Safety Parameters for the Use of Holmium:YAG Laser in the Treatment of Biliary Calculi: The Ex-Vivo Model

Background and Objectives: While studies have demonstrated the efficacy of cholangioscopy-guided Holmium-Yttrium aluminum garnet (Ho:YAG) laser lithotripsy for the treatment of refractory bile duct stones, data regarding the safety of the operating parameters for laser lithotripsy are lacking. The aim of this study was to determine safe, yet effective, energy settings for Ho:YAG laser in the ex-vivo model. Materials and Methods: This ex vivo experimental study utilized the Ho:YAG laser on porcine bile duct epithelium and human gallstones. Ho:YAG laser lithotripsy was applied in different power settings from 8 to 15 Watts (W) to six explanted porcine bile ducts. Settings that appeared safe were then utilized to fragment seventy-three human gallstones. Results: The median bile duct perforation times with the Ho:YAG laser between 8-15 W were: >60 s (8 W); 23 s (9 W); 29 s (10 W); 27 s (12 W); 12 s (14 W); and 8 s (15 W). Statistically significant differences in the median perforation times were noted between 8 W vs. 15 W, 9 W vs. 15 W, 10 W vs. 15 W, and 12 W vs. 15 W (p < 0.05). When using a 365 µm Ho:YAG laser probe at 8-12 W, the fragmentation rates on various size stones were: 100% (<1.5 cm); 80-100% (1.6-2.0 cm) and 0-32% (>2.0 cm). Optimal fragmentation was seen utilizing 12 W with high energy (2.4 J) and low frequency (5 Hz) settings. Using a larger 550 µm probe at these settings resulted in 100% fragmentation of stones larger than 2 cm. Conclusions: The Ho:YAG laser appears to be safe and effective in the treatment of large bile duct stones when used between 8-12 W in 5 s bursts in an ex vivo model utilizing porcine bile ducts and human gallstones.

Endoscopy versus early surgery for the management of chronic pancreatitis: a systematic review and meta-analysis

BACKGROUND AND AIM

Endoscopic stone removal and stenting of pancreatic strictures are the initial treatment for treating chronic pancreatitis-related pain. Surgery is considered when endoscopic interventions fail to improve symptoms. In this meta-analysis, we have compared early surgery versus endoscopic interventions.

METHODS

The study was performed as per the PRISMA statement. The literature search was conducted on online databases to identify studies that compared endoscopy and surgery for the management of chronic pancreatitis symptoms. Primary outcomes of interest were pain relief, complications, and exocrine/endocrine insufficiency. Secondary outcomes were mean length of stay and mean number of procedures. Pooled odds ratio (OR) was calculated using random-effects model with 95% confidence interval (CI).

RESULTS

Of a total of 9880 articles that were screened, three randomized controlled trials and two retrospective studies with 602 patients (71.4% males) were found to be eligible. Endoscopic interventions were performed in 317 patients and 285 patients underwent early surgery. Early surgery provided significantly better pain relief compared to endoscopy (OR 0.46; 95%CI 0.27-0.80; p = 0.01; I2 = 17.65%) and required less number of procedures (Mean difference 1.66; 95%CI 0.9-2.43; p = 0.00; I2 = 96.46%). There was no significant difference in procedure-related complication (OR 0.91; 95%CI 0.51-1.61; p = 0.74; I2 = 38.8%), endocrine (OR 1.18; 95%CI 0.63-2.20; p = 0.61; I2 = 28.24%), or exocrine insufficiency (OR 1.78; 95%CI 0.66-4.79; p = 0.25; I2 = 30.97%) or the length of stay (Mean difference 1.21; 95%CI -7.12 to 4.70; p = 0.69).

CONCLUSION

Compared to endoscopy, early surgery appears to be better in controlling chronic pancreatitis-related pain, with no significant difference in procedure-related complications. However, larger randomized controlled trials are needed to ascertain their efficacy.

Current advances in the management of chronic pancreatitis

Chronic pancreatitis is characterized by irreversible destruction of pancreatic parenchyma and its ductal system resulting from longstanding inflammation, leading to fibrosis and scarring due to genetic, environmental, and other risk factors. The diagnosis of chronic pancreatitis is made based on a combination of clinical features and characteristic findings on computed tomography or magnetic resonance imaging. Abdominal pain is the most common symptom of chronic pancreatitis. The main aim of treatment is to relieve symptoms, prevent disease progression, and manage complications related to chronic pancreatitis. Patients who do not respond to medical treatment or not a candidate for surgical treatment are usually managed with endoscopic therapies. Endoscopic therapies help with symptoms such as abdominal pain and jaundice by decompression of pancreatic and biliary ducts. This review summarizes the risk factors, pathophysiology, diagnostic evaluation, endoscopic treatment of chronic pancreatitis, and complications. We have also reviewed recent advances in endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-guided therapies for pancreatic duct obstruction due to stones, strictures, pancreatic divisum, and biliary strictures.

Management of Non-Variceal Upper GI Bleeding in the Geriatric Population: An Update

PURPOSE OF REVIEW

Upper gastrointestinal (GI) bleeding is a significant cause of morbidity and mortality in the geriatric (age > 65 years) population and presents a unique management challenge in the context of multiple medical comorbidities, polypharmacy, and increased risk of adverse outcomes and is confounded by an increased prevalence of obscure GI bleeds. A review of relevant guidelines, literature, and personal observations will enhance management strategies in the elderly.

RECENT FINDINGS

Non-variceal bleeding represents a significant proportion of upper GI bleeding (UGIB) in geriatric patients. Peptic ulcer disease (PUD) remains the most common cause in geriatric patients hospitalized for UGIB, but its incidence is decreasing. Esophagogastroduodenoscopy (EGD) is the gold standard for treating UGIB in geriatrics with a therapeutic yield of approximately 75%. Scoring systems such as Glasgow-Blatchford (GBS) and AIMS-65 may be useful for risk stratification but are not validated in trials. Obscure bleeds account for up to 30% of hospitalizations and must be considered during triage and management. Video capsule endoscopy (VCE) technology is efficacious for detecting obscure jejunal bleeding after failed EGD and may enhance the yield of balloon-assisted enteroscopy (BAE). The most significant factor for the increased morbidity and mortality in the geriatric population is the presence of multiple medical comorbidities and polypharmacy. An EGD should be done within 24 h of hospital presentation. If non-diagnostic, VCE may be a viable option for diagnosing an obscure small-bowel bleed, representing up to 30% of GI bleeds in this population.

Endoscopic management of benign recalcitrant esophageal strictures

Benign esophageal strictures are one of the common clinical conditions managed by endoscopists. Nearly 90% of the benign esophageal strictures respond to endoscopic dilation. However, a small percentage of patients progress to recalcitrant strictures. The benign recalcitrant esophageal strictures are difficult to manage both medically and endoscopically as they do not respond to conventional treatment with proton pump inhibitors and esophageal dilations. Patients with benign recalcitrant esophageal strictures are at a high risk of developing debilitating malnutrition and morbidity due to severe dysphagia. This condition is associated with psychological trauma to patients as treatments are usually prolonged with poor outcomes. Also, this can be a financial burden on the healthcare industry due to several sessions of treatment. In this article, we discuss the classification of benign esophageal strictures, evidence-based treatment strategies, endoscopic procedural techniques, and complications of endoscopic interventions. We aim to guide providers in managing benign esophageal strictures with a focus on endoscopic management of benign recalcitrant esophageal strictures.

Gastrointestinal Bleeding in Patients with Severe SARS-CoV-2

Gastrointestinal symptoms are common and frequently reported in Coronavirus Disease-2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It is unclear if SARS-CoV-2 is associated with increased risk of gastrointestinal bleeding (GIB). Nevertheless, GIB in COVID-19 patients poses unique challenges to patients due to high-risk of concomitant respiratory failure and to endoscopy personnel due to risk of airborne transmission during endoscopic procedures. Many management issues related to COVID-19 are still being studied. In this case series, we attempt to discuss the important clinical implications related to the management of GIB in COVID-19 patients.

Massive upper gastrointestinal hemorrhage due to invasive hepatocellular carcinoma and hepato-gastric fistula

A 36-year-old male Asian immigrant with a history of hepatitis B and hepatitis C related unresectable hepatocellular carcinoma in the left lobe of the liver presented with hematemesis and severe anemia. He was diagnosed with a liver mass that was resected 8 years ago described as a benign tumor in his home country. He had received trans-arterial chemoembolization (TACE) four months ago after subsequent diagnosis of unresectable hepatoma, and currently was receiving chemotherapy with Sorafenib. After resuscitation, a contrast enhanced computerized tomography was performed which showed fistulization of hepatocellular carcinoma into adjacent stomach. This finding was confirmed during endoscopy with direct visualization of the fistulous opening. Hepatocellular carcinoma (HCC) invading the gastrointestinal (GI) tract is rare. We present a case and literature review of HCC with local invasion of the stomach causing massive upper GI bleeding after receiving TACE.

Age-Dependent Impact of Fluoroscopic Radiation on the Gender of Off-Spring: An International Survey of Cardiologists

Background: Fluoroscopic radiation has been implicated in reducing the sex ratio (M:F) by potentially damaging the Y chromosome. We examined the effects of exposure to fluoroscopic radiation on gender of offspring of cardiologists across the world. Methods: An internet based survey was e-mailed worldwide to 8000 physicians who practice invasive electrophysiology and/or interventional cardiology. Survey questions included age, race, sub-specialty, hours of exposure to radiation, number of children, gender of off-spring, miscarriages and mutations and exposure to radiation prior to conception of each child. Logistic regression analyses were performed on years of exposure and gender of offspring born post radiation exposure. Results: Responses of 377 cardiologists (84% male and 16% female) were reviewed. With a total of 398 males and 402 females born to 377 cardiologists, although reduced, the overall sex ratio (0.99) was not significantly different from that observed in the general population (1.05). Univariate logistic regression analysis identified higher male births with increasing hours of radiation exposure (OR 1.034, CI 1.003-1.067 p=0.03) and increasing paternal age (OR 1.05, CI 1.01-1.08, p=0.002). Subgroup analysis of children of male cardiologists revealed higher incidence of male births with increasing age and radiation exposure and multivariate analysis only identified paternal age as predictor of higher incidence of male births (OR 1.05, CI 1.01-1.089, p=0.0027). Conclusion: Exposure to ionizing radiation leads to a decrease in the sex ratio (M/F) in younger male cardiologists, while this effect is reversed with greater number of male births in older male cardiologists.

Evolution of Paroxysmal Atrial Fibrillation to Persistent or Permanent Atrial Fibrillation: Predictors of Progression

Introduction: Paroxysmal atrial fibrillation (PAF) eventually progresses to persistent and permanent AF. The predictors of progression from PAF to persistent and permanent AF are poorly understood. Methods: Electronic medical records of 437 patients with PAF were reviewed in a retrospective cohort study. Patients were followed in time and progression to persistent/permanent AF was recorded. Demographic, clinical and echocardiographic information was collected. A logistic regression analysis was performed to identify predictors of progression to persistent/permanent AF. Results: Over a mean duration of 57.3±55.9 months, 32.4% of patients progressed to persistent/permanent AF. Mean age of the population was 67.9±13.4 years with 57% males and 92% Caucasian. Univariate analysis identified higher body higher mass index (BMI), cardiomyopathy, diabetes, valvular heart disease (VHD), larger left atrial size (LA) and higher pulmonary artery pressure as predictors of progression. Multivariate logistic regression analysis larger left atrial size (OR 1.46, CI 1.05-2.04, P 0.002), cardiomyopathy (OR 2, CI 1.1- 3.3, P 0.003), and moderate to severe valvular heart disease (OR 3.3, CI 1.4-5, P 0.008) as significant predictors of progression to persistent/permanent AF. Conclusions: Our study shows that PAF patients with larger LA, valvular heart disease and cardiomyopathy predict progression of PAF to persistent/permanent AF. Higher BMI and cardiomyopathy predicted progression to persistent AF while larger LA size and VHD predicted progression to permanent AF.

Esophageal adenocarcinoma in Barrett's esophagus after endoscopic ablative therapy: a meta-analysis and systematic review

OBJECTIVES

The extent of reduction of esophageal adenocarcinoma (EAC) incidence in Barrett's esophagus (BE) patients after endoscopic ablation is not known. The objective of this study was to determine the cancer incidence in BE patients after ablative therapy and compare these rates to cohort studies of BE patients not undergoing ablation.

METHODS

A MEDLINE search of the literature on the natural history and ablative modalities in BE patients was performed. Patients with nondysplastic BE (NDBE), low-grade dysplasia (LGD), or high-grade dysplasia (HGD) and follow-up of at least 6 months were included. The rate of cancer in patients undergoing ablation and from the natural history data was calculated using weighted-average incidence rates (WIR).

RESULTS

A total of 53 articles met the inclusion criteria for the natural history data. Pooled natural history data showed cancer incidence of 5.98/1,000 patient-years (95% CI 5.05-6.91) in NDBE; 16.98/1,000 patient-years (95% CI 13.1-20.85) in LGD; and 65.8/1,000 patient-years (95% CI 49.7-81.8) in HGD patients. A total of 65 articles met the inclusion criteria for BE patients undergoing ablation (1,457 patients, NDBE; 239 patients, LGD; and 611 patients, HGD). The WIR for cancer was 1.63/1,000 patient-years (95% CI 0.07-3.34) for NDBE; 1.58/1,000 patient-years (95% CI 0.66-3.84) for LGD; and 16.76/1,000 patient-years (95% CI 10.6-22.9) for HGD patients.

CONCLUSIONS

Compared to historical reports of the natural history of BE, ablation may be associated with a reduction in cancer incidence, although such a comparison is limited by likely heterogeneity between treatment and natural history studies. The greatest benefit of ablation was observed in BE patients with HGD.

Esophageal adenocarcinoma and Barrett's esophagus

Esophageal adenocarcinoma (EAC) is the most rapidly rising incidence cancer associated with a poor 5-year survival rate. Barrett's esophagus (BE) is a well established premalignant condition for the development of EAC and hence it is imperative that patients with BE or at risk for developing BE should be identified and managed appropriately. The endoscopic recognition of BE should include the assessment of the circumferential (C) and maximum (M) extent of the endoscopically visualized BE segment as well as endocsopic landmarks (The Prague C&M criteria). Although controversial, clinical strategies of screening and surveillance have focused on identification of esophageal neoplasia at an early asymptomatic and curable stage with the ultimate goal of preventing deaths from this cancer. Risk stratification that involves screening and surveillance of high risk individuals may improve the efficacy and effectiveness of these programs. The future of this endeavor lies in the identification and validation of biomarkers coupled with enhanced endoscopic techniques such as narrow band imaging, autofluorescence imaging, confocal laser endomicroscopy etc. Endoscopic therapies (endoscopic mucosal resection, ablative therapies) have become attractive alternatives for the treatment of high grade dysplasia and/or early EAC in BE patients. The main stays of treatment of advanced cancers are debulking surgery, chemotherapy, radiotherapy and palliative care measures.