Ivana Dzeletovic

Flexible endoscopic and surgical management of Zenker's diverticulum

Zenkers diverticulum is an outpouching of the mucosa through the Killians triangle. The etiology of Zenkers diverticulum is not well understood. It is thought to be due to the incoordination or incomplete relaxation of the cricopharyngeal muscle. Most patients are men who present with symptoms of dysphagia between the seventh and eighth decades of life. The diagnosis is made with a dynamic contrast swallowing study. Treatment options include open surgical diverticulectomy and diverticulopexy with myotomy or myotomy alone using flexible or rigid endoscopes. Rigid endoscopic treatment is currently the preferred initial choice for Zenkers diverticulum of any size. The flexible endoscopic technique is used when there is a high risk of general anesthesia, or neck extension is contraindicated. Some centers use flexible endoscopy as the initial treatment option. Due to a lack of prospective studies, the treatment choice should be tailored to the individual patient and local expertise.

Self-Dilation for Resistant, Benign Esophageal Strictures

Introduction Benign esophageal strictures can have significant and deleterious effects on patients’ quality of life. They can lead to important complications, such as malnutrition, weight loss, and aspiration. The prevalence of esophageal strictures is estimated to be 129 and 122 per 100,000 for men and women, respectively (1). The goals of therapy for benign esophageal strictures are the relief of dysphagia and the prevention of stricture recurrence. Presently, most esophageal dilations are performed in association with endoscopy. However, despite repeated endoscopic treatment and medical therapy, as many as 30–40% of patients will have symptom recurrence within the first year (2–5). As early as 1674, Thomas Willis reported the use of a sponge button mounted on whalebone as a dilator, and the first bougienage was reported in the 1800s (6,7). As more innovative techniques and materials have developed, dilators have evolved and continue to improve. Before the evolution of endoscopy, esophageal bougienage was for centuries the main therapy for esophageal strictures. Esophageal self-dilation is a treatment option for patients with resistant benign esophageal strictures. The best patients for this procedure are those who are selfmotivated and compliant and who may be poor surgical candidates. At present, self-dilation as a treatment choice remains underrecognized and rarely used. Technique of self-dilation Patient training for self-dilation. Initially, patients view an educational video on esophageal self-dilation. Afterward, each patient meets with another patient experienced with self-dilation to discuss issues and concerns. For each patient, the first dilation is completed in the endoscopy suite under conscious sedation. A minimum of three teaching sessions follow under the close supervision of a physician and a registered nurse. Self-dilation is initiated with a Maloney dilator a few sizes smaller than that used during the previous endoscopic dilation.

Impact of fentanyl in lieu of meperidine on endoscopy unit efficiency: a prospective comparative study in patients undergoing EGD

BACKGROUND Turnaround time is an important component of endoscopy unit efficiency. Any reduction in the total time from patient arrival in the endoscopy room to departure from the recovery area may translate into better endoscopy unit efficiency. OBJECTIVE To evaluate the effects on endoscopy unit efficiency of a change in narcotic choice for moderate sedation in patients undergoing EGD at an ambulatory surgery center. DESIGN Prospective, comparative, quality-improvement project. SETTING Endoscopy unit of a tertiary-care academic medical center. PATIENTS We enrolled consecutive patients (n = 1963) who underwent outpatient EGD by 1 of 5 endoscopists between November 2008 and November 2010. INTERVENTION Moderate sedation with midazolam plus fentanyl versus meperidine. MAIN OUTCOME MEASUREMENTS Sedation-dependent endoscopy unit efficiency and total procedure time (induction-to-intubation, intubation-to-extubation, and extubation-to-discharge). RESULTS Fentanyl was associated with reduced total procedure time by 10.1 minutes resulting from both shorter induction-to-intubation time and extubation-to-discharge time (P < .001). The mean (± SD) sedation-dependent endoscopy unit efficiency was 3.2 (± 1.9) procedures per hour for the meperidine group and 3.9 (± 2.7) procedures per hour for the fentanyl group (P = .012); this would translate into possibly increasing the endoscopy suite efficiency by 22%. Based on dosage equivalency conversion, equal doses of fentanyl and meperidine were used. No sedation-related complications or need for reversal agents were recorded. LIMITATIONS No randomization was performed. CONCLUSION Compared with meperidine, fentanyl in combination with midazolam was associated with significantly shorter total procedure time. By improving the turnaround time, sedation-dependent endoscopy unit efficiency may be improved by 22%.

Endoscopic balloon dilation to facilitate treatment of intraductal extension of ampullary adenomas (with video)

p fi f b t e t ( w i b i w m s Ampullary adenomas occur sporadically or in patients with familial adenomatous polyposis and are being diagnosed more often because of the widespread use of endoscopy. Adenomas may undergo malignant transformation through the adenoma-carcinoma sequence2; therefore, complete resection is advised. Because of the morbidity and mortality of surgery, endoscopic snare papillectomy is currently a preferred treatment option for removal of ampullary adenomas.3 Traditionally, ntraductal extension of an ampullary adenoma into the comon bile duct or pancreatic duct has been considered an ndication for surgery.4,5 Recently, adenomas with ductal exension have been treated endoscopically if the tissue can be xposed.6,7 Endoscopic treatment of intraductal extension includes maximal biliary sphincterotomy and adenoma eversion by using a stone retrieval balloon, followed by snare resection and argon plasma coagulation therapy.8 Endoscopic balloon dilation (EBD) with and without maximal biliary sphincterotomy is used for removal of bile duct stones.9 We hypothesized that balloon dilation would ermit exposure of intraductal tissue, allowing excision nd/or ablation.

Pancreatitis before pancreatic cancer clinical features and influence on outcome

Objectives: Pancreatitis is considered a possible risk factor for and a presentation of pancreatic adenocarcinoma (PA). We aimed to evaluate a large PA patient registry to determine whether prior history of pancreatitis influenced survival. Methods: We retrospectively analyzed the Mayo Clinic Biospecimen Resource for Pancreas Research database from January 1992 to September 2011. Data collected included demographic characteristics, history of tobacco or alcohol use, diabetes mellitus (DM), cholelithiasis, pseudocyst, and details regarding PA. Clinical characteristics and outcomes of PA patients with pancreatitis were compared with PA patients without pancreatitis history. Results: We analyzed 2573 patients with PA diagnosis. Among these patients, 195 (8%) were identified who had pancreatitis diagnosis ≥10 days before PA diagnosis. The cohort with pancreatitis history included more patients with DM (30% vs. 18%; P<0.001) and more smokers (68% vs. 58%; P=0.02). Compared with patients without pancreatitis history, these patients received diagnoses of PA at a younger age (63 vs. 65 y; P=0.005) and earlier stage (stages I and II; 52% vs. 37%; P<0.001). A greater percentage had history of surgery with curative intent (50% vs. 43%; P=0.001) and significantly better survival [median (range), 387 d (314 to 460 d) vs. 325 d (306 to 344 d); P=0.003]. Conclusions: Patients with PA and pancreatitis had more weight loss and DM, but had PA diagnosis at an earlier stage, were more likely to have pancreatic surgery, and therefore better survival than PA patients without pancreatitis, likely due to the earlier diagnosis. Further studies are needed to evaluate whether screening for PA in patients with pancreatitis history would provide survival benefit.

History of portal hypertension and endoscopic treatment of esophageal varices.

f g v 1 i T B F 1 Esophageal variceal bleeding is a major cause of morbidity and mortality, with only 1 in 5 patients surviving for 6 weeks. Endoscopic variceal ligation is currently the mainstay of therapy for actively bleeding esophageal varices. In addition, endoscopic variceal ligation is used as primary and secondary prophylaxis for variceal hemorrhage. Therefore, EVL has had a major impact on our current approach to treating variceal hemorrhage. In this month’s Fellows’ Corner, Dr. Dzeletovic and Dr. Baron shed light on the history of portal hypertension and the evolution of esophageal variceal therapy. Necessity is the mother of creation, and we hope that learning about the creativity of our ancestors stimulates today’s endoscopists to overcome current barriers in gastroenterology and endoscopy. Mouen Khashab, MD

Severe diarrhea following bone marrow transplantation is not always caused by GVHD.

Gastro Question: A 35-year-old man complained of persistent diarrhea 40 days after bone marrow transplant. Esophagogastroduodenoscopy (EGD) and biopsies showed graft-versus-host disease (GVHD) grade IV (of Lerner) and gastric ulcers with cytomegalovirus (CMV) infection. Biopsies from the colonoscopy showed GVHD (histologically compatible with grade II of Lerner). The patient was treated and showed improvement of his symptoms but diarrhea persisted. Follow-up EGD presented diffuse improvement of the erythema in stomach and duodenum, the colonoscopy was normal. The pathology in each site showed no evidence of GVHD or CMV, and regenerative changes of the mucosa. Four days later, worsening of symptoms occurred despite treatment, with severe diarrhea (4 L/d), intermittently bloody, and mild abdominal pain. The laboratory results were: hemoglobin, 10; white blood cell count, 2; platelets, 60; blood urea nitrogen/creatinine, normal; mild electrolyte abnormalities; lactate dehydrogenase, 450; and blood film, pancytopenia, no circulating lymphoma cells, no schistocytes. Colonoscopy (Figures A and B), with the lesions depicted present throughout the colon, and the colon biopsies histology (Figures C and D) are shown. What is this condition? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Tu1511 Pancreatitis Prior to Pancreatic Cancer: Clinical Features and Influence on Outcome

these 188 articles were fully reviewed and 41 met the pre-specified inclusion criteria. Overall there were 5788 patients and 3304 branch duct IPMNS included in the final analysis. There were 16 studies including 1058 patients in the analysis of cyst size. Cyst size greater than 3 cm substantially increased the risk of malignancy OR 62.4 [95% CL 30.8, 126.3]. Analysis of 19 studies and 1452 patients indicated that the presence of a mural nodule within the cyst was also a strong risk factor for malignancy OR 9.3 [5.3, 16.1]. 8 studies incorporating data from 358 patients were included in the analysis of main pancreatic duct dilation OR 7.27 [3.0, 17.4]. In addition, main duct IPMNs carried a higher risk of malignancy then branch duct IPMNs (OR 4.7 [3.3, 6.9]). There was a weak association between patient symptoms and malignancy OR 1.6 [1.0, 2.6]. There was moderate heterogeneity among studies (I2 range 3467). Conclusions: In this meta-analysis we confirmed that cyst features proposed by the international Sendai consensus guidelines for resection of IPMN were highly associated with malignancy. Despite inherent selection bias towards patients that underwent surgical resection, findings from this meta-analysis of the published literature indicate that not all cyst features should be weighted equally. Cyst size was most strongly associated with malignant IPMN.

Tu1496 Pancreatitis and Pancreatic Adenocarcinoma: Clinical Features and Effect on Stage and Survival

results show that CTGF is expressed in mouse acinar cells during ACP at a time that corresponds to increased infiltration of inflammatory cells as well as of acinar IL-1β expression. In Vitro, acinar-derived CTGF stimlulates IL-1 β-dependent chemokines or chemokine receptor expression, and CTGF-expressing acinar cells liberate soluble stimulators of T cell migration. Taken together, these data support a role for acinar cell-derived CTGF as a modulator of the immune response via its effects on Il-1β and identify a hitherto unrecognized role for CTGF that is distinct from its regulation of fibrogenic pathways in PSC.