Alex Geller

Safety and outcome of endoscopic snare excision of the major duodenal papilla

BACKGROUND The optimal management of adenoma of the major duodenal papilla is not established. Options include surgical excision, endoscopic ablative techniques, snare excision, and observation with periodic biopsies. The aims of this retrospective study were to determine the safety and outcome of snare excision of the papilla. METHODS Twenty-eight snare excisions of the papilla were performed in 26 patients. Sixteen had familial adenomatous polyposis. In 22 procedures, a minisnare was used, and in 6 cases a prototype snare was designed for excision of the papilla. Pancreatic stents were placed as a prophylactic measure at the discretion of the endoscopist (n = 10). RESULTS Histopathologically, resected tissue included 25 adenomas, 1 inflammatory polyp, 1 invasive malignancy, and 1 normal papilla. Immediate complications were minor bleeding (n = 2), mild pancreatitis (n = 4) and a duodenal perforation (n = 1). The presence (n = 10) or absence (n = 18) of a pancreatic stent did not correlate with subsequent pancreatitis (2 in each group, p = NS). Follow-up was available for 21 patients (median, 9 months; range, 2-32 months). Pancreatic duct stenosis at the papillectomy site resulted in pancreatitis in 2 patients (17%) at, respectively, 4 months and 24 months. Follow-up endoscopy revealed recurrent/residual adenomatous tissue in 2 (10%). CONCLUSIONS Snare excision of the major duodenal papilla was well tolerated. Most complications were mild except for a small duodenal perforation. Stenosis of the pancreatic duct orifice with pancreatitis may be a late complication.

Endoscopic surveillance and ablative therapy for periampullary adenomas

Abstract OBJECTIVES: Periampullary adenomas are an increasingly recognized condition, both in those with familial adenomatous polyposis syndromes (FAP) as well as sporadic cases. Endoscopic management has been advocated for these lesions without differentiating between these two patient groups regarding aim of therapy. The aims of this study were to determine the safety and effectiveness of endoscopic surveillance and ablative therapy of periampullary adenomas in patients with both sporadic and FAP-associated lesions. METHODS: Retrospective analysis of 59 patients with FAP and 32 with sporadic lesions who were all enrolled in a program of endoscopic surveillance and ablative therapy. Median follow-up was 24 months (range, 1–134 months). RESULTS: Ampullary ablative therapy has resulted in return to normal histology in 44 and 34% of sporadic and FAP-associated lesions, respectively. Complications of endoscopic therapy were mild in 12 patients and severe in 3 patients: the latter category involved one occurrence of asymptomatic duodenal stenosis and one occurrence of postcoagulation syndrome—both after Nd-YAG laser therapy—and necrotizing pancreatitis after ampullary biopsy in one patient. Thirteen patients have been referred for surgical intervention. There has been no mortality and no cases of advanced malignancy missed by endoscopy. CONCLUSIONS: Endoscopic surveillance and ablative therapy of periampullary lesions is safe and can be effective, although eradication of ampullary tissue requires multiple ablative sessions.

Diagnosis of foregut duplication cysts by endoscopic ultrasonography

BACKGROUND & AIMS Foregut duplication cysts are rare congenital anomalies of enteric origin found most commonly in children and rarely in adults. They are usually found in adults on routine radiological studies and represent a challenging diagnostic problem. Conventional imaging tests do not lead to a conclusive diagnosis. With endoscopic ultrasonography, it is possible to distinguish between cystic and solid masses and to accurately establish the location of the cyst in relation to the gastrointestinal wall and to the mediastinum. METHODS Seven patients who had endoscopic ultrasonography performed because of differentiation between a cystic or solid mass lesion in the chest or abdomen could not be made with conventional radiological methods are described. RESULTS In all patients, a definite diagnosis was established by endoscopic ultrasonography. The diagnosis was confirmed in 2 patients after surgical excision. CONCLUSIONS Surgery can be avoided in patients with asymptomatic enteric duplication cysts diagnosed by endoscopic ultrasonography.

Esophagogastric Hematoma Mimicking a Malignant Neoplasm: Clinical Manifestations, Diagnosis, and Treatment

Esophagogastric hematoma is a rare condition occurring spontaneously or after esophageal instrumentation. In this report, we describe a patient with acute dysphagia in whom a lower esophageal mass was detected radiographically. Upper endoscopy revealed an esophageal mass that extended from the mid-esophagus to the gastroesophageal junction and was associated with a malignant-appearing ulcerated mass (5 to 6 cm) in the cardia. Gastric cancer with esophageal extension was the presumptive diagnosis. Computed tomography showed that the esophageal mass had a density similar to blood, a finding suggesting the presence of an esophageal hematoma. Biopsy specimens of the ulcer revealed acute inflammation but no malignant involvement. The patient was treated conservatively, and the initial symptoms resolved. Esophagogastric hematomas can mimic a neoplasm; thus, establishing the correct diagnosis is important because this condition has a favorable prognosis, and only conservative treatment is needed.

Azathioprine-Induced Lymphoma Manifesting as Fulminant Hepatic Failure

Azathioprine and rheumatoid arthritis are known to be associated with an increased risk of the development of non-Hodgkins lymphoma; however, the manifestation of fulminant hepatic failure is extremely uncommon in patients with non-Hodgkins lymphoma. In this article, we describe a patient with rheumatoid arthritis who was taking azathioprine, in whom fulminant hepatic failure occurred because of massive lymphomatous infiltration of the liver.

CASE REPORT: Graft-Versus-Host-Like Colitis and Malignant Thymoma

Acute graft-versus-host disease (GVHD) classically occurs in the setting of bone marrow or peripheral blood progenitor (hematopoietic stem cell) transplantation following high doses of irradiation or chemotherapy (1). Billingham originally described three prerequisites for the development of GVHD: the grafted organ must contain immunologically competent cells, the tissue antigens of the host and donor must differ, and the recipient must be unable to destroy donor cells (2). The basic mechanism of GVHD is that activated donor T cells undergo clonal expansion with release of a variety of proinflammatory cytokines, resulting in secondary activation of cytotoxic T lymphocytes, natural killer cells, B cells, and macrophages to cause target cell death (3). The prototypic acute GVHD patient develops a red, macular skin rash, abdominal cramping with profuse watery diarrhea, and jaundice, with high serum alkaline phosphatase approximately 15–20 days after receiving a bone marrow transplant (1). Although most often caused by bone marrow or stem cell transplantation, GVHD may also occur following transfusion of unirradiated blood products or transplantation of solid organs containing lymphoid tissue (1). In the patient we present, disruption of T-cell function associated with malignant thymoma resulted in GVHD-like colitis; the patient’s severe diarrhea improved only after treatment with the somatostatin analog octreotide, despite metastatic spread of the primary tumor.

Cytolytic Response to HIV in Patients with HIV Disease Treated with Extracorporeal Photochemotherapy: Preliminary Study

Extracorporeal photochemotherapy (photopheresis), an immunomodulatory therapy that targets circulating T helper lymphocytes, has been applied to the management of human immunodeficiency virus (HIV) disease. Any therapy that exerts its actions on CD4+ T cells has the potential of exacerbating HIV infection. Therefore, it was necessary to observe immune function during treatment. Because cytotoxic T lymphocytes (CTL) and natural killer cells are thought to play an important role in the response against HIV infection, we examined the effect of photopheresis on HIV cytolytic activity. The study group consisted of seven patients with late‐stage HIV disease who had not received any previous treatment for HIV infection. Patients were treated exclusively with photopheresis on two consecutive days each month for 14–32 months (average, 25 months). Peripheral lymphocytes, collected at various points during treatment, were used as effectors in a Wr release assay. Epstein‐Barr virus (EBV)‐transformed autologous B cell lines transfected with recombinant vaccinia vectors that expressed the HIV env (gp120, gp41) and gag (p24) proteins were used as target cells. All seven patients demonstrated relatively constant levels of cytolysis (>10% above controls) during treatment in the context of stable CD4+ T cell counts and a stable clinical status. These results suggest that extracorporeal photochemotherapy did not impair the cytolytic response to HIV infection and may have enhanced it in some patients.

Surgical and interventional palliative treatment of upper gastrointestinal malignancies

Malignancies of the upper gastrointestinal tract, including the oesophagus, stomach, liver, bile ducts and pancreas, are highly virulent diseases. While curative therapies relieve symptoms caused by these cancers, most of these treatments prove unsuccessful in the control of tumour due to occult residual disease. This review covers only planned palliative procedures for these conditions where patient factors (e.g. performance status or patient wishes) or tumour factors (e.g. locally advanced or known metastatic disease) prevent potentially curative intervention. For most patients, palliation of luminal obstruction, pain or other symptoms is the most worthwhile treatment that can be offered with present therapies.

Enteroliths in a Kock continent ileostomy : endoscopic diagnosis and management

The continent ileostomy (Kock pouch) unlike the standard ileostomy consists of an intra-abdominal ileal reservoir and a continent valve.1 The Kock pouch has significant advantages over the standard ileostomy as it is appliance free and may be more acceptable individually and socially.2 This continent ileostomy is associated with complications including the following: valve malfunction, hernia, intestinal obstruction, abscesses, fistulae, reoperation, and in some cases pouch removal.3-5 Bacterial overgrowth secondary to the stasis may additionally result in pouchitis. This inflammatory condition is clinically characterized by pain, fatigue, nausea, fever, and increased ileostomy output that typically responds to antibiotic therapy.6 We describe an unusual Kock pouch complication in three patients.