1
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Alali A, Moris M, Martel M, Streutker C, Cirocco M, Mosko J, Kortan P, Barkun A, May GR. Predictors of Malignancy in Patients With Indeterminate Biliary Strictures and Atypical Biliary Cytology: Results From Retrospective Cohort Study. J Can Assoc Gastroenterol 2021; 4:222-228. [PMID: 34617004 PMCID: PMC8489527 DOI: 10.1093/jcag/gwaa043] [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: 10/01/2020] [Accepted: 03/15/2021] [Indexed: 11/12/2022] Open
Abstract
Background Atypical cellular features are commonly encountered in patients with indeterminate biliary strictures, which are nondiagnostic of malignancy yet cannot rule it out. This study aims to identify clinical features that could discriminate patients with indeterminate biliary strictures and atypical biliary cytology who may harbor underlying malignancy. Methods All patients with an indeterminate biliary stricture and an atypical brush cytology obtained during endoscopic brushings were identified in a large tertiary-care center. Demographical information, clinical data and the final pathological diagnosis were collected. The study cohort was divided based on the final diagnosis into benign and malignant groups. Descriptive and multivariable analyses were performed. Results A total of 151 patients were included in the analysis. Of these, 62.9% were males with mean age of 61.7 ± 16.4 years. Overall, there was an almost equal distribution of patients in the benign and malignant groups. Older age (≥65 years), jaundice, weight loss, intrahepatic biliary and pancreatic duct dilation, double-duct sign and presence of a mass were associated with malignancy in the univariate analysis. However, only older age (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.00 to 1.03), jaundice (OR 3.33, 95% CI 1.11 to 9.98) and presence of a mass (OR 12.10, 95% CI 4.94 to 29.67) were significantly associated with malignancy in the multivariate analysis. High CA19-9 was associated with malignancy only in patients with primary sclerosing cholangitis. Conclusion In patients with indeterminate biliary stricture and atypical brush cytology, older age, jaundice and presence of a mass are significant predictors of malignancy. Patients with such characteristics need prompt evaluation to rule out underlying malignancy.
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Affiliation(s)
- Ali Alali
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Haya Al-Habeeb Gastroenterology and Hepatology Center, Mubarak Al-Kabeer Hospital, Jabriya, Kuwait
| | - Maria Moris
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Digestive Disease Department, Marqués de Valdecilla University Hospital, Cantabria University, Santander, Spain
| | - Myriam Martel
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Catherine Streutker
- Department of Laboratory Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Maria Cirocco
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey Mosko
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Paul Kortan
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Alan Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Gary R May
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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2
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Li S, Mosko J, May G, Kandel G, Kortan P, Marcon N, Teshima C. A61 USE OF ADJUNCTIVE REMOVAL TECHNIQUES FOR ENDOSCOPIC MUCOSAL RESECTION OF LARGE NON-PEDUNCULATED COLONIC POLYPS IS PREDICTIVE OF POLYP RECURRENCE. J Can Assoc Gastroenterol 2021. [DOI: 10.1093/jcag/gwab002.059] [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] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Endoscopic mucosal resection (EMR) allows for safe and effective removal of large non-pedunculated colon polyps. However, prior studies have shown significant recurrence rates between 10–30% after EMR, which have led to recommendations for close endoscopic follow-up and the use of techniques such as snare tip soft coagulation (STSC) to EMR margins to prevent recurrence. Models such as the Size/Morphology/Site/Access score (SMSA) have been developed to aid in identifying polyp complexity and patients at high risk of recurrence. Numerous individual risk factors for recurrence have previously been reported, however the significance of these factors have varied between studies, with limited data from Canadian centres.
Aims
To evaluate predictors of recurrence for large non-pedunculated polyps following EMR.
Methods
Consecutive patients between April 1, 2017 to March 1, 2019 who underwent EMR were retrospectively identified from endoscopy unit administrative records. Patients with non-pedunculated colorectal polyps ≥ 2 cm that were removed by EMR were included if follow-up endoscopy data were available. Polyps found to contain invasive adenocarcinoma on histology and/or were referred for surgical resection were excluded. Patient demographic, pre-procedural, intra-procedural, and post-procedural data to time of first follow-up colonoscopy were extracted. Recurrence was defined as a positive pathology specimen from the EMR scar at follow-up. Adjunctive techniques were defined as the use of any non-snare resection or ablation technique for removal of visible adenoma at the time of the EMR. Chi-square and multivariate regression analyses were conducted for variables of interest.
Results
517 patients underwent large polyp EMR during the study time period with 265 patients satisfying inclusion criteria. Median age of patients was 67 years (IQR 14); 48% were female. STSC was performed to EMR margins in 94% of cases. 30.9% and 69.1% of polyps were SMSA grade 3 and grade 4 respectively. Adjunctive removal techniques were utilized in 31% of patients, 95% of which was hot avulsion. 15% of patients had recurrence on follow-up endoscopy. Higher SMSA grade was associated with the use of adjunctive techniques (20% vs. 37%, p=0.006). The use of adjunctive removal techniques (OR 2.92, p=0.007) and male gender (OR 3.45, p=0.002) were the only factors found to be significantly predictive of recurrence on multivariate analysis.
Conclusions
Male gender and the use of adjunctive removal techniques, particularly hot avulsion, are independently predictive of recurrence after EMR of large complex colorectal polyps. Male patients and those who require hot avulsion may be considered high risk for recurrence and warrant closer follow-up.
Funding Agencies
None
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Affiliation(s)
- S Li
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - J Mosko
- The Center for Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael’s Hospital, Toronto, ON, Canada
| | - G May
- The Center for Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael’s Hospital, Toronto, ON, Canada
| | - G Kandel
- The Center for Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael’s Hospital, Toronto, ON, Canada
| | - P Kortan
- The Center for Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael’s Hospital, Toronto, ON, Canada
| | - N Marcon
- The Center for Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael’s Hospital, Toronto, ON, Canada
| | - C Teshima
- The Center for Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael’s Hospital, Toronto, ON, Canada
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3
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Shimamura Y, Iwaya Y, Kobayashi R, Rodriguez de Santiago E, Muwanwella N, Raftopoulos S, Mosko JD, May GR, Kandel G, Kortan P, Marcon N, Teshima CW. Clinical and pathological predictors of failure of endoscopic therapy for Barrett's related high-grade dysplasia and early esophageal adenocarcinoma. Surg Endosc 2020; 35:5468-5479. [PMID: 32989547 DOI: 10.1007/s00464-020-08037-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 06/28/2020] [Accepted: 09/16/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS Multimodal endoscopic treatment for Barrett's esophagus (BE) related high-grade dysplasia (HGD) and early esophageal adenocarcinoma (EAC) is safe and effective. However, there is a paucity of data to predict the response to endoscopic treatment. This study aimed to identify predictors of failure to achieve complete eradication of neoplasia (CE-N) and complete eradication of intestinal metaplasia (CE-IM). METHODS We performed a retrospective analysis of prospectively collected data of all HGD/EAC cases treated endoscopically at a tertiary referral center. Only patients with confirmed HGD/EAC from initial endoscopic mucosal resection (EMR) were included. Potential predictive variables including clinical characteristics, endoscopic features, and index histologic parameters of the EMR specimens were evaluated using multivariate Cox regression. RESULTS A total of 457 patients were diagnosed with HGD/EAC by initial EMR from January 2008 to January 2019. Of these, 366 patients who underwent subsequent endoscopic treatment with or without RFA were included. Cumulative incidence rates at 3 years for CE-N and CE-IM were 91.4% (95% CI 87.8-94.2%) and 66.8% (95% CI 61.2-72.3%), respectively during a median follow-up period of 35 months. BE segment of 3-10 cm (HR 0.45; 95% CI 0.36-0.57) and > 10 cm (HR 0.25; 95% CI 0.15-0.40) were independent clinical predictors associated with failure to achieve CE-N. With respect to CE-IM, increasing age (HR 0.88; 95% CI 0.78-1.00) was another predictor along with BE segment of 3-10 cm (HR 0.37; 95% CI 0.28-0.49) and > 10 cm (HR 0.15; 95% CI 0.07-0.30). Lymphovascular invasion increased the risk of CE-N and CE-IM failure in EAC cases. CONCLUSION Failure to achieve CE-N and CE-IM is associated with long-segment BE and other clinical variables. Patients with these predictors should be considered for a more intensive endoscopic treatment approach at expert centers.
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Affiliation(s)
- Yuto Shimamura
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada.
| | - Yugo Iwaya
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Ryosuke Kobayashi
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Enrique Rodriguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramon Y Cajal, IRYCIS, Universidad de Alcala, Madrid, Spain
| | - Niroshan Muwanwella
- Department of Gastroenterology and Hepatology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Spiro Raftopoulos
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Jeffrey D Mosko
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Gary R May
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Gabor Kandel
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Paul Kortan
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Norman Marcon
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Christopher W Teshima
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
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4
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Khan U, Barkun AN, Benchimol EI, Salim M, Telford JJ, Enns RA, Mohamed R, Forbes N, Sandha GS, Mosko J, May G, Kortan P, Chatterjee A, James P. A272 THE CANADIAN DIRECT OBSERVATION OF PROCEDURAL SKILLS (CANDOPS) TOOL FOR ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY: A MULTI-CENTRE PROSPECTIVE STUDY. J Can Assoc Gastroenterol 2020. [DOI: 10.1093/jcag/gwz047.271] [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] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
Previous studies have demonstrated that many graduating trainees may not have all of the skills needed to independently practice endoscopic retrograde cholangiopancreatography (ERCP) safely and effectively. As a part of competency-based learning curriculum development, it is essential to provide formative feedback to trainees and ensure they acquire the knowledge and skills for independent practice.
Aims
To assess the performance of advanced endoscopy trainees across Canada using the Canadian Direct Observation of Procedural Skills (CanDOPS) ERCP assessment tool. Procedural items evaluated include both technical (cannulation, sphincterotomy, stone extraction, tissue sampling, and stent placement) and non-technical (leadership, communication and teamwork, judgment and decision making) skills.
Methods
We conducted a prospective national multi-centre prospective study. Advanced endoscopy trainees with at least two years of gastroenterology training or five years of general surgery in North America and minimal experience performing ERCPs (less than 100 ERCP procedures) were invited to participate. The CanDOPS tool was used to measure every fifth ERCP performed by trainees over a 12-month fellowship training period. ERCPs were evaluated by experienced staff endoscopists at each study site under standard clinical protocol. Cumulative sum (CUSUM) analyses were used to generate learning curves.
Results
The data from five Canadian sites and 11 trainees participated in the study. A total of 261ERCP evaluations were completed. Median number of evaluations by site and trainee was 49 (IQR 31–76) and 15 (IQR 11–45). Median number of cases trainees performed prior to their ERCP training was 50 (IQR 25–400). There was a significant improvement in almost all scores over time, including selective cannulation, sphincterotomy, biliary stenting and all non-technical skills (P<0.01). CUSUM analyses using acceptable and unacceptable failure rates of 20% and 50% demonstrated trainees achieved competency for most measures in their final month of their training. Competency in tissue sampling was not achieved within a one-year training period.
Conclusions
This is the first ERCP performance evaluation tool that examines multiple technical and non-technical aspects of the procedure. Although trainee ERCP skills do improve during their training period, there exists a notable variability in time to competency for the different skills measured using the CanDOPS tool. Large prospective research is required to determine if competency is achieved using more stringent definitions of ERCP competency and to determine factors associated with reaching competency.
Funding Agencies
None
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Affiliation(s)
- U Khan
- Medicine, University Health Network, Toronto, ON, Canada
| | - A N Barkun
- Gastroenterology, McGill University, The Montreal General Hospital, GI Division, Montreal, QC, Canada
| | - E I Benchimol
- Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - M Salim
- University Health Network, Toronto, ON, Canada
| | - J J Telford
- University of British Columbia, Vancouver, BC, Canada
| | - R A Enns
- Medicine, St Paul, Vancouver, BC, Canada
| | - R Mohamed
- University of Calgary, Calgary, AB, Canada
| | - N Forbes
- University of Calgary, Calgary, AB, Canada
| | - G S Sandha
- Medicine, University of Alberta, Edmonton, AB, Canada
| | - J Mosko
- Medicine, University of Toronto, Toronto, ON, Canada
| | - G May
- St. Michael, Toronto, ON, Canada
| | - P Kortan
- St. Michael’s Hospital, Toronto, ON, Canada
| | | | - P James
- Medicine, University Health Network, Toronto, ON, Canada
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5
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Iwaya Y, Shimamura Y, Goda K, Rodríguez de Santiago E, Coneys JG, Mosko JD, Kandel G, Kortan P, May G, Marcon N, Teshima C. Clinical characteristics of young patients with early Barrett’s neoplasia. World J Gastroenterol 2019; 25:3069-3078. [PMID: 31293342 PMCID: PMC6603815 DOI: 10.3748/wjg.v25.i24.3069] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 05/07/2019] [Accepted: 05/18/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Esophageal adenocarcinoma (EAC) and high-grade dysplasia (HGD) may appear in young patients with Barrett’s esophagus (BE). However, characteristics of Barrett’s-related neoplasia in this younger population remain unknown.
AIM To identify clinical characteristics that differ between young and old patients with early-stage Barrett’s-related neoplasia.
METHODS We conducted a retrospective analysis of a prospectively maintained database comprised of consecutive patients with early-stage EAC (pT1) and HGD at a tertiary-referral center between 2001 and 2017. Baseline characteristics, drug and risk factor exposures, clinicopathological staging of EAC/HGD and treatment outcomes [complete eradication of neoplasia (CE-N), complete eradication of intestinal metaplasia (CE-IM), recurrence of neoplasia and recurrence of intestinal metaplasia] were retrieved. Multivariate analyses were performed to identify factors that differed significantly between older and younger (≤ 50 years) patients.
RESULTS We identified 450 patients with T1 EAC and HGD (74% and 26%, respectively); 45 (10%) were ≤ 50 years. Compared to the older group, young patients were more likely to present with ongoing gastroesophageal reflux disease (GERD) symptoms (55% vs 38%, P = 0.04) and to be obese (body mass index > 30, 48% vs 32%, P = 0.04). Multivariate logistic regression analysis showed that young patients were significantly more likely to have ongoing GERD symptoms [odds ratio (OR) 2.00, 95% confidence interval (CI) 1.04-3.85, P = 0.04] and to be obese (OR 2.06, 95%CI 1.07-3.98, P = 0.03) whereas the young group was less likely to have a smoking history (OR 0.39, 95%CI 0.20-0.75, P < 0.01) compared to the old group. However, there were no significant differences regarding tumor histology, CE-N, CE-IM, recurrence of neoplasia and recurrence of intestinal metaplasia (mean follow-up, 44.3 mo).
CONCLUSION While guidelines recommend BE screening in patients > 50 years of age, younger patients should be considered for screening endoscopy if they suffer from obesity and GERD symptoms.
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Affiliation(s)
- Yugo Iwaya
- Advanced Therapeutic Endoscopy Centre, St Michael’s Hospital, University of Toronto, Toronto M5B 1W8, Ontario, Canada
| | - Yuto Shimamura
- Advanced Therapeutic Endoscopy Centre, St Michael’s Hospital, University of Toronto, Toronto M5B 1W8, Ontario, Canada
| | - Kenichi Goda
- Department of Gastroenterology, Dokkyo Medical University, Tochigi 321-0293, Japan
| | | | - John Gerard Coneys
- Advanced Therapeutic Endoscopy Centre, St Michael’s Hospital, University of Toronto, Toronto M5B 1W8, Ontario, Canada
| | - Jeffrey D Mosko
- Advanced Therapeutic Endoscopy Centre, St Michael’s Hospital, University of Toronto, Toronto M5B 1W8, Ontario, Canada
| | - Gabor Kandel
- Advanced Therapeutic Endoscopy Centre, St Michael’s Hospital, University of Toronto, Toronto M5B 1W8, Ontario, Canada
| | - Paul Kortan
- Advanced Therapeutic Endoscopy Centre, St Michael’s Hospital, University of Toronto, Toronto M5B 1W8, Ontario, Canada
| | - Gary May
- Advanced Therapeutic Endoscopy Centre, St Michael’s Hospital, University of Toronto, Toronto M5B 1W8, Ontario, Canada
| | - Norman Marcon
- Advanced Therapeutic Endoscopy Centre, St Michael’s Hospital, University of Toronto, Toronto M5B 1W8, Ontario, Canada
| | - Christopher Teshima
- Advanced Therapeutic Endoscopy Centre, St Michael’s Hospital, University of Toronto, Toronto M5B 1W8, Ontario, Canada
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6
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Alali A, Espino A, Moris M, Martel M, Schwartz I, Cirocco M, Streutker C, Mosko J, Kortan P, Barkun A, May GR. Endoscopic Resection of Ampullary Tumours: Long-term Outcomes and Adverse Events. J Can Assoc Gastroenterol 2019; 3:17-25. [PMID: 32010876 PMCID: PMC6985700 DOI: 10.1093/jcag/gwz007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 02/23/2019] [Indexed: 02/06/2023] Open
Abstract
Background The management of ampullary lesions has shifted from surgical approach to endoscopic resection. Previous reports were limited by small numbers of patients and short follow-up. The aim of this study is to describe short- and long-term outcomes in a large cohort of patients undergoing endoscopic ampullectomy. Methods Retrospective study of endoscopic ampullectomies performed at a tertiary center from January 1999 to October 2016. Information recorded includes patient demographics, clinical outcomes, lesion pathology, procedural events, adverse events and follow-up data. Results Overall, 103 patients underwent endoscopic resection of ampullary tumours (mean age 62.3 ± 14.3 years, 50.5% female, mean lesion size 20.9 mm; 94.9% adenomas, with a majority of lesions exhibiting low-grade dysplasia (72.7%). Complete endoscopic resection was achieved in 82.5% at initial procedure. Final complete endoscopic resection was achieved in all patients with benign pathology on follow-up procedures. Final pathology showed that 11% had previously undiagnosed invasive carcinoma. Delayed postprocedure bleeding occurred in 21.4%, all of which were managed successfully at endoscopy. Acute pancreatitis complicated 15.5% of procedures (mild in 93.8%). Perforation occurred in 5.8%, all treated conservatively except for one patient requiring surgery. Piecemeal resection was associated with significantly higher recurrence compared to en-bloc resection (54.3% versus 26.2%, respectively, P = 0.012). All recurrences were treated endoscopically. Conclusion Endoscopic ampullectomy appears both safe and effective in managing patients with ampullary tumours in experienced hands. Most adverse events can be managed conservatively. Many patients develop recurrence during long-term follow-up but can be managed endoscopically. Recurrence rates may be reduced by performing initial en-bloc resection.
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Affiliation(s)
- Ali Alali
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Haya Al-Habeeb Gastroenterology and Hepatology Center, Mubarak Al-Kabeer Hospital, Jabriya, Kuwait
| | - Alberto Espino
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Department of Gastroenterology, Pontificia Universidad Católica de Chile, Endoscopy Unit Hospital UC-Christus, Santiago, Chile
| | - Maria Moris
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Myriam Martel
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Ingrid Schwartz
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Maria Cirocco
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Catherine Streutker
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey Mosko
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Paul Kortan
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Alan Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Gary R May
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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7
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Affiliation(s)
- S A Taylor
- University of Toronto, Toronto, ON, Canada
| | - J Cygler
- University of Toronto, Toronto, ON, Canada
| | - P Kortan
- St. Michael’s Hospital, Toronto, ON, Canada
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8
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Aranda-Hernández J, Shimamura Y, Grin A, Iwaya Y, Cirocco M, Kandel G, May G, Kortan P, Raftopoulos S, Marcon N. Hot avulsion may be effective as salvage treatment for focal Barrett's esophagus remaining after endoscopic therapy for dysplasia or early cancer: a preliminary study. Endoscopy 2018; 50:8-13. [PMID: 29065436 DOI: 10.1055/s-0043-119986] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND STUDY AIM Both endoscopic mucosal resection (EMR) and radiofrequency ablation (RFA) are used to treat Barrett's esophagus (BE) complicated by dysplasia and intramucosal cancer. However, focal areas of BE can remain after otherwise successful application of these techniques. We report the results of hot avulsion using a hot biopsy forceps to resect these residual focal areas. PATIENTS AND METHODS This was a retrospective study from a prospective database in a tertiary reference center from August 2013 to May 2015. All included patients had undergone hot avulsion for eradication of residual focal areas of BE that were ≤ 1 cm and not suspicious for dysplasia, following at least one previous endoscopic treatment for dysplasia or intramucosal cancer. RESULTS 35 patients harboring 124 residual areas of 1 - 7 mm were treated with hot avulsion. After a mean follow-up of 17.4 months, all patients achieved complete eradication of residual focal BE. One of the patients required a second hot avulsion treatment. Hot avulsion provided samples in all cases but limited the assessment of dysplasia (cautery artifact) in 20.2 % of them. The only complication was bleeding in two patients, which was easily stopped by soft coagulation. CONCLUSIONS Hot avulsion appears to be effective and safe in removing focal BE ≤ 1 cm at its greatest length remaining after endoscopic treatment for dysplasia or early cancer. Further studies are required before this technique can be considered the standard of care.
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Affiliation(s)
- Javier Aranda-Hernández
- Division of Gastroenterology, Department of Medicine, The Center of Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Yuto Shimamura
- Division of Gastroenterology, Department of Medicine, The Center of Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Andrea Grin
- Division of Gastroenterology, Department of Medicine, The Center of Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Yugo Iwaya
- Division of Gastroenterology, Department of Medicine, The Center of Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Maria Cirocco
- Division of Gastroenterology, Department of Medicine, The Center of Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Gabor Kandel
- Division of Gastroenterology, Department of Medicine, The Center of Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Gary May
- Division of Gastroenterology, Department of Medicine, The Center of Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Paul Kortan
- Division of Gastroenterology, Department of Medicine, The Center of Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Spiro Raftopoulos
- Division of Gastroenterology, Department of Medicine, The Center of Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Norman Marcon
- Division of Gastroenterology, Department of Medicine, The Center of Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
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9
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Ramkumar S, Liang SV, Prince RM, Scheer AS, Hallet J, Wong RK, Krzyzanowska M, Kortan P, Zimmermann C, Easson AM. Understanding Palliative Interventions in Patients with End-Stage Colorectal Cancer. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.06.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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10
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Affiliation(s)
- S Chandran
- Department of Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - P Kortan
- Department of Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, Toronto, Ontario, Canada
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Aronson M, Gallinger S, Cohen Z, Cohen S, Dvir R, Elhasid R, Baris HN, Kariv R, Druker H, Chan H, Ling SC, Kortan P, Holter S, Semotiuk K, Malkin D, Farah R, Sayad A, Heald B, Kalady MF, Penney LS, Rideout AL, Rashid M, Hasadsri L, Pichurin P, Riegert-Johnson D, Campbell B, Bakry D, Al-Rimawi H, Alharbi QK, Alharbi M, Shamvil A, Tabori U, Durno C. Gastrointestinal Findings in the Largest Series of Patients With Hereditary Biallelic Mismatch Repair Deficiency Syndrome: Report from the International Consortium. Am J Gastroenterol 2016; 111:275-84. [PMID: 26729549 DOI: 10.1038/ajg.2015.392] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [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: 01/02/2015] [Accepted: 11/01/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Hereditary biallelic mismatch repair deficiency (BMMRD) is caused by biallelic mutations in the mismatch repair (MMR) genes and manifests features of neurofibromatosis type 1, gastrointestinal (GI) polyposis, and GI, brain, and hematological cancers. This is the first study to characterize the GI phenotype in BMMRD using both retrospective and prospective surveillance data. METHODS The International BMMRD Consortium was created to collect information on BMMRD families referred from around the world. All patients had germline biallelic MMR mutations or lack of MMR protein staining in normal and tumor tissue. GI screening data were obtained through medical records with annual updates. RESULTS Thirty-five individuals from seven countries were identified with BMMRD. GI data were available on 24 of 33 individuals (73%) of screening age, totaling 53 person-years. The youngest age of colonic adenomas was 7, and small bowel adenoma was 11. Eight patients had 19 colorectal adenocarcinomas (CRC; median age 16.7 years, range 8-25), and 11 of 18 (61%) CRC were distal to the splenic flexure. Eleven patients had 15 colorectal surgeries (median 14 years, range 9-25). Four patients had five small bowel adenocarcinomas (SBC; median 18 years, range 11-33). Two CRC and two SBC were detected during surveillance within 6-11 months and 9-16 months, respectively, of last consecutive endoscopy. No patient undergoing surveillance died of a GI malignancy. Familial clustering of GI cancer was observed. CONCLUSIONS The prevalence and penetrance of GI neoplasia in children with BMMRD is high, with rapid development of carcinoma. Colorectal and small bowel surveillance should commence at ages 3-5 and 8 years, respectively.
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Affiliation(s)
- Melyssa Aronson
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Steven Gallinger
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Zane Cohen
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Shlomi Cohen
- Pediatric Gastro-Enterology Unit, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Centre, Tel Aviv, Israel
| | - Rina Dvir
- Department of Pediatric Hemato-Oncology, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Centre, Tel Aviv, Israel
| | - Ronit Elhasid
- Department of Pediatric Hemato-Oncology, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Centre, Tel Aviv, Israel
| | - Hagit N Baris
- The Genetics Institute, Rambam Health Care Campus, Haifa, Israel, and Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Revital Kariv
- Department of Gastroenterology and Liver Disease, Tel Aviv Sourasky Medical Centre, Tel Aviv, Israel
| | | | - Helen Chan
- Hospital for Sick Children, Toronto, Ontario, Canada
| | - Simon C Ling
- Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Paul Kortan
- St Michael's Hospital, Toronto, Ontario, Canada
| | - Spring Holter
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Kara Semotiuk
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - David Malkin
- Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Roula Farah
- Saint George Hospital University Medical Center, Beirut, Lebanon
| | - Alain Sayad
- Lebanese American University Medical Centre, Beirut, Lebanon
| | | | | | | | | | | | | | | | | | | | - Doua Bakry
- Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hala Al-Rimawi
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Qasim Kholaif Alharbi
- Department of Pediatric Hematology/Oncology and Stem Cell Transplant, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | | | | | - Uri Tabori
- Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Carol Durno
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada.,Hospital for Sick Children, Toronto, Ontario, Canada
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12
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Hatlani MA, Kortan P, May G, Ling SC, Walters T, Avitzur Y. Wire-guided cannulation versus contrast-guided cannulation in pediatric endoscopic retrograde cholangiopancreatography. Saudi J Gastroenterol 2015; 21:25-9. [PMID: 25672235 PMCID: PMC4355858 DOI: 10.4103/1319-3767.151219] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND/AIM Wire-guided cannulation (WGC) of the common bile duct may be associated with fewer complications and higher success rate compared with contrast-guided cannulation (CGC) in adults. Data in children are lacking. The aim of this study was to compare the successful cannulation and complication rate of WGC and CGC in pediatric endoscopic retrograde cholangiopancreatography (ERCP). PATIENTS AND METHODS We report a retrospective cohort study comparing WGC to CGC in a pediatric cohort. We reviewed the medical records of 167 children who underwent ERCP over a 10-year time period (CGC, 1999-2003, WGC, 2003-2009). Indications, findings, and success were analyzed. RESULTS A total of 93 patients (56%) underwent WGC and 74 (44%) CGC. Children in the WGC group were younger (9.5 ± 4.7 vs. 11.5 ± 4.6 years in CGC; P = 0.006) and underwent more therapeutic ERCP interventions (70% vs. 40% in CGC), whereas diagnostic ERCP was more common in the CGC group (60%; P < 0.005). The overall success (96%) and complication rate (8%) were identical in both groups but a trend toward a reduction in the complication rate over time was noted in the WGC group. Post-ERCP pancreatitis (PEP) was documented in one patient in the WGC group (1.1%) and three patients (4.2%) in the CGC group (P-NS). CONCLUSION The success and complication rate in both CGC and WGC are comparable in children but considering the patient and procedure complexity and the trend toward lower PEP in the WGC group, WGC may be the preferable cannulation technique for ERCP in children.
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Affiliation(s)
- Maher Al Hatlani
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Canada,Department of Pediatrics and KAIMRC, King Abdulaziz Medical City, Ministry of National Guard, Riyadh, Saudi Arabia,Address for correspondence: Dr. Maher Mohammed Al Hatlani, Division of Gastroenterology, Hepatology and Nutrition, King Abdulaziz Medical City, Ministry of National Guard, Prince Miteb Bin Abdulaziz Road, Riyadh 11426 P.O Box 22490, Saudi Arabia. E-mail:
| | - Paul Kortan
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Gary May
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Simon C. Ling
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Canada
| | - Thomas Walters
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Canada
| | - Yaron Avitzur
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Canada
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13
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Alshehry NF, Kortan P, Lipton JH. Imatinib-induced gastric antral vascular ectasia in a patient with chronic myeloid leukemia. Clin Case Rep 2014; 2:77-8. [PMID: 25356253 PMCID: PMC4184597 DOI: 10.1002/ccr3.49] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 01/08/2014] [Indexed: 01/29/2023] Open
Abstract
Key Clinical Message Gastric antral vascular ectasia (GAVE) has been reported very rarely in imatinib-treated gastrointestinal stromal tumor (GIST) and scleroderma/pulmonary hypertension patients. We present the first report of a case of GAVE in a chronic myeloid leukemia (CML) patient after treatment with imatinib. This diagnosis should be considered in CML patients with upper gastrointestinal symptoms and anemia.
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Affiliation(s)
- Nawal F Alshehry
- Princess Margaret Cancer Centre Toronto, Ontario, Canada ; Queens University Kingston, Ontario, Canada
| | - Paul Kortan
- St. Michael's Hospital Toronto, Ontario, Canada ; University of Toronto 610 University Avenue, Toronto, Ontario, M5G 2M9, Canada
| | - Jeffrey H Lipton
- Princess Margaret Cancer Centre Toronto, Ontario, Canada ; University of Toronto 610 University Avenue, Toronto, Ontario, M5G 2M9, Canada
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14
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Patel H, Khalili K, Kyoung KT, Yazdi L, Lee E, May G, Kortan P, Coltescu C, Hirschfield GM. IgG4 related disease - a retrospective descriptive study highlighting Canadian experiences in diagnosis and management. BMC Gastroenterol 2013; 13:168. [PMID: 24321047 PMCID: PMC3878912 DOI: 10.1186/1471-230x-13-168] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Accepted: 11/15/2013] [Indexed: 02/06/2023] Open
Abstract
Background Appreciating the utility of published diagnostic criteria for autoimmune pancreatitis, when compared to the characteristics of patients clinically managed as having disease, informs and refines ongoing clinical practice. Methods Comparative retrospective descriptive evaluation of patients with autoimmune pancreatitis including dedicated radiology review. Results 66 subjects with radiographic OR clinical features of autoimmune pancreatitis were initially identifiable (Male: n = 50), with 55 confirmed for evaluation. The most common presentation included pain (67%), weight loss (65%), and jaundice (62%). Diffuse enlargement of the pancreas was evident in 38%, whilst multifocal, focal, or atrophic changes were seen in 7%, 33% and 9% respectively. 13% had no pancreatic parenchymal involvement. Peripheral rim enhancement was seen in 23 patients (42%). Where discernible, disease was a) Sclerosing pancreatitis and cholangitis, n = 21; b) Sclerosing cholangitis, n = 9; c) Sclerosing pancreatitis, n = 4; d) Sclerosing pancreatitis and cholangitis with pancreatic pseudotumour, n = 7; e) Sclerosing cholangitis with hepatic pseudotumour, n = 3; f) Sclerosing pancreatitis with pancreatic pseudotumour, n = 1. 56% of the patients had systemic manifestations and the median serum IgG4 at diagnosis was 5.12 g/L. The Korean criteria identified most patients (82%) compared to HISORt (55%) or the Japan Pancreas Society (56%). The majority (HISORt 60%; Japan Pancreas Society 55%; Korean 58%) met diagnostic criterion by radiological findings and elevated serum IgG4. Treatment and response did not differ when stratified by diagnostic criteria. Conclusion Our descriptive and retrospective dataset confirms that in non-expert practice settings, autoimmune pancreatitis scoring systems with a focus on radiology and serology capture most patients who are clinically felt to have disease.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Gideon M Hirschfield
- Centre for Liver Research and NIHR Biomedical Research Unit, Institute of Biomedical Research, The Medical School, University of Birmingham, 5th Floor, Birmingham B15 2TT, UK.
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15
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Ooi CY, Dupuis A, Ellis L, Jarvi K, Martin S, Ray PN, Steele L, Kortan P, Gonska T, Dorfman R, Solomon M, Zielenski J, Corey M, Tullis E, Durie P. Does extensive genotyping and nasal potential difference testing clarify the diagnosis of cystic fibrosis among patients with single-organ manifestations of cystic fibrosis? Thorax 2013; 69:254-60. [PMID: 24149827 DOI: 10.1136/thoraxjnl-2013-203832] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The phenotypic spectrum of cystic fibrosis (CF) has expanded to include patients affected by single-organ diseases. Extensive genotyping and nasal potential difference (NPD) testing have been proposed to assist in the diagnosis of CF when sweat testing is inconclusive. However, the diagnostic yield of extensive genotyping and NPD and the concordance between NPD and the sweat test have not been carefully evaluated. METHODS We evaluated the diagnostic outcomes of genotyping (with 122 mutations included as disease causing), sweat testing and NPD in a prospectively ascertained cohort of undiagnosed patients who presented with chronic sino-pulmonary disease (RESP), chronic/recurrent pancreatitis (PANC) or obstructive azoospermia (AZOOSP). RESULTS 202 patients (68 RESP, 42 PANC and 92 AZOOSP) were evaluated; 17.3%, 22.8% and 59.9% had abnormal, borderline and normal sweat chloride results, respectively. Only 17 (8.4%) patients were diagnosable as having CF by genotyping. Compared to sweat testing, NPD identified more patients as having CF (33.2%) with fewer borderline results (18.8%). The level of agreement according to kappa statistics (and the observed percentage of agreement) between sweat chloride and NPD in RESP, PANC and AZOOSP subjects was 'moderate' (65% observed agreement), 'poor' (33% observed agreement) and 'fair' (28% observed agreement), respectively. The degree of agreement only improved marginally when subjects with borderline sweat chloride results were excluded from the analysis. CONCLUSIONS The diagnosis of CF or its exclusion is not always straightforward and may remain elusive even with comprehensive evaluation, particularly among individuals who present at an older age with single-organ manifestations suggestive of CF.
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Affiliation(s)
- Chee Y Ooi
- Physiology and Experimental Medicine, Research Institute, The Hospital for Sick Children, , Toronto, Canada
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16
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Efthymiou M, Raftopoulos S, Kortan P. Pharyngeal webs in a patient with dysphagia and Behcet's disease. Endoscopy 2013; 44 Suppl 2 UCTN:E374. [PMID: 23012029 DOI: 10.1055/s-0032-1310066] [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)
- M Efthymiou
- St Michael's Hospital, Toronto, Ontario, Canada.
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17
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Walter T, Ho CS, Horgan AM, Warkentin A, Gallinger S, Greig PD, Kortan P, Knox JJ. Endoscopic or percutaneous biliary drainage for Klatskin tumors? J Vasc Interv Radiol 2012. [PMID: 23182938 DOI: 10.1016/j.jvir.2012.09.019] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Controversy exists regarding the preferred biliary drainage technique in patients with Klatskin tumors because few comparative studies exist. This study compared outcomes of endoscopic biliary drainage (EBD) and percutaneous transhepatic biliary drainage (PTBD). MATERIALS AND METHODS Consecutive patients (N = 129) with Klatskin tumors treated with initial EBD or PTBD were identified, and their clinical histories were retrospectively reviewed. The primary endpoint was the time to therapeutic success (TTS), defined as the time between the first drainage and a total bilirubin measurement of 40 μmol/L or lower. RESULTS EBD was the first biliary decompression procedure performed in 87 patients; PTBD was performed first in 42. Technical success rates (78% with EBD vs 98% with PTBD; P = .004) and therapeutic success rates (49% vs 79%, respectively; P = .002) were significantly lower in the EBD group than in the PTBD group. Forty-four patients in the EBD group (51%) subsequently underwent PTBD before therapeutic success was achieved or antitumoral treatment was started. Median TTSs were 61 days in the EBD group and 44 days in the PTBD group, and multivariate analysis showed a hazard ratio of 0.63 (95% confidence interval, 0.41-0.99; P = .045). In patients treated with surgery or chemotherapy with or without radiation therapy, median times to treatment were 76 and 68 days in the EBD and PTBD groups, respectively (P = .76). Cholangitis occurred in 25% and 21% of patients in the EBD and PTBD groups, respectively (P = .34). CONCLUSIONS PTBD should be seriously considered for biliary decompression when treating patients with Klatskin tumor.
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Affiliation(s)
- Thomas Walter
- Division of Medical Oncology, University of Toronto, Princess Margaret Hospital, Toronto, Ontario, Canada.
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18
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Ooi CY, Dupuis A, Ellis L, Jarvi K, Martin S, Gonska T, Dorfman R, Kortan P, Solomon M, Tullis E, Durie PR. Comparing the American and European diagnostic guidelines for cystic fibrosis: same disease, different language? Thorax 2012; 67:618-24. [DOI: 10.1136/thoraxjnl-2011-201454] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Walter T, Ho C, Horgan AM, Warkentin A, Gallinger S, Beecroft R, Hedley DW, Tan K, Kortan P, Knox JJ. Endoscopic or percutaneous biliary drainage for Klatskin tumors? A large retrospective study. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.4_suppl.277] [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
277 Background: Controversy exists over the preferred technique of biliary drainage in patients with Klatskin tumors as few comparative studies exist. This study compared outcomes of endoscopic biliary drainage (EBD) and percutaneous transhepatic biliary drainage (PTBD). Methods: 129 patients with Klatskin tumors with an initial EBD or PTBD were identified from 01/01/1991 to 31/05/2011 and their clinical histories were retrospectively reviewed. The primary end point was the time to therapeutic success (TTS: time between the first drainage and a total bilirubin<40µmol/L), estimated by Kaplan-Meier analysis. Results: The first biliary decompression procedure was EBD in 87 patients and PTBD in 42 patients. The technical (98% vs 78%, p=0.004) and therapeutic (79% vs 49%, p=0.002) successes were significantly higher in the PTBD group than EBD group, respectively; Forty four patients (51%) in the EBD group subsequently underwent a PTBD before achieving therapeutic success or starting their antitumoral treatment. The median TTS was 55 days in EBD group vs 44 days in the PTBD group (multivariate analysis: HR=0.63, 95% CI=0.41-0.99, p=0.045). In patients treated by surgery or chemotherapy +/− radiotherapy, the median time to treatment was 68 and 76 days in the PTBD group and the EBD group, respectively, p=0.76. 25% and 21% of cholangitis occurred in EBD and PTBD group, respectively (p=0.34). Conclusions: In the era where chemotherapy prolongs life even in advanced disease, shortening time to success matters. Our results suggest relying on PTB for biliary decompression would be an improved treatment strategy when treating patients with Klatskin tumor.
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Affiliation(s)
- Thomas Walter
- Princess Margaret Hospital, Toronto, ON, Canada; Department of Medical Imaging, University of Toronto, Toronto General Hospital, Toronto, ON, Canada; Toronto General Hospital, Toronto, ON, Canada; University Health Network and Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada; Ontario Cancer Institute, Toronto, ON, Canada; Princess Margaret Hospital, Toronto, ON, Canada; Center for Therapeutic Endoscopy and Endoscopic Oncology, St Michael’s Hospital, Toronto, ON, Canada
| | - Chia Ho
- Princess Margaret Hospital, Toronto, ON, Canada; Department of Medical Imaging, University of Toronto, Toronto General Hospital, Toronto, ON, Canada; Toronto General Hospital, Toronto, ON, Canada; University Health Network and Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada; Ontario Cancer Institute, Toronto, ON, Canada; Princess Margaret Hospital, Toronto, ON, Canada; Center for Therapeutic Endoscopy and Endoscopic Oncology, St Michael’s Hospital, Toronto, ON, Canada
| | - Anne M. Horgan
- Princess Margaret Hospital, Toronto, ON, Canada; Department of Medical Imaging, University of Toronto, Toronto General Hospital, Toronto, ON, Canada; Toronto General Hospital, Toronto, ON, Canada; University Health Network and Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada; Ontario Cancer Institute, Toronto, ON, Canada; Princess Margaret Hospital, Toronto, ON, Canada; Center for Therapeutic Endoscopy and Endoscopic Oncology, St Michael’s Hospital, Toronto, ON, Canada
| | - Andrew Warkentin
- Princess Margaret Hospital, Toronto, ON, Canada; Department of Medical Imaging, University of Toronto, Toronto General Hospital, Toronto, ON, Canada; Toronto General Hospital, Toronto, ON, Canada; University Health Network and Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada; Ontario Cancer Institute, Toronto, ON, Canada; Princess Margaret Hospital, Toronto, ON, Canada; Center for Therapeutic Endoscopy and Endoscopic Oncology, St Michael’s Hospital, Toronto, ON, Canada
| | - Steven Gallinger
- Princess Margaret Hospital, Toronto, ON, Canada; Department of Medical Imaging, University of Toronto, Toronto General Hospital, Toronto, ON, Canada; Toronto General Hospital, Toronto, ON, Canada; University Health Network and Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada; Ontario Cancer Institute, Toronto, ON, Canada; Princess Margaret Hospital, Toronto, ON, Canada; Center for Therapeutic Endoscopy and Endoscopic Oncology, St Michael’s Hospital, Toronto, ON, Canada
| | - Rob Beecroft
- Princess Margaret Hospital, Toronto, ON, Canada; Department of Medical Imaging, University of Toronto, Toronto General Hospital, Toronto, ON, Canada; Toronto General Hospital, Toronto, ON, Canada; University Health Network and Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada; Ontario Cancer Institute, Toronto, ON, Canada; Princess Margaret Hospital, Toronto, ON, Canada; Center for Therapeutic Endoscopy and Endoscopic Oncology, St Michael’s Hospital, Toronto, ON, Canada
| | - David W Hedley
- Princess Margaret Hospital, Toronto, ON, Canada; Department of Medical Imaging, University of Toronto, Toronto General Hospital, Toronto, ON, Canada; Toronto General Hospital, Toronto, ON, Canada; University Health Network and Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada; Ontario Cancer Institute, Toronto, ON, Canada; Princess Margaret Hospital, Toronto, ON, Canada; Center for Therapeutic Endoscopy and Endoscopic Oncology, St Michael’s Hospital, Toronto, ON, Canada
| | - Kongten Tan
- Princess Margaret Hospital, Toronto, ON, Canada; Department of Medical Imaging, University of Toronto, Toronto General Hospital, Toronto, ON, Canada; Toronto General Hospital, Toronto, ON, Canada; University Health Network and Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada; Ontario Cancer Institute, Toronto, ON, Canada; Princess Margaret Hospital, Toronto, ON, Canada; Center for Therapeutic Endoscopy and Endoscopic Oncology, St Michael’s Hospital, Toronto, ON, Canada
| | - Paul Kortan
- Princess Margaret Hospital, Toronto, ON, Canada; Department of Medical Imaging, University of Toronto, Toronto General Hospital, Toronto, ON, Canada; Toronto General Hospital, Toronto, ON, Canada; University Health Network and Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada; Ontario Cancer Institute, Toronto, ON, Canada; Princess Margaret Hospital, Toronto, ON, Canada; Center for Therapeutic Endoscopy and Endoscopic Oncology, St Michael’s Hospital, Toronto, ON, Canada
| | - Jennifer J. Knox
- Princess Margaret Hospital, Toronto, ON, Canada; Department of Medical Imaging, University of Toronto, Toronto General Hospital, Toronto, ON, Canada; Toronto General Hospital, Toronto, ON, Canada; University Health Network and Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada; Ontario Cancer Institute, Toronto, ON, Canada; Princess Margaret Hospital, Toronto, ON, Canada; Center for Therapeutic Endoscopy and Endoscopic Oncology, St Michael’s Hospital, Toronto, ON, Canada
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Raftopoulos SC, Efthymiou M, Kortan P. Education and imaging. Gastrointestinal: beware of the painful rectum. J Gastroenterol Hepatol 2011; 26:1578. [PMID: 21950749 DOI: 10.1111/j.1440-1746.2011.06861.x] [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: 12/09/2022]
Affiliation(s)
- S C Raftopoulos
- Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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21
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Thomas T, Ayaru L, Lee EY, Cirocco M, Kandel G, May G, Kortan P, Marcon NE. Length of Barrett's segment predicts success of extensive endomucosal resection for eradication of Barrett's esophagus with early neoplasia. Surg Endosc 2011; 25:3627-35. [PMID: 21858582 DOI: 10.1007/s00464-011-1769-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Accepted: 05/16/2011] [Indexed: 01/08/2023]
Abstract
BACKGROUND Although the efficacy and safety of extensive endomucosal resection (EMR) in eradicating Barrett's esophagus (BE) harbouring early neoplasia have been established, factors predicting efficacy remains unclear. AIM To determine the complete eradication rate of Barrett's esophagus with high-grade intraepithelial neoplasia (HGIN) or intramucosal carcinoma (IMC), safety, and factors predicting complete eradication by EMR. METHODS Patients with histological confirmation of Barrett's HGIN/IMC were prospectively identified. EMR was performed using Duette multiband ligator or cap technique by a single operator (NEM). RESULTS 99 patients (81 males) with median age 67 years [interquartile range (IQR) 60-77 years] and median Barrett's length 4 cm (IQR 2-6 cm) were included. Of 628 index EMRs [mean 6.3, median 5 (IQR 3-8)], 23% showed IMC, 58.5% showed HGIN, and 16% showed low-grade dysplasia only. A median of 8 EMR resections per patient (IQR 6-16, 1,064 resections in 89 patients) resulted in complete eradication of BE harboring neoplasia in 49.4% and eradication of HGIN/IMC in 81% (BE <5 cm subgroup: 65% complete eradication and 91% HGIN eradication) at median follow-up of 18 months (range 6-27 months). On univariate analysis, focal dysplasia (P = 0.003) and Barrett's length <5 cm (P = 0.001) were predictors of complete BE eradication. Barrett's length <5 cm was the only significant predictor [odds ratio (OR) 3.4, standard error (SE) 0.11, P = 0.0006] on multiple logistic regression analysis. Strictures developed in 27% and major bleeding in 2% with no procedure-related perforations or mortality. CONCLUSIONS Extensive EMR for removal of BE with early neoplasia is safe. Outcomes for complete BE eradication are modest at 49.4% and eradication of high-grade dysplasia at 81%. Barrett's length <5 cm is the only significant predictor of complete response.
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Affiliation(s)
- T Thomas
- Division of Advanced Therapeutic Endoscopy and GI Oncology, St Michael's Hospital, Toronto, Canada
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Nenshi R, Takata J, Stegienko S, Jacob B, Kortan P, Deitel W, Laporte A, Darling G, Urbach DR. The cost of achalasia: quantifying the effect of symptomatic disease on patient cost burden, treatment time, and work productivity. Surg Innov 2010; 17:291-4. [PMID: 20647236 DOI: 10.1177/1553350610376392] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Although the incidence of achalasia is low, the burden of suffering is high because it is a chronic incurable disease that predominantly affects young persons. This article aims to describe the impact of achalasia on health-related quality of life, patient cost burden, time dedicated to treatment, and work productivity. METHODS Consecutive patients enrolled in a clinical trial comparing laparoscopic myotomy with pneumatic dilatation from 4 sites across Canada (whose clinical and manometric diagnosis was confirmed) were studied using standardized patient-reported outcomes instruments, including the Achalasia Severity Questionnaire (ASQ), the Medical Outcomes Study 36-item Short Form Questionnaire (SF-36), and the Gastrointestinal Disease-Specific Quality of Life (GIQLI) questionnaire. The authors also measured health care utilization. RESULTS Questionnaires were completed by 54 patients (median age = 53.5 years; range = 25-78 years; 50.0% male). Patients had been experiencing symptoms for a mean of 4.5 years (standard deviation = 6.1), and 42.6% were on medication for symptom relief. Among them, 74.1% reported that their disease limited their lifestyle. Patients spent an average of CAD$30.70 a month on medication; 37.0% reported that their disease interfered with their work, and patients missed an average of 10.2 days per 6 months. Patients also spent an average of CAD$24.30 on transportation to and from each clinical appointment. CONCLUSION Achalasia substantially limits the lifestyle of patients with the disease. It also implies a financial burden of care for patients and leads to decreased work productivity.
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Cho S, Zanati S, Yong E, Cirocco M, Kandel G, Kortan P, May G, Marcon N. Endoscopic cryotherapy for the management of gastric antral vascular ectasia. Gastrointest Endosc 2008; 68:895-902. [PMID: 18640673 DOI: 10.1016/j.gie.2008.03.1109] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [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: 05/01/2007] [Accepted: 03/25/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND Gastric antral vascular ectasia (GAVE) is an uncommon but clinically significant cause of chronic GI bleeding. OBJECTIVE To assess the efficacy and safety of cryotherapy for endoscopic treatment of GAVE. DESIGN Patients received 3 sessions of endoscopic cryotherapy at 3-week to 6-week intervals and had a follow-up endoscopy 4 weeks thereafter. They were followed prospectively in terms of clinical and endoscopic response. SETTING Tertiary-care center, between October 2004 and April 2006. PATIENTS The patients were 43 to 89 years of age, with a diagnosis of GAVE and documented iron deficiency anemia. Eight patients had a history of overt GI bleeding. Eight patients (67%) had previously been treated with argon plasma coagulation (APC) (median 6 sessions, range 1-10 sessions) and failed to respond or had a recurrence. RESULTS Twelve patients were enrolled. Six patients (50%) had a complete response, and 6 patients had a partial response. The mean number of units of blood transfused in the period of 3 months before cryotherapy and during the period of follow-up of 3 months was 4.6 and 1.7 units, respectively. An increased mean Hb level, from 9.9 to 11.3 g/dL, was noted. The average duration of the cryotherapy was 5 minutes (range 1-15 minutes). In 32 of 36 cryotherapy treatment sessions performed (89%), it was technically possible to treat more than 90% of GAVE lesions. There were no immediate cryotherapy-related complications, and none of the patients required admission after the procedure. LIMITATIONS A pilot study from a single center. CONCLUSIONS Endoscopic cryotherapy is a safe and effective treatment for GAVE. It appears to be effective, even for GAVE refractory to APC therapy. Optimal cryogen, delivery device, and treatment protocols are yet to be determined.
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Affiliation(s)
- Sarah Cho
- The Centre for Therapeutic Endoscopy and Endoscopic Oncology, Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Saravanan R, Kamalaporn P, Streutker C, May G, Kandel G, Marcon N, Kortan P. Gastric polyp in pernicious anemia: an argument to remove even when biopsy shows hyperplasia. Endoscopy 2008; 40 Suppl 2:E77-8. [PMID: 18633890 DOI: 10.1055/s-2007-995506] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- R Saravanan
- Digestive Disease Centre, Bristol Royal Infirmary, Bristol, UK.
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Baerlocher MO, Asch MR, Dixon P, Kortan P, Myers A, Law C. Interdisciplinary Canadian guidelines on the use of metal stents in the gastrointestinal tract for oncological indications. Can Assoc Radiol J 2008; 59:107-122. [PMID: 18697717] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
OBJECTIVE To provide evidence-based guidelines regarding the appropriate use of gastrointestinal stents for oncologic indications. This document describes the use of gastrointestinal stents by appropriately trained physicians. METHODS This document is based on a review of the published evidence and supplemented by consensus expert opinion. Gastrointestinal stenting has been evaluated in terms of technical success, complications, patient satisfaction, clinical outcome, and cost-benefit analysis. This document was approved by the Canadian Interventional Radiology Association; approval from the other relevant Canadian societies is pending. CONCLUSION Gastrointestinal stenting has a valuable role in the management of gastrointestinal malignancy. The decision to use such devices should be taken after comprehensive multidisciplinary clinical, endoscopic, and radiologic evaluation.
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Al-Sukhni W, Gallinger S, Pratzer A, Wei A, Ho CS, Kortan P, Taylor BR, Grant DR, McGilvray I, Cattral MS, Langer B, Greig PD. Recurrent pyogenic cholangitis with hepatolithiasis--the role of surgical therapy in North America. J Gastrointest Surg 2008; 12:496-503. [PMID: 17999121 DOI: 10.1007/s11605-007-0398-2] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2007] [Accepted: 10/16/2007] [Indexed: 01/31/2023]
Abstract
PURPOSE To determine role of surgical intervention for Recurrent Pyogenic Cholangitis with hepatolithiasis at a North American hepatobiliary center. METHODS Retrospective analysis of 42 patients presenting between 1986 and 2005. RESULTS Mean age is 54.3 years (24-87). Twenty-seven patients (64%) underwent surgery, after unsuccessful endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous intervention in 19/27 patients. Surgical procedures were: 10 common bile duct explorations with choledochojejunostomy and a Hutson loop and 17 hepatectomies (10 with, 7 without Hutson loop). Liver resection was indicated for lobar atrophy or stones confined to single lobe. Operative mortality was zero; complication rates for hepatectomy and common bile duct exploration were comparable (35% vs. 30%). Median follow-up was 24 months (3-228). Of 21 patients with Hutson loops, only seven (33%) needed subsequent loop utilization, with three failures. At last follow-up, 4/27 (15%) surgical patients had stone-related symptoms requiring percutaneous intervention, compared to 4/11 (36%) surviving nonoperative patients. Cholangiocarcinoma was identified in 5/42 (12%) patients; four were unresectable and one was an incidental in-situ carcinoma in a resected specimen. CONCLUSION Surgery is a valuable part of multidisciplinary management of recurrent pyogenic cholangitis with hepatolithiasis. Hepatectomy is a useful option for selected cases. Hutson loops are useful in some cases for managing stone recurrence. Cholangiocarcinoma risk is elevated in this disease.
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Affiliation(s)
- Wigdan Al-Sukhni
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto General Hospital, NCSB11-1244, 585 University Avenue, Toronto, ON, M5G 2N2, Canada
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Tang SJ, Armstrong L, Lara LF, Kortan P. De novo stent-stone complex after long-term biliary stent placement: pathogenesis, diagnosis, and endotherapy. Gastrointest Endosc 2007; 66:193-200. [PMID: 17521649 DOI: 10.1016/j.gie.2006.12.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2006] [Accepted: 12/11/2006] [Indexed: 02/08/2023]
Abstract
BACKGROUND Long-term and permanent biliary stenting have been reported in many studies and are infrequently practiced in selected patients with irretrievable common bile duct stones and biliary strictures. PATIENTS Here we report 3 new cases and review 7 other cases of de novo stent-stone complex formation after long-term biliary stent placement. INTERVENTIONS De novo stent-stone complexes developed in 3 young patients after unintended long-term biliary stent placement of 4.5 to 11 years' duration. The stent-stone complexes were successfully removed during ERCP with electrohydrolic lithotripsy (EHL) in combination with choledochoscopy or extracorporeal shock wave lithotripsy (ESWL) with mechanical lithotripsy (ML). RESULTS The de novo radiolucent stones formed around and above the stent in the proximal and end part of the stent. The stones were generally large with a diameter>2 to 3 cm. The stent-stone complex usually assumed a 1-sided dumbbell configuration inside the bile duct. The mean duration to clinical presentation after initial biliary stenting is 5.64 years (range 2-11 years). CONCLUSIONS It is important to keep in mind that a biliary stent can act as a nidus for new biliary stone formation around the stent after long-term placement. We recommend that the optimal endotherapy in this situation is ML for the free-floating complexes with short stents, and choledochoscopy with EHL or laser lithotripsy and ESWL for impacted complexes with longer stents.
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Affiliation(s)
- Shou-jiang Tang
- Division of Digestive Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas 75390-8887, USA, and Center for Therapeutic Endoscopy and Endoscopic Oncology, St Michael's Hospital, Toronto, Ontario, Canada
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Affiliation(s)
- S J Tang
- Division of Digestive Diseases, Department of Medicine, University of Texas, Southwestern Medical Center at Dallas, Texas, USA, and The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, Toronto, Ontario, Canada
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Bishop MD, Freedman SD, Zielenski J, Ahmed N, Dupuis A, Martin S, Ellis L, Shea J, Hopper I, Corey M, Kortan P, Haber G, Ross C, Tzountzouris J, Steele L, Ray PN, Tsui LC, Durie PR. The cystic fibrosis transmembrane conductance regulator gene and ion channel function in patients with idiopathic pancreatitis. Hum Genet 2005; 118:372-81. [PMID: 16193325 DOI: 10.1007/s00439-005-0059-z] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2005] [Accepted: 08/09/2005] [Indexed: 12/15/2022]
Abstract
Cystic fibrosis transmembrane conductance regulator (CFTR) gene mutations are associated with cystic fibrosis (CF)-related monosymptomatic conditions, including idiopathic pancreatitis. We evaluated prospectively enrolled patients who had idiopathic recurrent acute pancreatitis or idiopathic chronic pancreatitis, healthy controls, CF heterozygotes, and CF patients (pancreatic insufficient or sufficient) for evidence of CFTR gene mutations and abnormalities of ion transport by sweat chloride and nasal potential difference testing. DNA samples from anonymous blood donors were controls for genotyping. At least one CFTR mutation or variant was carried in 18 of 40 patients (45%) with idiopathic chronic pancreatitis and in 6 of 16 patients (38%) with idiopathic recurrent acute pancreatitis but in only 11 of the 50 controls (22%, P=0.005). Most identified mutations were rare and would not be identified in routine genetic screening. CFTR mutations were identified on both alleles in six patient (11%). Ion transport measurements in patients with pancreatitis showed a wide range of results, from the values in patients with classically diagnosed CF to those in the obligate heterozygotes and healthy controls. In general, ion channel measurements correlated with the number and severity of CFTR mutations. Twelve of 56 patients with pancreatitis (21%) fulfilled current clinical criteria for the diagnosis of CF, but CFTR genotyping alone confirmed the diagnosis in only two of these patients. We concluded that extensive genotyping and ion channel testing are useful to confirm or exclude the diagnosis of CF in the majority of patients with idiopathic pancreatitis.
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Affiliation(s)
- Michele D Bishop
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard School of Medicine, Boston, MA, USA
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Yang VXD, Tang SJ, Gordon ML, Qi B, Gardiner G, Cirocco M, Kortan P, Haber GB, Kandel G, Vitkin IA, Wilson BC, Marcon NE. Endoscopic Doppler optical coherence tomography in the human GI tract: initial experience. Gastrointest Endosc 2005; 61:879-90. [PMID: 15933695 DOI: 10.1016/s0016-5107(05)00323-8] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Expanding the current endoscopic optical coherence tomography (OCT) system with Doppler capability may augment this novel high-resolution cross-sectional imaging technique with functional blood flow information. The aim of this feasibility study was to assess the clinical feasibility of an endoscopic Doppler OCT (EDOCT) system in the human GI tract. METHODS During routine endoscopy, 22 patients were imaged by using a prototype EDOCT system, which provided color-Doppler and velocity-variance images of mucosal and submucosal blood flow at one frame per second, simultaneously with high-spatial-resolution (10-25 mum) images of tissue microstructure. The images were acquired from normal GI tract and pathologic tissues. OBSERVATIONS Subsurface microstructure and microcirculation images of normal and pathologic GI tissues, including Barrett's esophagus, esophageal varices, portal hypertensive gastropathy, gastric antral vascular ectasia, gastric lymphoma, and duodenal adenocarcinoma, were obtained from 72 individual sites in vivo. Differences in vessel diameter, distribution, density, and blood-flow velocity were observed among the GI tissue pathologies imaged. CONCLUSIONS To our knowledge, this is the first study to demonstrate the feasibility of EDOCT imaging in the human GI tract during routine endoscopy procedures. EDOCT may detect the different microcirculation patterns exhibited by normal and diseased tissues, which may be useful for diagnostic imaging and treatment monitoring.
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Affiliation(s)
- Victor X D Yang
- Faculty of Medicine, Department of Medical Biophysics, University of Toronto, Canada
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Affiliation(s)
- Simon A Zanati
- The Centre for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Ontario, Canada
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Tang SJ, Haber GB, Kortan P, Zanati S, Cirocco M, Ennis M, Elfant A, Scheider D, Ter H, Dorais J. Precut papillotomy versus persistence in difficult biliary cannulation: a prospective randomized trial. Endoscopy 2005; 37:58-65. [PMID: 15657860 DOI: 10.1055/s-2004-826077] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND STUDY AIMS Failed biliary cannulation occurs in up to 10% of patients undergoing ERCP. There is some controversy as to the safety and efficacy of using precut techniques to achieve biliary cannulation in difficult cases. To date, no randomized trial has compared the success and complication rates of precut with the rates for persistence when biliary cannulation is difficult. The aim of this study was to compare the success rates and complication rates of precut with the success rates and complication rates of persistence in cases of difficult biliary cannulation. PATIENTS AND METHODS Patients without prior sphincterotomy who required biliary cannulation were screened. A "difficult biliary cannulation" was arbitrarily defined as failed cannulation after 12 minutes. These patients were then randomized to continue treatment by needle-knife cut over the roof of the papilla or by persistence with a non-wire-guided, single-lumen papillotome. "Primary" success was defined as deep cannulation within 15 minutes of randomization. Primary and final success rates and complication rates within 30 days after ERCP were compared. RESULTS Over a 38-month period a total of 642 patients were screened. Patients in whom biliary cannulation was successful within a time period of 12 minutes or less formed the reference group (n = 580). The remainder of the patients were randomly assigned to the "precut" arm (n = 32) or to the "persistence" arm (n = 30). Primary success rates and complication rates were similar in the precut and persistence arms (75% and 4% respectively for the precut arm vs. 73% and 9% for the persistence arm). The final successful cannulation rate in the entire group of 642 patients was 99.5%. CONCLUSIONS In experienced hands, precut papillotomy and persistence in cannulation are equally effective in cases of difficult cannulation, with a similar complication rate.
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Affiliation(s)
- S-J Tang
- The Center for Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Tang SJ, Christodoulou D, Zanati S, Dubcenco E, Petroniene R, Cirocco M, Kandel G, Haber GB, Kortan P, Marcon NE. Wireless capsule endoscopy for obscure gastrointestinal bleeding: a single-centre, one-year experience. Can J Gastroenterol 2004; 18:559-65. [PMID: 15457295 DOI: 10.1155/2004/205685] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Wireless capsule endoscopy (CE) is increasingly being used in the investigation of obscure gastrointestinal (GI) bleeding, but some studies have found that many of the bleeding lesions recognized by this technique are within the reach of conventional endoscopy. METHODS The results of CE performed in the authors' centre in a 12 month period for obscure GI bleeding were retrospectively reviewed. RESULTS Of the 46 patients with obscure GI bleeding, CE found a definite or probable cause in 19 (41%) and a possible cause in another 10 (22%), with an overall diagnostic yield of 63%. One of these lesions was found to be within reach of conventional gastroscopy, two were within reach of push enteroscopy, four were within reach of colonoscopy and one was within reach of retrograde enteroscopy through a stoma. The percentage of patients with a bleeding source within reach of routine endoscopy but missed during pre-CE endoscopy was significantly higher for those patients having endoscopy only in the community (30% [eight of 27]) versus in the authors' centre (0% [zero of 19]). CONCLUSIONS CE was valuable for diagnosing bleeding lesions not only within the small bowel, but also in the stomach and colon. However, "second-look" endoscopy may be considered before ordering CE for obscure GI bleeding when local expertise is available.
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Affiliation(s)
- Shou-jiang Tang
- Center for Therapeutic Endoscopy and Endoscopic Oncology, St Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada
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Tang SJ, Zanati S, Dubcenco E, Monkewich G, Arya N, Cirocco M, Kandel G, Kortan P, Haber GB, Marcon NE. Capsule endoscopy regional transit abnormality revisited. Gastrointest Endosc 2004; 60:1029-32. [PMID: 15605032 DOI: 10.1016/s0016-5107(04)02194-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Shou-jiang Tang
- Center for Therapeutic Endoscopy and Endoscopic Oncology, Victoria Wing 16-062, St. Michael's Hospital, Toronto, Ontario M5B 1W8, Canada
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Zanati SA, Ganc RL, Kortan P. Endoscopic modification of a Billroth II gastrojejunostomy by using metallic clips. Gastrointest Endosc 2004; 60:485-8. [PMID: 15332055 DOI: 10.1016/s0016-5107(04)01817-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Simon A Zanati
- The Centre for Therapeutic Endoscopy and Endoscopic Oncology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada M5B 1W8
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Affiliation(s)
- S-J Tang
- Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada
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Affiliation(s)
- Shou-jiang Tang
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Abstract
BACKGROUND Capsule endoscopy is being used increasingly to investigate GI bleeding of obscure origin and disorders of the small bowel. METHODS Four cases of small-bowel varices of various etiologies diagnosed by capsule endoscopy are described: a bleeding small-bowel varix because of hepatic portal hypertension, oozing small-bowel anastomotic or adhesion-related varices, small-bowel varices secondary to mesenteric vein thrombosis, and "idiopathic intestinal varices." OBSERVATIONS Over a 12-month period, small-bowel varices were found in 4 of 46 patients (8.7%) who underwent capsule endoscopy for GI bleeding. Fresh blood adjacent to the varices was documented in 3 patients. The small-bowel varices had serpiginous or nodular shapes, with or without a bluish coloration. The variceal mucosa appeared mosaic-like, shining, or normal compared with surrounding mucosa. CONCLUSIONS Capsule endoscopy is invaluable for the diagnosis of small-bowel varices. It is highly sensitive for detection of fresh blood in the small bowel. Clinical suspicion, capsule endoscopy image recognition, and alertness during capsule endoscopy interpretation are keys to diagnosis.
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Affiliation(s)
- Shou-jiang Tang
- Center for Therapeutic Endoscopy and Endoscopic, Oncology, St Michael's Hospital, University of Toronto, Ontario, Canada
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Mah D, Wales P, Njere I, Kortan P, Masiakos P, Kim PCW. Management of suspected common bile duct stones in children: role of selective intraoperative cholangiogram and endoscopic retrograde cholangiopancreatography. J Pediatr Surg 2004; 39:808-12; discussion 808-12. [PMID: 15185201 DOI: 10.1016/j.jpedsurg.2004.02.019] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Evidence for diagnostic accuracy and clinical efficacy of intraoperative cholangiogram (IOC) and endoscopic retrograde cholangiopancreatography (ERCP) in the management of common bile duct (CBD) stones in children is sparse and unclear. METHODS Retrospective analysis of 202 children who underwent laparoscopic cholecystectomy (LC) between 1996 and 2002 was performed. Forty-eight children had suspected CBD stones on clinical, biochemical, and radiologic grounds. Two clinical pathways, LC followed by ERCP (L-->E) versus ERCP followed by LC (E-->L) were compared. RESULTS From the cohort of 202 patients, 154 did not have suspected CBD stones. Of the 48 patients that did have suspected stones, 2 management pathways were followed: (1) ERCP first: 14 of 48 patients (including 1 failed examination). Three yielded positive findings on ERCP. Ten had negative findings on ERCP, 3 of which went on to have a subsequent IOC. All 3 had negative IOC examination findings. (2) LC +/- IOC first: 34 of 48 patients. Twenty-eight had negative findings on IOC and had no further investigations. Three patients had positive IOC examination findings and went on to have postoperative ERCP. Two of these 3 patients were positive for CBD stones. The remaining 3 of 34 patients had LC with no IOC followed by ERCP. Only 1 of 3 patients yielded a positive examination finding on ERCP. Therefore, of the 168 patients that did not have IOC, only 1 stone (0.6%) would have been missed using the selective criteria. Of those that did meet the criteria for IOC, only 2 of 31 (6.5%) had positive examination findings. There were no adverse effects of a retained or passed stone during our study, nor where there complications in those who had a concomitant sphincterotomy (12 of 20 ERCP patients, mean follow-up of 4.2 years). IOC and ERCP findings correlated in all 6 of the patients in which both procedures were performed. CONCLUSIONS Selective IOC with LC is an acceptable and safe initial approach in suspected CBD. Most CBD stones in children pass spontaneously. Endoscopic sphincterotomy appears to be safe with no long-term sequelae.
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Affiliation(s)
- Doug Mah
- Hospital for Sick Children, Toronto, Ontario, Canada
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Tang SJ, Zanati S, Dubcenco E, Christodoulou D, Cirocco M, Kandel G, Kortan P, Haber GB, Marcon NE. Capsule endoscopy regional transit abnormality: a sign of underlying small bowel pathology. Gastrointest Endosc 2003; 58:598-602. [PMID: 14520302] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Wireless capsule endoscopy is being used increasingly to investigate GI bleeding of obscure etiology and other small bowel abnormalities. Currently, there is no standard for capsule endoscopy image interpretation and classification METHODS This report describes an abnormality, termed "regional transit abnormality," noted during a review of capsule endoscopic images. Capsule regional transit abnormality simply refers to delayed capsule transit within a segment of small bowel, with or without visualization of a mucosal abnormality. The slowed transit usually is accompanied by mucosal collapse, sometimes with the appearance of the capsule pressing or impacting upon the mucosa. Regional transit abnormality usually persists more than 15 minutes CONCLUSIONS Capsule regional transit abnormality is considered to be a "red flag" sign that indicates a likelihood of some underlying small bowel pathology.
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Affiliation(s)
- Shou-Jiang Tang
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Tang SJ, Gordon ML, Yang VXD, Faughnan ME, Cirocco M, Qi B, Yue ES, Gardiner G, Haber GB, Kandel G, Kortan P, Vitkin A, Wilson BC, Marcon NE. In vivo Doppler optical coherence tomography of mucocutaneous telangiectases in hereditary hemorrhagic telangiectasia. Gastrointest Endosc 2003; 58:591-8. [PMID: 14520301 DOI: 10.1067/s0016-5107(03)01978-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia is characterized by mucocutaneous telangiectases and visceral arteriovenous malformations. Knowledge is limited concerning the development hemodynamics of mucocutaneous telangiectases. Doppler optical coherence tomography can demonstrate microvascular blood flow at flow rates as low as 20 microm/second, which is up to approximately 100 times more sensitive than Doppler US. The aims of this study were to collect in vivo Doppler optical coherence tomography images of mucocutaneous telangiectases and normal surrounding mucosa and skin, and to gain experience for an in vivo GI endoscopic study. It was hypothesized that visibly normal areas may have occult telangiectases and that mucocutaneous telangiectases that have bled may have a higher rate of blood flow than mucocutaneous telangiectases with no history of bleeding. METHODS Twelve patients with hereditary hemorrhagic telangiectasia and mucocutaneous telangiectases were studied. Two to 3 visible mucocutaneous telangiectases on the digits, lips, and tongue were imaged with Doppler optical coherence tomography, along with visually normal surrounding areas at each site. The Doppler optical coherence tomography images were obtained in 0.5 second by using 1310 nm light. RESULTS A total of 67 mucocutaneous telangiectases from the 12 patients were imaged (38 digit, 16 lip, 13 tongue). Blood flow was demonstrated within every mucocutaneous telangiectasis imaged. Doppler optical coherence tomography did not identify any abnormal vasculature within visually normal areas. Mucocutaneous telangiectases with a history of bleeding (n = 18) were situated closer to the surface, compared with mucocutaneous telangiectases with no bleeding history (n = 49), but there was no difference in the Doppler flow appearance. CONCLUSIONS Visually normal areas in patients with hereditary hemorrhagic telangiectasia did not appear to have abnormal vasculature. Mucocutaneous telangiectases with a history of bleeding were more superficial but were otherwise similar to mucocutaneous telangiectases with no bleeding history.
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Affiliation(s)
- Shou-Jiang Tang
- Center for Therapeutic Endoscopy and Endoscopic Oncology, Division of Respiratory Medicine, Department of Medicine, St. Michael's Hospital, Ontario, Canada
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42
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Poulin EC, Diamant NE, Kortan P, Seshadri PA, Schlachta CM, Mamazza J. Achalasia developing years after surgery for reflux disease: case reports, laparoscopic treatment, and review of achalasia syndromes following antireflux surgery. J Gastrointest Surg 2000; 4:626-31. [PMID: 11307099 DOI: 10.1016/s1091-255x(00)80113-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Two case reports demonstrate the paradoxical occurrence of achalasia many years after the successful surgical treatment of gastroesophageal reflux disease (GERD). These patients had remedial surgery laparoscopically. The three types of achalasia syndromes that can follow antireflux surgery are discussed. In type 1, primary achalasia is misdiagnosed as GERD and inappropriate antireflux surgery causes worsening dysphagia immediately after surgery without any symptom-free interval. In type 2, secondary iatrogenic achalasia is seen early after antireflux surgery and is characterized by the presence of stenosis and scar formation at the site of the fundic wrap. Although the motility studies resemble achalasia, the repair needs only to be taken down and refashioned when there is no response to balloon dilatation. In type 3, illustrated by the case reports, primary achalasia follows antireflux surgery after a significant symptom-free interval. There is complete absence of any stenosis or fibrosis of the esophagus and periesophageal tissues at remedial surgery. Moreover, surgical treatment of this condition needs to include esophageal myotomy.
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Affiliation(s)
- E C Poulin
- University of Toronto Centre for Minimally Invasive Surgery, St. Michael's Hospital, Toronto, Ontario, Canada
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43
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Abstract
BACKGROUND "Sphincterotomy stenosis" is a recognized late complication of endoscopic biliary sphincterotomy. The narrowing is limited to the biliary orifice and can be managed simply by repeat sphincterotomy. A similar but poorly characterized post-sphincterotomy complication involves narrowing that extends from the biliary orifice for a variable distance along the bile duct, beyond the duodenal wall. This lesion cannot be managed by repeating the sphincterotomy. METHODS Six patients (3 men) are described with sphincterotomy associated biliary strictures, all smooth and high grade, presenting at a median of 19 months (range 8 to 60 months) after sphincterotomy. Further sphincterotomy was not possible as an intra-duodenal segment of bile duct was no longer visible. Endoscopic management consisted of serial incremental stent exchange at 2- to 4-month intervals. The goal of therapy was to place two 11.5F stents side-by-side. RESULTS Stricture resolution was documented by cholangiography in all patients. One patient with a stricture resistant to treatment required three 10F stents side-by-side, and another underwent treatment to a maximum of adjacent 11.5F and 7F stents. Two 11.5F stents were eventually placed in the other four patients. Overall median duration of stent placement was 12.5 months. At a median of 26.5 months of stent-free follow-up, all patients remain asymptomatic. CONCLUSION Sphincterotomy-associated biliary strictures are a distinct late complication of biliary sphincterotomy. These recalcitrant lesions are not amenable to repeat sphincterotomy; however, the results of this study suggest that they may be managed successfully by serial placement of stents of incrementally increasing diameter.
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Affiliation(s)
- M J Bourke
- Centre for Therapeutic Endoscopy and Endoscopic Oncology, The Wellesley Hospital, University of Toronto, Toronto, Ontario, Canada
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44
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Abstract
BACKGROUND There is much controversy as to the importance of establishing drainage of both liver lobes in malignant hilar obstruction. The purpose of the present study was to compare survival data in patients with malignant hilar obstruction, stratified according to the Bismuth classification, who had cholangiography with filling of one or both hepatic ducts and subsequently endoscopic or percutaneous drainage of one or both ducts. METHODS A retrospective review was performed for the time period from July 1990 to July 1995, and 224 patients were identified with a presumed diagnosis of a bifurcation tumor. All x-ray films were reviewed and 150 patients finally diagnosed as hilar tumor were classified according to Bismuth type I, II, or III. Type II and III patients were further subclassified with respect to contrast injection into a single or both hepatic duct systems and whether one or both sides were eventually drained. RESULTS Data were obtained in 141 patients (4 patients still alive); there were 43 type I, 58 type II, and 40 type III. Type II and III patients were divided into three groups: group A, one lobe opacified with same lobe drained; group B, both lobes opacified with both lobes drained; and group C, both lobes opacified with one lobe drained. Overall median survival for type I, II, and III patients was 160, 131, and 62 days, respectively. Among type II and III patients the median survivals of groups A, B, and C were 145, 225, and 46 days, respectively. Survival was significantly longer in group A vs. group C (p < 0.001), group B vs. group C (p < 0.001, and group A + B (165 days) vs. group C p < 0.001). There was no difference in group A + B versus type I (p=0.90). In addition, when comparing single drain only (group A + C, 80 days) versus double drains (group B, 225 days), there was a significant survival advantage (p < 0.0001). CONCLUSION In bifurcation tumors the best survival was noted in those with bilateral drainage, and the worst survival in those with cholangiographic opacification of both lobes but drainage of only one.
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Affiliation(s)
- W H Chang
- Division of Gastroenterology, The Wellesley Hospital, University of Toronto, Ontario, Canada
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45
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Abstract
BACKGROUND There is much controversy as to the importance of establishing drainage of both liver lobes in malignant hilar obstruction. The purpose of the present study was to compare survival data in patients with malignant hilar obstruction, stratified according to the Bismuth classification, who had cholangiography with filling of one or both hepatic ducts and subsequently endoscopic or percutaneous drainage of one or both ducts. METHODS A retrospective review was performed for the time period from July 1990 to July 1995, and 224 patients were identified with a presumed diagnosis of a bifurcation tumor. All x-ray films were reviewed and 150 patients finally diagnosed as hilar tumor were classified according to Bismuth type I, II, or III. Type II and III patients were further subclassified with respect to contrast injection into a single or both hepatic duct systems and whether one or both sides were eventually drained. RESULTS Data were obtained in 141 patients (4 patients still alive); there were 43 type I, 58 type II, and 40 type III. Type II and III patients were divided into three groups: group A, one lobe opacified with same lobe drained; group B, both lobes opacified with both lobes drained; and group C, both lobes opacified with one lobe drained. Overall median survival for type I, II, and III patients was 160, 131, and 62 days, respectively. Among type II and III patients the median survivals of groups A, B, and C were 145, 225, and 46 days, respectively. Survival was significantly longer in group A vs. group C (p < 0.001), group B vs. group C (p < 0.001, and group A + B (165 days) vs. group C p < 0.001). There was no difference in group A + B versus type I (p=0.90). In addition, when comparing single drain only (group A + C, 80 days) versus double drains (group B, 225 days), there was a significant survival advantage (p < 0.0001). CONCLUSION In bifurcation tumors the best survival was noted in those with bilateral drainage, and the worst survival in those with cholangiographic opacification of both lobes but drainage of only one.
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Affiliation(s)
- W H Chang
- Division of Gastroenterology, The Wellesley Hospital, University of Toronto, Ontario, Canada
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46
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Kozarek RA, Raltz S, Marcon N, Kortan P, Haber G, Lightdale C, Stevens P, Lehman G, Rex D, Benjamin S, Fleischer D, Bashir R, Fry S, Waxman I, Benson J, Polio J. Use of the 25 mm flanged esophageal Z stent for malignant dysphagia: a prospective multicenter trial. Gastrointest Endosc 1997; 46:156-60. [PMID: 9283867 DOI: 10.1016/s0016-5107(97)70065-8] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND An initial multicenter study using a 21 mm flanged esophageal Z stent demonstrated excellent palliation but an 11% immediate complication rate at placement and a 27% migration rate at 1 month. This North American multicenter trial prospectively studied a 25 mm flanged Z stent to define its palliative ability and whether the increased diameter affected placement or migration problems. METHODS Fifty patients who had esophageal Z stents at seven university or regional referral hospitals were prospectively studied. Indications for prosthesis placement, previous therapy, patient demographics, incidence of concomitant tracheoesophageal fistula, and degree of dysphagia were defined, as were procedural and subsequent stent-related problems, survival times, the ability to occlude a tracheoesophageal fistula, and subsequent degree of dysphagia. RESULTS Twenty-four patients had infiltrating malignancy (16 exophytic and 10 extrinsic), 9 of whom had concomitant tracheoesophageal fistulas. Ten patients (20%) had misplaced stents requiring retrieval and replacement, 12 patients (24%) had subsequent stent-related problems including exsanguination (2), aspiration (3), tumor overgrowth (3), and postplacement migration (4) (8%). There was statistically significant improvement in prestent versus poststent dysphagia and two thirds of patients had complete occlusion of their tracheoesophageal fistula. CONCLUSIONS Redesign of the esophageal Z stent has decreased the migration rate without increasing placement or subsequent erosion problems. Its efficacy appears comparable to the currently marketed Z stent for the palliation of malignant dysphagia and occlusion of tracheoesophageal fistula.
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Affiliation(s)
- R A Kozarek
- Virginia Mason Medical Center, Seattle, Washington 98101, USA
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Scheider DM, Siemens M, Cirocco M, Haber GB, Kandel G, Kortan P, Marcon NE. Photodynamic therapy for the treatment of tumor ingrowth in expandable esophageal stents. Endoscopy 1997; 29:271-4. [PMID: 9255530 DOI: 10.1055/s-2007-1004188] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND STUDY AIMS Tumor ingrowth through self-expanding metal stents presents a difficult problem for management. The techniques for treating tumor ingrowth have not yet been well described, and the optimal endoscopic approach is not clear. We have recently used photodynamic therapy (PDT) to treat tumor ingrowth through uncovered nitinol mesh stents. PATIENTS AND METHODS Four patients (mean age 73) with obstructive adenocarcinomas of the distal esophagus had received self-expanding stents for palliation of their dysphagia. After stent placement, tumor ingrowth had caused progressive dysphagia in all of the patients; the dysphagia was graded on a scale from 0 (normal) to 4 (inability to swallow liquids). All of the patients received PDT treatment. RESULTS After PDT, excellent palliation of the dysphagia was seen in all of the patients, with a mean improvement in the dysphagia score of 2.25 and a mean dysphagia-free interval of 92 days. There were no major complications. CONCLUSION The use of PDT to treat tumor ingrowth through self-expanding metal esophageal stents is effective and safe.
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Affiliation(s)
- D M Scheider
- Center for Therapeutic Endoscopy and Endoscopic Oncology, Wellesley Hospital, Toronto, Canada
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Cohen J, Haber GB, Kortan P, Dorais JA, Scheider DM, Cirocco M, Habib J. A prospective study of the repeated use of sterilized papillotomes and retrieval baskets for ERCP: quality and cost analysis. Gastrointest Endosc 1997; 45:122-7. [PMID: 9040995 DOI: 10.1016/s0016-5107(97)70233-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The impact on instrument quality and cost of the practice of reusing ERCP accessories has not been fully addressed. METHODS Twenty-five new papillotomes and 15 new retrieval baskets were labeled and evaluated over time by staff blinded to the number of prior uses. Instruments were scored as to their function for the designated task. The cost of this practice was calculated from the purchase price of accessories and the costs of cleaning, sterilization, and disposal, and then compared with the estimated cost of a practice of one-time use of similar instruments. RESULTS Twenty-five papillotomes were used 246 times (median 8; mean 9.8). Fifteen retrieval baskets were used 193 times (median 13; mean 12.9). The median survival of both papillotomes and baskets before being considered inadequate (score < 6 out of 10) was 9 uses. There were no complications attributable to using reused equipment. The projected yearly cost savings of using reusable versus disposable instruments was $94,095 for papillotomes and $61,809 for baskets, a 475% and 322% cost reduction, respectively. CONCLUSION The papillotomes and baskets in this study could be reused reliably and safely multiple times, with considerable cost savings compared with the practice of using disposable instruments.
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Affiliation(s)
- J Cohen
- Wellesley Hospital, Toronto, Ontario, Canada
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49
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Kozarek RA, Raltz S, Brugge WR, Schapiro RH, Waxman I, Boyce HW, Baillie J, Branch MS, Stevens PD, Lightdale CJ, Lehman GA, Benjamin S, Fleischer DE, Axelrad A, Kortan P, Marcon N, Branch S, Stevens P. Prospective multicenter trial of esophageal Z-stent placement for malignant dysphagia and tracheoesophageal fistula. Gastrointest Endosc 1996; 44:562-7. [PMID: 8934162 DOI: 10.1016/s0016-5107(96)70009-3] [Citation(s) in RCA: 107] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Conventional esophageal prosthesis placement has been associated with a 6% to 8% perforation rate and numerous postplacement complications. Expandable esophageal stents have been developed to preclude the above but there are few studies that have prospectively defined clinical results and subsequent stent-related complications. METHODS All patients who underwent esophageal Z-stent placement at nine university or referral hospitals were prospectively assessed. Data collected included patient demographics, acute and subacute placement problems, the ability to occlude airway fistulas, prestent and poststent dysphagia scores, and patient survival. RESULTS Fifty-four of 56 patients (96%) with refractory dysphagia or malignant esophagoairway fistulae had 73 Z-stents successfully inserted. Initial distal deployment occurred in 13% of the patients and an additional 17% required balloon dilation to achieve maximal diameter. Acute placement complications occurred in 11% of patients and included severe pain (3), bleeding from necrotic tumor (2), and hiatal hernia intussusception (1). No perforations occurred. Eight of 11 patients (73%) had complete tracheoesophageal fistula occlusion and mean dysphagia score (+/- SD) improved from 2.6 (0.7) to 1.1 (1.2) (p < 0.01). Fifteen stents (27%) had delayed migration at a mean of 1 month and 3 required surgery for retrieval. Three patients had ultimate stent erosion resulting in bleeding in 2 (exsanguination 1) or fistula (treated with a conventional stent). CONCLUSIONS The authors conclude that esophageal Z-stents can be placed safely and successfully in the majority of patients. The tendency of distal deployment during placement and subsequent migration problems at a time distant from placement in a patient subset deserve attention and are currently being addressed.
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Affiliation(s)
- R A Kozarek
- Virginia Mason Medical Center, Seattle, Washington 98101, USA
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50
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Raijman I, Walden D, Kortan P, Haber GB, Fuchs E, Siemens M, Kandel G, Marcon NE. Expandable esophageal stents: initial experience with a new nitinol stent. Gastrointest Endosc 1994; 40:614-21. [PMID: 7527358 DOI: 10.1016/s0016-5107(94)70265-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- I Raijman
- Division of Gastroenterology, Wellesley Hospital, University of Toronto, Ontario, Canada
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