Craig S. Brown

Functional longevity of intraperitoneal drains

Various types of drains were inserted into the peritoneal cavity of twenty-eight dogs. After one to seven days, all drains failed to show the presence of 200 cc of colored fluid injected intraperitoneally. On autopsy, all tubes were surrounded and occluded by omentum.

Predicting Progression in Barrettʼs Esophagus: Development and Validation of the Barrettʼs Esophagus Assessment of Risk Score (BEAR Score)

Objective: To develop and validate a scoring tool capable of accurately predicting which patients with Barretts esophagus (BE) will progress to dysplasia and/or esophageal adenocarcinoma. Background: Endoscopic therapies have emerged capable of eradicating BE with high efficacy and low complication rates, but which patients should receive treatment is still debated. Current knowledge of risk factors is insufficient to allow for the accurate prediction of which patients will progress to dysplasia or adenocarcinoma. Methods: We retrospectively collected data from a cohort of BE patients over a 13-year period. A multivariable logistic regression model was constructed to predict progression. A simplified risk of progression (ROP) score was developed from weighted beta coefficients. Internal validation was performed using bootstrap analysis, and model discrimination was assessed using k-fold cross-validation. Results: The cohort included 2591 BE patients of which 133 progressed to dysplasia/adenocarcinoma. Multivariable analysis with bootstrap internal validation resulted in 5 variables associated with an increased ROP (age ≥70 years, male sex, lack of proton-pump inhibitor use, segment greater than 3 cm, and history of esophageal candidiasis). Using this model, we developed a simple ROP score between 0 and 8. Receiver operating characteristic analysis showed a cutoff of 3 or higher to have a sensitivity and specificity of 70% and 79%, respectively. Patients with a score of 3 or higher had an odds ratio of 9.04 (95% confidence interval 6.06–13.46). The c-statistic obtained from 10-fold cross-validation was 0.76 (95% confidence interval 0.72–0.79), indicating good overall discrimination. Conclusions: Our data show the development and internal validation of the Barretts Esophagus Assessment of Risk Score as capable of quantifying the likelihood of progression to dysplasia/adenocarcinoma. The Barretts Esophagus Assessment of Risk Score can be used clinically to guide treatment decisions in nondysplastic BE patients.

Risk factors affecting the Barrett's metaplasia-dysplasia-neoplasia sequence.

Esophageal adenocarcinoma has the fastest growing incidence rate of any cancer in the United States, and currently carries a very poor prognosis with 5 years relative survival rates of less than 15%. Current curative treatment options are limited to esophagectomy, a procedure that suffers from high complication rates and high mortality rates. Metaplasia of the esophageal epithelium, a condition known as Barretts esophagus (BE), is widely accepted as the precursor lesion for adenocarcinoma of the esophagus. Recently, radio-frequency ablation has been shown to be an effective method to treat BE, although there is disagreement as to whether radio-frequency ablation should be used to treat all patients with BE or whether treatment should be reserved for those at high risk for progressing to esophageal adenocarcinoma while continuing to endoscopically survey those with low risk. Recent research has been targeted towards identifying those at greater risk for progression to esophageal adenocarcinoma so that radio-frequency ablation therapy can be used in a more targeted manner, decreasing the total health care cost as well as improving patient outcomes. This review discusses the current state of the literature regarding risk factors for progression from BE through dysplasia to esophageal adenocarcinoma, as well as the current need for an integrated scoring tool or risk stratification system capable of differentiating those patients at highest risk of progression in order to target these endoluminal therapies.

231 Reflux Control Is an Important Component of the Management of Barrett's Esophagus – Results From a Retrospective Cohort of 1834 Patients

Introduction: Barretts esophagus (BE) is the most predictive risk factor for development of esophageal adenocarcinoma, a malignancy with the fastest increasing incidence rate in the US. Based on the assumption that all patients progress through low-grade dysplasia (LGD) to high-grade dysplasia (HGD) and finally to esophageal adenocarcinoma (EAC), we were interested in studying factors that may affect the rate of progression to LGD or greater. We were particularly interested in investigating the question of whether control of reflux, either surgically or medically, protects patients from progression to dysplastic disease or adenocarcinoma. Methods: We retrospectively collected and analyzed data from a cohort of BE patients participating in this single-center study comprised of all patients diagnosed with BE at a single health systems hospitals and clinics over a 10 year period. Patients were followed in order to identify those progressing from BE to LGD, HGD, and EAC. Mean follow up period was 5.4 years (9903 patient-years). We collected information from the patients electronic medical records regarding demographic data, endoscopic findings, histological findings, smoking and alcohol history, medication use including PPIs, and history of bariatric and antireflux surgery. Risk adjusted model was performed using multivariable logistic regression in SAS 9.3 (Cary, NC). Results: This study included 1834 total BE patients, 105 of which had their BE progress to LGD, HGD, or EAC (confirmed by biopsy) with an annual incidence rate of 1.1%. Compared to the group that did not progress, the group that progressed was older (63.8±13.5 vs. 68.8±13.1. p<.001) and likely to be male (61% vs. 69%, p=0.098). In the multivariable analysis, patients who had a history of antireflux surgery (n=44) or PPI use without surgery (n=1708) were found to progress at lower rates than patients who did not have antireflux surgery or were not taking PPIs (OR=0.23, 95% CI 0.12-0.42). Conclusions: In patients with BE without dysplasia, reflux control was associated with decreased risk of progression to LGD, HGD, or EAC. The results support the use of reflux control strategies such as PPI therapy or surgery in patients with non-dysplastic BE.

Improved technic for long-term venous catheterization

Abstract A technic for subclavian catheterization is described which minimizes motion at the catheterskin junction using a readily available catheter of the proper length for an average-sized adult.