Dysplasia severity is associated with poor quality of life in patients with Barrett's esophagus referred for endoscopic eradication therapy.

Limited data exist regarding patient-reported outcomes and quality of life (QOL) experienced by patients with Barrett's esophagus (BE) referred for endoscopic eradication therapy (EET). Specifically, the impact of grade of dysplasia has not been explored. The purpose of this study is to measure patient-reported symptoms and QOL and identify factors associated with poor QOL in BE patients referred for EET. This was a prospective multicenter study conducted from January 2015 to October 2017, which included patients with BE referred for EET. Participants completed a set of validated questionnaires to measure QOL, symptom severity, and psychosocial factors. The primary outcome was poor QOL defined by a PROMIS score >12. Multivariable logistic regression analysis was performed to identify factors associated with poor QOL. In total, 193 patients participated (mean age 64.6 years, BE length 5.5 cm, 82% males, 92% Caucasians) with poor QOL reported in 104 (53.9%) participants. On univariate analysis, patients with poor QOL had lower use of twice daily proton pump inhibitor use (61.5% vs. 86.5%, P = 0.03), shorter disease duration (4.9 vs. 5.9 years, P = 0.04) and progressive increase in grade of dysplasia (high-grade dysplasia: 68.8% vs. 31.3%, esophageal adenocarcinoma: 75.5% vs. 24.5%, P < 0.001). Multivariate analysis demonstrated that high-grade dysplasia was independently associated with poor QOL (OR: 5.57, 95% CI: 1.05, 29.5, P = 0.04). In summary, poor QOL is experienced by the majority of patients with BE referred for EET and the degree of dysplasia was independently associated with poor QOL, which emphasizes the need to incorporate patient-centered outcomes when studying treatment of BE-related dysplasia.

The impact of endoscopic ultrasonography with fine needle aspiration (EUS-FNA) on esophageal cancer staging: a survey of thoracic surgeons and gastroenterologists.

SUMMARY: Accurate staging of esophageal cancer is critical to achieving optimal treatment outcomes. End-oscopic ultrasound with fine needle aspiration (EUS-FNA) has emerged as a valuable tool for locoregional staging. However, it is unclear how different physician specialties perceive the benefit of EUS-FNA for esophageal cancer staging, and thus utilize this modality in clinical practice. A survey regarding utilization of EUS-FNA in esophageal cancer was distributed to 211 thoracic surgeons and 251 EUS-capable gastroenterologists. Seventy-six thoracic surgeons (36%) and 78 gastroenterologists (31%) responded to the survey. Most surgeons (75%) use EUS to stage potentially resectable esophageal cancer 75% of the time. Surgeons using EUS less often are less likely to have access to high-quality EUS services than their peers. Fewer surgeons believe EUS is the most accurate test for T and N-staging (84% and 71%, respectively) as compared with gastroenterologists (97% and 96%, P < 0.01 for both). Most endosonographers (68%) decide whether to dilate a malignant esophageal stricture to complete the staging exam on a case-by-case basis. Surgeons disagree as to whether involvement of celiac lymph nodes should preclude esophagectomy in distal esophageal cancer. While most thoracic surgeons have embraced EUS-FNA as the most accurate locoregional staging modality in esophageal cancer, this attitude is not fully reflected in utilization patterns due to a lack of quality EUS services in some centers. Controversial areas that warrant further study include dilation of malignant strictures to facilitate EUS staging, and the implication of involved celiac lymph nodes on management.

Transoral, flexible endoscopic suturing for treatment of GERD: a multicenter trial.

BACKGROUND: A totally transoral outpatient procedure for the treatment of GERD would be appealing. METHODS: A multicenter trial was initiated that included 64 patients with GERD treated with an endoscopic suturing device. Inclusion criteria were 3 or more heartburn episodes per week while not taking medication, dependency on antisecretory medicine, and documented acid reflux by pH monitoring. Exclusion criteria were dysphagia, grade 3 or 4 esophagitis, obesity, and hiatus hernia greater than 2 cm in length. Patients underwent manometry, endoscopy, 24-hour pH monitoring, and symptom severity scoring before and after the procedure. Patients were randomized to a linear or circumferential plication configuration. Adverse procedural events were recorded. RESULTS: Mean 6-month symptom score changes demonstrated procedural efficacy. Heartburn severity and frequency as well as regurgitation all improved (p > 0.0001 for each). Twenty-four-hour pH monitoring showed improvement in number of episodes below pH of 4 at 3 and 6 months (p < 0.0007 and 0.0002) and percentage of total time the pH was less than 4 at 6 months (p < 0.011). Plication configuration did not affect symptoms or pH monitoring results. One patient had a self-contained suture perforation that was successfully treated with antibiotics. CONCLUSION: Endoscopic gastroplasty is safe. It is associated with reduced symptoms and medication use at 6 month follow-up in patients with uncomplicated GERD.

Complications of percutaneous endoscopic gastrostomy.

Percutaneous endoscopic gastrostomy has become the procedure of choice for the establishment of enteral feedings in most clinical settings. Minor modifications in the technique and tools of PEG may have had some effect on the type of complications seen with this procedure. The major and minor complications of PEG are reviewed with a focus on those manipulations that may assist in reducing the incidence of common complications of this procedure.

Technology assessment status evaluation: balloon dilation of gastrointestinal tract strictures. American Society for Gastrointestinal Endoscopy.

Balloon dilation is an acceptable modality for the dilation of stenoses at various sites in the gastrointestinal tract. In the esophagus its reported efficacy and safety is similar to bougienage; in other sites it offers an alternative to surgical treatment, in most cases as the definitive therapy.

Technology assessment status evaluation: monitoring equipment for endoscopy. American Society for Gastrointestinal Endoscopy.

An understanding of the principles and limitations of monitoring devices is valuable for their appropriate use and interpretation. Reliable monitoring de available as an adjunct to skilled personnel to detect changes in patient condition during endoscopy. Combination units that provide pulse oximetry, automated sphygmomanometry and ECG monitoring appear to be the most convenient and cost effective products.

Technology assessment status evaluation: disposable endoscopic accessories. American Society for Gastrointestinal Endoscopy.

Data supporting the preferential use of disposable endoscopic accessories is limited. These devices have been widely disseminated without careful evaluation of their impact on the environment and medical costs. In addition, current facility reimbursement for endoscopic procedures does not adequately cover the costs of these accessories. Re-use of accessories labelled "for single use only" as a potential means to reduce costs has not been carefully evaluated. More prospective data comparing the efficacy, safety, and cost effectiveness of disposable versus reusable accessories is needed.

Role of laparoscopic cholecystectomy in the management of acute gallstone pancreatitis.

Laparoscopic cholecystectomy has rapidly become the prime modality for removal of the gallbladder. However, as laparoscopic techniques for treating choledocholithiasis are evolving, we reviewed our experience with acute gallstone pancreatitis since the inception of laparoscopic cholecystectomy. Between November 1989 and March 1993, we treated 57 patients with acute gallstone pancreatitis. Cholecystectomy was performed during the initial admission in 46 patients (81%, group I), while 11 (19%) underwent delayed cholecystectomy at a second admission 2 to 9 weeks later (group II). Within group I, eight patients (17%) were thought to have contraindications to laparoscopic cholecystectomy and underwent open cholecystectomy. In the remaining 38 patients of group I, laparoscopic cholecystectomy was completed successfully. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) was performed in 23 of these patients (61%) and endoscopic sphincterotomy was performed in 6 patients (26%). In four other patients, the intraoperative cholangiogram revealed common bile duct stones that were removed using laparoscopic techniques. The 11 patients in group II were all treated by laparoscopic cholecystectomy; of these patients, 3 underwent preoperative endoscopic stone removal and 1 had choledocholithiasis managed laparoscopically. Postoperative hospitalization averaged 4 +/- 1 days (mean +/- SEM), and there was no major morbidity or 30-day mortality. This is the first large series of acute gallstone pancreatitis in the era of laparoscopic cholecystectomy. Our experience suggests that laparoscopic cholecystectomy with or without ERCP should be the primary approach for treating acute gallstone pancreatitis in the 1990s.

Diagnosis and management of biliary complications of laparoscopic cholecystectomy.

Laparoscopic cholecystectomy has become the operation of choice for symptomatic cholelithiasis. However, this operation may result in serious biliary complications. Our aims were to review our experience with biliary complications of laparoscopic cholecystectomy and to document the mechanisms of the injuries and the techniques of managing these complications. We treated 20 patients with biliary complications of laparoscopic cholecystectomy. Symptomatic collections of bile (bilomas) were present in five patients. One of these patients underwent operative ligation of an accessory bile duct in the gallbladder bed, whereas the others had percutaneous or endoscopic therapy. In the remaining 15 patients (of whom 13 were referred from other hospitals), injuries to the major bile ducts were managed by combined radiologic, endoscopic, and operative therapies. In 10 of these patients (67%), the mechanism of injury was the misidentification of the common bile duct as the cystic duct. In 3 of 15 patients, a noncircumferential injury to the lateral aspect of the common bile duct occurred. The Bismuth levels of the remaining bile duct injuries were type I in 3, type II in 4, type III in 3, and type IV in 2. Early outcome of therapy for these bile duct injuries has been favorable. One patient was lost to follow-up, and 2 died of nonbiliary causes, whereas 12 patients are alive and well with normal serum liver enzyme levels at 4 to 19 months postoperatively (mean: 14 months). The most common cause of major bile duct injury during laparoscopic cholecystectomy is mistaking the common bile duct for the cystic duct. Most bilomas can be managed successfully with noninvasive methods. Coordinated efforts by radiologists, endoscopists, and surgeons are necessary to optimize the management of patients with major bile duct injury, suggesting that patients with biliary complications of laparoscopic cholecystectomy should be referred to specialty centers for optimal care.

Preliminary experience using endoscopic ultrasonography in the diagnosis of choledocholithiasis.

Twenty patients with symptomatic cholelithiasis and suspected choledocholithiasis were evaluated in an ongoing prospective trial using endoscopic ultrasonography (EUS), standard abdominal ultrasonography (US) and ERCP for the detection of choledocholithiasis prior to laparoscopic cholecystectomy. EUS was used successfully to image the extrahepatic bile duct in all patients. EUS detected three of four proven bile duct stones and correctly identified 16 bile ducts as stone free, thus being more accurate than standard abdominal US. The preliminary results of this ongoing prospective trial and the experience reported by other authors suggest that EUS may be as sensitive as ERCP in the detection of choledocholithiasis.

The use of hepatobiliary scintigraphy in patients with acalculous biliary colic.

Twelve patients with biliary colic had no evidence of gallstones but underwent cholecystokinin-augmented hepatobiliary scintigraphy that revealed gallbladder ejection fractions of less than 35%. All 12 patients underwent cholecystectomy. Biliary colic was relieved in all patients at a mean postoperative follow-up of 2.5 years. The biliary colic in these patients was probably caused by abnormal gallbladder emptying, itself apparently produced by either cystic duct obstruction or abnormal motility. Biliary abnormality was seen at operation in most patients, and all patients had abnormalities of the gallbladder or cystic duct seen grossly or histologically. These abnormalities included cystic duct stenosis or adhesions, chronic inflammation, and cholesterolosis.

Percutaneous cholecystolithotomy: analysis of results and complications in 58 consecutive patients.

Percutaneous cholecystolithotomy was attempted in 58 consecutive patients. Patients were considered for percutaneous cholecystolithotomy only if they had symptomatic gallstones and a strong contraindication to surgical cholecystectomy. The procedure consisted of three parts: (a) initial percutaneous cholecystostomy, (b) tract dilation and stone removal, and (c) tract evaluation and tube removal. Local anaesthesia and intravenously administered analgesia were used in all procedures. Percutaneous cholecystolithotomy was successful in removing all of the stones in 56 patients (97%), including cystic duct calculi in 15 patients and common duct calculi in 10 patients. Major complications occurred in five patients (9%); in four cases, they were related to bile leakage after the cholecystostomy tube was removed. Thirty-day mortality was 3% (two patients). Advantages of percutaneous cholecystolithotomy include avoidance of general anesthesia and the ability to treat patients in any disease setting, including acute cholecystitis. Percutaneous cholecystolithotomy, although technically demanding, is an effective alternative to surgical cholecystectomy in elderly and debilitated patients.

Percutaneous cholecystolithotomy: preliminary experience and technical considerations.

Surgical cholecystectomy is associated with a high morbidity and mortality in elderly patients with acute calculous cholecystitis and underlying cardiac or pulmonary disease. Currently there are few alternatives for treating these patients. The authors have used percutaneous cholecystolithotomy in 11 such high-risk patients for definitive treatment of gallbladder calculi. In all 11 patients all stones were successfully removed from the gallbladder and cystic duct. The entire procedure--from initial tube placement to final tube removal--lasted 17-40 days (mean, 21 days). There were two complications: one minor--local wound infection--and one major--bile peritonitis with eventual death. Percutaneous cholecystolithotomy is an effective alternative therapy for acute calculous cholecystitis in elderly, debilitated patients.