Esophageal Stenting With Sutures: Time to Redefine Our Standards?

BACKGROUND AND STUDY AIMS: Migration is the most common complication of the fully covered metallic self-expanding esophageal stent (FCSEMS). Recent studies have demonstrated migration rates between 30% and 60%. The aim of this study was to determine the effect of fixation of the FCSEMS by endoscopic suturing on migration rate. PATIENT AND METHODS: Patients who underwent stent placement for esophageal strictures and leaks over the last year were captured and reviewed retrospectively. Group A, cases, were patients who underwent suture placement and group B, controls, were patients who had stents without sutures. Basic demographics, indications, and adverse events (AEs) were collected. Kaplan-Meier analysis and Cox regression modeling were conducted to determine estimates and predictors of stent migration in patients with and without suture placement. RESULTS: Thirty-seven patients (18 males, 48.65%), mean age 57.2 years (±16.3 y), were treated with esophageal FCSEMS. A total of 17 patients received sutures (group A) and 20 patients received stents without sutures (group B). Stent migration was noted in a total of 13 of the 37 patients (35%) [2 (11%) in group A and 11 (55%) in group B]. Using Kaplan-Meier analysis and log-rank analysis, fixation of the stent with suturing reduced the risk of migration (P=0.04). There were no AEs directly related to suture placement. CONCLUSIONS: Anchoring of the upper flare of the FCSEMS with endoscopic sutures is technically feasible and significantly reduces stent migration rate when compared with no suturing, and is a safe procedure with very low AEs rates.

Early detection of pancreatic cancer.

Despite treatment advances pancreatic cancer remains one of the most lethal malignancies. It is expected that early detection and screening of high risk patient population may have the most significant impact on altering overall survival in this disease. Serologic biomarkers may be the most useful in early detection and histology-based markers may have the most significant role in differentiating benign, pre-malignant and malignant lesions. Here we review several serum and tissue-based biomarkers and summarize new data presented at the 2012 ASCO Gastrointestinal Cancers Symposium (Abstracts #151, #164, #188) on the potential role of PAM4 in pancreatic cancer screening and diagnosis.

Hepatocellular carcinoma at the University of Puerto Rico Liver Transplant Clinic.

UNLABELLED: The aim of this study was to determine the prevalence of hepatocellular carcinoma (HCC) in our liver transplant clinic, and describe the risk factors, predictors and treatment outcomes of primary liver cancer. METHODS: 459 of 469 records of patients attending the UPR Liver Transplant Clinic from September 1999 to January 2005 were reviewed. Frequency distributions were computed to describe the study group. RESULTS: 35 patients (7%) were included. 33 patients were diagnosed during the pre-transplant evaluation and 2 were diagnosed in the explant. Mean age at diagnosis in males was 54.5 years and 61.3 years in females. The main cause of liver disease was hepatitis C plus ethanolism in 42.9% (15 cases). The frequency of HCC in patients with a BMI > or = 25 Kg/m2 was more than twice that of patients with a BMI < 25 Kg/m2. Predominant presenting symptoms were ascites (40%), abdominal pain and jaundice (25%). Normal alpha-fetoprotein was found in 25%. 76% had a MELD score < 20. Treatment modalities included trans-arterial embolization (TAE/TACE) (49%), conservative treatment (34%), liver transplant (OLT, 23%), partial resection (9%) and systemic chemotherapy (3%). Eight patients underwent OLT and one developed primary graft failure, needing a second transplant. Two had T1N0M0 score, with a 100% survival at 2 yrs, and 6 patients had a T2N0M0 score, 5 of which underwent TAE before OLT, with an overall survival of 67%. Partial resection had an overall survival of 66%. CONCLUSIONS: The population of our clinic is similar in gender and age distribution, etiology of chronic liver disease, and clinical presentation of HCC to other studies previously described. The treatment outcomes and mortality rates compare with those observed in the literature.

Strategies for improving diagnostic accuracy of biliary strictures.

BACKGROUND: Brush cytology is the initial intervention when evaluating biliary strictures. Biliary brush cytology is known for its low sensitivity (but high specificity) and may be accompanied by biopsies and/or fluorescent in situ hybridization (FISH) to improve diagnostic yield. This study aimed to identify features to enhance cytological sensitivity, and assess which sampling method(s) improve identification of pancreatobiliary adenocarcinomas (PBCa). METHODS: Seventy-three biliary stricture cases were retrieved (38 PBCa and 35 control benign strictures). Biliary brushings, FISH, and biopsies were reviewed. Cytology specimens were evaluated for cellularity and presence of drunken honeycomb (DH), loosely cohesive clusters of round cells (LCCRC), large atypical cells with foamy cytoplasm (LACF), and single vacuolated malignant cells (SCs). Biopsies were examined for the presence of stromal invasion (SI). RESULTS: Biliary brushings were scantly cellular in 47.4% of PBCa and 51.4% of controls, resulting in 69.6% nondiagnostic/false-negative cytology diagnoses. DH, LACF, and SCs were significantly associated with adenocarcinoma (P < .00001, .0033, and .00002, respectively). By univariate analysis, SCs and LACF were predictors of malignancy in brushings (P = .0002 and .05). By multivariate analysis, only SCs were predictive of malignancy (P = .002). SI facilitated the diagnosis in 9 biopsies. Sensitivity/specificity of brush cytology, FISH, and biopsy were 39.5%/94.3%, 63.9%/94.3%, and 84.2%/100%, respectively. CONCLUSIONS: The low sensitivity of biliary brushings results from limited cellularity. Identification of LACF, DH, and SCs improves sensitivity. Sampling of stromal tissue may facilitate PBCa diagnosis. Concurrent biopsies and FISH are helpful in enhancing the diagnostic yield of PBCa.