Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) for advanced pancreatic and periampullary adenocarcinoma.

Long term prognosis and 5-year survival for pancreatic adenocarcinoma (PDAC) remains suboptimal. Endoscopic ultrasound (EUS) guided RFA (EUS-RFA) is an emerging technology and limited data exist regarding safety and long-term outcomes. The aim of this study is to report safety-profile, feasibility and outcomes of EUS-RFA for advanced PDAC. Prospective review of patients with diagnosis of locally-advanced or metastatic PDAC undergoing EUS-RFA between October 2016 to March 2018 with long-term follow up (> 30 months). Study patients underwent a total of 1-4 RFA sessions. All patients were enrolled in longitudinal cohort study and received standard of care chemotherapy. 10 patients underwent EUS-RFA. Location of the lesions was in the head(4), neck(2), body(2), and tail(2). 22 RFA sessions were performed with a range of 1-4 sessions per patient. There were no major adverse events (bleeding, perforation, infection, pancreatitis) in immediate (up to 72 h) and short-term follow up (4 weeks). Mild worsening of existing abdominal pain was noted during post-procedure observation in 12/22 (55%) of RFA treatments. Follow-up imaging demonstrated tumor progression in 2 patients, whereas tumor regression was noted in 6 patients (> 50% reduction in size in 3 patients). Median survival for the cohort was 20.5 months (95% CI, 9.93-42.2 months). Currently, 2 patients remain alive at 61 and 81 months follow-up since initial diagnosis. One patient had 3 cm PDAC with encasement of the portal confluence, abutment of the celiac axis, common hepatic and superior mesenteric artery. This patient had significant reduction in tumor size and underwent standard pancreaticoduodenectomy. In our experience, EUS-RFA was safe, well-tolerated and could be concurrently performed with standard chemotherapy. In this select cohort, median survival was improved when compared to published survival based upon SEER database and clinical trials. Future prospective trials are needed to understand the role of EUS-RFA in overall management of PDAC.

Diagnostic yield of inpatient capsule endoscopy.

BACKGROUND: Capsule endoscopy (CE) provides a novel approach to evaluate obscure gastrointestinal bleeding. Yet CE is not routinely utilized in the inpatient setting for a variety of reasons. We sought to identify factors that predict complete CE and diagnostically meaningful CE, as well as assess the impact of inpatient CE on further hospital management.1 na d2 METHODS: We conducted a retrospective review of patients undergoing inpatient CE at a tertiary referral, academic center over a 3 year period. We analyzed data on patient demographics, medical history, endoscopic procedures, hospital course, and results of CE. The primary outcome was complete CE and the secondary outcome was positive findings of pathology on CE. RESULTS: 131 patients were included (56.5% were men 43.5% women, median age of 71.0 years). Overall, CE was complete in 77.1% of patients. Complete CE was not related to motility risk factors, gender, or administration modality. Patients with incomplete CE tended to be older, have lower BMI, and Caucasian, however results did not reach statistical significance (p = 0.06; p = 0.06; p = 0.08 respectively). Positive CE was noted in 73.3% of patients, with 35.1% of all patients having active bleeding. Positive CE was not associated with AVM risk factors or medication use. 28.0% of patients underwent subsequent hospital procedures, among which 67.6% identified the same pathology seen on CE. CONCLUSIONS: Contrary to previous studies, we found the majority of inpatient CEs were complete and positive for pathology. We found high rates of correlation between CE and subsequent procedures. The use of CE in the inpatient setting helps to guide the diagnosis and treatment of hospitalized patients with obscure gastrointestinal bleeding.

Management of pancreatic fluid collections.

Pancreatic fluid collections often develop as a complication of acute pancreatitis but can be seen in a variety of conditions including chronic pancreatitis, trauma, malignancy or post-operatively. It is important to classify a pancreatic fluid collection in order to optimize treatment strategies and management. Most interventions are targeted towards the management of delayed complications of pancreatitis, including pancreatic pseudocysts and walled-off necrosis (WON), which often develop days to weeks after the initial episode of pancreatitis. Surgical, percutaneous, and endoscopic interventions are all possible methods for treatment of pancreatic fluid collections, however endoscopic drainage with endoscopic ultrasound has become first-line. Advances within endoscopic drainage strategies have also led to innovative changes in the specific stents used for treatment, with possible options including double pigtail plastic stents, fully covered self-expanding metal stents and lumen-apposing metal stents (LAMS).

Endoscopic Coil Embolization for Refractory Intrahepatic Biliary Duct Leak.

Bile leaks may be seen after blunt and penetrating trauma, as well as iatrogenic injury from surgical procedures. There are many articles on endoscopic treatment options for the management of biliary leaks, including sphincterotomy, endoscopic stent, or nasobiliary drain placement. Data, however, are scarce regarding the management of persistent biliary leaks after the initial intervention. We present a case of endoscopic coil embolization to treat a refractory bile leak after initial endoscopic sphincterotomy and stent placement in a patient with a grade IV liver laceration due to a gunshot wound.

Indications for the Use of Proton Pump Inhibitors for Stress Ulcer Prophylaxis and Peptic Ulcer Bleeding in Hospitalized Patients.

Proton pump inhibitors are widely used throughout the world for the treatment of gastrointestinal disorders that are related to acid secretion, such as peptic ulcer disease and dyspepsia. Another common indication for proton pump inhibitors is stress ulcer prophylaxis. Proton pump inhibitors have proven efficacy for the treatment of acid-related gastrointestinal disorders, but there is concern that their use may be associated with the development of significant complications, such as fractures, Clostridium difficile infection, acute kidney injury, chronic kidney disease, and hypomagnesemia. Proton pump inhibitors are overused in the hospital setting, both for stress ulcer prophylaxis and gastrointestinal bleeding, and then they are often inappropriately continued after discharge from the hospital. This narrative review article outlines the evidence surrounding appropriate proton pump inhibitor use for stress ulcer prophylaxis and peptic ulcer bleeding.

An Unusual Case of Biliary Obstruction Because of Human Papillomavirus-Associated Metastatic Squamous Cell Carcinoma From Head and Neck Primary.

Secondary pancreatic tumors are uncommon, with the majority originating from primary gastrointestinal or lung cancers. We present the case of a 42-year-old woman with squamous cell carcinoma of the pancreas, found to be human papillomavirus-positive on in situ hybridization. After extensive work-up, the patient was determined to have a previously undiagnosed, asymptomatic head and neck primary malignancy. There is sparse literature discussing metastatic human papillomavirus-positive squamous cell carcinoma to the pancreas. This report highlights the importance of including this diagnosis when considering a differential for secondary pancreatic tumors, especially squamous etiology.

Reducing Overuse of Proton Pump Inhibitors for Stress Ulcer Prophylaxis and Nonvariceal Gastrointestinal Bleeding in the Hospital: A Narrative Review and Implementation Guide.

Proton pump inhibitors (PPIs) are among the most commonly used medications in the world; however, these drugs carry the risk of patient harm, including acute and chronic kidney disease, Clostridium difficile infection, hypomagnesemia, and fractures. In the hospital setting, PPIs are overused for stress ulcer prophylaxis and gastrointestinal bleeding, and PPI use often continues after discharge. Numerous multifaceted interventions have demonstrated safe and effective reduction of PPI use in the inpatient setting. This narrative review and the resulting implementation guide summarize published interventions to reduce inappropriate PPI use and provide a strategy for quality improvement teams.

Gastrointestinal Bleeding in a Patient With Gastric Lymphoma, Tuberculosis Enteritis, and Cytomegalovirus Enteritis.

Bleeding from the small bowel can be challenging to identify by endoscopic or radiographic evaluation. We present the case of a patient with incompletely treated latent tuberculosis and medical history of T-cell lymphoma who developed gastrointestinal bleeding because of concurrent Burkitt lymphoma, tuberculosis enteritis, and cytomegalovirus enteritis. The interplay of these 3 diagnoses is discussed.

An Obstructing Fecal Bezoar in a Patient with Scleroderma with Successful Colonoscopic Disimpaction.

Scleroderma (SSc) is a disease caused by collagen deposition resulting in fibrosis within multiple organs, including the gastrointestinal tract, skin, joints, kidneys, lungs, and heart. We report a rare case of a patient with diffuse SSc who presented with a large bowel obstruction from a fecal bezoar impaction. The bezoar was successfully removed using colonoscopy after lavage, cold forceps, balloon dilator, and cap-assisted disimpaction. We demonstrate that patients with SSc are at risk for bezoar formation and true mechanical obstruction in the lower gastrointestinal tract, which may require more aggressive endoscopic treatment if conservative measures fail.

Calcium management after thyroidectomy: a simple and cost-effective method.

OBJECTIVE: Hypocalcemia is one of the principal complications of total or completion thyroidectomy. A number of different protocols for managing this potential complication have been published. Our simple postoperative regimen is described and the safety and cost-effectiveness assessed. STUDY DESIGN: Case series with planned data collection. SETTING: Academic medical center. SUBJECTS AND METHODS: All patients undergoing total or completion thyroidectomy from January 2008 through June 2010 were evaluated. Data collected included age; gender; procedure performed; levels of ionized calcium, parathyroid hormone, and vitamin D; complications; and need for readmission. Standard descriptive statistics were used to summarize these data. RESULTS: In total, 526 patients had thyroid surgery during the 30-month study period. Of these, 307 underwent completion or total thyroidectomy and were prescribed a 3-week tapering course of calcium carbonate postoperatively. Twenty-three patients (7.5%) experienced symptoms of hypocalcemia that were managed on an outpatient basis with additional doses of oral calcium. Two patients (0.7%) required readmission. The cost of a 3-week regimen of calcium carbonate is approximately $15. This is considerably less expensive than either the cost of overnight admission or published laboratory protocols that are designed to predict the risk of hypocalcemia. CONCLUSIONS: Prophylactic calcium supplementation without routine laboratory assessment proved to be a safe and cost-effective method of preventing and managing postoperative hypocalcemia following total or completion thyroidectomy.

Resource allocation in a social wasp: effects of breeding system and life cycle on reproductive decisions.

Organisms must make important decisions on how to allocate resources to reproduction. We investigated allocation decisions in the social wasp Vespula maculifrons to understand how social insects make reproductive choices. We first determined how annual colonies apportioned resources to growth and reproduction by analysing developing brood. In contrast to expectations, colonies invested in both growth (workers) and reproduction (males) simultaneously. In addition, colonies showed evidence of producing males in pulses and reversing their reproductive choices by decreasing investment in males late in the season. This reversal is consistent with theory suggesting that colonies decrease production in males if fitness of late emerging males is low. To further investigate reproductive decisions within colonies, we determined if the male mates of multiply-mated queens varied in their reproductive success over time. Sperm use by queens did vary over time suggesting that male success may depend on sperm clumping within the female reproductive tract. Finally, we tested if colony sex ratio conformed to expectations under kin selection theory that nestmate relatedness would positively correlate with investment in new queens if workers controlled sex allocation. Surprisingly, the proportion of queens produced by colonies was negatively correlated with nestmate relatedness, suggesting that allocation may be shaped by advantages arising from increased genetic diversity resulting from multiple mating by queens. Overall, our study suggests that the reproductive decisions of colonies are flexible and may depend both on environmental cues arising from energetic needs of the colony and genetic cues arising from mating behaviours of queens.