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Davidyuk V, Bhutiani N, Gold MK, Mortensen GF, Trestrail T, Brown AN, Vitale RJ, McClave SA, Vitale GC. Surgical Diagnoses of Pancreatic Adenocarcinoma Not Found on Previous Endoscopic Ultrasound: A Case Series and Review of the Literature. Am Surg 2023; 89:990-995. [PMID: 34743589 DOI: 10.1177/00031348211054531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Pancreatic cancer is a leading cause of death in North America and Western Europe with rising rates in the developing world. Endoscopic ultrasound (EUS) with FNA (fine needle aspiration) is a critical component in the evaluation and diagnosis of pancreatic lesions with a high sensitivity and specificity. In this paper, we report patients at our center who eventually developed pancreatic cancer despite an early negative EUS, and identifying factors that may result in a missed diagnosis. METHODS The University of Louisville database was queried for patients who had a Whipple procedure for presumed benign disease and had a pre-operative EUS between 2008 and 2018. Patients who had pancreatic adenocarcinoma on final pathology were identified. Demographic, clinical, EUS, operative, and pathologic details were reviewed for each case in efforts to identify factors associated with failure to diagnose a pancreatic malignancy on EUS. RESULTS Five patients who had pancreatic adenocarcinoma on final pathology were reviewed in detail and their cases are presented in the paper. Four of the patients had dilation of the common bile duct, three had chronic pancreatitis. Two of them had previous surgery on the pancreas or bile ducts. CONCLUSIONS All of the patients presented in the paper had variables that made their EUS evaluation challenging. A high index of suspicion must be maintained in patients that do not improve after appropriate treatment of their strictures or pancreatic lesions. In the future, new techniques, such as fine needle biopsy and biomarker assays, may improve diagnosis accuracy.
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Affiliation(s)
| | - Neal Bhutiani
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Maks K Gold
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | | | - Timothy Trestrail
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Amber N Brown
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Rebecca J Vitale
- Department of Medicine, Division of Endocrinology, Diabetes, and Hypertension, Brigham Women's Hospital, Boston, MA, USA
| | - Stephen A McClave
- Department of Medicine, Division of Gastroenterology, University of Louisville, Louisville, KY, USA
| | - Gary C Vitale
- Department of Surgery, University of Louisville, Louisville, KY, USA
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Bhutiani N, Bruenderman E, Davidyuk V, Mortensen GF, O'Brien S, Martin RCG, Vitale GC. Is More Anesthesia Care Better in Endoscopy? Comparing the Safety and Cost of Conscious Sedation and Anesthesia Provider-Based Care. J Gastrointest Surg 2022; 26:483-485. [PMID: 34506018 DOI: 10.1007/s11605-021-05120-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/04/2021] [Indexed: 01/31/2023]
Affiliation(s)
- N Bhutiani
- Department of Surgery, Division of Surgical Oncology, University of Louisville, 550 S. Jackson St, 2nd floor, Louisville, KY, 40202, USA
| | - E Bruenderman
- Department of Surgery, Division of Surgical Oncology, University of Louisville, 550 S. Jackson St, 2nd floor, Louisville, KY, 40202, USA
| | - V Davidyuk
- Department of Surgery, Albany Medical Center, Albany, NY, USA
| | - G F Mortensen
- Department of Surgery, Division of Surgical Oncology, University of Louisville, 550 S. Jackson St, 2nd floor, Louisville, KY, 40202, USA
| | - S O'Brien
- Department of Surgery, Division of Surgical Oncology, University of Louisville, 550 S. Jackson St, 2nd floor, Louisville, KY, 40202, USA
| | - R C G Martin
- Department of Surgery, Division of Surgical Oncology, University of Louisville, 550 S. Jackson St, 2nd floor, Louisville, KY, 40202, USA
| | - Gary C Vitale
- Department of Surgery, Division of Surgical Oncology, University of Louisville, 550 S. Jackson St, 2nd floor, Louisville, KY, 40202, USA.
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Mortensen GF, Bhutiani N, Brown AN, Davidyuk V, Palin H, Bahr MH, Vitale GC. Long-term Follow-up of Patients Undergoing Endoscopic Intervention for Abdominal Pain with Minimal Biliary Ductal Dilation, Stone Disease, or Malignancy. Am Surg 2021; 87:1426-1430. [PMID: 33393373 DOI: 10.1177/0003134820952823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Safety and efficacy of endoscopic methods in management of biliary colic after cholecystectomy in patients with minimal biliary ductal dilation and no evidence of biliary stones or malignancy have not been clearly demonstrated. This study aimed to assess the efficacy of endoscopic management of such patients. METHODS The University of Louisville database was queried for patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) for colicky abdominal pain between 1996 and 2016 who had a common bile duct (CBD) diameter of ≤12 mm. All patients had undergone prior cholecystectomy and were free of malignancy. Demographic, serologic, procedural, and outcome variables were assessed. RESULTS A total of 35 patients underwent a total of 99 ERCPs. Median CBD diameter was 10 (range 4-12) mm. A total of 31 patients (89%) underwent sphincterotomy, 28 (80%) underwent stent placement, and 5 (14%) underwent balloon dilation. The median number of ERCPs performed was 2 (range 1-10). Three of the 35 patients (9%) developed post-ERCP pancreatitis at some point during their treatment. At last follow-up since initial ERCP (median 16 months, range 2.4-184 months), 12 (34%) patients endorsed abdominal pain and 11 (31%) reported experiencing nausea. CONCLUSION For select patients with abdominal pain in the setting of minimal CBD dilation and no evidence of stone disease or malignancy, ERCP can safely and effectively be used to manage symptoms. While patients may require multiple interventions, they can derive long-term relief from these procedures.
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Affiliation(s)
| | - Neal Bhutiani
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Amber N Brown
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Vladimir Davidyuk
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Hannah Palin
- Department of Obstetrics and Gynecology, University of Miami, FL, USA
| | - Michael H Bahr
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Gary C Vitale
- Department of Surgery, University of Louisville, Louisville, KY, USA
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Bhutiani N, Davidyuk V, Mortensen GF, Brown AN, Bahr MH, Martin RCG, Vitale GC. Safety, Efficacy, and Technical Details of Endoscopic Retrograde Cholangiopancreatography After Irreversible Electroporation for Locally Advanced Pancreatic Cancer. J Gastrointest Surg 2020; 24:1077-1081. [PMID: 31093898 DOI: 10.1007/s11605-019-04223-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 12/19/2018] [Accepted: 03/28/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patients undergoing irreversible electroporation (IRE) for locally advanced pancreatic cancer (LAPC) may experience biliary obstruction owing to inflammation generated by tumor ablation. This study assessed the safety, efficacy, and technical details of endoscopic retrograde cholangiopancreatography (ERCP) for biliary decompression after IRE. METHODS A single-institution database of patients undergoing IRE for LAPC between 2012 and 2017 was queried for patients requiring post-IRE ERCP. Patients were evaluated along demographic, laboratory, procedural, and outcome measures. RESULTS Of 113 patients with LAPC who underwent IRE, 6 (5.3%) required subsequent ERCP for biliary obstruction. A total of 12 ERCPs were performed. Two patients (33%) had duodenal bulb narrowing requiring dilation, and one patient (17%) had a pancreatic head cyst complicating guidewire passage. Biliary cannulation was achieved in all patients in a median time of 30 min. Four patients (67%) underwent sphincterotomy, and 5 (83%) underwent stent placement. Post-procedurally, all showed liver test improvement. None developed pancreatitis. Four patients underwent a 2nd ERCP. All were successful and included stent placement. CONCLUSIONS For patients with biliary obstruction after IRE, ERCP with sphincterotomy and stent placement can safely relieve this obstruction. Duodenal dilation and careful guidewire manipulation may be required to maximize technical success in these patients.
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Affiliation(s)
- Neal Bhutiani
- University of Louisville Department of Surgery, 550 S. Jackson Street, Louisville, KY, 40202, USA
| | - Vladimir Davidyuk
- University of Louisville Department of Surgery, 550 S. Jackson Street, Louisville, KY, 40202, USA
| | - Garrett F Mortensen
- University of Louisville Department of Surgery, 550 S. Jackson Street, Louisville, KY, 40202, USA
| | - Amber N Brown
- University of Louisville Department of Surgery, 550 S. Jackson Street, Louisville, KY, 40202, USA
| | - Michael H Bahr
- University of Louisville Department of Surgery, 550 S. Jackson Street, Louisville, KY, 40202, USA
| | - Robert C G Martin
- University of Louisville Department of Surgery, 550 S. Jackson Street, Louisville, KY, 40202, USA
| | - Gary C Vitale
- University of Louisville Department of Surgery, 550 S. Jackson Street, Louisville, KY, 40202, USA.
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Trestrail T, Martin EK, Bhutiani N, Mortensen GF, Davidyuk V, Vitale GC. An unusual presentation of congenital superior mesenteric artery (SMA) syndrome. J Surg Case Rep 2019; 2019:rjz067. [PMID: 30886698 PMCID: PMC6413375 DOI: 10.1093/jscr/rjz067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 03/04/2019] [Indexed: 11/22/2022] Open
Abstract
A case of a 39-year-old woman diagnosed with superior mesenteric artery syndrome after a 25-year history of nausea, vomiting, and abdominal pain that began as a teenager and the absence of any significant weight loss illustrates the diagnostic complexity of this entity, particularly among teenagers and young adults who present with these symptoms. The patient underwent multiple upper endoscopies and serologic evaluations before a contrasted CT demonstrated an acutely angled SMA and duodenal compression, prompting the diagnosis of SMA syndrome. This case underscores the importance of including congenital SMA syndrome on the differential in young people without an obvious cause of persistent nausea, vomiting, and abdominal pain.
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Affiliation(s)
- Timothy Trestrail
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Emily K Martin
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Neal Bhutiani
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | | | - Vladimir Davidyuk
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Gary C Vitale
- Department of Surgery, University of Louisville, Louisville, KY, USA
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