Utility of Urgent Endoscopic Retrograde Cholangiopancreatography in Patients with Predicted Mild Acute Pancreatitis and Cholestasis.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) within 72 h is suggested for patients presenting with acute biliary pancreatitis (ABP) and biliary obstruction without cholangitis. This study aimed to identify if urgent ERCP (within 24 h) improved outcomes compared to early ERCP (24-72 h) in patients admitted with predicted mild ABP. METHODS: Patients admitted for predicted mild ABP defined as a bedside index of severity in acute pancreatitis score < 3 and underwent ERCP for biliary obstruction within 72 h of presentation during the study period were included. Patients with prior biliary sphincterotomy or surgically altered anatomy preventing conventional ERCP were excluded. The primary outcome was the development of moderately severe or severe pancreatitis based on the revised Atlanta classification. Secondary outcomes were the length of hospital stay, the need for ICU admission, and ERCP-related adverse events (AEs). RESULTS: Of the identified 166 patients, baseline characteristics were similar between both the groups except for the WBC count (9.4 vs. 8.3/µL; p < 0.044) and serum bilirubin level (3.0 vs. 1.6 mg/dL; p < 0.0039). Biliary cannulation rate and technical success were both high in the overall cohort (98.8%). Urgent ERCP was not associated with increased development of moderately severe pancreatitis (10.4% vs. 15.7%; p = 0.3115). The urgent ERCP group had a significantly shorter length of hospital stay [median 3 (IQR 2-3) vs. 3 days (IQR 3-4), p < 0.01]. CONCLUSION: Urgent ERCP did not impact the rate of developing more severe pancreatitis in patients with predicted mild ABP but was associated with a shorter length of hospital stay and a lower rate of hospital readmission.

Esophageal stent migration leading to distal small bowel perforation.

Covered oesophageal stents are often used to treat dysphagia in patients with inoperable oesophageal cancer. Stent migration is a well-known but usually benign complication. We report the case of a patient whose esophageal stent migrated into the distal ileum with perforation hereof. A laparoscopic stent extraction and intestinal repair was necessary to treat the perforation.

Isolated local recurrence or solitary solid organ metastasis after esophagectomy for cancer is not the end of the road.

Recurrent disease after esophagectomy bears an infaust prognosis, especially when multiple recurrences are present. But little is known about survival in patients with limited recurrence (solitary locoregional recurrence or solid organ metastasis). Herein, we report our experience with these subgroups. We analyzed 1754 consecutive patients surgically treated with curative resection for esophageal cancer and cancer of the gastroesophageal junction between 1990 and 2012. Seven subgroups were defined according to the recurrence type (locoregional vs. organ metastasis), the site of recurrence (abdominal, thoracic, cervical for lymph nodes and lung, liver, adrenals and others for organ metastasis) and also the number of lesions (one vs. multiple lymph node stations or organ metastasis) Of these groups; clinical isolated locoregional recurrence (ciLR) was defined as solitary lymph-node recurrence confined to one compartment (cervical, thoracic or abdominal, within or outside surgical dissection-field) at clinical staging. Clinical solitary solid organ metastasis (csSOM) was defined as metastasis in a resectable solid organ, i.e. liver, lung, brain or adrenal. Salvage therapies were grouped in five categories. Kaplan-Meier curves were used to calculate survival. Recurrent disease was observed in 766 patients (43.7%) with overall 5-year survival of 4.5% after diagnosis of recurrence. Fifty-seven patients (7.4%) showed ciLR and 110 (14.4%) csSOM. Median time-to-recurrence was 16.8 months in ciLR and 9.9 months in csSOM (P = 0.0074). Survival is significantly improved compared to supportive therapy when local therapy is possible (P < 0.0001). In 25 (15%) of ciLR or csSOM patients, surgical therapy with or without systemic therapy, yielded a 5-year survival of 49.9% (median 54.8 months) after diagnosis of recurrence. When surgery was impossible or contraindicated, the combination of chemoradiotherapy appeared to be superior to chemotherapy alone (respectively 27.0% vs. 4.6% 5-year survival) or radiotherapy alone (no 5-year survival). Recurrent disease after esophagectomy is a common problem with poor overall survival. However prolonged survival could be obtained in selected patients if the recurrent disease is limited to ciLR or csSOM, if surgery (+/- systemic therapy) can be performed. If not a combination of chemoradiotherapy seems to offer the second best option. Patients presenting with a ciLR or csSOM should be discussed in a dedicated multidisciplinary team meeting as to evaluate and define the place of salvage treatment which in well selected cases could offer a perspective of prolonged survival.

Combination of C-TRUS with multiparametric MRI: potential for improving detection of prostate cancer.

PURPOSE: To improve the detection of prostate cancer, especially in pre-biopsied patients, a guided biopsy based on radiologic findings is an option. We addressed the question, whether the combination of multiparametric MRI and computerized transrectal ultrasound (C-TRUS) improves the detection of prostate cancer. METHODS: Twenty patients suspicious of having prostate cancer were included. Seventeen patients were pre-biopsied once or more. Each patient was examined by multiparametric MRI and C-TRUS, followed by a guided transrectal prostate biopsy series. Patients were stratified in a "low-risk" and "high-risk" group. The results were analyzed using descriptive statistics. RESULTS: In 58 % (11 pat.) of patients, prostate cancer was found. In the "high-risk" group, biopsy in 73 % (8 pat.) of patients was positive for prostate cancer. All prostate cancer patients were found by C-TRUS-guided biopsies, whereas MRI did not reveal cancer in 27 %. 72 % (8 pat.) of patients had undergone radical prostatectomy. 65 % (6 pat.) had higher tumor stages after prostatectomy and 62.5 % (5 pat.) had higher Gleason-score. CONCLUSIONS: Combination of multiparametric MRI and C-TRUS seems to improve detection of prostate cancer, especially in high-risk patients. Detection rates of C-TRUS in this study could confirm those of the primary C-TRUS studies. The benefit of MRI is the additional visualization of the tumor extension. The technique is an option for pre-biopsied patients. Both imaging methods often fail to predict correct tumor stage, but further studies are necessary.

Transperineal MR-guided stereotactic prostate biopsy utilizing a commercially available anorectal biopsy device.

PURPOSE: To evaluate the feasibility of transperineal MR-guided prostate biopsy using a stereotactical targeting system originally designed for anorectal usage. MATERIALS AND METHODS: A commercially available DynaTRIM MR targeting system (Invivo corp., Gainesville FL, USA) originally designed only for anorectal application was used on a 70 cm wide-bore, whole-body 3 Tesla MR-system (Ingenia, Philips Healthcare, Best, NL). Transperineal biopsy was performed following mulitparametric MR imaging for targeting of the lesion. RESULTS: The anorectal device allowed for correct localization and successful MR-guided transperineal biopsy of the targeted lesion. CONCLUSION: MR-guided transperineal biopsy is feasible using a commercially available anorectal stereotactic biopsy device. This may lead to a broader acceptance of this approach for targeted prostate biopsies.

Esophageal rupture: Computed tomography with endoscopic correlation.

Boerhaave syndrome, or spontaneous rupture of the esophagus, is a complication of violent vomiting. Although the syndrome is rare, awareness of it is important because delayed or missed diagnosis can be fatal. Radiographic imaging, particularly computed tomography, is the mainstay of diagnosis, and endoscopy generally does not play a role. We present a case of Boerhaave syndrome diagnosed by computed tomography that was complemented by endoscopic direct visualization to optimize surgical management. True Boerhaave syndrome is extremely rare, and rarer still is an endoscopic view of a known full-thickness tear of the esophagus.