Laparoscopic renal cryoablation: Risk factor analysis to predict oncologic outcomes with minimum 5-year follow-up

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Background: We analysed risk factors to predict oncologic outcomes at 5–11 year after laparoscopic renal cryoablation (LRC). Methods: Between 09/1997 and 010/2008, we performed renal cryoablation in 340 patients. Of these, 102 patients treated before 10/2003 (all laparoscopic) have minimum 5-year follow-up. Follow-up involved MRI imaging on postoperative day 1, 3 months, 6 months, 12 months, and then annually. Cryolesion biopsy was performed at 6-months. All data were prospectively accrued. Results: In the 102 patients with minimum 5-year follow-up, mean age was 66 years. Mean tumor size was 2.3 cm (0.9–5.0 cm). Median ASA score was 3 and mean BMI was 28. Six patients developed locoregional recurrence, 2 had locoregional recurrence with metastases, and 5 had distant metastases without locoregional recurrence. Overall, there were 7 cancer deaths. In the 69 patients with biopsy-proven renal cell cancer (median follow-up 81 mos; range 60–132 mos), 5-year overall, disease-specific, and disease- free survival was 75%, 92%, and 82%, respectively, while 10-year overall, disease-specific, and disease-free survival was 46%, 83%, and 79%, respectively. On multivariate analysis, previous radical nephrectomy for RCC was the only significant predictor for both recurrence- free survival and cancer-specific survival (p = 0.023 and 0.030, respectively). Relative risk of patients who has a history of radical nephrectomy for RCC treatment was 4.1 (95% CIs, 1.2 to 13.4), and 5.4 (95% CIs, 1.2 to 27.7) for disease-free survival and disease-specific survival, respectively. Conclusions: Laparoscopic renal cryoablation is effective oncologic treatment for renal mass in select patients. Disease-specific survival of 92% at 5-years and 83% at 10-years is possible. Preceding radical nephrectomy for RCC treatment was the only independent predicting factor for both disease-free and disease-specific survival.

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No significant financial relationships to disclose.

Endoscopic full-thickness plication for the treatment of GERD: long-term multicenter results

BACKGROUND

The purpose of the present study was to assess the long-term safety and durability of effect for endoscopic full-thickness plication for the treatment of symptomatic gastroesophageal reflux disease (GERD). The Plicator (NDO Surgical, Inc., Mansfield, MA) used delivers a transmural suture through the gastric cardia to restructure the antireflux barrier. Published reports have shown the Plicator procedure to be effective in reducing GERD symptoms and medication use at 1 year post-plication.

METHODS

Twenty-nine patients with chronic heartburn requiring maintenance daily anti-secretory therapy were treated at five sites. Patients received a single full-thickness plication in the gastric cardia 1cm below the gastroesophageal junction (GE) junction. Re-treatments were not permitted. Patients were evaluated at baseline for GERD symptoms and medication use. Intermediate (12 month) and long-term subject follow-up (median follow-up: 36.4 months; range, 31.2-43.9 months) were completed to evaluate procedure safety and durability of effect.

RESULTS

Twenty-nine patients completed the 12-month and 36-month follow-up. All procedure-related adverse events occurred acutely, and no new events were observed during extended follow-up. At 36-months post-procedure, 57% (16/28) of baseline proton pump inhibitor (PPI)-dependent patients remained off daily PPI therapy. Treatment effect remained stable from 12- to 36-months, with 21/29 patients off daily PPI at 12 months compared to 17/29 patients at 36-months. Median GERD- Health Related Quality of Life (HRQL) scores remained significantly improved at 36 months versus baseline off-meds scores (8 versus 19, p < 0.001). In addition, the proportion of patients achieving > or = 50% improvement in GERD-HRQL score was consistent from 12 months (59%) to 36 months (55%).

CONCLUSIONS

Endoscopic full-thickness plication can reduce GERD symptoms and medication use for at least 3-years post-procedure. Treatment effect is stable from 1 to 3 years, and there are no long-term procedural adverse effects.

Endoscopic treatment of chronic pancreatitis: a multicenter study of 1000 patients with long-term follow-up

BACKGROUND AND STUDY AIMS

Endoscopic ductal decompression therapy has become an established method of treating patients with painful obstructive chronic pancreatitis. Smaller series, mostly with a medium-term follow-up period, have reported encouraging results. The present analysis presents long-term follow-up data from a large multicenter patient cohort.

PATIENTS AND METHODS

Patients with painful chronic pancreatitis and with ductal obstruction due to either strictures and/or stones treated endoscopically at eight different centers underwent follow-up after 2 - 12 years (mean 4.9 years). The patients' clinical data, the rate of technical success, and complications were recorded from the charts. Follow-up data were prospectively obtained using structured questionnaires; the main parameter for evaluating treatment success was a significant reduction in pain (no pain or only weak pain).

RESULTS

Follow-up data were obtained from 1018 of 1211 patients treated (84%) with mainly strictures (47%), stones (18%), or strictures plus stones (32%). At the long-term follow-up, 60% of the patients had their endotherapy completed, 16% were still receiving some form of endoscopic treatment, and 24% had undergone surgery. The long-term success of endotherapy was 86% in the entire group, but only 65% in an intention-to-treat analysis. There were no significant differences between the patient groups with regard to either strictures, stones, or both. Pancreatic function was not positively affected by endoscopic therapy.

CONCLUSIONS

Endoscopic ductal decompression therapy offers relief of pain in two-thirds of the patients when it is used as the only form of treatment. One-quarter of the patients have to undergo surgery.

Treating vaginal and external anogenital condylomas with electrosurgery vs CO2 laser ablation

Our objective was to assess the technical characteristics, side effects, complications, and effectiveness of electrosurgery vs continuous wave CO2 laser in the treatment of genital warts. This open clinical trial was made up of 208 evaluable patients (135 women and 73 men) with vaginal and external anogenital condylomas. To avoid selection bias, in each patient half of the lesions measuring 2 cm2 or greater total linear area were treated with loop electroexcision and ball electrofulguration, and the other half were treated with CO2 laser excision and vaporization in a continuous wave mode spot welding. All patients were followed for at least 6 months (maximum 18 months, mean 8 months) after the last treatment received. The average operative time was 6 min for electrosurgery and 8 min for laser. Healing was completed in 95% of patients with a lesional area of 5 cm2 or less and 100% of patients with 5 cm2 or larger by the third and sixth postoperative week, respectively. Severe discomfort occurred in 12% of patients, and 4% of patients developed delayed complications, including vitiligo and scarring, irrespective of treatment modalities used. Complete clearance of warts in women and men after a single (51% and 38%) and multiple (75% and 64%) treatments were similar in areas treated with electrosurgery and CO2 laser. Electrosurgery appears to be as effective as continuous wave CO2 laser for treating vaginal and external anogenital condylomas, particularly those limited to a 5 cm2 or less area.

Reutilization of accessories in gastrointestinal endoscopic practice

The key issues that determine the decision between reusable versus disposable accessories are cost and functionality. In most health-care systems the availability and dissemination of endoscopic services relates directly to the resources (i.e. budget) of that system. Given the limitations of health-care budgets, access to endoscopic services will depend upon the cost efficiency of endoscopic practice. The onus on endoscopists and health-care providers, therefore, is to meticulously evaluate the necessary steps for safe reutilization of accessories. This paper addresses the principles of reuse, quality assurance and particularly disinfection practices. Any change to a more costly disposable accessory policy must bear the responsibility of denied access to endoscopic services in a system with finite resources.

Long-term use of mesalamine (Rowasa) suppositories in remission maintenance of ulcerative proctitis

OBJECTIVE

The purpose of this study was to evaluate the efficacy and safety of a single nightly 500-mg Rowasa (mesalamine) suppository as maintenance therapy for patients with ulcerative proctitis in remission.

METHODS

In this 24-month, multicenter, double-blind trial, 65 patients with ulcerative proctitis in clinical and endoscopic remission were randomized to receive either a single nightly 500-mg rectal mesalamine (Rowasa) suppository or matching placebo as sole therapy. Efficacy was assessed by time to relapse (defined as rectal bleeding or increase in stool frequency for > or =1 wk and active inflammation upon endoscopy).

RESULTS

Mean time to relapse was 453.4 days for mesalamine-treated patients and 158.0 days for placebo-treated patients. Survival analysis demonstrated that time to relapse was significantly greater for mesalamine-treated patients than for placebo-treated patients (p < 0.001). In addition, at both 12 and 24 months, the proportion of placebo-treated patients (86% at 12 months and 89% at 24 months) who relapsed was significantly (p < or = 0.001) greater than mesalamine-treated patients (32% and 46%, respectively). No statistically significant differences occurred between treatment groups in the reporting of any particular adverse event or the number of patients reporting adverse events.

CONCLUSIONS

The results demonstrate that mesalamine suppositories are efficacious, well tolerated, and safe for the long-term maintenance of remission of ulcerative proctitis.

Management of advanced duodenal polyposis in familial adenomatous polyposis

Patients with familial adenomatous polyposis (FAP) are at increased risk for the development of periampullary cancer. The aim of this study was to evaluate the roles of endoscopic and surgical therapy in the management of advanced duodenal polyposis in FAP. From 1990 to 1995, seventy-four FAP patients were enrolled in a prospective endoscopic surveillance protocol. Among these, 11 (14.8%) developed advanced duodenal polyposis and one had duodenal adenocarcinoma. Six patients underwent endoscopic resection of duodenal (n=5) or ampullary adenomas (n=1). The following operations were performed in the remaining six patients: ampullectomy in four, open polypectomy in one, and a Whipple procedure in one. There was one patient who died of acute pancreatitis following endoscopic ampullectomy. The patient with invasive duodenal cancer died of local recurrence. Small polyps were observed at the site of previous resection in all (9 of 9) patients undergoing repeat endoscopy during a mean follow-up of 18 months (range 4 to 34 months). An endoscopic and local surgical resectional approach to advanced duodenal polyposis in FAP is fraught with high recurrence rates, although recurrent polyps are small and may be amenable to retreatment in the future. Long-term follow-up is necessary to prove that deaths from duodenal or ampullary cancer are prevented with this strategy.

Use of the 25 mm flanged esophageal Z stent for malignant dysphagia: a prospective multicenter trial

BACKGROUND

An initial multicenter study using a 21 mm flanged esophageal Z stent demonstrated excellent palliation but an 11% immediate complication rate at placement and a 27% migration rate at 1 month. This North American multicenter trial prospectively studied a 25 mm flanged Z stent to define its palliative ability and whether the increased diameter affected placement or migration problems.

METHODS

Fifty patients who had esophageal Z stents at seven university or regional referral hospitals were prospectively studied. Indications for prosthesis placement, previous therapy, patient demographics, incidence of concomitant tracheoesophageal fistula, and degree of dysphagia were defined, as were procedural and subsequent stent-related problems, survival times, the ability to occlude a tracheoesophageal fistula, and subsequent degree of dysphagia.

RESULTS

Twenty-four patients had infiltrating malignancy (16 exophytic and 10 extrinsic), 9 of whom had concomitant tracheoesophageal fistulas. Ten patients (20%) had misplaced stents requiring retrieval and replacement, 12 patients (24%) had subsequent stent-related problems including exsanguination (2), aspiration (3), tumor overgrowth (3), and postplacement migration (4) (8%). There was statistically significant improvement in prestent versus poststent dysphagia and two thirds of patients had complete occlusion of their tracheoesophageal fistula.

CONCLUSIONS

Redesign of the esophageal Z stent has decreased the migration rate without increasing placement or subsequent erosion problems. Its efficacy appears comparable to the currently marketed Z stent for the palliation of malignant dysphagia and occlusion of tracheoesophageal fistula.

Sulindac for periampullary polyps in FAP patients

BACKGROUND

Gastro-duodenal polyps develop in up to 90% of familial adenomatous polyposis (FAP) patients and periampullary carcinoma is one of the most common extra-colonic malignancies in this syndrome. Periampullary adenomas have been shown to be precursor lesions to periampullary carcinoma. Sulindac, a non-steroidal anti-inflammatory drug, has been reported to cause regression of rectal polyps in FAP patients, however its role in periampullary polyp regression is unclear.

METHODS

In May 1993, a prospective study was begun to evaluate the role of sulindac in prevention of polyp recurrence after resection of large (> 1 cm) duodenal polyps in FAP patients. Eight patients, mean age 50 years (range 35 to 65), with documented large periampullary polyps were placed on sulindac 150 mg twice daily. Prior to enrollment, all patients had their large polyps removed from the periampullary region by interventional endoscopy or by surgery. All patients had multiple small residual duodenal polyps. Follow-up was performed by one experienced endoscopist with a side-viewing video endoscope. Endoscopy was performed 6 monthly. Median follow-up time was 17.5 months (range 10 to 24 months).

RESULTS

In 3 patients, sulindac was discontinued due to side effects: abdominal cramps (n = 2) and upper G-I bleeding (n = 1). None of the patients had regression of small periampullary polyps. In addition, one patient developed an invasive periampullary carcinoma while on sulindac and 3 patients developed large recurrent periampullary polyps requiring further treatment.

SUMMARY

In our experience, sulindac is of no significant benefit for the control of periampullary polyps in FAP. Effective medical treatment of these polyps is still lacking.

Transgastric esophagoscopy with antegrade dilation

An 80-year-old man in whom successful dilation of an obstructed esophagus via retrograde esophagoscopy was carried out is reported here. His nutrition had been previously sustained by a feeding gastrostomy tube inserted under radiologic guidance. This gastrostomy stoma was dilated to allow passage of a pediatric gastroscope into the stomach and esophagus. A guide wire was then negotiated past the esophageal stricture, under endoscopic vision and fluoroscopic guidance, into the oropharynx. Savary dilators were then passed over the guide wire perorally to dilate the stenosis. The patient was able to swallow liquids soon after the procedure. The use of Savary dilators over a guide wire introduced by retrograde esophagoscopy has not been previously described.

Preliminary clinical experience with a thermal balloon endometrial ablation method to treat menorrhagia

OBJECTIVE

To evaluate the clinical effectiveness and safety of a thermal balloon system to ablate the endometrium.

METHODS

All 18 patients were candidates for hysteroscopic endometrial ablation or hysterectomy for menorrhagia and consented to a trial of the balloon technique of ablation. All procedures were done in the operating room under general anesthesia, except in one patient who had regional and another who had local anesthesia with analgesia. Follow-up of 6-34 months is reported.

RESULTS

Fifteen subjects (83%) reported significant reduction in bleeding or amenorrhea. Two patients underwent subsequent hysterectomy and one a follow-up hysteroscopic examination with biopsy. Histology in these three cases showed areas of scar as well as areas of normal endometrial histology. In one uterus, the entire cavity and the endometrium were normal. The others had endometrial bands of scar and some contraction of the cavity.

CONCLUSIONS

Based on follow-up results, the frequency of successful reduction of bleeding and/or amenorrhea in this small series is comparable to hysteroscopic methods of endometrial ablation. There were no complications. A larger trial is warranted to compare this method to hysteroscopic endometrial ablation.

Vaginal squamous cell carcinoma with sarcomatoid spindle cell features

A vaginal squamous cell carcinoma with prominent sarcomatoid spindle cell features found in a 25-year-old female is presented. The exclusively spindle-shaped growth pattern of the neoplastic cells in the initial biopsy led to the diagnostic impression of a sarcoma. This in turn has resulted in an attempt at completely resecting the tumor. The 5.2 x 3.5-cm resected lesion, however, blended peripherally with a poorly differentiated squamous cell carcinoma. Moreover, the sarcomatoid component reacted with vimentin and cytokeratin, and tonofilaments and desmosomes were seen by electron microscopy. This apparently unique case indicates the need for obtaining representative tissue samples for providing an appropriate diagnosis prior to definitive therapy for vaginal squamous cell carcinoma. The primary treatment for large stage I squamous cell lesions of the vagina is radiotherapy, whereas an equally large sarcoma is best treated by wide local excision alone.

Pigment resembling atmospheric dust in Peyer's patches

Terminal ileal pigmentation was observed during colonoscopy, in surgically resected specimens, and autopsy cases. Microscopically, black pigment was seen within macrophages in the lamina propria and submucosa, closely related to the Peyer's patches. Three ilia from autopsies with no macroscopic pigmentation showed deposits following digestion and X-ray microanalysis. X-ray microanalysis of tissue sections and digestates revealed a heterogenous population of particles. Approximately one third of the particles contained calcium and phosphorus and were considered endogenous. The rest of the particles were predominantly aluminum and magnesium-rich silicates, which were considered exogenous. Analysis of particulate extracted from lungs and ilea of four autopsy cases demonstrated remarkable similarities in composition. These findings suggest that the ileal deposits are derived from atmospheric dust. This pigment is believed to migrate into the Peyer's patches through the M cells of the follicle associated epithelium, although other mechanisms for pigment deposition cannot be ruled out.

Small colonic adenomas with adenocarcinoma. A retrospective analysis

The purpose of this study is to alert colonoscopists to a relatively high incidence of small colonic adenomas with invasive adenocarcinoma among a group of colonic adenomas with invasive adenocarcinoma removed colonoscopically. Retrospective analysis (1973 to 1983) documented nine such lesions that were 1 cm or smaller, representing 15 percent of all colonic adenomas with invasive adenocarcinoma removed during that period. These lesions had no distinctive gross features and could be easily confused with hyperplastic polyps. It is recommended that all colonic polyps be removed at colonoscopy regardless of their size, because even lesions 1 cm and smaller, with "benign" gross appearance, may harbor invasive adenocarcinoma.

Double-blind, placebo-controlled evaluation of 5-ASA suppositories in active distal proctitis and measurement of extent of spread using 99mTc-labeled 5-ASA suppositories

Patients with active distal proctitis received either 5-aminosalicylic (5-ASA) acid or identical placebo suppositories, 500 mg t.i.d. for 6 weeks. Activity at 3 and 6 wks was assessed using a Disease Activity Index (DAI), derived from four categories: number of daily evacuations more than usual, evacuations containing blood, sigmoidoscopy appearance, and physician's overall assessment. Each category was graded 0-3. There was thus 0-12 points scored ranging from complete remission to severe disease. A minimum score of 3 from two categories was necessary for study entry. Of 27 patients randomized, 14 received active medication and 13 placebo. Of the 14 patients, with initial mean DAI 7.1 +/- 1.8, 11 were in complete remission at 6 wks (78.6%). Whereas, there was no significant change in the placebo group, with initial mean DAI 7.1 +/- 1.8. An additional 6 patients with inflammatory bowel disease and 6 healthy volunteers were given 99mTc-labelled 5-aminosalicylic acid suppositories. The extent of spread was limited to the rectum, and the suppositories were retained for 3 hours. There was no absorbed radioactivity. 5-ASA suppositories are safe, well-tolerated, and effective treatment for active distal proctitis.

Comparison of selective and nonselective media for recovery of Campylobacter pylori from antral biopsies

Antral biopsy specimens from patients with acid peptic disease were cultured in parallel on Skirrow medium (SM) and sheep blood agar (SBA) for Campylobacter pylori. In institution 1, 23 of 88 (26.1%) endoscopies were positive on SBA compared with 37 of 88 (42.0%) on SM (P = 0.0001). In institution 2, 29 of 49 (59.2%) endoscopies were positive for C. pylori on SBA and 27 of 49 (55.1%) were positive on SM (P = 0.50). The addition of SM optimizes the recovery of C. pylori from antral biopsy specimens.

Mucosal changes associated with adenomatous colonic polyps

In order to assess the presence of morphologically recognizable colonic nonneoplastic mucosal alterations that may be associated with adenomatous transformation the authors undertook a retrospective analysis of 984 colonic polyps removed between 1979 and 1983. There were 708 adenomatous and 276 nonadenomatous polyps, all colonoscopically removed. In addition to adenomatous mucosa, three different mucosal patterns were recognized and labeled as transitional, eosinophilic, and, hyperplastic. Each polyp, but not the polyp's shoulder, was scored by two pathologists for the presence of these changes. Analysis of the data (Pearson's chi-square test) demonstrated a strong association between eosinophilic and transitional mucosa as well as between eosinophilic mucosa and adenomas. There was also a strong negative association between both eosinophilic and transitional mucosa and hyperplastic mucosa. On the basis of these data, it is postulated that transitional mucosa, representing a nonspecific reactive mucosal phenomenon, may precede eosinophilic mucosa, which subsequently may represent fertile soil for adenomatous transformation.

Sonographic demonstration of a patent umbilical vein in portal vein tumor thrombosis

A patent umbilical vein is a well-known sonographic sign of portal hypertension. We here describe this finding in a patient with extensive tumor thrombosis of the portal vein and its branches.