Preoperative Analysis of Venous Anatomy Before Deep Inferior Epigastric Perforator Free-Flap Breast Reconstruction Using Ferumoxytol-enhanced Magnetic Resonance Angiography.

BACKGROUND: Venous congestion after deep inferior epigastric artery perforator (DIEP) flap breast reconstruction is a complication that may be partially attributable to variations in venous abdominal wall anatomy. In previous work, we have shown that ferumoxytol may be used as a bloodpool contrast agent to perform high-resolution venous imaging. Our current aim was to use this technology to perform a detailed analysis of the venous anatomy among patients undergoing DIEP flap breast reconstruction. METHODS: All patients undergoing DIEP flap reconstruction with preoperative ferumoxytol-enhanced magnetic resonance angiography (FE-MRA) were retrospectively reviewed. A detailed anatomic analysis of each abdominal wall on FE-MRAwas performed before review of operative findings. Statistical analysis was used to determine venous characteristics associated with superficial inferior epigastric vein (SIEV) augmentation. RESULTS: From 2012 to 2016, 59 patients underwent preoperative FE-MRA. This resulted in imaging for 118 hemiabdomen and 99 flaps. Superficial-deep communication was identified in 117 of 118 hemiabdomen. Fifty (93%) of 59 patients had greater than 1-mm venous communication of the superficial system across midline. Reconstructed breasts were based on dominant medial row perforators in 82 (83%) of 99 flaps. The mean diameters of the SIEVand dominant venous perforator were 3.8 and 2.8mm, respectively. Anatomic characteristics associated with SIEVaugmentation included SIEVdiameter ( P = 0.01), dominant perforator diameter ( P = 0.04), and the ratio between these 2 variables ( P = 0.001). CONCLUSIONS: Ferumoxytol-enhanced magnetic resonance angiography provides excellent imaging of the venous system. Anatomic characteristics such as the diameter of the SIEVand the diameter of the dominant perforator may be useful in determining which flaps require venous augmentation using the SIEV.

Post-EMR for colorectal polyps, thermal ablation of defects reduces adenoma recurrence: A meta-analysis.

Background and study aims Adenoma recurrence is one of the key limitations of endoscopic mucosal resection (EMR), which occurs in 15 % to 30 % of cases during first surveillance colonoscopy. The main hypothesis behind adenoma recurrence is leftover micro-adenomas at the margins of post-EMR defects. In this systematic review and meta-analysis, we evaluated the efficacy of snare tip soft coagulation (STSC) at the margins of mucosal defects to reduce adenoma recurrence and bleeding complications. Methods Electronic databases such as PubMed and the Cochrane library were used for systematic literature search. Studies with polyps only resected by piecemeal EMR and active treatment: with STSC, comparator: non-STSC were included. A random effects model was used to calculate the summary of risk ratio and 95 % confidence intervals. The main outcome of the study was to compare the effect of STSC versus non-STSC with respect to adenoma recurrence at first surveillance colonoscopy after thermal ablation of post-EMR defects. Results Five studies were included in the systematic review and meta-analysis. The total number patients who completed first surveillance colonoscopy (SC1) in the STSC group was 534 and in the non-STSC group was 514. The pooled adenoma recurrence rate was 6 % (37 of 534 cases) in the STSC arm and 22 % (115 of 514 cases) in the non-STSC arm, (odds ratio [OR] 0.26, 95 % confidence interval [CI], 0.16-0.41, P  = 0.001). The pooled delayed post-EMR bleeding rate 19 % (67 of 343) in the STSC arm and 22 % (78 of 341) in the non-STSC arm (OR 0.82, 95 %CI, 0.57-1.18). Conclusions Thermal ablation of post-EMR defects significantly reduces adenoma recurrence at first surveillance colonoscopy.

Artificial intelligence (AI) real-time detection vs. routine colonoscopy for colorectal neoplasia: a meta-analysis and trial sequential analysis.

GOALS AND BACKGROUND: Studies analyzing artificial intelligence (AI) in colonoscopies have reported improvements in detecting colorectal cancer (CRC) lesions, however its utility in the realworld remains limited. In this systematic review and meta-analysis, we evaluate the efficacy of AI-assisted colonoscopies against routine colonoscopy (RC). STUDY: We performed an extensive search of major databases (through January 2021) for randomized controlled trials (RCTs) reporting adenoma and polyp detection rates. Odds ratio (OR) and standardized mean differences (SMD) with 95% confidence intervals (CIs) were reported. Additionally, trial sequential analysis (TSA) was performed to guard against errors. RESULTS: Six RCTs were included (4996 participants). The mean age (SD) was 51.99 (4.43) years, and 49% were females. Detection rates favored AI over RC for adenomas (OR 1.77; 95% CI: 1.570-2.08) and polyps (OR 1.91; 95% CI: 1.68-2.16). Secondary outcomes including mean number of adenomas (SMD 0.23; 95% CI: 0.18-0.29) and polyps (SMD 0.23; 95% CI: 0.17-0.29) detected per procedure favored AI. However, RC outperformed AI in detecting pedunculated polyps. Withdrawal times (WTs) favored AI when biopsies were included, while WTs without biopsies, cecal intubation times, and bowel preparation adequacy were similar. CONCLUSIONS: Colonoscopies equipped with AI detection algorithms could significantly detect previously missed adenomas and polyps while retaining the ability to self-assess and improve periodically. More effective clearance of diminutive adenomas may allow lengthening in surveillance intervals, reducing the burden of surveillance colonoscopies, and increasing its accessibility to those at higher risk. TSA ruled out the risk for false-positive results and confirmed a sufficient sample size to detect the observed effect. Currently, these findings suggest that AI-assisted colonoscopy can serve as a useful proxy to address critical gaps in CRC identification.

Comparison of endoscopic ultrasound-guided fine-needle biopsy versus fine-needle aspiration for genomic profiling and DNA yield in pancreatic cancer: a randomized crossover trial.

BACKGROUND: National guidelines recommend genomic profiling of tumor tissue to guide precision therapy. We compared the specimen adequacy for genomic profiling and yield of DNA between endoscopic ultrasound (EUS)-guided fine-needle biopsy (FNB) and EUS-guided fine-needle aspiration (FNA). METHODS: In our tandem, randomized controlled trial, consecutive patients undergoing EUS for evaluation of pancreatic masses underwent both conventional EUS-FNA with a 25-gauge needle and paired EUS-FNB (19 or 22-gauge needle), with the order randomized (EUS-FNA first followed by EUS-FNB, or vice versa). A minimum of one pass with each needle was obtained for histology. Second and third passes were performed to collect DNA. Specimens were evaluated by a cytopathologist blinded to the needle type. Specimen adequacy for genomic profiling was calculated based on FoundationOne clinical diagnostic (CDx) adequacy requirements. We compared the adequacy for genomic profiling DNA (quantity) and histology yields with both needles. RESULTS: Analysis included 50 patients (25 men; mean age 68 [standard deviation (SD) 13] years), with a mean lesion size of 38 (SD 17) mm; 37 lesions (74 %) were pancreatic ductal adenocarcinoma (PDAC). The mean DNA concentrations in PDAC by FNB and FNA needles were 5.930 (SD 0.881) µg/mL vs. 3.365 (SD 0.788) µg/mL, respectively (P = 0.01). The median standardized histology score per pass with EUS-FNB was 5 (sufficient for histology) and for EUS-FNA was 2 (enough for cytology). Specimen adequacy for genomic profiling and yield of DNA was significantly higher with FNB than with FNA needles. CONCLUSIONS: In this study, adequacy for genomic profiling, DNA, and histology yield were considerably superior using an EUS-FNB needle compared with an EUS-FNA needle.

Risk factors for serious adverse events associated with multiband mucosectomy in Barrett's esophagus: an international multicenter analysis of 3827 endoscopic resection procedures.

BACKGROUND AND AIMS: Multiband mucosectomy (MBM) is a widely used technique for the treatment of Barrett's esophagus (BE). However, large multicenter studies enabling a generalizable estimation of the risk of serious adverse events, such as perforation and postprocedural bleeding, are lacking. The aim of this study was to estimate the rate of, and risk factors for, serious adverse events associated with MBM. METHODS: In this retrospective analysis, consecutive patients who underwent MBM for treatment of BE in 14 tertiary referral centers in Europe, the United States, Canada, and Australia were included. Primary outcomes were perforation and postprocedural bleeding rate. Potential risk factors were identified by logistic regression. RESULTS: Between 2001 and 2016, a total of 3827 MBM procedures were performed in 2447 patients (84% male, mean age 66 years, median BE length C2M4). Perforation occurred in 17 procedures (0.4%; 95% confidence interval [CI], 0.3-0.7), of which 15 could be treated endoscopically or conservatively. Female gender was an independent risk factor for perforation (odds ratio [OR], 2.77; 95% CI, 1.02-7.57; P = .05). Postprocedural bleeding occurred after 35 procedures (0.9%; 95% CI, 0.6-1.3). The number of resections (OR, 1.15; 95% CI, 1.06-1.25; P < .001) was significantly associated with postprocedural bleeding. CONCLUSION: The results of this study show that MBM for BE is safe with a low risk of serious adverse events. In addition, most of the adverse events could be managed endoscopically or conservatively. The number of resections was an independent risk factor for postprocedural bleeding.

Development of a stratification tool to identify pancreatic intraductal papillary mucinous neoplasms at lowest risk of progression.

BACKGROUND: Because most pancreatic intraductal papillary mucinous neoplasms (IPMNs) will never become malignant, currently advocated long-term surveillance is low-yield for most individuals. AIM: To develop a score chart identifying IPMNs at lowest risk of developing worrisome features or high-risk stigmata. METHODS: We combined prospectively maintained pancreatic cyst surveillance databases of three academic institutions. Patients were included if they had a presumed side-branch IPMN, without worrisome features or high-risk stigmata at baseline (as defined by the 2012 international Fukuoka guidelines), and were followed ≥ 12 months. The endpoint was development of one or more worrisome features or high-risk stigmata during follow-up. We created a multivariable prediction model using Cox-proportional logistic regression analysis and performed an internal-external validation. RESULTS: 875 patients were included. After a mean follow-up of 50 months (range 12-157), 116 (13%) patients developed worrisome features or high-risk stigmata. The final model included cyst size (HR 1.12, 95% CI 1.09-1.15), cyst multifocality (HR 1.49, 95% CI 1.01-2.18), ever having smoked (HR 1.40, 95% CI 0.95-2.04), history of acute pancreatitis (HR 2.07, 95% CI 1.21-3.55), and history of extrapancreatic malignancy (HR 1.34, 95% CI 0.91-1.97). After validation, the model had good discriminative ability (C-statistic 0.72 in the Mayo cohort, 0.71 in the Columbia cohort, 0.64 in the Erasmus cohort). CONCLUSION: In presumed side branch IPMNs without worrisome features or high-risk stigmata at baseline, the Dutch-American Risk stratification Tool (DART-1) successfully identifies pancreatic lesions at low risk of developing worrisome features or high-risk stigmata.

Deep Learning to Classify Intraductal Papillary Mucinous Neoplasms Using Magnetic Resonance Imaging.

OBJECTIVE: This study aimed to evaluate a deep learning protocol to identify neoplasia in intraductal papillary mucinous neoplasia (IPMN) in comparison to current radiographic criteria. METHODS: A computer-aided framework was designed using convolutional neural networks to classify IPMN. The protocol was applied to magnetic resonance images of the pancreas. Features of IPMN were classified according to American Gastroenterology Association guidelines, Fukuoka guidelines, and the new deep learning protocol. Sensitivity and specificity were calculated using surgically resected cystic lesions or healthy controls. RESULTS: Of 139 cases, 58 (42%) were male; mean (standard deviation) age was 65.3 (11.9) years. Twenty-two percent had normal pancreas; 34%, low-grade dysplasia; 14%, high-grade dysplasia; and 29%, adenocarcinoma. The deep learning protocol sensitivity and specificity to detect dysplasia were 92% and 52%, respectively. Sensitivity and specificity to identify high-grade dysplasia or cancer were 75% and 78%, respectively. Diagnostic performance was similar to radiologic criteria. Areas under the receiver operating curves (95% confidence interval) were 0.76 (0.70-0.84) for American Gastroenterology Association, 0.77 (0.70-0.85) for Fukuoka, and 0.78 (0.71-0.85) for the deep learning protocol (P = 0.90). CONCLUSIONS: The deep learning protocol showed accuracy comparable to current radiographic criteria. Computer-aided frameworks could be implemented as aids for radiologists to identify high-risk IPMN.

Prophylactic Snare Tip Soft Coagulation and Its Impact on Adenoma Recurrence After Colonic Endoscopic Mucosal Resection.

BACKGROUND: Up to 20% of patients can have recurrence of adenomatous tissue at first surveillance study after colon endoscopic mucosal resection of large polyps. AIMS: To determine whether an educational intervention discussing thermal ablation of lateral margins of the mucosectomy site of post-endoscopic mucosal resection defect with snare tip soft coagulation (STSC) would decrease adenoma recurrence. METHODS: We performed a single-center quality improvement project from November 1, 2016, to November 30, 2017. Gastroenterologists underwent an educational intervention demonstrating the treatment of peripheral margins of mucosectomy site with STSC after standard mucosectomy technique. These cases (intervention group) were compared with consecutive procedures performed prior to commencement of the quality improvement study (pre-intervention group). Patients with large colorectal lesions (≥ 20 mm) were included. RESULTS: Of the 120 patients here included, overall demographics of the groups were similar and the most common histology was sessile serrated adenoma (study group 45% vs 32% control group). Adenoma recurrence on intervention group and pre-intervention group was 12% versus 30%; p = 0.01. On univariate analysis, biopsy prior to mucosectomy, intraprocedural bleeding, and application of STSC on mucosectomy defect were the strongest predictors of adenoma recurrence. Adenoma recurrence in the intervention group was significantly lower than in the pre-intervention group in both univariate (odds ratio, 0.3 [95% CI, 0.11-0.80]) and multivariate analyses (odds ratio, 0.2 [95% CI, 0.12-0.92]). CONCLUSIONS: The implementation of STSC of post-endoscopic mucosal resection peripheral defects is clinically feasible and significantly decreased adenoma recurrence.

Recent advancement in EUS-guided fine needle sampling.

EUS-guided tissue acquisition technique plays an essential role for evaluation of gastrointestinal tumors. Several components affect the yield of EUS-guided tissue acquisition outcomes such as sampling techniques, use of ROSE (rapid onsite evaluation), training and experience, and needle designs. In this review we discuss advancement in EUS-guided fine needle sampling.

Should We Resect and Discard Low Risk Diminutive Colon Polyps.

Diminutive colorectal polyps <5 mm are very common and almost universally benign. The current strategy of resection with histological confirmation of all colorectal polyps is costly and may increase the risk of colonoscopy. Accurate, optical diagnosis without histology can be achieved with currently available endoscopic technologies. The American Society of Gastrointestinal Endoscopy Preservation and Incorporation of Valuable endoscopic Innovations supports strategies for optical diagnosis of small non neoplastic polyps as long as two criteria are met. For hyperplastic appearing polyps <5 mm in recto-sigmoid colon, the negative predictive value should be at least 90%. For diminutive low grade adenomatous appearing polyps, a resect and discard strategy should be sufficiently accurate such that post-polypectomy surveillance recommendations based on the optical diagnosis, agree with a histologically diagnosis at least 90% of the time. Although the resect and discard as well as diagnose and leave behind approach has major benefits with regard to both safety and cost, it has yet to be used widely in practice. To fully implement such as strategy, there is a need for better-quality training, quality assurance, and patient acceptance. In the article, we will review the current state of the science on optical diagnose of colorectal polyps and its implications for colonoscopy practice.

Endoscopic scar assessment after colorectal endoscopic mucosal resection scars: when is biopsy necessary (EMR Scar Assessment Project for Endoscope (ESCAPE) trial).

OBJECTIVE: It is unclear whether endoscopic assessment of scars after colorectal endoscopic mucosal resection (EMR) has to include biopsies, even if endoscopy is negative. Vice versa, endoscopic diagnosis of recurrent adenoma may not require biopsy before endoscopic reinterventions. We prospectively analysed various endoscopic modalities in the diagnosis of recurrence following EMR. DESIGN: We conducted a prospective study of patients undergoing colonoscopy after EMR of large (≥20 mm) colorectal neoplasia. Endoscopists predicted recurrence and confidence level with four imaging modes: high-definition white light (WL) and narrow-band imaging (NBI) with and without near focus (NF). Separately, 26 experienced endoscopists assessed offline images. RESULTS: Two hundred and thirty patients with 255 EMR scars were included. The prevalence of recurrent adenoma was 24%. Diagnostic values were high for all modes (negative predictive value (NPV) ≥97%, positive predictive value (PPV) ≥81%, sensitivity ≥90%, specificity ≥93% and accuracy ≥93%). In high-confidence cases, NBI with NF had NPV of 100% (95% CI 98% to 100%) and sensitivity of 100% (95% CI 93% to 100%). Use of clips at initial EMR increased diagnostic inaccuracy (adjusted OR=1.68(95% CI 1.01 to 2.75)). In offline assessment, specificity was high for all imaging modes (mean: ≥93% (range: 55%-100%)), while sensitivity was significantly higher for NBI-NF (82%(72%-93%)%)) compared with WL (69%(38%-86%); p<0.001), WL-NF (68%(55%-83%); p<0.001) and NBI (71%(59%-90%); p<0.001). CONCLUSION: Our study demonstrates very high sensitivity and accuracy for all four imaging modalities, especially NBI with NF, for diagnosis of recurrent neoplasia after EMR. Our data strongly suggest that in cases of high confidence negative optical diagnosis based on NBI-NF, no biopsy is needed to confirm absence of recurrence during colorectal EMR follow-up. A high confidence positive optical diagnosis can lead to immediate resection of any suspicious area. In all cases of low confidence, biopsy is still required. TRIAL REGISTRATION NUMBER: NCT02668198.

Lung and Pancreatic Tumor Characterization in the Deep Learning Era: Novel Supervised and Unsupervised Learning Approaches.

Risk stratification (characterization) of tumors from radiology images can be more accurate and faster with computer-aided diagnosis (CAD) tools. Tumor characterization through such tools can also enable non-invasive cancer staging, prognosis, and foster personalized treatment planning as a part of precision medicine. In this papet, we propose both supervised and unsupervised machine learning strategies to improve tumor characterization. Our first approach is based on supervised learning for which we demonstrate significant gains with deep learning algorithms, particularly by utilizing a 3D convolutional neural network and transfer learning. Motivated by the radiologists' interpretations of the scans, we then show how to incorporate task-dependent feature representations into a CAD system via a graph-regularized sparse multi-task learning framework. In the second approach, we explore an unsupervised learning algorithm to address the limited availability of labeled training data, a common problem in medical imaging applications. Inspired by learning from label proportion approaches in computer vision, we propose to use proportion-support vector machine for characterizing tumors. We also seek the answer to the fundamental question about the goodness of "deep features" for unsupervised tumor classification. We evaluate our proposed supervised and unsupervised learning algorithms on two different tumor diagnosis challenges: lung and pancreas with 1018 CT and 171 MRI scans, respectively, and obtain the state-of-the-art sensitivity and specificity results in both problems.

INN: Inflated Neural Networks for IPMN Diagnosis.

Intraductal papillary mucinous neoplasm (IPMN) is a precursor to pancreatic ductal adenocarcinoma. While over half of patients are diagnosed with pancreatic cancer at a distant stage, patients who are diagnosed early enjoy a much higher 5-year survival rate of 34% compared to 3% in the former; hence, early diagnosis is key. Unique challenges in the medical imaging domain such as extremely limited annotated data sets and typically large 3D volumetric data have made it difficult for deep learning to secure a strong foothold. In this work, we construct two novel "inflated" deep network architectures, InceptINN and DenseINN, for the task of diagnosing IPMN from multisequence (T1 and T2) MRI. These networks inflate their 2D layers to 3D and bootstrap weights from their 2D counterparts (Inceptionv3 and DenseNet121 respectively) trained on ImageNet to the new 3D kernels. We also extend the inflation process by further expanding the pre-trained kernels to handle any number of input modalities and different fusion strategies. This is one of the first studies to train an end-to-end deep network on multisequence MRI for IPMN diagnosis, and shows that our proposed novel inflated network architectures are able to handle the extremely limited training data (139 MRI scans), while providing an absolute improvement of 8.76% in accuracy for diagnosing IPMN over the current state-of-the-art. Code is publicly available at https://github.com/lalonderodney/INN-Inflated-Neural-Nets.

Predictors of Progression Among Low-Risk Intraductal Papillary Mucinous Neoplasms in a Multicenter Surveillance Cohort.

OBJECTIVES: Our aim was to identify baseline characteristics associated with disease progression and malignant transformation in low-risk suspected intraductal papillary mucinous neoplasms (IPMNs). METHODS: This is a retrospective cohort study of prospectively maintained databases of pancreatic cysts at 3 international, academic institutions. Five hundred fifty-nine adult patients with clinically suspected asymptomatic IPMN evaluated by radiologic studies or endoscopic ultrasound between 2003 and 2013 without worrisome features and under surveillance for 12 months or longer were included. We evaluated the relationship of baseline demographics and cyst features to disease progression (size increase, development of worrisome features, or high-grade dysplasia/cancer). RESULTS: After a median of 44 months follow-up, 269 (48%) patients experienced cyst size increase, 68 (12%) developed worrisome features, and 11 (2%) developed high-grade dysplasia/cancer. In multivariable Cox-regression analysis, no baseline characteristics were associated with size increase. An initial cyst size of 2 cm or greater, multifocality, history of prostate cancer, and smoking were the strongest predictors of development of new worrisome features. Univariable analysis found male sex, diabetes, and recent weight loss associated with development of high-grade dysplasia/cancer. CONCLUSIONS: Our study demonstrates that low-risk suspected IPMNs carry a small but clinically relevant risk of disease progression and provides data on baseline characteristics that may help in risk stratification.

Adenoma recurrence after endoscopic mucosal resection: propensity score analysis of old and new colonoscopes and Sydney recurrence tool implementation.

BACKGROUND AND STUDY AIMS: Risk factors for colorectal adenoma recurrence after endoscopic mucosal resection (EMR) have been well documented. We assessed the efficacy of the newer 190 colonoscope versus the standard 180 colonoscope for complete resection of lateral spreading lesions. PATIENTS AND METHODS: A single-center, retrospective study of patients who underwent EMR with Olympus 180 or 190 colonoscopes from January 1, 2010 to September 30, 2016. We included patients with lesions ≥ 20 mm and surveillance colonoscopy (SC1) after index EMR. A propensity score approach with inverse probability weighting was used to control for potential confounders. A secondary aim was to identify risk factors for recurrence and assess the applicability of the Sydney EMR recurrence tool (SERT) by grading each lesion of our cohort and analyzing associations with recurrence. RESULTS: Two hundred ninety-one lesions met inclusion criteria for the study. Odds ratio (OR) for recurrence with the 190 colonoscope was 1.06 ( P  = .85). Adenoma size ( P  = .02) and use of argon plasma coagulation (APC; P  < .001) were risk factors for recurrence. Lesions with SERT scores > 0 had a higher recurrence risk during follow-up (32 % vs 21 %; OR 1.71; P  = .05). Lesions with SERT scores = 0 reached a plateau for recurrence at 12 and 18 months in Kaplan-Meier curves. CONCLUSIONS: The use of 190 colonoscopes did not measurably affect adenoma recurrence at SC1. Recurrence was associated with adenoma size, complementary APC for resection, and SERT scores > 0. Lesions with SERT scores = 0 that remain negative for recurrence at 18 months may return to routine surveillance.

Advanced EUS Guided Tissue Acquisition Methods for Pancreatic Cancer.

Pancreas cancer is a lethal cancer as the majority patients are diagnosed at an advanced incurable stage. Despite improvements in diagnostic modalities and management strategies, including surgery and chemotherapies, the outcome of pancreas cancer remains poor. Endoscopic ultrasound (EUS) is an important imaging tool for pancreas cancer. For decades, resected pancreas cancer and other cancer specimens have been used to identify tissue biomarkers or genomics for precision therapy; however, only 20% of patients undergo surgery, and thus, this framework is not useful for unresectable pancreas cancer. With advancements in needle technologies, tumor specimens can be obtained at the time of tissue diagnosis. Tumor tissue can be used for development of personalized cancer treatment, such as performing whole exome sequencing and global genomic profiling of pancreas cancer, development of tissue biomarkers, and targeted mutational assays for precise chemotherapy treatment. In this review, we discuss the recent advances in tissue acquisition of pancreas cancer.

Survival of Patients with Oligometastatic Pancreatic Ductal Adenocarcinoma Treated with Combined Modality Treatment Including Surgical Resection: A Pilot Study.

Purpose: To evaluate the overall survival of patients with oligometastatic pancreatic ductal adenocarcinoma (PDAC; metastatic tumor <4 cm, ≤2 metastatic tumors total) receiving neoadjuvant therapy, metastasectomy and/or ablation, and primary tumor resection. Methods: We performed a case-control study from January 2005 to December 2015. Patients who underwent curative-intent surgery combined modality therapy (M1 surgery group; 6 [14%], tumor [T]3, node [N]1, and oligo-metastases [M]1) were matched 1 to 3 based on TN stage with two control groups (M0 surgery and M1 no surgery). The M0 surgery group (18 [43%], T3, N1, and M0) included patients without metastases who underwent resection. The M1 no surgery group (18 [43%], T3, N1, and M1) included patients with metastatic PDAC who received palliative chemotherapy without surgical resection. Results: Median overall survival in the M1 surgery, M0 surgery, and M1 no surgery groups was 2.7 years (95% confidence interval [CI], 0.71-3.69), 2.02 years (95% CI, 0.98-3.05), and 0.98 years (95% CI, 0.55-1.25), respectively. Eastern Cooperative Oncology Group (ECOG) status was associated with survival (p = 0.01) after univariate analysis. After adjusting for ECOG status, multivariate analysis showed M1 surgery patients had improved survival compared with M1 no surgery patients and similar survival to M0 surgery patients. Conclusion: Multimodal therapy benefitted our M1 surgery patients. A larger, prospective study of this multidisciplinary management strategy is currently under way.

Laparoscopic repair of giant paraesophageal hernia: are there factors associated with anatomic recurrence?

BACKGROUND: Repair of giant paraesophageal hernia (PEH) is associated with a favorably high rate of symptom improvement; however, rates of recurrence by objective measures remain high. Herein we analyze our experience with laparoscopic giant PEH repair to determine what factors if any can predict anatomic recurrence. METHODS: We prospectively collected data on PEH characteristics, variations in operative techniques, and surgeon factors for 595 patients undergoing laparoscopic PEH repair from 2008 to 2015. Upper GI study was performed at 6 months postoperatively and selectively thereafter-any supra-diaphragmatic stomach was considered hiatal hernia recurrence. Exclusion criteria included revisional operation (22.4%), size <5 cm (17.6%), inadequate follow-up (17.8%), and confounding concurrent operations (6.9%). Inclusion criteria were met by 202 patients (31% male, median age 71 years, and median BMI 28.7). RESULTS: At a median follow-up of 6 months (IQR 6-12), overall anatomic recurrence rate was 34.2%. Symptom recurrence rate was 9.9% and revisional operation was required in ten patients (4.9%). Neither patient demographics nor PEH characteristics (size, presence of Cameron erosions, esophagitis, or Barrett's) correlated with anatomic recurrence. Technical factors at operation (mobilized intra-abdominal length of esophagus, Collis gastroplasty, number of anterior/posterior stitches, use of crural buttress, use of pledgeted or mattress sutures, or gastrostomy) were also not correlated with recurrence. Regarding surgeon factors, annual volume of fewer than ten cases per year was associated with increased risk of anatomic failure (54 vs 33%, P = 0.02). Multivariate analysis identified surgeon experience (<10 cases per year) as an independent factor associated with early hiatal hernia recurrence (OR 3.7, 95% CI 1.34-10.9). CONCLUSIONS: Laparoscopic repair of giant PEH is associated with high anatomic recurrence rate but excellent symptom control. PEH characteristics and technical operative variables do not appear to significantly affect rates of recurrence. In contrast, surgeon volume does appear to contribute significantly to durability of repair.

Colorectal endoscopic mucosal resection (EMR).

Colonoscopy has the benefit of detecting and treating precancerous adenomatous polyps and thus reduces mortality associated with CRC. Screening colonoscopy is the keystone for prevention of colorectal cancer. Over the last 20 years there has been increased in the management of large colorectal polyps from surgery to endoscopic removal techniques which is less invasive. Traditionally surgical resection was the treatment of choice for many years for larger polyps but colectomy poses significant morbidity of 14-46% and mortality of up to 7%. There are several advantages of endoscopic resection technique over surgery; it is less invasive, less expensive, has rapid recovery, and preserves the normal gut functions. In addition patient satisfaction and efficacy of EMR is higher with minor complications. Thus, this has facilitated the development of advanced resection technique for the treatment of large colorectal polyps called as endoscopic mucosal resection (EMR).

The Role of Adjunct Imaging in Endoscopic Detection of Dysplasia in Barrett's Esophagus.

Advances in imaging technologies have demonstrated promise in early detection of dysplasia and cancer in Barrett's esophagus (BE). Optical chromoendoscopy, dye-based chromoendoscopy, and novel technologies have provided the opportunity to visualize the cellular and subcellular structures. Only narrow-band imaging and acetic acid chromoendoscopy have reached benchmarks for clinical use. Volumetric laser endomicroscopy and molecular imaging are not established for routine use. Best practice in management of BE should be focused on careful endoscopic examination, resection, or ablation of the entire abnormal lesion, as well as the use of available imaging technique that has good diagnostic accuracy.