Patrick R. Pfau

Integrated PET/CT Fusion Imaging and Endoscopic Ultrasound in the Pre-operative Staging and Evaluation of Esophageal Cancer

PurposeAccurate staging of esophageal cancer (ECA) is critical in determining appropriate therapy. Endoscopic ultrasound (EUS), computed tomography (CT) and positron emission tomography (PET) scanning can be used, but limited data exists regarding the use of combined PET/CT fusion imaging and EUS in ECA staging. The objective of this study is to evaluate the role of integrated PET/CT imaging and EUS in the staging of ECA.ProceduresIdentification of patients diagnosed with ECA from 2004 to 2007 that underwent staging PET/CT and EUS. Data regarding tumor detection, lymph node identification, presence of metastatic disease, and affect on patient management were collected and compared between PET/CT and EUS.ResultsEighty-one patients (65 male, 16 female) were identified with mean age of 63.5xa0years who underwent EUS and PET/CT to stage known ECA. PET/CT identified the primary tumor in 74/81 (91.4%) of cases, compared to 81/81 (100%) with EUS. Locoregional adenopathy was seen by PET/CT in 29/81 (35.8%) of cases, compared to 49/81 (60.5%) by EUS (pu2009=u20090.0001). PET/CT identified celiac axis adenopathy in 8/81 (9.9%) of cases, compared to 11/81 (13.6%) with EUS (pu2009=u20090.5050). PET/CT identified 17/81 (21.0%) of patients with distant metastases who subsequently did not undergo attempt at curative surgical resection.ConclusionsIn ECA, EUS is superior to PET/CT for T staging and in identifying locoregional nodes, while PET/CT provides M staging. EUS and integrated PET/CT appear to independently affect treatment decisions, indicating complimentary and necessary roles in the staging of ECA.

Risk factors and outcomes in post–liver transplantation bile duct stones and casts: A case‐control study

Bile duct stones and casts (BDS) after liver transplantation are associated with significant morbidity. Risk factors for BDS formation and the efficacy of treatment in liver transplant recipients have not been systematically studied. The aim of this study was to evaluate potential risk factors for the formation of BDS in patients post–liver transplant. A case‐control study of consecutive liver transplant recipients at a university hospital from 1989 to 2007 was performed to identify risk factors for BDS formation. Cases included all liver transplant recipients with BDS, excluding those with concurrent t‐tubes or biliary stents. Controls were chosen randomly from the total liver transplant population matched for year of transplantation. Pre‐ and post‐OLT risk factors were analyzed with univariate and multivariate analyses. There were 49 cases and 101 controls over an 18‐year‐period (1289 liver transplants performed) with an incidence of 3.8% for BDS. In the cases, the median time to BDS diagnosis was 613 days from time of transplant. The controls had a median follow‐up of 1530 days. Use of ursodeoxycholic acid was protective (P = 0.005), whereas bile duct pathology (P = 0.003), total cholesterol ≥ 200 mg/dL (P = 0.008), and triglyceride ≥ 150 mg/dL (P = 0.008) were significant risk factors for BDS formation. Endoscopic retrograde cholangiopancreatography (ERCP) was technically successful in all cases with resolution or improvement of liver chemistries in 59% (29) of patients. In conclusion, significant risk factors for forming BDS included bile duct pathology and elevated total cholesterol and triglyceride levels. Ursodeoxycholic acid had a significant effect in preventing the development of posttransplant BDS and should be used in those that are at increased risk. ERCP is a safe and effective diagnostic and therapeutic modality for these patients. Liver Transpl 14:1461–1465, 2008.

Laparoscopic-assisted ERCP and EUS in patients with prior Roux-en-Y gastric bypass surgery: a dual-center case series experience

BackgroundPatients with Roux-en-Y gastric bypass (RYGB) develop pancreatobiliary issues after surgery. Endoscopic management via the conventional route with endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) is quite limited due to the altered anatomy. Laparoscopic-assisted ERCP (LA-ERCP) via the excluded stomach has been highly successful. Reported use of laparoscopic-assisted EUS (LA-EUS) is extremely rare.MethodsA retrospective review was conducted at two tertiary referral centers for cases that involved laparoscopic-assisted ERCP and EUS. Patient demographic data were collected along with data regarding procedure, indication, complications and length of stay.ResultsA total of 16 cases involving 15 patients were identified: 11 cases of LA-ERCP and five cases of combined LA-EUS plus LA-ERCP were performed. Four patients had previously undergone failed endoscopy via the conventional route (27xa0%). There was a 100xa0% biliary/pancreatic cannulation and intervention rate. There were no endoscopic-related complications. Therapeutic interventions included laparoscopic cholecystectomy, lysis of adhesions, biliary and pancreatic sphincterotomy, biliary and pancreatic stent placement, stone removal including mechanical lithotripsy and EUS biopsy and diagnosis of pancreatic cancer. Average discharge was on postoperative day 3.4. However, 50xa0% were discharged after 1xa0day.ConclusionsLA-ERCP and combined LA-EUS plus LA-ERCP are safe and highly successful diagnostic and therapeutic modalities for a wide variety of pancreatobiliary ailments in RYGB patients.

Hemorrhagic emphysematous cholecystitis presenting as obstructive jaundice and hemobilia.

A 49-year-old woman had right upper quadrant abdominal pain, jaundice, and a temperature of 104 F. Total bilirubin was 6.4 mg/dL (normal 0.0-1.4 mg/dL), and alkaline phosphatase was 313 U/L (normal 35-130 U/L). Shortly after admission, the patient had hematemesis. Upper endoscopy was performed and revealed blood in the second portion of the duodenum that appeared to originate from the area of the ampulla. With the use of a side-viewing duodenoscope, active hemorrhage was seen to be coming from the ampulla (A). CTof the abdomen with and without intravenous contrast revealed gallbladder wall thickening, high attenuation fluid in the gallbladder consistent with blood (B, arrowhead), gallstones in the cystic duct and gallbladder (B, arrow), and nondependent gas within the gallbladder lumen (C, arrow). Cholecystectomy was performed. Pathologic examination of the gallbladder revealed cholelithiasis and cholecystitis with diffusely hemorrhagic mucosa. The patient was discharged in good condition on postoperative day 10.

Rectal Indomethacin to Prevent Post-ERCP Pancreatitis

1 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 Dear Editors: We read with great interest the study by Levenick et al on the utility of rectal indomethacin in consecutive patients to prevent post-ERCP pancreatitis (PEP). We congratulate the authors on their publication, but query some additional limitations that may influence the generalizability of this study especially in patients at high risk for PEP. The aim of this study was to investigate the utility of rectal indomethacin for all patients undergoing ERCP including those at average risk. As such, 449 consecutive patients at a single tertiary medical center were randomized to receive 100 mg of rectal indomethacin or placebo and they found no significant difference in rates of PEP, severity of pancreatitis, or gastrointestinal bleeding. However, the trial was stopped by the Dartmouth Data and Safety Monitoring Committee prior to achieving the estimated number of patients required to achieve a power of 80% and allow for detection of a 50% reduction in the rate of PEP between the treatment and placebo group. 699 patients in each study group were required to provide adequate power based upon on internal estimates, however, approximately only 32% of the estimated population required were enrolled. Though there was a trend of increased incidence of PEP in the indomethacin group, the early termination of the study may have prevented these findings from becoming significant and even reversed if it had been allowed to achieve its aforementioned power. Consequently, the results of this study should not be used to avoid indomethacin in all patient groups as the results of this study are underpowered and may be due to chance. This study is in contrast to Elmunzer et al who demonstrated rectal indomethacin does decrease the incidence of PEP; albeit in patients at high risk. Patient related factors that increase the risk of PEP include female gender, history of PEP, and sphincter of Oddi dysfunction (SOD). A metaanalysis by Yaghoobi et al of four randomized controlled trials (RCTs) demonstrated a decrease of approximately 50% of PEP with the use of rectal indomethacin compared to placebo in both high and low risk patients. In review of the study by Levenick et al we find no difference regarding patient risk factors between the treatment and control