Pari Shah

Use of antimicrobials for EUS-guided FNA of pancreatic cysts: a retrospective, comparative analysis

BACKGROUND Pancreatic cystic lesions present a challenge for patients and physicians alike. Morphology alone is inaccurate in discriminating lesion pathology, and use of EUS-guided FNA (EUS-FNA) improves accuracy. Current American Society for Gastrointestinal Endoscopy guidelines recommend prophylactic antibiotics during FNA of cystic lesions to minimize infection risk. However, evidence pertaining to infection risk has been conflicting. The use of prophylactic antibiotics might not be free of other adverse events and might not prevent infection. OBJECTIVE To assess the impact of antimicrobial therapy for prophylaxis during EUS-FNA of pancreatic cysts. DESIGN Retrospective cohort study. PATIENTS This study involved all patients who underwent EUS-FNA of pancreatic cysts at one institution from May 2007 to April 2010. INTERVENTION Antibiotic prophylaxis for EUS-FNA. MAIN OUTCOME MEASUREMENTS Infection of a pancreatic cyst, fever, or bacteremia after EUS-FNA. Secondary variables included other complications of the procedure related to the use of prophylaxis (ie, allergic reactions, secondary infections). RESULTS EUS-FNA was performed on 253 patients in 266 procedures. Antibiotics were used in 88 endoscopy cases (ATB group), whereas no antibiotics were used in 178 cases (NATB group). There were no differences in patient or cyst characteristics between groups. There were 4 major complications in the NATB group (localized bleeding, 2; pancreatitis, 1; bile leakage, 1) and 2 in the ATB group (possible cyst infection, 1; bile leakage, 1) (P = 1.0). Eight mild adverse events were observed in the NATB group and 6 in the ATB group (P = .56). Infections and antibiotic-related complications occurred in 1 (0.6%) (transient fever) in the NATB group and 4 (4.5%) in the ATB group (local allergic reaction, 2; possible cyst infection, 1; Clostridium difficile diarrhea, 1) (P = .04). LIMITATIONS Retrospective analysis. CONCLUSION The incidence of infectious complications after EUS-FNA of pancreatic cystic lesions, with or without antibiotic prophylaxis, appears very low. We have not observed a protective effect from periprocedural prophylactic antibiotic administration.

Endoscopic retrograde cholangiopancreatography in the pediatric population is safe and efficacious

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is increasingly being used in the evaluation and management of biliary and pancreatic disorders in children. The aim of this study was to review the pediatric ERCP experience of a large academic referral center affiliated with a tertiary care childrens hospital. Methods: This is a retrospective review of medical records, endoscopic and operative reports, and radiography of those patients ages 0 to 21 years who underwent ERCP for any indication between 1993 and 2011 at a tertiary referral center affiliated with a large urban pediatric hospital. ERCP technical success was defined as cannulation of the desired duct. Serious adverse events included bleeding, perforation, pancreatitis, or death. Results: Four hundred twenty-nine ERCPs were performed on 296 patients. The mean age was 14.9 ± 4.8 years (3 months–21 years); 51.1% were boys. Patients with a history of previous liver transplant comprised 13.1% (56) of all ERCPs. Abnormal liver chemistries or suspected choledocholithiasis accounted for half of the indications. A therapeutic intervention was performed in 64.1%. Technical success was achieved in 95.2% of ERCPs. Serious adverse events occurred in 7.7%. Conclusions: Pediatric ERCP is highly efficacious in the pediatric population, with the rates of technical success and use of therapeutic interventions mirroring those in adults. There is a low overall rate of serious adverse events. The overall efficacy and safety support the performance of pediatric ERCP by experienced endoscopists at high-volume centers.

Endoscopic options for early stage esophageal cancer

Surgery has traditionally been the preferred treatment for early stage esophageal cancer. Recent advances in endoscopic treatments have been shown to be effective and safe. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) allow endoscopists to remove small, superficial lesions, providing tumor specimen that can be examined for accurate pathologic tumor staging and assessment of adequacy of resection. Endoscopic ablation procedures, including photodynamic therapy (PDT) and radio frequency ablation (RFA), have also been shown to safely and effectively treat esophageal dysplasia and early stage neoplasia, with excellent long-term disease control. Both approaches are becoming more widely available around the world, and provide an alternative, safe, low risk strategy for treating early stage disease, making combined endoscopic therapy the recommended treatment of choice for early stage esophageal cancers.

Hypochlorhydria and achlorhydria are associated with false-positive secretin stimulation testing for Zollinger-Ellison syndrome.

Objectives Secretin stimulation testing (SST) is used to evaluate patients with hypergastrinemia in the diagnosis of Zollinger-Ellison syndrome. Case series have documented false-positive SST in patients with achlorhydria. This study reviews our experience with SST in hypochlorhydric and achlorhydric patients. Methods We examined 27 patients with hypochlorhydria or achlorhydria based on a predefined basal acid output (BAO) measurement of less than 5.0 mEq/h who also underwent SST for diagnosis of Zollinger-Ellison syndrome. We report the frequency of false-positive SST results in this setting. Results Three hundred thirty patients underwent gastric analysis of which 27 had BAO of less than 5.0 mEq/h and SST conducted. The mean (SD) fasting gastrin level was 247 (304) pg/mL, and the mean (SD) BAO measurement was 1.6 (1.8) mEq/h. Twenty patients were off, and 7 were on antisecretory therapy at time of testing. Four patients had false-positive SST results: 3 with gastric atrophy (BAO = 0 mEq/h) and 1 with drug-induced hypochlorhydria (BAO = 0.5 mEq/hr). These false-positive test results were confirmed by structural and functional imaging studies. Conclusions We have identified a 14.8% false-positive rate in SST in patients with hypochlorhydria or achlorhydria. Growing literature has identified severe consequences associated with discontinuing antisecretory treatment for testing; therefore, SST will require interpretation in the setting of gastric acid suppression and needs to be interpreted in this context.

Endoscopic Management of Esophageal Anastomotic Leaks After Surgery for Malignant Disease

BACKGROUND Esophageal anastomotic leaks after cancer surgery remain a major cause of morbidity and mortality. Endoscopic interventions, including covered metal stents (cSEMS), clips, and direct percutaneous endoscopic jejunostomy (dPEJ) tubes are increasingly used despite limited published data regarding their utility in this setting. This study aimed to determine the efficacy and safety of a multimodality endoscopic approach to anastomotic leak management after operation for esophageal or gastric cancer. METHODS We performed a retrospective review of prospectively maintained databases of gastric and esophageal operations at our hospital between January 2003 and December 2012. Included patients had an operation for esophageal or gastric cancer, demonstrated evidence of an anastomotic leak at the esophageal anastomosis, and underwent attempted endoscopic therapy. Healing was defined as clinical and radiographic leak resolution. RESULTS Forty-nine patients with leaks underwent endoscopic management. Of the 49 patients, 31 (63%) received cSEMS, 40 (82%) had dPEJ tubes inserted, and 3 (6%) received clips. Twenty-three (47%) patients underwent a combined approach. Overall, 88% of patients achieved healing in a median of 83 days. Twenty-two of 23 patients (96%) who underwent a multimodality endoscopic approach healed. Only 1 patient had a major complication associated with stent erosion into the pulmonary artery, which was successfully treated with operative repair. CONCLUSIONS Esophageal anastomotic leaks after esophageal and gastric cancer operations can be managed successfully and safely with endoscopic therapy. Combining cSEMS for leak control and dPEJ tube placement for nutritional support was highly effective in achieving healing, without the need for surgical repair.

Risk factors for aggressive nonfunctional pancreatic neuroendocrine tumors and the role of endoscopic ultrasound guided fine-needle aspiration.

Background: Nonfunctional pancreatic neuroendocrine tumors (NF-pNETs) are increasingly being diagnosed but management, especially of small tumors, remains a clinical dilemma. Endoscopic ultrasound guided fine-needle aspiration (EUS-FNA) is now routinely used for diagnosis of pancreatic neuroendocrine tumors (pNETs) but has not been well studied as a tool for identifying aggressive disease. Materials and Methods: A systematic search of the cytology database identified all patients at our center who underwent EUS-FNA from 1999 through 2011 and were diagnosed with NF-pNET. Results: A total of 50 patients were identified. Though patients with metastatic disease had a mean tumor size of 40 mm compared to 25 mm in patients without metastatic disease (P = 0.04), we also identified several patients with tumors <20 mm who presented with metastatic disease. Furthermore, we found no statistically significant difference in metastatic disease between tumors <20 mm and >20 mm (P = 0.13). Using receiver operating characteristic (ROC) analysis, we found that using a cutoff point of 20 mm only led to a sensitivity of 85% in screening for metastases, while lowering the cutoff point to 18 mm allowed for a sensitivity of 95%. Conclusion: Currently, guidelines suggest that only patients with tumors greater than 20 mm undergo surgical resection, as tumors less than this size are thought to have low risk of metastases. Our analysis suggests that these recommendations could lead to undertreating patients with small tumors. Tumor size alone may be inadequate as a marker for aggressive NF-pNETs. Given this, other risk factors for aggressive pNETs should be studied to help identify the patients most likely to benefit from surgery.

Diagnosis of pernicious anemia and the risk of pancreatic cancer.

Objectives A number of studies have demonstrated a trophic effect of gastrin on pancreatic cancer cells in vitro. Pernicious anemia (PA) is a clinical condition characterized by chronic hypergastrinemia. The aim of this study was to determine if PA is a risk factor for pancreatic cancer. Methods This study is a retrospective cohort study using The Health Improvement Network database, which contains comprehensive health information on 7.5 million patients in the United Kingdom from 1993 to 2009. All patients with PA in the study cohort were identified and composed of the exposed group. Each exposed patient was matched on practice site, sex, and age with up to 4 unexposed patients without PA. The outcome was incident pancreatic cancer. The hazard ratio and 95% confidence intervals were estimated using multivariable Cox regression analysis. Results We identified 15,324 patients with PA and 55,094 unexposed patients. Mean follow-up time was similar between groups (exposed 4.31 [SD, 3.38] years, unexposed 4.63 [SD, 3.44] years). The multivariable adjusted hazard ratio for pancreatic cancer associated with PA was 1.16 (95% confidence interval, 0.77-1.76; P = 0.47). Conclusions There is no significant association between PA and the risk of pancreatic cancer.

Endoscopic Balloon Dilation: The Panacea for Crohn's Strictures?

Faten Aberra, Philadelphia, PA Nuzhat A. Ahmad, Philadelphia, PA Hans-Dieter Allescher, GermischPartenkirchen, Germany Jordi Bruix, Barcelona, Spain Lin Chang, Los Angeles, CA William Chey, Ann Arbor, MI Tsutomu Chiba, Kyoto, Japan Massimo Colombo, Milan, Italy Marcia Cruz-Corra, San Juan, PR Jason Dominitz, Seattle, WA James Farrell, Los Angeles, CA Lauren B. Gerson, Stanford, CA W. Ray Kim, Rochester, MN George Lau, Hong Kong, China Joseph M. Llovet, New York, NY Peter Mannon, Birmingham, AL Julian Panes, Barcelona, Spain Eamonn Quigley, Cork, Ireland Shiv K. Sarin, New Delhi, India Shamita B. Shah, Stanford, CA Nathan Subramaniam, Brisbane, Australia George Triadafilopoulos, Stanford, CA Kenneth K. Wang, Rochester, MN Thomas D. Wang, Ann Arbor, MI Alastair J. M. Watson, Liverpool, UK Sheila Crowe, Charlottesville, VA Raoul Poupon, Paris, France Stefan Zeuzem, Frankfurt, Germany

Tu1222 A Low CEA Cut-off Identifies Mucinous Pancreatic Cystic Lesions With Increased Diagnostic Accuracy

G A A b st ra ct s was used to measure CEA in cyst fluid. Results: Consistent with recent concerns1, the intra-class correlation (ICC) between undiluted cyst fluid CEA measurements and CEA measurements from cyst fluid diluted in UD or saline was only 0.5 (Figure 1). The low ICC was due to significant positive bias in the measurement of CEA in about 1/2 of the cyst fluids that were diluted with UD or saline (Mean bias UD or saline = 0.6, P-values , 0.0001). Similarly, the ICC between undiluted CEA measurements and CEA measurements diluted in RPD was only 0.5. However, about 1/2 RPD diluted fluids had significant negative bias in the measurement of CEA (Mean bias RPD = 2.5, P-value , 0.0001). Based on these observations, we determined cyst fluid biochemical characteristics that could identify fluids that when excluded from the analysis removed the positive and negative bias observed with each respective diluent. When these biochemical characteristics were used to dictate which diluent to implement, the resulting ICC between diluted and undiluted CEA was 0.9 (Figure 1). The use of each diluent based on these biochemical properties removed all significant bias in the CEA measurement (Mean bias saline [or UD] and RPD = 1.3, P-value = 0.4). Conclusions: Cyst fluid dilution can significantly impact the accuracy of CEA measurement. Dilution induced errors in CEA are due to properties of cyst fluid samples. The use of saline (or UD) and RedPaths novel diluent (RPD), based onmeasurable biochemical fluid properties, results in more accurate CEA measurement in diluted pancreatic cyst fluid. References: 1 Boot, C. S., et al. Clinical chemistry 56, 1351-1352, doi:10.1373/clinchem.2010.146373 (2010).

Gastric Polyps and Thickened Gastric Folds

Abstract Examination of the stomach by upper endoscopy (EGD) often results in the incidental finding of gastric polyps or thickened gastric folds. Gastric polyps have been identified in 6% to 8% of all upper endoscopy exams. Most series report that the most common type of polyp encountered is the fundic gland polyp (77% to 80%) followed by the hyperplastic polyp (17% to 19%), though series differ through time and based on the series of patients being evaluated. Generally, patients with gastric polyps are asymptomatic, but polyps may cause clinical manifestations including gastrointestinal bleeding, iron deficiency anemia, and gastric outlet obstruction. Many of these lesions are benign, whereas others have malignant potential; understanding and recognizing the various diagnoses and malignant risk may impact endoscopic treatment, future management, and surveillance recommendations. Gastric polyps are generally defined as lesions in the lumen of the stomach with protrusion above the mucosal plane. These lesions may be epithelial or subepithelial at their presentation. This chapter reviews the most common etiologies of epithelial gastric polyps and discusses the endoscopic approach to management of these lesions. At the conclusion of this chapter, we discuss the evaluation of thickened gastric folds and outline the endoscopic approach to these entities.