Bryan L. Balmadrid

Bariatric Embolization for Suppression of the Hunger Hormone Ghrelin in a Porcine Model

PURPOSE To prospectively test in a porcine model the hypothesis that bariatric embolization with commercially available calibrated microspheres can result in substantial suppression of systemic ghrelin levels and affect weight gain over an 8-week period. MATERIALS AND METHODS The institutional animal care and use committee approved this study. Twelve healthy growing swine (mean weight, 38.4 kg; weight range, 30.3-47.0 kg) were evaluated. Bariatric embolization was performed by infusion of 40-μm calibrated microspheres selectively into the gastric arteries that supply the fundus. Six swine underwent bariatric embolization, while six control animals underwent a sham procedure with saline. Weight and fasting plasma ghrelin and glucose levels were obtained in animals at baseline and at weeks 1-8. Statistical testing for differences in serum ghrelin levels and weight at each time point was performed with the Wilcoxon signed rank test for intragroup differences and the Wilcoxon rank sum test for intergroup differences. RESULTS The pattern of change in ghrelin levels over time was significantly different between control and experimental animals. Weekly ghrelin levels were measured in control and experimental animals as a change from baseline ghrelin values. Average postprocedure ghrelin values increased by 328.9 pg/dL ± 129.0 (standard deviation) in control animals and decreased by 537.9 pg/dL ± 209.6 in experimental animals (P = .004). The pattern of change in weight over time was significantly different between control and experimental animals. The average postprocedure weight gain in experimental animals was significantly lower than that in control animals (3.6 kg ± 3.8 vs 9.4 kg ± 2.8, respectively; P = .025). CONCLUSION Bariatric embolization can significantly suppress ghrelin and significantly affect weight gain. Further study is warranted before this technique can be used routinely in humans.

Recent advances in management of acalculous cholecystitis

Acalculous cholecystitis is a life-threatening gallbladder infection that typically affects the critically ill. A late diagnosis can have devastating outcomes because of the high risk of gallbladder perforation if untreated. The diagnosis is not straightforward as Murphy’s sign is difficult to illicit in the critically ill and many imaging findings are either insensitive or non-specific. This article reviews the current imaging literature to improve the interpretation of findings. Management involves a percutaneous cholecystostomy, surgical cholecystectomy, or more recently an endoscopically placed metal stent through the gastrointestinal tract into the gallbladder. This article reviews the current literature assessing the outcomes of each treatment option and suggests a protocol in determining the modality of choice on the basis of patient population. Specifically, endoscopic ultrasound-guided gallbladder drainage is a novel drainage approach for patients who are poor candidates for surgery and obviates the need for a percutaneous drain and all its complications. It has promising results but has caveats in its uses.

Use of the National Institutes of Health Consensus Guidelines Improves the Diagnostic Sensitivity of Gastrointestinal Graft-Versus-Host Disease

CONTEXT - Graft-versus-host disease of the gastrointestinal tract is a common complication of hematopoietic stem cell transplant associated with significant morbidity and mortality. Accurate diagnosis can be difficult and is a truly clinicopathologic endeavor. OBJECTIVES - To assess the diagnostic sensitivity of gastrointestinal graft-versus-host disease using the 2015 National Institutes of Health (NIH) histology consensus guidelines and to analyze histologic findings that support the guidelines. DESIGN - Patients with allogeneic hematopoietic stem cell transplants were identified via a retrospective search of our electronic medical records from January 1, 2005, to January 1, 2011. Endoscopies with available histology were reviewed by 2 pathologists using the 2015 NIH guidelines. The clinical diagnosis was used as the gold standard. A nontransplant set of endoscopic biopsies was used as a control. RESULTS - Of the 250 total endoscopies, 217 (87%) had a clinical diagnosis of gastrointestinal graft-versus-host disease. Use of the NIH consensus guidelines showed a sensitivity of 86% and a specificity of 65%. Thirty-seven of 58 (64%) cases with an initial false-negative histopathologic diagnosis were diagnosed as graft-versus-host disease on our review. CONCLUSIONS - Use of the NIH histology consensus guidelines results in a high sensitivity and specificity, thereby decreasing false-negatives. Additionally, use of the NIH guidelines aids in creating uniformity and diagnostic clarity. Correlation with clinical and laboratory findings is critical in evaluating the differential diagnosis and to avoid false-positives. As expected, increased apoptosis with decreased inflammation was associated with a pathologic diagnosis of graft-versus-host disease and supports the NIH guidelines.

Late Gastrointestinal Complications of Allogeneic Hematopoietic Stem Cell Transplantation in Adults

Gastrointestinal (GI) complications including graft-versus-host disease (GVHD) are a major cause of morbidity and mortality in allogenic stem transplant recipients. Although several studies have previously looked into the acute GI complications, fewer smaller studies have reported late complications. In this large study we focus on the late (100 days post-transplant) GI complications in allogenic stem transplant recipients. In this single-center, retrospective study of all adult allogenic stem cell transplant recipients who had their transplant at Duke University over a 6-year period, 479 patients underwent allogenic stem cell transplant, of whom 392 recipients survived for at least 100 days post-transplant. Late GI symptoms were noted in 71 patients, prompting endoscopic evaluation. The primary endpoint of our study was the diagnosis of GI-GVHD based on endoscopic findings, whereas overall survival and nonrelapse mortality were the secondary endpoints. Of the 71 patients who underwent endoscopy, 45 (63%) had GI-GVHD. Of these 45 patients, 39 (87%) had late acute GVHD, 1 (2%) had chronic GVHD, and 5 patients (11%) had overlap disease. Of the patients who did not have GVHD, the symptoms were mostly related to infectious and inflammatory causes. Less common causes included drug toxicity, food intolerance, disease relapse, and motility issues. In a multivariate analysis the factors most indicative of GI-GVHD were histologic findings of apoptosis on the tissue specimen (odds ratio, 2.35; 95% confidence interval, 1.18 to 4.70; P = .015) and clinical findings of diarrhea (odds ratio, 5.43; 95% confidence interval, 1.25 to 23.54; P = .024). The median survival time from the first endoscopy was 8.5 months. The incidence of nonrelapse mortality at 6 months was 31% in patients with GI-GVHD and 19% in patients without GI-GVHD (P = .42). All patients with GI-GVHD were on steroid therapy, and 31% of them received total parenteral nutrition. In our population close to one-fifth of allogenic transplant recipients experienced late GI complications, warranting endoscopic evaluation. Most of these patients were found to have GI-GVHD that had a high incidence of nonrelapse mortality at 6 months and close to one-third of these patients needed total parenteral nutrition.

895 Endoscopic Mucosal Resection of Duodenal Carcinoid Tumors: A Single Tertiary Care Center Experience

Background and Aims: There is no consensus on the optimal treatment of duodenal carcinoid tumors. Endoscopic mucosalresection (EMR) is considered appropriate for tumors <1cm in size confined to the mucosa/submucosa. In this retrospective study we examine the safety and efficacy of duodenal carcinoid EMRat a single tertiary care center. Methods: All patients with duodenal carcinoids resected via EMR at Duke University Medical Center from 1999 to 2012 were identified. All had pathologic diagnoses and endoscopic ultrasound (EUS), followed by EMR using cap-ligation or standard snare polypectomy. Results: 43 duodenal carcinoids were resected in 40 patients. 91% of tumors were located in the bulb. All tumors were limited to the mucosa or submucosa. Mean tumor size was 7.0mm. 28 tumors were removed using cap-ligation and 15 using snare polypectomy. Two post-procedure GI bleeds and two perforations occurred (one managed endoscopically, one managed surgically). 17 (40%) resected tumors had positive margins. 13 cases were lost to follow-up. Of the other 27 patients, 3 went on to surgical resection (all had positive margins at EMR). Mean follow-up time was 28.3 months. Three patients had local recurrence (2/3 had positive margins on initial resection), and three had lymph node metastases (all had positive margins on initial resection). Conclusion: This is the largest single center study of its kind. Endoscopic resection of duodenal carcinoids should be considered prior to surgical resection after EUS evaluation to exclude muscularis propria involvement and lymph node spread. The significance of positive margins requires further study. Careful follow-up is necessary.