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Ahmed W, Joshi D, Huggett MT, Everett SM, James M, Menon S, Oppong KW, On W, Paranandi B, Trivedi P, Webster G, Hegade VS. Update on the optimisation of endoscopic retrograde cholangiography (ERC) in patients with primary sclerosing cholangitis. Frontline Gastroenterol 2024; 15:74-83. [PMID: 38487565 PMCID: PMC10935540 DOI: 10.1136/flgastro-2023-102491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/28/2023] [Indexed: 03/17/2024] Open
Affiliation(s)
- Wafaa Ahmed
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Deepak Joshi
- Gastroenterology, King's College Hospital Liver Unit, London, UK
| | - Matthew T Huggett
- Gastroenterology, St James's University Hospital, The Leeds Teaching Hospitals NHS Foundation Trust, Leeds, UK
| | - Simon M Everett
- Gastroenterology, St James's University Hospital NHS Trust, Leeds, UK
| | - Martin James
- Gastroenterology, Nottingham University, Nottingham, UK
| | - Shyam Menon
- Department of Hepatology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Wei On
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Bharat Paranandi
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Palak Trivedi
- National Institute for Health Research, Centre for Liver Research, University Hospitals Birmingham, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - George Webster
- Department of Gastroenterology, University College London Hospital NHS Foundation Trust, London, UK
| | - Vinod S Hegade
- Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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El Menabawey T, McCrudden R, Shetty D, Hopper AD, Huggett MT, Bekkali N, Carroll NR, Henry E, Johnson GJ, Keane MG, Love M, McKay CJ, Norton S, Oppong K, Penman I, Ramesh J, Ryan B, Siau K, Nayar M. UK and Ireland Joint Advisory Group (JAG) consensus statements for training and certification in diagnostic endoscopic ultrasound (EUS). Gut 2023; 73:118-130. [PMID: 37739777 PMCID: PMC10715553 DOI: 10.1136/gutjnl-2023-329800] [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: 03/08/2023] [Accepted: 09/02/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND AND AIMS International endoscopy societies vary in their approach for credentialing individuals in endoscopic ultrasound (EUS) to enable independent practice; however, there is no consensus in this or its implementation. In 2019, the Joint Advisory Group on GI Endoscopy (JAG) commissioned a working group to examine the evidence relating to this process for EUS. The aim of this was to develop evidence-based recommendations for EUS training and certification in the UK. METHODS Under the oversight of the JAG quality assurance team, a modified Delphi process was conducted which included major stakeholders from the UK and Ireland. A formal literature review was made, initial questions for study were proposed and recommendations for training and certification in EUS were formulated after a rigorous assessment using the Grading of Recommendation Assessment, Development and Evaluation tool and subjected to electronic voting to identify accepted statements. These were peer reviewed by JAG and relevant stakeholder societies before consensus on the final EUS certification pathway was achieved. RESULTS 39 initial questions were proposed of which 33 were deemed worthy of assessment and finally formed the key recommendations. The statements covered four key domains, such as: definition of competence (13 statements), acquisition of competence (10), assessment of competence (5) and postcertification mentorship (5). Key recommendations include: (1) minimum of 250 hands-on cases before an assessment for competency can be made, (2) attendance at the JAG basic EUS course, (3) completing a minimum of one formative direct observation of procedural skills (DOPS) every 10 cases to allow the learning curve in EUS training to be adequately studied, (4) competent performance in summative DOPS assessments and (5) a period of mentorship over a 12-month period is recommended as minimum to support and mentor new service providers. CONCLUSIONS An evidence-based certification pathway has been commissioned by JAG to support and quality assure EUS training. This will form the basis to improve quality of training and safety standards in EUS in the UK and Ireland.
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Affiliation(s)
- Tareq El Menabawey
- Pancreatobiliary Medicine Unit, University College London Hospitals NHS Foundation Trust, London, UK
- Department of Gastroenterology, Homerton University Hospital, London, UK
| | - Raymond McCrudden
- Department of Gastroenterology, University Hospitals Dorset NHS Trust, Bournemouth, UK
| | - Dushyant Shetty
- Department of Radiology, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Andrew D Hopper
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Noor Bekkali
- Department of Gastroenterology and Hepatology, University of Oxford, Translational Gastroenterology Unit, Oxford, UK
| | - Nicholas R Carroll
- Radiology, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Elaine Henry
- Department of Gastroenterology, NHS Tayside, Dundee, UK
| | - Gavin J Johnson
- Pancreatobiliary Medicine Unit, University College London Hospitals NHS Foundation Trust, London, UK
| | - Margaret G Keane
- Gastroenterology and Hepatology, Johns Hopkins, Baltimore, Maryland, USA
| | - Mark Love
- Radiology, Belfast City Hospital, Belfast, UK
| | - Colin J McKay
- West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - Sally Norton
- Upper Gastrointestinal Surgery, Bristol Royal Infirmary, Bristol, UK
| | - Kofi Oppong
- HPB Unit & Department of Gastroenterology, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
- Translational and Clinical Research Institute, University of Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - Ian Penman
- Centre for Liver & Digestive Disorders, Royal Infirmary Edinburgh, Edinburgh, UK
| | - Jayapal Ramesh
- Department of Gastroenterology, Royal Liverpool Hospital NHS Trust, Liverpool, UK
| | - Barbara Ryan
- Department of Gastroenterology, Trinity College Dublin, Dublin, Ireland
| | - Keith Siau
- Gastroenterology, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Manu Nayar
- Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
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3
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Ahmed W, Mirzaali M, Young C, Sanni L, Everett S, Paranandi B, Huggett MT, On W. EUS-guided through the needle microbiopsy: a useful adjunct in the investigation of pancreatic cystic lesions. BMJ Open Gastroenterol 2023; 10:e001184. [PMID: 37399433 DOI: 10.1136/bmjgast-2023-001184] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 06/21/2023] [Indexed: 07/05/2023] Open
Abstract
OBJECTIVE Endoscopic ultrasound-guided through-the-needle microbiopsy (EUS-TTNB) forceps is a recent development that facilitates sampling of the walls of pancreatic cystic lesions (PCL) for histological analysis. We aimed to assess the impact of EUS-TTNB and its influence on patient management in a tertiary pancreas centre. DESIGN A prospective database of consecutive patients who underwent EUS-TTNB from March 2020 to August 2022 at a tertiary referral centre was retrospectively analysed. RESULTS Thirty-four patients (22 women) were identified. Technical success was achieved in all cases. Adequate specimens for histological diagnosis were obtained in 25 (74%) cases. Overall, EUS-TTNB led to a change in management in 24 (71%) cases. Sixteen (47%) patients were downstaged, with 5 (15%) discharged from surveillance. Eight (24%) were upstaged, with 5 (15%) referred for surgical resection. In the 10 (29%) cases without change in management, 7 (21%) had confirmation of diagnosis with no change in surveillance, and 3 (9%) had insufficient biopsies on EUS-TTNB. Two (6%) patients developed post-procedural pancreatitis, and 1 (3%) developed peri-procedural intracystic bleeding with no subsequent clinical sequelae. CONCLUSION EUS-TTNB permits histological confirmation of the nature of PCL, which can alter management outcomes. Care should be taken in patient selection and appropriately consented due to the adverse event rate.
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Affiliation(s)
- Wafaa Ahmed
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Mikaeil Mirzaali
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Caroline Young
- Department of Histopathology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Latifu Sanni
- Department of Histopathology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Simon Everett
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Bharat Paranandi
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Matthew T Huggett
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Wei On
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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On W, Huggett MT, Young A, Pine J, Smith AM, Tehami N, Maher B, Pereira SP, Johnson G, Paranandi B. Endoscopic ultrasound guided gastrojejunostomy in the treatment of gastric outlet obstruction: multi-centre experience from the United Kingdom. Surg Endosc 2023; 37:1749-1755. [PMID: 36217058 PMCID: PMC10017786 DOI: 10.1007/s00464-022-09692-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 09/25/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Endoscopic ultrasound guided gastrojejunostomy (EUS-GJ) with lumen apposing metal stents has recently emerged as a viable option, as an alternative to surgical gastrojejunostomy and endoscopic enteral stenting, for managing gastric outlet obstruction (GOO). We aim to perform a retrospective analysis of the efficacy, safety and outcomes of EUS-GJ performed at three tertiary institutions in the United Kingdom. METHODS Consecutive patients who underwent EUS-GJ between August 2018 and March 2021 were identified from a prospectively maintained database. Data were obtained from interrogation of electronic health records. RESULTS Twenty five patients (15 males) with a median age of 63 years old (range 29-80) were included for analysis. 88% (22/25) of patients had GOO due to underlying malignant disease. All patients were deemed surgically inoperable or at high surgical risk. Both technical and clinical success were achieved in 92% (23/25) of patients. There was an improvement in the mean Gastric Outlet Obstruction Scoring System scores following a technically successful EUS-GJ (2.52 vs 0.68, p < 0.01). Adverse events occurred in 2/25 patients (8%), both due to stent maldeployment necessitating endoscopic closure of the gastric defect with clips. Long-term follow-up data were available for 21 of 23 patients and the re-intervention rate was 4.8% (1/21) over a median follow-up period of 162 (range 5-474) days. CONCLUSION EUS-GJ in carefully selected patients is an effective and safe procedure when performed by experienced endoscopists.
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Affiliation(s)
- Wei On
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Matthew T Huggett
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Alistair Young
- Department of Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - James Pine
- Department of Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Andrew M Smith
- Department of Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nadeem Tehami
- Department of Gastroenterology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ben Maher
- Department of Interventional Radiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Stephen P Pereira
- Department of Gastroenterology, University College Hospitals NHS Foundation Trust, London, UK
| | - Gavin Johnson
- Department of Gastroenterology, University College Hospitals NHS Foundation Trust, London, UK
| | - Bharat Paranandi
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
- St James's University Hospital, 4th Floor, Bexley Wing, Beckett Street, Leeds, LS9 7TF, UK.
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5
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Ghandour B, Keane MG, Shinn B, Dawod QM, Fansa S, El Chafic AH, Irani SS, Pawa R, Gutta A, Ichkhanian Y, Paranandi B, Pawa S, Al-Haddad MA, Zuchelli T, Huggett MT, Sharaiha RZ, Kowalski TE, Khashab MA, Shrigiriwar A, Zhang L, Mony S, Khan A, Loren DE, Chiang A, Schlachterman A, Kumar A, Saab O, Blake B, Obri MS. Factors predictive of persistent fistulas in EUS-directed transgastric ERCP: a multicenter matched case-control study. Gastrointest Endosc 2023; 97:260-267. [PMID: 36228699 DOI: 10.1016/j.gie.2022.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 09/16/2022] [Accepted: 09/26/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND AIMS EUS-directed transgastric ERCP (EDGE) is an established method for managing pancreaticobiliary pathology in Roux-en-Y gastric bypass patients, with high rates of technical success and low rates of serious adverse events (AEs). However, widespread adoption of the technique has been limited because of concerns about the development of persistent gastrogastric or jejunogastric fistulas. Gastrogastric and jejunogastric fistulas have been reported in up to 20% of cases in some series, but predictive risk factors and long-term management and outcomes are lacking. Therefore, our aims were to assess factors associated with the development of persistent fistulas and the technical success of endoscopic fistula closure. METHODS This is a case-control study involving 9 centers (8 USA, 1 Europe) from February 2015 to September 2021. Cases of persistent fistulas were defined as endoscopic or imaging evidence of fistula more than 8 weeks after lumen-apposing metal stent (LAMS) removal. Control subjects were defined as endoscopic or imaging confirmation of no fistula more than 8 weeks after LAMS removal. AEs were defined and graded according to the American Society for Gastrointestinal Endoscopy lexicon. RESULTS Twenty-five patients identified to have evidence of a persistent fistula on follow-up surveillance (cases) were matched with 50 patients with no evidence of a persistent fistula on follow-up surveillance (control subjects) based on age and sex. Mean LAMS dwell time was 74.7 ± 106.2 days. After LAMS removal, argon plasma coagulation (APC) ablation of the fistula was performed in 46 patients (61.3%). Primary closure of the fistula was performed in 26.7% of patients (20: endoscopic suturing in 17, endoscopic tacking in 2, and over-the-scope clips + endoscopic suturing in 1). When comparing cases with control subjects, there was no difference in baseline demographics, fistula site, LAMS size, or primary closure frequency between the 2 groups (P > .05). However, in the persistent fistula group, the mean LAMS dwell time was significantly longer (127 vs 48 days, P = .02) and more patients had ≥5% total body weight gain (33.3% vs 10.3%, P = .03). LAMS dwell time was a significant predictor of persistent fistula (odds ratio, 4.5 after >40 days in situ, P = .01). The odds of developing a persistent fistula increased by 9.5% for every 7 days the LAMS was left in situ. In patients with a persistent fistula, endoscopic closure was attempted in 19 (76%) with successful resolution in 14 (73.7%). CONCLUSIONS Longer LAMS dwell time was found to be associated with a higher risk of persistent fistulas in EDGE patients. APC or primary closure of the fistula on LAMS removal was not found to be protective against developing a persistent fistula, which, if present, can be effectively managed through endoscopic closure in most cases.
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Affiliation(s)
- Bachir Ghandour
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Margaret G Keane
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Brianna Shinn
- Division of Gastroenterology and Hepatology, Thomas Jefferson Hospital, Philadelphia, Pennsylvania, USA
| | - Qais M Dawod
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Sima Fansa
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Abdul Hamid El Chafic
- Division of Gastroenterology and Hepatology, Ochsner Medical Center-New Orleans, New Orleans, Louisiana, USA
| | - Shayan S Irani
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Rishi Pawa
- Division of Gastroenterology and Hepatology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Aditya Gutta
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, Michigan, USA
| | - Bharat Paranandi
- Division of Gastroenterology and Hepatology, Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - Swati Pawa
- Division of Gastroenterology and Hepatology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Mohammad A Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Tobias Zuchelli
- Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, Michigan, USA
| | - Matthew T Huggett
- Division of Gastroenterology and Hepatology, Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - Reem Z Sharaiha
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Thomas E Kowalski
- Division of Gastroenterology and Hepatology, Thomas Jefferson Hospital, Philadelphia, Pennsylvania, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
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Chhabra P, On W, Paranandi B, Huggett MT, Robson N, Wright M, Maher B, Tehami N. Initial United Kingdom experience of endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography. Ann Hepatobiliary Pancreat Surg 2022; 26:318-324. [PMID: 36042580 PMCID: PMC9721259 DOI: 10.14701/ahbps.22-019] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/28/2022] [Accepted: 04/29/2022] [Indexed: 12/15/2022] Open
Abstract
Backgrounds/Aims Gallstone disease is a recognized complication of bariatric surgery. Subsequent management of choledocholithiasis may be challenging due to altered anatomy which may include Roux-en-Y gastric bypass (RYGB). We conducted a retrospective service evaluation study to assess the safety and efficacy of endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) in patients with RYGB anatomy. Methods All the patients who underwent EDGE for endoscopic retrograde cholangiopancreatography after RYGB at two tertiary care centers in the United Kingdom between January 2020 and October 2021 were included in the study. Clinical and demographic details were recorded for all patients. The primary outcome measures were technical and clinical success. Adverse events were recorded. Hot Axios lumen apposing metal stents measuring 20 mm in diameter and 10 mm in length were used in all the patients for creation of a gastro-gastric or gastro-jejunal fistula. Results A total of 14 patients underwent EDGE during the study period. The majority of the patients were female (85.7%) and the mean age of patients was 65.8 ± 9.8 years. Technical success was achieved in all but one patient at the first attempt (92.8%) and clinical success was achieved in 100% of the patients. Complications arose in 3 patients with 1 patient experiencing persistent fistula and weight gain. Conclusions In patients with RYGB anatomy, EDGE facilitated biliary access has a high rate of clinical success with an acceptable safety profile. Adverse events are uncommon and can be managed endoscopically.
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Affiliation(s)
- Puneet Chhabra
- Department of Gastroenterology, Calderdale and Huddersfield Foundation Trust, Huddersfield, United Kingdom
| | - Wei On
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Bharat Paranandi
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Matthew T. Huggett
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Naomi Robson
- Biomedical Communications, University of Toronto, Toronto, Ontario, Canada
| | - Mark Wright
- Department of Interventional Endoscopy, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Ben Maher
- Department of Interventional Endoscopy, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Nadeem Tehami
- Department of Interventional Endoscopy, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom,Corresponding author: Nadeem Tehami, BSc, FRCP (London), FRCPS (Glasg), FEBGH, MRCP Gastroenterology Department of Interventional Endoscopy, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, United Kingdom Tel: +44-23-8077-7222, E-mail: ORCID: https://orcid.org/0000-0003-3042-6574
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7
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Ghandour B, Shinn B, Dawod QM, Fansa S, El Chafic AH, Irani SS, Pawa R, Gutta A, Ichkhanian Y, Paranandi B, Pawa S, Al-Haddad MA, Zuchelli T, Huggett MT, Bejjani M, Sharaiha RZ, Kowalski TE, Khashab MA. EUS-directed transgastric interventions in Roux-en-Y gastric bypass anatomy: a multicenter experience. Gastrointest Endosc 2022; 96:630-638. [PMID: 35623383 DOI: 10.1016/j.gie.2022.05.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/14/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Placement of a lumen-apposing metal stent (LAMS) between the gastric pouch and the excluded stomach allows for EUS-guided transgastric interventions (EDGIs) in patients with Roux-en-Y gastric bypass (RYGB). Although EUS-guided transgastric ERCP (EDGE) outcomes have been reported, data are scant on other endoscopic interventions. We aimed to evaluate the outcomes and safety of EDGIs. METHODS This retrospective study involved 9 centers (United States, 8; Europe, 1) and included patients with RYGB who underwent EDGIs between June 2015 and September 2021. The primary outcome was the technical success of EDGIs. Secondary outcomes were adverse events (AEs), length of hospital stay, and fistula follow-up and management. RESULTS Fifty-four EDGI procedures were performed in 47 patients (mean age, 61 years; 72% women), most commonly for the evaluation of a pancreatic mass (n = 16) and management of pancreatic fluid collections (n = 10). A 20-mm LAMS was used in 26 patients and a 15-mm LAMS in 21, creating a gastrogastrostomy in 37 patients and jejunogastrostomy in 10. Most patients (n = 30, 64%) underwent a dual-session EDGI, with a median interval of 17 days between the 2 procedures. Single-session EDGI was performed in 17 patients, of whom 10 (59%) had anchoring of the LAMS. The most common interventions were diagnostic EUS (with or without FNA or fine-needle biopsy sampling; n = 28) and EUS-guided cystgastrostomy (n = 8). The mean procedural time was 97.6 ± 78.9 minutes. Technical success was achieved in 52 patients (96%). AEs occurred in 5 patients (10.6%), of which only 1 AE (2.1%) was graded as severe. Intraprocedural LAMS migration was the most common AE, occurring in 3 patients (6.4%), whereas delayed spontaneous LAMS migration occurred in 2 (4.3%). Four of the 5 LAMS migration events were managed endoscopically, and 1 required surgical repair. LAMS anchoring was found to be protective against LAMS migration (P = .001). The median duration of hospital stay was 2.1 ± 3.7 days. Of the 17 patients who underwent objective fistula assessment endoscopically or radiologically after LAMS removal, 2 (11.7%) were found to have persistent fistulas. In 1 case the fistula was intentionally left open to assist with weight gain. The other fistula was successfully closed endoscopically. CONCLUSIONS EDGI is effective and safe for the diagnosis and management of pancreaticobiliary and foregut disorders in RYGB patients. It is associated with high rates of technical success and low rates of severe AEs. LAMS migration is the most common AE with evidence that anchoring can be protective against its occurrence. Persistent fistulas may occur, but endoscopic closure seems to be effective.
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Affiliation(s)
- Bachir Ghandour
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Brianna Shinn
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Qais M Dawod
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Sima Fansa
- Department of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Abdul Hamid El Chafic
- Division of Gastroenterology and Hepatology, Ochsner Medical Center-New Orleans, New Orleans, Louisiana, USA
| | - Shayan S Irani
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Rishi Pawa
- Division of Gastroenterology and Hepatology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Aditya Gutta
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, Michigan, USA
| | - Bharat Paranandi
- Division of Gastroenterology and Hepatology, Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - Swati Pawa
- Division of Gastroenterology and Hepatology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Mohammad A Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Tobias Zuchelli
- Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, Michigan, USA
| | - Matthew T Huggett
- Division of Gastroenterology and Hepatology, Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - Michael Bejjani
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Reem Z Sharaiha
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Thomas E Kowalski
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
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8
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Bejjani M, Ghandour B, Subtil JC, Martínez-Moreno B, Sharaiha RZ, Watson RR, Kowalski TE, Benias PC, Huggett MT, Weber T, D'Souza LS, Anderloni A, Lajin M, Khara HS, Pham KDC, Pleskow D, Fabbri C, Nieto JM, Kumta NA, Pawa R, Jovani M, Khashab MA. Correction: Clinical and technical outcomes of patients undergoing endoscopic ultrasound-guided gastroenterostomy using 20-mm vs. 15-mm lumen-apposing metal stents. Endoscopy 2022; 54:C10. [PMID: 35297027 DOI: 10.1055/a-1797-5089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Michael Bejjani
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland, USA
| | - Bachir Ghandour
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland, USA
| | | | | | - Reem Z Sharaiha
- Weill Cornell Medicine, New York, New York State, United States
| | - Rabindra R Watson
- California Pacific Medical Center, San Francisco, California, United States
| | - Thomas E Kowalski
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Petros C Benias
- Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, New York, United States
| | | | - Tobias Weber
- University Hospital Augsburg, Augsburg, Bayern, Germany
| | - Lionel S D'Souza
- Stony Brook University Hospital, Stony Brook, New York, United States
| | - Andrea Anderloni
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Michael Lajin
- Sharp Grossmont Hospital, La Mesa, California, United States
| | - Harshit S Khara
- Geisinger Medical Center, Danville, Pennsylvania, United States
| | | | - Douglas Pleskow
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forli-Cesena Hospitals, AUSL Romagna, Romagna, Italy
| | - Jose M Nieto
- Borland Groover Clinic, Jacksonville, Florida, United States
| | - Nikhil A Kumta
- Icahn School of Medicine at Mount Sinai, New York, New York State, United States
| | - Rishi Pawa
- Wake Forest University School of Medicine, Winston-Salem, North Carolina, United States
| | - Manol Jovani
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland, USA
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9
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Bejjani M, Ghandour B, Subtil JC, Martínez-Moreno B, Sharaiha RZ, Watson RR, Kowalski TE, Benias PC, Huggett MT, Weber T, D'Souza LS, Anderloni A, Lajin M, Khara HS, Pham KDC, Pleskow D, Fabbri C, Nieto JM, Kumta NA, Pawa R, Jovani M, Khashab MA. Clinical and technical outcomes of patients undergoing endoscopic ultrasound-guided gastroenterostomy using 20-mm vs. 15-mm lumen-apposing metal stents. Endoscopy 2022; 54:680-687. [PMID: 34569611 DOI: 10.1055/a-1654-6914] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Most studies on endoscopic ultrasound (EUS)-guided gastroenterostomy (EUS-GE) for palliation of malignant gastric outlet obstruction (GOO) utilized a 15-mm lumen-apposing metal stent (LAMS). More recently, a 20-mm LAMS has become available. This study aimed to compare rates of technical and clinical success and adverse events (AEs) in patients undergoing EUS-GE using a 20-mm vs. 15-mm LAMS. METHODS Patients who underwent EUS-GE with 15-mm or 20-mm LAMS for malignant GOO during the period from January 2018 to October 2020 were included. The primary outcome was clinical success, defined as an increase in the gastric outlet obstruction score (GOOS) by at least 1 point during follow-up. Secondary outcomes were technical success, maximum tolerated diet, re-intervention rate, and rate/severity of AEs. RESULTS 267 patients (mean age 67 years, 43 % women) with malignant GOO from 19 centers underwent EUS-GE. Clinical success rates were similar for the 15-mm and 20-mm stents (89.2 % [95 %CI 84.2 %-94.2 %] vs. 84.1 % [77.4%-90.6 %], respectively). However, a significantly higher proportion of patients in the 20-mm group tolerated a soft solid/complete diet at the end of follow-up (91.2 % [84.4 %-95.7 %] vs. 81.2 % [73.9 %-87.2 %], P = 0.04). Overall, AEs occurred in 33 patients (12.4 % [8.4 %-16.3 %]), with similar rates for 15-mm and 20-mm stents (12.8 % [7.5 %-18.2 %] vs. 11.8 % [6 %-17.6 %]), including incidence of severe/fatal AEs (2 % [0.4 %-5.8 %] vs. 3.4 % [0.9 %-8.4 %]). CONCLUSIONS The 20-mm and 15-mm LAMS show similar safety and efficacy for patients undergoing EUS-GE for malignant GOO. The 20-mm LAMS allows a more advanced diet and is, thus preferred for EUS-GE.
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Affiliation(s)
- Michael Bejjani
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland, USA
| | - Bachir Ghandour
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland, USA
| | | | | | - Reem Z Sharaiha
- Weill Cornell Medicine, New York, New York State, United States
| | - Rabindra R Watson
- California Pacific Medical Center, San Francisco, California, United States
| | - Thomas E Kowalski
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Petros C Benias
- Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, New York, United States
| | | | - Tobias Weber
- University Hospital Augsburg, Augsburg, Bayern, Germany
| | - Lionel S D'Souza
- Stony Brook University Hospital, Stony Brook, New York, United States
| | - Andrea Anderloni
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Michael Lajin
- Sharp Grossmont Hospital, La Mesa, California, United States
| | - Harshit S Khara
- Geisinger Medical Center, Danville, Pennsylvania, United States
| | | | - Douglas Pleskow
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forli-Cesena Hospitals, AUSL Romagna, Romagna, Italy
| | - Jose M Nieto
- Borland Groover Clinic, Jacksonville, Florida, United States
| | - Nikhil A Kumta
- Icahn School of Medicine at Mount Sinai, New York, New York State, United States
| | - Rishi Pawa
- Wake Forest University School of Medicine, Winston-Salem, North Carolina, United States
| | - Manol Jovani
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland, USA
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10
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On W, Saleem MA, Hegade VS, Huggett MT, Paranandi B, Everett SM. Factors predicting 30-day mortality after ERCP in patients with inoperable malignant hilar biliary obstruction: a single tertiary referral centre experience and systematic review. BMJ Open Gastroenterol 2022; 9:bmjgast-2022-000878. [PMID: 35301232 PMCID: PMC8932256 DOI: 10.1136/bmjgast-2022-000878] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 02/21/2022] [Indexed: 12/07/2022] Open
Abstract
Objective There is a paucity of studies in the literature body evaluating short term outcomes following endoscopic retrograde cholangiopancreatography (ERCP) in patients with inoperable malignant hilar biliary obstruction (MHBO). We aimed to primarily evaluate 30-day mortality in these patients and secondarily, conduct a systematic review of studies reporting 30-day mortality. Design We conducted a retrospective analysis of all patients with inoperable MHBO who underwent ERCP at Leeds Teaching Hospitals NHS Trust between February 2015 and September 2020. Logistic regression models constructed from baseline patient data, the modified Glasgow Prognostic Score (mGPS) and Charlson Comorbidity Index (CCI) were evaluated as predictors of 30-day mortality. Results Eighty-seven patients (49 males) with a mean age of 70.4 years (SD ±12.3) were included. Cholangiocarcinoma was the most common aetiology of MHBO affecting 35/87 (40.2%). Technical success was achieved in 72/87 (82.8%). The 30-day mortality rate was 25.3% (22/87), of which 16 were due to progression of underlying malignant disease. On multivariate analysis, only leucocytosis (OR 4.12, 95% CI 2.70 to 7.41, p=0.02) was an independent predictor of 30-day mortality. Neither mGPS (p=0.47) nor CCI with a cut-off value of ≥7 (p=0.06) were significant predictors of 30-day mortality. Conclusion We demonstrated that 30-day mortality following ERCP for inoperable MHBO remains high despite technical success. Further studies are warranted to identify patients most appropriate for intervention.
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Affiliation(s)
- Wei On
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Muhammad A Saleem
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Vinod S Hegade
- Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Matthew T Huggett
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Bharat Paranandi
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Simon M Everett
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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11
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Stassen PMC, Goodchild G, de Jonge PJF, Erler NS, Anderloni A, Cennamo V, Church NI, Fernandez-Urien Sainz I, Huggett MT, James MW, Joshi D, Kylänpää L, Laleman W, Nayar MK, Oppong KW, Poley JW, Potts JR, Repici A, Udd M, Vila JJ, Wong T, Bruno MJ, Webster GJM. Diagnostic accuracy and interobserver agreement of digital single-operator cholangioscopy for indeterminate biliary strictures. Gastrointest Endosc 2021; 94:1059-1068. [PMID: 34216597 DOI: 10.1016/j.gie.2021.06.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 06/22/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Digital single-operator cholangioscopy (d-SOC) with cholangioscopic biopsy sampling has shown promise in the evaluation of indeterminate biliary strictures. Some studies have suggested higher sensitivity for visual impression compared with biopsy sampling, although assessors were not blinded to previous investigations. We aimed to investigate the diagnostic accuracy and interobserver agreement (IOA) of d-SOC in the visual appraisal of biliary strictures when blinded to additional information. METHODS A multicenter, international cohort study was performed. Cholangioscopic videos in patients with a known final diagnosis were systematically scored. Pseudonymized videos were reviewed by 19 experts in 2 steps: blinded for patient history and investigations and unblinded. RESULTS Forty-four high-quality videos were reviewed of 19 benign and 25 malignant strictures. The sensitivity and specificity for the diagnosis of malignancy was 74.2% and 46.9% (blinded) and 72.7% and 62.5% (unblinded). Cholangioscopic certainty of a malignant diagnosis led to overdiagnosis (sensitivity, 90.6%; specificity, 33%), especially if no additional information was provided. The IOA for the presence of malignancy was fair for both assessments (Fleiss' κ = .245 [blinded] and κ = .321 [unblended]). For individual visual features, the IOA ranged from slight to moderate for both assessments (κ = .059-.400 vs κ = .031-.452). CONCLUSIONS This study showed low sensitivity and specificity for blinded and unblinded d-SOC video appraisal of indeterminate biliary strictures, with considerable interobserver variation. Although reaching a consensus on the optical features of biliary strictures remains important, optimizing visually directed biopsy sampling may be the most important role of cholangioscopy in biliary stricture assessment.
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Affiliation(s)
- Pauline M C Stassen
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - George Goodchild
- Department of Gastroenterology, University College London Hospitals, London, UK
| | - Pieter Jan F de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nicole S Erler
- Department of Biostatistics, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center, Milan, Italy
| | - Vincenzo Cennamo
- Gastroenterology and Interventional Endoscopy Unit, Local Health Authority of Bologna, Bologna, Italy
| | - Nicholas I Church
- Department of Gastroenterology and Hepatology, Lothian University Hospitals NHS Trust, Edinburgh, UK
| | | | - Matthew T Huggett
- Department of Gastroenterology, St James's University Hospital, Leeds, UK
| | - Martin W James
- Nottingham Digestive Disease Centre (NDDC) and NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University and Nottingham University Hospitals NHS Trust, Queens Medical Centre, Nottingham, UK
| | - Deepak Joshi
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Leena Kylänpää
- Department of Gastroenterological surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic disorders, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Manu K Nayar
- HPB Unit Newcastle upon Tyne Hospitals, and Translational and Clinical Research Institute Newcastle University, Newcastle, UK
| | - Kofi W Oppong
- HPB Unit Newcastle upon Tyne Hospitals, and Translational and Clinical Research Institute Newcastle University, Newcastle, UK
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Alessandro Repici
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Marianne Udd
- Department of Gastroenterological surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juan J Vila
- Department of Gastroenterology and Hepatology, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Terence Wong
- Department of Gastroenterology and Hepatology, Guys and St Thomas' Hospital, London, UK
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - George J M Webster
- Department of Gastroenterology, University College London Hospitals, London, UK; Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK
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12
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Venkatachalapathy SV, James MW, Huggett MT, Paranandi B, Pereira SP, Johnson G, Aravinthan AD, Aithal GP. Utility of palliative EUS-guided biliary drainage using lumen-apposing metal stents: a prospective multicenter feasibility study (with video). Gastrointest Endosc 2021; 94:321-328. [PMID: 33545136 DOI: 10.1016/j.gie.2021.01.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 01/24/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Biliary drainage with ERCP is successful in only 80% to 90% of cases of extrahepatic cholangiocarcinoma and pancreatic cancer. We present the results of a multicenter prospective study assessing the safety, feasibility, and quality of life of patients after EUS-guided biliary drainage (EUS-BD) with lumen-apposing metal stents after failed ERCP. METHODS All consecutive adults with a dilated common bile duct (CBD) ≥14 mm secondary to inoperable malignant distal CBD stricture and failed ERCP biliary drainage were screened and recruited from 3 tertiary UK centers. Technical success of EUS-BD using lumen-apposing metal stents was the primary endpoint. Improvement in serum bilirubin level, 30-day mortality, procedure-related adverse events, and quality of life were secondary endpoints. Improvement in quality of life was measured using a validated questionnaire (EORTC QLQ-BIL21). RESULTS Twenty patients were included in the analysis. EUS-BD was technically successful in all patients and the clinical success rate was 95% (19 of 20) at day 7 (>50% reduction in bilirubin level) and 92.3% (12 of 13) at day 30 (bilirubin <50 μmol/L). There were significant improvements in overall quality of life score (49 vs 42, P = .03) at day 30. All-cause 30-day mortality was 20% and the moderate adverse event rate was 10% (1 cholangitis and 1 stent migration). CONCLUSION EUS-BD has acceptable technical success and safety as a second-line palliative treatment for inoperable malignant distal CBD strictures. Randomized controlled studies comparing EUS-BD with percutaneous transhepatic biliary drainage are needed to determine their effectiveness in clinical practice. (ISCRTN registration number: ISRCTN13196704.).
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Affiliation(s)
- Suresh Vasan Venkatachalapathy
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, United Kingdom
| | - Martin W James
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, United Kingdom
| | - Matthew T Huggett
- Leeds Teaching Hospitals NHS Trust - Gastroenterology, Leeds, United Kingdom
| | - Bharat Paranandi
- Leeds Teaching Hospitals NHS Trust - Gastroenterology, Leeds, United Kingdom
| | - Stephen P Pereira
- UCL Institute for Liver & Digestive Health, University College London, London, United Kingdom; Department of Gastroenterology, University College Hospitals NHS Foundation Trust, London, United Kingdom
| | - Gavin Johnson
- Department of Gastroenterology, University College Hospitals NHS Foundation Trust, London, United Kingdom
| | - Aloysious D Aravinthan
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, United Kingdom; Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Guruprasad P Aithal
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, United Kingdom; Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, United Kingdom
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13
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On W, Huggett MT. European Guideline on IgG4-related digestive disease: UEG and SGF evidence-based recommendations. Frontline Gastroenterol 2021; 13:171-174. [PMID: 35300469 PMCID: PMC8862498 DOI: 10.1136/flgastro-2021-101884] [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: 04/14/2021] [Accepted: 06/29/2021] [Indexed: 02/04/2023] Open
Abstract
Immunoglobulin subclass 4 related disease (IgG4-RD) is an increasingly recognised autoimmune disease with the potential of affecting various organs. It has a predilection for certain anatomical hotspots and the pancreatobiliary tract is the the most common area involved. Due to the relative novelty of IgG4-RD, the understanding of the disease process continues to involve. Recent European guidelines on IgG4-RD have been published by a working group collaboration between the United European Gastroenterology and Swedish Society of Gastroenterology. In our commentary, we aim to extract the key practical points with an emphasis on diagnosis and management of IgG4-RD with specific focus on the pancreatobiliary tract.
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Affiliation(s)
- Wei On
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Matthew T Huggett
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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14
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Runge TM, Chiang AL, Kowalski TE, James TW, Baron TH, Nieto J, Diehl DL, Krafft MR, Nasr JY, Kumar V, Khara HS, Irani S, Patel A, Law RJ, Loren DE, Schlachterman A, Hsueh W, Confer BD, Stevens TK, Chahal P, Al-Haddad MA, Mir FF, Pleskow DK, Huggett MT, Paranandi B, Trindade AJ, Brewer-Gutierrez OI, Ichkhanian Y, Dbouk M, Kumbhari V, Khashab MA. Endoscopic ultrasound-directed transgastric ERCP (EDGE): a retrospective multicenter study. Endoscopy 2021; 53:611-618. [PMID: 32882722 DOI: 10.1055/a-1254-3942] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [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: 02/07/2023]
Abstract
BACKGROUND Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP; EDGE) is an alternative to enteroscopy- and laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy. Although short-term results are promising, the long-term outcomes are not known. The aims of this study were: (1) to determine the rates of long-term adverse events after EDGE, with a focus on rates of persistent gastrogastric or jejunogastric fistula; (2) to identify predictors of persistent fistula; (3) to assess the outcomes of endoscopic closure when persistent fistula is encountered. METHODS This was a multicenter retrospective study involving 13 centers between February 2015 and March 2019. Adverse events were defined according to the ASGE lexicon. Persistent fistula was defined as an upper gastrointestinal series or esophagogastroduodenoscopy showing evidence of fistula. RESULTS 178 patients (mean age 58 years, 79 % women) underwent EDGE. Technical success was achieved in 98 % of cases (175/178), with a mean procedure time of 92 minutes. Periprocedural adverse events occurred in 28 patients (15.7 %; mild 10.1 %, moderate 3.4 %, severe 2.2 %). The four severe adverse events were managed laparoscopically. Persistent fistula was diagnosed in 10 % of those sent for objective testing (9/90). Following identification of a fistula, 5 /9 patients underwent endoscopic closure procedures, which were successful in all cases. CONCLUSIONS The EDGE procedure is associated with high clinical success rates and an acceptable risk profile. Persistent fistulas after lumen-apposing stent removal are uncommon, but objective testing is recommended to identify their presence. When persistent fistulas are identified, endoscopic treatment is warranted, and should be successful in closing the fistula.
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Affiliation(s)
- Thomas M Runge
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Austin L Chiang
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Thomas E Kowalski
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Theodore W James
- Division of Gastroenterology and Hepatology, University of North Carolina Hospitals, Chapel Hill, North Carolina, USA
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina Hospitals, Chapel Hill, North Carolina, USA
| | - Jose Nieto
- Borland Groover Clinic, Advanced Therapeutic Endoscopy Center, Jacksonville, Florida, USA
| | - David L Diehl
- Department of Gastroenterology, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Matthew R Krafft
- Section of Digestive Diseases, Department of Medicine, West Virginia University, Morgantown West Virginia, USA
| | - John Y Nasr
- Section of Digestive Diseases, Department of Medicine, West Virginia University, Morgantown West Virginia, USA
| | - Vikas Kumar
- Department of Gastroenterology, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Harshit S Khara
- Department of Gastroenterology, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Shayan Irani
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Arpan Patel
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Ryan J Law
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - David E Loren
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Alex Schlachterman
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - William Hsueh
- Section of Digestive Diseases, Department of Medicine, West Virginia University, Morgantown West Virginia, USA
| | - Bradley D Confer
- Department of Gastroenterology, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Tyler K Stevens
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Prabhleen Chahal
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Mohammad A Al-Haddad
- Division of Gastroenterology, Indiana School of Medicine, Indianapolis, Indiana, USA
| | - Fahad Faisal Mir
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconness Medical Center, Boston, Massachusetts, USA
| | - Douglas K Pleskow
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconness Medical Center, Boston, Massachusetts, USA
| | - Matthew T Huggett
- Department of Gastroenterology, St. James' University Hospital, Leeds, UK
| | - Bharat Paranandi
- Department of Gastroenterology, St. James' University Hospital, Leeds, UK
| | - Arvind J Trindade
- Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health, New Hyde Park, New York, USA
| | - Olaya I Brewer-Gutierrez
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Mohamad Dbouk
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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15
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Ishtiaq M, Rana F, Maurice J, Huggett MT, Everett SM. Controversies in ERCP: frontline Gastroenterology Twitter debate. Frontline Gastroenterol 2020; 12:158-161. [PMID: 33613950 PMCID: PMC7873538 DOI: 10.1136/flgastro-2020-101479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 04/27/2020] [Accepted: 04/30/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
| | - Fahd Rana
- Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - James Maurice
- Department of Gastroenterology, Barts Health NHS Trust, London, UK
| | - Matthew T Huggett
- Gastroenterology, St James's University Hospital, The Leeds Teaching Hospitals NHS Foundation Trust, Leeds, UK
| | - Simon M Everett
- Gastroenterology, St James's University Hospital NHS Trust, Leeds, UK
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16
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Parsa N, Nieto JM, Powers P, Mitsuhashi S, Abdelqader A, Hadzinakos G, Anderloni AA, Fugazza A, James TW, Arlt A, Ellrichmann M, Aparicio JR, Trindade AJ, Stevens TK, Chahal P, Shah SL, Messallam AA, Lang G, Fejleh MP, Benias PC, Sejpal DV, Jones J, Mir FF, Aghaie Meybodi M, Ichkhanian Y, Vosoughi K, Novikov AA, Irani SS, Pawa R, Ahmed AM, Sedarat A, Hsueh W, Hampe J, Sharaiha RZ, Berzin TM, Willingham FF, Kushnir VM, Brewer Gutierrez OI, Ngamruengphong S, Huggett MT, Baron TH, Repici A, Adler DG, Nasr JT, Kowalski TE, Kumbhari V, Singh VK, Khashab MA. Endoscopic ultrasound-guided drainage of pancreatic walled-off necrosis using 20-mm versus 15-mm lumen-apposing metal stents: an international, multicenter, case-matched study. Endoscopy 2020; 52:211-219. [PMID: 32000275 DOI: 10.1055/a-1096-3299] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUNDS Endoscopic ultrasound (EUS)-guided placement of lumen-apposing metal stents (LAMSs) has gained popularity for the treatment of pancreatic walled-off necrosis (WON). We compared the 20-mm and 15-mm LAMSs for the treatment of symptomatic WON in terms of clinical success and adverse events. METHODS We conducted a retrospective, case-matched study of 306 adults at 22 tertiary centers from 04/2014 to 10/2018. A total of 102 patients with symptomatic WON who underwent drainage with 20-mm LAMS (cases) and 204 patients who underwent drainage with 15-mm LAMS (controls) were matched by age, sex, and drainage approach. Conditional logistic regression analysis was performed to compare clinical success (resolution of WON on follow-up imaging without reintervention) and adverse events (according to American Society for Gastrointestinal Endoscopy criteria). RESULTS Clinical success was achieved in 92.2 % of patients with 20-mm LAMS and 91.7 % of patients with 15-mm LAMS (odds ratio 0.92; P = 0.91). Patients with 20-mm LAMS underwent fewer direct endoscopic necrosectomy (DEN) sessions (mean 1.3 vs. 2.1; P < 0.001), despite having larger WON collections (transverse axis 118.2 vs. 101.9 mm, P = 0.003; anteroposterior axis 95.9 vs. 80.1 mm, P = 0.01). There was no difference in overall adverse events (21.6 % vs. 15.2 %; P = 0.72) and bleeding events (4.9 % vs. 3.4 %; P = 0.54) between the 20-mm and 15-mm LAMS groups, respectively. CONCLUSIONS The 20-mm LAMS showed comparable clinical success and safety profile to the 15-mm LAMS, with the need for fewer DEN sessions for WON resolution.
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Affiliation(s)
- Nasim Parsa
- University of Missouri Health System, Columbia, Missouri, United States
| | - Jose M Nieto
- Borland Groover Clinic, Jacksonville, Florida, United States
| | - Patrick Powers
- University of Utah School of Medicine, Huntsman Cancer Hospital, Salt Lake City, Utah, United States
| | - Shuji Mitsuhashi
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | | | | | | | | | - Theodore W James
- University of North Carolina, Chapel Hill, North Carolina, United States
| | | | | | | | - Arvind J Trindade
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New York, New York, United States
| | | | | | - Shawn L Shah
- New York-Presbyterian/Weill Cornell Medical Center, New York, New York, United States
| | - Ahmed A Messallam
- Emory University School of Medicine, Atlanta, Georgia, United States
| | - Gabriel Lang
- Washington University School of Medicine, St Louis, Missouri, United States
| | | | - Petros C Benias
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New York, New York, United States
| | - Divyesh V Sejpal
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New York, New York, United States
| | - Jason Jones
- Wake Forest Baptist Medical Center, Winston Salem, North Carolina, United States
| | - Fahad Faisal Mir
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | | | | | - Kia Vosoughi
- Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Aleksey A Novikov
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Shayan S Irani
- Virginia Mason Medical Center, Seattle, Washington, United States
| | - Rishi Pawa
- Wake Forest Baptist Medical Center, Winston Salem, North Carolina, United States
| | - Ali M Ahmed
- University of Alabama, Birmingham, Alabama, United States
| | | | - William Hsueh
- West Virginia University Hospital, Morgantown, West Virginia, United States
| | - Jochen Hampe
- University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Reem Z Sharaiha
- New York-Presbyterian/Weill Cornell Medical Center, New York, New York, United States
| | - Tyler M Berzin
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | | | - Vladimir M Kushnir
- Washington University School of Medicine, St Louis, Missouri, United States
| | | | | | | | - Todd H Baron
- University of North Carolina, Chapel Hill, North Carolina, United States
| | - Alessandro Repici
- Digestive Endoscopy Unit, Humanitas Research Hospital, Rozzano, Italy
| | - Douglas G Adler
- University of Utah School of Medicine, Huntsman Cancer Hospital, Salt Lake City, Utah, United States
| | - John T Nasr
- West Virginia University Hospital, Morgantown, West Virginia, United States
| | - Thomas E Kowalski
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Vivek Kumbhari
- Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Vikesh K Singh
- Johns Hopkins Hospital, Baltimore, Maryland, United States
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17
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Keegan MJ, Bell J, Westwood A, Cairns A, Albazaz R, Huggett MT. Painless jaundice with pancreatic mass in 79-year-old man receiving bortezomib for relapsed multiple myeloma. Frontline Gastroenterol 2019; 11:335-336. [PMID: 32587677 PMCID: PMC7307266 DOI: 10.1136/flgastro-2018-101163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 05/02/2019] [Accepted: 05/03/2019] [Indexed: 02/04/2023] Open
Affiliation(s)
- Mathew James Keegan
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Joshua Bell
- Department of Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Alice Westwood
- Department of Histopathology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Alison Cairns
- Department of Histopathology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Raneem Albazaz
- Department of Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Matthew T Huggett
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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18
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Hegade VS, Sheridan MB, Huggett MT. Diagnosis and management of IgG4-related disease. Frontline Gastroenterol 2019; 10:275-283. [PMID: 31288262 PMCID: PMC6583577 DOI: 10.1136/flgastro-2018-101001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 09/09/2018] [Accepted: 09/29/2018] [Indexed: 02/04/2023] Open
Abstract
IgG subclass 4-related disease (IgG4-RD) is a rare but increasingly recognised fibroinflammatory condition known to affect multiple organs. IgG4-RD is characterised by unique histological features of lymphoplasmacytic infiltration, storiform fibrosis and obliterative phlebitis. In this review we describe the pancreaticobiliary manifestations of IgG4-RD, with particular emphasis on type 1 autoimmune pancreatitis (AIP) and IgG4-related sclerosing cholangitis (IgG4-SC). AIP and IgG4-SC can pose diagnostic challenges to the clinician as they may mimic pancreatic cancer and primary sclerosing cholangitis, respectively. We discuss current knowledge, clinical diagnostic criteria and recent advances and summarise the evidence base for current therapeutic approaches for AIP and IgG4-SC.
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Affiliation(s)
- Vinod S Hegade
- Department of Gastroenterology, St James University Hospital, Leeds, UK
| | - Maria B Sheridan
- Department of Radiology, St James University Hospital, Leeds, UK
| | - Matthew T Huggett
- Department of Gastroenterology, St James University Hospital, Leeds, UK
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19
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Hart AR, Johnson G, Huggett MT. Progressing pancreaticobiliary medicine in the UK. Frontline Gastroenterol 2019; 10:206-207. [PMID: 31288254 PMCID: PMC6583572 DOI: 10.1136/flgastro-2019-101192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 03/24/2019] [Accepted: 03/25/2019] [Indexed: 02/04/2023] Open
Affiliation(s)
- Andrew R Hart
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Gavin Johnson
- Gastroenterology, University College London Medical School, London, UK
| | - Matthew T Huggett
- Gastroenterology, St James' University Hospital, The Leeds Teaching Hospitals NHS Foundation Trust, Leeds, UK
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20
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Bekkali NLH, Nayar MK, Leeds JS, Charnley RM, Huggett MT, Oppong KW. A comparison of outcomes between a lumen-apposing metal stent with electrocautery-enhanced delivery system and a bi-flanged metal stent for drainage of walled-off pancreatic necrosis. Endosc Int Open 2017; 5:E1189-E1196. [PMID: 29202002 PMCID: PMC5698007 DOI: 10.1055/s-0043-120831] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 07/31/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Bi-flanged metal stents (BFMS) have shown promise in the drainage of walled-off pancreatic necrosis (WON), but their placement requires multiple steps and the use of other devices. More recently, a novel device consisting of a combined lumen-apposing metal stent (LAMS) and electrocautery-enhanced delivery system has been introduced. The aim of this study was to compare the placement and outcomes of the two devices. PATIENTS AND METHODS This was a retrospective review of consecutive patients undergoing endoscopic ultrasound-guided placement of BFMS or LAMS for drainage of symptomatic WON. Data from procedures between October 2012 and December 2016 were taken from a prospectively maintained database. We compared technical and clinical success, procedure time, costs, and composite end point of significant events (adverse events, stent migration, additional percutaneous drainage) between BFMS and LAMS. RESULTS 72 consecutive patients underwent placement of BFMS (40 patients, 44 stents) or LAMS (32 patients, 33 stents). Technical success was 91 % for BFMS and 97 % for LAMS. Clinical success was 65 % vs. 78 %, respectively. Median in-room procedure time was significantly shorter in the LAMS group (45 minutes [range 30 - 80]) than in the BFMS group (62.5 minutes [range 35 - 135]; P < 0.001) and fewer direct endoscopic necrosectomies (DEN) were performed (median 1 [0 - 2.0] vs. 2 [0 - 3.7], respectively; P = 0.005). If only inpatients were considered (35 BFMS and 19 LAMS), there was no significant difference in DEN 2 (range 0 - 11) and 2 (range 0 - 8), respectively. The composite end point of 32 % vs. 24 % was not significantly different. Median procedural costs for all patients with successful stent placement for WON treatment was €4427 (range 1630 - 12 926) for BFMS vs. €3500 (range 2509 - 13 393) for LAMS ( P = 0.10). CONCLUSION LAMS was superior to BFMS in terms of procedure time, with comparable adverse events, success, and costs.
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Affiliation(s)
- Noor L. H. Bekkali
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, United Kingdom,Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Manu K. Nayar
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, United Kingdom,Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - John S. Leeds
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, United Kingdom,Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Richard M. Charnley
- Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, United Kingdom,Department of Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Matthew T. Huggett
- Department of Gastroenterology, St. James’s University Hospital, Leeds, United Kingdom
| | - Kofi W. Oppong
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, United Kingdom,Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, United Kingdom,Corresponding author Kofi W. Oppong, MD HPB UnitFreeman HospitalNewcastle upon Tyne NE7 7DNUnited Kingdom+44-191-2231249
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21
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Ryan BM, Venkatachalapathy SV, Huggett MT. Safety of lumen-apposing metal stents (LAMS) for pancreatic fluid collection drainage. Gut 2017; 66:1530-1531. [PMID: 27986785 DOI: 10.1136/gutjnl-2016-313388] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 11/22/2016] [Accepted: 11/27/2016] [Indexed: 12/08/2022]
Affiliation(s)
- Barbara M Ryan
- Department of Gastroenterology, Tallaght Hospital and Trinity College, Dublin, Ireland
| | | | - Matthew T Huggett
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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22
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Huggett MT, Tudzarova S, Proctor I, Loddo M, Keane MG, Stoeber K, Williams GH, Pereira SP. Cdc7 is a potent anti-cancer target in pancreatic cancer due to abrogation of the DNA origin activation checkpoint. Oncotarget 2017; 7:18495-507. [PMID: 26921250 PMCID: PMC4951304 DOI: 10.18632/oncotarget.7611] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 01/23/2016] [Indexed: 02/06/2023] Open
Abstract
Purpose Cdc7 is a serine/threonine kinase which is responsible for the ‘firing’ of replication origins leading to initiation of DNA replication. Inhibition or depletion of Cdc7 in normal cells triggers a DNA origin activation checkpoint causing a reversible G1 arrest. Here we investigate Cdc7 as a novel therapeutic target in pancreatic cancer. Experimental design Cdc7 target validation was performed by immunoexpression profiling in a cohort of 73 patients with pancreatic adenocarcinoma including 24 controls. Secondly Cdc7 kinase was targeted in Capan-1 and PANC-1 pancreatic cancer cell line models using either an siRNA against Cdc7 or alternatively a small molecule inhibitor (SMI) of Cdc7 (PHA-767491). Results Cdc7 was significantly overexpressed in pancreatic adenocarcinoma compared to benign pancreatic tissue (median LI 34.3% vs. 1.3%; P<0.0001). Cdc7 knockdown using siRNA in Capan-1 and PANC-1 cells resulted in marked apoptotic cell death when compared with control cells. A prominent sub-G1 peak was seen on flow cytometry (sub-G1 51% vs. 3% and 45% vs. 0.7% in Capan-1 and PANC-1 cells, respectively). Annexin V labelling confirmed apoptosis in 64% vs. 11% and 75% vs. 8%, respectively. Western blotting showed cleavage of PARP-1 and caspase-3 and presence of γH2A.X. TUNEL assay showed strong staining in treated cells. These results were mirrored following Cdc7 kinase inhibition with PHA-767491. Conclusions Our findings show that Cdc7 is a potent anti-cancer target in pancreatic adenocarcinoma and that Cdc7 immunoexpression levels might be used as a companion diagnostic to predict response to therapeutic siRNAs or SMIs directed against this kinase.
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Affiliation(s)
- Matthew T Huggett
- UCL Institute for Liver and Digestive Health and UCL Cancer Institute, University College London, London, UK.,The Research Department of Pathology, UCL Cancer Institute, University College London, London, UK
| | - Slavica Tudzarova
- The Research Department of Pathology, UCL Cancer Institute, University College London, London, UK
| | - Ian Proctor
- The Research Department of Pathology, UCL Cancer Institute, University College London, London, UK
| | - Marco Loddo
- The Research Department of Pathology, UCL Cancer Institute, University College London, London, UK.,Oncologica Ltd, The Science Village, Chesterford Research Park, Cambridge, UK
| | - Margaret G Keane
- UCL Institute for Liver and Digestive Health and UCL Cancer Institute, University College London, London, UK
| | - Kai Stoeber
- The Research Department of Pathology, UCL Cancer Institute, University College London, London, UK
| | - Gareth H Williams
- The Research Department of Pathology, UCL Cancer Institute, University College London, London, UK.,Oncologica Ltd, The Science Village, Chesterford Research Park, Cambridge, UK
| | - Stephen P Pereira
- UCL Institute for Liver and Digestive Health and UCL Cancer Institute, University College London, London, UK
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23
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Jais B, Rebours V, Malleo G, Salvia R, Fontana M, Maggino L, Bassi C, Manfredi R, Moran R, Lennon AM, Zaheer A, Wolfgang C, Hruban R, Marchegiani G, Fernández Del Castillo C, Brugge W, Ha Y, Kim MH, Oh D, Hirai I, Kimura W, Jang JY, Kim SW, Jung W, Kang H, Song SY, Kang CM, Lee WJ, Crippa S, Falconi M, Gomatos I, Neoptolemos J, Milanetto AC, Sperti C, Ricci C, Casadei R, Bissolati M, Balzano G, Frigerio I, Girelli R, Delhaye M, Bernier B, Wang H, Jang KT, Song DH, Huggett MT, Oppong KW, Pererva L, Kopchak KV, Del Chiaro M, Segersvard R, Lee LS, Conwell D, Osvaldt A, Campos V, Aguero Garcete G, Napoleon B, Matsumoto I, Shinzeki M, Bolado F, Fernandez JMU, Keane MG, Pereira SP, Acuna IA, Vaquero EC, Angiolini MR, Zerbi A, Tang J, Leong RW, Faccinetto A, Morana G, Petrone MC, Arcidiacono PG, Moon JH, Choi HJ, Gill RS, Pavey D, Ouaïssi M, Sastre B, Spandre M, De Angelis CG, Rios-Vives MA, Concepcion-Martin M, Ikeura T, Okazaki K, Frulloni L, Messina O, Lévy P. Serous cystic neoplasm of the pancreas: a multinational study of 2622 patients under the auspices of the International Association of Pancreatology and European Pancreatic Club (European Study Group on Cystic Tumors of the Pancreas). Gut 2016; 65:305-12. [PMID: 26045140 DOI: 10.1136/gutjnl-2015-309638] [Citation(s) in RCA: 173] [Impact Index Per Article: 21.6] [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: 03/22/2015] [Accepted: 05/11/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Serous cystic neoplasm (SCN) is a cystic neoplasm of the pancreas whose natural history is poorly known. The purpose of the study was to attempt to describe the natural history of SCN, including the specific mortality. DESIGN Retrospective multinational study including SCN diagnosed between 1990 and 2014. RESULTS 2622 patients were included. Seventy-four per cent were women, and median age at diagnosis was 58 years (16-99). Patients presented with non-specific abdominal pain (27%), pancreaticobiliary symptoms (9%), diabetes mellitus (5%), other symptoms (4%) and/or were asymptomatic (61%). Fifty-two per cent of patients were operated on during the first year after diagnosis (median size: 40 mm (2-200)), 9% had resection beyond 1 year of follow-up (3 years (1-20), size at diagnosis: 25 mm (4-140)) and 39% had no surgery (3.6 years (1-23), 25.5 mm (1-200)). Surgical indications were (not exclusive) uncertain diagnosis (60%), symptoms (23%), size increase (12%), large size (6%) and adjacent organ compression (5%). In patients followed beyond 1 year (n=1271), size increased in 37% (growth rate: 4 mm/year), was stable in 57% and decreased in 6%. Three serous cystadenocarcinomas were recorded. Postoperative mortality was 0.6% (n=10), and SCN's related mortality was 0.1% (n=1). CONCLUSIONS After a 3-year follow-up, clinical relevant symptoms occurred in a very small proportion of patients and size slowly increased in less than half. Surgical treatment should be proposed only for diagnosis remaining uncertain after complete workup, significant and related symptoms or exceptionally when exists concern with malignancy. This study supports an initial conservative management in the majority of patients with SCN. TRIAL REGISTRATION NUMBER IRB 00006477.
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Affiliation(s)
- B Jais
- Department of Gastroenterology and Pancreatology, Beaujon Hospital, AP-HP, Clichy, France
| | - V Rebours
- Department of Gastroenterology and Pancreatology, Beaujon Hospital, AP-HP, Clichy, France
| | - G Malleo
- The Pancreas Institute, G.B. Rossi Hospital, University of Verona Hospital Trust, Verona, Italy
| | - R Salvia
- The Pancreas Institute, G.B. Rossi Hospital, University of Verona Hospital Trust, Verona, Italy
| | - M Fontana
- The Pancreas Institute, G.B. Rossi Hospital, University of Verona Hospital Trust, Verona, Italy
| | - L Maggino
- The Pancreas Institute, G.B. Rossi Hospital, University of Verona Hospital Trust, Verona, Italy
| | - C Bassi
- The Pancreas Institute, G.B. Rossi Hospital, University of Verona Hospital Trust, Verona, Italy
| | - R Manfredi
- The Pancreas Institute, G.B. Rossi Hospital, University of Verona Hospital Trust, Verona, Italy
| | - R Moran
- Division of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Division of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - A M Lennon
- Division of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Division of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - A Zaheer
- Division of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Division of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - C Wolfgang
- Division of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Division of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - R Hruban
- Division of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Division of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - G Marchegiani
- Departments of Surgery and Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - C Fernández Del Castillo
- Departments of Surgery and Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - W Brugge
- Departments of Surgery and Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Y Ha
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - M H Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - D Oh
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - I Hirai
- First Department of Surgery, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - W Kimura
- First Department of Surgery, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - J Y Jang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - S W Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - W Jung
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - H Kang
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - S Y Song
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - C M Kang
- Department of Surgery, Yonsei University College of Medicine, Pancreaticobiliary Cancer Clinic, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - W J Lee
- Department of Surgery, Yonsei University College of Medicine, Pancreaticobiliary Cancer Clinic, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - S Crippa
- Pancreatic Surgery Unit, Department of Surgery, Polytechnic University of Marche Region, Ancona-Torrette, Italy
| | - M Falconi
- Pancreatic Surgery Unit, Department of Surgery, Polytechnic University of Marche Region, Ancona-Torrette, Italy
| | - I Gomatos
- NIHR Pancreas Biomedical Research Unit, Department of Molecular and Clinical Cancer Medicine, Royal Liverpool University Hospital, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - J Neoptolemos
- NIHR Pancreas Biomedical Research Unit, Department of Molecular and Clinical Cancer Medicine, Royal Liverpool University Hospital, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - A C Milanetto
- Department of Surgery, Oncology and Gastroenterology, 3rd Surgical Clinic, University of Padua, Padua, Italy
| | - C Sperti
- Department of Surgery, Oncology and Gastroenterology, 3rd Surgical Clinic, University of Padua, Padua, Italy
| | - C Ricci
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - R Casadei
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - M Bissolati
- Pancreatic Surgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - G Balzano
- Pancreatic Surgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - I Frigerio
- Hepato-Pancreato-Biliary Unit, Pederzoli Hospital, Peschiera del Garda, Italy
| | - R Girelli
- Hepato-Pancreato-Biliary Unit, Pederzoli Hospital, Peschiera del Garda, Italy
| | - M Delhaye
- Department of Gastroenterology, Hepatopancreatology and GI Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - B Bernier
- Department of Gastroenterology, Hepatopancreatology and GI Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - H Wang
- Institute of Hepatopancreatobiliary Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - K T Jang
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - D H Song
- Department of Pathology, Gyeongsang National University School of Medicine, Jinju, Korea
| | - M T Huggett
- Hepato-Pancreato-Biliary Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - K W Oppong
- Hepato-Pancreato-Biliary Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - L Pererva
- National Institute of Surgery and Transplantology named after Shalimov, Kiev, Ukraine
| | - K V Kopchak
- National Institute of Surgery and Transplantology named after Shalimov, Kiev, Ukraine
| | - M Del Chiaro
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - R Segersvard
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - L S Lee
- Division of Gastroenterology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - D Conwell
- Division of Gastroenterology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - A Osvaldt
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - V Campos
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | - B Napoleon
- Hôpital Privé Mermoz, Gastroentérologie, Lyon, France
| | - I Matsumoto
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - M Shinzeki
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - F Bolado
- Gastroenterology Department, Hospital de Navarra, Pamplona, Spain
| | | | - M G Keane
- Department of Gastroenterology and Hepatology, University College Hospital, London, UK
| | - S P Pereira
- Department of Gastroenterology and Hepatology, University College Hospital, London, UK
| | - I Araujo Acuna
- Department of Gastroenterology, Hospital Clinic, CIBEREHD, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - E C Vaquero
- Department of Gastroenterology, Hospital Clinic, CIBEREHD, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - M R Angiolini
- Department of Pancreatic Surgery, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - A Zerbi
- Department of Pancreatic Surgery, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - J Tang
- Gastroenterology and Liver Services, Concord Hospital, Sydney, New South Wales, Australia
| | - R W Leong
- Gastroenterology and Liver Services, Concord Hospital, Sydney, New South Wales, Australia
| | - A Faccinetto
- Radiological Department, General Hospital Cá Foncello, Treviso, Italy
| | - G Morana
- Radiological Department, General Hospital Cá Foncello, Treviso, Italy
| | - M C Petrone
- Division of Gastroenterology and Gastrointestinal Endoscopy, San Raffaele Scientific Institute, Milan, Italy
| | - P G Arcidiacono
- Division of Gastroenterology and Gastrointestinal Endoscopy, San Raffaele Scientific Institute, Milan, Italy
| | - J H Moon
- Department of Internal Medicine, Digestive Disease Center and Research Institute, SoonChunHyang University School of Medicine, Bucheon, Korea
| | - H J Choi
- Department of Internal Medicine, Digestive Disease Center and Research Institute, SoonChunHyang University School of Medicine, Bucheon, Korea
| | - R S Gill
- Department of Gastroenterology, Bankstown-Lidcombe Hospital, Bankstown, New South Wales, Australia
| | - D Pavey
- Department of Gastroenterology, Bankstown-Lidcombe Hospital, Bankstown, New South Wales, Australia
| | - M Ouaïssi
- Department of Digestive Surgery, Timone Hospital, Marseille, France
| | - B Sastre
- Department of Digestive Surgery, Timone Hospital, Marseille, France
| | - M Spandre
- Gastrohepatology Department, San Giovanni Battista Molinette Hospital, University of Turin, Turin, Italy
| | - C G De Angelis
- Gastrohepatology Department, San Giovanni Battista Molinette Hospital, University of Turin, Turin, Italy
| | - M A Rios-Vives
- Gastroenterology Department, Hospital de la Santa Creu i Sant Pau, Institut de Reçerca-IIB Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - M Concepcion-Martin
- Gastroenterology Department, Hospital de la Santa Creu i Sant Pau, Institut de Reçerca-IIB Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - T Ikeura
- The Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
| | - K Okazaki
- The Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
| | - L Frulloni
- Department of Medicine, Pancreas Center, University of Verona, Verona, Italy
| | - O Messina
- Department of Medicine, Pancreas Center, University of Verona, Verona, Italy
| | - P Lévy
- Department of Gastroenterology and Pancreatology, Beaujon Hospital, AP-HP, Clichy, France
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Huggett MT, Oppong KW, Pereira SP, Keane MG, Mitra V, Charnley RM, Nayar MK. Endoscopic drainage of walled-off pancreatic necrosis using a novel self-expanding metal stent. Endoscopy 2015; 47:929-32. [PMID: 26126156 DOI: 10.1055/s-0034-1392413] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND STUDY AIMS This report describes the use of a novel, fully covered, self-expanding metal stent (FCSEMS) for endoscopic ultrasound (EUS)-guided drainage of walled-off pancreatic necrosis (WON). PATIENTS AND METHODS Patients with WON, as defined by the revised Atlanta Criteria, were included in this open-lable, two-center, observational study. The WON was punctured using a cystotome, and the FCSEMS was inserted under fluoroscopic guidance. Necrosectomy procedures were performed as necessary. RESULTS A total of 19 patients were included. The median maximum collection size was 15 cm with a median of 50 % necrosis. A total of 14/19 patients underwent necrosectomy, requiring a median of 4 procedures. Resolution or reduction in the size of collection by at least 80 % was achieved in all patients. Percutaneous or surgical drainage was required in three patients. Five stents migrated or dislodged. One patient had abdominal pain post-procedure. Five patients died during follow-up (three from multi-organ failure, and two unrelated to pancreatitis). CONCLUSIONS Use of this stent is feasible and safe for drainage of WON. However, stent displacement rates were high, and improvements to the stent design are required before it can be advocated for routine use in WON.
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Affiliation(s)
- Matthew T Huggett
- Department of Gastroenterology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
| | - Kofi W Oppong
- Department of Gastroenterology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
| | - Stephen P Pereira
- Department of Gastroenterology, University College Hospital, London, United Kingdom
| | - Margaret G Keane
- Department of Gastroenterology, University College Hospital, London, United Kingdom
| | - Vikramjit Mitra
- Department of Gastroenterology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
| | - Richard M Charnley
- Department of HPB Surgery, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
| | - Manu K Nayar
- Department of Gastroenterology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
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Huggett MT, Culver E, Kumar M, Hurst J, Rodriguez-Justo M, Chapman M, Johnson G, Pereira S, Chapman R, Webster GJ, Barnes E. Type 1 autoimmune pancreatitis and IgG4-related sclerosing cholangitis is associated with extrapancreatic organ failure, malignancy, and mortality in a prospective UK cohort. Am J Gastroenterol 2014; 109:1675-1683. [PMID: 25155229 PMCID: PMC4552254 DOI: 10.1038/ajg.2014.223] [Citation(s) in RCA: 157] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 07/25/2014] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Type I autoimmune pancreatitis (AIP) and IgG4-related sclerosing cholangitis (IgG4-related SC) are now recognized as components of a multisystem IgG4-related disease (IgG4-RD). We aimed to define the clinical course and long-term outcomes in patients with AIP/IgG4-SC recruited from two large UK tertiary referral centers. METHODS Data were collected from 115 patients identified between 2004 and 2013, and all were followed up prospectively from diagnosis for a median of 33 months (range 1-107), and evaluated for response to therapy, the development of multiorgan involvement, and malignancy. Comparisons were made with national UK statistics. RESULTS Although there was an initial response to steroids in 97%, relapse occurred in 50% of patients. IgG4-SC was an important predictor of relapse (P<0.01). Malignancy occurred in 11% shortly before or after the diagnosis of IgG4-RD, including three hepatopancreaticobiliary cancers. The risk of any cancer at diagnosis or during follow-up when compared with matched national statistics was increased (odds ratio=2.25, CI=1.12-3.94, P=0.02). Organ dysfunction occurred within the pancreas, liver, kidney, lung, and brain. Mortality occurred in 10% of patients during follow-up. The risk of death was increased compared with matched national statistics (odds ratio=2.07, CI=1.07-3.55, P=0.02). CONCLUSIONS Our findings suggest that AIP and IgG4-SC are associated with significant morbidity and mortality owing to extrapancreatic organ failure and malignancy. Detailed clinical evaluation for evidence of organ dysfunction and associated malignancy is required both at first presentation and during long-term follow-up.
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Affiliation(s)
- Matthew T. Huggett
- UCL Institute for Liver and Digestive Health, University College London, London, UK
,Department of Gastroenterology and Hepatology, University College Hospital, London, UK
| | - E.L. Culver
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
,NDM Oxford University, Oxford Martin School, Oxford University, Oxford, UK
| | - M. Kumar
- Department of Gastroenterology and Hepatology, University College Hospital, London, UK
| | - J.M. Hurst
- Institute of Emerging Diseases, Oxford Martin School, Oxford University, Oxford, UK
| | | | - M.H. Chapman
- Department of Gastroenterology and Hepatology, University College Hospital, London, UK
| | - G.J. Johnson
- Department of Gastroenterology and Hepatology, University College Hospital, London, UK
| | - S.P. Pereira
- UCL Institute for Liver and Digestive Health, University College London, London, UK
,Department of Gastroenterology and Hepatology, University College Hospital, London, UK
| | - R.W. Chapman
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
,NDM Oxford University, Oxford Martin School, Oxford University, Oxford, UK
| | - George J.M. Webster
- Department of Gastroenterology and Hepatology, University College Hospital, London, UK
| | - E. Barnes
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
,NDM Oxford University, Oxford Martin School, Oxford University, Oxford, UK
,Oxford NIHR BRC, Oxford University, Oxford, UK
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Huggett MT, Passant H, Hurt C, Pereira SP, Bridgewater J, Mukherjee S. Outcome and patterns of care in advanced biliary tract carcinoma (ABC): experience from two tertiary institutions in the United Kingdom. Tumori 2014. [PMID: 24852869 DOI: 10.1700/1491.16421] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS AND BACKGROUND The ABC-02 trial has defined the standard therapy for patients with advanced biliary tract cancer (ABC); however, outcome in an unselected patient population in the UK has not been described. We aimed to investigate the outcome of a series of patients with ABC from two large UK cancer networks. METHODS AND STUDY DESIGN We retrospectively reviewed all cases of ABC presenting to two UK cancer networks over a nine-year period. Overall survival (OS) and factors influencing OS were assessed. RESULTS Four hundred and two patients were available for analysis. The median OS was 6.2 months. On univariate analysis, age ≥70 years (P = 0.047), advanced disease stage (P <0.001), gall bladder primary (P = 0.033), poor performance status (P <0.001) and lack of chemotherapy (P <0.001) were associated with worse outcome. Survival was superior in the 36.4% of patients who received palliative chemotherapy (12.5 vs 4.3 months; P <0.001). On multivariate analysis of patients who had chemotherapy, those who did not receive fluoropyrimidine-based regimens (HR = 5.12; P = 0.022) or gemcitabine-based regimens (HR = 5.01; P = 0.021) had a higher mortality, whereas the effect of platinum-containing regimens was of borderline significance (HR = 2.23; P = 0.086). Sites, age, and multi-agent regimens were not significant. CONCLUSIONS This is one of the largest retrospective studies reporting outcome of palliative chemotherapy for ABC. It confirms the benefit of palliative chemotherapy in an unselected group of patients. Fluoropyrimidine-based regimens appear to be as effective as gemcitabine-based treatments.
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Jermyn M, Davis SC, Dehghani H, Huggett MT, Hasan T, Pereira SP, Bown SG, Pogue BW. CT contrast predicts pancreatic cancer treatment response to verteporfin-based photodynamic therapy. Phys Med Biol 2014; 59:1911-21. [PMID: 24651456 DOI: 10.1088/0031-9155/59/8/1911] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The goal of this study was to determine dominant factors affecting treatment response in pancreatic cancer photodynamic therapy (PDT), based on clinically available information in the VERTPAC-01 trial. This trial investigated the safety and efficacy of verteporfin PDT in 15 patients with locally advanced pancreatic adenocarcinoma. CT scans before and after contrast enhancement from the 15 patients in the VERTPAC-01 trial were used to determine venous-phase blood contrast enhancement and this was correlated with necrotic volume determined from post-treatment CT scans, along with estimation of optical absorption in the pancreas for use in light modeling of the PDT treatment. Energy threshold contours yielded estimates for necrotic volume based on this light modeling. Both contrast-derived venous blood content and necrotic volume from light modeling yielded strong correlations with observed necrotic volume (R² = 0.85 and 0.91, respectively). These correlations were much stronger than those obtained by correlating energy delivered versus necrotic volume in the VERTPAC-01 study and in retrospective analysis from a prior clinical study. This demonstrates that contrast CT can provide key surrogate dosimetry information to assess treatment response. It also implies that light attenuation is likely the dominant factor in the VERTPAC treatment response, as opposed to other factors such as drug distribution. This study is the first to show that contrast CT provides needed surrogate dosimetry information to predict treatment response in a manner which uses standard-of-care clinical images, rather than invasive dosimetry methods.
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Affiliation(s)
- Michael Jermyn
- Thayer School of Engineering, Dartmouth College, Hanover, NH-03755, USA
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Huggett MT, Passant H, Hurt C, Pereira SP, Bridgewater J, Mukherjee S. Outcome and patterns of care in advanced biliary tract carcinoma (ABC): experience from two tertiary institutions in the United Kingdom. Tumori 2014; 100:219-24. [PMID: 24852869 DOI: 10.1177/030089161410000217] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2024]
Abstract
AIMS AND BACKGROUND The ABC-02 trial has defined the standard therapy for patients with advanced biliary tract cancer (ABC); however, outcome in an unselected patient population in the UK has not been described. We aimed to investigate the outcome of a series of patients with ABC from two large UK cancer networks. METHODS AND STUDY DESIGN We retrospectively reviewed all cases of ABC presenting to two UK cancer networks over a nine-year period. Overall survival (OS) and factors influencing OS were assessed. RESULTS Four hundred and two patients were available for analysis. The median OS was 6.2 months. On univariate analysis, age ≥70 years (P = 0.047), advanced disease stage (P <0.001), gall bladder primary (P = 0.033), poor performance status (P <0.001) and lack of chemotherapy (P <0.001) were associated with worse outcome. Survival was superior in the 36.4% of patients who received palliative chemotherapy (12.5 vs 4.3 months; P <0.001). On multivariate analysis of patients who had chemotherapy, those who did not receive fluoropyrimidine-based regimens (HR = 5.12; P = 0.022) or gemcitabine-based regimens (HR = 5.01; P = 0.021) had a higher mortality, whereas the effect of platinum-containing regimens was of borderline significance (HR = 2.23; P = 0.086). Sites, age, and multi-agent regimens were not significant. CONCLUSIONS This is one of the largest retrospective studies reporting outcome of palliative chemotherapy for ABC. It confirms the benefit of palliative chemotherapy in an unselected group of patients. Fluoropyrimidine-based regimens appear to be as effective as gemcitabine-based treatments.
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Huggett MT, Passant H, Hurt C, Pereira SP, Bridgewater JA, Mukherjee S. Outcome and patterns of care in advanced biliary tract carcinoma (ABC): Experience from two tertiary institutions in the United Kingdom. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.4_suppl.272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
272 Background: The ABC-02 trial has defined the standard therapy for patients with advanced biliary tract cancer (ABC), however outcome in an unselected patient population in the UK has not been described. We report the outcome of a series of patients with ABC from two large UK cancer networks. Methods: We retrospectively reviewed all cases of ABC presenting to two UK cancer networks over a 9-year period. Patients with a diagnosis recorded under anatomical site (liver, gallbladder or biliary tree) or histological diagnosis (cholangiocarcinoma or adenocarcinoma, liver), were included. Any patients who had surgery with curative intent were excluded. Overall survival (OS) and factors influencing OS were assessed. For the analysis, chemotherapy regimens were considered as: (i) gemcitabine (G)-based vs. non-G-based, (ii) platinum (P)-based vs. non-P-based and (iii) fluoropyrimidine (F)-based vs. non-F-based. Results: 402 patients were available for analysis. The median OS was 6.2 months. On univariate analysis, age ≥ 70 years (p=0.047), advanced disease stage (p<0.001), gall bladder primary (p=0.033), poor performance status (p<0.001) and lack of chemotherapy (p<0.001) were associated with worse outcome. Survival was superior in the 36.4% of patients who received palliative chemotherapy (12.5 versus 4.3 months; p<0.001). In patients receiving chemotherapy, on multivariate analysis males had higher mortality than females (HR=1.71; p=0.006) and stage 4 disease had a higher mortality (HR=2.62; p=0.002) than stage 1-2 disease. Patients who did not receive F-based regimens (HR=5.12; p=0.022) or G-based regimens (HR=5.01; p=0.021) had a higher mortality, whereas the effect of P-containing regimens was of borderline significance (HR=2.23; p=0.086). Sites, age, and multi-agent regimens were not significant. Conclusions: This is the first retrospective series from the UK and one of the largest population-based studies in ABC and confirms the benefit of palliative chemotherapy in an unselected group of patients. F-based regimens appear to be as effective as G-based treatments.
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Affiliation(s)
| | | | - Chris Hurt
- Cardiff University, Cardiff, United Kingdom
| | | | | | - Somnath Mukherjee
- Gray Institute for Radiation Oncology and Biology, University of Oxford, Oxford, United Kingdom
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Huggett MT, Pereira SP. Diagnosing and managing pancreatic cancer. Practitioner 2011; 255:21-3. [PMID: 21932502 PMCID: PMC3234307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Adenocarcinoma of the pancreas is one of the top ten leading causes of cancer deaths and in the UK around 8,000 people are diagnosed with the disease each year. The incidence is similar in men and women and rises with age. Rates increase significantly in people aged 45 years and over and around three-quarters of patients diagnosed with pancreatic cancer are over the age of 65. Overall, the long-term prognosis of the disease is poor with a one-year survival rate of approximately 10-20%. The presenting symptoms are largely dependent on tumour location. Approximately half of patients are diagnosed with a tumour within the head of the pancreas and many of these will present with jaundice. Around half of patients with carcinoma of the head of pancreas will present with abdominal or back pain, which itself is an independent predictor of poor outcome. Rapid unintentional weight loss should raise clinical suspicion and is associated with shorter survival; and recent onset diabetes may serve as a warning sign. Individuals with two or more first-degree relatives with pancreatic cancer are at increased risk, even if no gene defect is identified. There are also a number of familial cancer syndromes which, although rare, carry a significantly higher risk. Patients with chronic pancreatitis from any aetiology have an approximately 15-fold higher risk than the general population, while diabetes mellitus, smoking and obesity have relative risks of around 2. In the UK, patients over the age of 40 with presenting symptoms of unexplained weight loss in combination with upper abdominal or back pain or late onset diabetes, in whom pancreatic cancer is suspected, should be referred for an urgent pancreatic protocol contrast-enhanced CT scan as a first-line investigation. GPs without direct access to CT should refer to a gastroenterologist or surgeon, in line with the two-week cancer target wait.
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Sweet DG, Huggett MT, Warner JA, Moss TJM, Kloosterboer N, Halliday HL, Newnham JP, Kallapur SG, Jobe AH, Kramer BW. Maternal betamethasone and chorioamnionitis induce different collagenases during lung maturation in fetal sheep. Neonatology 2008; 94:79-86. [PMID: 18264025 DOI: 10.1159/000115949] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2007] [Accepted: 10/29/2007] [Indexed: 11/19/2022]
Abstract
BACKGROUND Fetal lung maturation occurs after both maternal corticosteroid administration and chorioamnionitis. The effectors of this antenatally-induced lung maturation are not understood. Matrix metalloproteinases (MMPs) 2 and 9 are type-IV collagenases that can degrade alveolar basement membranes. OBJECTIVES We hypothesized that the structural changes of lung maturation by both antenatal corticosteroid treatment and chorioamnionitis would be associated with increases in these MMPs. METHODS 64 pregnant ewes were randomly assigned to one of four treatment groups: intra-amniotic injection of 10 mg endotoxin, maternal intramuscular injection of 0.5 mg/kg betamethasone, both treatments combined or saline-treated controls. We quantified MMP-2 which is derived from connective tissue and MMP-9 which is predominantly derived from neutrophils in fetal lung fluid of lambs after maternal corticosteroid therapy and induction of chorioamnionitis and the combination of both therapies given at 109-111 days' gestational age with delivery 1, 5 or 15 days later. RESULTS Betamethasone, endotoxin and the combined treatments increased both surfactant pool size, lung gas volume and reduced alveolar wall thickness at 15 days. MMP-2 concentration was increased after betamethasone. MMP-9 concentration increased after endotoxin-induced chorioamnionitis but decreased by the combined treatments. CONCLUSION Lung maturation via different pathways may use different forms of collagenases for remodelling lung structure.
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Affiliation(s)
- David G Sweet
- Department of Child Health, The Queen's University of Belfast, UK
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Huggett MT, Howieson A, Wakefield C, Gartell PC. An apparent splenic abscess. J R Soc Med 2005. [PMID: 16199818 DOI: 10.1258/jrsm.98.10.474] [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] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- M T Huggett
- Royal Hampshire County Hospital, Winchester SO22 5DG, UK
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Huggett MT, Howieson A, Wakefield C, Gartell PC. An Apparent Splenic Abscess. Med Chir Trans 2005; 98:474-5. [PMID: 16199818 PMCID: PMC1240106 DOI: 10.1177/014107680509801015] [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] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- M T Huggett
- Royal Hampshire County Hospital, Winchester SO22 5DG, UK
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