Adam W. Templeton

Screening and surgical outcomes of familial pancreatic cancer.

This article reviews the genetics and incipient pathology of familial pancreatic cancer and the screening modalities in current use, and summarizes the outcomes of reported screening programs.

Updates in Diverticular Disease

Diverticulosis and its major complications, diverticulitis and diverticular bleeding, are increasingly common indications for hospitalization and outpatient visits. Recent publications in the field of diverticular disease have challenged long-standing disease concepts and management strategies. This article will highlight studies which have helped to clarify the contribution of genetic factors, fiber consumption and medication use to the development of diverticular disease, the role of antibiotics in the treatment of acute diverticulitis, and the association between diverticulitis, irritable bowel syndrome, and colon cancer.

Confocal microscopy in the esophagus and stomach.

Probe-based confocal microscopy (pCLE) is actively being investigated for applications in the esophagus and stomach. The use of pCLE allows real-time in vivo microscopy to evaluate the microarchitecture of the mucosal epithelium. pCLE appears to be particularly useful in identifying mucosal dysplasia and early malignancies that cannot be clearly distinguished using high-definition white light endoscopy, chromoendoscopy, or magnification endoscopy. In addition, the ability to detect dysplastic tissue in real-time may shift the current screening practice from random biopsy to targeted biopsy of esophageal and gastric cancers and their precursor lesions. We will review the use of pCLE for detection and surveillance of upper gastrointestinal early luminal malignancy.

Scanning fiber endoscopy: a novel platform for cholangioscopy.

Indeterminate pancreaticobiliary strictures remain a difficult diagnostic dilemma with currently available endoscopic imaging. Currently available pancreaticobiliary endoscopic systems have improved the sensitivity of directed biopsy; however, they are limited by image quality. We present scanning fiber endoscopy (SFE) as a novel platform for improving diagnostic accuracy. This endoscopic platform works through a standard side-viewing endoscope. SFE works by using a singlemode optical fiber whose distal tip is resonantly scanned in a spiral pattern. This fiber traces up to 300 enlarging spirals to generate a video feed. Because there is no direct pixel to fiber input, there are no “honeycombed” or non-imaging areas in view. Additionally, the decreased number of fibers allows for a highly flexible shaft with an improved bending radius. Here, we present 3 cases in which SFE was used in human participants as part of a prospective internal review board– approved protocol: 2 benign biliary strictures and 1 cholangiocarcinoma arising from a biliary intraductal

Endoscopic resection of gastric adenocarcinoma by use of a full-thickness resection device

Figure 2. Representative axial CT image showing sequelae of cirrhosis A 62-year-old man with hepatitis C mediated Child’s A cirrhosis and severe chronic obstructive pulmonary disease presented for esophageal variceal screening with upper endoscopy. In addition to small varices, a small 6-mm irregular lesion was found in the gastric fundus (Fig. 1), which underwent biopsy and was found to be a gastric adenocarcinoma with signet ring features. Staging CT of the chest, abdomen, and pelvis did not reveal any distant metastases or other masses, although we did observe marked intra-abdominal vascular collaterals and splenomegaly (Fig. 2). EUS revealed a mucosal mass extending into the level of the submucosa, without adjacent lymphadenopathy. Surgical consultation was obtained, and, given the small size of the lesion and the significant comorbidities associated with an open total gastrectomy, the patient opted for an attempt at endoscopic removal with the full-thickness resection device (FTRD). Using an Olympus 1T190 endoscope (Olympus Corp, Tokyo, Japan), we identified the lesion and marked the borders with cautery (Fig. 3). The 1T endoscope was removed, and the Olympus 2T180 endoscope was fitted

Multicenter evaluation of the clinical utility of laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass

BACKGROUND AND AIMS The obesity epidemic has led to increased use of Roux-en-Y gastric bypass (RYGB). These patients have an increased incidence of pancreaticobiliary diseases, yet standard ERCP is not possible because of surgically altered gastroduodenal anatomy. Laparoscopy-assisted ERCP (LA-ERCP) has been proposed as an option, but supporting data are derived from single-center small case series. Therefore, we conducted a large multicenter study to evaluate the feasibility, safety, and outcomes of LA-ERCP. METHODS This is a retrospective cohort study of adult patients with RYGB who underwent LA-ERCP in 34 centers. Data on demographics, indications, procedure success, and adverse events were collected. Procedure success was defined when all the following were achieved: reaching the papilla, cannulating the desired duct, and providing endoscopic therapy as clinically indicated. RESULTS A total of 579 patients (median age, 51; 84% women) were included. Indication for LA-ERCP was biliary in 89%, pancreatic in 8%, and both in 3%. Procedure success was achieved in 98%. Median total procedure time was 152 minutes (interquartile range [IQR], 109-210), with a median ERCP time of 40 minutes (IQR, 28-56). Median hospital stay was 2 days (IQR, 1-3). Adverse events were 18% (laparoscopy related, 10%; ERCP related, 7%; both, 1%) with the clear majority (92%) classified as mild/moderate, whereas 8% were severe and 1 death occurred. CONCLUSIONS Our large multicenter study indicates that LA-ERCP in patients with RYGB is feasible with a high procedure success rate comparable with that of standard ERCP in patients with normal anatomy. The ERCP-related adverse events rate is comparable with conventional ERCP, but the overall adverse event rate was higher because of the added laparoscopy-related events.

Barrett’s Esophagus: Diagnosis and Management

Esophageal adenocarcinoma (EAC) is one of the most rapidly increasing cancers in developed countries. EAC is thought to always or near always arise from a specialized intestinal metaplasia in the esophagus, called Barrett’s esophagus (BE), which forms in the lower esophagus in response to chronic acid reflux injury [1]. Barrett’s esophagus occurs in 1–6.4 % of the US population and is the strongest risk factor for esophageal adenocarcinoma (EAC) [2]. As such, people with BE are placed in surveillance programs with the intent to decrease EAC-associated mortality. Unfortunately, despite years of study of BE and EAC, it is still controversial whether current BE surveillance programs effectively decrease mortality from EAC. The controversy likely stems from low sensitivity methods for identifying people with BE, the modest accuracy of current surveillance methods to identify people with BE at increased risk of EAC, and the morbidity of historical treatments for high-grade dysplasia and EAC. Recent advances have been made or are being made that address all these issues; thus, BE continues to be a promising target for screening and surveillance [3, 4].