (ERCP) represents the most powerful and widely employed platform for pancreaticobiliary interventions. Endoscopic retrograde cholangiopancreatography allows diagnosis and treatment of a broad spectrum of diseases of the pancreaticobiliary tree that are both benign and malignant in nature. Endoscopic retrograde cholangiopancreatography continues to evolve rapidly, and non-gastroenterologists need to understand the indications, contraindications, limitations, and role of ERCP to effectively manage and coordinate the care of patients with known or suspected pancreaticobiliary disease. This article will review the role of ERCP in detail to further an understanding of the procedure as a whole and to assess when referral of a patient for an ERCP or other related test is indicated.

Endoscopic biliary sphincterotomy is not required for transpapillary SEMS placement for biliary obstruction

BACKGROUND

Endoscopic retrograde cholangiopancreatography with biliary self-expanding metal stent placement is the preferred method of providing biliary drainage for pancreaticobiliary malignancies. Some endoscopists routinely perform biliary sphincterotomy to facilitate biliary stent placement and potentially minimize pancreatitis with transpapillary self-expanding metal stent placement.

AIMS

Our hypothesis was that biliary sphincterotomy has no effect on the success rate of transpapillary self-expanding metal stent placement and increases procedure-related complications.

METHODS

In a retrospective analysis, outcomes of two groups were compared: (1) self-expanding metal stent placement without biliary sphincterotomy, (2) self-expanding metal stent placement with biliary sphincterotomy during the same procedure. Complications and stent patency rates were evaluated.

RESULTS

There were 104 subjects included in the study. Post-sphincterotomy bleeding (p = 0.001) was associated with biliary sphincterotomy performed immediately prior to self-expanding metal stent placement. Importantly, self-expanding metal stent placement without biliary sphincterotomy was always technically successful and self-expanding metal stent placement without biliary sphincterotomy was not associated with pancreatitis.

CONCLUSIONS

Patients who undergo biliary sphincterotomy during transpapillary self-expanding metal stent placement experience more immediate complications than those who do not. Biliary sphincterotomy was not associated with longer stent patency. Self-expanding metal stent placement without a biliary sphincterotomy was not associated with pancreatitis regardless of the type of self-expanding metal stent used (covered or uncovered). Of the patients without a biliary sphincterotomy, 100% had successful stent placement, further arguing against its use in this setting.

What drives US gastroenterology fellows to pursue academic vs. non-academic careers?: Results of a national survey

OBJECTIVES

We conducted a nationwide survey of US gastroenterology fellows to identify key demographic and job-related factors relevant to the decision between an academic and a non-academic career.

METHODS

A survey was e-mailed to all US GI fellowship program directors and distributed at fellows' endoscopy courses. Data were evaluated via univariate and multivariate analysis.

RESULTS

One hundred eighty-four fellows completed surveys. Univariate analysis identified one factor that predisposed fellows to pursue non-academic practice: the perception that a non-academic salary would meet their financial needs. Four factors were identified that predisposed fellows to pursue academic practice: age>35 years, prior attainment of a master's or a PhD degree, and advanced fellowship. All factors were significant on multivariate analysis. If salaries were equal, 60% of respondents would choose academic over non-academic practice. Fellows selecting academic practice were motivated to publish and conduct research. Level of debt and a positive relationship with a mentor were not significant factors.

CONCLUSIONS

Fellows desiring more money strongly favor non-academic practice. Fellows choosing academic practice tend to be older, plan to pursue advanced training, desire fewer work hours per week, and have a higher rate of prior graduate study. If salaries were equal in academic medicine and non-academic practice, the majority of fellows would choose academic medicine.

Osteoclastic and pleomorphic giant cell tumors of the pancreas: A review of clinical, endoscopic, and pathologic features

Giant cell tumors of the pancreas come in three varieties-osteoclastic, pleomorphic, and mixed histology. These tumors have distinctive endoscopic, clinical, and cytological features. Giant cell tumors have a controversial histogenesis, with some authors favoring an epithelial origin and others favoring a mesenchymal origin. The true origin of these lesions remains unclear at this time. These are also very rare tumors but proper identification and differentiation from more common pancreatic adenocarcinoma is important. The risk factors of these tumors and the prognosis may be different from those associated with standard pancreatic adenocarcinoma. Recognition of these differences can significantly affect patient care. These lesions have a unique appearance when imaged with endoscopic ultrasound (EUS), and these lesions can be diagnosed via EUS guided Fine Needle Aspiration (FNA). This manuscript will review the endoscopic, clinical, and pathologic features of these tumors.

EUS in pediatric patients

BACKGROUND

The knowledge of EUS use in children is limited.

OBJECTIVE

We investigated the indications, feasibility, safety, and clinical utility of EUS in the management of pediatric GI, pancreatobiliary, and mediastinal diseases.

DESIGN

Retrospective study.

SETTING

Two tertiary referral university hospitals.

PATIENTS

Consecutive children age younger than 18 years referred over a 7-year period for EUS evaluation.

RESULTS

Forty EUS scans were performed in 38 children with a mean age of 13.5 years. The indications for pancreatobiliary endosonography were pancreatitis (n = 10), solid pancreatic mass (n = 7), cystic pancreatic mass (n = 1), cyst in the setting of chronic pancreatitis (n = 1), suspected annular pancreas (n = 1), celiac plexus block (n = 1), suspected common bile duct stone (n = 1), abdominal pain and atrophic pancreas (n = 1), ampullary adenoma (n = 1), and abnormal MRCP in a patient with jaundice (n = 1). The indications for gastric EUS were mucosal lesions (n = 2) and subepithelial lesions (n = 4). The indications for mediastinal endosonography were mediastinal masses/lymph nodes (n = 5). The remaining evaluations were performed for esophageal stricture (n = 1), unexplained abdominal pain (n = 1), unexplained abdominal pain with celiac axis block (n = 1), and perirectal fluid collection (n = 1). EUS-guided FNA (EUS-FNA) was performed in 12 (30%) cases and established the correct diagnosis in 9 (75%). EUS-guided fine-needle injections for celiac axis block were performed in 2 (5%) cases. The procedure was successful in all patients, and no complications related to sedation, EUS, or EUS-FNA were encountered.

LIMITATION

Retrospective study.

CONCLUSION

EUS and EUS-FNA are feasible and safe and have a significant impact on the management of pediatric GI, pancreatobiliary, and mediastinal diseases.

Placement of Polyflex stents in patients with locally advanced esophageal cancer is safe and improves dysphagia during neoadjuvant therapy

BACKGROUND

Patients with locally advanced esophageal cancer who require neoadjuvant therapy have significant dysphagia.

OBJECTIVES

To prospectively evaluate Polyflex stents to treat malignant dysphagia and to ameliorate weight loss in patients with locally advanced esophageal cancer who will undergo neoadjuvant therapy.

DESIGN

A prospective nonrandomized study.

SETTING

Tertiary-referral cancer center.

PATIENTS

Thirteen patients with esophageal cancer (11 adenocarcinoma, 2 squamous-cell carcinoma). All patients were men, with a mean age of 63 years.

INTERVENTIONS

EUS followed by stent placement.

MAIN OUTCOME MEASUREMENTS

Dysphagia scores and patient weights.

RESULTS

There were no perforations and no episodes of bleeding. Immediate complications included chest discomfort in 12 of 13 patients. The mean dysphagia score at the time of stent placement was 3. Mean dysphagia scores obtained at 1, 2, 3, and 4 weeks after stent placement were 1.1 (P = .005), 0.8 (P = .01), 0.9 (P = .02), and 1.0 (P = .008), respectively. Stent migration occurred at some point in 6 of 13 patients (46%).

LIMITATIONS

A single center and small size of study.

CONCLUSIONS

Simultaneous EUS staging and Polyflex stent placement is safe and allows oral feeding during neoadjuvant therapy. Dysphagia scores improved in a statistically significant manner. Stent migration was a common event, although not all patients with a migrated stent will require stent replacement, because migration may be a sign of tumor response to neoadjuvant therapy.

The role of gastroesophageal reflux in exercise-triggered asthma: a randomized controlled trial

BACKGROUND

Exercise-triggered asthma (ETA) develops when physical activity triggers asthma symptoms during or directly after exercise. In patients prone to symptoms of supra-esophageal reflux, exercise may trigger gastroesophageal reflux (GER), resulting in such symptoms.

AIMS

To determine the prevalence of abnormal pH in patients with ETA and to determine whether acid suppression improves symptoms in ETA patients.

METHODS

We performed a randomized double-blind trial of rabeprazole versus placebo in the treatment of patients with ETA. Patients underwent treadmill protocol to determine their VO(2 max). Next, pH testing was initiated while undergoing a 30-min treadmill program exercising them at 65% of their VO(2 max). They were subsequently randomized to rabeprazole or placebo for 10 weeks. At the end of 10 weeks, exercise testing was repeated.

RESULTS

A total of 31 patients completed the study (20 asthmatics, 11 non-asthmatics). Twenty-two out of 30 (73%) subjects had abnormal pH studies. For all subjects, rabeprazole improved symptoms more than placebo (P = 0.03). The association was stronger in the pH-positive group (P = 0.009).

CONCLUSION

Acid reflux is common in ETA patients. Many patients with exercise-related respiratory symptoms are misdiagnosed as chronic asthmatics. Exercise-related symptoms improve with the use of acid suppression. This study suggests that ETA patients may benefit from acid suppression.

Osteoclastic and pleomorphic giant cell tumors of the pancreas diagnosed via EUS-guided FNA: unique clinical, endoscopic, and pathologic findings in a series of 5 patients

INTRODUCTION

Osteoclastic and pleomorphic giant cell tumors of the pancreas are rare entities that have been typically described only in single case reports. We report on our experience with a series of 5 patients with pancreatic giant cell tumors seen at our institution.

METHODS

This was a retrospective study involving a search of the study institution's medical records from 2001 to 2007 for patients diagnosed with giant cell-containing neoplasms of the pancreas.

RESULTS

Five patients (2 women, 3 men) were identified. Age range was 59 to 81 years, with a mean of 70.2 years. None were current or former smokers. None had a history of alcohol abuse or preexisting pancreatitis of any kind. On EUS, tumors tended to be large, with a mean diameter of 47 mm (range 20-70 mm). All tumors had a heterogeneous echotexture and a distinct appearance when compared with the typical appearance of adenocarcinoma when viewed via EUS. The diagnosis of giant cell tumor of the pancreas, as well as the subtype, was made via EUS-guided FNA of the pancreatic lesion. Patients with pleomorphic giant cell tumors of the pancreas had a poor clinical course with a rapid decline, whereas those with mixed or osteoclastic giant cell tumors tended to have a better outcome, with a greater long-term survival. One patient is still alive more than 18 months after diagnosis.

LIMITATION

Retrospective study.

CONCLUSIONS

Giant cell tumors of the pancreas have unique clinical, endoscopic, and cytologic features. The risk factors for these lesions may be different from those associated with pancreatic adenocarcinoma. Some giant cell tumor subtypes may carry a more favorable prognosis than pancreatic adenocarcinoma, and awareness and recognition of these differences can affect patient care.

Eosinophilic oesophagitis in patients presenting with dysphagia--a prospective analysis

BACKGROUND

Eosinophilic oesophagitis (EoO) may be a common finding in adults presenting with dysphagia.

AIM

To identify the risk factors and prevalence of EoO in an adult population with dysphagia.

METHODS

All patients with dysphagia referred for an upper endoscopy (EGD) were asked to participate. Patients completed a detailed questionnaire followed by EGD with four quadrant biopsies in the distal and mid-oesophagus. Primary endpoint was the prevalence of EoO; secondary endpoints included age, gender, asthma, food allergies, gastro-oesophageal reflux disease/dysphagia score and endoscopic findings.

RESULTS

Two hundred and sixty-one patients enrolled between December 2005 and January 2007. Thirty-one patients (12%) met pathological criteria for EoO. There was no difference in EoO prevalence within each gender. Mean age of EoO patients was 42 +/- 15 vs. 61 +/- 15 for non-EoO patients (P < 0.001). EoO was diagnosed in 35% of patients <50 years of age. EoO was present in 22% of asthmatics vs. 9% non-asthmatics (P < 0.01). EoO was present in 36.8% of patients with self-reported food allergies vs. 9.3% those without allergy (P < 0.001). A 13/31(42%) of EoO patients did not have the classic EGD findings (rings +/- furrows) and would have been missed without oesophageal biopsies.

CONCLUSIONS

Eosinophilic oesophagitis was diagnosed in 12% of the patients presenting with dysphagia with relative risk of 9.5 if age <50 years. Oesophageal biopsies are warranted in patients presenting with dysphagia especially in the younger population. Patients may not present with classic endoscopic findings and EoO can be missed without biopsies.

DPEJ tube placement prevents aspiration pneumonia in high-risk patients

Percutaneous endoscopic gastrostomy (PEG) or PEG tube with transgastric jejunostomy tube (PEG-J) feeding has not been shown to decrease aspiration pneumonia. The aim of this study was to determine if direct percutaneous endoscopic jejunostomy (DPEJ) tube placement results in a decreased incidence of aspiration pneumonia in high-risk patients. The design was a retrospective review of all patients receiving DPEJ tube for aspiration pneumonia from 1999 to 2005. Demographics, incidence of aspiration pneumonia, and outcomes were collected and compared before and after the DPEJ placement. Eleven patients (4 women, 7 men) were identified; their mean age was 44.9 years (range, 18-94 years). The etiologies for recurrent aspiration pneumonia were neurologic disease (9), esophageal surgery (1), and severe debilitation (1). The mean follow-up was 20.9 months (range, 6-48 months). The patients' mean weight increased from 43.8 kg (range, 19-55 kg) to 48.3 kg (range, 30-65 kg) after placement (P < .001). The total number of documented aspiration pneumonia episodes for all patients decreased from 29 (mean, 3.64; range, 1-6) before DPEJ placement to 3 (mean, 0.27; range, 0-2) after DPEJ placement (P < .001). The mean number of aspiration pneumonia events per month prior to the DPEJ placement was 3.39 and postplacement was 0.42 (P < .001). DPEJ placement appears to decrease recurrent aspiration pneumonia in patients with history of aspiration pneumonia.

A randomized, prospective trial of electrosurgical incision followed by rabeprazole versus bougie dilation followed by rabeprazole of symptomatic esophageal (Schatzki's) rings

BACKGROUND

Lower esophageal (Schatzki's) rings are a common cause of solid food dysphagia. Standard treatment involves passage of a single large bougie to disrupt the ring, but symptoms recur in the majority of patients. Electrosurgical incision of the ring may provide a longer duration of symptom improvement. There are no data on the treatment of Schatzki's rings in the presence of acid suppression treatment.

OBJECTIVE

Our purpose was to compare the efficacy of bougie dilation with electrosurgical incision of symptomatic Schatzki's rings at 1-year follow-up in the presence of rabeprazole treatment.

DESIGN

Randomized, prospective trial.

SETTING

University of Utah Health Sciences Center and the Veterans Affairs Salt Lake.

PATIENTS

Fifty patients referred for endoscopic evaluation of dysphagia between January 2002 and March 2005.

MAIN OUTCOME MEASUREMENTS

Symptom-free survival time (in months), dysphagia, and GERD scores.

RESULTS

Twenty-five patients each underwent bougie dilation and electrical incision and were followed up for 12 months. Symptom-free survival times were significantly longer in the incision group (7.99 months) compared with the bougie dilation group (5.86 months) (P = .03). Dysphagia and GERD scores significantly improved in each group comparing baseline with each time interval. The incision group had greater relief of dysphagia at 1 month (P = .05) compared with the bougie group. There was no difference between GERD scores in both groups.

LIMITATIONS

Dysphagia and GERD symptoms were self-reported.

CONCLUSIONS

Electrosurgical incision of Schatzki's rings is safe and offers longer symptom-free survival compared with bougie dilation. The addition of rabeprazole offered significant improvement in GERD scores in both groups.

Success rate of direct percutaneous endoscopic jejunostomy in patients who are obese

BACKGROUND

Direct percutaneous endoscopic jejunostomy (DPEJ) is increasingly used as a method for obtaining jejunal enteral access. The most cited reason of unsuccessful placement is poor transillumination, which may be related to obesity. Whether obesity affects failure and complication rates has not been previously described.

OBJECTIVE

To compare the success rate and adverse events (AEs) associated with DPEJ placement in patients who were overweight and patients who were obese compared with patients who were normal or underweight defined by body mass index (BMI).

DESIGN

Retrospective database review.

SETTING

A tertiary-referral center.

PATIENTS

Eighty DPEJ placements between February 2000 and September 2005.

MAIN OUTCOME MEASUREMENTS

DPEJ placement success in patients who were overweight/obese (BMI >or= 25) versus patients who were normal or underweight (BMI <25). Secondary end points included procedure time and AEs.

RESULTS

Eighty DPEJs were placed in 75 patients. Of these DPEJs, 65 (81%) succeeded and 15 (19%) failed. Success rates were 23 of 24 for patients who were underweight (96%), 25 of 31 for patients with normal BMI (81%), 8 of 11 for patients who were overweight (73%), and 6 of 10 for persons who were obese (60%) (odds ratio 3.43, 95% CI 1.03-11.44; P< .05 for BMI >or= 25 vs BMI<25). Overall, AEs were not significantly different for patients with BMI <25 versus BMI >or=25 (24/55 vs 9/21, respectively; P= .64). However, 4 of the 5 severe AEs occurred in patients with a BMI >or= 25 (P= .07).

LIMITATIONS

Retrospective single center.

CONCLUSIONS

DPEJ placement in patients who were overweight or obese was feasible, but procedural success was less frequent, and a trend toward more frequent major AEs was seen than in persons with normal or decreased BMI. BMI was an easily assessed preprocedural factor for DPEJ success and complication rates.

Retrievable esophageal stents for benign indications

Until recently, esophageal stents have not been a realistic option for the management of benign disease owing to difficulty removing the stents and associated high complication rates. However, progress in esophageal stent design has led to the development of retrievable esophageal stents. Clinical experience has shown promise for the management of benign esophageal diseases with retrievable stents, including refractory strictures, esophageal leaks, fistula and perforations. They have been shown to be safe and effective, though stent migration remains a concern. This article reviews the current designs, indications, efficacy and complications of retrievable esophageal stents.

In vivo evaluation of argon plasma coagulation in a porcine model

BACKGROUND

Argon plasma coagulation (APC) is a noncontact form of monopolar electrocautery. One purported advantage of APC includes a limit to the depth of injury. It is unclear from previous studies whether the depth of injury is limited to superficial tissue layers with the settings used in clinical practice.

OBJECTIVE

To evaluate the depth and the area of APC-induced injury by using new modes of APC delivery in an in vivo porcine model in the setting of colonoscopy.

DESIGN

Blinded quasi-experiment.

SUBJECTS

Six swine.

INTERVENTION

Colonoscopy with the swine under general anesthesia, with application of APC in 2 different pulsed modes and varying power settings and duration of application.

MAIN OUTCOME MEASUREMENTS

Surface area and depth of colonic mucosal injury. Qualitative histologic analysis of each site of APC application was performed on formalin-fixed specimens after euthanizing the swine.

RESULTS

Muscularis propria injury occurred in 22% of lesions with 10 W, 62% of lesions with 20 W, 86% of lesions with 40 W, and 80% of lesions with 60 W. Muscularis propria injury occurred in 42% of lesions at 1 second, 66% of lesions at 3 seconds, and 69% of lesions at 5 seconds. Depth of injury was significantly correlated with total energy delivered (P = .001, r = 0.75). Surface area was significantly associated with total energy delivered (P < .001, r = 0.81).

LIMITATIONS

This study was performed in distal swine colon rather than human colon. Colon tissue response to APC injury may differ from swine to human colon. The application distance from the APC probe to the colonic tissue may have varied between applications.

CONCLUSIONS

Muscularis propria injury occurs across a broad range of clinically used APC settings. The frequency of deep injury and the surface area of the lesion increases with total energy delivered. The lowest power settings (10-20 W) and the shortest durations have the lowest risk of deep tissue injury.

Retrospective analysis of esophageal food impaction: differences in etiology by age and gender

Eosinophilic Esophagitis (EE) is an emerging cause of esophageal food impaction (EFI) not accounted for in previous studies. We sought to determine the causes of EFI in a recent cohort with recognition of EE. A retrospective chart review of all patients with EFI during the past 5 years was performed. Etiology was determined by endoscopy report, pathology results, and follow-up studies. A total of 85 EFIs occurred, in 79 patients (55 men, 30 women, age 18-100). The most common etiologies of EFI were Schatzki's ring (n = 18), peptic stricture (n = 18), EE (n = 9), esophagitis (n = 9), and no underlying diagnosis (n = 20). EE was significantly more frequent in men (P < .025) and those <50 years old (P < .025). There was a significant difference in the age at which men (median age = 44) and women (median age = 71) present with EFI (P < .001). The etiology of EFI differs significantly by age and gender. This information may be useful in evaluation and management of EFI.

Percutaneous endoscopic cecostomy in adults: a case series

BACKGROUND

Percutaneous cecostomy is used to treat recurrent colonic pseudoobstruction or obstipation in children and adults with multiple medical comorbidities. Percutaneous endoscopic cecostomy is a potentially attractive alternative to surgical or fluoroscopic cecostomy placement. A few reports describe percutaneous endoscopic cecostomy for management of these problems in children, whereas there are no large series of percutaneous endoscopic cecostomy in adult patients describing the indications, complications, and outcomes.

OBJECTIVE

Report our experience with percutaneous endoscopic cecostomy in adults.

DESIGN

Case series.

SETTING

Single tertiary referral center in the United States.

PATIENTS

Five patients with recurrent colonic pseudoobstruction and 2 with chronic refractory constipation.

INTERVENTIONS

Percutaneous endoscopic cecostomy.

RESULTS

Eight cases of percutaneous endoscopic cecostomy were performed from May 2001 through October 2005: 6 for colonic pseudoobstruction and 2 for chronic constipation. Seven of 8 cases were successful and resulted in clinical improvement. One patient required surgical removal of the percutaneous endoscopic cecostomy tube at 4 days for fecal spillage resulting in peritonitis despite successful tube placement for chronic constipation. Removal of the cecostomy tube occurred in 3 of 6 cases of pseudoobstruction (the other 3 remain in place). In the other patient with chronic constipation, clinical improvement occurred, but the patient died of underlying illness 21 days after placement. No other serious complications occurred.

LIMITATIONS

Retrospective, single-center study.

CONCLUSIONS

Percutaneous endoscopic cecostomy is a viable alternative to surgically or fluoroscopically placed cecostomy in a select group of patients with recurrent colonic pseudoobstruction or chronic intractable constipation.

Transnasal endoscopy vs. fluoroscopy for the placement of nasoenteric feeding tubes in critically ill patients

BACKGROUND

Placement of a nasoenteric feeding tube (NET) beyond the pylorus in critically ill patients is desirable. Bedside methods are unreliable, and fluoroscopic methods require transport and/or radiation exposure. Traditional endoscopic methods require sedation and oronasal transfer techniques. Transnasal techniques of NET placement by using recently developed ultrathin endoscopes have been described. The object of this prospective study was to compare the efficacy of NET placement by using ultrathin transnasal endoscopy vs. fluoroscopic placement.

METHODS

This is a prospective randomized study of endoscopic vs. fluoroscopic NET placement. The settings of the study were intensive care units at academic medical center. The study included 100 consecutive patients who required NET placement. They received endoscopic NET placement at the bedside with a 5.1-mm, ultrathin endoscope by using a transnasal over-the-wire technique vs. fluoroscopic NET placement by using standard techniques. The procedure success was defined as postpyloric (beyond the duodenal bulb) NET placement, jejunal placement success, and procedure time.

RESULTS

Tube placement success was not significantly different between endoscopic and fluoroscopic methods (90% with both methods; p = 1.00). The endoscopic procedure duration (12.8 +/- 6.4 minutes) was significantly shorter than fluoroscopic procedure duration (19.3 +/- 12.0 minutes) (p < 0.001). Procedure duration decreased significantly (from 17.3 +/- 6.2 minutes to 8.0 minutes +/- 4.2 minutes, p = 0.04), and jejunal placement increased significantly (from 60% to 100%, p = 0.04) from the first to the last 10 endoscopic procedures.

CONCLUSIONS

NET placement success with an ultrathin transnasal endoscope is equivalent to fluoroscopic placement with faster procedure times. More distal placement and procedure times improve with increasing experience with the endoscopic technique. Endoscopic NET placement can be performed at the bedside without the need for oronasal transfer, additional sedation, or fluoroscopy.

Comparison of air-coupled balloon esophageal and anorectal manometry catheters with solid-state esophageal manometry and water-perfused anorectal manometry catheters

Clinical gastrointestinal manometry studies are currently performed with multilumen water-perfused polyvinyl or strain gauge sensor solid-state catheters. A disposable catheter incorporating air-filled balloons has been developed with performance characteristics suitable for esophageal and anorectal manometry studies. Our aim was to compare esophageal and anorectal pressure measurements using this newly developed catheter with measurements obtained using standard solid-state or water-perfused catheters. Measurements of resting LES pressure, esophageal contraction amplitudes, and anorectal rest and squeeze pressures were obtained in 10 healthy volunteers using a solid-state esophageal catheter, a water-perfused anorectal catheter, and air-filled balloon esophageal and anorectal catheters. Correlation coefficient analysis demonstrated that LES pressures, esophageal contraction amplitudes, and anorectal resting and squeeze pressures were not significantly among between the different catheters. We conclude that recently developed air-filled balloon esophageal and anorectal manometry catheters provide very similar measurements of LES, esophageal body, and anorectal sphincter pressures compared to presently used manometry catheters.

Evaluation of mammary blood flow measurements in lactating goats using the ultrasound Doppler principle

1. Non-invasive methods were developed for measuring mammary blood flow in lactating goats. 2. A Doppler principle ultrasound device was equipped with an external detector measuring maximal blood velocity (Vmax) and average blood velocity (Vav) was calculated as Vmax/2. Volume flow then depended on determination of the angle of insonation and the cross-sectional area of the milk vein (the caudal superficial epigastric or subcutaneous abdominal vein). 3. Blood velocities were measured on the milk vein of either side of the animal while clamping the pudendal veins manually. Blood velocities ranged from 7-34 cm/sec. 4. The milk vein diameter was measured by means of a slide gauge which, for clearly protruding veins, gave similar results to that measured by ultrasound scanning. In protruding veins the cross-section was circular. In non-protruding veins the cross-section was elliptical and the slide gauge significantly (P less than 0.01) overestimated the cross-sectional area. The milk vein diameter of either side measured in 10 lactating goats was 8.8 +/- 1.1 mm (means +/- SD). 5. Blood flow ranged from 90-675 ml/min in a dry and a high-yielding (3.4 l milk daily) goat, respectively. The reproducibility of the blood flow measurements was 12-16%. 6. It is concluded that the present method may be used for quantitative measurements of mammary blood flow in goats.