Endoscopic management of peri-pancreatic fluid collections (PFC) with or without organizing necrosis has been shown to decrease morbidity and mortality compared to early surgical management. Plastic stents are often used for transmural drainage, although the use of self-expanding metal stents (SEMS) has been reported. Theoretical benefits of SEMS include a large diameter for drainage and facilitation of endoscopic necrosectomy. We report a single-center experience to evaluate the efficacy and safety of SEMS for management of PFC.

Methods

A single-center retrospective review was performed of patients undergoing endoscopic management of PFC using SEMS from January through November 2011. Electronic database and medical records were reviewed for demographics, medical history, imaging and procedure data. The primary outcome, successful drainage, was defined as a 50% or greater decrease in PFC cross-sectional area. Secondary outcomes were achieving complete resolution, time to resolution, and complications.

Results

Thirteen patients with 14 PFCs were included. Mean age was 63 years (range 50-85), 77% were male. Gallstone disease was the cause of acute pancreatitis in 69%. Time from initial diagnosis of acute pancreatitis to endoscopic drainage of PFC was 9.1 weeks (range 1-28). Necrotic debris within the collection was present in 50% of PFCs. The mean size prior to intervention was 13.2 x 8.1 cm. A single fully covered biliary SEMS (10mm X 60 or 80mm) was initially placed in 12 of 14 cysts (86%) with one or two double-pigtail plastic stents through the SEMS lumen to prevent migration. The two remaining cysts were initially drained with plastic stents and subsequently revised to fully covered esophageal SEMS due to drainage failure from debris occluding the track. Both patients underwent successful necrosectomy (4 sessions in one case and 5 in the other). Thirteen collections were drained by trans-gastric approach, one through the duodenum. Mean follow-up was 7.2 weeks.Successful PFC drainage was achieved in 12 PFCs (86%) to date with a mean reduction in cross-sectional area of 87.5%. Complete resolution occurred in 4 (29%). Overall a mean of 1.9 procedures were performed.Stent occlusion (n=3) was the most frequent complication. Migration (n=1) and bleeding attributed to SEMS (n=1) occurred. All cases were successfully managed with endoscopic stent revision.

Conclusions

Fully covered self-expanding metal stents are an effective option for initial endoscopic access of peri-pancreatic fluid collections for the purposes of drainage and necrosectomy. Successful management can be achieved in the majority of patients with relatively few procedures. SEMS can be effectively utilized as salvage therapy for PFCs that fail endoscopic management with plastic stents and prevent the need for surgery or percutaneous drainage.

Copyright © 2012 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.

Methods: A retrospective search of inpatient and outpatient records was conducted for the diagnoses "Boerhaave's", "eosinophilic esophagitis", and "esophageal rupture" from January 2001 to January 2011 within the gastroenterology division at an urban tertiary care hospital. For each subject identified, medical records, endoscopy reports, biopsy reports and radiographic studies were reviewed. A faculty member of the Department of Pathology blindly reviewed all esophageal biopsy specimens. Eosinophilic esophagitis was defined as 15 or more eosinophils (EOS) in at least 2 high-power fields (HPFs) or 25 or more eosinophils in any single high power field.

Results: Over a period of ten years, 447 patients were identified with a diagnosis of eosinophilic esophagitis. Of these, four patients presented with spontaneous esophageal rupture in the setting of eosinophilic esophagitis in the absence of food impaction or endoscopy (4/447, less than 1%). None of the patients had an established diagnosis of eosinophilic esophagitis prior to presentation. All four cases presented with a triad of vomiting, chest pain and pneumomediastinum. Three of the four patients were male (75%), and ages ranged from 22 to 56 (mean 37) years-old. In two of the four patients, water-soluble contrast extravasation was seen on imaging prompting surgical intervention (50%); one of these patients required esophageal resection. The other two patients demonstrated no contrast extravasation. These two patients were observed for resolution. A unique opportunity to examine full thickness surgical specimen showed invasion of eosinophils into the muscularis propria. Intraepithelial eosinophil infiltration was seen on all mucosal biopsies (>30 EOS/HPF) with significant improvement after steroid (topical or systemic) treatment.

Conclusion: Spontaneous esophageal rupture is a rare (less than 1%) but critical presentation of eosinophilic esophagitis manifesting with vomiting, chest pain and pneumomediastinum. Surgery is required if extravasation is seen with water-soluble contrast. We suggest that eosinophilic esophagitis is a transmural disease rather than a simple mucosal process, thus making the esophageal wall susceptible to rupture with endoscopy, bolus impaction now spontaneously (Boerhaave's Syndrome).

Background: Tyrosine kinase inhibitors (TKI) are the current standard therapy for patients with chronic myeloid leukemia (CML). Fluid retention and pleural effusions have been reported in patients treated with TKIs, particularly with dasatinib. Although TKIs have been shown to reverse pulmonary hypertension (PH) in animal models, there have been some reports of development of reversible PH with dasatinib.

Methods: We conducted a retrospective analysis on 401 patients diagnosed with CML in chronic phase (CP) who were treated with TKIs (imatinib, dasatinib, or nilotinib) as initial therapy for CML and had a transthoracic echocardiogram (TTE) done at some point during the course of therapy. PH was diagnosed if the patient had an estimated right ventricular systolic pressure (RVSP) of 35 mm Hg or greater. Secondary causes of PH (systolic or diastolic dysfunction on TTE, chronic obstructive pulmonary diseases [COPD], obstructive sleep apnea [OSA] and pulmonary embolism) were investigated during chart review.

Results: Twenty (23%) out of 87 patients had evidence of PH by TTE; median age 57 years, with 46% being males. Six pts (30%) received nilotinib 400mg twice daily, 4 (20%) patients had imatinib (400mg; n=1, 600mg; n=1 and 800mg daily; n=2), and 10 (50%) patients received dasatinib (dose varied 40-140mg daily). Five (25%) patients had coronary artery disease, 9 (45%) had systemic hypertension, 2 (10%) had COPD and 3 (15%) had OSA. Thirteen pts had serial TTE to compare the progression of PH including 6 (7%) who had a TTE prior to starting TKI. Among these 13 pts with serial TTE, 7 had rising RVSP with one patient having mild global hypokinesia, another with diastolic dysfunction and another with OSA. Four of those 7 patients had normal RVSP on their TTE prior to starting therapy. Six other pts had improvement in the RVSP on serial TTE, 4 of them with systemic hypertension. Two of those 6 patients had elevated RVSP on their TTE prior to starting therapy; one pt had no change. Eleven patients had pleural effusions (7 dasatinib, 3 imatinib, 1 nilotinib) associated with PH.

Conclusions: TKI therapy is occasionally associated with development of PH, but RVSP may improve spontaneously in some patients. A prospective study is needed to further investigate the relationship between TKIs and the development of PH.

METHODS: This was a single-center, prospective, randomized, investigator-blinded, non-inferiority study comparing AM-only to PM/AM PEG-ELS for afternoon outpatient colonoscopy. The primary end point was whole colon prep adequacy. Tolerance and polyp detection were secondary outcomes.

RESULTS: Overall, 125 patients were randomized and 9 withdrew without taking any prep. Of 116 analyzed, 62 received AM-only prep and 54 received PM/AM prep. The whole colon prep was adequate in 92% in the AM-only group vs. 94% in the PM/AM group (95% lower confidence limit, LCL, for the difference=-11.3%, non-inferiority P=0.013), whereas the right colon prep was adequate in 93 and 92%, respectively (95% LCL=-7.8%, non-inferiority P=0.003). Polyp detection was greater, and not inferior, in the AM-only group (mean=1.57 vs. 0.94 polyps/patient, non-inferiority P=0.007). The overall incidence of adverse events was not significantly different between the two groups (P=0.273), but the AM-only group had lower incidence of abdominal pain (P=0.024). The AM-only group also had better sleep quality (P=0.007) and less interference with the previous workday (P=0.019).

CONCLUSIONS: AM-only and PM/AM PEG-ELS are clinically equivalent with respect to cleansing efficacy and polyp detection. AM-only prep was associated with a lower incidence of abdominal pain, superior sleep quality, and less interference with workday before colonoscopy.

The novel commercial method of cyst fluid analysis allows for accurate measurement of cyst fluid CEA even on cyst fluid aspirates of less than 1ml, and potentially less than 100ul of fluid.

This measurement tool increases the yield of EUS FNA for pancreatic cysts, particularly for those in whom cyst fluid volumes are small.

By optimizing specimen handling, it is possible to satisfy information needs more effectively thereby contributing to more comprehensive and better diagnosis and management.

1. Colonic bubbles that could interfere with polyp detection are present in 35% of patients receiving split dose PEG-ELS.

2. Most bubbles occur in the right and transverse colon.

3. Advanced age is an independent risk for bubbles.