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de Ortiz de Choudens S, Visotcky A, Banerjee A, Aldakkak M, Tsai S, Evans DB, Christians KK, Clarke CN, George B, Shreenivas A, Kamgar M, Chakrabarti S, Dua KS, Khan AH, Madhavan S, Erickson BA, Hall WA. Characterization of an oligometastatic state in patients with metastatic pancreatic adenocarcinoma undergoing systemic chemotherapy. Cancer Med 2023; 13:e6582. [PMID: 38140796 PMCID: PMC10807686 DOI: 10.1002/cam4.6582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 06/28/2023] [Accepted: 09/13/2023] [Indexed: 12/24/2023] Open
Abstract
PURPOSE/OBJECTIVES Most patients with pancreatic adenocarcinoma (PDAC) will present with distant metastatic disease at diagnosis. We sought to identify clinical characteristics associated with prolonged overall survival (OS) in patients presenting with metastatic PDAC. MATERIALS/METHODS Patients presenting with metastatic PDAC that received treatment at our institution with FOLFIRINOX or gemcitabine-based chemotherapies between August 1, 2011 and September 1, 2017 were included in the study. Metastatic disease burden was comprehensively characterized radiologically via individual diagnostic imaging segmentation. Landmark analysis was performed at 18 months, and survival curves were estimated using the Kaplan-Meier method and compared between groups via the log-rank test. ECOG and Charlson Comorbidity Index (CCI) were calculated for all patients. RESULTS 121 patients were included with a median age of 62 years (37-86), 40% were female, 25% had ECOG 0 at presentation. Of the 121 patients included, 33% (n = 41) were alive at 12 months and 25% (n = 31) were alive at 18 months. Landmark analysis demonstrated a significant difference between patients surviving <18 months and ≥18 months regarding the presence of lung only metastases (36% vs. 16%, p = 0.04), number of organs with metastases (≥2 vs. 1, p = 0.04), and disease volume (mean of 19.1 cc vs. 1.4 cc, p = 0.04). At Year 1, predictors for improved OS included ECOG status at diagnosis (ECOG 0 vs. ECOG 1, p = 0.04), metastatic disease volume at diagnosis (≤0.1 cc vs. >60 cc, p = 0.004), metastasis only in the liver (p = 0.04), and normalization of CA 19-9 (p < 0.001). At Year 2, the only predictor of improved OS was normalization of the CA 19-9 (p = 0.03). In those patients that normalized their CA 19-9, median overall survival was 16 months. CONCLUSIONS In this exploratory analysis normalization of CA-19-9 or volumetric metastatic disease burden less than 0.2 cc demonstrated a remarkable OS, similar to that of patients with non-metastatic disease. These metrics are useful for counseling patients and identifying cohorts that may be optimal for trials exploring metastatic and/or local tumor-directed interventions.
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Affiliation(s)
| | - Alexis Visotcky
- Division of BiostatisticsMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Anjishnu Banerjee
- Division of BiostatisticsMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Mohammed Aldakkak
- Department of SurgeryMedical College of WisconsinMilwaukeeWisconsinUSA
- LaBahn Pancreatic Cancer ProgramMilwaukeeWisconsinUSA
| | - Susan Tsai
- Department of SurgeryMedical College of WisconsinMilwaukeeWisconsinUSA
- LaBahn Pancreatic Cancer ProgramMilwaukeeWisconsinUSA
| | - Douglas B. Evans
- Department of SurgeryMedical College of WisconsinMilwaukeeWisconsinUSA
- LaBahn Pancreatic Cancer ProgramMilwaukeeWisconsinUSA
| | - Kathleen K. Christians
- Department of SurgeryMedical College of WisconsinMilwaukeeWisconsinUSA
- LaBahn Pancreatic Cancer ProgramMilwaukeeWisconsinUSA
| | - Callisia N. Clarke
- Department of SurgeryMedical College of WisconsinMilwaukeeWisconsinUSA
- LaBahn Pancreatic Cancer ProgramMilwaukeeWisconsinUSA
| | - Ben George
- LaBahn Pancreatic Cancer ProgramMilwaukeeWisconsinUSA
- Division of Medical OncologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Aditya Shreenivas
- Division of Medical OncologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Mandana Kamgar
- LaBahn Pancreatic Cancer ProgramMilwaukeeWisconsinUSA
- Division of Medical OncologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Sakti Chakrabarti
- Division of Medical OncologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Kulwinder S. Dua
- Division of Medical OncologyMedical College of WisconsinMilwaukeeWisconsinUSA
- Division of GastroenterologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Abdul Haq Khan
- Division of Medical OncologyMedical College of WisconsinMilwaukeeWisconsinUSA
- Division of GastroenterologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Srivats Madhavan
- Division of Medical OncologyMedical College of WisconsinMilwaukeeWisconsinUSA
- Division of GastroenterologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Beth A. Erickson
- Department of Radiation OncologyMedical College of WisconsinMilwaukeeWisconsinUSA
- LaBahn Pancreatic Cancer ProgramMilwaukeeWisconsinUSA
| | - William A. Hall
- Department of Radiation OncologyMedical College of WisconsinMilwaukeeWisconsinUSA
- LaBahn Pancreatic Cancer ProgramMilwaukeeWisconsinUSA
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Thalji SZ, Fernando D, Dua KS, Madhavan S, Chisholm P, Smith ZL, Aldakkak M, Christians KK, Clarke CN, George B, Kamgar M, Erickson BA, Hall WA, Evans DB, Tsai S. Biliary Adverse Events During Neoadjuvant Therapy for Pancreatic Cancer. Ann Surg 2023; 278:e1224-e1231. [PMID: 37078282 DOI: 10.1097/sla.0000000000005884] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
OBJECTIVE To describe a high-volume experience with biliary drainage before neoadjuvant therapy (NAT) for patients with operable pancreatic cancer (PC) and characterize the association between biliary adverse events (BAEs) and patient outcome. BACKGROUND Patients with PC presenting with biliary obstruction require durable decompression before NAT. METHODS Patients with operable PC and tumor-associated biliary obstruction were examined and grouped by the presence or absence of a BAE during NAT. The incidence, timing, and management of BAEs are described, and outcomes, including the completion of all treatment and overall survival (OS), were compared. RESULTS Of 426 patients who received pretreatment biliary decompression, 92 (22%) experienced at least 1 BAE during NAT, and 56 (13%) required repeat intervention on their biliary stent. The median duration of NAT was 161 days for all patients and was not different in the group that experienced BAEs. The median time from initial stent placement to BAE was 64 days. An interruption in the delivery of NAT (median 7 days) occurred in 25 (6%) of 426 patients. Among 426 patients, 290 (68%) completed all NAT, including surgery: 60 (65%) of 92 patients with BAE and 230 (69%) of 334 patients without BAE ( P =0.51). Among 290 patients who completed NAT and surgery, the median OS was 39 months, 26 months for the 60 patients with BAE, and 43 months for the 230 patients without BAE ( P =0.02). CONCLUSIONS During extended multimodal NAT for PC, 22% of patients experienced a BAE. Although BAEs were not associated with a significant interruption of treatment, patients who experienced a BAE had worse OS.
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Affiliation(s)
- Sam Z Thalji
- Division of Surgical Oncology, Department of Surgery, LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Deemantha Fernando
- Division of Surgical Oncology, Department of Surgery, LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Kulwinder S Dua
- Division of Gastroenterology, Department of Medicine, LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Srivats Madhavan
- Division of Gastroenterology, Department of Medicine, LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Phillip Chisholm
- Division of Gastroenterology, Department of Medicine, LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Zachary L Smith
- Division of Gastroenterology, Department of Medicine, LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Mohammed Aldakkak
- Division of Surgical Oncology, Department of Surgery, LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Kathleen K Christians
- Division of Surgical Oncology, Department of Surgery, LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Callisia N Clarke
- Division of Surgical Oncology, Department of Surgery, LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Ben George
- Division of Medical Oncology, Department of Medicine, LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Mandana Kamgar
- Division of Medical Oncology, Department of Medicine, LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Beth A Erickson
- Department of Radiation Oncology, LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - William A Hall
- Department of Radiation Oncology, LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Douglas B Evans
- Division of Surgical Oncology, Department of Surgery, LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Susan Tsai
- Division of Surgical Oncology, Department of Surgery, LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
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Ponce SEB, Small CJ, Ahmad T, Patel K, Tsai S, Kamgar M, George B, Kharofa JR, Saeed H, Dua KS, Clarke C, Aldakkak M, Evans DB, Christians K, Paulson ES, de Choudens SO, Erickson BA, Hall WA. Patterns of Locoregional Pancreatic Cancer Recurrence after Total Neoadjuvant Therapy and Implications on Optimal Neoadjuvant Radiation Treatment Volumes. Int J Radiat Oncol Biol Phys 2023; 117:e284-e285. [PMID: 37785058 DOI: 10.1016/j.ijrobp.2023.06.1270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Neoadjuvant treatment for patients with localized pancreatic adenocarcinoma (PDAC) has improved survival duration. As survival increases, local disease control becomes even more important. We sought to understand the patterns of locoregional recurrence following total neoadjuvant therapy (TNT) and determine the impact of treatment volumes on recurrence. MATERIALS/METHODS Patients with PDAC managed with neoadjuvant chemotherapy and chemoradiation (TNT) followed by surgery who developed an isolated locoregional or simultaneously locoregional and distant recurrence were identified. Locoregional recurrences were individually contoured utilizing commercially available software. When available, original neoadjuvant dose distributions were registered to the scans on which the locoregional recurrences were contoured. Recurrences where then classified as in-field (> 95% of prescription dose), marginal (50-95% of prescription dose), or out of field (< 50% of prescription dose). Target volumes were created using four commonly utilized PDAC contouring guidelines to characterize the relationship of the local recurrence to the RT dose distribution. RESULTS Of 474 patients treated with TNT and surgery, 80 (17%) patients developed a locoregional recurrence with or without distant recurrence, visible on diagnostic imaging. Of the 80 patients, 56 (70%) had tumors in the pancreatic head; 46 (57.5%) were borderline resectable, 23 (28.8%) locally advanced, and 11 (13.6%) resectable. The most common initial neoadjuvant therapies were FOLFIRINOX (57.5%) and gemcitabine/nab-paclitaxel (18.8%). Chemoradiation included concurrent gemcitabine (47.5%) or 5-fluorouracil (26.3%). RT dose distributions were available for 38 patients; 22 (57.9%) had in-field failures, 9 (23.7%) marginal failures, and 7 (18.4%) out of field failures. Each published contouring atlas covered a relatively low percentage of recurrences, which are summarized in Table 1. Regions at particularly high likelihood of recurrence that were under covered on existing atlases included: aortic-diaphragmic junction, retro-pancreatic duodenal nodal basin, and the region to the right of the superior mesenteric artery (SMA). CONCLUSION We present the largest series (to our knowledge) of mapped locoregional recurrences for patients being treated with TNT in PDAC. These recurrences differ substantially from established atlases and highlight anatomical regions of highest priority for RT coverage. A novel visual contouring volume highlighting these regions will be presented which will strive to advance the use of RT in the TNT setting.
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Affiliation(s)
- S E Beltran Ponce
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - C J Small
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - T Ahmad
- Medical College of Wisconsin, Milwaukee, WI
| | - K Patel
- Medical College of Wisconsin, Milwaukee, WI
| | - S Tsai
- Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - M Kamgar
- Department of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - B George
- Department of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - J R Kharofa
- University of Cincinnati, Department of Radiation Oncology, University of Cincinnati Cancer Center, Cincinnati, OH
| | - H Saeed
- Lynn Cancer Institute, Boca Raton Regional Hospital, Baptist Health South Florida, Boca Raton, FL
| | - K S Dua
- Department of Gastroenterology, Medical College of Wisconsin, Milwaukee, WI
| | - C Clarke
- Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - M Aldakkak
- Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - D B Evans
- Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - K Christians
- Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - E S Paulson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - S Ortiz de Choudens
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI; Department of Radiation Oncology, Froedtert & the Medical College of Wisconsin, Milwaukee, WI
| | - B A Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - W A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI
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Asombang AW, Chishinga N, Mohamed MF, Nkhoma A, Chipaila J, Nsokolo B, Manda-Mapalo M, Montiero JFG, Banda L, Dua KS. Systematic review of cholangiocarcinoma in Africa: epidemiology, management, and clinical outcomes. BMC Gastroenterol 2023; 23:66. [PMID: 36906562 PMCID: PMC10007746 DOI: 10.1186/s12876-023-02687-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 02/20/2023] [Indexed: 03/13/2023] Open
Abstract
BACKGROUND The prevalence, management, and clinical outcomes of cholangiocarcinoma in Africa are unknown. The aim is to conduct a comprehensive systematic review on the epidemiology, management, and outcomes of cholangiocarcinoma in Africa. METHODS We searched PubMed, EMBASE, Web of Science and CINHAL from inception up to November 2019 for studies on cholangiocarcinoma in Africa. The results reported follow PRISMA guidelines. Quality of studies and risk of bias were adapted from a standard quality assessment tool. Descriptive data were expressed as numbers with proportions and Chi-squared test was used to compare proportions. P values < 0.05 were considered significant. RESULTS A total of 201 citations were identified from the four databases. After excluding duplicates, 133 full texts were reviewed for eligibility, and 11 studies were included. The 11 studies are reported from 4 countries only: 8 are from North Africa (Egypt 6 and Tunisia 2), and 3 in Sub-Saharan Africa (2 in South Africa, 1 in Nigeria). Ten studies reported management and outcomes, while one study reported epidemiology and risk factors. Median age for cholangiocarcinoma ranged between 52 and 61 years. Despite the proportion with cholangiocarcinoma being higher among males than females in Egypt, this gender disparity could not be demonstrated in other African countries. Chemotherapy is mainly used for palliative care. Surgical interventions are curative and prevent cancer progression. Statistical analyses were performed with Stata 15.1. CONCLUSION The known global major risk factors such as primary sclerosing cholangitis, Clonorchis sinensis and Opisthorchis viverrini infestation are rare. Chemotherapy treatment was mainly used for palliative treatment and was reported in three studies. Surgical intervention was described in at least 6 studies as a curative modality of treatment. Diagnostic capabilities such as radiographic imaging and endoscopic are lacking across the continent which most likely plays a role in accurate diagnosis.
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Affiliation(s)
- Akwi W Asombang
- Division of Gastroenterology/Hepatology, Massachusetts General Hospital, 15 Parkman Street, Wang 5, Boston, MA, 02114, USA.
| | - Nathaniel Chishinga
- Department of Internal Medicine, Piedmont Athens Regional Hospital, 1270 Prince Avenue, Suite 102, Athens, GA, 30606, USA
| | - Mouhand F Mohamed
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, 02903, USA
| | - Alick Nkhoma
- Department of Gastroenterology, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Staffordshire, ST4 6QG, UK
| | - Jackson Chipaila
- Department of Surgery, University Teaching Hospital-Adult Hospital, Lusaka, 10101, Zambia
| | - Bright Nsokolo
- Department of Internal Medicine, Levy Mwanawasa Medical University, Levy Mwanawasa University Teaching Hospital, Lusaka, 10101, Zambia
| | - Martha Manda-Mapalo
- Division of Hematology/Oncology, Department of Internal Medicine, The University of New Mexico, Albuquerque, NM, 87106, USA
| | | | - Lewis Banda
- Hematology/Oncology, Cancer Disease Hospital, Lusaka, 10101, Zambia
| | - Kulwinder S Dua
- Department of Medicine and Pediatrics, Medical College of Wisconsin, Milwaukee, WI, 53226, USA
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5
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Nakai Y, Smith Z, Chang KJ, Dua KS. Advanced Endoscopic Techniques for the Diagnosis of Pancreatic Cancer and Management of Biliary and GastricOutlet Obstruction. Surg Oncol Clin N Am 2021; 30:639-656. [PMID: 34511187 DOI: 10.1016/j.soc.2021.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Following high-quality imaging studies for staging, endoscopic ultrasound examination fine needle aspiration/biopsy is the preferred modality for tissue diagnosis of pancreatic cancer. Endoscopic retrograde cholangiopancreatography with metal stent placement is used for palliation of malignant biliary obstruction. Metal stents can be placed in patients with resectable pancreatic cancer in whom surgery is going to be delayed. For palliation of gastric outlet obstruction, endoscopic enteral stenting is often selected because of its less invasiveness. Endoscopic ultrasound-guided biliary drainage for malignant biliary obstruction or gastrojejunostomy for gastric outlet obstruction are emerging less invasive techniques as compared with palliative surgery.
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Affiliation(s)
- Yousuke Nakai
- Department of Endoscopy and Endoscopic Surgery, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, Japan
| | - Zachary Smith
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, 9200, West Wisconsin Avenue, Milwaukee, WI, USA
| | - Kenneth J Chang
- Division of Gastroenterology and Hepatology, Digestive Health Institute, University of California, Irvine, 101 The City Drive, Building 22C, Orange, CA, USA
| | - Kulwinder S Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, 9200, West Wisconsin Avenue, Milwaukee, WI, USA.
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Elmunzer BJ, Spitzer RL, Foster LD, Merchant AA, Howard EF, Patel VA, West MK, Qayed E, Nustas R, Zakaria A, Piper MS, Taylor JR, Jaza L, Forbes N, Chau M, Lara LF, Papachristou GI, Volk ML, Hilson LG, Zhou S, Kushnir VM, Lenyo AM, McLeod CG, Amin S, Kuftinec GN, Yadav D, Fox C, Kolb JM, Pawa S, Pawa R, Canakis A, Huang C, Jamil LH, Aneese AM, Glamour BK, Smith ZL, Hanley KA, Wood J, Patel HK, Shah JN, Agarunov E, Sethi A, Fogel EL, McNulty G, Haseeb A, Trieu JA, Dixon RE, Yang JY, Mendelsohn RB, Calo D, Aroniadis OC, LaComb JF, Scheiman JM, Sauer BG, Dang DT, Piraka CR, Shah ED, Pohl H, Tierney WM, Mitchell S, Condon A, Lenhart A, Dua KS, Kanagala VS, Kamal A, Singh VK, Pinto-Sanchez MI, Hutchinson JM, Kwon RS, Korsnes SJ, Singh H, Solati Z, Willingham FF, Yachimski PS, Conwell DL, Mosier E, Azab M, Patel A, Buxbaum J, Wani S, Chak A, Hosmer AE, Keswani RN, DiMaio CJ, Bronze MS, Muthusamy R, Canto MI, Gjeorgjievski VM, Imam Z, Odish F, Edhi AI, Orosey M, Tiwari A, Patwardhan S, Brown NG, Patel AA, Ordiah CO, Sloan IP, Cruz L, Koza CL, Okafor U, Hollander T, Furey N, Reykhart O, Zbib NH, Damianos JA, Esteban J, Hajidiacos N, Saul M, Mays M, Anderson G, Wood K, Mathews L, Diakova G, Caisse M, Wakefield L, Nitchie H, Waljee AK, Tang W, Zhang Y, Zhu J, Deshpande AR, Rockey DC, Alford TB, Durkalski V. Digestive Manifestations in Patients Hospitalized With Coronavirus Disease 2019. Clin Gastroenterol Hepatol 2021; 19:1355-1365.e4. [PMID: 33010411 PMCID: PMC7527302 DOI: 10.1016/j.cgh.2020.09.041] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 09/21/2020] [Accepted: 09/22/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS The prevalence and significance of digestive manifestations in coronavirus disease 2019 (COVID-19) remain uncertain. We aimed to assess the prevalence, spectrum, severity, and significance of digestive manifestations in patients hospitalized with COVID-19. METHODS Consecutive patients hospitalized with COVID-19 were identified across a geographically diverse alliance of medical centers in North America. Data pertaining to baseline characteristics, symptomatology, laboratory assessment, imaging, and endoscopic findings from the time of symptom onset until discharge or death were abstracted manually from electronic health records to characterize the prevalence, spectrum, and severity of digestive manifestations. Regression analyses were performed to evaluate the association between digestive manifestations and severe outcomes related to COVID-19. RESULTS A total of 1992 patients across 36 centers met eligibility criteria and were included. Overall, 53% of patients experienced at least 1 gastrointestinal symptom at any time during their illness, most commonly diarrhea (34%), nausea (27%), vomiting (16%), and abdominal pain (11%). In 74% of cases, gastrointestinal symptoms were judged to be mild. In total, 35% of patients developed an abnormal alanine aminotransferase or total bilirubin level; these were increased to less than 5 times the upper limit of normal in 77% of cases. After adjusting for potential confounders, the presence of gastrointestinal symptoms at any time (odds ratio, 0.93; 95% CI, 0.76-1.15) or liver test abnormalities on admission (odds ratio, 1.31; 95% CI, 0.80-2.12) were not associated independently with mechanical ventilation or death. CONCLUSIONS Among patients hospitalized with COVID-19, gastrointestinal symptoms and liver test abnormalities were common, but the majority were mild and their presence was not associated with a more severe clinical course.
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Affiliation(s)
- B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Department of Medicine, Charleston, South Carolina.
| | - Rebecca L Spitzer
- Division of Gastroenterology and Hepatology, Department of Medicine, Charleston, South Carolina
| | - Lydia D Foster
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Ambreen A Merchant
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Eric F Howard
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Vaishali A Patel
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Mary K West
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Emad Qayed
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; Division of Digestive Diseases, Department of Medicine, Grady Memorial Hospital, Atlanta, Georgia
| | - Rosemary Nustas
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; Division of Digestive Diseases, Department of Medicine, Grady Memorial Hospital, Atlanta, Georgia
| | - Ali Zakaria
- Division of Gastroenterology, Department of Medicine, Ascension Providence Hospital/Michigan State University, College of Human Medicine, Southfield, Michigan
| | - Marc S Piper
- Division of Gastroenterology, Department of Medicine, Ascension Providence Hospital/Michigan State University, College of Human Medicine, Southfield, Michigan
| | - Jason R Taylor
- Division of Gastroenterology and Hepatology, Department of Medicine, Saint Louis University, St. Louis, Missouri
| | - Lujain Jaza
- Division of Gastroenterology and Hepatology, Department of Medicine, Saint Louis University, St. Louis, Missouri
| | - Nauzer Forbes
- Division of Gastroenterology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Millie Chau
- Division of Gastroenterology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Luis F Lara
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Georgios I Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Michael L Volk
- Division of Gastroenterology, Department of Medicine, Loma Linda University, Loma Linda, California
| | - Liam G Hilson
- Division of Gastroenterology, Department of Medicine, University of Southern California, Los Angeles, California
| | - Selena Zhou
- Division of Gastroenterology, Department of Medicine, University of Southern California, Los Angeles, California
| | - Vladimir M Kushnir
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Alexandria M Lenyo
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Caroline G McLeod
- Division of Gastroenterology and Hepatology, Department of Medicine, Charleston, South Carolina
| | - Sunil Amin
- Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Gabriela N Kuftinec
- Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Dhiraj Yadav
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Charlie Fox
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jennifer M Kolb
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Swati Pawa
- Division of Gastroenterology, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Rishi Pawa
- Division of Gastroenterology, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Andrew Canakis
- Section of Gastroenterology, Department of Medicine, Boston University Medical Center, Boston, Massachusetts
| | - Christopher Huang
- Section of Gastroenterology, Department of Medicine, Boston University Medical Center, Boston, Massachusetts
| | - Laith H Jamil
- Section of Gastroenterology and Hepatology, Department of Internal Medicine, Beaumont Health, Royal Oak, Michigan; Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Andrew M Aneese
- Section of Gastroenterology and Hepatology, Department of Internal Medicine, Beaumont Health, Royal Oak, Michigan
| | - Benita K Glamour
- Division of Gastroenterology, Department of Medicine, University Hospitals of Cleveland Medical Center, Cleveland, Ohio
| | - Zachary L Smith
- Division of Gastroenterology, Department of Medicine, University Hospitals of Cleveland Medical Center, Cleveland, Ohio
| | - Katherine A Hanley
- Division of Gastroenterology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jordan Wood
- Division of Gastroenterology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Harsh K Patel
- Department of Gastroenterology, Ochsner Health, New Orleans, Louisiana
| | - Janak N Shah
- Department of Gastroenterology, Ochsner Health, New Orleans, Louisiana
| | - Emil Agarunov
- Division of Gastroenterology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Amrita Sethi
- Division of Gastroenterology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Evan L Fogel
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Gail McNulty
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Abdul Haseeb
- Division of Gastroenterology and Nutrition, Department of Medicine, Loyola University Medical Center, Chicago, Illinois
| | - Judy A Trieu
- Division of Gastroenterology and Nutrition, Department of Medicine, Loyola University Medical Center, Chicago, Illinois
| | - Rebekah E Dixon
- The Dr. Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jeong Yun Yang
- The Dr. Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Robin B Mendelsohn
- Gastroenterology, Hepatology and Nutrition service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Delia Calo
- Gastroenterology, Hepatology and Nutrition service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Olga C Aroniadis
- Division of Gastroenterology, Department of Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
| | - Joseph F LaComb
- Division of Gastroenterology, Department of Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
| | - James M Scheiman
- Division of Gastroenterology, Department of Medicine, University of Virginia Medical School, Charlottesville, Virginia
| | - Bryan G Sauer
- Division of Gastroenterology, Department of Medicine, University of Virginia Medical School, Charlottesville, Virginia
| | - Duyen T Dang
- Division of Gastroenterology, Department of Medicine, Henry Ford Health System, Detroit, Michigan
| | - Cyrus R Piraka
- Division of Gastroenterology, Department of Medicine, Henry Ford Health System, Detroit, Michigan
| | - Eric D Shah
- Section of Gastroenterology and Hepatology, Department of Medicine, Dartmouth-Hitchcock Health, Lebanon, New Hampshire
| | - Heiko Pohl
- Section of Gastroenterology and Hepatology, Department of Medicine, Dartmouth-Hitchcock Health, Lebanon, New Hampshire; Section of Gastroenterology and Hepatology, Department of Medicine, VA Medical Center, White River Junction, Vermont
| | - William M Tierney
- Section of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Stephanie Mitchell
- Section of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Ashwinee Condon
- Division of Gastroenterology, Department of Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Adrienne Lenhart
- Division of Gastroenterology, Department of Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Kulwinder S Dua
- Division of Gastroenterology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Vikram S Kanagala
- Division of Gastroenterology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ayesha Kamal
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Vikesh K Singh
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Maria Ines Pinto-Sanchez
- Division of Gastroenterology, Department of Medicine, McMaster University Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Joy M Hutchinson
- Division of Gastroenterology, Department of Medicine, McMaster University Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Richard S Kwon
- Division of Gastroenterology and Hepatology, Department of Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Sheryl J Korsnes
- Division of Gastroenterology and Hepatology, Department of Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Harminder Singh
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Zahra Solati
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Field F Willingham
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Patrick S Yachimski
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Darwin L Conwell
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Evan Mosier
- Division of Gastroenterology, Department of Medicine, Loma Linda University, Loma Linda, California
| | - Mohamed Azab
- Division of Gastroenterology, Department of Medicine, Loma Linda University, Loma Linda, California
| | - Anish Patel
- Division of Gastroenterology, Department of Medicine, Loma Linda University, Loma Linda, California
| | - James Buxbaum
- Division of Gastroenterology, Department of Medicine, University of Southern California, Los Angeles, California
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Amitabh Chak
- Division of Gastroenterology, Department of Medicine, University Hospitals of Cleveland Medical Center, Cleveland, Ohio
| | - Amy E Hosmer
- Division of Gastroenterology, Department of Medicine, University Hospitals of Cleveland Medical Center, Cleveland, Ohio
| | - Rajesh N Keswani
- Division of Gastroenterology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Christopher J DiMaio
- The Dr. Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michael S Bronze
- Section of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Raman Muthusamy
- Division of Gastroenterology, Department of Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Marcia I Canto
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - V Mihajlo Gjeorgjievski
- Section of Gastroenterology and Hepatology, Department of Internal Medicine, Beaumont Health, Royal Oak, Michigan
| | - Zaid Imam
- Section of Gastroenterology and Hepatology, Department of Internal Medicine, Beaumont Health, Royal Oak, Michigan
| | - Fadi Odish
- Section of Gastroenterology and Hepatology, Department of Internal Medicine, Beaumont Health, Royal Oak, Michigan
| | - Ahmed I Edhi
- Section of Gastroenterology and Hepatology, Department of Internal Medicine, Beaumont Health, Royal Oak, Michigan
| | - Molly Orosey
- Section of Gastroenterology and Hepatology, Department of Internal Medicine, Beaumont Health, Royal Oak, Michigan
| | - Abhinav Tiwari
- Section of Gastroenterology and Hepatology, Department of Internal Medicine, Beaumont Health, Royal Oak, Michigan
| | - Soumil Patwardhan
- Section of Gastroenterology and Hepatology, Department of Internal Medicine, Beaumont Health, Royal Oak, Michigan
| | - Nicholas G Brown
- Division of Gastroenterology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Anish A Patel
- Division of Gastroenterology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Collins O Ordiah
- Division of Gastroenterology and Hepatology, Department of Medicine, Charleston, South Carolina
| | - Ian P Sloan
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Lilian Cruz
- Division of Gastroenterology, Department of Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
| | - Casey L Koza
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Uchechi Okafor
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Thomas Hollander
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Nancy Furey
- Division of Gastroenterology, Department of Medicine, University Hospitals of Cleveland Medical Center, Cleveland, Ohio
| | - Olga Reykhart
- Division of Gastroenterology, Department of Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
| | - Natalia H Zbib
- Section of Gastroenterology and Hepatology, Department of Medicine, Dartmouth-Hitchcock Health, Lebanon, New Hampshire
| | - John A Damianos
- Section of Gastroenterology and Hepatology, Department of Medicine, Dartmouth-Hitchcock Health, Lebanon, New Hampshire
| | - James Esteban
- Division of Gastroenterology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nick Hajidiacos
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Melissa Saul
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Melanie Mays
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Gulsum Anderson
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kelley Wood
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Laura Mathews
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Galina Diakova
- Division of Gastroenterology, Department of Medicine, University of Virginia Medical School, Charlottesville, Virginia
| | - Molly Caisse
- Section of Gastroenterology and Hepatology, Department of Medicine, Dartmouth-Hitchcock Health, Lebanon, New Hampshire
| | - Lauren Wakefield
- Division of Gastroenterology and Hepatology, Department of Medicine, Charleston, South Carolina
| | - Haley Nitchie
- Division of Gastroenterology and Hepatology, Department of Medicine, Charleston, South Carolina
| | - Akbar K Waljee
- Division of Gastroenterology and Hepatology, Department of Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Weijing Tang
- Department of Statistics, University of Michigan, Ann Arbor, Michigan
| | - Yueyang Zhang
- Department of Statistics, University of Michigan, Ann Arbor, Michigan
| | - Ji Zhu
- Department of Statistics, University of Michigan, Ann Arbor, Michigan
| | - Amar R Deshpande
- Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Don C Rockey
- Division of Gastroenterology and Hepatology, Department of Medicine, Charleston, South Carolina
| | - Teldon B Alford
- Division of Gastroenterology and Hepatology, Department of Medicine, Charleston, South Carolina
| | - Valerie Durkalski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina
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Alatise OI, Owojuyigbe AM, Omisore AD, Ndububa DA, Aburime E, Dua KS, Asombang AW. Endoscopic management and clinical outcomes of obstructive jaundice. Niger Postgrad Med J 2020; 27:302-310. [PMID: 33154282 DOI: 10.4103/npmj.npmj_242_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background This study aimed at evaluating the endoscopic management and clinical outcomes in patients with obstructive jaundice undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP) within a newly established apprenticeship teaching model at an academic centre in a resource-limited setting. Materials and Methods We employed an apprenticeship-style model of ERCP training with graded responsibility, multidisciplinary group feedback and short-interval repetition. We collected sociodemographic and clinicopathologic data on consecutive patients who underwent ERCP from March 2018 to February 2020. Results A total of 177 patients were referred, of which 146 patients had an ERCP performed for obstructive jaundice and 31 excluded during the study period. The median age was 55 years, age range from 8 to 83 years. The most common referral diagnosis was pancreatic head cancer 56/146 (38.1%), followed by choledocholithiasis 29/146 (19.7%), cholangiocarcinoma 22/146 (15.0%) and gall bladder cancer 11/146 (7.5%). In all, 102 patients had a malignant indication for ERCP. The cannulation rate was 92%. The most common site for malignant biliary obstruction was proximal bile stricture in 31/102 (30.4%), followed by distal bile strictures in 30/102 (28.4%), periampullary cancer 20/102 (19.6%) and mid bile duct stricture in 9/102 (8.8%). The common benign obstructive etiology includes choledocholithiasis in 33/44 (75%) and mid duct obstruction from post-cholecystectomy bile duct injury in 3/44 (2.9%) while 2/44 (2.0%) patients had choledochal cyst. Overall complications were post-ERCP pancreatitis (8/146 patients), cholangitis (3/146 patients), stent migration and post-sphincterotomy bleeding (one patient each). Peri-procedural mortality was 5/146 (3.4%). Conclusion ERCP is an effective and safe method of treatment of patients with benign and malignant biliary obstruction. The low morbidity and mortality and its immediate therapeutic benefits, together with the short duration of hospitalization, indicate that this procedure is an important asset in the management of such patients.
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Affiliation(s)
- Olusegun Isaac Alatise
- Department of Surgery, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
| | - Afolabi Muyiwa Owojuyigbe
- Department of Anaesthesia, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
| | - Adeleye Dorcas Omisore
- Department of Radiology, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
| | - Dennis A Ndububa
- Department of Medicine, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
| | | | - Kulwinder S Dua
- Division of Gastroenterology/Hepatology, Froedtert and Medical College of Wisconsin Health Centers Clinics, Milwaukee, USA
| | - Akwi W Asombang
- Division of Gastroenterology/Hepatology, Warren Alpert Medical School of Brown University, Rhode Island, USA
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Seo DW, Sherman S, Dua KS, Slivka A, Roy A, Costamagna G, Deviere J, Peetermans J, Rousseau M, Nakai Y, Isayama H, Kozarek R. Covered and uncovered biliary metal stents provide similar relief of biliary obstruction during neoadjuvant therapy in pancreatic cancer: a randomized trial. Gastrointest Endosc 2019; 90:602-612.e4. [PMID: 31276674 DOI: 10.1016/j.gie.2019.06.032] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [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: 03/25/2019] [Accepted: 06/15/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Preoperative biliary drainage with self-expanding metal stents (SEMSs) brings liver function within an acceptable range in preparation for neoadjuvant therapy (NATx) and provides relief of obstructive symptoms in patients with pancreatic cancer. We compared fully-covered SEMSs (FCSEMSs) and uncovered SEMSs (UCSEMSs) for sustained biliary drainage before and during NATx. METHODS Patients with pancreatic cancer and planned NATx who need treatment of jaundice and/or cholestasis before pancreaticoduodenectomy were randomized to FCSEMSs versus UCSEMSs. The primary endpoint was sustained biliary drainage, defined as the absence of reinterventions for biliary obstructive symptoms, and was assessed from SEMS placement until curative intent surgery or at 1 year. RESULTS The intention-to-treat population included 119 patients (59 FCSEMSs, 60 UCSEMSs). Sustained biliary drainage was equally successful with FCSEMSs and UCSEMSs (72.2% vs 72.9%, noninferiority P = .01). Reasons for FCSEMS and UCSEMS failure differed significantly between the groups and included tumor ingrowth in 0% versus 16.7% (P < .01), and stent migration in 6.8% versus 0% (P = .03), respectively. Serious adverse event rates related to stent placement were not significantly different in both groups (23.7% [14/59] vs 20.0% [12/60], P = .66), as were acute cholecystitis rates when the gallbladder was in situ (9.3% [4/43] vs 4.8% [2/42], P = .68) for FCSEMSs and UCSEMSs, respectively. In our study, independent of stent type, predictors of reinterventions were 4-cm stent length and presence of the gallbladder. CONCLUSION FCSEMSs and UCSEMSs provide similar preoperative management of biliary obstruction in patients with pancreatic cancer receiving NATx, but mechanisms of stent dysfunction depend on stent type, stent length, and presence of the gallbladder. (Clinical trial registration number: NCT02238847.).
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Affiliation(s)
- Dong Wan Seo
- Internal Medicine, Asan Medical Center University of Ulsan, Seoul, South Korea
| | - Stuart Sherman
- Division of Gastroenterology and Hepatology Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kulwinder S Dua
- Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Adam Slivka
- Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Andre Roy
- Surgery, Centre hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Guido Costamagna
- Fondazione Policlinico A. Gemelli - IRCCS, Digestive Endoscopy Unit; Università Cattolica del S. Cuore, Rome, Italy
| | - Jacques Deviere
- Gastro-Entérologie et d'Hépato-Pancréatologie, Université Libre de Bruxelles Hôpital Erasme, Brussels, Belgium
| | | | | | | | | | - Richard Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
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Asombang AW, Chishinga N, Nkhoma A, Chipaila J, Nsokolo B, Manda-Mapalo M, Montiero JFG, Banda L, Dua KS. Systematic review and meta-analysis of esophageal cancer in Africa: Epidemiology, risk factors, management and outcomes. World J Gastroenterol 2019; 25:4512-4533. [PMID: 31496629 PMCID: PMC6710188 DOI: 10.3748/wjg.v25.i31.4512] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/05/2019] [Accepted: 07/19/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Esophageal cancer (EC) is associated with a poor prognosis, particularly so in Africa where an alarmingly high mortality to incidence ratio prevails for this disease. AIM To provide further understanding of EC in the context of the unique cultural and genetic diversity, and socio-economic challenges faced on the African continent. METHODS We performed a systematic review of studies from Africa to obtain data on epidemiology, risk factors, management and outcomes of EC. A non-systematic review was used to obtain incidence data from the International Agency for Research on Cancer, and the Cancer in Sub-Saharan reports. We searched EMBASE, PubMed, Web of Science, and Cochrane Central from inception to March 2019 and reviewed the list of articles retrieved. Random effects meta-analyses were used to assess heterogeneity between studies and to obtain odds ratio (OR) of the associations between EC and risk factors; and incidence rate ratios for EC between sexes with their respective 95% confidence intervals (CI). RESULTS The incidence of EC is higher in males than females, except in North Africa where it is similar for both sexes. The highest age-standardized rate is from Malawi (30.3 and 19.4 cases/year/100000 population for males and females, respectively) followed by Kenya (28.7 cases/year/100000 population for both sexes). The incidence of EC rises sharply after the age of 40 years and reaches a peak at 75 years old. Meta-analysis shows a strong association with tobacco (OR 3.15, 95%CI: 2.83-3.50). There was significant heterogeneity between studies on alcohol consumption (OR 2.28, 95%CI: 1.94-2.65) and on low socioeconomic status (OR 139, 95%CI: 1.25-1.54) as risk factors, but these could also contribute to increasing the incidence of EC. The best treatment outcomes were with esophagectomy with survival rates of 76.6% at 3 years, and chemo-radiotherapy with an overall combined survival time of 267.50 d. CONCLUSION Africa has high incidence and mortality rates of EC, with preventable and non-modifiable risk factors. Men in this setting are at increased risk due to their higher prevalence of tobacco and alcohol consumption. Management requires a multidisciplinary approach, and survival is significantly improved in the setting of esophagectomy and chemoradiation therapy.
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Affiliation(s)
- Akwi W Asombang
- Division of Gastroenterology/Hepatology, Warren Alpert Medical School of Brown University, Providence, RI 02903, United States
| | - Nathaniel Chishinga
- Department for HIV Elimination, Fulton County Government, Atlanta, GA 30303, United States
| | - Alick Nkhoma
- Department of Gastroenterology, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Staffordshire ST4 6QG, United Kingdom
| | - Jackson Chipaila
- Department of Surgery, University Teaching Hospital-Adult Hospital, Lusaka 10101, Zambia
| | - Bright Nsokolo
- Department of Medicine, Levy Mwanawasa University Teaching Hospital, Tropical Gastroenterology and Nutrition Group (TROPGAN), Lusaka 10101, Zambia
| | - Martha Manda-Mapalo
- Department of Medicine, The University of New Mexico, Albuquerque, NM 87106, United States
| | | | - Lewis Banda
- Hematology/Oncology, Cancer Disease Hospital, Lusaka 10101, Zambia
| | - Kulwinder S Dua
- Department of Medicine and Pediatrics, Medical College of Wisconsin, Milwaukee, WI 53226, United States
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Dua KS, DeWitt JM, Kessler WR, Diehl DL, Draganov PV, Wagh MS, Kahaleh M, Wong Kee Song LM, Khara HS, Khan AH, Aburajab MM, Ballard D, Forsmark CE, Edmundowicz SA, Brauer BC, Tyberg A, Buttar NS, Adler DG. A phase III, multicenter, prospective, single-blinded, noninferiority, randomized controlled trial on the performance of a novel esophageal stent with an antireflux valve (with video). Gastrointest Endosc 2019; 90:64-74.e3. [PMID: 30684601 DOI: 10.1016/j.gie.2019.01.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 10/18/2018] [Accepted: 01/09/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Self-expanding metal stents (SEMSs) when deployed across the gastroesophageal junction (GEJ) can lead to reflux with risks of aspiration. A SEMS with a tricuspid antireflux valve (SEMS-V) was designed to address this issue. The aim of this study was to evaluate the efficacy and safety of this stent. METHODS A phase III, multicenter, prospective, noninferiority, randomized controlled trial was conducted on patients with malignant dysphagia requiring SEMSs to be placed across the GEJ. Patients were randomized to receive SEMSs with no valve (SEMS-NV) or SEMS-V. Postdeployment dysphagia score at 2 weeks and Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) questionnaire score at 4 weeks were measured. Patients were followed for 24 weeks. RESULTS Sixty patients were randomized (SEMS-NV: 30 patients, mean age 67 ± 13 years; SEMS-V: 30 patients, mean age 65 ± 12 years). Baseline dysphagia scores (SEMS-NV, 2.5 ± .8; SEMS-V, 2.5 ± .8) and GERD-HRQL scores (SEMS-NV, 11.1 ± 8.2; SEMS-V, 12.8 ± 8.3) were similar. All SEMSs were successfully deployed. A similar proportion of patients in both arms improved from advanced dysphagia to moderate to no dysphagia (SEMS-NV, 71%; SEMS-V, 74%; 95% confidence interval, 1.93 [-17.8 to 21.7]). The dysphagia scores were also similar across all follow-up time points. Mean GERD-HRQL scores improved by 7.4 ± 10.2 points in the SEMS-V arm and by 5.2 ± 8.3 in the SEMS-NV group (P = .96). The GERD-HRQL scores were similar across all follow-up time points. Aspiration pneumonia occurred in 3.3% in the SEMS-NV arm and 6.9% in the SEMS-V arm (P = .61). Migration rates were similar (SEMS-NV, 33%; SEMS-V, 48%; P = .29). Two SEMS-V spontaneously fractured. There was no perforation, food impaction, or stent-related death in either group. CONCLUSIONS The SEMS-V was equally effective in relieving dysphagia as compared with the SEMS-NV. Presence of the valve did not increase the risks of adverse events. GERD symptom scores were similar between the 2 stents, implying either that the valve was not effective or that all patients on proton pump inhibitors could have masked the symptoms of GERD. Studies with objective evaluations such as fluoroscopy and/or pH/impedance are recommended. (Clinical trial registration number: NCT02159898.).
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Affiliation(s)
- Kulwinder S Dua
- Department of Medicine, Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - John M DeWitt
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University Hospital, Indianapolis, Indiana, USA
| | - William R Kessler
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University Hospital, Indianapolis, Indiana, USA
| | - David L Diehl
- Department of Medicine, Division of Gastroenterology and Hepatology, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Peter V Draganov
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Mihir S Wagh
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Colorado Denver, Aurora, Colorado, USA
| | - Michel Kahaleh
- Department of Medicine, Division of Gastroenterology and Hepatology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Louis M Wong Kee Song
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Harshit S Khara
- Department of Medicine, Division of Gastroenterology and Hepatology, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Abdul H Khan
- Department of Medicine, Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Murad M Aburajab
- Department of Medicine, Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Darren Ballard
- Department of Medicine, Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Chris E Forsmark
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Steven A Edmundowicz
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Colorado Denver, Aurora, Colorado, USA
| | - Brian C Brauer
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Colorado Denver, Aurora, Colorado, USA
| | - Amy Tyberg
- Department of Medicine, Division of Gastroenterology and Hepatology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Najtej S Buttar
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Douglas G Adler
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Affiliation(s)
- Kulwinder S Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Mitnala Sasikala
- Institute of Basic Sciences and Translational Research, Asian Healthcare Foundation, Asian Institute of Gastroenterology, Hyderabad, India
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Zaninotto G, Bennett C, Boeckxstaens G, Costantini M, Ferguson MK, Pandolfino JE, Patti MG, Ribeiro U, Richter J, Swanstrom L, Tack J, Triadafilopoulos G, Markar SR, Salvador R, Faccio L, Andreollo NA, Cecconello I, Costamagna G, da Rocha JRM, Hungness ES, Fisichella PM, Fuchs KH, Gockel I, Gurski R, Gyawali CP, Herbella FAM, Holloway RH, Hongo M, Jobe BA, Kahrilas PJ, Katzka DA, Dua KS, Liu D, Moonen A, Nasi A, Pasricha PJ, Penagini R, Perretta S, Sallum RAA, Sarnelli G, Savarino E, Schlottmann F, Sifrim D, Soper N, Tatum RP, Vaezi MF, van Herwaarden-Lindeboom M, Vanuytsel T, Vela MF, Watson DI, Zerbib F, Gittens S, Pontillo C, Vermigli S, Inama D, Low DE. The 2018 ISDE achalasia guidelines. Dis Esophagus 2018; 31:5087687. [PMID: 30169645 DOI: 10.1093/dote/doy071] [Citation(s) in RCA: 155] [Impact Index Per Article: 25.8] [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] [Indexed: 02/06/2023]
Abstract
Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.
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Affiliation(s)
- G Zaninotto
- Department of Surgery and Cancer, Imperial College, London, UK
| | - C Bennett
- Office of Research and Innovation, Royal College of Surgeons in Ireland, Ireland
| | - G Boeckxstaens
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - M Costantini
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - M K Ferguson
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - J E Pandolfino
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - M G Patti
- Department of Medicine and Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - U Ribeiro
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - J Richter
- Department of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - L Swanstrom
- Institute of Image-Guided Surgery, Strasbourg, France; Interventional Endoscopy and Foregut Surgery, Oregon Health Science University, Portland, Oregon, USA
| | - J Tack
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - G Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford Esophageal Multidisciplinary Program in Innovative Research Excellence (SEMPIRE), Stanford University, Stanford, California, USA
| | - S R Markar
- Department of Surgery and Cancer, Imperial College, London, UK
| | - R Salvador
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - L Faccio
- Division of Surgery, Padova University Hospital, Padova, Italy
| | - N A Andreollo
- Faculty of Medical Science, State University of Campinas, Campinas, São Paulo, Brazil
| | - I Cecconello
- Digestive Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - G Costamagna
- Digestive Endoscopy Unit, A. Gemelli Hospital, Catholic University, Rome, Italy
| | - J R M da Rocha
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - E S Hungness
- Department of Surgery, Northwestern University, Chicago, Illinois, USA
| | - P M Fisichella
- Department of Surgery, Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, Massachusetts, USA
| | - K H Fuchs
- Department of Surgery, AGAPLESION-Markus-Krankenhaus, Frankfurt, Germany
| | - I Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - R Gurski
- Department of Surgery, School of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - C P Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - F A M Herbella
- Department of Surgery, School of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - R H Holloway
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, The University of Adelaide, Adelaide, Australia
| | - M Hongo
- Department of Medicine, Kurokawa Hospital, Taiwa, Kurokawa, Miyagi, Japan
| | - B A Jobe
- Esophageal and Lung Institute, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania, USA
| | - P J Kahrilas
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - D A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - K S Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - D Liu
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - A Moonen
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - A Nasi
- Digestive Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - P J Pasricha
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - R Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico; Department of Pathophysiology and Transplantation; Università degli Studi, Milan, Italy
| | - S Perretta
- Institute for Image Guided Surgery IHU-Strasbourg, Strasbourg, France
| | - R A A Sallum
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - G Sarnelli
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Naples, Italy
| | - E Savarino
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - F Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - D Sifrim
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - N Soper
- Department of Surgery, Northwestern University, Chicago, Illinois, USA
| | - R P Tatum
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - M F Vaezi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - M van Herwaarden-Lindeboom
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - T Vanuytsel
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - M F Vela
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - D I Watson
- Department of Surgery, Flinders University, Adelaide, Australia
| | - F Zerbib
- Department of Gastroenterology, University of Bordeaux, Bordeaux, France
| | - S Gittens
- ECD Solutions, Atlanta, Georgia, USA
| | - C Pontillo
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - S Vermigli
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - D Inama
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - D E Low
- Department of Thoracic Surgery Virginia Mason Medical Center, Seattle, Washington, USA
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Dua KS. Response. Gastrointest Endosc 2018; 88:410-411. [PMID: 30012416 DOI: 10.1016/j.gie.2018.03.026] [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: 03/29/2018] [Accepted: 03/31/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Kulwinder S Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Dua KS. Response. Gastrointest Endosc 2018; 87:1597. [PMID: 29759171 DOI: 10.1016/j.gie.2018.01.039] [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: 01/29/2018] [Accepted: 01/30/2018] [Indexed: 02/08/2023]
Affiliation(s)
- Kulwinder S Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Ballard DD, Rahman S, Ginnebaugh B, Khan A, Dua KS. Safety and efficacy of self-expanding metal stents for biliary drainage in patients receiving neoadjuvant therapy for pancreatic cancer. Endosc Int Open 2018; 6:E714-E721. [PMID: 29868636 PMCID: PMC5979217 DOI: 10.1055/a-0599-6190] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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: 11/08/2017] [Accepted: 02/20/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Durable biliary drainage is essential during neoadjuvant therapy (NAT) in patients with pancreatic cancer who present with biliary obstruction. Plastic stents (PS) tend to occlude readily, resulting in delay/interruption of treatment. Our aim was to evaluate the safety and efficacy of self-expanding metal stents (SEMS) for biliary drainage in patients receiving NAT for pancreatic cancer. PATIENTS AND METHODS From 2009 to 2014, all consecutive patients with resectable pancreatic cancer at one tertiary center had SEMS placed for biliary drainage before NAT was started. Data on biliary drainage efficacy, stent malfunction rates and procedural adverse events were collected. RESULTS One hundred forty-two consecutive patients with pancreatic cancer (mean age 66 ± 9 SD years; 81 male, 61 female; 67 resectable, 75 borderline resectable) were enrolled. Eight-seven patients (61 %) had prior PS exchanged to SEMS and 55 (39 %) had SEMS placed upfront. Median duration from SEMS placement to the end of NAT/surgery was 111 days (range 44 - 282). During NAT, SEMS malfunction requiring reintervention occurred in 16 patients (11.2 %): tissue ingrowth 11, stent occlusion from food 6, stent migration 3, incomplete expansion 1, "tissue cheese-cutter" effect 1, and cystic duct obstruction 1. On subgroup analysis, no correlation between SEMS malfunction and stage of disease, prior PS, or duration of NAT was found (r 2 = 0.05, P = 0.34). Presence of SEMS in situ did not affect pancreaticoduodenectomy. CONCLUSION SEMS provide safe, effective and durable biliary drainage during NAT for pancreas cancer. Previously placed PS can be exchanged for SEMS. SEMS do not require removal prior to surgery.
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Affiliation(s)
- Darren D. Ballard
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, U.S.A.
| | - Syed Rahman
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, U.S.A.
| | - Brian Ginnebaugh
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, U.S.A.
| | - Abdul Khan
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, U.S.A.
| | - Kulwinder S. Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, U.S.A.,Corresponding author Kulwinder S. Dua, MD, FRCP, FACP, FASGE, Professor of Medicine and Pediatrics Division of Gastroenterology and HepatologyMedical College of Wisconsin Milwaukee, WI+1-414 955 6815
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16
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Smith ZL, Dua A, Saeian K, Ledeboer NA, Graham MB, Aburajab M, Ballard DD, Khan AH, Dua KS. A Novel Protocol Obviates Endoscope Sampling for Carbapenem-Resistant Enterobacteriaceae: Experience of a Center with a Prior Outbreak. Dig Dis Sci 2017; 62:3100-3109. [PMID: 28681083 DOI: 10.1007/s10620-017-4669-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [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: 04/11/2017] [Accepted: 06/27/2017] [Indexed: 12/09/2022]
Abstract
BACKGROUND Numerous published outbreaks, including one from our institution, have described endoscope-associated transmission of multidrug-resistant organisms (MDROs). Individual centers have adopted their own protocols to address this issue, including endoscope culture and sequestration. Endoscope culturing has drawbacks and may allow residual bacteria, including MDROs, to go undetected after high-level disinfection. AIM To report the outcome of our novel protocol, which does not utilize endoscope culturing, to address our outbreak. METHODS All patients undergoing procedures with elevator-containing endoscopes were asked to permit performance of a rectal swab. All endoscopes underwent high-level disinfection according to updated manufacturer's guidance. Additionally, ethylene oxide (EtO) sterilization was done in the high-risk settings of (1) positive response to a pre-procedure risk stratification questionnaire, (2) positive or indeterminate CRE polymerase chain reaction (PCR) from rectal swab, (3) refusal to consent for PCR or questionnaire, (4) purulent cholangitis or infected pancreatic fluid collections. Two endoscopes per weekend were sterilized on a rotational basis. RESULTS From September 1, 2015 to April 30, 2016, 556 endoscopy sessions were performed using elevator-containing endoscopes. Prompted EtO sterilization was done on 46 (8.3%) instances, 3 from positive/indeterminate PCR tests out of 530 samples (0.6%). No CRE transmission was observed during the study period. Damage or altered performance of endoscopes related to EtO was not observed. CONCLUSION In this pilot study, prompted EtO sterilization in high-risk patients has thus far eliminated endoscope-associated MDRO transmission, although no CRE infections were noted throughout the institution during the study period. Further studies and a larger patient sample will be required to validate these findings.
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Affiliation(s)
- Zachary L Smith
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA. .,Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA. .,Division of Gastroenterology, Washington University School of Medicine, 660 S Euclid Ave, Campus Box 8124, Saint Louis, MO, 63110, USA.
| | - Arshish Dua
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kia Saeian
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.,Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Nathan A Ledeboer
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mary Beth Graham
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.,Division of Infectious Diseases, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Murad Aburajab
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.,Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Darren D Ballard
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.,Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Abdul H Khan
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.,Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kulwinder S Dua
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.,Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
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Smith ZL, Daniel KE, Pant M, Dua KS, Aburajab M. Invasive intraductal papillary carcinoma of the bile duct masquerading as a common hepatic duct stone. VideoGIE 2016; 1:68-69. [PMID: 29905233 PMCID: PMC5990414 DOI: 10.1016/j.vgie.2016.09.004] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Zachary L Smith
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Kimberly E Daniel
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mamta Pant
- Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Kulwinder S Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Murad Aburajab
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Abstract
Patients with non-metastatic esophageal cancer routinely undergo endoscopic ultrasound (EUS) for loco-regional staging. Neoadjuvant therapy is recommended for ≥T3 tumors while upfront surgery can be considered for ≤T2 lesions. The aim of this study was to determine if the degree of dysphagia can predict the EUS T-stage of esophageal cancer. One hundred eleven consecutive patients with non-metastatic esophageal cancer were retrospectively reviewed from a database. Prior to EUS, patients' dysphagia grade was recorded. Correlation between dysphagia grade and EUS T-stage, especially in reference to predicting ≥T3 stage, was determined. The correlation of dysphagia grade with EUS T-stage (Kendall's tau coefficient) was 0.49 (P < 0.001) for the lower and 0.59 (P = 0.008) for the middle esophagus. The sensitivity and specificity of dysphagia grade ≥2 (can only swallow semi-solids/liquids) for T3 cancer were 56% (95% confidence interval [CI] 43-67%) and 93% (95% CI 79-98%), respectively. The sensitivity, specificity, and positive predictive value of dysphagia grade ≥3 (can only swallow liquids or total dysphagia) for T3 lesions were 36% (95% CI 25-48%), 100% (95% CI 89-100%), and 100% (95% CI 83-100%), respectively. Overall, there was a significant positive correlation between dysphagia grade and the EUS T-stage of esophageal cancer. All patients with dysphagia grade ≥3 had T3 lesions. This may have clinical implications for patients who can only swallow liquids or have complete dysphagia by allowing for prompt initiation of neoadjuvant therapy, especially in countries/centers where EUS service is difficult to access in a timely manner or not available.
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Affiliation(s)
- T C Fang
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Y S Oh
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - A Szabo
- Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - A Khan
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - K S Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin, USA
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Abstract
BACKGROUND Tissue-engineered extracellular matrix populated with autologous pluripotent cells can result in de-novo organogenesis, but the technique is complex, not widely available, and has not yet been used to repair large oesophageal defects in human beings. We aimed to use readily available stents and extracellular matrix to regenerate the oesophagus in vivo in a human being to re-establish swallowing function. METHODS In a patient aged 24 years, we endoscopically placed a readily available, fully covered, self-expanding, metal stent (diameter 18 mm, length 120 mm) to bridge a 5 cm full-thickness oesophageal segment destroyed by a mediastinal abscess and leading to direct communication between the hypopharynx and the mediastinum. A commercially available extracellular matrix was used to cover the stent and was sprayed with autologous platelet-rich plasma adhesive gel. The sternocleidomastoid muscle was placed over the matrix. After 4 weeks, stent removal was needed due to stent migration, and was replaced with three stents telescopically aligned to improve anchoring. The stents were removed after 3·5 years and the oesophagus was assessed by endoscopy, biopsy, endoscopic ultrasonography, and high-resolution impedance manometry. FINDINGS After stent removal we saw full-thickness regeneration of the oesophagus with stratified squamous epithelium, a normal five-layer wall, and peristaltic motility with bolus transit. 4 years after stent removal, the patient was eating a normal diet and maintaining a steady weight. INTERPRETATION Maintenance of the structural morphology of the oesophagus with off-the-shelf non-biological scaffold and stimulation of regeneration with commercially available extracellular matrix led to de-novo structural and functional regeneration of the oesophagus. FUNDING None.
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Affiliation(s)
- Kulwinder S Dua
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Walter J Hogan
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Abdul A Aadam
- Division of Gastroenterology and Hepatology, Northwestern University, Evanston, IL, USA
| | - Mario Gasparri
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
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Smith ZL, Oh YS, Saeian K, Edmiston CE, Khan AH, Massey BT, Dua KS. Transmission of carbapenem-resistant Enterobacteriaceae during ERCP: time to revisit the current reprocessing guidelines. Gastrointest Endosc 2015; 81:1041-5. [PMID: 25638508 DOI: 10.1016/j.gie.2014.11.006] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [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: 08/19/2014] [Accepted: 11/04/2014] [Indexed: 02/08/2023]
Affiliation(s)
- Zachary L Smith
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Young S Oh
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Kia Saeian
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Charles E Edmiston
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Abdul H Khan
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Benson T Massey
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Kulwinder S Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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21
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Dua KS, Latif SU, Yang JF, Fang TC, Khan A, Oh Y. Efficacy and safety of a new fully covered self-expandable non-foreshortening metal esophageal stent. Gastrointest Endosc 2014; 80:577-585. [PMID: 24685007 DOI: 10.1016/j.gie.2014.02.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [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: 08/09/2013] [Accepted: 02/03/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Fully covered esophageal self-expandable metal stents (SEMSs) are potentially removable but can be associated with high migration rates. For precise positioning, non-foreshortening SEMSs are preferred. Recently, a new fully covered non-foreshortening SEMS with anti-migration features was introduced. OBJECTIVE To evaluate the efficacy and safety of this new esophageal SEMS. DESIGN Retrospective study. SETTING Single, tertiary-care center. PATIENTS Consecutive patients with malignant and benign strictures with dysphagia grade of ≥3 and patients with fistulas/leaks were studied. INTERVENTIONS Stent placement and removal. MAIN OUTCOME MEASUREMENTS Technical success in stent deployment/removal, efficacy in relieving dysphagia and sealing fistulas/leaks, and adverse events. RESULTS Forty-three stents were placed in 35 patients (mean [± standard deviation] age 65 ± 11 years; 31 male), 24 for malignant and 11 for benign (5 strictures, 6 leaks) indications. Technical success in precise SEMS placement was 100%. The after-stent dysphagia grade improved significantly (at 1 week: 1.5 ± 0.7; at 4 weeks: 1.2 ± 0.4; baseline: 3.8 ± 0.4; P < .0001). Twenty stents were removed for clinical indications, with technical success of 100%. All leaks sealed after SEMS placement and did not recur after stent removal. All benign strictures recurred after stent removal. Adverse events included migration (14%), chest pain (11%), and dysphagia from tissue hyperplasia (6%). There was no stent-related mortality. LIMITATIONS Nonrandomized, single-center study. CONCLUSION The new esophageal SEMS was effective in relieving malignant dysphagia, allowed for precise placement, and was easily removable. It was effective in treating benign esophageal fistulas and leaks. Stent-related adverse events were acceptable.
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Affiliation(s)
- Kulwinder S Dua
- Department of Gastroenterology and Hepatology, Medical College of Wisconsin and the Clement Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Sahibzada U Latif
- Department of Gastroenterology and Hepatology, Medical College of Wisconsin and the Clement Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Juliana F Yang
- Department of Gastroenterology and Hepatology, Medical College of Wisconsin and the Clement Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Tom C Fang
- Department of Gastroenterology and Hepatology, Medical College of Wisconsin and the Clement Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Abdul Khan
- Department of Gastroenterology and Hepatology, Medical College of Wisconsin and the Clement Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Young Oh
- Department of Gastroenterology and Hepatology, Medical College of Wisconsin and the Clement Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
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Dua KS, Surapaneni SN, Kuribayashi S, Hafeezullah M, Shaker R. Effect of aging on hypopharyngeal safe volume and the aerodigestive reflexes protecting the airways. Laryngoscope 2014; 124:1862-8. [PMID: 24281906 DOI: 10.1002/lary.24539] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 11/05/2013] [Accepted: 11/25/2013] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS Studies on young volunteers have shown that aerodigestive reflexes are triggered before the maximum volume of fluid that can safely collect in the hypopharynx before spilling into the larynx is exceeded (hypopharyngeal safe volume [HPSV]). The objective of this study was to determine the influence of aging on HPSV and pharyngo-glottal closure reflex (PGCR), pharyngo-UES contractile reflex (PUCR), and reflexive pharyngeal swallow (RPS). STUDY DESIGN Comparison between two groups of different age ranges. METHODS Ten young (25 ± 3 standard deviation [SD] years) and 10 elderly (77 ± 3 SD years) subjects were studied. PGCR, PUCR, and RPS were elicited by perfusing water into the pharynx rapidly and slowly. HPSV was determined by abolishing RPS with pharyngeal anesthesia. RESULTS Frequency-elicitation of PGCR and PUCR were significantly lower in the elderly compared to the young during slow water perfusion (47% vs. 97% and 40% vs. 90%, respectively, P < .001). RPS was absent in five of the 30 (17%) slow injections in the elderly group. In these elderly subjects, HPSV was exceeded and laryngeal penetration of the water was seen. The threshold volume to elicit PGCR, PUCR, and RPS was significantly lower than the HPSV during rapid injections. Except for RPS, these volumes were also significantly lower than HPSV during slow injections. CONCLUSIONS PGCR, PUCR, and RPS reflexes are triggered at a threshold volume significantly lower than the HPSV in both young and elderly subjects. Lower frequency-elicitation of PGCR, PUCR, and RPS in the elderly can predispose them to the risks of aspiration.
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Affiliation(s)
- Kulwinder S Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A.; VA Medical Center, Milwaukee, Wisconsin, U.S.A
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Hourneaux de Moura EG, Toma K, Goh KL, Romero R, Dua KS, Felix VN, Levine MS, Kochhar R, Appasani S, Gusmon CC. Stents for benign and malignant esophageal strictures. Ann N Y Acad Sci 2013; 1300:119-143. [PMID: 24117639 DOI: 10.1111/nyas.12242] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This paper presents commentaries on endotherapy for esophageal perforation/leaks; treatment of esophageal perforation; whether esophageal stents should be used for treating benign esophageal strictures; what determines the optimal stenting period in benign esophageal strictures/leaks; how to choose an esophageal stent; how a new fistula secondary to an esophageal stent should be treated; which strategy should be adopted when a fistula of a cervical anastomosis occurs; intralesional steroids for refractory esophageal strictures; balloon and bougie dilators for esophageal strictures and predictors of response to dilation; whether refractory strictures from different etiologies respond differently to endotherapy; surgical therapy of benign esophageal strictures; and whether stenoses following severe esophageal burns should be treated by esophageal resection or esophageal bypass.
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Affiliation(s)
| | - Kengo Toma
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Khean-Lee Goh
- Division of Gastroenterology and GI Endoscopy, University of Malaya, Kuala Lumpur, Malaysia
| | - Ronald Romero
- Division of Gastroenterology and GI Endoscopy, University of Malaya, Kuala Lumpur, Malaysia
| | - Kulwinder S Dua
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Marc S Levine
- Department of Gastrointestinal Radiation, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania.,Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rakesh Kochhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sreekanth Appasani
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Carla Cristina Gusmon
- Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universdade de São Paulo, São Paulo, Brazil
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Hourneaux de Moura EG, Toma K, Goh KL, Romero R, Dua KS, Felix VN, Levine MS, Kochhar R, Appasani S, Gusmon CC. Stents for benign and malignant esophageal strictures. Ann N Y Acad Sci 2013. [PMID: 24117639 DOI: 10.1111/nyas.12242.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This paper presents commentaries on endotherapy for esophageal perforation/leaks; treatment of esophageal perforation; whether esophageal stents should be used for treating benign esophageal strictures; what determines the optimal stenting period in benign esophageal strictures/leaks; how to choose an esophageal stent; how a new fistula secondary to an esophageal stent should be treated; which strategy should be adopted when a fistula of a cervical anastomosis occurs; intralesional steroids for refractory esophageal strictures; balloon and bougie dilators for esophageal strictures and predictors of response to dilation; whether refractory strictures from different etiologies respond differently to endotherapy; surgical therapy of benign esophageal strictures; and whether stenoses following severe esophageal burns should be treated by esophageal resection or esophageal bypass.
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Affiliation(s)
| | - Kengo Toma
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Khean-Lee Goh
- Division of Gastroenterology and GI Endoscopy, University of Malaya, Kuala Lumpur, Malaysia
| | - Ronald Romero
- Division of Gastroenterology and GI Endoscopy, University of Malaya, Kuala Lumpur, Malaysia
| | - Kulwinder S Dua
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Marc S Levine
- Department of Gastrointestinal Radiation, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania.,Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rakesh Kochhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sreekanth Appasani
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Carla Cristina Gusmon
- Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universdade de São Paulo, São Paulo, Brazil
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Abstract
BACKGROUND Vagal reflex initiated by esophageal stimulation and microaspiration can cause chronic cough in patients with gastroesophageal reflux disease (GERD). By raising intraabdominal pressure,cough can, in turn, predispose to GERD. The role of the upper esophageal sphincter (UES)in preventing esophagopharyngeal reflux during coughing is not well known. The aim of this study was to evaluate the UES response during coughing. METHODS We studied 20 healthy young (10 women; age, 27 ± 5 years) and 15 healthy elderly(nine women; age, 73 ± 4 years) subjects. Hard and soft cough-induced pressure changes in the UES, distal esophagus, lower esophageal sphincter, and stomach were determined simultaneously using high-resolution manometry and concurrent acoustic cough recordings. RESULTS Resting UES pressure was significantly higher in the young compared with the elderly subjects (42 ± 14 mm Hg vs 24 ± 9 mm Hg; P < .001). Cough induced a UES contractile response in all subjects. Despite lower UES resting pressures in the elderly subjects, the maximum UES pressure during cough was similar between the young and the elderly subjects (hard cough, 230 ± 107 mm Hg vs 278 ± 125 mm Hg, respectively; soft cough, 156 ± 85 mm Hg vs 164 ± 119 mm Hg, respectively; P not significant for both). The UES pressure increase over baseline during cough was significantly higher than that in the esophagus, lower esophageal sphincter, and stomach for both groups ( P < .001). CONCLUSIONS Cough induces a rise in UES pressure, and this response is preserved in elderly people. A cough-induced rise in UES pressure is significantly higher than that in the esophagus and stomach,thereby providing a barrier against retrograde entry of gastric contents into the pharynx.
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Affiliation(s)
- Manuel Amaris
- Medical College of Wisconsin Dysphagia Institute and VA Medical Center, Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI
| | - Kulwinder S Dua
- Medical College of Wisconsin Dysphagia Institute and VA Medical Center, Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI
| | - Sohrab Rahimi Naini
- Medical College of Wisconsin Dysphagia Institute and VA Medical Center, Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI
| | - Erica Samuel
- Medical College of Wisconsin Dysphagia Institute and VA Medical Center, Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI
| | - Reza Shaker
- Medical College of Wisconsin Dysphagia Institute and VA Medical Center, Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI.
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Dua KS, Merrill J, Komorowski R. Neosquamous epithelium after ablation of Barrett's epithelium: cause for concern? Gastrointest Endosc 2012; 76:1082-3. [PMID: 23078943 DOI: 10.1016/j.gie.2012.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 07/05/2012] [Indexed: 12/11/2022]
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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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van Boeckel PGA, Dua KS, Weusten BLAM, Schmits RJH, Surapaneni N, Timmer R, Vleggaar FP, Siersema PD. Fully covered self-expandable metal stents (SEMS), partially covered SEMS and self-expandable plastic stents for the treatment of benign esophageal ruptures and anastomotic leaks. BMC Gastroenterol 2012; 12:19. [PMID: 22375711 PMCID: PMC3313862 DOI: 10.1186/1471-230x-12-19] [Citation(s) in RCA: 132] [Impact Index Per Article: 11.0] [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: 08/03/2011] [Accepted: 02/29/2012] [Indexed: 12/14/2022] Open
Abstract
Background Benign esophageal ruptures and anastomotic leaks are life-threatening conditions that are often treated surgically. Recently, placement of partially and fully covered metal or plastic stents has emerged as a minimally invasive treatment option. We aimed to determine the clinical effectiveness of covered stent placement for the treatment of esophageal ruptures and anastomotic leaks with special emphasis on different stent designs. Methods Consecutive patients who underwent placement of a fully covered self-expandable metal stent (FSEMS), a partially covered SEMS (PSEMS) or a self-expanding plastic stent (SEPS) for a benign esophageal rupture or anastomotic leak after upper gastrointestinal surgery in the period 2007-2010 were included. Data on patient demographics, type of lesion, stent placement and removal, clinical success and complications were collected Results A total of 52 patients received 83 esophageal stents (61 PSEMS, 15 FSEMS, 7 SEPS) for an anastomotic leak (n = 32), iatrogenic rupture (n = 13), Boerhaave's syndrome (n = 4) or other cause (n = 3). Endoscopic stent removal was successful in all but eight patients treated with a PSEMS due to tissue ingrowth. Clinical success was achieved in 34 (76%, intention-to-treat: 65%) patients (PSEMS: 73%, FSEMS: 83%, SEPS: 83%) after a median of 1 (range 1-5) stent and a median stenting time of 39 (range 7-120) days. In total, 33 complications in 24 (46%) patients occurred (tissue in- or overgrowth (n = 8), stent migration (n = 10), ruptured stent cover (all Ultraflex; n = 6), food obstruction (n = 3), severe pain (n = 2), esophageal rupture (n = 2), hemorrhage (n = 2)). One (2%) patient died of a stent-related cause. Conclusions Covered stents placed for a period of 5-6 weeks may well be an alternative to surgery for treating benign esophageal ruptures or anastomotic leaks. As efficacy between PSEMS, FSEMS and SEPS is not different, stent choice should depend on expected risks of stent migration (SEPS and FSEMS) and tissue in- or overgrowth (PSEMS).
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Affiliation(s)
- Petra G A van Boeckel
- Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Room F02,618, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
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van Boeckel PGA, Dua KS, Weusten BLAM, Schmits RJH, Surapaneni N, Timmer R, Vleggaar FP, Siersema PD. Fully covered self-expandable metal stents (SEMS), partially covered SEMS and self-expandable plastic stents for the treatment of benign esophageal ruptures and anastomotic leaks. BMC Gastroenterol 2012. [PMID: 22375711 DOI: 10.1186/1471-230x-12-19.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Benign esophageal ruptures and anastomotic leaks are life-threatening conditions that are often treated surgically. Recently, placement of partially and fully covered metal or plastic stents has emerged as a minimally invasive treatment option. We aimed to determine the clinical effectiveness of covered stent placement for the treatment of esophageal ruptures and anastomotic leaks with special emphasis on different stent designs. METHODS Consecutive patients who underwent placement of a fully covered self-expandable metal stent (FSEMS), a partially covered SEMS (PSEMS) or a self-expanding plastic stent (SEPS) for a benign esophageal rupture or anastomotic leak after upper gastrointestinal surgery in the period 2007-2010 were included. Data on patient demographics, type of lesion, stent placement and removal, clinical success and complications were collected RESULTS A total of 52 patients received 83 esophageal stents (61 PSEMS, 15 FSEMS, 7 SEPS) for an anastomotic leak (n=32), iatrogenic rupture (n=13), Boerhaave's syndrome (n=4) or other cause (n=3). Endoscopic stent removal was successful in all but eight patients treated with a PSEMS due to tissue ingrowth. Clinical success was achieved in 34 (76%, intention-to-treat: 65%) patients (PSEMS: 73%, FSEMS: 83%, SEPS: 83%) after a median of 1 (range 1-5) stent and a median stenting time of 39 (range 7-120) days. In total, 33 complications in 24 (46%) patients occurred (tissue in- or overgrowth (n=8), stent migration (n=10), ruptured stent cover (all Ultraflex; n=6), food obstruction (n=3), severe pain (n=2), esophageal rupture (n=2), hemorrhage (n=2)). One (2%) patient died of a stent-related cause. CONCLUSIONS Covered stents placed for a period of 5-6 weeks may well be an alternative to surgery for treating benign esophageal ruptures or anastomotic leaks. As efficacy between PSEMS, FSEMS and SEPS is not different, stent choice should depend on expected risks of stent migration (SEPS and FSEMS) and tissue in- or overgrowth (PSEMS).
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Affiliation(s)
- Petra G A van Boeckel
- Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Room F02,618, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
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Adler DG, Bakis G, Coyle WJ, DeGregorio B, Dua KS, Lee LS, McHenry L, Pais SA, Rajan E, Sedlack RE, Shami VM, Faulx AL. Principles of training in GI endoscopy. Gastrointest Endosc 2012; 75:231-5. [PMID: 22154419 DOI: 10.1016/j.gie.2011.09.008] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Accepted: 09/08/2011] [Indexed: 12/17/2022]
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Dua KS, Merrill JT, Komorowski R. Neosquamous epithelium after Barrett's ablation: cause for concern? Gastrointest Endosc 2011; 74:1424-5. [PMID: 21429488 DOI: 10.1016/j.gie.2010.12.023] [Citation(s) in RCA: 2] [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] [Received: 11/10/2010] [Accepted: 12/17/2010] [Indexed: 12/11/2022]
Affiliation(s)
- Kulwinder S Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA
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Parise P, Rosati R, Savarino E, Locatelli A, Ceolin M, Dua KS, Tatum RP, Braghetto I, Gyawali CP, Hejazi RA, McCallum RW, Sarosiek I, Bonavina L, Wassenaar EB, Pellegrini CA, Jacobson BC, Canon CL, Badaloni A, del Genio G. Barrett's esophagus: surgical treatments. Ann N Y Acad Sci 2011; 1232:175-95. [PMID: 21950813 DOI: 10.1111/j.1749-6632.2011.06051.x] [Citation(s) in RCA: 3] [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] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The following on surgical treatments for Barrett's esophagus includes commentaries on the indications for antireflux surgery after medical treatment; the effects of the various procedures on the lower esophageal sphincter; the role of impaired esophageal motility and delayed gastric emptying in the choice of the surgical procedure; indications for associated highly selective vagotomy, duodenal switch, and gastric electrical stimulation; therapeutic strategies for detection and treatment of shortened esophagus; the role of antireflux surgery on the regression of metaplastic mucosa and the risk of malignant progression; the detection of asymptomatic reflux brfore bariatric surgery; the role of non-GERD symptoms on the results of surgery; and the indications of Collis gastroplasty and choice of the type of fundoplication.
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Affiliation(s)
- Paolo Parise
- Department of General Surgery IV, Regional Referal Center for Esophageal Pathology, Pisa, Italy
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Abstract
Partially covered self-expandable esophageal stents have been associated with unacceptable complications when used for benign esophageal disorders. With the introduction of removable or potentially removable fully covered stents and biodegradable stents, interest in using expandable stents for benign indications has been revived. Although expandable stents can offer a minimally invasive alternative to surgery, they can be associated with serious complications; hence, this approach should be considered in carefully selected patients, preferably on a protocol basis.
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Affiliation(s)
- Kulwinder S Dua
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA.
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Ulitsky A, Werlin S, Dua KS. Role of ERCP in the management of non-iatrogenic traumatic bile duct injuries in the pediatric population. Gastrointest Endosc 2011; 73:823-7. [PMID: 21295302 DOI: 10.1016/j.gie.2010.11.054] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [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: 09/20/2010] [Accepted: 11/29/2010] [Indexed: 02/08/2023]
Affiliation(s)
- Alex Ulitsky
- Division of Gastroenterology and Hepatology, Froedtert Memorial Hospital, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA
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Dua KS. Expanding Role of Self Expanding Esophageal Stents. Journal of Digestive Endoscopy 2011. [DOI: 10.1055/s-0039-1700253] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Indexed: 10/25/2022] Open
Abstract
ABSTRACTEsophageal cancer is often diagnosed at a late stage and hence carries a poor prognosis with an overall 5-year survival rate of 10% to 15%. Therefore, palliative treatment primarily aimed at the relieving dysphagia is the only available option. Endoscopic placement of self expanding metal stents (SEMS) has become a widely used method for palliation offering prompt relief of dysphagia and numerous reports have shown it to be safe and effective. Secondary to tissue in-growth into the uncovered segments of the stent, SEMS cannot be removed and hence are not approved for benign indications. With the advent of the removable self expanding plastic stents, the indications for esophageal stent insertion have expanded to as bridge to surgery for patients undergoing neoadjuvant chemotherapy, for refractory benign esophageal strictures, for non- malignant esophageal perforations, leaks and fistulae, and even for variceal hemorrhage. Newer fully covered SEMS that are potentially removable are also being tried for benign indications but await FDA clearance. Similarly biodegradeable stents for benign disorders and radioactive or drug-eluding stents for malignant disease are hoped to improve the management of esophageal diseases. The purpose of this article is to review the expanding role of self expanding stents in the management of esophageal disorders other than palliating malignant dysphagia and fistulae.(J Dig Endos 2011;2(1):9-14)
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Affiliation(s)
- Kulwinder S Dua
- Director, Advanced GI Endoscopy Fellowship, Medical College of Wisconsin, Milwaukee, USA
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Hernandez LV, Dua KS, Surapaneni SN, Rittman T, Shaker R. Anatomic-manometric correlation of the upper esophageal sphincter: a concurrent US and manometry study. Gastrointest Endosc 2010; 72:587-92. [PMID: 20579650 PMCID: PMC4142490 DOI: 10.1016/j.gie.2010.04.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Accepted: 04/15/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND The pharyngoesophageal segment commonly referred to as the upper esophageal sphincter (UES) generates a high-pressure zone (HPZ) between the pharynx and the esophagus. However, the exact anatomical components of the UES-HPZ remain incompletely determined. OBJECTIVE To systematically define the US signature of various components of the pharyngoesophageal junction and to determine how these structures contribute to the development of the UES-HPZ. DESIGN Prospective, experimental study. SETTING Tertiary Academic Medical Center. PATIENTS This study involved 18 healthy volunteers. INTERVENTION We studied 5 participants by using a high-frequency US miniprobe (US-MP) and concurrent fluoroscopy and another 13 participants by using the US-MP and concurrent manometry. MAIN OUTCOME MEASUREMENTS Relative contribution of various muscles in the UES-HPZ. RESULTS Manometrically, the UES-HPZ had a median length of 4.0 cm (range 3.0-4.5 cm). A C-shaped muscle, believed to represent the cricopharyngeus muscle, was observed for a median length of 3.5 cm (range 2.0-4.0 cm). The oval configuration representing the esophageal contribution to the UES was seen in 10 of 13 participants (77%) at the distal HPZ (esophagus to UES transition zone). The flat configuration of the inferior constrictor muscle was noted in 7 of 13 participants (54%) at the proximal HPZ (UES to pharynx transition zone). There were 4 to 5 wall layers versus 3 layers in the distal and proximal HPZ, respectively. The mean (+/- SD) muscle thickness was relatively constant along the length of the UES-HPZ. LIMITATIONS Air artifacts in the UES-HPZ. CONCLUSION The configuration and layers of the UES-HPZ vary along its length. The upper esophagus is a significant contributor to the distal UES-HPZ.
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Dua KS, Vijayapal AS, Kengis J, Shidham VB. Ciliated foregut cyst of the pancreas: preoperative diagnosis using endoscopic ultrasound guided fine needle aspiration cytology--a case report with a review of the literature. Cytojournal 2009; 6:22. [PMID: 19876385 PMCID: PMC2762695 DOI: 10.4103/1742-6413.56362] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2009] [Accepted: 08/01/2009] [Indexed: 01/06/2023] Open
Abstract
A 51-year-old male presented with a 4-month history of abdominal pain, decreased appetite, and postprandial bloating. A CT scan showed a solitary, 5.3 x 4.4 cm, cystic lesion in the body/tail of the pancreas. Endoscopic retrograde cholangiopancreatography did not show communication between the pancreatic duct and the cystic lesion. Endoscopic ultrasound (EUS) examination revealed a 6.9 x 2.4 cm cystic lesion in the body/tail region of the pancreas without septae or solid components. The pancreatic parenchyma, pancreatic duct, and common bile duct were unremarkable. EUS-guided fine needle aspiration (EUS-FNA) was performed using a 22-gauge EchotipTM needle. Only a few drops of viscous fluid could be aspirated. Papanicolaou-stained direct smears and SurePath (Autocyte) preparations were evaluated. The direct smears were hypocellular; however, the concentration method producing liquid-based cytology preparation showed detached ciliary tufts (degenerated debris with ciliated cellular fragments of cell tops without nuclei) and occasional intact ciliated cells consistent with a ciliated foregut cyst. Although benign, the cyst was resected to alleviate the symptoms. The surgical pathology confirmed the benign preoperative interpretation of the ciliated foregut cyst. To the best of our knowledge, this is the first case of pancreatic ciliated foregut cyst reported to be diagnosed preoperatively by EUS-FNA. For a proper preoperative cytologic diagnosis, the needle rinses should be processed adequately. Otherwise, these hypocellular specimens with mucin may be misinterpreted as mucinous cystic lesions.
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Affiliation(s)
- Kulwinder S Dua
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
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Abstract
OBJECTIVES Injection of water into the pharynx induces contraction of the upper esophageal sphincter (UES), triggers the pharyngo-UES contractile reflex (PUCR), and at a higher volume, triggers an irrepressible swallow, the reflexive pharyngeal swallow (RPS). These aerodigestive reflexes have been proposed to reduce the risks of aspiration. Alcohol ingestion can predispose to aspiration and previous studies have shown that cigarette smoking can adversely affect these reflexes. It is not known whether this is a local effect of smoking on the pharynx or a systemic effect of nicotine. The aim of this study was to elucidate the effect of systemic alcohol and nicotine on PUCR and RPS. METHODS Ten healthy non-smoking subjects (8 men, 2 women; mean age: 32+/-3 s.d. years) and 10 healthy chronic smokers (7 men, 3 women; 34+/-8 years) with no history of alcohol abuse were studied. Using previously described techniques, the above reflexes were elicited by rapid and slow water injections into the pharynx, before and after an intravenous injection of 5% alcohol (breath alcohol level of 0.1%), before and after smoking, and before and after a nicotine patch was applied. Blood nicotine levels were measured. RESULTS During rapid and slow water injections, alcohol significantly increased the threshold volume (ml) to trigger PUCR and RPS (rapid: PUCR: baseline 0.2+/-0.05, alcohol 0.4+/-0.09; P=0.022; RPS: baseline 0.5+/-0.17, alcohol 0.8+/-0.19; P=0.01, slow: PUCR: baseline 0.2+/-0.03, alcohol 0.4+/-0.08; P=0.012; RPS: baseline 3.0+/-0.3, alcohol 4.6+/-0.5; P=0.028). During rapid water injections, acute smoking increased the threshold volume to trigger PUCR and RPS (PUCR: baseline 0.4+/-0.06, smoking 0.67+/-0.09; P=0.03; RPS: baseline 0.7+/-0.03, smoking 1.1+/-0.1; P=0.001). No similar increases were noted after a nicotine patch was applied. CONCLUSIONS Acute systemic alcohol exposure inhibits the elicitation PUCR and RPS. Unlike cigarette smoking, systemic nicotine does not alter the elicitation of these reflexes.
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Affiliation(s)
- Kulwinder S. Dua
- Department of Gastroenterology and Hepatology, MCW
Dysphagia Institute, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sri Naveen Surapaneni
- Department of Gastroenterology and Hepatology, MCW
Dysphagia Institute, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Rajesh Santharam
- Department of Gastroenterology and Hepatology, MCW
Dysphagia Institute, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - David Knuff
- Department of Gastroenterology and Hepatology, MCW
Dysphagia Institute, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Candy Hofmann
- Department of Gastroenterology and Hepatology, MCW
Dysphagia Institute, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Reza Shaker
- Department of Gastroenterology and Hepatology, MCW
Dysphagia Institute, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Dua KS, Vleggaar FP, Santharam R, Siersema PD. Removable self-expanding plastic esophageal stent as a continuous, non-permanent dilator in treating refractory benign esophageal strictures: a prospective two-center study. Am J Gastroenterol 2008; 103:2988-94. [PMID: 18786110 DOI: 10.1111/j.1572-0241.2008.02177.x] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.8] [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] [Indexed: 12/11/2022]
Abstract
BACKGROUND Refractory benign esophageal strictures (RBES) are difficult to treat requiring frequent dilatations or surgery. Conceptually, while maintaining luminal patency, if a dilator is kept in place continuously for several weeks, the benefits may be longer lasting. An expandable esophageal stent will be ideal in achieving the above. Preliminary results on using a removable self-expanding plastic esophageal stent, Polyflex stent (PS), for treating RBES have been mixed. AIM To evaluate the efficacy of PS in the treatment of RBES. METHODS Forty patients with RBES [mean age 60 +/- 15 SD yrs, female 14, male 26, Anastomotic 12 (fistula 4), Corrosive 8, Radiation 7, Pill induced 4, Post trauma 3 (fistula 3), Peptic 2, Others 4 (fistula 1)] were prospectively studied. Continuous non-permanent dilation was performed by placing a PS and removing it after 4 wk. The patients were then followed at regular intervals. Pre-insertion baseline data and post-removal information on dysphagia status, complications, and change in outcome were prospectively collected. RESULTS The technical success in stent placement and stent removal were 95% and 94%, respectively. Mean post-stent dysphagia score was 0.6 +/- 0.7 SD, which was significantly better than pre-stent scores (3.0 +/- 0.8 SD; P < 0.001). At median follow-up of 53 wk (range 11-156), only 40% (intention to treat 30%) patients were dysphagia-free. However, the overall change in outcome from baseline options (ongoing dilatations, or surgery) was 66% (dysphagia-free 12, did not want removal 2, did not remove 1, preferred long-term stenting 10). The stent was successful in closing the fistula in five of eight (63%) patients. Complications observed were migration eight (22%), severe chest pain four (11%), bleeding three (8%), perforation two (5.5%), GE reflux two (5.5%), impaction two (5.5%), and new fistula one (2.7%). There was one mortality from massive bleeding. CONCLUSIONS It was feasible to deploy and remove PS stents in the majority of patients with RBES. Some patients achieved long-term relief without further re-interventions while several others re-strictured and preferred long-term stenting over repeated dilations or surgery. The procedure carries significant risks and hence should only be considered in carefully selected patients.
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Affiliation(s)
- Kulwinder S Dua
- Division of Gastroenterology & Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Bajaj JS, Dua KS, Hanson K, Presberg K. Prospective, randomized trial comparing effect of oral versus intravenous pantoprazole on rebleeding after nonvariceal upper gastrointestinal bleeding: a pilot study. Dig Dis Sci 2007; 52:2190-4. [PMID: 17429726 DOI: 10.1007/s10620-006-9282-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [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: 12/14/2005] [Accepted: 03/01/2006] [Indexed: 12/09/2022]
Abstract
Proton pump inhibitors (PPIs) reduce the rate of rebleeding in patients with nonvariceal upper GI bleed (NVGIB). Oral (PO) and intravenous (IV) pantoprazole are equipotent in raising gastric pH. We conducted a pilot study comparing the efficacy of PO vs. IV pantoprazole for reducing rebleeding after NVGIB. Patients with NVGIB were randomized to receive PO (80 mg BID for 3 days) or IV (80-mg IV bolus and 8 mg/hr infusion for 3 days) pantoprazole followed by pantoprazole, 40 mg PO BID, for 30 days. All patients underwent endoscopy within 24 hr and endotherapy was applied where necessary. Twelve patients randomized to the PO and 13 to the IV pantoprazole group were comparable in age, hematocrit, Rockall scores, ulcer characteristics, and endoscopic interventions. Two patients in the IV arm rebled and another in the IV arm developed reversible renal failure. No patient in the PO arm rebled, had organ failure, or had to be changed to IV pantoprazole. We conclude that in this pilot study, the effect of PO pantoprazole on 30-day rebleeding rate in patients with NVGIB was similar to that of IV pantoprazole.
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Affiliation(s)
- Jasmohan S Bajaj
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, 9200 W. Wisconsin Avenue, Milwaukee, Wisconsin 53226, USA
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Dua KS, Reddy ND, Rao VG, Banerjee R, Medda B, Lang I. Impact of reducing duodenobiliary reflux on biliary stent patency: an in vitro evaluation and a prospective randomized clinical trial that used a biliary stent with an antireflux valve. Gastrointest Endosc 2007; 65:819-28. [PMID: 17383650 DOI: 10.1016/j.gie.2006.09.011] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [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: 05/27/2006] [Accepted: 09/05/2006] [Indexed: 12/27/2022]
Abstract
BACKGROUND The mechanisms leading to occlusion of plastic biliary stents (PBS) are not known. OBJECTIVE To evaluate the impact of reducing duodenobiliary reflux on stent patency rate. DESIGN A newly designed antireflux PBS (AR-PBS) was tested in vitro by using ox bile. A prospective randomized trial in human beings was conducted. SETTING Tertiary medical center. PATIENTS Patients with malignant bile-duct strictures were studied. INTERVENTIONS A PBS or an AR-PBS stent was placed by using standard techniques, and the patients were followed at regular intervals. Patients presenting with stent occlusion underwent re-stent placement with either a PBS or a metal stent. MAIN OUTCOME MEASUREMENTS In vitro: resistance to retrograde flow and comparison of the basal and peak antegrade flow pressures between the 2 stents. In vivo: stent patency rates, complications, and the efficacy of the stents in improving the liver test. RESULTS The AR-PBS stent could withstand a retrograde pressure gradient of >320 mm Hg compared with <1 mm Hg for the PBS. Secondary to the siphon effect of the valve, the antegrade flow resistance offered by the AR-PBS was on the negative side for all flow rates compared with PBS (P < .001). The median patency of the AR-PBS in human studies was 145 days (range, 52-252 days) compared with 101 days (range, 41-210 days) for the PBS (P = .002). Both stents were equally effective in improving the liver test, and complication rates were similar in the 2 groups. LIMITATIONS The occluded stents were not examined microscopically. CONCLUSIONS The antireflux biliary stent remains patent for a longer time and hence duodenobiliary reflux may be contributing to stent occlusion.
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Affiliation(s)
- Kulwinder S Dua
- Pancreatico-biliary Center, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Abstract
Traumatic noniatrogenic biliary injuries, unlike iatrogenic injuries, are usually complex in nature and are frequently associated with other multiorgan trauma and infection. Bile leaks following these injuries are an important source of short- and long-term morbidity. Repeat surgery for primary repair of complex bile leaks is difficult and can be complicated by anastomotic leakage and biliary stricture formation. Endoscopic retrograde cholangiopancreatography (ERCP) was initially used only as a diagnostic technique to guide surgical repair in this setting. However, with the high success rates observed in treatment of iatrogenic bile leaks, ERCP has emerged as a nonoperative treatment option for noniatrogenic biliary leaks as well. Recent data show that ERCP is effective in managing bile leaks after blunt and sharp liver injuries, using transpapillary stenting, endoscopic sphincterotomy, or both, with greater than 80% healing rates. The evidence is not clear regarding which ERCP maneuver - endoscopic sphincterotomy, transpapillary stenting, or both - should be used.
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Affiliation(s)
- Jasmohan S Bajaj
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, 9200 W. Wisconsin Avenue, Milwaukee, WI 53226, USA
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Dua KS, Bajaj JS, Rittmann T, Hofmann C, Shaker R. Safety and feasibility of evaluating airway-protective reflexes during sleep: new technique and preliminary results. Gastrointest Endosc 2007; 65:483-6. [PMID: 17321251 DOI: 10.1016/j.gie.2006.10.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [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] [Received: 01/16/2006] [Accepted: 10/09/2006] [Indexed: 02/08/2023]
Abstract
BACKGROUND The airway is vulnerable to aspiration during sleep. The integrity of aerodigestive-protective reflexes during sleep has not been studied previously because of a lack of adequate techniques. OBJECTIVE To determine the safety and the feasibility of a new technique to elicit pharyngoglottal closure reflex (PGCR), pharyngo-upper-esophageal sphincter (UES) pressure contractile reflex (PUCR), and reflexive pharyngeal swallow (RPS) during sleep. SETTING Outpatient sleep laboratory. DESIGN AND INTERVENTION PGCR, PUCR, and RPS were elicited in 3 subjects by injecting colored water into the pharynx through a specially designed UES manometry catheter to which a thin videoendoscope was taped. This assembly was passed transnasally and positioned to obtain UES-pressure recordings and adequate endoscopic glottic views. Sleep was monitored by polysomnography, and all modalities were synchronized by using a timer. Subjects were evaluated while awake and during stage I sleep. RESULTS All subjects were monitored for 3 hours of natural sleep, during which several periods of stage I sleep were observed. While awake, PGCR, PUCR, and RPS were elicited in all subjects. During sleep, PGCR was present in all, PUCR in 2, and RPS in 2 (1 after arousal) subjects. Threshold volumes for reflex elicitation were not significantly different between the awake state and stage I sleep. None of the subjects exhibited laryngeal penetration or aspiration. LIMITATIONS Small numbers of subjects were studied only in stage I sleep. CONCLUSIONS When using the above technique, it is safe and feasible to study aerodigestive reflexes during sleep. Preliminary data suggest that PGCR, PUCR, and RPS can be elicited during sleep.
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Affiliation(s)
- Kulwinder S Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Abstract
Malignant gastric outlet obstruction (MGO) is a late complication of pancreatobiliary and gastric cancers. Although surgical gastrojejunostomy provides good palliation, many of these patients may be nonoperative candidates or underwent previous extensive resection such as a Whipple procedure. Recently, endoscopically placed self-expanding metallic stents (SEMS) have been used to palliate MGO. The aim of this study was to evaluate the efficacy of SEMS for palliation of late MGO. Medical records of patients with endoscopic placement of SEMS for palliation of MGO were reviewed. Results showed that 30 patients with MGO had SEMS placed for late gastroduodenal (n = 20) or jejunal (n = 10) obstruction. Twenty-one patients (70%) had previous surgery. Return to oral feeding was observed in 90% of patients who presented with recurrent obstruction after prior bypass surgery and in 88% of nonoperative patients in whom SEMS were placed as the primary therapy for obstruction. No major complications were observed, and median survival after SEMS was 4.1 months (0.1 to 10.5 months). SEMS also did not interfere with biliary drainage. In conclusion, endoscopically placed SEMS are safe and provide good palliation for late malignant gastroduodenal and jejunal strictures and are an excellent complement to recurrent obstruction after surgical gastrojejunostomy.
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Affiliation(s)
- James M Kiely
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226-3596, USA
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Bajaj JS, Spinelli KS, Dua KS. Postoperative management of noniatrogenic traumatic bile duct injuries: role of endoscopic retrograde cholangiopancreaticography. Surg Endosc 2006; 20:974-7. [PMID: 16738995 DOI: 10.1007/s00464-005-0472-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2005] [Accepted: 01/05/2006] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic therapy for iatrogenic bile duct injuries is well established. Abdominal trauma-related biliary injuries, however, are complex in nature. The role of endoscopic therapy for these patients needs further evaluation. METHODS A retrospective study investigated nine patients who had surgery for abdominal trauma (4 gunshot, 4 crush, and 1 stab injury), presented postoperatively with noniatrogenic biliary injuries, and underwent endoscopic retrograde cholangiopancreaticography (ERCP). RESULTS The ERCP was successful for all the patients. Eight patients had significant bile leak at intra- or extra-hepatic sites, and one patient was discovered to have complete cutoff of the common hepatic duct. All bile leaks were treated successfully using biliary sphincterotomy with or without transpapillary stenting. No complications of ERCP were observed. CONCLUSIONS In this case series, ERCP was found to be useful as a diagnostic and therapeutic method for managing noniatrogenic traumatic biliary injuries in patients who had undergone previous surgery for abdominal trauma. The ERCP results were similar to those for iatrogenic bile duct injuries.
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Affiliation(s)
- J S Bajaj
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, 9200, W. Wisconsin Avenue, Milwaukee 53226, USA
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47
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Iqbal MA, Lawatsch EJ, Coyle DJ, Rowe JJ, Li R, Dua KS, Kochar MS. Signet-ring cell carcinoma of the urinary bladder mimicking retroperitoneal fibrosis. WMJ 2006; 105:55-8. [PMID: 16749327] [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] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
We present the case of a 77-year-old white woman with a past medical history of transitional cell carcinoma of the urinary bladder that presented with symptoms of acute renal failure and duodenal obstruction and posed a diagnostic dilemma. Initially, she presented with bilateral ureteral strictures and eventually required bilateral nephrostomy tubes. Later, the patient developed intractable nausea and vomiting secondary to a duodenal stricture. The finding of a "stranding appearance" on computed tomography imaging of the retroperitoneal space raised the suspicion of retroperitoneal fibrosis. Subsequent endoscopic placement of metal stents to relieve the duodenal obstruction failed to relieve her symptoms. The patient's poor general condition precluded an exploratory laparotomy. The patient expired shortly thereafter and an autopsy was performed. The autopsy results revealed full wall thickness signet-ring cell carcinoma of the urinary bladder with extensive metastasis to the retroperitoneum.
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Affiliation(s)
- M Asif Iqbal
- Department Internal of Medicine, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226, USA
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Bajaj JS, Bajaj S, Dua KS, Jaradeh S, Rittmann T, Hofmann C, Shaker R. Influence of sleep stages on esophago-upper esophageal sphincter contractile reflex and secondary esophageal peristalsis. Gastroenterology 2006; 130:17-25. [PMID: 16401464 DOI: 10.1053/j.gastro.2005.10.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [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] [Received: 01/31/2005] [Accepted: 09/21/2005] [Indexed: 01/20/2023]
Abstract
BACKGROUND & AIMS Airways are most vulnerable to aspiration during sleep. Esophago-upper esophageal sphincter (UES) contractile reflex (EUCR) and secondary peristalsis (2P) have been proposed to protect the airway by reflexively contracting the UES and clearing the esophagus of refluxate, respectively. Our aim was to study EUCR and 2P elicitation in "awake" state, stage II, slow-wave (stage III/IV), and rapid eye movement (REM) sleep. METHODS Thirteen healthy volunteers were studied in the supine position using concurrent UES and esophageal manometry and polysomnography. Threshold volume (Tvol) to trigger EUCR and 2P and changes in sleep stages were recorded during injection of 2.7 mL/min water into the proximal esophagus after sleep stages were confirmed. RESULTS UES pressure progressively declined with deeper stages of sleep. Tvol for EUCR and 2P elicitation was not significantly different between the stage II and "awake" state (EUCR: 4.0 +/- 1.8 mL vs 6.1 +/- 3.6 mL stage II; 2P: 5.8 +/- 2.2 mL vs 8.0 +/- 4.0 mL stage II). Tvol for EUCR and 2P elicitation during REM sleep were significantly lower than during the stage II and "awake" state (REM EUCR: 2.2 +/- 1.1 mL; 2P: 3.5 +/- 1.2 mL). Arousal and cough preempted development of EUCR and 2P during slow-wave sleep. CONCLUSIONS (1) EUCR/2P can be elicited in stage II and REM but is preempted by arousal in slow-wave sleep. (2) Tvol for EUCR/2P elicitation is significantly lower in REM, compared with the stage II and "awake" state, suggesting a heightened sensitivity of these reflexes during REM sleep. (3) Although UES pressure progressively declines with deeper stages of sleep, it can still reflexively contract during REM sleep, despite generalized hypotonia.
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Affiliation(s)
- Jasmohan S Bajaj
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA
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Cheng CL, Sherman S, Watkins JL, Barnett J, Freeman M, Geenen J, Ryan M, Parker H, Frakes JT, Fogel EL, Silverman WB, Dua KS, Aliperti G, Yakshe P, Uzer M, Jones W, Goff J, Lazzell-Pannell L, Rashdan A, Temkit M, Lehman GA. Risk factors for post-ERCP pancreatitis: a prospective multicenter study. Am J Gastroenterol 2006; 101:139-47. [PMID: 16405547 DOI: 10.1111/j.1572-0241.2006.00380.x] [Citation(s) in RCA: 404] [Impact Index Per Article: 22.4] [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] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Pancreatitis is the most common and serious complication of diagnostic and therapeutic ERCP. The aim of this study is to examine the potential patient- and procedure-related risk factors for post-ERCP pancreatitis in a prospective multicenter study. METHODS A 160-variable database was prospectively collected by a defined protocol on patients undergoing diagnostic or therapeutic ERCP at 15 centers in the Midwest Pancreaticobiliary Group and participating in a randomized controlled study evaluating whether prophylactic corticosteroids will reduce the incidence of post-ERCP pancreatitis. Data were collected prior to the procedure, at the time of procedure, and 24-72 h after discharge. Post-ERCP pancreatitis was diagnosed and its severity graded according to consensus criteria. RESULTS Of the 1,115 patients enrolled, diagnostic ERCP with or without sphincter of Oddi manometry (SOM) was performed in 536 (48.1%) and therapeutic ERCP in 579 (51.9%). Suspected sphincter of Oddi dysfunction (SOD) was the indication for the ERCP in 378 patients (33.9%). Pancreatitis developed in 168 patients (15.1%) and was graded mild in 112 (10%), moderate in 45 (4%), and severe in 11(1%). There was no difference in the incidence of pancreatitis or the frequency of investigated potential pancreatitis risk factors between the corticosteroid and placebo groups. By univariate analysis, the incidence of post-ERCP pancreatitis was significantly higher in 19 of 30 investigated variables. In the multivariate risk model, significant risk factors with adjusted odds ratios (OR) were: minor papilla sphincterotomy (OR: 3.8), suspected SOD (OR: 2.6), history of post-ERCP pancreatitis (OR: 2.0), age <60 yr (OR: 1.6), > or =2 contrast injections into the pancreatic duct (OR: 1.5), and trainee involvement (OR: 1.5). Female gender, history of recurrent idiopathic pancreatitis, pancreas divisum, SOM, difficult cannulation, and major papilla sphincterotomy (either biliary or pancreatic) were not multivariate risk factors for post-ERCP pancreatitis. CONCLUSION This study emphasizes the role of patient factors (age, SOD, prior history of post-ERCP pancreatitis) and technical factors (number of PD injections, minor papilla sphincterotomy, and operator experience) as the determining high-risk predictors for post-ERCP pancreatitis.
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Affiliation(s)
- Chi-Liang Cheng
- Indiana University Medical Center, Indianapolis, Indiana 46202, USA
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Abstract
BACKGROUND AND STUDY AIMS Scintigraphy is the currently accepted method for evaluation of gastric emptying. Although quantitative, this method is complicated, time-consuming, and costly. If a simple endoscopic technique was available for those instances when quantification of an emptying abnormality is not needed, the same clinical information could be obtained in less time and with resource savings. Our aims in this study were therefore to assess the technical feasibility, tolerability, and safety of unsedated transnasal esophagogastroscopy (T-EG) as a technique for qualitative assessment of gastric emptying. METHODS The study was done in two phases. In the first phase, 18 volunteers (ten men, eight women) underwent T-EG at 4 hours, 5 hours, or 6 hours after ingestion of a standard meal used for scintigraphic evaluation of gastric emptying without radiolabeling. In the second phase, ten volunteers underwent T-EG after scintigraphic imaging had demonstrated complete gastric emptying. RESULTS Subjects in both phases tolerated the procedure well and completed the study. In the first phase, 13 of 15 volunteers exhibited complete gastric emptying at 6 hours (87%), while two (13%) revealed some particulate matter in the stomach at that time. In the second phase, one of the ten volunteers exhibited a small amount of solid food residue in the stomach despite documentation of scintigraphic complete emptying. CONCLUSIONS Evaluation of gastric emptying by unsedated T-EG is both feasible and safe. In healthy, asymptomatic individuals, complete gastric emptying of solid food may take as long as 6 hours.
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Affiliation(s)
- T Attila
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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