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Hart PA, Osypchuk Y, Hovbakh I, Shah RJ, Nieto J, Cote GA, Avgaitis S, Kremzer O, Buxbaum J, Inamdar S, Fass R, Phillips RW, Yadav D, Ladd AM, Al-Assi MT, Gardner T, Conwell DL, Irani S, Sheikh A, Nuttall J. A Randomized Controlled Phase 2 Dose-Finding Trial to Evaluate the Efficacy and Safety of Camostat in the Treatment of Painful Chronic Pancreatitis: The TACTIC Study. Gastroenterology 2024; 166:658-666.e6. [PMID: 38103842 DOI: 10.1053/j.gastro.2023.12.008] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 12/08/2023] [Accepted: 12/10/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND & AIMS Chronic pancreatitis (CP) causes an abdominal pain syndrome associated with poor quality of life. We conducted a clinical trial to further investigate the efficacy and safety of camostat, an oral serine protease inhibitor that has been used to alleviate pain in CP. METHODS This was a double-blind randomized controlled trial that enrolled adults with CP with a baseline average daily worst pain score ≥4 on a numeric rating system. Participants were randomized (1:1:1:1) to receive camostat at 100, 200, or 300 mg 3 times daily or placebo. The primary end point was a 4-week change from baseline in the mean daily worst pain intensity score (0-10 on a numeric rating system) using a mixed model repeated measure analysis. Secondary end points included changes in alternate pain end points, quality of life, and safety. RESULTS A total of 264 participants with CP were randomized. Changes in pain from baseline were similar between the camostat groups and placebo, with differences of least squares means of -0.11 (95% CI, -0.90 to 0.68), -0.04 (95% CI, -0.85 to 0.78), and -0.11 (95% CI, -0.94 to 0.73) for the 100 mg, 200 mg, and 300 mg groups, respectively. Multiple subgroup analyses were similar for the primary end point, and no differences were observed in any of the secondary end points. Treatment-emergent adverse events attributed to the study drug were identified in 42 participants (16.0%). CONCLUSION We were not able to reject the null hypothesis of no difference in improvements in pain or quality of life outcomes in participants with painful CP who received camostat compared with placebo. Studies are needed to further define mechanisms of pain in CP to guide future clinical trials, including minimizing placebo responses and selecting targeted therapies. CLINICALTRIALS gov, Number: NCT02693093.
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Affiliation(s)
- Phil A Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio.
| | - Yurii Osypchuk
- Department of General Surgery, Odesa Regional Hospital, Odesa, Ukraine
| | - Iryna Hovbakh
- Department of General Practice-Family Medicine, Kharkov Medical Academy of Postgraduate Education, Kharkiv, Ukraine
| | - Raj J Shah
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jose Nieto
- Advanced Therapeutic Endoscopy Center, Borland Groover Clinic, Jacksonville, Florida
| | - Gregory A Cote
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | | | | | - James Buxbaum
- University of Southern California, Keck School of Medicine, Los Angeles, California
| | - Sumant Inamdar
- Division of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Ronnie Fass
- Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Cleveland, Ohio
| | | | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Antonio Mendoza Ladd
- Division of Gastroenterology, Texas Tech University Health Sciences Center, El Paso, Texas
| | | | - Timothy Gardner
- Division of Gastroenterology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Darwin L Conwell
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Shayna Irani
- Division of Gastroenterology, Virginia Mason Hospital and Medical Center, Seattle, Washington
| | - Aasim Sheikh
- Gastrointestinal Specialists of Georgia, Marietta, Georgia
| | - Janet Nuttall
- Kangen Pharmaceuticals, America LLC, Kansas City, Kansas
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Wong N, Gu C, Yadav D, Cote GA. PHOSPHATIDYLETHANOL DETECTS OCCULT HEAVY ALCOHOL USE IN PATIENTS WITH ACUTE AND CHRONIC PANCREATITIS. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00216-7. [PMID: 38423344 DOI: 10.1016/j.cgh.2024.02.013] [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: 01/09/2024] [Revised: 02/05/2024] [Accepted: 02/12/2024] [Indexed: 03/02/2024]
Affiliation(s)
- Nicole Wong
- Department of Medicine, Oregon Health and Science University, Portland, OR
| | - Cihang Gu
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Dhiraj Yadav
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Gregory A Cote
- Department of Medicine, Oregon Health and Science University, Portland, OR.
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Inamdar S, Cote GA, Yadav D. Endotherapy for Pancreas Divisum. Gastrointest Endosc Clin N Am 2023; 33:789-805. [PMID: 37709411 DOI: 10.1016/j.giec.2023.04.012] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Pancreas divisum (PD) is a common anatomic variant of the pancreatic duct. Causal association between PD and pancreatitis has been debated for many years. Minor papilla sphincterotomy (miES) is offered in clinical practice to patients with idiopathic acute recurrent pancreatitis (iRAP) and PD. However, available data originate mainly from observational studies with many limitations. An ongoing international, multicenter, sham-controlled trial is evaluating the efficacy of miES in iRAP and PD. Endoscopic therapy for pain relief has limited to no benefit in patients with chronic abdominal pain or chronic pancreatitis who have PD and is not recommended.
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Affiliation(s)
- Sumant Inamdar
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Arkansas for Medical Sciences, Shorey Building, 8th Floor, 4301 West Markham Street, Little Rock, AR 72205, USA.
| | - Gregory A Cote
- Division of Gastroenterology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code L461, Portland, OR, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburg Medical Center, 200 Lothrop Street, M2, C-wing, Pittsburgh, PA 15213, USA
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Ashat M, Kandula S, Cote GA, Gromski MA, Fogel EL, Sherman S, Lehman GA, Watkins JL, Bick BL, Easler JJ. Utilization pattern of prophylactic measures for prevention of post-ERCP pancreatitis: a National Survey Study. Gastrointest Endosc 2023; 97:1059-1066.e3. [PMID: 36738796 DOI: 10.1016/j.gie.2023.01.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 01/05/2023] [Accepted: 01/28/2023] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Post-ERCP pancreatitis (PEP) is the most frequent adverse event of ERCP. Various prophylactic measures are endorsed by the American Society for Gastrointestinal Endoscopy and the European Society of Gastrointestinal Endoscopy to both lower the incidence of PEP and to decrease its severity. The extent to which these interventions are practiced throughout the United States is unclear. The aim of this study was to describe the utilization pattern of various PEP measures and determine factors that affect utilization of these measures. METHODS A 27-question electronic survey was distributed using a cloud-based program (Qualtrics). The questions assessed ERCP training, practice setting, experience, practice patterns, and perceptions for PEP prophylaxis interventions. Endoscopists with practices based in the United States listed in the American Society for Gastrointestinal Endoscopy member directory received a survey invitation via e-mail. The invitation outlined the study and contained a link with instructions to complete the voluntary survey if they had an active ERCP practice. Data were de-identified for the purposes of analysis. RESULTS Of survey respondents (N = 319), 46% reported therapeutic endoscopy fellowship training and 37% practiced in teaching programs. Annualized ERCP volume of >100 cases per year were reported by 47%, with pancreatic ERCP comprising ≤5% of procedure volume reported by the majority of respondents (61%). The majority of respondents used prophylactic pancreatic stent (PPS), and 54% reported frequent use during high-risk ERCP. The most common indications for PPS were difficult cannulation, to assist biliary access, and multiple pancreatic duct injections. Most respondents reported frequent use of indomethacin (89%). Of physicians who did not use PPS, use of indomethacin was the most common reason (80%). Variables associated with frequent use of PPS were ERCP fellowship training (P ≤ .001), practice at a teaching program (P ≤ .001), <10 years in practice (P = .005), higher procedure volume (P ≤ .001), and higher proportion of pancreatic cases (P ≤ .001). CONCLUSIONS Physicians with higher annual ERCP volume, who teach at hospital-based ERCP practices, and who regularly perform pancreatic ERCP are more likely to use PPS. Therapeutic ERCP fellowship training and recent entry into practice were also associated with PPS utilization. Indomethacin use seems to be more frequent than PPS. Our findings suggest that indomethacin is supplanting PPS as the preferred method of PEP prophylaxis.
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Affiliation(s)
- Munish Ashat
- Department of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
| | - Sailesh Kandula
- Department of Statistics and Data Science, The University of Texas at Austin, Austin, Texas, USA
| | - Gregory A Cote
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Mark A Gromski
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Evan L Fogel
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Stuart Sherman
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Glen A Lehman
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - James L Watkins
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Benjamin L Bick
- Division of Gastroenterology and Hepatology, Rockford Gastroenterology Associates, Rockford, Illinois, USA
| | - Jeffrey J Easler
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
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Lee PJ, Lahooti A, Culp S, Boutsicaris A, Holovach P, Wozniak K, Lahooti I, Paragomi P, Hinton A, Pothoulakis I, Talukdar R, Kochhar R, Goenka MK, Gulla A, Gonzalez JA, Singh V, Bogado MF, Stevens T, Babu ST, Nawaz H, Gutierrez SC, Zarnescu N, Capurso G, Easler J, Triantafyllou K, Peláez Luna M, Thakkar S, Ocampo C, de-Madaria E, Cote GA, Wu BU, Hart PA, Krishna SG, Lara L, Han S, Papachristou GI. Obesity and alcoholic etiology as risk factors for multisystem organ failure in acute pancreatitis: Multinational study. United European Gastroenterol J 2023; 11:383-391. [PMID: 37096304 PMCID: PMC10165322 DOI: 10.1002/ueg2.12390] [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: 12/28/2022] [Accepted: 03/28/2023] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND Multisystem organ failure (MSOF) is the most important determinant of mortality in acute pancreatitis (AP). Obesity and alcoholic etiology have been examined as potential risk factors for MSOF, but prior studies have not adequately elucidated their independent effects on the risk of MSOF. OBJECTIVE We aimed to determine the adjusted effects of body mass index (BMI) and alcoholic etiology on the risk of MSOF in subjects with AP. METHODS A prospective observational study of 22 centers from 10 countries was conducted. Patients admitted to an APPRENTICE consortium center with AP between August 2015 and January 2018 were enrolled. Multivariable logistic regression was used to estimate the adjusted effects of BMI, etiology, and other relevant covariates on the risk of MSOF. Models were stratified by sex. RESULTS Among 1544 AP subjects, there was a sex-dependent association between BMI and the risk of MSOF. Increasing BMI was associated with increased odds of MSOF in males (OR 1.10, 95% confidence interval [CI] 1.04-1.15) but not in females (OR 0.98, 95% CI 0.90-1.1). Male subjects with AP, whose BMIs were 30-34 and >35 kg/m2 , had odds ratios of 3.78 (95% CI 1.62-8.83) and 3.44 (95% CI 1.08-9.99), respectively. In females, neither higher grades of obesity nor increasing age increased the risk of MSOF. Alcoholic etiology was independently associated with increased odds of MSOF compared with non-alcohol etiologies (OR 4.17, 95% CI 2.16-8.05). CONCLUSION Patients with alcoholic etiology and obese men (but not women) are at substantially increased risk of MSOF in AP.
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Affiliation(s)
- Peter J Lee
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ali Lahooti
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Weill Cornell Medicine, New York, New York, USA
| | - Stacey Culp
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Andrew Boutsicaris
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Phillip Holovach
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Kayla Wozniak
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ila Lahooti
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Pedram Paragomi
- University of Pittsburgh Medical Center, Pennsylvania, Pittsburgh, USA
| | | | | | | | - Rakesh Kochhar
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Aiste Gulla
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | | | - Vikesh Singh
- Division of Gastroenterology, John Hopkins Medical Institution, Baltimore, Maryland, USA
| | | | | | - Sorin Traian Babu
- University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania
| | - Haq Nawaz
- Northern Light Eastern Maine Medical Center, Bangor, Maine, USA
| | | | - Narcis Zarnescu
- Department of Gastroenterology, "Carol Davila" University of Medicine and Pharmacy, University Emergency Hospital Bucharest, Bucharest, Romania
| | - Gabriele Capurso
- Department of Pancreato-Biliary Endoscopy and Endosonography, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | - Jeffrey Easler
- Division of Gastroenterology, Department of Gastroenterology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Mario Peláez Luna
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán-Universidad-Autónoma de Mexico, Mexico City, Mexico
| | - Shyam Thakkar
- Division of Gastroenterology, West Virginia University, Morgantown, West Virginia, USA
| | - Carlos Ocampo
- Hospital General de Argudos "Dr. Cosme Argerich", Buenos Aires, Argentina
| | - Enrique de-Madaria
- Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL - Fundación FISABIO), Alicante, Spain
| | - Gregory A Cote
- Oregon Health & Science University, Portland, Oregon, USA
| | | | - Phil A Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Somashekar G Krishna
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Luis Lara
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Samuel Han
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Georgios I Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Cote GA, Durkalski-Mauldin V, Williams A, Nitchie H, Serrano J, Yadav D. Design and execution of sham-controlled endoscopic trials in acute pancreatitis: Lessons learned from the SHARP trial. Pancreatology 2023; 23:187-191. [PMID: 36585282 PMCID: PMC9992275 DOI: 10.1016/j.pan.2022.12.011] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/29/2022] [Accepted: 12/16/2022] [Indexed: 01/01/2023]
Abstract
Using the ongoing NIDDK-funded multicenter randomized clinical trial, Sphincterotomy for Acute Recurrent Pancreatitis (SHARP) as an example, this article discusses the rationale and key aspects of study design that need to be considered when conducting a clinical trial of endoscopic therapy in acute pancreatitis. SHARP, the first trial using a sham ERCP in the placebo group, is designed to address a decades long controversy in clinical pancreatology, i.e. whether minor papilla sphincterotomy benefits patients with idiopathic acute recurrent pancreatitis who also have pancreas divisum. Although the trial has already enrolled and randomized over 5 times the number of subjects enrolled in the only randomized trial in this area published in 1992 (107 vs. 19), recruitment has been challenging and we are at ∼46% of target recruitment. The review discusses the challenges in the execution of the trial and strategies the SHARP team has used to address these, which investigators planning or considering treatment trials in pancreatitis may find helpful. It will also inform the general gastroenterologists the importance of discussing and referring potentially eligible subjects to centers participating in clinical trials. Developing evidence-based treatment will provide a solid scientific basis for physicians to recommend evidence-based treatments for pancreatitis.
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Affiliation(s)
- Gregory A Cote
- Division of Gastroenterology, Oregon Health and Science University, Portland, OR, USA
| | | | - April Williams
- Medical University of South Carolina, Department of Biostatistics, Charleston, SC, USA
| | - Haley Nitchie
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Jose Serrano
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Singh VK, Whitcomb DC, Banks PA, AlKaade S, Anderson MA, Amann ST, Brand RE, Conwell DL, Cote GA, Gardner TB, Gelrud A, Guda N, Forsmark CE, Lewis M, Sherman S, Muniraj T, Romagnuolo J, Tan X, Tang G, Sandhu BS, Slivka A, Wilcox CM, Yadav D, Guda N, Banks P, Conwell D, Lo SK, Gelrud A, Gardner T, Baillie J, Forsmark CE, Muniraj T, Sherman S, Singh VK, Lewis M, Romagnuolo J, Hawes R, Cote GA, Lawrence C, Anderson MA, Amann ST, Etemad B, DeMeo M, Kochman M, Abberbock JN, Barmada MM, Bauer E, Brand RE, Kennard E, LaRusch J, O'Connell M, Stello K, Slivka A, Talluri J, Tang G, Whitcomb DC, Wisniewski SR, Yadav D, Burton F, AlKaade S, DiSario J, Sandhu BS, Money M, Steinberg W. Acute pancreatitis precedes chronic pancreatitis in the majority of patients: Results from the NAPS2 consortium. Pancreatology 2022; 22:1091-1098. [PMID: 36404201 PMCID: PMC10122210 DOI: 10.1016/j.pan.2022.10.004] [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: 06/12/2022] [Revised: 09/19/2022] [Accepted: 10/22/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The mechanistic definition of chronic pancreatitis (CP) identifies acute pancreatitis (AP) as a precursor stage. We hypothesized that clinical AP frequently precedes the diagnosis of CP and is associated with patient- and disease-related factors. We describe the prevalence, temporal relationship and associations of AP in a well-defined North American cohort. METHODS We evaluated data from 883 patients with CP prospectively enrolled in the North American Pancreatitis Studies across 27 US centers between 2000 and 2014. We determined how often patients had one or more episodes of AP and its occurrence in relationship to the diagnosis of CP. We used multivariable logistic regression to determine associations for prior AP. RESULTS There were 624/883 (70.7%) patients with prior AP, among whom 161 (25.8%) had AP within 2 years, 115 (18.4%) within 3-5 years, and 348 (55.8%) >5 years prior to CP diagnosis. Among 504 AP patients with available information, 436 (86.5%) had >1 episode. On multivariable analyses, factors associated with increased odds of having prior AP were a younger age at CP diagnosis, white race, abdominal pain, pseudocyst(s) and pancreatic duct dilatation/stricture, while factors associated with a lower odds of having prior AP were exocrine insufficiency and pancreatic atrophy. When compared with patients with 1 episode, those with >1 AP episode were diagnosed with CP an average of 5 years earlier. CONCLUSIONS Nearly three-quarters of patients were diagnosed with AP prior to CP diagnosis. Identifying which AP patients are at-risk for future progression to CP may provide opportunities for primary and secondary prevention.
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Affiliation(s)
- Vikesh K Singh
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
| | - David C Whitcomb
- Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Peter A Banks
- Division of Gastroenterology, Brigham & Women's Hospital, Boston, MA, USA
| | | | | | | | - Randall E Brand
- Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Darwin L Conwell
- Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Gregory A Cote
- Division of Gastroenterology, Oregon Health Science University, Portland, OR, USA
| | - Timothy B Gardner
- Division of Gastroenterology & Hepatology, Dartmouth-Hitchcock Medical Center, Hanover, NH, USA
| | | | - Nalini Guda
- Aurora St. Luke's Medical Center, Milwaukee, WI, USA
| | - Christopher E Forsmark
- Division of Gastroenterology, Hepatology & Nutrition, University of Florida, Gainesville, FL, USA
| | - Michele Lewis
- Division of Gastroenterology & Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Stuart Sherman
- Division of Gastroenterology & Hepatology, Indiana University, Indianapolis, IN, USA
| | | | - Joseph Romagnuolo
- Palmetto Health, Columbia Gastroenterology Associates, Columbia, SC, USA
| | - Xiaoqing Tan
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Gong Tang
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Adam Slivka
- Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - C Mel Wilcox
- Division of Gastroenterology & Hepatology, University of Alabama, Birmingham, AL, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Paragomi P, Hinton A, Pothoulakis I, Talukdar R, Kochhar R, Goenka MK, Gulla A, Gonzalez JA, Singh VK, Bogado MF, Stevens T, Barbu ST, Nawaz H, Gutierrez SC, Zarnescu N, Archibugi L, Easler JJ, Triantafyllou K, Peláez-Luna M, Thakkar S, Ocampo C, de-Madaria E, Cote GA, Lee PJ, Krishna S, Lara LF, Han S, Wu BU, Papachristou GI. The Modified Pancreatitis Activity Scoring System Shows Distinct Trajectories in Acute Pancreatitis: An International Study. Clin Gastroenterol Hepatol 2022; 20:1334-1342.e4. [PMID: 34543736 PMCID: PMC9060638 DOI: 10.1016/j.cgh.2021.09.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 07/17/2021] [Revised: 09/09/2021] [Accepted: 09/14/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The aims of this study were to: (1) assess the performance of the Pancreatitis Activity Scoring System (PASS) in a large intercontinental cohort of patients with acute pancreatitis (AP); and (2) investigate whether a modified PASS (mPASS) yields a similar predictive accuracy and produces distinct early trajectories between severity subgroups. METHODS Data was prospectively collected through the Acute Pancreatitis Patient Registry to Examine Novel Therapies In Clinical Experience (APPRENTICE) consortium (2015-2018) involving 22 centers from 4 continents. AP severity was categorized per the revised Atlanta classification. PASS trajectories were compared between the three severity groups using the generalized estimating equations model. Four mPASS models were generated by modifying the morphine equivalent dose (MED), and their trajectories were compared. RESULTS A total of 1393 subjects were enrolled (median age, 49 years; 51% males). The study cohort included 950 mild (68.2%), 315 (22.6%) moderately severe, and 128 (9.2%) severe AP. Mild cases had the lowest PASS at each study time point (all P < .001). A subset of patients with outlier admission PASS values was identified. In the outlier group, 70% of the PASS variation was attributed to the MED, and 66% of these patients were from the United States centers. Among the 4 modified models, the mPASS-1 (excluding MED from PASS) demonstrated high performance in predicting severe AP with an area under the receiver operating characteristic curve of 0.88 (vs area under the receiver operating characteristic of 0.83 in conventional PASS) and produced distinct trajectories with distinct slopes between severity subgroups (all P < .001). CONCLUSION We propose a modified model by removing the MED component, which is easier to calculate, predicts accurately severe AP, and maintains significantly distinct early trajectories.
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Affiliation(s)
- Pedram Paragomi
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania;,University of Pittsburgh Medical Center Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - Alice Hinton
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, Ohio
| | - Ioannis Pothoulakis
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania;,MedStar Washington Hospital Center, Washington, District of Columbia
| | | | - Rakesh Kochhar
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Aiste Gulla
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania;,Georgetown University Hospital, Washington DC
| | | | - Vikesh K. Singh
- Division of Gastroenterology, John Hopkins Medical Institution, Baltimore, MA
| | | | | | - Sorin T. Barbu
- University of Medicine and Pharmacy “Iuliu Hatieganu,” Cluj-Napoca, Romania
| | - Haq Nawaz
- Eastern Maine Medical Center, Bangor, Maine
| | | | | | - Livia Archibugi
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy;,Digestive and Liver Disease Unit, Sant’Andrea Hospital, Rome, Italy
| | | | | | - Mario Peláez-Luna
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán-Universidad Autónoma de Mexico, Mexico City, Mexico
| | - Shyam Thakkar
- Division of Gastroenterology, West Virginia University, Morgantown, West Virginia
| | - Carlos Ocampo
- Hospital General de Argudos “Dr. Cosme Argerich,” Buenos Aires, Argentina
| | - Enrique de-Madaria
- Gastroenterology Department, Alicante University General Hospital, ISABIAL, Alicante, Spain
| | - Gregory A. Cote
- Medical University of South Carolina, Charleston, South Carolina
| | - Peter J. Lee
- Division of Gastroenterology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Somashekar Krishna
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Luis F. Lara
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Samuel Han
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | | | - Georgios I. Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Wexner Medical Center, Columbus, Ohio
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9
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Chong B, Cote GA. Hurdles in ERCP Trials: Do We Need to Change the Diagnostic Criteria for Post-ERCP Pancreatitis? Clin Gastroenterol Hepatol 2022; 20:1218-1219. [PMID: 34673255 DOI: 10.1016/j.cgh.2021.10.019] [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] [Received: 10/06/2021] [Accepted: 10/09/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Bradford Chong
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon
| | - Gregory A Cote
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon
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10
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Prakash S, Elmunzer BJ, Forster EM, Cote GA, Moran RA. Endoscopic ultrasound-directed transgastric ERCP (EDGE): a systematic review describing the outcomes, adverse events, and knowledge gaps. Endoscopy 2022; 54:52-61. [PMID: 33506456 PMCID: PMC8783372 DOI: 10.1055/a-1376-2394] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND : Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) has emerged as a viable completely endoscopic method for performing pancreaticobiliary interventions in patients with Roux-en-Y gastric bypass anatomy. The aims of this systematic review were: (1) to describe the indications, outcomes, and complications of EDGE; and (2) to identify deficiencies in our knowledge of important technical approaches and clinical outcomes. METHODS : A systematic review was conducted via comprehensive searches of Medline, Scopus, CINAHL, and Cochrane to identify studies focusing on EDGE outcomes. Simple descriptive statistics were derived from case series only. Case reports were only included to qualitatively describe additional indications, techniques, and adverse events. RESULTS : The initial search identified 2143 abstracts. Nine case series and eight case reports were included. In the nine case series, 169 patients underwent EDGE. The technical success rate was 99 % (168 /169) for gastrogastrostomy/jejunogastrostomy creation and 98 % (166 /169) for subsequent ERCP. Minor adverse events specifically related to EDGE occurred in 18 % (31/169) and included intraprocedural stent migration/malposition (n = 27) and abdominal pain (n = 4). Moderate adverse events specific to EDGE occurred in 5 % (9/169): including bleeding (2 %), persistent fistula (1 %), and perforation (1 %). Severe adverse events occurred in one patient with a perforation requiring surgery. Deficiency in reporting on the clinical significance of adverse events was identified. CONCLUSION : Based on limited observational data, in expert hands, EDGE has a high rate of technical success and an acceptable rate of adverse events. As a novel procedure, many knowledge gaps need to be addressed to inform the design of meaningful comparative studies and guide informed consent.
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Affiliation(s)
- Shaurya Prakash
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - B. Joseph Elmunzer
- Department of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Erin M. Forster
- Department of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Gregory A. Cote
- Department of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Robert A. Moran
- Department of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
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11
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Paragomi P, Tuft M, Pothoulakis L, Singh VK, Stevens T, Nawaz H, Easler JJ, Thakkar S, Cote GA, Lee PJ, Akshintala V, Kamal A, Gougol A, Phillips AE, Machicado JD, Whitcomb DC, Greer PJ, Buxbaum JL, Hart P, Conwell D, Tang G, Wu BU, Papachristou GI. Dynamic changes in the pancreatitis activity scoring system during hospital course in a multicenter, prospective cohort. J Gastroenterol Hepatol 2021; 36:2416-2423. [PMID: 33604947 PMCID: PMC9058811 DOI: 10.1111/jgh.15430] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 12/09/2020] [Accepted: 02/03/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM The primary aim was to validate the Pancreatitis Activity Scoring System (PASS) in a multicenter prospectively ascertained acute pancreatitis (AP) cohort. Second, we investigated the association of early PASS trajectories with disease severity and length of hospital stay (LOS). METHODS Data were prospectively collected through the APPRENTICE consortium (2015-2018). AP severity was categorized based on revised Atlanta classification. Delta PASS (ΔPASS) was calculated by subtracting activity score from baseline value. PASS trajectories were compared between severity subsets. Subsequently, the cohort was subdivided into three LOS subgroups as short (S-LOS): 2-3 days; intermediate (I-LOS): 3-7 days; and long (L-LOS): ≥7 days. The generalized estimating equations model was implemented to compare PASS trajectories. RESULTS There were 434 subjects analyzed including 322 (74%) mild, 86 (20%) moderately severe, and 26 (6%) severe AP. Severe AP subjects had the highest activity levels and the slowest rate of decline in activity (P = 0.039). Focusing on mild AP, L-LOS subjects (34%) had 28 points per day slower decline; whereas, S-LOS group (13%) showed 34 points per day sharper decrease compared with I-LOS (53%; P < 0.001). We noticed an outlier subset with a median admission-PASS of 466 compared with 140 in the rest. Morphine equivalent dose constituted 80% of the total PASS in the outliers (median morphine equivalent dose score = 392), compared with only 25% in normal-range subjects (score = 33, P value < 0.001). CONCLUSIONS This study highlighted that PASS can quantify AP activity. Significant differences in PASS trajectories were found both in revised Atlanta classification severity and LOS groups, which can be harnessed in AP monitoring/management (ClincialTrials.gov number, NCT03075618).
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Affiliation(s)
- Pedram Paragomi
- Department of Medicine, Division of Gastroenterology, UPMC, Pittsburgh, USA
| | - Marie Tuft
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, USA
| | - loannis Pothoulakis
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, UPMC, Pittsburgh, USA,MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Vikesh K Singh
- Division of Gastroenterology, John Hopkins Medical Institution, Baltimore, Maryland, USA
| | | | - Haq Nawaz
- Eastern Maine Medical Center, Bangor, Maine, USA
| | - Jeffrey J Easler
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Shyam Thakkar
- Division of Gastroenterology, West Virginia University, Morgantown, USA
| | - Gregory A Cote
- Division of Gastroenterology, Medical University of South Carolina, Charleston, West Virginia, USA
| | - Peter J Lee
- Division of Gastroenterology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia. Pennsylvania, USA
| | - Venkata Akshintala
- Division of Gastroenterology, John Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Ayesha Kamal
- Division of Gastroenterology, John Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Amir Gougol
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Anna Evans Phillips
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Jorge D Machicado
- Division of Gastroenterology, Mayo Clinic Healthcare System, Eau Claire, Wisconsin, USA
| | - David C Whitcomb
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Phil J Greer
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - James L Buxbaum
- Division of Gastroenterology, Department of Internal Medicine, University of Southern California Keck School of Medicine, Los Angeles, USA
| | - Phil Hart
- Division of Gastroenterology, Hepatology, and Nutrition, Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
| | - Darwin Conwell
- Division of Gastroenterology, Hepatology, and Nutrition, Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
| | - Gong Tang
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, USA
| | - Bechien U Wu
- Division of Gastroenterology, Kaiser Permanente, Pasadena, California, USA
| | - Georgios I Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
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12
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Machicado JD, Gougol A, Tan X, Gao X, Paragomi P, Pothoulakis I, Talukdar R, Kochhar R, Goenka MK, Gulla A, Gonzalez JA, Singh VK, Ferreira M, Stevens T, Barbu ST, Nawaz H, Gutierrez SC, Zarnescu NO, Capurso G, Easler JJ, Triantafyllou K, Pelaez-Luna M, Thakkar S, Ocampo C, de-Madaria E, Cote GA, Wu BU, Conwell DL, Hart PA, Tang G, Papachristou GI. Mortality in acute pancreatitis with persistent organ failure is determined by the number, type, and sequence of organ systems affected. United European Gastroenterol J 2021; 9:139-149. [PMID: 33871926 PMCID: PMC8259236 DOI: 10.1002/ueg2.12057] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 12/23/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Persistent organ failure (POF) is the strongest determinant of mortality in acute pancreatitis (AP). There is a paucity of data regarding the impact of different POF attributes on mortality and the role of different characteristics of systemic inflammatory response syndrome (SIRS) in the risk of developing POF. OBJECTIVE We aimed to assess the association of POF dynamic features with mortality and SIRS characteristics with POF. METHODS We studied 1544 AP subjects prospectively enrolled at 22 international centers (APPRENTICE consortium). First, we estimated the association of onset, duration, and maximal score of SIRS with POF. Then, we evaluated the risk of mortality based on POF onset, duration, number, type, and sequence of organs affected. Analyses were adjusted for potential confounders. RESULTS 58% had SIRS, 11% developed POF, and 2.5% died. Early SIRS, persistent SIRS, and maximal SIRS score ≥ 3 were independently associated with higher risk of POF (p < 0.05). Mortality risk in POF was higher with two (33%, odds ratio [OR] = 10.8, 3.3-34.9) and three (48%, OR = 20.2, 5.9-68.6) organs failing, in comparison to single POF (4%). In subjects with multiple POF, mortality was higher when the cardiovascular and respiratory systems failed first or concurrently as compared to when the renal system failed first or concurrently with other organ (p < 0.05). In multivariate regression model, the number and sequence of organs affected in POF were associated with mortality (p < 0.05). Onset and duration of POF had no impact mortality. CONCLUSION In AP patients with POF, the risk of mortality is influenced by the number, type, and sequence of organs affected. These results are useful for future revisions of AP severity classification systems.
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Affiliation(s)
| | - Amir Gougol
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Xiaoqing Tan
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Xiaotian Gao
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Pedram Paragomi
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | | | - Rakesh Kochhar
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Aiste Gulla
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Georgetown University Hospital, Washington DC, USA
| | | | - Vikesh K Singh
- Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | | | | | - Sorin T Barbu
- University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania
| | - Haq Nawaz
- Eastern Maine Medical Center, Bangor, Maine, USA
| | | | - Narcis O Zarnescu
- "Carol Davila" University of Medicine and Pharmacy, University Emergency Hospital, Bucharest, Romania
| | - Gabriele Capurso
- San Raffaele Scientific Institute (IRCCS), Vita Salute San Raffaele University, Milan, Italy.,Andrea Hospital, Rome, Italy
| | - Jeffrey J Easler
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Mario Pelaez-Luna
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán-Universidad Autónoma de Mexico, Mexico City, Mexico
| | - Shyam Thakkar
- Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Carlos Ocampo
- Hospital General de Argudos "Dr. Cosme Argerich", Buenos Aires, Argentina
| | - Enrique de-Madaria
- Gastroenterology Department, Alicante University General Hospital, ISABIAL, Alicante, Spain
| | - Gregory A Cote
- Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - Darwin L Conwell
- The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Phil A Hart
- The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Gong Tang
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Georgios I Papachristou
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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13
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Pothoulakis I, Nawaz H, Paragomi P, Jeong K, Talukdar R, Kochhar R, Goenka MK, Gulla A, Singh VK, Gonzalez JA, Ferreira M, Barbu ST, Stevens T, Gutierrez SC, Zarnescu NO, Capurso G, Easler J, Triantafyllou K, Pelaez-Luna M, Thakkar S, Ocampo C, de-Madaria E, Wu BU, Cote GA, Abebe K, Tang G, Lahooti A, Phillips AE, Papachristou GI. Incidence and risk factors of oral feeding intolerance in acute pancreatitis: Results from an international, multicenter, prospective cohort study. United European Gastroenterol J 2021; 9:54-62. [PMID: 32883182 PMCID: PMC8259260 DOI: 10.1177/2050640620957243] [Citation(s) in RCA: 3] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/06/2020] [Indexed: 12/15/2022] Open
Abstract
Background Inability to advance to an oral diet, or oral feeding intolerance, is a common complication in patients with acute pancreatitis associated with worse clinical outcomes. The factors related to oral feeding intolerance are not well studied. Objective We aimed to determine the incidence and risk factors of oral feeding intolerance in acute pancreatitis. Methods Patients were prospectively enrolled in the Acute Pancreatitis Patient Registry to Examine Novel Therapies in Clinical Experience, an international acute pancreatitis registry, between 2015 and 2018. Oral feeding intolerance was defined as worsening abdominal pain and/or vomiting after resumption of oral diet. The timing of the initial feeding attempt was stratified based on the day of hospitalization. Multivariable logistic regression was performed to assess for independent risk factors/predictors of oral feeding intolerance. Results Of 1233 acute pancreatitis patients included in the study, 160 (13%) experienced oral feeding intolerance. The incidence of oral feeding intolerance was similar irrespective of the timing of the initial feeding attempt relative to hospital admission day (p = 0.41). Patients with oral feeding intolerance were more likely to be younger (45 vs. 50 years of age), men (61% vs. 49%), and active alcohol users (44% vs. 36%). They also had higher blood urea nitrogen (20 vs. 15 mg/dl; p < 0.001) and hematocrit levels (41.7% vs. 40.5%; p = 0.017) on admission; were more likely to have a nonbiliary acute pancreatitis etiology (69% vs. 51%), systemic inflammatory response syndrome of 2 or greater on admission (49% vs. 35%) and at 48 h (50% vs. 26%), develop pancreatic necrosis (29% vs. 13%), moderate to severe acute pancreatitis (41% vs. 24%), and have a longer hospital stay (10 vs. 6 days; all p < 0.04). The adjusted analysis showed that systemic inflammatory response syndrome of 2 or greater at 48 h (odds ratio 3.10; 95% confidence interval 1.83–5.25) and a nonbiliary acute pancreatitis etiology (odds ratio 1.65; 95% confidence interval 1.01–2.69) were independent risk factors for oral feeding intolerance. Conclusion Oral feeding intolerance occurs in 13% of acute pancreatitis patients and is independently associated with systemic inflammatory response syndrome at 48 h and a nonbiliary etiology.
Current knowledge on this subject
Oral feeding intolerance is a relatively common complication of acute pancreatitis. Oral feeding intolerance results in longer hospitalization and frequent readmissions.
What is new in this study
The incidence of oral feeding intolerance is similar irrespective of the timing of the initial feeding attempt. Oral feeding intolerance is independently associated with systemic inflammatory response syndrome at 48 h and nonbiliary etiology.
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Affiliation(s)
- Ioannis Pothoulakis
- Department of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Medicine, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Haq Nawaz
- Department of Gastroenterology, Eastern Maine Medical Center, Bangor, Maine, USA
| | - Pedram Paragomi
- Department of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kwonho Jeong
- Department of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Rupjyoti Talukdar
- Department of Gastroenterology, Asian Gastroenterology Institute, Hyderabad, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Aiste Gulla
- Department of Gastroenterology, Georgetown University Hospital, Washington, District of Columbia, USA.,Department of Medicine, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
| | - Vikesh K Singh
- Department of Gastroenterology, John Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Jose A Gonzalez
- Department of Gastroenterology, Universidad Autonoma de Nueva León, Monterrey, Mexico
| | - Miguel Ferreira
- Department of Gastroenterology, Hospital Nacional de Itaguá, Itagua, Paraguay
| | - Sorin T Barbu
- Department of Surgery, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania
| | - Tyler Stevens
- Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Silvia C Gutierrez
- Department of Gastroenterology, Hospital Nacional "Profesor Alejandro Posadas", Buenos Aires, Argentina
| | - Narcis O Zarnescu
- Department of Gastroenterology, University Emergency Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Gabriele Capurso
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Jeffrey Easler
- Department of Gastroenterology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Mario Pelaez-Luna
- Department of Gastroenterology, Instituto Nacional de Ciencias Módicas y Nutrición Salvador Zubirán-Universidad Autonoma d Mexico, Mexico City, Mexico
| | - Shyam Thakkar
- Department of Gastroenterology, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Carlos Ocampo
- Department of Surgery, Hospital General de Argudos "Dr. Cosme Argerich", Buenos Aires, Argentina
| | - Enrique de-Madaria
- Gastroenterology Department, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Bechien U Wu
- Department of Gastroenterology, Kaiser Permanente, Pasadena, California, USA
| | - Gregory A Cote
- Department of Gastroenterology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Kaleab Abebe
- Department of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Gong Tang
- Department of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ali Lahooti
- Department of Gastroenterology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Anna E Phillips
- Department of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Georgios I Papachristou
- Department of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Gastroenterology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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14
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Duloy A, Keswani R, Hall M, Wang AY, Cote GA, Aagaard EM, Carlin L, DiMaio CJ, Edmundowicz S, Ellert S, Han S, Komanduri S, Muthusamy R, Rastogi A, Shah RJ, Simon V, Wani S. Time Given to Trainees to Attempt Cannulation During Endoscopic Retrograde Cholangiopancreatography Varies by Training Program and Is Not Associated With Competence. Clin Gastroenterol Hepatol 2020; 18:3040-3042.e1. [PMID: 31589970 DOI: 10.1016/j.cgh.2019.09.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 09/23/2019] [Accepted: 09/26/2019] [Indexed: 02/07/2023]
Abstract
Advanced endoscopy training programs (AETPs) were developed as a result of the lack of comprehensive endoscopic retrograde cholangiopancreatography (ERCP) training during gastroenterology fellowships. There is no standardized curriculum for AETPs and the influence of program- and trainer-associated factors on trainee competence in ERCP has not been investigated adequately. In prior work, we showed that advanced endoscopy trainees (AETs) achieve ERCP competence at varying rates.1,2 The aims of this study were to measure the variability in time given to AETs to attempt cannulation between AETPs and throughout the 1-year training period, and to determine the association between AET cannulation time and AET competence at the end of training.
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Affiliation(s)
- Anna Duloy
- Department of Gastroenterology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Rajesh Keswani
- Department of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - Matt Hall
- Department of Biostatistics and Informatics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia
| | - Gregory A Cote
- Department of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | - Eva M Aagaard
- Division of Internal Medicine, Washington University in St Louis, St Louis, Missouri
| | - Linda Carlin
- Department of Gastroenterology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Christopher J DiMaio
- Department of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Steven Edmundowicz
- Department of Gastroenterology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Swan Ellert
- Colorado Clinical and Translational Sciences Institute, Aurora, Colorado
| | - Samuel Han
- Department of Gastroenterology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Sri Komanduri
- Department of Gastroenterology and Hepatology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Raman Muthusamy
- Department of Gastroenterology, University of California-Los Angeles, Los Angeles, California
| | - Amit Rastogi
- Department of Gastroenterology, Hepatology, and Motility, University of Kansas, Kansas City, Kansas
| | - Raj J Shah
- Department of Gastroenterology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Violette Simon
- Department of Gastroenterology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Sachin Wani
- Department of Gastroenterology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado.
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15
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Ellison PL, Holman N, Wallace K, Cote GA, Elmunzer BJ, Brock AS. Multimodal intervention for avoiding inappropriate cessation of aspirin prior to outpatient endoscopy. Endosc Int Open 2020; 8:E708-E716. [PMID: 32490153 PMCID: PMC7247888 DOI: 10.1055/a-1134-4813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 10/14/2019] [Indexed: 11/01/2022] Open
Abstract
Background and study aims Existing guidelines recommend continuation of aspirin therapy prior to outpatient endoscopic procedures, as it reduces peri-procedural cardiovascular events and is not associated with an increased risk of bleeding. Despite this, many patients at our institution inappropriately alter their aspirin prior to endoscopy. We sought to identify why this occurs and implement an intervention that could reduce improper aspirin alteration. Patients and methods All adult patients undergoing outpatient endoscopy at the Medical University of South Carolina were administered a survey querying demographics, aspirin use, endoscopic procedure, thromboembolic risk factors, and pre-procedural aspirin alteration, if any. An intervention involving revised written and verbal instructions as well as an automated voicemail aimed at ensuring patients adhere to guidelines was then undertaken. The same survey was administered after the intervention to assess for improved adherence. Results A total of 240 patients from the initial survey reported daily aspirin use, of which 114 (47.5 %) inappropriately altered aspirin therapy. A total of 182 patients from the post-intervention survey reported daily aspirin use, of which 66 (36.3 %) inappropriately altered aspirin therapy. This was a statistically significant reduction ( P = 0.04), which included adjustments for age, sex, procedure type, and thromboembolic risk. Conclusions A high proportion of patients at our institution inappropriately alter aspirin therapy prior to outpatient endoscopy. The reasons for this behavior include patient self-direction, misguidance from staff, and instruction from other physicians. This alteration can be reduced significantly through an intervention that educates both patients and staff on continuation of aspirin therapy prior to outpatient endoscopy.
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Affiliation(s)
- Parker L. Ellison
- Department of Internal Medicine and the Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Nathan Holman
- Department of Internal Medicine and the Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Kristin Wallace
- Department of Internal Medicine and the Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Gregory A. Cote
- Department of Internal Medicine and the Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, United States
| | - B. Joseph Elmunzer
- Department of Internal Medicine and the Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Andrew S. Brock
- Department of Internal Medicine and the Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, United States
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16
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Pothoulakis I, Paragomi P, Archibugi L, Tuft M, Talukdar R, Kochhar R, Goenka MK, Gulla A, Singh VK, Gonzalez JA, Ferreira M, Barbu ST, Stevens T, Nawaz H, Gutierrez SC, Zarnescu NO, Easler J, Triantafyllou K, Pelaez-Luna M, Thakkar S, Ocampo C, de-Madaria E, Wu BU, Cote GA, Tang G, Papachristou GI, Capurso G. Clinical features of hypertriglyceridemia-induced acute pancreatitis in an international, multicenter, prospective cohort (APPRENTICE consortium). Pancreatology 2020; 20:325-330. [PMID: 32107193 DOI: 10.1016/j.pan.2020.02.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 01/27/2020] [Accepted: 02/16/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND The clinical features and outcomes of hypertriglyceridemia-induced acute pancreatitis (HTG-AP) are not well-established. OBJECTIVE To evaluate the clinical characteristics of HTG-AP in an international, multicenter prospective cohort. METHODS Data collection was conducted prospectively through APPRENTICE between 2015 and 2018. HTG-AP was defined as serum TG levels >500 mg/dl in the absence of other common etiologies of AP. Three multivariate logistic regression models were performed to assess whether HTG-AP is associated with SIRS positive status, ICU admission and/or moderately-severe/severe AP. RESULTS 1,478 patients were included in the study; 69 subjects (4.7%) were diagnosed with HTG-AP. HTG-AP patients were more likely to be younger (mean 40 vs 50 years; p < 0.001), male (67% vs 52%; p = 0.018), and with a higher BMI (mean 30.4 vs 27.5 kg/m2; p = 0.0002). HTG-AP subjects reported more frequent active alcohol use (71% vs 49%; p < 0.001), and diabetes mellitus (59% vs 15%; p < 0.001). None of the above risk factors/variables was found to be independently associated with SIRS positive status, ICU admission, or severity in the multivariate logistic regression models. These results were similar when including only the 785 subjects with TG levels measured within 48 h from admission. CONCLUSION HTG-AP was found to be the 4th most common etiology of AP. HTG-AP patients had distinct baseline characteristics, but their clinical outcomes were similar compared to other etiologies of AP.
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Affiliation(s)
- Ioannis Pothoulakis
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA; MedStar Washington Hospital Center, Washington, DC, USA
| | - Pedram Paragomi
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Livia Archibugi
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy; Digestive and Liver Disease Unit, Sant Andrea Hospital, Rome, Italy
| | - Marie Tuft
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Rakesh Kochhar
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Aiste Gulla
- Lithuanian University of Health Sciences, Kaunas, Lithuania
| | | | | | | | - Sorin T Barbu
- University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania
| | | | - Haq Nawaz
- Eastern Maine Medical Center, Maine, Bangor, USA
| | | | | | - Jeffrey Easler
- Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Mario Pelaez-Luna
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán-Universidad Autónoma de Mexico, Mexico City, Mexico
| | | | - Carlos Ocampo
- Hospital General de Argudos "Dr. Cosme Argerich", Buenos Aires, Argentina
| | - Enrique de-Madaria
- Investigación Sanitaria y Biomédica de Alicante (ISABIAL - Fundación FISABIO), Alicante, Spain
| | | | - Gregory A Cote
- Medical University of South Carolina, Charleston, SC, USA
| | - Gong Tang
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Georgios I Papachristou
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - Gabriele Capurso
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy; Digestive and Liver Disease Unit, Sant Andrea Hospital, Rome, Italy
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17
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Fogel EL, Lehman GA, Tarnasky P, Cote GA, Schmidt SE, Waljee AK, Higgins PDR, Watkins JL, Sherman S, Kwon RSY, Elta GH, Easler JJ, Pleskow DK, Scheiman JM, El Hajj II, Guda NM, Gromski MA, McHenry L, Arol S, Korsnes S, Suarez AL, Spitzer R, Miller M, Hofbauer M, Elmunzer BJ. Rectal indometacin dose escalation for prevention of pancreatitis after endoscopic retrograde cholangiopancreatography in high-risk patients: a double-blind, randomised controlled trial. Lancet Gastroenterol Hepatol 2020; 5:132-141. [PMID: 31780277 PMCID: PMC10576534 DOI: 10.1016/s2468-1253(19)30337-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 10/03/2019] [Accepted: 10/03/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Although rectal indometacin 100 mg is effective in reducing the frequency and severity of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) in high-risk patients, the optimal dose is unknown, and pancreatitis incidence remains high. The aim of this study was to compare the efficacy of two dose regimens of rectal indometacin on the frequency and severity of pancreatitis after ERCP in high-risk patients. METHODS In this randomised, double-blind, comparative effectiveness trial, we enrolled patients from six tertiary medical centres in the USA. Eligible patients were those at high risk for the development of pancreatitis after ERCP. We randomly assigned eligible patients (1:1) immediately after ERCP to receive either two 50 mg indometacin suppositories and a placebo suppository (standard-dose group) or three 50 mg indometacin suppositories (high-dose group). 4 h after the procedure, patients assigned to the high-dose group received an additional 50 mg indometacin suppository, whereas patients in the standard-dose group received an additional placebo suppository. The randomisation schedule, stratified according to study centre and with no other restrictions, was computer generated by an investigator who was uninvolved in the clinical care of any participants, distributed to the sites, and kept by personnel not directly involved with the study. These same personnel were responsible for packaging the drug and placebo in opaque envelopes. Patients, study personnel, and treating physicians were masked to study group assignment. The primary outcome of the study was the development of pancreatitis after ERCP. Analyses were done on an intention-to-treat basis. This trial is registered with ClinicalTrials.gov, number NCT01912716, and enrolment is complete. FINDINGS Between July 9, 2013, and March 22, 2018, 1037 eligible patients were enrolled and randomly assigned to receive either standard-dose (n=515) or high-dose indometacin (n=522). Pancreatitis after ERCP occurred in 141 (14%) of 1037 patients-76 (15%) of 515 patients in the standard-dose indometacin group and 65 (12%) of 522 patients in the high-dose indometacin group (risk ratio [RR] 1·19, 95% CI 0·87-1·61; p=0·32). We observed 19 adverse events that were potentially attributable to study drug. Clinically significant bleeding occurred in 14 (1%) of 1037 patients-six (1%) of 515 patients in the standard-dose indometacin group and eight (2%) of 522 patients in the high-dose indometacin group (p=0·79). Three (1%) of 522 patients in the high-dose indometacin group developed acute kidney injury versus none in the standard-dose group (p=0·25). A non-ST elevation myocardial infarction occurred in the standard-dose indometacin group 2 days after ERCP. A transient ischaemic attack occurred in the high-dose indometacin group 5 days after ERCP. All 19 adverse events, in addition to the 141 patients who developed pancreatitis after ERCP, were considered serious as all required admission to hospital. We observed no allergic reactions or deaths at 30 day follow-up. INTERPRETATION Dose escalation to rectal indometacin 200 mg did not confer any advantage compared with the standard 100 mg regimen, with pancreatitis incidence remaining high in high-risk patients. Current practice should continue unchanged. Further research should consider the pharmacokinetics of non-steroidal anti-inflammatory drugs to determine the optimal timing of their administration to prevent pancreatitis after ERCP. FUNDING American College of Gastroenterology.
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Affiliation(s)
- Evan L Fogel
- Division of Gastoenterology and Hepatology, Indiana University, Indianapolis, IN, USA.
| | - Glen A Lehman
- Division of Gastoenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Paul Tarnasky
- University of Texas Southwestern, Digestive Health Associates of Texas, Dallas, TX, USA
| | - Gregory A Cote
- Division of Gastroenterology, Medical University of South Carolina, Charleston, SC, USA
| | - Suzette E Schmidt
- Division of Gastoenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Akbar K Waljee
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Peter D R Higgins
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - James L Watkins
- Division of Gastoenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Stuart Sherman
- Division of Gastoenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Richard S Y Kwon
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Grace H Elta
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Jeffrey J Easler
- Division of Gastoenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Douglas K Pleskow
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - James M Scheiman
- Division of Gastroenterology, University of Virginia, Charlottesville, VA, USA
| | - Ihab I El Hajj
- Division of Gastoenterology and Hepatology, Indiana University, Indianapolis, IN, USA; Division of Gastroenterology, University of Balamand, Beirut, Lebanon
| | - Nalini M Guda
- Division of Gastroenterology, University of Wisconsin, Milwaukee, WI, USA; Aurora St Luke's Medical Center, Milwaukee, WI, USA
| | - Mark A Gromski
- Division of Gastoenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Lee McHenry
- Division of Gastoenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Seena Arol
- University of Texas Southwestern, Digestive Health Associates of Texas, Dallas, TX, USA
| | - Sheryl Korsnes
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Alejandro L Suarez
- Division of Gastroenterology, Medical University of South Carolina, Charleston, SC, USA; Division of Gastroenterology, Yale University, New Haven, CT, USA
| | - Rebecca Spitzer
- Division of Gastroenterology, Medical University of South Carolina, Charleston, SC, USA
| | - Marilyn Miller
- Division of Gastroenterology, University of Wisconsin, Milwaukee, WI, USA
| | - Maria Hofbauer
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - B Joseph Elmunzer
- Division of Gastroenterology, Medical University of South Carolina, Charleston, SC, USA
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18
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Smith ZL, Park KH, Llano EM, Donboli K, Fayad L, Han S, Kang L, Simril RT, Patel R, Hollander T, Rogers MC, Elmunzer BJ, Siddiqui UD, Aadam AA, Mullady DK, Lang GD, Das KK, Jamil LH, Lo SK, Gaddam S, Chapman CG, Keswani RN, Wani S, Cote GA, Kumbhari V, Kushnir VM. Outcomes of endoscopic treatment of leaks and fistulae after sleeve gastrectomy: results from a large multicenter U.S. cohort. Surg Obes Relat Dis 2019; 15:850-855. [DOI: 10.1016/j.soard.2019.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/06/2019] [Accepted: 04/06/2019] [Indexed: 02/07/2023]
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19
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Cote GA, Yadav D, Gardner TB. Response to Hao et al. Am J Gastroenterol 2018; 113:1900-1901. [PMID: 30361623 PMCID: PMC6768576 DOI: 10.1038/s41395-018-0375-2] [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: 07/27/2018] [Accepted: 09/18/2018] [Indexed: 12/11/2022]
Affiliation(s)
| | - Dhiraj Yadav
- 2University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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20
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Greer JB, Greer P, Sandhu BS, Alkaade S, Wilcox CM, Anderson MA, Sherman S, Gardner TB, Lewis MD, Guda NM, Muniraj T, Conwell D, Cote GA, Forsmark CE, Banks PA, Tang G, Stello K, Gelrud A, Brand RE, Slivka A, Whitcomb DC, Yadav D. Nutrition and Inflammatory Biomarkers in Chronic Pancreatitis Patients. Nutr Clin Pract 2018; 34:387-399. [PMID: 30101991 DOI: 10.1002/ncp.10186] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Chronic pancreatitis (CP) patients frequently experience malabsorption and maldigestion, leading to micronutrient and macronutrient deficiencies. Comorbid diabetes and lifestyle habits, such as alcohol consumption, may impact nutrition status. METHODS We compared micronutrient antioxidant, bone metabolism, serum protein, and inflammatory marker levels in 301 CP patients and 266 controls with no known pancreatic disease. We analyzed serum prealbumin and retinol binding protein; vitamins A, D, E, and B12; osteocalcin; tumor necrosis factor-α; and C-reactive protein (CRP). We also evaluated biomarkers among subsets of patients, examining factors including time since diagnosis, body mass index, alcohol as primary etiology, diabetes mellitus, vitamin supplementation, and pancreatic enzyme replacement. RESULTS After correcting for multiple comparisons, CP patients had significantly lower levels than controls of the following: vitamin A (40.9 vs 45.4 μg/dL) and vitamin E (α-tocopherol [8.7 vs 10.3 mg/L] and γ-tocopherol [1.8 vs 2.2 mg/L]), as well as osteocalcin (7.9 vs 10 ng/mL) and serum prealbumin (23 vs 27 mg/dL). Both patients and controls who took vitamin supplements had higher serum levels of vitamins than those not taking supplements. Compared with controls, in controlled analyses, CP patients had significantly lower levels of vitamins A, D, and E (both α-tocopherol and γ-tocopherol). CP patients also had significantly lower levels of osteocalcin, serum prealbumin, and retinol binding protein, and higher CRP. CONCLUSIONS CP patients demonstrated lower levels of selected nutrition and bone metabolism biomarkers than controls. Diabetes and alcohol did not impact biomarkers. Vitamin supplements and pancreatic enzyme replacement therapy improved nutrition biomarkers in CP patients.
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Affiliation(s)
- Julia B Greer
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Phil Greer
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Samer Alkaade
- Department of Medicine, Saint Louis University, St. Louis, Missouri
| | - C Mel Wilcox
- Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama
| | | | - Stuart Sherman
- Department of Medicine, Indiana University, Indianapolis, Indiana
| | - Timothy B Gardner
- Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Nalini M Guda
- GI Associates LLC, Aurora Health Care, St. Luke's Medical Center, Milwaukee, Wisconsin
| | | | - Darwin Conwell
- Department of Medicine, The Ohio State University, Columbus, Ohio
| | - Gregory A Cote
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | | | - Peter A Banks
- Department of Medicine, Brigham and Women's Hospital, Boston Massachusetts
| | - Gong Tang
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kim Stello
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Andres Gelrud
- GastroHealth and Miami Cancer Institute, Baptist Hospital, Miami, Florida
| | - Randall E Brand
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Adam Slivka
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David C Whitcomb
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dhiraj Yadav
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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21
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Wani S, Keswani R, Hall M, Han S, Ali MA, Brauer B, Carlin L, Chak A, Collins D, Cote GA, Diehl DL, DiMaio CJ, Dries A, El-Hajj I, Ellert S, Fairley K, Faulx A, Fujii-Lau L, Gaddam S, Gan SI, Gaspar JP, Gautamy C, Gordon S, Harris C, Hyder S, Jones R, Kim S, Komanduri S, Law R, Lee L, Mounzer R, Mullady D, Muthusamy VR, Olyaee M, Pfau P, Saligram S, Piraka C, Rastogi A, Rosenkranz L, Rzouq F, Saxena A, Shah RJ, Simon VC, Small A, Sreenarasimhaiah J, Walker A, Wang AY, Watson RR, Wilson RH, Yachimski P, Yang D, Edmundowicz S, Early DS. A Prospective Multicenter Study Evaluating Learning Curves and Competence in Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography Among Advanced Endoscopy Trainees: The Rapid Assessment of Trainee Endoscopy Skills Study. Clin Gastroenterol Hepatol 2017; 15. [PMID: 28625816 PMCID: PMC7042954 DOI: 10.1016/j.cgh.2017.06.012] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS On the basis of the Next Accreditation System, trainee assessment should occur on a continuous basis with individualized feedback. We aimed to validate endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) learning curves among advanced endoscopy trainees (AETs) by using a large national sample of training programs and to develop a centralized database that allows assessment of performance in relation to peers. METHODS ASGE recognized training programs were invited to participate, and AETs were graded on ERCP and EUS exams by using a validated competency assessment tool that assesses technical and cognitive competence in a continuous fashion. Grading for each skill was done by using a 4-point scoring system, and a comprehensive data collection and reporting system was built to create learning curves by using cumulative sum analysis. Individual results and benchmarking to peers were shared with AETs and trainers quarterly. RESULTS Of the 62 programs invited, 20 programs and 22 AETs participated in this study. At the end of training, median number of EUS and ERCP performed/AET was 300 (range, 155-650) and 350 (125-500), respectively. Overall, 3786 exams were graded (EUS, 1137; ERCP-biliary, 2280; ERCP-pancreatic, 369). Learning curves for individual end points and overall technical/cognitive aspects in EUS and ERCP demonstrated substantial variability and were successfully shared with all programs. The majority of trainees achieved overall technical (EUS, 82%; ERCP, 60%) and cognitive (EUS, 76%; ERCP, 100%) competence at conclusion of training. CONCLUSIONS These results demonstrate the feasibility of establishing a centralized database to report individualized learning curves and confirm the substantial variability in time to achieve competence among AETs in EUS and ERCP. ClinicalTrials.gov: NCT02509416.
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Affiliation(s)
- Sachin Wani
- University of Colorado Anschutz Medical Campus, Aurora, Colorado.
| | | | - Matt Hall
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Samuel Han
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Meer Akbar Ali
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Brian Brauer
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Linda Carlin
- Colorado Clinical and Translational Sciences Institute, Aurora, Colorado
| | - Amitabh Chak
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Dan Collins
- Carolinas Medical Center, Charlotte, North Carolina
| | - Gregory A. Cote
- Medical University of South Carolina, Charleston, South Carolina
| | | | | | - Andrew Dries
- Carolinas Medical Center, Charlotte, North Carolina
| | | | - Swan Ellert
- Colorado Clinical and Translational Sciences Institute, Aurora, Colorado
| | | | - Ashley Faulx
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | - Srinivas Gaddam
- Washington University School of Medicine, St Louis, Missouri
| | - Seng-Ian Gan
- Virginia Mason Medical Center, Seattle, Washington
| | | | | | - Stuart Gordon
- Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Sarah Hyder
- Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Ross Jones
- Carolinas Medical Center, Charlotte, North Carolina
| | - Stephen Kim
- University of California, Los Angeles, Los Angeles, California
| | | | - Ryan Law
- Northwestern University, Chicago, Illinois
| | - Linda Lee
- Brigham and Women’s Hospital, Boston, Massachusetts
| | - Rawad Mounzer
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Daniel Mullady
- Washington University School of Medicine, St Louis, Missouri
| | | | | | | | | | | | | | | | - Fadi Rzouq
- University of Kansas, Kansas City, Kansas
| | | | - Raj J. Shah
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Aaron Small
- Virginia Mason Medical Center, Seattle, Washington
| | | | | | - Andrew Y. Wang
- University of Virginia Health System, Charlottesville, Virginia
| | | | - Robert H. Wilson
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Dennis Yang
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Dayna S. Early
- Washington University School of Medicine, St Louis, Missouri
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22
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Bellin MD, Whitcomb DC, Abberbock J, Sherman S, Sandhu BS, Gardner TB, Anderson MA, Lewis MD, Alkaade S, Singh VK, John Baillie, Banks PA, Conwell D, Cote GA, Guda NM, Muniraj T, Tang G, Brand RE, Gelrud A, Amann ST, Forsmark CE, Wilcox CM, Slivka A, Yadav D. Patient and Disease Characteristics Associated With the Presence of Diabetes Mellitus in Adults With Chronic Pancreatitis in the United States. Am J Gastroenterol 2017; 112:1457-1465. [PMID: 28741615 PMCID: PMC6168293 DOI: 10.1038/ajg.2017.181] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 04/24/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Diabetes mellitus (DM) is a common complication of chronic pancreatitis (CP). Past studies for DM risk factors in CP have been limited to single centers or highly focused on a single etiology such as alcoholic or hereditary disease. We studied risk factors for DM in a large population of patients with CP of all etiologies enrolled in the North American Pancreatitis 2 studies. METHODS Participants (1,171) with CP (n=383 with DM, n=788 without DM) were enrolled prospectively from 26 participating centers. Questionnaires were completed by patients and physicians in a cross-sectional assessment. Patient demographics and disease characteristics were compared for CP with DM vs. without DM. Logistic regression was performed to assess the variables associated with DM diagnosis in a multivariable model. RESULTS Diabetics were more likely to be black (P=0.02), overweight, or obese (P<0.001), and with a family history of DM (P=0.0005). CP patients with DM were more likely to have pancreatic calcifications (63% vs. 54%, P=0.002), atrophy (44% vs. 32%, P<0.0001), and prior pancreas surgery (26.9% vs. 16.9%, P<0.0001). In multivariate logistic regression modeling, the strongest risk factors for DM were obesity (odds ratio (OR) 2.8, 95% confidence interval (CI) 1.9, 4.2) and exocrine insufficiency (OR 2.4, 95% CI 1.8, 3.2). CONCLUSIONS In this large multicenter cohort of patients with CP, exocrine insufficiency, calcifications, and pancreas surgery conveyed higher odds of having DM. However, the traditional 'type 2 DM' risk factors of obesity and family history were similarly important in conveying risk for DM.
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Affiliation(s)
- Melena D. Bellin
- Department of Pediatrics, University of Minnesota Medical Center and Masonic Children’s Hospital, Minneapolis, Minnesota, USA
| | - David C. Whitcomb
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Judah Abberbock
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Stuart Sherman
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | | | | | | | | | - Samer Alkaade
- Department of Internal Medicine, Saint Louis University, St Louis, Missouri, USA
| | - Vikesh K. Singh
- Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - John Baillie
- Virginia Commonwealth University, Richmond, Virginia, USA
| | - Peter A. Banks
- Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Darwin Conwell
- Department of Internal Medicine, Ohio State University, Columbus, Ohio, USA
| | - Gregory A. Cote
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nalini M. Guda
- Aurora St. Luke’s Medical Center, Milwaukee, Wisconsin, USA
| | | | - Gong Tang
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Randall E. Brand
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Andres Gelrud
- Department of Internal Medicine, University of Chicago, Chicago, Illinois, USA
| | | | | | - C. Mel Wilcox
- Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Adam Slivka
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Dhiraj Yadav
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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23
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Conwell DL, Banks PA, Sandhu BS, Sherman S, Al-Kaade S, Gardner TB, Anderson MA, Wilcox CM, Lewis MD, Muniraj T, Forsmark CE, Cote GA, Guda NM, Tian Y, Romagnuolo J, Wisniewski SR, Brand R, Gelrud A, Slivka A, Whitcomb DC, Yadav D. Validation of Demographics, Etiology, and Risk Factors for Chronic Pancreatitis in the USA: A Report of the North American Pancreas Study (NAPS) Group. Dig Dis Sci 2017; 62:2133-2140. [PMID: 28600657 PMCID: PMC6040886 DOI: 10.1007/s10620-017-4621-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [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: 12/04/2016] [Accepted: 05/16/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND/OBJECTIVES Our aim was to validate recent epidemiologic trends and describe the distribution of TIGAR-O risk factors in chronic pancreatitis (CP) patients. METHODS The NAPS-2 Continuation and Validation (NAPS2-CV) study prospectively enrolled 521 CP patients from 13 US centers from 2008 to 2012. CP was defined by definitive changes in imaging, endoscopy, or histology. Data were analyzed after stratification by demographic factors, physician-defined etiology, participating center, and TIGAR-O risk factors. RESULTS Demographics and physician-defined etiology in the NAPS2-CV study were similar to the original NAPS2 study. Mean age was 53 years (IQR 43, 62) with 55% males and 87% white. Overall, alcohol was the single most common etiology (46%) followed by idiopathic etiology (24%). Alcohol etiology was significantly more common in males, middle-aged (35-65 years), and non-whites. Females and elderly (≥65 years) were more likely to have idiopathic etiology, while younger patients (<35 years) to have genetic etiology. Variability in etiology was noted by participating centers (e.g., alcohol etiology ranged from 27 to 67% among centers enrolling ≥25 patients). Smoking was the most commonly identified (59%) risk factor followed by alcohol (53%), idiopathic (30%), obstructive (19%), and hyperlipidemia (13%). The presence of multiple TIGAR-O risk factors was common, with 1, 2, ≥3 risk factors observed in 27.6, 47.6, and 23.6% of the cohort, respectively. CONCLUSION Our data validate the current epidemiologic trends in CP. Alcohol remains the most common physician-defined etiology, while smoking was the most commonly identified TIGAR-O risk factor. Identification of multiple risk factors suggests CP to be a complex disease.
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Affiliation(s)
- Darwin L Conwell
- Brigham and Women's Hospital, Boston, MA, USA.
- Division of Gastroenterology, Hepatology and Nutrition, Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA.
| | | | - Bimaljit S Sandhu
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Stuart Sherman
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Samer Al-Kaade
- Saint Louis University School of Medicine, St. Louis, MO, USA
| | | | | | - C Mel Wilcox
- University of Alabama at Birmingham Hospital, Birmingham, AL, USA
| | | | | | | | - Gregory A Cote
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nalini M Guda
- University of Wisconsin School of Medicine, Milwaukee, WI, USA
| | - Ye Tian
- Department of Epidemiology, University of Pittsburg Graduate School of Public Health, Pittsburgh, PA, USA
| | | | - Stephen R Wisniewski
- Department of Epidemiology, University of Pittsburg Graduate School of Public Health, Pittsburgh, PA, USA
| | - Randall Brand
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Andres Gelrud
- University of Chicago School of Medicine, Chicago, IL, USA
| | - Adam Slivka
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Dhiraj Yadav
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Kwon RS, Davila RE, Mullady DK, Al-Haddad MA, Bang JY, Bingener-Casey J, Bosworth BP, Christie JA, Cote GA, Diamond S, Jorgensen J, Kowalski TE, Kubiliun N, Law JK, Obstein KL, Qureshi WA, Ramirez FC, Sedlack RE, Tsai F, Vignesh S, Wagh MS, Zanchetti D, Coyle WJ, Cohen J. EGD core curriculum. VideoGIE 2017; 2:162-168. [PMID: 29905301 PMCID: PMC5991610 DOI: 10.1016/j.vgie.2017.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Machicado JD, Amann ST, Anderson MA, Abberbock J, Sherman S, Conwell D, Cote GA, Singh VK, Lewis M, Alkaade S, Sandhu BS, Guda NM, Muniraj T, Tang G, Baillie J, Brand R, Gardner TB, Gelrud A, Forsmark CE, Banks PA, Slivka A, Wilcox CM, Whitcomb DC, Yadav D. Quality of Life in Chronic Pancreatitis is Determined by Constant Pain, Disability/Unemployment, Current Smoking, and Associated Co-Morbidities. Am J Gastroenterol 2017; 112:633-642. [PMID: 28244497 PMCID: PMC5828017 DOI: 10.1038/ajg.2017.42] [Citation(s) in RCA: 122] [Impact Index Per Article: 17.4] [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: 10/02/2016] [Accepted: 01/09/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Chronic pancreatitis (CP) has a profound independent effect on quality of life (QOL). Our aim was to identify factors that impact the QOL in CP patients. METHODS We used data on 1,024 CP patients enrolled in the three NAPS2 studies. Information on demographics, risk factors, co-morbidities, disease phenotype, and treatments was obtained from responses to structured questionnaires. Physical and mental component summary (PCS and MCS, respectively) scores generated using responses to the Short Form-12 (SF-12) survey were used to assess QOL at enrollment. Multivariable linear regression models determined independent predictors of QOL. RESULTS Mean PCS and MCS scores were 36.7±11.7 and 42.4±12.2, respectively. Significant (P<0.05) negative impact on PCS scores in multivariable analyses was noted owing to constant mild-moderate pain with episodes of severe pain or constant severe pain (10 points), constant mild-moderate pain (5.2), pain-related disability/unemployment (5.1), current smoking (2.9 points), and medical co-morbidities. Significant (P<0.05) negative impact on MCS scores was related to constant pain irrespective of severity (6.8-6.9 points), current smoking (3.9 points), and pain-related disability/unemployment (2.4 points). In women, disability/unemployment resulted in an additional 3.7 point reduction in MCS score. Final multivariable models explained 27% and 18% of the variance in PCS and MCS scores, respectively. Etiology, disease duration, pancreatic morphology, diabetes, exocrine insufficiency, and prior endotherapy/pancreatic surgery had no significant independent effect on QOL. CONCLUSIONS Constant pain, pain-related disability/unemployment, current smoking, and concurrent co-morbidities significantly affect the QOL in CP. Further research is needed to identify factors impacting QOL not explained by our analyses.
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Affiliation(s)
| | | | | | - Judah Abberbock
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | | | | | - Gregory A. Cote
- Medical University of South Carolina, Charleston, SC, United States
| | - Vikesh K. Singh
- Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | | | - Samer Alkaade
- Saint Louis University, St. Louis, MO, United States
| | | | | | | | - Gong Tang
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - John Baillie
- Virginia Commonwealth University, Richmond, VA, United States
| | - Randall Brand
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | | | | | | | | | - Adam Slivka
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - C. Mel Wilcox
- University of Alabama at Birmingham, Birmingham, AL, United States
| | - David C. Whitcomb
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Dhiraj Yadav
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
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26
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Sheth SG, Conwell DL, Whitcomb DC, Alsante M, Anderson MA, Barkin J, Brand R, Cote GA, Freedman SD, Gelrud A, Gorelick F, Lee LS, Morgan K, Pandol S, Singh VK, Yadav D, Mel Wilcox C, Hart PA. Academic Pancreas Centers of Excellence: Guidance from a multidisciplinary chronic pancreatitis working group at PancreasFest. Pancreatology 2017; 17:419-430. [PMID: 28268158 PMCID: PMC5525332 DOI: 10.1016/j.pan.2017.02.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [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: 01/04/2017] [Revised: 02/22/2017] [Accepted: 02/26/2017] [Indexed: 12/11/2022]
Abstract
Chronic pancreatitis (CP) is a progressive inflammatory disease, which leads to loss of pancreatic function and other disease-related morbidities. A group of academic physicians and scientists developed comprehensive guidance statements regarding the management of CP that include its epidemiology, diagnosis, medical treatment, surgical treatment, and screening. The statements were developed through literature review, deliberation, and consensus opinion. These statements were ultimately used to develop a conceptual framework for the multidisciplinary management of chronic pancreatitis referred to as an academic pancreas center of excellence (APCOE).
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Affiliation(s)
- Sunil G. Sheth
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Darwin L. Conwell
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - David C. Whitcomb
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh and UPMC, Pittsburgh, PA, United States
| | | | - Michelle A. Anderson
- Division of Gastroenterology, University of Michigan Hospital and Health Systems, Ann Arbor, MI, United States
| | - Jamie Barkin
- University of Miami, Miller School of Medicine, Miami, FL, United States
| | - Randall Brand
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh and UPMC, Pittsburgh, PA, United States
| | - Gregory A. Cote
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, United States
| | - Steven D. Freedman
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Andres Gelrud
- Center for Endoscopic Research and Therapeutics, University of Chicago, Chicago, IL, United States
| | - Fred Gorelick
- Section of Digestive Diseases, Yale University and VA Healthcare, West Haven, CT, United States
| | - Linda S. Lee
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women’s Hospital, Boston, MA, United States
| | - Katherine Morgan
- Division of Gastrointestinal and Laparoscopic Surgery, Medical University of South Carolina, Charleston, SC, United States
| | - Stephen Pandol
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Vikesh K. Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh and UPMC, Pittsburgh, PA, United States
| | - C. Mel Wilcox
- Division of Gastroenterology, University of Alabama, Birmingham, AL, United States
| | - Phil A. Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, United States,Corresponding author. Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, 410 West Tenth Avenue, Columbus, OH 43210, United States., (P.A. Hart)
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Papachristou GI, Machicado JD, Stevens T, Goenka MK, Ferreira M, Gutierrez SC, Singh VK, Kamal A, Gonzalez-Gonzalez JA, Pelaez-Luna M, Gulla A, Zarnescu NO, Triantafyllou K, Barbu ST, Easler J, Ocampo C, Capurso G, Archibugi L, Cote GA, Lambiase L, Kochhar R, Chua T, Tiwari SC, Nawaz H, Park WG, de-Madaria E, Lee PJ, Wu BU, Greer PJ, Dugum M, Koutroumpakis E, Akshintala V, Gougol A. Acute pancreatitis patient registry to examine novel therapies in clinical experience (APPRENTICE): an international, multicenter consortium for the study of acute pancreatitis. Ann Gastroenterol 2016; 30:106-113. [PMID: 28042246 PMCID: PMC5198234 DOI: 10.20524/aog.2016.0109] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 11/01/2016] [Indexed: 12/15/2022] Open
Abstract
Background We have established a multicenter international consortium to better understand the natural history of acute pancreatitis (AP) worldwide and to develop a platform for future randomized clinical trials. Methods The AP patient registry to examine novel therapies in clinical experience (APPRENTICE) was formed in July 2014. Detailed web-based questionnaires were then developed to prospectively capture information on demographics, etiology, pancreatitis history, comorbidities, risk factors, severity biomarkers, severity indices, health-care utilization, management strategies, and outcomes of AP patients. Results Between November 2015 and September 2016, a total of 20 sites (8 in the United States, 5 in Europe, 3 in South America, 2 in Mexico and 2 in India) prospectively enrolled 509 AP patients. All data were entered into the REDCap (Research Electronic Data Capture) database by participating centers and systematically reviewed by the coordinating site (University of Pittsburgh). The approaches and methodology are described in detail, along with an interim report on the demographic results. Conclusion APPRENTICE, an international collaboration of tertiary AP centers throughout the world, has demonstrated the feasibility of building a large, prospective, multicenter patient registry to study AP. Analysis of the collected data may provide a greater understanding of AP and APPRENTICE will serve as a future platform for randomized clinical trials.
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Affiliation(s)
- Georgios I Papachristou
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA (Georgios I. Papachristou, Jorge D. Machicado, Phil J. Greer, Mohannad Dugum, Efstratios Koutroumpakis Amir Gougol)
| | - Jorge D Machicado
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA (Georgios I. Papachristou, Jorge D. Machicado, Phil J. Greer, Mohannad Dugum, Efstratios Koutroumpakis Amir Gougol)
| | - Tyler Stevens
- Cleveland Clinic Foundation, Cleveland, Ohio, USA (Tyler Stevens, Tiffany Chua)
| | - Mahesh Kumar Goenka
- Apollo Gleneagles Hospitals Kolkata, Kolkata, India (Mahesh Kumar Goenka, Subhash Ch. Tewari)
| | - Miguel Ferreira
- Hospital Nacional de Itauguá, Itaugua, Paraguay (Miguel Ferreira)
| | - Silvia C Gutierrez
- Hospital Nacional "Profesor Alejandro Posadas", Buenos Aires, Argentina (Silvia C. Gutierrez)
| | - Vikesh K Singh
- Johns Hopkins Medical Institutions, Baltimore, Maryland, USA (Vikesh K. Singh Ayesha Kamal, Venkata Akshintalaf)
| | - Ayesha Kamal
- Johns Hopkins Medical Institutions, Baltimore, Maryland, USA (Vikesh K. Singh Ayesha Kamal, Venkata Akshintalaf)
| | | | - Mario Pelaez-Luna
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán-Universidad Autónoma de Mexico, Mexico City, Mexico (Mario Pelaez-Luna)
| | - Aiste Gulla
- Georgetown University Hospital, Washington, DC, USA (Aiste Gulla); Lithuanian University of Health Sciences, Kaunas, Lithuania (Aiste Gulla)
| | - Narcis O Zarnescu
- Second Department of Surgery, University Emergency Hospital Bucharest, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania (Narcis O. Zarnescu)
| | | | - Sorin T Barbu
- University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania (Sorin T. Barbu)
| | - Jeffrey Easler
- Indiana University School of Medicine, Indianapolis, Indiana, USA (Jeffrey Easler)
| | - Carlos Ocampo
- Hospital General de Argudos "Dr. Cosme Argerich", Buenos Aires, Argentina (Carlos Ocampo)
| | - Gabriele Capurso
- Digestive and Liver Disease Unit, S. Andrea Hospital, Sapienza University of Rome, Rome, Italy (Gabriele Capurso, Livia Archibugi)
| | - Livia Archibugi
- Digestive and Liver Disease Unit, S. Andrea Hospital, Sapienza University of Rome, Rome, Italy (Gabriele Capurso, Livia Archibugi)
| | - Gregory A Cote
- Medical University of South Carolina, Charleston, South Carolina, USA (Gregory A. Cote)
| | - Louis Lambiase
- University of Tennessee College of Medicine, Chattanooga, Tennessee, USA (Louis Lambiase)
| | - Rakesh Kochhar
- Postgraduate Institute of Medical Education and Research, Chandigarh, India (Rakesh Kochhar)
| | - Tiffany Chua
- Cleveland Clinic Foundation, Cleveland, Ohio, USA (Tyler Stevens, Tiffany Chua)
| | - Subhash Ch Tiwari
- Apollo Gleneagles Hospitals Kolkata, Kolkata, India (Mahesh Kumar Goenka, Subhash Ch. Tewari)
| | - Haq Nawaz
- Eastern Maine Medical Center, Maine, Bangor, USA (Haq Nawaz)
| | - Walter G Park
- Stanford University, Stanford, California, USA (Walter G. Park)
| | - Enrique de-Madaria
- Department of Gastroenterology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL - Fundación FISABIO), Alicante, Spain (Enrique de-Madaria)
| | - Peter J Lee
- University Hospitals Cleveland Medical Center, Ohio, USA (Peter J. Lee)
| | - Bechien U Wu
- Kaiser Permanente, Pasadena, California, USA (Bechien U. Wu)
| | - Phil J Greer
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA (Georgios I. Papachristou, Jorge D. Machicado, Phil J. Greer, Mohannad Dugum, Efstratios Koutroumpakis Amir Gougol)
| | - Mohannad Dugum
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA (Georgios I. Papachristou, Jorge D. Machicado, Phil J. Greer, Mohannad Dugum, Efstratios Koutroumpakis Amir Gougol)
| | - Efstratios Koutroumpakis
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA (Georgios I. Papachristou, Jorge D. Machicado, Phil J. Greer, Mohannad Dugum, Efstratios Koutroumpakis Amir Gougol)
| | - Venkata Akshintala
- Johns Hopkins Medical Institutions, Baltimore, Maryland, USA (Vikesh K. Singh Ayesha Kamal, Venkata Akshintalaf)
| | - Amir Gougol
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA (Georgios I. Papachristou, Jorge D. Machicado, Phil J. Greer, Mohannad Dugum, Efstratios Koutroumpakis Amir Gougol)
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Madhoun MF, Cote GA, Ahlawat SK, Ahmad NA, Buscaglia JM, Calderwood AH, Crockett S, Early DS, Gleeson FC, Gurudu SR, Imperiale TF, Liu JJ, Mosler P, Pannala R, Pfau PR, Romagnuolo J, Samadder J, Sethi A, Shergill AK, Shin EJ, Willingham F, Dominitz JA. Impact and outcomes of research sponsored by the American Society for Gastrointestinal Endoscopy. Gastrointest Endosc 2016; 84:385-391.e2. [PMID: 27349928 DOI: 10.1016/j.gie.2016.04.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 04/11/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Since 1985, the American Society for Gastrointestinal Endoscopy (ASGE) has awarded grants for endoscopic-related research. The goals of this study were to examine trends in ASGE grant funding and to assess productivity of previous recipients of the ASGE grant awards. METHODS This was a retrospective cohort analysis of all research grants awarded by the ASGE through 2009. Measures of academic productivity and self-assessment of the ASGE awards' impact on the recipients' careers were defined by using publicly available resources (eg, National Library of Medicine-PubMed) and administration of an electronic survey to award recipients. RESULTS The ASGE awarded 304 grants totaling $12.5 million to 214 unique awardees. Funding increased 7.5-fold between 1985 and 1989 (mean $102,000/year) and between 2005 and 2009 (mean $771,000/year). The majority of awardees were men (83%), were at or below the level of assistant professor (82%), with a median of 3 years of postfellowship experience at the time of the award, and derived from a broad spectrum of institutions as measured by National Institutes of Health funding rank (median 26, interquartile range [IQR] 12-64). Nineteen percent had a master's degree in a research-related field. Awardees' median publications per year increased from 3.5 (IQR 1.2-9.0) before funding to 5.7 (IQR 1.8-9.5) since funding; P = .04, and median h-index scores increased from 3 (IQR 1-8) to 17 (IQR 8-26); P < .001. Multivariate analysis found that the presence of a second advanced degree (eg, masters or doctorate) was independently predictive of high productivity (odds ratio [OR] 2.92; 95% confidence interval [CI], 1.09-7.81). Among 212 unique grant recipients, 82 (40%) completed the online survey. Of the respondents, median peer-reviewed publications per year increased from 3.4 (IQR 1.9-5.5) to 4.5 (IQR 2.0-9.5); P = .17. Ninety-one percent reported that the ASGE grant had a positive or very positive impact on their careers, and 85% of respondents are currently practicing in an academic environment. Most of the grants resulted in at least 1 peer-reviewed publication (67% per Internet-based search and 81% per survey). CONCLUSIONS The ASGE research program has grown considerably since 1985, with the majority of grants resulting in at least 1 grant-related publication. Overall academic productivity increased after the award, and the majority of awardees report a positive or very positive impact of the award on their careers. Medical professional societies are an important sponsor of clinical research.
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Gore J, Craven KE, Wilson JL, Cote GA, Cheng M, Nguyen HV, Cramer HM, Sherman S, Korc M. TCGA data and patient-derived orthotopic xenografts highlight pancreatic cancer-associated angiogenesis. Oncotarget 2016; 6:7504-21. [PMID: 25762644 PMCID: PMC4480696 DOI: 10.18632/oncotarget.3233] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [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: 01/24/2015] [Accepted: 01/28/2015] [Indexed: 12/18/2022] Open
Abstract
Pancreatic ductal adenocarcinomas (PDACs) overexpress pro-angiogenic factors but are not viewed as vascular. Using data from The Cancer Genome Atlas we demonstrate that a subset of PDACs exhibits a strong pro-angiogenic signature that includes 37 genes, such as HDAC9, that are overexpressed in PDAC arising in KRC mice, which express mutated Kras and lack RB. Moreover, patient-derived orthotopic xenografts can exhibit tumor angiogenesis, whereas conditioned media (CM) from KRC-derived pancreatic cancer cells (PCCs) enhance endothelial cell (EC) growth and migration, and activate canonical TGF-β signaling and STAT3. Inhibition of the type I TGF-β receptor with SB505124 does not alter endothelial activation in vitro, but decreases pro-angiogenic gene expression and suppresses angiogenesis in vivo. Conversely, STAT3 silencing or JAK1-2 inhibition with ruxolitinib blocks CM-enhanced EC proliferation. STAT3 disruption also suppresses endothelial HDAC9 and blocks CM-induced HDAC9 expression, whereas HDAC9 re-expression restores CM-enhanced endothelial proliferation. Moreover, ruxolitinib blocks mitogenic EC/PCC cross-talk, and suppresses endothelial p-STAT3 and HDAC9, and PDAC progression and angiogenesis in vivo, while markedly prolonging survival of KRC mice. Thus, targeting JAK1-2 with ruxolitinib blocks a final pathway that is common to multiple pro-angiogenic factors, suppresses EC-mediated PCC proliferation, and may be useful in PDACs with a strong pro-angiogenic signature.
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Affiliation(s)
- Jesse Gore
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,The Melvin and Bren Simon Cancer Center, and The Center for Pancreatic Cancer Research, Indianapolis, IN 46202, USA
| | - Kelly E Craven
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Julie L Wilson
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Gregory A Cote
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,The Melvin and Bren Simon Cancer Center, and The Center for Pancreatic Cancer Research, Indianapolis, IN 46202, USA.,Department of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Monica Cheng
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Hai V Nguyen
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Harvey M Cramer
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Stuart Sherman
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,The Melvin and Bren Simon Cancer Center, and The Center for Pancreatic Cancer Research, Indianapolis, IN 46202, USA
| | - Murray Korc
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,The Melvin and Bren Simon Cancer Center, and The Center for Pancreatic Cancer Research, Indianapolis, IN 46202, USA
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30
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Carr RA, Rejowski BJ, Cote GA, Pitt HA, Zyromski NJ. Systematic review of hypertriglyceridemia-induced acute pancreatitis: A more virulent etiology? Pancreatology 2016; 16:469-76. [PMID: 27012480 DOI: 10.1016/j.pan.2016.02.011] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 02/02/2016] [Accepted: 02/19/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We sought to define the severity and natural history of hypertriglyceridemia induced acute pancreatitis (HTG-AP), specifically whether HTG-AP causes more severe AP than that caused by other etiologies. METHODS Systematic review of the English literature. RESULTS Thirty-four studies (15 countries; 1972-2015) included 1340 HTG-AP patients (weighted mean prevalence of 9%). The median admission triglyceride concentration was 2622 mg/dl (range 1160-9769). Patients with HTG have a 14% weighted mean prevalence of AP. Plasmapheresis decreased circulating triglycerides, but did not conclusively affect AP mortality. Only 7 reports (n = 392 patients) compared severity of HTG-AP to that of AP from other etiologies. Of these, 2 studies found no difference in severity, while 5 suggested that HTG-AP patients may have increased severity compared to AP of other etiology. CONCLUSIONS 1) hypertriglyceridemia is a relatively uncommon (9%) cause of acute pancreatitis; however, patients with hypertriglyceridemia have a high (14%) incidence of acute pancreatitis; 2) plasmapheresis may offer specific therapy unique to this patient population; and 3) data specifically comparing the severity of HTG-AP with AP caused by other etiologies are heterogeneous and scarce.
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Affiliation(s)
- Rosalie A Carr
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Benjamin J Rejowski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Gregory A Cote
- Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Henry A Pitt
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
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31
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Kubiliun NM, Adams MA, Akshintala VS, Conte ML, Cote GA, Cotton PB, Dumonceau JM, Elta GH, Fogel EL, Freeman ML, Lehman GA, Naveed M, Romagnuolo J, Scheiman JM, Sherman S, Singh VK, Elmunzer BJ. Evaluation of Pharmacologic Prevention of Pancreatitis After Endoscopic Retrograde Cholangiopancreatography: A Systematic Review. Clin Gastroenterol Hepatol 2015; 13:1231-9; quiz e70-1. [PMID: 25579870 DOI: 10.1016/j.cgh.2014.11.038] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 11/19/2014] [Accepted: 11/20/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There is controversy over the efficacy of pharmacologic agents for preventing pancreatitis after endoscopic retrograde cholangiopancreatography (PEP). We performed a systematic review of PEP pharmacoprevention to evaluate safety and efficacy. METHODS We performed a systematic search of the literature for randomized controlled trials (RCTs) and meta-analyses of PEP pharmacoprevention through February 2014. After identifying relevant studies, 2 reviewers each extracted information on study characteristics, clinical outcomes, and risk of bias. A research classification scale was developed to identify pharmacologic agents ready for clinical use, agents for which a confirmatory RCT should be considered a high priority, agents for which exploratory studies are still necessary, and agents for which additional research should be of low priority. Clinical and research recommendations for each agent were made by consensus after considering research classification results and other important factors such as magnitude of benefit, safety, availability, and cost. RESULTS After screening 851 citations and 263 potentially relevant articles, 2 reviewers identified 85 RCTs and 28 meta-analyses that were eligible. On the basis of these studies, rectal nonsteroidal anti-inflammatory drugs were found to be appropriate for clinical use, especially for high-risk cases. Sublingual nitroglycerin, bolus-administered somatostatin, and nafamostat were found to be promising agents for which confirmatory research is warranted. Additional research was found to be required to justify confirmatory RCTs for topical epinephrine, aggressive intravenous fluids, gabexate, ulinastatin, secretin, and antibiotics. CONCLUSIONS On the basis of a systematic review, NSAIDs are appropriate for use in prevention of PEP, especially for high-risk cases. Additional research is necessary to clarify the role of other pharmacologic agents. These findings could inform future research and guide clinical decision-making and policy.
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Affiliation(s)
- Nisa M Kubiliun
- Division of Digestive and Liver Diseases, University of Texas Southwestern, Dallas, Texas
| | - Megan A Adams
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Venkata S Akshintala
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Marisa L Conte
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, Michigan
| | - Gregory A Cote
- Division of Gastroenterology, Indiana University Medical Center, Indianapolis, Indiana; Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | - Peter B Cotton
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | | | - Grace H Elta
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Evan L Fogel
- Division of Gastroenterology, Indiana University Medical Center, Indianapolis, Indiana
| | - Martin L Freeman
- Division of Gastroenterology, University of Minnesota, Minneapolis, Minnesota
| | - Glen A Lehman
- Division of Gastroenterology, Indiana University Medical Center, Indianapolis, Indiana
| | - Mariam Naveed
- Division of Digestive and Liver Diseases, University of Texas Southwestern, Dallas, Texas
| | - Joseph Romagnuolo
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | - James M Scheiman
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Stuart Sherman
- Division of Gastroenterology, Indiana University Medical Center, Indianapolis, Indiana
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - B Joseph Elmunzer
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan; Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina.
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Luz LP, Cote GA, Al-Haddad MA, McHenry L, LeBlanc JK, Sherman S, Moreira DM, El Hajj II, McGreevy K, DeWitt J. Utility of EUS following endoscopic polypectomy of high-risk rectosigmoid lesions. Endosc Ultrasound 2015; 4:137-44. [PMID: 26020049 PMCID: PMC4445172 DOI: 10.4103/2303-9027.156744] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 08/21/2014] [Indexed: 12/17/2022] Open
Abstract
Background: The utility of endoscopic ultrasound (EUS) compared with standard white light endoscopy (WLE) following recent polypectomy of high-risk colorectal polyps is unknown. Objective: To assess the incremental yield of EUS after endoscopic polypectomy of a high-risk rectal lesion. Design: Retrospective cohort. Setting: Tertiary referral center. Materials and Methods: Patients referred for EUS following attempted endoscopic resection of a high-risk rectal neoplasm, defined as a tubulovillous adenoma, tubular adenoma with high-grade dysplasia, carcinoid, carcinoma in-situ or adenocarcinoma (CA). Interventions: Sigmoidoscopy ± mucosal biopsy and EUS ± fine-needle aspiration (FNA) to evaluate for: (1) Residual polyp/tumor in the rectal wall or (2) peritumoral adenopathy. Main Outcome: Sensitivity and specificity for detection of residual neoplasia for WLE ± biopsy (WLE/BX) and EUS ± FNA for cancer (CA group) or benign disease (non-CA group). The incremental yield of EUS defined as: (1) Residual intramural neoplasia not present on WLE ± BX and; (2) abnormal peritumoral adenopathy. Results: A total of 70 patients (mean age 64 ± 11 years, 61% male) with a final diagnosis of CA (n = 38) and non-CA (n = 32) were identified. There was no difference between the sensitivity and specificity of WLE alone (65% and 84%), WLE with biopsy (71% and 95%), and EUS (59% and 84%), for the detection of residual neoplasia (P > 0.05 for all). EUS identified 3 masses missed by WLE, all in the CA group. A malignant (n = 2) or benign (n = 3) node was identified in 5 (13%) CA patients; EUS-FNA in two showed residual malignancy in one and a reactive lymph node (LN) in one. No LNs were identified in the non-CA patients. Limitations: Retrospective design, incomplete follow-up in some patients. Conclusion: Following endoscopic polypectomy of high-risk rectal neoplasia, the incremental yield of EUS compared with WLE/BX for evaluation of residual disease appears limited, especially in patients with benign disease.
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Affiliation(s)
- Leticia P Luz
- Medicine Service, Division of Gastroenterology, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA ; Department of Internal Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Gregory A Cote
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mohammad A Al-Haddad
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lee McHenry
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Julia K LeBlanc
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Stuart Sherman
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Ihab I El Hajj
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kathleen McGreevy
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - John DeWitt
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
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Choksi NS, Fogel EL, Cote GA, Romagnuolo J, Elta GH, Scheiman JM, Chak A, Mosler P, Higgins PDR, Korsnes SJ, Schmidt SE, Sherman S, Lehman GA, Elmunzer BJ. The risk of post-ERCP pancreatitis and the protective effect of rectal indomethacin in cases of attempted but unsuccessful prophylactic pancreatic stent placement. Gastrointest Endosc 2015; 81:150-5. [PMID: 25527053 DOI: 10.1016/j.gie.2014.07.033] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [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: 04/03/2014] [Accepted: 07/11/2014] [Indexed: 01/15/2023]
Abstract
BACKGROUND It is believed, based on limited observational data, that an unsuccessful attempt to place a prophylactic pancreatic stent substantially increases the risk of post-ERCP pancreatitis (PEP). OBJECTIVE To better understand the risk of PEP in patients with failed pancreatic stent placement (FPS) and the impact of rectal indomethacin on this risk. DESIGN Secondary analysis of randomized, controlled trial data. SETTING University of Michigan and Indiana University. PATIENTS A total of 577 clinical trial participants at elevated risk for PEP. INTERVENTIONS Pancreatic stent placement. MAIN OUTCOME MEASUREMENTS Within the placebo group, we compared PEP rates in patients with FPS, patients who underwent successful stent placement, and in those without a stent attempt. We also performed a regression analysis evaluating the association between FPS and PEP. To define the protective effect of indomethacin, we repeated these analyses in the indomethacin group and in the full study cohort. RESULTS The incidence of PEP among patients in the placebo group who experienced FPS was 34.7%, significantly exceeding rates in patients who underwent successful stent placement (16.4%) and in those without a stent attempt (12.1%). After we adjusted for known PEP risk factors, FPS was found to be independently associated with PEP. Among the indomethacin group and in the full cohort, FPS was not associated with a higher risk of PEP. LIMITATIONS Low event rate, FPS not prospectively captured. CONCLUSION FPS appears to confer an increased risk of PEP, which is attenuated by rectal indomethacin administration. These findings highlight the importance of adequate training and proficiency before endoscopists attempt pancreatic stent placement and the routine use of rectal indomethacin in high-risk ERCP cases.
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Affiliation(s)
- Neel S Choksi
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Evan L Fogel
- Division of Gastroenterology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Gregory A Cote
- Division of Gastroenterology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Joseph Romagnuolo
- Division of Gastroenterology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Grace H Elta
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - James M Scheiman
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Amitabh Chak
- Division of Gastroenterology, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - Patrick Mosler
- Division of Digestive Diseases and Nutrition, University of Kentucky Medical Center, Lexington, Kentucky, USA; Division of Gastroenterology and Hepatology, Kantonsspital Graubuenden, Chur, Switzerland
| | - Peter D R Higgins
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Sheryl J Korsnes
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Suzette E Schmidt
- Division of Gastroenterology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Stuart Sherman
- Division of Gastroenterology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Glen A Lehman
- Division of Gastroenterology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - B Joseph Elmunzer
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
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Affiliation(s)
- Alejandro L Suarez
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | - Gregory A Cote
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
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Cote GA, Gore AJ, McElyea SD, Heathers LE, Xu H, Sherman S, Korc M. A pilot study to develop a diagnostic test for pancreatic ductal adenocarcinoma based on differential expression of select miRNA in plasma and bile. Am J Gastroenterol 2014; 109:1942-52. [PMID: 25350767 PMCID: PMC4261139 DOI: 10.1038/ajg.2014.331] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 09/01/2014] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Accurate peripheral markers for the diagnosis of pancreatic ductal adenocarcinoma (PDAC) are lacking. We measured the differential expression of select microRNAs (miRNAs) in plasma and bile among patients with PDAC, chronic pancreatitis (CP), and controls. METHODS We identified patients (n=215) with treatment-naive PDAC (n=77), CP with bile/pancreatic duct pathology (n=67), and controls (n=71) who had been prospectively enrolled in a Pancreatobiliary Biorepository at the time of endoscopic retrograde cholangiopancreatography or endoscopic ultrasound. Controls were patients with choledocholithiasis but normal pancreata. The sample was separated into training (n=95) and validation (n=120) cohorts to establish and then test the performance of PDAC Signature Panels in diagnosing PDAC. The training cohort (n=95) included age-matched patients with PDAC, CP, and controls. Panels were derived from the differential expression of 10 candidate miRNAs in plasma or bile. We selected miRNAs having excellent accuracy for inclusion in regression models. RESULTS Using the training cohort, we confirmed the differential expression of 9/10 miRNAs in plasma (miR-10b, -30c, -106b, -132, -155, -181a, -181b, -196a, and -212) and 7/10 in bile (excluding miR-21, -132, and -181b). Of these, five (miR-10b, -155, -106b, -30c, and -212) had excellent accuracy for distinguishing PDAC. In the training and validation cohorts, the sensitivity/specificity for a PDAC Panel derived from plasma was 95/100% and 100/100%, respectively; in bile, these were 96/100% and 100/100%. CONCLUSIONS Increased expression of miRNA-10b, -155, and -106b in plasma appears highly accurate in diagnosing PDAC. Additional studies are needed to confirm this Panel and explore its value as a prognostic test.
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Affiliation(s)
- Gregory A Cote
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - A Jesse Gore
- Department of Medicine, Division of Endocrinology, Biochemistry and Molecular Biology, and the Pancreatic Cancer Signature Center at the IU Simon Cancer Center, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Samantha D McElyea
- Department of Medicine, Division of Endocrinology, Biochemistry and Molecular Biology, and the Pancreatic Cancer Signature Center at the IU Simon Cancer Center, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Laura E Heathers
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Huiping Xu
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Stuart Sherman
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Murray Korc
- Department of Medicine, Division of Endocrinology, Biochemistry and Molecular Biology, and the Pancreatic Cancer Signature Center at the IU Simon Cancer Center, Indiana University School of Medicine, Indianapolis, Indiana, USA,IU Simon Cancer Center, Indiana University School of Medicine, Walther Hall, R3 C528, 980 West Walnut Street, Indianapolis, Indiana 46202, USA. E-mail:
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Elmunzer BJ, Cote GA, Rockey DC. Treatment for patients at intermediate risk of a common duct stone. JAMA 2014; 312:2043. [PMID: 25399286 DOI: 10.1001/jama.2014.13419] [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)
- B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston
| | - Gregory A Cote
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston
| | - Don C Rockey
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston
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Tirkes T, Sandrasegaran K, Sanyal R, Sherman S, Schmidt CM, Cote GA, Akisik F. Secretin-enhanced MR cholangiopancreatography: spectrum of findings. Radiographics 2014; 33:1889-906. [PMID: 24224585 DOI: 10.1148/rg.337125014] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Magnetic resonance cholangiopancreatography (MRCP) is the most effective, safe, noninvasive magnetic resonance (MR) imaging technique for the evaluation of the pancreaticobiliary ductal system. The MRCP imaging technique has substantially improved during the past 2 decades and is based mainly on the acquisition of heavily T2-weighted MR images, with variants of fast spin-echo sequences. MRCP can also be performed by utilizing the hormone secretin, which stimulates a normal pancreas to secrete a significant amount of fluid while transiently increasing the tone of the sphincter of Oddi. The transient increase in the diameter of the pancreatic duct improves the depiction of the ductal anatomy, which can be useful in patients in whom detailed evaluation of the pancreatic duct is most desired because of a suspicion of pancreatic disease. Improved depiction of the ductal anatomy can be important in (a) the differentiation of side-branch intraductal papillary mucinous neoplasms from other cystic neoplasms and (b) the diagnosis and classification of chronic pancreatitis, the disconnected pancreatic duct syndrome, and ductal anomalies such as anomalous pancreaticobiliary junction and pancreas divisum. In patients examined after pancreatectomy, stimulation with secretin can give information about the patency of the pancreaticoenteric anastomosis. Duodenal filling during the secretin-enhanced phase of the MRCP examination can be used to estimate the excretory reserve of the pancreas. Secretin is well tolerated, and complications are rarely seen. Secretin-enhanced MRCP is most useful in (a) the evaluation of acute and chronic pancreatitis, congenital variants of the pancreaticoduodenal junction, and intraductal papillary mucinous neoplasms and (b) follow-up of patients after pancreatectomy.
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Affiliation(s)
- Temel Tirkes
- From the Department of Radiology and Clinical Sciences (T.T., K.S., F.A.), Division of Gastroenterology (S.S., G.A.C.), and Department of Surgery (C.M.S.), Indiana University School of Medicine, 550 N University Blvd, UH0663, Indianapolis, IN 46202; and the Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (R.S.)
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Pokhrel B, Choi EK, Khalid O, Sandrasegaran K, Fogel EL, McHenry L, Sherman S, Watkins J, Cote GA, Pitt HA, Zyromski NJ, Juliar B, Lehman GA. Increased fat in pancreas not associated with risk of pancreatitis post-endoscopic retrograde cholangiopancreatography. Clin Exp Gastroenterol 2014; 7:199-204. [PMID: 24959090 PMCID: PMC4061141 DOI: 10.2147/ceg.s31333] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background A preliminary study has shown increased pancreatic fat in patients with idiopathic pancreatitis and sphincter of Oddi dysfunction. In this study, we aimed to determine if an increased quantity of pancreatic fat is an independent risk factor for pancreatitis post-endoscopic retrograde cholangiopancreatography (ERCP). Methods In this case control study, we retrospectively reviewed a local radiological and ERCP database to identify patients who had had abdominal magnetic resonance imaging (MRI) followed by ERCP no more than 60 days later between September 2003 and January 2011. Percentage of fat was determined by recording signal intensity in the in-phase (Sin) and out-of-phase (Sout) T1-weighted gradient sequences, and calculation of the fat fraction as (Sin − Sout)/(Sin) × 2 by an abdominal radiologist blinded to clinical history. Controls matched for age, gender, and other pancreatobiliary disease were selected from a group with no post-ERCP pancreatitis (before fat content of the pancreas was analyzed). Results Forty-seven patients were enrolled. Compared with controls, subjects with post-ERCP pancreatitis were similar in terms of age (41.4 years versus 41.1 years), gender (21.2% versus 20.2% males), pancreatobiliary disease characteristics, and most ERCP techniques. Measurements of pancreatic head, body, and tail fat and body mass index were similar in patients and controls. Conclusion Increased pancreatic fat on MRI criteria is not an independent predictor of post-ERCP pancreatitis.
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Affiliation(s)
- Bhupesh Pokhrel
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Eun Kwang Choi
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Omer Khalid
- Department of Gastroenterology, St Louis University School of Medicine, St Louis, MO
| | - Kumar Sandrasegaran
- Department of Radiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Evan L Fogel
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Lee McHenry
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Stuart Sherman
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - James Watkins
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Gregory A Cote
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Henry A Pitt
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Beth Juliar
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Glen A Lehman
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
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Bellin MD, Freeman ML, Gelrud A, Slivka A, Clavel A, Humar A, Schwarzenberg SJ, Lowe ME, Rickels MR, Whitcomb DC, Matthews JB, Amann S, Andersen DK, Anderson MA, Baillie J, Block G, Brand R, Chari S, Cook M, Cote GA, Dunn T, Frulloni L, Greer JB, Hollingsworth MA, Kim KM, Larson A, Lerch MM, Lin T, Muniraj T, Robertson RP, Sclair S, Singh S, Stopczynski R, Toledo FGS, Wilcox CM, Windsor J, Yadav D. Total pancreatectomy and islet autotransplantation in chronic pancreatitis: recommendations from PancreasFest. Pancreatology 2014; 14:27-35. [PMID: 24555976 PMCID: PMC4058640 DOI: 10.1016/j.pan.2013.10.009] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [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: 08/19/2013] [Revised: 10/23/2013] [Accepted: 10/25/2013] [Indexed: 12/11/2022]
Abstract
DESCRIPTION Total pancreatectomy with islet autotransplantation (TPIAT) is a surgical procedure used to treat severe complications of chronic pancreatitis or very high risk of pancreatic cancer while reducing the risk of severe diabetes mellitus. However, clear guidance on indications, contraindications, evaluation, timing, and follow-up are lacking. METHODS A working group reviewed the medical, psychological, and surgical options and supporting literature related to TPIAT for a consensus meeting during PancreasFest. RESULTS Five major areas requiring clinical evaluation and management were addressed: These included: 1) indications for TPIAT; 2) contraindications for TPIAT; 3) optimal timing of the procedure; 4) need for a multi-disciplinary team and the roles of the members; 5) life-long management issues following TPIAP including diabetes monitoring and nutrition evaluation. CONCLUSIONS TPIAT is an effective method of managing the disabling complications of chronic pancreatitis and risk of pancreatic cancer in very high risk patients. Careful evaluation and long-term management of candidate patients by qualified multidisciplinary teams is required. Multiple recommendations for further research were also identified.
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Affiliation(s)
- Melena D. Bellin
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Martin L. Freeman
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Andres Gelrud
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Adam Slivka
- Department of Medicine, University of Pittsburgh, Pennsylvania, USA
| | - Alfred Clavel
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Abhinav Humar
- Department of Surgery, University of Pittsburgh, Pennsylvania, USA
| | | | - Mark E. Lowe
- Department of Pediatrics, University of Pittsburgh, Pennsylvania, USA,Children’s Hospital of Pittsburgh, Pennsylvania, USA
| | - Michael R. Rickels
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David C Whitcomb
- Department of Medicine, University of Pittsburgh, Pennsylvania, USA
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Elmunzer BJ, Scheiman JM, Lehman GA, Chak A, Mosler P, Higgins PDR, Hayward RA, Romagnuolo J, Elta GH, Sherman S, Waljee AK, Repaka A, Atkinson MR, Cote GA, Kwon RS, McHenry L, Piraka CR, Wamsteker EJ, Watkins JL, Korsnes SJ, Schmidt SE, Turner SM, Nicholson S, Fogel EL. A randomized trial of rectal indomethacin to prevent post-ERCP pancreatitis. N Engl J Med 2012; 366:1414-22. [PMID: 22494121 PMCID: PMC3339271 DOI: 10.1056/nejmoa1111103] [Citation(s) in RCA: 459] [Impact Index Per Article: 38.3] [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] [Indexed: 12/11/2022]
Abstract
BACKGROUND Preliminary research suggests that rectally administered nonsteroidal antiinflammatory drugs may reduce the incidence of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). METHODS In this multicenter, randomized, placebo-controlled, double-blind clinical trial, we assigned patients at elevated risk for post-ERCP pancreatitis to receive a single dose of rectal indomethacin or placebo immediately after ERCP. Patients were determined to be at high risk on the basis of validated patient- and procedure-related risk factors. The primary outcome was post-ERCP pancreatitis, which was defined as new upper abdominal pain, an elevation in pancreatic enzymes to at least three times the upper limit of the normal range 24 hours after the procedure, and hospitalization for at least 2 nights. RESULTS A total of 602 patients were enrolled and completed follow-up. The majority of patients (82%) had a clinical suspicion of sphincter of Oddi dysfunction. Post-ERCP pancreatitis developed in 27 of 295 patients (9.2%) in the indomethacin group and in 52 of 307 patients (16.9%) in the placebo group (P=0.005). Moderate-to-severe pancreatitis developed in 13 patients (4.4%) in the indomethacin group and in 27 patients (8.8%) in the placebo group (P=0.03). CONCLUSIONS Among patients at high risk for post-ERCP pancreatitis, rectal indomethacin significantly reduced the incidence of the condition. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT00820612.).
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Affiliation(s)
- B Joseph Elmunzer
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, MI 48109, USA.
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Ginsberg GG, Chand B, Cote GA, Dallal RM, Edmundowicz SA, Nguyen NT, Pryor A, Thompson CC. A pathway to endoscopic bariatric therapies. Gastrointest Endosc 2011; 74:943-53. [PMID: 22032311 DOI: 10.1016/j.gie.2011.08.053] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Accepted: 08/29/2011] [Indexed: 02/08/2023]
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Mohamadnejad M, DeWitt JM, Sherman S, LeBlanc JK, Pitt HA, House MG, Jones KJ, Fogel EL, McHenry L, Watkins JL, Cote GA, Lehman GA, Al-Haddad MA. Role of EUS for preoperative evaluation of cholangiocarcinoma: a large single-center experience. Gastrointest Endosc 2011; 73:71-8. [PMID: 21067747 DOI: 10.1016/j.gie.2010.08.050] [Citation(s) in RCA: 177] [Impact Index Per Article: 13.6] [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: 06/14/2010] [Accepted: 08/28/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Accurate preoperative diagnosis and staging of cholangiocarcinoma (CCA) remain difficult. OBJECTIVE To evaluate the utility of EUS in the diagnosis and preoperative evaluation of CCA. DESIGN Observational study of prospectively collected data. SETTING Single tertiary referral hospital in Indianapolis, Indiana. PATIENTS Consecutive patients with CCA from January 2003 through October 2009. INTERVENTIONS EUS and EUS-guided FNA (EUS-FNA). MAIN OUTCOME MEASUREMENTS Sensitivity of EUS for the detection of a tumor and prediction of unresectability compared with CT and magnetic resonance imaging (MRI); sensitivity of EUS-FNA to provide tissue diagnosis, by using surgical pathology as a reference standard. RESULTS A total of 228 patients with biliary strictures undergoing EUS were identified. Of these, 81 (mean age 70 years, 45 men) had CCA. Fifty-one patients (63%) had distal and 30 (37%) had proximal CCA. For those with available imaging, tumor detection was superior with EUS compared with triphasic CT (76 of 81 [94%] vs 23 of 75 [30%], respectively; P < .001). MRI identified the tumor in 11 of 26 patients (42%; P = .07 vs EUS). EUS identified CCA in all 51 (100%) distal and 25 (83%) of 30 proximal tumors (P < .01). EUS-FNA (median, 5 passes; range, 1-12 passes) was performed in 74 patients (91%). The overall sensitivity of EUS-FNA for the diagnosis of CCA was 73% (95% confidence interval, 62%-82%) and was significantly higher in distal compared with proximal CCA (81% vs 59%, respectively; P = .04). Fifteen tumors were definitely unresectable. EUS correctly identified unresectability in 8 of 15 and correctly identified the 38 of 39 patients with resectable tumors (53% sensitivity and 97% specificity for unresectability). CT and/or MRI failed to detect unresectability in 6 of these 8 patients. LIMITATION Single-center study. CONCLUSION EUS and EUS-FNA are sensitive for the diagnosis of CCA and very specific in predicting unresectability. The sensitivity of EUS-FNA is significantly higher in distal than in proximal CCA.
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Affiliation(s)
- Mehdi Mohamadnejad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA
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DeWitt J, Emerson RE, Sherman S, Al-Haddad M, McHenry L, Cote GA, Leblanc JK. Endoscopic ultrasound-guided Trucut biopsy of gastrointestinal mesenchymal tumor. Surg Endosc 2010; 25:2192-202. [DOI: 10.1007/s00464-010-1522-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Accepted: 11/27/2010] [Indexed: 02/06/2023]
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DeWitt J, Sherman S, Al-Haddad M, McHenry L, Cote GA, Leblanc JK. EUS-guided FNA of local recurrence of pancreatic cancer after surgical resection. Gastrointest Endosc 2010; 72:1076-80. [PMID: 20869713 DOI: 10.1016/j.gie.2010.07.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [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: 06/28/2010] [Accepted: 07/10/2010] [Indexed: 12/14/2022]
Abstract
BACKGROUND EUS-guided FNA (EUS-FNA) is a sensitive test for the preoperative diagnosis of pancreatic cancer. Its use for diagnosing local tumor recurrence after surgical resection has not been described. OBJECTIVE To determine the sensitivity of EUS-FNA for this indication. DESIGN Retrospective cohort study. SETTING Tertiary referral hospital in the United States. PATIENTS Consecutive patients referred for EUS with clinical and/or radiographic suspicion of pancreatic cancer recurrence. INTERVENTIONS EUS ± FNA of retroperitoneal mass. MAIN OUTCOME MEASUREMENT Sensitivity of EUS-FNA. RESULTS Seventeen patients (9 male, median age 71 years) underwent EUS at a median of 17 months (range 7-46 months) after a classic Whipple procedure (n = 7), pylorus-sparing Whipple procedure (n = 7), or distal pancreatectomy (n = 3) for suspected local recurrence of pancreatic cancer. The primary tumor (median size 2.5 cm, range 1.5-7.9 cm) was located in the head in 14 patients, the body in 1, and the tail in 2. Final surgical margins at any site were positive in only 1 of 17 patients (+ retroperitoneal margin). At the time of suspected recurrence, 4 patients (24%) were asymptomatic. EUS disclosed a mass (median size 21 mm, range 12-30 mm) in 16 of 17 patients (94%). Transgastric EUS-FNA (n = 16, median 4.5 passes, range 2-10) disclosed recurrent malignancy in 13 of 16 (79%), atypical cells in 1 of 16 (7%), and benign cytology in 2 of 16 (14%). Subsequent radiographic evidence of increasing tumor burden was seen in 1 of 2 patients with benign cytology; however, follow-up for the 2 other patients with benign biopsy specimens was not available. Depending on the status of the 2 patients without available follow-up, the sensitivity, specificity, and accuracy of EUS-FNA for the diagnosis of recurrent cancer ranged from 81% to 93%, was 100%, and ranged from 81% to 93%, respectively. LIMITATIONS Small, single-center retrospective cohort. CONCLUSIONS EUS-FNA is sensitive for the diagnosis of retroperitoneal recurrence of pancreatic cancer after surgical resection.
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Affiliation(s)
- John DeWitt
- Department of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana 46202, USA
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