Irving Waxman

Prospective multicenter trial of esophageal Z-stent placement for malignant dysphagia and tracheoesophageal fistula

BACKGROUNDnConventional esophageal prosthesis placement has been associated with a 6% to 8% perforation rate and numerous postplacement complications. Expandable esophageal stents have been developed to preclude the above but there are few studies that have prospectively defined clinical results and subsequent stent-related complications.nnnMETHODSnAll patients who underwent esophageal Z-stent placement at nine university or referral hospitals were prospectively assessed. Data collected included patient demographics, acute and subacute placement problems, the ability to occlude airway fistulas, prestent and poststent dysphagia scores, and patient survival.nnnRESULTSnFifty-four of 56 patients (96%) with refractory dysphagia or malignant esophagoairway fistulae had 73 Z-stents successfully inserted. Initial distal deployment occurred in 13% of the patients and an additional 17% required balloon dilation to achieve maximal diameter. Acute placement complications occurred in 11% of patients and included severe pain (3), bleeding from necrotic tumor (2), and hiatal hernia intussusception (1). No perforations occurred. Eight of 11 patients (73%) had complete tracheoesophageal fistula occlusion and mean dysphagia score (+/- SD) improved from 2.6 (0.7) to 1.1 (1.2) (p < 0.01). Fifteen stents (27%) had delayed migration at a mean of 1 month and 3 required surgery for retrieval. Three patients had ultimate stent erosion resulting in bleeding in 2 (exsanguination 1) or fistula (treated with a conventional stent).nnnCONCLUSIONSnThe authors conclude that esophageal Z-stents can be placed safely and successfully in the majority of patients. The tendency of distal deployment during placement and subsequent migration problems at a time distant from placement in a patient subset deserve attention and are currently being addressed.

Use of the 25 mm flanged esophageal Z stent for malignant dysphagia: a prospective multicenter trial ☆ ☆☆ ★

BACKGROUNDnAn initial multicenter study using a 21 mm flanged esophageal Z stent demonstrated excellent palliation but an 11% immediate complication rate at placement and a 27% migration rate at 1 month. This North American multicenter trial prospectively studied a 25 mm flanged Z stent to define its palliative ability and whether the increased diameter affected placement or migration problems.nnnMETHODSnFifty patients who had esophageal Z stents at seven university or regional referral hospitals were prospectively studied. Indications for prosthesis placement, previous therapy, patient demographics, incidence of concomitant tracheoesophageal fistula, and degree of dysphagia were defined, as were procedural and subsequent stent-related problems, survival times, the ability to occlude a tracheoesophageal fistula, and subsequent degree of dysphagia.nnnRESULTSnTwenty-four patients had infiltrating malignancy (16 exophytic and 10 extrinsic), 9 of whom had concomitant tracheoesophageal fistulas. Ten patients (20%) had misplaced stents requiring retrieval and replacement, 12 patients (24%) had subsequent stent-related problems including exsanguination (2), aspiration (3), tumor overgrowth (3), and postplacement migration (4) (8%). There was statistically significant improvement in prestent versus poststent dysphagia and two thirds of patients had complete occlusion of their tracheoesophageal fistula.nnnCONCLUSIONSnRedesign of the esophageal Z stent has decreased the migration rate without increasing placement or subsequent erosion problems. Its efficacy appears comparable to the currently marketed Z stent for the palliation of malignant dysphagia and occlusion of tracheoesophageal fistula.

Endoscopic Ultrasound and Related Technologies for the Diagnosis and Treatment of Pancreatic Disease - Research Gaps and Opportunities: Summary of a National Institute of Diabetes and Digestive and Kidney Diseases Workshop

Abstract A workshop was sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases to address the research gaps and opportunities in pancreatic endoscopic ultrasound (EUS). The event occurred on July 26, 2017 in 4 sessions: (1) benign pancreatic diseases, (2) high-risk pancreatic diseases, (3) diagnostic and therapeutics, and (4) new technologies. The current state of knowledge was reviewed, with identification of numerous gaps in knowledge and research needs. Common themes included the need for large multicenter consortia of various pancreatic diseases to facilitate meaningful research of these entities; to standardize EUS features of different pancreatic disorders, the technique of sampling pancreatic lesions, and the performance of various therapeutic EUS procedures; and to identify high-risk disease early at the cellular level before macroscopic disease develops. The need for specialized tools and accessories to enable the safe and effective performance of therapeutic EUS procedures also was discussed.

Endoscopic Evaluation and Management of Pancreaticobiliary Disease

Abstract The diagnostic and therapeutic armamentarium available to practitioners managing pancreaticobiliary disease has expanded significantly in the past two decades. The rapid and dramatic increase in novel endoscopic technology has permitted less invasive diagnostic and therapeutic maneuvers in the pancreatic and bile ducts that had previously required open surgical and percutaneous techniques. Advances in radiographic technology have mirrored the endoscopic evolution, and although it has effectively transitioned the role of endoscopic retrograde cholangiopancreatography (ERCP) to a modality primarily for pancreatobiliary therapeutics, technologic advances, including confocal laser endomicroscopy, direct cholangioscopy, and pancreatoscopy, have been built on the scaffold of ERCP. Endoscopic ultrasound (EUS) provides continuous, real-time images of the intramural gastrointestinal tract and organs and adjacent structures that otherwise would not be visible. The advent of echoendoscopes containing an elevator and therapeutic channel allowed for the passage of aspiration needles, guidewires, and stents under direct endosonographic visualization effectively increasing the therapeutic role and indications for EUS. This chapter discusses ERCP and EUS techniques that can aid in the management of pancreaticobiliary disease.

Endoscopic and Minimally Invasive Therapy for Complications of Pancreatitis

Abstract Although acute pancreatitis (AP) and chronic pancreatitis (CP) have historically been approached as separate clinical entities, advances in the understanding of the pathogenesis of both diseases have led to the recognition that AP, recurrent AP, and CP represent a disease continuum. As a part of the spectrum of disease, these inflammatory conditions can result in local complications that necessitate invasive treatment. In AP, these complications can include inflammatory pancreatic fluid collections, biliary, gastric, or duodenal obstruction, splenic and portal vein thrombosis, gastrointestinal bleeding/pseudoaneurysms, and internal/external fistulization. Patients with CP remain at risk for pseudocysts and biliary obstruction, in addition to chronic pain with pancreaticolithiasis or pancreatic ductal strictures. In the past decade, less-invasive endoscopic, percutaneous, and laparoscopic therapies to address these complications have been developed in an effort to reduce the morbidity associated with traditional open surgical techniques. Rapid expansion of medical technology continues to evolve clinical management strategies, and revised definitions for inflammatory pancreatic fluid collections have provided more homogeneous data on outcomes. Given the heterogeneity of clinical manifestations, local technical expertise, and anatomic variation, the therapies chosen should be individualized, preferably within the context of a multidisciplinary team of surgeons, gastroenterologists, and radiologists, taking into account the natural history and pathophysiology of the disease process.