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Pancreatic cancer has known precursor lesions with potential to develop into malignancy over time. At least 20% of pancreatic cancer evolves from mucinous cystic neoplasms and intraductal papillary mucinous neoplasms, which are often discovered incidentally.1,2 Current guidelines for the management of mucinous cystic neoplasms and intraductal papillary mucinous neoplasms include long-term surveillance, which is expensive and nontherapeutic, or surgical resection, which is associated with major risk and may not be an option for patients with significant concomitant illness.3.

Aim To evaluate the efficacy and safety of liquid nitrogen cryotherapy as a primary or rescue treatment for BE, with and without dysplasia, or intramucosal adenocarcinoma (IMC). Methods This was a retrospective, single-center study carried out in a tertiary care center including 45 patients with BE who was treatment-naive or who had persistent intestinal metaplasia (IM), dysplasia, or IMC despite prior therapy. Barrett's mucosa was resected via EMR when clinically appropriate, then patients underwent cryotherapy until eradication or until deemed to have failed treatment. Surveillance biopsies were taken at standard intervals. Results From 2010 through 2014, 33 patients were studied regarding the efficacy of cryotherapy. Overall, 29 patients (88%) responded to cryotherapy, with 84% having complete regression of all dysplasia and cancer. Complete eradication of cancer and dysplasia was seen in 75% of subjects with IMC; the remaining two subjects did not respond to cryotherapy. Following cryotherapy, 15 patients with high-grade dysplasia (HGD) had 30% complete regression, 50% IM, and 7% low-grade dysplasia (LGD); one subject had persistent HGD. Complete eradication of dysplasia occurred in all 5 patients with LGD. In 5 patients with IM, complete regression occurred in 4, and IM persisted in one. In 136 cryotherapy sessions amongst 45 patients, adverse events included chest pain (1%), stricture (4%), and one gastrointestinal bleed in a patient on dual antiplatelet therapy who had previously undergone EMR. Conclusion Cryotherapy is an efficacious and safe treatment modality for Barrett's esophagus with and without dysplasia or intramucosal adenocarcinoma.

INTRODUCTION The need for factor concentrate (FC) prior to uncomplicated endoscopies in persons with hemophilia (PWH) is not well characterized. Infusion of FC is time consuming, costly, and increases risk of inhibitor development. There is no general consensus on management of PWH undergoing endoscopies and the incidence of bleeding is not well established. At our Hemophilia Treatment Center (HTC), our standard of care (SOC) for many years was to manage PWH with an infusion of FC prior to any endoscopy for any indication regardless of severity of hemophilia. In November 2017, we changed our SOC for persons with mild hemophilia (factor VIII or IX >5%) to use only antifibrinolytics pre-endoscopy for those in whom no procedural intervention was anticipated, followed by infusion of FC post-endoscopy if a biopsy or polypectomy was performed or if there was bleeding associated with the procedure. Persons with moderate or severe hemophilia (factor VIII or IX ≤5%) continued to receive infusion of FC prior to all endoscopies. We report our experience managing PWH of all severities undergoing EGD and colonoscopy between 2008 and 2019. We compare incidence of bleeding, cost of medical care, and outcomes before and after the change in SOC for persons with mild hemophilia. METHODS Subjects were identified from a database of patients treated at our HTC. Those with factor VIII inhibitors were excluded. Cost of FC and antifibrinolytics were determined from average wholesale pharmacy prices in 2019. Gastrointestinal (GI) bleeding was assessed by review of medical records within 30 days after endoscopy. Documentation of any patient or clinician reported hematemesis or rectal bleeding, requiring or not requiring medical attention or treatment, was recorded as GI bleeding. Adequacy of hemostasis, as assessed by review of medical records, was classified as poor if the subject had unexpected hypotension, required intensive or intermediate care, or transfusion; fair if unplanned doses of FC were required, but the event did not meet criteria for poor hemostasis; and excellent for events that did not meet any of the above criteria. RESULTS Sixty-seven subjects met eligibility criteria; 12 were excluded due to inadequate records of endoscopies. Data were collected on 110 endoscopies performed in 55 subjects, range 1 to 5 per subject. Subject demographics are noted in Table 1. Endoscopy characteristics and outcomes are shown in Table 2. GI bleeding occurred within 30 days after 10 endoscopies prior to the change in SOC. This included 7 endoscopies performed because of preexisting bleeding due to esophageal varices, or gastric, duodenal, or colonic ulcers. In addition, post endoscopy bleeding occurred in one patient after colonoscopy following the use of hot snare cautery resection of polyps, and in another after resection of a rectal polyp by cold snare following an EGD with colonoscopy. No GI bleeding occurred within 30 days of the endoscopies performed after we changed our SOC. FC was used prior to 97.1% of 68 endoscopies performed before we changed our SOC, compared to 73.8% of 42 endoscopies performed after. Hospital stay of 2 days was equivalent across all groups when subjects with preexisting bleeding were excluded. Hemostasis was excellent in 79.4% of endoscopies before we changed our SOC and 100% of endoscopies after. Endoscopy characteristics and outcomes in subjects with mild hemophilia before and after we changed our SOC are shown in Table 3. Reasons for using FC pre-endoscopy in these subjects included preexisting bleeding, planned intervention, or anticipated complex procedure. Treatment costs in subjects with mild hemophilia are noted in Table 4. CONCLUSION We describe our HTC's experience with endoscopies in PWH. In our cohort of persons with mild hemophilia, we demonstrate that the use of antifibrinolytics rather than FC pre-endoscopy did not result in any difference in adequacy of hemostasis or development of GI bleeding within 30 days post endoscopy. This practice was associated with significant cost-savings and no difference of hospitalization rate or length of stay. We conclude that persons with mild hemophilia, who are not actively bleeding or undergoing complex procedures, can be safely managed with antifibrinolytics alone pre-endoscopy. However, patient-specific and procedure-specific factors must be considered when determining the appropriate pre-endoscopy treatment for bleeding prophylaxis in PWH. Disclosures Eyster: Novo Nordisk: Research Funding; SPARK: Research Funding; Sanofi: Research Funding; Baxalta/Shire: Research Funding.

INTRODUCTION: Large polyps >20 mm make up 5% of all polyps removed and are considered high-risk precancerous lesions Endoscopic mucosal resection (EMR) is a technique used to remove these polyps, but has a local recurrence rate of 10-30% at first follow up Recurrence is thought to be due to residual microscopic disease at the edge or base of the resected polyp Hybrid argon plasma coagulation (APC) is an innovative technique which can be used to ablate the remaining microscopic disease at the base and edge of the polyp thereby reducing local recurrence The aim of this study was to assess recurrence at 6 months following hybrid APC assisted EMR Secondary endpoints including post polypectomy bleeding and post polypectomy syndrome were also assessed METHODS: Patients in this single-center, prospective data collection study were referred to our institution for resection of polyps >20 mm After obtaining consent, eligible patients underwent endoscopy using the hybrid APC assisted EMR technique Participants were contacted 30 days after their procedure to assess adverse events At 6 months, patients were brought back in for a surveillance colonoscopy, and rate of polyp recurrence was calculated This study was approved by the Penn State Institutional Review Board RESULTS: At the time of this report, 25 (62 5%) of the 40 treated patients had completed the 6-month follow-up colonoscopy Three patients were lost to follow up, one patient withdrew for personal reasons, and 11 patients are currently awaiting rescheduling due to the COVID-19 pandemic Demographics of the included patients and characteristics of the study polyps are displayed in Table 1 and Table 2, respectively Post polypectomy bleeding was reported by 3 (7 5%) patients, and post polypectomy syndrome was reported by 1 (2 5%) patient None of the 25 patients who have completed the study showed recurrence at 6 months CONCLUSION: This prospective data collection study assessing 6-month recurrence rate using hybrid APC assisted EMR preliminarily resulted in a 0% local recurrence rate Secondary end points assessing post polypectomy syndrome and post polypectomy bleeding revealed an incidence of 2 5% and 7 5%, respectively This suggests that hybrid APC assisted EMR may be more effective at reducing the rate of polyp recurrence Additional studies assessing a larger population of patients in a randomized control trial would be recommended to ensure this data is generalizable to the general population

Acute, high-grade esophageal perforation and postoperative leak after esophagogastrostomy are associated with high morbidity and mortality due to the development of mediastinitis and thoracic contamination. Endoscopic vacuum therapy has proven to be a feasible, safe therapy for management of esophageal wall defects, but with limited success. We describe a retrospective single-center analysis of two patients who underwent endoscopic vacuum therapy for significant esophageal disruptions with a median cross-sectional diameter of 10.7 cm. The technique involved the use of a standard upper video endoscope, nasogastric tube, and vacuum-assisted closure dressing kit, with endoscopic placement of a polyurethane sponge and nasogastric tube assembly into the mediastinal or thoracic cavity. Serial washout and debridement were performed prior to each sponge insertion. Data were collected on indication, size of the cavities, time to intervention, number of procedures, time to resolution, outcomes, and adverse events. Two patients underwent therapy with a mean age of 69.5. The median size of the collections via longest cross-sectional diameter was 10.7 cm. The average number of endoscopic vacuum therapy performed was six and average duration of therapy was 49 days. Complete resolution was achieved in both patients. One patient died 6 weeks later due to severe sepsis from aspiration pneumonia. Endoscopic washout and debridement followed by endoscopic vacuum therapy can be effective for large, even multiple, thoracic and mediastinal contaminations following esophageal perforation and gastroesopagheal anastomotic dehiscence and leaks in appropriately selected patients.

Background and study aims: In this study, we aim to determine the safety and feasibility of an alcohol-free approach to pancreatic cyst ablation using a chemotherapeutic ablation cocktail. Patients and methods: In this prospective, randomized, double-blinded pilot study, 10 patients with known mucinous type pancreatic cysts underwent endoscopic ultrasound (EUS)-guided fine needle aspiration and then lavage with either 80 % ethanol or normal saline. Both groups were then treated with a cocktail of paclitaxel and gemcitabine. Primary outcomes were reduction in cyst volume and rates of complications. Results: At 6 months, patients randomized to the alcohol arm had an 89 % average volume reduction, with a 91 % reduction noted in the alcohol-free arm. Complete ablation was achieved in 67 % of patients in the alcohol-free arm at both 6 and 12 months, whereas the alcohol group recorded complete ablation rates of 50 % and 75 % at 6 and 12 months, respectively. One patient in the alcohol arm developed acute pancreatitis (20 %) with no adverse events in the alcohol-free arm. Conclusions: This study revealed similar ablation rates between the alcohol ablation group and the alcohol-free arm and demonstrates the safety and feasibility of an alcohol-free ablation protocol. This pilot study suggests that alcohol may not be required for effective cyst ablation.

Bovine mammary gland biopsies allow researchers to collect tissue samples to study cell biology including gene expression, histological analysis, signaling pathways, and protein translation. This article describes two techniques for biopsy of the bovine mammary gland (MG). Three healthy Holstein dairy cows were the subjects. Before biopsies, cows were milked and subsequently restrained in a cattle chute. An analgesic (flunixin meglumine, 1.1 to 2.2 mg/kg of body weight) was administered via jugular intravenous [IV] injection 15-20 min prior to biopsy. For standing sedation, xylazine hydrochloride (0.01-0.05 mg/kg of body weight) was injected via the coccygeal vessels 5-10 min before the procedure. Once adequately sedated, the biopsy site was aseptically prepared and locally anaesthetized with 6 mL of 2% lidocaine hydrochloride via subcutaneous injection. Using aseptic technique, a 2 to 3 cm vertical incision was made using a number 10 scalpel. Core and needle biopsy tools were used. The core biopsy tool was attached to a cordless drill and inserted into the MG tissue through the incision using a clock-wise drill action. The needle biopsy tool was manually inserted into the incision site. Immediately after the procedure, an assistant applied pressure on the incision site for 20 to 25 min using a sterile towel to achieve hemostasis. Stainless steel surgical staples were used to oppose the skin incision. The staples were removed 10 days post-procedure. The main advantages of core and needle biopsies is that both approaches are minimally invasive procedures that can be safely performed in healthy cows. Milk yield following the biopsy was unaffected. These procedures require a short recovery time and result in fewer risks of complications. Specific limitations may include bleeding after the biopsy and infection on the biopsy site. Applications of these techniques include tissue collection for clinical diagnosis and research purposes, such as primary cell culture.

An important concern when planning research studies is to obtain maximum precision of an estimate of a treatment effect given a budget constraint. When research designs have a multilevel or hierarchical structure changes in sample size at different levels of the design will impact precision differently. Furthermore, there will typically be differential costs of enrolling additional units at different levels of the hierarchy. The optimal design problem in multilevel research studies involves determining the optimal sample size at each level of the design given specified design parameters and a specified marginal cost of recruitment at each level. The current work extends existing results by considering optimal design for (a) unbalanced random assignment designs and (b) regression discontinuity designs.

The frequency of anemia, iron deficiency, and the long-term need for IV iron following Roux-en-y gastric bypass (RYGB) surgery has not been well characterized. Three-hundred and nineteen out of 904 consecutive subjects who underwent RYGB at Penn State Hershey Medical Center from 1999 to 2006 met the inclusion criteria for a preoperative complete blood count (CBC) and at least one CBC >6 months following surgery. Cumulative incidence of anemia 7 years post procedure was 58%. Menstruation status and presence of preoperative anemia were predictive of anemia by univariate analysis and multivariable Cox regression ( P= 0.0014 and 0.044, respectively). Twenty-seven subjects, primarily premenopausal women, representing 8.5% of the cohort and 22% of the 122 anemic subjects, needed intravenous (IV) iron a mean of 51 months postoperatively for anemia unresponsive or refractory to oral iron. The risk for development of anemia necessitating IV iron therapy following RYGB is highest in menstruating women and continues to increase for many years, even in post-menopausal women. Well-designed prospective studies are needed to identify the incidence of iron deficiency anemia and the patient populations at increased risk for requiring IV iron replacement after RYGB surgery.

Background & Aims Endoscopic ultrasound (EUS)−guided chemoablation with ethanol lavage followed by infusion of paclitaxel is effective for the treatment of mucinous pancreatic cysts. However, complications arise in 3%−10% of patients, presumably linked to the inflammatory effects of ethanol. We aimed to determine whether alcohol is required for effective pancreatic cyst ablation, if removing alcohol from the ablation process would improve complication rates, and whether a multi-agent chemotherapeutic cocktail could increase the rate of complete cyst resolution compared with findings reported from previous trials using alcohol followed by paclitaxel alone. Methods Between November 2011 and December 2016, we conducted a single-center, prospective, double-blind trial of 39 patients with mucinous-type pancreatic cysts. Patients were randomly assigned to 1 of 2 groups that underwent EUS-guided pancreatic cyst lavage with either 80% ethanol (control) or normal saline (alcohol-free group). Cysts in both groups were then infused with an admixture of paclitaxel and gemcitabine. Primary outcomes were the rates of complete ablation 12 months after the procedure, and rates of serious and minor adverse events within 30 days of the procedure. Results At 12 months, 67% of patients who underwent alcohol-free EUS-guided cyst chemoablation had complete ablation of cysts compared with 61% of patients in the control group. Serious adverse events occurred in 6% of patients in the control group vs none of the patients in the alcohol-free group. Minor adverse events occurred in 22% of patients in the control group and none of the patients in the alcohol-free group. The overall rate of complete ablation was 64%. Conclusions In this prospective, randomized, controlled trial, we found that alcohol is not required for effective EUS-guided pancreatic cyst ablation, and when alcohol is removed from the ablation process, there is a significant reduction in associated adverse events. A multi-agent chemotherapeutic ablation admixture did not appear to significantly improve rates of complete ablation compared with the current standard of alcohol lavage followed by paclitaxel alone. ClinicalTrials.gov ID: NCT01475331.

The double layer stent (DLS) has a unique design and has been used for palliation of malignant biliary obstruction, but literature on this stent is limited. Our aim was to compare plastic (PS), DLS and metal stents (MS) in terms of complication rates, time to occlusion, and patency rate in patients with malignant biliary obstruction (MBO). A retrospective review of stents placed for MBO at our institution in the period between January 2009 and April 2011 was conducted. A total of 114 stents were identified, of which 44 were MS (39 %), 37 DLS (32 %), and 33 PS (29 %). A stent was considered occluded when an unplanned stent removal or intervention occurred due to clinical suspicion of biliary obstruction. Stents remained patent for 95 days (range 7–359 days) in the DLS group and 59 days (range 7–228 days) in the PS group (P = 0.014) and 128.7 days (range 4–602 days) in the metal stent group. Twenty-seven percent (n = 9) of PS occluded after a mean of 60 days while 16 % (n = 7) of MS occluded after a mean of 87 days and 5 % (n = 2) of DLS occluded after a mean of 85 days (DLS vs. PS P = 0.012, DLS vs. MS P = 0.13, MS vs. PS P = 0.22). DLS are superior to PS in patients with MBO and appear to be comparable to MS. MS had a longer patency rate but were comparable to DLS in early and late complications. We speculate that the less expensive DLS may be a cost effective alternative in the palliation of MBO.

Osteonecrosis (ON) is rare while arthropathy is common in persons with haemophilia. A recent case of bilateral ON of the femoral head prompted us to review our experience with hip arthroplasty. We identified nine patients with presumed end-stage haemophilic arthropathy. Four of the nine individuals had radiographic findings suggestive of ON, but without unequivocal microscopic evidence of ON. It is important to recognize ON at an early stage because there are surgical interventions which may prolong the life of the joint and improve quality of life. We suggest that ON should be included in the differential diagnosis of hip pathology in persons with haemophilia presenting with hip pain or dysfunction.

Over the past decade, endoscopic technology has changed our approach to small bowel disorders. This chapter reviews newer endoscopic modalities, including indications, techniques, and limitations pertaining to their use. Concluding thoughts center on concepts and equipment for small bowel endoscopy that remain investigational.

Endoscopic ultrasonography with fine needle infusion (EUS-FNI) of alcohol is the most reported method for EUS-guided tumor ablation. Several studies have reported successful EUS-guided ablation of pancreatic neuroendocrine tumors. However, these tumors have been relatively small (

The last decade has seen several advances which have opened the door to diagnostic and therapeutic endoscopy within the small intestine, an area long considered the “final frontier” of endoscopic imaging. The introduction of the double balloon enteroscope into clinical practice has allowed for the application of several therapeutic techniques within the small intestine. This chapter will review two such techniques: enteral stenting and balloon dilation.

Background Small bowel mass lesions (SBML) are a relatively common cause of obscure gastrointestinal bleeding (OGIB). Their detection has been limited by the inability to endoscopically examine the entire small intestine. This has changed with the introduction of capsule endoscopy (CE) and double balloon enteroscopy (DBE) into clinical practice. Study Aim To evaluate the detection of SBML by DBE and CE in patients with OGIB who were found to have SBML by DBE and underwent both procedures. Methods A retrospective review of a prospectively collected database of all patients undergoing DBE for OGIB at seven North American tertiary centers was performed. Those patients who were found to have SBML as a cause of their OGIB were further analyzed. Results During an 18 month period, 183 patients underwent DBE for OGIB. A small bowel mass lesion was identified in 18 patients. Of these, 15 patients had prior CE. Capsule endoscopy identified the mass lesion in five patients; fresh luminal blood with no underlying lesion in seven patients, and non-specific erythema in three patients. Capsule endoscopy failed to identify all four cases of primary small bowel adenocarcinoma. Conclusions Double balloon enteroscopy detects small bowel mass lesions responsible for OGIB that are missed by CE. Additional endoscopic evaluation of the small bowel by DBE or intraoperative enteroscopy should be performed in patients with ongoing OGIB and negative or non-specific findings on CE.

Background Surveillance and treatment of small-bowel polyps in patients with Peutz-Jeghers syndrome (PJS) can be challenging and may require intraoperative enteroscopy. While initial reports that used double-balloon enteroscopy (DBE) for the resection of small-bowel polyps in patients with PJS appear promising, complete enteroscopy when using this technique may require multiple procedures or may not be possible at all. Objective To develop a single-procedure approach to the surveillance and the treatment of small-bowel polyps in patients with PJS. Design Retrospective review. Setting Single, North American tertiary-care center. Patients Individuals with PJS and small-bowel polyps identified by other modalities. Interventions DBE was combined with laparoscopy as a single-procedure surveillance and therapeutic strategy for small-bowel PJS polyps. Main Outcome Measurements Completion of enteroscopy, number of polyps resected, procedure duration, complications. Results Three patients with a history of PJS and known small-bowel polyps underwent laparoscopic-assisted DBE (LADBE). Complete enteroscopy was performed, and all polyps larger than 0.5 cm were resected endoscopically. No cases of cancer or dysplasia were noted; procedure times lasted from 1 to 4 hours. Postoperative complications included ileus in 2 patients. Limitations Small sample size, single-center experience. Conclusions LADBE holds promise as a new technique that can be used as both a surveillance and a therapeutic tool for small-bowel polyps in patients with PJS.

Background and Study Aims: Endoscopic mucosal resection and photodynamic therapy are exciting, minimally invasive curative techniques that represent an alternative to surgery in patients with Barrett's esophagus and high-grade dysplasia or intramucosal adenocarcinoma. However, there is lack of uniformity regarding which staging method should be used prior to therapy, and some investigators even question whether staging is required prior to ablation. We report our experience with a protocol of conventional endoscopic ultrasound staging prior to endoscopic therapy. Patients and Methods: A total of 25 consecutive patients with a diagnosis of high-grade dysplasia or intramucosal adenocarcinoma in Barrett's esophagus who had been referred to the University of Chicago for staging in preparation for endoscopic therapy between March 2002 and November 2004 were included in the study. All 25 patients underwent repeat diagnostic endoscopy and conventional endosonography with a radial echo endoscope. Any suspicious lymph nodes that were detected were sampled using endoscopic ultrasound-guided fine-needle aspiration. Results: Baseline pathology in the 25 patients (mean age 70, range 49-85) revealed high-grade dysplasia in 12 patients and intramucosal carcinoma in 13 patients. Five patients were found to have submucosal invasion on conventional endosonography. Seven patients had suspicious adenopathy, six regional (N1) and one metastatic to the celiac axis (M1a). Fine-needle aspiration confirmed malignancy in five of these seven patients. Based on these results, five patients (20%) were deemed to be unsuitable candidates for endoscopic therapy. Conclusions: By detecting unsuspected malignant lymphadenopathy, conventional endosonography and endoscopic ultrasound with fine-needle aspiration dramatically changed the course of management in 20% of patients referred for endoscopic therapy of Barrett's esophagus with high-grade dysplasia or intramucosal carcinoma. Based on our results, we believe that conventional endosonography and endoscopic ultrasound with fine-needle aspiration when nodal disease is present should be performed routinely in all patients referred for endoscopic therapy in this setting.

Background The capability of obtaining tissue samples for histologic examination during EUS has theoretical advantages over cytology alone. The objective was to evaluate the feasibility and the yield of EUS-guided FNA tissue acquisition (EUS-FNTA) by using high negative pressure suction. Methods The study design is a prospective, observational pilot study set at a tertiary referral center. Twenty-seven patients with a solid mass amenable to sampling with EUS were included in the study. FNA with a 22-gauge needle was used for a total of 5 passes. An additional pass with the same needle was performed by applying continuous high negative pressure suction using the Alliance II inflation system. The main outcome measurements were the rate of tissue acquisition and the diagnostic accuracy of EUS-FNTA. Observations Tissue samples were obtained in 26 of the 27 patients (96%). Malignancy was detected in 20 of the 26 biopsy specimens obtained by FNTA and in 20 of the 27 FNA specimens. In 3 patients, EUS-FNTA failed to disclose malignancy, which in two of the patients was diagnosed by FNA. Conversely, EUS-FNTA diagnosed a recurrent malignant thymoma and a schwannoma in two FNA-negative patients. In 3 patients with both FNTA and FNA negative for malignancy, a definitive diagnosis could not be established. Overall, diagnostic accuracy was 76.9% for both EUS-FNTA and EUS-FNA. When combined, a correct diagnosis was achieved in 84.6% of the patients. Immunostaining of the retrieved tissue allowed characterization of the primary tumor in 5 cases and the diagnosis of a schwannoma and two neuroendocrine tumors. Limitations of the study were small sample size and a pilot study. Conclusions EUS-FNTA has a high yield for the retrieval of core tissue samples. Further studies in which EUS-FNTA is performed before FNA and with variable number of passes are needed to better define its diagnostic role and performance characteristics.

Summary. Total joint replacement (TJR) is an option for the management of chronic haemophilic arthropathy. Because surgery is technically challenging, there is a high rate of deep prosthetic infections, particularly in human immunodeficiency virus (HIV)-infected individuals. We determined the incidence of deep infection rates following total knee and hip arthroplasties in HIV-seropositive and HIV-seronegative persons with haemophilia. Fifty-one primary joint replacements were performed on 32 patients seen at a regional comprehensive haemophilia care center from 1975 to 2002. Thirty prostheses were placed in patients who were HIV-seropositive prior to surgery (n = 14) or seroconverted later (n = 16). Median age at the time of surgery was 33 years (range: 20–61) among 19 HIV-seropositive patients and 35 years (range: 26–74) among 13 HIV-negative patients. Median duration of follow-up was 83 months (range: 2–323). Rate of primary joint infection per artificial joint-year by HIV status was compared by Poisson regression. Main outcome measures were the incidence of primary replacement joint infections by HIV status. Deep infections developed in five (9.8%) of 51 replacement joints. There were two infections during 204.15 joint-years without HIV infection and three infections during 205.28 joint-years with HIV infection. The incidence rate of joint infection (0.98 vs. 1.46 per 100 joint-years) was not increased with HIV (relative risk, RR: 1.49, 95% CI: 0.25–8.93, P = 0.66). We conclude that HIV infection is not a contraindication to knee or hip replacement arthroplasty in the appropriate clinical setting.

Background The Stretta procedure is an endoluminal antireflux procedure using radio frequency to induce collagen tissue contraction, remodeling, and modulation of lower esophageal sphincter physiology in an effort to treat gastroesophageal reflux disease (GERD). Although Stretta has been widely reported in the adult GERD literature as a viable initial surgical option, similar use in children has not been reported. The authors present the first report of Stretta as the initial antireflux procedure in children with GERD, evaluating indications, safety, and efficacy. Method The charts of 8 children (aged 11-16 years) who received Stretta between January 2003 and September 2003 were retrospectively reviewed under an Institutional Review Board protocol. All patients had documented GERD preoperatively. Three children required concomitant feeding tube placement (percutaneous gastrostomy tube, group A). Five children with isolated severe GERD refractory to aggressive medical therapy received Stretta only (group B). Results Stretta was successfully completed in all 8 children. In group A, 1 child developed a postoperative aspiration, which was successfully treated. All 3 children had resolution of their GERD symptoms (ie, feeding intolerance, emesis) and were able to tolerate full enteral nutrition post-Stretta. In group B, 3 of 5 children are currently off medications and asymptomatic on short-term follow-up (6-15 months). Of the remaining 2, 1 experienced symptomatic relief immediately postprocedure, but symptoms recurred off medications. Stretta was deemed unsuccessful in the remaining patient, and Nissen fundoplication was subsequently performed without difficulty. Conclusions Stretta can be safely and successfully used as the initial antireflux procedure for children with GERD. Concomitant Stretta with PEG is an attractive option in children with preexisting GERD who require long-term feeding access. Longer follow-up and a larger patient population are needed to better confirm the safety and efficacy of Stretta presented in this report.

Endoscopic ultrasound-guided fine needle aspiration (EUS-guided FNA) is becoming a preferred modality for diagnosing and staging GI and mediastinal malignancies. Although experts advocate on-site cytopathology assessment for tissue sample adequacy, there are few data to support this claim. Our goal was to determine whether on-site cytopathology interpretation improves the diagnostic yield of EUS-guided FNA.EUS-guided FNA results from two university hospital centers were reviewed and compared. At center 1, where EUS-guided FNA was performed with a cytopathologist on site, the results of 108 consecutive patients were evaluated. At center 2, where a cytopathologist is unavailable, the results of 87 consecutive patients were reviewed. One endoscopist performed all procedures at both institutions. Cytologic diagnoses were categorized as positive or negative for malignancy, suspicious for malignancy, atypical/indeterminate, or unsatisfactory. The number of repeat procedures, needle passes, medication use, target site, age, and sex were compared between the two sites.Patients at center 2 were older (p = 0.04) and predominantly female (p = 0.03). Pancreas was the most common target site at center 2, whereas thoraco-abdominal nodes were the most common at center 1 (p = 0.0001). Patients at center 1 had a diagnosis of positive or negative for malignancy more frequently (p = 0.001) and were less likely to have an unsatisfactory specimen (p = 0.035) or repeat procedure, although the latter was not significant (p = 0.156).On-site cytopathology interpretation improves the diagnostic yield of EUS-guided FNA. EUS centers should allocate resources to cover for on-site cytopathology evaluation.

Techniques of endoscopic mucosal resection (EMR) can dramatically improve the ability to diagnose and treat superficial lesions in the gastrointestinal tract. Early cancers, subepithelial tumors, and sessile polyps can be safely and completely removed in a single procedure. Recovery of the entire lesion with margins enables precise staging and evolution of the most effective management plan. Because necessary instruments are routinely stocked in most endoscopy units, EMR can be readily incorporated into practice. The procedure carries low complication rates, provided that endoscopists are familiar with indications and steps for implementation. This article is intended to acquaint those not performing EMR with the procedure and to review pertinent clinical experience.

Introduction. Gastric emphysema can present both a diagnostic challenge and a life-threatening condition for patients and has only once been reported as being recurrent.Background. A 64-year-old male presented with chronic abdominal pain and was found to have gastric pneumatosis on CT scan. The patient was successfully managed conservatively. The cause was attributed to aberrant arterial anatomy and atherosclerosis along with hypotension. The patient has since had 3 episodes of recurrent gastric emphysema, all managed nonoperatively.Discussion. To our knowledge, this is the first case of both serial episodes of gastric pneumatosis and gastric mucosal ischemia as a precipitating factor for the development of gastric emphysema.

Background Double-balloon enteroscopy (DBE) is effective in visualizing the small bowel to perform biopsy sampling and interventions. Few studies have evaluated the utility of DBE in patients with known or suspected Crohn's disease (CD). Objective To evaluate the use of DBE in the diagnosis and impact on patient management in known and suspected CD and to compare capsule endoscopy (CE) with DBE findings. Design Retrospective study from August 2004 to August 2009 of DBE procedures. Setting Five academic, tertiary U.S. centers. Patients Patients with known or suspected CD. Main Outcome Measures Diagnostic yield, impact on patient management, and comparison of DBE to CE findings in patients with known and suspected CD. Results We analyzed 98 DBE procedures performed in 81 patients (38 with known CD and 43 with suspected CD). For patients with CD, common indications were abdominal pain and bleeding/anemia. The diagnostic yield was 87% (33/38 patients). The impact on subsequent management decisions was 82% (31/38). Common indications for DBE in patients with suspected CD were abnormal CE or other imaging. The diagnostic yield was 79% (34/43 patients). The impact on subsequent management decisions was 77% (33/43). In 17% of patients (14/81), DBE failed to reach the target lesion. There was 1 perforation, 3 strictures dilated, and 1 of 2 retained capsules recovered. When CE was followed by DBE, 46% of lesions were confirmed on DBE. Limitations Retrospective analysis, imperfect criterion standard. Conclusions DBE is an effective technique for assessment of the small bowel in known and suspected CD and affects management. Failure to reach target areas with DBE is not uncommon, and perforations can occur. There is poor correlation between CE and DBE.

Traditionally, the diagnosis of small bowel disorders has been challenging secondary to the small intestine's length, tortuosity, and anatomic location. Recent technologic advancements in the field of enteroscopy and radiographic imaging have facilitated a more thorough endoscopic evaluation of patients with small bowel disease ranging from obscure gastrointestinal bleeding to inflammatory bowel disease and small bowel tumors. Such developments have made it possible to avoid invasive surgical procedures in certain clinical scenarios where they were previously the gold standard. In this review, we report an update on the diagnostic and management approach to patients with small bowel disease, emphasizing the advantages and limitations of the latest modalities now available to primary care physicians and gastroenterologists for evaluating patients with presumed disease of the small intestine.

Clinical management of esophageal cancer is a multidisciplinary challenge. Diagnosis is associated with a high mortality and approximately 40% of patients have locally advanced disease at clinical presentation. Surgery remains one of the fundamental parts of treatment, but multimodal approaches including chemotherapy and radiation are associated with improved outcomes. This comprehensive review addresses the multidisciplinary management of early and locally advanced esophageal cancer.