Joan Kheder

A Prospective, Multicenter Study of the AIMS65 Score Compared With the Glasgow-Blatchford Score in Predicting Upper Gastrointestinal Hemorrhage Outcomes.

Background: The AIMS65 score and the Glasgow-Blatchford risk score (GBRS) are validated preendoscopic risk scores for upper gastrointestinal hemorrhage (UGIH). Goals: To compare the 2 scores’ performance in predicting important outcomes in UGIH. Study: A prospective cohort study in 2 tertiary referral centers and 1 community teaching hospital. Adults with UGIH were included. The AIMS65 score and GBRS were calculated for each patient. The primary outcome was inpatient mortality. Secondary outcomes were 30-day mortality, in-hospital rebleeding, 30-day rebleeding, length of stay, and a composite endpoint of in-hospital mortality, transfusions, or need for intervention (endoscopic, radiologic, or surgical treatment). The area under the receiver operating characteristic curve (AUROC) was calculated for each score and outcome. Results: A total of 298 patients were enrolled. The AIMS65 score was superior to the GBRS in predicting in-hospital mortality (AUROC, 0.85 vs. 0.66; P<0.01) and length of stay (Somer’s D, 0.21 vs. 0.13; P=0.04). The scores were similar in predicting 30-day mortality (AUROC, 0.74 vs. 0.65; P=0.16), in-hospital rebleeding (AUROC, 0.69 vs. 0.62; P=0.19), 30-day rebleeding (AUROC, 0.63 vs. 0.63; P=0.90), and the composite outcome (AUROC, 0.57 vs. 0.59; P=0.49). The optimal cutoffs for predicting in-hospital mortality were an AIMS65 score of 3 and a GBRS score of 10. For predicting rebleeding, the optimal cutoffs were 2 and 10, respectively. Conclusions: The AIMS65 score is superior to the GBRS for predicting in-hospital mortality and hospital length of stay for patients with UGIH. The AIMS65 score and GBRS are similar in predicting 30-day mortality, rebleeding, and a composite endpoint.

Smoking Cessation in a Chronic Pancreatitis Population.

Objectives Smoking is a known risk factor for developing chronic pancreatitis and accelerates disease progression. Smoking cessation remains an important treatment recommendation, but little is known about its effects. This study evaluated smoking cessation in this population and its impact on quality of life. Methods Twenty-seven smokers with chronic pancreatitis participated in a smoking cessation program incorporating the QuitWorks program and individual counseling. Their smoking cessation rates were compared with a control population (n = 200) consisting of inpatients without chronic pancreatitis who smoked. Smokers were also compared with nonsmokers (n = 25) with chronic pancreatitis in terms of quality-of-life indicators. Results In 27 patients, 0 had quit smoking at 6 months, 1 at 12 months, and 0 patients at 18 months. There was a 19% quit rate in the control population at the 6-month period. Smokers had a worse quality of life, higher rates of depression and anxiety, and worse coping skills than nonsmokers. Conclusions Smoking cessation in the chronic pancreatitis population is extremely challenging, as shown by our 0% quit rate after 18 months. Given that smokers with chronic pancreatitis also experience a worse quality of life, it becomes even more important to stress the importance of smoking cessation in these patients.

Comparing efficacy of lumen-apposing stents to plastic stents in the endoscopic management of mature peripancreatic fluid collections: a single-center experience

Introduction Mature peripancreatic fluid collection (MPFC) is a known and often challenging consequence of acute pancreatitis and often requires intervention. The most common method accepted is the “step-up approach,” which consists of percutaneous drainage followed, if necessary, by minimally invasive retroperitoneal necrosectomy. Our paper aims to distinguish between plastic stents and lumen-apposing stents in the endoscopic management of MPFC in terms of morbidity, mortality, and haste of fluid collection resolution. Methods A retrospective analysis was performed at UMass Memorial Medical Center in patients with a diagnosis of MPFC. Utilizing medical records, clinical data, radiology, as well as endoscopic evidence, patients were differentiated by stent type used (plastic versus lumen-apposing) for the management of the MPFC. The primary outcome of the study was to assess the time to MPFC resolution following the placement of either plastic or lumen-apposing stents (on endoscopic ultrasound or computerized tomography scan) using a multivariate analysis with a logistic regression model. Results A total of 54 patients were included in this study from UMass Memorial Medical Center between 2012 and 2015. Twelve (22%) of these patients received lumen-apposing stents and 42 (78%) of these patients received plastic pigtail stents. For the lumen-apposing stent group, the mean interval between stent placement and resolution of MPFC was 57 days as compared to 102 days for plastic pigtail stents (p=0.02). The mean interval for placement/removal of lumen-apposing stents was 48 days as compared to 81 days for plastic pigtail stents (p=0.01). Stent migration was seen in 5 patients (11%) who received a plastic pigtail stent compared to 0 (0%) patients who received a lumen-apposing stent. Discussion Our study demonstrates that lumen-apposing stents result in a significant reduction in the interval between stent placement and MPFC resolution as well as the time from stent placement to removal, when compared to plastic pigtail stents, the prior standard-of-care. Our study reached similar conclusions regarding the number of stents placed. However, we did not find a significant difference between the complication rates, specifically peri- and postprocedural bleeding or perforation, between the 2 study groups, as demonstrated in prior papers.

Successful Endoscopic Pancreatic Necrosectomy in 5-Year-Old Child.

placed over the wire to maintain track patency ( Figure 3 ). Four weeks aft er the cystgastrostomy, the patient underwent endoscopic necrosectomy (EN). First, the cystgastrostomy track was dilated with a 12–13.5–15 mm balloon dilator. Subsequently, the pseudocyst was entered with the upper endoscope. Necrosectomy was performed with a variety of endoscopic tools (forceps, Roth nets, and snares) to remove necrotic material until the granulation tissue was reached. Follow-up CT scan showed resolution of the collection, and the cystgastrostomy stents were removed 3 weeks later. Th e patient continued to be asymptomatic a year post intervention. Walled-off Pancreatic Necrosis (WOPN) can occur in 1–9% of all acute pancreatitis fl uid collection seen on ultrasound. Ten days later, the patient developed fever and abdominal pain. A computed tomography (CT) scan was performed showing a left upper quadrant organized fl uid collection between the pancreas and the posterior gastric wall. Th e collection measured approximately 7.5×6×9 cm ( Figure 1 ). Th e patient underwent percutaneous ultrasound guided drainage with the placement of an 8Fr pigtail catheter into the peripancreatic collection and was treated with antibiotics. Th e patient had recurrent hospitalizations because of persistent fever and pain, but eventually the symptoms resolved and the drain was removed. Less than 2 weeks aft er the drain removal, the patient presented again with abdominal pain and fever. Abdominal CT showed recurrence of the fl uid collection adjacent to the pancreatic tail measuring 5×5×5 cm. Ultrasound guided aspiration of the fl uid collection showed thick green fl uid. Cultures grew Enterococcus Faecium. Th e patient was referred to the gastroenterology service for endoscopic cystgastrostomy/necrosectomy. Endoscopic ultrasound revealed a 45 mm by 50 mm peripancreatic fl uid collection ( Figure 2 ). Cystgastrostomy was performed by passing a 19-gauge needle through the stomach into the fl uid collection; the fl uid was cloudy, brown, and watery. A wire was threaded through the needle under fl uoroscopic guidance. Th e track was dilated with a 10–12 mm then 12–15 balloons dilators. Four plastic double pigtail stents (one 7Fr×4 cm and three 10Fr×1 cm) were a Pouchitis Disease Activity Index . Mayo Clin Proc 1994 ; 69 : 409 – 15 . 5. Satokari R , Mattila E , Kainulainen V et al. Simple faecal preparation and effi cacy of frozen inoculum in faecal microbiota transplantation for recurrent Clostridium diffi cile infection–an observational cohort study . Aliment Pharmacol Th er 2015 ; 41 : 46 – 53 . 6. Camarinha-Silva A , Jauregui R , Chaves-Moreno D et al. Comparing the anterior nare bacterial community of two discrete human populations using Illumina amplicon sequencing . Environ Microbiol 2014 ; 16 : 2939 – 52 . 7. Youngster I , Russell GH , Pindar C et al. Oral, capsulized, frozen fecal microbiota transplantation for relapsing Clostridium diffi cile infection . JAMA 2014 ; 312 : 1772 – 8 . 8. Stollman N , Smith M , Giovanelli A et al. Frozen encapsulated stool in recurrent Clostridium diffi cile : exploring the role of pills in the treatment hierarchy of fecal microbiota transplant nonresponders . Am J Gastroenterol 2015 ; 110 : 600 – 1 .