-
Gastrointestinal endoscopy 02/2011; 73(5):1036-7. · 6.71 Impact Factor
-
Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association 11/2010; 8(11):A22. · 5.64 Impact Factor
-
Douglas Morgan,
Bennie Upchurch, Peter Draganov,
Kenneth F Binmoeller,
Oleh Haluszka,
Sreeni Jonnalagadda,
Patrick Okolo,
Ian Grimm,
Joel Judah,
Jeff Tokar,
Michael Chiorean
[show abstract]
[hide abstract]
ABSTRACT: The performance characteristics of spiral enteroscopy have not been well-described.
To determine the technical performance, diagnostic and therapeutic yields, and safety of oral spiral enteroscopy in patients with suspected or established small-bowel pathology.
Prospective, multicenter, cohort study, with centralized database.
Ten U.S. tertiary-care medical centers.
This study involved 148 participants, of whom 101 were referred for obscure bleeding. All participants referred for antegrade deep enteroscopy were considered eligible.
Spiral enteroscopy.
Examination duration, depth of insertion, spiral enteroscopy findings, mucosal assessment upon withdrawal, and patient symptom assessment (day 1 and day 7 after the procedure).
Spiral enteroscopy was successful in 93% of patients, with a median depth of insertion beyond the angle of Treitz of 250 cm (range 10-600 cm). The mean (± standard deviation) total procedure time was 45.0 ± 16.2 minutes for all procedures, and 35.4 minutes for diagnostic procedures. The diagnostic yield was 65%, of which 48% revealed more than one abnormality. The most common findings were angiectasias (61.5%), inflammation (7.5%), and neoplasia (6.8%). Argon plasma coagulation ablation accounted for 64% of therapeutic interventions.
This was not a randomized, controlled trial of deep enteroscopy modalities.
Spiral enteroscopy appears to be safe and effective for evaluation of the small bowel. The procedure duration, depth of insertion, and diagnostic and therapeutic yields compare favorably with previously published data on other deep enteroscopy techniques such as single-balloon and double-balloon enteroscopy. Comparative studies are warranted.
Gastrointestinal endoscopy 11/2010; 72(5):992-8. · 6.71 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Short-wire endoscopic retrograde cholangiopancreatography (ERCP) systems are perceived to carry advantage over traditional long-wire devices. To date, this potential advantage has not been well documented, and gastroenterologists are confronted in everyday practice with the dilemma of choosing a particular system without the benefit of having objective comparative data.
The aim of this study was to compare the performance characteristics of the Fusion ERCP short-wire system with traditional long-wire devices.
This is a prospective, blinded, randomized, controlled trial. Patients with a clinical indication for ERCP were randomized to undergo the procedure with the Fusion short-wire system or long-wire devices. All procedures were done by one experienced endoscopist who was blinded to the outcomes of the study. The person recording the outcomes was an independent observer not involved in the procedure and was blinded to the study hypothesis. The main outcome was device exchange time. Secondary outcomes included stent insertion time, total procedure time, fluoroscopy time, cannulation time, successful cannulation of the desired duct, and complications.
A total of 71 patients were enrolled. The short-wire system provided for significantly faster mean device exchange time (125 versus 177 s; P = 0.05) and stent insertion time (135 versus 254 s; P < 0.001) as compared with the long-wire system. A trend towards shorter total procedure time, fluoroscopy time, and cannulation time was noted with the short-wire system but did not reach statistical significance. Successful cannulation of the desired duct was achieved in all patients. Post-ERCP pancreatitis occurred in one patient in the short-wire and in two patients in the long-wire group.
This short-wire system provides for significantly shorter device exchange and stent insertion times compared with traditional long-wire devices.
Digestive Diseases and Sciences 12/2009; 55(2):510-5. · 2.12 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Evaluate the efficacy and safety of large size balloon dilation of the biliary orifice after maximal biliary sphincterotomy to facilitate removal of difficult bile duct stones in a Western population.
Some bile duct stones may be difficult to remove with standard endoscopic retrograde cholangiopancreatography (ERCP) techniques. Even after multiple procedures, and the use of advanced, labor-intense techniques complete stone clearance may be difficult to achieve.
This is retrospective review of prospectively collected data. Patients who had failed stone extraction with standard balloon technique after maximal biliary sphincterotomy at the index ERCP underwent large size balloon dilation of the biliary orifice to facilitate stone removal. The main outcomes were complete stone clearance and complications.
Forty-four patients were evaluated. Thirty-one (70%) had a prior failed ERCP in the past. Periampullary diverticulum was present in 13 patients (30%). Complete stone removal was accomplished in 42 patients (95%). In 37 patients (84%), complete stone clearance was accomplished at the index ERCP without the need for mechanical lithotripsy. Three patients (6%) required an additional ERCP and 2 patients (5%) required 2 additional ERCPs to accomplish complete stone removal. Three mild complications occurred (6.8%). None of the patients developed perforation or pancreatitis.
Large size balloon dilation after biliary sphincterotomy is simple, safe, and highly effective technique that can greatly assist in the management of difficult to extract bile duct stones.
Journal of clinical gastroenterology 04/2009; 43(8):782-6. · 2.21 Impact Factor
-
Peter Draganov
Gastroenterology and Hepatology 07/2008; 4(7):469-70.
-
[show abstract]
[hide abstract]
ABSTRACT: Post-liver-transplant anastomotic biliary strictures generally have been managed through ERCP with gradual balloon dilation and placement of multiple stents over an extended period of time.
Our purpose was to evaluate the long-term outcome of rapid sequence dilation and to shorten the duration of stenting as a therapy for anastomotic biliary strictures.
Prospective case series.
Academic tertiary referral center.
ERCP with rapid-sequence balloon dilation of post-liver-transplant anastomotic biliary strictures followed by stenting with multiple stents over a short time period.
Long-term anastomotic stricture resolution.
Thirty-eight patients were prospectively enrolled into a standardized ERCP treatment protocol. The mean number of ERCPs per patient was 3.4 (range 2-6), the mean number of maximum stents inserted was 2.5 (range 1-6), and the mean total stenting period was 107 days (range 20-198 days); the mean follow-up time from completion of the endoscopic therapy was 360 days (range 140-1347 days). Long-term stricture resolution was achieved in 33 of the 38 (87%) patients.
Lack of control group, relatively small patient population.
Accelerated dilation and shorter total length of stenting leads to long-term success in the majority of patients with post-liver-transplant anastomotic biliary strictures.
Gastrointestinal Endoscopy 06/2008; 67(6):879-85. · 4.88 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Endoscopic mucosal resection (EMR) is a technique used to locally excise lesions confined to the mucosa. Its main role is the treatment of advanced dysplasia and early gastrointestinal cancers. EMR was originally described as a therapy for early gastric cancer. Recently its use has expanded as a therapeutic option for ampullary masses, colorectal cancer, and large colorectal polyps. In the Western world, the predominant indication for EMR in the upper gastrointestinal tract is the staging and treatment of advance dysplasia and early neoplasia in Barrett's esophagus. This review will describe the basis, indications, techniques, and complications of EMR, and its role in the management of Barrett's esophagus.
World Journal of Gastroenterology 05/2008; 14(13):1984-9. · 2.47 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Autoimmune pancreatocholangitis is characterized by sclerosing inflammation of the biliary tree or pancreatic duct and can mimic pancreaticobiliary malignancy. Serum immunoglobin (Ig) G4 values seem to be helpful in distinguishing autoimmune pancreatocholangitis from pancreatic malignancy in the Japanese population; however, its significance in the Western population has not been well studied.
We report a retrospective analysis of 7 consecutive patients with autoimmune pancreatocholangitis and compare them to 23 patients with pancreatic malignancy. Clinical presentation, diagnostic tests, and preoperative IgG4 levels were reviewed in all patients. Presence of autoimmune pancreatocholangitis or pancreatic malignancy was determined by pathologic analysis in all patients and reviewed by a single pathologist.
In all patients, autoimmune pancreatocholangitis manifested in a similar fashion to pancreatic malignancy. Median IgG4 levels were far lower in pancreatic cancer patients with localized, resectable disease (24 mg/dL), locally advanced disease (24 mg/dL), and metastatic disease (28 mg/dL) as compared with patients with autoimmune pancreatocholangitis (142 mg/dL, P < .05). Only one patient with pancreatic cancer had an IgG4 level that was >100 mg/dL. In contrast, all patients with autoimmune pancreatitis or cholangitis had levels >100 mg/dL. However, in five of these seven patients, IgG4 levels were below the upper limits of normal.
Autoimmune pancreatocholangitis mimics pancreatobiliary malignancy. Serum IgG4 values seem to be helpful in distinguishing autoimmune pancreatocholangitis from malignancy in the Western population. However, absolute values seem to be lower in the United States compared with Japan. The upper limit of normal as reported in laboratories in the United States may not be useful in identifying abnormally high IgG4 values. A new upper limit of normal may need to be defined because IgG subclass determinations are being used more frequently in Western patients with biliary obstruction.
Annals of Surgical Oncology 05/2008; 15(4):1147-54. · 4.17 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Ampullectomy may be an appropriate oncologic procedure in selected patients. Sparse data exist on procedure-related complications and the relationship between histologic analysis and outcomes.
We retrospectively reviewed our experience with ampullectomy in 29 patients with a preoperative benign histologic diagnosis over 15 years (1991 to 2006). Presenting signs, symptoms, and preoperative diagnostic studies were reviewed. Postoperative complications and followup for recurrence were recorded. The abilities of preoperative histologic biopsy, intraoperative frozen section, and final histologic analysis to guide management and predict outcomes were determined.
Median age was 63 years. Jaundice was present in 30% of patients. Median length of hospital stay was 9 days. Forty-five percent of patients had a complication, and there was one postoperative mortality (3%). Ampullary adenomatous neoplasms were present in 89% of patients. Preoperative biopsy had complete concordance with final pathology in 76% of patients. Preoperative biopsy and intraoperative frozen section failed to identify carcinoma in four patients. Pancreaticoduodenectomy was performed within 7 days in the postoperative period in three of these patients. After ampullectomy (median followup=16 months), recurrences were identified in two patients (8%) with benign tumors. No patients with high-grade dysplasia (n=4) have had recurrence.
Preoperative biopsy and intraoperative frozen section analysis have limitations in the management of patients undergoing ampullectomy. High-grade dysplasia on preoperative biopsy is not an absolute contraindication to ampullectomy. Morbidity of ampullectomy is significant, but longterm outcomes of this procedure, in patients without invasive malignancy, are acceptable.
Journal of the American College of Surgeons 04/2008; 206(3):466-71. · 4.55 Impact Factor
-
Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association 04/2007; 5(3):302-6. · 5.64 Impact Factor
-
Nature Clinical Practice Gastroenterology & Hepatology 08/2006; 3(7):356-7. · 5.33 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Diagnosis of a foregut duplication cyst is of great clinical impact. A definitive diagnosis of a foregut duplication cyst can avert the need for major thoracic surgery in the otherwise asymptomatic individual. This study sought to evaluate the safety and the utility of EUS and EUS-guided FNA (EUS-FNA) in the diagnosis of foregut duplication cysts.
Over a period of 4 years, 4771 patients underwent EUS for various indications at two EUS referral centers. EUS findings were consistent with a mediastinal cyst in 30 cases. EUS-FNA was performed in 22 patients. A definitive diagnosis was established based on cytology, surgical pathology, and/or clinical follow-up. FNA was done with 22-gauge needles and antibiotic prophylaxis.
The appearance of cyst contents on EUS ranged from completely anechoic (23 cases) to hypoechoic (7 cases). Hypoechoic cystic lesions contained echogenic foci. All anechoic lesions were confirmed as benign duplication cysts based on cytology, pathology, and clinical follow-up. Hypoechoic cystic lesions were confirmed to be benign duplication cysts in 4 cases. Three cases proved to be malignant or granulomatous necrotizing lymph nodes. No periprocedural complications occurred.
Variation exists in the EUS appearance of benign mediastinal cysts. EUS-FNA of mediastinal cysts with smaller-gauge needles, and antibiotic prophylaxis appears safe and can provide a definitive diagnosis in atypical mediastinal cystic lesions.
Gastrointestinal Endoscopy 11/2005; 62(4):575-80. · 4.88 Impact Factor
-
Digestive Diseases and Sciences 09/2005; 50(8):1461. · 2.12 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The standard secretin stimulation test (SST) is the accepted gold standard for pancreatic function testing. The intraductal secretin stimulation test (IDST) performed at the time of endoscopic retrograde cholangiopancreatography (ERCP) has been proposed as a more feasible way to evaluate pancreatic function. The accuracy of the IDST for the diagnosis of chronic pancreatitis (CP) has not been well defined.
We prospectively evaluated patients with suspected CP. The IDST, SST, and ERCP were performed in each of the 19 study patients. The SST and ERCP were used as independent diagnostic standards against which the results of the IDST were compared directly to determine the sensitivity, specificity, and accuracy of the IDST.
When the SST was used as a diagnostic standard for CP, the sensitivity of the IDST was 80% (95% confidence interval [CI], 44%-97%), the specificity was 22% (95% CI, 2%-60%), and the overall accuracy was 52% (95% CI, 28%-75%). The positive predictive value was 53% and the negative predictive value was 50%. When the pancreatogram was used as the diagnostic standard, the sensitivity of the IDST was 100% (95% CI, 69%-100%), the specificity was 55% (95% CI, 21%-86%), and the overall accuracy was 79% (95% CI, 54%-93%). Receiver operator curves showed that there was no optimal cut-off value for peak bicarbonate concentration that led to acceptable sensitivity and specificity.
The IDST is not accurate for the diagnosis of CP.
Clinical Gastroenterology and Hepatology 07/2005; 3(7):695-9. · 5.63 Impact Factor
-
Gastroenterology 04/2005; 128(3):756-63. · 11.68 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To evaluate efficacy and safety of endoscopic balloon dilation with or without intralesional steroid injection, of symptomatic upper gastrointestinal (UGI) and lower gastrointestinal (LGI) Crohn's disease (CD) strictures.
Patients with CD commonly develop obstructive symptoms secondary to gastrointestinal strictures. When these do not resolve with medical management, surgery is usually the only alternative. Limited data are available on the safety and efficacy of endoscopic through-the-scope (TTS) balloon dilation of CD strictures.
We performed a retrospective review of TTS balloon dilations done on CD-related UGI and LGI strictures. Postdilation intralesional steroid injections were done at the discretion of the endoscopist. Stricture was defined as luminal stenosis <10 mm in diameter, through which a scope could not be passed. Technical success was defined as the ability of the scope to traverse the stricture postdilation. Long-term success rate was claimed if a patient remained asymptomatic and did not require surgery or further endoscopic dilation.
Over 4 years, we performed 29 stricture dilations on 17 patients (10 female, 7 male) with 20 strictures. The mean follow-up period was 18.8 months (range, 5-50 months). Stricture locations were as follows: rectal, 5; sigmoid colon, 2; colo-colonic anastomosis, 3; ileocolonic anastomosis, 4; ileum, 1; descending colon, 1; cecum, 1; and distal duodenal bulb, 3 patients. Technical success was achieved in 28 of 29 stricture dilations (96.5%). Ten strictures (34.5%) were dilated to <15 mm and 19 (65.5%) to > or = 15 mm diameter. Long-term success rate in the <15 mm group was 70%, and in > or = 15 mm group was 68.4%. Four quadrant steroid injections were done on 11 strictures. The recurrence rate in this group was 10% and that in the nonsteroid group was 31.3%. The overall long-term success rate was 76.5% by intent-to-treat analysis. Three perforations occurred (all colonic) during 29 stricture dilations, a complication rate of 10% with no mortalities.
We report the first series of TTS balloon dilations with or without intralesional steroid injection, of both primary and anastomotic UGI and LGI strictures in CD patients. Long-term success was achieved in 76.5% patients with a complication rate of 10%. This mode of therapy appears safe and effective and can be considered as an alternative to surgery in selected patients with medically refractory CD-associated GI strictures. Success rates were better in patients who received four quadrant steroid injections. No difference was seen in stricture recurrence rate or complications based on diameter of TTS balloon used.
Journal of Clinical Gastroenterology 04/2005; 39(4):284-90. · 3.16 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Patients with the Zollinger-Ellison syndrome are characterized by islet-cell tumors, striking gastric acid hypersecretion, and peptic ulcer disease. They often experience severe abdominal pain, diarrhea, and gastrointestinal bleeding with potentially life-threatening consequences. It is a rare syndrome caused by non-beta cell islet-cell tumors (gastrinomas) located in or in proximity to the pancreas. These tumors freely secrete gastrin, a peptide hormone that serves as a powerful stimulant of gastric acid secretion. Exuberant secretion of gastrin from the gastrinomas produces severe gastric acid hypersecretion that often leads to impressive peptic ulcer disease and the constellation of symptoms listed above. We describe a patient presenting with clinical manifestations characteristic of the ZES with strikingly elevated gastric acid secretion,multiple ulcers in the first and second portions of the duodenum and diarrhea, but in absence of islet-cell tumor and/or hypergastrinemia.
International Journal of Gastrointestinal Cancer 02/2005; 35(2):157-61.
-
[show abstract]
[hide abstract]
ABSTRACT: The use of endoscopic ultrasound (EUS) in pancreatic disease is rapidly evolving as the field moves from a primarily diagnostic role to one of therapeutic intervention. Therapeutic EUS includes techniques such as the celiac block and transmural pseudocyst drainage. Newer techniques include EUS-guided fine-needle injection therapy in which a variety of agents are being investigated for the treatment of pancreatic cancer. Novel EUS-guided techniques are being devised to drain and alleviate pancreaticobiliary and gastroduodenal obstruction.
Current Gastroenterology Reports 05/2004; 6(2):104-10.
-
[show abstract]
[hide abstract]
ABSTRACT: The role of osmolality of contrast media (CM) in the development of post-ERCP pancreatitis (PEP) is debated. We therefore performed a metanalysis to determine whether osmolality affects the incidence of PEP. A literature search of English-language studies was performed using computerized databases and manual searching of abstracts and article bibliographies. Randomized controlled trials comparing the incidence of PEP associated with high- and low-osmolality contrast media (HOCM, LOCM) were considered. The outcome assessed was clinical pancreatitis as evidenced by both elevation of pancreatic enzymes and pain. Data were analyzed using logistic regression with terms for study and osmolality. Fisher's exact test was done to compare PEP rates. Homogeneity between studies was indicated by the nonsignificance of the study effect in the logistic regression model. Logistic regression also indicated no difference in PEP rates between LOCM and HOCM (P = 0.399). Comparison of PEP rates in both groups using Fisher's exact test did not indicate a difference in any individual study (all P values > 0.05). Due to the large variation of study sample sizes, we repeated the analysis by creating three study groups. The effect of osmolality was invariant to how the data were combined. The results of this metanalysis indicate that there is no significant difference between HOCM and LOCM with respect to clinical PEP.
Digestive Diseases and Sciences 03/2004; 49(3):503-8. · 2.12 Impact Factor
