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Individuals diagnosed with colorectal adenomas with high-risk features during screening colonoscopy have increased risk for the development of subsequent adenomas and colorectal cancer. While US guidelines recommend surveillance colonoscopy at 3 years in this high-risk population, surveillance uptake is suboptimal. To inform future interventions to improve surveillance uptake, we sought to assess surveillance rates and identify facilitators of uptake in a large integrated health system. We utilized a cohort of patients with a diagnosis of ≥ 1 tubular adenoma (TA) with high-risk features (TA ≥ 1 cm, TA with villous features, TA with high-grade dysplasia, or ≥ 3 TA of any size) on colonoscopy between 2013 and 2016. Surveillance colonoscopy completion within 3.5 years of diagnosis of an adenoma with high-risk features was our primary outcome. We evaluated surveillance uptake over time and utilized logistic regression to detect factors associated with completion of surveillance colonoscopy. The final cohort was comprised of 405 patients. 172 (42.5%) patients successfully completed surveillance colonoscopy by 3.5 years. Use of a patient reminder (telephone, electronic message, or letter) for due surveillance (adjusted odds = 1.9; 95%CI = 1.2–2.8) and having ≥ 1 gastroenterology (GI) visit after diagnosis of an adenoma with high-risk features (adjusted odds = 2.6; 95%CI = 1.6–4.2) significantly predicted surveillance colonoscopy completion at 3.5 years. For patients diagnosed with adenomas with high-risk features, surveillance colonoscopy uptake is suboptimal and frequently occurs after the 3-year surveillance recommendation. Patient reminders and visitation with GI after index colonoscopy are associated with timely surveillance completion. Our findings highlight potential health system interventions to increase timely surveillance uptake for patients diagnosed with adenomas with high-risk features.

Early aggressive intravenous hydration is recommended for acute pancreatitis treatment although randomized trials have not documented benefit. We performed a randomized trial of aggressive vs. standard hydration in the initial management of mild acute pancreatitis.Sixty patients with acute pancreatitis without systemic inflammatory response syndrome (SIRS) or organ failure were randomized within 4 h of diagnosis to aggressive (20 ml/kg bolus followed by 3 ml/kg/h) vs. standard (10 ml/kg bolus followed by 1.5 mg/kg/h) hydration with Lactated Ringer's solution. Patients were assessed at 12-h intervals. At each interval, in both groups, if hematocrit, blood urea nitrogen (BUN), or creatinine was increased, a bolus of 20 ml/kg followed by 3 ml/kg/h was given; if labs were decreased and epigastric pain was decreased (measured on 0-10 visual analog scale), hydration was then given at 1.5 ml/kg/h and clear liquid diet was started. The primary endpoint, clinical improvement within 36 h, was defined as the combination of decreased hematocrit, BUN, and creatinine; improved pain; and tolerance of oral diet.The mean age of the patients was 45 years and only 14 (23%) had comorbidities. A higher proportion of patients treated with aggressive vs. standard hydration showed clinical improvement at 36 h: 70 vs. 42% (P=0.03). The rate of clinical improvement was greater with aggressive vs. standard hydration by Cox regression analysis: adjusted hazard ratio=2.32, 95% confidence interval 1.21-4.45. Persistent SIRS occurred less commonly with aggressive hydration (7.4 vs. 21.1%; adjusted odds ratio (OR)=0.12, 0.02-0.94) as did hemoconcentration (11.1 vs. 36.4%, adjusted OR=0.08, 0.01-0.49). No patients developed signs of volume overload.Early aggressive intravenous hydration with Lactated Ringer's solution hastens clinical improvement in patients with mild acute pancreatitis.

Author(s): Shao, Paul; Corona, Edgar; Bastani, Roshan; Yang, Liu; Mwengela, Didi; Didero, Michelle; Asokan, Ishan; Bui, Alex; Hsu, William; May, Folasade Fola P

Author(s): Corona, Edgar; Bastani, Roshan; Yang, Liu; Shao, Paul; Mwengela, Didi; Didero, Michelle; Asokan, Ishan; Bui, Alex; Hsu, William; May, Folasade

Author(s): May, Folasade; Corona, Edgar; Yang, Liu; Nguyen, B Sean; Lin, Christina; Huang, Marcela Zhou; Shao, Paul; Mwengela, Didi; Didero, Michelle; Asokan, Ishan; Bui, Alex; Hsu, William; Maehara, Cleo; Naini, Bita; Kang, Yuna; Bastani, Roshan

Endoscopic retrograde cholangiopancreatography (ERCP) is frequently used to clear the common bile duct (CBD) in patients with choledocholithiasis. While a single ERCP is usually effective, many patients undergo multiple ERCP attempts before cholecystectomy. Here we sought to identify preoperative factors predictive of surgical complexity beyond routine laparoscopic cholecystectomy after ERCP. Data were prospectively collected for all ERCPs between September 2010 and February 2012 at a public academic medical center including demographics, indication, stone presence, CBD diameter, sphincterotomy, stent placement, and ERCP number. A total of 124 ERCPs were attempted in 73 patients with choledocholithiasis, 10 per cent of whom presented with cholangitis. Fifty-six per cent of patients underwent one ERCP, whereas 16 per cent required ≥ 3 procedures. Laparoscopic cholecystectomy was performed in 58 (79%) patients whereas 15 (21%) patients required more complex operations including eight open CBD explorations and two hepaticojejunostomies. The likelihood of requiring more complex surgery correlated with increasing number of ERCPs with an adjusted odds ratio of 5.75 (95% confidence interval: 2.31–14.3, P ≤ 0.001). Increased CBD diameter also correlated with complex surgery with adjusted odds ratio of 1.5 (95% confidence interval: 1.10–2.06, P = 0.012) for each millimeter. The number of pre-operative ERCPs and CBD diameter in choledocholithiasis patients are strong predictors of the need for open surgery and CBD exploration and should be considered in surgical planning and consent for patients requiring more than one ERCP procedure.

The story of dilation-assisted stone extraction is characterized by tragedy and triumph. Although initially proposed as a means to preserve the native state of the bile duct, controlled studies indicated that dilation without endoscopic sphincterotomy (EST) was associated with a high risk of pancreatitis [1, 2]. However, dilation after EST is a safe and effective means of treating large bile duct stones. In this month’s Digestive Diseases and Sciences, Li et al. [3] extend the use of this method to manage bile duct stones of all sizes. Although generalizability may be limited by the specific study population and techniques, the approach suggests exciting possibilities of more widespread potential application. Balloon dilation that facilitates bile duct stone removal was first espoused as a means of avoiding long-term exposure of the biliary tree to enteric contents. Nevertheless, a multicenter randomized controlled trial of balloon dilation versus EST revealed a concerning incidence of pancreatitis among those who underwent balloon dilation compared with those who underwent EST [2]. In addition, nearly half of these cases were severe and two study patients died. Further confirmatory work led investigators to conclude that balloon dilation was not appropriate for clinical practice [1]. Endoscopic biliary sphincterotomy combined with balloon and basket maneuvers enables removal of 85 % of bile duct stones [4]. Nevertheless, perivaterian diverticuli and other anatomic abnormalities of the papilla complicate removal [5]. Large or impacted concretions may also be difficult to retrieve. Although, for these refractory stones, intraductal and extracorporeal shock wave and intraductal laser lithotripsy have been used, these approaches require extensive technical expertise, are not widely available, and are time consuming [6–8]. A critical variation of papillary balloon dilation has been proposed for removal of difficult bile duct stones [9]. By dilating the papilla after endoscopic sphincterotomy, complete clearance of difficult bile duct stones was achieved for 93 % of patients without elevated incidence of pancreatitis [9]. Subsequent work has confirmed that balloon dilation after EST is of comparable efficacy and as safe as conventional approaches for removal of large bile duct stones, and may be less likely to result in complications [10–13]. It is postulated that the biliary sphincter separates the biliary orifice from the pancreatic orifice, directing the force of dilation predominantly toward the bile duct and away from the pancreas [13]. Large retrospective studies also suggest that EST combined with large balloon dilation requires less mechanical lithotripsy, and that the duration of the procedure is shorter [11, 12]. In their study, Li et al. randomized 462 patients with bile duct stones to small EST combined with balloon dilation (sEST ? EPBD) compared with EST. The study differed from previous controlled trials in that the number of subjects was much larger and that subjects bearing stones of all sizes were included. Consistent with previous work, complete stone removal and incidence of complications were equivalent in the sEST ? EPBD and EST groups. This prospective study also convincingly demonstrated that procedure and fluoroscopy duration are briefer for sEST ? EPBD, with reduced requirement for mechanical lithotripsy than EST. The authors contributed equally to all aspects of this project.