Self-expanding metal stents (SEMS) for preoperative biliary decompression in patients with resectable and borderline-resectable pancreatic cancer: outcomes in 241 patients.

BACKGROUND AND AIM: Obstructive jaundice caused by distal biliary obstruction can present in up to 70 % of patients with localized cancer of the head of the pancreas. The aim of this study was to report our experience in using self-expanding metal stents (SEMS) for preoperative biliary decompression in patients with resectable and borderline resectable carcinoma of the pancreatic head. METHODS: We performed a retrospective study evaluating patients from two tertiary referral centers. Two-hundred and forty-one patients with resectable and borderline resectable pancreatic carcinoma underwent ERCP with metal biliary stent placement between September 2006 and August 2011. We assessed the effectiveness of SEMS to adequately decompress the biliary tree, procedural success, patient survival, stent patency, and stent-related complications. RESULTS: Two-hundred and forty-one patients were evaluated [123 male, mean age (± SD) 67.4 ± 9.8 years; resectable 174, borderline resectable 67]. Patients with borderline-resectable cancer underwent neoadjuvant therapy and restaging before possible curative surgery. Successful placement of a metal biliary stent was achieved in all patients and improved jaundice. Patients were followed for mean duration of 6.3 months. The overall survival was 49 % at 27 months. Fourteen (5.8 %) patients experienced stent occlusion; the mean time to stent occlusion was 6.6 (range 1-20) months. Immediate complications included: post-ERCP pancreatitis (n = 14), stent migration (n = 3), and duodenal perforation (n = 3). Long-term complications included stent migration (n = 9) and hepatic abscess (n = 1). A total of 144/174 patients deemed to have resectable cancer at time of diagnosis underwent curative surgery. Due to disease progression or the discovery of metastasis after neoadjuvant therapy, only 22/67 patients with borderline-resectable cancer underwent curative surgery. CONCLUSIONS: SEMS should be considered for patients with obstructive jaundice and resectable or borderline resectable pancreatic cancer, especially if surgery is not planned immediately as a result of preoperative chemoradiation. These stents appear to be safe and effective.

Placement of fully covered self-expandable metal stents in patients with locally advanced esophageal cancer before neoadjuvant therapy.

BACKGROUND: Most patients with locally advanced esophageal cancer requiring neoadjuvant therapy have significant dysphagia. OBJECTIVE: To report our experience in using a fully covered self-expandable metal stent (FCSEMS) to treat malignant dysphagia and for maintenance of nutritional support during neoadjuvant therapy. DESIGN: Retrospective study. SETTING: Two tertiary-care referral centers. PATIENTS: This study involved 55 patients with locally advanced esophageal cancer (50 adenocarcinoma, 5 squamous cell carcinoma). Forty-three patients were men, and the mean age was 65.8 years. INTERVENTION: EUS followed by FCSEMS placement. MAIN OUTCOME MEASUREMENTS: Procedural success, dysphagia scores, patient weights, stent migration, and stent-related complications. RESULTS: All stents were successfully placed. Tumors were located in the middle esophagus (n = 10) and distal esophagus (n = 45). The mean dysphagia score obtained at 1 week after stent placement had improved significantly from baseline (2.4 and 1, respectively; P < .001). Patients maintained their weights at 1 month follow-up when compared with baseline (153 and 149 pounds, respectively; P = .58). Immediate complications included chest discomfort in 13 patients; 2 patients required stent removal because of intractable pain. One patient had stent removal because of significant acid reflux. Stent migration occurred at some point in 17 of 55 patients (31%). There was a delayed perforation in 1 patient. Because of disease progression or the discovery of metastasis after neoadjuvant therapy, only 8 of 55 patients underwent curative surgery. LIMITATIONS: Retrospective study. CONCLUSION: Placement of FCSEMSs in patients with locally advanced esophageal cancer significantly improves dysphagia and allows for oral nutrition during neoadjuvant therapy. FCSEMSs appear to be effective for palliating dysphagia. Migration was not associated with injury or harm to the patient and usually represented a positive response to neoadjuvant therapy. Few patients undergoing stenting in this situation ultimately undergo surgery because of disease progression or poor operative candidacy.

Combined ERCP and EUS in one session is safe in elderly patients when compared to non-elderly patients: outcomes in 206 combined procedures.

AIMS: Combined ERCP/EUS is becoming common. Combined procedures are frequently performed in elderly patients. We hypothesized that combined ERCP/EUS is equally safe in elderly patients when compared to non-elderly patients. METHODS: This was a retrospective single-center study comparing outcomes in elderly and non-elderly patients undergoing combined ERCP/EUS. RESULTS: A total of 206 patients were included. Mean age was 65 years (M:F 113:93); 99 were <65 years and 107 were >65. Indications included: jaundice (51%), abnormal imaging (17%), pancreatic tumor (11%), abdominal pain (5%), stent placement/change (5%), acute or chronic pancreatitis (5%), other (6%). Fine needle aspiration was performed in 134 (65%) procedures. Malignancy was identified in 142/206 (69%) patients. Mean Charlson Comorbidity Index (CCI) was 7.5 (range 0-22). Among patients <65 years old there were no immediate adverse events. Long-term adverse events in patients <65 (within 30 days) included cholangitis (1), increasing abdominal pain (4), post-ERCP pancreatitis (3), nausea/vomiting (1), increasing fatigue (1), and increasing jaundice (1). A subgroup analysis among geriatric patients (>65) was performed. Mean CCI was 8.2 (range 0-22). There was one immediate adverse event of non-sustained ventricular tachycardia in a 76-year old. Long-term adverse events included increasing fatigue (1), nausea/vomiting (2), increasing abdominal pain (2), urosepsis (1), fever (2) and dehydration (1). There were no statistically significant differences in outcomes in elderly compared to non-elderly patients. Elderly patients had higher CCI scores (p = 0.04). CONCLUSION: Combined ERCP/EUS in one session is safe in the general population and elderly patients, with no more adverse events than in non-elderly patients.

Incidental pancreatography via ERCP in patients with anomalous pancreaticobiliary junction does not result in pancreatitis in a North American population.

INTRODUCTION: Anomalous pancreaticobiliary junction (APBJ) is the term used to describe anatomical variants of pancreatic and biliary ductal junctional anatomy. Patients have junction of the pancreatic and bile ducts located outside the duodenal wall, forming a long common channel. We report our findings and clinical outcomes in a North American series of patients with APBJ undergoing ERCP. METHODS: Retrospective chart review. RESULTS: We reviewed 2,218 ERCP performed on 1,050 patients. Twelve patients (1.1%) with APBJ were identified (5F, 7M). No patient had an associated choledochocele. Mean age was 53.2 (range 17-85). A total of 43 ERCP procedures were performed on these 12 patients. All patients experienced passive pancreatography. No patient developed post-ERCP pancreatitis. Only one patient had a history of antecedent pancreatitis. CONCLUSIONS: In North American patients undergoing ERCP, 1.1% of patients had APBJ. Our study population was predominately Caucasian, male, and in all but one patient lacked a history of prior pancreatitis. No patient developed post-ERCP pancreatitis. This suggests that APBJ may have different clinical manifestations in a North American population when compared to Asian populations.

Duodenal and colonic stent placement with 0.025″ and 0.035″ guidewires is equally safe and effective.

BACKGROUND: The overwhelming majority of reported duodenal and colonic SEMS placements in the literature have used the 0.035″ guidewire almost to the exclusion of guidewires of other diameters. AIMS: The purpose of this study was to compare technical and clinical outcomes in patients undergoing duodenal or colonic SEMS placement with 0.025″ or 0.035″ guidewires. METHODS: This was a retrospective study to compare technical and clinical outcomes and complications of patients receiving duodenal or colonic SEMS placement with a 0.035″ guidewire to those undergoing placement with a 0.025″ guidewire. RESULTS: A total of 34 duodenal and 30 colonic stent placement procedures were performed in 59 patients. Technical success was achieved in all duodenal stent placement procedures. The difference in mean GOOSS score increase after stent placement was not statistically significant between the 0.035″ and 0.025″ guidewire groups (P = 0.49). Complications were not statistically significantly different between the two groups undergoing gastroduodenal stenting. Technical and clinical success was achieved in all colonic stent placement procedures. There were no statistically significant differences in complication rates between the two groups undergoing colonic stenting. Procedure times were not significantly different using either wire type. CONCLUSIONS: Our study shows that both 0.035″ and 0.025″ guidewires were equally effective with regards to technical success, clinical success, and with regards to the development of complications.

Endoscopic findings in patients presenting with dysphagia: analysis of a national endoscopy database.

Dysphagia is a common problem and an indication for upper endoscopy. There is no data on the frequency of the different endoscopic findings and whether they change according to demographics or by single versus repeat endoscopy. To determine the prevalence of endoscopic findings in patients with dysphagia and whether findings differ in regard to age, gender, ethnicity, and repeat procedure. This was a retrospective study using a national endoscopic database (CORI). A total of 30,377 patients underwent esophagogastroduodenoscopy (EGD) for dysphagia of which 4,202 patients were repeat endoscopies. Overall frequency of endoscopic findings was determined by gender, age, ethnicity, and single vs. repeat procedures. Esophageal stricture was the most common finding followed by normal, esophagitis/ulcer (EU), Schatzki ring (SR), esophageal food impaction (EFI), and suspected malignancy. Males were more likely to undergo repeat endoscopies and more likely to have stricture, EU, EFI, and suspected malignancy (P = 0.001). Patients 60 years or older had a higher prevalence of stricture, EU, SR, and suspected malignancy (P < 0.0001). Esophageal stricture was most common in white non-Hispanic patients compared to other ethnic groups. In patients undergoing repeat EGD, stricture, SR, EFI, and suspected malignancy were more common (P < 0.0001). The prevalence of endoscopic findings differs significantly by gender, age, and repeat procedure. The most common findings in descending order were stricture, normal, EU, SR, EFI, and suspected malignancy. For patients undergoing a repeat procedure, normal and EU were less common and all other abnormal findings were significantly more common.

Comorbidities, sphincterotomy, and balloon dilation predict post-ERCP adverse events in PSC patients: operator experience is protective.

BACKGROUND: Primary sclerosing cholangitis (PSC) is a chronic cholestatic disease. Interventional ERCP improves survival in PSC patients. AIMS: To describe the frequency and risk factors for post-ERCP adverse events in patients with PSC via multivariate analysis. METHODS: Retrospective cohort study included patients with a diagnosis of PSC who underwent ERCP at academic institutions between February 2000 and October 2009. Demographis, co-morbid conditions, antibiotic use, cannulation method, ERCP maneuvers and 30-day post-ERCP adverse events were collected. Multivariate analysis was performed using logistic regression. RESULTS: A total of 185 procedures were performed on 75 PSC patients (58 M,17 F). Seven endoscopists performed ERCPs. Comorbidies included ulcerative colitis (44%, n = 33), Crohn's disease (12%, n = 9 patients), Cirrhosis (8%, n = 6 patients) and autoimmune hepatitis (2.7%, n = 2). Cannulation was achieved using dye-free guidewire cannulation techniques in 139/185 procedures (76%) and with contrast-based techniques in 46/185 procedures (24%). Thirty-day post-ERCP adverse events included post-ERCP pancreatitis (5%, n = 9, cholangitis (1%, n = 2), acute cholecystitis (0.5%, n = 1), stent occlusion (0.5%, n = 1), stent migration (0.5%, n = 1), and bile leak (0.5%, n = 1). In the multivariate analysis, associations with specific endoscopists who performed the procedure (P = 0.01), biliary dilation (P = 0.02), sphincterotomy (P = 0.03), presence of cirrhosis (P = 0.05), Crohn's disease (P < 0.001), and autoimmune hepatitis (P < 0.001) significantly predicted a complication following ERCP. Gender, stenting during procedure, presence of a dominant stricture, and cholangitis were not predictive for post-ERCP adverse events. CONCLUSIONS: Factors predicting 30-day post-ERCP adverse events included certain co-morbid conditions, the endoscopist ERCP volume, maneuvers during ERCP including dilation and sphincterotomy. Stenting was not associated with adverse events.

Endoscopic biliary sphincterotomy is not required for transpapillary SEMS placement for biliary obstruction.

BACKGROUND: Endoscopic retrograde cholangiopancreatography with biliary self-expanding metal stent placement is the preferred method of providing biliary drainage for pancreaticobiliary malignancies. Some endoscopists routinely perform biliary sphincterotomy to facilitate biliary stent placement and potentially minimize pancreatitis with transpapillary self-expanding metal stent placement. AIMS: Our hypothesis was that biliary sphincterotomy has no effect on the success rate of transpapillary self-expanding metal stent placement and increases procedure-related complications. METHODS: In a retrospective analysis, outcomes of two groups were compared: (1) self-expanding metal stent placement without biliary sphincterotomy, (2) self-expanding metal stent placement with biliary sphincterotomy during the same procedure. Complications and stent patency rates were evaluated. RESULTS: There were 104 subjects included in the study. Post-sphincterotomy bleeding (p = 0.001) was associated with biliary sphincterotomy performed immediately prior to self-expanding metal stent placement. Importantly, self-expanding metal stent placement without biliary sphincterotomy was always technically successful and self-expanding metal stent placement without biliary sphincterotomy was not associated with pancreatitis. CONCLUSIONS: Patients who undergo biliary sphincterotomy during transpapillary self-expanding metal stent placement experience more immediate complications than those who do not. Biliary sphincterotomy was not associated with longer stent patency. Self-expanding metal stent placement without a biliary sphincterotomy was not associated with pancreatitis regardless of the type of self-expanding metal stent used (covered or uncovered). Of the patients without a biliary sphincterotomy, 100% had successful stent placement, further arguing against its use in this setting.

Nurse-administered propofol sedation is safe for patients with obstructive sleep apnea undergoing routine endoscopy: a pilot study.

BACKGROUND: Nurse-administered propofol sedation (NAPS) is now in widespread use. The safety profile of NAPS for routine endoscopic procedures in patients with obstructive sleep apnea (OSA) is unknown. AIMS: To compare outcomes of patients with and without OSA undergoing routine endoscopic procedures with NAPS and standard conscious sedation (CS) with benzodiazepines and narcotics. METHODS: Retrospective cohort study. RESULTS: A total of 215 patients were placed in one of four groups: OSA patients undergoing endoscopy with NAPS, OSA patients undergoing endoscopy with standard CS, non-OSA patients undergoing endoscopy with NAPS, and non-OSA patients undergoing endoscopy with standard CS. Procedures were generally accomplished faster with NAPS. There was no statistically significant difference in complication rates or overall outcomes in patients with OSA when compared to non-OSA patients when either NAPS or CS was utilized. CONCLUSIONS: Routine endoscopic procedures using NAPS are safe in patients with documented OSA, with complication rates comparable to when using CS. NAPS helped to decrease procedure times in general.

What drives US gastroenterology fellows to pursue academic vs. non-academic careers?: Results of a national survey.

OBJECTIVES: We conducted a nationwide survey of US gastroenterology fellows to identify key demographic and job-related factors relevant to the decision between an academic and a non-academic career. METHODS: A survey was e-mailed to all US GI fellowship program directors and distributed at fellows' endoscopy courses. Data were evaluated via univariate and multivariate analysis. RESULTS: One hundred eighty-four fellows completed surveys. Univariate analysis identified one factor that predisposed fellows to pursue non-academic practice: the perception that a non-academic salary would meet their financial needs. Four factors were identified that predisposed fellows to pursue academic practice: age>35 years, prior attainment of a master's or a PhD degree, and advanced fellowship. All factors were significant on multivariate analysis. If salaries were equal, 60% of respondents would choose academic over non-academic practice. Fellows selecting academic practice were motivated to publish and conduct research. Level of debt and a positive relationship with a mentor were not significant factors. CONCLUSIONS: Fellows desiring more money strongly favor non-academic practice. Fellows choosing academic practice tend to be older, plan to pursue advanced training, desire fewer work hours per week, and have a higher rate of prior graduate study. If salaries were equal in academic medicine and non-academic practice, the majority of fellows would choose academic medicine.

Dye-free wire-guided cannulation of the biliary tree during ERCP is associated with high success and low complication rates: outcomes in a single operator experience of 822 cases.

BACKGROUND: Deep biliary cannulation (DBC) is a prerequisite to most endoscopic retrograde cholangiopancreatographies (ERCPs). Numerous techniques have been described to maximize success and minimize ERCP-related complications, most notably post-ERCP pancreatitis. Dye-free cannulation by using guidewires with hydrophilic tips has been proposed as a technique with a high rate of success and a low rate of complications. We report the outcomes 822 consecutive ERCP procedures by using dye-free guidewire cannulation techniques. OBJECTIVE: To evaluate the success rate for DBC and rates of complications by using dye-free guidewire cannulation techniques. DESIGN: Retrospective. Consecutive ERCP procedures with intent to achieve DBC exclusively by using dye-free guidewire technique were included. Complication data on post-ERCP pancreatitis, bleeding, perforation, and cholangitis were extracted. SETTING: University. PATIENTS: Patients undergoing biliary ERCP. INTERVENTIONS: ERCP. MAIN OUTCOME MEASUREMENTS: Success, complication rates. RESULTS: Eight hundred and twenty-two ERCPs were performed on 744 patients. Five hundred and fifty-nine (68%) procedures were performed on inpatients, 263 (32%) on outpatients. DBC was successful in 801 of 822 (97%) ERCPs. In 795 of 801 (99%) ERCPs with successful DBC procedures, DBC was achieved in a dye-free fashion. Eleven patients (1.3%) developed post-ERCP pancreatitis-all cases were mild. Guidewire perforations occurred 11 times (1.3%), none required surgery. Ten of 11 patients with known or suspected (91%) guidewire perforation achieved successful DBC on repeat ERCP by the same endoscopist by using dye-free techniques. LIMITATIONS: Retrospective. CONCLUSIONS: In this large retrospective case series, a high success rate of DBC was achieved by using dye-free guidewire techniques. This technique has associated lower rates of complications in comparison to those reported earlier.

Comparison of esomeprazole to aerosolized, swallowed fluticasone for eosinophilic esophagitis.

BACKGROUND: Both gastroesophageal reflux disease and allergy/atopy have been implicated in the pathogenesis of eosinophilic esophagitis (EoE). There are no prospective studies comparing treatment of EoE with acid suppression versus topical corticosteroids. OBJECTIVE: To determine the outcome of adult eosinophilic esophagitis patients treated with esomeprazole versus topical fluticasone. DESIGN: Prospective randomized controlled trial. SETTING: Academic medical center. PARTICIPANTS: Adults (18-80) diagnosed with EoE by symptoms of dysphagia and esophageal biopsies with >or=15 eosinophils/hpf. INTERVENTIONS: Subjects were randomized to esomeprazole (40 mg by mouth every morning) or aerosolized, swallowed fluticasone (440 mcg by mouth twice a day) for 8 weeks. MAIN OUTCOME MEASUREMENTS: Improvement in dysphagia (8-point scale), esophageal eosinophil infiltration before and after treatment, prevalence of GERD measured by validated questionnaire and baseline pH study. RESULTS: About 56% (14/25) had acid reflux by pH study. There was no difference between treatment groups in improvement in dysphagia scores [3/12 (25%) of the esomeprazole group versus 6/12 (50%) in the fluticasone group, P = 0.40]. Eosinophil infiltration decreased with treatment in both groups, and there was no difference in the amount of decrease between groups (P = 0.70). LIMITATIONS: Small sample size, unexpectedly high drop-out rate. CONCLUSIONS: Gastroesophageal reflux disease is common in adult eosinophilic esophagitis patients. Dysphagia improves and esophageal eosinophilic infiltration decreases with either treatment. There was no difference in degree of improvement in dysphagia or eosinophil infiltration in patients treated with either topical fluticasone or oral esomeprazole. GERD may be important in the pathogenesis of adult EoE.

EUS in pediatric patients.

BACKGROUND: The knowledge of EUS use in children is limited. OBJECTIVE: We investigated the indications, feasibility, safety, and clinical utility of EUS in the management of pediatric GI, pancreatobiliary, and mediastinal diseases. DESIGN: Retrospective study. SETTING: Two tertiary referral university hospitals. PATIENTS: Consecutive children age younger than 18 years referred over a 7-year period for EUS evaluation. RESULTS: Forty EUS scans were performed in 38 children with a mean age of 13.5 years. The indications for pancreatobiliary endosonography were pancreatitis (n = 10), solid pancreatic mass (n = 7), cystic pancreatic mass (n = 1), cyst in the setting of chronic pancreatitis (n = 1), suspected annular pancreas (n = 1), celiac plexus block (n = 1), suspected common bile duct stone (n = 1), abdominal pain and atrophic pancreas (n = 1), ampullary adenoma (n = 1), and abnormal MRCP in a patient with jaundice (n = 1). The indications for gastric EUS were mucosal lesions (n = 2) and subepithelial lesions (n = 4). The indications for mediastinal endosonography were mediastinal masses/lymph nodes (n = 5). The remaining evaluations were performed for esophageal stricture (n = 1), unexplained abdominal pain (n = 1), unexplained abdominal pain with celiac axis block (n = 1), and perirectal fluid collection (n = 1). EUS-guided FNA (EUS-FNA) was performed in 12 (30%) cases and established the correct diagnosis in 9 (75%). EUS-guided fine-needle injections for celiac axis block were performed in 2 (5%) cases. The procedure was successful in all patients, and no complications related to sedation, EUS, or EUS-FNA were encountered. LIMITATION: Retrospective study. CONCLUSION: EUS and EUS-FNA are feasible and safe and have a significant impact on the management of pediatric GI, pancreatobiliary, and mediastinal diseases.

Placement of Polyflex stents in patients with locally advanced esophageal cancer is safe and improves dysphagia during neoadjuvant therapy.

BACKGROUND: Patients with locally advanced esophageal cancer who require neoadjuvant therapy have significant dysphagia. OBJECTIVES: To prospectively evaluate Polyflex stents to treat malignant dysphagia and to ameliorate weight loss in patients with locally advanced esophageal cancer who will undergo neoadjuvant therapy. DESIGN: A prospective nonrandomized study. SETTING: Tertiary-referral cancer center. PATIENTS: Thirteen patients with esophageal cancer (11 adenocarcinoma, 2 squamous-cell carcinoma). All patients were men, with a mean age of 63 years. INTERVENTIONS: EUS followed by stent placement. MAIN OUTCOME MEASUREMENTS: Dysphagia scores and patient weights. RESULTS: There were no perforations and no episodes of bleeding. Immediate complications included chest discomfort in 12 of 13 patients. The mean dysphagia score at the time of stent placement was 3. Mean dysphagia scores obtained at 1, 2, 3, and 4 weeks after stent placement were 1.1 (P = .005), 0.8 (P = .01), 0.9 (P = .02), and 1.0 (P = .008), respectively. Stent migration occurred at some point in 6 of 13 patients (46%). LIMITATIONS: A single center and small size of study. CONCLUSIONS: Simultaneous EUS staging and Polyflex stent placement is safe and allows oral feeding during neoadjuvant therapy. Dysphagia scores improved in a statistically significant manner. Stent migration was a common event, although not all patients with a migrated stent will require stent replacement, because migration may be a sign of tumor response to neoadjuvant therapy.

Osteoclastic and pleomorphic giant cell tumors of the pancreas diagnosed via EUS-guided FNA: unique clinical, endoscopic, and pathologic findings in a series of 5 patients.

INTRODUCTION: Osteoclastic and pleomorphic giant cell tumors of the pancreas are rare entities that have been typically described only in single case reports. We report on our experience with a series of 5 patients with pancreatic giant cell tumors seen at our institution. METHODS: This was a retrospective study involving a search of the study institution's medical records from 2001 to 2007 for patients diagnosed with giant cell-containing neoplasms of the pancreas. RESULTS: Five patients (2 women, 3 men) were identified. Age range was 59 to 81 years, with a mean of 70.2 years. None were current or former smokers. None had a history of alcohol abuse or preexisting pancreatitis of any kind. On EUS, tumors tended to be large, with a mean diameter of 47 mm (range 20-70 mm). All tumors had a heterogeneous echotexture and a distinct appearance when compared with the typical appearance of adenocarcinoma when viewed via EUS. The diagnosis of giant cell tumor of the pancreas, as well as the subtype, was made via EUS-guided FNA of the pancreatic lesion. Patients with pleomorphic giant cell tumors of the pancreas had a poor clinical course with a rapid decline, whereas those with mixed or osteoclastic giant cell tumors tended to have a better outcome, with a greater long-term survival. One patient is still alive more than 18 months after diagnosis. LIMITATION: Retrospective study. CONCLUSIONS: Giant cell tumors of the pancreas have unique clinical, endoscopic, and cytologic features. The risk factors for these lesions may be different from those associated with pancreatic adenocarcinoma. Some giant cell tumor subtypes may carry a more favorable prognosis than pancreatic adenocarcinoma, and awareness and recognition of these differences can affect patient care.

The role of gastroesophageal reflux in exercise-triggered asthma: a randomized controlled trial.

BACKGROUND: Exercise-triggered asthma (ETA) develops when physical activity triggers asthma symptoms during or directly after exercise. In patients prone to symptoms of supra-esophageal reflux, exercise may trigger gastroesophageal reflux (GER), resulting in such symptoms. AIMS: To determine the prevalence of abnormal pH in patients with ETA and to determine whether acid suppression improves symptoms in ETA patients. METHODS: We performed a randomized double-blind trial of rabeprazole versus placebo in the treatment of patients with ETA. Patients underwent treadmill protocol to determine their VO(2 max). Next, pH testing was initiated while undergoing a 30-min treadmill program exercising them at 65% of their VO(2 max). They were subsequently randomized to rabeprazole or placebo for 10 weeks. At the end of 10 weeks, exercise testing was repeated. RESULTS: A total of 31 patients completed the study (20 asthmatics, 11 non-asthmatics). Twenty-two out of 30 (73%) subjects had abnormal pH studies. For all subjects, rabeprazole improved symptoms more than placebo (P = 0.03). The association was stronger in the pH-positive group (P = 0.009). CONCLUSION: Acid reflux is common in ETA patients. Many patients with exercise-related respiratory symptoms are misdiagnosed as chronic asthmatics. Exercise-related symptoms improve with the use of acid suppression. This study suggests that ETA patients may benefit from acid suppression.

DPEJ tube placement prevents aspiration pneumonia in high-risk patients.

Percutaneous endoscopic gastrostomy (PEG) or PEG tube with transgastric jejunostomy tube (PEG-J) feeding has not been shown to decrease aspiration pneumonia. The aim of this study was to determine if direct percutaneous endoscopic jejunostomy (DPEJ) tube placement results in a decreased incidence of aspiration pneumonia in high-risk patients. The design was a retrospective review of all patients receiving DPEJ tube for aspiration pneumonia from 1999 to 2005. Demographics, incidence of aspiration pneumonia, and outcomes were collected and compared before and after the DPEJ placement. Eleven patients (4 women, 7 men) were identified; their mean age was 44.9 years (range, 18-94 years). The etiologies for recurrent aspiration pneumonia were neurologic disease (9), esophageal surgery (1), and severe debilitation (1). The mean follow-up was 20.9 months (range, 6-48 months). The patients' mean weight increased from 43.8 kg (range, 19-55 kg) to 48.3 kg (range, 30-65 kg) after placement (P < .001). The total number of documented aspiration pneumonia episodes for all patients decreased from 29 (mean, 3.64; range, 1-6) before DPEJ placement to 3 (mean, 0.27; range, 0-2) after DPEJ placement (P < .001). The mean number of aspiration pneumonia events per month prior to the DPEJ placement was 3.39 and postplacement was 0.42 (P < .001). DPEJ placement appears to decrease recurrent aspiration pneumonia in patients with history of aspiration pneumonia.