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Background: Ampullary adenomas are lesions at the duodenum's major papilla commonly associated with familial adenomatous polyposis (FAP) but may also occur sporadically. Historically, ampullary adenomas were removed surgically, however endoscopic resection has become the preferred method of resection. Most of the literature on management of ampullary adenomas are small single-center retrospective reviews. The objective of this study is to describe endoscopic papillectomy outcomes to further refine management guidelines. Methods: This is a retrospective study of patients who underwent endoscopic papillectomy. Demographic data were included. Details regarding lesions and procedures were also collected, including endoscopic impression, size, resection method and adjunctive therapies. Chi-square, Kruskal-Wallis rank-sum, and t-tests were performed. Results: A total of 90 patients were included. 60% patients (54 of 90) had pathology-proven adenomas. 14.4% of all lesions (13 of 90) and 18.5% of adenomas (10 of 54) were treated with APC. Among APC-treated lesions, 36.4% developed recurrence (4 of 11) vs. 7.1% developed residual lesion (1 of 14) (P=0.019). 15.6% of all lesions (14 of 90) and 18.5% of adenomas (10 of 54) reported complications, and the most common was pancreatitis (11.1% and 5.6%). Median follow-up time was 8 months for all lesions and 14 months (range, 1-177 months) for adenomas, with time to recurrence 30 and 31 months (range, 1-137 months), respectively. Recurrence was observed in 16.7% of all lesions (15 of 90) and 20.4% of adenomas (11 of 54). Endoscopic success was observed in 69.2% of all lesions (54 of 78) and 71.4% of adenomas (35 of 49) after removing patients lost to follow-up. Conclusions: Endoscopic papillectomy is an effective method for managing duodenal adenomas. Pathology-proven adenoma should undergo surveillance for at least 31 months. Lesions treated with APC may require closer follow-up and for a prolonged period.
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AIM: To investigate the current management of gastric antral webs (GAWs) among adults and identify optimal endoscopic and/or surgical management for these patients. METHODS: We reviewed our endoscopy database seeking to identify patients in whom a GAW was visualized among 24640 esophagogastroduodenoscopies (EGD) over a seven-year period (2006-2013) at a single tertiary care center. The diagnosis of GAW was suspected during EGD if aperture size of the antrum did not vary with peristalsis or if a "double bulb" sign was present on upper gastrointestinal series. Confirmation of the diagnosis was made by demonstrating a normal pylorus distal to the GAW. RESULTS: We identified 34 patients who met our inclusion criteria (incidence 0.14%). Of these, five patients presented with gastric outlet obstruction (GOO), four of whom underwent repeated sequential balloon dilations and/or needle-knife incisions with steroid injection for alleviation of GOO. The other 29 patients were incidentally found to have a non-obstructing GAW. Age at diagnosis ranged from 30-87 years. Non-obstructing GAWs are mostly incidental findings. The most frequently observed symptom prompting endoscopic work-up was refractory gastroesophageal reflux (n = 24, 70.6%) followed by abdominal pain (n = 11, 33.4%), nausea and vomiting (n = 9, 26.5%), dysphagia (n = 6, 17.6%), unexplained weight loss, (n = 4, 11.8%), early satiety (n = 4, 11.8%), and melena of unclear etiology (n = 3, 8.82%). Four of five GOO patients were treated with balloon dilation (n = 4), four-quadrant needle-knife incision (n = 3), and triamcinolone injection (n = 2). Three of these patients required repeat intervention. One patient had a significant complication of perforation after needle-knife incision. CONCLUSION: Endoscopic intervention for GAW using balloon dilation or needle-knife incision is generally safe and effective in relieving symptoms, however repeat treatment may be needed and a risk of perforation exists with thermal therapies.
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Despite its declining incidence, gastric cancer (GC) remains a leading cause of cancer-related deaths worldwide. A multimodal approach to GC is critical to ensure optimal patient outcomes. Pretherapy fine resolution contrast-enhanced cross-sectional imaging, endoscopic ultrasound and staging laparoscopy play an important role in patients with newly diagnosed ostensibly operable GC to avoid unnecessary non-therapeutic laparotomies. Currently, margin negative gastrectomy and adequate lymphadenectomy performed at high volume hospitals remain the backbone of GC treatment. Importantly, adequate GC surgery should be integrated in the setting of a multimodal treatment approach. Treatment for advanced GC continues to expand with the emergence of additional lines of systemic and targeted therapies.
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INTRODUCTION: The year 2013 continued to highlight numerous aspects of drug-induced liver injury (DILI), with new information communicated via > 1500 publications. New reports of DILI were described and FDA warnings and alerts were issued for a number of products, emphasizing the risks related to hepatotoxicity. AREAS COVERED: We provide a summary of the year's published reports of new causes of DILI, along with reviews and reports of established hepatotoxins, new and expanded DILI registries and the continuing emphasis placed on genetic and other risk factors. Several new analyses of data generated from the US DILI Network are included. EXPERT OPINION: The clinical usefulness of pharmacogenetic testing remains to be determined; the number of patients who must be tested is large and the overall risk of DILI is quite small. The role that dose and hepatic metabolism play in causing idiosyncratic DILI was reviewed; daily doses > 50 - 100 mg of medications with high lipophilicity appear to be most predictive of severe DILI, but not in all cases. Restricting access to paracetamol in certain parts of the UK continues to demonstrate a successful reduction in the number of acute liver failure cases and patients listed for liver transplant.