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Wise E, Leslie D, Amateau S, Hocking K, Scott A, Dutta N, Ikramuddin S. Prediction of thirty-day morbidity and mortality after duodenal switch using an artificial neural network. Surg Endosc 2023; 37:1440-1448. [PMID: 35764835 DOI: 10.1007/s00464-022-09378-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 06/03/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Understanding factors that increase risk of both mortality and specific measures of morbidity after duodenal switch (DS) is important in deciding to offer this weight loss operation. Artificial neural networks (ANN) are computational deep learning approaches that model complex interactions among input factors to optimally predict an outcome. Here, a comprehensive national database is examined for patient factors associated with poor outcomes, while comparing the performance of multivariate logistic regression and ANN models in predicting these outcomes. METHODS 2907 DS patients from the 2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database were assessed for patient factors associated with the previously validated composite endpoint of 30-day postoperative reintervention, reoperation, readmission, or mortality using bivariate analysis. Variables associated (P ≤ 0.05) with the endpoint were imputed in a multivariate logistic regression model and a three-node ANN with 20% holdback for validation. Goodness-of-fit was assessed using area under receiver operating curves (AUROC). RESULTS There were 229 DS patients with the composite endpoint (7.9%), and 12 mortalities (0.4%). Associated patient factors on bivariate analysis included advanced age, non-white race, cardiac history, hypertension requiring 3 + medications (HTN), previous foregut/obesity surgery, obstructive sleep apnea (OSA), and higher creatinine (P ≤ 0.05). Upon multivariate analysis, independently associated factors were non-white race (odds ratio 1.40; P = 0.075), HTN (1.55; P = 0.038), previous foregut/bariatric surgery (1.43; P = 0.041), and OSA (1.46; P = 0.018). The nominal logistic regression multivariate analysis (n = 2330; R2 = 0.02, P < 0.001) and ANN (R2 = 0.06; n = 1863 [training set], n = 467 [validation]) models generated AUROCs of 0.619, 0.656 (training set) and 0.685 (validation set), respectively. CONCLUSION Readily obtainable patient factors were identified that confer increased risk of the 30-day composite endpoint after DS. Moreover, use of an ANN to model these factors may optimize prediction of this outcome. This information provides useful guidance to bariatricians and surgical candidates alike.
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Affiliation(s)
- Eric Wise
- Department of Surgery, University of Minnesota, 420 East Delaware St, Mayo Mail Code 195, Minneapolis, MN, 55455, USA.
| | - Daniel Leslie
- Department of Surgery, University of Minnesota, 420 East Delaware St, Mayo Mail Code 195, Minneapolis, MN, 55455, USA
| | - Stuart Amateau
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Kyle Hocking
- Department of Surgery, Vanderbilt University School of Medicine, Nashville, TN, USA.,Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA
| | - Adam Scott
- University of Minnesota Medical School- Twin Cities Campus, Minneapolis, MN, USA
| | - Nirjhar Dutta
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Sayeed Ikramuddin
- Department of Surgery, University of Minnesota, 420 East Delaware St, Mayo Mail Code 195, Minneapolis, MN, 55455, USA
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Trikudanathan G, Hashmi H, Dirweesh A, Amateau S, Azeem N, Mallery S, Freeman ML. Rendezvous transgastric and percutaneous sinus tract endoscopy (STE) for debridement of necrotic collections with deep retroperitoneal extension: a case series (with video): Meeting presentations: Digestive Disease Week 2018. Endosc Int Open 2020; 8:E668-E672. [PMID: 32355886 PMCID: PMC7165004 DOI: 10.1055/a-1134-4786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 01/06/2019] [Indexed: 11/12/2022] Open
Abstract
Background and study aims Infected necrotic collections extending deep into the retroperitoneum may not be amenable solely to endoscopic necrosectomy. Rendezvous transgastric and percutaneous sinus tract endoscopic necrosectomy was conceived to maximize debridement and obviate the need for open necrosectomy or video-assisted retroperitoneal debridement. Patients and methods Patients who underwent simultaneous rendezvous transgastric and sinus tract endoscopic transluminal necrosectomy at the same session were identified from a prospectively maintained database. Demographic data, clinical outcomes, immediate and late complications were evaluated. Results Among 415 patients with necrotizing pancreatitis, four patients (three males, median age 47 years) underwent this intervention after a median 29.5 days following placement of percutaneous drain. Intra-procedural bleeding following dilation of percutaneous tract required placement of esophageal stent for tamponade. No patients required rescue open necrosectomy or video assisted retroperitoneal debridement. Complete removal of percutaneous drains was accomplished in all patients after a median of 78.5 days. Conclusions Our novel approach is safe and effective and can expand the available armamentarium for management of large necrotic collection with deep retroperitoneal extension.
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Affiliation(s)
- Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, United States
| | - Hiba Hashmi
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, United States
| | - Ahmed Dirweesh
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, United States
| | - Stuart Amateau
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, United States
| | - Nabeel Azeem
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, United States
| | - Shawn Mallery
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, United States
| | - Martin L. Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, United States
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Adler DG, Mallery S, Amateau S, Nieto J, Taylor LJ, Siddiqui A. A pilot study of a 20-mm lumen-apposing metal stent to treat pancreatic fluid collections: First reported multicenter use of a new device. Endosc Ultrasound 2019; 8:136-138. [PMID: 31006708 PMCID: PMC6482603 DOI: 10.4103/eus.eus_58_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Douglas G Adler
- Division of Gastroenterology, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Shawn Mallery
- Division of Gastroenterology, School of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Stuart Amateau
- Division of Gastroenterology, School of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jose Nieto
- Division of Gastroenterology, Borland Groover Clinic, Jacksonville, Florida, USA
| | - Linda Jo Taylor
- Division of Gastroenterology, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Ali Siddiqui
- Division of Gastroenterology, School of Medicine, Jefferson University, Philadelphia, PA, USA
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4
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Trikudanathan G, Munigala S, Barlass U, Malli A, Han Y, Sekulic M, Bellin M, Chinnakotla S, Dunn T, Pruett T, Beilman G, Peralta JV, Arain M, Amateau S, Mallery S, Freeman ML, Attam R. Evaluation of Rosemont criteria for non-calcific chronic pancreatitis (NCCP) based on histopathology - A retrospective study. Pancreatology 2016; 17:63-69. [PMID: 27836330 DOI: 10.1016/j.pan.2016.10.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 10/12/2016] [Accepted: 10/21/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Rosemont classification for chronic pancreatitis has not been evaluated specifically in non-calcific chronic pancreatitis (NCCP) patients and to this date, it has not been correlated with the gold standard namely histopathology. OBJECTIVE To assess the correlation of EUS Rosemont criteria for NCCP with histopathology from surgical specimens and evaluate the impact of age, sex, BMI, smoking and alcohol on Rosemont classification. METHODS Adult patients undergoing TPIAT for NCCP between July 2009 and January 2013 were identified from our institutional database. The presence or absence of standard and Rosemont (major and minor) criteria were determined by expert endosonographers using linear endosonography. Patients were categorized into normal, indeterminate and suggestive with CP based on Rosemont classification. Histology was obtained at time of TPIAT from the resected pancreas by wedge biopsy of head, body and tail. All histopathology were re-reviewed by a GI pathologist blinded to endosonographic features and clinical outcomes. Available pancreatic tissue was graded for severity of intralobular and perilobular pancreatic fibrosis by the Ammann classification system. RESULTS 50 patients with NCCP (42 females, mean age± SD = 37.9 ± 10.8) underwent TPIAT with preoperative EUS during the study period. Univariate analysis of features such as age, sex, BMI, smoking and alcohol history showed no significant difference between patients identified as normal and those identified as indeterminate/suggestive (p > 0.05). Rosemont "Normal" was poor in excluding CP as 5/9 patients (55.5%) had CP on histopathology. 25/26 patients (96.2%) with features "suggestive" of CP had evidence of CP on histopathology. 12/15 patients (80.0%) with "indeterminate" features had CP on histopathology. CONCLUSIONS Rosemont classification can be used independent of patient characteristics (age, sex and BMI) and environmental factors (smoking and alcohol exposure). In our cohort, Rosemont classification was strongly predictive of CP in patients with features "suggestive" of CP. However, "normal" Rosemont classification had poor correlation in this study. This is maybe due to lack of true comparator "normal" pancreas which cannot be obtained reasonably. The strength of agreement for diagnosis of CP was substantial between the standard and Rosemont criteria.
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Affiliation(s)
| | - Satish Munigala
- Division of Gastroenterology, St Louis University School of Medicine, USA
| | - Usman Barlass
- Department of Surgery, University of Minnesota, Minneapolis, USA
| | - Ahmad Malli
- Department of Internal Medicine, University of Minnesota, Minneapolis, USA
| | - Yusheng Han
- Department of Pathology, University of Minnesota, Minneapolis, USA
| | - Miroslav Sekulic
- Department of Pathology, University of Minnesota, Minneapolis, USA
| | - Melena Bellin
- The Schulze Diabetes Institute, University of Minnesota, Minneapolis, MN, USA
| | | | - Ty Dunn
- Department of Surgery, University of Minnesota, Minneapolis, USA
| | - Timothy Pruett
- Department of Surgery, University of Minnesota, Minneapolis, USA
| | - Gregory Beilman
- Department of Surgery, University of Minnesota, Minneapolis, USA
| | - Jose-Vega Peralta
- Division of Gastroenterology, University of Minnesota, Minneapolis, USA
| | - Mustafa Arain
- Division of Gastroenterology, University of Minnesota, Minneapolis, USA
| | - Stuart Amateau
- Division of Gastroenterology, University of Minnesota, Minneapolis, USA
| | - Shawn Mallery
- Division of Gastroenterology, University of Minnesota, Minneapolis, USA
| | - Martin L Freeman
- Division of Gastroenterology, University of Minnesota, Minneapolis, USA
| | - Rajeev Attam
- Division of Gastroenterology, University of Minnesota, Minneapolis, USA.
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5
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Mounzer R, Yen R, Marshall C, Sams S, Mehrotra S, Said MS, Obuch JC, Brauer B, Attwell A, Fukami N, Shah R, Amateau S, Hall M, Hosford L, Wilson R, Rastogi A, Wani S. Interobserver agreement among cytopathologists in the evaluation of pancreatic endoscopic ultrasound-guided fine needle aspiration cytology specimens. Endosc Int Open 2016; 4:E812-9. [PMID: 27556103 PMCID: PMC4993880 DOI: 10.1055/s-0042-108188] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 04/25/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND AIMS Endoscopic ultrasound with fine needle aspiration (EUS-FNA) has become the standard of care in the evaluation of solid pancreatic lesions. Limited data exist on interobserver agreement (IOA) among cytopathologists in assessing solid pancreatic EUS-FNA specimens. This study aimed to evaluate IOA among cytopathologists in assessing EUS-FNA cytology specimens of solid pancreatic lesions using a novel standardized scoring system and to assess individual clinical and cytologic predictors of IOA. METHODS Consecutive patients who underwent EUS-FNA of solid pancreatic lesions at a tertiary care referral center were included. EUS-FNA slides were evaluated by four blinded cytopathologists using a standardized scoring system that assessed final cytologic diagnosis and quantitative (number of nucleated/diagnostic cells) and qualitative (bloodiness, inflammation/necrosis, contamination, artifact) cytologic parameters. Final clinical diagnosis was based on final cytology, surgical pathology, or 1-year clinical follow-up. IOA was calculated using multi-rater kappa (κ) statistics. Bivariate analyses were performed comparing cases with and without uniform agreement among the cytopathologists followed by logistic regression with backward elimination to model likelihood of uniform agreement. RESULTS Ninety-nine patients were included (49 % males, mean age 64 years, mean lesion size 26 mm). IOA for final diagnosis was moderate (κ = 0.45, 95 % confidence interval (CI) 0.4 - 0.49) with minimal improvement when combining suspicious and malignant diagnoses (κ = 0.54, 95 %CI 0.49 - 0.6). The weighted kappa value for overall diagnosis was 0.65 (95 %CI 0.54 - 0.76). IOA was slight to fair (κ = 0.04 - 0.32) for individual cytologic parameters. A final clinical diagnosis of malignancy was the most significant predictor of agreement [OR 3.99 (CI 1.52 - 10.49)]. CONCLUSIONS Interobserver agreement among cytopathologists for pancreatic EUS-FNA specimens is moderate-substantial for the final cytologic diagnosis. The final clinical diagnosis of malignancy was the strongest predictor of agreement. These results have significant implications for patient management and need to be validated in future trials.
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Affiliation(s)
- Rawad Mounzer
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Roy Yen
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Carrie Marshall
- Department of Pathology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Sharon Sams
- Department of Pathology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Sanjana Mehrotra
- Department of Pathology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | | | - Joshua C. Obuch
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Brian Brauer
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Augustin Attwell
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Norio Fukami
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Raj Shah
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Stuart Amateau
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Matthew Hall
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Lindsay Hosford
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Robert Wilson
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Amit Rastogi
- Division of Gastroenterology, University of Kansas School of Medicine and Veterans Affairs Medical Center, Kansas City, MO, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, CO, USA,Corresponding author Sachin Wani, MD Division of Gastroenterology and HepatologyUniversity of Colorado Anschutz Medical CenterMail Stop F7351635 Aurora CourtRm 2.031AuroraCO 80045USA+1-720-848-2749
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6
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Li L, Masica D, Ishida M, Tomuleasa C, Umegaki S, Kalloo AN, Georgiades C, Singh VK, Khashab M, Amateau S, Li Z, Okolo P, Lennon AM, Saxena P, Geschwind JF, Schlachter T, Hong K, Pawlik TM, Canto M, Law J, Sharaiha R, Weiss CR, Thuluvath P, Goggins M, Ji Shin E, Peng H, Kumbhari V, Hutfless S, Zhou L, Mezey E, Meltzer SJ, Karchin R, Selaru FM. Human bile contains microRNA-laden extracellular vesicles that can be used for cholangiocarcinoma diagnosis. Hepatology 2014; 60:896-907. [PMID: 24497320 PMCID: PMC4121391 DOI: 10.1002/hep.27050] [Citation(s) in RCA: 166] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 01/29/2014] [Indexed: 12/15/2022]
Abstract
UNLABELLED Cholangiocarcinoma (CCA) presents significant diagnostic challenges, resulting in late patient diagnosis and poor survival rates. Primary sclerosing cholangitis (PSC) patients pose a particularly difficult clinical dilemma because they harbor chronic biliary strictures that are difficult to distinguish from CCA. MicroRNAs (miRs) have recently emerged as a valuable class of diagnostic markers; however, thus far, neither extracellular vesicles (EVs) nor miRs within EVs have been investigated in human bile. We aimed to comprehensively characterize human biliary EVs, including their miR content. We have established the presence of extracellular vesicles in human bile. In addition, we have demonstrated that human biliary EVs contain abundant miR species, which are stable and therefore amenable to the development of disease marker panels. Furthermore, we have characterized the protein content, size, numbers, and size distribution of human biliary EVs. Utilizing multivariate organization of combinatorial alterations (MOCA), we defined a novel biliary vesicle miR-based panel for CCA diagnosis that demonstrated a sensitivity of 67% and specificity of 96%. Importantly, our control group contained 13 PSC patients, 16 with biliary obstruction of varying etiologies (including benign biliary stricture, papillary stenosis, choledocholithiasis, extrinsic compression from pancreatic cysts, and cholangitis), and 3 with bile leak syndromes. Clinically, these types of patients present with a biliary obstructive clinical picture that could be confused with CCA. CONCLUSION These findings establish the importance of using extracellular vesicles, rather than whole bile, for developing miR-based disease markers in bile. Finally, we report on the development of a novel bile-based CCA diagnostic panel that is stable, reproducible, and has potential clinical utility.
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Affiliation(s)
- Ling Li
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA,Division of Gastroenterology, Third hospital of Peking University Health Science Center, Beijing, China
| | - David Masica
- Department of Biomedical Engineering and Institute for Computational Medicine Johns Hopkins University, Baltimore, Maryland, USA
| | - Masaharu Ishida
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Ciprian Tomuleasa
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA,Center for Genomics and Translational Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, and Department of Hematology, Ion Chiricuta Comprehensive Cancer Center, Cluj Napoca, Romania
| | - Sho Umegaki
- Tohoku University School of Medicine, Sendai, Miyagi, Japan
| | - Anthony N. Kalloo
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Christos Georgiades
- Division of Gastroenterology and Hepatology, Department of Radiology, Johns Hopkins Hospital, Baltimore, Maryland, USA,Vascular & Interventional Radiology, American Medical Center, Nicosia, Cyprus
| | - Vikesh K. Singh
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Mouen Khashab
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Stuart Amateau
- Division of Gastroenterology and Hepatology, University of Colorado, Denver, Colorado, USA
| | - Zhiping Li
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Patrick Okolo
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Anne-Marie Lennon
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Payal Saxena
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jean-Francois Geschwind
- Division of Gastroenterology and Hepatology, Department of Radiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Todd Schlachter
- Division of Gastroenterology and Hepatology, Department of Radiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Kelvin Hong
- Division of Gastroenterology and Hepatology, Department of Radiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Timothy M. Pawlik
- Division of Gastroenterology and Hepatology, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Marcia Canto
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Joanna Law
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Reem Sharaiha
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, USA
| | - Clifford R. Weiss
- Division of Gastroenterology and Hepatology, Department of Radiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Paul Thuluvath
- The Institute for Digestive Health & Liver Disease at Mercy, Baltimore, USA
| | - Michael Goggins
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Eun Ji Shin
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Haoran Peng
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Susan Hutfless
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Liya Zhou
- Division of Gastroenterology, Third hospital of Peking University Health Science Center, Beijing, China
| | - Esteban Mezey
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Stephen J. Meltzer
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Rachel Karchin
- Department of Biomedical Engineering and Institute for Computational Medicine Johns Hopkins University, Baltimore, Maryland, USA
| | - Florin M. Selaru
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA,Sidney Kimmel Cancer Center, Johns Hopkins Hospital, Baltimore, Maryland, USA,Correspondence: Florin M. Selaru, MD, Johns Hopkins University, 720 Rutland Ave, Suite 950, Tel: (410) 614-3369, Fax: (410) 614-9612,
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7
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Khashab M, Alawad AS, Shin EJ, Kim K, Bourdel N, Singh VK, Lennon AM, Hutfless S, Sharaiha RZ, Amateau S, Okolo PI, Makary MA, Wolfgang C, Canto MI, Kalloo AN. Enteral stenting versus gastrojejunostomy for palliation of malignant gastric outlet obstruction. Surg Endosc 2013; 27:2068-75. [PMID: 23299137 DOI: 10.1007/s00464-012-2712-7] [Citation(s) in RCA: 111] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2012] [Accepted: 11/06/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Endoscopic placement of enteral self-expandable metallic stents is an alternative to surgical gastrojejunostomy (GJ) for palliation of malignant gastric outlet obstruction (GOO). Factors associated with clinical outcomes are not known. The aims of this study are to compare the overall complication rate and effectiveness (duration of oral intake) between endoscopic stenting (ES) and GJ in patients with GOO and identify predictors of clinical outcomes. PATIENTS AND METHODS This was a retrospective cohort study at a single tertiary academic center. Patients who underwent ES or GJ for treatment of GOO between 1/2001 and 12/2010 were identified using an institutional claims database. The electronic medical records for each patient were reviewed. Univariate and multivariate logistic regression analyses were performed to study the association of treatment outcomes with patient factors and cancer therapy. RESULTS 120 patients had ES while 227 had GJ. Technical success was higher for GJ (99 vs. 96 %, p = 0.004). Complication rates were higher in the GJ group (22.10 vs. 11.66 %, p = 0.02). Reintervention was more common with ES [adjusted odds ratio (OR) 9.18, p < 0.0001]. Mean length of hospital stay (LOHS) was shorter (adjusted p = 0.005) in the ES compared with the GJ group. However, mean hospital charges, including reinterventions, were greater in the ES group (US $34,250 vs. US $27,599, p = 0.03). ES and GJ had comparable reintervention-free time in patients who had reintervention (88 vs. 106 days, respectively, p = 0.79). Chemotherapy [adjusted hazard ratio (HR) 3 > 0.57, p = 0.04] and radiation therapy (adjusted HR 0.35, p = 0.03) were associated with significantly longer duration of oral intake after ES or GJ. CONCLUSION ES is associated with fewer complications, shorter LOHS, but higher reintervention rates and overall charges.
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Affiliation(s)
- Mouen Khashab
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, 1830 E. Monument Street, Room 424, Baltimore, MD 21205, USA.
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8
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Khashab MA, Shin EJ, Amateau S, Canto MI, Hruban RH, Fishman EK, Cameron JL, Edil BH, Wolfgang CL, Schulick RD, Giday S. Tumor size and location correlate with behavior of pancreatic serous cystic neoplasms. Am J Gastroenterol 2011; 106:1521-6. [PMID: 21468008 DOI: 10.1038/ajg.2011.117] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The majority of pancreatic serous cystic neoplasms (SCNs) are benign. However, these neoplasms can cause symptoms and rarely can be aggressive. Identification of factors associated with symptomatic or aggressive SCNs may aid management decisions. The aim of this study was to identify variables that predict aggressive SCNs. METHODS Prospective pathology database was queried for SCNs that were surgically resected at Johns Hopkins Hospital. Tumors were considered aggressive if they invaded surrounding structures and/or vessels or if they metastasized to lymph nodes or distant organs. The associations of gender, tumor size, and tumor location, with the presence or absence of symptoms and tumor behavior were examined using Fisher's exact test, logistic regression, and multivariate analyses. RESULTS A total of 257 patients with SCNs underwent surgical resection. Mean tumor diameter was 4.9 cm. Tumor location in the head of pancreas (HOP) was associated with symptoms (odds ratio (OR) 1.87, 95% confidence interval (CI) 1.1-3.3). Computed tomography (CT) predicted the diagnosis of SCN in approximately a quarter of patients. Thirteen tumors (mean 10.5 cm) were considered aggressive. Multivariate analysis showed that tumor diameter (OR 1.53, 95% CI 1.24-1.89) and location of tumor in pancreatic head (OR 10.44, 95% CI 1.73-63.04) were independently associated with aggressive behavior. CONCLUSIONS We describe the largest case series of patients with pathologically proven SCNs. CT performed poorly in preoperative diagnosis of SCNs. Large tumor size and head location predicted aggressive behavior. These factors should be considered in the management of patients with SCN.
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Affiliation(s)
- Mouen A Khashab
- Department of Medicine and Division of Gastroenterology and Hepatology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical Institutions, Baltimore, Maryland 21205, USA
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Khashab MA, Yong E, Lennon AM, Shin EJ, Amateau S, Hruban RH, Olino K, Giday S, Fishman EK, Wolfgang CL, Edil BH, Makary M, Canto MI. EUS is still superior to multidetector computerized tomography for detection of pancreatic neuroendocrine tumors. Gastrointest Endosc 2011; 73:691-6. [PMID: 21067742 DOI: 10.1016/j.gie.2010.08.030] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.8] [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: 05/11/2009] [Accepted: 08/19/2010] [Indexed: 12/12/2022]
Abstract
BACKGROUND The role of EUS for detection of pancreatic neuroendocrine tumors (PNETs) is not clearly defined in institutions that use multidetector CT for pancreatic imaging. OBJECTIVE The aims of this study were to (1) compare the detection rates of EUS and CT by type and size of PNET and calculate the incremental benefit of EUS over CT, (2) evaluate the CT detection rate for PNETs adjusted for improved CT technology over time, and (3) determine the factors associated with CT-negative PNETs. DESIGN Retrospective single-center cohort study. SETTING Johns Hopkins Hospital. PATIENTS Patients with pathologically proven PNETs with preoperative CT. Incidentally found PNETs (resection specimens) and those without Johns Hopkins Hospital CT imaging were excluded. MAIN OUTCOME MEASUREMENT Detection rates of CT and EUS were compared by using pathology as the reference standard. RESULTS In 217 patients (with 231 PNETs) studied, CT detected 84% of tumors (54.3% of insulinomas). The sensitivity of CT for the detection of PNETs significantly increased with improvement in CT technology (P = .02; χ(2) for trend). CT was more likely to miss lesions <2 cm (P = .005) and insulinomas (P < .0001). In 56 patients who had both CT and EUS, the sensitivity of EUS was greater than CT (91.7% vs 63.3%; P = .0002), particularly for insulinomas (84.2% vs 31.6%; P = .001). EUS detected 20 of 22 CT-negative tumors (91%). LIMITATIONS Retrospective nonrandomized design and referral bias. CONCLUSIONS The detection rate of CT has significantly improved over time. CT-negative tumors are small and more likely to be insulinomas. A sequential approach of CT followed by EUS can detect most PNETs. EUS is a more sensitive initial test for the detection of suspected insulinomas.
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Affiliation(s)
- Mouen A Khashab
- Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University, 1830 East Monument Street, Baltimore, MD 21205, USA
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