Outcomes of submucosal (T1b) esophageal adenocarcinomas removed by endoscopic mucosal resection

AIM: To investigate the outcomes and recurrences of pT1b esophageal adenocarcinoma (EAC) following endoscopic mucosal resection (EMR) and associated treatments. METHODS: Patients undergoing EMR with pathologically confirmed T1b EAC at two academic referral centers were retrospectively identified. Patients were divided into 4 groups based on treatment following EMR: Endoscopic therapy alone (group A), endoscopic therapy with either chemotherapy, radiation or both (group B), surgical resection (group C) or no further treatment/lost to follow-up (< 12 mo) (group D). Pathology specimens were reviewed by a central pathologist. Follow-up data was obtained from the academic centers, primary care physicians and/or referring physicians. Univariate analysis was performed to identify factors predicting recurrence of EAC. RESULTS: Fifty-three patients with T1b EAC underwent EMR, of which 32 (60%) had adequate follow-up ≥ 12 mo (median 34 mo, range 12-103). There were 16 patients in group A, 9 in group B, 7 in group C and 21 in group D. Median follow-up in groups A to C was 34 mo (range 12-103). Recurrent EAC developed overall in 9 patients (28%) including 6 (38%) in group A (median: 21 mo, range: 6-73), 1 (11%) in group B (median: 30 mo, range: 30-30) and 2 (29%) in group C (median 21 mo, range: 7-35. Six of 9 recurrences were local; of the 6 recurrences, 5 were treated with endoscopy alone. No predictors of recurrence of EAC were identified. CONCLUSION: Endoscopic therapy of T1b EAC may be a reasonable strategy for a subset of patients including those either refusing or medically unfit for esophagectomy

Internal biliary stenting during orthotopic liver transplantation: anastomotic complications, post‐transplant biliary interventions, and survival

BackgroundBiliary complications are a leading source of surgical morbidity following orthotopic liver transplantation (OLT).MethodsWe examined how prophylactic internal biliary stent placement during OLT affected post‐transplant morbidity and mortality in a single‐center retrospective cohort study of 513 recipients (2006–2012). Recipient and donor covariates were collected. Biliary complications included major and minor anastomotic leaks, strictures, or stenoses. Multivariate regression models were created to estimate how operative biliary stents affected outcomes.ResultsAbout 87.3% (n = 448) of recipients had a duct‐to‐duct biliary anastomosis, and 43.1% (n = 221) had biliary stents placed. The biliary complication rate was <15% at five yr, and 44.8% (n = 230) overall. Stenting was not protective from anastomotic biliary complications (p = 0.06). Stenting was associated with a 74% higher adjusted risk of needing multiple endoscopic retrograde cholangiographies (ERCs; odds ratio [OR] 1.74, p = 0.011), and trended toward a lower adjusted risk for repetitive percutaneous transhepatic cholangiography (PTCs; OR 0.56, p = 0.063). Stenting had no effect on the cumulative freedom from biliary complications (p = 0.94). Biliary complications were associated with mortality (HR 1.86, p = 0.014) and was unaffected by stenting (aHR = 0.72, p = 0.246).ConclusionsBiliary stenting during OLT does not deter biliary complications and is associated with higher risk of multiple invasive biliary interventions, particularly ERCs. Surgeons should evaluate the utility of biliary stents at OLT within this context.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/111147/1/ctr12518.pd

Systematic review with network meta‐analysis: the efficacy of anti‐ TNF agents for the treatment of Crohn's disease

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/107372/1/apt12749.pd

Letter: biological drugs for inducing remission in ulcerative colitis – authors' reply

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/106897/1/apt12724.pd

Letter: comparative efficacy of biological therapy in patients with ulcerative colitis – authors’ reply

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/107370/1/apt12773.pd

Response to “Post-Infectious Disorders of Gut-Brain Interaction: A brainstorming story”.

In a Letter to the Editors of this journal, Christian Lambiase and colleagues discuss the findings of our recent paper titled “Prolonged Gastrointestinal Manifestations After Recovery From COVID-19,” which reported a high prevalence of disorders of gut-brain interaction (DGBI) among 116 patients surveyed 12 to 18 months after hospitalization with coronavirus disease 2019 (COVID-19)

Effect of Covered Metallic Stents Compared With Plastic Stents on Benign Biliary Stricture Resolution A Randomized Clinical Trial

Importance Endoscopic placement of multiple plastic stents in parallel is the first-line treatment for most benign biliary strictures; it is possible that fully covered, self-expandable metallic stents (cSEMS) may require fewer endoscopic retrograde cholangiopancreatography procedures (ERCPs) to achieve resolution. Objective To assess whether use of cSEMS is noninferior to plastic stents with respect to stricture resolution. Design, Setting, and Participants Multicenter (8 endoscopic referral centers), open-label, parallel, randomized clinical trial involving patients with treatment-naive, benign biliary strictures (N = 112) due to orthotopic liver transplant (n = 73), chronic pancreatitis (n = 35), or postoperative injury (n = 4), who were enrolled between April 2011 and September 2014 (with follow-up ending October 2015). Patients with a bile duct diameter less than 6 mm and those with an intact gallbladder in whom the cystic duct would be overlapped by a cSEMS were excluded. Interventions Patients (N = 112) were randomized to receive multiple plastic stents or a single cSEMS, stratified by stricture etiology and with endoscopic reassessment for resolution every 3 months (plastic stents) or every 6 months (cSEMS). Patients were followed up for 12 months after stricture resolution to assess for recurrence. Main Outcomes and Measures Primary outcome was stricture resolution after no more than 12 months of endoscopic therapy. The sample size was estimated based on the noninferiority of cSEMS to plastic stents, with a noninferiority margin of −15%. Results There were 55 patients in the plastic stent group (mean [SD] age, 57 [11] years; 17 women [31%]) and 57 patients in the cSEMS group (mean [SD] age, 55 [10] years; 19 women [33%]). Compared with plastic stents (41/48, 85.4%), the cSEMS resolution rate was 50 of 54 patients (92.6%), with a rate difference of 7.2% (1-sided 95% CI, −3.0% to ∞; P < .001). Given the prespecified noninferiority margin of −15%, the null hypothesis that cSEMS is less effective than plastic stents was rejected. The mean number of ERCPs to achieve resolution was lower for cSEMS (2.14) vs plastic (3.24; mean difference, 1.10; 95% CI, 0.74 to 1.46; P < .001). Conclusions and Relevance Among patients with benign biliary strictures and a bile duct diameter 6 mm or more in whom the covered metallic stent would not overlap the cystic duct, cSEMS were not inferior to multiple plastic stents after 12 months in achieving stricture resolution. Metallic stents should be considered an appropriate option in patients such as these

Cold snare piecemeal resection of colonic and duodenal polyps ≥1 cm

BACKGROUND: Endoscopic removal of duodenal and colorectal adenomas is currently considered to be the standard of care for prevention of adenocarcinoma. The use of cautery carries a risk of delayed bleeding, post-polypectomy syndrome, and perforation. We examined the safety and feasibility of removing colonic and duodenal polyps ≥ 1 cm using a piecemeal cold snare polypectomy technique. PATIENTS: The study included 15 patients with duodenal polyps ≥ 1 cm and 15 patients with colonic polyps ≥ 1 cm. MAIN OUTCOME MEASUREMENTS: Bleeding, perforation, abdominal pain, or hospitalization occurring within 2 weeks of polypectomy. RESULTS: Between 24 August 2011 and 29 April 2013, 15 patients had removal of duodenal polyps ≥ 1 cm. Mean patient age was 64 years and 9/15 patients were male. The mean polyp size was 24 mm (10 - 60 mm). All polyps were removed with a cold snare and some required cold biopsy forceps. One patient required hospitalization for gastrointestinal blood loss 7 days post-polypectomy; this patient was using Coumadin. Between 27 February 2012 and 30 May 2013, 15 patients underwent resection of a ≥ 1 cm colonic polyp. Mean patient age was 68 years and 9/15 were male. The mean polyp size was 20 mm (10 - 45 mm). All polyps were primarily removed with a cold snare. None of the patients required hemostatic clips for control of immediate bleeding. One patient presented to the emergency department with abdominal pain 1 day after initial endoscopy. CT scan showed no abnormalities and the patient was discharged. CONCLUSIONS: Cold snare polypectomy for large duodenal and colonic polyps is technically feasible and may have a favorable safety profile compared to standard electrocautery-based endoscopic resection. Comparative trials are required to determine the relative safety and efficacy of cold snare techniques for complete and durable resection of large polyps compared to standard hot snare methods

EURECCA colorectal: multidisciplinary mission statement on better care for patients with colon and rectal cancer in Europe

Background: Care for patients with colon and rectal cancer has improved in the last twenty years however still considerable variation exists in cancer management and outcome between European countries. Therefore, EURECCA, which is the acronym of European Registration of cancer care, is aiming at defining core treatment strategies and developing a European audit structure in order to improve the quality of care for all patients with colon and rectal cancer. In December 2012 the first multidisciplinary consensus conference about colon and rectum was held looking for multidisciplinary consensus. The expert panel consisted of representatives of European scientific organisations involved in cancer care of patients with colon and rectal cancer and representatives of national colorectal registries. Methods: The expert panel had delegates of the European Society of Surgical Oncology (ESSO), European Society for Radiotherapy & Oncology (ESTRO), European Society of Pathology (ESP), European Society for Medical Oncology (ESMO), European Society of Radiology (ESR), European Society of Coloproctology (ESCP), European CanCer Organisation (ECCO), European Oncology Nursing Society (EONS) and the European Colorectal Cancer Patient Organisation (EuropaColon), as well as delegates from national registries or audits. Experts commented and voted on the two web-based online voting rounds before the meeting (between 4th and 25th October and between the 20th November and 3rd December 2012) as well as one online round after the meeting (4th-20th March 2013) and were invited to lecture on the subjects during the meeting (13th-15th December 2012). The sentences in the consensus document were available during the meeting and a televoting round during the conference by all participants was performed. All sentences that were voted on are available on the EURECCA website www.canceraudit.eu. The consensus document was divided in sections describing evidence based algorithms of diagnostics, pathology, surgery, medical oncology, radiotherapy, and follow-up where applicable for treatment of colon cancer, rectal cancer and stage IV separately. Consensus was achieved using the Delphi method. Results: The total number of the voted sentences was 465. All chapters were voted on by at least 75% of the experts. Of the 465 sentences, 84% achieved large consensus, 6% achieved moderate consensus, and 7% resulted in minimum consensus. Only 3% was disagreed by more than 50% of the members. Conclusions: It is feasible to achieve European Consensus on key diagnostic and treatment issues using the Delphi method. This consensus embodies the expertise of professionals from all disciplines involved in the care for patients with colon and rectal cancer. Diagnostic and treatment algorithms were developed to implement the current evidence and to define core treatment guidance for multidisciplinary team management of colon and rectal cancer throughout Europe