Frank Lukens

Donor age affects fibrosis progression and graft survival after liver transplantation for hepatitis C

Background. The use of liver allografts from an older donor (OD) (age >50 years) is a widespread strategy to manage the disparity between supply and demand of organs for liver transplantation. This study determines the effect of OD allografts on fibrosis progression and graft survival after liver transplantation in patients with and without infection caused by hepatitis C virus (HCV). Methods. All patients undergoing liver transplantation at our center from March 1998 to December 2001 were analyzed. Protocol liver biopsies were performed at 1, 16, and 52 weeks after transplantation and yearly thereafter. One liver pathologist scored all biopsy specimens for modified hepatic activity index (0–18) and fibrosis (0–6). Results. A total of 402 patients (167 with HCV and 235 without HCV) underwent liver transplantation during the study period. Among patients with HCV, baseline characteristics of OD recipients were similar to younger donor (YD) (age <50 years) recipients. In patients with HCV, graft survival was shorter in OD graft recipients than in YD recipients (P <0.001). In patients without HCV, graft survival was independent of donor age. In patients with HCV, a fibrosis score of 3 or greater was present in 17% of OD recipients at 4 months and in 26% at 12 months after transplantation, compared with 8% of YD recipients at 4 months and 13% at 12 months (P <0.001). Conclusions. Liver transplantation with OD grafts is associated with rapid progression of fibrosis and decreased graft survival in patients with HCV, but not in patients without HCV. OD grafts should be considered preferentially for patients without HCV.

Colonoscopy in octogenarians: a prospective outpatient study

OBJECTIVES: The number of octogenarians (age ≥80 yr) referred for colonoscopy is increasing. Reported success rates regarding colonoscopy completion and adequacy of colonic preparation are poor overall in this group. This may be the result of age-related differences or biases due to retrospective data. The aims of this study were to prospectively determine differences between octogenarians and nonoctogenarians in adequacy of colonic preparation, success in completing colonoscopy, and complications of conscious sedation. METHODS: Prospective cohort study of 250 consecutive outpatients (150 nonoctogenarians and 100 octogenarians) referred for colonoscopy. Colonic preparation tolerance was assessed before colonoscopy, and the success rate and preparation were evaluated after the procedure. Conscious sedation complications were compared. RESULTS: In octogenarians and nonoctogenarians preparation tolerance (86% and 90%, respectively) was similar. Endoscopic success rate was slightly lower in octogenarians (90% vs 99%, p = 0.002). Preparation was poor in 16% of octogenarians compared with 4% of nonoctogenarians (p = 0.001). This was independent of the type of preparation used. Oxygen desaturation was more common in octogenarians (27% vs 19%, p = 0.0007) and associated with a higher meperidine dose (1.05 vs 0.75 mg/kg). No adverse outcomes occurred in either study group. CONCLUSIONS: Colonic preparations were well tolerated and colonoscopic success rates were high in octogenarians and nonoctogenarians. However, poor colonic preparation was four times as likely in octogenarians and was the most important impediment to adequate colonoscopy.

Small bowel tumors discovered during double-balloon enteroscopy: Analysis of a large prospectively collected single-center database

Background: The emergence of capsule endoscopy and double-balloon enteroscopy (DBE) has greatly enhanced the management of small bowel tumors (SBTs). DBE is particularly useful as a diagnostic modality because it allows for direct investigation of the gastrointestinal lumen, yet little data exist regarding its clinical efficacy. Aim: To determine the diagnostic yield of DBE in detection of SBTs. Methods: We restrospectively reviewed our large prospectively collected DBE database from September 2005 to May 2012. Patients who were diagnosed with SBTs by DBE were included in the study. The diagnostic yield of DBE in detection of SBTs was calculated by frequency analysis. Results: A total of 1106 patients underwent 1652 DBE procedures. Of these patients, 134 (12.1%) were found to have an SBT. The majority (56.7%) of patients diagnosed with SBT were male, and the average age at the time of diagnosis was 64 years (SD±14 y). Indications for performing DBE included suspected mass lesion in 54.5% (73/134) of SBT patients, obscure gastrointestinal bleeding in 26.9% (36/134), and overt gastrointestinal bleeding in 14.9% (20/134). The most common SBTs identified were: carcinoid (26/134, 19.4%), hamartoma (14/134, 10.4%), inflammatory polyp (11/134, 8.2%), gastrointestinal stromal tumor (10/134, 7.5%), and lymphoma (10/134, 7.5%). Conclusions: DBE is a valuable tool in the evaluation of SBTs. The incidence of SBTs in our patient population was significantly higher than the generally accepted incidence for the overall population, but was comparable with other similar studies. Carcinoid tumor was the most common SBT identified, and was most often seen in the ileum.

Esophageal sarcoidosis: an unusual diagnosis.

We report a 48-year-old patient who developed secondary achalasia because of esophageal sarcoidosis. Sarcoidosis can involve many gastrointestinal tract organs and can affect the esophagus in different ways. We describe how achalasia was diagnosed and treated in our patient and provide a review of the presentations of esophageal sarcoidosis.

Assessment of competency in endoscopy: establishing and validating generalizable competency benchmarks for colonoscopy

BACKGROUND AND AIMS The Mayo Colonoscopy Skills Assessment Tool (MCSAT) has previously been used to describe learning curves and competency benchmarks for colonoscopy; however, these data were limited to a single training center. The newer Assessment of Competency in Endoscopy (ACE) tool is a refinement of the MCSAT tool put forth by the Training Committee of the American Society for Gastrointestinal Endoscopy, intended to include additional important quality metrics. The goal of this study is to validate the changes made by updating this tool and establish more generalizable and reliable learning curves and competency benchmarks for colonoscopy by examining a larger national cohort of trainees. METHODS In a prospective, multicenter trial, gastroenterology fellows at all stages of training had their core cognitive and motor skills in colonoscopy assessed by staff. Evaluations occurred at set intervals of every 50 procedures throughout the 2013 to 2014 academic year. Skills were graded by using the ACE tool, which uses a 4-point grading scale defining the continuum from novice to competent. Average learning curves for each skill were established at each interval in training and competency benchmarks for each skill were established using the contrasting groups method. RESULTS Ninety-three gastroenterology fellows at 10 U.S. academic institutions had 1061 colonoscopies assessed by using the ACE tool. Average scores of 3.5 were found to be inclusive of all minimal competency thresholds identified for each core skill. Cecal intubation times of less than 15 minutes and independent cecal intubation rates of 90% were also identified as additional competency thresholds during analysis. The average fellow achieved all cognitive and motor skill endpoints by 250 procedures, with >90% surpassing these thresholds by 300 procedures. CONCLUSIONS Nationally generalizable learning curves for colonoscopy skills in gastroenterology fellows are described. Average ACE scores of 3.5, cecal intubation rates of 90%, and intubation times less than 15 minutes are recommended as minimal competency criteria. On average, it takes 250 procedures to achieve competence in colonoscopy. The thresholds found in this multicenter cohort by using the ACE tool are nearly identical to the previously established MCSAT benchmarks and are consistent with recent gastroenterology training recommendations but far higher than current training requirements in other specialties.

Use of Acid Suppressive Medications After Laparoscopic Antireflux Surgery: Prevalence and Clinical Indications

Laparoscopic antireflux surgery (LARS) provides effective control of gastroesophageal reflux (GER) in more than 90% of patients. Despite this high success rate, some patients continue to consume acid suppressive medications after surgical intervention. In this study we evaluate the prevalence, clinical indications, and cause of use of acid reducing drugs in patients after LARS. Consecutive patients undergoing LARS for GERD were surveyed 2–3 years after surgery regarding use of acid suppressive medications, surgical outcome, and GERD specific symptoms. During the study period, 119 patients underwent LARS at our center. Ninety-eight (82%) were available for interview. Two patients died of unrelated causes and two declined to be interviewed. The remaining 94 individuals are the subject of this report. Ninety-four percent were satisfied with the outcome of surgery. Despite this high satisfaction rate, 37 of 94 (39%) were on antireflux medication (ARM; 62% proton pump inhibitors, 22% H2-receptor antagonists, and 16% others), with 70% using continuous medication. Of these patients, 54% took ARM after surgery for GERD-related symptoms, 95% of these patients responded to medical therapy, and yet again, 85% remained satisfied with the surgical outcome. Forty-six percent of patients on ARM after surgery had no GERD symptoms and took ARM for nonappropriate indications such as bloating. Only 47% of these responded to ARM; 82% of this group was satisfied with the surgical outcome. In conclusion, the use of ARM after LARS is a common occurrence despite a high satisfaction rate with this operation. Nearly half of patients consuming ARS after LARS are taking these medications for symptoms not necessarily related to GER. These findings underscore the importance of patient education in the use of these agents.

Arterioportal fistula causing acute pancreatitis and hemobilia after liver biopsy.

We report the case of a 49-year-old patient who developed hemobilia and acute pancreatitis from an arterioportal fistula after a percutaneous liver biopsy, and we analyze diagnostic testing and management based on a concise review of the available literature. Hemobilia can present as late as 10 days after liver biopsy. Acute pancreatitis is a rare complication of hemobilia. To our knowledge, this is the first documented case of an arterioportal fistula after percutaneous liver biopsy with the late manifestation of hemobilia and acute pancreatitis.

Colonic endoscopic mucosal resection of large polyps: Is it safe in the very elderly?

BACKGROUND Outcomes on colon endoscopic mucosal resection in the very elderly patient population are unknown. AIMS Aims of this study were to evaluate the outcomes and safety of colon endoscopic mucosal resection in this target population. METHODS Observational, retrospective study of patients ≥ 80 years of age that underwent colon endoscopic mucosal resection ≥ 2 cm. Demographics, American Society of Anesthesiologists classification, procedural data, and surgical treatment data were collected. RESULTS One-hundred-and-thirty-one colon endoscopic mucosal resections were performed on 99 patients ≥ 80 years of age with a mean age of 84. The majority of American Society of Anesthesiologists class was II. Mean lesion size was 3.3 cm (range, 2-12.5 cm), more procedures were performed in the right colon and adenoma/tubulovillous adenoma was the most common pathology. En bloc resection was performed on 26.7% of polyps (N=35). Eight procedure-related adverse events (8/131, 6.1%) occurred. No anaesthesia related adverse events or deaths occurred. Six patients required a colonic operation, and overall, 94% of the patient cohort evaded a colon operation. CONCLUSIONS Colon endoscopic mucosal resection in very elderly patients can be performed at experienced endoscopy centres with a low rate of complications and offers these patients a non-surgical option of management of colorectal lesions.

Endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis: Testing the current guidelines

BACKGROUND Current guidelines include an algorithm for predicting choledocholithiasis. Presence of any very strong predictor or both strong predictors confers a high (>50%) probability of choledocholithiasis. Absence of predictors confers low risk (<10%) of choledocholithiasis. Other combinations have an intermediate risk of choledocholithiasis. AIM Determine accuracy of the proposed algorithm in predicting choledocholithiasis. METHODS Retrospective analysis of all endoscopic retrograde cholangiopancreatographies performed for suspected choledocholithiasis in 3 years in a Tertiary care hospital and a community hospital serviced by The University of Texas Health Science Center at Houston Division of Gastroenterology. Application of the guidelines, and comparing results to endoscopic retrograde cholangiopancreatography findings. RESULTS A total of 1080 endoscopic retrograde cholangiopancreatographies were performed; 521 for choledocholithiasis. Most patients were Hispanic and female. Univariate analysis: presence of any very strong predictor and both strong predictors had an OR for choledocholithiasis of 3.30 and 2.36 respectively. Multivariate analysis: odds of choledocholithiasis with any very strong predictor was 2.87, and both strong predictors 3.24. Choledocholithiasis was present in 71.5%, and 41% of patients with high, and intermediate risk respectively. CONCLUSION This study confirms the utility of clinical predictors for the diagnosis of choledocholithiasis. All of the very strong predictors and one of the strong predictors increased the odds of choledocholithiasis. Patients with high risk for choledocholithiasis had a probability of 79% of choledocholithiasis. Sensitivity and specificity of current predictors are too low to obviate the possible need of non-invasive tests to confirm or exclude choledocholithiasis in all risk groups.

Anaplastic and sarcomatoid carcinoma of the small intestine: an unusual tumor.

Primary malignant tumors of the small intestine are rare, and sarcomatoid carcinomas have rarely been reported at this site. Anaplastic and sarcomatoid carcinomas are well described in the upper aerodigestive tract, particularly in the esophagus and the larynx. The authors report a case of anaplastic and sarcomatoid carcinoma of the ileum presenting as gastrointestinal bleeding. Their patient and the literature suggest that these tumors are much more aggressive than other small intestinal tumors. The importance of a systematic diagnostic approach in diagnosing these tumors is also discussed.