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2. Management of adverse events of EUS-directed transgastric ERCP procedure

Author

Yervant Ichkhanian, MD, Thomas Runge, MD, Manol Jovani, MD, Kia Vosoughi, MD, Olaya I. Brewer Gutierrez, MD, and Mouen A. Khashab, MD

Subjects
Diseases of the digestive system. Gastroenterology, RC799-869
Abstract

Background and Aims: Accessing the pancreatobiliary region in patients with a history of Roux-en-Y gastric bypass (RYGB) can be challenging. Traditionally, techniques such as percutaneous biliary drainage, enteroscopy-assisted ERCP, and laparoscopy-assisted ERCP have been used. However, each technique has its limitations. EUS–directed transgastric ERCP (EDGE) using a lumen-apposing metal stent (LAMS) has emerged as a novel endoscopic technique for ERCP in patients who have undergone RYGB. The aim of this case series was to highlight LAMS-related shortcomings and adverse events during the periprocedural period. Methods: This was a retrospective review of 4 patients with RYGB anatomy who underwent EDGE for the management of pancreaticobiliary disease and experienced LAMS-related adverse events. Techniques for managing and avoiding these events are discussed. Results: Four patients underwent EDGE with both technical and clinical success. Slight LAMS migration with partial mucosal overgrowth was encountered in 1 case and was managed by LAMS removal. A large, bleeding, distal marginal ulcer after the EDGE procedure was encountered in the second case and was managed with proton pump inhibitor and removal of the LAMS, with fistula treatment with argon plasma coagulation used to enhance closure. The third case was complicated by moderate intraprocedural bleeding after LAMS dilation, which was managed by applying balloon tamponade and placing a through-the-scope esophageal stent across the LAMS. Last, preferential food passage to the excluded stomach was noted in the fourth case and resulted in symptomatic distention. The symptomatic distention was managed by another de novo jejunogastrostomy using a LAMS for drainage. Conclusions: Despite its feasibility and acceptable safety profile, the use of LAMSs during EDGE could be associated with several procedure-specific adverse events, which can be avoided or managed endoscopically with no further consequence.

Published
2020
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4. Cardiovascular Risk Factors Are Associated With Future Cancer

Author

Bernard E. Kreger, Thomas J. Wang, Jennifer E. Ho, Navin Suthahar, Manol Jovani, Greta Lee Splansky, James L. Januzzi, Samantha M. Paniagua, Martin G. Larson, Daniel Levy, Rudolf A. de Boer, Susan Cheng, Emily S. Lau, Shawn X. Li, Katherine Takvorian, Elizabeth Liu, Ramachandran S. Vasan, and Cardiovascular Centre (CVC)

Subjects
Oncology, medicine.medical_specialty, GROWTH-FACTOR, BMI, body mass index, Cardiovascular risk factors, BIOMARKERS, NP, natriuretic peptide, Disease, CVD, cardiovascular disease, HF, heart failure, DISEASE, EVENTS, Breast cancer, hs-cTn, high-sensitivity cardiac troponin, prevention, Internal medicine, DM, diabetes mellitus, medicine, BREAST-CANCER, Risk factor, Original Research, NT-pro-BNP, N-terminal pro-B-type natriuretic peptide, AHA, American Heart Association, business.industry, SBP, systolic blood pressure, CV, cardiovascular, Cancer, Guideline, medicine.disease, Obesity, HR, hazard ratio, lifestyle risk factors, CI, confidence interval, HTN, hypertension, Heart failure, GUIDELINE, OBESITY, MI, myocardial infarction, HEART-FAILURE, ASCVD, atherosclerotic cardiovascular disease, Cardiology and Cardiovascular Medicine, business
Abstract

Background The extent to which co-occurrence of cardiovascular disease (CVD) and cancer is due to shared risk factors or other mechanisms is unknown. Objectives This study investigated the association of standard CVD risk factors, CVD biomarkers, pre-existing CVD, and ideal cardiovascular (CV) health metrics with the development of future cancer. Methods This study prospectively followed Framingham Heart Study and PREVEND (Prevention of Renal and Vascular End-Stage Disease) study participants free of cancer at baseline and ascertained histology-proven cancer. This study assessed the association of baseline CV risk factors, 10-year atherosclerotic (ASCVD) risk score, established CVD biomarkers, prevalent CVD, and the American Heart Association (AHA) Life’s Simple 7 CV health score with incident cancer using multivariable Cox models. Analyses of interim CVD events with incident cancer used time-dependent covariates. Results Among 20,305 participants (mean age 50 ± 14 years; 54% women), 2,548 incident cancer cases occurred over a median follow-up of 15.0 years (quartile 1 to 3: 13.3 to 15.0 years). Traditional CVD risk factors, including age, sex, and smoking status, were independently associated with cancer (p < 0.001 for all). Estimated 10-year ASCVD risk was also associated with future cancer (hazard ratio [HR]: 1.16 per 5% increase in risk; 95% confidence interval [CI] 1.14 to 1.17; p < 0.001). The study found that natriuretic peptides (tertile 3 vs. tertile 1; HR: 1.40; 95% CI: 1.03 to 1.91; p = 0.035) were associated with incident cancer but not high-sensitivity troponin (p = 0.47). Prevalent CVD and the development of interim CV events were not associated with higher risk of subsequent cancer. However, ideal CV health was associated with lower future cancer risk (HR: 0.95 per 1-point increase in the AHA health score; 95% CI: 0.92 to 0.99; p = 0.009). Conclusions CVD risk, as captured by traditional CVD risk factors, 10-year ASCVD risk score, and natriuretic peptide concentrations are associated with increased risk of future cancer. Conversely, a heart healthy lifestyle is associated with a lower risk of future cancer. These data suggest that the association between CVD and future cancer is attributable to shared risk factors., Central Illustration

Published
2021

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