Search

Background & aimsThe goal of treatment for Barrett's esophagus (BE) with dysplasia is complete eradication of intestinal metaplasia (CEIM). The long-term durability of CEIM has not been well characterized, so the frequency and duration of surveillance are unclear. We report results from a 5-year follow-up analysis of patients with BE and dysplasia treated by radiofrequency ablation (RFA) in the randomized controlled Ablation of Intestinal Metaplasia Containing Dysplasia (AIM) trial.MethodsParticipants for the AIM Dysplasia trial (18-80 years old) were recruited from 19 sites in the United States and had endoscopic evidence of non-nodular dysplastic BE ≤8 cm in length. Subjects (n = 127) were randomly assigned (2:1 ratio) to receive either RFA (entire BE segment ablated circumferentially) or a sham endoscopic procedure; patients in the sham group were offered RFA treatment 1 year later, and all patients were followed for 5 years. We collected data on BE recurrence (defined as intestinal metaplasia in the tubular esophagus) and dysplastic BE recurrence among patients who achieved CEIM. We constructed Kaplan-Meier estimates and applied parametric survival analysis to examine proportions of patients without any recurrence and without dysplastic recurrence.ResultsOf 127 patients in the AIM Dysplasia trial, 119 received RFA and met inclusion criteria. Of those 119, 110 (92%) achieved CEIM. Over 401 person-years of follow-up (mean, 3.6 years per patient; range, 0.2-5.8 years), 35 of 110 (32%) patients had recurrence of BE or dysplasia, and 19 (17%) had dysplasia recurrence. The incidence rate of BE recurrence was 10.8 per 100 person-years overall (95% CI, 7.8-15.0); 8.3 per 100 person-years among patients with baseline low-grade dysplasia (95% CI, 4.9-14.0), and 13.5 per 100 person-years among patients with baseline high-grade dysplasia (95% CI 8.8-20.7). The incidence rate of dysplasia recurrence was 5.2 per 100 person-years overall (95% CI 3.3-8.2); 3.3 per 100 person-years among patients with baseline low-grade dysplasia (95% CI 1.5-7.2), and 7.3 per 100 person-years among patients with baseline high-grade dysplasia (95% CI 4.2-12.5). Neither BE nor dysplasia recurred at a constant rate. There was a greater probability of recurrence in the first year following CEIM than in the following 4 years combined.ConclusionsIn this analysis of prospective cohort data from the AIM Dysplasia trial, we found BE to recur after CEIM by RFA in almost one third of patients with baseline dysplastic disease; most recurrences occurred during the first year after CEIM. However, patients who achieved CEIM and remained BE free at 1 year after RFA had a low risk of BE recurrence. Studies are needed to determine when surveillance can be decreased or discontinued; our study did not identify any BE or dysplasia recurrence after 4 years of surveillance.

BACKGROUND: Detection of hepatic metastases during EUS is an important component of tumor staging. OBJECTIVE: To describe our experience with EUS-guided FNA (EUS-FNA) of solid hepatic masses and derive and validate criteria to help distinguish between benign and malignant hepatic masses. DESIGN: Retrospective study, survey. SETTING: Single, tertiary-care referral center. PATIENTS: Medical records were reviewed for all patients undergoing EUS-FNA of solid hepatic masses over a 12-year period. INTERVENTIONS: EUS-FNA of solid hepatic masses. MAIN OUTCOME MEASUREMENTS: Masses were deemed benign or malignant according to predetermined criteria. EUS images from 200 patients were used to create derivation and validation cohorts of 100 cases each, matched by cytopathologic diagnosis. Ten expert endosonographers blindly rated 15 initial endosonographic features of each of the 100 images in the derivation cohort. These data were used to derive an EUS scoring system that was then validated by using the validation cohort by the expert endosonographer with the highest diagnostic accuracy. RESULTS: A total of 332 patients underwent EUS-FNA of a hepatic mass. Interobserver agreement regarding the initial endosonographic features among the expert endosonographers was fair to moderate, with a mean diagnostic accuracy of 73% (standard deviation 5.6). A scoring system incorporating 7 EUS features was developed to distinguish benign from malignant hepatic masses by using the derivation cohort with an area under the receiver operating curve (AUC) of 0.92; when applied to the validation cohort, performance was similar (AUC 0.86). The combined positive predictive value of both cohorts was 88%. LIMITATIONS: Single center, retrospective, only one expert endosonographer deriving and validating the EUS criteria. CONCLUSION: An EUS scoring system was developed that helps distinguish benign from malignant hepatic masses. Further study is required to determine the impact of these EUS criteria among endosonographers of all experience.

Objectives: Approach to management of common bile duct stones (CBDS) by endoscopic retrograde cholangiopancreatography (ERCP) is not standardized. We examined outcomes by applying predetermined protocol for CBDS management. Methods: When standard extraction techniques failed at ERCP, presence of tapered bile duct and stone–duct ratio were calculated. Large balloon sphincteroplasty (LBS) and/or mechanical/single‐operator cholangioscopy‐guided lithotripsy was performed based on presence of tapered bile duct and stone–duct mismatch. Primary outcome was single‐session ductal clearance. Secondary outcome was adverse events. Results: Of 409 patients treated over 16 months, 321 (78.5%) had no tapered bile duct or stone–duct mismatch, and single‐session ductal clearance was achieved using standard techniques in 99.7% over median duration of 14 min (interquartile range [IQR] 9–21 min). Of 88 (21.5%) patients with difficult CBDS, tapered duct was seen in 79 (89.8%) and/or stone–duct mismatch in 36 (40.9%). Single‐session ductal clearance was achieved in all 88 patients (100%) by LBS in 79 (89.8%), mechanical lithotripsy in 20 (22.7%), and single‐operator cholangioscopy‐guided lithotripsy in 16 (18.2%) over a median duration of 29 min (IQR 17–47 min). Overall, single‐session ductal clearance was achieved in 99.8% with adverse events in 17 (4.2%) that included perforation in two, postsphincterotomy bleeding in one, and mild/moderate post‐ERCP pancreatitis in 14 patients. Conclusions: A predetermined protocol optimized outcomes by enabling single‐session ductal clearance of CBDS with high technical success and low adverse events. [ABSTRACT FROM AUTHOR]

Pancreatitis is a complex, progressively destructive inflammatory disorder. Alcohol was long thought to be the primary causative agent, but genetic contributions have been of interest since the discovery that rare PRSS1, CFTR and SPINK1 variants were associated with pancreatitis risk. We now report two associations at genome-wide significance identified and replicated at PRSS1-PRSS2 (P < 1 × 10(-12)) and X-linked CLDN2 (P < 1 × 10(-21)) through a two-stage genome-wide study (stage 1: 676 cases and 4,507 controls; stage 2: 910 cases and 4,170 controls). The PRSS1 variant likely affects disease susceptibility by altering expression of the primary trypsinogen gene. The CLDN2 risk allele is associated with atypical localization of claudin-2 in pancreatic acinar cells. The homozygous (or hemizygous in males) CLDN2 genotype confers the greatest risk, and its alleles interact with alcohol consumption to amplify risk. These results could partially explain the high frequency of alcohol-related pancreatitis in men (male hemizygote frequency is 0.26, whereas female homozygote frequency is 0.07).

Background Walled-off necrosis (WON) is highly morbid disease most effectively managed by endoscopic drainage with lumen-apposing metal stents (LAMSs) or plastic stents, with or without necrosectomy. This meta-analysis compared the clinical outcomes of patients included in randomized trials treated using LAMSs or plastic stents. Methods The MEDLINE and EMBASE databases were searched to identify all data collected from randomized trials comparing LAMSs and plastic stents for the treatment of WON. The primary outcome measure was need for endoscopic necrosectomy. Results Three studies comprising 206 patients met inclusion criteria. Except for procedure duration, which was significantly shorter for LAMSs (standardized mean difference [SMD] −1.22, 95%CI −1.64 to −0.79), there was no significant difference in need for necrosectomy (38.5% vs. 41.2%; risk ratio [RR] 1.07, 95%CI 0.79–1.45), number of interventions (SMD −0.09, 95%CI −0.40 to 0.22), treatment success (90.7% vs. 94.5%; RR 0.96, 95%CI 0.87–1.06), recurrence (4.6% vs. 0.6%; RR 3.73, 95%CI 0.42–33.0), readmission (42.6% vs. 50.2%; RR 0.84, 95%CI 0.62–1.14), length of hospitalization (SMD −0.06, 95%CI −0.55 to 0.43), mortality (8.5% vs. 9.8%; RR 0.70, 95%CI 0.30–1.66), new-onset organ failure (10.6% vs. 14.6%; RR 0.72, 95%CI 0.16–3.32), bleeding (11.0% vs. 10.7%; RR 1.09, 95%CI 0.34–3.44), procedural adverse events (23.6% vs. 19.2%; RR 1.38, 95%CI 0.82–2.33), or overall costs (SMD −0.04, 95%CI −0.31 to 0.24) between LAMSs and plastic stents, respectively. Conclusions Except for procedure duration, there is no significant difference in clinical outcomes for patients with WON treated using LAMSs or plastic stents. [ABSTRACT FROM AUTHOR]