1
|
Thiruvengadam NR, Saumoy M, Schaubel DE, Cotton PB, Elmunzer BJ, Freeman ML, Varadarajulu S, Kochman ML, Coté GA. Rise In First-Time ERCP For Benign Indications >1 Year After Cholecystectomy Is Associated With Worse Outcomes. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00309-4. [PMID: 38599308 DOI: 10.1016/j.cgh.2024.03.027] [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: 01/18/2024] [Revised: 03/20/2024] [Accepted: 03/21/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND & AIMS Greater availability of less invasive biliary imaging to rule out choledocholithiasis should reduce the need for diagnostic endoscopic retrograde cholangiopancreatography (ERCP) in patients who have a remote history of cholecystectomy. The primary aims were to determine the incidence, characteristics, and outcomes of individuals who undergo first-time ERCP > 1 year after cholecystectomy (late-ERCP). METHODS Data from a commercial insurance claim database (Optum Clinformatics) identified 583,712 adults who underwent cholecystectomy, 4,274 of whom underwent late-ERCP, defined as first-time ERCP for nonmalignant indications > 1 year after cholecystectomy. Outcomes were exposure and temporal trends in late-ERCP, biliary imaging utilization, and post-ERCP outcomes. Multivariable logistic regression was used to examine patient characteristics associated with undergoing late ERCP. RESULTS Despite a temporal increase in the use of non-invasive biliary imaging (35.9% in 2004 to 65.6% in 2021, p<0.001), the rate of late-ERCP increased eight-fold: 0.5 to 4.2/1,000 person-years from 2005 to 2021, p<0.001). While only 44% of patients who underwent late-ERCP had gallstone removal, there were high rates of post-ERCP pancreatitis (7.1%), hospitalization (13.1%), and new chronic opioid use (9.7%). Factors associated with late-ERCP included concomitant disorder of gut-brain interaction (OR 6.48, 95%CI:5.88-6.91) and metabolic dysfunction steatotic liver disease (OR 3.27 95%CI:2.79-3.55) along with use of anxiolytic (OR 3.45 95%CI:3.19-3.58), anti-spasmodic (OR 1.60 95%CI:1.53-1.72), and chronic opioids (OR 6.24 95%CI:5.79-6.52). CONCLUSION The rate of late-ERCP post-cholecystectomy is increasing significantly, particularly in patients with comorbidities associated with disorder of gut-brain interaction and mimickers of choledocholithiasis. Late-ERCPs are associated with disproportionately higher rates of adverse events, including initiation of chronic opioid use.
Collapse
Affiliation(s)
- Nikhil R Thiruvengadam
- Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, CA; Center for Endoscopic Innovation, Research, and Training, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA.
| | - Monica Saumoy
- Center for Digestive Health, Penn Medicine Princeton Medical Center, Plainsboro, NJ
| | - Douglas E Schaubel
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Peter B Cotton
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC
| | - Martin L Freeman
- Division of Gastroenterology and Hepatology, University of Minnesota School of Medicine, Minneapolis, MN
| | | | - Michael L Kochman
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, Philadelphia, PA; Center for Endoscopic Innovation, Research, and Training, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Gregory A Coté
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, OR
| |
Collapse
|
2
|
Phillips AE, Hughes SJ, Andersen DK, Bell A, Brand R, Coté GA, Cowdin A, Diazgranados N, Dudeja V, Duggan SN, Fogel E, Forsmark CE, Freeman AJ, Gittes G, Hart PA, Jeon C, Nealon W, Neoptolemos J, Palermo TM, Pandol S, Roberts KM, Rosenthal M, Singh VK, Yadav D, Whitcomb DC, Zyromski N. Interventions for Pancreatitis-New Approaches, Knowledge Gaps, and Research Opportunities: Summary of a National Institute of Diabetes and Digestive and Kidney Diseases Workshop. Pancreas 2024; 53:e368-e377. [PMID: 38518063 PMCID: PMC10963039 DOI: 10.1097/mpa.0000000000002333] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
ABSTRACT There exists no cure for acute, recurrent acute or chronic pancreatitis and treatments to date have been focused on managing symptoms. A recent workshop held by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) focused on interventions that might disrupt or perhaps even reverse the natural course of this heterogenous disease, aiming to identify knowledge gaps and research opportunities that might inform future funding initiatives for NIDDK. The breadth and variety of identified active or planned clinical trials traverses the spectrum of the disease and was conceptually grouped for the workshop into behavioral, nutritional, pharmacologic and biologic, and mechanical interventions. Cognitive and other behavioral therapies are proven interventions for pain and addiction, but barriers exist to their use. Whilst a disease specific instrument quantifying pain is now validated, an equivalent is lacking for nutrition - and both face challenges in ease and frequency of administration. Multiple pharmacologic agents hold promise. Ongoing development of Patient Reported Outcome (PRO) measurements can satisfy Investigative New Drug (IND) regulatory assessments. Despite multiple randomized clinical trials demonstrating benefit, great uncertainty remains regarding patient selection, timing of intervention, and type of mechanical intervention (endoscopic versus surgery). Challenges and opportunities to establish beneficial interventions for patients were identified.
Collapse
Affiliation(s)
- Anna Evans Phillips
- From the Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Steven J Hughes
- Division of Surgical Oncology, Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Dana K Andersen
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Adam Bell
- Translational Medicine and Regulatory Affairs, Theraly Fibrosis, Gaithersburg, MD
| | - Randall Brand
- From the Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Gregory A Coté
- Division of Gastroenterology and Hepatology, School of Medicine, Oregon Health and Science University, Portland, OR
| | | | - Nancy Diazgranados
- National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD
| | - Vikas Dudeja
- Division of Surgical Oncology, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Sinead N Duggan
- Department of Surgery, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Evan Fogel
- Digestive and Liver Disorders, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Chris E Forsmark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, FL
| | - A Jay Freeman
- Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, The Ohio State College of Medicine, Columbus, OH
| | - George Gittes
- Pediatric General and Thoracic Surgery, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Phil A Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Christie Jeon
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA
| | - William Nealon
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, NY
| | | | - Tonya M Palermo
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle Children's Research Institute, Seattle, WA
| | - Stephen Pandol
- Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Kristen M Roberts
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH
| | | | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dhiraj Yadav
- From the Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Nicholas Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| |
Collapse
|
3
|
Elmunzer BJ, Foster LD, Serrano J, Coté GA, Edmundowicz SA, Wani S, Shah R, Bang JY, Varadarajulu S, Singh VK, Khashab M, Kwon RS, Scheiman JM, Willingham FF, Keilin SA, Papachristou GI, Chak A, Slivka A, Mullady D, Kushnir V, Buxbaum J, Keswani R, Gardner TB, Forbes N, Rastogi A, Ross A, Law J, Yachimski P, Chen YI, Barkun A, Smith ZL, Petersen B, Wang AY, Saltzman JR, Spitzer RL, Ordiah C, Spino C, Durkalski-Mauldin V. Indomethacin with or without prophylactic pancreatic stent placement to prevent pancreatitis after ERCP: a randomised non-inferiority trial. Lancet 2024; 403:450-458. [PMID: 38219767 PMCID: PMC10872215 DOI: 10.1016/s0140-6736(23)02356-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 07/12/2023] [Revised: 10/11/2023] [Accepted: 10/18/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND The combination of rectally administered indomethacin and placement of a prophylactic pancreatic stent is recommended to prevent pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) in high-risk patients. Preliminary evidence suggests that the use of indomethacin might eliminate or substantially reduce the need for stent placement, a technically complex, costly, and potentially harmful intervention. METHODS In this randomised, non-inferiority trial conducted at 20 referral centres in the USA and Canada, patients (aged ≥18 years) at high risk for post-ERCP pancreatitis were randomly assigned (1:1) to receive rectal indomethacin alone or the combination of indomethacin plus a prophylactic pancreatic stent. Patients, treating clinicians, and outcomes assessors were masked to study group assignment. The primary outcome was post-ERCP pancreatitis. To declare non-inferiority, the upper bound of the two-sided 95% CI for the difference in post-ERCP pancreatitis (indomethacin alone minus indomethacin plus stent) would have to be less than 5% (non-inferiority margin) in both the intention-to-treat and per-protocol populations. This trial is registered with ClinicalTrials.gov (NCT02476279), and is complete. FINDINGS Between Sept 17, 2015, and Jan 25, 2023, a total of 1950 patients were randomly assigned. Post-ERCP pancreatitis occurred in 145 (14·9%) of 975 patients in the indomethacin alone group and in 110 (11·3%) of 975 in the indomethacin plus stent group (risk difference 3·6%; 95% CI 0·6-6·6; p=0·18 for non-inferiority). A post-hoc intention-to-treat analysis of the risk difference between groups showed that indomethacin alone was inferior to the combination of indomethacin plus prophylactic stent (p=0·011). The relative benefit of stent placement was generally consistent across study subgroups but appeared more prominent among patients at highest risk for pancreatitis. Safety outcomes (serious adverse events, intensive care unit admission, and hospital length of stay) did not differ between groups. INTERPRETATION For preventing post-ERCP pancreatitis in high-risk patients, a strategy of indomethacin alone was not as effective as a strategy of indomethacin plus prophylactic pancreatic stent placement. These results support prophylactic pancreatic stent placement in addition to rectal indomethacin administration in high-risk patients, in accordance with clinical practice guidelines. FUNDING US National Institutes of Health.
Collapse
Affiliation(s)
- B Joseph Elmunzer
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, SC, USA.
| | - Lydia D Foster
- Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Jose Serrano
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Gregory A Coté
- Division of Gastroenterology & Hepatology, Oregon Health & Science University, Portland, OR, USA
| | - Steven A Edmundowicz
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Raj Shah
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ji Young Bang
- Orlando Health Digestive Health Institute, Orlando Health, Orlando, FL, USA
| | - Shyam Varadarajulu
- Orlando Health Digestive Health Institute, Orlando Health, Orlando, FL, USA
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Mouen Khashab
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Richard S Kwon
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - James M Scheiman
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Field F Willingham
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Steven A Keilin
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Georgios I Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Amitabh Chak
- Division of Gastroenterology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Adam Slivka
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Daniel Mullady
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
| | - Vladimir Kushnir
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
| | - James Buxbaum
- Division of Gastroenterology, University of Southern California, Los Angeles, CA, USA
| | - Rajesh Keswani
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Timothy B Gardner
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Health, Lebanon, NH, USA
| | - Nauzer Forbes
- Division of Gastroenterology, University of Calgary, Calgary, AB, Canada
| | - Amit Rastogi
- Division of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Andrew Ross
- Division of Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Joanna Law
- Division of Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Patrick Yachimski
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yen-I Chen
- Division of Gastroenterology, McGill University, Montreal, QC, Canada
| | - Alan Barkun
- Division of Gastroenterology, McGill University, Montreal, QC, Canada
| | - Zachary L Smith
- Division of Gastroenterology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Bret Petersen
- Department of Gastroenterology, Mayo Clinic, Rochester, MN, USA
| | - Andrew Y Wang
- Division of Gastroenterology, University of Virginia, Charlottesville, VA, USA
| | - John R Saltzman
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, USA
| | - Rebecca L Spitzer
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Collins Ordiah
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Cathie Spino
- Department of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Valerie Durkalski-Mauldin
- Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| |
Collapse
|
4
|
Coté GA, Nitchie H, Elmunzer BJ, Kwon RS, Willingham FF, Wani S, Mullady D, Chak A, Singh V, Slivka A, Varadarajulu S, Freeman M, Gaddam S, Jamidar P, Tarnasky P, Foster L, Cotton PB. Characteristics of Patients Undergoing Endoscopic Retrograde Cholangiopancreatography for Sphincter of Oddi Disorders. Clin Gastroenterol Hepatol 2022; 20:e627-e634. [PMID: 33716141 PMCID: PMC9053091 DOI: 10.1016/j.cgh.2021.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 12/22/2020] [Revised: 03/02/2021] [Accepted: 03/05/2021] [Indexed: 02/07/2023]
Abstract
The concept that sphincter of Oddi dysfunction (SOD) can cause attacks of biliary-type pain in postcholecystectomy patients and those with unexplained recurrent acute pancreatitis, and that endoscopic sphincterotomy can ameliorate symptoms, remains unproven. The Evaluating Predictors and Interventions in Sphincter of Oddi Dysfunction (EPISOD) study of patients without objective evidence for biliary obstruction showed no difference in outcomes between those who underwent sphincterotomy or sham treatment.1 To date, there have been no studies examining the characteristics of patients who still are being offered endoscopic retrograde cholangiopancreatography (ERCP) for SOD since the EPISOD publication, although the absolute number appears to have declined.2.
Collapse
Affiliation(s)
- Gregory A. Coté
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Haley Nitchie
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - B. Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Richard S. Kwon
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Field F. Willingham
- Division of Digestive Diseases, Department of Medicine, School of Medicine, Emory University, Atlanta, Georgia
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Daniel Mullady
- Division of Gastroenterology, Department of Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Amitabh Chak
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Vikesh Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Adam Slivka
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Martin Freeman
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Srinivas Gaddam
- Department of Medicine, Cedars Sinai School of Medicine, Los Angeles, California
| | - Priya Jamidar
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | | | - Lydia Foster
- Department of Public Health, Medical University of South Carolina, Charleston, South Carolina
| | - Peter B. Cotton
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| |
Collapse
|
5
|
Saloman JL, Tang G, Stello KM, Hall KE, Wang X, AlKaade S, Banks PA, Brand RE, Conwell DL, Coté GA, Forsmark CE, Gardner TB, Gelrud A, Lewis MD, Sherman S, Slivka A, Whitcomb DC, Yadav D. Serum biomarkers for chronic pancreatitis pain patterns. Pancreatology 2021; 21:1411-1418. [PMID: 34602367 PMCID: PMC8629935 DOI: 10.1016/j.pan.2021.09.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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] [Received: 06/08/2021] [Revised: 09/15/2021] [Accepted: 09/25/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Chronic pancreatitis (CP) is associated with debilitating refractory pain. Distinct subtypes of CP pain have been previously characterized based on severity (none, mild-moderate, severe) and temporal (none, intermittent, constant) nature of pain, but no mechanism-based tools are available to guide pain management. This exploratory study was designed to determine if potential pain biomarkers could be detected in patient serum and whether they associate with specific pain patterns. METHODS Cytokines, chemokines, and peptides associated with nociception and pain were measured in legacy serum samples from CP patients (N = 99) enrolled in the North American Pancreatitis Studies. The unsupervised hierarchical cluster analysis was applied to cluster CP patients based on their biomarker profile. Classification and regression tree was used to assess whether these biomarkers can predict pain outcomes. RESULTS The hierarchical cluster analysis revealed a subset of patients with predominantly constant, mild-moderate pain exhibited elevated interleukin-1β (IL-1β), interleukin-6 (IL-6), interleukin-2 (IL-2), tumor necrosis factor alpha (TNFα), and monocyte chemoattractant protein-1 (MCP1) whereas patients with higher interleukin-4 (IL-4), interleukin-8 (IL-8) and calcitonin gene related peptide (CGRP) were more likely to have severe pain. Interestingly, analyses of each individual biomarker revealed that patients with constant pain had reduced circulating TNFα and fractalkine. Patients with severe pain exhibited a significant reduction in TNFα as well as trends towards lower levels of IL-6 and substance P. DISCUSSION The observations from this study indicate that unique pain experiences within the chronic pancreatitis population can be associated with distinct biochemical signatures. These data indicate that further hypothesis-driven analyses combining biochemical measurements and detailed pain phenotyping could be used to develop precision approaches for pain management in patients with chronic pancreatitis.
Collapse
Affiliation(s)
- Jami L. Saloman
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, School of Medicine, University of Pittsburgh, PA, USA,Pittsburgh Center for Pain Research, School of Medicine, University of Pittsburgh, PA, USA,Department of Neurobiology, School of Medicine, University of Pittsburgh, PA, USA
| | - Gong Tang
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kimberly M. Stello
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, School of Medicine, University of Pittsburgh, PA, USA
| | - Kristen E. Hall
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, School of Medicine, University of Pittsburgh, PA, USA
| | - Xianling Wang
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | - Randall E. Brand
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, School of Medicine, University of Pittsburgh, PA, USA
| | - Darwin L. Conwell
- The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Gregory A. Coté
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Christopher E. Forsmark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, FL, USA
| | - Timothy B. Gardner
- Section of Gastroenterology and Hepatology, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Andres Gelrud
- Department of Internal Medicine, Miami Cancer Institute, Gastro Health, Miami, FL, USA
| | - Michele D. Lewis
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Stuart Sherman
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Adam Slivka
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, School of Medicine, University of Pittsburgh, PA, USA
| | - David C. Whitcomb
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, School of Medicine, University of Pittsburgh, PA, USA,Pittsburgh Center for Pain Research, School of Medicine, University of Pittsburgh, PA, USA,Departments of Cell Biology & Physiology, and Human Genetics, University of Pittsburgh, PA, USA
| | - Dhiraj Yadav
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, School of Medicine, University of Pittsburgh, PA, USA
| | | |
Collapse
|
6
|
Elmunzer BJ, Smith ZL, Tarnasky P, Wang AY, Yachimski P, Banovac F, Buscaglia JM, Buxbaum J, Chak A, Chong B, Coté GA, Draganov PV, Dua K, Durkalski V, Geller BS, Jamil LH, Keswani RN, Khashab MA, Law R, Lo SK, McCarthy S, Selby JB, Singh VK, Taylor JR, Willingham FF, Spitzer RL, Foster LD. An Unsuccessful Randomized Trial of Percutaneous vs Endoscopic Drainage of Suspected Malignant Hilar Obstruction. Clin Gastroenterol Hepatol 2021; 19:1282-1284. [PMID: 32454259 PMCID: PMC8776356 DOI: 10.1016/j.cgh.2020.05.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 02/27/2020] [Revised: 04/17/2020] [Accepted: 05/15/2020] [Indexed: 02/07/2023]
Abstract
Percutaneous transhepatic biliary drainage (PTBD) and endoscopic retrograde cholangiopancreatography (ERCP) are widely accepted but competing approaches for the management of malignant obstruction at the hilum of the liver. ERCP is favored in the United States on the basis of high success rates for non-hilar indications, the perceived safety and superior tissue sampling capability of ERCP relative to PTBD, and the avoidance of external drains that are undesirable to patients. A recent randomized controlled trial (RCT) comparing the 2 modalities in patients with resectable hilar cholangiocarcinoma was terminated prematurely because of higher mortality in the PTBD group.1 In contrast, most observational data suggest that PTBD is superior for achieving complete drainage.2-6 Because the preferred procedure remains uncertain, we aimed to compare PTBD and ERCP as the primary intervention in patients with cholestasis due to malignant hilar obstruction (MHO).
Collapse
Affiliation(s)
- B. Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | - Zachary L. Smith
- Division of Gastroenterology and Liver Disease, Case Western Reserve University, Cleveland, Ohio
| | - Paul Tarnasky
- Division of Gastroenterology, Methodist Dallas Medical Center, Dallas, Texas
| | - Andrew Y. Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia
| | - Patrick Yachimski
- Division of Gastroenterology, Vanderbilt University, Nashville, Tennessee
| | - Filip Banovac
- Division of Interventional Radiology, Vanderbilt University, Nashville, Tennessee
| | | | - James Buxbaum
- Division of Gastroenterology, University of Southern California, Los Angeles, California
| | - Amitabh Chak
- Division of Gastroenterology and Liver Disease, Case Western Reserve University, Cleveland, Ohio
| | - Bradford Chong
- Division of Gastroenterology, University of Southern California, Los Angeles, California
| | - Gregory A. Coté
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | - Peter V. Draganov
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida
| | - Kulwinder Dua
- Division of Gastroenterology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Valerie Durkalski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Brian S. Geller
- Division of Interventional Radiology, University of Florida, Gainesville, Florida
| | - Laith H. Jamil
- Division of Gastroenterology, Cedars Sinai Medical Center, Los Angeles, California
| | - Rajesh N. Keswani
- Division of Gastroenterology, Northwestern University, Chicago, Illinois
| | - Mouen A. Khashab
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Ryan Law
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan
| | - Simon K. Lo
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | - Sean McCarthy
- Division of Gastroenterology, Ohio State University, Columbus, Ohio
| | - J. Bayne Selby
- Division of Interventional Radiology, Medical University of South Carolina, Charleston, South Carolina
| | - Vikesh K. Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Jason R. Taylor
- Division of Gastroenterology, Saint Louis University, St Louis, Missouri
| | | | - Rebecca L. Spitzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | - Lydia D. Foster
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina
| | | |
Collapse
|
7
|
Gaddam S, Coté GA. The importance of the "endoscopic oncologist" in the treatment of nonoperable cholangiocarcinoma. Gastrointest Endosc 2020; 92:1213-1215. [PMID: 33236993 DOI: 10.1016/j.gie.2020.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 06/05/2020] [Accepted: 06/07/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Srinivas Gaddam
- Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Gregory A Coté
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| |
Collapse
|
8
|
Branch LL, Elmunzer BJ, Forster E, Hoffman B, Moran RA, Coté GA. High Frequency of Multiple Imaging Studies During the Diagnostic Workup for Pancreatic Ductal Adenocarcinoma. Pancreas 2020; 49:e79-e80. [PMID: 33003088 DOI: 10.1097/mpa.0000000000001643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
|
9
|
Dunbar E, Greer PJ, Melhem N, Alkaade S, Amann ST, Brand R, Coté GA, Forsmark CE, Gardner TB, Gelrud A, Guda NM, LaRusch J, Lewis MD, Machicado JD, Muniraj T, Papachristou GI, Romagnuolo J, Sandhu BS, Sherman S, Wilcox CM, Singh VK, Yadav D, Whitcomb DC. Constant-severe pain in chronic pancreatitis is associated with genetic loci for major depression in the NAPS2 cohort. J Gastroenterol 2020; 55:1000-1009. [PMID: 32681239 PMCID: PMC9124361 DOI: 10.1007/s00535-020-01703-w] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [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: 05/07/2020] [Accepted: 06/17/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pain is the most debilitating symptom of recurrent acute pancreatitis (RAP) and chronic pancreatitis (CP) and often requires chronic opioids or total pancreatectomy with islet autotransplantation to manage. Pain is a complex experience that can be exacerbated by depression and vice versa. Our aim was to test the hypothesis that depression-associated genes are associated with a constant-severe pain experience in RAP/CP patients. STUDY A retrospective study was done using North American Pancreatitis Study II (NAPS2) genotyped RAP and CP patients with completed case report forms (n = 1,357). Subjects were divided based on pattern of pain and pain severity as constant-severe pain (n = 787) versus not constant-severe pain (n = 570) to conduct a nested genome-wide association study. The association between reported antidepressant medication use and depression gene loci was tested. RESULTS Constant-severe pain was reported in 58% (n = 787) of pancreatitis patients. No differences in sex or alcohol consumption were found based on pain severity. Antidepressant use was reported in 28% (n = 223), and they had lower SF-12 mental quality of life (MCS, p < 2.2 × 10- 16). Fifteen loci associated with constant-severe pain (p < 0.00001) were found to be in or near depression-associated genes including ROBO2, CTNND2, SGCZ, CNTN5 and BAIAP2. Three of these genes respond to antidepressant use (SGCZ, ROBO2, and CTNND2). CONCLUSION Depression is a major co-factor in the pain experience. This genetic predisposition to depression may have utility in counseling patients and in instituting early antidepressant therapy for pain management of pancreatitis patients. Prospective randomized trials are warranted. CLINICAL TRIALS REGISTRATION Clinicaltriasl.gov.# NCT01545167.
Collapse
Affiliation(s)
- Ellyn Dunbar
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA,Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Phil J. Greer
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nadine Melhem
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Samer Alkaade
- Department of Medicine, St. Louis University, St. Louis, MO, USA
| | | | - Randall Brand
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | - Timothy B. Gardner
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Andres Gelrud
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA,Department of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | | | - Jessica LaRusch
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michele D. Lewis
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville FL, USA
| | | | | | | | - Joseph Romagnuolo
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | | | | | - Charles M. Wilcox
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Vikesh K. Singh
- Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Dhiraj Yadav
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - David C. Whitcomb
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA,Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA,Department of Cell Biology & Molecular Physiology, University of Pittsburgh, Pittsburgh, PA, USA
| | | |
Collapse
|
10
|
Abstract
Background and Aims Pancreaticobiliary stone extraction during endoscopic retrograde cholangiopancreatography can be challenging when working space is limited or the duct is irregular and strictured. We aimed to demonstrate several difficult anatomic scenarios in which stone extraction was accomplished by ductoscopic grasping and retrieval using miniature devices. Methods In 2 cases, a miniature retrieval basket and snare are used during cholangioscopy to grasp refractory stones in the intrahepatic and cystic ducts, respectively. In cases 3 and 4, a miniature basket and snare are used during pancreatoscopy to facilitate stone extraction from stenotic and tortuous pancreatic ducts. In case 5, a miniature forceps is used to extract a stone from within a dilated pancreatic side branch. Results Stone extraction was successful in all cases without adverse events. Conclusions Miniature grasping accessories that fit through the working channel of the cholangioscope/pancreatoscope may allow stone retrieval in difficult anatomic scenarios and thus represent a meaningful addition to our therapeutic armamentarium for the treatment of this condition.
Collapse
Affiliation(s)
- B Joseph Elmunzer
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | - Erin Forster
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | - Robert A Moran
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | - Gregory A Coté
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, South Carolina
| |
Collapse
|
11
|
Elmunzer BJ, Serrano J, Chak A, Edmundowicz SA, Papachristou GI, Scheiman JM, Singh VK, Varadarajulu S, Vargo JJ, Willingham FF, Baron TH, Coté GA, Romagnuolo J, Wood-Williams A, Depue EK, Spitzer RL, Spino C, Foster LD, Durkalski V. Correction to: Rectal indomethacin alone versus indomethacin and prophylactic pancreatic stent placement for preventing pancreatitis after ERCP: study protocol for a randomized controlled trial. Trials 2020; 21:471. [PMID: 32493506 PMCID: PMC7271536 DOI: 10.1186/s13063-020-04458-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, MSC 702, 114 Doughty St., Suite 249, Charleston, SC, 29425, USA.
| | - Jose Serrano
- Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Amitabh Chak
- Division of Gastroenterology, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Steven A Edmundowicz
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
| | - Georgios I Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - James M Scheiman
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | | | - John J Vargo
- Department of Gastroenterology and Hepatology, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Field F Willingham
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Gregory A Coté
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, MSC 702, 114 Doughty St., Suite 249, Charleston, SC, 29425, USA
| | | | - April Wood-Williams
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, MSC 702, 114 Doughty St., Suite 249, Charleston, SC, 29425, USA
| | - Emily K Depue
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, MSC 702, 114 Doughty St., Suite 249, Charleston, SC, 29425, USA
| | - Rebecca L Spitzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, MSC 702, 114 Doughty St., Suite 249, Charleston, SC, 29425, USA
| | - Cathie Spino
- Department of Public Health, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Lydia D Foster
- Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Valerie Durkalski
- Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | | |
Collapse
|
12
|
Moran RA, Coté GA. EXPAND your practice by using fully covered metallic stents as first-line treatment for chronic pancreatitis-induced bile duct strictures. Gastrointest Endosc 2020; 91:370-372. [PMID: 32036943 DOI: 10.1016/j.gie.2019.10.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 10/01/2019] [Accepted: 10/15/2019] [Indexed: 02/08/2023]
Affiliation(s)
- Robert A Moran
- Division of Gastroenterology & Hepatology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Gregory A Coté
- Division of Gastroenterology & Hepatology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| |
Collapse
|
13
|
Coté GA, Durkalski-Mauldin VL, Serrano J, Klintworth E, Williams AW, Cruz-Monserrate Z, Arain M, Buxbaum JL, Conwell DL, Fogel EL, Freeman ML, Gardner TB, van Geenen E, Groce JR, Jonnalagadda SS, Keswani RN, Menon S, Moffatt DC, Papachristou GI, Ross A, Tarnasky PR, Wang AY, Wilcox CM, Hamilton F, Yadav D. SpHincterotomy for Acute Recurrent Pancreatitis Randomized Trial: Rationale, Methodology, and Potential Implications. Pancreas 2019; 48:1061-1067. [PMID: 31404020 PMCID: PMC6699897 DOI: 10.1097/mpa.0000000000001370] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [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] [Indexed: 12/16/2022]
Abstract
OBJECTIVES In patients with acute recurrent pancreatitis (ARP), pancreas divisum, and no other etiologic factors, endoscopic retrograde cholangiopancreatography (ERCP) with minor papilla endoscopic sphincterotomy (miES) is often performed to enlarge the minor papillary orifice, based on limited data. The aims of this study are to describe the rationale and methodology of a sham-controlled clinical trial designed to test the hypothesis that miES reduces the risk of acute pancreatitis. METHODS The SpHincterotomy for Acute Recurrent Pancreatitis (SHARP) trial is a multicenter, international, sham-controlled, randomized trial comparing endoscopic ultrasound + ERCP with miES versus endoscopic ultrasound + sham for the management of ARP. A total of 234 consented patients having 2 or more discrete episodes of acute pancreatitis, pancreas divisum confirmed by magnetic resonance cholangiopancreatography, and no other clear etiology for acute pancreatitis will be randomized. Both cohorts will be followed for a minimum of 6 months and a maximum of 48 months. RESULTS The trial is powered to detect a 33% risk reduction of acute pancreatitis frequency. CONCLUSIONS The SHARP trial will determine whether ERCP with miES benefits patients with idiopathic ARP and pancreas divisum. Trial planning has informed the importance of blinded outcome assessors and long-term follow-up.
Collapse
Affiliation(s)
| | | | - Jose Serrano
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | - Erin Klintworth
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - April W Williams
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Zobeida Cruz-Monserrate
- Division of Gastroenterology, Hepatology, and Nutrition
- Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Mustafa Arain
- Department of Medicine, University of California, San Francisco, San Francisco
| | - James L Buxbaum
- Department of Medicine, Keck School of Medicine of USC, Los Angeles, CA
| | | | - Evan L Fogel
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Martin L Freeman
- Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Timothy B Gardner
- Department of Medicine, Dartmouth Geisel School of Medicine, Lebanon, NH
| | - Erwin van Geenen
- Division of Gastroenterology and Hepatology, University Medical Center St Radboud, Nijmegen, Netherlands
| | - J Royce Groce
- Division of Gastroenterology, Hepatology, and Nutrition
| | | | - Rajesh N Keswani
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Shyam Menon
- Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Dana C Moffatt
- Department of Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | | | - Andrew Ross
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA
| | | | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA
| | - C Mel Wilcox
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Frank Hamilton
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | - Dhiraj Yadav
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| |
Collapse
|
14
|
Sahar N, Ross A, Lakhtakia S, Coté GA, Neuhaus H, Bruno MJ, Haluszka O, Kozarek R, Ramchandani M, Beyna T, Poley JW, Maranki J, Freeman M, Kedia P, Tarnasky P. Reducing the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis using 4-Fr pancreatic plastic stents placed with common-type guidewires: Results from a prospective multinational registry. Dig Endosc 2019; 31:299-306. [PMID: 30506606 DOI: 10.1111/den.13311] [Citation(s) in RCA: 2] [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] [Received: 07/18/2018] [Accepted: 11/26/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIM Pancreatic plastic stents (PPS) can reduce the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). Prospective multicenter documentation of PEP rate after PPS placement is scarce. A new 4-Fr stent designed to be deployed over a 0.035-inch guidewire was used to assess the effectiveness of PEP prophylaxis. METHODS High-PEP-risk patients received a 4-Fr PPS for primary or secondary prophylaxis at seven centers in four countries. Patients were followed until spontaneous PPS migration, endoscopic stent removal, or for 4 months, whichever came first. Main outcome was PEP rate. RESULTS One hundred six (106) patients received PPS for PEP prophylaxis [61 (58%) primary, 45 (42%) secondary prophylaxis]. Median age was 54 years. Eighty-one (76%) PPS were placed using a 0.035-inch guidewire. By investigator choice 99 (93%) stents were single pigtail. Median stent length was 8 cm (range 3-12 cm). Technical success achieved in 100% of cases. Two patients in the primary prophylaxis group (3%, 95% CI 0.4-11%) experienced mild/moderate PEP. Seventy-eight PPS available for analysis underwent spontaneous migration after a median of 29 days. There were no reports of stent-induced ductal trauma. Post-hoc analysis of migration rate by PPS length showed no statistically significant trend. CONCLUSIONS Among high-risk patients in the primary prophylaxis group, observed rates of PEP are low (3%, 95% CI 0.4-11%) with the use of prophylactic 4-Fr pancreatic duct stents compatible with a 0.035-inch guidewire. This low rate is not unequivocally due to the prophylactic stent.
Collapse
Affiliation(s)
| | | | | | | | - Horst Neuhaus
- Evangelical Hospital Dusseldorf, Dusseldorf, Germany
| | - Marco J Bruno
- Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Oleh Haluszka
- Temple University Health System, Philadelphia.,Southern Arizona VA Health Care System, Tucson
| | | | | | - Torsten Beyna
- Evangelical Hospital Dusseldorf, Dusseldorf, Germany
| | - Jan W Poley
- Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Jennifer Maranki
- Temple University Health System, Philadelphia.,Penn State Milton S. Hershey Medical Center, Hershey
| | | | | | | | | |
Collapse
|
15
|
Lowe ME, Goodman MT, Coté GA, Glesby MJ, Haupt M, Schork NJ, Singh VK, Andersen DK, Pandol SJ, Uc A, Whitcomb DC. Accelerating the Drug Delivery Pipeline for Acute and Chronic Pancreatitis: Summary of the Working Group on Drug Development and Trials in Recurrent Acute Pancreatitis at the National Institute of Diabetes and Digestive and Kidney Diseases Workshop. Pancreas 2019; 47:1193-1199. [PMID: 30325857 PMCID: PMC6195328 DOI: 10.1097/mpa.0000000000001164] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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] [Indexed: 02/07/2023]
Abstract
Recurrent acute pancreatitis (RAP) is a complex clinical syndrome with significant morbidity, unpredictable outcomes, and limited treatment options. The National Institute of Diabetes and Digestive and Kidney Disease sponsored a workshop on July 25, 2018, in Pittsburgh, Pennsylvania, to address research gaps impeding development of effective therapies for pancreatitis. The RAP working group identified challenges to clinical progress using existing definitions, risk assessment, diagnostic and severity criteria, disease trajectories, outcomes, and research methods. Recurrent acute pancreatitis includes all the risk of acute pancreatitis and often progresses to chronic pancreatitis with variable complications of chronic pain, exocrine insufficiency, diabetes, and pancreatic cancer. However, the great variability among individuals with RAP requires better precision in defining the risks, individual episodes, as well as their frequency, pathogenic pathways, and specific outcome measures for each of the systems affected by pancreatic inflammation. Because of disease complexity, few patients are similar enough for traditional studies and methods to conduct clinical trials with small sample sizes are required. The need for genetic testing, biomarker development, and better imaging methods was highlighted. Adaptive and N-of-one study designs, better endpoints, and outcome measures including patient-reported outcomes should considered early in developing future therapeutic trial design and include all stakeholders.
Collapse
Affiliation(s)
- Mark E. Lowe
- Department of Pediatrics, Washington University School of Medicine, Saint Louis, MO
| | - Marc T. Goodman
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Gregory A. Coté
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | | | - Mark Haupt
- ARIEL Precision Medicine, Pittsburgh, PA
| | - Nicholas J. Schork
- Department of Quantitative Medicine, The Transcriptional Genomics Research Institute, Phoenix, AZ
| | - Vikesh K. Singh
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dana K. Andersen
- Division of Digestive Diseases and Nutrition, National Institutes of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health, Bethesda, MD
| | - Stephen J. Pandol
- Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Aliye Uc
- Division of Gastroenterology, Hepatology, Pancreatology and Nutrition, Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA
| | - David C. Whitcomb
- Department of Medicine, University of Pittsburgh School of Medicine and UPMC, Pittsburgh, PA
| |
Collapse
|
16
|
Coté GA. Response. Gastrointest Endosc 2018; 88:885. [PMID: 30309496 DOI: 10.1016/j.gie.2018.07.022] [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: 07/09/2018] [Accepted: 07/18/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Gregory A Coté
- Medical University of South Carolina, Division of Gastroenterology and Hepatology, Charleston, South Carolina, USA
| |
Collapse
|
17
|
Wani S, Keswani RN, Han S, Aagaard EM, Hall M, Simon V, Abidi WM, Banerjee S, Baron TH, Bartel M, Bowman E, Brauer BC, Buscaglia JM, Carlin L, Chak A, Chatrath H, Choudhary A, Confer B, Coté GA, Das KK, DiMaio CJ, Dries AM, Edmundowicz SA, Chafic AHE, Hajj IE, Ellert S, Ferreira J, Gamboa A, Gan IS, Gangarosa LM, Gannavarapu B, Gordon SR, Guda NM, Hammad HT, Harris C, Jalaj S, Jowell PS, Kenshil S, Klapman J, Kochman ML, Komanduri S, Lang G, Lee LS, Loren DE, Lukens FJ, Mullady D, Muthusamy VR, Nett AS, Olyaee MS, Pakseresht K, Perera P, Pfau P, Piraka C, Poneros JM, Rastogi A, Razzak A, Riff B, Saligram S, Scheiman JM, Schuster I, Shah RJ, Sharma R, Spaete JP, Singh A, Sohail M, Sreenarasimhaiah J, Stevens T, Tabibian JH, Tzimas D, Uppal DS, Urayama S, Vitterbo D, Wang AY, Wassef W, Yachimski P, Zepeda-Gomez S, Zuchelli T, Early D. Competence in Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography, From Training Through Independent Practice. Gastroenterology 2018; 155:1483-1494.e7. [PMID: 30056094 PMCID: PMC6504935 DOI: 10.1053/j.gastro.2018.07.024] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [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] [Received: 06/21/2018] [Revised: 07/18/2018] [Accepted: 07/21/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND & AIMS It is unclear whether participation in competency-based fellowship programs for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) results in high-quality care in independent practice. We measured quality indicator (QI) adherence during the first year of independent practice among physicians who completed endoscopic training with a systematic assessment of competence. METHODS We performed a prospective multicenter cohort study of invited participants from 62 training programs. In phase 1, 24 advanced endoscopy trainees (AETs), from 20 programs, were assessed using a validated competence assessment tool. We used a comprehensive data collection and reporting system to create learning curves using cumulative sum analysis that were shared with AETs and trainers quarterly. In phase 2, participating AETs entered data into a database pertaining to every EUS and ERCP examination during their first year of independent practice, anchored by key QIs. RESULTS By the end of training, most AETs had achieved overall technical competence (EUS 91.7%, ERCP 73.9%) and cognitive competence (EUS 91.7%, ERCP 94.1%). In phase 2 of the study, 22 AETs (91.6%) participated and completed a median of 136 EUS examinations per AET and 116 ERCP examinations per AET. Most AETs met the performance thresholds for QIs in EUS (including 94.4% diagnostic rate of adequate samples and 83.8% diagnostic yield of malignancy in pancreatic masses) and ERCP (94.9% overall cannulation rate). CONCLUSIONS In this prospective multicenter study, we found that although competence cannot be confirmed for all AETs at the end of training, most meet QI thresholds for EUS and ERCP at the end of their first year of independent practice. This finding affirms the effectiveness of training programs. Clinicaltrials.gov ID NCT02509416.
Collapse
Affiliation(s)
- Sachin Wani
- University of Colorado Anschutz Medical Center, Aurora, Colorado.
| | - Rajesh N. Keswani
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Samuel Han
- University of Colorado Anschutz Medical Center, Aurora, Colorado
| | | | | | - Violette Simon
- University of Colorado Anschutz Medical Center, Aurora, Colorado
| | | | | | - Todd H. Baron
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Michael Bartel
- Mayo Clinic School of Graduate Medical Education, Jacksonville, Florida
| | | | - Brian C. Brauer
- University of Colorado Anschutz Medical Center, Aurora, Colorado
| | | | - Linda Carlin
- University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Amitabh Chak
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Hemant Chatrath
- University of California-Los Angeles, Los Angeles, California
| | | | | | - Gregory A. Coté
- Medical University of South Carolina, Charleston, South Carolina
| | | | | | | | | | | | | | - Swan Ellert
- University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Jason Ferreira
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Ian S. Gan
- Virginia Mason Medical Center, Seattle, Washington
| | - Lisa M. Gangarosa
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | | | | | - Hazem T. Hammad
- University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Cynthia Harris
- Moffitt Cancer Center, University of South Florida, Tampa, Florida
| | - Sujai Jalaj
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Sana Kenshil
- University of Alberta, Edmonton, Alberta, Canada
| | - Jason Klapman
- Moffitt Cancer Center, University of South Florida, Tampa, Florida
| | | | - Srinadh Komanduri
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Gabriel Lang
- Washington University in St Louis, St Louis, Missouri
| | - Linda S. Lee
- Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Frank J. Lukens
- Mayo Clinic School of Graduate Medical Education, Jacksonville, Florida
| | | | | | | | | | | | | | | | | | | | | | | | - Brian Riff
- Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Shreyas Saligram
- Moffitt Cancer Center, University of South Florida, Tampa, Florida
| | | | | | - Raj J. Shah
- University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Rishi Sharma
- University of California-Davis, Davis, California
| | | | - Ajaypal Singh
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Muhammad Sohail
- University of Massachusetts Medical Center, Worcester, Massachusetts
| | | | | | | | | | - Dushant S. Uppal
- University of Virginia School of Medicine, Charlottesville, Virginia
| | | | | | - Andrew Y. Wang
- University of Virginia School of Medicine, Charlottesville, Virginia
| | - Wahid Wassef
- University of Massachusetts Medical Center, Worcester, Massachusetts
| | | | | | | | - Dayna Early
- Washington University in St Louis, St Louis, Missouri
| |
Collapse
|
18
|
Suarez AL, Xu H, Cotton PB, Elmunzer BJ, Adams D, Morgan KA, Sheafor D, Coté GA. Trends in the timing of inpatient ERCP relative to cholecystectomy: a nationwide database studied longitudinally. Gastrointest Endosc 2018; 88:502-510.e4. [PMID: 29730227 DOI: 10.1016/j.gie.2018.04.2354] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [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: 09/18/2017] [Accepted: 04/24/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS ERCP has largely replaced common bile duct exploration for therapy of common bile duct pathology, yet its use as a purely diagnostic test has declined. Among inpatients, we hypothesized that timing between ERCP and cholecystectomy (CCY) has changed. The objectives were to measure temporal trends in the timing between inpatient ERCP and CCY and to examine factors associated with delays. METHODS We used the National Inpatient Sample between 1998 and 2013 to classify admissions for gallstone-related diagnoses undergoing inpatient CCY and ERCP by timing relative to CCY: within (±) 1 day, ≥2 days before, and ≥2 days after. Logistic regression and Poisson regression were used to determine pattern utilization and association of ERCP timing on hospital length of stay. RESULTS Between 1998 and 2013, the proportion of admissions for CCY associated with same-stay ERCP increased (14.5% in 1998 to 17.3% in 2013, P < .001), and approximately two-thirds of ERCPs were performed within 1 day of CCY. After adjusting for covariates, the mean adjusted length of stay remained significantly shorter for patients who underwent CCY within 1 day of ERCP (5.13 vs 7.48 days for ERCP ≥2 days before and vs 7.41 days for ERCP ≥2 days after, P < .001). CONCLUSIONS Use of inpatient ERCP in conjunction with CCY has increased minimally between 1998 and 2013, whereas length of stay has decreased. ERCPs performed within 1 day of CCY were associated with shorter hospital length of stay, suggesting delays between inpatient procedures should be minimized unless medical comorbidities preclude it.
Collapse
Affiliation(s)
- Alejandro L Suarez
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Huiping Xu
- Department of Biostatistics, Richard M. Fairbanks School of Public Health, Indianapolis, Indiana, USA
| | - Peter B Cotton
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - B Joseph Elmunzer
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - David Adams
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Katherine A Morgan
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Douglas Sheafor
- Department of Radiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Gregory A Coté
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| |
Collapse
|
19
|
Phillips AE, LaRusch J, Greer P, Abberbock J, Alkaade S, Amann ST, Anderson MA, Baillie J, Banks PA, Brand RE, Conwell D, Coté GA, Forsmark CE, Gardner TB, Gelrud A, Guda N, Lewis M, Money ME, Muniraj T, Sandhu BS, Sherman S, Singh VK, Slivka A, Tang G, Wilcox CM, Whitcomb DC, Yadav D. Known genetic susceptibility factors for chronic pancreatitis in patients of European ancestry are rare in patients of African ancestry. Pancreatology 2018; 18:528-535. [PMID: 29859674 PMCID: PMC8715541 DOI: 10.1016/j.pan.2018.05.482] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 11/21/2017] [Revised: 03/06/2018] [Accepted: 05/18/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Multiple pathogenic genetic variants are associated with pancreatitis in patients of European (EA) and Asian ancestries, but studies on patients of African ancestry (AA) are lacking. We evaluated the prevalence of known genetic variations in African-American subjects in the US. METHODS We studied prospectively enrolled controls (n = 238) and patients with chronic (CP) (n = 232) or recurrent acute pancreatitis (RAP) (n = 45) in the NAPS2 studies from 2000-2014 of self-identified AA. Demographic and phenotypic information was obtained from structured questionnaires. Ancestry and admixture were evaluated by principal component analysis (PCA). Genotyping was performed for pathogenic genetic variants in PRSS1, SPINK1, CFTR and CTRC. Prevalence of disease-associated variants in NAPS2 subjects of AA and EA was compared. RESULTS When compared with CP subjects of EA (n = 862), prevalence of established pathogenic genetic variants was infrequent in AA patients with CP, overall (29 vs. 8.19%, OR 4.60, 95% CI 2.74-7.74, p < 0.001), and after stratification by alcohol etiology (p < 0.001). On PCA, AA cases were more heterogeneous but distinct from EA subjects; no difference was observed between AA subjects with and without CP-associated variants. Of 19 A A patients with CP who had pathogenic genetic variants, 2 had variants in PRSS1 (R122H, R122C), 4 in SPINK1 (all N34S heterozygotes), 12 in CFTR (2 CFTRsev, 9 CFTRBD, 1 compound heterozygote with CFTRsev and CFTRBD), and 1 in CTRC (R254W). CONCLUSION Pathogenic genetic variants reported in EA patients are significantly less common in AA patients. Further studies are needed to determine the complex risk factors for AA subjects with pancreatitis.
Collapse
Affiliation(s)
- Anna Evans Phillips
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jessica LaRusch
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States,Ariel Precision Medicine, Pittsburgh PA, United States
| | - Phil Greer
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Judah Abberbock
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Samer Alkaade
- Department of Medicine, Saint Louis University, St. Louis, MO, United States
| | | | | | - John Baillie
- Department of Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Peter A. Banks
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA, United States
| | - Randall E. Brand
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Darwin Conwell
- Department of Medicine, Ohio State University, Columbus, OH, United States
| | - Gregory A. Coté
- Department of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | | | - Timothy B. Gardner
- Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, United States
| | - Andres Gelrud
- Department of Medicine, University of Chicago, Chicago, IL, United States
| | - Nalini Guda
- GI Associates LLC, Aurora Health Care, St. Luke’s Medical Center, Milwaukee, WI, United States
| | - Michele Lewis
- Department of Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Mary E. Money
- Washington County Hospital, Hagerstown, MD, United States
| | - Thiruvengadam Muniraj
- Department of Medicine, Griffin Hospital, Yale Affiliate, New Haven, CT, United States
| | - Bimaljit S. Sandhu
- Richmond Gastroenterology Associates, St. Mary’s Hospital, Richmond, VA, United States
| | - Stuart Sherman
- Department of Medicine, Indiana University, Indianapolis, IN, United States
| | - Vikesh K. Singh
- Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - Adam Slivka
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Gong Tang
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - C. Mel Wilcox
- Department of Medicine, University of Alabama Birmingham, Birmingham, AL, United States
| | - David C. Whitcomb
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States,Department of Cell Biology & Physiology, University of Pittsburgh, Pittsburgh, PA, United States,Department of Human Genetics, University of Pittsburgh, Pittsburgh, PA, United States
| | - Dhiraj Yadav
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States,Corresponding author. Division of Gastroenterology & Hepatology, University of Pittsburgh Medical Center, 200 Lothrop Street, M2, C-wing, Pittsburgh, PA 15213, United States. (D. Yadav)
| |
Collapse
|
20
|
Coté GA, Yadav D, Abberbock JA, Whitcomb DC, Sherman S, Sandhu BS, Anderson MA, Lewis MD, Alkaade S, Singh VK, Baillie J, Banks PA, Conwell D, Guda NM, Muniraj T, Tang G, Brand R, Gelrud A, Amann ST, Forsmark CE, Wilcox MC, Slivka A, Gardner TB. Recurrent Acute Pancreatitis Significantly Reduces Quality of Life Even in the Absence of Overt Chronic Pancreatitis. Am J Gastroenterol 2018; 113:906-912. [PMID: 29867178 PMCID: PMC6136830 DOI: 10.1038/s41395-018-0087-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [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: 07/24/2017] [Accepted: 03/13/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The impact of recurrent acute pancreatitis (RAP) on quality of life (QOL) is unknown. We hypothesized that RAP would reduce QOL even in the absence of chronic pancreatitis (CP). METHODS Data were pooled from three prospective, cross-sectional studies conducted across 27 U.S. centers (the North American Pancreatitis Studies); these included subjects with chronic pancreatitis (n = 1086), RAP alone (n = 508), and non-disease controls (n = 1025). QOL was measured using the Short Form 12 (SF-12), generating a Physical Component Summary (PCS) and the Mental Component Summary score (MCS). Multivariable regression models were developed to measure the effect of RAP on QOL, the predictors of lower QOL in those with RAP, and the differential effect QOL predictors between CP and RAP. RESULTS Compared to controls (51.0 ± 9.4), subjects with RAP (41.1 ± 11.4) and CP (37.2 ± 11.8) had lower PCS (p < 0.01). Subjects with CP had lower PCS compared to those with RAP (p < 0.01). Similarly, MCS was lower among RAP (44.6 ± 11.5) and CP (42.8 ± 12.2) subjects compared to controls (51.7 ± 9.1, p < 0.01). Subjects with CP had lower MCS compared to those with RAP (p < 0.01). After controlling for independent predictors of PCS, RAP was associated with lower PCS (estimate -8.46, p < 0.01) and MCS (estimate -6.45, p < 0.0001) compared to controls. The effect of endocrine insufficiency on PCS was differentially greater among RAP subjects (-1.28 for CP vs. -4.9 for RAP, p = 0.0184). CONCLUSIONS Even in the absence of CP, subjects with RAP have lower physical and mental QOL. This underscores the importance of identifying interventions to attenuate RAP before the development of overt CP.
Collapse
Affiliation(s)
- Gregory A Coté
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Dhiraj Yadav
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Judah A Abberbock
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - David C Whitcomb
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Stuart Sherman
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Bimaljit S Sandhu
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Michelle A Anderson
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Michele D Lewis
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Samer Alkaade
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Vikesh K Singh
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - John Baillie
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Peter A Banks
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Darwin Conwell
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Nalini M Guda
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Thiruvengadam Muniraj
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Gong Tang
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Randall Brand
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Andres Gelrud
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Stephen T Amann
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Christopher E Forsmark
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Mel C Wilcox
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Adam Slivka
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Timothy B Gardner
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| |
Collapse
|
21
|
Coté GA. Editorial: the sphincter of Oddi strikes again-eluxadoline illuminates a controversial mechanism for the pathogenesis of acute pancreatitis. Aliment Pharmacol Ther 2018; 47:1324-1325. [PMID: 29644734 DOI: 10.1111/apt.14596] [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: 12/08/2022]
Affiliation(s)
- G A Coté
- Division of Gastroenterology & Hepatology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| |
Collapse
|
22
|
Al-Kawas F, Aslanian H, Baillie J, Banovac F, Buscaglia JM, Buxbaum J, Chak A, Chong B, Coté GA, Draganov PV, Dua K, Durkalski V, Elmunzer BJ, Foster LD, Gardner TB, Geller BS, Jamidar P, Jamil LH, Keswani RN, Khashab MA, Lang GD, Law R, Lichtenstein D, Lo SK, McCarthy S, Melo S, Mullady D, Nieto J, Bayne Selby J, Singh VK, Spitzer RL, Strife B, Tarnaksy P, Taylor JR, Tokar J, Wang AY, Williams A, Willingham F, Yachimski P. Percutaneous transhepatic vs. endoscopic retrograde biliary drainage for suspected malignant hilar obstruction: study protocol for a randomized controlled trial. Trials 2018; 19:108. [PMID: 29444707 PMCID: PMC5813390 DOI: 10.1186/s13063-018-2473-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [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: 07/08/2017] [Accepted: 01/16/2018] [Indexed: 12/11/2022] Open
Abstract
Background The optimal approach to the drainage of malignant obstruction at the liver hilum remains uncertain. We aim to compare percutaneous transhepatic biliary drainage (PTBD) to endoscopic retrograde cholangiography (ERC) as the first intervention in patients with cholestasis due to suspected malignant hilar obstruction (MHO). Methods The INTERCPT trial is a multi-center, comparative effectiveness, randomized, superiority trial of PTBD vs. ERC for decompression of suspected MHO. One hundred and eighty-four eligible patients across medical centers in the United States, who provide informed consent, will be randomly assigned in 1:1 fashion via a web-based electronic randomization system to either ERC or PTBD as the initial drainage and, if indicated, diagnostic procedure. All subsequent clinical interventions, including crossover to the alternative procedure, will be dictated by treating physicians per usual clinical care. Enrolled subjects will be assessed for successful biliary drainage (primary outcome measure), adequate tissue diagnosis, adverse events, the need for additional procedures, hospitalizations, and oncological outcomes over a 6-month follow-up period. Subjects, treating clinicians and outcome assessors will not be blinded. Discussion The INTERCPT trial is designed to determine whether PTBD or ERC is the better initial approach when managing a patient with suspected MHO, a common clinical dilemma that has never been investigated in a randomized trial. Trial registration ClinicalTrials.gov, Identifier: NCT03172832. Registered on 1 June 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-2473-2) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Firas Al-Kawas
- Division of Gastroenterology, Johns Hopkins Sibley Memorial Hospital, Washington, DC, USA
| | - Harry Aslanian
- Division of Gastroenterology, Yale University, New Haven, CT, USA
| | - John Baillie
- Division of Gastroenterology, Virginia Commonwealth University, Richmond, VA, USA
| | - Filip Banovac
- Division of Interventional Radiology, Vanderbilt University, Nashville, TN, USA
| | | | - James Buxbaum
- Division of Gastroenterology, University of Southern California, Los Angeles, CA, USA
| | - Amitabh Chak
- Division of Gastroenterology, Case Western Reserve University, Cleveland, OH, USA
| | - Bradford Chong
- Division of Gastroenterology, University of Southern California, Los Angeles, CA, USA
| | - Gregory A Coté
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, FL, USA
| | - Kulwinder Dua
- Division of Gastroenterology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Valerie Durkalski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA.
| | - Lydia D Foster
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Timothy B Gardner
- Division of Gastroenterology, Dartmouth University, Lebanon, NH, USA
| | - Brian S Geller
- Division of Interventional Radiology, University of Florida, Gainesville, FL, USA
| | - Priya Jamidar
- Division of Gastroenterology, Yale University, New Haven, CT, USA
| | - Laith H Jamil
- Division of Gastroenterology, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Rajesh N Keswani
- Division of Gastroenterology, Northwestern University, Chicago, IL, USA
| | - Mouen A Khashab
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Gabriel D Lang
- Division of Gastroenterology, Washington University, St. Louis, MO, USA
| | - Ryan Law
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | | | - Simon K Lo
- Division of Gastroenterology, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Sean McCarthy
- Division of Gastroenterology, Ohio State University, Columbus, OH, USA
| | - Silvio Melo
- Division of Gastroenterology, University of Florida-Jacksonville, Jacksonville, FL, USA
| | - Daniel Mullady
- Division of Gastroenterology, Washington University, St. Louis, MO, USA
| | - Jose Nieto
- The Borland-Groover Clinic, Jacksonville, FL, USA
| | - J Bayne Selby
- Division of Interventional Radiology, Medical University of South Carolina, Charleston, SC, USA
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Rebecca L Spitzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Brian Strife
- Division of Interventional Radiology, Virginia Commonwealth University, Richmond, VA, USA
| | - Paul Tarnaksy
- Division of Gastroenterology, Methodist Dallas Medical Center, Dallas, TX, USA
| | - Jason R Taylor
- Division of Gastroenterology, Saint Louis University, St. Louis, MO, USA
| | - Jeffrey Tokar
- Division of Gastroenterology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Andrew Y Wang
- Division of Gastroenterology, University of Virginia, Charlottesville, VA, USA
| | - April Williams
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Field Willingham
- Division of Gastroenterology, Emory University, Atlanta, GA, USA
| | - Patrick Yachimski
- Division of Gastroenterology, Vanderbilt University, Nashville, TN, USA
| | | |
Collapse
|
23
|
Imler TD, Sherman S, Imperiale TF, Xu H, Ouyang F, Beesley C, Hilton C, Coté GA. Provider-specific quality measurement for ERCP using natural language processing. Gastrointest Endosc 2018; 87:164-173.e2. [PMID: 28476375 PMCID: PMC5670027 DOI: 10.1016/j.gie.2017.04.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [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: 10/04/2016] [Accepted: 04/22/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Natural language processing (NLP) is an information retrieval technique that has been shown to accurately identify quality measures for colonoscopy. There are no systematic methods by which to track adherence to quality measures for ERCP, the highest risk endoscopic procedure widely used in practice. Our aim was to demonstrate the feasibility of using NLP to measure adherence to ERCP quality indicators across individual providers. METHODS ERCPs performed by 6 providers at a single institution from 2006 to 2014 were identified. Quality measures were defined using society guidelines and from expert opinion, and then extracted using a combination of NLP and data mining (eg, ICD9-CM codes). Validation for each quality measure was performed by manual record review. Quality measures were grouped into preprocedure (5), intraprocedure (6), and postprocedure (2). NLP was evaluated using measures of precision and accuracy. RESULTS A total of 23,674 ERCPs were analyzed (average patient age, 52.9 ± 17.8 years, 14,113 were women [59.6%]). Among 13 quality measures, precision of NLP ranged from 84% to 100% with intraprocedure measures having lower precision (84% for precut sphincterotomy). Accuracy of NLP ranged from 90% to 100% with intraprocedure measures having lower accuracy (90% for pancreatic stent placement). CONCLUSIONS NLP in conjunction with data mining facilitates individualized tracking of ERCP providers for quality metrics without the need for manual medical record review. Incorporation of these tools across multiple centers may permit tracking of ERCP quality measures through national registries.
Collapse
Affiliation(s)
- Timothy D. Imler
- Division of Gastroenterology and Hepatology; Indiana University School of Medicine. Indianapolis, IN
- Department of Medicine; Indiana University School of Medicine. Indianapolis, IN
- Department of Biomedical Informatics; Regenstrief Institute, LLC. Indianapolis, IN
| | - Stuart Sherman
- Division of Gastroenterology and Hepatology; Indiana University School of Medicine. Indianapolis, IN
- Department of Medicine; Indiana University School of Medicine. Indianapolis, IN
| | - Thomas F. Imperiale
- Division of Gastroenterology and Hepatology; Indiana University School of Medicine. Indianapolis, IN
- Department of Medicine; Indiana University School of Medicine. Indianapolis, IN
- Center of Innovation; Health Services Research and Development; Richard L. Roudebush VA Medical Center. Indianapolis, IN
- Health Services Research, Regenstrief Institute, LLC. Indianapolis, IN
| | - Huiping Xu
- Department of Biostatistics; Indiana University School of Medicine. Indianapolis, IN
| | - Fangqian Ouyang
- Department of Biostatistics; Indiana University School of Medicine. Indianapolis, IN
| | - Christopher Beesley
- Department of Biomedical Informatics; Regenstrief Institute, LLC. Indianapolis, IN
| | - Charity Hilton
- Department of Biomedical Informatics; Regenstrief Institute, LLC. Indianapolis, IN
| | - Gregory A. Coté
- Division of Gastroenterology and Hepatology; Indiana University School of Medicine. Indianapolis, IN
- Division of Gastroenterology and Hepatology; Medical University of South Carolina. Charleston, SC
| |
Collapse
|
24
|
Easler JJ, Sherman S, Coté GA. Optimizing palliation of malignant hilar strictures by the use of endobiliary stents. Gastrointest Endosc 2017; 86:828-830. [PMID: 29061256 DOI: 10.1016/j.gie.2017.06.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 06/19/2017] [Accepted: 06/23/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Jeffery J Easler
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Stuart Sherman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Gregory A Coté
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| |
Collapse
|
25
|
Coté GA, Xu H, Easler JJ, Imler TD, Teal E, Sherman S, Korc M. Informative Patterns of Health-Care Utilization Prior to the Diagnosis of Pancreatic Ductal Adenocarcinoma. Am J Epidemiol 2017; 186:944-951. [PMID: 28541521 PMCID: PMC5860250 DOI: 10.1093/aje/kwx168] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 12/08/2016] [Accepted: 12/09/2016] [Indexed: 12/15/2022] Open
Abstract
Early-detection tests for pancreatic ductal adenocarcinoma (PDAC) are needed. Since a hypothetical screening test would be applied during antecedent clinical encounters, we sought to define the variability in health-care utilization leading up to PDAC diagnosis. This was a retrospective cohort study that included patients diagnosed with PDAC in the Indianapolis, Indiana, area between 1999 and 2013 with at least 1 health-care encounter during the antecedent 36-month period (n = 1,023). Patients were classified by unique patterns of health-care utilization using a group-based trajectory model. The prevalences of PDAC signals, such as diabetes mellitus (DM) and chronic pancreatitis, were compared. Four distinct trajectories were identified, the most common (42.0%) being having few clinical encounters more than 6 months prior to PDAC diagnosis (late acceleration). In all cases, a minority of persons had DM (30.6%, with 9.5% <1.5 years before PDAC) or any pancreatic disorder (39.9%); these were least common in the late-acceleration group (DM, 14.7%; any pancreatic disorder, 32.1% (P < 0.001)). The most common pattern of antecedent care was having few clinical encounters until shortly before PDAC diagnosis. Since the majority of patients diagnosed with PDAC do not have an antecedent PDAC signal, early-detection strategies limited to these groups may not apply to the majority of cases.
Collapse
Affiliation(s)
- Gregory A Coté
- Correspondence to Dr. Gregory A. Coté, Department of Medicine, Medical University of South Carolina, 114 Doughty Street, MSC 702, Suite 249, Charleston, SC 29425 (e-mail: )
| | | | | | | | | | | | | |
Collapse
|
26
|
Coté GA. The Countdown to a Paradigm Shift in Diagnosing Pancreatic Ductal Adenocarcinoma. Clin Gastroenterol Hepatol 2017; 15:1000-1002. [PMID: 28300695 PMCID: PMC5474177 DOI: 10.1016/j.cgh.2017.03.003] [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: 02/27/2017] [Revised: 03/07/2017] [Accepted: 03/08/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Gregory A. Coté
- Division of Gastroenterology & Hepatology, Department of Medicine, Medical University of South Carolina, Charleston, USA
| |
Collapse
|
27
|
Banerjee N, Parepally M, Byrne TK, Pullatt RC, Coté GA, Elmunzer BJ. Systematic review of transgastric ERCP in Roux-en-Y gastric bypass patients. Surg Obes Relat Dis 2017; 13:1236-1242. [PMID: 28336200 DOI: 10.1016/j.soard.2017.02.005] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 01/20/2017] [Accepted: 02/06/2017] [Indexed: 12/28/2022]
Abstract
Balloon-assisted endoscopic retrograde cholangiopancreatoscopy (ERCP) in Roux-en-Y gastric bypass (RYGB) patients is technically challenging due to anatomic and accessory constraints, thus success rates are modest. Transgastric ERCP (TG-ERCP) offers a viable alternative. We aimed to systematically review the literature on TG-ERCP in RYGB patients to better define the technical approaches, success rates, and adverse events of this procedure. A computer-assisted search of the Embase and PubMed databases was performed to identify studies that focused on the techniques and clinical outcomes of TG-ERCP. Two investigators independently identified studies and abstracted relevant data. The literature search yielded 26 eligible studies comprising 509 TG-ERCP cases. Access to the excluded stomach to facilitate ERCP was achieved laparoscopically in 58% of reported cases, via open surgery (6% of reported cases), by antecedent placement of a percutaneous gastrostomy tube (33%), or with endoscopic ultrasound assistance (3%). Successful gastric access was reported in 100% of cases and successful ductal cannulation in 98.5%. Adverse events were reported in 14% of cases; 80% of these were related to gastrostomy creation and the rest were attributable to ERCP. Wound infections (n = 19, 3.7%) were the most common gastrostomy-related adverse event, and post-ERCP pancreatitis (n = 7, 1.4%) was the most common ERCP-related adverse event. No deaths were reported. Based on existing observational studies, TG-ERCP appears to be a safe and highly effective approach in patients with RYGB anatomy. Additional research and clinical experience are needed to more precisely define the risk-benefit ratio and optimal technique of TG-ERCP.
Collapse
Affiliation(s)
- Nikhil Banerjee
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina.
| | - Mayur Parepally
- Division of Gastroenterology, Department of Medicine, Loyola University Medical Center, Maywood, Illinois
| | - T Karl Byrne
- Division of Gastrointestinal and Laparoscopic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Rana C Pullatt
- Division of Gastrointestinal and Laparoscopic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Gregory A Coté
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| |
Collapse
|
28
|
Elmunzer BJ, Coté GA. Mechanical debridement of walled-off pancreatic necrosis remains necessary despite lumen-apposing metal stent use. Gastrointest Endosc 2016; 84:1059-1060. [PMID: 27432804 DOI: 10.1016/j.gie.2016.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 04/23/2016] [Accepted: 07/01/2016] [Indexed: 12/11/2022]
Affiliation(s)
- B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Gregory A Coté
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| |
Collapse
|
29
|
Affiliation(s)
- Gregory A Coté
- Department of Medicine, Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | - B Joseph Elmunzer
- Department of Medicine, Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, South Carolina
| |
Collapse
|
30
|
Affiliation(s)
- B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Gregory A Coté
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| |
Collapse
|
31
|
Coté GA. Metallic vs Plastic Stents for Benign Biliary Strictures--Reply. JAMA 2016; 316:540-1. [PMID: 27483071 DOI: 10.1001/jama.2016.7306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Gregory A Coté
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston
| |
Collapse
|
32
|
Suarez AL, Coté GA, Elmunzer BJ. Adjunctive radiofrequency ablation for the endoscopic treatment of ampullary lesions with intraductal extension (with video). Endosc Int Open 2016; 4:E748-51. [PMID: 27556089 PMCID: PMC4993901 DOI: 10.1055/s-0042-107665] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [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: 12/28/2015] [Accepted: 04/11/2015] [Indexed: 12/17/2022] Open
Abstract
Catheter-based radiofrequency ablation (RFA) delivered during endoscopic retrograde cholangiopancreatography (ERCP) may represent a viable treatment option for intraductal extension of ampullary neoplasms, however, clinical experience with this modality is limited. After ampullary resection, 4 patients with intraductal extension underwent adjunctive RFA of the distal bile duct. All patients received a temporary pancreatic stent to reduce the risk of pancreatitis, as well as a plastic biliary stent to prevent biliary obstruction. Three patients were treated for adenoma and 1 for adenoma with a focus of adenocarcinoma. During a short follow-up period, 3 patients experienced complete eradication of the target lesion, whereas the patient with a focus of adenocarcinoma had progression to overt invasive cancer. There were no immediate adverse events. One patient developed a post-RFA bile duct stricture, which has required additional endoscopic therapy. Catheter-based RFA of ampullary lesions that extend up the bile duct is technically feasible. Additional research is necessary to understand the risks and long-term benefits of this technique.
Collapse
Affiliation(s)
- Alejandro L. Suarez
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, S.C. USA.,Corresponding author Alejandro L. Suarez, MD Division of Gastroenterology & HepatologyMedical University of South Carolina114 Doughty St. MSC 702, Suite 249Charleston, SC 29425+1-843-876-7232
| | - Gregory A. Coté
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, S.C. USA.
| | - B. Joseph Elmunzer
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, S.C. USA.
| |
Collapse
|
33
|
Coté GA, Zyromski NJ. Clarifying the Role of Endoscopic Retrograde Cholangiopancreatography in the Treatment of Patients With Pancreatic Fluid Collections. Gastroenterology 2016; 150:1243-1245. [PMID: 27018183 DOI: 10.1053/j.gastro.2016.03.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 12/02/2022]
Affiliation(s)
- Gregory A Coté
- Department of Medicine, Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| |
Collapse
|
34
|
Coté GA, Slivka A, Tarnasky P, Mullady DK, Elmunzer BJ, Elta G, Fogel E, Lehman G, McHenry L, Romagnuolo J, Menon S, Siddiqui UD, Watkins J, Lynch S, Denski C, Xu H, Sherman S. Effect of Covered Metallic Stents Compared With Plastic Stents on Benign Biliary Stricture Resolution: A Randomized Clinical Trial. JAMA 2016; 315:1250-7. [PMID: 27002446 PMCID: PMC5544902 DOI: 10.1001/jama.2016.2619] [Citation(s) in RCA: 145] [Impact Index Per Article: 18.1] [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] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Endoscopic placement of multiple plastic stents in parallel is the first-line treatment for most benign biliary strictures; it is possible that fully covered, self-expandable metallic stents (cSEMS) may require fewer endoscopic retrograde cholangiopancreatography procedures (ERCPs) to achieve resolution. OBJECTIVE To assess whether use of cSEMS is noninferior to plastic stents with respect to stricture resolution. DESIGN, SETTING, AND PARTICIPANTS Multicenter (8 endoscopic referral centers), open-label, parallel, randomized clinical trial involving patients with treatment-naive, benign biliary strictures (N = 112) due to orthotopic liver transplant (n = 73), chronic pancreatitis (n = 35), or postoperative injury (n = 4), who were enrolled between April 2011 and September 2014 (with follow-up ending October 2015). Patients with a bile duct diameter less than 6 mm and those with an intact gallbladder in whom the cystic duct would be overlapped by a cSEMS were excluded. INTERVENTIONS Patients (N = 112) were randomized to receive multiple plastic stents or a single cSEMS, stratified by stricture etiology and with endoscopic reassessment for resolution every 3 months (plastic stents) or every 6 months (cSEMS). Patients were followed up for 12 months after stricture resolution to assess for recurrence. MAIN OUTCOMES AND MEASURES Primary outcome was stricture resolution after no more than 12 months of endoscopic therapy. The sample size was estimated based on the noninferiority of cSEMS to plastic stents, with a noninferiority margin of -15%. RESULTS There were 55 patients in the plastic stent group (mean [SD] age, 57 [11] years; 17 women [31%]) and 57 patients in the cSEMS group (mean [SD] age, 55 [10] years; 19 women [33%]). Compared with plastic stents (41/48, 85.4%), the cSEMS resolution rate was 50 of 54 patients (92.6%), with a rate difference of 7.2% (1-sided 95% CI, -3.0% to ∞; P < .001). Given the prespecified noninferiority margin of -15%, the null hypothesis that cSEMS is less effective than plastic stents was rejected. The mean number of ERCPs to achieve resolution was lower for cSEMS (2.14) vs plastic (3.24; mean difference, 1.10; 95% CI, 0.74 to 1.46; P < .001). CONCLUSIONS AND RELEVANCE Among patients with benign biliary strictures and a bile duct diameter 6 mm or more in whom the covered metallic stent would not overlap the cystic duct, cSEMS were not inferior to multiple plastic stents after 12 months in achieving stricture resolution. Metallic stents should be considered an appropriate option in patients such as these. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01221311.
Collapse
Affiliation(s)
- Gregory A Coté
- Department of Medicine, Indiana University School of Medicine, Indianapolis2Department of Medicine, Medical University of South Carolina, Charleston
| | - Adam Slivka
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Daniel K Mullady
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - B Joseph Elmunzer
- Department of Medicine, Medical University of South Carolina, Charleston6Department of Medicine, University of Michigan, Ann Arbor
| | - Grace Elta
- Department of Medicine, University of Michigan, Ann Arbor
| | - Evan Fogel
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Glen Lehman
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Lee McHenry
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Joseph Romagnuolo
- Department of Medicine, Medical University of South Carolina, Charleston
| | - Shyam Menon
- Royal Wolverhampton Trust, Wolverhampton, United Kingdom
| | - Uzma D Siddiqui
- Center for Endoscopic Research and Therapeutics, University of Chicago School of Medicine, Chicago, Illinois
| | - James Watkins
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Sheryl Lynch
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Cheryl Denski
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis
| | - Huiping Xu
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis
| | - Stuart Sherman
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| |
Collapse
|
35
|
Elmunzer BJ, Serrano J, Chak A, Edmundowicz SA, Papachristou GI, Scheiman JM, Singh VK, Varadarajulu S, Vargo JJ, Willingham FF, Baron TH, Coté GA, Romagnuolo J, Wood-Williams A, Depue EK, Spitzer RL, Spino C, Foster LD, Durkalski V. Rectal indomethacin alone versus indomethacin and prophylactic pancreatic stent placement for preventing pancreatitis after ERCP: study protocol for a randomized controlled trial. Trials 2016; 17:120. [PMID: 26941086 PMCID: PMC4778337 DOI: 10.1186/s13063-016-1251-2] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 02/23/2016] [Indexed: 12/15/2022] Open
Abstract
Background The combination of prophylactic pancreatic stent placement (PSP) – a temporary plastic stent placed in the pancreatic duct – and rectal non-steroidal anti-inflammatory drugs (NSAIDs) is recommended for preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in high-risk cases. Preliminary data, however, suggest that PSP may be unnecessary if rectal NSAIDs are administered. Given the costs and potential risks of PSP, we aim to determine whether rectal indomethacin obviates the need for pancreatic stent placement in patients undergoing high-risk ERCP. Methods/Design The SVI (Stent vs. Indomethacin) trial is a comparative effectiveness, multicenter, randomized, double-blind, non-inferiority study of rectal indomethacin alone versus the combination of rectal indomethacin and PSP for preventing PEP in high-risk cases. One thousand four hundred and thirty subjects undergoing high-risk ERCP, in whom PSP is planned solely for PEP prevention, will be randomized to indomethacin alone or combination therapy. Those who are aware of study group assignment, including the endoscopist, will not be involved in the post-procedure care of the patient for at least 48 hours. Subjects will be assessed for PEP and its severity by a panel of independent and blinded adjudicators. Indomethacin alone will be declared non-inferior to combination therapy if the two-sided 95 % upper confidence bound of the treatment difference is less than 5 % between the two groups. Biological specimens will be obtained from trial participants and centrally banked. Discussion The SVI trial is designed to determine whether PSP remains necessary in the era of NSAIDs pharmacoprevention. The associated bio-repository will establish the groundwork for important scientific breakthrough. Trial registration NCT02476279, registered June 2015.
Collapse
Affiliation(s)
- B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, MSC 702, 114 Doughty St., Suite 249, Charleston, SC, 29425, USA.
| | - Jose Serrano
- Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA.
| | - Amitabh Chak
- Division of Gastroenterology, University Hospitals Case Medical Center, Cleveland, OH, USA.
| | - Steven A Edmundowicz
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA.
| | - Georgios I Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - James M Scheiman
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, MI, USA.
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
| | - Shyam Varadarajulu
- Center for Interventional Endoscopy, Florida Hospital, Orlando, FL, USA.
| | - John J Vargo
- Department of Gastroenterology and Hepatology, The Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Field F Willingham
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA.
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
| | - Gregory A Coté
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, MSC 702, 114 Doughty St., Suite 249, Charleston, SC, 29425, USA.
| | | | - April Wood-Williams
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, MSC 702, 114 Doughty St., Suite 249, Charleston, SC, 29425, USA.
| | - Emily K Depue
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, MSC 702, 114 Doughty St., Suite 249, Charleston, SC, 29425, USA.
| | - Rebecca L Spitzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, MSC 702, 114 Doughty St., Suite 249, Charleston, SC, 29425, USA.
| | - Cathie Spino
- Department of Public Health, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Lydia D Foster
- Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA.
| | - Valerie Durkalski
- Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA.
| | | |
Collapse
|
36
|
Affiliation(s)
- Gregory A Coté
- Department of Medicine, Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, South Carolina
| |
Collapse
|
37
|
Coté GA. Probe-Based Confocal Laser Endomicroscopy for Indeterminate Bile Duct Strictures: The Inaccuracies of Accuracy When Appraising the Value of a Diagnostic Test. Gastroenterology 2015; 149:817-9. [PMID: 26231604 DOI: 10.1053/j.gastro.2015.07.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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: 12/02/2022]
Affiliation(s)
- Gregory A Coté
- Department of Medicine, Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, South Carolina
| |
Collapse
|
38
|
Ridtitid W, Halawi H, DeWitt JM, Sherman S, LeBlanc J, McHenry L, Coté GA, Al-Haddad MA. Cystic pancreatic neuroendocrine tumors: outcomes of preoperative endosonography-guided fine needle aspiration, and recurrence during long-term follow-up. Endoscopy 2015; 47:617-25. [PMID: 25763832 DOI: 10.1055/s-0034-1391712] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [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] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND STUDY AIMS The role of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in the diagnosis and management of cystic pancreatic neuroendocrine tumors (PNETs) is unclear. We aimed to compare clinical/endosonographic characteristics of cystic with solid PNETs, determine diagnostic accuracy of preoperative EUS-FNA, and evaluate recurrence rates after resection. PATIENTS AND METHODS All patients with cystic or solid PNET confirmed by EUS-FNA between 2000 and 2014 were identified. A matched case-control study compared 50 consecutive patients with cystic PNETs with 50 consecutive patients with solid PNETs, matched by gender and age at diagnosis of index cystic PNET. We compared clinical/endosonographic characteristics, assessed diagnostic accuracy of preoperative EUS-FNA for identifying malignancy, and analyzed tumor-free survival of patients with cystic and solid PNETs. RESULTS Cystic PNETs tended to be larger than solid PNETs (mean 26.8 vs. 20.1 mm, P = 0.05), more frequently nonfunctional (96 % vs. 80 %, P = 0.03), and less frequently associated with multiple endocrine neoplasia type 1 (10 % vs. 28 %, P = 0.04). With surgical pathology as reference standard, EUS-FNA accuracies for malignancy of cystic and solid PNETs were 89.3 % and 90 %, respectively; cystic PNETs were less associated with metastatic adenopathy (22 % vs. 42 %, P = 0.03) and liver metastasis (0 % vs. 26 %, P < 0.001). Cystic fluid analysis (n = 13), showed benign cystic PNETs had low carcinoembryonic antigen (CEA), Ki-67 ≤ 2 %, and no loss of heterozygosity. Patients with cystic and solid PNETs had similar recurrence risk up to 5 years after complete resection. CONCLUSIONS Cystic PNETs have distinct clinical and EUS characteristics, but were associated with less aggressive biological behavior compared with solid PNETs. EUS-FNA is accurate for determining malignant potential on preoperative evaluation. Despite complete resection, recurrence is observed up to 5 years following surgery.
Collapse
Affiliation(s)
| | - Houssam Halawi
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - John M DeWitt
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Stuart Sherman
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Julia LeBlanc
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Lee McHenry
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Gregory A Coté
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | |
Collapse
|
39
|
Affiliation(s)
- Gregory A Coté
- Department of Medicine, Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, South Carolina
| |
Collapse
|
40
|
Ridtitid W, Schmidt SE, Al-Haddad MA, LeBlanc J, DeWitt JM, McHenry L, Fogel EL, Watkins JL, Lehman GA, Sherman S, Coté GA. Performance characteristics of EUS for locoregional evaluation of ampullary lesions. Gastrointest Endosc 2015; 81:380-8. [PMID: 25293823 PMCID: PMC4322681 DOI: 10.1016/j.gie.2014.08.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [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] [Received: 06/16/2014] [Accepted: 08/04/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND The accuracy of EUS in the locoregional assessment of ampullary lesions is unclear. OBJECTIVES To compare EUS with ERCP and surgical pathology for the evaluation of intraductal extension and local staging of ampullary lesions. DESIGN Retrospective cohort study. SETTING Tertiary-care referral center. PATIENTS All patients who underwent EUS primarily for the evaluation of an ampullary lesion between 1998 and 2012. INTERVENTION EUS. MAIN OUTCOME MEASUREMENTS Comparison of EUS sensitivity/specificity for intraductal and local extension with ERCP and surgical pathology by using the area under the receiver-operating characteristic (AUROC) curves and outcomes of the subgroup referred for endoscopic papillectomy. RESULTS We identified 119 patients who underwent EUS for an ampullary lesion, of whom 99 (83%) had an adenoma or adenocarcinoma. Compared with ERCP (n = 90), the sensitivity/specificity of EUS for any intraductal extension was 56%/97% (AUROC = 0.77; 95% confidence interval [CI], 0.64-0.89). However, when using surgical pathology as the reference (n = 102), the sensitivity/specificity of EUS (80%/93%; AUROC = 0.87; 95% CI, 0.76-0.97) and ERCP (83%/93%; AUROC = 0.88; 95% CI, 0.77-0.99) were comparable. The overall accuracy of EUS for local staging was 90%. Of 58 patients referred for endoscopic papillectomy, complete resection was achieved in 53 (91%); in those having intraductal extension by EUS or ERCP, complete resection was achieved in 4 of 5 (80%) and 4 of 7 (57%), respectively. LIMITATION Retrospective design. CONCLUSIONS EUS and ERCP perform similarly in evaluating intraductal extension of ampullary adenomas. Additionally, EUS is accurate in T-staging ampullary adenocarcinomas. Future prospective studies should evaluate whether EUS can identify characteristics of ampullary lesions that appropriately direct patients to endoscopic or surgical resection.
Collapse
Affiliation(s)
- Wiriyaporn Ridtitid
- Indiana University School of Medicine, Indianapolis, Indiana, USA, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | | | | | - Julia LeBlanc
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - John M. DeWitt
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Lee McHenry
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Evan L. Fogel
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - James L. Watkins
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Glen A. Lehman
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Stuart Sherman
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Gregory A. Coté
- Medical University of South Carolina, Charleston, South Carolina, USA
| |
Collapse
|
41
|
Affiliation(s)
- Peter B Cotton
- Digestive Disease Center, Medical University of South Carolina, USA
| | - Gregory A Coté
- Digestive Disease Center, Medical University of South Carolina, USA
| |
Collapse
|
42
|
Young Bang J, Coté GA. Rare and underappreciated complications of endoscopic retrograde cholangiopancreatography. Techniques in Gastrointestinal Endoscopy 2014. [DOI: 10.1016/j.tgie.2014.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
43
|
Coté GA. Endoscopic treatment of acute biliary diseases: have we optimized the value of inpatient endoscopic retrograde cholangiopancreatography? Clin Gastroenterol Hepatol 2014; 12:1160-2. [PMID: 24262939 PMCID: PMC4419360 DOI: 10.1016/j.cgh.2013.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Revised: 11/07/2013] [Accepted: 11/12/2013] [Indexed: 02/06/2023]
Affiliation(s)
- Gregory A Coté
- Indiana University School of Medicine, Indianapolis, Indiana
| |
Collapse
|
44
|
Sagi SV, Schmidt S, Fogel E, Lehman GA, McHenry L, Sherman S, Watkins J, Coté GA. Association of greater intravenous volume infusion with shorter hospitalization for patients with post-ERCP pancreatitis. J Gastroenterol Hepatol 2014; 29:1316-20. [PMID: 24372871 DOI: 10.1111/jgh.12511] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [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] [Accepted: 12/17/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM There are no data specifically correlating early intravenous volume infusion (IVI) with the length of hospitalization for postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). METHODS We conducted a retrospective cohort study of patients admitted within 24 h after ERCP to our institute with PEP. IVI during the first 24 h after ERCP was assessed. Primary outcome was severity of PEP, defined by length of hospitalization according to consensus guidelines: mild ≤ 3, moderate 4-10, and severe > 10 days. RESULTS Of 72 eligible patients, 41 (56.9%) had mild and 31 (43.1%) moderate/severe PEP. Both groups had comparable demographics, indications, and procedural factors except patients with moderate/severe PEP were older (median age 49 vs 36 years, P = 0.05) and more likely to be discharged and readmitted within the first 24 h (41.9% vs 14.6%, P < 0.01). Patients with mild PEP received significantly greater IVI during the first 24 h (2834 mL [2046, 3570] vs 2044 mL [1227, 2875], P < 0.02) and 50% more fluid post-ERCP (2270 mL [1435, 2961] vs 1515 [950-2350], P < 0.02) compared with those with at least moderate PEP. CONCLUSION In patients with PEP, greater IVI during the first 24 h after ERCP is associated with reduced length of hospitalization. Lower IVI was more commonly observed in individuals who were discharged and then readmitted during the first 24 h.
Collapse
Affiliation(s)
- Sashidhar V Sagi
- Department of Medicine, Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | | | | | | | | | | | | |
Collapse
|
45
|
Coté GA. Patient-controlled propofol for sedation in endoscopic retrograde cholangiopancreatography: an alternative to anesthesia-administered sedation? Gastroenterology 2014; 146:1818-9. [PMID: 24768592 DOI: 10.1053/j.gastro.2014.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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: 12/02/2022]
Affiliation(s)
- Gregory A Coté
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| |
Collapse
|
46
|
Affiliation(s)
- Gregory A Coté
- Department of Medicine, Division of Gastroenterology & Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| |
Collapse
|
47
|
Ridtitid W, Tan D, Schmidt SE, Fogel EL, McHenry L, Watkins JL, Lehman GA, Sherman S, Coté GA. Endoscopic papillectomy: risk factors for incomplete resection and recurrence during long-term follow-up. Gastrointest Endosc 2014; 79:289-96. [PMID: 24094466 PMCID: PMC4413454 DOI: 10.1016/j.gie.2013.08.006] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [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: 07/04/2013] [Accepted: 08/08/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic papillectomy is increasingly used as an alternative to surgery for ampullary adenomas and other noninvasive ampullary lesions. OBJECTIVE To measure short-term safety and efficacy of endoscopic papillectomy, define patient and lesion characteristics associated with incomplete endoscopic resection, and measure adenoma recurrence rates during long-term follow-up. DESIGN Retrospective cohort study. SETTING Tertiary-care academic medical center. PATIENTS All patients who underwent endoscopic papillectomy for ampullary lesions between July 1995 and June 2012. INTERVENTION Endoscopic papillectomy. MAIN OUTCOME MEASUREMENTS Patient and lesion characteristics associated with incomplete endoscopic resection and ampullary adenoma-free survival analysis. RESULTS We identified 182 patients who underwent endoscopic papillectomy, 134 (73.6%) having complete resection. Short-term adverse events occurred in 34 (18.7%). Risk factors for incomplete resection were jaundice at presentation (odds ratio [OR] 0.21; 95% confidence interval [CI] 0.07-0.69; P = .009), occult adenocarcinoma (OR 0.06; 95% CI, 0.01-0.36; P = .002), and intraductal involvement (OR 0.29; 95% CI, 0.11-0.75; P = .011). The en bloc resection technique was strongly associated with a higher rate of complete resection (OR 4.05; 95% CI, 1.71-9.59; P = .001). Among patients with ampullary adenoma who had complete resection (n = 107), 16 patients (15%) developed recurrence up to 65 months after resection. LIMITATIONS Retrospective analysis. CONCLUSION Jaundice at presentation, occult adenocarcinoma in the resected specimen, and intraductal involvement are associated with a lower rate of complete resection, whereas en bloc papillectomy increases the odds of complete endoscopic resection. Despite complete resection, recurrence was observed up to 5 years after papillectomy, confirming the need for long-term surveillance.
Collapse
Affiliation(s)
- Wiriyaporn Ridtitid
- Indiana University School of Medicine, Indianapolis, Indiana, USA; Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Damien Tan
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Evan L Fogel
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Lee McHenry
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - James L Watkins
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Glen A Lehman
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Stuart Sherman
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Gregory A Coté
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| |
Collapse
|
48
|
Choi EK, Chiorean MV, Coté GA, El Hajj II, El Hajj I, Ballard D, Fogel EL, Watkins JL, McHenry L, Sherman S, Lehman GA. ERCP via gastrostomy vs. double balloon enteroscopy in patients with prior bariatric Roux-en-Y gastric bypass surgery. Surg Endosc 2013; 27:2894-9. [PMID: 23793801 DOI: 10.1007/s00464-013-2850-6] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 01/30/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) is the most common bariatric surgery. The performance of ERCP in bariatric RYGB is challenging due to the long Roux limb. We herein compared the indications and technical outcomes of ERCP via percutaneous gastrostomy (GERCP) and double balloon enteroscopy (DBERCP) for patients with prior bariatric RYGB anatomy. METHODS Between December 2005 and November 2011, consecutive ERCP patients who had undergone RYGB were identified using a prospectively maintained electronic ERCP database. Medical records were abstracted for ERCP indications and outcomes. In most cases, the gastrostomy was done by either laparoscopic or open surgery and allowed to mature at least 1 month before performing ERCP. The choice of route for ERCP was at discretion of managing physician. RESULTS Forty-four patients (F = 42) with GERCP and 28 patients (F = 26) with DBERCP were identified. The mean age was younger in GERCP than DBERCP (44.8 vs. 56.1, p < 0.001). GERCP patients were more likely to have suspected sphincter of Oddi dysfunction (77 %) as the primary indication whereas DBERCP was suspected CBD stone (57 %). The mean total number of sessions/patient in GERCP and DBERCP was 1.7 ± 1.0 and 1.1 ± 0.4, respectively (p = 0.004). GERCP access to the major papilla was successful in all but two (97 %), whereas duct cannulation and interventions were successful in all. In DBERCP, the success rate of accessing major papilla, cannulation and therapeutic intervention was 78, 63, 56 %, respectively. There was one (3.1 %) post-ERCP pancreatitis in DBERCP. Complications occurred in 11 GERCP procedures (14.5 %) and 10 were related to the gastrostomy. This was significantly higher than that of DBERCP (p = 0.022). CONCLUSIONS GERCP is more effective than DBERCP in gaining access to the pancreatobiliary tree in patients with RYGB, but it is hindered by the gastrostomy maturation delay and a higher morbidity. Technical improvements in each method are needed.
Collapse
Affiliation(s)
- Eun Kwang Choi
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University Medical Center, 550 N. University Boulevard, UH 4100, Indianapolis, IN 46202, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Coté GA, Smith J, Sherman S, Kelly K. Technologies for imaging the normal and diseased pancreas. Gastroenterology 2013; 144:1262-71.e1. [PMID: 23622136 DOI: 10.1053/j.gastro.2013.01.076] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [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: 10/10/2012] [Revised: 12/27/2012] [Accepted: 01/03/2013] [Indexed: 02/06/2023]
Abstract
The prognosis is poor for most patients with pancreatic cancer, chronic pancreatitis, or other pancreatic diseases. Advances in pancreatic imaging could help identify these diseases at earlier stages, when they are easier to treat. Radiographic imaging and endoscopic imaging of the pancreas have progressed from the abdominal roentogram and endoscopic retrograde pancreatography to multi-detector computed tomography, magnetic resonance cholangiopancreatography, endoscopic ultrasonography, and pancreatoscopy. These technologies have improved the diagnosis and treatment of benign disease but have not significantly increased our ability to detect early-stage disease or affect outcomes of patients with pancreatic cancer or chronic pancreatitis. Advances in endoscopic imaging and molecular-based radiographic tests could allow physicians to identify pancreatic lesions and their precursors at earlier stages. Furthermore, research studies that include these tools could improve our understanding of disease pathogenesis and identify diagnostic markers and therapeutic targets. We review endoscopic imaging modalities, focusing on new endoscopic and molecular-based radiographic imaging tests that have the potential to substantially improve diagnosis and treatment of pancreatic disease.
Collapse
Affiliation(s)
- Gregory A Coté
- Division of Gastroenterology & Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.
| | | | | | | |
Collapse
|
50
|
Coté GA, Sherman S. Reply: To PMID 22982183. Gastroenterology 2013; 144:1571-2. [PMID: 23628268 DOI: 10.1053/j.gastro.2013.04.045] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
|