Geoffrey C. Jiranek

Papillectomy for ampullary neoplasm: results of a single referral center over a 10-year period

BACKGROUND Tumors arising from the duodenal papilla account for approximately 5% of GI neoplasms, but are increasingly identified. OBJECTIVE To describe the clinical characteristics and outcomes in a large single-center experience with patients referred for ampullary lesions. DESIGN A retrospective review of the Virginia Mason Medical Center endoscopy and hospital service database. SETTING Tertiary referral center. PATIENTS One hundred ninety-three patients referred for ampullary lesions from 1997 to 2007. INTERVENTIONS Endoscopic management of ampullary lesions. MAIN OUTCOME MEASUREMENTS The relationship of demographic and clinical data with endoscopic treatment and clinical outcomes in these patients. RESULTS One hundred ninety-three patients underwent endoscopy for ampullary lesions. Fifteen juxta-ampullary lesions and 10 normal variants were excluded. Among 168 patients, there were 112 (67%) adenomas, 38 (23%) adenocarcinomas, and 18 (10%) nonadenomatous lesions. There were 88 men and 80 women, with a mean age of 64 years. Clinical presentation included cholestasis/cholangitis (72 patients), abdominal pain (54 patients), incidental/asymptomatic (51 patients), pancreatitis (9 patients), and bleeding (7 patients). Of the 57 patients referred to surgery, 42 were sent directly without papillectomy, and 16 were sent after papillectomy. Papillectomies were performed in 102 patients with adenomatous lesions. The mean tumor size was 2.4 cm (range 0.5-6 cm). The papillectomy complication rate was 21%: mild pancreatitis in 10 (10%) patients, cholangitis in 1, retroperitoneal perforation in 1 (adenocarcinoma), intraperitoneal perforation in 1 (lateral extension), bleeding in 5 (lateral extension in 2 of these 5), and delayed papillary stenosis in 3. Recurrences were seen in 8%. The endoscopic success rate was 84%. Factors affecting success were a smaller adenoma size and the absence of dilated ducts. CONCLUSIONS Most ampullary adenomas are amenable to endoscopy. Underlying malignancy and lateral extension may be risk factors for bleeding and perforation. Smaller lesion size and the absence of dilated ducts are factors favorably affecting success.

Endoscopic treatment of pancreatic ascites

Pancreatic ascites, etiologically related to a leaking pseudocyst or ductal disruption, has been treated medically with hyperalimentation, somatostatin analog, and large-volume paracentesis. Surgery is ultimately required in more than 50% of such patients. Mortality figures in patients with pancreatic ascites approximate 15% to 25% with either treatment modality. We describe 4 patients who were found to have ductal disruptions in conjunction with pancreatic ascites who responded to transpapillary pancreatic duct endoprosthesis placement. There has been no recurrence of ascites in these patients at a mean follow-up of 12 months following stent-retrieval. Further evaluation of endoscopic therapy for pancreatic ascites appears warranted.

Emergent Treatment of a Primary Aortoenteric Fistula with N-butyl 2-cyanoacrylate and Endovascular Stent

A novel endovascular treatment involving cyanoacrylate injection followed by endovascular stent placement is described in the setting of life-threatening acute exsanguination through a primary aortoenteric fistula. In a patient in unstable condition, N-butyl 2-cyanoacrylate was injected into the fistula tract. Rapid polymerization first provided hemostasis and allowed the patient to be resuscitated and stabilized for several hours, and then an AneuRx endovascular stent-graft was deployed to reinforce the aortic wall and permanently occlude the fistula. This approach can benefit patients whose condition would otherwise be too unstable for open surgery.

Explosion From Argon Cautery During Proctoileoscopy of a Patient With a Colectomy

We report a unique case of a 70-year-old woman with Gardners syndrome who had a subtotal colectomy with ileoproctostomy. Since then, she has undergone 12 uncomplicated proctoileoscopies, each time with argon plasma coagulation ablation of small polyps without any bowel preparation. However, during the most recent procedure, when we attempted to cauterize some rectal polyps, an immediate explosion occurred, leading to multiple rectal and ileal perforations that required surgical repair with a temporary end ileostomy. This event suggests that bacterial fermentation of colonic content or visible feces is not necessary for combustion because we observed a cautery-related explosion in the absence of a colon. This case shows the need for adequate bowel preparation if cautery is to be used, even in patients who have undergone a colectomy.

Comparison of spiral CT, EUS and EUS/FNA for staging pancreatic neoplasms

Background: Studies have shown that endoscopic ultrasound (EUS) more accurately stages pancreatic neoplasms than CT. However, most studies were performed before the era of spiral CT scanners. This study compares spiral CT with EUS for staging pancreatic neoplasms at one institution.