Endoscopic mucosal resection for gastroesophageal cancer in a U.K. population. Long-term follow-up of a consecutive series.

BACKGROUND: Endoscopic mucosal resection (EMR) of early gastric and esophageal tumors is effective and avoids the morbidity and mortality of surgery. We report the long-term results of a consecutive series of 93 endoscopic resections, during a 7-year period, in a U.K. population. METHODS: Eighty-eight patients with 93 lesions were included. EMR was performed for 64 and 29 malignant and benign lesions, respectively. Patients with malignant disease were subgrouped into "high risk" or "low risk" for recurrence. RESULTS: Of the 35 lesions in the low-risk group, local control was achieved in 31; 29 after 1 EMR session. Two had residual invasive carcinoma, one had treatment ceased due to pancreatic cancer, and one patient did not attend follow-up. Of the 29 lesions in the high-risk group, local control was achieved in 15; 13 after 1 EMR session. Median follow-up was 53 months. Cancer specific survival for the 45 invasive cancers (T1m and T1sm) was 93%; three patients died from their disease. CONCLUSIONS: This study has shown for the first time in a U.K. population that EMR is effective in controlling disease in patients with local high grade dysplasia (HGD) and early invasive carcinoma, with no mortality and low morbidity.

COVID-19 associated pancreatitis: A mini case-series.

INTRODUCTION: One of the recognized causes of acute pancreatitis is viral-induced pancreatitis. The SARS-COV-2 virus has been linked to pancreatic injury and hence the causation of acute pancreatitis. This paper reports three cases of acute pancreatitis linked to COVID-19 infection adding to serving to further consolidate evidence. CASE PRESENTATION: Three patients aged between 63 and 87 years were diagnosed with acute pancreatitis and concomitant or previous COVID-19 infection. Criteria for diagnosis of pancreatitis were according to the revised Atlanta criteria. None of the patients had had previous episodes of pancreatitis and other aetiologies were not suggestive. The patients were not vaccinated against SARS-CoV-2. Supportive treatment was instituted for the three patients, and all made an uneventful recovery. Mean hospital stay was 4 days. DISCUSSION: The diagnosis of acute pancreatitis in the presented cases is being linked to COVID-19 infection, as other causes were not evident. There is however a confounding factor, as the patient in case 2 had slightly elevated triglyceride levels and had been on long-term low dose atorvastatin, both of which are associated with a low risk of acute pancreatitis. However, she had never had pancreatitis prior to this presentation. CONCLUSION: The novel virus SARS-COV-2 has also been linked to pancreatic damage and thus a possible causative factor in acute pancreatitis. This mini-case series presents three cases of acute pancreatitis in COVID-19 positive patients, in the absence of other risk factors. This phenomenon linking COVID-19 and pancreatitis has been expounded by other case reports and cohort studies from around the world. It is reasonable to acknowledge that, like other viruses, SARS CoV-2 may cause acute pancreatitis, although sounder evidence from the international community needs to be compiled.

Systematic four-quadrant biopsy detects Barrett's dysplasia in more patients than nonsystematic biopsy.

AIMS: To compare detection of Barrett's dysplasia and adenocarcinoma by systematic versus nonsystematic surveillance biopsy protocols. METHODS: Upper GI consultation and open-access endoscopy are provided jointly at Glasgow Royal Infirmary by medical and surgical teams. The surgical team adopted annual systematic four-quadrant biopsy Barrett's surveillance in 1995. The medical team continued annual Barrett's surveillance with nonsystematic biopsy until 2004. We compare detection of Barrett's dysplasia and esophageal adenocarcinoma in unselected patients by these two biopsy strategies over 10 yr. All patients had > or = 3 cm Barrett's esophagus and histological proof of intestinal metaplasia. Patients referred for dysplasia management or with prevalent adenocarcinoma were excluded. Cohort A (N = 180) had four-quadrant biopsy every 2 cm while cohort B (N = 182) had nonsystematic biopsies. RESULTS: Cohort A versus cohort B: Median number of biopsies per endoscopy: 16 versus 4. Prevalence of low-grade dysplasia (per patient): 18.9% versus 1.6% (P << 0.001). Prevalence of high-grade dysplasia: 2.8% versus 0% (P = 0.03). Incidence of low-grade dysplasia: 2.2% versus 6.6% (NS). Incidence of high-grade dysplasia: 2.8% versus 0% (P = 0.03). Nine cohort A patients (total 5%, 1.4% per patient-year) were treated for HGD (eight endoscopically, one by esophagectomy). Two had intramucosal adenocarcinoma. No cohort A patient developed advanced cancer but three cohort B patients developed and died of invasive Barrett's adenocarcinoma (0.6% per patient-year). CONCLUSIONS: Patient age, gender, Barrett's segment length, and follow-up were similar (though not identical) in both cohorts, but confounding seems unlikely to account for a 13-fold difference in detection of prevalent dysplasia between the two groups. Our data support the hypothesis that systematic four-quadrant biopsy is considerably more effective than nonsystematic biopsy sampling in detecting Barrett's dysplasia and early adenocarcinoma. Greater biopsy numbers and the systematic pattern of biopsy taking may both contribute to this greater effectiveness.

Haemobilia causing cholangitis in a patient on dual anti-platelet treatment suffering from acute acalculous cholecystitis.

INTRODUCTION: Haemobilia is a rare cause of upper gastro-intestinal haemorrhage which can be difficult to diagnose. PRESENTATION OF CASE: We present the case of a patient who suffered from acute acalculous cholecystitis while on dual anti-platelet therapy with aspirin and clopidogrel. We describe the diagnostic and treatment challenges arising from the patient's complicated past history and the steps leading to the diagnosis of haemobilia causing biliary obstruction and cholangitis. Our patient did not, at any point, manifest anaemia or evidence of haemorrhage. DISCUSSION: Haemobilia has a varied aetiology. To our knowledge there is no association with dual anti-platelet treatment in the literature to date. Diagnosis is difficult and relies on multiple modalities. In our patient the final diagnosis was only made in the course of open bile duct exploration. CONCLUSION: In acute biliary obstruction we recommend the consideration of haemobilia in the differential diagnosis, especially in patients with a bleeding tendency.

Denture impacted in the oesophagus for 9 months: successful endoscopic retrieval.

This case report describes the presentation and successful endoscopic retrieval of an impacted denture plate from the distal oesophagus where it had been in-situ for nine months.

Endo-biliary stents for benign disease: not always benign after all!

This case report describes the presentation, management and treatment of a patient who suffered small bowel perforation due to the migration of his biliary stent which had been inserted for benign disease.

Exhaled ethane concentration in patients with cancer of the upper gastrointestinal tract - a proof of concept study.

There has been growing interest in the measurement of breath ethane as an optimal non-invasive marker of oxidative stress. High concentrations of various breath alkanes including ethane have been reported in a number of malignancies. Our aim was to investigate the use of novel laser spectroscopy for rapid reporting of exhaled ethane and to determine whether breath ethane concentration is related to a diagnosis of upper gastrointestinal malignancy. Two groups of patients were recruited. Group A (n = 20) had a histo-pathological diagnosis of either esophageal or gastric malignancy. Group B (n = 10) was made up of healthy controls. Breath samples were collected from these subjects and the ethane concentration in these samples was subsequently measured to an accuracy of 0.2 parts per billion, ppb. Group A patients had a corrected exhaled breath ethane concentration of 2.3 +/- 0.8 (mean +/- SEM) ppb. Group B patients registered a mean of 3.1 +/- 0.5 ppb. There was no statistically significant difference between the two groups (p = 0.39). In conclusion, concentrations of ethane in collected breath samples were not significantly elevated in upper gastrointestinal malignancy. The laser spectroscopy system provided a reliable and rapid turnaround for breath sample analysis.

Cancer of the proximal colon after a "normal" colonoscopy.

In common with other diagnostic tests, colonoscopy has a false negative rate which is infrequently assessed. The available literature suggests that lesion miss rate is higher for proximal colonic tumors. A total of 367 patients were diagnosed with cancer of the colon and rectum over a period of 2 years. Ninety-two of these patients had tumors proximal to the splenic flexure. Their 5-year pre-diagnosis colonoscopic exposure was analyzed. The primary end-point of this study was to confirm the false negative colonoscopy rate in patients subsequently diagnosed with cancer of the proximal colon. The secondary endpoint was to assess the effects of diagnostic delay on tumor stage and presentation. In the group of patients with proximal colon cancer (n = 92) we identified 10 patients (11%) who, as a result of incomplete (2 cases) or falsely negative (8 cases) colonoscopies, suffered a median diagnostic delay of 17 months (range 3-60). At diagnosis, 4 of these patients had Dukes' D caecal cancer, 4 had Dukes' C caecal cancer and 2 had Dukes' B transverse colon cancer; 3 presented with perforated tumours and 1 with intestinal obstruction. In this small subgroup of patients therefore 40% presented with emergency complications compared to 8% in the rest of the group with proximal cancers (p < 0.01). Missed cancers are more likely to present with complications. This study highlights the importance of recognition of an incomplete examination and the adverse impact of missed diagnosis on subsequent presentation.