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Low EE, Fehmi SA, Yadlapati R. Tailored myotomy for the treatment of type 3 achalasia: Is there a role for the functional lumen imaging probe? Neurogastroenterol Motil 2023; 35:e14670. [PMID: 37691561 PMCID: PMC10759927 DOI: 10.1111/nmo.14670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 08/21/2023] [Indexed: 09/12/2023]
Affiliation(s)
- Eric E Low
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Syed A Fehmi
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
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Ahmad W, Fehmi SA, Savides TJ, Anand G, Chang MA, Kwong WT. Protocol of early lumen apposing metal stent removal for pseudocysts and walled off necrosis avoids bleeding complications. Scand J Gastroenterol 2020; 55:242-247. [PMID: 31942808 DOI: 10.1080/00365521.2019.1710246] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background: EUS-guided drainage of pancreatic fluid collections (PFCs; pancreatic pseudocyst (PPC) or walled-off necrosis (WON)) using lumen apposing metal stents (LAMSs) is now standard of care. We adopted a protocol of early LAMS removal and prospectively followed patients to determine if this protocol avoids bleeding complications.Methods: Prospective, consecutive case series of all patients with PPC and WON who underwent drainage with LAMS at a tertiary care referral center from July 2016 to November 2018. LAMS was removed within 4 weeks for PPC and within 6 weeks for WON. Patients with residual necrosis after 6 weeks underwent removal of initial LAMS and replacement with new LAMS every 6 weeks until resolution. Patients were followed within protocol while monitoring for bleeding complications and clinical success. We also performed a literature review to determine rates of LAMS related bleeding at various timepoints.Results: Forty patients (PPC n = 19, WON n = 21) underwent drainage with LAMS. Median time for LAMS removal was 21.0 days for PPC and 33.5 days for WON. Technical success and clinical success were achieved in 40/40 patients with zero cases of delayed bleeding. A literature review of 21 studies and 1378 patients showed 52/1378 (3.8%) bleeding events with 24/52 (46.2%) events occurring within 1 week of LAMS placement.Conclusions: An early removal LAMS protocol for PFC is highly efficacious and prevents delayed bleeding. Based on analysis of published cases, half of LAMS related bleeding occurs within the first week suggesting procedural factors rather than stent dwell time impact risk of bleeding.
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Affiliation(s)
- Waseem Ahmad
- Department of Medicine, University of California San Diego, La Jolla, CA, USA.,Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Syed A Fehmi
- Department of Medicine, University of California San Diego, La Jolla, CA, USA.,Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Thomas J Savides
- Department of Medicine, University of California San Diego, La Jolla, CA, USA.,Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Gobind Anand
- Department of Medicine, University of California San Diego, La Jolla, CA, USA.,Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Michael A Chang
- Department of Medicine, University of California San Diego, La Jolla, CA, USA.,Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Wilson T Kwong
- Department of Medicine, University of California San Diego, La Jolla, CA, USA.,Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
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Lawson RD, Hunt GC, Giap AQ, Krinsky ML, Slezak J, Tang RS, Gonzalez I, Kwong WT, Fehmi SA, Savides TJ. Pancreatic cysts suspected to be branch duct intraductal papillary mucinous neoplasm without concerning features have low risk for development of pancreatic cancer. Ann Gastroenterol 2015; 28:487-94. [PMID: 26423829 PMCID: PMC4585397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND The risk of developing pancreatic cancer is uncertain in patients with clinically suspected branch duct intraductal papillary mucinous neoplasm (BD-IPMN) based on the "high-risk stigmata" or "worrisome features" criteria proposed in the 2012 international consensus guidelines ("Fukuoka criteria"). METHODS Retrospective case series involving patients referred for endoscopic ultrasound (EUS) of indeterminate pancreatic cysts with clinical and EUS features consistent with BD-IPMN. Rates of pancreatic cancer occurring at any location in the pancreas were compared between groups of patients with one or more Fukuoka criteria ("Highest-Risk Group", HRG) and those without these criteria ("Lowest-Risk Group", LRG). RESULTS After exclusions, 661 patients comprised the final cohort (250 HRG and 411 LRG patients), 62% female with an average age of 67 years and 4 years of follow up. Pancreatic cancer, primarily adenocarcinoma, occurred in 60 patients (59 HRG, 1 LRG). Prevalent cancers diagnosed during EUS, immediate surgery, or first year of follow up were found in 48/661 (7.3%) of cohort and exclusively in HRG (33/77, 42.3%). Using Kaplan-Meier method, the cumulative incidence of cancer at 7 years was 28% in HRG and 1.2% in LRG patients (P<0.001). CONCLUSIONS This study supports using Fukuoka criteria to stratify the immediate and long-term risks of pancreatic cancer in presumptive BD-IPMN. The risk of pancreatic cancer was highest during the first year and occurred exclusively in those with "high-risk stigmata" or "worrisome features" criteria. After the first year all BD-IPMN continued to have a low but persistent cancer risk.
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Affiliation(s)
- Robert D. Lawson
- Department of Gastroenterology, Naval Medical Center, San Diego, California (Robert D. Lawson),
Correspondence to: Robert D. Lawson, MD, Department of Gastroenterology, Naval Medical Center, Bob Wilson Drive, San Diego, California 92134, USA, Fax: +619 532 9720, e-mail:
| | - Gordon C. Hunt
- Department of Gastroenterology, Kaiser Permanente, San Diego, California (Gordon C. Hunt)
| | - Andrew Q. Giap
- Department of Gastroenterology, Kaiser Permanente, Anaheim, California (Andrew Q. Giap)
| | - Mary L. Krinsky
- Department of Gastroenterology, Veterans Affairs Medical Center, La Jolla, California (Mary L. Krinsky)
| | - Jeff Slezak
- Department of Gastroenterology, Department of Research and Evaluation, Kaiser Permanente, Pasadena, California (Jeff Slezak)
| | - Raymond S. Tang
- Department of Gastroenterology, Institute of Digestive Disease, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong (Raymond S. Tang)
| | - Ingrid Gonzalez
- Department of Gastroenterology, Digestive Health Specialists, Winston-Salem, North Carolina (Ingrid Gonzalez)
| | - Wilson T. Kwong
- Department of Gastroenterology, Division of Gastroenterology, University of California, La Jolla, California (Wilson T. Kwong, Sayed A. Fehmi, Thomas J. Savides)
| | - Syed A. Fehmi
- Department of Gastroenterology, Division of Gastroenterology, University of California, La Jolla, California (Wilson T. Kwong, Sayed A. Fehmi, Thomas J. Savides)
| | - Thomas J. Savides
- Department of Gastroenterology, Division of Gastroenterology, University of California, La Jolla, California (Wilson T. Kwong, Sayed A. Fehmi, Thomas J. Savides)
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