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Khan S, Chandran S, Chin J, Karim S, Mangira D, Nasr M, Ermerak G, Trinh A, Kia CYH, Mules T, Zad M, Ang TL, Johns E, Tee D, Kaul A, Ratanachu-Ek T, Jirathan-Opas J, Fisher L, Cameron R, Welch C, Lim G, Metz AJ, Moss A, Bassan M, Saxena P, Kaffes A, St John A, Hourigan LF, Tagkalidis P, Weilert F, Vaughan R, Devereaux B. Drainage of pancreatic fluid collections using a lumen-apposing metal stent with an electrocautery-enhanced delivery system. J Gastroenterol Hepatol 2021; 36:3395-3401. [PMID: 34370869 DOI: 10.1111/jgh.15658] [Citation(s) in RCA: 2] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 06/05/2021] [Accepted: 07/25/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Our aim was to evaluate the efficacy and safety of a lumen-apposing metal stent with an electrocautery-enhanced delivery system (EDS-LAMS) for endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs) in regular clinical practice. METHODS A retrospective and subsequent prospective analysis was undertaken of all patients who underwent EUS-guided drainage of their PFCs using the EDS-LAMS at 17 tertiary therapeutic endoscopy centers. RESULTS Two hundred eight cases of EDS-LAMS deployment were attempted in 202 patients (mean age 52.9 years) at time of evaluation. Ninety-seven patients had pancreatic pseudocysts (PPs), 75 walled-off pancreatic necrosis (WOPN), 10 acute peripancreatic fluid collections (APFCs), 6 acute necrotic collections (ANCs), and 14 postoperative collections (POCs). Procedural technical success was achieved in 202/208 cases (97.1%). Maldeployment occurred in 7/208 cases (3.4%). Clinical success was achieved in 142/160 (88.8%) patients (PP 90%, WOPN 85.2%, APFC 100%, ANC 75%, POC 100%). Delayed adverse events included stent migration in 15/202 (7.4%), stent occlusion and infection in 16/202 (7.9%), major bleeding in 4/202 (2%), and buried EDS-LAMS in 2/202 (1%). PFC recurrence occurred in 13/142 (9.2%) patients; 9/202 (4.5%) required surgical or radiological intervention for PFC management after EDS-LAMS insertion. CONCLUSIONS This large international multicenter study evaluating the EDS-LAMS for drainage of PFCs in routine clinical practice suggests that the EDS-LAMS are safe and effective for drainage of all types of PFCs; however, further endoscopic therapy is often required for WOPN. Major bleeding was a rare complication in our cohort.
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Affiliation(s)
- Saad Khan
- Department of Gastroenterology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Department of Gastroenterology, Austin Health, Melbourne, Victoria, Australia
| | - Sujievvan Chandran
- Department of Gastroenterology, Austin Health, Melbourne, Victoria, Australia
| | - Jerry Chin
- Department of Gastroenterology, Waikato Hospital, Waikato District Health Board, Hamilton, New Zealand
| | - Shwan Karim
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Dileep Mangira
- Department of Gastroenterology, Western Health, Melbourne, Victoria, Australia
| | - Mohamad Nasr
- Department of Gastroenterology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Goktug Ermerak
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Andrew Trinh
- Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Christopher Y H Kia
- Department of Gastroenterology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Thomas Mules
- Department of Gastroenterology, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Mohammadali Zad
- Department of Gastroenterology, Townsville Hospital, Townsville, Queensland, Australia
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Estella Johns
- Department of Gastroenterology, Wellington Hospital, Capital and Coast District Health Board, Wellington, New Zealand
| | - Derrick Tee
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Abha Kaul
- Department of Gastroenterology, Peninsula Health, Melbourne, Victoria, Australia
| | | | - Jirat Jirathan-Opas
- Department of Gastroenterology, Hatyai Hospital, Hat Yai, Songkhla Province, Thailand
| | - Leon Fisher
- Department of Gastroenterology, Peninsula Health, Melbourne, Victoria, Australia
| | - Rees Cameron
- Department of Gastroenterology, Wellington Hospital, Capital and Coast District Health Board, Wellington, New Zealand
| | - Christine Welch
- Department of Gastroenterology, Townsville Hospital, Townsville, Queensland, Australia
| | - Gary Lim
- Department of Gastroenterology, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Andrew J Metz
- Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Alan Moss
- Department of Gastroenterology, Western Health, Melbourne, Victoria, Australia
| | - Milan Bassan
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Payal Saxena
- Department of Gastroenterology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Arthur Kaffes
- Department of Gastroenterology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Andrew St John
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Department of Medicine, Toowoomba Hospital, Toowoomba, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Luke F Hourigan
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Gallipoli Medical Research Institute, School of Medicine, University of Queensland, Greenslopes Private Hospital, Brisbane, Queensland, Australia
| | - Peter Tagkalidis
- Department of Gastroenterology, Western Health, Melbourne, Victoria, Australia.,Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Frank Weilert
- Department of Gastroenterology, Waikato Hospital, Waikato District Health Board, Hamilton, New Zealand
| | - Rhys Vaughan
- Department of Gastroenterology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Austin Health, Melbourne, Victoria, Australia
| | - Benedict Devereaux
- Department of Gastroenterology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
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Schauer C, Mules T, Rijnsoever MV, Gane E. Increasing burden of advanced hepatocellular carcinoma in New Zealand-the need for better surveillance. N Z Med J 2020; 133:25-34. [PMID: 32438374] [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] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Regular surveillance for hepatocellular carcinoma (HCC) in patients with chronic hepatitis B viral (HBV) infection and hepatitis C (HCV) cirrhosis improves survival by earlier detection of the cancer at an earlier stage when curative intervention may still be possible. We compared patient characteristics, surveillance history and outcomes in patients presenting with advanced HCC secondary to HBV and HCV. METHOD In this retrospective study, clinical databases and notes were reviewed in all cases of advanced HCC related to HBV or HCV referred to the tertiary HCC service in Auckland, New Zealand between 1 January 2003 and 31 December 2017. RESULTS Over the 15-year period, 368 patients were referred with advanced HCC secondary to HBV (HBV-HCC) and 278 secondary to HCV (HCV-HCC), representing over 50% of all cases of HCC cases secondary to viral hepatitis. Of these 646 patients with advanced HCC, 75% of patients were not receiving guideline-recommended surveillance. More patients with advanced HBV-HCC were diagnosed with HCC prior to the diagnosis of HBV, compared to patients with advanced HCV-HCC (40% vs 28%, p<0.01). Fewer patients with previously diagnosed HBV infection were undergoing HCC surveillance than patients with previously diagnosed HCV infection (26% vs 42%, p<0.01). Late diagnosed patients had the worst outcomes, with 88% receiving palliative care and surviving on average only seven months (HBV five months vs HCV eight months, p=0.05). CONCLUSION Survival in New Zealanders with hepatocellular carcinoma remains poor because the cancer is incurable in most patients at the time of detection. Because most cases are secondary to chronic hepatitis B and C infections, improved screening and linkage to antiviral therapy and HCC surveillance should improve outcomes.
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Affiliation(s)
- Cameron Schauer
- Hepatology Registrar, New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland
| | - Thomas Mules
- Hepatology Research Registrar, New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland
| | - Marius van Rijnsoever
- Consultant Gastroenterologist, North Shore Hospital Gastroenterology Department, Waitemata District Health Board, Auckland
| | - Ed Gane
- New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland
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Mules T, Gane E, Lithgow O, Bartlett A, McCall J. Hepatitis B virus-related hepatocellular carcinoma presenting at an advanced stage: is it preventable? N Z Med J 2018; 131:27-35. [PMID: 30496164] [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] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
AIM Earlier diagnosis of hepatitis B virus (HBV) related hepatocellular carcinoma (HCC) increases treatment options and survival. The aim of this study is to evaluate which factors are associated with late presentation of HBV-related HCC. METHOD This is a retrospective review of all cases of HBV-related HCC diagnosed with late-stage/incurable HCC in New Zealand between 2003 and 2017. Cases were defined as patients with a positive hepatitis B surface antigen (HBsAg), and advanced (not amenable to potentially curable treatments) HCC at initial diagnosis. Patients were categorised into four groups according to potential reasons for late presentation: no previous diagnosis of HBV infection (Group A); known HBV diagnosis but not receiving HCC surveillance (Group B); known HBV diagnosis and receiving suboptimal HCC surveillance (Group C); and known HBV diagnosis and receiving optimised HCC surveillance (Group D). RESULTS A total of 368 patients were reviewed. The average age at death was 59 years, and the majority of patients were Māori (39%), Pacific (34%) or Asian (20%). The incidence of patients presenting with HBV-related advanced HCC increased from 4.5 cases to 6.3 cases per million people over the review period. Of the cases, 40% were categorised into Group A, 26% into Group B, 12% into Group C and 23% in Group D. Overall, the median survival was 138 days, and this did not change during the study period. Patients receiving optimised surveillance (Group D) survived longer (mean 469 days) than patients in Group A (90 days), Group B (145 days) or Group C (152 days) (p<0.05). Patients in Group D were more likely to be treated with transarterial chemoembolisation than patients in other groups (40% vs 15%, p<0.05). CONCLUSION This study has highlighted the need for improved rates of HBV diagnosis, better follow-up of those infected and the importance of optimal HCC surveillance. In New Zealand, HBV-related HCC disproportionately affects minority ethnic groups, and given the increasing incidence, provides a potential domain to reduce health inequities.
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Affiliation(s)
- Thomas Mules
- New Zealand Liver Unit, Auckland District Health Board, Auckland
| | - Ed Gane
- New Zealand Liver Unit, Auckland District Health Board, Auckland
| | - Oonagh Lithgow
- New Zealand Liver Unit, Auckland District Health Board, Auckland
| | - Adam Bartlett
- New Zealand Liver Unit, Auckland District Health Board, Auckland
| | - John McCall
- New Zealand Liver Unit, Auckland District Health Board, Auckland
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Mules T, Taylor J, Price R, Walker L, Singh B, Newsam P, Palaniyappan T, Snook T, Ruselan M, Ryan J, Santhirasegaran J, Shearman P, Watson P, Zino R, Signal L, Fougere G, Moriarty H, Jenkin G. Addressing patient alcohol use: a view from general practice. J Prim Health Care 2012; 4:217-222. [PMID: 22946070] [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: 06/01/2023] Open
Abstract
INTRODUCTION General practitioners (GPs) have the potential to promote alcohol harm minimisation via discussion of alcohol use with patients, but knowledge of GPs' current practice and attitudes on this matter is limited. Our aim was to assess GPs' current practice and attitudes towards discussing alcohol use with their patients. METHODS This qualitative study involved semi-structured, face-to-face interviews with 19 GPs by a group of medical students in primary care practices in Wellington, New Zealand. FINDINGS Despite agreement amongst GPs about the importance of their role in alcohol harm minimisation, alcohol was not often raised in patient consultations. GPs' usual practice included referral to drug and alcohol services and advice. GPs were also aware of national drinking guidelines and alcohol screening tools, but in practice these were rarely utilised. Key barriers to discussing alcohol use included its societal 'taboo' nature, time constraints, and perceptions of patient dishonesty. CONCLUSION In this study there is a fundamental mismatch between the health community's expectations of GPs to discuss alcohol with patients and the reality. Potential solutions to the most commonly identified barriers include screening outside the GP consultation, incorporating screening tools into existing software used by GPs, exploring with GPs the social stigma associated with alcohol misuse, and framing alcohol misuse as a health issue. As it is unclear if these approaches will change GP practice, there remains scope for the development and pilot testing of potential solutions identified in this research, together with an assessment of their efficacy in reducing hazardous alcohol consumption.
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Affiliation(s)
- Thomas Mules
- Department of Public Health, University of Otago, Wellington, New Zealand
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Mules T, Taylor J, Price R, Walker L, Singh B, Newsam P, Palaniyappan T, Snook T, Ruselan M, Ryan J, Santhirasegaran J, Shearman P, Watson P, Zino R, Signal L, Fouge G. Addressing patient alcohol use: a view from general practice. J Prim Health Care 2012. [DOI: 10.1071/hc12217] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION: General practitioners (GPs) have the potential to promote alcohol harm minimisation via discussion of alcohol use with patients, but knowledge of GPs current practice and attitudes on this matter is limited. Our aim was to assess GPs current practice and attitudes towards discussing alcohol use with their patients. METHODS: This qualitative study involved semi-structured, face-to-face interviews with 19 GPs by a group of medical students in primary care practices in Wellington, New Zealand. FINDINGS: Despite agreement amongst GPs about the importance of their role in alcohol harm minimisation, alcohol was not often raised in patient consultations. GPs usual practice included referral to drug and alcohol services and advice. GPs were also aware of national drinking guidelines and alcohol screening tools, but in practice these were rarely utilised. Key barriers to discussing alcohol use included its societal taboo nature, time constraints, and perceptions of patient dishonesty. CONCLUSION: In this study there is a fundamental mismatch between the health communitys expectations of GPs to discuss alcohol with patients and the reality. Potential solutions to the most commonly identified barriers include screening outside the GP consultation, incorporating screening tools into existing software used by GPs, exploring with GPs the social stigma associated with alcohol misuse, and framing alcohol misuse as a health issue. As it is unclear if these approaches will change GP practice, there remains scope for the development and pilot testing of potential solutions identified in this research, together with an assessment of their efficacy in reducing hazardous alcohol consumption. KEYWORDS: Primary health care; general practice; alcohol drinking; alcohol-related disorders, attitude of health personnel
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