Daniel E. Polter

Neoadjuvant chemotherapy and liver transplantation for hepatocellular carcinoma: A pilot study in 20 patients

BACKGROUND Liver transplantation for unresectable hepatocellular carcinoma yields disappointing results. Most cases recur within 2 years, often in the transplanted liver. METHODS A combination of neoadjuvant doxorubicin and orthotopic liver transplantation was used in 20 patients with unresectable hepatocellular carcinoma confined to the liver. Seventeen patients had tumors > 5 cm in greatest diameter, and 11 cases were stage IVA by the TNM classification. Doxorubicin was administered preoperatively, intraoperatively, and postoperatively at a dose of 10 mg/m2 weekly, totaling 200 mg/m2. RESULTS Chemotherapy was well tolerated although leukopenia was observed in 70% of patients. Eight patients died, five of recurrent tumor and three of hepatitis B. Three others remain alive 8-22 months after tumor recurrence. One patient had initial tumor recurrence in the allograft. Actuarial survival is 59% and tumor-free survival is 54% at 3 years. For the 17 patients with tumors > 5 cm, overall survival is 63% and tumor-free survival is 49% at 3 years. CONCLUSION The results of this pilot study suggest that neoadjuvant doxorubicin chemotherapy favorably alters the post-transplant survival of patients with hepatocellular carcinoma.

Impact of experience with a retrograde-viewing device on adenoma detection rates and withdrawal times during colonoscopy: the Third Eye Retroscope study group

BACKGROUND Colonoscopy has been adopted as the preferred method to screen for colorectal neoplasia in the United States. However, lesions can be missed because of numerous factors, including location on the proximal aspect of folds or flexures, where they may be difficult to detect with the forward-viewing colonoscope. The Third Eye Retroscope (TER) is a disposable device that is passed through the instrument channel of a standard colonoscope to provide a retrograde view that complements the forward view of the colonoscope during withdrawal. OBJECTIVE To evaluate whether experience with the TER affects polyp detection rates and procedure times in experienced endoscopists who had not previously used the equipment. DESIGN, SETTING, PATIENTS This was an open-label, prospective, multicenter study at 9 U.S. sites, involving 298 patients presenting for colonoscopy, evaluating the use of the TER in combination with a standard colonoscope. INTERVENTIONS After cecal intubation, the TER was inserted through the instrument channel of the colonoscope. During withdrawal, the forward and retrograde video images were observed simultaneously on a wide-screen monitor. MAIN OUTCOME MEASUREMENTS Primary outcome measures were the number and size of adenomas and all polyps detected with the standard colonoscope and with the colonoscope combined with the TER. Secondary outcome measures were withdrawal phase time and total procedure time. Each endoscopist examined 20 subjects, divided into quartiles according to the order of their procedures, and results were compared among quartiles. RESULTS Overall, 182 polyps were detected with the colonoscope and 27 additional polyps with the TER, a 14.8% increase (P < .001). A total of 100 adenomas were detected with the colonoscope and 16 more with the TER, a 16.0% increase (P < .001). For procedures performed after each endoscopist had completed 15 procedures while using the TER, the mean additional detection rates with the TER were 17.0% for all polyps (P < .001) and 25.0% for adenomas (P < .001). For lesions 6 mm or larger, the overall additional detection rates with the TER for all polyps and for adenomas were 23.2% and 24.3%, respectively. For lesions 10 mm or larger, the overall additional detection rates with the TER for all polyps and for adenomas were 22.6% and 19.0%, respectively. The mean withdrawal times in the first and fourth quartiles were 10.6 and 9.2 minutes, respectively (P = .044). LIMITATIONS There was no randomization or separate control group. The endoscopists judged whether each lesion could have been detected with the colonscope alone by using their standard technique. CONCLUSIONS Polyp detection rates improved significantly with the TER, especially after 15 procedures, when the mean additional detection rate for adenomas was 25.0%. Additional detection rates with the TER for medium-size and large adenomas were greater than for smaller lesions. These results suggest that, compared with a colonoscope alone, a retrograde-viewing device can increase detection rates for clinically significant adenomas without detriment to procedure time or procedure complications. ( CLINICAL TRIAL REGISTRATION NUMBER NCT00969124.).

Anaerobic Bacteria as Cause of the Blind Loop Syndrome: A case report with observations on response to antibacterial agents

Summary A patient with malabsorption due to the blind loop syndrome was studied with quantitative aerobic and anaerobic cultures of afferent loop material and feces while he was exposed to a variety of antibacterial agents. Abnormalities in absorption of vitamin B 12 and fat chiefly paralleled the presence of large numbers of anaerobes, especially Bacteroides, in the afferent loop. We suggest that anaerobic bacteria, particularly Gram-negative anaerobic bacilli, may be important in the pathogenesis of the blind loop syndrome, at least in some patients. We feel that bacteriological studies of patients with this syndrome should be done quantitatively and that techniques appropriate for recovery of fastidious anaerobes should be included.

Preliminary experience with hydrostatic balloon dilation of gastric outlet obstruction

In treating a group of 15 patients with gastric outlet obstruction, 12 (80%) had good to excellent relief of symptoms. Two patients required surgical intervention. One patient has symptoms that were persistent but mild enough to forego surgery. Balloon dilation offers an alternative to the surgical management of gastric outlet obstruction.

Neoadjuvant chemotherapy and orthotopic liver transplantation for hepatocellular carcinoma

From 1987 to 1992, 27 patients with unresectable hepatocellular carcinoma were included in a neoadjuvant chemotherapy study prior to undergoing orthotopic liver transplantation. The results are reported. Other studies of patients involving orthotopic liver transplantation are reviewed.

Olmesartan-Associated Enteropathy

Olmesartan, an angiotensin-receptor blocker frequently prescribed for hypertension, has been commercially available since 2002. In 2012, olmesartan-associated enteropathy was described, and the Food and Drug Administration now requires a black-box warning for olmesartan regarding severe diarrhea. The disorder can be life-threatening and often requires hospitalization. We present three cases that represent different aspects of this disorder, as well as some unusual features.

S1133 Effectiveness of Third Eye Retroscope in Detection of Colonic Adenomas in Elderly Patients (> 65 Years)

Background: Colonoscopy is considered to be the standard of care for the diagnosis of colorectal cancer. However, population-based studies have reported a subset of patients with cancer who do not undergo colonoscopy. The purpose of this study was to estimate the prevalence and identify the predictors of not having a colonoscopy in the period preceding colorectal cancer diagnosis. Methods: Using the population-based SEER registries, we identified patients aged >= 69 with colorectal cancer diagnosed from 1994-2005. Linked inpatient and outpatientMedicare claimswere used to identify receipt of colonoscopy prior to diagnosis. We divided this group into patients who had did not have colonoscopy within 3 years of diagnosis (Group I) and those who had 1 or more colonoscopies from 6 months prior to 30 days after diagnosis (Group II). Patient, sociodemographic and tumor factors were used to identify predictors of not having colonoscopy in univariate and multivariable logistic regression analysis. Results: We identified 79,032 patients, including 19.6% in Group I and 80.4% in Group II. Among patients in Group I, 31.6% had barium enema, 21.4% had flexible sigmoidoscopy and 57.3% underwent CT scan within 6 months prior to and 30 days after diagnosis. Independent predictors of Group I included age > 85, African American race, non-married, nursing home residence, rural residence, lower comorbidity score, diagnosis before 2000, AJCC Stage II-IV, left sided or rectal tumor site, and emergency presentation. Patients without colonoscopy were also less likely to undergo surgical resection (OR 0.55, CI 0.52-0.59). In a Cox proportional hazards model that adjusted for demographics, stage and treatment, not undergoing colonoscopy was associated with a higher risk of death (HR 1.31, CI 1.28-1.33). Conclusions: In this large, population based analysis, almost 20% of newly diagnosed colorectal cancer patients did not undergo colonoscopy at the time of diagnosis. Although these patients were more likely to be elderly with advanced disease, lack of colonoscopy appears to be an indicator of emergency presentation, less aggressive treatment and poorer prognosis.

Colocutaneous fistula after a PEG.

A 69-year-old manwith a history of traumatic brain injury had a PEG tube placed at the time of surgery for the injury; this tube was to be used to administer medications and nutrition.Twoweekslater,hewasnotedtohaveliquid,nonbloody diarrhea and weight loss. Stool studies showed no infectious etiology. A colonoscopy revealed the PEG button withinthedistaltransversecolon(A).AtthetimeofthePEG placement,thebutton hadbeenconfirmedtobewithinthe stomach. The patient underwent surgical repair of the fistula and replacement of the PEG, with immediate resolution of the diarrhea. DISCLOSURE