Multicenter evaluation of the clinical utility of laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass.

BACKGROUND AND AIMS: The obesity epidemic has led to increased use of Roux-en-Y gastric bypass (RYGB). These patients have an increased incidence of pancreaticobiliary diseases, yet standard ERCP is not possible because of surgically altered gastroduodenal anatomy. Laparoscopy-assisted ERCP (LA-ERCP) has been proposed as an option, but supporting data are derived from single-center small case series. Therefore, we conducted a large multicenter study to evaluate the feasibility, safety, and outcomes of LA-ERCP. METHODS: This is a retrospective cohort study of adult patients with RYGB who underwent LA-ERCP in 34 centers. Data on demographics, indications, procedure success, and adverse events were collected. Procedure success was defined when all the following were achieved: reaching the papilla, cannulating the desired duct, and providing endoscopic therapy as clinically indicated. RESULTS: A total of 579 patients (median age, 51; 84% women) were included. Indication for LA-ERCP was biliary in 89%, pancreatic in 8%, and both in 3%. Procedure success was achieved in 98%. Median total procedure time was 152 minutes (interquartile range [IQR], 109-210), with a median ERCP time of 40 minutes (IQR, 28-56). Median hospital stay was 2 days (IQR, 1-3). Adverse events were 18% (laparoscopy related, 10%; ERCP related, 7%; both, 1%) with the clear majority (92%) classified as mild/moderate, whereas 8% were severe and 1 death occurred. CONCLUSIONS: Our large multicenter study indicates that LA-ERCP in patients with RYGB is feasible with a high procedure success rate comparable with that of standard ERCP in patients with normal anatomy. The ERCP-related adverse events rate is comparable with conventional ERCP, but the overall adverse event rate was higher because of the added laparoscopy-related events.

Incidence and Determinants of Hepatocellular Carcinoma in Autoimmune Hepatitis: A Systematic Review and Meta-analysis.

BACKGROUND & AIMS: The risk of hepatocellular carcinoma (HCC) in patients with autoimmune hepatitis (AIH) is unclear. We conducted a systematic review and meta-analysis of the incidence of HCC and associated risk factors among patients with AIH. METHODS: We searched PubMed, Embase, and reference lists from relevant articles through June 2016 to identify cohort studies that examined the incidence of HCC in patients with AIH. We used random effects models to estimate pooled incidence rates overall and in subgroup of patients with cirrhosis. The between-study heterogeneity was assessed using I2 statistic. RESULTS: A total of 25 studies (20 papers and 5 abstracts), including 6528 patients, met the eligibility criteria. The median cohort size was 170 patients with AIH (range, 25-1721 patients), followed for a median of 8.0 years (range, 3.3-16.0 years). The pooled incidence rate for HCC in patients with AIH was 3.06 per 1000 patient-years (95% confidence interval, 2.22-4.23; I2 = 51.5%; P = .002). The pooled incidence of HCC in patients with cirrhosis at AIH diagnosis was 10.07 per 1000 patient-years (95% confidence interval, 6.89-14.70; I2 = 48.8%; P = .015). In addition, 92 of 93 patients who had HCC had evidence of cirrhosis before or at the time of their HCC diagnosis. The risk of HCC seems to be lower in patients with AIH and cirrhosis than that reported for patients with cirrhosis from hepatitis B, hepatitis C, or primary biliary cholangitis. CONCLUSIONS: Based on the increased risked of HCC shown in this meta-analysis, there may be a role for HCC surveillance in patients with AIH and cirrhosis.

Risk of upper gastrointestinal cancers in patients with gastroesophageal reflux disease after a negative screening endoscopy.

BACKGROUND & AIMS: Practice guidelines recommend a 1-time screening endoscopy for patients with gastroesophageal reflux disease (GERD) who are at high risk for Barrett's esophagus or malignancy. However, little is known about the risk of cancer in patients with negative findings from screening endoscopies. METHODS: We conducted a retrospective cohort study using data from 121 Veterans Health Administration facilities nationwide to determine the incidence rate of esophageal adenocarcinoma (EA) separately, as well as any upper gastrointestinal cancers, in patients with an initial negative screening endoscopy (esophagogastroduodenoscopy [EGD]). We included veteran patients with GERD diagnosed between 2004 and 2009 who had a negative screening EGD within 1 year of diagnosis. We estimated the incidence rate of EA, and any upper gastrointestinal cancer, in patients with GERD who had a negative screening EGD. We examined differences in demographic, clinical, and facility factors among patients with and without cancer. RESULTS: We identified 68,610 patients with GERD and a negative screening EGD (mean age, 55.5 y; 90% men; 67.5% white). During a mean follow-up period of 3.2 years, 10 patients developed EA and 29 patients developed any upper gastrointestinal malignancies, including EA. The incidence of subsequent EA in this group was 4.6/100,000 patient-years of follow-up evaluation, whereas the incidence of any upper gastrointestinal cancers was 13.2/100,000 patient-years of follow-up evaluation. Patients with a subsequent cancer were significantly older and had higher comorbidity scores than patients without cancer. Other clinical and facility factors did not differ significantly between these 2 groups. CONCLUSIONS: The risk of cancer is low, over a mean 3-year period, for patients with GERD who had a negative screening endoscopy. These findings justify recommendations for a 1-time screening endoscopy for patients with GERD.

The incidence of esophageal adenocarcinoma in a national veterans cohort with Barrett's esophagus.

OBJECTIVES: The increasing incidence of esophageal adenocarcinoma (EA) in the United States may have leveled off in recent years. The risk of EA among patients with Barrett's esophagus (BE) seems to be decreasing in several European cohorts, but these estimates are unknown in the United States. We aimed to determine the risk of developing EA in a national cohort of BE patients in the US Veterans Health Administration and to account for the use of endoscopic ablation and esophagectomy. METHODS: This was a retrospective cohort study from a total of 121 facilities in the Veterans Health Administration. Veteran patients with BE diagnosed between 1 October 2003 and 30 September 2009 were included and followed until esophageal cancer diagnosis, death or 30 September 2011. All EA diagnoses were verified in detailed structured reviews of medical records. RESULTS: We identified 29,536 patients with BE who met our eligibility criteria. Most were men (96.9%) and White (83.2%), with a mean age of 61.8 years. During 144,949 person-years of follow-up, 466 patients developed EA, yielding an incidence rate of 3.21 per 1,000 person-years (95% confidence interval (CI) 2.94-3.52). Excluding those who developed EA within 1 year of their index BE date lowered the incidence rate to 1.75 per 1,000 person-years. However, including additional patients who underwent endoscopic ablation or esophagectomy for HGD or EA increased the incidence rate to 4.79 (95% CI 4.44-5.16). CONCLUSIONS: The incidence of EA in a US national cohort of mostly male veterans may be lower than previous estimates. Almost half of the EA cases were diagnosed within 1 year of their BE index date.

Pancreatic Inflammatory Pseudotumor-Like Follicular Dendritic Cell Tumor.

Follicular dendritic cell sarcoma (FDCS) is a rare and underdiagnosed malignant neoplasm which characteristically presents as a solitary, slow-growing mass with no discrete symptoms. Histologically, lymphocytes and spindle cells featuring large nucleoli in a whorled pattern are usually seen. FDCS is classically found in cervical and axillary lymph nodes, with occasional involvement of extranodal sites. Inflammatory pseudotumor-like follicular dendritic cell tumor (IPT-like FDCT) is an uncommon subcategory of this neoplasm, demonstratively linked to the Epstein-Barr virus (EBV). This neoplasm can present similarly to FDCS, but systemic symptoms may be seen. Although, often found in the spleen and occasionally the liver, IPT-like FDCT has not previously been described within the pancreas. Presented, is an IPT-like FDCT of the pancreas and spleen of a 70 years old woman. Histologic features include variably sized geographic suppurative granulomas with chronic inflammatory cells and an atypical spindle cell proliferation with prominent nucleoli. Positivity for CD45 and CD68 in the larger spindled cells points to an inflammatory pseudotumor subtype and co-expression of CD21, CD23, and CD35 were indicative of follicular dendritic differentiation. The pseudotumor additionally demonstrated EBV-encoded RNA (EBER) positivity typical of IPT-like FDCT. Differentiation between inflammatory pseudotumor (IPT) and inflammatory myofibroblastic tumor (IMT) is additionally discussed.

A tale of two LAMS: a report of benign tissue ingrowth resulting in recurrent gastric outlet obstruction.

Background and study aims Endoscopic ultrasound (EUS)-guided gastroenterostomy is a novel, off-label, procedure that has been facilitated by availability of a novel lumen apposing metal stent (LAMS) (Axios, Boston Scientific, Marlbourough Massachusetts, United States). The literature suggests its efficacy to be comparable to surgical gastrojejunostomy. In theory, this procedure overcomes the issues associated with woven enteral stents, which are subject to continuous, straightening, axial forces. We report the adverse event of tissue ingrowth in an Axios stent placed as an EUS-guided gastroduodenostomy, resulting in recurrence of gastric outlet obstruction, treated by a stent-inside-stent technique.

A comparison of endoscopic and non-endoscopic biliary intervention outcomes in patients with prior bariatric surgery.

BACKGROUND AND STUDY AIMS: Endoscopic biliary intervention (BI) is often difficult to perform in patients with prior bariatric surgery (BRS). We sought to analyze outcomes of patients with prior BRS undergoing endoscopic and non-endoscopic BI. PATIENTS AND METHODS: The Nationwide Inpatient Sample (2007 - 2011) was reviewed to identify all adult inpatients (≥ 18 years) with a history of BRS undergoing BI. The clinical outcomes of interest were in-patient mortality, length of stay (LOS), and total hospital charges. RESULTS: There were 7,343 patients with prior BRS who underwent BIs where a majority were endoscopic (4,482 vs. 2,861, P  < 0.01). The mean age was 50±30.8 years and the majority were females (80.5 %). Gallstone-related disease was the most common indication for BI and managed more often with primary endoscopic management (2,146 vs. 1,132, P  < 0.01). Inpatient mortality was not significantly different between patients undergoing primary endoscopic versus non-endoscopic BI (0.2 % vs. 0.7 %, P  = 0.2). Patients with sepsis were significantly more likely to incur failed primary endoscopic BI (OR 2.74, 95 % CI 1.15, 6.53) and were more likely to be managed with non-endoscopic BI (OR 2.13, 95 % CI 1.3, 3.5). Primary non-endoscopic BI and failed endoscopic BI were both associated with longer LOS (by 1.77 days, P  < 0.01 and by 2.17 days, P  < 0.01, respectively) and higher hospitals charges (by $11,400, P  < 0.01 and by $ 14,200, P  < 0.01, respectively). CONCLUSION: Primary endoscopic management may be a safe and cost-effective approach for patients with prior BRS who need BI. While primary endoscopic biliary intervention is more common, primary non-endoscopic intervention may be used more often for sepsis.

Use of a novel through-the-needle biopsy forceps in endoscopic ultrasound.

BACKGROUND AND AIMS: Pancreatic cysts are becoming more common. Their differential diagnosis includes benign, premalignant, and malignant lesions. Distinguishing the type of cyst helps in the management decision making. We report on a novel tissue acquisition device for pancreatic cysts. METHODS: Data on two patients who underwent endoscopic ultrasound (EUS) - guided fine-needle aspiration with a new micro forceps device are presented. RESULTS: Two patients had large pancreatic cystic lesions in the pancreatic head. Linear EUS was performed, and tissue samples were obtained with the Moray micro forceps through a 19-gauge needle. In both patients, mucinous columnar epithelium lined the cystic walls. One patient underwent surgical resection, and the other elected surveillance. Examination of the surgical specimen from the first patient confirmed the cyst was a side-branch intraductal papillary mucinous neoplasm (IPMN), gastric type. CONCLUSIONS: The Moray micro forceps is a new tool that can be used to help determine the nature of pancreatic cysts and aid in their risk stratification and management.