Pancreatitis before pancreatic cancer: clinical features and influence on outcome.

OBJECTIVES: Pancreatitis is considered a possible risk factor for and a presentation of pancreatic adenocarcinoma (PA). We aimed to evaluate a large PA patient registry to determine whether prior history of pancreatitis influenced survival. METHODS: We retrospectively analyzed the Mayo Clinic Biospecimen Resource for Pancreas Research database from January 1992 to September 2011. Data collected included demographic characteristics, history of tobacco or alcohol use, diabetes mellitus (DM), cholelithiasis, pseudocyst, and details regarding PA. Clinical characteristics and outcomes of PA patients with pancreatitis were compared with PA patients without pancreatitis history. RESULTS: We analyzed 2573 patients with PA diagnosis. Among these patients, 195 (8%) were identified who had pancreatitis diagnosis ≥ 10 days before PA diagnosis. The cohort with pancreatitis history included more patients with DM (30% vs. 18%; P<0.001) and more smokers (68% vs. 58%; P=0.02). Compared with patients without pancreatitis history, these patients received diagnoses of PA at a younger age (63 vs. 65 y; P=0.005) and earlier stage (stages I and II; 52% vs. 37%; P<0.001). A greater percentage had history of surgery with curative intent (50% vs. 43%; P=0.001) and significantly better survival [median (range), 387 d (314 to 460 d) vs. 325 d (306 to 344 d); P=0.003]. CONCLUSIONS: Patients with PA and pancreatitis had more weight loss and DM, but had PA diagnosis at an earlier stage, were more likely to have pancreatic surgery, and therefore better survival than PA patients without pancreatitis, likely due to the earlier diagnosis. Further studies are needed to evaluate whether screening for PA in patients with pancreatitis history would provide survival benefit.

Self-dilation as a treatment for resistant, benign esophageal strictures.

GOALS AND BACKGROUND: Simple benign strictures may be relieved with one to three dilation sessions. Resistant benign strictures are anatomically complex and resistant to therapy. We sought to determine the efficacy and safety of esophageal self-dilation with bougie dilators in the largest series to date. STUDY: A retrospective chart review was performed to identify patients who underwent esophageal self-dilation at two tertiary referral centers (Mayo Clinic, Scottsdale, Arizona and Mayo Clinic Rochester, Minnesota) between January 1, 2003 and June 30, 2012. Demographic details and clinical information regarding relief of dysphagia, complications, and frequency of endoscopic and self-dilation were abstracted. RESULTS: Of the 32 patients who began self-dilation for nonmalignant strictures, 30 [22 men; median (range) age, 62 years (22-86 years)] were included in the study. Median (range) follow-up was 37 months (14-281 months). Stricture etiology included radiation therapy (n = 8), anastomotic stricture (n = 9), eosinophilic esophagitis (n = 4), caustic ingestion (n = 3), photodynamic therapy (n = 2), granulation tissue (n = 2), peptic stricture (n = 1) and one patient had radiation therapy and peptic stricture. The average number (range) of physician performed dilations before self-dilation was 12 (4-55). Esophageal self-dilation was successful in treating 90 % of patients. Dysphagia score (2 vs. 1; P < 0.001), stricture diameter (median; 5 vs. 12 mm; P < 0.001) and weight (median; 73 vs. 77 kg; P < 0.001) were significantly different between EDG dilation versus self-dilation. CONCLUSIONS: Esophageal self-dilation is a safe, effective treatment for resistant, benign esophageal strictures. This management strategy should be strongly considered in this patient population.

Impact of fentanyl in lieu of meperidine on endoscopy unit efficiency: a prospective comparative study in patients undergoing EGD.

BACKGROUND: Turnaround time is an important component of endoscopy unit efficiency. Any reduction in the total time from patient arrival in the endoscopy room to departure from the recovery area may translate into better endoscopy unit efficiency. OBJECTIVE: To evaluate the effects on endoscopy unit efficiency of a change in narcotic choice for moderate sedation in patients undergoing EGD at an ambulatory surgery center. DESIGN: Prospective, comparative, quality-improvement project. SETTING: Endoscopy unit of a tertiary-care academic medical center. PATIENTS: We enrolled consecutive patients (n = 1963) who underwent outpatient EGD by 1 of 5 endoscopists between November 2008 and November 2010. INTERVENTION: Moderate sedation with midazolam plus fentanyl versus meperidine. MAIN OUTCOME MEASUREMENTS: Sedation-dependent endoscopy unit efficiency and total procedure time (induction-to-intubation, intubation-to-extubation, and extubation-to-discharge). RESULTS: Fentanyl was associated with reduced total procedure time by 10.1 minutes resulting from both shorter induction-to-intubation time and extubation-to-discharge time (P < .001). The mean (± SD) sedation-dependent endoscopy unit efficiency was 3.2 (± 1.9) procedures per hour for the meperidine group and 3.9 (± 2.7) procedures per hour for the fentanyl group (P = .012); this would translate into possibly increasing the endoscopy suite efficiency by 22%. Based on dosage equivalency conversion, equal doses of fentanyl and meperidine were used. No sedation-related complications or need for reversal agents were recorded. LIMITATIONS: No randomization was performed. CONCLUSION: Compared with meperidine, fentanyl in combination with midazolam was associated with significantly shorter total procedure time. By improving the turnaround time, sedation-dependent endoscopy unit efficiency may be improved by 22%.

Flexible endoscopic and surgical management of Zenker's diverticulum.

Zenker's diverticulum is an outpouching of the mucosa through the Killian's triangle. The etiology of Zenker's diverticulum is not well understood. It is thought to be due to the incoordination or incomplete relaxation of the cricopharyngeal muscle. Most patients are men who present with symptoms of dysphagia between the seventh and eighth decades of life. The diagnosis is made with a dynamic contrast swallowing study. Treatment options include open surgical diverticulectomy and diverticulopexy with myotomy or myotomy alone using flexible or rigid endoscopes. Rigid endoscopic treatment is currently the preferred initial choice for Zenker's diverticulum of any size. The flexible endoscopic technique is used when there is a high risk of general anesthesia, or neck extension is contraindicated. Some centers use flexible endoscopy as the initial treatment option. Due to a lack of prospective studies, the treatment choice should be tailored to the individual patient and local expertise.

Comparison of single- versus double-balloon assisted-colonoscopy for colon examination after previous incomplete standard colonoscopy.

BACKGROUND: Colonoscopy fails to achieve cecal intubation in 5-10 % of cases. Many of these cases can be completed using balloon-assisted colonoscopy, either with the single-balloon colonoscopy (SBC) or the double-balloon colonoscopy (DBC) techniques. AIM: To compare the completion rates of SBC and DBC in patients with previous incomplete conventional colonoscopy. METHODS: Between August 2009 and July 2011 either SBC or DBC was performed in 53 patients in whom previous conventional colonoscopy did not achieve cecal intubation. The medical records of these 53 patients were reviewed retrospectively for details regarding (1) indication for the initial colonoscopy, (2) patient characteristics, (3) data from the initial colonoscopy, and (4) details on both SBC and DBC. RESULTS: SBC was successful in intubating the cecum in 100 % (26/26) of patients and DBC was successful in 93 % (25/27) of patients. The median (range) time to reach the cecum was 17 (9-43) min in the SBC group and 20 (7-58) min in the DBC group (P = 0.37). The presence of polyps was an entirely new finding in 35 % (9/26) of patients in the SBC group and 30 % (8/27) of patients in DBC group. Therapeutics were performed in 73 % (19/26) of patients in SBC group and 67 % (18/27) of patients in DBC group. CONCLUSION: For patients with incomplete conventional colonoscopy, SBC and DBC offer high cecal intubation rates as well as detection of additional polyps and therapeutic capability. Either SBC or DBC can be considered after incomplete conventional colonoscopy.

Self dilation as a treatment for resistant benign esophageal strictures: outcome, technique, and quality of life assessment.

BACKGROUND: Resistant benign esophageal strictures can have a negative impact on patients' quality of life. A portion of these patients require frequent physician performed dilations, leading to numerous interactions with their attendant inconvenience and sense of dependence. This study demonstrates the efficacy, safety and effect on quality of life of this under-utilized technique. METHODS: A retrospective chart review was performed for all patients undergoing esophageal self dilation at our institution between January 2003 and November 2009. The impact on quality of life was evaluated using a telephone questionnaire specifically designed to explore emotional, social and financial impacts. RESULTS: Of the 11 patients who initially began self dilation for non-malignant strictures, nine are included in this study. Median follow-up was 35.4 months (range 6-168). No significant complications were reported. When asked to compare self dilation with physician performed dilation a large proportion of patients reported financial benefits, and a majority reported being more socially active. Overall quality of life improvement was reported by almost all of the participants in the study. Global scores for dysphagia and overall quality of life were significantly improved under conditions of self dilation versus physician performed dilation (P = 0.008 and P = 0.016, respectively). CONCLUSIONS: Our results suggest that esophageal self dilation can be a safe and effective treatment modality in motivated patients with benign resistant esophageal strictures. Esophageal self dilation has a positive impact on emotional, social, and financial aspects of patient's life. Self dilation should be considered a treatment option in all patients with benign resistant esophageal strictures.