Jan Leyden

Do the benefits of metal stents justify the costs? A systematic review and meta-analysis of trials comparing endoscopic stents for malignant biliary obstruction.

Background A variety of stent designs has been studied for endoscopic stenting of the bile duct in patients with malignant biliary obstruction. Although metal stents are associated with longer patency, their costs are significantly higher than plastic stents. Aims To compare clinical outcome and cost-effectiveness of endoscopic metal and plastic stents for malignant biliary obstruction by a systematic review and meta-analysis of all randomized controlled trials in this area. Methods We conducted searches to identify all randomized controlled trials in any language from 1966 to 2006 using electronic databases and hand-searching of conference abstracts. Meta-analysis was performed with RevMan software [Review Manager (RevMan) version 4.2 for Windows. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2003]. Results Seven randomized controlled trials were identified that met the inclusion criteria, and 724 participants were randomized to either metal or plastic endoscopic stents. No significant difference between the two stent types in terms of technical success, therapeutic success, 30-day mortality or complications was observed. Metal stents were associated with a significantly less relative risk (RR) of stent occlusion at 4 months than plastic stents [RR, 0.44; 95% confidence interval (CI) 0.3, 0.63; P<0.01]. The overall risk of recurrent biliary obstruction was also significantly lower in patients treated with metal stents (RR, 0.52; 95% confidence interval 0.39, 0.69; P<0.01). The median incremental cost-effectiveness ratio of metal stents was

Multispectral scanning during endoscopy guides biopsy of dysplasia in Barrett's esophagus

1820 per endoscopic retrograde cholangiopancreatography prevented. Conclusion Endoscopic metal stents for malignant biliary obstruction are associated with significantly higher patency rates than plastic stents as early as 4 months after insertion. Metal stents will be cost-effective if the unit cost of additional endoscopic retrograde cholangiopancreatographies per patient exceeds

Net1 and Myeov: computationally identified mediators of gastric cancer

1820.

Palliative stenting of recurrent malignancy at gastrojejunostomy anastomotic sites

Esophageal cancer is increasing in frequency in the United States faster than any other cancer. Barretts esophagus, an otherwise benign complication of esophageal reflux, affects approximately three million Americans and precedes almost all cases of esophageal cancer. If detected as high-grade dysplasia (HGD), most esophageal cancers can be prevented. Standard-of-care screening for dysplasia uses visual endoscopy and a prescribed pattern of biopsy. This procedure, in which a tiny fraction of the affected tissue is selected for pathological examination, has a low probability of detection because dysplasia is highly focal and visually indistinguishable. We developed a system called endoscopic polarized scanning spectroscopy (EPSS), which performs rapid optical scanning and multispectral imaging of the entire esophageal surface and provides diagnoses in near real time. By detecting and mapping suspicious sites, guided biopsy of invisible, precancerous dysplasia becomes practicable. Here we report the development of EPSS and its application in several clinical cases, one of which merits special consideration.

The celtic coincidence--the frequency and clinical characterisation of hereditary haemochromatosis in patients with coeliac disease.

Gastric adenocarcinoma (GA) is a significant cause of mortality worldwide. The molecular mechanisms of GA remain poorly characterised. Our aim was to characterise the functional activity of the computationally identified genes, NET 1 and MYEOV in GA. Digital Differential Display was used to identify genes altered expression in GA-derived EST libraries. mRNA levels of a subset of genes were quantitated by qPCR in a panel of cell lines and tumour tissue. The effect of pro- and anti-inflammatory stimuli on gene expression was investigated. Cell proliferation and invasion were measured using in an in-vitro GA model following inhibition of expression using siRNA. In all, 23 genes not previously reported in association with GA were identified. Two genes, Net1 and Myeov, were selected for further analysis and increased expression was detected in GA tissue compared to paired normal tissue using quantitative PCR. siRNA-mediated downregulation of Net1 and Myeov resulted in decreased proliferation and invasion of gastric cancer cells in vitro. These functional studies highlight a putative role for NET1 and Myeov in the development and progression of gastric cancer. These genes may provide important targets for intervention in GA, evidenced by their role in promoting invasion and proliferation, key phenotypic hallmarks of cancer cells.

STREAMLINING INPATIENT COLONOSCOPY IN A TERTIARY CARE GI SERVICE

AbstractBackground Surgical bypass procedures often provide excellent palliation in cases of malignant gastric outlet obstruction. Not uncommonly outlet obstruction can recur due to tumour involvement of the gastroenterostomy site. A further surgical procedure may not be feasible in these circumstances. Aims To report on the successful use of expandable metal stents in two such cases.

Cryptogenic cirrhosis: or is it? An unusual case of portal hypertension

BackgroundHereditary Haemochromatosis (HH) and Coeliac disease (CD) are common disorders in Northern European populations, particularly the Irish population.AimsTo investigate whether there was increased frequency of the two commonHFE gene mutations, C282Y and H63D, associated with HH amongst a cohort of CD patients, and to determine the penetrance of the HH associated genotypes in this cohort.MethodsHFE genotypes of a cohort of CD patients were determined using standard PCR techniques.HFE allele frequencies were compared to those of a previously reported, ethnically similar, cohort of 800 neonates, using Fishers exact test. Patients with HH-associated genotypes were subsequently evaluated.ResultsThe C282Y and H63D allele frequencies, 24/222 (11%) and 28/222 (13%) respectively, in the CD patients were similar to those of the neonatal group, 171/1600 (11%) and 242/1600 (15%). Eight patients had HH-associated genotypes, of which two demonstrated biochemical evidence of iron overload.ConclusionTheHFE mutations associated with Hereditary Haemochromatosis are not more common in Irish CD patients.

Measuring colonoscopy performance among gastroenterology trainees

Introduction Greater than 20% of all colonoscopies are associated with suboptimal bowel preparation,1 resulting in lower caecal intubation rates, longer procedure times, decreased adenoma detection rates and higher costs.2 Inadequate bowel cleansing is more common in hospitalized patients.3 Aims/Background To critically analyse the utilisation of inpatient colonoscopy in a tertiary care university hospital. Method We performed a retrospective review of our electronic database for inpatient colonoscopies over a two month period from September to October 2012. Patient demographics, clinical details and key performance indicators were reviewed. Univariate and bivariate statistical analyses were performed using Mann Whitney and Fishers exact tests, where appropriate. Results Fifty six inpatient colonoscopies were performed during the study period. Twenty colonoscopies (36%) were normal and polyps were found in 15 (27%). There were 2 cancers (4%) and one high grade adenoma (2%). Fourteen (25%) colonoscopies were incomplete. Bowel preparation was suboptimal in 31 (56%) of cases. The reason for admission to hospital related primarily to a GI complaint in 23 (41%) of cases. These patients had significantly shorter median overall lengths of stay (10 versus 18 days, p=0.007) and time to colonoscopy (4 versus 10 days, p<0.0001) when compared with patients admitted for non-GI reasons. No difference was seen in rates of pathology encountered in these patients but there was a trend towards better cancer detection rates (3/23, 13% versus 0/33, 0%; p=0.06). Conclusion We observed very high rates of inadequate bowel preparation and relatively low caecal intubation rates for inpatient colonoscopy. Cancer detection rates may be higher in patients admitted with GI complaints, although this needs to be confirmed by expansion of the cohort. The data suggest inpatient colonoscopy should be used sparingly and perhaps reserved for patients with primary GI complaints.

An unusual finding in a patient with iron deficiency anaemia

The patient presented with a 5-week history of abdominal swelling and malaise. She had no medical history apart from a mastectomy for breast cancer 21 years earlier. She consumed 6 units of alcohol per week. Physical examination revealed moderate ascites. Laboratory values were: bilirubin 49 (0–17) μmol/l; aspartate aminotransferase 80 (<35) U/l; alanine aminotransferase 190 (<35) U/l; γ-glutamyltranferase 252 (<58) U/l; alkaline phosphatase 386 (42–121), prothrombin time (PT) 17.9 s/ international normalised ratio (INR) 1.45, serum albumin 30 mg/l and platelet count 95×109/litre. The ascitic fluid cytology was benign. A viral, autoimmune …

Bioinformatic analysis of the colonic polyp-cancer pathway

1. Onozato Y, Kakizaki S, Ishihara H, et al. Endoscopic management of duodenal diverticular bleeding. Gastrointest Endosc 2007;66: 1042-9. 2. Chen YY, Yen HH, Soon MS. Impact of endoscopy in the management of duodenal diverticular bleeding: experience of a single medical center and a review of recent literature. Gastrointest Endosc 2007;66: 831-5. 3. Tseng GY, Jeng TK, Yang HB, et al. Is there a role for intravenous omeprazole in patients with duodenal diverticular bleeding after successful initial endoscopic hemostasis? Gastrointest Endosc 2008;68:405-6. 4. Sugimoto M, Kajimura M, Hanai H, Kaneko E. Prevention of hemorrhage from intradiverticular ulcer in the duodenum by Helicobacter pylori eradication. Am J Gastroenterol 2000;95:561-2.