Preoperative biliary drainage in resectable pancreatic cancer: a systematic review and network meta-analysis.

BACKGROUND: Controversy remains about the best pre-operative management of jaundice in patients with resectable pancreatic head cancer (RPC) undergoing planned pancreaticoduodenectomy (PD). OBJECTIVE: The aim of this study was to compare rates of post-operative complications in patients undergoing four pre-operative approaches (POA): preoperative biliary drainage with plastic stent (PBD-PS), metal stent (PBD-MS), and percutaneous transhepatic drain (PBD-PT), or no pre-operative biliary drainage (NPBD). METHOD: A study was included in the systematic review if it assessed the effects of PBD on post-operative outcomes in jaundiced patients with RPC. Endpoints were the rate of any post-operative complication, wound infection, intra-abdominal infection and post-operative bleeding. A network meta-analysis (NMA) was performed to rank the POAs from the best to worst, for each outcome. RESULTS: Thirty-two studies were included in the systematic review. Ten out of 32 studies included in the systematic review reported at least one of the 4 outcomes of interest and thus were used for NMA. The calculated odds ratios and P-scores ranked NPBD as the best approach. There was insufficient evidence to determine the best modality of PBD among PBD-PS, PBD-MS and PBD-PT. CONCLUSIONS: No preoperative biliary drainage may be the best management of preoperative jaundice in patients with RPC before PD. Further studies are needed to determine the best modality in patients that need PBD.

De Novo Development of Hamartomatous Duodenal Polyps in a Patient With Short Bowel Syndrome During Teduglutide Therapy: A Case Report.

Teduglutide (TG) is approved for the treatment of parenteral nutrition (PN)-dependent adult patients with short bowel syndrome (SBS). Its well-known adverse effect is expedited growth of colon polyps and potential formation of new polyps. Apart from animal studies, de novo development of duodenal polyps in a patient during TG therapy has not been reported in the literature. We report a case of a 71-year-old man with SBS on TG who developed multiple new duodenal polyps that were found incidentally during a diagnostic endoscopy. Furthermore, an accelerated growth of duodenal polyps was noted while on TG therapy, suggesting a potential trophic effect of TG on these polyps. There are no current recommendations for the surveillance of intestinal polyps in patients on TG therapy, but we recommend exercising caution and possible need for surveillance based on this case report.

Crohn's disease presenting as acute gastrointestinal hemorrhage.

Severe gastrointestinal (GI) hemorrhage is a rare complication of Crohn's disease (CD). Although several surgical and non-surgical approaches have been described over the last 2 decades this complication still poses significant diagnostic and therapeutic challenges. Given the relative infrequency of severe bleeding in CD, available medical literature on this topic is mostly in the form of retrospective case series and reports. In this article we review the risk factors, diagnostic modalities and treatment options for the management of CD presenting as GI hemorrhage.

Effect of quality of bowel preparation on quality indicators of adenoma detection rates and colonoscopy completion rates.

BACKGROUND AND AIM: Adequate bowel preparation is important for safe and effective colonoscopy. Quality indicators (QI) for colonoscopy include achieving at least 95% completion rate and an adenoma detection rate (ADR) of at least 25% in average-risk men and 15% in average-risk women aged over 50. Our aim was to investigate the impact of bowel preparation on ADR and colonoscopy completion rates. METHODS: This retrospective cohort study included patients who underwent colonoscopy between January 2008 and December 2009. The main outcome measurements were ADR and colonoscopy completion rates to the cecum. RESULTS: A total of 2519 patients was included; 1030 (41.0%) had excellent preparation, 1145 (45.5%) good-, 240 (9.5%) fair-, and 104 (4.1%) poor preparation. Colonoscopy completion rates were significantly lower in patients with poor or fair preparation (72.1% and 75.4%, respectively) than in those with good and excellent preparation (99.7% and 99.9%, respectively; P < 0.001), and significantly lower than the QI of 95% (P < 0.001). ADR in men and women combined was similar in all four grades of preparation (excellent, good, fair and poor) at 24.2% vs. 26.8% vs. 32.1% vs. 22.1%, respectively; P = 0.06. All the groups had ADR above the QI (25% for men and 15% for women) with evidence of significantly higher ADR in the women with excellent or good preparation and in men with excellent, good or fair preparation. On multivariate analysis, male gender was significantly associated with increased ADR (P < 0.001), while the quality of bowel preparation did not influence ADR. CONCLUSIONS: Patients with fair and poor standards of preparation have significantly lower colonoscopy completion rates than those with excellent and good preparation. However, there was no difference in ADR between the different grades of preparation.

Adenoma detection rate in high-risk patients differs from that in average-risk patients.

BACKGROUND: Adenoma detection rates (ADRs) are established as quality targets in average-risk (AR) individuals undergoing colorectal cancer (CRC) screening colonoscopy. Little is known about the ADR in high-risk (HR) individuals undergoing index or surveillance colonoscopy. OBJECTIVE: To determine and compare ADR in HR versus AR individuals undergoing colonoscopy. DESIGN AND SETTING: Retrospective study, tertiary care center. PATIENTS AND INTERVENTION: We reviewed records of 7357 patients who underwent colonoscopy by 66 multispecialty endoscopists at our institution during the period 2008 to 2009. Both screening and surveillance colonoscopies in AR and HR patients for CRC were studied. HR patients were further divided into 3 subgroups: those with a (1) personal history of polyps (PHP), (2) family history of polyps (FHP), and (3) family history of CRC (FHCRC). Multivariable logistic regression analysis was performed to evaluate differences in ADR between the groups after adjusting for possible confounders. MAIN OUTCOME MEASUREMENTS: ADR in HR patients. RESULTS: The study included 4141 patients, of whom 2170 were AR and 1971 were HR. Patients in the HR group were older (64.5 ± 9.1 years vs 59.1 ± 7.9 years, P < .001). HR patients were more likely to have adenomas (30.7% vs 25.6%, P < .001). Adenomas were detected more often in the proximal colon than in the distal colon (29.3% vs 21.0%, P < .001 and 22.8% vs 15.8%, P < .001, respectively). Patients with a PHP had the highest ADR (33.1%, P < .001). However, after adjusting for confounders, HR status was not found to be associated with ADR (odds ratio [OR] 1.2; 95% confidence interval [CI], 0.93-1.6; P = .15 for females and 0.93; 95% CI, 0.70-1.2; P = .61 for males). HR females were found to have a 40% greater likelihood of having proximal adenomas than AR females (1.4; 95% CI, 1.01-2; P = .04). LIMITATIONS: Retrospective design, single tertiary center. CONCLUSIONS: Patients with a PHP have a significantly higher ADR compared with AR patients. Defining a minimum target ADR for individuals with a PHP undergoing surveillance colonoscopy is important.

Decreased Severity in Recurrent Versus Initial Episodes of Acute Pancreatitis.

OBJECTIVES: The comparative outcomes of initial versus recurrent acute pancreatitis (AP) have not been clearly established. AIM: The aim was to compare the clinical outcomes of those with an initial episode of AP to those with recurrent AP stratified by the number of prior episodes. METHODS: This retrospective cohort study included consecutive patients with AP admitted to the Cleveland Clinic between 2008 and 2011. The odds of severe AP, multisystem organ failure, ICU admission, new local complications, elevated blood urea nitrogen and bedside index for severity in acute pancreatitis score, systemic inflammatory response syndrome, and mortality were compared using univariable and multivariable logistic regression. RESULTS: Two hundred and ninety two patients were included, of which 213 (72%) were admitted on their initial AP episode. Mortality in patients experiencing first episode was 4.7%, compared to 0% in patients with recurrent attack of pancreatitis (P = 0.047). Prior episodes of AP were found to be protective against multisystem organ failure (odds ratio, 0.14 for each prior episode; confidence interval, 0.01-0.76) and intensive care unit admission (0.24, confidence interval, 0.06-0.91), adjusting for potential confounding factors such as transfer status and obesity. CONCLUSIONS: Patients presenting with recurrent AP may be at decreased risk of a clinically severe course and incur decreased mortality.

Adenoma and sessile serrated polyp detection rates: variation by patient sex and colonic segment but not specialty of the endoscopist.

BACKGROUND: Adenoma detection rate is an important quality indicator. High adenoma detection rate is related to fewer interval cancers. Interval cancers arise from sessile serrated polyps, often in the proximal colon. The detection of adenomas and sessile serrated polyps by location may enhance colonoscopy efficacy. OBJECTIVE: The aim of this study was to determine entire colon and segmental adenoma and sessile serrated polyp detection rates and to assess the impact of endoscopist specialty on polyp detection. DESIGN: Colonoscopies performed by 65 multispecialty endoscopists were studied. SETTING: This study was conducted at an academic medical center. PATIENTS: Average-risk outpatients undergoing screening colonoscopy were selected. MAIN OUTCOME MEASURES: Polyp detection rates were determined by sex, colon segment, and each endoscopist. RESULTS: Included were 2167 patients. Adenoma and sessile serrated polyp detection rates were 25% and 2% and not significantly different by specialty of the endoscopist. The adenoma detection rate was higher in men (31%) than in women (20%), including each segment in the colon. It was higher proximally (20%) than distally (16%) (p = 0.027) in men, but no different in proximal (11%) and distal colon (11%) (p = 0.66) in women. Sessile serrated polyp detection was the same in men and women at 2% (p = 0.84) and 3-fold higher in the proximal than in the distal colon (1.4% vs 0.5%), but only significantly so in women (p = 0.041). We found a poor correlation between adenoma and sessile serrated polyp detection rates (r = 0.35). LIMITATIONS: This study was limited by its retrospective nature. CONCLUSIONS: Prevalent adenomas are detected more often in men than in women, including overall and by colon segment. The proximal adenoma detection rate is significantly higher than the distal adenoma detection rate in men, but segmental rates are similar in women. Sessile serrated polyp detection rates are low, albeit 3-fold higher in the proximal colon, and are found as frequently in men and women. High-quality colonoscopy, as evidenced by adenoma detection rate, varies by endoscopist but is independent of colonoscopist subspecialty.

Polypectomy rate: a surrogate for adenoma detection rate varies by colon segment, gender, and endoscopist.

BACKGROUND & AIMS: The adenoma detection rate (ADR) is an important measure of the quality of colonoscopy; it is associated with interval colorectal cancer and varies among sexes and locations. Recommended indicators of competence for colonoscopy include minimal ADRs >25% for average-risk men and >15% for women. These ADRs are rigorous, so polypectomy detection rate (PR) has been suggested as a surrogate. Colonoscopy is less effective in the proximal colon, where interval cancers are more likely to occur. We compared ADRs and PRs in different segments of colon and between sexes. METHODS: We performed a cross-sectional review of findings from 2167 screening colonoscopies performed by 65 endoscopists on average-risk outpatients at the Cleveland Clinic, 2008-2009. We reviewed colonoscopy and pathology reports of randomly selected procedures (mean, 33 ± 16 procedures per endoscopist). We calculated PRs, ADRs, and correlation between PR and ADR for each colon segment and sex. RESULTS: The mean overall PR was 42% ± 16.7%, and ADR was 25% ± 3.3%. The correlation between overall ADR and PR was strong (r = 0.80). PR of 40% in men and 30% in women correlated with the established minimum benchmark ADRs of 25% and 15% for men and women, respectively. PR was more strongly correlated with ADR in the proximal colon (r = 0.92) than the distal colon (r = 0.58). The correlation was stronger in men than in women, as well as in the entire colon (r = 0.88 vs 0.75), the proximal colon (r = 0.91 vs 0.87), and the distal colon (r = 0.75 vs 0.55). The advanced ADR was 4% and did not correlate with PR (r = 0.32). CONCLUSIONS: On the basis of a review of findings from screening colonoscopies, overall PR correlates with ADR for the entire colon, but PR and ADR correlate most strongly for the proximal colon, where many adenomas can be missed and interval cancers develop. The correlation between PR and ADR is weaker for women than men and for distal colon. If PR is used as a surrogate for ADR, colon location and patient sex should be considered.