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Yang D, Samarasena JB, Jamil LH, Chang KJ, Lee D, Ona MA, Lo SK, Gaddam S, Liu Q, Draganov PV. Endoscopic ultrasound-guided through-the-needle microforceps biopsy in the evaluation of pancreatic cystic lesions: a multicenter study. Endosc Int Open 2018; 6:E1423-E1430. [PMID: 30574535 PMCID: PMC6281441 DOI: 10.1055/a-0770-2700] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 07/24/2018] [Indexed: 12/16/2022] Open
Abstract
Background and study aims Accurate diagnosis and classification of pancreatic cysts (PCs) remains a challenge. The aims of this study were to: (1) evaluate the safety and technical success of a novel microforceps for EUS-guided through-the-needle biopsy (TTNB) of PCs; and (2) assess its diagnostic yield for mucinous PCs when compared to FNA cyst fluid analysis and cytology. Patients and methods This was a multicenter retrospective analysis of 47 patients who underwent EUS-FNA and TTNB for PCs between January 2014 and June 2017. Technical success was defined as acquisition of a specimen adequate for cytologic or histological evaluation. Cyst fluid carcinoembryonic antigen (CEA) was used to initially categorize cysts as non-mucinous (CEA < 192 ng/mL) or mucinous (CEA ≥ 192 ng/mL). Final diagnosis was based on identifiable mucinous pancreatic cystic epithelium on cytology, microforceps histology and/or surgical histology when available. Results Forty-seven patients with PCs (mean size 30.7 mm) were included. TTNB was successfully performed in 46 of 47 (97.9 %). Technical success was significantly lower with FNA (48.9 %) compared to TTNB (85.1 %) ( P < .001). For cysts with insufficient amount of fluid for CEA (n = 19) or CEA < 192 ng/mL, the cumulative incremental diagnostic yield of a mucinous PC was significantly higher with TTNB vs. FNA (52.6 % vs 18.4 %; P = .004). TTNB alone (34.4 %) diagnosed more mucinous PCs than either CEA ≥ 192 ng/mL alone (6.3 %) or when combined with FNA cytology (9.4 %). One episode of self-limited bleeding (2.1 %) and one of pancreatitis (2.1 %) occurred. Conclusions EUS-TTNB is safe and effective for evaluating PCs. TTNB may help increase the diagnostic yield of mucinous PCs.
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Affiliation(s)
- Dennis Yang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, United States,Corresponding author Dennis Yang
1329 SW 16
th
Street, Room #5252
Gainesville, FL 32608United States+1-352-627-9002
| | - Jason B. Samarasena
- Division of Gastroenterology and Hepatology, University of California Irvine, Irvine, California, United States
| | - Laith H. Jamil
- Division of Digestive and Liver Diseases, Cedars Sinai Medical Center, Los Angeles, California, United States
| | - Kenneth J. Chang
- Division of Gastroenterology and Hepatology, University of California Irvine, Irvine, California, United States
| | - David Lee
- Division of Gastroenterology and Hepatology, University of California Irvine, Irvine, California, United States
| | - Mel A. Ona
- Division of Gastroenterology and Hepatology, University of California Irvine, Irvine, California, United States
| | - Simon K. Lo
- Division of Digestive and Liver Diseases, Cedars Sinai Medical Center, Los Angeles, California, United States
| | - Srinivas Gaddam
- Division of Digestive and Liver Diseases, Cedars Sinai Medical Center, Los Angeles, California, United States
| | - Quin Liu
- Division of Digestive and Liver Diseases, Cedars Sinai Medical Center, Los Angeles, California, United States
| | - Peter V. Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, United States
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Preston K, Krumian R, Hattner J, de Montigny D, Stewart M, Gaddam S. Lactobacillus acidophilus CL1285, Lactobacillus casei LBC80R and Lactobacillus rhamnosus CLR2 improve quality-of-life and IBS symptoms: a double-blind, randomised, placebo-controlled study. Benef Microbes 2018; 9:697-706. [PMID: 29888656 DOI: 10.3920/bm2017.0105] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
A combination of Lactobacillus acidophilus CL1285, Lactobacillus casei LBC80R and Lactobacillus rhamnosus CLR2 was compared to placebo for relief of symptoms of irritable bowel syndrome (IBS). A total of 113 subjects at 3 clinical sites were randomised in a 2:1 ratio and followed for 12 weeks. Subjects ingested either 2 capsules of active study product, containing 50×109 cfu of live organisms, or 2 placebo capsules daily. Endpoints included improvement in abdominal pain, days of pain, distention, stool consistency and frequency, quality of life (QOL), and adequate relief (AR) of IBS symptoms. IBS subtypes constipation (IBS-C), diarrhoea (IBS-D), and mixed (IBS-M) were evaluated separately; the effect of gender was also examined. For all efficacy endpoints improvement of 30% or more vs placebo was considered clinically significant. With the exception of pain intensity and AR, the endpoints demonstrated a therapeutic advantage of active over placebo for IBS symptoms in at least some subject subgroups. The IBS-D and female subgroups showed the largest and most consistent effects. Stool frequency and consistency were evaluated in the IBS-C and IBS-D subgroups, and improvement of active vs placebo was noted in both. QOL improvement was seen overall and in specific domains. Adverse events (AEs) were limited to 7 subjects; all were of mild or moderate intensity except one, severe cramping. Four AEs in the same subject in the placebo group were judged to be related to study product; these resolved by the end of study. There were no serious AEs.
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Affiliation(s)
- K Preston
- 1 Westlake Medical Research, 550 St. Charles St., Ste. 208, Thousand Oaks, CA 91360, USA
| | - R Krumian
- 1 Westlake Medical Research, 550 St. Charles St., Ste. 208, Thousand Oaks, CA 91360, USA
| | - J Hattner
- 2 Sprim Americas, 254 Front St. Ph, New York, NY 10038, USA
| | - D de Montigny
- 3 Bio-K Plus International, Inc., 495 Blvd. Armand-Frappier, Laval, H7V 4B3, Canada
| | - M Stewart
- 2 Sprim Americas, 254 Front St. Ph, New York, NY 10038, USA
| | - S Gaddam
- 4 Digestive and Liver Disease Specialists, 11922 Seacrest Dr., Ste. A, Garden Grove, CA 92840, USA
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Parasa S, Vennalaganti S, Gaddam S, Vennalaganti P, Young P, Gupta N, Thota P, Cash B, Mathur S, Sampliner R, Moawad F, Lieberman D, Bansal A, Kennedy KF, Vargo J, Falk G, Spaander M, Bruno M, Sharma P. Development and Validation of a Model to Determine Risk of Progression of Barrett's Esophagus to Neoplasia. Gastroenterology 2018; 154:1282-1289.e2. [PMID: 29273452 DOI: 10.1053/j.gastro.2017.12.009] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 12/11/2017] [Accepted: 12/13/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS A system is needed to determine the risk of patients with Barrett's esophagus for progression to high-grade dysplasia (HGD) and esophageal adenocarcinoma (EAC). We developed and validated a model to determine of progression to HGD or EAC in patients with BE, based on demographic data and endoscopic and histologic findings at the time of index endoscopy. METHODS We performed a longitudinal study of patients with BE at 5 centers in United States and 1 center in Netherlands enrolled in the Barrett's Esophagus Study database from 1985 through 2014. Patients were excluded from the analysis if they had less than 1 year of follow-up, were diagnosed with HGD or EAC within the past year, were missing baseline histologic data, or had no intestinal metaplasia. Seventy percent of the patients were used to derive the model and 30% were used for the validation study. The primary outcome was development of HGD or EAC during the follow-up period (median, 5.9 years). Survival analysis was performed using the Kaplan-Meier method. We assigned a specific number of points to each BE risk factor, and point totals (scores) were used to create categories of low, intermediate, and high risk. We used Cox regression to compute hazard ratios and 95% confidence intervals to determine associations between risk of progression and scores. RESULTS Of 4584 patients in the database, 2697 were included in our analysis (84.1% men; 87.6% Caucasian; mean age, 55.4 ± 20.1 years; mean body mass index, 27.9 ± 5.5 kg/m2; mean length of BE, 3.7 ± 3.2 cm). During the follow-up period, 154 patients (5.7%) developed HGD or EAC, with an annual rate of progression of 0.95%. Male sex, smoking, length of BE, and baseline-confirmed low-grade dysplasia were significantly associated with progression. Scores assigned identified patients with BE that progressed to HGD or EAC with a c-statistic of 0.76 (95% confidence interval, 0.72-0.80; P < .001). The calibration slope was 0.9966 (P = .99), determined from the validation cohort. CONCLUSIONS We developed a scoring system (Progression in Barrett's Esophagus score) based on male sex, smoking, length of BE, and baseline low-grade dysplasia that identified patients with BE at low, intermediate, and high risk for HGD or EAC. This scoring system might be used in management of patients.
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Affiliation(s)
- Sravanthi Parasa
- Division of Gastroenterology, Swedish Medical Group, Seattle, Washington
| | - Sreekar Vennalaganti
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri
| | - Srinivas Gaddam
- Division of Gastroenterology, Cedar-Sinai Medical Center, Los Angeles, California
| | - Prashanth Vennalaganti
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri; Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, Kansas
| | - Patrick Young
- Department of Gastroenterology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Neil Gupta
- Division of Gastroenterology, Loyola University Medical Center, Maywood, Illinois
| | - Prashanthi Thota
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio
| | - Brooks Cash
- University of South Alabama, Mobile, Alabama; American Gastroenterological Association
| | - Sharad Mathur
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri
| | - Richard Sampliner
- Department of Gastroenterology and Hepatology, University of Arizona, Tucson, Arizona
| | - Fouad Moawad
- Department of Gastroenterology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - David Lieberman
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon
| | - Ajay Bansal
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri; Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, Kansas
| | - Kevin F Kennedy
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri
| | - John Vargo
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio
| | - Gary Falk
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Manon Spaander
- Department of Gastroenterology, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Marco Bruno
- Department of Gastroenterology, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Prateek Sharma
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri; Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, Kansas.
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Gaddam S. Prediction of Barrett's esophagus: are we there yet? Dis Esophagus 2018; 31:4807356. [PMID: 29346553 DOI: 10.1093/dote/dox147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- S Gaddam
- Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Wani S, Keswani R, Hall M, Han S, Ali MA, Brauer B, Carlin L, Chak A, Collins D, Cote GA, Diehl DL, DiMaio CJ, Dries A, El-Hajj I, Ellert S, Fairley K, Faulx A, Fujii-Lau L, Gaddam S, Gan SI, Gaspar JP, Gautamy C, Gordon S, Harris C, Hyder S, Jones R, Kim S, Komanduri S, Law R, Lee L, Mounzer R, Mullady D, Muthusamy VR, Olyaee M, Pfau P, Saligram S, Piraka C, Rastogi A, Rosenkranz L, Rzouq F, Saxena A, Shah RJ, Simon VC, Small A, Sreenarasimhaiah J, Walker A, Wang AY, Watson RR, Wilson RH, Yachimski P, Yang D, Edmundowicz S, Early DS. A Prospective Multicenter Study Evaluating Learning Curves and Competence in Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography Among Advanced Endoscopy Trainees: The Rapid Assessment of Trainee Endoscopy Skills Study. Clin Gastroenterol Hepatol 2017; 15. [PMID: 28625816 PMCID: PMC7042954 DOI: 10.1016/j.cgh.2017.06.012] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS On the basis of the Next Accreditation System, trainee assessment should occur on a continuous basis with individualized feedback. We aimed to validate endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) learning curves among advanced endoscopy trainees (AETs) by using a large national sample of training programs and to develop a centralized database that allows assessment of performance in relation to peers. METHODS ASGE recognized training programs were invited to participate, and AETs were graded on ERCP and EUS exams by using a validated competency assessment tool that assesses technical and cognitive competence in a continuous fashion. Grading for each skill was done by using a 4-point scoring system, and a comprehensive data collection and reporting system was built to create learning curves by using cumulative sum analysis. Individual results and benchmarking to peers were shared with AETs and trainers quarterly. RESULTS Of the 62 programs invited, 20 programs and 22 AETs participated in this study. At the end of training, median number of EUS and ERCP performed/AET was 300 (range, 155-650) and 350 (125-500), respectively. Overall, 3786 exams were graded (EUS, 1137; ERCP-biliary, 2280; ERCP-pancreatic, 369). Learning curves for individual end points and overall technical/cognitive aspects in EUS and ERCP demonstrated substantial variability and were successfully shared with all programs. The majority of trainees achieved overall technical (EUS, 82%; ERCP, 60%) and cognitive (EUS, 76%; ERCP, 100%) competence at conclusion of training. CONCLUSIONS These results demonstrate the feasibility of establishing a centralized database to report individualized learning curves and confirm the substantial variability in time to achieve competence among AETs in EUS and ERCP. ClinicalTrials.gov: NCT02509416.
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Affiliation(s)
- Sachin Wani
- University of Colorado Anschutz Medical Campus, Aurora, Colorado.
| | | | - Matt Hall
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Samuel Han
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Meer Akbar Ali
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Brian Brauer
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Linda Carlin
- Colorado Clinical and Translational Sciences Institute, Aurora, Colorado
| | - Amitabh Chak
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Dan Collins
- Carolinas Medical Center, Charlotte, North Carolina
| | - Gregory A. Cote
- Medical University of South Carolina, Charleston, South Carolina
| | | | | | - Andrew Dries
- Carolinas Medical Center, Charlotte, North Carolina
| | | | - Swan Ellert
- Colorado Clinical and Translational Sciences Institute, Aurora, Colorado
| | | | - Ashley Faulx
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | - Srinivas Gaddam
- Washington University School of Medicine, St Louis, Missouri
| | - Seng-Ian Gan
- Virginia Mason Medical Center, Seattle, Washington
| | | | | | - Stuart Gordon
- Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Sarah Hyder
- Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Ross Jones
- Carolinas Medical Center, Charlotte, North Carolina
| | - Stephen Kim
- University of California, Los Angeles, Los Angeles, California
| | | | - Ryan Law
- Northwestern University, Chicago, Illinois
| | - Linda Lee
- Brigham and Women’s Hospital, Boston, Massachusetts
| | - Rawad Mounzer
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Daniel Mullady
- Washington University School of Medicine, St Louis, Missouri
| | | | | | | | | | | | | | | | - Fadi Rzouq
- University of Kansas, Kansas City, Kansas
| | | | - Raj J. Shah
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Aaron Small
- Virginia Mason Medical Center, Seattle, Washington
| | | | | | - Andrew Y. Wang
- University of Virginia Health System, Charlottesville, Virginia
| | | | - Robert H. Wilson
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Dennis Yang
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Dayna S. Early
- Washington University School of Medicine, St Louis, Missouri
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Mohamadnejad M, Mullady D, Early DS, Collins B, Marshall C, Sams S, Yen R, Rizeq M, Romanas M, Nawaz S, Ulusarac O, Hollander T, Wilson RH, Simon VC, Kushnir V, Amateau SK, Brauer BC, Gaddam S, Azar RR, Komanduri S, Shah R, Das A, Edmundowicz S, Muthusamy VR, Rastogi A, Wani S. Increasing Number of Passes Beyond 4 Does Not Increase Sensitivity of Detection of Pancreatic Malignancy by Endoscopic Ultrasound-Guided Fine-Needle Aspiration. Clin Gastroenterol Hepatol 2017; 15:1071-1078.e2. [PMID: 28025154 DOI: 10.1016/j.cgh.2016.12.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 12/10/2016] [Accepted: 12/12/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS It is not clear exactly how many passes are required to determine whether pancreatic masses are malignant using endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). We aimed to define the per-pass diagnostic yield of EUS-FNA for establishing the malignancy of a pancreatic mass, and identify factors associated with detection of malignancies. METHODS In a prospective study, 239 patients with solid pancreatic masses were randomly assigned to groups that underwent EUS-FNA, with the number of passes determined by an on-site cytopathology evaluation or set at 7 passes, at 3 tertiary referral centers. A final diagnosis of pancreatic malignancy was made based on findings from cytology, surgery, or a follow-up evaluation at least 1 year after EUS-FNA. The cumulative sensitivity of detection of malignancy by EUS-FNA was calculated after each pass; in the primary analysis, lesions categorized as malignant or suspicious were considered as positive findings. RESULTS Pancreatic malignancies were found in 202 patients (84.5% of the study population). EUS-FNA detected malignancies with 96% sensitivity (95% confidence interval [CI], 92%-98%); 4 passes of EUS-FNA detected malignancies with 92% sensitivity (95% CI, 87%-95%). Tumor size greater than 2 cm was the only variable associated with positive results from cytology analysis (odds ratio, 7.8; 95% CI, 1.9-31.6). In masses larger than 2 cm, 4 passes of EUS-FNA detected malignancies with 93% sensitivity (95% CI, 89%-96%) and in masses ≤2 cm, 6 passes was associated with 82% sensitivity (95% CI, 61%-93%). Sensitivity of detection did not increase with increasing number of passes. CONCLUSIONS In a prospective study, we found 4 passes of EUS-FNA to be sufficient to detect malignant pancreatic masses; increasing the number of passes did not increase the sensitivity of detection. Tumor size greater than 2 cm was associated with malignancy, and a greater number of passes may be required to evaluate masses 2 cm or less. ClinicalTrials.gov number, NCT01386931.
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Affiliation(s)
- Mehdi Mohamadnejad
- University of California, Los Angeles, Los Angeles, California; Liver and Pancreatobiliary Disease Research Center, Digestive Disease Research Institute, Tehran University of Medical Science, Tehran, Iran
| | - Daniel Mullady
- Washington University School of Medicine, St. Louis, Missouri
| | - Dayna S Early
- Washington University School of Medicine, St. Louis, Missouri
| | - Brian Collins
- Washington University School of Medicine, St. Louis, Missouri
| | - Carrie Marshall
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Sharon Sams
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Roy Yen
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Mona Rizeq
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Maria Romanas
- Kansas City VA Medical Center and University of Kansas, Kansas City, Missouri
| | - Samia Nawaz
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ozlem Ulusarac
- Kansas City VA Medical Center and University of Kansas, Kansas City, Missouri
| | | | - Robert H Wilson
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Violette C Simon
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Stuart K Amateau
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Brian C Brauer
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Srinivas Gaddam
- Washington University School of Medicine, St. Louis, Missouri
| | - Riad R Azar
- Washington University School of Medicine, St. Louis, Missouri
| | - Srinadh Komanduri
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Raj Shah
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ananya Das
- Arizona Center for Digestive Health, Gilbert, Arizona
| | | | | | - Amit Rastogi
- Kansas City VA Medical Center and University of Kansas, Kansas City, Missouri
| | - Sachin Wani
- University of Colorado Anschutz Medical Campus, Aurora, Colorado.
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Fujii-Lau LL, Cinnor B, Shaheen N, Gaddam S, Komanduri S, Muthusamy VR, Das A, Wilson R, Simon VC, Kushnir V, Mullady D, Edmundowicz SA, Early DS, Wani S. Recurrence of intestinal metaplasia and early neoplasia after endoscopic eradication therapy for Barrett's esophagus: a systematic review and meta-analysis. Endosc Int Open 2017; 5:E430-E449. [PMID: 28573176 PMCID: PMC5451278 DOI: 10.1055/s-0043-106578] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 02/15/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Conflicting data exist with regard to recurrence rates of intestinal metaplasia (IM) and dysplasia after achieving complete eradication of intestinal metaplasia (CE-IM) in Barrett's esophagus (BE) patients. AIM (i) To determine the incidence of recurrent IM and dysplasia achieving CE-IM and (ii) to compare recurrence rates between treatment modalities [radiofrequency ablation (RFA) with or without endoscopic mucosal resection (EMR) vs stepwise complete EMR (SRER)]. METHODS A systematic search was performed for studies reporting on outcomes and estimates of recurrence rates after achieving CE-IM. Pooled incidence [per 100-patient-years (PY)] and risk ratios with 95 %CI were obtained. Heterogeneity was measured using the I2 statistic. Subgroup analyses, decided a priori, were performed to explore heterogeneity in results. RESULTS A total of 39 studies were identified (25-RFA, 13-SRER, and 2 combined). The pooled incidence of any recurrence was 7.5 (95 %CI 6.1 - 9.0)/100 PY with a pooled incidence of IM recurrence rate of 4.8 (95 %CI 3.8 - 5.9)/100 PY, and dysplasia recurrence rate of 2.0 (95 %CI 1.5 - 2.5)/100 PY. Compared to the SRER group, the RFA group had significantly higher overall [8.6 (6.7 - 10.5)/100 PY vs. 5.1 (3.1 - 7)/100 PY, P = 0.01] and IM recurrence rates [5.8 (4.3 - 7.3)/100 PY vs. 3.1 (1.7 - 4)/100 PY, P < 0.01] with no difference in recurrence rates of dysplasia. Significant heterogeneity between studies was identified. The majority of recurrences were amenable to repeat endoscopic eradication therapy (EET). CONCLUSION The results of this study demonstrate that the incidence rates of overall, IM, and dysplasia recurrence rates post-EET are not inconsiderable and reinforce the importance of close surveillance after achieving CE-IM.
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Affiliation(s)
| | - Birtukan Cinnor
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Srinivas Gaddam
- Washington University School of Medicine, St. Louis, MO, USA
| | - Srinadh Komanduri
- Feinberg School of Medicine Northwestern University, Chicago, IL, USA
| | | | - Ananya Das
- Arizona Center for Digestive Health, Gilbert, AZ, USA
| | - Robert Wilson
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | | | - Daniel Mullady
- Washington University School of Medicine, St. Louis, MO, USA
| | | | - Dayna S. Early
- Washington University School of Medicine, St. Louis, MO, USA
| | - Sachin Wani
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA,Corresponding author Sachin Wani, MD Division of Gastroenterology and HepatologyUniversity of Colorado Anschutz Medical CenterMail Stop F7351635 Aurora CourtRm 2.031AuroraCO 80045USA+1-720-848-2749
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Thota PN, Vennalaganti P, Vennelaganti S, Young P, Gaddam S, Gupta N, Lieberman D, Sampliner R, Falk GW, Mathur S, Kennedy K, Cash BD, Moawad F, Bansal A, Spaander MC, Bruno MJ, Vargo J, Sharma P. Low Risk of High-Grade Dysplasia or Esophageal Adenocarcinoma Among Patients With Barrett's Esophagus Less Than 1 cm (Irregular Z Line) Within 5 Years of Index Endoscopy. Gastroenterology 2017; 152:987-992. [PMID: 27988383 DOI: 10.1053/j.gastro.2016.12.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 12/05/2016] [Accepted: 12/06/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Many patients with a < 1 cm segment of columnar metaplasia in the distal esophagus, also called an irregular Z line, are encountered. These patients, often referred to as patients with Barrett's esophagus (BE), are enrolled in surveillance programs. However, little is known about their risk of high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC). We aimed to determine the incidence of HGD and EAC in patients with irregular Z line with intestinal metaplasia. METHODS We performed a prospective, multicenter cohort study of patients who underwent endoscopic examination for BE at tertiary care referral centers in the United States and Europe. We analyzed data from 1791 patients (mean age, 56 ± 17 years) found to have non-dysplastic BE at the index endoscopy and after 1 year or more of follow-up. Patients were followed for a median of 5.9 years (interquartile range, 3.1-8.3 years). We calculated rates of progression to HGD or EAC between groups of patients with irregular Z line (n = 167) and those with BE of ≥ 1 cm (n = 1624). RESULTS A higher proportion of patients in the irregular Z-line group were female (26.3%) than in the BE group (14.8% female BE) (P <.001). A lower proportion of patients in the irregular Z-line group were smokers (33.5%) than in the BE group (52.6% smokers). None of the patients with irregular Z line developed HGD or EAC during a median follow-up period of 4.8 years (interquartile range, 3.2-8.3 years). All 71 incident cases of HGD or EAC developed in patients with BE of ≥1 cm in length. On multivariate analysis, patients with irregular Z line and patients with BE of ≥ 1 cm did not differ significantly in age, race, or duration of follow-up. CONCLUSIONS In a prospective, multicenter cohort study, we found that patients with irregular Z line do not develop HGD or esophageal cancer within 5 years after index endoscopy.
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Affiliation(s)
- Prashanthi N Thota
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio.
| | - Prashanth Vennalaganti
- Department of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, Kansas
| | - Sreekar Vennelaganti
- Department of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri
| | - Patrick Young
- Department of Gastroenterology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Srinivas Gaddam
- Department of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Neil Gupta
- Department of Gastroenterology and Hepatology, Loyola University Medical Center, Maywood, Illinois
| | - David Lieberman
- Department of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, Oregon
| | - Richard Sampliner
- Department of Gastroenterology and Hepatology, University of Arizona, Tucson, Arizona
| | - Gary W Falk
- Department of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Sharad Mathur
- Department of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri
| | - Kevin Kennedy
- Department of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri
| | - Brooks D Cash
- Department of Gastroenterology and Hepatology, University of South Alabama, Mobile, Alabama
| | - Fouad Moawad
- Department of Gastroenterology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Ajay Bansal
- Department of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri
| | - Manon C Spaander
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, Netherlands
| | - John Vargo
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio
| | - Prateek Sharma
- Department of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, Kansas; Department of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri
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Iskandar H, Gray DM, Vu H, Mirza F, Rude MK, Regan K, Abdalla A, Gaddam S, Almaskeen S, Mello M, Marquez E, Meyer C, Bolkhir A, Kanuri N, Sayuk G, Gyawali CP. Coeliac disease screening is suboptimal in a tertiary gastroenterology setting. Postgrad Med J 2017; 93:472-475. [PMID: 28069744 DOI: 10.1136/postgradmedj-2016-134005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 12/13/2016] [Accepted: 12/16/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS Coeliac disease (CD) is widely prevalent in North America, but case-finding techniques currently used may not be adequate for patient identification. We aimed to determine the adequacy of CD screening in an academic gastroenterology (GI) practice. METHODS Consecutive initial visits to a tertiary academic GI practice were surveyed over a 3-month period as a fellow-initiated quality improvement project. All electronic records were reviewed to look for indications for CD screening according to published guidelines. The timing of screening was noted (before or after referral), as well as the screening method (serology or biopsy). Data were analysed to compare CD screening practices across subspecialty clinics. RESULTS 616 consecutive patients (49±0.6 years, range 16-87 years, 58.5% females, 94% Caucasian) fulfilled inclusion criteria. CD testing was indicated in 336 (54.5%), but performed in only 145 (43.2%). The need for CD screening was highest in luminal GI and inflammatory bowel disease clinics, followed by biliary and hepatology clinics (p<0.0001); CD screening rate was highest in the luminal GI clinic (p=0.002). Of 145 patients screened, 4 patients (2.4%) had serology consistent with CD, of which 2 were proven by duodenal biopsy. Using this proportion, an additional 5 patients might have been diagnosed in 191 untested patients with indications for CD screening. CONCLUSIONS More than 50% of patients in a tertiary GI clinic have indications for CD screening, but <50% of indicated cases are screened. Case-finding techniques therefore are suboptimal, constituting a gap in patient care and an important target for future quality improvement initiatives.
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Affiliation(s)
- Heba Iskandar
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA.,Digestive Diseases Division, Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Darrell M Gray
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA.,The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Hongha Vu
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Faiz Mirza
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Mary Katherine Rude
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Kara Regan
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Adil Abdalla
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Srinivas Gaddam
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Sami Almaskeen
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Michael Mello
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Evelyn Marquez
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Claire Meyer
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Ahmed Bolkhir
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Navya Kanuri
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Gregory Sayuk
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA.,John Cochran Veterans Affairs Medical Center, St Louis, Missouri, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
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60
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Gaddam S, Reddy CA, Munigala S, Patel A, Kanuri N, Almaskeen S, Rude MK, Abdalla A, Gyawali CP. The learning curve for interpretation of oesophageal high-resolution manometry: a prospective interventional cohort study. Aliment Pharmacol Ther 2017; 45:291-299. [PMID: 27859421 PMCID: PMC5148725 DOI: 10.1111/apt.13855] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 05/18/2016] [Accepted: 10/15/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND High-resolution manometry has become the preferred choice of oesophagologists for oesophageal motor assessment, but the learning curve among trainees remains unclear. AIM To determine the learning curve of high-resolution manometry interpretation. METHODS A prospective interventional cohort study was performed on 18 gastroenterology trainees, naïve to high-resolution manometry (median age 32 ± 4.0 years, 44.4% female). An intake questionnaire and a 1-h standardised didactic session were performed at baseline. Multiple 1-h interpretation sessions were then conducted periodically over 15 months where 10 studies were discussed; 5 additional test studies were provided for interpretation, and results were compared to gold standard interpretation by the senior author. Hypothetical management decisions based on trainee interpretation were separately queried. Accuracy was compared across test interpretations and sessions to determine the learning curve, with a goal of 90% accuracy. RESULTS Baseline accuracy was low for abnormal body motor patterns (53.3%), but higher for achalasia/outflow obstruction (65.9%). Recognition of achalasia reached 90% accuracy after six sessions (P = 0.01), while overall accurate management decisions reached this threshold by the 4th session (P < 0.001). Based on our data, the threshold of 90% accuracy for recognition of any abnormal from normal pattern was reached after 30 studies (3rd session) but fluctuated. Diagnosis of oesophageal body motor patterns remained suboptimal; accuracy of advisability of fundoplication improved, but did not reach 90%. CONCLUSIONS High-resolution manometry has a steep learning curve among trainees. Achalasia recognition is achieved early, but diagnosis of other abnormal motor patterns and management decisions require further supervised training.
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Affiliation(s)
- S Gaddam
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - C A Reddy
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - S Munigala
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - A Patel
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - N Kanuri
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - S Almaskeen
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - M K Rude
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - A Abdalla
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - C P Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
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Gaddam S, Sathyamurthy A, Kushnir V, Drapekin J, Sayuk G, Gyawali CP. Changes in symptom reflux association using dynamic pH thresholds during ambulatory pH monitoring: an observational cross-sectional study. Dis Esophagus 2016; 29:1013-1019. [PMID: 26471871 DOI: 10.1111/dote.12423] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Symptom reflux association (SRA) assesses symptoms associated with reflux events defined by pH <4.0, but limited symptoms associate with reflux events. We evaluated the impact of alternate pH thresholds on SRA in a large ambulatory pH database. Acid exposure time (AET), reflux events, and associated symptoms (within 2 minutes following a reflux event) were extracted from ambulatory pH studies performed off antireflux therapy (722 patients, 49.1 ± 0.5 years, 66.8% F) over a 7-year period. Symptom association probability (SAP) and symptom index (SI) were calculated at pH 3.5, 4.0, 4.5, and 5. Receiver operating characteristics (ROC) were generated using SRA at any pH as gold standard; areas under the curve (AUCs) were determined. Discordant cases were reanalyzed to determine changes in SRA and predictors of change using multivariate regression. At pH 4.0, 41% had a positive SAP, and 34% had a positive SI. While there was sustained gain in SI positivity from acidic to more weakly acidic pH thresholds, SAP positivity was highest at pH 4.5. On ROC analysis, performance characteristics were best at pH 4.0 (AUC 0.97) for SAP, and at pH 4.5 and 5.0 (AUC 0.92-0.94) for SI. On multivariate logistic regression adjusting for age, gender, and change in AET and reflux events, only number of associated symptoms predicted change in SRA (P < 0.0001). Changing pH thresholds for reflux events augments SRA by increasing reflux events associated with existing symptoms, while symptom recording remains the principal determinant of SRA.
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Affiliation(s)
- S Gaddam
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, USA
| | - A Sathyamurthy
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, USA
| | - V Kushnir
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, USA
| | - J Drapekin
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, USA
| | - G Sayuk
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, USA.,Division of Gastroenterology, Veterans Affairs Medical Center, St. Louis, USA
| | - C P Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, USA
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Bill JG, Darcy M, Fujii-Lau LL, Mullady DK, Gaddam S, Murad FM, Early DS, Edmundowicz SA, Kushnir VM. A comparison between endoscopic ultrasound-guided rendezvous and percutaneous biliary drainage after failed ERCP for malignant distal biliary obstruction. Endosc Int Open 2016; 4:E980-5. [PMID: 27652305 PMCID: PMC5025302 DOI: 10.1055/s-0042-112584] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 07/05/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Selective biliary cannulation is unsuccessful in 5 % to 10 % of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) for malignant distal biliary obstruction (MDBO). Percutaneous biliary drainage (PBD) has been the gold standard, but endoscopic ultrasound guided rendezvous (EUSr) have been increasingly used for biliary decompression in this patient population. Our aim was to compare the initial success rate, long-term efficacy, and safety of PBD and EUSr in relieving MDBO after failed ERC Patients and methods: A retrospective study involving 50 consecutive patients who had an initial failed ERCP for MDBO. Twenty-five patients undergoing EUSr between 2008 - 2014 were compared to 25 patients who underwent PBD immediately prior to the introduction of EUSr at our center (2002 - 2008). Comparisons were made between the two groups with regard to technical success, duration of hospital stay and adverse event rates after biliary decompression. RESULTS The mean age at presentation was 66.5 (± 12.6 years), 28 patients (54.9 %) were female. The etiology of MDBO was pancreaticobiliary malignancy in 44 (88 %) and metastatic disease in 6 (12 %) cases. Biliary drainage was technically successful by EUSr in 19 (76 %) cases and by PBD in 25 (100 %) (P = 0.002). Median length of hospital stay after initial drainage was 1 day in the EUSr group vs 5 days in PBD group (P = 0.02). Repeat biliary intervention was required for 4 patients in the EUSr group and 15 in the PBD group (P = 0.001). CONCLUSIONS Initial technical success with EUSr was significantly lower than with PBD, however when EUSr was successful, patients had a significantly shorter post-procedure hospital stay and required fewer follow-up biliary interventions. Meeting presentations: Annual Digestive Diseases Week 2015.
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Affiliation(s)
- Jason G. Bill
- Division of Gastroenterology, Washington University School of Medicine in St Louis, Missouri, United States,Corresponding author Jason G. Bill, MD Division of GastroenterologyWashington University School of Medicine660 South Euclid Ave Campus Box 8124St Louis, Missouri 63110+1-314-454-8977+1-314-747-1080
| | - Michael Darcy
- Division of Interventional Radiology, Washington University School of Medicine in St Louis, Missouri, United States
| | - Larissa L. Fujii-Lau
- Division of Gastroenterology, Washington University School of Medicine in St Louis, Missouri, United States
| | - Daniel K. Mullady
- Division of Gastroenterology, Washington University School of Medicine in St Louis, Missouri, United States
| | - Srinivas Gaddam
- Division of Gastroenterology, Washington University School of Medicine in St Louis, Missouri, United States
| | - Faris M. Murad
- Division of Gastroenterology, Washington University School of Medicine in St Louis, Missouri, United States
| | - Dayna S. Early
- Division of Gastroenterology, Washington University School of Medicine in St Louis, Missouri, United States
| | - Steven A. Edmundowicz
- Division of Gastroenterology, Washington University School of Medicine in St Louis, Missouri, United States
| | - Vladimir M. Kushnir
- Division of Gastroenterology, Washington University School of Medicine in St Louis, Missouri, United States
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Yang D, Amin S, Gonzalez S, Mullady D, Hasak S, Gaddam S, Edmundowicz SA, Gromski MA, DeWitt JM, El Zein M, Khashab MA, Wang AY, Gaspar JP, Uppal DS, Nagula S, Kapadia S, Buscaglia JM, Bucobo JC, Schlachterman A, Wagh MS, Draganov PV, Jung MK, Stevens T, Vargo JJ, Khara HS, Huseini M, Diehl DL, Keswani RN, Law R, Komanduri S, Yachimski PS, DaVee T, Prabhu A, Lapp RT, Kwon RS, Watson RR, Goodman AJ, Chhabra N, Wang WJ, Benias P, Carr-Locke DL, DiMaio CJ. Transpapillary drainage has no added benefit on treatment outcomes in patients undergoing EUS-guided transmural drainage of pancreatic pseudocysts: a large multicenter study. Gastrointest Endosc 2016; 83:720-9. [PMID: 26548849 DOI: 10.1016/j.gie.2015.10.040] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 10/29/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The need for transpapillary drainage (TPD) in patients undergoing transmural drainage (TMD) of pancreatic fluid collections (PFCs) remains unclear. The aims of this study were to compare treatment outcomes between patients with pancreatic pseudocysts undergoing TMD versus combined (TMD and TPD) drainage (CD) and to identify predictors of symptomatic and radiologic resolution. METHODS This is a retrospective review of 375 consecutive patients with PFCs who underwent EUS-guided TMD from 2008 to 2014 at 15 academic centers in the United States. Main outcome measures included TMD and CD technical success, treatment outcomes (symptomatic and radiologic resolution) at follow-up, and predictors of treatment outcomes on logistic regression. RESULTS A total of 375 patients underwent EUS-guided TMD of PFCs, of which 174 were pseudocysts. TMD alone was performed in 95 (55%) and CD in 79 (45%) pseudocysts. Technical success was as follows: TMD, 92 (97%) versus CD, 35 (44%) (P = .0001). There was no difference in adverse events between the TMD (15%) and CD (14%) cohorts (P = .23). Median long-term (LT) follow-up after transmural stent removal was 324 days (interquartile range, 72-493 days) for TMD and 201 days (interquartile range, 150-493 days) (P = .37). There was no difference in LT symptomatic resolution (TMD, 69% vs CD, 62%; P = .61) or LT radiologic resolution (TMD, 71% vs CD, 67%; P = .79). TPD attempt was negatively associated with LT radiologic resolution of pseudocyst (odds ratio, 0.11; 95% confidence interval, 0.02-0.8; P = .03). CONCLUSIONS TPD has no benefit on treatment outcomes in patients undergoing EUS-guided TMD of pancreatic pseudocysts and negatively affects LT resolution of PFCs.
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Affiliation(s)
- Dennis Yang
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sunil Amin
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Susana Gonzalez
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Daniel Mullady
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Stephen Hasak
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Srinivas Gaddam
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Steven A Edmundowicz
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Mark A Gromski
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - John M DeWitt
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mohamad El Zein
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jonathan P Gaspar
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Dushant S Uppal
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Satish Nagula
- Division of Gastroenterology and Hepatology, Stony Brook University School of Medicine, Stony Brook, New York, USA
| | - Samir Kapadia
- Division of Gastroenterology and Hepatology, Stony Brook University School of Medicine, Stony Brook, New York, USA
| | - Jonathan M Buscaglia
- Division of Gastroenterology and Hepatology, Stony Brook University School of Medicine, Stony Brook, New York, USA
| | - Juan Carlos Bucobo
- Division of Gastroenterology and Hepatology, Stony Brook University School of Medicine, Stony Brook, New York, USA
| | - Alex Schlachterman
- Division of Gastroenterology, University of Florida, Gainesville, Florida, USA
| | - Mihir S Wagh
- Division of Gastroenterology, University of Florida, Gainesville, Florida, USA
| | - Peter V Draganov
- Division of Gastroenterology, University of Florida, Gainesville, Florida, USA
| | - Min Kyu Jung
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tyler Stevens
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - John J Vargo
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Harshit S Khara
- Department of Gastroenterology and Nutrition, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Mustafa Huseini
- Department of Gastroenterology and Nutrition, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - David L Diehl
- Department of Gastroenterology and Nutrition, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Rajesh N Keswani
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ryan Law
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Patrick S Yachimski
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Tomas DaVee
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anoop Prabhu
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Robert T Lapp
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Richard S Kwon
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Rabindra R Watson
- Division of Digestive Diseases, University of California at Los Angeles School of Medicine, Los Angeles, California, USA
| | - Adam J Goodman
- Division of Gastroenterology, New York University School of Medicine, New York, New York, USA
| | - Natasha Chhabra
- Division of Gastroenterology, New York University School of Medicine, New York, New York, USA
| | - Wallace J Wang
- Division of Digestive Diseases, Beth Israel Medical Center, New York, New York, USA
| | - Petros Benias
- Division of Digestive Diseases, Beth Israel Medical Center, New York, New York, USA
| | - David L Carr-Locke
- Division of Digestive Diseases, Beth Israel Medical Center, New York, New York, USA
| | - Christopher J DiMaio
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Moawad FJ, Young PE, Gaddam S, Vennalaganti P, Thota PN, Vargo J, Cash BD, Falk GW, Sampliner RE, Lieberman D, Sharma P. Barrett's oesophagus length is established at the time of initial endoscopy and does not change over time: results from a large multicentre cohort. Gut 2015; 64:1874-80. [PMID: 25652086 DOI: 10.1136/gutjnl-2014-308552] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 01/11/2015] [Indexed: 12/08/2022]
Abstract
OBJECTIVE It is unclear whether Barrett's oesophagus (BO) length changes over time or whether the full length of the segment is established at the onset of disease recognition. The objectives of this study were to evaluate the association of age and BO length and to evaluate the changes in BO length over time. DESIGN This is a prospective, multicentre cohort study involving patients with BO from five centres. Patients were divided into groups based on the decade of initial diagnosis of BO. The mean BO length and the mean change in BO length were calculated for each age decade. The mean change in BO length was also calculated between the index endoscopy and the last surveillance endoscopy. RESULTS 3635 patients with BO were included in the study: 87.8% men, 92.8% Caucasians, mean age 60.9 years and mean BO length 3.5 cm. The mean change in BO length was 0.9 cm. The mean BO length did not significantly change for each age category: <30 years (4.6 cm), 30-39.9 years (3.2 cm), 40-49.9 years (3.1 cm), 50-59.9 years (3.1 cm), 60-69.9 years (3.6 cm), 70-79.7 (4.0 cm) and >80 years (4.5 cm), p=0.47. On subgroup analysis of patients with non-dysplastic BO who had at least 1 year of endoscopic follow up, there was a significant decrease in mean change in BO length across age categories ranging from +1.7 to -0.8 cm, p=0.03. CONCLUSIONS There was no significant difference in BO length by age category in decades. In addition, the change in BO length from index to follow-up endoscopy was similar among patients >30 years. These findings suggest that a patient's BO segment length attains its full extent by the time of the initial endoscopic examination.
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Affiliation(s)
- Fouad J Moawad
- Gastroenterology Service, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Patrick E Young
- Gastroenterology Service, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Srinivas Gaddam
- Gastroenterology Division, Washington University in St Louis, St Louis, Missouri, USA
| | - Prashanth Vennalaganti
- Division of Gastroenterology, Kansas City Veterans Affairs Medical Center, Kansas City, Missouri, USA
| | - Prashanthi N Thota
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA
| | - John Vargo
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brooks D Cash
- Division of Gastroenterology, University of South Alabama, Mobile, Alabama, USA
| | - Gary W Falk
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Richard E Sampliner
- Division of Gastroenterology and Hepatology, University of Arizona, Tucson, Arizona, USA
| | - David Lieberman
- Division of Gastroenterology and Hepatology, Oregon Health & Sciences University, Portland, Oregon, USA
| | - Prateek Sharma
- Division of Gastroenterology, Kansas City Veterans Affairs Medical Center, Kansas City, Missouri, USA Division of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, Kansas, USA
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65
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Gaddam S, Ge PS, Keach JW, Mullady D, Fukami N, Edmundowicz SA, Azar RR, Shah RJ, Murad FM, Kushnir VM, Watson RR, Ghassemi KF, Sedarat A, Komanduri S, Jaiyeola DM, Brauer BC, Yen RD, Amateau SK, Hosford L, Hollander T, Donahue TR, Schulick RD, Edil BH, McCarter M, Gajdos C, Attwell A, Muthusamy VR, Early DS, Wani S. Suboptimal accuracy of carcinoembryonic antigen in differentiation of mucinous and nonmucinous pancreatic cysts: results of a large multicenter study. Gastrointest Endosc 2015; 82:1060-9. [PMID: 26077458 DOI: 10.1016/j.gie.2015.04.040] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 04/26/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The exact cutoff value at which pancreatic cyst fluid carcinoembryonic antigen (CEA) level distinguishes pancreatic mucinous cystic neoplasms (MCNs) from pancreatic nonmucinous cystic neoplasms (NMCNs) is unclear. The aim of this multicenter retrospective study was to evaluate the diagnostic accuracy of cyst fluid CEA levels in differentiating between MCNs and NMCNs. METHODS Consecutive patients who underwent EUS with FNA at 3 tertiary care centers were identified. Patients with histologic confirmation of cyst type based on surgical specimens served as the criterion standard for this analysis. Demographic characteristics, EUS morphology, FNA fluid, and cytology results were recorded. Multivariate logistic regression analysis to identify predictors of MCNs was performed. Receiver-operating characteristic (ROC) curves were generated for CEA levels. RESULTS A total of 226 patients underwent surgery (mean age, 61 years, 96% white patients, 39% female patients) of whom 88% underwent Whipple's procedure or distal pancreatectomy. Based on surgical histopathology, there were 150 MCNs and 76 NMCNs cases. The median CEA level was 165 ng/mL. The area under the ROC curve for CEA levels in differentiating between MCNs and NMCNs was 0.77 (95% confidence interval, 0.71-0.84, P < .01) with a cutoff of 105 ng/mL, demonstrating a sensitivity and specificity of 70% and 63%, respectively. The cutoff value of 192 ng/mL yielded a sensitivity of 61% and a specificity of 77% and would misdiagnose 39% of MCN cases. CONCLUSIONS Cyst fluid CEA levels have a clinically suboptimal accuracy level in differentiating MCNs from NMCNs. Future studies should focus on novel cyst fluid markers to improve risk stratification of pancreatic cystic neoplasms.
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Affiliation(s)
- Srinivas Gaddam
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Phillip S Ge
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Joseph W Keach
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Centennial, Colorado, USA
| | - Daniel Mullady
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Norio Fukami
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Centennial, Colorado, USA
| | - Steven A Edmundowicz
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Riad R Azar
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Raj J Shah
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Centennial, Colorado, USA
| | - Faris M Murad
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Vladimir M Kushnir
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Rabindra R Watson
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Kourosh F Ghassemi
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Alireza Sedarat
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Srinadh Komanduri
- Division of Gastroenterology, Feinberg School of Medicine Northwestern University, Chicago, Illinois, USA
| | - Diana-Marie Jaiyeola
- Division of Gastroenterology, Feinberg School of Medicine Northwestern University, Chicago, Illinois, USA
| | - Brian C Brauer
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Centennial, Colorado, USA
| | - Roy D Yen
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Centennial, Colorado, USA
| | - Stuart K Amateau
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Centennial, Colorado, USA
| | - Lindsay Hosford
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Centennial, Colorado, USA
| | - Thomas Hollander
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Timothy R Donahue
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Richard D Schulick
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Centennial, Colorado, USA
| | - Barish H Edil
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Centennial, Colorado, USA
| | - Martin McCarter
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Centennial, Colorado, USA
| | - Csaba Gajdos
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Centennial, Colorado, USA
| | - Augustin Attwell
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Centennial, Colorado, USA
| | - V Raman Muthusamy
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Dayna S Early
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Centennial, Colorado, USA; Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Denver, Colorado, USA
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Kanakadandi V, Parasa S, Sihn P, Singh M, Giacchino M, Gupta N, Gaddam S, Rastogi A, Bansal A, Petrini J, Sharma P. Patterns of antiplatelet agent use in the US. Endosc Int Open 2015; 3:E173-8. [PMID: 26171425 PMCID: PMC4486037 DOI: 10.1055/s-0034-1390750] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 09/08/2014] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND The American Society of Gastrointestinal Endoscopy (ASGE) published updated guidelines in 2009 to help endoscopists manage the treatment of their patients who have been prescribed antiplatelet therapy (APT). STUDY AIM To assess the use of APT among endoscopists, and to identify factors guiding their use of APT while treating their patients. METHOD A survey questionnaire was distributed to endoscopists at two national meetings to assess their usage of APT while treating patients during the peri-endoscopic period. RESULTS The survey was provided to 400 attendees of whom 239 (60 %) responded. Only 30 % of respondents followed the ASGE guidelines for treating their patients and 26 % percent of respondents withheld all APT before engaging in any patient procedure. Endoscopists' decisions appeared to be influenced by their own particular experiences rather than any specific APT usage guidelines (46 % vs 22 %; P < 0.05). As expected, more endoscopists (P < 0.05) continued APT for patients who underwent low risk procedures (90 %) than for patients who underwent high risk procedures (47 %). Approximately 50 % of the respondents did not perform high risk procedures for patients prescribed aspirin therapy. CONCLUSIONS About one-fourth of endoscopists surveyed discontinued APT treatment of patients who underwent any endoscopic procedure, and one-half of them discontinued use of non-steroidal anti-inflammatory drug treatment of patients who underwent a high risk endoscopic procedure. Inappropriate withdrawal of APT medications may expose patients to unnecessary risks, and efforts to improve endoscopists' application of ASGE guidelines for the use of APT to treat patients during the peri-endoscopic period are warranted.
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Affiliation(s)
- Vijay Kanakadandi
- University of Kansas Medical Center, Gastroenterology, Kansas, City, Kansas, United States,Kansas City Veterans Administration Medical Center, Gastroenterology, Kansas, City, Kansas, United States
| | - Sravanthi Parasa
- University of Kansas Medical Center, Gastroenterology, Kansas, City, Kansas, United States,Kansas City Veterans Administration Medical Center, Gastroenterology, Kansas, City, Kansas, United States
| | - Preetika Sihn
- University of Kansas Medical Center, Gastroenterology, Kansas, City, Kansas, United States,Kansas City Veterans Administration Medical Center, Gastroenterology, Kansas, City, Kansas, United States
| | - Mandeep Singh
- University of Kansas Medical Center, Gastroenterology, Kansas, City, Kansas, United States
| | - Maria Giacchino
- Kansas City Veterans Administration Medical Center, Gastroenterology, Kansas, City, Kansas, United States,University of Genova, Dipartimento di Medicina Interna e Specialità Mediche, Genova, Italy
| | - Neil Gupta
- Loyola University Medical Center, Gastroenterology, Chicago, Illinois, United States
| | - Srinivas Gaddam
- Washington University School of Medicine, Gastroenterology, St Louis, Missouri, United States
| | - Amit Rastogi
- University of Kansas Medical Center, Gastroenterology, Kansas, City, Kansas, United States,Kansas City Veterans Administration Medical Center, Gastroenterology, Kansas, City, Kansas, United States
| | - Ajay Bansal
- University of Kansas Medical Center, Gastroenterology, Kansas, City, Kansas, United States,Kansas City Veterans Administration Medical Center, Gastroenterology, Kansas, City, Kansas, United States
| | - John Petrini
- Sansum Clinic, Gastroenterology, Santa Barbara, California, United States
| | - Prateek Sharma
- University of Kansas Medical Center, Gastroenterology, Kansas, City, Kansas, United States,Corresponding author Prateek Sharma, MD University of Kansas Medical Center, Gastroenterology3901 Rainbow BoulevardKansas City, Kansas, 66160+1–816–922–3362
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Klassert TE, Goyal S, Hussain A, Driesch D, Binding-Liermann R, Gaddam S, Valluri V, Ahmed N, Schumann R, Slevogt H. The Role of Single Nucleotide Polymorphisms in C-type Lectin Receptors for Susceptibility towards Pulmonary Tuberculosis in Hyderabad (India). Pneumologie 2015. [DOI: 10.1055/s-0035-1544808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Balasubramanian G, Gupta N, Giacchino M, Singh M, Kanakadandi V, Gaddam S, Wani SB, Higbee AD, Rastogi A, Bansal A, Sharma P. Cigarette smoking is a modifiable risk factor for Barrett's oesophagus. United European Gastroenterol J 2014; 1:430-7. [PMID: 24917994 DOI: 10.1177/2050640613504917] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 08/19/2013] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Cigarette smoking has been associated with an increased risk of oesophageal adenocarcinoma (OAC). However, the impact of smoking and more importantly smoking cessation on Barrett's oesophagus (BO) is unclear. OBJECTIVE The aim of the study is to evaluate the association between cigarette smoking and presence of BO in a large prospective cohort of patients with gastro-oesophageal reflux disease (GORD). METHODS Patients presenting to the endoscopy unit for upper endoscopy completed a validated GORD questionnaire and information on demographics (age, gender, and ethnicity), cigarette smoking [status (current/past), amount (pack years) and duration of smoking cessation], clinical data [medication history, body mass index (BMI), and family history] and endoscopic findings [BO and hiatal hernia] were recorded. Cigarette smokers (current and past) and nonsmokers were compared using Fisher's Exact test for categorical variables and Mann-Whitney test for continuous variables. Effects of cigarette smoking and smoking cessation on BO risk was assessed by stepwise logistic regression analysis. RESULTS A total of 1056 patients were included in the analysis [mean age: 57.2 ± 12.7years, Caucasian 880 (83.3%), male 985 (93.3%), and mean BMI 29.6 (SD: ± 5.6)]. 827 (78.3%) were smokers and 229 (21.6%) were nonsmokers. 474 subjects (44.9%) had a previous history of smoking. Anytime smokers were more likely to have BO (adjusted OR: 3.3; 95 CI: 1.7-6.3; p < 0.01). Higher smoking burden (pack years) was associated with higher risk of BO in this GORD cohort (p for trend < 0.01). Duration of smoking cessation was inversely associated with risk of BO (p for trend: 0.01). CONCLUSION This study shows that smokers with reflux symptoms have about threefold higher risk of BO compared with nonsmokers, whereas discontinuing smoking is associated with a significant reduced risk. Smoking cessation appears to be a viable option to reduce BO risk in patients with reflux disease.
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Affiliation(s)
| | - Neil Gupta
- Gastroenterology and Hepatology, Loyola University Medical Center, Maywood, IL, USA
| | - Maria Giacchino
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, MO, USA
| | - Mandeep Singh
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, MO, USA ; Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Vijay Kanakadandi
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, MO, USA
| | - Srinivas Gaddam
- Gastroenterology and Hepatology, Washington University in St.Louis, St.Louis, MO, USA
| | - Sachin B Wani
- Gastroenterology and Hepatology, University of Colorado, Denver, CO, USA
| | - April D Higbee
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, MO, USA
| | - Amit Rastogi
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, MO, USA ; Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Ajay Bansal
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, MO, USA ; Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Prateek Sharma
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, MO, USA ; Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, KS, USA
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Sivangala R, Ponnana M, Thada S, Joshi L, Ansari S, Hussain H, Valluri V, Gaddam S. Association of Cytokine Gene Polymorphisms in Patients with Tuberculosis and Their Household Contacts. Scand J Immunol 2014; 79:197-205. [DOI: 10.1111/sji.12136] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 11/18/2013] [Indexed: 01/30/2023]
Affiliation(s)
- R. Sivangala
- Bhagwan Mahavir Medical Research Centre; Hyderabad India
| | - M. Ponnana
- Bhagwan Mahavir Medical Research Centre; Hyderabad India
| | - S. Thada
- Bhagwan Mahavir Medical Research Centre; Hyderabad India
| | - L. Joshi
- Bhagwan Mahavir Medical Research Centre; Hyderabad India
| | - S. Ansari
- Bhagwan Mahavir Medical Research Centre; Hyderabad India
| | - H. Hussain
- Bhagwan Mahavir Medical Research Centre; Hyderabad India
| | - V. Valluri
- Bhagwan Mahavir Medical Research Centre; Hyderabad India
- LEPRA India; Blue Peter Public Health & Research Centre; Cherlapally Hyderabad India
| | - S. Gaddam
- Bhagwan Mahavir Medical Research Centre; Hyderabad India
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Joshi L, Ponnana M, Penmetsa SR, Nallari P, Valluri V, Gaddam S. Serum Vitamin D Levels and VDR Polymorphisms (BsmI and FokI) in Patients and their Household Contacts Susceptible to Tuberculosis. Scand J Immunol 2014; 79:113-9. [DOI: 10.1111/sji.12127] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 10/08/2013] [Indexed: 11/29/2022]
Affiliation(s)
- L. Joshi
- Bhagwan Mahavir Medical Research Centre; Hyderabad Andhra Pradesh India
| | - M. Ponnana
- Bhagwan Mahavir Medical Research Centre; Hyderabad Andhra Pradesh India
| | - S. R. Penmetsa
- Bhagwan Mahavir Medical Research Centre; Hyderabad Andhra Pradesh India
| | - P. Nallari
- Department of Genetics; Osmania University; Hyderabad Andhra Pradesh India
| | - V. Valluri
- Bhagwan Mahavir Medical Research Centre; Hyderabad Andhra Pradesh India
- LEPRA India-Blue Peter Public Health & Research Centre; Hyderabad Andhra Pradesh India
| | - S. Gaddam
- Bhagwan Mahavir Medical Research Centre; Hyderabad Andhra Pradesh India
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Desai N, Gaddam S, Gupta N, Singh M, Balasubramanian G, Kanakadandi V, Bansal A, Sharma P. Developing a database of high definition endoscopic videos and images in your institution. Endoscopy 2014; 45:370-6. [PMID: 23381949 DOI: 10.1055/s-0032-1326093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- N Desai
- Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center Kansas City, Missouri, USA
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Anaparthy R, Gaddam S, Kanakadandi V, Alsop BR, Gupta N, Higbee AD, Wani SB, Singh M, Rastogi A, Bansal A, Cash BD, Young PE, Lieberman DA, Falk GW, Vargo JJ, Thota P, Sampliner RE, Sharma P. Association between length of Barrett's esophagus and risk of high-grade dysplasia or adenocarcinoma in patients without dysplasia. Clin Gastroenterol Hepatol 2013; 11:1430-6. [PMID: 23707463 DOI: 10.1016/j.cgh.2013.05.007] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Revised: 04/23/2013] [Accepted: 05/04/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS It is not clear whether length of Barrett's esophagus (BE) is a risk factor for high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) in patients with nondysplastic BE. We studied the risk of progression to HGD or EAC in patients with nondysplastic BE, based on segment length. METHODS We analyzed data from a large cohort of patients participating in the BE Study-a multicenter outcomes project comprising 5 US tertiary care referral centers. Histologic changes were graded as low-grade dysplasia, HGD, or EAC. The study included patients with BE of documented length without dysplasia and at least 1 year of follow-up evaluation (n = 1175; 88% male), and excluded patients who developed HGD or EAC within 1 year of their BE diagnosis. The mean follow-up period was 5.5 y (6463 patient-years). The annual risk of HGD and EAC was plotted in 3-cm increments (≤3 cm, 4-6 cm, 7-9 cm, 10-12 cm, and ≥13 cm). We calculated the association between time to progression and length of BE. RESULTS The mean BE length was 3.6 cm; 44 patients developed HGD or EAC, with an annual incidence rate of 0.67%/y. Compared with nonprogressors, patients who developed HGD or EAC had longer BE segments (6.1 vs 3.5 cm; P < .001). Logistic regression analysis showed a 28% increase in risk of HGD or EAC for every 1-cm increase in BE length (P = .01). Patients with BE segment lengths of 3 cm or shorter took longer to develop HGD or EAC than those with lengths longer than 4 cm (6 vs 4 y; P = nonsignificant). CONCLUSIONS In patients with BE without dysplasia, length of BE was associated with progression to HGD or EAC. The results support the development of a risk stratification scheme for these patients based on length of BE segment.
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Affiliation(s)
- Rajeswari Anaparthy
- Department of Gastroenterology and Hepatology, Veterans Affairs Medical Center and University of Kansas School of Medicine, Kansas City, Missouri
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Singh M, Gupta N, Gaddam S, Balasubramanian G, Wani S, Sinh P, Aghaie K, Higbee AD, Rastogi A, Kanakadandi V, Bansal A, Sharma P. Practice patterns among U.S. gastroenterologists regarding endoscopic management of Barrett's esophagus. Gastrointest Endosc 2013; 78:689-95. [PMID: 23769458 DOI: 10.1016/j.gie.2013.05.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Accepted: 05/06/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic management of Barrett's esophagus (BE) has evolved over the past decade; however, the practice patterns for managing BE among gastroenterologists remain unclear. OBJECTIVE To assess practice patterns for management of BE among gastroenterologists working in various practice settings. DESIGN A random questionnaire-based survey of practicing gastroenterologists in the United States. The questionnaire contained a total of 10 questions pertaining to practice setting, physician demographics, and strategies used for managing BE. SETTING Survey of gastroenterologists working in various practice settings. INTERVENTION Questionnaire. MAIN OUTCOME MEASUREMENTS Practice patterns for endoscopic imaging and management of BE. RESULTS The response rate was 45% (236/530). The majority (85%) were gastroenterologists in community practice, 72% were aged 41 to 60 years, 80% had >10 years of experience, and 81% had attended postgraduate courses and/or seminars on BE management. A total of 78% did not use the Prague C & M classification, and about a third used advanced endoscopic imaging routinely (37%) or in selected cases (31%). For nondysplastic BE, 86% practiced surveillance, 12% performed ablation, and 3% did no intervention. For BE with low-grade dysplasia, 56% practiced surveillance, 26% performed endoscopic ablation in all low-grade dysplasia cases, and 18% performed endoscopic ablation in only selected patients with low-grade dysplasia. The majority of respondents (58%) referred their patients with high-grade dysplasia to centers with BE expertise, 13% performed endoscopic ablation in all patients with high-grade dysplasia, 25% performed endoscopic ablation in selected cases only, and 3% referred these patients for surgery. The most frequently used endoscopic eradication therapy was radiofrequency ablation (39%) followed by EMR (17%). LIMITATIONS The sample may be unrepresentative, participation in the study was voluntary, and responses may be skewed toward following the guidelines. CONCLUSION Results from this survey show that the majority of practicing gastroenterologists in the United States practice surveillance endoscopy in patients with nondysplastic BE and provide endoscopic therapy for those with high-grade dysplasia. The Prague C & M classification and advanced imaging techniques are used by less than a third of gastroenterologists. Practice patterns did not appear to be affected by respondent age or duration of clinical practice.
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Affiliation(s)
- Mandeep Singh
- Gastroenterology and Hepatology, Kansas City Veterans Affairs Medical Center, Kansas City, Missouri, USA; Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, Missouri, USA
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Tofteland N, Singh M, Gaddam S, Wani SB, Gupta N, Rastogi A, Bansal A, Kanakadandi V, McGregor DH, Ulusarac O, Cherian R, Mathur SC, Sharma P. Evaluation of the updated confocal laser endomicroscopy criteria for Barrett's esophagus among gastrointestinal pathologists. Dis Esophagus 2013; 27:623-9. [PMID: 24006939 DOI: 10.1111/dote.12121] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Previously developed novel probe-based confocal laser endomicroscopy (pCLE) criteria have been found to have high accuracy and substantial interobserver agreement (IOA) for diagnosing dysplasia in Barrett's esophagus (BE) when used by endoscopists. These updated criteria are: (i) epithelial surface: saw toothed, (ii) cells: enlarged, (iii) cells: pleomorphic, (iv) glands: not equidistant, (v) glands: unequal in size and shape, and (vi) goblet cells: not easily identified. The accuracy and IOA among pathologists in the diagnosis of dysplasia using the novel pCLE criteria is not known. The primary objective of the study was to evaluate the accuracy, overall IOA and learning curve among three gastrointestinal (GI) pathologists in diagnosing dysplasia in BE using the updated pCLE criteria. The secondary aim was to compare the accuracy and IOA between GI pathologists and gastroenterology endoscopists. Ninety pCLE videos and respective histology were retrieved from a previously conducted multicenter, prospective, randomized, controlled trial evaluating the utility of pCLE in BE patients. Videos were obtained from 101 BE patients previously enrolled for surveillance or endoscopic treatment of high-grade dysplasia or early esophageal adenocarcinoma. Three GI pathologists reviewed 90 pCLE video clips for dysplasia versus no dysplasia, confidence in their diagnosis, and image quality. The overall accuracy for the diagnosis of dysplasia (low-grade dysplasia/high-grade dysplasia/esophageal adenocarcinoma) was 77.8% (95% confidence interval [CI]: 72.4-82.3). The accuracy was higher when pathologists had 'high confidence' in their assessment of the videos (93.8% vs. 69.3%, P < 0.001). There was no significant difference in accuracy between the first set of 30 and second set of 60 videos (84% vs. 74%, P = 0.065). IOA among GI pathologists was substantial, k = 0.65 (95% CI: 0.53-0.73). The sensitivity for detecting dysplasia was 85% (95% CI: 78.1-90.7) and the specificity was 70% (95% CI: 61.91-77.92). These results were comparable with the evaluation of the same set of videos by endoscopists. GI pathologists have high accuracy and substantial IOA for diagnosing BE dysplasia with pCLE. Pathologists appear to have similar accuracy and IOA as endoscopists. These results provide further support of endoscopists accurately interpreting the in vivo optical histology provided by pCLE.
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Affiliation(s)
- N Tofteland
- Department of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri, USA; Department of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, Kansas, USA
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Affiliation(s)
- Srinivas Gaddam
- Washington University School of Medicine, St. Louis, Missouri, USA.
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Affiliation(s)
- Srinivas Gaddam
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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Gaddam S, Singh M, Balasubramanian G, Thota P, Gupta N, Wani S, Higbee AD, Mathur SC, Horwhat JD, Rastogi A, Young PE, Cash BD, Bansal A, Vargo JJ, Falk GW, Lieberman DA, Sampliner RE, Sharma P. Persistence of nondysplastic Barrett's esophagus identifies patients at lower risk for esophageal adenocarcinoma: results from a large multicenter cohort. Gastroenterology 2013; 145:548-53.e1. [PMID: 23714382 DOI: 10.1053/j.gastro.2013.05.040] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 04/29/2013] [Accepted: 05/15/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS Recent population-based studies have shown a low risk of esophageal adenocarcinoma (EAC) in patients with nondysplastic Barrett's esophagus (NDBE). We evaluated whether persistence of NDBE over multiple consecutive surveillance endoscopic examinations could be used in risk stratification of patients with Barrett's esophagus (BE). METHODS We performed a multicenter outcomes study of a large cohort of patients with BE. Based on the number of consecutive surveillance endoscopies showing NDBE, we identified 5 groups of patients. Patients in group 1 were found to have NDBE at their first esophagogastroduodenoscopy (EGD). Patients in group 2 were found to have NDBE on their first 2 consecutive EGDs. Similarly, patients in groups 3, 4, and 5 were found to have NDBE on 3, 4, and 5 consecutive surveillance EGDs. A logistic regression model was built to determine whether persistence of NDBE independently protected against development of cancer. RESULTS Of a total of 3515 patients with BE, 1401 patients met the inclusion criteria (93.3% white; 87.5% men; median age, 60 ±17 years). The median follow-up period was 5 ± 3.9 years (7846 patient-years). The annual risk of EAC in groups 1 to 5 was 0.32%, 0.27%, 0.16%, 0.2%, and 0.11%, respectively (P for trend = .03). After adjusting for age, sex, and length of BE, persistence of NDBE, based on multiple surveillance endoscopies, was associated with a gradually lower likelihood of progression to EAC. CONCLUSIONS Persistence of NDBE over several endoscopic examinations identifies patients who are at low risk for development of EAC. These findings support lengthening surveillance intervals or discontinuing surveillance of patients with persistent NDBE.
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Affiliation(s)
- Srinivas Gaddam
- Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, MO, USA
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Madhoun MF, Wani SB, Rastogi A, Early D, Gaddam S, Tierney WM, Maple JT. The diagnostic accuracy of 22-gauge and 25-gauge needles in endoscopic ultrasound-guided fine needle aspiration of solid pancreatic lesions: a meta-analysis. Endoscopy 2013; 45:86-92. [PMID: 23307148 DOI: 10.1055/s-0032-1325992] [Citation(s) in RCA: 146] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND STUDY AIMS It is uncertain if needle gauge impacts the diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of pancreatic mass lesions. Our aim was to use meta-analysis to more robustly define the diagnostic accuracy of EUS-FNA for pancreatic masses using 22 G and 25 G needles. PATIENTS AND METHODS Studies were identified by searching nine medical databases for reports published between 1994 and 2011, using a reproducible search strategy comprised of relevant terms. Only studies comparing the overall diagnostic accuracy of 22 G vs. 25 G EUS needles that used surgical histology or at least 6 months clinical follow up for a gold standard were included. Two reviewers independently scored the identified studies for methodology and abstracted pertinent data. When required, the original investigators were contacted to provide additional data. Pooling was conducted by both fixed-effects and random-effects models. Diagnostic characteristics (sensitivity, specificity, positive and negative likelihood ratios) with 95% confidence intervals (CIs) were calculated. RESULTS Eight studies involving 1292 subjects met the defined inclusion criteria. Of the 1292 patients, 799 were in the 22 G group and 565 were in the 25 G group (both needles were used in 72 patients). The pooled sensitivity and specificity of the 22 G needle were 0.85 (95%CI 0.82-0.88) and 1 (95%CI 0.98-1) respectively. The pooled sensitivity and specificity of the 25 G needle were 0.93 (95%CI 0.91-0.96) and 0.97 (95%CI 0.93-0.99) respectively. The bivariate generalized linear random-effect model indicated that the 25 G needle is associated with a higher sensitivity (P = 0.0003) but comparable specificity (P = 0.97) to the 22 G needle. CONCLUSIONS This meta-analysis suggests 25 G needle systems are more sensitive than 22 G needles for diagnosing pancreatic malignancy.
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Affiliation(s)
- M F Madhoun
- Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma 73117, USA
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Wani S, Abrams J, Edmundowicz SA, Gaddam S, Hovis CE, Green D, Gupta N, Higbee A, Bansal A, Rastogi A, Early D, Lightdale CJ, Sharma P. Endoscopic mucosal resection results in change of histologic diagnosis in Barrett's esophagus patients with visible and flat neoplasia: a multicenter cohort study. Dig Dis Sci 2013; 58:1703-9. [PMID: 23633158 PMCID: PMC4309270 DOI: 10.1007/s10620-013-2689-7] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Accepted: 04/09/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND There are limited data on the effect of endoscopic mucosal resection (EMR) on changes of histopathologic diagnosis for Barrett's esophagus (BE) patients undergoing endoscopic eradication therapy (EET); especially those without visible lesions. AIM To compare the frequency of changes of diagnosis by EMR compared with pre-EMR biopsy diagnosis for patients with and without visible lesions. METHODS In this multicenter outcomes project, patients with Barrett's-related neoplasia undergoing EET at three tertiary-care centers were included. Patients undergoing biopsies followed by EMR within six months were included. The main outcome measures were frequency of overall change of histopathologic diagnosis, change based on pre-EMR biopsy diagnosis, and change based on the presence of visible lesions. RESULTS One-hundred and thirty-eight BE patients (low-grade dysplasia (LGD) 15 (10.9 %), high-grade dysplasia (HGD) 87 (63 %), esophageal adenocarcinoma (EAC) 36 (26.1 %)) were included; 114 (82.6 %) patients had visible lesions. EMR resulted in a change of diagnosis for 43 (31.1 %) patients (upgrade 14 (10.1 %); downgrade 29 (21 %)). For HGD patients, EMR downstaged dysplasia grade for 17 (19.5 %) cases and upstaged it to EAC for nine (10.3 %) cases. There was a change of diagnosis for 26 (29.9 %) HGD patients, irrespective of the presence or absence of visible lesions (p = 0.76). For EAC patients, EMR downstaged dysplasia grade in 10 (27.8 %) cases. There was a change of diagnosis for 10 (27.8 %) EAC patients, irrespective of the presence or absence of endoscopically visible lesions (p = 0.48). CONCLUSIONS EMR results in a change of diagnosis for approximately 30 % of BE patients with early neoplasia (with and without visible lesions) referred for EET.
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Affiliation(s)
- Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado and Veterans Affairs Medical Center, Denver, CO, USA
| | - Julian Abrams
- Division of Digestive and Liver Diseases, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Steven A. Edmundowicz
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, MO, USA
| | - Srinivas Gaddam
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, MO, USA
| | - Christine E. Hovis
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel Green
- Division of Digestive and Liver Diseases, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Neil Gupta
- Division of Gastroenterology and Hepatology, Department of Veterans Affairs Medical Center and University of Kansas School of Medicine, 4801 E. Linwood Blvd, Kansas City, MO 64128-2295, USA
| | - April Higbee
- Division of Gastroenterology and Hepatology, Department of Veterans Affairs Medical Center and University of Kansas School of Medicine, 4801 E. Linwood Blvd, Kansas City, MO 64128-2295, USA
| | - Ajay Bansal
- Division of Gastroenterology and Hepatology, Department of Veterans Affairs Medical Center and University of Kansas School of Medicine, 4801 E. Linwood Blvd, Kansas City, MO 64128-2295, USA
| | - Amit Rastogi
- Division of Gastroenterology and Hepatology, Department of Veterans Affairs Medical Center and University of Kansas School of Medicine, 4801 E. Linwood Blvd, Kansas City, MO 64128-2295, USA
| | - Dayna Early
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, MO, USA
| | - Charles J. Lightdale
- Division of Digestive and Liver Diseases, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Prateek Sharma
- Division of Gastroenterology and Hepatology, Department of Veterans Affairs Medical Center and University of Kansas School of Medicine, 4801 E. Linwood Blvd, Kansas City, MO 64128-2295, USA
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Giacchino M, Bansal A, Kim RE, Singh V, Hall SB, Singh M, Rastogi A, Moloney B, Wani SB, Gaddam S, Mathur SC, Wallace MB, Kanakadandi V, Balasubramanian G, Gupta N, Sharma P. Clinical utility and interobserver agreement of autofluorescence imaging and magnification narrow-band imaging for the evaluation of Barrett's esophagus: a prospective tandem study. Gastrointest Endosc 2013; 77:711-8. [PMID: 23433595 DOI: 10.1016/j.gie.2013.01.029] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Accepted: 11/24/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND New endoscopic imaging techniques, such as autofluorescence imaging (AFI) and narrow-band imaging (NBI), have been developed to improve the detection of neoplastic lesions in Barrett's esophagus (BE). OBJECTIVE To evaluate the clinical utility of AFI and magnification NBI to detect high-grade dysplasia (HGD) and early esophageal adenocarcinoma (EAC) and the interobserver agreement. DESIGN Prospective tandem study of eligible patients. SETTING Single, academic tertiary care center. PATIENTS Forty-two patients with a history of confirmed BE were prospectively enrolled. INTERVENTIONS The BE segment was examined under high-definition white-light endoscopy, and the presence of visible lesions was recorded. Subsequently, AFI and magnification NBI were performed in tandem on areas of the BE segment away from visible lesions; images obtained by these 2 systems were graded according to the color of reflected light and surface patterns, respectively. Biopsy specimens were obtained at the end of the procedure. MAIN OUTCOME MEASUREMENTS The sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of the AFI and NBI patterns for the detection of HGD/EAC and interobserver agreement. RESULTS Of the 42 patients enrolled, 14 (33%) had HGD/EAC. On patient-based analysis, AFI alone had a sensitivity, specificity, and NPV of 50%, 61%, and 71%, respectively, and the overall accuracy for the detection of HGD/EAC patients was 57%. By using magnification NBI in tandem fashion, the sensitivity and NPV improved to 71% and 76%, respectively, with a decrease in specificity to 46% and in overall accuracy to 55%. The 2 techniques had moderate interobserver agreement for both the patterns and prediction of histology. LIMITATIONS Uncontrolled study performed at an academic center by expert endoscopists in a high-risk population. CONCLUSIONS By using a multimodality endoscope, both AFI and magnification NBI had limited clinical accuracy and moderate overall interobserver agreement. AFI does not appear to be useful as a broad-based technique for the detection of neoplasia in patients with BE.
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Affiliation(s)
- Maria Giacchino
- Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missour, USA
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Singh M, Lee J, Gupta N, Gaddam S, Smith BK, Wani SB, Sullivan DK, Rastogi A, Bansal A, Donnelly JE, Sharma P. Weight loss can lead to resolution of gastroesophageal reflux disease symptoms: a prospective intervention trial. Obesity (Silver Spring) 2013; 21:284-90. [PMID: 23532991 PMCID: PMC3853378 DOI: 10.1002/oby.20279] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Accepted: 05/30/2012] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Weight gain is an important risk factor for gastroesophageal reflux disease (GERD); however, whether weight loss can lead to resolution of GERD symptoms is not clear. Our aim was to measure the impact of weight loss on GERD symptoms. DESIGN AND METHODS In a prospective cohort study at a tertiary referral center, overweight/obese subjects (BMI 25-39.9 kg/m2) were enrolled in a structured weight loss program. Weight loss strategies included dietary modifications, increased physical activity and behavioral changes. At baseline and at 6 months, BMI and waist circumference were measured and all participants completed a validated reflux disease questionnaire. RESULTS A total of 332 adult subjects, mean age 46 years and 66% women were prospectively enrolled. At baseline, the mean body weight, BMI, and waist circumference were 101 (±18) kg, 35 (±5) kg/m2 and 103 (±13) cm. At 6 months, majority of the subjects (97%) lost weight (average weight loss: 13 ± 7.7 kg) and as compared with baseline, there was a significant decrease in the overall prevalence of GERD (15 vs. 37%; P < 0.01) and the mean GERD symptom score (1.8 vs. 5.5; P < 0.01). Overall, 81% of the subjects had reduction in GERD symptom scores; 65% had complete resolution and 15% had partial resolution of reflux symptoms. There was a significant correlation between % body weight loss and reduction in GERD symptom scores (r = 0.17, P < 0.05). CONCLUSIONS In conclusion, the overall prevalence of GERD symptoms is high (37%) in overweight and obese subjects. A structured weight loss program can lead to complete resolution of GERD symptoms in the majority of these subjects.
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Affiliation(s)
- Mandeep Singh
- Department of Gastroenterology, Veterans Affairs Medical Center, Kansas City, Missouri, USA
- Department of Gastroenterology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jaehoon Lee
- Center for Research Methods and Data Analysis, The University of Kansas, Lawrence, Kansas, USA
| | - Neil Gupta
- Department of Gastroenterology, Veterans Affairs Medical Center, Kansas City, Missouri, USA
- Department of Gastroenterology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Srinivas Gaddam
- Department of Gastroenterology, Veterans Affairs Medical Center, Kansas City, Missouri, USA
| | - Bryan K. Smith
- Center for Research Methods and Data Analysis, The University of Kansas, Lawrence, Kansas, USA
- Department of Dietetics and Nutrition, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Sachin B. Wani
- Department of Gastroenterology, Veterans Affairs Medical Center, Kansas City, Missouri, USA
- Department of Gastroenterology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Debra K. Sullivan
- Department of Dietetics and Nutrition, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Amit Rastogi
- Department of Gastroenterology, Veterans Affairs Medical Center, Kansas City, Missouri, USA
- Department of Gastroenterology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Ajay Bansal
- Department of Gastroenterology, Veterans Affairs Medical Center, Kansas City, Missouri, USA
- Department of Gastroenterology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Joseph E. Donnelly
- Department of Energy Balance Laboratory, Center for Physical Activity and Weight Management, University of Kansas Medical Center, Lawrence, Kansas, USA
| | - Prateek Sharma
- Department of Gastroenterology, Veterans Affairs Medical Center, Kansas City, Missouri, USA
- Department of Gastroenterology, University of Kansas Medical Center, Kansas City, Kansas, USA
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Abstract
Barrett esophagus (BE) is a well-established premalignant condition for esophageal adenocarcinoma (EAC), a lethal cancer with a dismal survival rate. The current guidelines recommend surveillance of patients with BE to detect dysplasia or early cancer before the development of invasive EAC. Recently, endoscopic eradication therapies have been shown to be safe and effective in the treatment of BE-related high-grade dysplasia and early EAC. This article reviews the various treatment options for BE and discusses the current evidence and gaps in knowledge in the understanding of treatment of this condition. In addition, recommendations are provided in context to the recently published guidelines by the American Gastroenterological Association.
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Affiliation(s)
- Srinivas Gaddam
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St Louis, MO 63110-1093, USA
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Sharma P, Hawes RH, Bansal A, Gupta N, Curvers W, Rastogi A, Singh M, Hall M, Mathur SC, Wani SB, Hoffman B, Gaddam S, Fockens P, Bergman JJ. Standard endoscopy with random biopsies versus narrow band imaging targeted biopsies in Barrett's oesophagus: a prospective, international, randomised controlled trial. Gut 2013; 62:15-21. [PMID: 22315471 DOI: 10.1136/gutjnl-2011-300962] [Citation(s) in RCA: 250] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND White light endoscopy with random biopsies is the standard for detection of intestinal metaplasia (IM) and neoplasia in patients with Barrett's oesophagus (BO). Narrow band imaging (NBI) highlights surface patterns that correlate with IM and neoplasia in BO. OBJECTIVE To compare high-definition white light (HD-WLE) and NBI for detection of IM and neoplasia in BO. DESIGN International, randomised, crossover trial comparing HD-WLE and NBI. Patients referred for BO screening/surveillance at three tertiary referral centres were prospectively enrolled and randomised to HD-WLE or NBI followed by other procedures in 3-8 weeks. During HD-WLE, four quadrant biopsies every 2 cm, together with targeted biopsies of visible lesions (Seattle protocol), were obtained. During NBI examination, mucosal and vascular patterns were noted and targeted biopsies were obtained. All biopsies were read by a single expert gastrointestinal pathologist in a blinded fashion. RESULTS 123 patients with BO (mean age 61; 93% male; 97% Caucasian) with mean circumferential and maximal extents of 1.8 and 3.6 cm, respectively, were enrolled. Both HD-WLE and NBI detected 104/113 (92%) patients with IM, but NBI required fewer biopsies per patient (3.6 vs 7.6, p<0.0001). NBI detected a higher proportion of areas with dysplasia (30% vs 21%, p=0.01). During examination with NBI, all areas of high-grade dysplasia and cancer had an irregular mucosal or vascular pattern. CONCLUSIONS NBI targeted biopsies can have the same IM detection rate as an HD-WLE examination with the Seattle protocol while requiring fewer biopsies. In addition, NBI targeted biopsies can detect more areas with dysplasia. Regular appearing NBI surface patterns did not harbour high-grade dysplasia/cancer, suggesting that biopsies could be avoided in these areas.
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Affiliation(s)
- Prateek Sharma
- Division of Gastroenterology, Department of Veterans Affairs Medical Center, 4801 E Linwood Blvd, Kansas City, MO 64128, USA.
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84
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Gupta N, Gaddam S, Wani SB, Bansal A, Rastogi A, Sharma P. Longer inspection time is associated with increased detection of high-grade dysplasia and esophageal adenocarcinoma in Barrett's esophagus. Gastrointest Endosc 2012; 76:531-8. [PMID: 22732877 DOI: 10.1016/j.gie.2012.04.470] [Citation(s) in RCA: 137] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2012] [Accepted: 04/23/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Current guidelines recommend that endoscopic surveillance of Barrett's esophagus (BE) be performed by using a strict biopsy protocol. However, novel methods to improve BE surveillance are still needed. OBJECTIVE To evaluate the impact of Barrett's inspection time (BIT) on yield of surveillance. DESIGN Post hoc analysis of data obtained from a clinical trial. SETTING Five tertiary referral centers. PATIENTS Patients undergoing BE surveillance. INTERVENTIONS Coordinators prospectively recorded the time spent inspecting the BE mucosa with a stopwatch. MAIN OUTCOME MEASUREMENTS Endoscopically suspicious lesions, high-grade dysplasia (HGD)/esophageal adenocarcinoma (EAC). RESULTS A total of 112 patients underwent endoscopic surveillance by 11 individual endoscopists. Patients with longer BITs were more likely to have an endoscopically suspicious lesion (P < .001) and more endoscopically suspicious lesions (P = .0001) and receive a diagnosis of HGD/EAC (P = .001). There was a direct correlation between the endoscopist's mean BIT per centimeter of BE and the detection of patients with HGD/EAC (ρ = .63, P = .03). Endoscopists who had an average BIT longer than 1 minute per centimeter of BE detected more patients with endoscopically suspicious lesions (54.2% vs 13.3%, P = .04), and there was a trend toward a higher detection rate of HGD/EAC (40.2% vs 6.7%, P = .06). LIMITATIONS Post hoc analysis of an enriched study population and experienced endoscopists at tertiary referral centers. CONCLUSIONS Longer time spent inspecting the BE segment is associated with the increased detection of HGD/EAC. Taking additional time to perform a thorough examination of the BE mucosa may serve as an easy and widely available method to improve the yield of BE surveillance.
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Affiliation(s)
- Neil Gupta
- Division of Gastroenterology, Kansas City Veterans Affairs Medical Center, Kansas City, Missouri 64128-2295, USA
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85
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Kushnir VM, Sathyamurthy A, Drapekin J, Gaddam S, Sayuk GS, Gyawali CP. Assessment of concordance of symptom reflux association tests in ambulatory pH monitoring. Aliment Pharmacol Ther 2012; 35:1080-7. [PMID: 22428660 PMCID: PMC3959626 DOI: 10.1111/j.1365-2036.2012.05066.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2012] [Revised: 02/22/2012] [Accepted: 02/27/2012] [Indexed: 12/20/2022]
Abstract
BACKGROUND Both simple proportions and statistical tests are utilised for symptom-reflux association. We systematically compared three such tests in a clinical setting. AIM To compare the three commonly used symptom reflux association tests in a large cohort of patients undergoing ambulatory pH monitoring for the evaluation of oesophageal symptoms. METHODS Ambulatory pH data from 772 symptomatic subjects (49.1 ± 0.5 years; 479 F) tested off therapy were assessed for acid exposure time (AET, elevated when pH <4 for ≥4%), symptom index (SI, ≥50% when positive), and symptom association probability (SAP) and Ghillebert probability estimate (GPE, P < 0.05 when positive). Test concordance and discordance were individually assessed; discordance between statistical tests was minor if one had P < 0.1 while the other was positive. Logistic regression determined independent predictors of test discordance. RESULTS The SAP, GPE and SI were positive in 42.7%, 39.3% and 33.9% respectively. GPE performed extremely well compared to SAP (sensitivity 0.95, specificity 0.91), with major discordance in only 2.8%. Positive concordance was significantly higher when AET was abnormal. GPE underestimated symptom association compared to SAP, whereas SAP was subject to symptom over-counting in 33.3% of discordant cases. GPE-SAP discordance was associated with higher AET (7.5% vs. 5.1%) and more symptoms (19.3 vs. 10.7, P > 0.001 for each comparison with concordant tests); both remained significant on logistic regression analysis (P ≤ 0.003). SI was discordant with SAP when symptoms were extremely frequent (median 19, IQR 10-32) or limited (median 1, IQR 1-2), and concordant when median 6 symptoms (IQR 3-12) were recorded. CONCLUSIONS The GPE can be used interchangeably with SAP in symptom reflux association. SI has uncertain value with very high and very low symptom counts.
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Affiliation(s)
- V M Kushnir
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
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Kushnir VM, Sathyamurthy A, Drapekin J, Gaddam S, Sayuk GS, Gyawali CP. Assessment of concordance of symptom reflux association tests in ambulatory pH monitoring. Aliment Pharmacol Ther 2012. [PMID: 22428660 DOI: 10.1111/j.1365-2036.2012.05066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Both simple proportions and statistical tests are utilised for symptom-reflux association. We systematically compared three such tests in a clinical setting. AIM To compare the three commonly used symptom reflux association tests in a large cohort of patients undergoing ambulatory pH monitoring for the evaluation of oesophageal symptoms. METHODS Ambulatory pH data from 772 symptomatic subjects (49.1 ± 0.5 years; 479 F) tested off therapy were assessed for acid exposure time (AET, elevated when pH <4 for ≥4%), symptom index (SI, ≥50% when positive), and symptom association probability (SAP) and Ghillebert probability estimate (GPE, P < 0.05 when positive). Test concordance and discordance were individually assessed; discordance between statistical tests was minor if one had P < 0.1 while the other was positive. Logistic regression determined independent predictors of test discordance. RESULTS The SAP, GPE and SI were positive in 42.7%, 39.3% and 33.9% respectively. GPE performed extremely well compared to SAP (sensitivity 0.95, specificity 0.91), with major discordance in only 2.8%. Positive concordance was significantly higher when AET was abnormal. GPE underestimated symptom association compared to SAP, whereas SAP was subject to symptom over-counting in 33.3% of discordant cases. GPE-SAP discordance was associated with higher AET (7.5% vs. 5.1%) and more symptoms (19.3 vs. 10.7, P > 0.001 for each comparison with concordant tests); both remained significant on logistic regression analysis (P ≤ 0.003). SI was discordant with SAP when symptoms were extremely frequent (median 19, IQR 10-32) or limited (median 1, IQR 1-2), and concordant when median 6 symptoms (IQR 3-12) were recorded. CONCLUSIONS The GPE can be used interchangeably with SAP in symptom reflux association. SI has uncertain value with very high and very low symptom counts.
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Affiliation(s)
- V M Kushnir
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
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Gugnani HC, Sharma S, Gupta B, Gaddam S. Prevalence of keratinophilic fungi in soils of St. Kitts and Nevis. J Infect Dev Ctries 2012; 6:347-51. [PMID: 22505445 DOI: 10.3855/jidc.1962] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Revised: 06/11/2011] [Accepted: 07/21/2011] [Indexed: 10/31/2022] Open
Abstract
INTRODUCTION Information on the prevalence of keratinophilic fungi in West Indies is scanty. Occurrence of keratinophilic fungi in soils of St. Kitts and Nevis has not been investigated previously. METHODOLOGY The prevalence of keratinophilic fungi was investigated in 108 samples of soils of varying habitats from St. Kitts and 55 such samples from Nevis by hair-baiting technique. Fungal growths appearing on the hair baits after four to eight weeks of incubation at room temperature were microscopically examined and cultured on mycological media. Cultures were identified on the basis of colonial and microscopic features. RESULTS Forty-nine (45%) of the samples from St. Kitts and 38 (69%) from Nevis were positive for keratinophilic fungi. Microsporum gypseum complex, a well-known geophilic dermatophyte, was the most frequently recovered species being present in 15.7% of soils of St. Kitts and 40% of soils of Nevis. The next commonest species recovered was Chrysosporium indicum, represented by 15 (13.9%) isolates from St. Kitts and seven (12.7%) isolates from Nevis. Other infrequently isolated keratinophilic species included Chrysosporium tropicum, Chrysosporium keratinophilum, and unidentified Chrysosporium species. CONCLUSIONS This study is the first of its kind in the islands of St. Kitts and Nevis. A high incidence of M. gypseum complex in the soil of these islands is a noteworthy finding of public health significance.
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Lynch CR, Wani S, Rastogi A, Keighley J, Mathur S, Higbee A, Bansal A, Gaddam S, Sharma P. Effect of acid-suppressive therapy on narrow band imaging findings in gastroesophageal reflux disease: a pilot study. Dis Esophagus 2012; 26:124-9. [PMID: 22404535 DOI: 10.1111/j.1442-2050.2012.01335.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Standard endoscopy is an insensitive test for gastroesophageal reflux disease (GERD). Narrow band imaging (NBI) endoscopy enhances visualization of the distal esophagus. NBI patterns like intrapapillary capillary loop (IPCL) dilatation, tortuosity, and increased number; microerosions; increased vascularity at the squamocolumnar junction (SCJ); ridge-villous pattern below the SCJ; and presence of columnar islands in the distal esophagus have been suggested as features of GERD. We evaluated the effect of proton pump inhibitor (PPI) therapy on NBI findings in GERD patients. Patients prospectively underwent NBI upper endoscopy before and after PPI therapy. NBI findings were recorded at each endoscopy. Twenty-one patients with GERD symptoms (mean age 60.0 years; males 90.5%; white 90.5%) were studied. After PPI therapy, there was a significant reduction in the proportion of patients with the following NBI features: IPCL tortuosity (90% vs. 4.8%, P < 0.0001), dilated IPCLs (86% vs. 9.5%, P < 0.0001), and increased vascularity at the SCJ (43% vs. 9.5%, P= 0.0082). PPI led to healing of all microerosions (71% vs. 0%, P < 0.0001) and disappearance of ridge-villous patterns below the SCJ (14% vs. 0%, P < 0.0001). There was no significant change in the proportion of patients with increased numbers of IPCLs pre- and post-PPI therapy (71% vs. 48%, P= 0.09) or columnar islands in the distal esophagus (38% vs. 29%, P= 0.31). In patients with GERD symptoms, NBI features suggestive of GERD respond to PPI; suggesting these features are truly acid-mediated. These findings need to be confirmed by randomized controlled trials.
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Affiliation(s)
- C R Lynch
- Division of Gastroenterology and Hepatology, Department Veterans Affairs Medical Center, University of Kansas School of Medicine, Kansas City, Missouri 64128-2295, USA
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89
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Rastogi A, Bansal A, Rao DS, Gupta N, Wani SB, Shipe T, Gaddam S, Singh V, Sharma P. Higher adenoma detection rates with cap-assisted colonoscopy: a randomised controlled trial. Gut 2012; 61:402-8. [PMID: 21997547 DOI: 10.1136/gutjnl-2011-300187] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Cap-assisted colonoscopy (CAC) uses a small plastic transparent cap attached to the tip of the colonoscope that can depress and flatten colonic folds and thus improve visualisation of their proximal aspects. The aim of this study was to compare CAC with standard colonoscopy (SC; high-definition white light) for adenoma detection rates. DESIGN This is a prospective randomised controlled trial. SETTING The study was performed in a tertiary-care Veterans Affairs Medical Center in the USA. PATIENTS Subjects undergoing screening or surveillance colonoscopy were enrolled. INTERVENTIONS Subjects were randomised to undergo either CAC or SC. MAIN OUTCOME MEASURES The outcome measures were the proportion of subjects with at least one adenoma, the number of adenomas detected per subject, insertion time, caecal intubation rates and complications. RESULTS 420 subjects were enrolled and included in the study (210 in each group). The proportion of subjects with at least one adenoma was higher with CAC compared to SC (69% vs 56%, p=0.009). CAC also detected a higher number of adenomas per subject (2.3 vs 1.4, p<0.001). The caecal intubation time was shorter with CAC (3.29 min vs 3.98 min, p<0.001). The caecal intubation rates were similar in the two groups (99% vs 98%, p=0.37). There were no complications associated with CAC or SC. CONCLUSIONS CAC detected a 13% higher number of subjects with at least one adenoma and 59% higher adenomas per subject. CAC is a safe, effective and practical means to improve adenoma detection rates. CLINICAL TRIAL REGISTRATION NCT 01211132.
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Affiliation(s)
- Amit Rastogi
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri 64128-2295, USA.
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90
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Wani S, Falk GW, Post J, Yerian L, Hall M, Wang A, Gupta N, Gaddam S, Singh M, Singh V, Chuang KY, Boolchand V, Gavini H, Kuczynski J, Sud P, Bansal A, Rastogi A, Mathur SC, Young P, Cash B, Goldblum J, Lieberman DA, Sampliner RE, Sharma P. Risk factors for progression of low-grade dysplasia in patients with Barrett's esophagus. Gastroenterology 2011; 141:1179-86, 1186.e1. [PMID: 21723218 DOI: 10.1053/j.gastro.2011.06.055] [Citation(s) in RCA: 198] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2011] [Revised: 05/31/2011] [Accepted: 06/17/2011] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Data vary on the progression of low-grade dysplasia (LGD) in patients with Barrett's esophagus (BE); in patients with LGD, we investigated the incidence of high-grade dysplasia (HGD) and esophageal adenocarcinoma (EAC) and compared progression in patients with different forms of LGD (prevalent vs incident and multifocal vs unifocal). We assessed the effects of consensus diagnosis of LGD on progression rates to HGD and EAC among expert pathologists. METHODS In a multicenter outcomes project, 210 patients with BE and LGD (classified as incident, prevalent, or persistent) were included. Patients were followed up for an average of 6.2 years (959.6 patient-years). Persistent LGD was defined as detection of LGD on ≥2 consecutive occasions during the follow-up period and extent as either unifocal (LGD at one level of BE segment) or multifocal (>1 level). Histology specimens were reviewed by 2 blinded pathologists. RESULTS Six patients developed EAC (incidence of 0.44%/year), and 21 developed HGD (incidence of 1.6%/year). The incidence of the combination of HGD and EAC was 1.83%/year. There were no associations between presence of prevalent, incident, or persistent LGD and the extent of LGD with progression rates. Based on consensus diagnosis of 88 reviewed specimens, there was no difference in the progression of LGD to either EAC (the incidence based on analyses by the local pathologist was 0.18%/year, the incidence when there was agreement between the local and one central pathologist was 0.21%/year, and the incidence when all 3 pathologists were in agreement was 0.39%/year) or combined HGD and EAC (0.94%/year, 0.87%/year, and 0.84%/year, respectively). CONCLUSIONS Overall, patients with BE and LGD have a low annual incidence of EAC, similar to nondysplastic BE. There are no risk factors for progression and there is significant interobserver variation in diagnosis, even among expert pathologists.
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Affiliation(s)
- Sachin Wani
- Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center and University of Kansas School of Medicine, Kansas City, Missouri 64128-2295, USA
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91
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Rastogi A, Early DS, Gupta N, Bansal A, Singh V, Ansstas M, Jonnalagadda SS, Hovis CE, Gaddam S, Wani SB, Edmundowicz SA, Sharma P. Randomized, controlled trial of standard-definition white-light, high-definition white-light, and narrow-band imaging colonoscopy for the detection of colon polyps and prediction of polyp histology. Gastrointest Endosc 2011; 74:593-602. [PMID: 21802078 DOI: 10.1016/j.gie.2011.04.050] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Accepted: 04/30/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Missing adenomas and the inability to accurately differentiate between polyp histology remain the main limitations of standard-definition white-light (SD-WL) colonoscopy. OBJECTIVE To compare the adenoma detection rates of SD-WL with those of high-definition white-light (HD-WL) and narrow-band imaging (NBI) as well as the accuracy of predicting polyp histology. DESIGN Multicenter, prospective, randomized, controlled trial. SETTING Two academic medical centers in the United States. PATIENTS Subjects undergoing screening or surveillance colonoscopy. INTERVENTION Subjects were randomized to undergo colonoscopy with one of the following: SD-WL, HD-WL, or NBI. MAIN OUTCOME MEASUREMENTS The proportion of subjects detected with adenomas, adenomas detected per subject, and the accuracy of predicting polyp histology real time. RESULTS A total of 630 subjects were included. The proportion of subjects with adenomas was 38.6% with SD-WL compared with 45.7% with HD-WL and 46.2% with NBI (P = .17 and P = .14, respectively). Adenomas detected per subject were 0.69 with SD-WL compared with 1.12 with HD-WL and 1.13 with NBI (P = .016 and P = .014, respectively). HD-WL and NBI detected more subjects with flat and right-sided adenomas compared with SD-WL (all P values <.005). NBI had a superior sensitivity (90%) and accuracy (82%) to predict adenomas compared with SD-WL and HD-WL (all P values <.005). LIMITATIONS Academic medical centers with experienced endoscopists. CONCLUSIONS There was no difference in the proportion of subjects with adenomas detected with SD-WL, HD-WL, and NBI. However, HD-WL and NBI detected significantly more adenomas per subject (>60%) compared with SD-WL. NBI had the highest accuracy in predicting adenomas in real time during colonoscopy. ( CLINICAL TRIAL REGISTRATION NUMBER NCT 00614770.).
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Affiliation(s)
- Amit Rastogi
- University of Kansas School of Medicine, Veterans Affairs Medical Center, Kansas City, Missouri 64128-2295, USA.
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92
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Wani S, Gupta N, Gaddam S, Singh V, Ulusarac O, Romanas M, Bansal A, Sharma P, Olyaee MS, Rastogi A. A comparative study of endoscopic ultrasound guided fine needle aspiration with and without a stylet. Dig Dis Sci 2011; 56:2409-14. [PMID: 21327919 DOI: 10.1007/s10620-011-1608-z] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Accepted: 01/29/2011] [Indexed: 12/22/2022]
Abstract
BACKGROUND Despite lack of evidence, use of a stylet during endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is assumed to improve the quality and diagnostic yield of specimens. AIM The purpose of this study was to compare EUS-FNA specimens obtained with stylet (S+) and without stylet (S-) for: (i) cellularity, contamination, adequacy, and amount of blood and (ii) diagnostic yield of malignancy. METHODS Patients who underwent EUS-FNA of solid lesions by two experienced endosonographers at a tertiary referral center using a 22-gauge FNA needle with suction were included. Stylet was used for all EUS-FNA procedures performed between January 2006 and September 2007 and no stylet was used between October 2007 and April 2009 allowing comparison between the two techniques. Cytology slides were retrieved, de-identified and evaluated by two experienced cytopathologists blinded to FNA technique. Slides were evaluated for cellularity, degree of contamination, adequacy, amount of blood and cytologic diagnosis. Fisher's exact and unpaired t-test were used for comparative analysis. RESULTS A total of 162 patients with 228 lesions were included. FNA of 106 and 122 lesions each was performed in the S+ and S- groups, respectively. FNA sites included pancreas [41 (18%)], lymph node [125 (55%)], liver [20 (9%)], adrenal [21 (9%)] and others [21 (9%)]. No significant differences in the cellularity (P=0.37), contamination (P=0.18), significant blood (P=0.42) and adequacy of specimen (P=0.45) were found between S+ and S- specimens. There was no statistically significant difference in the diagnostic yield of malignant lesions (P=0.48). CONCLUSIONS The use of stylet during FNA does not appear to confer any advantage with regards to the adequacy of specimen or diagnostic yield of malignancy.
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Affiliation(s)
- Sachin Wani
- Division of Gastroenterology and Hepatology, Department of Pathology, Veterans Affairs Medical Center, University of Kansas School of Medicine, 4801 E. Linwood Blvd, Kansas City, MO 64128-2295, USA
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93
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Tadiparthi RA, Bansal A, Wani S, Mathur S, Hall SB, Rastogi A, Higbee A, Gaddam S, Sharma P. Dilated intercellular spaces and lymphocytes on biopsy relate to symptoms in erosive GERD but not NERD. Aliment Pharmacol Ther 2011; 33:1202-8. [PMID: 21453401 DOI: 10.1111/j.1365-2036.2011.04643.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Mechanisms of symptom perception among patients with gastro-oesophageal reflux disease (GERD) remain to be fully elucidated. AIM To correlate quantitative reflux symptom scores with microscopic oesophageal histopathology. METHODS Prior to endoscopy, patients with reflux symptoms completed a validated reflux disease questionnaire (score 0-36). Erosive oesophagitis (EO) was graded using the LA classification. Oesophageal biopsies were graded 0-2 for basal cell hyperplasia, papillary elongation, dilated intercellular spaces (DIS), necrosis or erosion, eosinophils and neutrophils by a blinded gastrointestinal pathologist as previously described. Additionally, lymphocyte density was also evaluated. Pearson's correlation coefficients were computed. RESULTS Thirty-two EO and 21 non-erosive reflux disease (NERD) patients were prospectively enrolled. For EO vs. NERD, mean reflux symptom scores (10.7 vs. 8.8, P=0.35) and histology scores were similar (4.29 vs. 4.25; P=0.9). However, when symptom scores were compared with histology scores, a correlation was found in the EO group, but not in the NERD group (r=0.34, P=0.05 vs. r=0.22, P=0.36). On further analysis, DIS was associated with symptom scores in the EO group (P≤0.001), but not in the NERD group (P=N.S.). Similarly, lymphocyte density was associated with symptom scores in the EO group (r=0.56, P=0.0009), but not in the NERD group (r=0.002, P=0.9). CONCLUSIONS Although mean symptom and histology scores were similar in the EO and NERD groups, a significant correlation of symptom scores with histology scores, DIS and lymphocytes was found in the former, but not in the latter. EO and NERD patients may have different symptom perception mechanisms and thus, dissimilar symptom resolution rates with acid suppression.
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Affiliation(s)
- R A Tadiparthi
- Division of Gastroenterology and Hepatology, Department of Veterans Affairs Medical Center, 4801 E. Linwood Blvd, Kansas City, MO 64128-2295, USA
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94
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Gaddam S, Sharma P. Shedding light on the epidemiology of gastroesophageal reflux disease in India--a big step forward. Indian J Gastroenterol 2011; 30:105-7. [PMID: 21785993 DOI: 10.1007/s12664-011-0108-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2011] [Accepted: 07/01/2011] [Indexed: 02/04/2023]
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95
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Abstract
Barrett's esophagus (BE) is defined as abnormal specialized columnar metaplasia with intestinalization in place of the normal squamous esophageal epithelium. Gastroesophageal reflux disease is a known risk factor for BE; nonetheless BE is also detected in asymptomatic individuals. Other risk factors for BE include smoking, male gender, age over 50 and obesity. Patients diagnosed with BE (without dysplasia) are recommended to undergo endoscopic surveillance every 3-5 years. Advances in imaging techniques (such as narrow band imaging, autofluorescence imaging and confocal laser endomicroscopy) have the potential to improve the detection of dysplasia and early cancer, thus making surveillance a more cost-effective endeavor. Patients with high grade dysplasia (HGD) and early cancer have a high rate of progression to invasive adenocarcinoma and traditionally these patients were treated with esophagectomy. The rapid advancement of endoscopic therapeutic techniques along with a low risk of complications have made endoscopic therapy an acceptable alternative to an esophagectomy in patients with HGD and early cancer. Several endoscopic treatment techniques such as endoscopic mucosal resection, multipolar electrocoagulation, photodynamic therapy, argon plasma coagulation, cryotherapy, and radiofrequency ablation have been studied for endoscopic treatment.
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Affiliation(s)
- Srinivas Gaddam
- Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri 64128-2295, USA
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96
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Gaddam S, Wani S, Ahmed H, Maddur P, Hall SB, Gupta N, Puli SR, Higbee A, Rastogi A, Bansal A, Sharma P. The impact of pre-endoscopy proton pump inhibitor use on the classification of non-erosive reflux disease and erosive oesophagitis. Aliment Pharmacol Ther 2010; 32:1266-74. [PMID: 20955446 DOI: 10.1111/j.1365-2036.2010.04468.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Factors associated with non-erosive reflux disease (NERD) and erosive oesophagitis (EO) are incompletely understood and the overlap between the two entities is debated. AIM To compare clinical, demographic, and endoscopic findings in a large cohort of NERD and EO patients. METHODS After they completed a validated GERD questionnaire, patients who presented for index endoscopy were enrolled and categorized as NERD or EO. Analysis was performed using Chi-square, Mann-Whitney U-test and multivariate logistic regression. RESULTS A total of 696 GERD patients [455 (65.4%) NERD; 241 (34.6%) EO]; mean age 57 years; 92% men and 82% Caucasian were prospectively enrolled. Using logistic regression, patients on PPI were more likely to be classified as NERD (OR: 3.2; P < 0.001). NERD patients were older (OR: 1.50; P = 0.05), less likely to have nocturnal symptoms (OR: 0.63; P = 0.04) and hiatal hernia (OR: 0.32; P < 0.001). Compared with PPI-naïve NERD patients, those on PPI were more likely to have nocturnal symptoms (69% vs. 29%, P = 0.048) and less likely to have mild-moderate symptoms (63% vs. 79%, P < 0.001) - similar to the EO group. CONCLUSIONS Pre-endoscopy PPI usage contributes significantly to the classification of GERD patients into the NERD-phenotype. NERD patients on PPI therapy demonstrate some features that are significantly different from PPI-naïve patients, but similar to EO patients. This observation supports the notion that some PPI NERD patients are actually healed EO patients, and that an overlap does exist between the GERD phenotypes.
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Affiliation(s)
- S Gaddam
- Veterans Affairs Medical Center, Kansas City, MO 64128-2295, USA
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97
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Wani S, Mathur SC, Curvers WL, Singh V, Alvarez Herrero L, Hall SB, Ulusarac O, Cherian R, McGregor DH, Bansal A, Rastogi A, Ahmed B, Singh M, Gaddam S, Ten Kate FJ, Bergman J, Sharma P. Greater interobserver agreement by endoscopic mucosal resection than biopsy samples in Barrett's dysplasia. Clin Gastroenterol Hepatol 2010; 8:783-8. [PMID: 20472096 DOI: 10.1016/j.cgh.2010.04.028] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Revised: 03/25/2010] [Accepted: 04/26/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endoscopic mucosal resection (EMR) is an important diagnostic, staging, and therapeutic tool for patients with Barrett's esophagus (BE)-associated neoplasia. We analyzed the histopathologic characteristics of specimens collected during EMR compared with biopsy specimens from patients with BE and assessed interobserver variability in pathologists' assessment of EMR and biopsy specimens. METHODS We evaluated EMR (n = 251) and biopsy (n = 269) specimens collected from patients with BE at 2 tertiary referral centers. A detailed histologic analysis was performed for each EMR and biopsy specimen to determine the grade of dysplasia, depth of the specimen, proportion of specimen with dysplasia, and quality of samples. Interobserver agreement for both biopsy and EMR specimens (among 4 experienced pathologists) was calculated by using kappa statistics. RESULTS Histologic analysis showed that submucosa was present in the majority of EMRs, compared with biopsy specimens (88% vs 1%, P < .0001). Almost all biopsy specimens (99%) included lamina propria. However, the muscularis mucosa was observed in only 58% of biopsy specimens. For both EMR and biopsy specimens, the highest grade of dysplasia comprised < or =25% of the total area in >50% of the specimens. Interobserver agreement on the diagnosis of dysplasia was significantly greater for EMR specimens than biopsy specimens (low-grade dysplasia, 0.33 vs 0.22, P < .001; high-grade dysplasia, 0.43 vs 0.35, P = .018). CONCLUSIONS Submucosa can be examined in most samples collected from EMR; the distribution of neoplasia is focal within biopsy and EMR specimens. There is more interobserver agreement among pathologists in the analysis of EMR samples than biopsy specimens for the diagnosis of dysplasia.
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Affiliation(s)
- Sachin Wani
- Division of Gastroenterology and Hepatology and Department of Pathology, Veterans Affairs Medical Center and University of Kansas School of Medicine, Kansas City, Missouri 64128-2295, USA
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