Hala Fatima

Treatment of esophageal leaks, fistulae, and perforations with temporary stents: Evaluation of efficacy, adverse events, and factors associated with successful outcomes

BACKGROUND Factors associated with successful endoscopic therapy with temporary stents for esophageal leaks, fistulae, and perforations (L/F/P) are not well known. OBJECTIVES To evaluate the safety, efficacy, and outcomes of esophageal stenting in these patients and identify factors associated with successful closure. DESIGN Retrospective. SETTING Academic tertiary referral center. PATIENTS All patients with attempted stent placement for esophageal L/F/P between January 2003 and May 2012. INTERVENTION Esophageal stent placement and removal. MAIN OUTCOME MEASUREMENTS Factors predictive of therapeutic success defined as complete closure after index stent removal (primary closure) or after further endoscopic stenting (secondary closure). RESULTS Sixty-seven patients with 132 attempted stents for esophageal L/F/P were considered; 13 patients were excluded. Among the remaining 54 patients, 117 stents were placed for leaks (29 patients; 64 stents), fistulae (15 patients; 36 stents), and perforations (10 patients; 17 stents). Procedural technical success was achieved in all patients (100%). Primary closure was successful in 40 patients (74%) and secondary closure in an additional 5 (83% overall). On short-term (<3 months) follow-up, 27 patients (50%) were asymptomatic, whereas 22 (41%) had technical adverse events, including stent migration in 15 patients (28%). Factors associated with successful primary closure include a shorter time between diagnosis of esophageal L/F/P and initial stent insertion (9.03 vs 22.54 days; P = .003), and a smaller luminal opening size (P = .002). LIMITATIONS Retrospective, single-center study. CONCLUSIONS Temporary stents are safe and effective in treating esophageal L/F/P. Defect opening size and time from diagnosis to stent placement appear to be candidate predictors for successful closure.

Nurse-Administered Propofol Sedation for Upper Endoscopic Ultrasonography

BACKGROUND:Limited data exist regarding the safety of nurse-administered propofol sedation (NAPS) for advanced endoscopy.AIMS:To evaluate the frequency of and the risk factors for complications associated with NAPS for upper endoscopic ultrasound (EUS).METHODS:Consecutive upper EUS examinations using NAPS were retrospectively identified. Clinical data and adverse events were recorded. Univariate and multivariable repeated measures logistic regression models were used to identify independent risk factors for complications.RESULTS:Among 806 EUS procedures, the mean procedure duration, time for sedation induction, and postprocedure recovery time were: 34 ± 20 min, 3.6 ± 1.4 min, and 27 ± 23 min, respectively. A decline in systolic blood pressure (SBP) to <90 mm Hg occurred in 104 patients (13%). Six patients (0.7%) had a decline in oxygen saturation (SpO2) to <90%. Four patients (0.5%; 95% confidence interval [CI] 0.14–1.27) required assisted positive pressure ventilation. There were no major complications. The minor complication rate from sedation was 21% (95% CI 17.2–25.3). All of the complications were clinically insignificant. Overall complication risk was not related to age, dose, or procedure time. Sedation-related complication rates for advanced experience-level (≥100 NAPS procedures) nurses were lower compared to the least-experienced (≤30 NAPS procedures) nurses (17.2% vs 25.4%, odds ratio [OR] 0.61, 95% CI 0.41–0.92).CONCLUSIONS:NAPS for upper EUS is safe and may be performed without major complications. Four patients (0.5%) required assisted ventilation. Minor complications occurred in 21% of patients, but were not associated with patient age, propofol dose, or procedure time.

Outcomes of submucosal (T1b) esophageal adenocarcinomas removed by endoscopic mucosal resection

AIM To investigate the outcomes and recurrences of pT1b esophageal adenocarcinoma (EAC) following endoscopic mucosal resection (EMR) and associated treatments. METHODS Patients undergoing EMR with pathologically confirmed T1b EAC at two academic referral centers were retrospectively identified. Patients were divided into 4 groups based on treatment following EMR: Endoscopic therapy alone (group A), endoscopic therapy with either chemotherapy, radiation or both (group B), surgical resection (group C) or no further treatment/lost to follow-up (< 12 mo) (group D). Pathology specimens were reviewed by a central pathologist. Follow-up data was obtained from the academic centers, primary care physicians and/or referring physicians. Univariate analysis was performed to identify factors predicting recurrence of EAC. RESULTS Fifty-three patients with T1b EAC underwent EMR, of which 32 (60%) had adequate follow-up ≥ 12 mo (median 34 mo, range 12-103). There were 16 patients in group A, 9 in group B, 7 in group C and 21 in group D. Median follow-up in groups A to C was 34 mo (range 12-103). Recurrent EAC developed overall in 9 patients (28%) including 6 (38%) in group A (median: 21 mo, range: 6-73), 1 (11%) in group B (median: 30 mo, range: 30-30) and 2 (29%) in group C (median 21 mo, range: 7-35. Six of 9 recurrences were local; of the 6 recurrences, 5 were treated with endoscopy alone. No predictors of recurrence of EAC were identified. CONCLUSION Endoscopic therapy of T1b EAC may be a reasonable strategy for a subset of patients including those either refusing or medically unfit for esophagectomy.

Impact of the development of an endoscopic eradication program for Barrett’s esophagus with high grade dysplasia or early adenocarcinoma on the frequency of surgery

Background and aims  The impact of the advent of an institutional endoscopic eradication therapy (EET) program on surgical practice for Barrett’s esophagus (BE)-associated high grade dysplasia (HGD) or suspected T1a esophageal adenocarcinoma (EAC) is unknown. The aims of this study are to evaluate the different endoscopic modalities used during development of our EET program and factors associated with the use of EET or surgery for these patients after its development. Methods  Patients who underwent primary endoscopic or surgical treatment for BE-HGD or early EAC at our hospital between January 1992 and December 2014 were retrospectively identified. They were categorized by their initial modality of treatment during the first year, and the impact over time for choice of therapy was assessed by multivariable logistic regression. Results  We identified 386 patients and 80 patients who underwent EET and surgery, respectively. EET included single modality therapy in 254 (66 %) patients and multimodal therapy in 132 (34 %) patients. Multivariable logistic regression showed that, for each subsequent study year, EET was more likely to be performed in patients who were older ( P  = 0.0009), with shorter BE lengths ( P  < 0.0001), and with a pretreatment diagnosis of HGD ( P  = 0.0054) compared to surgical patients. The diagnosis of EAC did not increase the utilization of EET compared to surgery as time progressed ( P  = 0.8165). Conclusion  The introduction of an EET program at our hospital increased the odds of utilizing EET versus surgery over time for initial treatment of patients who were older, had shorter BE lengths or the diagnosis of BE-HGD, but not in patients with EAC.

Stenting of Esophageal Perforation in the Setting of Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a chronic, immunemediated inflammatory condition of the esophagus that often presents with food bolus impaction requiring endoscopic therapy. The incidence of EoE has increased significantly over the last few decades [1–3]. The disease is characterized by dense eosinophilic infiltration of the esophageal epithelium, and its endoscopic appearance is classically described as concentric rings with linear furrowing [4]. Since eosinophilic infiltration leads to esophageal wall remodeling, the mucosa is extremely friable and easily torn during routine endoscopy and in particular during retrieval of an impacted food bolus [5, 6]. While there are a number of reports of esophageal perforations in the setting of EoE [6–17], none have described the use of an esophageal stent for short-term treatment of the perforation and for palliation of dysphagia. We present two cases of esophageal perforation in patients with EoE who were managed with short-term esophageal stents.