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Mittal C, Muthusamy VR, Simon VC, Brauer BC, Mullady DK, Hollander T, Sloan I, Kushnir V, Early D, Rastogi A, Hammad HT, Edmundowicz SA, Han S, Thaker AM, Ezekwe E, Wani S, Kwasny MJ, Komanduri S. Threshold evaluation for optimal number of endoscopic treatment sessions to achieve complete eradication of Barrett's metaplasia. Endoscopy 2022; 54:927-933. [PMID: 35135015 DOI: 10.1055/a-1765-7197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Endoscopic eradication therapy (EET) is the standard of care for Barrett's esophagus (BE)-associated neoplasia. Previous data suggest the mean number of EET sessions required to achieve complete eradication of intestinal metaplasia (CE-IM) is 3. This study aimed to define the threshold of EET sessions required to achieve CE-IM. METHODS The TREAT-BE Consortium is a multicenter outcomes cohort including prospectively enrolled patients with BE undergoing EET. All patients achieving CE-IM were included. Demographic, endoscopic, and histologic data were recorded at treatment onset along with treatment details and surveillance data. Kaplan-Meier analysis was performed to define a threshold of EET sessions, with 95 %CI, required to achieve CE-IM. A secondary analysis examined predictors of incomplete response to EET using multiple logistic regression and recurrence rates. RESULTS 623 patients (mean age 65.2 [SD 11.6], 79.6 % male, 86.5 % Caucasian) achieved CE-IM in a mean of 2.9 (SD 1.7) EET sessions (median 2) and a median total observation period of 2.7 years (interquartile range 1.4-5.0). After three sessions, 73 % of patients achieved CE-IM (95 %CI 70 %-77 %). Age (odds ratio [OR] 1.25, 95 %CI 1.05-1.50) and length of BE (OR 1.24, 95 %CI 1.17-1.31) were significant predictors of incomplete response. CONCLUSION The current study found that a threshold of three EET sessions would achieve CE-IM in the majority of patients. Alternative therapies and further diagnostic testing should be considered for patients who do not have significant response to EET after three sessions.
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Affiliation(s)
- Chetan Mittal
- Interventional Oncology and Surgical Endoscopy, Parkview Health, Fort Wayne, Indiana, United States
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, University of California, Los Angeles, Los Angeles, California, United States
| | - Violette C Simon
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Brian C Brauer
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Daniel K Mullady
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Thomas Hollander
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Ian Sloan
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Vladimir Kushnir
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Dayna Early
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Amit Rastogi
- Division of Gastroenterology, Kansas University, Kansas City, Kansas, United States
| | - Hazem T Hammad
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Steven A Edmundowicz
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Samuel Han
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Adarsh M Thaker
- Vatche and Tamar Manoukian Division of Digestive Diseases, University of California, Los Angeles, Los Angeles, California, United States
| | - Ezenwanyi Ezekwe
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Mary J Kwasny
- Interventional Oncology and Surgical Endoscopy, Parkview Health, Fort Wayne, Indiana, United States
| | - Srinadh Komanduri
- Interventional Oncology and Surgical Endoscopy, Parkview Health, Fort Wayne, Indiana, United States
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Das KK, Mullady DK. Main Pancreatic Duct Dilation in IPMN: When (and Where) to Get "Worried"? Clin Gastroenterol Hepatol 2022; 20:272-275. [PMID: 33581356 DOI: 10.1016/j.cgh.2021.02.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 02/08/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Koushik K Das
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Daniel K Mullady
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
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Das KK, Hasak S, Elhanafi S, Visrodia KH, Ginsberg GG, Ahmad NA, Hollander T, Lang G, Kushnir VM, Mullady DK, Abu Dayyeh BK, Buttar NS, Wong Kee Song LM, Kochman ML, Chandrasekhara V. Performance and Predictors of Migration of Partially and Fully Covered Esophageal Self-Expanding Metal Stents for Malignant Dysphagia. Clin Gastroenterol Hepatol 2021; 19:2656-2663.e2. [PMID: 32898705 DOI: 10.1016/j.cgh.2020.09.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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] [Received: 05/22/2020] [Revised: 08/24/2020] [Accepted: 09/02/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Self-expanding metal stents (SEMS) are routinely used to palliate malignant dysphagia. However esophageal SEMS can migrate or obstruct due to epithelial hyperplasia. The aim of this study was to evaluate the rates and factors predicting migration and obstruction, and the nutritional outcomes in partially covered (pc) vs. fully covered (fc) SEMS vs. fcSEMS with antimigration fins (AF) placed for malignant dysphagia. METHODS A retrospective review of consecutive patients undergoing SEMS placement for malignant dysphagia at three academic medical centers. RESULTS Among 357 patients, there were 55 (15.4%) stent migrations, 45 (12.6%) obstructions from epithelial hyperplasia, and 20 (5.6%) food impactions. Median overall survival was 79 days (IQR 41,199). The percent weight change/change in albumin at 30 and 60 days after SEMS placement were -2.24%/-0.544 g/dL and -2.98%/-0.55 g/dL, respectively. Stent migration occurred significantly more often with fcSEMS than pcSEMS (25.3% vs 10.9%; P < .003), but there was no difference when either group was compared to fcSEMS-AF (19.3%). The overall rate of epithelial hyperplasia resulting in stent obstruction was low (12.6%) and not different between stent types. Factors associated with increased risk of SEMS migration on multivariable logistic regression included stricture traversability with a diagnostic endoscope (OR, 2.37; 95% CI, 1.29-4.35) and use of fcSEMS (OR, 2.56; 1.31-5.00) or fcSEMS-AF (OR, 2.30, 1.03-5.14). CONCLUSIONS Traversability of a malignant esophageal stenosis predicts SEMS migration. In these patients with a limited overall survival, pcSEMS are associated with lower rates of stent migration and similar rates of obstruction compared to fcSEMS.
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Affiliation(s)
- Koushik K Das
- Division of Gastroenterology, Washington University, St. Louis, Missouri.
| | - Stephen Hasak
- Division of Gastroenterology, Washington University, St. Louis, Missouri
| | - Sherif Elhanafi
- Division of Gastroenterology, Texas Tech University Health Sciences Center, El Paso, Texas
| | - Kavel H Visrodia
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Gregory G Ginsberg
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Nuzhat A Ahmad
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Thomas Hollander
- Division of Gastroenterology, Washington University, St. Louis, Missouri
| | - Gabriel Lang
- Division of Gastroenterology, Washington University, St. Louis, Missouri
| | - Vladimir M Kushnir
- Division of Gastroenterology, Washington University, St. Louis, Missouri
| | - Daniel K Mullady
- Division of Gastroenterology, Washington University, St. Louis, Missouri
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Navtej S Buttar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | - Michael L Kochman
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Bill JG, Ryou M, Hathorn KE, Cortes P, Maple JT, Al-Shahrani A, Lang G, Mullady DK, Das K, Cosgrove N, Salameh H, Kumta NA, DiMaio CJ, Zia H, Orr J, Yachimski P, Kushnir VM. Endoscopic ultrasound-guided biliary drainage in benign biliary pathology with normal foregut anatomy: a multicenter study. Surg Endosc 2021; 36:1362-1368. [PMID: 33712939 DOI: 10.1007/s00464-021-08418-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 02/23/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND AIMS Biliary drainage using endoscopic ultrasound (EUS-BD) has been developed as a novel technique to obtain biliary access and drainage when ERCP fails. Numerous studies have demonstrated its safety and efficacy specifically pertaining to those with malignant distal biliary obstruction or altered foregut anatomy. The aim of this study is to evaluate the safety and efficacy of EUS-BD in benign indications in patients with normal foregut anatomy. METHODS We performed a retrospective comparative study from 5 academic medical centers (2008-2018) involving patients with benign biliary obstruction and native foregut anatomy who had an initial failed ERCP with subsequent attempt at biliary decompression via EUS-BD or by repeating ERCP. RESULTS 36 patients (mean age 61.6 ± 2.2, 38.9% female) who underwent attempted EUS-BD following initial failed ERCP were compared to 50 patients (mean age 62.7 ± 2.3, 73.5% female) who underwent repeat ERCP following an initial failed cannulation. EUS-BD was technically successful in 28 (77.8%) patients with rendezvous being the most common approach (86.1%). A higher level of pre-procedural bilirubin was found to be associated with technical success of EUS-BD (3.65 ± 0.63 versus 1.1 ± 0.4, p value 0.04). Success of repeat ERCP following failed cannulation was 86%. Adverse events were significantly more frequent in the EUS-BD cohort when compared to the repeat ERCP (10 (27.8%) versus 4 (8.0%), p = 0.02, OR 4.32. CONCLUSIONS EUS-BD remains a viable therapeutic option in the setting of benign biliary disease, with success rates of 77.8%. Adverse events were significantly more common with EUS-BD vs. repeat ERCP, emphasizing the need to perform in expert centers with appropriate multidisciplinary support and to strongly consider the urgency of biliary decompression before considering same session EUS-BD after failed initial biliary access.
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Affiliation(s)
- Jason G Bill
- Division of Gastroenterology, Washington University in Saint Louis, Saint Louis, USA.
- University of Illinois College of Medicine - Peoria, 5105 North Glen Park Place, Peoria, IL, 61614, USA.
| | - Marvin Ryou
- Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Kelly E Hathorn
- Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Pedro Cortes
- Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | | | - Abdullah Al-Shahrani
- Division of Gastroenterology, Washington University in Saint Louis, Saint Louis, USA
| | - Gabriel Lang
- Division of Gastroenterology, Washington University in Saint Louis, Saint Louis, USA
| | - Daniel K Mullady
- Division of Gastroenterology, Washington University in Saint Louis, Saint Louis, USA
| | - Koushik Das
- Division of Gastroenterology, Washington University in Saint Louis, Saint Louis, USA
| | - Natalie Cosgrove
- Division of Gastroenterology, Washington University in Saint Louis, Saint Louis, USA
| | | | | | | | | | | | | | - Vladimir M Kushnir
- Division of Gastroenterology, Washington University in Saint Louis, Saint Louis, USA
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Mullady DK, Wang AY, Waschke KA. AGA Clinical Practice Update on Endoscopic Therapies for Non-Variceal Upper Gastrointestinal Bleeding: Expert Review. Gastroenterology 2020; 159:1120-1128. [PMID: 32574620 DOI: 10.1053/j.gastro.2020.05.095] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [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] [Received: 03/25/2020] [Revised: 05/17/2020] [Accepted: 05/18/2020] [Indexed: 12/19/2022]
Abstract
DESCRIPTION The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available evidence and best practice advice statements regarding the use of endoscopic therapies in treating patients with non-variceal upper gastrointestinal bleeding. METHODS This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. This review is framed around the 10 best practice advice points agreed upon by the authors, which reflect landmark and recent published articles in this field. This expert review also reflects the experiences of the authors who are gastroenterologists with extensive experience in managing and teaching others to treat patients with non-variceal upper gastrointestinal bleeding (NVUGIB). BEST PRACTICE ADVICE 1: Endoscopic therapy should achieve hemostasis in the majority of patients with NVUGIB. BEST PRACTICE ADVICE 2: Initial management of the patient with NVUGIB should focus on resuscitation, triage, and preparation for upper endoscopy. After stabilization, patients with NVUGIB should undergo endoscopy with endoscopic treatment of sites with active bleeding or high-risk stigmata for rebleeding. BEST PRACTICE ADVICE 3: Endoscopists should be familiar with the indications, efficacy, and limitations of currently available tools and techniques for endoscopic hemostasis, and be comfortable applying conventional thermal therapy and placing hemoclips. BEST PRACTICE ADVICE 4: Monopolar hemostatic forceps with low-voltage coagulation can be an effective alternative to other mechanical and thermal treatments for NVUGIB, particularly for ulcers in difficult locations or those with a rigid and fibrotic base. BEST PRACTICE ADVICE 5: Hemostasis using an over-the-scope clip should be considered in select patients with NVUGIB, in whom conventional electrosurgical coagulation and hemostatic clips are unsuccessful or predicted to be ineffective. BEST PRACTICE ADVICE 6: Hemostatic powders are a noncontact endoscopic option that may be considered in cases of massive bleeding with poor visualization, for salvage therapy, and for diffuse bleeding from malignancy. BEST PRACTICE ADVICE 7: Hemostatic powder should be preferentially used as a rescue therapy and not for primary hemostasis, except in cases of malignant bleeding or massive bleeding with inability to perform thermal therapy or hemoclip placement. BEST PRACTICE ADVICE 8: Endoscopists should understand the risk of bleeding from therapeutic endoscopic interventions (eg, endoluminal resection and endoscopic sphincterotomy) and be familiar with the endoscopic tools and techniques to treat intraprocedural bleeding and minimize the risk of delayed bleeding. BEST PRACTICE ADVICE 9: In patients with endoscopically refractory NVUGIB, the etiology of bleeding (peptic ulcer disease, unknown source, post surgical); patient factors (hemodynamic instability, coagulopathy, multi-organ failure, surgical history); risk of rebleeding; and potential adverse events should be taken into consideration when deciding on a case-by-case basis between transcatheter arterial embolization and surgery. BEST PRACTICE ADVICE 10: Prophylactic transcatheter arterial embolization of high-risk ulcers after successful endoscopic therapy is not encouraged.
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Affiliation(s)
- Daniel K Mullady
- Division of Gastroenterology, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia.
| | - Kevin A Waschke
- Division of Gastroenterology, McGill University, Montreal, Quebec, Canada
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Affiliation(s)
- Jason G Bill
- Washington University School of Medicine, St. Louis, Missouri, USA
- OSF St. Francis Medical Center/University of Illinois College of Medicine, Peoria, Illinois
| | - Deyali Chaterjee
- Washington University School of Medicine, St. Louis, Missouri, USA
| | - Daniel K Mullady
- Washington University School of Medicine, St. Louis, Missouri, USA
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Brewer Gutierrez OI, Raijman I, Shah RJ, Elmunzer BJ, Webster GJ, Pleskow D, Sherman S, Sturgess RP, Sejpal DV, Ko C, Maurano A, Adler DG, Mullady DK, Strand DS, DiMaio CJ, Piraka C, Sharahia R, Dbouk MH, Han S, Spiceland CM, Bekkali NL, Gabr M, Bick B, Dwyer LK, Han D, Buxbaum J, Zulli C, Cosgrove N, Wang AY, Carr-Locke D, Kerdsirichairat T, Aridi HD, Moran R, Shah S, Yang J, Sanaei O, Parsa N, Kumbhari V, Singh VK, Khashab MA. Safety and efficacy of digital single-operator pancreatoscopy for obstructing pancreatic ductal stones. Endosc Int Open 2019; 7:E896-E903. [PMID: 31281875 PMCID: PMC6609233 DOI: 10.1055/a-0889-7743] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Abstract
Background and study aims The role of the digital single-operator pancreatoscopy (D-SOP) with electrohydraulic (EHL) or laser lithotripsy (LL) in treating pancreatic ductal stones is unclear. We investigated the safety and efficacy of D-SOP with EHL or LL in patients with obstructing pancreatic duct stones.
Patients and methods Retrospective analysis of 109 patients who underwent D-SOP for pancreatic stones at 17 tertiary centers in the United States and Europe from February 2015 to September 2017. Logistic regression was performed to identify factors associated with the need for more than one D-SOP with EHL/LL.
Results Most patients were males (70.6 %),mean age 54.7 years. Fifty-nine (54.1 %) underwent EHL and 50 (45.9 %) underwent LL. Mean procedure time was longer in the EHL group (74.4 min vs 53.8 min; P < 0.001). Ducts were completely cleared (technical success) in 89.9 % of patients (94.1 % in EHL vs 100 % in LL; P = 0.243), achieved in a single session in 73.5 % of patients (77.1 % by EHL and 70 % by LL; P= 0.5).D-SOP failed in 11 patients (10.1 %); 6 patients were treated with extracorporeal shockwave lithotripsy (ESWL), 1 with surgery,1 with combined treatment (ESWL + D-SOP EHL) and 3 with other. Fourteen adverse events occurred in 11 patients (10.1 %). Patients with more than three ductal stones were more likely to have technical failure compared to those with less than three stones (17 % vs. 4.8 %; P = 0.04). Having more than three stones was independently associated with the need for more than one D-SOC EHL/LL session (OR 2.94, 95 % CI 1.13 – 7.65).
Conclusion D-SOP with EHL or LL is effective and safe in patients with pancreatic ductal stones.
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Affiliation(s)
| | - Isaac Raijman
- Greater Houston Gastroenterology, Texas, United States
| | - Raj J. Shah
- Division of Gastroenterology and Hepatology University of Colorado-Denver Medical School, Colorado, United States
| | - B. Joseph Elmunzer
- Division of Gastroenterology and Hepatology. Medical University of South Carolina, Charleston, South Carolina, United States
| | | | - Douglas Pleskow
- Division of Gastroenterology and Hepatology Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Stuart Sherman
- Division of Gastroenterology and Hepatology Indiana University Medical Center, Indiana, United States
| | - Richard P. Sturgess
- Division of Gastroenterology and Hepatology, Aintree University Hospital, Liverpool, United Kingdom
| | - Divyesh V. Sejpal
- Division of Gastroenterology and Hepatology Hofstra-Northwell School of Medicine, New York, United States
| | - Christopher Ko
- Division of Gastroenterology and Hepatology University of Southern California Keck School of Medicine, California, United States
| | - Attilio Maurano
- University Hospital of Salerno, G. Fucito Center, Mercato San Severino (SA), Italy
| | - Douglas G. Adler
- Division of Gastroenterology and Hepatology University of Utah School of Medicine, Utah, United States
| | - Daniel K. Mullady
- Division of Gastroenterology and Hepatology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, United States
| | - Daniel S. Strand
- Division of Gastroenterology and Hepatology University of Virginia Health System, Virginia, United States
| | - Christopher J. DiMaio
- Division of Gastroenterology Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, United States
| | - Cyrus Piraka
- Henry Ford Hospital, Detroit, Michigan, United States
| | - Reem Sharahia
- Division of Gastroenterology and Hepatology Weil Cornell, New York, New York, United States
| | - Mohamad H. Dbouk
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland United States
| | - Samuel Han
- Division of Gastroenterology and Hepatology University of Colorado-Denver Medical School, Colorado, United States
| | - Clayton M. Spiceland
- Division of Gastroenterology and Hepatology. Medical University of South Carolina, Charleston, South Carolina, United States
| | | | - Moamen Gabr
- Division of Gastroenterology and Hepatology Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Benjamin Bick
- Division of Gastroenterology and Hepatology Indiana University Medical Center, Indiana, United States
| | - Laura K. Dwyer
- Division of Gastroenterology and Hepatology, Aintree University Hospital, Liverpool, United Kingdom
| | - Dennis Han
- Division of Gastroenterology and Hepatology Hofstra-Northwell School of Medicine, New York, United States
| | - James Buxbaum
- Division of Gastroenterology and Hepatology University of Southern California Keck School of Medicine, California, United States
| | - Claudio Zulli
- University Hospital of Salerno, G. Fucito Center, Mercato San Severino (SA), Italy
| | - Natalie Cosgrove
- Division of Gastroenterology and Hepatology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, United States
| | - Andrew Y. Wang
- Division of Gastroenterology and Hepatology University of Virginia Health System, Virginia, United States
| | - David Carr-Locke
- Division of Gastroenterology and Hepatology Weil Cornell, New York, New York, United States
| | | | - Hanaa Dakour Aridi
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland United States
| | - Robert Moran
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland United States
| | - Shawn Shah
- Division of Gastroenterology and Hepatology Weil Cornell, New York, New York, United States
| | - Juliana Yang
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland United States
| | - Omid Sanaei
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland United States
| | - Nasim Parsa
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland United States
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland United States
| | - Vikesh K. Singh
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland United States
| | - Mouen A. Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland United States,Corresponding author Mouen A. Khashab, MD Johns Hopkins Hospital1800 Orleans StreetSheikh Zayed TowerBaltimore, MD 21287+1-410-502-7010
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Smith ZL, Park KH, Llano EM, Donboli K, Fayad L, Han S, Kang L, Simril RT, Patel R, Hollander T, Rogers MC, Elmunzer BJ, Siddiqui UD, Aadam AA, Mullady DK, Lang GD, Das KK, Jamil LH, Lo SK, Gaddam S, Chapman CG, Keswani RN, Wani S, Cote GA, Kumbhari V, Kushnir VM. Outcomes of endoscopic treatment of leaks and fistulae after sleeve gastrectomy: results from a large multicenter U.S. cohort. Surg Obes Relat Dis 2019; 15:850-855. [DOI: 10.1016/j.soard.2019.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/06/2019] [Accepted: 04/06/2019] [Indexed: 02/07/2023]
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Abstract
Benign and malignant biliary strictures are common indications for endoscopic retrograde cholangiopancreatography. Diagnosis involves high-quality cross-sectional imaging and cholangiography with various endoscopic sampling techniques. Treatment options include placement of plastic biliary stents and self-expanding metal stents, which differ in patency duration and cost effectiveness. Whether the etiology is benign or malignant, a multidisciplinary strategy should be implemented. This article will discuss general principles of biliary stenting in both benign and malignant conditions.
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Affiliation(s)
- Jason G Bill
- Washington University School of Medicine in St. Louis, 660 South Euclid Avenue, Campus Box 8124, St Louis, MO 63110, USA
| | - Daniel K Mullady
- Interventional Endoscopy, Washington University School of Medicine in St. Louis, 660 South Euclid Avenue, Campus Box 8124, St Louis, MO 63110, USA.
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10
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Smith ZL, Mullady DK, Lang GD, Das KK, Hovis RM, Patel RS, Hollander TG, Elsner J, Ifune C, Kushnir VM. A randomized controlled trial evaluating general endotracheal anesthesia versus monitored anesthesia care and the incidence of sedation-related adverse events during ERCP in high-risk patients. Gastrointest Endosc 2019; 89:855-862. [PMID: 30217726 DOI: 10.1016/j.gie.2018.09.001] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 09/03/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS ERCP is a complex procedure often performed in patients at high risk for sedation-related adverse events (SRAEs). However, there is no current standard of care with regard to mode of sedation and airway management during ERCP. The aim of this study was to assess the safety of general endotracheal anesthesia (GEA) versus propofol-based monitored anesthesia care (MAC) without endotracheal intubation in patients undergoing ERCP at high risk for SRAEs. METHODS Consecutive patients undergoing ERCP at high risk for SRAEs at a single center were invited to participate in this randomized controlled trial comparing GEA and MAC. Inclusion criteria were STOP-BANG score ≥3, abdominal ascites, body mass index ≥35, chronic lung disease, American Society of Anesthesiologists class >3, Mallampati class 4 airway, and moderate to heavy alcohol use. Exclusion criteria were preceding EUS, emergent ERCP, tracheostomy, unstable airway, gastric outlet obstruction or delayed gastric emptying, and altered foregut anatomy. The primary endpoint was composite incidence of SRAEs: hypoxemia, use of airway maneuvers, hypotension requiring vasopressors, sedation-related procedure interruption, cardiac arrhythmia, and respiratory failure. Secondary outcomes included procedure duration, cannulation success, in-room time, and immediate adverse events. RESULTS Two hundred patients (mean age, 61.1 ± 13.6 years; 36.5% women) were randomly assigned to GEA (n = 101) or MAC (n = 99) groups. Composite SRAEs were significantly higher in the MAC group compared with the GEA group (51.5% vs 9.9%, P < .001). This was primarily driven by the frequent need for airway maneuvers in the MAC group. Additionally, ERCP was interrupted in 10.1% of patients in the MAC group to convert to GEA because of respiratory instability refractory to airway maneuvers (n = 8) or significant retained gastric contents (n = 2). There were no statistically significant differences in cannulation, in-room, procedure, or fluoroscopy times between the 2 groups. All patients undergoing GEA were successfully extubated in the procedure room at completion of ERCP, and Aldrete scores in recovery did not differ between the 2 groups. There were no immediate adverse events. CONCLUSION In patients at high risk for SRAEs undergoing ERCP, sedation with GEA is associated with a significantly lower incidence of SRAEs, without impacting procedure duration, success, recovery, or in-room time. These data suggest that GEA should be used for ERCP in patients at high risk for SRAEs (Clinical trial registration number: NCT02850887.).
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Affiliation(s)
- Zachary L Smith
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Daniel K Mullady
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Gabriel D Lang
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Koushik K Das
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Robert M Hovis
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Riddhi S Patel
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Thomas G Hollander
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jeffery Elsner
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Catherine Ifune
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Vladimir M Kushnir
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
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11
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Smith ZL, Gregory MH, Elsner J, Alajlan BA, Kodali D, Hollander T, Sayuk GS, Lang GD, Das KK, Mullady DK, Early DS, Kushnir VM. Health-related quality of life and long-term outcomes after endoscopic therapy for walled-off pancreatic necrosis. Dig Endosc 2019; 31:77-85. [PMID: 30152143 DOI: 10.1111/den.13264] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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] [Received: 02/21/2018] [Accepted: 08/20/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIM Walled-off pancreatic necrosis (WON) frequently develops after necrotizing pancreatitis. Endoscopic drainage has become the preferred modality for symptomatic or infected WON. The aim of the present study was to assess health-related quality of life (HR-QOL) and long-term outcomes in patients undergoing endoscopic drainage for WON. METHODS Patients undergoing endoscopic drainage of WON from January 2006 to May 2016 were identified. Data recorded included demographic information, and the incidence of long-term sequelae including pancreatic endocrine and exocrine insufficiency. Attempts were made to contact all patients. HR-QOL was assessed using the SF-36 questionnaire. RESULTS Eighty patients were analyzed, 41 (51.3%) of whom completed the SF-36. One-year all-cause mortality was 6.2%, and disease-related mortality was 3.7%. A notable proportion of patients developed exocrine insufficiency (32.5%), endocrine insufficiency (27.7%), and long-term opiate use (42.5%). Development of exocrine insufficiency was predictive of lower total SF-36 scores (P = 0.016). Patients with WON had better HR-QOL compared with cohorts of irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD). In patients developing exocrine insufficiency versus healthy controls, poorer scores in the physical role (P < 0.001), general health (P < 0.001), vitality (P = 0.001), and emotional role (P = 0.029) domains were observed. Exocrine insufficiency patients had better HR-QOL than the IBS and IBD cohorts, although these differences were less pronounced. CONCLUSION After undergoing endoscopic drainage for WON, patients have relatively preserved HR-QOL. The subset of patients that develop exocrine insufficiency have significantly poorer HR-QOL compared to healthy controls, although not to the degree of chronic gastrointestinal disorders such as IBS and IBD.
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Affiliation(s)
- Zachary L Smith
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Martin H Gregory
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Jeffrey Elsner
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Bader A Alajlan
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Divya Kodali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Thomas Hollander
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Gregory S Sayuk
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Gabriel D Lang
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Koushik K Das
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Daniel K Mullady
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Dayna S Early
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Vladimir M Kushnir
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
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12
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Lang GD, Mullady DK, Early DS, Hollander T, Edmundowicz SA, Murad FM, Strasberg SM, Fields RC, Hawkins WG, Doyle MB, Chapman WC, Wang-Gillam A, Kushnir VM. Utility of Endoscopic Ultrasound in Evaluating Local Recurrence After Surgery for Pancreatic Cancer. Clin Gastroenterol Hepatol 2018; 16:1834-1835. [PMID: 29505906 DOI: 10.1016/j.cgh.2018.02.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 09/27/2017] [Accepted: 02/22/2018] [Indexed: 02/07/2023]
Abstract
Pancreatic adenocarcinoma recurrence after surgery (PARaS) is associated with poor outcomes. PARaS is locoregional in 50%-80%, effecting the resection bed and adjacent lymphatics.1-3 Detection of PARaS via endoscopic ultrasound (EUS) is challenging because recurrent malignancy is difficult to distinguish from normal postoperative changes. Diagnosing PARaS is important, because salvage chemotherapy/radiation improves survival.4,5 The purpose of this investigation is to determine the clinical utility of EUS fine-needle aspiration (FNA) in patients with suspected PARaS.
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Affiliation(s)
- Gabriel D Lang
- Department of Gastroenterology, Washington University in Saint Louis, Saint Louis, Missouri
| | - Daniel K Mullady
- Department of Gastroenterology, Washington University in Saint Louis, Saint Louis, Missouri
| | - Dayna S Early
- Department of Gastroenterology, Washington University in Saint Louis, Saint Louis, Missouri
| | - Thomas Hollander
- Department of Gastroenterology, Washington University in Saint Louis, Saint Louis, Missouri
| | - Steven A Edmundowicz
- Department of Medicine, Washington University in Saint Louis, Saint Louis, Missouri; Division of Gastroenterology, University of Colorado, Aurora, Colorado
| | - Faris M Murad
- Department of Gastroenterology, Northshore University Health System, Evanston, Illinois
| | | | - Ryan C Fields
- Department of Surgery, Washington University, Saint Louis, Missouri
| | | | - Maria B Doyle
- Department of Surgery, Washington University, Saint Louis, Missouri
| | | | - Andrea Wang-Gillam
- Department of Hematology and Oncology, Washington University, Saint Louis, Missouri
| | - Vladimir M Kushnir
- Department of Gastroenterology, Washington University in Saint Louis, Saint Louis, Missouri.
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13
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Agnihotri A, Xie A, Bartalos C, Kushnir V, Sullivan S, Islam S, Islam E, Lamet M, Lamet A, Farboudmanesch R, Overholt BF, Altawil J, Early DS, Bennett M, Lowe A, Mullady DK, Adeyeri CS, El Zein M, Mishra P, Fayad L, Dunlap M, Oberbach A, Cheskin LJ, Kalloo AN, Khashab MA, Kumbhari V. Real-World Safety and Efficacy of Fluid-Filled Dual Intragastric Balloon for Weight Loss. Clin Gastroenterol Hepatol 2018; 16:1081-1088.e1. [PMID: 29481969 DOI: 10.1016/j.cgh.2018.02.026] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [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] [Received: 11/21/2017] [Revised: 01/23/2018] [Accepted: 02/16/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Reshape Duo is a saline-filled dual, integrated intragastric balloon (IGB) approved by the Food and Drug Administration for weight loss in patients with obesity. In a prospective, randomized trial, obese patients who received the balloon had significantly greater percent excess weight loss (%EWL) compared with patients treated with diet and exercise alone. However, there are limited data on the real-world efficacy of the Reshape balloon. METHODS We performed a retrospective study of data collected from 2 academic centers and 5 private practices in which all patients paid for the IGB and follow-up visits out of pocket. The IGB was removed after 6 months. We collected data (demographic, medical, and laboratory) from 202 adults (mean age 47.8 ± 10.8 years; 83% female) with a baseline mean body mass index of 36.8 + 8.4 kg/m2 who had IGB insertion for weight loss therapy, along with counselling on lifestyle modifications focused on diet and exercise. Primary outcomes were percent total body weight loss (%TBWL) and %EWL at 1, 3, 6, 9, and 12 months after the procedure. RESULTS Mean %TBWL at 1, 3, 6, 9 and 12 months was 4.8 ± 2.4%, 8.8 ± 4.3%, 11.4 ± 6.7%, 13.3 ± 7.8%, and 14.7 ± 11.8%, respectively. Data were available from 101 patients at 6 months and 12 patients at 12 months; 60.4% of patients achieved more than 10% TBWL and 55.4% had more than 25% EWL. Seventeen patients (8.4%) had esophageal tears during balloon insertion, with no intervention required. Thirteen patients (6.4%) had their IGB removed before the end of the 6-month treatment period. Nausea, vomiting, and abdominal pain were the most common adverse effects, occurring in 149 (73.8%), 99 (49%), and 51 (25.2%) patients. In one patient, the IGB migrated distally leading to small intestinal obstruction requiring surgical removal. CONCLUSION In a retrospective analysis of real-world patients who received the Reshape Duo IGB, we found it to be a safe and efficacious endoscopic method for producing weight loss, with most patients achieving greater than 10% TBWL at 6 months.
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Affiliation(s)
- Abhishek Agnihotri
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Amy Xie
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Vladimir Kushnir
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri
| | | | | | - Ebtesam Islam
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Mark Lamet
- Center for Gastrointestinal Disorders, Hollywood, Florida
| | - Ari Lamet
- Center for Gastrointestinal Disorders, Hollywood, Florida
| | - Ramin Farboudmanesch
- Advanced Gastroenterology and Hepatology of Greater Washington, Vienna, Virginia
| | | | | | - Dayna S Early
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri
| | - Michael Bennett
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri
| | - Abigail Lowe
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri
| | - Daniel K Mullady
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri
| | | | - Mohamad El Zein
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Priya Mishra
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lea Fayad
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Margo Dunlap
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Andreas Oberbach
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lawrence J Cheskin
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Anthony N Kalloo
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mouen A Khashab
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Vivek Kumbhari
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Abstract
Endoscopy has an important role in the pre- and post-treatment staging of esophageal cancer. Complete pathologic response following neoadjuvant chemoradiation therapy occurs in approximately 25% of patients. However, the ability to accurately detect this preoperatively with currently available endoscopic modalities is limited such that the default pathway is for fit patients to proceed with surgical resection. This article discusses the available endoscopic modalities (primarily Esophagogastroduodenoscopy [EGD] with mucosal biopsies and endoscopic ultrasonography with or without fine needle aspiration) used for post-treatment staging of esophageal cancer. We present data regarding the benefits and limitations of endoscopic methods in assessing for residual disease. Unfortunately, endoscopic modalities are not accurate enough to identify complete pathological responsers who may avoid surgical resection.
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Affiliation(s)
- N D Cosgrove
- Division of Gastroenterology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - D K Mullady
- Division of Gastroenterology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
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15
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Affiliation(s)
- Gabriel D Lang
- Washington University, Section of Gastroenterology, Saint Louis, Missouri, USA
| | - Daniel K Mullady
- Washington University, Section of Gastroenterology, Saint Louis, Missouri, USA
| | - Vladimir M Kushnir
- Washington University, Section of Gastroenterology, Saint Louis, Missouri, USA
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16
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Bill JG, Smith Z, Brancheck J, Elsner J, Hobbs P, Lang GD, Early DS, Das K, Hollander T, Doyle MBM, Fields RC, Hawkins WG, Strasberg SM, Hammill C, Chapman WC, Edmundowicz S, Mullady DK, Kushnir VM. The importance of early recognition in management of ERCP-related perforations. Surg Endosc 2018; 32:4841-4849. [PMID: 29770887 DOI: 10.1007/s00464-018-6235-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 05/09/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Iatrogenic perforations related to endoscopic retrograde cholangiopancreatography (ERCP) are rare events, carrying with it a mortality of up to 8%. Given the rarity of this adverse event, there remains limited data and continued uncertainties when choosing therapeutic strategies. Our aims were to evaluate the management of ERCP-related perforations and compare outcomes based on timing of recognition. METHODS The endoscopic databases of two tertiary care centers were interrogated to identify consecutive adult patients who sustained ERCP-related perforation over a 10-year period from 2006 to 2016. Electronic medical records were reviewed to extract demographic data, perforation type, management strategies, clinical data, and patient outcomes. RESULTS 14,045 ERCP's were performed during our 10-year study period. Sixty-three patients (average age 62.3 ± 2.38 years, 76% female) with ERCP-related perforations were included. Stapfer I perforations were found in 14 (22.2%) patients, Stapfer II in 24 (38.1%), and Stapfer III and IV perforations were identified in 16 (25.4%) and 9 (14.28%), respectively. Forty-seven (74.6%) perforations were recognized immediately during the ERCP, whereas 16 (25.4%) were recognized late. Endoscopic therapy was attempted in 35 patients in whom perforations were identified immediately, and was technically successful in 33 (94.3%). In all, 4 (1 immediate/ 3 delayed) patients required percutaneous drainage and 9 (5 immediate/ 4 delayed) surgery. Length of hospital stay, ICU admission were significantly shorter and incidence of SIRS was significantly lower when perforation was recognized immediately. CONCLUSIONS Immediate recognition of ERCP-related perforations leads to more favorable patient outcomes; with lower incidence of SIRS, less need for ICU level care, and shorter hospital stay.
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Affiliation(s)
- Jason G Bill
- Division of Gastroenterology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8124, St. Louis, MO, 63110, USA.
| | - Zachary Smith
- Division of Gastroenterology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8124, St. Louis, MO, 63110, USA
- Division of Gastroenterology and Liver Disease, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Joseph Brancheck
- Division of Gastroenterology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8124, St. Louis, MO, 63110, USA
| | - Jeffrey Elsner
- Division of Gastroenterology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8124, St. Louis, MO, 63110, USA
| | - Paul Hobbs
- Division of Gastroenterology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8124, St. Louis, MO, 63110, USA
| | - Gabriel D Lang
- Division of Gastroenterology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8124, St. Louis, MO, 63110, USA
| | - Dayna S Early
- Division of Gastroenterology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8124, St. Louis, MO, 63110, USA
| | - Koushik Das
- Division of Gastroenterology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8124, St. Louis, MO, 63110, USA
| | - Thomas Hollander
- Division of Gastroenterology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8124, St. Louis, MO, 63110, USA
| | | | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - William G Hawkins
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Steven M Strasberg
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Chet Hammill
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - William C Chapman
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Steven Edmundowicz
- Division of Gastroenterology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Daniel K Mullady
- Division of Gastroenterology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8124, St. Louis, MO, 63110, USA
| | - Vladimir M Kushnir
- Division of Gastroenterology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8124, St. Louis, MO, 63110, USA
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17
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Cho JY, Baron TH, Carr-Locke DL, Chapman WC, Costamagna G, de Santibanes E, Dominguez Rosado I, Garden OJ, Gouma D, Lillemoe KD, Angel Mercado M, Mullady DK, Padbury R, Picus D, Pitt HA, Sherman S, Shlansky-Goldberg R, Tornqvist B, Strasberg SM. Proposed standards for reporting outcomes of treating biliary injuries. HPB (Oxford) 2018; 20:370-378. [PMID: 29397335 DOI: 10.1016/j.hpb.2017.10.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 10/06/2017] [Accepted: 10/21/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND There is no standard nor widely accepted way of reporting outcomes of treatment of biliary injuries. This hinders comparison of results among approaches and among centers. This paper presents a proposal to standardize terminology and reporting of results of treating biliary injuries. METHODS The proposal was developed by an international group of surgeons, biliary endoscopists and interventional radiologists. The method is based on the concept of "patency" and is similar to the approach used to create reporting standards for arteriovenous hemodialysis access. RESULTS The group considered definitions and gradings under the following headings: Definition of Patency, Definition of Index Treatment Periods, Grading of Severity of Biliary Injury, Grading of Patency, Metrics, Comparison of Surgical to Non Surgical Treatments and Presentation of Case Series. CONCLUSIONS A standard procedure for reporting outcomes of treating biliary injuries has been produced. It is applicable to presenting results of treatment by surgery, endoscopy, and interventional radiology.
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Affiliation(s)
- Jai Young Cho
- Department of Surgery, Seoul National University, Bundang Hospital, Seoul National University College of Medicine, Seongnam, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si 13620, Republic of Korea
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, 130 Mason Farm Road CB 7080, Chapel Hill, NC 27599, USA
| | - David L Carr-Locke
- The Center for Advanced Digestive Care, Weill Cornell Medicine, New York Presbyterian Hospital, 1305 York Avenue, 4th Floor, New York, NY 10021, USA
| | - William C Chapman
- Section of Transplantation, Department of Surgery, Washington University in St Louis, 1 Barnes Hospital Plaza, St Louis, MO 63110, USA
| | - Guido Costamagna
- Digestive Endoscopy Unit, Catholic University of the Sacred Heart, Gemelli Hospital, Largo Agostino Gemelli, 8, Roma, RM 00168, Italy
| | - Eduardo de Santibanes
- Department of Surgery, Hospital Italiano de Buenos Aires, Juan D. Peron 4190, C1181ACH CABA, Buenos Aires, Argentina
| | - Ismael Dominguez Rosado
- Department of Surgery, National Institute of Medical Sciences and Nutrition, Vasco de Quiroga 15 Col. Seccion XVI, Tlalpan C.P. 14000, Mexico City, Mexico
| | - O James Garden
- Clinical Surgery, University of Edinburgh, Royal Infirmary, 51 Little France Crescent, Edinburgh EH16 4SA, UK
| | - Dirk Gouma
- Department of Surgery, Faculty of Medicine AMC, University of Amsterdam, Sweelincklaan 15, 1217 CK, Hilversum, The Netherlands
| | - Keith D Lillemoe
- Department of Surgery, White 506, 55 Fruit Street, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Miguel Angel Mercado
- Department of Surgery, National Institute of Medical Sciences and Nutrition, Vasco de Quiroga 15 Col. Seccion XVI, Tlalpan C.P. 14000, Mexico City, Mexico
| | - Daniel K Mullady
- Washington University in St Louis, Department of Medicine, Division of Gastroenterology, Campus Box 8124 660 S Euclid Ave, St Louis, MO 63110, USA
| | - Robert Padbury
- Department of Surgery, Flinders Medical Centre and Flinders University, Flinders Dr, Bedford Park SA 5042, Australia
| | - Daniel Picus
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 South Kingshighway Blvd, St Louis, MO 63110, USA
| | - Henry A Pitt
- Department of Surgery, Lewis Katz School of Medicine at Temple University, 3509 N. Broad Street, Boyer Pavilion, E 938, Philadelphia, PA 19140, USA
| | - Stuart Sherman
- Department of Medicine, Division of Digestive and Liver Disorders, Indiana University Health-University Hospital, 550 North University Blvd, Suite 1634, Indianapolis, IN 46202, USA
| | - Richard Shlansky-Goldberg
- Division of Interventional Radiology, Perelman School of Medicine at the University of Pennsylvania, Hospital of the University of Pennsylvania, Silverstein 1st floor, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Bjorn Tornqvist
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Steven M Strasberg
- Section of HPB Surgery, Washington University in St Louis, 1 Barnes Hospital Plaza, St Louis, MO 63110, USA.
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18
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Lang GD, Mullady DK. Response. Gastrointest Endosc 2018; 87:320. [PMID: 29241859 DOI: 10.1016/j.gie.2017.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 09/19/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Gabriel D Lang
- Department of Gastroenterology, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Daniel K Mullady
- Department of Gastroenterology, Washington University School of Medicine, Saint Louis, Missouri, USA
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19
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Kwon RS, Davila RE, Mullady DK, Al-Haddad MA, Bang JY, Bingener-Casey J, Bosworth BP, Christie JA, Cote GA, Diamond S, Jorgensen J, Kowalski TE, Kubiliun N, Law JK, Obstein KL, Qureshi WA, Ramirez FC, Sedlack RE, Tsai F, Vignesh S, Wagh MS, Zanchetti D, Coyle WJ, Cohen J. EGD core curriculum. VideoGIE 2017; 2:162-168. [PMID: 29905301 PMCID: PMC5991610 DOI: 10.1016/j.vgie.2017.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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20
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Lim KH, Langley E, Gao F, Luo J, Li L, Meyer G, Kim P, Singh S, Kushnir VM, Early DS, Mullady DK, Edmundowicz SA, Wani S, Murad FM, Cao D, Azar RR, Wang-Gillam A. A clinically feasible multiplex proteomic immunoassay as a novel functional diagnostic for pancreatic ductal adenocarcinoma. Oncotarget 2017; 8:24250-24261. [PMID: 28445954 PMCID: PMC5421844 DOI: 10.18632/oncotarget.15653] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Accepted: 02/16/2017] [Indexed: 02/07/2023] Open
Abstract
To date, targeted therapy for pancreatic ductal adenocarcinoma (PDAC) remains largely unsuccessful in the clinic. Current genomics-based technologies are unable to reflect the quantitative, dynamic signaling changes in the tumor, and require larger tumor samples that are difficult to obtain in PDAC patients. Therefore, a highly sensitive functional tool that can reliably and comprehensively inform intra-tumoral signaling events is direly needed to guide treatment decision. We tested the utility of a highly sensitive proteomics-based functional diagnostic platform, Collaborative Enzyme Enhanced Reactive-immunoassay (CEERTM), on fine-needle aspiration (FNA) samples obtained from 102 patients with radiographically-evident pancreatic tumors. Two FNA passes were collected from each patient, hybridized to customized chips coated with an array of capture antibodies, and detected using two enzyme-conjugated antibodies which emit quantifiable signals. We demonstrate that this technique is highly sensitive in detecting total and phosphorylated forms of multiple signaling molecules in FNA specimens, with reasonable correlation of marker intensities between two different FNA passes. Notably, signals of several markers were significantly higher in PDAC compared to non-cancerous samples. In PDAC samples, we found high total c-Met signal to be associated with poor survival, and confirmed this finding using an independent PDAC tissue microarray.
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Affiliation(s)
- Kian-Huat Lim
- Division of Oncology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Emma Langley
- Prometheus Laboratories Inc., San Diego, CA, USA
| | - Feng Gao
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - Jingqin Luo
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - Lin Li
- Division of Oncology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Gary Meyer
- Prometheus Laboratories Inc., San Diego, CA, USA
| | - Phillip Kim
- Prometheus Laboratories Inc., San Diego, CA, USA
| | - Sharat Singh
- Prometheus Laboratories Inc., San Diego, CA, USA
| | - Vladamir M. Kushnir
- Division of Gastroenterology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Dayna S. Early
- Division of Gastroenterology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel K. Mullady
- Division of Gastroenterology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Steven A. Edmundowicz
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Dengfeng Cao
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Riad R. Azar
- Division of Gastroenterology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Andrea Wang-Gillam
- Division of Oncology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
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21
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Brauer DG, Strand MS, Sanford DE, Kushnir VM, Lim KH, Mullady DK, Tan BR, Wang-Gillam A, Morton AE, Ruzinova MB, Parikh PJ, Narra VR, Fowler KJ, Doyle MB, Chapman WC, Strasberg SS, Hawkins WG, Fields RC. Utility of a multidisciplinary tumor board in the management of pancreatic and upper gastrointestinal diseases: an observational study. HPB (Oxford) 2017; 19:133-139. [PMID: 27916436 PMCID: PMC5477647 DOI: 10.1016/j.hpb.2016.11.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 08/08/2016] [Accepted: 11/11/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND & OBJECTIVES Multidisciplinary tumor boards (MDTBs) are frequently employed in cancer centers but their value has been debated. We reviewed the decision-making process and resource utilization of our MDTB to assess its utility in the management of pancreatic and upper gastrointestinal tract conditions. METHODS A prospectively-collected database was reviewed over a 12-month period. The primary outcome was change in management plan as a result of case discussion. Secondary outcomes included resources required to hold MDTB, survival, and adherence to treatment guidelines. RESULTS Four hundred seventy cases were reviewed. MDTB resulted in a change in the proposed plan of management in 101 of 402 evaluable cases (25.1%). New plans favored obtaining additional diagnostic workup. No recorded variables were associated with a change in plan. For newly-diagnosed cases of pancreatic ductal adenocarcinoma (n = 33), survival time was not impacted by MDTB (p = .154) and adherence to National Comprehensive Cancer Network guidelines was 100%. The estimated cost of physician time per case reviewed was $190. CONCLUSIONS Our MDTB influences treatment decisions in a sizeable number of cases with excellent adherence to national guidelines. However, this requires significant time expenditure and may not impact outcomes. Regular assessments of the effectiveness of MDTBs should be undertaken.
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Affiliation(s)
- David G Brauer
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Matthew S Strand
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Dominic E Sanford
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Vladimir M Kushnir
- Department of Medicine, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Kian-Huat Lim
- Department of Medicine, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Daniel K Mullady
- Department of Medicine, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Benjamin R Tan
- Department of Medicine, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Andrea Wang-Gillam
- Department of Medicine, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Ashley E Morton
- Department of Medicine, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Marianna B Ruzinova
- Department of Pathology and Immunology, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Parag J Parikh
- Department of Radiation Oncology, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Vamsi R Narra
- Mallinckrodt Institute of Radiology, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Kathryn J Fowler
- Mallinckrodt Institute of Radiology, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Majella B Doyle
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - William C Chapman
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Steven S Strasberg
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - William G Hawkins
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Ryan C Fields
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA.
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22
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Sullivan S, Swain JM, Woodman G, Antonetti M, De La Cruz-Muñoz N, Jonnalagadda SS, Ujiki M, Ikramuddin S, Ponce J, Ryou M, Reynoso J, Chhabra R, Sorenson GB, Clarkston WK, Edmundowicz SA, Eagon JC, Mullady DK, Leslie D, Lavin TE, Thompson CC. Randomized sham-controlled trial evaluating efficacy and safety of endoscopic gastric plication for primary obesity: The ESSENTIAL trial. Obesity (Silver Spring) 2017; 25:294-301. [PMID: 28000425 DOI: 10.1002/oby.21702] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 09/22/2016] [Accepted: 10/04/2016] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Evaluate safety and efficacy of the pose™ procedure for obesity treatment. METHODS Subjects with Class I to II obesity were randomized (2:1) to receive active or sham procedure, after each investigator performed unblinded lead-in cases. All subjects were provided low-intensity lifestyle therapy. Efficacy end points were the mean difference in percent total body weight loss (%TBWL) at 12 months between randomized groups, and responder rate achieving ≥5% TBWL. The primary safety end point was incidence of reported adverse events. RESULTS Three hundred thirty-two subjects were randomized (active, n = 221; sham, n = 111); thirty-four subjects were included in the unblinded lead-in cohort. Twelve-month results were mean TBWL 7.0 ± 7.4% in lead-in, 4.95 ± 7.04% in active, and 1.38 ± 5.58% in sham groups, respectively. Responder rate was 41.55% in active and 22.11% in sham groups, respectively (P < 0.0001); mean responder result was 11.5% TBWL. The differences observed between active and sham groups for co-primary end points were statistically significant (P < 0.0001); however, super superiority margin as set forth in the study design was not met. No unanticipated adverse events or deaths occurred. Procedure-related serious adverse event rates were 5.0% (active) and 0.9% (sham), P = 0.068. CONCLUSIONS The pose procedure was safe and resulted in statistically significant and clinically meaningful weight loss over sham through 1 year.
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Affiliation(s)
- Shelby Sullivan
- Internal Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - James M Swain
- HonorHealth Bariatric Center, Scottsdale, Arizona, USA
- Department of Surgery, University of Arizona School of Medicine, Scottsdale, Arizona, USA
| | - George Woodman
- Bariatric Surgery, Baptist Weight Loss Center, Memphis, Tennessee, USA
| | - Marc Antonetti
- Surgery, Lexington Medical Center, West Columbia, South Carolina, USA
| | - Nestor De La Cruz-Muñoz
- Laparoendoscopic and Bariatric Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Sreeni S Jonnalagadda
- Gastroenterology, St. Luke's Hospital of Kansas City (SLH), Saint Luke's GI Specialists, Kansas City, Missouri, USA
| | - Michael Ujiki
- Bariatric Surgery, NorthShore University Health System Evanston, Illinois, USA
| | - Sayeed Ikramuddin
- Bariatric Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jaime Ponce
- Bariatrics, Chattanooga Bariatrics, Chattanooga, Tennessee, USA
- Hamilton Medical Center, Dalton, Georgia, USA
| | - Marvin Ryou
- Gastroenterology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jason Reynoso
- HonorHealth Bariatric Center, Scottsdale, Arizona, USA
| | - Rajiv Chhabra
- Gastroenterology, St. Luke's Hospital of Kansas City (SLH), Saint Luke's GI Specialists, Kansas City, Missouri, USA
| | - G Brent Sorenson
- Bariatric Surgery, St. Luke's Hospital of Kansas City, Kansas City, Missouri, USA
| | - Wendell K Clarkston
- Gastroenterology, University of Missouri Kansas City School of Medicine and St. Luke's Hospital of Kansas City, Kansas City, Missouri, USA
| | - Steven A Edmundowicz
- Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | | | - Daniel K Mullady
- Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Daniel Leslie
- Bariatric Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Thomas E Lavin
- Surgery, Surgical Specialists of Louisiana, Metairie, Louisiana, USA
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Bill JG, Darcy M, Fujii-Lau LL, Mullady DK, Gaddam S, Murad FM, Early DS, Edmundowicz SA, Kushnir VM. A comparison between endoscopic ultrasound-guided rendezvous and percutaneous biliary drainage after failed ERCP for malignant distal biliary obstruction. Endosc Int Open 2016; 4:E980-5. [PMID: 27652305 PMCID: PMC5025302 DOI: 10.1055/s-0042-112584] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 07/05/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Selective biliary cannulation is unsuccessful in 5 % to 10 % of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) for malignant distal biliary obstruction (MDBO). Percutaneous biliary drainage (PBD) has been the gold standard, but endoscopic ultrasound guided rendezvous (EUSr) have been increasingly used for biliary decompression in this patient population. Our aim was to compare the initial success rate, long-term efficacy, and safety of PBD and EUSr in relieving MDBO after failed ERC Patients and methods: A retrospective study involving 50 consecutive patients who had an initial failed ERCP for MDBO. Twenty-five patients undergoing EUSr between 2008 - 2014 were compared to 25 patients who underwent PBD immediately prior to the introduction of EUSr at our center (2002 - 2008). Comparisons were made between the two groups with regard to technical success, duration of hospital stay and adverse event rates after biliary decompression. RESULTS The mean age at presentation was 66.5 (± 12.6 years), 28 patients (54.9 %) were female. The etiology of MDBO was pancreaticobiliary malignancy in 44 (88 %) and metastatic disease in 6 (12 %) cases. Biliary drainage was technically successful by EUSr in 19 (76 %) cases and by PBD in 25 (100 %) (P = 0.002). Median length of hospital stay after initial drainage was 1 day in the EUSr group vs 5 days in PBD group (P = 0.02). Repeat biliary intervention was required for 4 patients in the EUSr group and 15 in the PBD group (P = 0.001). CONCLUSIONS Initial technical success with EUSr was significantly lower than with PBD, however when EUSr was successful, patients had a significantly shorter post-procedure hospital stay and required fewer follow-up biliary interventions. Meeting presentations: Annual Digestive Diseases Week 2015.
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Affiliation(s)
- Jason G. Bill
- Division of Gastroenterology, Washington University School of Medicine in St Louis, Missouri, United States,Corresponding author Jason G. Bill, MD Division of GastroenterologyWashington University School of Medicine660 South Euclid Ave Campus Box 8124St Louis, Missouri 63110+1-314-454-8977+1-314-747-1080
| | - Michael Darcy
- Division of Interventional Radiology, Washington University School of Medicine in St Louis, Missouri, United States
| | - Larissa L. Fujii-Lau
- Division of Gastroenterology, Washington University School of Medicine in St Louis, Missouri, United States
| | - Daniel K. Mullady
- Division of Gastroenterology, Washington University School of Medicine in St Louis, Missouri, United States
| | - Srinivas Gaddam
- Division of Gastroenterology, Washington University School of Medicine in St Louis, Missouri, United States
| | - Faris M. Murad
- Division of Gastroenterology, Washington University School of Medicine in St Louis, Missouri, United States
| | - Dayna S. Early
- Division of Gastroenterology, Washington University School of Medicine in St Louis, Missouri, United States
| | - Steven A. Edmundowicz
- Division of Gastroenterology, Washington University School of Medicine in St Louis, Missouri, United States
| | - Vladimir M. Kushnir
- Division of Gastroenterology, Washington University School of Medicine in St Louis, Missouri, United States
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24
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Bill JG, Kushnir VM, Mullady DK, Murad FM, Azar RR, Easler JJ, Early DS, Edmundowicz SA. Evaluation of patients with abnormalities on intraoperative cholangiogram: time to abandon endoscopic retrograde cholangiopancreatography as the initial follow-up study. Frontline Gastroenterol 2016; 7:105-109. [PMID: 28839843 PMCID: PMC5369474 DOI: 10.1136/flgastro-2015-100597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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] [Received: 03/15/2015] [Revised: 05/28/2015] [Accepted: 05/30/2015] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is currently the method of choice for the postoperative evaluation of suspected bile duct stones seen on intraoperative cholangiogram (IOC); however, the sensitivity of IOC for identifying biliary pathology is unclear, with studies reporting false positive rates between 30% and 60%. OBJECTIVE Evaluate the sensitivity of IOC for biliary pathology, using ERCP with sphincterotomy and balloon sweep as gold standard. DESIGN Retrospective cohort study. SETTING Tertiary medical centre. PATIENTS 130 consecutive patients (age 51.3±1.7 years, 69.2% women) who underwent ERCP for the evaluation of abnormalities identified on IOC between 2005 and 2013. INTERVENTIONS Endoscopic retrograde cholangiopancreatography. MAIN OUTCOME MEASUREMENTS Sensitivity of IOC, identify predictors of positive postoperative ERCP and ERCP-related complications. RESULTS ERCP was successful in all 130 subjects. ERCP-related adverse events occurred in six (4.3%) patients, including self-limited post-sphincterotomy bleeding in three (2.3%) and mild post-ERCP pancreatitis in three (2.3%). Overall, 41 (31.5%) patients had normal cholangiogram at time of ERCP. Finding of a filling defect on IOC was the only predictor for the presence of common bile duct stones on postoperative ERCP (OR 3.3, 95% CI 1.0 to 10.8, p=0.05). LIMITATIONS Retrospective study design. CONCLUSIONS Nearly one-third of patients with abnormal IOC had a normal postoperative ERCP. Significant pathology could have been missed in 1/130 patients. Based on these findings, we believe the use of less-invasive diagnostic modalities may be used in place of ERCP in patients with suspected choledocholithiasis on IOC.
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Affiliation(s)
- Jason G Bill
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Vladimir M Kushnir
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Daniel K Mullady
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Faris M Murad
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Riad R Azar
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jeffery J Easler
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Dayna S Early
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Steven A Edmundowicz
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
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Coté GA, Slivka A, Tarnasky P, Mullady DK, Elmunzer BJ, Elta G, Fogel E, Lehman G, McHenry L, Romagnuolo J, Menon S, Siddiqui UD, Watkins J, Lynch S, Denski C, Xu H, Sherman S. Effect of Covered Metallic Stents Compared With Plastic Stents on Benign Biliary Stricture Resolution: A Randomized Clinical Trial. JAMA 2016; 315:1250-7. [PMID: 27002446 PMCID: PMC5544902 DOI: 10.1001/jama.2016.2619] [Citation(s) in RCA: 145] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Endoscopic placement of multiple plastic stents in parallel is the first-line treatment for most benign biliary strictures; it is possible that fully covered, self-expandable metallic stents (cSEMS) may require fewer endoscopic retrograde cholangiopancreatography procedures (ERCPs) to achieve resolution. OBJECTIVE To assess whether use of cSEMS is noninferior to plastic stents with respect to stricture resolution. DESIGN, SETTING, AND PARTICIPANTS Multicenter (8 endoscopic referral centers), open-label, parallel, randomized clinical trial involving patients with treatment-naive, benign biliary strictures (N = 112) due to orthotopic liver transplant (n = 73), chronic pancreatitis (n = 35), or postoperative injury (n = 4), who were enrolled between April 2011 and September 2014 (with follow-up ending October 2015). Patients with a bile duct diameter less than 6 mm and those with an intact gallbladder in whom the cystic duct would be overlapped by a cSEMS were excluded. INTERVENTIONS Patients (N = 112) were randomized to receive multiple plastic stents or a single cSEMS, stratified by stricture etiology and with endoscopic reassessment for resolution every 3 months (plastic stents) or every 6 months (cSEMS). Patients were followed up for 12 months after stricture resolution to assess for recurrence. MAIN OUTCOMES AND MEASURES Primary outcome was stricture resolution after no more than 12 months of endoscopic therapy. The sample size was estimated based on the noninferiority of cSEMS to plastic stents, with a noninferiority margin of -15%. RESULTS There were 55 patients in the plastic stent group (mean [SD] age, 57 [11] years; 17 women [31%]) and 57 patients in the cSEMS group (mean [SD] age, 55 [10] years; 19 women [33%]). Compared with plastic stents (41/48, 85.4%), the cSEMS resolution rate was 50 of 54 patients (92.6%), with a rate difference of 7.2% (1-sided 95% CI, -3.0% to ∞; P < .001). Given the prespecified noninferiority margin of -15%, the null hypothesis that cSEMS is less effective than plastic stents was rejected. The mean number of ERCPs to achieve resolution was lower for cSEMS (2.14) vs plastic (3.24; mean difference, 1.10; 95% CI, 0.74 to 1.46; P < .001). CONCLUSIONS AND RELEVANCE Among patients with benign biliary strictures and a bile duct diameter 6 mm or more in whom the covered metallic stent would not overlap the cystic duct, cSEMS were not inferior to multiple plastic stents after 12 months in achieving stricture resolution. Metallic stents should be considered an appropriate option in patients such as these. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01221311.
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Affiliation(s)
- Gregory A Coté
- Department of Medicine, Indiana University School of Medicine, Indianapolis2Department of Medicine, Medical University of South Carolina, Charleston
| | - Adam Slivka
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Daniel K Mullady
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - B Joseph Elmunzer
- Department of Medicine, Medical University of South Carolina, Charleston6Department of Medicine, University of Michigan, Ann Arbor
| | - Grace Elta
- Department of Medicine, University of Michigan, Ann Arbor
| | - Evan Fogel
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Glen Lehman
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Lee McHenry
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Joseph Romagnuolo
- Department of Medicine, Medical University of South Carolina, Charleston
| | - Shyam Menon
- Royal Wolverhampton Trust, Wolverhampton, United Kingdom
| | - Uzma D Siddiqui
- Center for Endoscopic Research and Therapeutics, University of Chicago School of Medicine, Chicago, Illinois
| | - James Watkins
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Sheryl Lynch
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Cheryl Denski
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis
| | - Huiping Xu
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis
| | - Stuart Sherman
- Department of Medicine, Indiana University School of Medicine, Indianapolis
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Kushnir VM, Keswani RN, Hollander TG, Kohlmeier C, Mullady DK, Azar RR, Murad FM, Komanduri S, Edmundowicz SA, Early DS. Compliance with surveillance recommendations for foregut subepithelial tumors is poor: results of a prospective multicenter study. Gastrointest Endosc 2016; 81:1378-84. [PMID: 25660977 DOI: 10.1016/j.gie.2014.11.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 11/05/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND American Gastroenterological Association guidelines recommend performing EUS to characterize subepithelial lesions (SELs) discovered on upper endoscopy (EGD), followed by surveillance if no high-risk features are identified. However, limited data are available on the impact of and compliance with surveillance recommendations. OBJECTIVE To determine the natural history of SELs<30 mm in size evaluated by EUS and to determine the degree of patient compliance with surveillance recommendations. DESIGN Prospective registry. SETTING Two tertiary centers. PATIENTS We studied 187 consecutive adult patients referred for EUS evaluation of foregut SELs. MAIN OUTCOME MEASUREMENTS Proportion of patients in whom SELs change in size or echo-features and compliance with follow-up recommendations. RESULTS Surveillance was recommended in 65 patients with hypoechoic SELs (44.6% women, age 59.5±13.2 years); of these, 29 (44.6%) underwent surveillance EUS as recommended and were followed for a median of 30 months (range, 12-105). During follow-up, 16 SELs (25%) increased in size, with a mean increase of 3.4±3.9 mm (range, 1-15). No changes in echo-texture of the SELs were observed. One patient was referred to surgery during follow-up (because of SEL growth>30 mm). LIMITATIONS Short follow-up duration; compliance was a secondary aim. CONCLUSIONS During a median follow-up of 30 months, growth in size was observed in 25% of small foregut SELs. However, change in size was minimal, and only 1 patient was referred for surgery based on surveillance EUS findings. Compliance with surveillance recommendations is poor, with fewer than 50% of patients undergoing surveillance EUS as recommended.
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Affiliation(s)
- Vladimir M Kushnir
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Rajesh N Keswani
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Thomas G Hollander
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Cara Kohlmeier
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Daniel K Mullady
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Riad R Azar
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Faris M Murad
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Srinadh Komanduri
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Steven A Edmundowicz
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Dayna S Early
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
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Rajan EA, Pais SA, Degregorio BT, Adler DG, Al-Haddad M, Bakis G, Coyle WJ, Davila RE, Dimaio CJ, Enestvedt BK, Jorgensen J, Lee LS, Mullady DK, Obstein KL, Sedlack RE, Tierney WM, Faulx AL. Small-bowel endoscopy core curriculum. Gastrointest Endosc 2013; 77:1-6. [PMID: 23261090 DOI: 10.1016/j.gie.2012.09.023] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 09/18/2012] [Indexed: 12/13/2022]
Abstract
This is one of a series of documents prepared by the ASGE Training Committee. This curriculum document contains recommendations for training, intended for use by endoscopy training directors, endoscopists involved in teaching endoscopy, and trainees in endoscopy. It was developed as an overview of techniques currently favored for the performance and training of small-bowel endoscopy and to serve as a guide to published references, videotapes, and other resources available to the trainer. By providing information to endoscopy trainers about the common practices used by experts in performing the technical aspects of the procedure, the ASGE hopes to improve the teaching and performance of small-bowel endoscopy.
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Coté GA, Mullady DK, Jonnalagadda SS, Keswani RN, Wani SB, Hovis CE, Ammar T, Al-Lehibi A, Edmundowicz SA, Komanduri S, Azar RR. Use of a pancreatic duct stent or guidewire facilitates bile duct access with low rates of precut sphincterotomy: a randomized clinical trial. Dig Dis Sci 2012; 57:3271-8. [PMID: 22732831 DOI: 10.1007/s10620-012-2269-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Accepted: 05/31/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND STUDY AIMS Among cases of difficult biliary cannulation, alternatives include use of a pancreatic duct stent (PDS) or guidewire (PDW) to facilitate access. We compared the effectiveness of a PDS versus a PDW to facilitate common bile duct (CBD) cannulation. PATIENTS AND METHODS We conducted a randomized, crossover trial at two endoscopy referral centers, limited to patients undergoing ERCP without a history of biliary sphincterotomy. After meeting predefined criteria for difficult cannulation, patients were randomized to using a PDS or PDW to facilitate CBD cannulation. Outcomes included cannulation rate within 6 min, overall cannulation rate, frequency of precut, and complication rates. RESULTS Among 442 eligible patients, 87 (19.7 %) met criteria for difficult cannulation. Forty two were randomized to PDW, 54 to PDS (including 9 PDW patients crossed over to PDS). The rate of CBD cannulation within 6 min was similar in the PDW (38.1 %) and PDS (51.9 %) groups (p = 0.18). In a secondary analysis limited to patients who successfully underwent PDW or PDS deployment, the rate was also comparable (PDW 59.3 %, PDS 65.1 %; p = 0.62). The overall frequency of CBD cannulation was 66.7 % in PDW and 90.7 % in PDS patients. Precut was required in 9.5 % of PDW and 25.9 % of PDS patients. Complication rates were similar, with 4 (4.6 %) patients having post-ERCP pancreatitis and 1 (1.1 %) having post-ERCP pain without confirmation of pancreatitis. CONCLUSIONS Use of a PDS or PDW facilitates CBD cannulation while maintaining a low complication rate and reducing the need for precut sphincterotomy in the majority of cases.
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Affiliation(s)
- Gregory A Coté
- Washington University School of Medicine in St. Louis, 660 S. Euclid Avenue, Campus Box 8124, St. Louis, MO 63110, USA
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Abstract
CONTEXT Spontaneous development of fistulae is an uncommon complication of acute pancreatitis. Until recently, surgical management has been the standard of care. Endoscopic treatment has been described with hemoclips and glue. CASE REPORT We report a case of a gentleman with a history of recurrent episodes of acute pancreatitis who presented with symptoms correlating with the development of a pancreatic-colonic fistula. Closure of the fistula was attempted with an over-the-scope clip. CONCLUSION More evidence is needed to determine criteria for use of over-the-scope clip in closure of GI and pancreatic fistulae.
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Affiliation(s)
- Darrell M Gray
- Department of Medicine, Washington University School of Medicine. St. Louis, MO, USA.
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Hunt GC, Coyle WJ, Pais SA, Adler DG, Degregorio B, Dimaio CJ, Dua KS, Enestvedt BK, Lee LS, McHenry L, Mullady DK, Rajan E, Sedlack RE, Shami VM, Tierney WM, Faulx AL. Core curriculum for EMR and ablative techniques. Gastrointest Endosc 2012; 76:725-9. [PMID: 22985639 DOI: 10.1016/j.gie.2012.04.440] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 04/05/2012] [Indexed: 02/08/2023]
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Mullady DK, Yadav D, Amann ST, O’Connell MR, Barmada MM, Elta GH, Scheiman JM, Wamsteker EJ, Chey WD, Korneffel ML, Weinman BM, Slivka A, Sherman S, Hawes RH, Brand RE, Burton FR, Lewis MD, Gardner TB, Gelrud A, DiSario J, Baillie J, Banks PA, Whitcomb DC, Anderson MA. Type of pain, pain-associated complications, quality of life, disability and resource utilisation in chronic pancreatitis: a prospective cohort study. Gut 2011; 60:77-84. [PMID: 21148579 PMCID: PMC6748627 DOI: 10.1136/gut.2010.213835] [Citation(s) in RCA: 209] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To compare patients with chronic pancreatitis (CP) with constant pain patterns to patients with CP with intermittent pain patterns. METHODS This was a prospective cohort study conducted at 20 tertiary medical centers in the USA comprising 540 subjects with CP. Patients with CP were asked to identify their pain from five pain patterns (A-E) defined by the temporal nature (intermittent or constant) and the severity of the pain (mild, moderate or severe). Pain pattern types were compared with respect to a variety of demographic, quality of life (QOL) and clinical parameters. Rates of disability were the primary outcome. Secondary outcomes included: use of pain medications, days lost from school or work, hospitalisations (preceding year and lifetime) and QOL as measured using the Short Form-12 (SF-12) questionnaire. RESULTS Of the 540 CP patients, 414 patients (77%) self-identified with a particular pain pattern and were analysed. Patients with constant pain, regardless of severity, had higher rates of disability, hospitalisation and pain medication use than patients with intermittent pain. Patients with constant pain had lower QOL (by SF-12) compared with patients who had intermittent pain. Additionally, patients with constant pain were more likely to have alcohol as the aetiology for their pancreatitis. There was no association between the duration of the disease and the quality or severity of the pain. CONCLUSIONS This is the largest study ever conducted of pain in CP. These findings suggest that the temporal nature of pain is a more important determinant of health-related QOL and healthcare utilisation than pain severity. In contrast to previous studies, the pain associated with CP was not found to change in quality over time. These results have important implications for improving our understanding of the mechanisms underlying pain in CP and for the goals of future treatments and interventions.
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Affiliation(s)
- Daniel K Mullady
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dhiraj Yadav
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Michael R O’Connell
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael M Barmada
- Department of Human Genetics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Grace H Elta
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - James M Scheiman
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Erik-Jan Wamsteker
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - William D Chey
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Meredith L Korneffel
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Beth M Weinman
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Adam Slivka
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Stuart Sherman
- Department of Medicine, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Robert H Hawes
- Digestive Disease Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Randall E Brand
- Department of Medicine, Evanston Northwestern Healthcare, Chicago, Illinois, USA
| | - Frank R Burton
- Department of Internal Medicine, St Louis University School of Medicine, St Louis, Missouri, USA
| | - Michele D Lewis
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Andres Gelrud
- Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - James DiSario
- Department of Medicine, University of Utah Health Science Center, Salt Lake City, Utah, USA
| | - John Baillie
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Peter A Banks
- Division of Gastroenterology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - David C Whitcomb
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA,Department of Human Genetics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michelle A Anderson
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Coté GA, Kumar N, Ansstas M, Edmundowicz SA, Jonnalagadda S, Mullady DK, Azar RR. Risk of post-ERCP pancreatitis with placement of self-expandable metallic stents. Gastrointest Endosc 2010; 72:748-54. [PMID: 20630513 DOI: 10.1016/j.gie.2010.05.023] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2010] [Accepted: 05/11/2010] [Indexed: 12/11/2022]
Abstract
BACKGROUND There are conflicting data on the risk of post-ERCP pancreatitis (PEP) related to self-expandable metallic stents (SEMSs). OBJECTIVE To compare rates of PEP in patients who undergo biliary drainage with SEMSs or polyethylene stents (PSs). DESIGN Retrospective, cohort study. SETTING Tertiary-care medical center. PATIENTS This study involved patients undergoing ERCP for malignant biliary obstruction between January 2005 and October 2008. INTERVENTION First-time placement of a SEMS or PS for biliary decompression. MAIN OUTCOME MEASUREMENTS Early post-ERCP complications, particularly PEP. RESULTS We identified 544 eligible patients, 248 SEMSs (102 covered), and 296 PSs. The etiology of malignant biliary obstruction was similar between groups, with 55% from pancreatic cancer. The frequency of PEP was significantly higher in the SEMS group (7.3%) versus the PS group (1.3%) (OR 5.7 [95% CI, 1.9-17.1]). On univariate analysis, patient age of <40 years, a history of PEP, and at least 1 pancreatic duct injection were also significant predictors of PEP, whereas female sex and having pancreatic cancer were not. When significant variables were added to a multiple-predictor regression model, the odds of PEP from SEMS placement increased to 6.8 (95% CI, 2.2, 21.4). However, the frequency of PEP was similar between covered (6.9%) and uncovered (7.5%) SEMSs (OR 0.9 [CI, 0.3-2.4]). Purported SEMS-specific risk factors, including the use of cSEMSs, overlapping SEMSs, or having a biliary sphincterotomy were not found to be significant contributors to the higher risk. LIMITATIONS Retrospective design. CONCLUSION After we controlled for confounding variables, the frequency of PEP was significantly higher with placement of a SEMS compared with a PS. Rates of PEP were comparable with use of covered and uncovered SEMSs.
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Affiliation(s)
- Gregory A Coté
- Division of Gastroenterology, Washington University, St Louis School of Medicine, St Louis, Missouri, USA.
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Coté GA, Hovis CE, Hovis RM, Waldbaum L, Early DS, Edmundowicz SA, Azar RR, Mullady DK, Jonnalagadda SS. A screening instrument for sleep apnea predicts airway maneuvers in patients undergoing advanced endoscopic procedures. Clin Gastroenterol Hepatol 2010; 8:660-665.e1. [PMID: 20580942 DOI: 10.1016/j.cgh.2010.05.015] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2010] [Revised: 05/07/2010] [Accepted: 05/08/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Among patients undergoing advanced endoscopy, unrecognized obstructive sleep apnea (OSA) could predict sedation-related complications (SRCs) and the need for airway maneuvers (AMs). By using an OSA screening tool, we sought to define the prevalence of patients at high risk for OSA and to correlate OSA with the frequency of AMs and SRCs. METHODS We enrolled 231 consecutive patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) (n = 176) and endoscopic ultrasound (n = 55). Propofol-based sedation and patient monitoring were performed by a nurse anesthetist and an anesthesiologist. A previously validated screening tool for OSA (STOP-BANG) was used to identify patients at high risk for OSA (score, > or =3 of 8; SB+) or low risk (SB-). AMs were defined as a chin lift, modified mask ventilation, nasal airway, bag-mask ventilation, and endotracheal intubation. SRCs were defined as any duration of pulse oximetry less than 90%, systolic blood pressure less than 90 mm Hg, apnea, or early procedure termination. RESULTS The prevalence of SB+ was 43.3%. The frequency of hypoxemia was significantly higher among patients with SB+ than SB- (12.0% vs 5.2%; relative risk [RR], 1.83; 95% confidence interval [CI], 1.32-2.54). The rate of AMs was also significantly higher among SB+ (20.0%) compared with SB- (6.1%) patients (RR, 1.8; 95% CI, 1.3-2.4). These rates remained significant after adjusting for American Society of Anesthesiologists class 3 or higher (RR, 1.70; 95% CI, 1.28-2.2 for AMs; RR, 1.63; 95% CI, 1.19-2.25 for hypoxemia). Each element of the STOP-BANG was reported more commonly in SB+ patients (P < .0001 for each comparison). CONCLUSIONS A significant number of patients undergoing advanced endoscopic procedures are at risk for OSA. AMs and hypoxemia occur at an increased frequency in these patients.
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Affiliation(s)
- Gregory A Coté
- Department of Medicine, Division of Gastroenterology and Hepatology, Washington University, St. Louis, Missouri, USA.
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Kularatna G, Azar RR, Mullady DK, Anderson CD, Gru AA. Nearly missed GI stromal tumor: EUS diagnosis of a jejunal GI stromal tumor mistaken for a pancreatic mass on CT. Gastrointest Endosc 2010; 71:1065-6; discussion 1066. [PMID: 20438896 DOI: 10.1016/j.gie.2009.12.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2009] [Accepted: 12/23/2009] [Indexed: 12/10/2022]
Affiliation(s)
- Gowri Kularatna
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
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Coté GA, Hovis RM, Ansstas MA, Waldbaum L, Azar RR, Early DS, Edmundowicz SA, Mullady DK, Jonnalagadda SS. Incidence of sedation-related complications with propofol use during advanced endoscopic procedures. Clin Gastroenterol Hepatol 2010; 8:137-42. [PMID: 19607937 DOI: 10.1016/j.cgh.2009.07.008] [Citation(s) in RCA: 177] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2009] [Revised: 07/02/2009] [Accepted: 07/04/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Propofol is an effective sedative in advanced endoscopy. However, the incidence of sedation-related complications is unclear. We sought to define the frequency of sedation-related adverse events, particularly the rate of airway modifications (AMs), with propofol use during advanced endoscopy. We also evaluated independent predictors of AMs. METHODS Patients undergoing sedation with propofol for advanced endoscopic procedures, including endoscopic retrograde cholangiopancreatography, endoscopic ultrasound, and small-bowel enteroscopy, were studied prospectively. Sedative dosing was determined by a certified registered nurse anesthetist with the goal of achieving deep sedation. Sedation-related complications included AMs, hypoxemia (pulse oximetry [SpO(2)] < 90%), hypotension requiring vasopressors, and early procedure termination. AMs were defined as chin lift, modified face mask ventilation, and nasal airway. We performed a regression analysis to compare characteristics of patients requiring AMs (AM+) with those who did not (AM-). RESULTS A total of 799 patients were enrolled over 7 months. Procedures included endoscopic ultrasound (423), endoscopic retrograde cholangiopancreatography (336), and small-bowel enteroscopy (40). A total of 87.2% of patients showed no response to endoscopic intubation. Hypoxemia occurred in 12.8%, hypotension in 0.5%, and premature termination in 0.6% of the patients. No patients required bag-mask ventilation or endotracheal intubation. There were 154 AMs performed in 115 (14.4%) patients, including chin lift (12.1%), modified face mask ventilation (3.6%), and nasal airway (3.5%). Body mass index, male sex, and American Society of Anesthesiologists class of 3 or higher were independent predictors of AMs. CONCLUSIONS Propofol can be used safely for advanced endoscopic procedures when administered by a trained professional. Independent predictors of AMs included male sex, American Society of Anesthesiologists class of 3 or higher, and increased body mass index.
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Affiliation(s)
- Gregory A Coté
- Division of Gastroenterology & Hepatology, Washington University, St. Louis, Missouri 63110, USA
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Ryou M, Mullady DK, Lautz DB, Thompson CC. Pilot study evaluating technical feasibility and early outcomes of second-generation endosurgical platform for treatment of weight regain after gastric bypass surgery. Surg Obes Relat Dis 2009; 5:450-4. [PMID: 19632645 DOI: 10.1016/j.soard.2009.03.217] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2008] [Revised: 03/16/2009] [Accepted: 03/17/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND For some gastric bypass patients, dilation of the gastrojejunal anastomosis (GJA) and/or gastric pouch is believed to contribute to weight regain. The present study had 2 objectives: (1) to assess the technical feasibility and safety of a novel endoscopic procedure called "revision obesity surgery endoscopic" (ROSE) using a second-generation, prototype endoscopic operating system that creates tissue plications to reduce the diameter of the GJA and the size of the gastric pouch; and (2) to assess the early outcomes regarding weight loss at a university hospital in the United States. METHODS This was a prospective study of 5 patients who had regained a mean of 14.7 kg after gastric bypass with a dilated pouch and GJA on screening endoscopy. The gastric pouch and the GJA were measured before and after the procedure. The patients were followed up for a minimum of 3 months after the procedure. Weight changes were recorded. RESULTS Technical success was achieved in all 5 patients (100%). The mean weight loss in the successful cases was 7.8 kg at 3 months. No major complications developed. CONCLUSION The results of our study have shown that the ROSE procedure using this second-generation prototype endoscopic operating system is technically feasible and appears safe. Our preliminary results suggest that the ROSE procedure is effective in reducing the size of both the GJA and the gastric pouch and could therefore be an alternative therapy for weight regain in postgastric bypass patients.
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Affiliation(s)
- Marvin Ryou
- Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Mullady DK, Carr-Locke DL. Traumatic biliary stricture. Medscape J Med 2008; 10:114. [PMID: 18596943 PMCID: PMC2438481] [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] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Daniel K Mullady
- Division of Gastroenterology, Harvard Medical School, Boston, Massachusetts, USA.
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Mullady DK, Ahmad J. Clinical challenges and images in GI. Gallstone impacted in duodenum causing gastric outlet obstruction (Bouveret syndrome). Gastroenterology 2007; 133:1075, 1394. [PMID: 17919482 DOI: 10.1053/j.gastro.2007.08.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Daniel K Mullady
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Mullady DK, Harrison JR. Clinical challenges and images in GI. Perforated diverticulum with neck abscess. Gastroenterology 2007; 132:1655, 2083. [PMID: 17484861 DOI: 10.1053/j.gastro.2007.03.080] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Daniel K Mullady
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Mullady DK, McGee JB. A Rare Iatrogenic Cause of Upper Gastrointestinal Bleeding. Anesthesiology 2006; 105:1063-4. [PMID: 17065909 DOI: 10.1097/00000542-200611000-00037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bedeir A, Jukic DM, Wang L, Mullady DK, Regueiro M, Krasinskas AM. Systemic Mastocytosis Mimicking Inflammatory Bowel Disease: A Case Report and Discussion of Gastrointestinal Pathology in Systemic Mastocytosis. Am J Surg Pathol 2006; 30:1478-82. [PMID: 17063092 DOI: 10.1097/01.pas.0000213310.51553.d7] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Gastrointestinal (GI) symptoms are present in up to 80% of patients with systemic mastocytosis (SM). GI symptoms include mainly abdominal pain, diarrhea, nausea, and vomiting. It is believed that most of the GI symptoms are due to the secondary effect of mast cell mediators on the GI tract. Direct involvement of the GI tract by neoplastic mast cell infiltration has not been well documented. We report a case of SM that initially mimicked inflammatory bowel disease based on clinical, radiographic, endoscopic, and histopathologic findings. On routine histologic sections of small bowel and colonic mucosal biopsies, there was expansion of the lamina propria by mononuclear inflammatory cells, foci of erosions with associated acute inflammation, and evidence of chronic mucosal injury with architectural distortion and gland foreshortening. Only on repeat biopsies and with ancillary tests for mast cells was a diagnosis of SM made, with extensive involvement of the GI tract. This is the first reported case of SM presenting as and mimicking inflammatory bowel disease. It is critical that clinicians and pathologists are aware that neoplastic mast cells in patients with SM can infiltrate the mucosa throughout the GI tract and that this infiltration can lead to symptoms and findings that can mimic inflammatory bowel disease.
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Affiliation(s)
- Ahmed Bedeir
- Department of Pathology, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, PA, USA
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Abstract
Intestinal failure can result from surgical resection, obstruction, dysmotility, congenital deficiencies or disease-associated loss of absorption. Before the development of intravenous feeding in the late 1960s, the condition was fatal, but by the 1990s approximately 40,000 patients were being successfully managed on long-term home parenteral nutrition (HPN) annually in the US. Survival on HPN depends on the nature of the underlying medical condition: over 80% of Crohn's disease patients survive for 5 years, but only 20% of cancer patients survive for 1 year. Although a patient's nutritional status is easy to maintain, there are serious long-term complications that arise from bypassing the gut and infusing nutrients directly into the systemic circulation. Catheter sepsis occurs about once per year (range 0-12 times). Abnormalities in liver function tests are common, but end-stage liver disease is rare. Central venous thrombosis develops in nearly all patients after 5 years. Although approximately 80% of patients on HPN are completely rehabilitated at home, their quality of life is impaired by the perpetual dependence on nocturnal intravenous infusions (every 8-12 h). In conclusion, HPN has allowed patients with previously fatal intestinal failure to survive and lead relatively normal lives at home, but their quality of life remains impaired by the dependence on intravenous infusions and complications that progress with time.
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Affiliation(s)
- Daniel K Mullady
- Center for Intestinal Health and Nutrition Support, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, 200 Lothrop Street, Pittsburgh, PA 15213, USA
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West-Mays JA, Cook JR, Sadow PM, Mullady DK, Bargagna-Mohan P, Strissel KJ, Fini ME. Differential inhibition of collagenase and interleukin-1alpha gene expression in cultured corneal fibroblasts by TGF-beta, dexamethasone, and retinoic acid. Invest Ophthalmol Vis Sci 1999; 40:887-96. [PMID: 10102285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
PURPOSE Expression of the genes for collagenase and interleukin-1alpha (IL-1alpha) are induced as stromal cells become activated to the repair fibroblast phenotype after injury to the cornea. This investigation examines the mechanisms whereby expression of these genes is inhibited by transforming growth factor-beta (TGF-beta), dexamethasone (DEX), or retinoic acid (RET A). METHODS A model of freshly isolated cultures of corneal stromal cells and early passage cultures of corneal fibroblasts was used in these studies. This model reproduces the events of stromal cell activation in the corneal wound. RESULTS In early passage cultures of corneal fibroblasts, expression of collagenase is under obligatory control by autocrine IL-1alpha. IL-1alpha controls its own expression through an autocrine feedback loop that is dependent on transcription factor NF-kappaB. TGF-beta, DEX, and RET A were each effective inhibitors of collagenase gene expression in these cells. Furthermore, these agents have the capacity to inhibit expression of IL-1alpha and this was correlated with their ability to affect DNA-binding activity of NF-kappaB. However, TGF-beta, DEX, and RET A were also effective inhibitors of the low level of collagenase expressed by freshly isolated corneal stromal cells that cannot express IL-1alpha. CONCLUSIONS In cells with an active IL-1alpha autocrine loop there are at least two distinct signaling pathways by which collagenase gene expression can be modulated. The results of this study demonstrate that TGF-beta, DEX, and RET A differentially inhibit collagenase and IL-1alpha gene expression. This information will be useful in the design of therapeutic modalities for fibrotic disease in the cornea and other parts of the eye.
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Affiliation(s)
- J A West-Mays
- New England Medical Center, and Department of Ophthalmology, Tufts University School of Medicine, Boston, Massachusetts 02111, USA
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