Christopher D. Wells

Circumferential and Focal Ablation of Barrett's Esophagus Containing Dysplasia

OBJECTIVES:Dysplasia in a Barretts esophagus (BE) is associated with an increased risk for developing esophageal adenocarcinoma. Ablation using the HALO system has shown promise for the treatment of BE with dysplasia. The objective of this study was to assess the safety and efficacy of a stepwise regimen of circumferential and focal ablation using the HALO system for the treatment of BE with dysplasia.METHODS:BE patients with low-grade dysplasia (LGD) or high-grade dysplasia (HGD) were enrolled. Primary circumferential ablation was followed every 3 months by further circumferential ablation or focal ablation until complete endoscopic eradication of BE was achieved. At 3- or 6-month intervals, depending on baseline grade, targeted and four quadrant random biopsies were obtained to assess the histological response to ablation. A complete response (CR) is defined as all biopsies negative for intestinal metaplasia (IM) (CR-IM) or dysplasia (CR-D) at last available follow-up.RESULTS:A total of 63 patients were treated (57 men; median age 71 years; median BE length 5 cm), with worst grade of dysplasia being LGD (n=39) and HGD (n=24). Follow-up is available for 62 patients (median 24 months). Overall, CR-IM is 79% and CR-D is 89%. For the LGD cohort, CR-IM is 87% and CR-D is 95%. For the HGD cohort, CR-IM is 67% and CR-D is 79%.CONCLUSIONS:Stepwise circumferential and focal ablation of BE containing dysplasia appears to be a safe and effective intervention, achieving a CR for dysplasia in 95% and 79% of LGD and HGD patients, respectively.

Treatment of gastric antral vascular ectasia (watermelon stomach) with endoscopic band ligation

BACKGROUND Gastric antral vascular ectasia (GAVE) is characterized by mucosal and submucosal vascular ectasia causing recurrent GI hemorrhage. Treatment of GAVE with endoscopic thermal therapy (ETT) requires multiple sessions for destruction of vascular ectasia and control of bleeding. Endoscopic band ligation (EBL) has become the standard treatment of varices because it effectively obliterates the submucosal plexus of esophageal varices with an acceptably low rate of complications. Additionally, EBL has been used for control of bleeding from other GI vascular lesions. In patients with GAVE and recurrent GI hemorrhage, EBL may offer an alternative to ETT for treatment of large areas of diseased mucosa and submucosa. OBJECTIVE Our purpose was to compare EBL (n = 9) with ETT (n = 13) for the treatment of bleeding from GAVE. DESIGN Observational comparative study. PATIENTS Patients with gastric antral vascular ectasia with occult or overt bleeding. SETTING Mayo Clinic Arizona, a multispecialty academic medical center. INTERVENTION EBL or ETT with argon plasma coagulation or electrocautery. MAIN OUTCOME AND MEASUREMENTS Number of treatments to cessation of bleeding and posttreatment hemoglobin, hospitalization, and transfusion requirement. RESULTS There were no significant differences in the demographics, clinical presentation, associated portal hypertension, or mean hemoglobin values or the mean number of transfusions or hospitalizations between the 2 groups before treatment. Four patients in the EBL group had failed prior ETT. Compared with ETT, in exploratory statistical testing EBL had a significantly higher rate of bleeding cessation (67% vs 23%, P = .04), fewer treatment sessions required for cessation of bleeding (1.9 vs 4.7, P = .05), a greater increase in hemoglobin values (2.8 g/dL vs 0.9 g/dL, P = .05), a greater decrease in transfusion requirements (-12.7 vs -5.2, P = .02), and a greater decrease in hospital admissions (-2.6 vs -0.5, P = .02) during the follow-up period. Analysis of covariance showed significantly superior efficacy of EBL for cessation of bleeding, postprocedure transfusion, and hospitalization. One patient in the EBL group had postprocedure emesis and 1 in the ETT group had immediate post procedure bleeding. All patients in the EBL group had complete mucosal healing with minimal residual GAVE at follow-up endoscopy failed post-EBL. CONCLUSIONS Our initial experience suggests that EBL is superior to ETT for the management of GAVE. EBL required fewer treatment sessions for control of bleeding, had higher rates for cessation of bleeding, had a reduction in hospitalizations and transfusion requirements, and allowed for a significant increase in hemoglobin values.

Incidental Cystic Neoplasms of Pancreas: What Is the Optimal Interval of Imaging Surveillance?

BACKGROUND:The optimal interval of imaging studies for surveillance of incidental pancreatic cystic neoplasms is not known.OBJECTIVE:A retrospective analysis of longitudinal medical records of patients with pancreatic cystic neoplasms was performed to examine the natural history of incidentally detected cystic pancreatic neoplasms with respect to the development of significant growth and to identify predictors of such growth.RESULTS:After excluding patients with small (<10 mm) cysts (N = 144) and inadequate clinical follow-up of less than 6 months (N = 79) and those with a clinical diagnosis of pancreatic pseudocysts, serous cystadenoma, main duct intraductal papillary mucinous neoplasm (N = 29), and neuroendocrine tumor (N = 3), in total, 166 cysts in 150 patients were available for analysis. The working diagnoses on these cysts (based on clinical, radiological features, aspiration cytology, cyst fluid analysis, and surgical pathology data when available) were mucinous cystic neoplasm in 117 and branch-type intraductal papillary mucinous neoplasm in 49. The mean standard error (SE) initial size of these cysts was 2 (0.1) cm. Over a median period of follow-up of 32 (IQR [inter-quartile range] 19–48) months, 89% of all the cysts did not show significant growth during the follow-up. In a multivariate Cox proportional hazards model, the initial size of the cystic lesion was an independent predictor of significant growth during follow-up (relative risk 1.28, 95% confidence interval [CI] 1.08–1.61, P= 0.01); the only other significant variable was the presence of intracystic or mural nodule (relative risk 38.6, 95% CI 2.3–654, P= 0.01).CONCLUSION:Most incidentally detected cystic neoplasms of the pancreas did not have significant growth during follow-up. Such growth is unlikely to occur before 2 yr of the baseline evaluation, and we suggest that the optimal imaging interval during follow-up of these patients should be at 2 yr from the baseline evaluation, particularly in cystic lesions 3.0 cm or less in size and without intracystic or mural nodules.

An economic analysis of endoscopic ablative therapy for management of nondysplastic Barrett's esophagus.

BACKGROUND AND AIMS Advances have occurred in the development of safe and effective ablative therapies for Barretts esophagus. The aim of the current study was to perform an economic analysis evaluating the cost-effectiveness of endoscopic ablation of nondysplastic Barretts esophagus. METHODS A Markov model evaluated three competing strategies in a hypothetical 50-year-old cohort with nondysplastic Barretts esophagus from a societal perspective. Strategy I -- natural history of Barretts disease (without surveillance); Strategy II -- surveillance performed according to the American College of Gastroenterology practice guidelines; Strategy III -- endoscopic ablative therapy. The model was biased against ablative therapy with a conservative estimate of complete response and continued standard surveillance even after complete ablation. All potential complications were accounted for, and an incomplete histological response after ablation was presumed to have the same risk of progression as untreated Barretts. Transitional probabilities, discounted cost, and utility values to estimate quality-adjusted life-years (QALY) were obtained from published information. Direct costs were used in our analysis. RESULTS In baseline analysis, the ablative strategy yielded the highest QALY and was more cost-effective than endoscopic surveillance. In a Monte Carlo analysis, the relative risk of developing cancer in the strategy based on endoscopic ablation was decreased compared with the other strategies. In threshold analysis, the critical determinants of cost-effectiveness of the ablative strategy were rate of complete response to ablation, total cost of ablation, and risk of progression to dysplasia. CONCLUSIONS Within the limits of the model, ablation for nondysplastic Barretts esophagus is more cost-effective than endoscopic surveillance. Clinical trials of ablative therapy in nondysplastic Barretts esophagus are needed to establish its effectiveness in reducing cancer risk.

Comparison of morning versus afternoon cecal intubation rates

BackgroundMany factors impacting cecal intubation rates have been examined in detail; however, little information exists regarding the effect of the timing of the procedure. We sought to examine any difference in cecal intubation rates between morning and afternoon colonoscopies and identify factors contributing to a discrepancy.MethodsRetrospective, single-center study comparing cecal intubation rates for colonoscopies performed in the morning (begun prior to 12 noon) and colonoscopies performed in the afternoon (begun after 12 noon) over an approximately 12 month period. Univariate and multivariate analyses were performed evaluating patient demographics, procedure indication(s), endoscopist, bowel preparation type and quality, and participation by a gastroenterology fellow.Results6087 colonoscopies were evaluated in this study. Colonoscopies (n = 3729) performed in the morning were compared to colonoscopies performed in the afternoon (n = 2358). The crude completion rate to the cecum was 95.0% in the morning group while the completion rate to the cecum was 93.6% of the afternoon exams (p = 0.02). The morning colonoscopies had better bowel preparation quality (p < 0.001). The multivariate analyses demonstrated that gender, age, and bowel preparation quality impacted completion rates. After correcting for these factors, there was no significant difference in completion rates in the morning versus afternoon.ConclusionUncorrected cecal intubation rates were lower in the afternoon compared to the morning in outpatients undergoing colonoscopy. Bowel preparation quality was worse in the afternoon compared with the morning. Efforts at improving afternoon bowel preparation may improve the outcome of afternoon colonoscopies.

Pyogenic Liver Abscess After Colonoscopy in a Patient With Ulcerative Colitis

3 62-year-old man with a 20-year history of ulcerative colitis in remission sought medical atention for fever, chills, and malaise of 2 weeks’ uration. He had no abdominal pain or hematocheia. Two weeks before the onset of symptoms, he nderwent an uneventful colonoscopy during hich 29 biopsies were performed with cold bipsy forceps for surveillance or polypectomy. here was no significant mucosal inflammation oted during the colonoscopy. At presentation he ad an increased white blood cell count, transamiase levels, and alkaline phosphatase levels. A comuted tomographic scan of the abdomen showed ultiple low-attenuation lesions in the right hepatic obe compatible with liver abscesses (see Figure). rainage of the abscesses yielded Fusobacterium ucleatum. Clinical and radiographic resolution of he abscesses occurred after drainage and intraveous antibiotics. Six cases of pyogenic liver abscess in ulcerative olitis have been reported in the literature and it ppears that liver abscess occurs more frequently in rohn’s disease. Liver abscesses after endoscopic etrograde cholangiopancreatography have been eported and after a colonoscopy in which an imacted fish bone was removed. No prior reports f liver abscess after surveillance colonoscopy in he setting of inflammatory bowel disease or among rocedures in the general population have been dentified. This case highlights the possibility that olonoscopy, with inflammatory bowel disease and ucosal biopsy examination as additional risk facors, may be associated with the development of iver abscess.

Bezoar Formation Requiring Endoscopic Removal After Intentional Overdose of Extended‐Release Nifedipine

A 61‐year‐old Caucasian woman was transported to the emergency department after intentionally ingesting several different prescription drugs. She had been found by her husband in an unconscious state with empty bottles of extended‐release venlafaxine, extended‐release nifedipine, sertraline, and atorvastatin. She was intubated in the emergency department and transferred to the intensive care unit. After 36 hours in the intensive care unit, she was stabilized and brought to a general medical ward. She later developed profound recurrent hypotension with systolic blood pressures ranging from 40–70 mm Hg and diastolic blood pressures of 0–40 mm Hg. She was readmitted to the intensive care unit, where a computed tomography scan revealed a mass in her stomach. A gastroenterology consultation was obtained, and an esophagogastroduodenoscopy (EGD) was performed, during which a large drug bezoar was discovered and removed. The drugs were identified as extended‐release nifedipine with a few granules of extended‐release venlafaxine. Unfortunately, the patient died 3 days after the EGD from multisystem organ failure related to the overdose. Clinicians who encounter drug overdoses should be aware of the possibility of drug bezoar formation and should consider endoscopic removal as a potential treatment option.

Portal hypertension due to a splenic arteriovenous fistula : A case report

We present an unusual case of portal hypertension due to splenic arteriovenous fistula. The patient was a multiparous woman who presented with portal hypertension manifested by variceal bleeding with no evidence of liver disease. Mesenteric angiography confirmed the presence of a 3.5-cm distal splenic artery aneurysm and a high-flow arteriovenous fistulous communication from the aneurysm into the splenic vein. Arteriovenous fistula should be suspected in a patient who presents with portal hypertension but without liver disease, especially in a multiparous woman who presents with variceal bleeding after a delivery. Surgical ligation of the fistula and angiographic embolization has been reported to be equally successful for this condition. Angiographic coil embolization, done in our patient, is a safe alternative to surgery for the treatment of splenic AVF in unstable patients.

Overtubes in Gastrointestinal Endoscopy

Gastrointestinal endoscopy is an evolving field kindled by technologic advances, scientific discoveries, and the innovative minds of endoscopists. The development and subsequent applications of overtubes in gastrointestinal endoscopy mirror this larger evolution. In this article, we review the development, applications, and complications associated with overtubes in gastrointestinal endoscopy.

Barrett’s esophagus following treatment of achalasia with botulinum toxin

Achalasia is an uncommon primary motor disorder of the esophagus with an annual incidence of 0.8/100,000. Very few cases of coexistent Barrett’s esophagus (BE) and achalasia in patients without prior surgical myotomy or pneumatic dilation have been reported. We report the case of a 65 year old female who was diagnosed with achalasia in June 2002. Endoscopy at that time revealed biopsy-confirmed normal esophageal mucosa. The patient subsequently underwent two trials of botox injection with progressively worsening dysphagia. A repeat endoscopy two years later showed a short segment of salmon-colored mucosa in the distal esophagus which was biopsy-confirmed Barrett’s epithelium with no dysplasia. The patient eventually underwent laparoscopic Heller myotomy and Toupet fundoplication. Postoperatively, she recovered well and with significant alleviation of her dysphagia. This study reviews reported cases of coexistent achalasia and BE, and discusses possible etiologies of concurrent BE and achalasia, and implications for treatment.