Saad F. Jazrawi

Acute pancreatitis during pregnancy.

BACKGROUND & AIMS Acute pancreatitis is rare during pregnancy; limited data are available about maternal and fetal outcomes. We investigated the effects of acute pancreatitis during pregnancy on fetal outcome. METHODS This retrospective cohort study, performed at a single academic center, included consecutive pregnant women who presented with (n = 96) or developed acute pancreatitis in the hospital (n = 7) in 2000-2006 (mean age, 26 y). Patient histories and clinical data were collected from medical records. RESULTS Of the 96 patients with spontaneous pancreatitis, 4 had complications: 1 patient in the first trimester had acute peripancreatic fluid collection, and 3 patients in the third trimester developed disseminated vascular coagulation (DIC). None of these patients achieved term pregnancy, and 1 of the patients with DIC died. Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 23 patients with acute pancreatitis; post-ERCP pancreatitis was diagnosed in 4 patients (a total of 11 patients developed ERCP-associated pancreatitis). Term pregnancy was achieved in 73 patients (80.2%). Patients who developed pancreatitis in the first trimester had the lowest percentage of term pregnancy (60%) and highest risks of fetal loss (20%) and preterm delivery (16%). Of the patients with pancreatitis in the second and third trimesters, only one had fetal loss. Fetal malformations were not observed. CONCLUSIONS The majority of pregnant patients with acute pancreatitis did not have complications; most adverse fetal outcomes (fetal loss and preterm delivery) occurred during the first trimester. Acute pancreatitis, complicated by DIC, occurred most frequently in the third trimester and was associated with poor fetal and maternal outcomes.

Flexible endoscopic clip-assisted Zenker's diverticulotomy: The first case series (with videos)

Background: In treating Zenkers diverticulum (ZD), there are potential risks associated with performing flexible endoscopic diverticulotomy without suturing or stapling. We recently introduced flexible endoscopic clip‐assisted diverticulotomy (ECD) in treating ZD by securing the septum prior to dissection.

Iatrogenic esophageal submucosal dissection after attempted diagnostic gastroscopy (with videos)

Diagnostic esophagogastroduodenoscopy (EGD) is generally a very safe procedure. We report the first case of iatrogenic esophageal submucosal dissection after an attempted diagnostic gastroscopy in a patient with a small previously undiagnosed Zenkers diverticulum (ZD). After EGD, she developed severe dysphagia with the inability to swallow solids, liquids, and even her own saliva. On barium swallow study, there was a column of contrast below the upper esophageal sphincter, and this was misdiagnosed as a large ZD by the radiologist. The resultant stricture was successfully managed with endoscopic balloon dilatation under fluoroscopy with wire‐guided cannulation. The ZD was treated with flexible endoscopic clip‐assisted diverticulotomy. Iatrogenic submucosal dissection is a unique complication of upper endoscopy. Endoscopists, otolaryngologists, radiologists, and cardiothoracic surgeons should be aware of this condition and prepare to manage it appropriately. If the patient is stable and the possibility of perforation is small, conservative and supportive care can be tried first. A surgical gastrostomy tube can be placed for enteral feeding. In patients with ZD, ZD recognition and gentle manipulation is strongly recommended during esophageal intubation. Laryngoscope, 119:36–38, 2009

Live video manipulator for endoscopy and natural orifice transluminal endoscopic surgery (with videos)

BACKGROUND During fluoroscopy, radiologists and gastroenterologists are able to manipulate live fluoroscopic video for better orientation and visualization. During endoscopy and natural orifice transluminal endoscopic surgery (NOTES), this function is not currently available. Particularly during NOTES, the endoscopic image is sometimes inverted, and off-axis operation is required. OBJECTIVE Our purpose was to develop and test a prototype live video manipulator (LVM) for endoscopy, laparoscopy, and NOTES. DESIGN Prospective ex vivo and in vivo feasibility study. INTERVENTIONS We developed a prototype LVM software for video image manipulation that can be easily installed on any computer. The video input is streamed into the computer and can be displayed on a standard monitor. LVM was tested ex vivo in the following functions: (1) instant live video rotation, (2) vertical or horizontal video inversion, (3) mirror imaging, and (4) digital zooming. These functions were also tested during upper and lower GI endoscopy, ERCP, diagnostic laparoscopy, and various transvaginal NOTES procedures (cholecystectomy, gastroenterostomy, and sleeve gastrectomy) in porcine models. MAIN OUTCOME MEASUREMENTS Image quality observation between unmanipulated and manipulated live videos. RESULTS LVM reliably and easily performed live video manipulation during these tests. Besides standard definition video signals, LVM is fully compatible with high-definition video endoscopy. Three observers reported that the subjective image quality was the same in specified areas between manipulated and unmanipulated live videos. LIMITATIONS Observation and feasibility study. CONCLUSIONS LVM reliably and conveniently performed live video manipulations. LVM requires minimal equipment, capital investment, and maintenance, and is easy to set up. LVM can be a useful tool in many medical imaging studies, including endoscopy, laparoscopy, and NOTES, either as a built-in technology or as an as-needed add-on feature.

Endotherapy in Unusual Bariatric Surgical Complications (with Videos)

Roux-en-Y gastric bypass (RYGBP) is the most commonly performed bariatric operation in the USA. We hypothesize that therapeutic endoscopy can be used to treat some unusual post-operative complications. We report two cases of early post-operative complications: (1) gastrogastrotomy (GG) stricture and (2) “trans-mesenteric tunnel” or “mesocolic” jejunal stricture. Endoscopic strictureplasty/revision of the gastric pouch of a bypass after gastroplasty was performed. The mesocolic stricture was managed with endoscopic dilatation using the achalasia dilating balloon under fluoroscopic and endoscopic guidance. With endotherapy, the patient with the GG stricture did not require re-operation, and there were no complications or stricture recurrence. The patient with mesocolic stricture responded short-term to endotherapy but ultimately required surgical adhesion lysis. None of these patients developed any procedure-related complications. Thus, in patients with unusual post-operative complications after RYGBP, endotherapy may be useful when there is good collaboration between the endoscopist and the surgeon.

Circumferential endoscopic mucosal resection of a 14-cm Barrett's dysplasia with the Duette mucosectomy device (with videos)

Barrett’s esophagus (BE) is associated with a 30to 50fold increased risk for development of esophageal adenocarcinoma. For Barrett’s high-grade dysplasia (HGD) and mucosal cancer, endoscopic ablation such as EMR is emerging as a viable option for potential cure. In EMR, the ‘‘suck and cut’’ technique uses either a transparent cap (‘‘lift and cut’’ method) or a band ligator hood (‘‘ligate and cut’’) method. The ‘‘suck and cut’’ method is the most commonly practiced method for esophageal EMR. The band ligation technique often uses the multiband ligator to place bands on flat mucosa creating a ‘‘pseudopolyp’’ followed by resection with an electrocautery snare. Soehendra et al brilliantly modified the multiband ligator to allow sequential banding and snare resection without the need to withdraw the endoscope. This innovation led to the Duette mucosectomy device (Cook Medical, WinstonSalem, NC). With the availability of the Duette mucosectomy device, endoscopists are able to perform EMR without preinjection and repeated snare loading within the cap, with good endoscopic view, and requiring minimal technical expertise. Although the Duette device is increasingly being used for ablation of localized lesion or short-segment BE, many endoscopists have doubts about using Duette in removing long segments of BE. We report a case of a 14-cm BE with HGD that was circumferentially removed with the Duette device in 2 endoscopic sessions: the distal 2 cm during the first session of EMR for staging and ablation and the proximal 12 cm during the second therapeutic EMR session.

407 Comparison of K-RAS-2 and LOH Mutational Analysis with Pancreas Cyst Fluid CEA Levels and Histology

BACKGROUND: The main objective of pancreatic cyst fluid analysis is to differentiate cysts of mucinous or malignant variety from other cysts which have a benign course. Previous investigators have reported that K-ras-2 point mutation and at least two mutations of allelic imbalance or loss of heterozygosity (LOH) with good quality DNA is characteristic of mucinous cystic neoplasm (MCN). OBJECTIVE: Identify the clinical impact of DNA analysis of pancreatic cyst fluid with its correlation to cyst fluid chemistry and histologic analysis. METHODS: This is a retrospective analysis of all consecutive patients with pancreatic cysts who presented for endoscopic ultrasound (EUS) examination with fine-needle aspiration (FNA) biopsy over an 18 month period until October 2007. DNA analysis was performed by RedPath Integrated Pathology (Pittsburg, PA). Fluid analysis included carcinogenic embryonic antigen (CEA) with values >192ng/dL suggestive of MCN. The standard for comparison was surgical histopathology when available. RESULTS: 27 consecutive patients with cysts and samples submitted for DNA analysis were examined including 15 men and 12 women (mean age 62.8 and 61.3 years, respectively). In 20 patients, all parameters including cyst fluid, DNA analysis, and histology were available for comparison. Consistent findings were seen in 7/20 (35%) in which all parameters suggested negative benign findings. 3/20 (15%) had positive K-ras-2 mutations of which only 2/3 had true histologic MCN suggesting a 33% false positivity. 7/20 (35%) of patients had at least 2 LOH mutations; however only 2/7 were actually positive on histology for MCN suggesting 71% false positivity. In the same group, CEA levels >192ng/dL were seen in 7/20 of which 4/7 had histologic malignancy demonstrating 42.9% false positivity. In a group of 9 malignant cysts (MCN, side branch intraductal papillary mucinous neoplasm, and cystic degeneration of adenocarcinoma), 7 (78%) had CEA levels >192ng/dL. In this group, 7 had DNA analysis of which 4/7 (57.1%) were falsely negative for K-ras-2 and 3/7 (42.9%) falsely negative for LOH. CONCLUSIONS: Consistency in histology, CEA levels, and K-ras-2 and LOH mutations was seen in only 35% of cases, all of which were benign cysts. In the detection of malignant cysts, elevated CEA levels were more predictive of histology in comparison to K-ras-2 or LOH mutations. Additionally, false positivity of LOH mutations was noted to be considerably higher than K-ras-2mutations or even fluid CEA levels. These findings suggest that DNAmutation analysis should not be used routinely but rather selectively in the evaluation of pancreatic cysts.