Otto S. Lin

Cost-effectiveness of screening for hepatocellular carcinoma in patients with cirrhosis due to chronic hepatitis C.

Background : Screening for hepatocellular carcinoma in cirrhotic patients using abdominal ultrasonography and alpha‐foetoprotein levels is widely practiced.

Screening colonoscopy in chinese and western patients : A comparative study

OBJECTIVES:The aim of this study was to compare findings on screening colonoscopy in a Chinese cohort versus a concurrent Western cohort.METHODS:Asymptomatic adults aged 40 years or older concurrently underwent screening colonoscopy in two hospitals, one in Taiwan and the other in Seattle. The prevalence and distribution of colonic neoplasia and advanced neoplasia (defined as an adenoma ≥10 mm or with villous, high-grade dysplastic, or malignant features) were compared between the two groups.RESULTS:The Taiwan cohort was composed of 1,456 subjects. Colonic neoplasms were found in 214 (14.7%), advanced neoplasms in 58 (4%), and colon cancers in 4 subjects (0.3%). The Seattle cohort was composed of 3,403 subjects. Neoplasms were found in 705 (20.7%), advanced neoplasms in 166 (4.9%), and cancers in 11 subjects (0.3%). Age and male sex were risk factors for neoplasia in both groups. The adjusted risk ratio was 1.30 (95% confidence interval: 1.08–1.57) in Western versus Chinese patients. However, the prevalence of advanced neoplasms was not statistically different between the two cohorts. The Chinese cohort had a higher proportion of distal neoplasia (66.4% vs 52.6%; p = 0.0004). The sensitivity of a sigmoidoscopic screening strategy for detecting advanced neoplasia was higher in Chinese (79.3%) than in Western patients (67.5%).CONCLUSIONS:Compared to Westerners, Chinese patients have a slightly lower prevalence of colon neoplasia (but not advanced neoplasia), more distal distribution of neoplasia, and higher likelihood of concomitant proximal advanced neoplasia and distal neoplasia. Colonoscopy is safe, well-tolerated, and a viable screening option in Chinese patients, but its advantage over sigmoidoscopy as a screening tool may be smaller.

Treatment of Barrett's esophagus with early neoplasia: a comparison of endoscopic therapy and esophagectomy.

BACKGROUND Endoscopic therapies for early neoplasia in Barretts esophagus may be a viable alternative to esophagectomy. OBJECTIVE Our purpose was to compare endoscopic therapy and esophagectomy. DESIGN Retrospective review from a single institution. SETTING A medium-sized tertiary referral center. PATIENTS AND INTERVENTIONS All patients with Barretts esophagus and dysplasia or intramucosal carcinoma treated by photodynamic therapy (PDT), EMR, or argon plasma coagulation (APC) or esophagectomy with curative intent from May 1998 until November 2005. MAIN OUTCOME MEASUREMENTS Survival, progression to cancer, eradication of dysplasia and Barretts esophagus, major and minor complications, and costs were compared. RESULTS Sixty-two patients who underwent endoscopic therapy (2 APC alone, 18 EMR + APC, 20 PDT + APC, and 22 EMR + PDT + APC) and 32 patients who underwent esophagectomy met the inclusion criteria. The 30-day mortality rate included 1 patient in the endotherapy group (2%) and none in the surgical group (P = .49). No deaths from esophageal cancer occurred in either group. Cancer developed in 6% of endotherapy patients and in none in the surgical cohort (P < .05). Major and minor complications occurred in 8% and 31% of endotherapy patients, respectively, and 13% and 63% of surgery patients (P = .50, P < .001). Median cost to date was

Endoscopic and Percutaneous Drainage of Symptomatic Walled-Off Pancreatic Necrosis Reduces Hospital Stay and Radiographic Resources

40,079 for endotherapy and

Dual Modality Drainage for Symptomatic Walled-Off Pancreatic Necrosis Reduces Length of Hospitalization, Radiological Procedures, and Number of Endoscopies Compared to Standard Percutaneous Drainage

66,060 for esophagectomy (P < .001). LIMITATIONS Retrospective study, relatively short follow-up, small numbers. CONCLUSIONS Both endotherapy and esophagectomy can effectively treat high-grade dysplasia and intramucosal carcinoma associated with Barretts esophagus. Endotherapy is associated with a higher risk of tumor progression, although this is uncommon. Esophagectomy incurs higher initial costs and results in more frequent minor complications but is usually curative.

Dietary habits and right-sided colonic diverticulosis

BACKGROUND & AIMS Walled-off pancreatic necrosis (WOPN), a complication of severe acute pancreatitis (SAP), can become infected, obstruct adjacent structures, and result in clinical deterioration of patients. Patients with WOPN have prolonged hospitalizations, needing multiple radiologic and medical interventions. We compared an established treatment of WOPN, standard percutaneous drainage (SPD), with combined modality therapy (CMT), in which endoscopic transenteric stents were added to a regimen of percutaneous drains. METHODS Symptomatic patients with WOPN between January 2006 and August 2009 were treated with SPD (n = 43, 28 male) or CMT (n = 23, 17 male) and compared by disease severity, length of hospitalization, duration of drainage, complications, and number of radiologic and endoscopic procedures. RESULTS Patient age (59 vs 54 years), sex (77% vs 58% male), computed tomography severity index (8.0 vs 7.2), number of endoscopic retrograde cholangiopancreatographies (2.0 vs 2.6), and percentage with disconnected pancreatic ducts (50% vs 46%) were equivalent in the CMT and SPD arms, respectively. Patients undergoing CMT had significantly decreased length of hospitalization (26 vs 55 days, P < .0026), duration of external drainage (83.9 vs 189 days, P < .002), number of computed tomography scans (8.95 vs 14.3, P < .002), and drain studies (6.5 vs 13, P < .0001). Patients in the SPD arm had more complications. CONCLUSIONS For patients with symptomatic WOPN, CMT provided a more effective and safer management technique, resulting in shorter hospitalizations and fewer radiologic procedures than SPD.

Ascitic fluid carcinoembryonic antigen and alkaline phosphatase levels for the differentiation of primary from secondary bacterial peritonitis with intestinal perforation

BackgroundSymptomatic walled-off pancreatic necrosis (WOPN) treated with dual modality endoscopic and percutaneous drainage (DMD) has been shown to decrease length of hospitalization (LOH) and use of radiological resources in comparison to standard percutaneous drainage (SPD).AimThe aim of this study is to demonstrate that as the cohort of DMD and SPD patients expand, the original conclusions are durable.MethodsThe database of patients receiving treatment for WOPN between January 2006 and April 2011 was analyzed retrospectively.PatientsOne hundred two patients with symptomatic WOPN who had no previous drainage procedures were evaluated: 49 with DMD and 46 with SPD; 7 were excluded due to a salvage procedure.ResultsPatient characteristics including age, sex, etiology of pancreatitis, and severity of disease based on computed tomographic severity index were indistinguishable between the two cohorts. The DMD cohort had shorter LOH, time until removal of percutaneous drains, fewer CT scans, drain studies, and endoscopic retrograde cholangiopancreatography (ERCPs; p < 0.05 for all). There were 12 identifiable complications during DMD, which were successfully treated without the need for surgery. The 30-day mortality in DMD was 4% (one multi-system organ failure and one out of the hospital with congestive heart failure). Three patients receiving SPD had surgery, and three (7%) died in the hospital.ConclusionDMD for symptomatic WOPN reduces LOH, radiological procedures, and number of ERCPs compared to SPD.

The utility of liver function test abnormalities concomitant with biliary symptoms in predicting a favorable response to endoscopic sphincterotomy in patients with presumed sphincter of Oddi dysfunction.

PURPOSE: In Asian populations, there is a high prevalence of right-sided colonic diverticulosis, the cause of which is uncertain. It is suspected that dietary habits may interact with a congenital predilection to cause this condition. To evaluate the relationship between long-term dietary habits and the prevalence of right-sided diverticulosis in the general population, we performed a retrospective case-control study. METHODS: We reviewed the records of 3,105 screening colonoscopies performed on healthy, asymptomatic adults. All cases of right-sided diverticulosis were selected, and a similar number of gender-matched and age-matched controls with negative colonoscopies were randomly sampled from the same cohort. All case and control subjects were interviewed by a single-blinded nurse to establish their dietary habits during the past decade, in addition to other demographic characteristics. Based on consumption frequency, they were assigned to one of three diet classes for each of three food categories of interest: meat, vegetable, and fruit products. Staple foods such as rice were not included. Odds ratios were then calculated using multivariate conditional logistic regression and tests for trend were performed. RESULTS: A total of 86 cases of right-sided diverticulosis were included, whereas 106 controls were randomly selected. There was a marked association between meat consumption frequency and right-sided diverticulosis, with a trendP value of <0.01 and an odds ratio of 24.81 between the most and least frequent consumers of meat products. Conclusions: The prevalence of right-sided diverticulosis is strongly positively associated with past meat consumption frequency. There is no association with vegetable or fruit consumption frequency, laxative use, supplemental fiber intake, smoking, or family history.

Spiral overtube–assisted colonoscopy after incomplete colonoscopy in the redundant colon

BACKGROUND/AIMS In cirrhotic patients, spontaneous bacterial peritonitis (SBP) may be difficult to distinguish from secondary peritonitis with occult intestinal perforation; Runyons criteria (based on ascitic fluid glucose, protein and lactate dehydrogenase levels) are sensitive but not specific. Ascitic fluid carcinoembryonic antigen (CEA) and alkaline phosphatase (AP) are potential markers for secondary peritonitis. METHODS Ascitic fluid CEA and AP levels were prospectively compared among three subject groups--cirrhotic patients with sterile ascites, cirrhotic patients with SBP, and patients (cirrhotic and non-cirrhotic) with perforation-related secondary peritonitis. RESULTS The secondary peritonitis group (n = 38 including 11 cirrhotic patients) had significantly higher mean CEA and AP levels than the SBP (n = 34) and sterile ascites patients (n = 63). Of secondary peritonitis patients, 92% fulfilled predetermined criteria (either CEA >5 ng/ml or AP >240 units/l) versus only 12% of SBP patients; sensitivity was 92% and specificity 88% for differentiating secondary peritonitis from SBP. Runyons criteria had a sensitivity of 97% and specificity of 56%. Stratification of secondary peritonitis patients by the presence or absence of cirrhosis did not alter our results. CONCLUSIONS Ascitic fluid CEA or AP elevations appear to be sensitive and specific markers for perforation-related secondary peritonitis in cirrhotic as well as non-cirrhotic patients.

Upright versus supine reflux in gastroesophageal reflux disease

Objectives:We sought to study the utility of liver function test abnormalities concomitant with biliary symptoms in predicting a favorable response to endoscopic sphincterotomy in patients with Geenen class II sphincter of Oddi dysfunction.Methods:We reviewed the clinical course and liver function test results of 24 Geenen-Hogan class II postcholecystectomy patients with biliary colic secondary to sphincter of Oddi dysfunction who did not undergo sphincter of Oddi manometry before treatment with endoscopic sphincterotomy.Results:Twenty of the 24 patients had an average of 1.4 episodes of abnormal liver function tests associated with biliary colic; eight patients had dilated common bile duct on cholangiogram. Eighteen of the 20 patients with abnormal liver function tests (90%) were pain-free after sphincterotomy; in contrast, only one of four patients (25%) without liver function test changes responded to sphincterotomy. Fisher exact analysis showed that abnormal liver function tests was a significant predictor for favorable response to sphincterotomy with a two-tail p value of 0.018. Of the eight patients with bile duct dilatation, six (75%) responded favorably to sphincterotomy, whereas 13 of 16 patients (81%) without dilatation also responded to sphincterotomy. Analysis of common bile duct dilatation as a predictive factor showed no significance (p= 1.00).Conclusions:We conclude that the occurrence of abnormal liver function tests during biliary colic may be used to select patients for endoscopic sphincterotomy. Sphincter of Oddi manometry may not be needed in these cases.