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Shinn B, Burdick J, Berk K, Hwang JH, El-Dika S, Juakiem W, Han S, Krishna S, Khashab MA, Mony S, Kadkhodayan K, Khara HS, Ahmed AM, Boortalary T, Agnohortri A, Kumar A, Chiang A, Kamal F, Schlachterman A, Loren D, Kowalski T. Safety, Efficacy and Clinical Utility of the 5.1mm EndoRotor Powered Debridement Catheter for Treatment of Walled-Off Pancreatic Necrosis. Gastrointest Endosc 2024:S0016-5107(24)00131-7. [PMID: 38431104 DOI: 10.1016/j.gie.2024.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 07/18/2023] [Revised: 12/28/2023] [Accepted: 02/18/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND AND AIMS Direct endoscopic necrosectomy (DEN) is a recommended strategy for treatment of walled-off-necrosis (WON). DEN uses a variety of devices including the EndoRotor (Interscope, Inc.) debridement catheter. Recently, a 5.1 mm EndoRotor with increased chamber size and rate of tissue removal was introduced. The aim of this study was to assess the efficacy and safety of this device. METHODS A multi-center cohort study was conducted at eight institutions including patients who underwent DEN with the 5.1 mm EndoRotor. The primary outcome was the number of DEN sessions needed for WON resolution. Secondary outcomes included the average percent reduction in solid WON debris and decrease in WON area per session, total time spent performing EndoRotor therapy for WON resolution, and adverse events. RESULTS 64 procedures in 41 patients were included. For patients in which the 5.1 mm EndoRotor catheter was the sole therapeutic modality, an average of 1.6 DEN sessions resulted in WON resolution with an average cumulative time of 85.5 minutes. Of the 21 procedures with data regarding percent of solid debris, the average reduction was 85% +/- 23% per session. Of the 19 procedures with data regarding WON area, the mean area significantly decreased from 97.6 +/- 72.0 cm2 to 27.1 +/- 35.5 cm2 (p<0.001) per session. Adverse events included two intra-procedural LAMS dislodgements managed endoscopically and three perforations none of which were related to EndoRotor. Bleeding was reported in seven cases, none required embolic or surgical therapy and two required blood transfusions. CONCLUSIONS This is the first multi-center retrospective study to investigate the efficacy and safety of the 5.1 mm EndoRotor catheter for WON. Results from this study showed an average of 1.6 DEN sessions were needed to achieve WON resolution with an 85% single session reduction in solid debris and a 70% single session decrease in WON area with minimal adverse events.
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Affiliation(s)
- Brianna Shinn
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.
| | | | | | - Joo Ha Hwang
- Stanford University Medical Center, Palo Alto, California
| | - Samer El-Dika
- Stanford University Medical Center, Palo Alto, California
| | - Wassem Juakiem
- Stanford University Medical Center, Palo Alto, California
| | - Samuel Han
- The Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | | | - Shruti Mony
- Johns Hopkins University Hospital, Baltimore, Maryland
| | | | | | - Ali M Ahmed
- University of Alabama Medical Center, Birmingham, Alabama
| | - Tina Boortalary
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | | | - Anand Kumar
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Austin Chiang
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Faisal Kamal
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | | | - David Loren
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Thomas Kowalski
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Bi D, Zhang LY, Alqaisieh M, Shrigiriwar A, Farha J, Mahmoud T, Akiki K, Almario JA, Shah-Khan SM, Gordon SR, Adler JM, Radetic M, Draganov PV, David YN, Shinn B, Mohammed Z, Schlachterman A, Yuen S, Al-Taee A, Yunseok N, Trasolini R, Bejjani M, Ghandour B, Ramberan H, Canakis A, Ngamruengphong S, Storm AC, Singh S, Pohl H, Bucobo JC, Buscaglia JM, D'Souza LS, Qumseya B, Kumta NA, Kumar A, Haber GB, Aihara H, Sawhney M, Kim R, Berzin TM, Khashab MA. Novel through-the-scope suture closure of colonic EMR defects (with video). Gastrointest Endosc 2023; 98:122-129. [PMID: 36889364 DOI: 10.1016/j.gie.2023.02.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 02/07/2023] [Accepted: 02/23/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND AND AIMS Large colon polyps removed by EMR can be complicated by delayed bleeding. Prophylactic defect clip closure can reduce post-EMR bleeding. Larger defects can be challenging to close using through-the-scope clips (TTSCs), and proximal defects are difficult to reach using over-the-scope techniques. A novel, through-the-scope suturing (TTSS) device allows direct closure of mucosal defects without scope withdrawal. The goal of this study was to evaluate the rate of delayed bleeding after the closure of large colon polyp EMR sites with TTSS. METHODS A multicenter retrospective cohort study was performed involving 13 centers. All defect closure by TTSS after EMR of colon polyps ≥2 cm from January 2021 to February 2022 were included. The primary outcome was rate of delayed bleeding. RESULTS A total of 94 patients (52% female; mean age, 65 years) underwent EMR of predominantly right-sided (n = 62 [66%]) colon polyps (median size, 35 mm; interquartile range, 30-40 mm) followed by defect closure with TTSS during the study period. All defects were successfully closed with TTSS alone (n = 62 [66%]) or with TTSS and TTSCs (n = 32 [34%]), using a median of 1 (interquartile range, 1-1) TTSS system. Delayed bleeding occurred in 3 patients (3.2%), with 2 requiring repeated endoscopic evaluation/treatment (moderate). CONCLUSION TTSS alone or with TTSCs was effective in achieving complete closure of all post-EMR defects, despite a large lesion size. After TTSS closure with or without adjunctive devices, delayed bleeding was seen in 3.2% of cases. Further prospective studies are needed to validate these findings before wider adoption of TTSS for large polypectomy closure.
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Affiliation(s)
- Danse Bi
- Johns Hopkins Medicine, Baltimore, Maryland, USA
| | | | | | | | - Jad Farha
- Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Tala Mahmoud
- Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Karl Akiki
- Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | | | | | - Stuart R Gordon
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Jeffrey M Adler
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Mark Radetic
- University of Florida, Gainesville, Florida, USA
| | | | | | - Brianna Shinn
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Zahraa Mohammed
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | - Sofia Yuen
- NYU Langone Health, New York, New York, USA
| | | | | | | | | | | | | | | | | | | | | | - Heiko Pohl
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | | | | | | | | | | | - Anand Kumar
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | | | - Mandeep Sawhney
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Raymond Kim
- University of Maryland, Baltimore, Maryland, USA
| | - Tyler M Berzin
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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3
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Farha J, Ramberan H, Aihara H, Zhang LY, Mehta A, Hage C, Schlachterman A, Kumar A, Shinn B, Canakis A, Kim RE, DʼSouza LS, Buscaglia JM, Storm AC, Samarasena J, Chang K, Friedland S, Draganov PV, Qumseya BJ, Jawaid S, Othman MO, Hasan MK, Yang D, Khashab MA, Ngamruengphong S. A novel through-the-scope helix tack-and-suture device for mucosal defect closure following colorectal endoscopic submucosal dissection: a multicenter study. Endoscopy 2023; 55:571-577. [PMID: 36323330 DOI: 10.1055/a-1970-5528] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Complete closure of large mucosal defects following colorectal endoscopic submucosal dissection (ESD) with through-the-scope (TTS) clips is oftentimes not possible. We aimed to report our early experience of using a novel TTS suturing system for the closure of large mucosal defects after colorectal ESD. METHODS We performed a retrospective multicenter cohort study of consecutive patients who underwent attempted prophylactic defect closure using the TTS suturing system after colorectal ESD. The primary outcome was technical success in achieving complete defect closure, defined as a < 5 mm residual mucosal defect in the closure line using TTS suturing, with or without adjuvant TTS clips. RESULTS 82 patients with a median defect size of 30 (interquartile range 25-40) mm were included. Technical success was achieved in 92.7 % (n = 76): TTS suturing only in 44 patients (53.7 %) and a combination of TTS suturing to approximate the widest segment followed by complete closure with TTS clips in 32 (39.0 %). Incomplete/partial closure, failure of appropriate TTS suture deployment, and the need for over-the-scope salvage closure methods were observed in 7.3 % (n = 6). One intraprocedural bleed, one delayed bleed, and three intraprocedural perforations were observed. There were no adverse events related to placement of the TTS suture. CONCLUSION The TTS suture system is an effective and safe tool for the closure of large mucosal defects after colorectal ESD and is an alternative when complete closure with TTS clips alone is not possible.
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Affiliation(s)
- Jad Farha
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Hemchand Ramberan
- Division of Gastroenterology and Hepatology, Riverside Regional Medical Center, Newport News, Virginia, USA
| | - Hiroyuki Aihara
- Division of Gastroenterology and Hepatology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Linda Y Zhang
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Amit Mehta
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Camille Hage
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Alexander Schlachterman
- Department of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Anand Kumar
- Department of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Brianna Shinn
- Department of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Andrew Canakis
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Raymond E Kim
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Lionel S DʼSouza
- Division of Gastroenterology and Hepatology, Stony Brook University Hospital, Stony Brook, New York, USA
| | - Jonathan M Buscaglia
- Division of Gastroenterology and Hepatology, Stony Brook University Hospital, Stony Brook, New York, USA
| | - Andrew C Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason Samarasena
- H. H. Chao Comprehensive Digestive Disease Center, University of California, Department of Medicine, Irvine Medical Center, Orange, California, USA
| | - Kenneth Chang
- H. H. Chao Comprehensive Digestive Disease Center, University of California, Department of Medicine, Irvine Medical Center, Orange, California, USA
| | - Shai Friedland
- Division of Gastroenterology and Hepatology, Stanford University, Redwood City, California, USA
- Veterans Affairs Palo Alto Health System, Palo Alto, California, USA
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, USA
| | - Bashar J Qumseya
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, USA
| | - Salmaan Jawaid
- Division of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
| | - Mohamed O Othman
- Division of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
| | - Muhammad K Hasan
- Division of Gastroenterology and Hepatology, Advent Health, Orlando, Florida, USA
| | - Dennis Yang
- Division of Gastroenterology and Hepatology, Advent Health, Orlando, Florida, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Ghandour B, Keane MG, Shinn B, Dawod QM, Fansa S, El Chafic AH, Irani SS, Pawa R, Gutta A, Ichkhanian Y, Paranandi B, Pawa S, Al-Haddad MA, Zuchelli T, Huggett MT, Sharaiha RZ, Kowalski TE, Khashab MA, Shrigiriwar A, Zhang L, Mony S, Khan A, Loren DE, Chiang A, Schlachterman A, Kumar A, Saab O, Blake B, Obri MS. Factors predictive of persistent fistulas in EUS-directed transgastric ERCP: a multicenter matched case-control study. Gastrointest Endosc 2023; 97:260-267. [PMID: 36228699 DOI: 10.1016/j.gie.2022.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 06/03/2022] [Revised: 09/16/2022] [Accepted: 09/26/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND AIMS EUS-directed transgastric ERCP (EDGE) is an established method for managing pancreaticobiliary pathology in Roux-en-Y gastric bypass patients, with high rates of technical success and low rates of serious adverse events (AEs). However, widespread adoption of the technique has been limited because of concerns about the development of persistent gastrogastric or jejunogastric fistulas. Gastrogastric and jejunogastric fistulas have been reported in up to 20% of cases in some series, but predictive risk factors and long-term management and outcomes are lacking. Therefore, our aims were to assess factors associated with the development of persistent fistulas and the technical success of endoscopic fistula closure. METHODS This is a case-control study involving 9 centers (8 USA, 1 Europe) from February 2015 to September 2021. Cases of persistent fistulas were defined as endoscopic or imaging evidence of fistula more than 8 weeks after lumen-apposing metal stent (LAMS) removal. Control subjects were defined as endoscopic or imaging confirmation of no fistula more than 8 weeks after LAMS removal. AEs were defined and graded according to the American Society for Gastrointestinal Endoscopy lexicon. RESULTS Twenty-five patients identified to have evidence of a persistent fistula on follow-up surveillance (cases) were matched with 50 patients with no evidence of a persistent fistula on follow-up surveillance (control subjects) based on age and sex. Mean LAMS dwell time was 74.7 ± 106.2 days. After LAMS removal, argon plasma coagulation (APC) ablation of the fistula was performed in 46 patients (61.3%). Primary closure of the fistula was performed in 26.7% of patients (20: endoscopic suturing in 17, endoscopic tacking in 2, and over-the-scope clips + endoscopic suturing in 1). When comparing cases with control subjects, there was no difference in baseline demographics, fistula site, LAMS size, or primary closure frequency between the 2 groups (P > .05). However, in the persistent fistula group, the mean LAMS dwell time was significantly longer (127 vs 48 days, P = .02) and more patients had ≥5% total body weight gain (33.3% vs 10.3%, P = .03). LAMS dwell time was a significant predictor of persistent fistula (odds ratio, 4.5 after >40 days in situ, P = .01). The odds of developing a persistent fistula increased by 9.5% for every 7 days the LAMS was left in situ. In patients with a persistent fistula, endoscopic closure was attempted in 19 (76%) with successful resolution in 14 (73.7%). CONCLUSIONS Longer LAMS dwell time was found to be associated with a higher risk of persistent fistulas in EDGE patients. APC or primary closure of the fistula on LAMS removal was not found to be protective against developing a persistent fistula, which, if present, can be effectively managed through endoscopic closure in most cases.
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Affiliation(s)
- Bachir Ghandour
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Margaret G Keane
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Brianna Shinn
- Division of Gastroenterology and Hepatology, Thomas Jefferson Hospital, Philadelphia, Pennsylvania, USA
| | - Qais M Dawod
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Sima Fansa
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Abdul Hamid El Chafic
- Division of Gastroenterology and Hepatology, Ochsner Medical Center-New Orleans, New Orleans, Louisiana, USA
| | - Shayan S Irani
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Rishi Pawa
- Division of Gastroenterology and Hepatology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Aditya Gutta
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, Michigan, USA
| | - Bharat Paranandi
- Division of Gastroenterology and Hepatology, Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - Swati Pawa
- Division of Gastroenterology and Hepatology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Mohammad A Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Tobias Zuchelli
- Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, Michigan, USA
| | - Matthew T Huggett
- Division of Gastroenterology and Hepatology, Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - Reem Z Sharaiha
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Thomas E Kowalski
- Division of Gastroenterology and Hepatology, Thomas Jefferson Hospital, Philadelphia, Pennsylvania, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
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5
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Boortalary T, Erwin R, Dong M, Shinn B, Infantolino A, Tofani C. RHEMITT Score Predicts Rebleed After Capsule Endoscopy: First Validation at a U.S. Tertiary Care Center. Dig Dis Sci 2023; 68:187-192. [PMID: 35543830 DOI: 10.1007/s10620-022-07527-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 02/20/2022] [Accepted: 04/18/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patients with obscure gastrointestinal bleeding undergo small bowel capsule endoscopy (SBCE), but often return for recurrent bleeding or anemia. The RHEMITT score evaluates patients based on 7 variables (heart failure, chronic kidney disease, Saurin P1/P2 lesions, major bleeding, incomplete SBCE, smoking status, and endoscopic treatment) and seeks to predict the risk of rebleeding. AIMS This study aims to perform an external validation of the RHEMITT score in the United States. METHODS SBCEs performed to evaluate anemia or GI bleeding from a tertiary-care center's PillCam database between 1/22/2018 and 7/21/2020 were reviewed. Variables based on the RHEMITT score were collected. The primary outcome was rebleeding, defined as (1) melena or hematochezia or (2) hemoglobin drop of 2 g/dL. Patient were categorized into low, intermediate, and high-risk categories based on RHEMITT score. The accuracy of the RHEMITT score for predicting rebleeding was assessed. RESULTS A total of 361 SBCEs were included in the study. Age, indication for SBCE, endoscopic treatment, antiplatelet use, cirrhosis, heart failure, chronic kidney disease, and major bleeding were significantly associated with risk of rebleed (p < 0.05). Each increasing risk category for the RHEMITT score predicted increased probability of this study's primary outcome, rebleeding (p < 0.001). There was a significant association between RHEMITT risk category and rebleeding-free survival (log-rank p < 0.001). An area under the receiver operating characteristic curve for the RHEMITT score was 0.790 (p < 0.001). CONCLUSION Our findings validate the RHEMITT score and confirm acceptable performance for predicting rebleeding at a tertiary referral center in the United States.
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Affiliation(s)
- Tina Boortalary
- Department of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, 132 S. 10th St. Main Building, Suite 480, Philadelphia, PA, 19107, USA
| | - Ryan Erwin
- Department of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, 132 S. 10th St. Main Building, Suite 480, Philadelphia, PA, 19107, USA
| | - Michael Dong
- Department of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, 132 S. 10th St. Main Building, Suite 480, Philadelphia, PA, 19107, USA
| | - Brianna Shinn
- Department of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, 132 S. 10th St. Main Building, Suite 480, Philadelphia, PA, 19107, USA
| | - Anthony Infantolino
- Department of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, 132 S. 10th St. Main Building, Suite 480, Philadelphia, PA, 19107, USA
| | - Christina Tofani
- Department of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, 132 S. 10th St. Main Building, Suite 480, Philadelphia, PA, 19107, USA.
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6
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Ghandour B, Shinn B, Dawod QM, Fansa S, El Chafic AH, Irani SS, Pawa R, Gutta A, Ichkhanian Y, Paranandi B, Pawa S, Al-Haddad MA, Zuchelli T, Huggett MT, Bejjani M, Sharaiha RZ, Kowalski TE, Khashab MA. EUS-directed transgastric interventions in Roux-en-Y gastric bypass anatomy: a multicenter experience. Gastrointest Endosc 2022; 96:630-638. [PMID: 35623383 DOI: 10.1016/j.gie.2022.05.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [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: 03/09/2022] [Accepted: 05/14/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Placement of a lumen-apposing metal stent (LAMS) between the gastric pouch and the excluded stomach allows for EUS-guided transgastric interventions (EDGIs) in patients with Roux-en-Y gastric bypass (RYGB). Although EUS-guided transgastric ERCP (EDGE) outcomes have been reported, data are scant on other endoscopic interventions. We aimed to evaluate the outcomes and safety of EDGIs. METHODS This retrospective study involved 9 centers (United States, 8; Europe, 1) and included patients with RYGB who underwent EDGIs between June 2015 and September 2021. The primary outcome was the technical success of EDGIs. Secondary outcomes were adverse events (AEs), length of hospital stay, and fistula follow-up and management. RESULTS Fifty-four EDGI procedures were performed in 47 patients (mean age, 61 years; 72% women), most commonly for the evaluation of a pancreatic mass (n = 16) and management of pancreatic fluid collections (n = 10). A 20-mm LAMS was used in 26 patients and a 15-mm LAMS in 21, creating a gastrogastrostomy in 37 patients and jejunogastrostomy in 10. Most patients (n = 30, 64%) underwent a dual-session EDGI, with a median interval of 17 days between the 2 procedures. Single-session EDGI was performed in 17 patients, of whom 10 (59%) had anchoring of the LAMS. The most common interventions were diagnostic EUS (with or without FNA or fine-needle biopsy sampling; n = 28) and EUS-guided cystgastrostomy (n = 8). The mean procedural time was 97.6 ± 78.9 minutes. Technical success was achieved in 52 patients (96%). AEs occurred in 5 patients (10.6%), of which only 1 AE (2.1%) was graded as severe. Intraprocedural LAMS migration was the most common AE, occurring in 3 patients (6.4%), whereas delayed spontaneous LAMS migration occurred in 2 (4.3%). Four of the 5 LAMS migration events were managed endoscopically, and 1 required surgical repair. LAMS anchoring was found to be protective against LAMS migration (P = .001). The median duration of hospital stay was 2.1 ± 3.7 days. Of the 17 patients who underwent objective fistula assessment endoscopically or radiologically after LAMS removal, 2 (11.7%) were found to have persistent fistulas. In 1 case the fistula was intentionally left open to assist with weight gain. The other fistula was successfully closed endoscopically. CONCLUSIONS EDGI is effective and safe for the diagnosis and management of pancreaticobiliary and foregut disorders in RYGB patients. It is associated with high rates of technical success and low rates of severe AEs. LAMS migration is the most common AE with evidence that anchoring can be protective against its occurrence. Persistent fistulas may occur, but endoscopic closure seems to be effective.
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Affiliation(s)
- Bachir Ghandour
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Brianna Shinn
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Qais M Dawod
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Sima Fansa
- Department of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Abdul Hamid El Chafic
- Division of Gastroenterology and Hepatology, Ochsner Medical Center-New Orleans, New Orleans, Louisiana, USA
| | - Shayan S Irani
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Rishi Pawa
- Division of Gastroenterology and Hepatology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Aditya Gutta
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, Michigan, USA
| | - Bharat Paranandi
- Division of Gastroenterology and Hepatology, Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - Swati Pawa
- Division of Gastroenterology and Hepatology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Mohammad A Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Tobias Zuchelli
- Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, Michigan, USA
| | - Matthew T Huggett
- Division of Gastroenterology and Hepatology, Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - Michael Bejjani
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Reem Z Sharaiha
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Thomas E Kowalski
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
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7
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Holmes I, Shinn B, Mitsuhashi S, Boortalary T, Bashir M, Kowalski T, Loren D, Kumar A, Schlachterman A, Chiang A. Response. Gastrointest Endosc 2022; 95:815-816. [PMID: 35303988 DOI: 10.1016/j.gie.2021.12.012] [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] [Received: 12/06/2021] [Accepted: 12/17/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Ian Holmes
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Brianna Shinn
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Shuji Mitsuhashi
- Division of Internal Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Tina Boortalary
- Division of Internal Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Muhammad Bashir
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Thomas Kowalski
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - David Loren
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Anand Kumar
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Alexander Schlachterman
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Austin Chiang
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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8
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Holmes I, Shinn B, Mitsuhashi S, Boortalary T, Bashir M, Kowalski T, Loren D, Kumar A, Schlachterman A, Chiang A. Prediction and management of bleeding during endoscopic necrosectomy for pancreatic walled-off necrosis: results of a large retrospective cohort at a tertiary referral center. Gastrointest Endosc 2022; 95:482-488. [PMID: 34678298 DOI: 10.1016/j.gie.2021.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 07/01/2021] [Accepted: 10/12/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Lumen-apposing metal stents (LAMSs) provide an endoscopic method for management of walled-off necrosis (WON) and a gateway for the performance of endoscopic necrosectomy (EN). However, bleeding may occur in up to 20% of EN procedures. Predictive factors for bleeding in this patient population are unknown, and there is no agreed-on algorithm for the management of bleeding. The aim of this study was to evaluate preprocedural risk factors for bleeding in patients undergoing endoscopic drainage or EN for WON. METHODS A retrospective cohort of patients undergoing EN for WON was reviewed. Demographics, comorbidities, concurrent medications, and etiology of pancreatitis were recorded. Pre-, peri-, and postprocedural clinical variables were compared using the χ2 test and independent t test. RESULTS Between June 2014 and October 2020, 536 ENs were performed in 151 patients. Intraprocedural bleeding occurred during 28 procedures (5.2%) in 18 patients (11.9%). Endoscopic hemostasis was attempted in 8 patients (10 procedures). Eight patients (10 procedures) in total were treated by interventional radiology (IR). Thrombocytopenia (P = .006) and cirrhosis (P = .049) were associated with intraprocedural bleeding, although thrombocytopenia was present in only 1 patient. Identification of a vessel within the cavity endoscopically was also associated with bleeding (P < .001). On multivariate analysis, identification of a vessel within the cavity endoscopically remained a strong predictor of bleeding (P < .001), whereas cirrhosis was no longer significant. Patients who required IR for hemostasis were transfused with significantly more blood before the procedure than patients who did not (3.4 units vs .67 units, P = .002). CONCLUSIONS EN for WON was associated with a 5.2% per-procedure risk of bleeding and an 11.9% per-patient bleeding risk. Identification of a vessel within the cavity during endoscopy is predictive of bleeding during EN. Patients who require more transfusions before endoscopy may require earlier intervention by IR.
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Affiliation(s)
- Ian Holmes
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Brianna Shinn
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Shuji Mitsuhashi
- Division of Internal Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Tina Boortalary
- Division of Internal Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Muhammad Bashir
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Thomas Kowalski
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - David Loren
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Anand Kumar
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Alexander Schlachterman
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Austin Chiang
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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9
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Ichkhanian Y, Barawi M, Seoud T, Thakkar S, Kothari TH, Halabi ME, Ullah A, Edris W, Aepli P, Kowalski T, Shinn B, Shariaha RZ, Mahadev S, Mosko JD, Andrisani G, Di Matteo FM, Albrecht H, Giap AQ, Tang SJ, Naga YM, van Geenen E, Friedland S, Tharian B, Irani S, Ross AS, Jamil LH, Lew D, Nett AS, Farha J, Runge TM, Jovani M, Khashab MA. Endoscopic full-thickness resection of polyps involving the appendiceal orifice: a multicenter international experience. Endoscopy 2022; 54:16-24. [PMID: 33395714 DOI: 10.1055/a-1345-0044] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 12/15/2022]
Abstract
BACKGROUND Endoscopic resection of lesions involving the appendiceal orifice remains a challenge. We aimed to report outcomes with the full-thickness resection device (FTRD) for the resection of appendiceal lesions and identify factors associated with the occurrence of appendicitis. METHODS This was a retrospective study at 18 tertiary-care centers (USA 12, Canada 1, Europe 5) between November 2016 and August 2020. Consecutive patients who underwent resection of an appendiceal orifice lesion using the FTRD were included. The primary outcome was the rate of R0 resection in neoplastic lesions, defined as negative lateral and deep margins on post-resection histologic evaluation. Secondary outcomes included the rates of: technical success (en bloc resection), clinical success (technical success without need for further surgical intervention), post-resection appendicitis, and polyp recurrence. RESULTS 66 patients (32 women; mean age 64) underwent resection of colonic lesions involving the appendiceal orifice (mean [standard deviation] size, 14.5 (6.2) mm), with 40 (61 %) being deep, extending into the appendiceal lumen. Technical success was achieved in 59/66 patients (89 %), of which, 56 were found to be neoplastic lesions on post-resection pathology. Clinical success was achieved in 53/66 (80 %). R0 resection was achieved in 52/56 (93 %). Of the 58 patients in whom EFTR was completed who had no prior history of appendectomy, appendicitis was reported in 10 (17 %), with six (60 %) requiring surgical appendectomy. Follow-up colonoscopy was completed in 41 patients, with evidence of recurrence in five (12 %). CONCLUSIONS The FTRD is a promising non-surgical alternative for resecting appendiceal lesions, but appendicitis occurs in 1/6 cases.
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Affiliation(s)
- Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA.,Department of Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Mohammed Barawi
- Division of Gastroenterology and Hepatology, Ascension St. John Hospital, Detroit, Michigan, USA
| | - Talal Seoud
- Center for Advanced Endoscopy, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Shyam Thakkar
- Center for Advanced Endoscopy, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Truptesh H Kothari
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, New York, USA
| | - Maan El Halabi
- Department of Internal Medicine, Mount Sinai West, New York, New York, USA
| | - Asad Ullah
- Department of Gastroenterology, Gastrointestinal Oncology and Interventional Endoscopy, Sana Klinikum, Offenbach, Germany
| | - Wedi Edris
- Department of Gastroenterology, Gastrointestinal Oncology and Interventional Endoscopy, Sana Klinikum, Offenbach, Germany
| | - Patrick Aepli
- Department of Gastroenterology and Hepatology, Luzerner Kantonsspital, Luzerne, Switzerland
| | - Thomas Kowalski
- Division of Gastroenterology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Brianna Shinn
- Division of Gastroenterology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Reem Z Shariaha
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine/New York, Presbyterian Hospital, New York, New York, USA
| | - Srihari Mahadev
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine/New York, Presbyterian Hospital, New York, New York, USA
| | - Jeffrey D Mosko
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gianluca Andrisani
- Digestive Endoscopy Unit, Campus Bio-Medico, University of Rome, Rome, Italy
| | | | - Heinz Albrecht
- Department of Medicine, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Andrew Q Giap
- Department of Gastroenterology, Kaiser Permanente, Anaheim, California, USA
| | - Shou-Jiang Tang
- Division of Digestive Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Yehia M Naga
- Division of Digestive Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | | | - Shai Friedland
- Division of Gastroenterology, Department of Medicine, Stanford University, Stanford, California, USA
| | - Benjamin Tharian
- Department of Gastroenterology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Shayan Irani
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Andrew S Ross
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Laith H Jamil
- Section of Gastroenterology and Hepatology, Beaumont Health-Royal Oak, Royal Oak, Michigan, USA.,Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Daniel Lew
- Pancreatic and Biliary Diseases Program, Cedars-Sinai Medical Center, West Hollywood, California, USA
| | - Andrew S Nett
- Division of Gastroenterology, Sutter Health, Sacramento, California, USA
| | - Jad Farha
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Thomas M Runge
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA.,Division of Gastroenterology and Hepatology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Manol Jovani
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
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10
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Shinn B, Boortalary T, Raijman I, Nieto J, Khara HS, Kumar SV, Confer B, Diehl DL, El Halabi M, Ichkhanian Y, Runge T, Kumbhari V, Khashab M, Tyberg A, Shahid H, Sarkar A, Gaidhane M, Bareket R, Kahaleh M, Piraka C, Zuchelli T, Law R, Sondhi A, Kedia P, Robbins J, Calogero C, Bakhit M, Chiang A, Schlachterman A, Kowalski T, Loren D. Maximizing success in single-session EUS-directed transgastric ERCP: a retrospective cohort study to identify predictive factors of stent migration. Gastrointest Endosc 2021; 94:727-732. [PMID: 33957105 DOI: 10.1016/j.gie.2021.04.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [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] [Received: 01/18/2021] [Accepted: 04/27/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS EUS-directed transgastric ERCP (the EDGE procedure) is a simplified method of performing ERCP in Roux-en-Y gastric bypass patients. The EDGE procedure involves placement of a lumen-apposing metal stent (LAMS) into the excluded stomach to serve as a conduit for passage of the duodenoscope for pancreatobiliary intervention. Originally a multistep process, urgent indications for ERCP have led to the development of single-session EDGE (SS-EDGE) with LAMS placement and ERCP performed in the same session. The goal of this study was to identify predictive factors of intraprocedural LAMS migration in SS-EDGE. METHODS We conducted a multicenter retrospective review that included 9 tertiary medical centers across the United States. Data were collected and analyzed from 128 SS-EDGE procedures. The primary outcome was intraprocedural LAMS migration. Secondary outcomes were other procedural adverse events such as bleeding and perforation. RESULTS Eleven LAMS migrations were observed in 128 procedures (8.6%). Univariate analysis of clinically relevant variables was performed, as was a binary logistic regression analysis of stent diameter and stent dilation. This revealed that use of a smaller (15 mm) diameter LAMS was an independent predictor of intraprocedural stent migration (odds ratio, 5.36; 95% confidence interval, 1.29-22.24; P = .021). Adverse events included 3 patients who required surgery and 2 who experienced intraprocedural bleeding. CONCLUSIONS Use of a larger-diameter LAMS is a predictive factor for a nonmigrated stent and improved procedural success in SS-EDGE. Although larger patient cohorts are needed to adequately assess these findings, performance of LAMS dilation and fixation may also decrease risk of intraprocedural LAMS migration and improve procedural success.
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Affiliation(s)
- Brianna Shinn
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Tina Boortalary
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | - Jose Nieto
- Borland Groover Clinic, Jacksonville, Florida, USA
| | | | - S Vikas Kumar
- Geisinger Health System, Danville, Pennsylvania, USA
| | | | - David L Diehl
- Geisinger Health System, Danville, Pennsylvania, USA
| | - Maan El Halabi
- Johns Hopkins University Hospital, Baltimore, Maryland, USA
| | | | - Thomas Runge
- Johns Hopkins University Hospital, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Johns Hopkins University Hospital, Baltimore, Maryland, USA
| | - Mouen Khashab
- Johns Hopkins University Hospital, Baltimore, Maryland, USA
| | - Amy Tyberg
- Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Haroon Shahid
- Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Avik Sarkar
- Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Monica Gaidhane
- Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Romy Bareket
- Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Michel Kahaleh
- Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Cyrus Piraka
- Henry Ford Health System, Detroit, Michigan, USA
| | | | - Ryan Law
- University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Arjun Sondhi
- University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | | | - Justin Robbins
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Cristina Calogero
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Mena Bakhit
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Austin Chiang
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | - Thomas Kowalski
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - David Loren
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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11
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Shieh C, Chalikonda D, Block P, Shinn B, Kistler CA. Gastrointestinal toxicities of immune checkpoint inhibitors: a multicenter retrospective analysis. Ann Gastroenterol 2021; 34:46-52. [PMID: 33414621 PMCID: PMC7774670 DOI: 10.20524/aog.2020.0552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 07/14/2020] [Indexed: 12/12/2022] Open
Abstract
Background Immune checkpoint inhibitors are monoclonal antibodies that augment immune cell function and are used to treat malignancy. However, they may cause proinflammatory adverse events. This study investigated gastrointestinal (GI) adverse events associated with specific immune checkpoint inhibitors. Methods Charts of patients aged >18 years with a solid tumor who underwent treatment with immune checkpoint inhibitors between 1st April 2011 and 1st August 2019 were reviewed for GI toxicities. Clinical data, including interventions, treatment duration and outcomes, were recorded. Results One hundred patients were included in the study, of whom 22 experienced a GI adverse event directly attributable to immune checkpoint inhibitors. Transaminitis (9/22; 40.9%) and colitis (8/22; 36.3%) were most prevalent. The majority of events occurred within 4 cycles of treatment onset and were most prevalent with the nivolumab + ipilimumab combination (7/12; 58.3%). In 91% of cases (20/22), patients showed improvement or resolution of the event. Among the colitis cases, there was a significant difference (P=0.004) in recovery time between those who received infliximab and those who did not. Despite symptom resolution, only 7/22 were left on the same or part of the same treatment regimen. Conclusions Most patients experienced their GI adverse events within 4 cycles of starting treatment, the most common being transaminitis and colitis. Nivolumab + ipilimumab dual therapy was most strongly associated with colitis. Most adverse events self-resolved, with infliximab being particularly helpful in improving colitis symptoms. However, most patients were unable to tolerate the same immunotherapy regimen and ultimately expired.
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Affiliation(s)
| | - Divya Chalikonda
- Department of Division of Gastroenterology and Hepatology (Divya Chalikonda, Brianna Shinn, C. Andrew Kistler), Thomas Jefferson University Hospital, USA
| | - Peter Block
- Department of Medicine (Christine Shieh, Peter Block)
| | - Brianna Shinn
- Department of Division of Gastroenterology and Hepatology (Divya Chalikonda, Brianna Shinn, C. Andrew Kistler), Thomas Jefferson University Hospital, USA
| | - C Andrew Kistler
- Department of Division of Gastroenterology and Hepatology (Divya Chalikonda, Brianna Shinn, C. Andrew Kistler), Thomas Jefferson University Hospital, USA
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12
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Block PD, Shinn B, Kim JH, Hann HW. Hepatitis B-related hepatocellular carcinoma and stress: untangling the host immune response from clinical outcomes. Hepat Oncol 2020; 8:HEP35. [PMID: 33680431 PMCID: PMC7907965 DOI: 10.2217/hep-2020-0028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 12/01/2020] [Indexed: 02/06/2023] Open
Abstract
Chronic hepatitis B virus (HBV) infection is a major public health challenge on the global scale. Affecting hundreds of millions worldwide, HBV is a leading risk factor for hepatocellular carcinoma (HCC). Clinical outcomes from chronic HBV infection are varied and appear to be influenced by a complex and dysregulated host immune response. In turn, much attention has been given to the immunologic response to HBV in an effort to identify host factors that lead to the development of HCC. However, the role of nonimmunologic host factors, such as chronic stress, in HBV-related HCC is poorly defined. Indeed, a growing appreciation for the effects of stress on chronic liver diseases raises the question of its role in chronic HBV infection. In this light, the present review will untangle the roles of key host factors in HBV-related HCC with an emphasis on chronic stress as a viable contributor. First discussed is the interplay of stress, inflammation and chronic liver disease. The host immune response's role as a driver of HBV-related HCC is then reviewed, allowing for a close exploration of the effects of stress on immune function in chronic hepatitis B and as a potential risk factor for HBV-related HCC.
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Affiliation(s)
- Peter D Block
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
| | - Brianna Shinn
- Department of Gastroenterology & Hepatology, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
| | - Jin Hyang Kim
- Bristol-Myers Squibb, 3401 Princeton Pike, Lawrenceville, NJ 08648, USA
| | - Hie-Won Hann
- Department of Gastroenterology & Hepatology, Liver Disease Prevention Center, Philadelphia, PA 19107, USA
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13
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Block P, Shinn B, Roth C, Needleman L, Rosato E, Hann HW. Vagaries of the Host Response in the Development of Hepatitis B-related Hepatocellular Carcinoma: A Case Series. CCTR 2020. [DOI: 10.2174/1573394716666200129121051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The hepatitis B virus (HBV) is one of the leading causes of hepatocellular carcinoma
(HCC) worldwide. In the endemic region, the infection is commonly spread through vertical
transmission in which mother and child possess genetically identical viral genotypes in the setting
of similar host genomes. Despite these genetic similarities, clinical outcomes from chronic hepatitis
B (CHB) can vary widely, ranging from lifelong asymptomatic infection to terminal HCC. Presented
here are the longitudinal observations over multiple decades of three family clusters, including
monozygotic twins with non-discordant HCC, that demonstrate the heterogeneity of
HBV-related outcomes. These findings emphasize the important need to untangle the role of genetic
and non-genetic host factors in the development of HBV-related HCC, as well as highlight
the novel research avenues that can clarify the contributions of such factors in HBV-related HCC.
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Affiliation(s)
- Peter Block
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA 19107, United States
| | - Brianna Shinn
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, PA 19107, United States
| | - Christopher Roth
- Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, PA 19107, United States
| | - Laurence Needleman
- Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, PA 19107, United States
| | - Ernest Rosato
- Department of General Surgery, Thomas Jefferson University Hospital,, Philadelphia, PA 19107, United States
| | - Hie-Won Hann
- Division of Gastroenterology and Hepatology, Liver Disease Prevention Center, Philadelphia, PA 19107, United States
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14
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Brahmbhatt Y, Burke P, Shinn B, Menachem B, Abai B, Salvatore D, Sorokin R. A Quality Improvement Intervention to Improve the Efficiency of Arteriovenous Access Placement for Pre-Dialysis Inpatients. Am J Med Qual 2019; 34:376-380. [DOI: 10.1177/1062860618810847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The authors aimed to improve the rate of pre-dialysis arteriovenous (AV) access placement for hospitalized patients with advanced chronic kidney disease. The authors developed and implemented a protocol for hospitalized adult patients with an estimated glomerular filtration rate <20 mL/min to streamline the workflow for obtaining AV access. The protocol was piloted on 5 inpatient medical services over 3 months at 1 institution. Specific-Measurable-Achievable-Realistic-Timely (SMART) aims, Fishbone diagrams, Plan-Do-Study-Act cycles, and run charts were used to assess the process and outcomes of the intervention. There were 22 patients in the baseline group and 27 patients in the intervention group. Pre-dialysis AV access increased from 23% to 46%. Length of stay did not differ significantly between the baseline group (8.31 days) and the intervention group (8.4 days). Pathways can improve pre-dialysis AV access without significantly increasing length of stay.
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Affiliation(s)
- Yasmin Brahmbhatt
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Peter Burke
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Brianna Shinn
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Brandon Menachem
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Babak Abai
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Dawn Salvatore
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Rachel Sorokin
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
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15
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Shinn B, Kistler C, Roth C, Hann HW. Need For HBV Cure: Persistent Risk For Subsequent New And Recurrent HCC Even After A Decade Of Successful Anti-HBV Therapy And Initial Tumor Ablation. ACTA ACUST UNITED AC 2018. [DOI: 10.21767/2254-6081.100172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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16
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Hilleman DE, Mohiuddin SM, Lucas BD, Shinn B, Elsasser GN. Conversion from sustained-release to immediate-release calcium entry blockers: outcome in patients with mild-to-moderate hypertension. Clin Ther 1993; 15:1002-10. [PMID: 8111798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
We evaluated 110 patients with mild-to-moderate hypertension (diastolic blood pressure 95 to 110 mmHg) whose blood pressure was initially controlled on monotherapy with once-daily sustained-release calcium entry blockers; these patients were then switched to their respective immediate-release formulations TID. The study group consisted of 35 patients on diltiazem controlled delivery (CD) switched to immediate-release diltiazem, 41 patients on nifedipine gastrointestinal therapeutic system (GITS) switched to immediate-release nifedipine, and 34 patients on verapamil sustained-release (SR) switched to immediate-release verapamil. Outcome evaluation included a pair-wise comparison of the following during treatment with both formulations: blood pressure control, need for additional hypertensive agents, side effects, compliance, and cost of therapy. Blood pressure was controlled in 94% of patients switched from diltiazem CD to immediate-release diltiazem; 6% of patients required additional antihypertensive agents. Side effects and compliance were not significantly different between groups. Blood pressure was controlled in 78% of patients switched from nifedipine GITS to immediate-release nifedipine; 22% of patients required additional antihypertensive agents. Side effects, compliance, and cost of therapy were significantly different between groups. Side effects increased from 32% on nifedipine GITS to 58% on immediate-release nifedipine; and compliance decreased from 93% on nifedipine GITS to 76% on immediate-release nifedipine (P < 0.05). Blood pressure was controlled in 91% of patients switched from verapamil SR to verapamil immediate release; 9% of patients required additional antihypertensive agents. Side effects and compliance were not significantly different between groups, but immediate-release verapamil was significantly less expensive than verapamil SR.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- D E Hilleman
- Creighton University Medical Center, Omaha, Nebraska
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17
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Abstract
Splendore-Hoeppli phenomenon, the in vivo formation of eosinophilic radiate structures around microorganisms and biologically inert substances, may simulate actinomycotic sulfur granules and has been recognized in extragenital sites. In the lower female genital tract, the authors have noted these pseudoactinomycotic radiate granules (PAMRAGs) in both the presence and the absence of intrauterine contraceptive devices. To elucidate the nature and morphogenesis of PAMRAGs, the light microscopic morphologic features of PAMRAGs were studied by means of a battery of special stains. The absence of central branching filaments or diptheroid forms in PAMRAGs serves to distinguish them from true actinomycotic sulfur granules. Using the immunoperoxidase technique, the authors examined PAMRAGs for the presence of immunoglobulin, complement, and fibrin. Their studies showed that PAMRAGs contain neutral glycoproteins, lipid, and calcium with no demonstrable microorganisms, immunoglobulin, complement, or fibrin. The authors do not support the assertions of others that Splendore-Hoeppli radiate bodies are immune complexes derived from host serum proteins. They speculate that PAMRAGs of the genital tract are derived from host leukocytes that aggregate in response to the commonly present bacteria, parasites, or inert foreign bodies that initiate the Splendore-Hoeppli phenomenon and the morphogenesis of PAMRAGs.
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18
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Miley WM, Shinn B. Effect of arousal by social isolation, grouping, and d-amphetamine on inter-male aggression in mice (Mus musculus). Psychol Rep 1976; 38:635-8. [PMID: 944458 DOI: 10.2466/pr0.1976.38.2.635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
24 adult male Swiss-Webster mice were randomly assigned to one of four equal experimental groups: a socially isolated group (8 days) which received a high dose of d-amphetamine prior to testing, a socially isolated group which received distilled water prior to testing, a social group of six (8 days) which received a high dose of d-amphetamine prior to testing, and a social group of six which received distilled water prior to testing. In the tests in which experimental animals were paired with stimulus animals which had their olfactory bulbs removed, inter-male aggression occurred even in the absence of aggressive retaliation by the stimulus animals. This suggests mutual arousal is sufficient to initiate and maintain biting attacks, aggressive retaliation is not necessary. Also, extremely high arousal in experimental mice induced by d-amphetamine and social isolation completely suppressed inter-male aggression whereas neither variable did so alone.
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