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Keung CY, Morgan A, Le ST, Robertson M, Urquhart P, Swan MP. Survival outcomes and predictors of mortality, re-bleeding and complications for acute severe variceal bleeding requiring balloon tamponade. World J Hepatol 2022; 14:1584-1597. [PMID: 36157875 PMCID: PMC9453467 DOI: 10.4254/wjh.v14.i8.1584] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/22/2022] [Accepted: 07/26/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute severe variceal bleeding (AVB) refractory to medical and endoscopic therapy is infrequent but associated with high mortality. Historical cohort studies from 1970-1980s no longer represent the current population as balloon tamponade is no longer first-line therapy for variceal bleeding; treatments including vasoactive therapies, intravenous antibiotics, endoscopic variceal band ligation are routinely used, and there is improved access to definitive treatments including transjugular intrahepatic portosystemic shunts. However, only a few studies from the current era exist to describe the practice of balloon tamponade, its outcomes, and predictors with a requirement for further updated information.
AIM To describe current management of AVB requiring balloon tamponade and identify the outcomes and predictors of mortality, re-bleeding and complications.
METHODS A retrospective multi-centre cohort study of 80 adult patients across two large tertiary health networks from 2008 to 2019 in Australia who underwent balloon tamponade using a Sengstaken-Blakemore tube (SBT) were included for analysis. Patients were identified using coding for balloon tamponade. The primary outcome of this study was all-cause mortality at 6 wk after the index AVB. Secondary outcomes included re-bleeding during hospitalisation and complications of balloon tamponade. Predictors of these outcomes were determined using univariate and multivariate binomial regression.
RESULTS The all-cause mortality rates during admission and at 6-, 26- and 52 wk were 48.8%, 51.2% and 53.8%, respectively. Primary haemostasis was achieved in 91.3% and re-bleeding during hospitalisation occurred in 34.2%. Independent predictors of 6 wk mortality on multivariate analysis included the Model for Endstage Liver disease (MELD) score (OR 1.21, 95%CI 1.06-1.41, P = 0.006), advanced hepatocellular carcinoma (OR 11.51, 95%CI 1.61-82.20, P = 0.015) and re-bleeding (OR 13.06, 95%CI 3.06-55.71, P < 0.001). There were no relevant predictors of re-bleeding but a large proportion in which this occurred did not survive 6 wk (76.0% vs 24%). Although mucosal trauma was the most common documented complication after SBT insertion (89.5%), serious complications from SBT insertion were uncommon (6.3%) and included 1 patient who died from oesophageal perforation.
CONCLUSION In refractory AVB, balloon tamponade salvage therapy is associated with high rates of primary haemostasis with low rates of serious complications. Re-bleeding and mortality however, remain high.
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Affiliation(s)
- Charlotte Y Keung
- Department of Gastroenterology, Monash Health, Melbourne 3168, Victoria, Australia
- Department of Gastroenterology, Eastern Health, Melbourne 3128, Victoria, Australia
- Department of Medicine, Monash University, Melbourne 3168, Victoria, Australia
| | - Aparna Morgan
- Department of Gastroenterology, Monash Health, Melbourne 3168, Victoria, Australia
| | - Suong T Le
- Department of Gastroenterology, Monash Health, Melbourne 3168, Victoria, Australia
- Department of Medicine, Monash University, Melbourne 3168, Victoria, Australia
- Monash Digital Therapeutics and Innovation Laboratory, Monash University, Melbourne 3168, Victoria, Australia
| | - Marcus Robertson
- Department of Gastroenterology, Monash Health, Melbourne 3168, Victoria, Australia
- Department of Medicine, Monash University, Melbourne 3168, Victoria, Australia
| | - Paul Urquhart
- Department of Gastroenterology, Eastern Health, Melbourne 3128, Victoria, Australia
| | - Michael P Swan
- Department of Gastroenterology, Monash Health, Melbourne 3168, Victoria, Australia
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Varma P, Ket S, Paul E, Barnes M, Devonshire DA, Croagh D, Swan MP. Does ERCP position matter? A randomized controlled trial comparing efficacy and complications of left lateral versus prone position (POSITION study). Endosc Int Open 2022; 10:E403-E412. [PMID: 35433220 PMCID: PMC9010096 DOI: 10.1055/a-1749-5043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 11/10/2021] [Indexed: 11/08/2022] Open
Abstract
Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) is traditionally performed with patients in the prone position (PP). However, this poses a potentially increased risk of anesthetic complications. An alternative is the left lateral (LL) decubitus position, which is commonly used for endoscopic procedures. Our aim was to compare cannulation rate, time, and outcomes in ERCP performed in LL versus PP. Patients and methods We conducted a non-inferiority, prospective, randomized control trial with 1:1 randomization to either LL or PP position. Patients > 18 years of age with native papillae requiring a therapeutic ERCP were recruited between March 2017 and November 2018 in a single tertiary center. Results A total of 253 patients were randomized; 132 to LL (52.2 %) and 121 to PP (47.8 %). Cannulation rates were 97.0 % in LL vs 99.2 % in PP (difference -2.2 % (one-sided 95 % CI: -5 % to 0.6 %). Median time to biliary cannulation was 03:50 minutes in LL vs 02:57 minutes in PP ( P = 0.62). Pancreatitis rates were 2.3 % in LL vs 5.8 % in PP ( P = 0.20). There were significantly lower radiation doses used in PP (0.23 mGy/m 2 in LL vs 0.16 mGy/m 2 in PP, P = 0.008) without a difference in fluoroscopy times. Conclusions Our analysis comparing LL to PP during ERCP shows comparable procedural and anesthetic outcomes, with significantly lower radiation exposure when performed in PP. We conclude that ERCP undertaken in the LL position is not inferior to PP, except for higher radiation exposure, and should be considered as a safe alternate position for patients undergoing ERCP.
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Affiliation(s)
- Poornima Varma
- Department of Gastroenterology & Hepatology, Austin Health, Heidelberg, Australia
| | - Shara Ket
- Department of Gastroenterology & Hepatology, Monash Medical Centre, Clayton, Australia
| | - Eldho Paul
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Monash Medical Centre, Clayton, Australia
| | - Malcolm Barnes
- Department of Gastroenterology & Hepatology, Monash Medical Centre, Clayton, Australia
| | - David A. Devonshire
- Department of Gastroenterology & Hepatology, Monash Medical Centre, Clayton, Australia
| | - Daniel Croagh
- Department of Upper GI Surgery, Monash Medical Centre, Clayton, Australia,Department of Surgery, Monash University, Clayton, Australia
| | - Michael P. Swan
- Department of Gastroenterology & Hepatology, Monash Medical Centre, Clayton, Australia
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Varma P, Rajadurai AS, Holt DQ, Devonshire DA, Desmond CP, Swan MP, Nathan D, Shelton ET, Prideaux L, Sorrell C, Rusli F, Crantock LRF, Dev A, Ratnam DT, Pianko S, Moore GT. Immunomodulator use does not prevent first loss of response to anti-tumour necrosis factor alpha therapy in inflammatory bowel disease: long-term outcomes in a real-world cohort. Intern Med J 2020; 49:753-760. [PMID: 30381884 DOI: 10.1111/imj.14150] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 10/22/2018] [Accepted: 10/25/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND Recent prospective studies suggest combination therapy with immunomodulators improves efficacy, but long-term data is limited. AIM To assess whether anti-tumour necrosis factor alpha (anti-TNF) monotherapy was associated with earlier loss of response (LOR) than combination therapy in a real-world cohort with long-term follow up. METHODS A retrospective audit was conducted of inflammatory bowel disease patients receiving anti-TNF therapy in a tertiary centre and specialist private practices. All patients with accurate data for anti-TNF commencement and adequate correspondence to determine end-points were included. Outcomes measured included time to first LOR, causes and biochemical parameters. RESULTS Two hundred and twenty-four patients were identified; 139 (62.1%) on combination therapy and 85 (37.9%) on monotherapy. Forty-five percent of patients had LOR during follow up until a maximum of 8.5 years; 59.4% on combination therapy and 40.6% on monotherapy (P = 0.533). The median time to LOR was not different between groups; 1069 days for combination therapy and 1489 days for monotherapy (P = 0.533). There was no difference in time to LOR between patients treated with different combination regimens or different anti-TNF agents. CONCLUSION In this large cohort of patients in a real-world setting, patients treated with anti-TNF monotherapy had similar rates of LOR as patients on anti-TNF combination therapy, at both short- and long-term follow up.
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Affiliation(s)
- Poornima Varma
- Department of Gastroenterology and Hepatology, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Anton S Rajadurai
- Department of Gastroenterology and Hepatology, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Darcy Q Holt
- Department of Gastroenterology and Hepatology, Monash Medical Centre, Melbourne, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - David A Devonshire
- Department of Gastroenterology and Hepatology, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Chris P Desmond
- Department of Gastroenterology and Hepatology, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Michael P Swan
- Department of Gastroenterology and Hepatology, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Debra Nathan
- Department of Gastroenterology and Hepatology, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Edward T Shelton
- Department of Gastroenterology and Hepatology, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Lani Prideaux
- Department of Gastroenterology and Hepatology, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Catherine Sorrell
- Department of Gastroenterology and Hepatology, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Ferry Rusli
- Department of Gastroenterology and Hepatology, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Luke R F Crantock
- Department of Gastroenterology and Hepatology, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Anouk Dev
- Department of Gastroenterology and Hepatology, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Dilip T Ratnam
- Department of Gastroenterology and Hepatology, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Stephen Pianko
- Department of Gastroenterology and Hepatology, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Gregory T Moore
- Department of Gastroenterology and Hepatology, Monash Medical Centre, Melbourne, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
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Poh BR, Ho SPS, Sritharan M, Yeong CC, Swan MP, Devonshire DA, Cashin PA, Croagh DG. Randomized clinical trial of intraoperative endoscopic retrograde cholangiopancreatography versus laparoscopic bile duct exploration in patients with choledocholithiasis. Br J Surg 2016; 103:1117-24. [PMID: 27302483 DOI: 10.1002/bjs.10207] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 03/05/2016] [Accepted: 04/05/2016] [Indexed: 01/27/2023]
Abstract
BACKGROUND Various minimally invasive approaches exist for the management of choledocholithiasis at the time of laparoscopic cholecystectomy. The aim of this study was to compare endoscopic retrograde cholangiopancreatography (ERCP) with laparoscopic bile duct exploration (LBDE) and test the hypothesis that intraoperative ERCP is no different to LBDE in terms of rate of bile duct clearance or retained stones. METHODS Eligible patients with choledocholithiasis undergoing emergency laparoscopic cholecystectomy were randomized to intraoperative ERCP or LBDE in a 1 : 1 ratio. The primary outcomes were rates of bile duct clearance and retained stones. Secondary outcomes were postprocedure complication rate, mortality rate, postoperative length of hospital stay, conversion to open surgery rate, procedural time and total duration of surgery. RESULTS Some 104 patients were randomized, and 52 patients in each group were included in an intention-to-treat analysis. Duct clearance rates were 87 per cent for patients who had intraoperative ERCP and 69 per cent for those in the LBDE group (P = 0·057). The rate of retained stones was lower in the ERCP group than in the LBDE group: 15 versus 42 per cent respectively (P = 0·004). Median postoperative length of stay was shorter with ERCP (2 days versus 3 days for LBDE; P = 0·015). CONCLUSION Intraoperative ERCP is more effective than LBDE in terms of minimizing the rate of retained stones in patients with choledocholithiasis undergoing emergency laparoscopic cholecystectomy. REGISTRATION NUMBER ACTRN12613000761763 (http://www.anzctr.org.au/).
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Affiliation(s)
- B R Poh
- Upper Gastrointestinal/Hepato-Pancreato-Biliary and General Surgery Unit, Monash University, Victoria, Australia
| | - S P S Ho
- Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Victoria, Australia
| | - M Sritharan
- Upper Gastrointestinal/Hepato-Pancreato-Biliary and General Surgery Unit, Monash University, Victoria, Australia
| | - C C Yeong
- Upper Gastrointestinal/Hepato-Pancreato-Biliary and General Surgery Unit, Monash University, Victoria, Australia
| | - M P Swan
- Gastroenterology and Hepatology Unit, Monash Health, Monash University, Victoria, Australia
| | - D A Devonshire
- Gastroenterology and Hepatology Unit, Monash Health, Monash University, Victoria, Australia
| | - P A Cashin
- Upper Gastrointestinal/Hepato-Pancreato-Biliary and General Surgery Unit, Monash University, Victoria, Australia.,Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Victoria, Australia
| | - D G Croagh
- Upper Gastrointestinal/Hepato-Pancreato-Biliary and General Surgery Unit, Monash University, Victoria, Australia.,Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Victoria, Australia
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Abstract
Current regulations emphasize that good husbandry practices allow animals to engage in species appropriate postural adjustments without touching the enclosure walls. This study evaluated the well-being of rats housed in a commercially available multilevel rat caging system, with or without access to the upper level of the caging. The evaluation methodologies included assessment of behavioral observations in the home cage, physiological assessment of metabolism and immune function, and determination of the affective state using a spatial cognitive bias assay. The study determined that rats that were provided access to the full multilevel cage during testing after initial restriction to the lower level of the cage demonstrated behavioral changes consistent with a positive affective state, while those with no changes to their housing situation had no significant differences in their affective states. Rats that were consistently housed with access restricted to the lower level of the cage exhibited a tendency to increased neutrophil:lymphocyte ratios as compared with those provided with access to all levels of the multilevel cage. There were no differences in body weight demonstrated between the experimental groups. Overall use of the cage space, as documented through analysis of behavioral observations in the home cage, demonstrated no significant differences in preferred location in the cage during the light or dark cycles, though rats with access to both levels of the cage were significantly more active during the light cycle. The results of this study suggest that the use of a multilevel caging system may improve the well-being of rats used in research.
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Affiliation(s)
- R R Wheeler
- Laboratory Animal Resource Center, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - M P Swan
- Laboratory Animal Resource Center, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - D L Hickman
- Laboratory Animal Resource Center, School of Medicine, Indiana University, Indianapolis, Indiana, USA
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Swan MP, Alexander S, Moss A, Williams SJ, Ruppin D, Hope R, Bourke MJ. Needle knife sphincterotomy does not increase the risk of pancreatitis in patients with difficult biliary cannulation. Clin Gastroenterol Hepatol 2013; 11:430-436.e1. [PMID: 23313840 DOI: 10.1016/j.cgh.2012.12.017] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [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] [Received: 08/14/2012] [Revised: 11/27/2012] [Accepted: 12/07/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Biliary cannulation is unsuccessful during 5%-10% of endoscopic retrograde cholangiopancreatography (ERCP) procedures. Needle knife sphincterotomy (NKS) can improve success of cannulation but is often used as a last resort and is associated with post-ERCP pancreatitis (PEP). We evaluated the safety and efficacy of performing NKS during early stages of difficult cannulation and the relationship between difficult cannulation and the risk of PEP. METHODS We performed a prospective trial of consecutive patients with an intact papilla who were undergoing ERCP at tertiary referral center; 73 patients were defined as having difficult biliary cannulation according to predefined cannulation parameters. These patients were randomly assigned to groups that received either NKS or continued standard cannulation. Main outcome measures were PEP and successful biliary cannulation. RESULTS Of 464 patients with an intact papilla undergoing ERCP, 73 met the criteria for difficult cannulation. Cannulation success in difficult cannulation cases was 86%, with a PEP rate of 19%. There was no difference in eventual cannulation success between the groups. However, 65% of the patients assigned to the standard cannulation group required crossover to NKS. There was no significant difference in development of PEP among patients in the early NKS group (20.5%) vs standard cannulation (17.6%). Pancreatic duct stents were inserted in 23 of the patients in the early NKS arm and in 15 in the standard cannulation arm. The number of cannulation attempts (more than 7) increased the risk of PEP (P < .01). On the basis of multivariate analysis, independent risk factors for PEP were failure of early cannulation and failure of biliary cannulation. CONCLUSIONS Early application of NKS during difficult cannulation does not increase the risk of PEP. The risk of PEP increases greatly after 7-8 attempts at or failure of cannulation. Further studies are required to assess whether early implementation of NKS during difficult cannulation reduces the development of PEP. Australia and New Zealand Clinical Trials registry: ANZTRN 12,612,000,060,842.
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Affiliation(s)
- Michael P Swan
- Department of Gastroenterology, Westmead Hospital, Sydney, Australia
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Swan MP, Bourke MJ, Williams SJ, Alexander S, Moss A, Hope R, Ruppin D. Failed biliary cannulation: Clinical and technical outcomes after tertiary referral endoscopic retrograde cholangiopancreatography. World J Gastroenterol 2011; 17:4993-8. [PMID: 22174549 PMCID: PMC3236589 DOI: 10.3748/wjg.v17.i45.4993] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 05/26/2011] [Accepted: 06/02/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: Prospective evaluation of repeat endoscopic retrograde cholangiopancreatography (ERCP) for failed Schutz grade 1 biliary cannulation in a high-volume center.
METHODS: Prospective intention-to-treat analysis of patients referred for biliary cannulation following recent unsuccessful ERCP.
RESULTS: Fifty-one patients (35 female; mean age: 62.5 years; age range: 40-87 years) with previous failed biliary cannulation were referred for repeat ERCP. The indication for ERCP was primarily choledocholithiasis (45%) or pancreatic malignancy (18%). Successful biliary cannulation was 100%. The precut needle knife sphincterotomy (NKS) rate was 27.4%. Complications occurred in 3.9% (post-ERCP pancreatitis). An identifiable reason for initial unsuccessful biliary cannulation was present in 55% of cases. Compared to a cohort of 940 naïve papilla patients (female 61%; mean age: 59.9 years; age range: 18-94 years) who required sphincterotomy over the same time period, there was no statistical difference in the cannulation success rate (100% vs 98%) or post-ERCP pancreatitis (3.1% vs 3.9%). Precut NKS use was more frequent (27.4% vs 12.7%) (P = 0.017).
CONCLUSION: Referral to a high-volume center following unsuccessful ERCP is associated with high technical success, with a favorable complication rate, compared to routine ERCP procedures.
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Affiliation(s)
- F Donnellan
- Center for Therapeutic Endoscopy and Endoscopic Oncology, St Michael's Hospital, Toronto, Ontario, Canada.
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9
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Abstract
BACKGROUND AND STUDY AIMS Endoscopic mucosal resection (EMR) for large colonic laterally spreading tumors (LSTs) is a safe, efficacious, and cost-effective treatment. The most common serious complication is delayed bleeding, which reduces these advantages, but consensus guidelines for large-polyp EMR do not exist. PATIENTS AND METHODS Data from two large prospective intention-to-treat studies of EMR for colonic LSTs 20 mm or greater in size were analyzed. Data collection was comprehensive, and included patient and lesion characteristics. EMR technique and cessation of anticoagulant and antiplatelet therapy was standardized. Clinically significant delayed bleeding was defined as that requiring hospital admission. RESULTS EMR was performed on 302 lesions in 288 patients. There was clinically significant delayed bleeding in 21 cases (7 %). Ten underwent colonoscopy. One required angiography. One required surgery after perforation following hemostatic clip placement. There were no deaths. Risk factors for bleeding on multivariate analysis were right colon location [adjusted odds ratio (OR) 4.4, P = 0.01], use of aspirin (OR 6.3, P = 0.005), and age (OR per decade of age 1.70). All bleeds occurred before aspirin was restarted. Patient characteristics, including ASA grade and co-morbidity type, were not predictive. Despite requiring more complex EMR, larger lesion size ( P = 0.2), multiple excisions rather than en bloc resection ( P = 0.1), polyp morphology ( P = 0.2), and previous attempts ( P = 0.5), were not associated with increased risk. CONCLUSIONS Proximal lesion location is a highly significant risk for clinically significant delayed bleeding following colonic EMR, and this knowledge could form the basis of a targeted therapeutic trial. Recent aspirin use also increases bleeding risk--specific consensus guidelines in this area are required for colonic EMR.
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Affiliation(s)
- A J Metz
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
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10
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Abstract
Esophageal lichen planus is a rare condition, and although the majority of cases occur in conjunction with lichen planus at other sites, the endoscopic features are often misinterpreted resulting in a delay in diagnosis. We report a series of five patients presenting to our unit between 2005 and 2009. All five patients were female and presented with dysphagia. Endoscopy demonstrated proximal esophageal stricturing in four patients. Characteristic histological findings were found in four patients. Lichen planus was diagnosed at other sites, and preceded gastrointestinal symptoms, in all patients; five had oral involvement, two had genital involvement, and one had dermal involvement. All patients received proton pump inhibitor therapy without demonstrable benefit. Administration of oral fluticasone proprionate resulted in symptomatic improvement in three patients.
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Affiliation(s)
- F Donnellan
- Centre for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, Toronto, Canada.
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11
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Swan MP, Bourke MJ, Moss A, Williams SJ, Hopper A, Metz A. The target sign: an endoscopic marker for the resection of the muscularis propria and potential perforation during colonic endoscopic mucosal resection. Gastrointest Endosc 2011; 73:79-85. [PMID: 21184872 DOI: 10.1016/j.gie.2010.07.003] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2010] [Accepted: 07/02/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND EMR of large sessile polyps and laterally spreading tumors (LSTs) of the colon is safe and cost-effective. Perforation remains a feared and well-recognized complication; however, endoscopic detection is often absent, and most commonly, diagnosis is delayed and depends on clinical signs and/or radiology findings. To date, an endoscopic sign to identify muscularis propria (MP) resection and potential perforation has not been described. OBJECTIVE To describe an endoscopic sign for prompt recognition of EMR-related MP resection. DESIGN Prospective analysis. SETTINGS Tertiary referral academic gastroenterology unit. PATIENTS Patients with the target sign were identified prospectively in 2 large prospective studies of EMR for colonic LSTs 20 mm or larger. INTERVENTION A standardized EMR approach was used. MP defects were closed endoscopically with clips. MAIN OUTCOME MEASUREMENTS The presence or absence of the target sign in the polypectomy specimen and its influence on subsequent endoscopic management of polypectomy complications. RESULTS A total of 445 patients with LSTs or sessile polyps 20 mm or larger (mean size 33 mm, range 20-85 mm) were prospectively enrolled in 2 studies. Ten patients (mean age 70.3 years, range 48-83 years, 50% male) with target lesions and histologically confirmed MP resection were identified prospectively at the time of EMR, with 3 having full-thickness resection. All cases were identified intraprocedurally by a target sign on the underside of the specimen and a mirror target evident in the mucosal defect. All patients were treated endoscopically with 1 to 5 endoscopic clips. None required operative management. Thirteen inpatient days were required to treat the 10 patients (mean 1.3 days). LIMITATIONS Nonrandomized study. CONCLUSIONS Careful analysis of the post-EMR specimen and resection defect may reveal a target sign, an easily recognized and reliable marker of either partial- or full-thickness MP resection and potential perforation. Prompt recognition of this sign facilitates endoscopic management.
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Affiliation(s)
- Michael P Swan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia.
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Swan MP, Moore GTC, Sievert W, Devonshire DA. Efficacy and safety of single-session argon plasma coagulation in the management of chronic radiation proctitis. Gastrointest Endosc 2010; 72:150-4. [PMID: 20493484 DOI: 10.1016/j.gie.2010.01.065] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Accepted: 01/22/2010] [Indexed: 12/12/2022]
Abstract
BACKGROUND Chronic radiation proctitis (CRP) manifests as rectal bleeding 12 to 24 months after pelvic radiotherapy. No criterion standard of treatment has been established, although argon plasma coagulation (APC) has increasingly become the treatment of choice. Previous studies have applied APC over multiple sessions, necessitating increased numbers of treatments. OBJECTIVE To assess the safety and efficacy of large-volume APC application in the treatment of CRP with the intention of a single-session treatment protocol. DESIGN Prospective study. SETTING Tertiary referral hospital. PATIENTS Over an 8-year period, consecutive patients with CRP with rectal bleeding were prospectively enrolled. INTERVENTION Large-volume APC application to affected rectal mucosa. MAIN OUTCOME MEASUREMENTS Number of treatments, bleeding scores, complications. RESULTS Fifty patients (mean age 72.1 years; range 51-87 years) were treated; 45 were men (prostate cancer). The mean period between radiotherapy and initial APC treatment was 23 months (range 4-140 months). Seventeen (34%) patients had grade A endoscopic severity, 23 (46%) grade B, and 10 (20%) grade C. Other therapies failed in 16 (32%) patients. The mean number of treatments was 1.36 (range 1-3) with a mean follow-up of 20.6 months (range 6-48 months). Sixty-eight percent of patients were successfully treated after 1 session and 96% after 2 sessions. Bleeding scores improved in all patients (P < .001). Seventeen (34%) patients experienced short-term, self-limiting complications; 1 (2%) patient experienced a long-term complication. LIMITATIONS Nonrandomized study. CONCLUSIONS Large-volume APC treatment was successful in the treatment of CRP, including those in whom other therapies had previously failed, and resulted in a decreased number of treatments compared with other published studies. The benefits were offset by an increased incidence of short-term complications but no increase in long-term complications.
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Affiliation(s)
- Michael P Swan
- Endoscopy Unit, Monash Medical Centre, Clayton, Victoria, Australia
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13
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Swan MP, Bourke MJ, Hopper AD, Moss A, Walker SL. Endoscopic treatment of a transversely impacted perforating fish bone in the esophagus with pneumomediastinum. Endoscopy 2010; 42 Suppl 2:E75-6. [PMID: 20195973 DOI: 10.1055/s-0029-1215415] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- M P Swan
- Department of Gastroenterology, Westmead Hospital, Cnr. Darcy and Hawkesbury Road, Sydney, New South Wales, Australia.
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Moss A, Bourke MJ, Hourigan LF, Gupta S, Williams SJ, Tran K, Swan MP, Hopper AD, Kwan V, Bailey AA. Endoscopic resection for Barrett's high-grade dysplasia and early esophageal adenocarcinoma: an essential staging procedure with long-term therapeutic benefit. Am J Gastroenterol 2010; 105:1276-83. [PMID: 20179694 DOI: 10.1038/ajg.2010.1] [Citation(s) in RCA: 144] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Patients with Barrett's high-grade dysplasia (HGD) or early esophageal adenocarcinoma (EAC) that is shown on biopsy alone continue to undergo esophagectomy without more definitive histological staging. Endoscopic resection (ER) may provide more accurate histological grading and local tumor (T) staging, definitive therapy, and complete Barrett's excision (CBE); however, long-term outcome data are limited. Our objective was to demonstrate the effect on histological grade or local T stage, efficacy, safety and long-term outcome of ER for Barrett's HGD/EAC and of CBE in suitable patients. METHODS This prospective study at two Australian academic hospitals involved 75 consecutive patients over 7 years undergoing ER for biopsy-proven HGD or EAC, using multiband mucosectomy or cap technique. In addition, CBE by 2-3-stage radical mucosectomy was attempted for all Barrett's segments<or=3 cm in length in patients aged<75 years with minimal comorbidities. RESULTS Biopsy histology showed HGD in 89% of patients and EAC in 11%. However, ER histology resulted in altered grading or staging in 48% of patients (down 28%, up 20%), with HGD in 53%, low-grade dysplasia (LGD) in 19%, mucosal adenocarcinoma in 13%, submucosal adenocarcinoma in 9%, and no dysplasia in 4% of patients. The CBE success rate was 94%. Complications were one aspiration (hospitalization with full recovery) and six strictures successfully dilated endoscopically. During the mean follow-up of 31 months (range 3-89), there was no recurrence at ER sites, 11% developed metachronous lesions and five patients underwent esophagectomy for ER-demonstrated submucosal invasion. Esophagectomy specimens were T0N0M0 in three and T1N0M0 in two patients. There were no deaths due to adenocarcinoma. CONCLUSIONS ER alters histological grade or local T stage in 48% of patients and dramatically reduces esophagectomy rates by providing safe and effective therapy. ER has a high success rate (94%) for CBE in short segment Barrett's esophagus.
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Affiliation(s)
- Alan Moss
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
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Hopper AD, Bourke MJ, Williams SJ, Swan MP. Giant laterally spreading tumors of the papilla: endoscopic features, resection technique, and outcome (with videos). Gastrointest Endosc 2010; 71:967-75. [PMID: 20226451 DOI: 10.1016/j.gie.2009.11.021] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [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: 09/09/2009] [Accepted: 11/10/2009] [Indexed: 12/15/2022]
Abstract
BACKGROUND Successful endoscopic treatment of conventional papillary adenomas is well described. However, many authors recommend surgical resection for larger lesions with extrapapillary extension. OBJECTIVE To describe the classification, technique, and outcome for the endoscopic resection of giant laterally spreading tumors of the papilla (LST-P). DESIGN Single-center case series. SETTINGS Tertiary referral academic gastroenterology unit. PATIENTS Patients referred for endoscopic treatment of LST-P. INTERVENTION Pre-resection staging and single-session endoscopic removal of papillary adenomas. For those classified as LST-P (>30 mm, extending beyond the papilla onto the duodenal wall and involving as much as two thirds of the duodenal circumference), a standardized single-session EMR technique was used. MAIN OUTCOME MEASUREMENTS Technical success, complications, and adenoma recurrence for single-session removal of LST-P. Outcomes were compared with those of conventional ampullary adenoma resection during the same period. RESULTS Twenty-five patients with ampullary adenomas were referred. In 10 patients identified with LST-P (mean age 70.2 years; adenoma size 30-80 mm), combination EMR and papillectomy was performed in a single session. The median admission duration was 1 night (range 0-35). Complications included bleeding (30%) and cholecystitis (10%), with no cases of pancreatitis or perforation. Adenoma recurrence at 3 months was found in 1 patient (10%). Complication and recurrence rates in smaller (<30 mm) ampullary adenoma resections were not significantly different. LIMITATIONS A relatively uncommon entity and thus small sample size. CONCLUSIONS Endoscopic resection of carefully staged LST-P is a viable therapeutic alternative to surgery. In experienced hands, the outcomes are comparable to those for conventional ampullary adenomas.
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Affiliation(s)
- Andrew D Hopper
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
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Swan MP, Bourke MJ, Alexander S, Moss A, Williams SJ. Large refractory colonic polyps: is it time to change our practice? A prospective study of the clinical and economic impact of a tertiary referral colonic mucosal resection and polypectomy service (with videos). Gastrointest Endosc 2009; 70:1128-36. [PMID: 19748615 DOI: 10.1016/j.gie.2009.05.039] [Citation(s) in RCA: 155] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2009] [Accepted: 05/29/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients who have large, difficult, colorectal lesions not readily amenable to endoscopic resection are often referred directly to surgery. The application of advanced polypectomy and endoscopic mucosal resection (EMR) techniques undertaken by a tertiary referral colonic mucosal resection and polypectomy service (TRCPS) is not often considered but may be superior to surgery. OBJECTIVE To evaluate the safety, efficacy, and cost savings of a TRCPS for colorectal lesions. DESIGN Prospective intention-to-treat analysis. SETTING Tertiary academic referral center. PATIENTS In a 21-month period ending in April 2008, consecutive patients with large or complex colorectal polyps referred by other specialist endoscopists were prospectively enrolled on an intention-to-treat basis. INTERVENTION For sessile lesions, a standardized EMR approach was used. Pedunculated lesions were removed with or without pretreatment with an Endoloop procedure. MAIN OUTCOME MEASUREMENTS Complete resection, complications, recurrence, and potential cost savings comparing actual outcome of the cohort with a hypothetical analysis of surgical management. RESULTS This study included 174 patients (mean age 68 years) who were referred with 193 difficult polyps (186 laterally spreading, mean size 30 mm [range 10-80 mm]). We totally excised 173 laterally spreading lesions by EMR (115 piecemeal, 58 en bloc). Invasive adenocarcinoma was found in 6 lesions-5 treated successfully with EMR. Eleven patients were referred directly to surgery without an endoscopic attempt due to suspected invasive carcinoma. Seven >30-mm, pedunculated polyps were removed. There were no perforations. A total of 20 bed days was used because of endoscopic complications. Among all patients referred, 90% avoided the need for surgery. Excluding patients who were treated surgically for invasive cancer, the procedural success was 95% (157 of 168). By using Australian cost estimates applied to the entire group and compared with cost estimates assuming all patients had undergone surgery, we calculated the total medical cost savings was $6990 (U.S.) per patient, or a total savings of $1,216,231 (U.S.). LIMITATION Not a randomized trial. CONCLUSIONS Colonoscopic polypectomy performed by a TRCPS on large or difficult polyps is technically effective and safe. This approach results in major cost savings and avoids the potential complications of colonic surgery. This type of clinical pathway should be developed to enhance patient outcomes and reduce health care costs.
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Affiliation(s)
- Michael P Swan
- Department of Gastroenterology, Westmead Hospital, Sydney, Australia
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Hopper AD, Bourke MJ, Hourigan LF, Tran K, Moss A, Swan MP. En-bloc resection of multiple type 1 gastric carcinoid tumors by endoscopic multi-band mucosectomy. J Gastroenterol Hepatol 2009; 24:1516-21. [PMID: 19743997 DOI: 10.1111/j.1440-1746.2009.05909.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Gastric carcinoid tumors are rare but increasing in incidence. Current recommendations suggest endoscopic resection for type I carcinoids found in the stomach, however reports of incomplete resection have led to difficulty planning future management. Our purpose was to describe the application of the endoscopic multi-band mucosectomy (MBM) device to achieve en-bloc resection of multiple gastric carcinoid tumors. METHODS Over a 30-month period (June 2006-January 2009) eight patients attending for endoscopic assessment of gastric carcinoid tumors were identified at two tertiary referral centers. Patients underwent endoscopic resection of the carcinoids with an MBM device. En-bloc specimens underwent histological evaluation for identification and tumor resection margins. Patients with type I carcinoids were subsequently enrolled in an endoscopic follow-up program. RESULTS A total of 34 gastric carcinoid tumors were removed from eight patients. On histological analyses seven out of eight patients were diagnosed with type I tumors. In the remaining patient a single, sporadic (type III) gastric carcinoid was diagnosed. No complications of severe bleeding or perforation occurred. All specimens were shown to have clear deep and peripheral histological resection margins. CONCLUSION Complete 'en-bloc' endoscopic resection of multiple 'type I' gastric carcinoid tumors can be safely and easily performed with an MBM technique.
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Affiliation(s)
- Andrew D Hopper
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
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