Gandhi Lanke

Biliary Decompression in Perihilar Cholangiocarcinoma Improves Survival: A Single-Center Retrospective Analysis

Background and AimsThe complex biliary strictures of perihilar cholangiocarcinoma present significant challenges for providing adequate and long-lasting biliary drainage. The best approach to relieve obstruction remains controversial. The purpose of this study was to assess stenting outcomes in perihilar cholangiocarcinoma.MethodsThis study was approved by the center’s institutional review board. Subjects with a diagnosis of perihilar cholangiocarcinoma who underwent endoscopic retrograde cholangiopancreatography (ERCP) were identified from endoscopic and pathologic databases from 1997 to 2014. Patient characteristics, endoscopic data, and follow-up evaluation data were retrospectively collected via review of available medical records.ResultsA total of 199 patients with perihilar cholangiocarcinoma who underwent a total of 504 ERCPs were included in the study. Nine of 504 (1.8%) procedures were technical failures. Among the 495 technically successful procedures, 347 (70.1%) procedures were clinical successes. Clinical success was significantly associated with longer overall survival (HR 0.57; p = 0.002). A higher proportion of patients with bilateral drainage had clinical success, compared with those with unilateral drainage. Cholangitis was not more common in the bilateral group compared to the unilateral group except in the group where a segment was not drained (1.9% vs 1.6% vs 7.1%, respectively). Patients with metal stents were 3.8 times more likely to have clinical success than those with plastic stents.ConclusionsIn conclusion, adequate biliary drainage improves overall survival. Bilateral stenting if anatomy permits with self-expanding metal stents rather than plastic stents appears to provide the optimal chance of clinical success.

How best to manage gastrointestinal stromal tumor

Gastrointestinal stromal tumors (GISTs) are rare but most common nonepithelial tumor of gastrointestinal tract. They are often found incidentally on computed tomography and endoscopic investigations. Increasing knowledge of the pathogenesis of GISTs and the advent of tyrosine kinase inhibitors revolutionized the management of GISTs. The newer advanced endoscopic techniques have challenged the conventional surgery although the true efficacy and safety of endoscopic approach is not clear at this time. This review article focuses on pathogenesis, diagnosis and management of GISTs.

Plummer-Vinson syndrome presenting as squamous cell carcinoma of esophagus

Plummer-Vinson syndrome (PVS) also known as Paterson-Brown-Kelly syndrome is a rare syndrome which comprises iron deficiency anemia, dysphagia, and esophageal webs. The pathogenesis of PVS is not clear. Iron deficiency anemia is essential for diagnosis of PVS. If left untreated, there is an increased risk of developing pharyngeal or esophageal cancer in about 10% of patients. There are no strict guidelines for endoscopic surveillance in patients with PVS. Iron replacement can improve dysphagia and potentially lead to regression of esophageal webs. In this case report, we present a patient who had long-standing dysphagia for years which progressed to squamous cell cancer of esophagus by the time she sought medical treatment.

Clinical update on the management of pseudopapillary tumor of pancreas

Solid pseudopapillary neoplasm (SPN) is a rare tumor with malignant potential which is generally located in the tail of pancreas. The prevalence of SPN has increased with widespread use of cross sectional imaging. SPN is often misdiagnosed due to nonspecific clinical presentation and accurate diagnosis is essential for optimal management. Endoscopic ultrasound-FNA with immunohistochemistry can help in preoperative diagnosis. Surgery is the treatment of choice and a successful R0 resection is curative. Overall, SPN has a good prognosis. This review article focuses on pathogenesis, diagnosis and management of SPN.

Tu2027 Endoscopic Versus Percutaneous Drainage for Management of Hilar Cholangiocarcinoma

Background: The incidence of hepatocellular carcinoma (HCC) has increased significantly in United States over the last few decades in parallel with the epidemic of nonalcoholic fatty liver disease (NAFLD). Limited data suggest that HCC could arise in steatotic livers without the presence of cirrhosis. The aim of the current study was to characterize patients with NAFLD presenting with HCC in non-cirrhotic liver (NCL) compared to those with HCC in association with liver cirrhosis (LC). Methods: A retrospective analysis was performed on all patients with HCC and NAFLD diagnosis seen at our institution between 2003 and 2012. We characterized the patients with respect to demographic, clinical, histological and tumor features. Comparisons between the NCL and LC groups were done using t-test, Mann Whitney U test, and Chi square test as appropriate. P value 5 cm) (77.8% vs. 23 %), and receive hepatic resection as the modality for HCC treatment (66.7% vs. 17%); and were less likely to receive loco-regional therapy (16.7% vs. 51.1%) or liver transplant (0% vs. 72.3%), p value < 0.001 for all. Furthermore, 62% of patients without cirrhosis had HCC recurrence compared to only 12.5% in patients with cirrhosis (p < 0.001) and had worse survival with mortality rate of 41.7% at last follow up for the HCC-NCL group compared to 27.7% in the cirrhotic group (p = 0.008). Conclusion: Patients with HCC in the absence of liver cirrhosis are more likely to present at an older age with larger tumor and have higher rates of tumor recurrence. Studies to assess the cost-effectiveness of HCC surveillance in this group should be conducted.

Sa1090 Management of Non-Ampullary Duodenal Adenomas in Patients With Familial Adenomatous Polyposis (FAP) and Non-FAP Patients: Should We Manage Them Differently?

Background: Non-ampullary duodenal adenomas are either sporadic or associated with a hereditary syndrome such as familial adenomatous polyposis (FAP). Duodenal adenomas are common in this syndrome, found in approximately 80 to 90% of patients. Objective: The aim of this study is to compare characteristics of sporadic and FAP-associated duodenal adenomas. Methods: This study was approved by the institutional review board. This was a retrospective review at a single center tertiary care institution. Subjects were identified from a pathological database. Subjects with ampullary adenomas only and with less than 2 month follow up were excluded. Data were obtained via review of medical records. Results: A total of 213 subjects were identified. Of those subjects, 117 subjects had FAP and the remainder were considered sporadic. Median age at diagnosis was 40 and 67 for subjects with FAP-associated adenomas and sporadic adenomas, respectively (P<0.0001). Length of follow up was 75±67 months for FAP subjects and 31±30 months for subjects with sporadic adenomas. At time of last follow up, 87.2% of those patients with FAP-associated adenomas had undergone colectomy versus 13% in the sporadic group. 52.1% of had ampullary involvement in addition compared to 7.3% in those subjects with sporadic adenomas (P<0.0001). FAP subjects were more likely to have multifocal disease within the duodenum (69% vs 33%, P<0.0001). On average FAP subjects underwent 6.5 endoscopies during the follow up period, and those with sporadic adenomas underwent 5.3 endoscopies. On initial pathology, there were 71 tubular adenomas (TA) and 46 tubulovillous adenomas (TVA), 15 of which had dysplasia (4 with low grade dysplasia (LGD) and 12 with high grade dysplasia (HGD)), within the FAP group. There were 48 TAs, 47 TVAs, and 1 villous adenoma, 14 of which had dysplasia (2 with LGD and 12 with HGD), in the sporadic group. 14 of 117 (12%) with FAP and 33 of 96 (34%) subjects with sporadic duodenal adenomas underwent endoscopic mucosal resection (EMR). Histologic progression to dysplasia or cancer was seen in 27 (23%) subjects with FAP and 13 (14%) with sporadic disease (P= 0.08). 6 patients within the cohort progressed to cancer, 2 within the FAP group and 4 within the sporadic group. Range of time to progression in those with cancer was 3 to 161 months. Median time to progression was 99.0 months in the FAP group and 122.2 months in the sporadic group. Conclusions: Those patients with FAP were significantly younger, more likely to have ampullary involvement, and more likely to have multifocal disease. Median time to progression to dysplasia or cancer as well as percent of subjects who progress is similar among FAP-associated and sporadic adenomas. Progression to cancer is infrequent, however unpredictable, and an interval for surveillance cannot be recommended given the current data.