Cost-effectiveness analysis of infected necrotizing pancreatitis management in an academic setting.

BACKGROUND AND AIMS: Traditional management for infected necrotizing pancreatitis (INP) often utilizes open necrosectomy, which carries high morbidity and complication rates. Thus, minimally invasive strategies have gained favor, specifically step-up approaches utilizing endoscopic or minimally-invasive surgery (MIS); however, the ideal management modality for INP has not been identified. METHODS: A decision tree model was designed to analyze costs and survival associated with open necrosectomy, endoscopic step-up, and MIS step-up protocols for management of INP after 4 weeks of necrosis development with adequate retroperitoneal access. Costs were based on a third-party payer perspective using Medicare reimbursement rates. The model's effectiveness was represented by quality-adjusted life-years (QALYs). Sensitivity analyses were performed to validate results. RESULTS: Endoscopic step-up was the dominant economic strategy with 7.92 QALYs for $90,864.09. Surgical step-up resulted in a decrease of 0.09 QALYs and a cost increase of $10,067.89 while open necrosectomy resulted in a decrease of 0.4 QALYs and an increased cost of $18,407.52 over endoscopic step-up. In 100,000 random-sampling simulations, 65.5% of simulations favored endoscopic step-up. MIS step-up was favored when MIS acute mortality rates fell and when MIS drainage success rates rose. CONCLUSIONS: In our simulated patients with INP, the most cost-effective management strategy is endoscopic step-up. Cost-effectiveness varies with changes in acute mortality and drainage success, which will depend on local expertise.

Cost-effectiveness of palliative emergent surgery versus endoscopic stenting for acute malignant colonic obstruction.

BACKGROUND: Endoscopic stenting has demonstrated value over emergent surgery as a palliative intervention for patients with acute large bowel obstruction due to advanced colorectal cancer. However, concerns regarding high reintervention rates and the risk of perforation have brought into question its cost-effectiveness. METHODS: A decision tree analysis was performed to analyze costs and survival in patients with unresectable or metastatic colorectal cancer who present with acute large bowel obstruction. The model was designed with two treatment arms: self-expanding metallic stent (SEMS) placement and emergent surgery. Costs were derived from medicare reimbursement rates (US$), while effectiveness was represented by quality-adjusted life years (QALYs). The primary outcome measure was the incremental cost-effectiveness ratio (ICER). The model was tested for validation using one-way, two-way, and probabilistic sensitivity analyses. RESULTS: Endoscopic stenting resulted in an average cost of $43,798.06 and 0.68 QALYs. Emergent surgery cost $5865.30 more, while only yielding 0.58 QALYs. This resulted in an ICER of - $58,653.00, indicating that SEMS placement is the dominant strategy. One-way and two-way sensitivity analyses demonstrated that emergent surgery would require an improved survival rate in comparison to endoscopic stenting to become the favored treatment modality. In 100,000 probabilistic simulations, endoscopic stenting was favored 96.3% of the time. CONCLUSIONS: In patients with acute colonic obstruction in the presence of unresectable or metastatic disease, endoscopic stenting is a more cost-effective palliative intervention than emergent surgery. This recommendation would favor surgery over SEMS placement with improved surgical survival, or if the majority of patients undergoing stenting required reintervention.

Correction to: Treatment of Rare and Aggressive Pancreatic Carcinosarcoma.

[This corrects the article on p. e00379 in vol. 7, PMID: 32607379.].

Treatment of Rare and Aggressive Pancreatic Carcinosarcoma.

A 42-year-old African American woman presented with 4 days of worsening midepigastric pain that radiated to her back. Computed tomography confirmed a diagnosis of acute pancreatitis and revealed a mass within the distal body and tail of the pancreas. After an endoscopic ultrasound with fine-needle aspiration yielding atypical cells suspicious for adenocarcinoma, the patient underwent an en bloc resection of the intra-abdominal mass with subtotal pancreatectomy, splenectomy, left colectomy, and left partial adrenalectomy. Histopathologic examination findings, in addition to immunohistochemical staining, revealed a diagnosis of pancreatic carcinosarcoma. Postoperatively, the patient has undergone 20 cycles of chemotherapy and has been transitioned to comfort measures at 16 months postoperatively because of progressive disease.

Malignant Granular Cell Tumor of the Bile Duct.

A 56-year-old man presented to the emergency department with painless jaundice and weight loss. Abdominal ultrasound detected dilation of the common bile duct and the intrahepatic bile ducts. Follow-up with endoscopic retrograde cholangiography exposed a stricture of the common hepatic duct, with cholangioscopy identifying an infiltrating tumor. Biopsy revealed a granular cell tumor, which was confirmed by positive S-100 immunohistochemical staining. Surgical excision confirmed granular cell tumor of the bile duct with morphological features suggestive of malignancy.

Design of an immunohistochemistry biomarker panel for diagnosis of pancreatic adenocarcinoma.

BACKGROUND: Challenges still exist in differentiating pancreatic adenocarcinoma from benign disease. The use of adjuvant testing of tissue biopsies has demonstrated potential diagnostic value. We designed a proof of concept study to first validate four individual immunohistochemistry biomarkers and then combine them into a panel to boost overall diagnostic sensitivity. METHODS: Malignant and benign pancreas from 27 pancreaticoduodenectomy specimens underwent immunohistochemistry staining with VHL, IMP3, S100A4, S100P. Using ROC curve analysis, threshold criteria for number of cells staining were chosen for each biomarker. Biomarkers were then evaluated as a panel for their ability to discriminate malignant from benign specimens. RESULTS: Diagnostic sensitivity of VHL, IMP3, S100A4, and S100P were 75.0%, 79.2%, 45.8%, and 0%. When VHL, IMP3, and S100A4 were grouped into a panel, they were able to distinguish cancer from normal tissue with a sensitivity of 100% and a specificity of 96%. CONCLUSIONS: The high diagnostic value of an IHC panel consisting of VHL, IMP3, and S100A4 on surgical specimens suggests the need for future prospective studies of these biomarkers on biopsy specimens.

Obesity, Metabolic Syndrome, and Cardiovascular Risk in Gluten-Free Followers Without Celiac Disease in the United States: Results from the National Health and Nutrition Examination Survey 2009-2014.

BACKGROUND: Despite unclear benefits of gluten-free diets (GFD) in the general population, gluten-free followers without medical indications are driving the market. Few studies have investigated health benefits of GFD in the general population. AIMS: To estimate metabolic and cardiovascular disease (CVD) risk profiles among gluten-free followers without celiac disease (CD). METHODS: Data were obtained from the National Health and Nutrition Examination Survey (NHANES) 2009-2014. There were 13,523 persons without CD who had GFD information. People with known CVD were excluded. We compared gluten-free followers without CD and the general population by selective metabolic and CVD risk profiles using survey-weighted generalized logistic regression. RESULTS: There were 155 gluten-free followers without CD and CVD, corresponding to a weighted prevalence of 1.3% (3.2 million Americans). Gluten-free followers tended to be women and have a smaller waist circumference and higher HDL cholesterol. They also had a lower BMI with a borderline p value (0.053) and significant self-reported weight loss (-1.33 kg) over one year. Moreover, gluten-free followers were more likely to consider their weight appropriate. There was no statistical difference by age, smoking, hypertension, total cholesterol, triglyceride cholesterol, HbA1c, or fasting glucose. Despite a lower probability of having metabolic syndrome (33.0 vs 38.5%) and lower 10-year CVD risk score (4.52 vs 5.70%) in gluten-free followers, there was no statistical difference. CONCLUSIONS: Although being on a GFD may be beneficial in weight management, there was no significant difference in terms of prevalence of metabolic syndrome and CVD risk score in gluten-free followers without CD.

Impact and outcomes of research sponsored by the American Society for Gastrointestinal Endoscopy.

BACKGROUND AND AIMS: Since 1985, the American Society for Gastrointestinal Endoscopy (ASGE) has awarded grants for endoscopic-related research. The goals of this study were to examine trends in ASGE grant funding and to assess productivity of previous recipients of the ASGE grant awards. METHODS: This was a retrospective cohort analysis of all research grants awarded by the ASGE through 2009. Measures of academic productivity and self-assessment of the ASGE awards' impact on the recipients' careers were defined by using publicly available resources (eg, National Library of Medicine-PubMed) and administration of an electronic survey to award recipients. RESULTS: The ASGE awarded 304 grants totaling $12.5 million to 214 unique awardees. Funding increased 7.5-fold between 1985 and 1989 (mean $102,000/year) and between 2005 and 2009 (mean $771,000/year). The majority of awardees were men (83%), were at or below the level of assistant professor (82%), with a median of 3 years of postfellowship experience at the time of the award, and derived from a broad spectrum of institutions as measured by National Institutes of Health funding rank (median 26, interquartile range [IQR] 12-64). Nineteen percent had a master's degree in a research-related field. Awardees' median publications per year increased from 3.5 (IQR 1.2-9.0) before funding to 5.7 (IQR 1.8-9.5) since funding; P = .04, and median h-index scores increased from 3 (IQR 1-8) to 17 (IQR 8-26); P < .001. Multivariate analysis found that the presence of a second advanced degree (eg, masters or doctorate) was independently predictive of high productivity (odds ratio [OR] 2.92; 95% confidence interval [CI], 1.09-7.81). Among 212 unique grant recipients, 82 (40%) completed the online survey. Of the respondents, median peer-reviewed publications per year increased from 3.4 (IQR 1.9-5.5) to 4.5 (IQR 2.0-9.5); P = .17. Ninety-one percent reported that the ASGE grant had a positive or very positive impact on their careers, and 85% of respondents are currently practicing in an academic environment. Most of the grants resulted in at least 1 peer-reviewed publication (67% per Internet-based search and 81% per survey). CONCLUSIONS: The ASGE research program has grown considerably since 1985, with the majority of grants resulting in at least 1 grant-related publication. Overall academic productivity increased after the award, and the majority of awardees report a positive or very positive impact of the award on their careers. Medical professional societies are an important sponsor of clinical research.

Minimizing Radiation Exposure During ERCP by Avoiding Live or Continuous Fluoroscopy.

GOALS: The aim of this study was to assess the cumulative radiation exposure incurred by patients when using single-frame fluoroscopy. BACKGROUND: Single-frame fluoroscopy is a technique that can be used instead of pulsed fluoroscopy or continuous live fluoroscopy to minimize radiation exposure during endoscopic retrograde cholangiopancreatography (ERCP). STUDY: We retrospectively reviewed ERCPs performed at our academic medical center. We recorded fluoroscopy time (FT, minutes), total radiation dose (mGy), dose area product (DAP, Gy cm²), and effective dose (ED, mSv). ERCP degree of difficulty was graded based on procedure complexity level. RESULTS: There were 400 ERCP procedures performed on 210 patients, 32 ERCPs were unsuccessful. The mean FT for all procedures was 1.57 minutes (median, 1.2 min); the mean FT for complexity score 1 procedures (0.78 min) was significantly shorter than for all other procedures (P<0.0001). The mean total radiation dose delivered for all procedures was 23.02 mGy (median, 14.95 mGy). The total radiation dose for complexity score 1 procedures (13.15 mGy) was significantly lower than for all other complexity scores (P<0.0001). The mean total DAP was 3.62 Gy cm² and the mean ED was 0.94 mSv. Procedure complexity score 1 DAP (2.1 Gy cm²) and ED (0.55 mSv) were significantly lower than for all other procedures (P<0.0001 for both). There was no statistically significant difference in these parameters when comparing successful and unsuccessful procedures. CONCLUSIONS: Successful ERCP can be performed using single-frame fluoroscopy only. Our results demonstrate lower radiation exposure using this technique than what is reported in the literature.

Polypoid dysplasia in Barrett's esophagus: case report and qualitative systematic review of the literature.

Dysplasia in Barrett's esophagus (BE) occurs as a flat, grossly undetectable lesion. Dysplasia growing as a polypoid lesion in BE is extremely rare. Only a handful of cases are reported in the literature. BE associated polypoid dysplastic lesions have been referred to as "adenomas" because of their histologic similarity to a colonic adenoma. We describe a patient with esophageal polypoid lesion associated with BE and review clinical and pathological features of other cases of BE associated polypoid dysplasia or "adenomas" as reported in the literature.

Large colorectal polyps: endoscopic management and rate of malignancy: does size matter?

BACKGROUND AND STUDY AIMS: High rate of malignancy has been reported in large colorectal polyps. However, studies were limited by including surgically resected polypoid lesions, only polyp ≥3 cm, only sessile polyps or carcinoma in situ. The aim of the study was to define the prevalence of invasive carcinoma among colorectal polyps ≥2 cm in diameter detected by colonoscopy and also to study the success of endoscopic resection. PATIENTS AND METHODS: All polypectomies of ≥2 cm colorectal polyps were identified from our endoscopy and pathology database and patients' medical records were reviewed for gross features, techniques of resection, complications, histology, and follow-up. Standard statistical tests were applied for calculating the rates, prevalence, and difference in proportions. RESULTS: Colonoscopic resection of 183 large polyps was performed in 174 patients over a period of 6 years (55% men and 45% women), mean age 64 years (median 67 y and range 25-91 y). The majority of polyps were sessile (84%). Fifty-six percent were located in the right colon. Invasive cancer was found in 10% of polyps. Endoscopic resection was successful in 89% of patients. Postpolypectomy bleeding and perforation was noted in 5% and 2% of patients, respectively. No death was observed. Seventy-eight percent of patients completed >1 year of follow-up after initial polypectomy. Recurrence of adenoma was noted in 12%, which was managed successfully by colonoscopic polypectomy techniques. CONCLUSIONS: The rate of invasive cancer is low among endoscopically resected large colorectal polyps and most of these polyps can be resected successfully via colonoscopy with minimal morbidity and no mortality. A close endoscopic follow-up is required to monitor for recurrence.

Repair of an EUS--induced duodenal perforation with endoscopic clips.

Endoscopic ultrasound (EUS) is considered a safe procedure; however, rare deaths have been reported due to complications such as perforation of the gastrointestinal tract. Several factors including age, the presence or absence of cervical osteophytes or duodenal diverticula, history of difficult intubation with prior endoscopic procedure, endosonographer's inexperience, or EUS guided interventions such as the drainage of the pancreatic duct or pseudocyst and fine needle aspiration may increase the risk of EUS related perforation of the gastrointestinal tract. We report a patient with pancreatic mass who developed duodenal perforation during EUS and was treated successfully with an immediate closure of perforation using endoscopic clips combined with bowel rest and antibiotics. Based on our patient and others reported in the literature, immediate recognition and closure of perforation with endoscopic clips may be useful in the management of patients with EUS induced duodenal perforation. However, surgical consultation and close clinical monitoring is required in the management of these patients.

Acute acalculous cholecystitis simulating Mirizzi syndrome: a very rare condition.

Mirizzi syndrome, a rare complication of chronic cholelithiasis, is caused by an impacted stone in the cystic duct or the neck of the gallbladder. Patients present with abdominal pain, fever, and obstructive jaundice. The cholangiographic finding is a smooth stricture caused by lateral compression of the common hepatic duct. A similar appearance on cholangiogram can result from carcinoma of the gallbladder, carcinoma of the cystic duct, or hilar adenopathy. Acute acalculous cholecystitis simulating Mirizzi syndrome is extremely rare. This is the report of such a case in which marked inflammatory changes around the neck of the gallbladder likely caused significant mechanical obstruction of the common hepatic duct.

Cystic duct remnant mucocele in a liver transplant recipient.

Cystic duct remnant mucocele is an extremely rare complication of liver transplantation in children. Surgical correction is usually required for cystic duct remnant mucocele when it causes biliary obstruction. We describe a 14-month-old liver transplant recipient who presented with biliary obstruction 1 month after orthotopic liver transplantation with an end-to-end choledochocholedocal biliary anastomosis for hepatoblastoma. US, CT and cholangiography findings were consistent with mucocele of the allograft cystic duct remnant. Surgery was not needed in our patient because the mucocele and biliary obstruction had resolved on repeat imaging most likely due to guidewire manipulation during cholangiography, resulting in opening of the cystic duct remnant orifice and drainage into the common duct.

Endoscopic management of upper esophageal strictures after treatment of head and neck malignancy.

BACKGROUND: Dysphagia, usually due to proximal esophageal strictures, is a debilitating complication of therapy (surgery, radiotherapy, or chemotherapy) for head and neck malignancy. Scant attention has been given in the literature to the endoscopic management of these proximal esophageal strictures. OBJECTIVE: Our purpose was to assess the technical and functional outcomes of endoscopic management of proximal esophageal strictures after therapy for head and neck cancers. DESIGN: Retrospective case series. SETTING: Academic medical center. PATIENTS: Consecutive patients undergoing endoscopy and dilation of proximal esophageal strictures caused by chemoradiation or surgery for head and neck malignancy. MAIN OUTCOME MEASUREMENT: Technical and functional success after endoscopic dilation. RESULTS: Twenty-four patients were included. The mean age of patients was 70.4 years (range 42 to 82 years). The primary tumor site was larynx in 10 patients, oropharynx or hypopharynx in 4 patients, upper esophagus in 4 patients, and other sites in the remainder. Technical success (a luminal diameter of 42F or greater) was achieved in 80% of patients. Adequate dysphagia relief was achieved in 84% of patients whose esophageal stricture was dilated at least up to 42F. The average follow-up was 22 months (range 1-96 months). Repeat dilation was needed in 58% of patients. No complications or death occurred during the study period. LIMITATIONS: Retrospective design and highly selected patient population. Dysphagia assessment in conjuction with a speech pathologist was not performed in all patients. Results may not be applicable to other settings. CONCLUSION: In this case series, proximal esophageal strictures after treatment of head and neck malignancy were amenable to antegrade endoscopic dilation; however, no patient in our study had complete lumen obstruction. Repeat dilations are often needed and are effective in achieving and maintaining adequate dysphagia relief.

Lymphoepithelial cyst of pancreas. Role of endoscopic ultrasound guided fine needle aspiration.

Lymphoepithelial cysts of the pancreas are extremely rare, benign, nonneoplastic cysts that may simulate pseudocysts or cystic neoplasm of the pancreas. Endosonographic and cytologic features of pancreatic lymphoepithelial cysts are poorly characterized because of their rarity. However, appropriate prospective diagnosis of pancreatic lymphoepithelial cysts using endoscopic ultrasound-guided fined needle aspiration (EUS-FNA) cytology may permit conservative management because of their benign nature. We conducted a MEDLINE search using the MeSH terms "pancreas", "cyst" and identified 16 patients who were diagnosed with endosonography or computerized tomography (CT) guided fine needle aspiration. Usefulness and pitfalls of EUS- or CT-guided cyst fluid analysis in the pre-operative diagnosis of pancreatic lymphoepithelial cysts are discussed.