Emir Charles Roach

Endoscopic clips for the closure of acute iatrogenic perforations: Where do we stand?

Iatrogenic perforation of the gut during endoscopy remains an uncommon but critical complication with significant morbidity and probable mortality than usual surgical treatment. Some authors have adopted a non‐surgical closure method in chosen cases and, since 1993, endoclips have been used to close perforation in the stomach. The endoscopic practice of endoclips has been commonly used in the gut for hemostasis. Currently, the use of endoscopic techniques is increasing for the closure of endoscopic submucosal dissection or endoscopic mucosal resection. Endoscopic perforations that improved with endoscopic closure in the literature prior to 2008 have been previously described. In the present article, we present a descriptive review of cases with iatrogenic perforation in the gut treated with endoclips between 2008 and 2014.

Pulmonary arterial hypertension treatment with carvedilol for heart failure: a randomized controlled trial

BACKGROUND Right-sided heart failure is the leading cause of death in pulmonary arterial hypertension (PAH). Similar to left heart failure, sympathetic overactivation and β-adrenoreceptor (βAR) abnormalities are found in PAH. Based on successful therapy of left heart failure with β-blockade, the safety and benefits of the nonselective β-blocker/vasodilator carvedilol were evaluated in PAH. METHODS PAH Treatment with Carvedilol for Heart Failure (PAHTCH) is a single-center, double-blind, randomized, controlled trial. Following 1-week run-in, 30 participants were randomized to 1 of 3 arms for 24 weeks: placebo, low-fixed-dose, or dose-escalating carvedilol. Outcomes included clinical measures and mechanistic biomarkers. RESULTS Decreases in heart rate and blood pressure with carvedilol were well tolerated; heart rate correlated with carvedilol dose. Carvedilol-treated groups had no decrease in exercise capacity measured by 6-minute walk, but had lower heart rates at peak and after exercise, and faster heart rate recovery. Dose-escalating carvedilol was associated with reduction in right ventricular (RV) glycolytic rate and increase in βAR levels. There was no evidence of RV functional deterioration; rather, cardiac output was maintained. CONCLUSIONS Carvedilol is likely safe in PAH over 6 months of therapy and has clinical and mechanistic benefits associated with improved outcomes. The data provide support for longer and larger studies to establish guidelines for use of β-blockers in PAH. TRIAL REGISTRATION ClinicalTrials.gov NCT01586156FUNDING. This project was supported by NIH R01HL115008 and R01HL60917 and in part by the National Center for Advancing Translational Sciences, UL1TR000439.

Hemobilia as a result of right hepatic artery pseudoaneurysm rupture: An unusual complication of laparoscopic cholecystectomy

INTRODUCTION Laparoscopic cholecystectomy has many complications which may be seen due to anatomical variations, lack of experience of the surgeon or three dimensional visualization, or insufficient exposure of the surgical field; including vascular injuries. Here we present a case of pseudoaneurysm of the right hepatic artery leading to hemobilia after rupturing into the biliary system. PRESENTATION OF CASE A 43-year-old male patient presented to our clinic 3 weeks post laparoscopic cholecystectomy with right upper quadrant pain, melena and hematemesis. After stabilizing the patient, Doppler ultrasonography, abdominal computer tomography and selective right hepatic artery angiography were performed and a pseudoaneurysm was established on the anterior posterior bifurcation of right hepatic artery. Right hepatic artery ligation and a T-tube placement after choledocotomy were performed. The patient recovered completely. DISCUSSION Pseudoaneurysms of the hepatic artery may arise as a complication of laparoscopic cholecystectomy. Clip encroachments, mechanical or thermal injury during the procedure are likely to be precipitating factors. Today, transarterial embolization (TAE) is the gold standard for the management of hemobilia, and if it fails, the next step in management is surgical. Surgery is limited to extra-hepatic or gallbladder bleeding, and for TAE failure. CONCLUSION In cases of GI bleeding the awareness of the surgeon should be drawn to a clinical suspicion of hemobilia and an underlying hepatic artery pseudoaneurysm that can arise as a complication. CT angiography should be performed for early diagnosis and management in such patients.

Impaired right ventricular-pulmonary vascular function in myeloproliferative neoplasms

BACKGROUND Increased bone marrow hemangioblast numbers, alterations in erythroid/myeloid lineages, increased reticulin, and greater circulating bone marrow progenitor cells are present in patients with pulmonary arterial hypertension (PAH). The data suggest that myeloid progenitors contribute to the pathogenesis of PAH, but there are little data on the prevalence of pulmonary vascular disease among the different forms of myeloid diseases. We hypothesized that there would be a higher prevalence of pulmonary vascular disease in myeloproliferative neoplasms that have high circulating progenitor cells, such as myelofibrosis and chronic myelogenous leukemia (CML), compared with those with low circulating progenitors, such as in aplastic anemia. METHODS Patients with myelofibrosis, CML, and aplastic anemia who underwent echocardiographic evaluation of cardiac function in preparation for bone marrow transplantation at the Cleveland Clinic between 1997 and 2012 were identified and their electronic medical records were queried for demographic data, blood cell counts, and pulmonary function tests. All echocardiograms were uniformly analyzed in a blinded fashion by an advanced sonographer and cardiologist for measures of right and left ventricular function and estimation of pulmonary vascular disease. RESULTS Gender and race distribution among disease groups was similar. Patients with myelofibrosis (n = 19) and aplastic anemia (n = 30) had increased right ventricle (RV) wall thickness compared with CML (n = 82) patients (aplastic anemia, 0.7 ± 0.1; CML, 0.5 ± 0.1; and myelofibrosis, 0.7 ± 0.1; p = 0.02). Patients with myelofibrosis had higher levels of estimated RV systolic pressure compared with the other groups (aplastic anemia, 29.9 ± 1.5; CML, 26.2 ± 1.1; and myelofibrosis, 36.7 ± 3.7 mm Hg; p < 0.01). CONCLUSIONS The findings suggest an important role for myeloid progenitors in the maintenance of pulmonary-vascular health, in which abnormal myeloproliferative progenitors are associated with RV pathology.

Metabolic and functional evaluation of the heart and lungs in pulmonary hypertension by gated 2-[18F]-Fluoro-2-deoxy-D-glucose positron emission tomography

Pulmonary hypertension (PH) is associated with a metabolic shift towards glycolysis in both the right ventricle and lung. This results in increased glucose uptake to compensate for the lower energy yield of glycolysis, which creates a potential for 2-[18F] fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) to be a useful tool in the evaluation of participants with PH. We investigated the utility of PET for PH by comparing FDG-PET uptake in the right ventricle and lungs in 30 participants with PH and eight healthy controls and correlating these measurements with echocardiographic (ECHO) measurements and other traditional assessments commonly used in PH. All participants underwent gated FDG-PET scanning in the fasting state, ECHO, six-minute walk test (6MWT), and blood draw for NT-proBNP. Participants also completed the CAMPHOR questionnaire. Right ventricular (RV) end-diastolic and end-systolic volumes, RV ejection fraction, and FDG uptake by PET were significantly different between PH and healthy controls and strongly correlated with plasma NT-proBNP levels and RV ECHO parameters including TAPSE, RV systolic pressure, Tei index, and global peak systolic strain. In addition, lung standardized uptake value (SUV) was also found to be significantly higher in participants with PH than healthy controls. However, lung SUV did not show any significant correlations with NT-proBNP levels, 6MWT, or functional and pressure measurements by ECHO. In this study, we demonstrated the ability to evaluate both lung and right heart metabolism and function in PH by using a single gated FDG-PET scan.

Air leak syndrome after endoscopic retrograde cholangiopancreatography: A rare and fatal complication

Endoscopic retrograde cholangiopancreatography (ERCP) is a state of the art diagnostic and therapeutic procedure for various pancreatic and biliary problems. In spite of the well-established safety of the procedure, there is still a risk of complications such as pancreatitis, cholangitis, bleeding and perforation. Air leak syndrome has rarely been reported in association with ERCP and the optimal management of this serious condition can be difficult to establish. Our group successfully managed a case of air leak syndrome following ERCP which was caused by a 3cm Stapfer type I perforation in the posterolateral aspect of the second part of the duodenum and was repaired surgically. Hereby, we describe the presentation and subsequent therapeutic approach.

Prognosis of breast cancer in patients with peritoneal metastasis

Number of Patients (n) 21 Age at Breast Cancer Diagnosis Mean (range) 48 (31–64) Median (range) 50 (31–64) Age at Peritoneal Metastasis Mean (range) 56 (38–71) Menopausal Status Post-menopausal 12 (57.1%) Pre-menopausal 6 (28.6%) Peri-menopausal 3 (14.3%) Patient Survival Number of dead patients 7 (33.3%) Number of living patients 13 (61.9%) Molecular Subtype Luminal A 8 (38.1%) Luminal B 5 (23.8%) Triple negative 2 (9.5%) Her-2 overexpressing 0 (0%) Unknown 6 (28.6%) Hormone Receptor Status ER status Positive 14 (66.7%) Negative 3 (14.3%) Unknown 4 (19.0%) PR status Positive 11 (52.4%) Negative 6 (28.6%) Unknown 4 (19.0%) Her2 status Positive 5 (23.8%) Negative 10 (47.6%) Histological Subtype IDC 7 (33.3) ILC 5 (23.8) Mixed 3 (14.3) Unknown 6 (28.6) To the Editor

Skin cancer in immunosuppressed transplant patients: Vigilance matters

Liver transplantation (LT) is a widely-accepted, definitive therapy of irreversible liver diseases including hepatitis C, alcoholic liver disease and metabolic liver disease. After transplantation, patients generally use a variety of immunosuppressive medications for the rest of their lives to prevent rejection of transplanted liver. Mortality after LT is mainly caused by recurrence of alcoholic hepatitis which is mostly seen in the patients who resume heavy drinking. On the other hand, de-novo malignancies after LT are not seldom. Skin cancers make up 13.5% of the de-novo malignancies seen in these patients. Malignancies tend to affect survival earlier in the course with a 53% risk of death at 5 years after diagnosis. We aimed to report a case who underwent LT secondary to alcoholic liver disease and developed squamous cell carcinoma of the skin eighteen years after transplantation. In summary, transplant recipients are recommended to be educated on self examination for skin cancer; health care providers should be further suspicious during routine dermatological examinations of the transplant patients and biopsies of possible lesions for skin cancer is warranted even many years after transplantation.

RIGHT VENTRICULAR FDG-PET UPTAKE SUGGESTS A SHIFT TO GLYCOLYTIC METABOLISM IN THE SETTING OF RIGHT VENTRICULAR DYSFUNCTION RELATED TO PULMONARY ARTERIAL HYPERTENSION

Pulmonary arterial hypertension (PAH) features intimal proliferation and smooth muscle hypertrophy of pulmonary vasculature. Resultant increased afterload leads to right ventricular (RV) failure. The metabolic state of cardiac myocytes is thought to determine how the RV responds to this increased

Serpentine Supravenous Hyperpigmentation Resulting from Vinorelbine Administration

tal and lobular epithelium and adjacent stroma (hormone and growth factor receptors and their ligands, cell cycle factors, vascular and angiogenic factors, and others), which are usually studied on biphasic breast tumors such as phyllodes tumors. Our hypothesis is that the stromal-epithelial interdependence has changed in some parts of presented TA, resulting in excessive fibrous proliferation and FA formation. Similar type of tumor phenotypic change is visible in phyllodes tumors that have progressed from FAs, what was demonstrated by clonal analysis.