Whitney Jones

Risk factors for post-ERCP pancreatitis: a prospective multicenter study.

OBJECTIVES:Pancreatitis is the most common and serious complication of diagnostic and therapeutic ERCP. The aim of this study is to examine the potential patient- and procedure-related risk factors for post-ERCP pancreatitis in a prospective multicenter study.METHODS:A 160-variable database was prospectively collected by a defined protocol on patients undergoing diagnostic or therapeutic ERCP at 15 centers in the Midwest Pancreaticobiliary Group and participating in a randomized controlled study evaluating whether prophylactic corticosteroids will reduce the incidence of post-ERCP pancreatitis. Data were collected prior to the procedure, at the time of procedure, and 24–72 h after discharge. Post-ERCP pancreatitis was diagnosed and its severity graded according to consensus criteria.RESULTS:Of the 1,115 patients enrolled, diagnostic ERCP with or without sphincter of Oddi manometry (SOM) was performed in 536 (48.1%) and therapeutic ERCP in 579 (51.9%). Suspected sphincter of Oddi dysfunction (SOD) was the indication for the ERCP in 378 patients (33.9%). Pancreatitis developed in 168 patients (15.1%) and was graded mild in 112 (10%), moderate in 45 (4%), and severe in 11(1%). There was no difference in the incidence of pancreatitis or the frequency of investigated potential pancreatitis risk factors between the corticosteroid and placebo groups. By univariate analysis, the incidence of post-ERCP pancreatitis was significantly higher in 19 of 30 investigated variables. In the multivariate risk model, significant risk factors with adjusted odds ratios (OR) were: minor papilla sphincterotomy (OR: 3.8), suspected SOD (OR: 2.6), history of post-ERCP pancreatitis (OR: 2.0), age <60 yr (OR: 1.6), ≥2 contrast injections into the pancreatic duct (OR: 1.5), and trainee involvement (OR: 1.5). Female gender, history of recurrent idiopathic pancreatitis, pancreas divisum, SOM, difficult cannulation, and major papilla sphincterotomy (either biliary or pancreatic) were not multivariate risk factors for post-ERCP pancreatitis.CONCLUSION:This study emphasizes the role of patient factors (age, SOD, prior history of post-ERCP pancreatitis) and technical factors (number of PD injections, minor papilla sphincterotomy, and operator experience) as the determining high-risk predictors for post-ERCP pancreatitis.

A prospective, randomized, controlled trial of covered expandable metal stents in the palliation of malignant esophageal obstruction at the gastroesophageal junction

OBJECTIVE:Palliation of malignant esophageal obstruction is an important clinical problem. Expandable metal stents are a major advance in therapy, but many stents become obstructed because of tumor ingrowth. The aim of this study was to compare a new, membrane-covered expandable metal stent to conventional prostheses in a randomized controlled trial.METHODS:Sixty-two patients with malignant inoperable esophageal obstruction at the gastroesophageal junction participated in the study. Patients were randomly assigned to covered or uncovered stents. The principal outcome measure was the need for reintervention because of recurrent dysphagia or migration. Secondary endpoints were relief of dysphagia measured by a dysphagia score (grade 0 = no dysphagia, grade 1 = able to eat solid food, grade 2 = semisolids only, grade 3 = liquids only, grade 4 = complete dysphagia) and the rate of complications and functional status. All patients were observed at monthly intervals until death or for 6 months.RESULTS:One week after stenting the dysphagia score improved significantly in both the uncovered (n = 32, 3 ± 0.1 to 1 ± 0.1 [means ± SEMs], p < 0.001) and covered (n = 30, 3 ± 0.1 to 1 ± 0.2 [means ± SEMs], p < 0.001) stents. Obstructing tumor ingrowth was significantly more likely in the uncovered stent group (9/30) than in the covered group (1/32) (p = 0.005). Significant stent migration occurred in 2/30 patients with uncovered stents, as compared with 4/32 patients in the covered group (p = 0.44). Reinterventions for tumor ingrowth were significantly greater in the uncovered stent group (27%), as compared with 0% in the covered group (p = 0.002). Life table analysis showed similar survival in both groups.CONCLUSION:Membrane-covered stents have significantly better palliation than conventional bare metal stents because of decreased rates of tumor ingrowth that necessitate endoscopic reintervention for dysphagia.

The Increasing Incidence of Young-Onset Colorectal Cancer: A Call to Action

In the United States, colorectal cancer (CRC) is the third most common and second most lethal cancer. More than one-tenth of CRC cases (11% of colon cancers and 18% of rectal cancers) have a young onset (ie, occurring in individuals younger than 50 years). The CRC incidence and mortality rates are decreasing among all age groups older than 50 years, yet increasing in younger individuals for whom screening use is limited and key symptoms may go unrecognized. Familial syndromes account for approximately 20% of young-onset CRCs, and the remainder are typically microsatellite stable cancers, which are more commonly diploid than similar tumors in older individuals. Young-onset CRCs are more likely to occur in the distal colon or rectum, be poorly differentiated, have mucinous and signet ring features, and present at advanced stages. Yet, stage-specific survival in patients with young-onset CRC is comparable to that of patients with later-onset cancer. Primary care physicians have an important opportunity to identify high-risk young individuals for screening and to promptly evaluate CRC symptoms. Risk modification, targeted screening, and prophylactic surgery may benefit individuals with a predisposing hereditary syndrome or condition (eg, inflammatory bowel disease) or a family history of CRC or advanced adenomatous polyps. When apparently average-risk young adults present with CRC-like symptoms (eg, unexplained persistent rectal bleeding, anemia, and abdominal pain), endoscopic work-ups can expedite diagnosis. Early screening in high-risk individuals and thorough diagnostic work-ups in symptomatic young adults may improve young-onset CRC trends.

A Novel External Esophageal Perfusion Model for Reflux Esophageal Injury

The current animal models of esophagitis and Barrett’s esophagus consist of surgeries that divert the gastroduodenal contents to the esophagus. The limitations of these models are the inability to control the amount and concentration of the refluxate and the causing of significant postoperative stress and morbidity. Eighteen adult rats were cannulated at the upper esophagus and connected to a subcutaneous osmotic micropump to perfuse the esophageal lumen with bile and acid. Animals were sacrificed after 7 days of perfusion. Histological changes were determined. Cell proliferation, apoptosis, lipid peroxidation, and glutathione were measured. Histopathological changes in the bile- or acid-perfused esophagus were consistent with the findings associated with reflux esophagitis. Enhanced proliferation and apoptosis were seen, along with increased oxidative stress. The external esophageal perfusion model enabled precise control of the injurious agent. It induced the histologic and cellular injurreflux esophagitis after 7 days.

Association of Metallothionein Expression and Lack of Apoptosis with Progression of Carcinogenesis in Barrett’s Esophagus

Barretts esophagus is the transformation of normal esophageal squamous epithelium to specialized intestinal metaplasia (SIM). Among the Barretts specialized cells, those that can develop protective mechanisms against apoptosis may have potential to become malignant. Studies have shown that overexpression of metallothionein (MT), low molecular protein that protects cells from apoptotic stimuli, appears to be associated with more advanced, highly malignant tumors. We thus investigated the relationship between MT expression and apoptosis in different stages of Barretts carcinogenesis. Terminal deoxyribonucleotidyl transferase-mediated dUTP-digoxigenin nick end labeling and immunohistochemical dual-staining assay were performed in human biopsy samples of normal, SIM, dysplasia, and adenocarcinoma. Apoptotic index and MT expression were quantified by using an image system to analyze the converted digital data. A negative correlation between MT expression and apoptotic index was found. MT expression was significantly increased along with the histologic progression towards adenocarcinoma. This study thus suggests that MT may contribute to cytoprotection, thereby inhibiting apoptosis and leading to carcinogenesis of Barretts esophageal cells.

Role of esophageal stents in the nutrition support of patients with esophageal malignancy.

Endoluminal stents are commonly used for palliative treatment of dysphagia in patients with advanced esophageal malignancies. The most frequently used esophageal stents are self-expanding metal stents. Removable self-expanding plastic stents have recently been used in the management of esophageal cancer patients treated with curative intent. Esophageal stents effectively alleviate dysphagia in most patients, and stent placement is associated with a low rate of complications. This article reviews the use of self-expanding esophageal stents in patients with esophageal cancer. Nutrition considerations following stent placement are addressed.

Does obesity confer an increased risk and/or more severe course of post-ERCP pancreatitis?: A retrospective, multicenter study

Background Pancreatitis is the most common major complication of endoscopic retrograde cholangiopancreatography (ERCP). Recent studies have suggested that obesity may serve as a prognostic indicator of poor outcome in non-ERCP–induced acute pancreatitis. However, to our knowledge, no one has ever investigated the potential association of obesity and ERCP-induced pancreatitis. Thus, the purpose of our study was to determine whether obesity conferred an increased risk and/or more severe course of post-ERCP pancreatitis. Methods A 160 variable database was prospectively collected by a defined protocol on patients undergoing diagnostic or therapeutic ERCP at 15 centers in the Midwest Pancreaticobiliary Group and participating in a randomized controlled study, evaluating whether prophylactic corticosteroids reduces the incidence of post-ERCP pancreatitis. Body mass indices (BMIs) were available on 964 of the 1115 patients from the original study. A BMI ≥30 kg/m2 was defined as obese (World Health Organization) and used as a cutoff point in this study. BMIs were analyzed in a retrospective fashion to determine whether obesity confers an increased risk and/or more severe course of post-ERCP pancreatitis. Data were collected before the ERCP, at the time of procedure, and 24 to 72 hours after discharge. Standardized criteria were used to diagnose and grade the severity of postprocedure pancreatitis. Results Nine hundred sixty four patients were enrolled in the study. Pancreatitis occurred in 149 patients (15.5%) and was graded as mild in 101 (67.8%), moderate in 42 (28.2%), and severe in 6 (4.0%). The patients were categorized by BMI (kg/m2) using the following breakdowns: BMI <20, 20 to <25, 25 to <30, and ≥30, as well as BMI <30 or ≥30. The groups were similar with respect to the patient and procedure risk factors for post-ERCP pancreatitis except the group with BMI≥30 had a higher frequency of females, were younger, had less frequent chronic pancreatitis, a lower number of pancreatic duct injections, and fewer patients received more than 2 pancreatic duct injections. Of the patients with a BMI <30, 119 (16.4%) developed post-ERCP pancreatitis compared with 30 (12.5%) of those with a BMI≥30 (P=0.14). There was no association between the presence of obesity and the severity of pancreatitis (P=0.74). Patients with a BMI <20, 20 to <25, 25 to <30, and ≥30 had a similar incidence of post-ERCP pancreatitis. Conclusions Obesity did not seem to confer an increased risk for ERCP-induced pancreatitis. A statistically significant association between obesity and the severity of ERCP-induced pancreatitis was not apparent.

Do physician attitudes and practices limit use of EUS in the staging and the treatment of esophageal carcinoma

BACKGROUND Although EUS provides superior local staging of esophageal carcinoma when compared with other tests, EUS seems to be underused by physicians. We designed this prospective study to determine whether EUS is ordered in the evaluation of esophageal cancer and whether staging information obtained would change management. METHODS A total of 114 physicians were mailed a questionnaire that surveyed which tests are used in evaluating patients with esophageal cancer, the order in which they are requested, and their estimated cost. Physicians were asked to estimate prognosis and to indicate which therapy would be used for each specific TNM cancer stage. RESULTS Of 114 physicians, 71 (62.3%) physicians from 4 disciplines responded. Only 47.3% of physicians would use EUS in the patient workup for esophageal cancer. Physicians would only order EUS after first obtaining an endoscopy, then a barium swallow, and then a CT scan ( p < 0.0001). A significantly greater number of internists (78.9%, p = 0.055) would not order EUS, and 31.6% of internists would not use any staging data before referral to another physician for definitive management. Physicians were accurate in their assessment of the prognosis for each cancer stage and the cost of each test. There was no difference in the use of surgery between disciplines for stages O, I, IIA, and IV. However, significantly more surgeons than nonsurgeons would use surgery for stage IIB (100.0% vs. 71.3%, p = 0.019), with a trend toward greater use by surgeons for stage III (64.3% vs. 34.1%, p = 0.11). Except for significantly greater use of chemotherapy by surgeons and oncologists for stage IIA than internists and gastroenterologists (36.6% vs. 3.1%, p = 0.0006), there were no differences between subspecialties with use of chemotherapy for all other stages or use of radiation therapy for any stage. CONCLUSIONS Clinicians have an adequate understanding of patient survival based on cancer stage and a reasonable appreciation of cost for diagnostic tests regarding esophageal carcinoma. Specific data on cancer staging does impact treatment choices and management decisions. EUS is grossly underused by clinicians for staging esophageal cancer. Although internists may serve as gatekeepers, they fail to order EUS, order EUS only after less accurate tests, or fail to use staging data in management (especially referral) decisions. The ultimate modality of treatment may be more related to the type of physician that the patient is referred to, instead of the specific cancer stage. Education of primary care clinicians may be needed before the full impact of EUS on patient care can be appreciated.

7055 Management decision making in esophageal carcinoma: does use of eus obviate the need for ct scanning?

INTRO: Despite greater accuracy with EUS, CT scan is used as the initial staging modality by most physicians.We designed this study to determine whether use of EUS as the primary diagnostic test would change management strategy and impact the utility of information obtained by CT scan. METHODS: Patients with esophageal cancer referred for EUS with concurrent CT scan were studied. EUS TNM stage, determined prospectively, was compared retrospectively to CT scan. Decisions for chemoRx, XRT, and surgery for each stage were determined from our previous survey (Gastro Endo 1996;43:553) by majority of 71 physicians from 4 specialties. Impact of testing sequence was determined by alternating the order of the 2 tests, evaluating change in treatment based on the first test due to information obtained by the second test. Statistical analysis was done by Chi square test. RESULTS: 43 CT and EUS evaluations were done in 42 patients (mean age 61.3 yrs; 93% male) out of 63 referred for EUS. Overall TNM stage by EUS was higher than CT in 29 patients (due to greater T stage in 6, N stage in 10, both T+N stage in 13), lower in 6 patients (lower T stage in 2, missed M stage in 4). With variation between specialties, differences in staging between the 2 tests would not always lead to changes in management. Table below shows % of patients whose therapy determined by the first test would be changed by information from the second test. Performing EUS first would have resulted in significantly fewer changes in management following subsequent CT scan, than if the sequence of tests were reversed (p

Vascular lesions of the esophagus

The worlds literature regarding vascular lesions of the esophagus is focused again on the diagnosis, management, and clinical outcome of patients with varices secondary to portal hypertension. Novel diagnostic modalities, in addition to endoscopic visualization, are described for gastroesophageal varices. Reports of medical management with infusion of vasoactive agents, minimally invasive management with endoscopy, or radiologic techniques continue to expand. Orthotopic liver transplantation is the surgical procedure of choice in patients with varices and end-stage liver disease; portal systemic shunting and devascularization procedures are declining but continue to be studied in some centers and remain a treatment alternative. Only small descriptive accounts are found in the literature regarding endoscopically identified esophageal vascular lesions, other than varices.