Endoscopic management of duodenal adenomas in familial adenomatous polyposis--a single-center experience.

BACKGROUND: Duodenal lesions (DLS) are common in patients with familial adenomatosis polyposis (FAP), and screening for duodenal adenocarcinoma (DA) is currently recommended. Endoscopic treatment of DLS is controversial. AIM: To report management and outcomes of endoscopic therapy for DLS in patients with FAP. METHODS: The records of patients with FAP who underwent endoscopic surveillance or therapy for DLS over a 15-year period were reviewed. Endoscopic intervention included endoscopic surveillance with biopsies, argon plasma coagulation (APC), endoscopic mucosal resection (EMR), EMR with APC, and ampullectomy. Main outcome measurements were recurrence and histology of DLS after endoscopic therapy, complications of endoscopic therapy, and need for duodenectomy. RESULTS: Seventy-one patients with FAP and DLS were identified from our endoscopy database as undergoing upper endoscopy for screening and/or surveillance (1995-2009). Mean follow up was 4.5 years (1-15 years). Seventy of the seventy-one (98.5%) patients had multiple flat DLS. Most of the patients were followed with yearly biopsies. APC was performed in 17 patients and EMR was performed in eight patients; in five of the eight EMR patients, APC was also performed to treat the edges of EMR site. During the follow up, 17/55 (31%) patients had histological progression (HP). HP was seen in 5/16 (31%) patients who underwent APC (one was lost to follow-up) and 12/40 (30%) patients followed with biopsies alone. Recurrence of lesions was noted in all patients. Two patients underwent duodenectomy. None of the patients developed DA during follow up. CONCLUSIONS: Endoscopic surveillance with directed endotherapy for DLS in FAP is feasible and safe when diligently performed.

Intraprocedural tissue diagnosis during ERCP employing a new cytology preparation of forceps biopsy (Smash protocol).

OBJECTIVES: Techniques of tissue sampling at endoscopic retrograde cholangiopancreatography (ERCP) have been underutilized due to technical demands, low yield, and lack of immediate intraprocedural diagnosis. The objective of this study was to describe a new inexpensive, highly efficient ERCP tissue processing, and interpretation technique to address these issues. METHODS: A retrospective, institutional review board approved, single-center study was done at a tertiary-care medical center. Between June 2004 and February 2009, 133 patients (age 38-95 years; men 53%) with suspicious biliary strictures underwent ERCP with tissue sampling using a new technique. Small forceps biopsy specimens were forcefully smashed between two dry glass slides, immediately fixed, stained with rapid Papanicolaou, and interpreted by an on-site pathologist during the procedure (Smash protocol). RESULTS: Of the 117 proven to have cancer, true-positive Smash preps included pancreatic cancer 49/66 (74%), cholangiocarcinoma 23/29 (79%), metastatic cancer 8/15 (53%), and other 4/7 (57%). The median number of Smash biopsies to diagnosis was 3 (range 1-17). Suspicious or atypical results were considered to be negative in this study. There were no false positives and no complications. Smash had an overall sensitivity of 89/117 (76%) for all cases. The true-positive yield of immediate Smash prep cytology, combined with ERCP fine needle aspirate (FNA) and forceps biopsy histology was 77/95 (81%) for primary pancreaticobiliary cancers. CONCLUSIONS: Immediate cytopathologic diagnosis at ERCP was established in 72% of patients presenting with suspected malignant biliary obstruction using a new cytological preparation of forceps biopsies. This approach to ERCP tissue sampling permits immediate diagnosis and avoids the need for subsequent procedures, adds little cost and time, and is safe to perform.

Optimum palliation of inoperable hilar cholangiocarcinoma: comparative assessment of the efficacy of plastic and self-expanding metal stents.

BACKGROUND: Endoscopic retrograde biliary drainage (ERBD) with plastic or self-expanding metal stents (SEMS) is often performed for palliative care for cholangiocarcinoma. OBJECTIVE: The objective was to compare the clinical effectiveness, including stent patency, complication rate, and need for salvage percutaneous transhepatic biliary drainage, of SEMS and plastic stents. METHODS: A total of 100 patients with inoperable cholangiocarcinoma were identified from an endoscopic database from 1/1/01 to 9/30/06 at a tertiary cancer hospital and their clinical history was retrospectively reviewed. All patients were followed to death, re-intervention, or for at least one year. Stent patency and patient survival were estimated by Kaplan-Meier analysis, supplemented by the log-rank test for comparisons between groups. RESULTS: Forty-eight patients had SEMS placed and 52 patients had plastic stents placed. ERBD was successful in 46 (95.8%) in the SEMS group and 49 (94.2%) in the plastic group (P = 0.67). Median patency times were 1.86 months in the plastic group and 5.56 months in the SEMS group (P < 0.0001). A mean of 1.53 and 4.60 re-interventions were performed in the SEMS and plastic groups, respectively (P < 0.05). Complications occurred in 4/48 (8.3%) in the SEMS group and 4/52 (7.7%) in the plastic group (P = 0.79). Median survival was 9.08 and 8.22 months in the SEMS and plastic stent groups, respectively (P = 0.50). CONCLUSION: Metallic stent patency was superior to that of plastic stents in all Bismuth-Corlette classifications of hilar cholangiocarcinoma with similar complication rates. SEMS seem to be cost-effective and, when feasible, should be considered as an initial intervention in patients with inoperable hilar cholangiocarcinoma.

Self-expanding metal stents for biliary drainage in patients with resectable pancreatic cancer: single-center experience with 79 cases.

BACKGROUND AND AIMS: To study pre-operative and peri-operative course and outcome on follow up after pancreaticoduodenenctomy (PD) for resectable pancreatic cancer amongst patients receiving self-expanding metal stents (SEMS). METHODS: Medical charts of consecutively reviewed patients (2005-2009) with resectable pancreatic cancer and SEMS placement before PD at the MD Anderson Cancer Center (MDACC) were studied. RESULTS: Seventy-nine patients (mean age, 68 ± 9 years; 54% males) undergoing PD after SEMS placement were analyzed. Of these, 70% (55/79) had come with previous plastic stents placed within a median of 29 (5-216) days because of presentation and most (95%) underwent neoadjuvant chemoradiation after SEMS placement. The median interval between SEMS placement and PD was 120 (range 28-306) days. There were no technical difficulties during PD. The resected tumor was stage T3 in 72 patients, positive node in 44, lymphovascular invasion in 47, and perineural invasion in 62. Within 30 days after surgery, 26 (33%) patients developed complications requiring intervention, but none died. During a median follow-up of 349 (14-1,508) days after surgery, 32 (41%) patients developed metastatic disease, and 20 (25%) died; median survival was approximately 3 years. Development of metastatic disease during follow-up independently predicted survival with hazard ratio of 16 (95% CI: 4-68; P = 0.0001). CONCLUSIONS: Contrary to the tendency of avoiding the use of metal stents for biliary decompression amongst patients with resectable pancreatic cancer, our study demonstrated that SEMS did not adversely affect surgical technique, postoperative course, or long-term outcome. Therefore, metal stents should be considered for patients with resectable pancreatic cancer who will undergo preoperative chemoradiation.

Chemoprevention of colorectal cancer.

Colorectal cancer is a major public health concern in all developed countries. Despite decades of advances in the treatment and prevention of colorectal cancer, it remains the second most common cause of cancer death. However, the optimal method for early detection remains unknown and patient compliance with screening recommendations remains poor. This has led to the development of complementary strategies, such as chemoprevention to reduce morbidity and mortality from colorectal cancer. Chemoprevention is defined as the use of specific pharmacologic or nutrient agents to prevent, reverse, or inhibit the process of carcinogenesis. This review was designed to discuss the most promising agents in colorectal chemoprevention.