Showing papers by "Todd H. Baron published in 2015"

Interventional Approaches to Gallbladder Disease.

Abstract: This review summarizes recent innovations in the approaches to gallbladder disease, including laparoscopic cholecystectomy, cholecystectomy with natural orifice transluminal endoscopic surgery, percutaneous cholecystostomy, and peroral endoscopic gallbladder drainage.

Immediate technical and delayed clinical outcome of fistula closure using an over-the-scope clip device.

Abstract: An over-the-scope clip (OTSC) device was designed for closure of acute perforations, fistulas, leaks, and non-variceal gastrointestinal bleeding. Previous data show a high rate of early fistula closure using the OTSC; however, data on long-term fistula closure are scant. We report our experience using an OTSC for closure of chronic gastrointestinal fistulas. Retrospective review of all patients, who underwent OTSC placement at Mayo Clinic Rochester and Virginia Mason Medical Center for closure of chronic fistulas from October 2011 to September 2012, was performed. Initial technical success was defined by lack of contrast extravasation immediately after OTSC placement. Delayed success was defined by resolution of the fistula without the need for additional therapies. Recurrent fistula was defined by the recurrence of symptoms and/or re-demonstration of fistula after initial success. Forty-seven unique patients (24 men; mean age 57 ± 14 years) underwent 60 procedures using the OTSC for closure of gastrointestinal fistulas. Fistula locations were: small bowel (n = 18), stomach (n = 16), colo-rectum (n = 10), and esophagus (n = 3). Fistulas related to previous percutaneous endoscopic gastrostomy/jejunostomy (n = 10) or prior bariatric procedure (n = 10) were the most common etiologies. Initial technical success occurred in 42/47 (89 %) index cases; however, 19/41 (46 %) patients developed fistula recurrence at a median of 39 days (IQR 26–86 days). The retained OTSC was present adjacent to the fistula in 16/19 (84 %) at repeat intervention. Patients were followed for a median length of 178 days (IQR 63–326 days), and only 25/47 (53 %) patients demonstrated delayed clinical success using OTSC. Initial technical fistula closure can be achieved using OTSCs. Recurrent fistulas at the same location occur in approximately 50 % of cases despite frequent OTSC clip retention.

Endoscopic ultrasound-guided liver biopsy.

Abstract: Liver biopsy remains the cornerstone in the diagnosis and management of liver disorders. Results of liver biopsy can often drive therapeutic decision-making. Unfortunately, studies have shown conventional biopsy techniques to carry significant sampling variability that can potentially impact patient care. Endoscopic ultrasound (EUS) is gaining traction as an alternative method of biopsy. For parenchymal disease, it can decrease sampling variability. It offers a more targeted approach for focal lesions. Its diagnostic yield and limited adverse event profile make it a promising approach for liver biopsy.

Surgery or EUS-guided choledochoduodenostomy for malignant distal biliary obstruction after ERCP failure

Abstract: Background and Objectives: Endoscopic retrograde cholangiopancreatography (ERCP) is the method of choice for drainage in patients with distal malignant biliary obstruction, but it fails in up to 10% of cases. Percutaneous transhepatic cholangiography (PTC) and surgical bypass are the traditional drainage alternatives. This study aimed to compare technical and clinical success, quality of life, and survival of surgical biliary bypass or hepaticojejunostomy (HJT) and endoscopic ultrasound (EUS)-guided choledochoduodenostomy (CDT) in patients with distal malignant bile duct obstruction and failed ERCP. Patients and Methods: A prospective, randomized trial was conducted. From March 2011 to September 2013, 32 patients with malignant distal biliary obstruction and failed ERCP were studied. The HJT group consisted of 15 patients and the CDT group consisted of 14 patients. Technical and clinical success, quality of life, and survival were assessed prospectively. Results: Technical success was 94% (15/16) in the HJT group and 88% (14/16) in the CDT group (P = 0.598). Clinical success occurred in 14 (93%) patients in the HJT group and in 10 (71%) patients in the CDT group (P = 0.169). During follow-up, a statistically significant difference was seen in mean functional capacity scores, physical health, pain, social functioning, and emotional and mental health aspects in both techniques (P < 0.05). The median survival time in both groups was the same (82 days). Conclusion: Data relating to technical and clinical success, quality of life, and survival were similar in patients who underwent HJT and CDT drainage after failed ERCP for malignant distal biliary obstruction.

Endoscopically inserted nasobiliary catheters for high dose-rate brachytherapy as part of neoadjuvant therapy for perihilar cholangiocarcinoma

Abstract: Background and aim: Selected patients with unresectable perihilar cholangiocarcinoma can undergo neoadjuvant chemoradiotherapy followed by liver transplantation, which has been shown to improve survival. The aim of this study was to determine the feasibility and safety of endoscopic transpapillary insertion of nasobiliary tubes (NBTs) and brachytherapy catheters for high dose-rate (HDR) brachytherapy as part of this neoadjuvant chemoradiotherapy. Patients and methods: Medical records of patients undergoing biliary brachytherapy for hilar cholangiocarcinoma at the Mayo Clinic, Rochester were reviewed. Patients were treated with curative intent using external beam radiotherapy (4500 cGy), chemotherapy (5-FU or capecitabine), and HDR brachytherapy (930 – 1600 cGy in one to four fractions delivered over 1 – 2 days) prior to planned liver transplantation. Results: Between 2009 and 2013, 40 patients underwent biliary HDR brachytherapy via endoscopically placed NBTs (8.5 – 10 Fr). Patients had a median age of 55 years (range 28 – 68); 25 patients (62.5 %) had primary sclerosing cholangitis. Prior to therapy, 29 patients (72.5 %) had plastic stents, two (5 %) had metal stents, and nine (22.5 %) had no stents. Bilateral NBTs were placed in five patients (12.5 %). NBT/brachytherapy catheter displacement was seen in eight patients (20 %) – five intraprocedure and three post-procedure. A radiotherapy error and NBT kinking each occurred once. Post-procedure adverse events included: cholangitis (n = 5; 12.5 %), severe abdominal pain (n = 3; 7.5 %), duodenopathy (n = 3; 7.5 %), gastropathy (n = 3; 7.5 %), and both duodenopathy and gastropathy (n = 2; 5 %). Conclusion: HDR biliary brachytherapy administered via endoscopically placed NBTs and brachytherapy catheters is technically feasible and appears reasonably safe in selected patients with unresectable perihilar cholangiocarcinoma.

New ex-vivo porcine model for endoscopic ultrasound-guided training in transmural puncture and drainage of pancreatic cysts and fluid collections (with videos).

Abstract: Background and Objectives: Endoscopic transmural puncture cysts and drainage pancreatic fluid collections are an important part of endoscopic ultrasound practices, but can be technically difficult to master, particularly with regards to placing stents We developed an ex-vivo model that is inexpensive and can be used for cyst puncture and fluid collection drainage Methods: Over the last 5 years, we have perfected the creation of this ex-vivo model The model is easy and inexpensive to create and multiple aspirations and device placements and removals into a single cavity with decompression The model allows the use of cautery devices and placement of expandable metal stents Additionally, the contents in the model can be altered to appear as walled-off necrotic collections endosonographically Results: The model can be created for <300 US dollars It has been used at multiple international conferences for teaching purposes and can withstand up to 10 puncture and drainages without having to replace the cyst The cyst can easily be exchanged for other prepared cysts Preliminary surveys obtained from users show ratings that are realistic Conclusions: A new ex-vivo model can be easily and economically created, is realistic and can be used multiple times during the single training session

Bench-top testing of suction forces generated through endoscopic ultrasound-guided aspiration needles.

Abstract: Background Adequate needle size and tissue acquisition techniques for endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) need further elucidation. Moreover, the actual negative pressure and suction forces of FNA needles remain unknown. We evaluated the suction forces of 19-gauge, 22-gauge, and 25-gauge conventional FNA needles and side hole aspiration needles using conventional negative pressure and the slow pull technique. Methods Using a manometer, we determined the mean (SD) negative pressure and suction force for needle gauge, aspiration volume, and aspiration technique. We also evaluated the time to reach the maximum negative pressure. Results Suction force was comparatively higher in the 19-gauge needle when 50 ml of negative pressure was applied. Suction force using the slow pull method was very weak at 5% of pressure found with conventional methods. With the use of a 20-ml syringe, the time to reach the maximum negative pressure was 4 s in the 19-gauge needle, 11 s in the 22-gauge needle, and 80 s in the 25-gauge needle. Conclusions Bench-top testing showed that suction force increases with a larger gauge needle and larger aspiration volume. The slow pull method produces a very weak suction force. The time to reach the maximum negative pressure was longest in the 25-gauge needle.

Outcome of stenting in biliary and pancreatic benign and malignant diseases: A comprehensive review.

Abstract: Endoscopic stenting has become a widely method for the management of various malignant and benign pancreatico-biliary disorders. Biliary and pancreatic stents are devices made of plastic or metal used primarily to establish patency of an obstructed bile or pancreatic duct and may also be used to treat biliary or pancreatic leaks, pancreatic fluid collections and to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis. In this review, relevant literature search and expert opinions have been used to evaluate the outcome of stenting in biliary and pancreatic benign and malignant diseases.

Endoscopic management of benign biliary strictures

Abstract: Endoscopic management of biliary obstruction has evolved tremendously since the introduction of flexible fiberoptic endoscopes over 50 years ago. For the last several decades, endoscopic retrograde cholangiopancreatography (ERCP) has become established as the mainstay for definitively diagnosing and relieving biliary obstruction. In addition, and more recently, endoscopic ultrasonography (EUS) has gained increasing favor as an auxiliary diagnostic and therapeutic modality in facilitating decompression of the biliary tree. Here, we provide a review of the current and continually evolving role of gastrointestinal endoscopy, including both ERCP and EUS, in the management of biliary obstruction with a focus on benign biliary strictures.

Endoscopic ultrasound-guided drainage and necrosectomy of walled-off pancreatic necrosis using a metal stent with an electrocautery-enhanced delivery system and hydrogen peroxide.

Abstract: Direct endoscopic necrosectomy of walled-off pancreatic necrosis (WOPN) has recently been reported to have comparable success rates to surgery, but with lower morbidity and mortality [1,2]. The procedure is, however, time consuming and requires multiple device exchanges [3], whichmay increase the risk of complications. A novel, dedicated device, the Hot AXIOS (Xlumena Inc., Mountain View, California, USA) (●\" Fig.1), has recently become available. This consists of a large-diameter, fully covered self-expanding metal stent (FCSEMS) with antimigration flanges, which is mounted on a 10.8-Fr delivery system with an electrocautery blade at its distal tip. We performed endoscopic ultrasound (EUS)-guideddrainageof aWOPN (median size 17cm, range 10–20cm) in four patients using the Hot AXIOS to directly create a transmural fistula, enter the cavity, and place a 15-mm×10-mm FCSEMS, which was completely deployed under real-time EUS guidance (●\" Fig.2). A standard gastroscope was then used to perform balloon dilation of the lumen of the FCSEMS up to 15mm to allow entry into the cavity and perform direct endoscopic necrosectomy. Preliminary data have suggested that irrigation of the necrotic content of areas of WOPN with hydrogen peroxide (H2O2) can facilitate necrosectomy [4,5], so we injected 40– 60mL hydrogen peroxide (3%) into the cavity at the beginning and at the end of each session of direct endoscopic necrosectomy. We then used extraction nets, baskets, and forceful irrigation to clean the necrotic material (●\" Video 1). The four patients underwent a median of five endoscopy sessions (range 4–6). A pneumoperitoneum occurred in one patient and was treated conservatively. The FCSEMSs were easily removed in three patients. In the remaining patient, who did not present for follow-up until 138 days after insertion of the FCSEMS, overgrowth of normal mucosa had occurred and a decisionwasmade to leave the stent permanently in place. No recurrence of WOPN has been observed after a mean follow-up of 8.5 months (range 5–10 months).

Endoscopic management of pancreatic pseudocysts and necrosis.

Abstract: Over the last several years, there have been refinements in the understanding and nomenclature regarding the natural history of acute pancreatitis. Patients with acute pancreatitis frequently develop acute pancreatic collections that, over time, may evolve into pancreatic pseudocysts or walled-off necrosis. Endoscopic management of these local complications of acute pancreatitis continues to evolve. Treatment strategies range from simple drainage of liquefied contents to repeated direct endoscopic necrosectomy of a complex necrotic collection. In patients with chronic pancreatitis, pancreatic pseudocysts may arise as a consequence of pancreatic ductal obstruction that then leads to pancreatic ductal disruption. In this review, we focus on the indications, techniques and outcomes for endoscopic therapy of pancreatic pseudocysts and walled-off necrosis.

Optimizing bowel cleansing for colonoscopy

Abstract: Adequate bowel cleansing is essential for complete examination of the colon mucosa during colonoscopy. Suboptimal bowel preparation has potential adverse consequences, such as missed pathologic abnormalities, the need for repeated procedures, and increased procedure-related complications. Several factors can predict individuals at increased risk for inadequate bowel preparation. If predictors of inadequate bowel preparation are identified, then education should be intensified and a more aggressive bowel regimen recommended. On completion of this article, you should be able to (1) define the frequency of inadequate colon preparations, (2) identify predictors of poor bowel preparation, and (3) use a more aggressive bowel regimen when clinically indicated.

Transgastric endoscopic ultrasound with fine-needle aspiration and ERCP using percutaneous-assisted transprosthetic endoscopic therapy in a gastric bypass patient.

Abstract: Percutaneous-assisted transprosthetic endoscopic therapy (PATENT) is a novel endoscopic technique recently developed which uses a nonnatural orifice to gain access to the gastrointestinal tract for performance of interventional procedures during a single session [1]. PATENT permits endoscopic retrograde cholangiopancreatography (ERCP) in patientswith longlimb Roux-en-Y gastric bypass (RYGB) and overcomes limitations of other accessgaining techniques [2,3]. We present the first case of endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) using PATENT. A 66-year-old woman with prior RYGB presented for evaluation of obstructive jaundice (total bilirubin 10.1mg/dL). Abdominal CT demonstrated a 2-cm pancreas head mass suggestive of adenocarcinoma with intraand extrahepatic biliary dilatation and pancreatic ductal dilatation. There was no definitive vascular invasion or encasement. Prominent lymph nodes were also noted. The patient was deemed a borderline candidate for pancreaticoduodenectomy. Neoadjuvant chemotherapy and biliary decompression were recommended. A peroral EUS exam from the small gastric pouch showed limited views of the tumor and FNAwas nondiagnostic. ERCP was attempted using a single-balloon enteroscope, but cannulation of the biliary tree was unsuccessful. Repeat ERCP and EUS were successfully performed 4 days later with the patient supine and under general anesthesia, using the PATENT technique [2,3]. After passing a single-balloon enteroscope via the mouth to the excluded stomach, a gastrostomy tract was created using the Russell introducer method and a 7cm× 18mm fully covered esophageal self-expandable metal stent (SEMS) (AlimaxxES; Merit Medical Endotek, South Jordan, UT, USA) was placed across the tract. A linear-array echoendoscope (GF-UCT180; Olympus America, Center Valley, PA, USA) was passed via the gastrostomy tract through the esophageal SEMS to the excluded stomach and duodenum (●\" Fig.1, ●\" Fig.2a). Standard EUS images were obtained (●\" Fig.2b) and revealed a mass abutting the portal venous confluence. FNA with rapid on-site cytopathology demonstrated adenocarcinoma. ERCP (TJF-Q180V; Olympus America) was performed with placement of a 4cm×10mm transpapillary uncovered biliary SEMS (Wallflex; Boston Scientific, Natick, MA, USA) (●\" Fig.2c). Following ERCP the esophageal SEMS was removed by traction and a standard 26-Fr balloon-tipped gastrostomy tube was placed in the tract. Neoadjuvant therapy was followed by restaging with abdominal CT 3 months later, which suggested development of metastases. The patient is receiving palliative chemoradiation. This case demonstrates that the PATENT approach is an option in patients with RYGB in whom biliary or pancreas head pathology is strongly suspected and EUS with ERCP is deemed necessary. PATENT is successful when therapeutic ERCP interventions are needed in RYGB patients [2,3]. As in the present case, PATENT appears useful for diagnostic purposes. Using PATENT in our patient allowed routine EUS with diagnostic FNA cytology when an initial EUS exam was limited and yielded a nondiagnostic specimen. Wilson et al. [4] recently identified challenges of EUS in patients with surgically altered anatomy. EUS failed to image the common bile duct and pancreas head in 86% of patients with RYGB; however, the pancreas body and tail were visible for examination and accessible for adequate FNA. Thus, routine peroral EUS appears adequate for distal pancreas lesions in RYGB patients. Nearly 70% of pancreas adenocarcinomas occur in the pancreatic head, and EUS evaluation and the ability to perform diagnostic FNA in this area are paramount [5].

Endoscopic ultrasound (EUS)-guided duodenogastroenterostomy: why not do it from the other side?

Abstract: troenterostomy: why not do it from the other side? A 76-year-old woman, with previous resection of a metastatic mixed adenocarcinoma-neuroendocrine tumor of smallbowel origin presented with gastric outlet obstruction. Abdominal computed tomography revealed a submucosal mass in the third portion of the duodenum, with upstream gastroduodenal dilatation. There was intimate contact between the wall of the fourth duodenal portion and the stomach (●\" Fig.1). Retrograde gastroenterostomy was performed as follows, with the patient under general anesthesia. A forward-viewing curved linear endoscopic ultrasound (EUS) scope (TGF-UC180J; Olympus) was advanced distally from the stenosis and proximally to the ligament of Treitz, with the tip of the echoendoscope apposed to the gastric wall under fluoroscopic view. Instillation of water into the stomach via a nasogastric tube aided echo visualization. Direct puncture into the stomach was done with a standard 19-gauge fineneedle aspiration (FNA) needle and a gastrogram was obtained using contrast under fluoroscopic guidance (●\" Fig.2a). A 0.025-inch guidewire (450cm, angled-tip VisiGlide; Olympus) was advanced into the stomach and allowed to loop once (●\" Fig.2b). The echoendoscope was withdrawn and re-introduced to grasp the gastric portion of the wire, allowing control of both ends. Then the echoendoscope was re-introduced over the duodenal portion of the guidewire and a 15-10 biflanged lumen-apposing stent (Axios; Boston Scientific) was advanced into the stomach (●\" Fig.3) and deployed without cautery or balloon dilation (●\" Fig.4a, ●\" Fig.4b). The patient did well without adverse events. Despite previous reports of EUS gastroenterostomies [1–4], to our knowledge this has never previously been performed from the duodenum to the stomach, as described here. This approach avoids puncture into the duodenal lumen, which has a small caliber and is mobile, and obviated the need for a targeting balloon [2]. In addition, the forward-viewing endoscope allows stent advancement without the need for tract dilation, minimizing the risk of luminal leakage. Although the gastric wall may tent away during stent advancement, having both ends of the wire under pressure allows this to be overcome.

Endoscopic Treatment of Complications of Inflammatory Bowel Diseases

Abstract: Inflammatory bowel diseases affect about 1 in 200 persons in Western countries. Patients with Crohn’s disease (CD) in particular often require surgery as disease evolves from a primarily luminal inflammatory process to a stricturing and/or penetrating disease. Endoscopic modalities are emerging as a viable and exciting alternative to surgery in a subset of patients with IBD. Endoscopic balloon dilation, with or without topical corticosteroid injection, for IBD-related strictures is a safe and effective intervention for patients with short, bland, symptomatic strictures, and may avoid the need for surgery. Novel strategies such as endoscopic needle-knife stricturotomy and stent placement may improve the durability of balloon dilation. Endoscopic intrafistular injection of fibrin glue, in conjunction with medical management, may be a therapeutic intervention for patients with CD-related fistulae; addition of adipose-derived or mesenchymal stem cells to fibrin glue may significantly improve fistula healing, but is awaiting further study. Endotherapy for an acutely bleeding Crohn’s ulcer and colonoscopic polypectomy and endoscopic mucosal resection are safe and effective treatments for adenoma and flat but raised colitis-associated colorectal neoplasia, and may obviate colectomy in patients with IBD. Endoscopy is fast emerging from a purely diagnostic modality, to a potentially therapeutic intervention in the armamentarium of gastroenterologists involved in the care of patients with IBD.

Reply to Whiteley et al.

Abstract: triplicate testing. Reliance by Visrodia et al. upon the sample means of groups of singular ATP readings is undermined by the knowledge of variability where the standard deviation can be as high as 40% of the data mean for the individual brand of device used. The authors themselves note the risk of singular testing in the body of the discussion: “to sample more than one... and to use more than 1 rapid indicator,” but we wonder how the statistical assumptions hold valid without multiple (replicate) samples taken for the ATP testing. We also note 2 problems with the scaling of all commercial ATP devices. First, the scale of RLU is completely relative and cannot be used interoperatively between differently branded devices. Second, the variability for each of the brands is so high that without a sampling approach that accounts for multiple samples at any one point, the ability of the scientists involved to meaningfully apply statistical methods renders the article subject to first principle flaws. Reporting the RLU readings on a log scale is not the same as taking multiple samples, identifying the median value, and then log plotting the data. Perhaps this was done, but it remains unclear within the text. We feel obliged to inform those who may be reliant upon the work to take care in not applying the work using one brand of ATP device to another brand of ATP device, as noted in the commentary by Petersen. Likewise, we caution against relying on the statistical positioning in the field use of ATP without an appropriately constructed sampling plan to account for inherent variability. This overlay of concern will continue to apply until all ATP device manufacturers can agree to a commonly applicable scale that minimizes the impact of variability, no matter what the assignation given to the replacement reading scale.

Gastro-pancreaticojejunostomy for treatment of pancreatic ductal obstruction in a post-Whipple procedure patient.

Abstract: We report a case of a woman with a medical history of classic Whipple surgery who underwent endoscopic ultrasound (EUS)-guided pancreatic drainage due to smouldering acute pancreatitis secondary to an obstructing pancreatic ductal stone. A gastro-pancreaticojejunostomy anastomosis was created anterogradely, with dilation of both the anastomoses in the same procedure, with subsequent decompression of the pancreatic duct. Endoscopic retrograde pancreatography (ERP) is often impossible to perform in patients with post-Whipple procedure anatomy due to inaccessibility to the pancreaticojejunostomy anastomosis. EUS-guided pancreatic drainage may be offered in these patients in whom the pancreatic duct cannot be accessed at ERP. It has been used as a platform for access to and drainage of the pancreatic duct either by rendezvous or transmural drainage. However, only one of four patients achieve successful completion of the rendezvous procedure. There are limited data regarding safety and long-term outcome of this procedure, as well as scant guidelines on the optimal time for leaving stents in place. We believe definitive endoscopic therapy should be attempted, whenever possible, after relief of obstruction. In our case, we expect that stent occlusion is inevitable and that long-term drainage is possible due to drainage occurring between the stent and the stone.