Milind A. Phadnis

Endoscopic Transmural Drainage of Peripancreatic Fluid Collections: Outcomes and Predictors of Treatment Success in 211 Consecutive Patients

ObjectivesEndoscopy is a minimally invasive technique for the drainage of peripancreatic fluid collections. This study evaluated the clinical outcomes and predictors of treatment success in consecutive patients undergoing endoscopic transmural drainage of peripancreatic fluid collections.MethodsThis is a retrospective study of patients who underwent endoscopic drainage of peripancreatic fluid collections over 7xa0years. Prior to drainage, an ERCP was attempted for stent placement in all patients with a pancreatic duct leak. Drainages were performed using conventional endoscopy or endoscopic ultrasound. Transmural stents and/or drainage catheters were deployed and endoscopic necrosectomy was undertaken when required. Data on clinical outcomes and complications were collected prospectively.ResultsA total of 211 patients underwent drainage of peripancreatic fluid collections that was classified as pseudocyst in 45%, abscess in 28%, and necrosis in 27%. Mean diameter of the fluid collection was 100.6xa0mm, and 34.5% of patients had pancreatic duct stent placement. Median duration of follow-up was 356xa0days. Treatment success was 85.3% and was higher for pseudocyst and abscess compared to necrosis (93.5% vs. 63.2%, pu2009<u20090.0001). Complications were encountered in 17 patients (8.5%) and was higher for drainage of necrosis than pseudocyst or abscess (15.8% vs. 5.2%, pu2009=u20090.02). Treatment success was more likely for patients with pseudocyst or abscess than necrosis (adjusted ORu2009=u20097.6, 95% CI [2.9, 20.1], pu2009<u20090.0001) when adjusted for serum albumin and white cell count, type of endoscopic modality or accessory used, pancreatic duct stenting, luminal compression, size and location of fluid collection.ConclusionsEndoscopic therapy is a highly effective technique for the management of patients with non-necrotic peripancreatic fluid collections.

Multiple transluminal gateway technique for EUS-guided drainage of symptomatic walled-off pancreatic necrosis

BACKGROUNDnWalled-off pancreatic necrosis often leads to severe clinical deterioration necessitating open debridement or endoscopic necrosectomy. A new EUS-based approach was devised to manage this condition by creating multiple transluminal gateways to facilitate effective drainage of the necrotic contents.nnnOBJECTIVEnTo compare treatment outcomes between patients with walled-off pancreatic necrosis managed endoscopically by a multiple transluminal gateway technique (MTGT) or a conventional drainage technique (CDT).nnnDESIGNnRetrospective study.nnnSETTINGnTertiary-care referral center.nnnPATIENTSnThis study involved patients with severe acute pancreatitis complicated by walled-off pancreatic necrosis managed endoscopically.nnnINTERVENTIONnIn MTGT, 2 or 3 transmural tracts were created by using EUS guidance between the necrotic cavity and the GI lumen. While one tract was used to flush normal saline solution via a nasocystic catheter, multiple stents were deployed in others to facilitate drainage of necrotic contents. In the CDT, two stents with a nasocystic catheter were deployed via 1 transmural tract.nnnMAIN OUTCOME MEASUREMENTSnResolution of symptoms, radiological findings on follow-up CT, and the need for subsequent surgery or endoscopic necrosectomy.nnnRESULTSnOf 60 patients with symptomatic walled-off pancreatic necrosis, 12 (3 women, mean age 55.1 years) were managed by MTGT and 48 (12 women, mean age 55.2 years) by CDT. Treatment was successful in 11 of 12 (91.7%) patients managed by MTGT versus 25 of 48 (52.1%) managed by CDT (P = .01). Although 1 patient in the MTGT cohort required endoscopic necrosectomy, in the CDT cohort, 17 required surgery, 3 underwent endoscopic necrosectomy, and 3 died of multiple-organ failure. Treatment success was more likely for patients treated by MTGT than by CDT (adjusted odds ratio = 9.24; 95% confidence interval, 1.08-79.02; P = .04) when we adjusted for the size of the walled-off pancreatic necrosis and pancreatic duct stent placement.nnnLIMITATIONSnSelective patient population.nnnCONCLUSIONnThe EUS-guided MTGT is an effective treatment option for the management of symptomatic walled-off pancreatic necrosis because it obviates the need for surgery and endoscopic necrosectomy and its attendant procedure-related morbidity. Prospective studies are required to confirm these preliminary but promising data.

Biliary metal stents are superior to plastic stents for preoperative biliary decompression in pancreatic cancer

BackgroundIt is unclear whether plastic or metal stents are more suitable for preoperative biliary decompression in pancreatic cancer. The objective of this study was to compare the rate of endoscopic reinterventions in patients with pancreatic cancer undergoing plastic or self-expandable metal stent (SEMS) placements for preoperative biliary decompression.MethodsThis was a retrospective study of all patients with obstructive jaundice secondary to pancreatic head cancer who underwent their index endoscopic retrograde cholangiopancreatography (ERCP) and all follow-up biliary stent placements at our center before undergoing pancreaticoduodenectomy. Plastic or SEMS were placed at ERCP for biliary decompression. The main outcome measure was to compare the rate of endoscopic reinterventions between the plastic and SEMS cohorts.Results29 patients who underwent pancreaticoduodenectomy had preoperative biliary stent placement (18 plastic, 11 SEMS) at our center. Whereas none of the 11 patients who underwent SEMS placement had stent dysfunction, 7 of 18 (39%) patients with plastic stents required endoscopic reintervention before surgery (Pxa0=xa00.02). Reinterventions were due to cholangitis (nxa0=xa01) or persistent elevation in serum bilirubin levels (nxa0=xa06). Two patients with SEMS underwent EUS-guided fine-needle aspiration after ERCP, which yielded a positive diagnosis of cancer in all cases; SEMS did not impair visualization of the tumor mass at EUS. Pancreaticoduodenectomy was undertaken successfully in all 29 patients and the presence of a SEMS did not interfere with biliary anastomosis. On univariate logistic regression, only SEMS placement was associated with less need for endoscopic reintervention (Pxa0=xa00.02).ConclusionsSEMS are superior to plastic stents for preoperative biliary decompression in pancreatic cancer.

Atrial fibrillation and risk of stroke in dialysis patients

PURPOSEnBoth stroke and chronic atrial fibrillation (AF) are common in dialysis patients, but uncertainty exists in the incidence of new strokes and the risk conferred by chronic AF.nnnMETHODSnA cohort of dually eligible (Medicare and Medicaid) incident dialysis patients was constructed. Medicare claims were used to determine the onset of chronic AF, which was specifically treated as a time-dependent covariate. Cox proportional hazards models were used to model time to stroke.nnnRESULTSnOf 56,734 patients studied, 5629 (9.9%) developed chronic AF. There were 22.8 ischemic and 5.0 hemorrhagic strokes per 1000 patient-years, a ratio of approximately 4.5:1. Chronic AF was independently associated with time to ischemic (hazard ratio [HR], 1.26; 99% confidence interval [CI], 1.06-1.49; Pxa0=xa0.0005), but not hemorrhagic, stroke. Race was strongly associated with hemorrhagic stroke: African Americans (HR, 1.46; 99% CI, 1.08-1.96), Hispanics (HR, 1.64; 99% CI, 1.16-2.31), and others (HR, 1.76; 99% CI, 1.16-2.78) had higher rates than did Caucasians (all Pxa0<xa0.001).nnnCONCLUSIONSnChronic AF has a significant, but modest, association with ischemic stroke. Race/ethnicity is strongly associated with hemorrhagic strokes. The proportion of strokes owing to hemorrhage is much higher than in the general population.

Biliary stent placement is associated with post-ERCP pancreatitis.

BACKGROUNDnA variety of factors have been linked to post-ERCP pancreatitis. However, the role of biliary stenting has not been well studied.nnnOBJECTIVEnTo evaluate the relationship between biliary stenting and post-ERCP pancreatitis.nnnDESIGNnProspective study of all patients undergoing ERCP with biliary stenting over a 7.5-year period. All patients had follow-up at 24 to 48 hours after the procedure and at 1 month.nnnSETTINGnA single-center tertiary referral academic medical center.nnnPATIENTSnConsecutive patients undergoing ERCP over a 7.5-year period.nnnINTERVENTIONSnEndoscopic therapy based on the indication for and findings of ERCP.nnnMAIN OUTCOME MEASUREMENTSnThe rate of post-ERCP pancreatitis.nnnRESULTSnA total of 3499 patients underwent ERCP with bile duct stent placement of a native papilla performed in 660: 544 (83%) 10F and 116 (17%) 7F. The most common indication for stent placement was pancreaticobiliary malignancy in 250 patients (37%). The overall rate of pancreatitis for the entire cohort was 3.17%. Multivariate analysis identified 6 factors that were associated with pancreatitis: previous ERCP pancreatitis (odds ratio [OR], 2.44; 95% CI, 1.31-4.55), age (OR, 2.30; 95% CI, 1.44-3.67), history of acute pancreatitis (OR, 1.78; 95% CI, 1.12-2.88), pancreatic sphincterotomy (OR, 2.30, 95% CI, 1.43-3.70), suspected sphincter of Oddi dysfunction (OR, 3.91; 95% CI, 2.36-6.46), and bile duct stenting (OR, 1.72; 95% CI, 1.03-2.88). The rates of pancreatitis were not significantly different based on performing sphincterotomy before stent placement, stent type, stent length, stent size, or indication.nnnLIMITATIONSnSingle-center study.nnnCONCLUSIONSnBile duct stent placement is an independent predictor for pancreatitis, and pancreatitis is not related to performing sphincterotomy before stenting or to stent characteristics.

Stroke and the “Stroke Belt” in Dialysis: Contribution of Patient Characteristics to Ischemic Stroke Rate and Its Geographic Variation

Geographic variation in stroke rates is well established in the general population, with higher rates in the South than in other areas of the United States. ESRD is a potent risk factor for stroke, but whether regional variations in stroke risk exist among dialysis patients is unknown. Medicare claims from 2000 to 2005 were used to ascertain ischemic stroke events in a large cohort of 265,685 incident dialysis patients. A Poisson generalized linear mixed model was generated to determine factors associated with stroke and to ascertain state-by-state geographic variability in stroke rates by generating observed-to-expected (O/E) adjusted rate ratios for stroke. Older age, female sex, African American race and Hispanic ethnicity, unemployed status, diabetes, hypertension, history of stroke, and permanent atrial fibrillation were positively associated with ischemic stroke, whereas body mass index >30 kg/m(2) was inversely associated with stroke (P<0.001 for each). After full multivariable adjustment, the three states with O/E rate ratios >1.0 were all in the South: North Carolina, Mississippi, and Oklahoma. Regional efforts to increase primary prevention in the stroke belt or to better educate dialysis patients on the signs of stroke so that they may promptly seek care may improve stroke care and outcomes in dialysis patients.

Endoscopic ultrasound evaluation in the surgical treatment of duodenal and peri-ampullary adenomas

AIMnTo investigate endoscopic ultrasound (EUS) for predicting depth of mucosal invasion and to analyze outcomes following endoscopic and transduodenal resection.nnnMETHODSnRecords of 111 patients seen at our institution from November 1999 to July 2011 with the post-operative pathological diagnosis of benign ampullary and duodenal adenomas were reviewed. Records of patients who underwent preoperative EUS for diagnostic purposes were identified. The accuracy of EUS in predicting the absence of muscular invasion was assessed by comparing EUS reports to the final surgical pathological results. In addition, the incidence of the post-operative complications over a period of 30 d and the subsequent long-term outcome (recurrence) over a period of 30 mo associated with endoscopic and transduodenal surgical resection was recorded, compared and analyzed.nnnRESULTSnAmong 111 patients with benign ampullary and duodenal adenomas, 47 underwent preoperative EUS for 29 peri-ampullary lesions and 18 duodenal lesions. In addition, computed tomography was performed in 18 patients, endoscopic retrograde cholangio-pancreatography in 10 patients and esophagogastroduodenoscopy in 22 patients. There were 43 patients with sporadic adenomas and 4 patients with familial adenomatous polyposis (FAP)/other polyposis syndromes. In 38 (81%, P < 0.05) patients, EUS reliably identified absence of submucosal and muscularis invasion. In 4 cases, EUS underestimated submucosal invasion that was proven by pathology. In the other 5 patients, EUS predicted muscularis invasion which could not be demonstrated in the resected specimen. EUS predicted tumor muscularis invasion with a specificity of 88% and negative predictive value of 90% (P < 0.05). Types of resection performed included endoscopic resection in 22 cases, partial duodenectomy in 9 cases, transduodenal ampullectomy with sphincteroplasty in 10 cases and pancreaticoduodenectomy in 6 cases. The main post-operative final pathological results included villous adenoma (n = 5), adenoma (n = 8), tubulovillous adenoma (n = 10), tubular adenoma (n = 20) and hyperplastic polyp (n = 2). Among the 47 patients who underwent resection, 8 (17%, 5 of which corresponded to surgical resection) developed post-procedural complications which included retroperitoneal hematoma, intra-abdominal abscess, wound infection, delayed gastric emptying and prolonged ileus. After median follow-up of 20 mo there were 6 local recurrences (13%, median follow-up = 20 mo) 4 of which were in patients with FAP.nnnCONCLUSIONnEUS accurately predicts the depth of mucosal invasion in suspected benign ampullary and duodenal adenomas. These patients can safely undergo endoscopic or local resection.

Impact of biliary stents on EUS-guided FNA of pancreatic mass lesions

BACKGROUNDnFew studies have evaluated the impact of biliary stents on EUS-guided FNA.nnnAIMnTo compare diagnostic yield of EUS-FNA in patients with or without biliary stents.nnnDESIGNnRetrospective study.nnnSETTINGnTertiary referral center.nnnPATIENTSnPatients with obstructive jaundice secondary to solid pancreatic mass lesions who underwent EUS-FNA over 5 years.nnnMAIN OUTCOME MEASURESnThe primary objective was to compare the diagnostic accuracy of EUS-FNA in patients with or without biliary stents and between patients with plastic stents or self-expandable metal stents (SEMSs). Secondary objectives were to assess the technical difficulty of EUS-FNA by comparing the number of passes required to establish diagnosis and to identify predictors of a false-negative diagnosis.nnnRESULTSnOf 214 patients who underwent EUS-FNA, 150 (70%) had biliary stents and 64 (30%) had no stents in place. Of 150 patients with biliary stents, 105 (70%) were plastic and 45 (30%) were SEMSs. At EUS-FNA, the diagnosis was pancreatic cancer in 155 (72%), chronic pancreatitis in 17 (8%), other cancer in 31 (14%), and indeterminate in 11 (5%). There was no difference in rates of diagnostic accuracy between patients with or without stents (93.7% vs 95.3%; P = .73) and between plastic or SEMSs (95.2% vs 95.5%, P = .99), respectively. Median number of passes to diagnosis was not significantly different between patients with or without stents (2 [interquartile ratio range (IQR) = 1-3] vs 2 [IQR = 1-4]; P = .066) and between plastic or SEMS (2.5 [IQR = 1-4] vs 2 [IQR = 1-4], P = .69), respectively. On univariate analysis, EUS-FNA results were false-negative in patients with large pancreatic masses (>3 cm vs <3 cm, 9.35% vs 0.93%, P = .005) that required more FNA passes (<2 vs >2 passes, 0% vs 11.8%, P < .0001).nnnLIMITATIONSnRetrospective study.nnnCONCLUSIONSnThe presence or absence of a biliary stent, whether plastic or metal, does not have an impact on the diagnostic yield or technical difficulty of EUS-FNA.

Race, Ethnicity, and State-by-State Geographic Variation in Hemorrhagic Stroke in Dialysis Patients

BACKGROUND AND OBJECTIVESnGeographic variation in stroke rates is well established in the general population, with higher rates in the South than in other areas of the United States. A similar pattern of geographic variation in ischemic strokes has also recently been reported in patients undergoing long-term dialysis, but whether this is also the case for hemorrhagic stroke is unknown.nnnDESIGN, SETTING, PARTICIPANTS, & MEASUREMENTSnMedicare claims from 2000 to 2005 were used to ascertain hemorrhagic stroke events in a large cohort of incident dialysis patients. A Poisson generalized linear mixed model was generated to determine factors associated with stroke and to ascertain state-by-state geographic variability in stroke rates by generating observed-to-expected (O/E) adjusted rate ratios (ARRs) for stroke.nnnRESULTSnA total of 265,685 Medicare-eligible incident dialysis patients were studied. During a median follow-up of 15.5 months, 2397 (0.9%) patients sustained a hemorrhagic stroke. African Americans (ARR, 1.43; 95% confidence interval [CI], 1.30 to 1.57), Hispanics (ARR, 1.78; 95% CI, 1.57 to 2.03), and individuals of other races (ARR, 1.51; 95% CI, 1.26 to 1.80) had a significantly higher risk for hemorrhagic stroke compared with whites. In models adjusted for age and sex, four states had O/E ARRs for hemorrhagic stroke that were significantly greater than 1.0 (California, 1.15; Maryland, 1.25; North Carolina, 1.25; Texas, 1.19), while only 1 had an ARR less than 1.0 (Wisconsin, 0.79). However, after adjustment for race and ethnicity, no states had ARRs that varied significantly from 1.0.nnnCONCLUSIONnRace and ethnicity, or other factors that covary with these, appear to explain a substantial portion of state-by-state geographic variation in hemorrhagic stroke. This finding suggests that the factors underlying the high rate of hemorrhagic strokes in dialysis patients are likely to be system-wide and that further investigations into regional variations in clinical practices are unlikely to identify large opportunities for preventive interventions for this disorder.

Relationship between Stroke and Mortality in Dialysis Patients

BACKGROUND AND OBJECTIVESnStroke is common in patients undergoing long-term dialysis, but the implications for mortality after stroke in these patients are not fully understood.nnnDESIGN, SETTING, PARTICIPANTS, & MEASUREMENTSnA large cohort of dually-eligible (Medicare and Medicaid) patients initiating dialysis from 2000 to 2005 and surviving the first 90 days was constructed. Medicare claims were used to ascertain ischemic and hemorrhagic strokes occurring after 90-day survival. A semi-Markov model with additive hazard extension was generated to estimate the association between stroke and mortality, to calculate years of life lost after a stroke, and to determine whether race was associated with differential survival after stroke.nnnRESULTSnThe cohort consisted of 69,371 individuals representing >112,000 person-years of follow-up. Mean age±SD was 60.8±15.5 years. There were 21.1 (99% confidence interval [99% CI], 20.0 to 22.3) ischemic strokes and 4.7 (99% CI, 4.2 to 5.3) hemorrhagic strokes after cohort entry per 1000 patient-years. At 30 days, mortality was 17.9% for ischemic stroke and 53.4% for hemorrhagic stroke. The adjusted hazard ratio (AHR) depended on time since entry into the cohort; for patients who experienced a stroke at 1 year after cohort entry, for example, the AHR of hemorrhagic stroke for mortality was 25.4 (99% CI, 22.4 to 28.4) at 1 week, 9.9 (99% CI, 8.4 to 11.6) at 3 months, 5.9 (99% CI, 5.0 to 7.0) at 6 months, and 1.8 (99% CI, 1.5 to 2.1) at 24 months. The corresponding AHRs for ischemic stroke were 11.7 (99% CI, 10.2 to 13.1) at 1 week, 6.6 (99% CI, 6.4 to 6.7) at 3 months, and 4.7 (99% CI, 4.5 to 4.9) at 6 months, remaining significantly >1.0 even at 48 months. Median months of life lost were 40.7 for hemorrhagic stroke and 34.6 for ischemic stroke. For both stroke types, mortality did not differ by race.nnnCONCLUSIONSnDialysis recipients have high mortality after a stroke with corresponding decrements in remaining years of life. Poststroke mortality does not differ by race.