Rebecca Burbridge

Endoscopic versus surgical ampullectomy: an algorithm to treat disease of the ampulla of Vater.

Objective: The objective of this study was to compare the effectiveness, morbidity, and mortality associated with endoscopic ampullectomy (EA) and surgical ampullectomy (SA). Background: The proposed management of benign ampullary lesions includes local resection (EA or SA) and en bloc resection (pancreaticoduodenectomy). Most agree that en bloc resection entails a significant morbidity and mortality. No study has previously compared EA and SA for the treatment of benign ampullary lesions. Methods: Medical records of patients selected for ampullectomy at Duke University Medical Center from 1991 to 2010 were reviewed. Results: After review, 109 patients were confirmed to have undergone ampullectomy for a suspected benign ampullary lesion. Sixty-eight patients underwent EA, whereas 41 patients underwent SA. Patients in each group were identical in terms of age, sex, race, and comorbid conditions, except that EA had a higher rate of severe obesity (body mass index >35). Endoscopic ampullectomy was found to have a significantly reduced length of stay, lower morbidity, and readmission rates, but it had similar rates of mortality, margin-positive excisions, and reinterventions. Conclusions: In patients selected for ampullectomy for benign ampullary lesions, EA was found to have equivalent efficacy when compared with SA. Moreover, EA had lower morbidity and identical mortality. These findings suggest that patients would likely benefit from an aggressive endoscopic approach before consideration for surgery.

Variation in Aptitude of Trainees in Endoscopic Ultrasonography, Based on Cumulative Sum Analysis

BACKGROUND & AIMS Studies have reported substantial variation in the competency of advanced endoscopy trainees, indicating a need for more supervised training in endoscopic ultrasound (EUS). We used a standardized, validated, data collection tool to evaluate learning curves and measure competency in EUS among trainees at multiple centers. METHODS In a prospective study performed at 15 centers, 17 trainees with no prior EUS experience were evaluated by experienced attending endosonographers at the 25th and then every 10th upper EUS examination, over a 12-month training period. A standardized data collection form was used (using a 5-point scoring system) to grade the EUS examination. Cumulative sum analysis was applied to produce a learning curve for each trainee; it tracked the overall performance based on median scores at different stations and also at each station. Competency was defined by a median score of 1, with acceptable and unacceptable failure rates of 10% and 20%, respectively. RESULTS Twelve trainees were included in the final analysis. Each of the trainees performed 265 to 540 EUS examinations (total, 4257 examinations). There was a large amount of variation in their learning curves: 2 trainees crossed the threshold for acceptable performance (at cases 225 and 245), 2 trainees had a trend toward acceptable performance (after 289 and 355 cases) but required continued observation, and 8 trainees needed additional training and observation. Similar results were observed at individual stations. CONCLUSIONS A specific case load does not ensure competency in EUS; 225 cases should be considered the minimum caseload for training because we found that no trainee achieved competency before this point. Ongoing training should be provided for trainees until competency is confirmed using objective measures.

Rotational assisted endoscopic retrograde cholangiopancreatography in patients with reconstructive gastrointestinal surgical anatomy

AIM To evaluate the success rates of performing therapy utilizing a rotational assisted enteroscopy device in endoscopic retrograde cholangiopancreatography (ERCP) in surgically altered anatomy patients. METHODS Between June 1, 2009 and November 8, 2012, we performed 42 ERCPs with the use of rotational enteroscopy for patients with altered anatomy (39 with gastric bypass Roux-en-Y, 2 with Billroth II gastrectomy, and 1 with hepaticojejunostomy associated with liver transplant). The indications for ERCP were: choledocholithiasis: 13 of 42 (30.9%), biliary obstruction suggested on imaging: 20 of 42 (47.6%), suspected sphincter of Oddi dysfunction: 4 of 42 (9.5%), abnormal liver enzymes: 1 of 42 (2.4%), ascending cholangitis: 2 of 42 (4.8%), and bile leak: 2 of 42 (4.8%). All procedures were completed with the Olympus SIF-Q180 enteroscope and the Endo-Ease Discovery SB overtube produced by Spirus Medical. RESULTS Successful visualization of the major ampulla was accomplished in 32 of 42 procedures (76.2%). Cannulation of the bile duct was successful in 26 of 32 procedures reaching the major ampulla (81.3%). Successful therapeutic intervention was completed in 24 of 26 procedures in which the bile duct was cannulated (92.3%). The overall intention to treat success rate was 64.3%. In terms of cannulation success, the intention to treat success rate was 61.5%. Ten out of forty two patients (23.8%) required admission to the hospital after procedure for abdominal pain and nausea, and 3 of those 10 patients (7.1%) had a diagnosis of post-ERCP pancreatitis. The average hospital stay was 3 d. CONCLUSION It is reasonable to consider an attempt at rotational assisted ERCP prior to a surgical intervention to alleviate biliary complications in patients with altered surgical anatomy.

Endoscopic Approaches for Early-Stage Esophageal Cancer: Current Options

Early esophageal cancer is confined to the mucosa or submucosa of the esophagus. While most esophageal cancer is detected at an advanced stage (requiring surgical resection, chemotherapy, and radiation), early-stage mucosal lesions may be detected through Barrett’s surveillance programs or incidentally on diagnostic upper endoscopies performed for other reasons. These early-stage cancers are often amenable to endoscopic therapies, including mucosal resection, ablation, and cryotherapy. Studies suggest equivalent survival rates and reduced morbidity but higher recurrence rates with endoscopic removal of early-stage cancers compared to surgical resection. There is emerging data regarding the efficacy and long-term outcomes of endoscopic therapy for early esophageal cancer that is promising, and further research is needed to better define the role of endoscopic therapy in the management of early esophageal cancer.

Groove Pancreatitis: Four Cases from a Single Center and Brief Review of the Literature.

Groove pancreatitis is a rare form of chronic pancreatitis that affects the groove anatomical area between the head of the pancreas, duodenum, and common bile duct. We provide a summary of the clinical findings of 4 groove pancreatitis cases diagnosed at a tertiary academic medical center over a 5-year period. A detailed review of the current literature surrounding this clinical entity is also provided. Although rare, groove pancreatitis should be considered in the differential diagnosis of patients presenting with pancreatic head mass lesions, as appropriate diagnosis can help avoid unnecessary surgical procedures.

Review of complications associated with endoscopic pancreatic cyst-gastrostomy: a single-institution experience.

Background: Pancreatic fluid collections can form after episodes of pancreatitis, either acute or chronic. The majority will resolve spontaneously but when decompression is mandated, endoscopic drainage is the method of choice. However, it is not void of complications. Methods: We retrospectively reviewed the charts of 65 patients who underwent endoscopic drainage of pancreatic fluid collections in our institution. The primary outcomes examined included the incidence and type of complications associated with the endoscopic approach. Results: Endoscopic ultrasound was utilized in 86.2% and transgastric approach was used in 81.5% of the cases. The complication rate was 17%. Specifically, complications recorded were infection (6%), perforation and acute abdomen necessitating surgical intervention (4.6%), pneumoperitoneum that was managed nonoperatively (3%), upper gastrointestinal bleed in the knife puncture site that resolved spontaneously (1.5%), and stent migration (1.5%). One patient died remotely to the endoscopic drainage after paracentesis of ascites that resulted in hemorrhagic shock. Conclusions: This study is one of the largest studies reporting the associated morbidity and mortality after endoscopic cyst-gastrostomy. Major and minor complications occurred at a rate of 17% in our study. Endoscopic approach is a safe draining method and should remain the approach of choice for pancreatic fluid collection decompression.

Pancreatitis Secondary to Celiac Trunk Dissection

Dissection of the visceral arteries happens infrequently, with the superior mesenteric artery being the most commonly affected. Isolated dissection of the celiac trunk is rare, and only a few cases have been reported in the medical literature. We report the case of a 51-year-old male who presented with abdominal pain and was subsequently diagnosed with a celiac trunk dissection with secondary pancreatitis and pancreatic infarction. The patients symptoms improved with conservative medical management. We review the current literature involving celiac trunk dissection and its management, and provide discussion regarding this unrecognized complication of pancreatitis.

Retroperitoneal cystic lymphangioma diagnosed by endoscopic ultrasound-guided fine needle aspiration.

Retroperitoneal cystic lymphangiomas are rare tumors of the lymphatic system. These tumors usually present in childhood and are often diagnosed incidentally with imaging procedures. Although benign, they can grow to large sizes and become symptomatic due to their compressive effects. They can cause diagnostic dilemmas with other retroperitoneal cystic tumors including those arising from the liver, kidney, and pancreas. Endoscopic ultrasound (EUS) has become an invaluable tool in the assessment of cystic lesions in the region of the pancreas. This case describes a 66-year-old female who presented with 3 months of abdominal pain. Radiographic imaging was suggestive of a cystic lesion in the region of the pancreas. EUS was performed confirming a cystic lesion adjacent to the tail of the pancreas with subsequent fine needle aspiration fluid analysis consistent with a cystic lymphangioma.

Does ampullary adenoma size predict invasion on EUS? Does invasion on EUS predict presence of malignancy?

Background and study aims: It is common practice to perform ampullectomy without endoscopic ultrasound (EUS) for ampullary lesions < 1 cm but no data exists to support it. No studies have explored whether EUS findings of invasion correlate with malignancy or high-grade dysplasia (HGD) on pathology. We explored the association between adenoma size, pathology results, and invasion on EUS.  Patients and methods: This was a single-center retrospective cohort study at a large tertiary care academic hospital. Chart review was performed for 161 patients with benign ampullary lesions on endoscopic biopsy (identified by pathology records). The primary outcomes were mean size (mm) of adenomas and pathology findings with and without intraductal and/or duodenal wall invasion on EUS.  Results: Invasion was identified by EUS in 41 (34.1 %) of 120 patients who underwent EUS. The mean size of the lesion in these patients was 20.9 mm (± 11.6 mm) compared to 13.9 mm (± 11.3 mm, P = 0.0001) in patients without invasion. A receiver operating characteristic (ROC) curve (AUC 0.73, 95 % CI 0.63 – 0.83) revealed 100 % sensitivity for absence of invasion on EUS in lesions less than 6.5 mm. Invasion on EUS had sensitivity of 63.0 % (95 % CI 47.0 % – 77.0 %) and specificity 88.0 % (95 % CI 78.0 % – 95.0 %) for presence of malignancy, HGD or invasion on pathology. Conclusions: EUS should be considered for ampullary lesions > 6.5 mm. This study provides evidence to support the practice of ampullectomy without EUS for smaller adenomas. EUS evidence of invasion is highly specific for pathologic malignancy, HGD, or invasion (which preclude endoscopic ampullectomy).

Sa1378 Repeat Endoscopic Ultrasound-Guided Fine Needle Aspiration in Patients With Suspected Pancreatic Neoplasm

G A A b st ra ct s mass prompting biopsy, were excluded. MRI scans performed in patients without a diagnosis of pancreatic cancer served as controls. We used a ratio of 1 control patient for every 3 cancer patients.MRI scans were reviewed in a blinded fashion by two experienced radiologists. A descriptive analysis was performed of MRI findings at 2-24 months prior to the diagnosis of cancer. Agreement between reviewers was assessed via McNemars test and a kappa statistic. Differences between cancer and control group were assessed using chi square tests or fisher exact tests. Results: 550 patients were diagnosed with adenocarcinoma of the pancreas during the study period. 58.3% of patients were men. The average age was 69.9 years (+10.3). Of the cancer patients, 306 had MRI scans. 63 scans were performed in the 2 months to 2 years prior to diagnosis of cancer. 91.3% of scans were unenhanced. MRI Findings are noted in Table 1 and interobserver agreement in Table 2. Comparing MRI of cancer patients to control patients, a solid mass was identified in 41.3% v. 11.8%, p = 0.024. A cystic lesion was identified in 29% v. 17.6%, p = 0.347. Cysts with mural nodules or septations were noted in 11.1% v. 5.9%, p= 0.46. Pancreatic duct (PD) dilation was noted in 54% v. 17.6%, p=0.007. A PD stricture was identified in 47.6% v. 11.8%, p = 0.007. A duct cut-off sign was noted in 42.9% v. 5.9%, p =0.046. Interobserver agreement (kappa) was >0.7 for PD abnormalities. Conclusions: Abnormal findings including solid masses, cystic masses and PD abnormalities were described in nearly 76% of patients undergoing MRI scanning of the abdomen in the 2 years preceding a diagnosis of cancer. Inter-observer agreement was low for the detection of solid or cystic masses. More agreement was noted for the findings of PD abnormalities. Based on high level of association and interobserver agreement, we suggest PD dilation, PD stricture, and PD cut-off sign as the earliest signs for an underlying pancreatic cancer. Table 1: Frequency of MRI Findings in Pancreatic Cancer Patients and Controls