Anoop Prabhu

The synergistic effects of alcohol and tobacco consumption on the risk of esophageal squamous cell carcinoma: A meta-analysis

OBJECTIVES:Tobacco and alcohol use are established risk factors for esophageal squamous cell carcinoma (ESCC). We sought to determine whether these factors act synergistically to increase the risk of ESCC.METHODS:We performed a systematic literature search in multiple electronic databases regardless of language. Eligible studies were population-based case–control or cohort studies of ESCC that assessed the effects of tobacco and/or alcohol. Departures from multiplicative effects were quantified by the synergy factor (SF); SF >1 indicates positive synergy. Meta-analyses were performed to estimate summary-adjusted odds ratios (ORs) and the summary crude SF using random-effect models. Heterogeneity was defined by Cochranes Q P<0.10 and the inconsistency index.RESULTS:Systematic review identified 7,629 unique citations, of which 5 were eligible. Either tobacco or alcohol use was associated with a 20–30% increased risk for ESCC compared with nonuse, but the use of both was associated with an approximately threefold risk for ESCC; the summary-adjusted OR for combined alcohol and tobacco use was 3.28 (95% confidence interval (CI)=2.11, 508; Cochranes Q P value=0.05; I2=55.3%). The summary SF for ever-use of both tobacco and alcohol was 1.85 (95% CI=1.45, 2.38; Cochranes Q P value=0.49; I2=0.0%).CONCLUSIONS:There is a positive synergistic effect of alcohol and tobacco use for ESCC. The observed combined effect of the two factors is almost double if there were no synergy. Efforts for controlling the burden of ESCC should focus on individuals who use both alcohol and tobacco.

Transpapillary drainage has no added benefit on treatment outcomes in patients undergoing EUS-guided transmural drainage of pancreatic pseudocysts: a large multicenter study.

BACKGROUND AND AIMS The need for transpapillary drainage (TPD) in patients undergoing transmural drainage (TMD) of pancreatic fluid collections (PFCs) remains unclear. The aims of this study were to compare treatment outcomes between patients with pancreatic pseudocysts undergoing TMD versus combined (TMD and TPD) drainage (CD) and to identify predictors of symptomatic and radiologic resolution. METHODS This is a retrospective review of 375 consecutive patients with PFCs who underwent EUS-guided TMD from 2008 to 2014 at 15 academic centers in the United States. Main outcome measures included TMD and CD technical success, treatment outcomes (symptomatic and radiologic resolution) at follow-up, and predictors of treatment outcomes on logistic regression. RESULTS A total of 375 patients underwent EUS-guided TMD of PFCs, of which 174 were pseudocysts. TMD alone was performed in 95 (55%) and CD in 79 (45%) pseudocysts. Technical success was as follows: TMD, 92 (97%) versus CD, 35 (44%) (P = .0001). There was no difference in adverse events between the TMD (15%) and CD (14%) cohorts (P = .23). Median long-term (LT) follow-up after transmural stent removal was 324 days (interquartile range, 72-493 days) for TMD and 201 days (interquartile range, 150-493 days) (P = .37). There was no difference in LT symptomatic resolution (TMD, 69% vs CD, 62%; P = .61) or LT radiologic resolution (TMD, 71% vs CD, 67%; P = .79). TPD attempt was negatively associated with LT radiologic resolution of pseudocyst (odds ratio, 0.11; 95% confidence interval, 0.02-0.8; P = .03). CONCLUSIONS TPD has no benefit on treatment outcomes in patients undergoing EUS-guided TMD of pancreatic pseudocysts and negatively affects LT resolution of PFCs.

Variation in learning curves and competence for ERCP among advanced endoscopy trainees by using cumulative sum analysis

BACKGROUND AND AIMS There are limited data on learning curves and competence in ERCP. By using a standardized data collection tool, we aimed to prospectively define learning curves and measure competence among advanced endoscopy trainees (AETs) by using cumulative sum (CUSUM) analysis. METHODS AETs were evaluated by attending endoscopists starting with the 26th hands-on ERCP examination and then every ERCP examination during the 12-month training period. A standardized ERCP competency assessment tool (using a 4-point scoring system) was used to grade the examination. CUSUM analysis was applied to produce learning curves for individual technical and cognitive components of ERCP performance (success defined as a score of 1, acceptable and unacceptable failures [p1] of 10% and 20%, respectively). Sensitivity analyses varying p1 and by using a less-stringent definition of success were performed. RESULTS Five AETs were included with a total of 1049 graded ERCPs (mean ± SD, 209.8 ± 91.6/AET). The majority of cases were performed for a biliary indication (80%). The overall and native papilla allowed cannulation times were 3.1 ± 3.6 and 5.7 ± 4, respectively. Overall learning curves demonstrated substantial variability for individual technical and cognitive endpoints. Although nearly all AETs achieved competence in overall cannulation, none achieved competence for cannulation in cases with a native papilla. Sensitivity analyses increased the proportion of AETs who achieved competence. CONCLUSION This study demonstrates that there is substantial variability in ERCP learning curves among AETs. A specific case volume does not ensure competence, especially for native papilla cannulation.

Systematic review with meta-analysis: race-specific effects of alcohol and tobacco on the risk of oesophageal squamous cell carcinoma.

Oesophageal squamous cell carcinoma (OSCC) is associated with alcohol use, tobacco use and African or Asian descent. However, little is known about how racial background modifies the effects of alcohol or tobacco.

Autoimmune Pancreatitis Diagnosed with Core Biopsy Obtained from a Novel Fork-Tip EUS Needle

The endoscopic diagnosis of autoimmune pancreatitis from histologic criteria remains challenging as it requires adequate architectural details rather than cytology alone. A 67-year-old man presented with progressive abdominal pain and weight loss. Cross-sectional imaging showed inflammatory changes of the pancreatic body and tail and periaortitis on abdominal computed tomography, but normal serum immunoglobulin G4. A mass-like lesion of the pancreatic body and tail was identified on endoscopic ultrasonography. A histologic diagnosis of autoimmune pancreatitis was accomplished through needle biopsy using a novel fork-tip needle.

The Race-Specific Incidence of Esophageal Squamous Cell Carcinoma in Individuals With Exposure to Tobacco and Alcohol.

Objectives:The relative impact of esophageal squamous cell carcinoma (ESCC) in minority populations is incompletely understood. We aimed to estimate the race-specific incidences of ESCC and place these in the context of the incidence of esophageal adenocarcinoma (EAC) in white men with gastroesophageal reflux disease (GERD).Methods:The race- and sex-specific exposures to tobacco and alcohol in the United States were obtained from the National Health Interview Survey. The standardized incidence ratios of exposure to tobacco smoke and/or alcohol for ESCC were estimated from meta-analyses. Existing incidences of ESCC in the United States were obtained from the Surveillance, Epidemiology, and End Results (SEER) program. We then used this data to inform a Markov computer model estimating the incidence of ESCC.Results:The incidence of ESCC reported in SEER was the greatest among African-Americans compared with white non-Hispanics, Hispanics, or Asians. In our model, the estimated incidence of ESCC in African-American men exposed to tobacco and alcohol approached the risk of EAC in white non-Hispanic men with weekly GERD. For instance, at age 60 years, the incidence of ESCC in African-American men who have used both tobacco and alcohol was 30/100,000 compared with an incidence of EAC in white men with GERD of 40/100,000. In comparison, the risk of EAC in white non-Hispanic women with weekly GERD at this age was 6.2/100,000.Conclusions:The incidence of ESCC in African-American men who use alcohol and tobacco is the highest and comparable to other screened diseases. Development of screening and prevention programs for ESCC in high-risk populations should be considered.

Upper GI Bleeding in a Post-Liver Transplant Patient

Question: A 45-year-old man presented to the emergency room with large-volume hematochezia and subsequent hematemesis. His medical history is notable for alpha-1 antitrypsin deficiency with eventual liver failure. He underwent orthotopic liver transplantation 9 months prior, which was complicated by ischemic cholangiopathy with recurrent cholangitis and need for serial percutaneous cholangiogram tube exchanges. He underwent retransplantation 2 months before presentation, this time with a relatively uncomplicated postoperative course. The patient was not on aspirin or any nonsteroidal anti-inflammatory drugs. On this presentation, he was afebrile but hemodynamically unstable with a blood pressure of 82/60 mmHg and a heart rate of 110 bpm. Nasogastric lavage returned bright red blood with clot. Laboratory values were as follows: White blood cell count, 8300/ L (neutrophils, 82%); hemoglobin, 8.2 g/dL; platelet count, 92,000/mm3; blood urea nitrogen, 24 mg/dL; creatinine, 1.0 mg/dL; prothrombin time, 12.4 seconds; and International Normalzed Ratio, 1.2. Between admission and intervention, the patient required a total transfusion of 12 U of packed red blood cells for emodynamic support. Upper gastrointestinal endoscopy revealed a normal esophagus. The stomach contained a large amount of blood clot, but no site f active bleeding. Examination of the duodenum showed an adherent blood clot emanating from the ampulla of Vater (Figure A). he patient was referred to interventional radiology for visceral angiography (Figure B). What is the diagnosis? Look on page 1624 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information n submitting your favorite image to Clinical Challenges and Images in GI.

Management of an esophagojejunal anastomotic stricture using a lumen-apposing metal stent

re 1. A, Esophagram demonstrating the esophagojejunal anastomotic stricture. B, Endoscopic view of the esophagojejunal stricture before serial on dilation. C, Endoscopic view of the esophagojejunal stricture immediately before the second balloon dilation procedure. D, Deep submucosal g at 5 o’clock position after 12-mm balloon dilation, precluding safe dilation with larger-diameter balloons. E, Placement of a lumen-apposing metal across the esophagojejunal anastomotic stricture. F, Esophagojejunostomy after removal of lumen-apposing metal stent after a 4-week dwell.

Use of combined methylene blue chromoendoscopy and intravenous secretin for endoscopic therapy in pancreas divisum

ecretin-enhanced MRCP (S-MRCP) demonstrating complete visum with a separate dorsal pancreatic duct (PD) headed minor papilla, and a short ventral PD merging with the comuct toward the major papilla. Reproduced with permission EL, Sherman S. Pancreas divisum: Clinical manifestations is. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. n July 1, 2018.) Copyright 2018 UpToDate, Inc. For more insit wwwuptodate.com.

Safety and rate of delayed adverse events with lumen-apposing metal stents (LAMS) for pancreatic fluid collections: a multicenter study

Background and study aims  Endoscopic drainage with dedicated lumen-apposing metal stents (LAMS) is routinely performed for symptomatic pancreatic fluid collections (PFCs), walled-off necrosis (WON) and pseudocyst (PP). There has been increasing concern regarding delayed adverse events associated with the indwelling LAMS.  Patients and methods  Multicenter retrospective analysis of consecutive patients who underwent endoscopic ultrasound (EUS)-guided LAMS placement for PFC from January 2010 to May 2017. Main outcomes included: (1) resolution of the PFC, (2) rate of delayed adverse events at follow-up, and (3) predictors of treatment failure and delayed adverse events on logistic regression. Results  A total of 122 patients (mean age 50.9 years, 68 % male) underwent LAMS insertion for 64 WON (98.4 %) and 58 PP (98.3 %). PFC mean size was 10.6 cm. PFC resolution was significantly lower for WON (62.3 %) vs. PP (96.5 %) ( P < 0.001) on imaging at a median of 4 weeks. Stent occlusion was identified in 18 (29.5 %) and 10 (17.5 %) patients with WON and PP, respectively ( P  = 0.13). There were no cases of delayed bleeding or buried stent on follow-up endoscopy. Use of electrocautery-enhanced LAMS was the only factor associated with treatment failure of WON (OR = 13.2; 95 % ci: 3.33 – 51.82, P  = 0.02) on logistic regression. There were no patient, operator, or procedure-related factors predictive of stent occlusion. Conclusions  EUS-guided LAMS for PFC is associated with a low incidence of delayed adverse events. While nearly all PPs resolve at 4 weeks permitting LAMS removal shortly thereafter, many WON persist, with use of electrocautery-enhanced LAMS being the sole predictor of treatment failure.