Cuong C. Nguyen

Endoscopic treatment of anastomotic biliary strictures after living donor liver transplantation: outcomes after maximal stent therapy

BACKGROUNDnThe optimal endoscopic treatment for anastomotic biliary strictures after deceased donor liver transplantation is undefined. Endoscopic therapy with conventional methods of biliary dilation and stent placement has been successful but often requires prolonged therapy.nnnOBJECTIVEnTo determine the outcomes of an aggressive endoscopic approach that uses endoscopic dilation followed by maximal stent placement.nnnSETTINGnTertiary-care academic medical center.nnnPATIENTSnOf 176 patients who underwent deceased donor liver transplantation between June 1999 and July 2004, 25 were diagnosed with anastomotic biliary strictures.nnnINTERVENTIONSnPatients were treated endoscopically with a combined technique of balloon dilation and maximal stent placement.nnnMAIN OUTCOME MEASUREMENTSnTreatment outcomes, including bile-duct patency, a need for surgical intervention, morbidity, and mortality, were evaluated retrospectively.nnnRESULTSnEndoscopic dilation followed by maximal stent placement was performed until resolution of strictures in 22 of 25 patients (88% immediate success on intent-to-treat analysis). Persistent resolution of strictures was achieved in 18 of these 22 patients. Re-treatment was successful in 2 of 4 patients with recurrent strictures. Overall, 20 of 22 patients who completed endoscopic therapy (91%) avoided surgical intervention. Median duration of endoscopic treatment was 4.6 months. Patients with early onset strictures required a significantly shorter duration of endoscopic therapy (3 vs 9 months; P<.01). Multiple stent placement was not technically difficult, and no major complications were encountered.nnnCONCLUSIONSnAggressive endoscopic therapy with combined biliary dilation and maximal stent placement allows resolution of anastomotic biliary strictures after deceased donor liver transplantation in a relatively short period, with sustained success and minimal complications.

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 5u2009cm), 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.

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.

Esophageal perforation as a complication of esophagogastroduodenoscopy.

Fifty years ago, esophageal perforation was common after rigid upper endoscopy. The arrival of flexible endoscopic instruments and refinement in technique have decreased its incidence; however, esophageal perforation remains an important cause of morbidity and mortality. This complication merits a high index of clinical suspicion to prevent sequelae of mediastinitis and fulminant sepsis. Although the risk of perforation with esophagogastroduodenoscopy alone is only 0.03%, this risk can increase to 17% with therapeutic interventions in the setting of underlying esophageal and systemic diseases. A wide spectrum of management options exist, ranging from conservative treatment to surgical intervention. Prompt recognition and management, within 24 hours of perforation, is critical for favorable outcomes.

Subcutaneous metastasis at a surgical drain site after the resection of pancreatic cancer

The aggressive nature of pancreatic cancer makes surgical control of disease an arduous challenge. Tumor seeding during resection is a feared complication during operations performed for this disease. Recurrence within the peritoneal cavity commonly occurs after resection for curative intent. Cutaneous metastasis, however, is a rare event. The majority of skin metastasis reported in the literature occurred after palliative procedures, in which the tumor burden remains. In this report, we describe an unusual case of cutaneous recurrence at the site of a surgical drain after resection for curative intent and discuss the impact of surgery on tumor-growth characteristics.

Digital Image Analysis Is a Useful Adjunct to Endoscopic Ultrasonographic Diagnosis of Subepithelial Lesions of the Gastrointestinal Tract

Objective. The purpose of this study was to explore the role of digital image analysis in differentiating endoscopic ultrasonographic (EUS) features of potentially malignant gastrointestinal subepithelial lesions (SELs) from those of benign lesions. Methods. Forty‐six patients with histopathologically confirmed gastrointestinal stromal tumors (GISTs), carcinoids, and lipomas who had undergone EUS evaluation were identified from our database. Representative regions of interest (ROIs) were selected from the EUS images, and features were extracted by texture analysis. On the basis of these features, an artificial neural network (ANN) was built, trained, and internally validated by unsupervised learning followed by supervised learning. Outcomes were the performance characteristics of the ANN. Results. A total of 106, 111, and 124 ROIs were selected from EUS images of 8, 10, and 28 patients with lipomas, carcinoids, and GISTs, respectively. For each ROI, 228 statistical parameters were extracted and later reduced to the 11 most informative features by principal component analysis. After training with 50% of the data, the remainder of the data were used to validate the ANN. The model was “good” in differentiating carcinoids and GISTs, with area under the receiver operating characteristic curve (AUC) values of 0.86 and 0.89, respectively. The model was “excellent” in identifying lipomas correctly, with an AUC of 0.92. Conclusions. Digital image analysis of EUS images is a useful noninvasive adjunct to EUS evaluation of SELs.

The Natural History of a Branch Duct Intraductal Papillary Mucinous Neoplasm in a Patient with Lady Windermere Syndrome: A Case Report

CONTEXTnLow-risk branch duct intraductal papillary mucinous neoplasm (IPMN) is defined as pancreatic epithelial cellular proliferation of small branch ducts that lack malignant characteristics. At present, our understanding of the natural history of low-risk branch duct IPMN is still evolving. Lady Windermere syndrome is a disorder seen in non-smoking women with no pre-existing pulmonary disease affecting the lingula and/or right middle lobe with Mycobacterium avium-intracellulare complex. We present a case with pancreatic adenocarcinoma after a six-year surveillance of low-risk branch duct IPMN in an asymptomatic elderly white woman with Lady Windermere syndrome.nnnCASE REPORTnA 79-year-old woman was referred to our institution because of pancreatic cystic abnormalities and elevated carbohydrate antigen 19-9 (CA 19-9). While at our institution, she was also diagnosed with Lady Windermere syndrome. Multiple abdominal imaging studies, endoscopic retrograde cholangiopancreatography, computer tomography, and magnetic resonance cholangiopancreatography (MRCP) were performed in the ensuing 6 years, all consistent with low-risk branch duct IPMN. No progression was seen until year 6 when MRCP showed a 2 cm pancreatic cancer. Because of multiple comorbidities, the patient chose chemotherapy over a pancreaticoduodenectomy. She developed respiratory failure and died after one cycle of gemcitabine.nnnCONCLUSIONSnLow-risk branch duct IPMN may be a heterogeneous disease in which some cases can transform into malignant pancreatic neoplasms despite the absence of the so-called high risk features on imaging studies. Clinical management, therefore, requires individualized flexibility. In addition, when there is coexistence of Lady Windermere syndrome and pancreatic cancer, prompt diagnosis and treatment of Lady Windermere syndrome should be considered prior to chemoradiotherapy or surgery.

Prospective study of the feasibility of point-of-care testing strategy for carbapenem-resistant organism detection

Background/aims u2002In an investigator-initiated, prospective study, we evaluated the feasibility of a five-gene sequence point-of-care (POC) testing strategy (Xpert CARBA-R Assay, Cepheid Inc., Sunnyvale, CA, USA), compared to reference laboratory PCR (48u200a–u200a72 hours turnaround time, two gene sequences), in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and in a hospital outbreak investigation. Methods u2002After informed consent, patients undergoing ERCP (September 2015 – April 2016, nu200a=u200a191) at Mayo Clinic and potential hospital contacts (nu200a=u200a9) of an index carbapenem-resistant organism (CRO)-positive inpatient were included. Two rectal swabs, one each for reference and POC assays were obtained. The Xpert CARBA-R Assay enables qualitative rapid detection of five beta-lactamase gene sequences associated with carbapenem-non-susceptibility in Gram-negative bacteria. Feasibility parameters (specimen processing and assay run time, ease of use) and percent agreement between the tests were calculated using JMP Pro11 (SAS Corp, Cary, NC, USA). Results u2002Mean age was 62u200a±u200a15 years; 108 (54u200a%) were male. Both tests were successfully performed in all patients. The POC test was rated by endoscopy nurses as easy/very easy to conduct in 193 patients (97u200a%); median assay run time and median time for specimen collection and processing were 55 minutes (interquartile range IQR: 53u200a–u200a55 minutes) and 3 minutes (IQR: 3u200a–u200a6 minutes), respectively. In 200/201 (99.5u200a%) tests, there was agreement between the POC and reference PCR. Conclusions u2002The more comprehensive POC CRO testing of patients in the endoscopy suite is feasible and results are available in <u200a1 hour. This strategy may enable rapid risk stratification of duodenoscope exposure to CRO and potentially improve operational efficiency and decrease costs.

Multimodality imaging of esophageal perforation by a wire bristle

Complete extra-esophageal migration of a foreign object is rare. Its early and accurate diagnosis by complementary imaging modalities is crucial for a successful extraction. We present a case of ingested wire bristle, which completely traversed the esophageal mucosa to position itself in the soft tissue of the left neck adjacent to the internal carotid artery. We discuss the importance of imaging in the detection of migrating foreign bodies, and raise awareness of this serious complication.

Gastrointestinal cancer staging by endoscopic ultrasound: Esophagus and gastric

Endoscopic ultrasound (EUS) is the latest major innovation in gastrointestinal endoscopy. The coupling of ultrasound with endoscopy allows visualization of the gastrointestinal mucosa and adjacent structures in such exquisite details heretofore unavailable with any other imaging modalities. EUS has made major impact on the practice of digestive diseases, particularly in the evaluation of esophageal and gastric cancer. EUS is now universally accepted as the imaging modality of choice for precise local-regional staging of these 2 malignancies. The application of EUS in esophageal and gastric cancer are described.