Milan Dodig

Esophageal Capsule Endoscopy After Radiofrequency Catheter Ablation for Atrial Fibrillation Documented Higher Risk of Luminal Esophageal Damage With General Anesthesia as Compared With Conscious Sedation

Background—Left atrioesophageal fistula is a rare but devastating complication that may occur after catheter ablation of atrial fibrillation. We used capsule endoscopy to assess esophageal injury after catheter ablation for atrial fibrillation in a population randomized to undergo general anesthesia or conscious sedation. Methods and Results—Fifty patients undergoing atrial fibrillation ablation for paroxysmal symptomatic atrial fibrillation refractory to antiarrhythmic drugs were enrolled and randomized, including those undergoing the procedure under general anesthesia (25 patients, group 1) and those receiving conscious sedation with fentanyl or midazolam (25 patients, group 2). All patients underwent esophageal temperature monitoring during the procedure. The day after ablation, all patients had capsule endoscopy to assess the presence of endoluminal tissue damage of the esophagus. We observed esophageal tissue damage in 12 (48%) patients of group 1 and 1 esophageal tissue damage in a single patient (4%) of group 2 (P<0.001). The maximal esophageal temperature was significantly higher in patients undergoing general anesthesia (group 1) versus patients undergoing conscious sedation (group 2) (40.6±1°C versus 39.6±0.8°C; P< 0.003). The time to peak temperature was 9±7 seconds in group 1 and 21±9 seconds in group 2, and this difference was statistically significant (P<0.001). No complication occurred during or after the administration of the pill cam or during the procedures. All esophageal lesions normalized at the 2-month repeat endoscopic examination. Conclusion—The use of general anesthesia increases the risk of esophageal damage detected by capsule endoscopy.

Sarcopenia associated with portosystemic shunting is reversed by follistatin

BACKGROUND & AIMS The distinct role of portosystemic shunting (PSS) in the pathogenesis of sarcopenia (skeletal muscle loss) that occurs commonly in cirrhosis is unclear. We have previously shown increased expression of myostatin (inhibitor of skeletal muscle mass) in the portacaval anastamosis (PCA) rat model of sarcopenia of PSS. The present study was performed to examine the mechanisms of sarcopenia following PCA. METHODS In PCA and sham operated pair fed control rats, the phenylalanine flooding dose method was used to quantify the fractional and absolute protein synthesis rates in the skeletal muscle over time and in response to follistatin, a myostatin antagonist. The expression of myostatin and markers of satellite cell (myocyte precursors) proliferation and differentiation were quantified by real-time PCR and Western blot analyses. RESULTS The absolute synthesis rate (ASR) was lower at 2, 4, and 6 weeks (p<0.05) and the fractional synthesis rate (FSR) of skeletal muscle protein was significantly lower (p<0.05) at week 2 in the PCA rats compared to control rats. Expression of myostatin was elevated while markers of satellite cell proliferation and differentiation were lower at 4 and 6 weeks after PCA. Follistatin increased skeletal muscle mass, muscle FSR and ASR, decreased expression of myostatin protein, and increased expression of markers of satellite cell function. CONCLUSIONS Sarcopenia associated with PSS is caused by impaired protein synthesis and reduced satellite cell function due to increased myostatin expression. Confirming these alterations in human patients with cirrhosis will provide novel therapeutic targets for sarcopenia of liver disease.

Capsule endoscopy in examination of esophagus for lesions after radiofrequency catheter ablation: a potential tool to select patients with increased risk of complications.

Capsule Endoscopy in Examination of Esophagus. Background: Esophageal injury can result from left atrial radiofrequency ablation (RFA) therapy, with added concern because of its possible relationship to the development of atrial‐esophageal (A‐E) fistulas.

Factors Affecting the Yield of Brush Cytology for the Diagnosis of Pancreatic and Biliary Cancers

Objective: Pancreatobiliary malignancies often present as biliary strictures. Biliary brush cytology is an established diagnostic technique in the investigation of such strictures. The main shortcoming of the test, however, is its low sensitivity. The aim of this was to identify factors associated with a positive yield on biliary brush cytology. Methods: Consecutive patients who had brush cytology for investigation of biliary strictures from 2005 to 2007 were included. Association of several factors with a positive result on brush cytology was studied using univariable and multivariable logistic regression analyses. Results: Two hundred eighty patients were evaluated. One hundred nineteen (42.5%) patients had a final diagnosis of malignancy; of whom, 55 had a positive brush cytology (sensitivity, 46%; specificity, 100%). On multivariable analysis, age (odds ratio [OR], 1.2; 95% confidence interval [CI], 1.06-10.4 per 5-year increase), total serum bilirubin levels (OR, 1.3; 95% CI, 1.01-1.6 per 5-unit increase), and presence of a mass on cross-sectional imaging (OR, 11.7; 95% CI 5.1-27.2) were independent predictors of a positive brush cytology result. Conclusions: Increasing age, higher serum bilirubin levels, and presence of a mass on cross-sectional imaging are independent factors associated with a positive result on biliary brush cytology. These findings suggest use of complementary tissue acquisition techniques in selected cases.Abbreviations: CI - confidence interval, ERCP - endoscopic retrograde cholangiopancreatography, OR - odds ratio, P25 - 25th percentile, P75 - 75th percentile

Diagnostic and therapeutic yield is not influenced by the timing of small-bowel enteroscopy: morning versus afternoon

BACKGROUND Small-bowel enteroscopies (BEs) are tedious and prolonged, and their efficacy may be affected by the timing of procedures. OBJECTIVE We aimed to evaluate the differences in diagnostic yield, insertion depth, procedure duration, therapeutic yield, and adverse events (AEs) of enteroscopies performed in the morning versus the afternoon. DESIGN Retrospective cohort study. SETTING Tertiary referral center. PATIENTS Patients who underwent BE for suspected small-bowel disease at a single institution between January 2008 and August 2009. MAIN OUTCOME MEASUREMENT Differences in diagnostic yield, insertion depth, procedure duration, therapeutic yield, and AEs between morning (started before noon) and afternoon (after noon) procedures. RESULTS A total of 250 enteroscopies were performed on 250 patients, of which 125 patients (50%) underwent a procedure in the morning and 125 patients (50%) underwent the procedure in the afternoon. The diagnostic yield with anterograde enteroscopy was the same in both the morning and afternoon (63.7% and 63.7%, respectively; P = .99). The procedure durations were also similar (42.4 ± 21.5 minutes vs 46.2 ± 22.4 minutes, respectively; P = .25). Similarly the diagnostic yield with retrograde enteroscopy was similar in morning and afternoon (44.1% and 35.3%, respectively; P = .46). However, the procedure durations of retrograde BE were significantly shorter in the morning compared with the afternoon (51.3 ± 21.3 minutes vs 66.6 ± 32.9 minutes, respectively; P = .03). Therapeutic yield and AEs were similar. LIMITATIONS Retrospective study. CONCLUSIONS The timing of procedure, morning versus afternoon, did not affect the diagnostic and therapeutic efficacy of BE in patients with suspected small-bowel disease.

Comparison of Autoanalyzer and Back Titration for Measurement of Bicarbonate Concentration in Endoscopically Collected Pancreatic Fluid

Objectives: In secretin-stimulated pancreatic function testing, the standard technique for bicarbonate measurement is back titration (BT). Chemistry autoanalyzers (AAs) automate bicarbonate measurement and are universally available; however, this method has not been validated in pancreatic fluid. The aims of the study were (1) to compare the AA and BT for measurement of bicarbonate in pancreatic fluid and (2) to determine the effects of variable conditions on bicarbonate concentration. Methods: Pancreatic fluid samples were analyzed for bicarbonate concentration using both BT and AA. Additional experiments were conducted to determine the effect of different sample conditions. Results: The results obtained by BT and AA were highly concordant (Lin concordance coefficient, 0.96). An AA cutpoint of 84 mM optimized sensitivity (91.1%) and specificity (94.1%) compared with the BT reference standard. Blood contamination spuriously increased the bicarbonate, an effect that was eliminated by centrifugation. The bicarbonate levels were not significantly affected by delayed analysis, storage condition, nitrogen gas treatment, or the addition of mineral oil or protease inhibitors. Conclusions: The bicarbonate concentrations obtained by AA are highly concordant with those obtained by BT. Secretin pancreatic function testing fluid analysis may now be performed in any hospital.Abbreviations: AA - autoanalyzer, BT - back-titration, CI - confidence interval, ePFT - endoscopic pancreatic function test, HCl - hydrochloric acid, PFT - pancreatic function testing, mM - millimolarity