Eoin Slattery

Comparison of Adverse Events for Endoscopic vs Percutaneous Biliary Drainage in the Treatment of Malignant Biliary Tract Obstruction in an Inpatient National Cohort.

IMPORTANCE Nonsurgical biliary drainage in malignant biliary tract obstruction can be performed endoscopically by endoscopic retrograde cholangiopancreatography (ERCP) or by percutaneous transhepatic biliary drainage (PTBD). The published body of literature to support either approach is surprisingly sparse, is conflicting on the preferred approach, and is limited by small studies with heterogeneous groups. OBJECTIVE To evaluate the procedure-related adverse event rate with endoscopic vs percutaneous drainage in patients with malignant biliary tract obstruction. DESIGN, SETTING, AND PARTICIPANTS This was a retrospective analysis from the National Inpatient Sample (NIS) database from 2007 through 2009. Data analysis was performed in 2015. Patients from the NIS database are representative of the US population and are included from both community and tertiary care hospitals in the United States. MAIN OUTCOMES AND MEASURES Procedure-related adverse event rates. RESULTS A total of 7445 patients were included for ERCP and 1690 for PTBD. The overall adverse event rate was 8.6% for endoscopic drainage (640 events) and 12.3% for percutaneous biliary drainage (208 events) (P < .001). When analyzed by type of malignant neoplasm, ERCP was associated with a lower rate of adverse events compared with PTBD for pancreatic cancer (2.9% vs 6.2%; odds ratio [OR], 0.46 [95% CI, 0.35-0.61]; P < .001) and cholangiocarcinoma (2.6% vs 4.2% OR, 0.62 [95% CI, 0.35-1.10]; P = .10). For pancreatic cancer, endoscopic procedures were associated with a lower rate of adverse events regardless of the volume of percutaneous procedures performed by a center. For cholangiocarcinoma, centers that performed a low volume of percutaneous biliary drainage procedures were more likely to have adverse events compared with endoscopic procedures performed at the same center (5.7% vs 2.5%; OR, 2.28 [95% CI, 1.02-5.11]; P = .04). In centers that performed a high volume of percutaneous drainage procedures, rates of adverse events were similar to those of endoscopic adverse events (3.5% vs 3.0%; OR, 1.18 [95% CI, 0.53-2.66]; P = .68). CONCLUSIONS AND RELEVANCE Our results support the finding that endoscopic biliary drainage for malignant biliary obstruction is a first-line intervention. Endoscopic drainage is superior to percutaneous drainage, in regard to adverse event rate, for patients with pancreatic cancer. For patients with cholangiocarcinoma, endoscopic drainage is superior in centers that perform a low volume of percutaneous biliary drainage procedures.

Pancreatic cancer surgery and nutrition management: a review of the current literature.

Surgery remains the only curative treatment for pancreaticobiliary tumors. These patients typically present in a malnourished state. Various screening tools have been employed to help with preoperative risk stratification. Examples include the subjective global assessment (SGA), malnutrition universal screening tool (MUST), and nutritional risk index (NRI). Adequate studies have not been performed to determine if perioperative interventions, based on nutrition risk assessment, result in less morbidity and mortality. The routine use of gastric decompression with nasogastric sump tubes may be unnecessary following elective pancreatic resections. Instead, placement should be selective and employed on a case-by-case basis. A wide variety of feeding modalities are available, oral nutrition being the most effective. Artificial nutrition may be provided by temporary nasal tube (nasogastric, nasojejunal, or combined nasogastrojejunal tube) or surgically placed tube [gastrostomy (GT), jejunostomy (JT), gastrojejunostomy tubes (GJT)], and intravenously (parenteral nutrition, PN). The optimal tube for enteral feeding cannot be determined based on current data. Each is associated with a specific set of complications. Dual lumen tubes may be useful in the presence of delayed gastric emptying (DGE) as the stomach may be decompressed while feeds are delivered to the jejunum. However, all feeding tubes placed in the small intestine, except direct jejunostomies, commonly dislodge and retroflex into the stomach. Jejunostomies are associated with less frequent, but more serious complications. These include intestinal torsion and bowel necrosis. PN is associated with septic, metabolic, and access-related complications and should be the feeding strategy of last-resort. Enteral feeds are clearly preferred over parental nutrition. A sound understanding of perioperative nutrition may improve patient outcomes. Patients undergoing pancreatic cancer surgery should undergo multidisciplinary nutrition screening and intervention, and the surgical/oncological team should include nutrition professionals in managing these patients in the perioperative period.

Use of a cap in single-balloon enteroscopy-assisted endoscopic retrograde cholangiography.

BACKGROUND AND STUDY AIM Cannulation of the native papilla in surgically altered anatomy is difficult in endoscopic retrograde cholangiography (ERC). There are limited data regarding the success of single-balloon enteroscopy-assisted ERC (SBE-ERC) in patients with a native papilla and Roux-en-Y gastric bypass. Use of a plastic cap may assist cannulation in these cases. The aim of the current study was to investigate the use of SBE-ERC with a cap (Cap-SBE-ERC) in patients with surgically altered anatomy referred for ERC. PATIENTS AND METHODS Patients with surgically altered anatomy (hepaticojejunostomy, gastric bypass surgery, and Whipples surgery) who underwent Cap-SBE-ERC were identified from a prospectively maintained database. Outcomes were diagnostic and procedural success. Patients with a native papilla were compared with those with a biliary-enteric anastomosis. RESULTS Among 56 patients with surgically altered anatomy, high rates of diagnostic and procedural success were observed (78.6 % and 71.4 %, respectively). High diagnostic and procedural success rates of 72.7 % and 65.9 %, respectively, were also observed for patients with Roux-en-Y gastric bypass anatomy with a native papilla (n = 44). CONCLUSION High rates of diagnostic and procedural success were reported for SBE-ERC with the use of a cap, including a large subgroup of patients with Roux-en-Y gastric bypass and a native papilla.

Albumin as a marker of nutrition: a common pitfall.

patient’s illness.4 For example, patients with anorexia nervosa have normal serum albumin levels, yet these patients are considered malnourished.5 Conversely, in patients with inflammatory bowel disease, serum albumin has been found to be a good marker of active inflammation but not of nutritional status.6 It has become clear that albumin is a negative acute phase protein, meaning that in times of illness or trauma, hepatic production of albumin is decreased in favor of acute phase proteins such as globulins, fibrinogen, and haptoglobin. In addition, the inflammatory cascade induced by a severe illness or trauma increases vascular permeability, leading to the loss of serum albumin into the interstitium, further decreasing serum albumin levels. It is now recognized that serum albumin levels reflect the severity of the illness or trauma more accurately than nutritional status. It is in this role that serum albumin levels have been reported to be the best preoperative patient characteristic for predicting operative morbidity and mortality.2 Obese surgical patients are at increased risk of postoperative infections, delayed wound healing, and respiratory, and venous thromboembolic complications.7 Obese patients are at increased risk of SSI for a variety of reasons, such as increased wound dead space, poor wound healing, and poor glycemic control. More recently, it has been suggested that these patient have a high inflammatory burden and that a state of chronic inflammation and dysmetabolism in visceral obese patients can negatively influences postoperative outcomes.7 To investigate the relationship between low serum albumin and SSI, we performed a retrospective analysis of 524 patients who underwent gastrointestinal surgery. Patients included in our study were those who underwent operations on the gastrointestinal tract, including gastroduodenal, gallbladder, small intestine, colon, and rectum. We acknowledge that our patient population was heterogeneous; however, the population chosen were patients who underwent “major” gastrointestinal surgery. The diagnosis of SSI in each case was made by the attending doctor who was blinded to the patient’s serum albumin to prevent bias. We noted that there was no statistical difference between operation site and the development of SSI. The incidence of SSI after gastric surgery was 10.7%, small bowel was 24.5%, and colorectal 18.3%. The high incidence of SSI after small bowel surgery may reflect our surgical population. The majority of these patients had chronic inflammatory bowel disease that was either refractory to medical therapy or surgically correctable complications such as intestinal obstruction or internal fistula and abscess. In our study, we reported that hypoalbuminemia was a risk factor for the development of SSI, in addition to previously recognized risk factors such as American Society of Anesthetics (ASA) grade III/IV, contaminated wounds and emergency surgery. The mean preoperative albumin level of patients that developed a SSI was 30 (25-34.5) mg/dL; in patients that did not develop SSI, it was 36 (32-39) mg/dL. We reported that 46.4% of patients that developed a superficial SSI had an albumin level less than 30 mg/dL. In contrast, 80% of patients that developed a deep wound infection had an albumin level less than 30 mg/dL.1 These results suggest that hypoalbuminemia in the development of a SSI is selective to the type of SSI. Those patients with a low serum albumin level are at increased risk of a deep SSI rather than superficial SSI.

Metastatic Melanoma presenting 24 years after surgical resection: a case report and review of the literature

IntroductionMalignant Melanoma is becoming increasingly common. Recurrence is common in, with late recurrence up to 10 years being recognised. We present a case of recurrent metastatic melanoma 24 years after initial presentation, which is the longest interval reported to date.Case presentationEF presented with iron-deficiency anaemia, lethargy, and weight loss. He had an enucleation of his left eye 24 years previously for a uveal melanoma. Endoscopy and biopsy confirmed recurrent duodenal and gastric metastasis. A staging CT demonstrated wide spread thoracic, liver, adrenal and bone metastasis. He was treated with palliative chemotherapy, and died 3 months later.ConclusionLate presentation of metastatic melanoma is common, and should be remembered in patients with a distant history of melanoma. Even, as in our case, if the history is more than two decades previously. Treatment options are poor; earlier recognition may lead to improved survival.

Surgery, Crohn's disease, and the biological era: has there been an impact?

Introduction The management of Crohns disease (CD) has changed considerably over the last 20 years. Immunomodulators and biological therapies now play a role in treating patients with CD, but little is known of their influence on surgical rates. Aim To review the surgery rates for CD in an Irish university hospital over a 20-year period and to determine whether newer therapies had an impact on surgical rates. Method Seven hundred twenty-two patients attending St Vincents University Hospital, Dublin, with CD over a 20-year period (January 1986 to December 2005) were identified. The patients were divided into quartiles. Resection rates were determined in all the quartiles, at both 1 and 3 years from diagnosis. Results A decline in surgery, 3 years from diagnosis, was noted between the first quartile (72 patients, 40%) and the second quartile (58 patients, 32%; P=0.03). No significant change in surgical rates at 3 years occurred between the other 3 quartiles (32%, 30%, and 35%, respectively; P=NS). The patients who required a resection within 3 years were diagnosed at a younger age in later years. There was a similar predominance of 60% of female patients requiring surgery in all groups. The patients requiring surgery were twice as likely to be ex-smokers or current smokers in all groups. Use of infliximab, within 3 years from diagnosis, increased from 0, 0, and 16 patients (8.8%) to 40 patients (22.1%) in the last quartile. The majority of patients were treated with infliximab on an “on demand” basis. Use of infliximab earlier within the course of the disease was seen in later quartiles (ie, within 1 y of diagnosis): 0, 0, 6, and 21 patients. Conclusion Despite the introduction of infliximab over the past 10 years, no demonstrable difference has been seen in the rates of patients requiring resection surgery within 3 years of diagnosis. The reasons for this are unclear, but may relate to episodic treatment, rather than regular maintenance treatment. Female patients and smokers seem to be particularly at risk of resection surgery.

Endoscopic ultrasound-guided fine-needle aspiration of solid lesions on clopidogrel may not be a high-risk procedure for bleeding: A case series.

The major gastrointestinal endoscopy society guidelines list endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA) as a high‐risk procedure for bleeding. However, there are no studies evaluating the risk of bleeding for EUS‐FNA of solid organs while patients continue to take clopidogrel. The aim of the present case series was to evaluate the rate of bleeding in a cohort of patients who underwent EUS‐FNA for solid lesions while on clopidogrel. Bleeding was measured at the time of the procedure by bleeding seen on EUS, endoscopic visualization of blood, or drop in hemoglobin after the procedure. From 2013 to 2015, 10 patients were identified for this case series. Lesions that underwent EUS‐FNA included gastric and rectal subepithelial lesions, pancreas masses, and liver masses. No immediate or delayed bleeding was observed in any of the patients. EUS‐FNA of solid lesions on clopidogrel may not be a high‐risk procedure for bleeding. Larger studies are needed to confirm this finding.

Myocarditis associated with infliximab: a case report and review of the literature.

To the Editor: Infliximab is a recombinant immunoglobulin G1 kappa chimeric monoclonal antibody that specifically and potently binds to and neutralizes the soluble tumor necrosis factor alpha (TNF-a) homotrimer and its membrane-bound precursor. It has been shown to be effective in the management of Crohn’s disease (CD) and, more lately, ulcerative colitis (UC). The safety profile of infliximab continues to evolve. The most commonly reported adverse event associated with its use is an increased risk of infections. There are also concerns around the use of these biological agents relating to reports of hematological and lymphoproliferative malignancies. Cardiac toxicity has been well reported with infliximab. Infliximab has been shown to adversely affect the clinical condition of patients with moderate to severe chronic heart failure. Kwon et al reported on infliximab inducing new-onset heart failure in six patients treated with infliximab under the age of 50, with no discernible risk factor. We report on the case of a previously fit, young male patient who presented with myocarditis 10 days after his first infliximab infusion. D.D. is a 21-year-old Irish male who presented to the emergency department for the first time with a 2-month history of diarrhea. Subsequent investigations (including stool cultures, plain film radiology, and colonoscopy with biopsies) confirmed that his symptoms were attributable to acute severe UC. He was treated with intravenous hydrocortisone (100 mg, 6-hourly) and rectal 5-aminosalicylate (Mesalazine, 4 g od) but failed to make any improvement by 72 hours. A decision was therefore made to proceed to salvage treatment in the form of infliximab. Chest x-ray and tuberculin skin test were performed as a standard precaution prior to administration, both of which were normal. Infliximab was subsequently administered (at a dose of 5 mg/kg intravenously). He made a rapid improvement and was discharged home a few days later on reducing dose oral corticosteroids with an appointment to return for his second infusion. He represented 10 days later feeling unwell. He described being intermittently feverish and had developed a rash on his legs, shoulders, and neck. A mild derangement of his liver function tests was noted (alanine aminotransferase 39 IU/L, range 0–35 IU/L; alkaline phosphatase 132 IU/L, range 42–121 IU/L). The remainder of his laboratory indices were unremarkable. His diarrhea had not recurred. He was treated empirically with oral antibiotics and antivirals because of a concern of opportunistic infection and discharged home. He returned to the emergency department 2 days later with worsening fevers, fatigue, and vomiting and was admitted urgently. His temperature was 38.2 C, with a tachycardia of 120 bpm. He was anemic, with a hemoglobin of 11.4 g/dL (range 13–17.5 g/dL). Further investigations revealed an elevated Creactive protein (CRP) of 286 mg/L (range 0–10 mg/L). His chest x-ray was normal. A flexible sigmoidoscopy was performed and confirmed significant mucosal healing. A computed tomography (CT) scan demonstrated the presence of colitis in remission but no other source of intraabdominal sepsis. His colitis was felt to be responding to treatment at this stage. Over the next 48 hours he developed significant sinus tachycardia and chest pain. ECG revealed anterolateral ST-T changes. A subsequent troponin I was elevated at 2.87 lg/L (range 0– 0.06 lg/L) and so he was treated with beta-blockade and antiplatelet agents. An echocardiogram showed severe left ventricular dysfunction with an ejection fraction of 30% and akinetic anteroseptal walls, supporting a diagnosis of focal segmental myocarditis, with a secondary dilated cardiomyopathy. A repeat chest x-ray and subsequent CT pulmonary angiogram revealed cardiomegaly along with diffuse interstitial infiltrates consistent with pulmonary edema. In order to further identify a cause for his cardiac decompensation, a cardiac magnetic resonance imaging (MRI) was obtained. This again showed a dilated and poorly functioning left ventricle with pleural effusions and pulmonary infiltrates bibasally. There was subtle wall enhancement in the septum which was felt to be consistent with myocarditis. There was no evidence of acute or recent myocardial infarction. A full viral and immune profile failed to identify a cause for his myocarditis. However, he was noted to be weakly positive for pANCA. He was treated with supportive care and received beta-blockers, ACE inhibitors, and diuretics. An episode of atrial fibrillation was treated with amiodarone, and he subsequently reverted to sinus rhythm. He made a gradual improvement while in the coronary care unit and was subsequently discharged home. His colitis remained quiescent on a reducing dose of oral corticosteroids. Myocarditis, an inflammatory disease of the myocardium, can be produced by a variety of different disorders. Infections (especially viruses) are a particularly common cause, but also implicated are systemic conditions (such as sarcoidosis, collagen-vascular disorders, and rarely CD). Hypersensitivity reactions to drugs are also an important potential etiological factor. Hypersensitivity myocarditis is usually characterized by acute rash, fever, abnormal liver function, and nonspecific ECG abnormalities. It may present with rapidly progressive heart Copyright VC 2010 Crohn’s & Colitis Foundation of America, Inc. DOI 10.1002/ibd.21546 Published online 25 October 2010 inWiley Online Library (wileyonlinelibrary.com).

Cigarette smoking in Crohn's disease: Can we do more?

Dear Sir, Cigarette smokers are twice as likely to develop Crohns Disease (CD) as non-smokers1. Furthermore, cigarette smokers are more likely to have a complicated course of disease than non-smokers2. Cessation of smoking has also been shown to have important protective effects in reduction of activity of CD (by up to 65%)3. Current estimates are that approximately 50% of CD patients in Europe smoke4. Our aim in this study was to assess the knowledge of patients with IBD regarding smoking and disease …

Performing forward-viewing endoscopy at time of pancreaticobiliary EUS and ERCP may detect additional upper gastrointestinal lesions

Background and study aims: It is unknown whether significant incidental upper gastrointestinal lesions are missed when using non-forward-viewing endoscopes without completing a forward-viewing exam in linear endoscopic ultrasound (EUS) or endoscopic retrograde cholangiopancreatography (ERCP) exams. We evaluated whether significant upper GI lesions are missed during EUS and ERCP when upper endoscopy is not performed routinely with a gastroscope. Patients and methods: A retrospective analysis was performed in which an EGD with a forward-viewing gastroscope was performed after using a non-forward-viewing endoscope (linear echoendoscope, duodenoscope, or both) during a single procedure. Upper gastrointestinal tract findings were recorded separately for each procedure. Significant lesions found with a forward-viewing gastroscope were defined as findings that led to a change in the patient’s medication regimen, additional endoscopic surveillance/interventions, or the need for other imaging studies. Results: A total of 168 patients were evaluated. In 83 patients, a linear echoendoscope was used, in 52 patients a duodenoscope was used, and in 33 patients both devices were used. Clinically significant additional lesions diagnosed with a gastroscope but missed by a non-forward-viewing endoscope were found in 30 /168 patients (18 %). EGD after linear EUS resulted in additional lesion findings in 17 /83 patients (20.5 %, χ2 = 13.385, P = 0.00025). EGD after use of a duodenoscope resulted in additional lesions findings in 10 /52 patients (19.2 %, χ2 = 9.987, P = 0.00157). EGD after the use of both a linear echoendoscope and a duodenoscope resulted in additional lesions findings in 3/33 patients (9 %, χ2 = 3.219, P = 0.07). Conclusion: Non forward-viewing endoscopes miss a significant amount of incidental upper gastrointestinal lesions during pancreaticobiliary endoscopy. Performing an EGD with a gastroscope at the time of linear EUS or ERCP can lead to increased yield of upper gastrointestinal lesions.