Showing papers by "Todd H. Baron published in 2013"

Management of antithrombotic therapy in patients undergoing invasive procedures.

Abstract: When patients receiving anticoagulation therapy undergo invasive procedures, management requires an individualized assessment of the risk of bleeding versus the risk of thrombosis. This review explains management, including bridging anticoagulation for patients receiving warfarin.

Factors Predictive of Adverse Events Following Endoscopic Papillary Large Balloon Dilation: Results from a Multicenter Series

Abstract: Lack of established guidelines for endoscopic papillary large balloon dilation (EPLBD) may be a reason for aversion of its use in removal of large common bile duct (CBD) stones. We sought to identify factors predictive of adverse events (AEs) following EPLBD. This multicenter retrospective study investigated 946 consecutive patients who underwent attempted removal of CBD stones ≥10 mm in size using EPLBD (balloon size 12–20 mm) with or without endoscopic sphincterotomy (EST) at 12 academic medical centers in Korea and Japan. Ninety-five (10.0 %) patients exhibited AEs including bleeding in 56, pancreatitis in 24, perforation in nine, and cholangitis in six; 90 (94.7 %) of these were classified as mild or moderate in severity. There were four deaths, three as a result of perforation and one due to delayed massive bleeding. Causative factors identified in fatal cases were full-EST and continued balloon inflation despite a persistent waist seen fluoroscopically. Multivariate analyses showed that cirrhosis (OR 8.03, p = 0.003), length of EST (full-EST: OR 6.22, p < 0.001) and stone size (≥16 mm: OR 4.00, p < 0.001) were associated with increased bleeding, and distal CBD stricture (OR 17.08, p < 0.001) was an independent predictor for perforation. On the other hand, balloon size was associated with deceased pancreatitis (≥14 mm: OR 0.27, p = 0.015). EPLBD appears to be a safe and effective therapeutic approach for retrieval of large stones in patients without distal CBD strictures and when performed without full-EST.

A meta-analysis of endoscopic stenting as bridge to surgery versus emergency surgery for left-sided colorectal cancer obstruction.

Abstract: The best approach to resolve colonic obstruction in patients with left-sided colon cancer is not established. In this meta-analysis the efficacy of stenting as bridge-to-surgery was compared to emergency surgery for the management of left-sided colonic obstruction. Fourteen studies (randomized and non controlled studies) were identified, including 405 patients in the stent group and 471 in the emergency group. The difference between proportions was evaluated as effect size (ESi). There was large heterogeneity among the studies. Stenting offered advantages over emergency surgery in terms of increase in primary anastomosis (ES=25.1%, p<0.001), successful primary anastomosis (ES=23.7%, p<0.001), reduction of stoma creation (ES=-27.1%, p=0.03), infections (ES=-7.9%, p=0.006) and other morbidities (ES=-13.4%, p<0.001). The interventions were similar in regards to length of hospitalization, preoperative mortality and long-term survival.

Endoscopic retrograde cholangiopancreatography: utilisation and outcomes in a 10-year population-based cohort

Abstract: Objective To determine utilisation of endoscopic retrograde cholangiopancreatography (ERCP); incidence of inpatient admissions for complications occurring within 30 days of ERCP and risk factors for procedural-related complications, in a population-based study. Design Retrospective cohort study. Setting Olmsted County, Minnesota. Participants All adult residents of Olmsted County, Minnesota, who underwent ERCP from 1997 to 2006. Interventions Diagnostic and therapeutic ERCPs were assessed. Primary and secondary outcome measures Patient and procedural characteristics and complications within 30 days; and rates of ERCP utilisation and unplanned admissions and risk factors for admissions. Results In 10 years, 1072 ERCPs were performed on 827 individual patients. Average utilisation of ERCP was 83.1 ERCPs/100 000 persons/year, with an increase from 58 to 104.8 ERCPs/100 000 persons/year over time, driven by increases in therapeutic procedures. Within 30 days after 236 procedures, 62 admissions were definitely related to the index ERCP. The complication rate was 5.3%, including pancreatitis (26, 2.4%), infection/cholangitis (16, 1.5%), bleeding (15, 1.4%) and perforation (4, 0.37%). 30-day mortality was 2.4%, none of which was directly related to the ERCP or complications thereof. Risk factors identified through multivariate analysis to be associated with adverse events included: age Limitations Retrospective study. Conclusions Population utilisation of ERCP rose during the study period, specifically in therapeutic procedures. Admissions within 30 days of ERCP are common but often unrelated. Complications of ERCP remain infrequent and deaths quite unusual.

Bilateral Metal Stents for Hilar Biliary Obstruction Using a 6Fr Delivery System: Outcomes Following Bilateral and Side-by-Side Stent Deployment

Abstract: Background and Study Aim Controversy exists on optimal endoscopic management for palliation of malignant hilar obstruction, with advocates for metal “side-by-side” (SBS) and “stent-in-stent” (SIS) techniques. We sought to evaluate the technical feasibility, efficacy, and outcomes of bilateral biliary self-expanding metal stents (SEMS) for treatment of malignant hilar obstruction using a stent with a 6Fr delivery system.

The role of peroral video cholangioscopy in patients with IgG4-related sclerosing cholangitis.

Abstract: The cholangioscopic features of IgG4-related sclerosing cholangitis (IgG4-SC) remain undefined. The aim of this study was to clarify these endoscopic features using peroral video cholangioscopy (PVCS) in IgG4-SC patients. PVCS was performed in 33 patients: IgG4-SC (n = 13); primary sclerosing cholangitis (PSC; n = 5); and cholangiocarcinoma (n = 15), which included hilar cholangiocarcinoma (HCCA; n = 5) and distal cholangiocarcinoma (DCCA; n = 10). The most frequent findings on PVCS in the IgG4-SC patients were dilated (62 %) and tortuous (69 %) vessels, and absence of partially enlarged vessels. The incidence of dilated and tortuous vessels was significantly higher in IgG4-SC patients than in PSC patients (p = 0.015). Scarring and pseudodiverticula were found significantly more often in PSC patients than in IgG4-SC patients (p = 0.001 and p = 0.0007, respectively). The incidence of partially enlarged vessels was significantly higher in DCCA patients than in IgG4-SC patients (p = 0.004). In contrast, the incidence of dilated vessels was significantly higher in IgG4-SC patients than in HCCA patients (p = 0.015). PVCS performed after corticosteroid therapy showed resolution of bile duct stenosis and dilated, tortuous, or partially enlarged vessels, as well as resolution of friability in all patients with IgG4-SC. Cholangioscopy was useful in differentiating IgG4-SC from PSC. In addition, monitoring the patterns of proliferative vessels on PVCS may be useful to differentiate IgG4-SC from cholangiocarcinoma.

Single-session ERCP in patients with previous Roux-en-Y gastric bypass using percutaneous-assisted transprosthetic endoscopic therapy: a case series

Abstract: Endoscopic retrograde cholangiopancreatography (ERCP) remains technically challenging following Roux-en-Y gastric bypass (RYGB). Various techniques have been described to access the excluded stomach. We describe our experience using percutaneous-assisted transprosthetic endoscopic therapy (PATENT) to perform antegrade ERCP. Balloon enteroscopy was used to access the excluded stomach. Direct retrograde percutaneous endoscopic gastrostomy (RPEG) was performed and an esophageal self-expandable metal stent (SEMS) was deployed within the gastrostomy tract. A duodenoscope was advanced through the SEMS and antegrade ERCP was performed. Following ERCP, a gastrostomy tube was placed through the SEMS to maintain patency. Five patients underwent successful antegrade ERCP using PATENT. All patients had a diagnosis of sphincter of Oddi dysfunction. Biliary sphincterotomy was performed in all patients and liver enzymes normalized in four patients with preprocedural elevations. In conclusion, antegrade ERCP employing PATENT is feasible and can be performed during a single endoscopic session in patients with previous RYGB.

Increased risk of prosthetic joint infection associated with esophago-gastro-duodenoscopy with biopsy.

Abstract: Background There are no prospective data regarding the risk of prosthetic joint infection following routine gastrointestinal endoscopic procedures. We wanted to determine the risk of prosthetic hip or knee infection following gastrointestinal endoscopic procedures in patients with joint arthroplasty. Methods We conducted a prospective, single-center, case-control study at a single, tertiary-care referral center. Cases were defined as adult patients hospitalized for prosthetic joint infection of the hip or knee between December 1, 2001 and May 31, 2006. Controls were adult patients with hip or knee arthroplasties but without a diagnosis of joint infection, hospitalized during the same time period at the same orthopedic hospital. The main outcome measure was the odds ratio (OR) of prosthetic joint infection after gastrointestinal endoscopic procedures performed within 2 years before admission. Results 339 cases and 339 controls were included in the study. Of these, 70 cases (21%) cases and 82 controls (24%)...

Feasibility of NOTES Omental Plug Repair of Perforated Peptic Ulcers – Results from a Clinical Pilot Trial

Abstract: Ulcer perforation carries up to a 30 % 1-year mortality rate. Intervention-related adverse events are among statistically significant predictors of 1-year mortality. A natural orifice transluminal endoscopic surgical (NOTES) approach may be less invasive and may decrease procedure-related adverse events by diminishing the so-called second hit, thus leading to decreased morbidity and mortality. We sought to assess the feasibility of an endoscopic transluminal omental plug technique in patients with perforated gastroduodenal ulcers under laparoscopic guidance. Patients with suspected acute gastroduodenal ulcer perforations were offered participation in this prospective pilot study. Closure of the perforation was attempted using the NOTES omental plug technique. Demographic, clinical, endoscopic, and radiographic data were abstracted, as were data for morbidity, mortality, and pilot data regarding quality of life (QOL). From February 2010 through February 2012, a total of 17 patients presented to a tertiary care center with clinically suspected perforated ulcer. Of seven patients (mean age 79 years, range 64–89 years) who consented to the study, three underwent the study procedure. All patients had multiple comorbidities. Two patients presented with 4–6 mm perforated peptic ulcers and underwent successful laparoscopic-assisted NOTES omental and falciform ligament patch closure, respectively. Postoperative radiographic contrast studies showed no leak, and patients were discharged home on postoperative days 3 and 4. The third patient had undergone enterocutaneous fistula repair with herniorrhaphy 6 weeks before. Although a transluminal endoscopic approach was feasible, the omentum was under too much tension to be secured. This procedure was converted to an open omental patch repair. For all but one patient who provided consent, obtaining QOL data was feasible. Initial results from a laparoscopic-assisted NOTES approach for closure of perforated peptic ulcers appear promising and enable swift recovery in selected patients. This is especially important in elderly and/or immunocompromised patients. Technical details and patient selection criteria continue to evolve.

Hepatic artery pseudoaneursym formation following intraductal biliary radiofrequency ablation

Abstract: A 73-year-old man with a history of liver transplantation developed cholestasis. No abnormality was seen on magnetic resonance imaging. Percutaneous cholangioscopy via a left-sided transhepatic tract (●\" Fig.1) demonstrated carpet-like villous change with biopsies showing highgrade dysplasia in the right and left ducts. Intraductal ultrasound (IDUS) showed a T1 lesion, with bile duct wall thickening to 2.4mm. Radiofrequency ablation (RFA) was performed in the right and left hepatic ducts with an 8-French catheter (Habib EndoHPB, EMcision, Montreal, Canada) at 10W for 90 seconds. Sixteen days later the patient presented with melena, requiring transfusion of 6 units packed red blood cells. Angiography showed a 1.2-cm pseudoaneurysm of the right hepatic artery, which was thrombosed with percutaneous thrombin injection. Subsequent cholangioscopy demonstrated successful ablation of the biliary dysplasia (●\" Fig.1). The close temporal relationship of RFA to pseudoaneurysm formation, and the absence of other apparent etiologies, implicate intraductal RFA as the likely cause. RFA may be used to treat cholangiocarcinoma [1,2] and intraductal extension of ampullary polyp [3]. The cross-sectional diameter of the RFA tissue ablation zone varies from 4.3 to 11.3mm depending on the power and duration of treatment [4]. These values are probably underestimates, since they are based on ex-vivo experiments and do not take into account delayed tissue necrosis. We hypothesize that RFA induced necrosis of the bile duct wall and a portion of adjacent right hepatic artery, leading to pseudoaneurysm formation with subsequent rupture into the right hepatic duct. The right hepatic artery may focally approach within 1mm of the bile duct wall [5]. We now utilize IDUS immediately prior to RFA, and avoid performing RFA at 10W wherever a vessel passes within 4mm of the IDUS probe (●\" Fig.2). However, when a closely approximating vessel cannot be avoided, we decrease the RFA energy setting.

Improving early detection of gastric cancer: a novel systematic alphanumeric-coded endoscopic approach.

Abstract: Despite extensive worldwide use of standard esophagogastroduodenoscopy (EGD) examinations, gastric cancer (GC) is one of the most common forms of cancer and ranks as the most common malignant tumor in East Asia, Eastern Europe and parts of Latin America. Current limitations of using non systematic examination during standard EGD could be at least partially responsible for the low incidence of early GC diagnosis in countries with a high prevalence of the disease. Originally proposed by Emura et al., systematic alphanumeric-coded endoscopy (SACE) is a novel method that facilitates complete examination of the upper GI tract based on sequential systematic overlapping photo-documentation using an endoluminal alphanumeric-coded nomenclature comprised of eight regions and 28 areas covering the entire surface upper GI surface. For precise localization or normal or abnormal areas, SACE incorporates a simple coordinate system based on the identification of certain natural axes, walls, curvatures and anatomical endoluminal landmarks. Efectiveness of SACE was recently demonstrated in a screening study that diagnosed early GC at a frequency of 0.30% (2/650) in healthy, average-risk volunteer subjects. Such a novel approach, if uniformly implemented worldwide, could significantly change the way we practice upper endoscopy in our lifetimes.

A multicenter, prospective study of a new fully covered expandable metal biliary stent for the palliative treatment of malignant bile duct obstruction

Abstract: Background and Study Aims. Endoscopic placement of self-expanding metal stents (SEMSs) is indicated for palliation of inoperable malignant biliary obstruction. A fully covered biliary SEMS (WallFlex Biliary RX Boston Scientific, Natick, USA) was assessed for palliation of extrahepatic malignant biliary obstruction. Patients and Methods. 58 patients were included in this prospective, multicenter series conducted under an FDA-approved IDE. Main outcome measurements included (1) absence of stent occlusion within six months or until death, whichever occurred first and (2) technical success, need for reintervention, bilirubin levels, stent patency, time to stent occlusion, and adverse events. Results. Technical success was achieved in 98% (57/58), with demonstrated acute removability in two patients. Adequate clinical palliation until completion of followup was achievedin 98% (54/55) of evaluable patients, with 1 reintervention due to stent obstruction after 142 days. Mean total bilirubin decreased from 8.9 mg/dL to 1.2 mg/dL at 1 month. Device-related adverse events were limited and included 2 cases of cholecystitis. One stent migrated following radiation therapy. Conclusions. The WallFlex Biliary fully covered stent yielded technically successful placement with uncomplicated acute removal where required, appropriate reduction in bilirubin levels, and low rates of stent migration and occlusion. This SEMS allows successful palliation of malignant extrahepatic biliary obstruction.

Acute biliary conditions.

Abstract: Acute biliary complications may result from several medical conditions such as gallstone pancreatitis, acute cholangitis, acute cholecystitis, bile leak, liver abscess and hepatic trauma. Gallstones are the most common cause of acute pancreatitis. About 25% of theses patients will develop clinically severe acute pancreatitis, usually due to necrotizing pancreatitis. Choledocholithiasis, malignant and benign biliary strictures, and stent dysfunction may cause partial or complete obstruction and infection in the biliary tract with acute cholangitis. Bile leaks are most commonly associated with hepatobiliary surgeries or invasive procedures such as open or laparoscopic cholecystectomy, hepatic resection, hepatic transplantation, liver biopsy, and percutaneous transhepatic cholangiography. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) may have an essential role in the management of these complications.

Self-expandable stents in the gastrointestinal tract

Abstract: Self-expandable stents in the gastrointestinal tract / , Self-expandable stents in the gastrointestinal tract / , کتابخانه دیجیتال جندی شاپور اهواز

Managing severe acute pancreatitis.

Abstract: Severe acute pancreatitis causes high rates of illness and death. Simple scoring predictors can help identify patients at risk so that treatment, primarily supportive, can begin promptly after presentation. Medical therapy is the mainstay, with supportive therapy consisting of controlled volume resuscitation and enteral feeding. Minimally invasive drainage and debridement play a role in managing infective pancreatic necrosis but in general should not be used until at least 4 weeks after the acute illness.

Recommended intervals between screening and surveillance colonoscopies.

Abstract: Colonoscopy has become the mainstay for screening and surveillance of colorectal cancer. The guidelines for screening and surveillance colonoscopy have recently been updated, particularly in light of greater recognition of the importance of sessile serrated lesions in the role of cancer. It is important for practitioners to be aware of and understand the recommendations for screening and surveillance to optimize patient safety and to decrease health care use. We searched PubMed for articles and guidelines related to screening and surveillance of colonic polyps and serrated adenomas. The related citations feature was also used. The search was conducted from February 22, 2013, to March 2, 2013, and we included the search terms colorectal cancer screening, colonoscopy, guidelines, colorectal polyps, and colorectal surveillance. We selected the most recent guidelines and pertinent articles for this review, in which we discuss the basis of screening and surveillance colonoscopy and provide recommendations for colonoscopy intervals.

Antithrombotic therapy and invasive procedures.

Abstract: n engl j med 369;11 nejm.org september 12, 2013 1077 geography (distance from home to hospital), and even hospital administrative factors (prioritization of patients in a crowded ward). Possible varying practice among hospitals is unlikely to have influenced the main results, because we found no significant hospital–treatment interaction. Havard Ove Skjerven, M.D. Kai-Hakon Carlsen, M.D., Ph.D. Karin C. Lodrup Carlsen, M.D., Ph.D.