- Email: [email protected]
Continuing Medical Education Exam: March 2010
GIE
CME ACTIVITY
Continuing Medical Education Exam: March 2010 Raquel E. Davila, MD, Jeffrey H. Lee, MD, William Ross, MD, Shou-Jiang Tang, MD, Co-Editors, CME Section G. S. Raju, MD, Editor, CME Section Glenn M. Eisen, MD, MPH, Editor-in-Chief, Gastrointestinal Endoscopy
Instructions: The GIE: Gastrointestinal Endoscopy CME Activity can now be completed entirely on-line. To complete this CME activity, you will need to do the following: 1. Read the following articles that have been designated for CME in this issue: Jeurnink S, Steyerberg EW, van Hooft JE, et al. Surgical gastrojejunostomy or endoscopic stent placement for the palliation of malignant gastric outlet obstruction (SUSTENT Study): a multicenter randomized trial. Gastrointest Endosc 2010;71:490-9. Hassan H, Vilmann P, Sharma V. Impact of EUS-guided FNA on management of gastric carcinoma. Gastrointest Endosc 2010;71:500-4. Gotthardt D, Rudolph G, Klöters-Plachky P, et al. Endoscopic dilatation of dominant stenoses in primary sclerosing cholangitis: outcome after long-term treatment. Gastrointest Endosc 2010;71:527-34. Small AJ, Coelho-Prabhu N, Baron TH. Endoscopic placement of self-expandable metal stents for malignant colonic obstruction: long-term outcomes and complication factors. Gastrointest Endosc 2010;71:560-72. 2. Log-in on-line to complete a single exam with multiple choice questions followed by a brief post-test evaluation. Visit the Journal’s Web site at www.asge.org (members) or www.giejournal.org (nonmembers). 3. Persons scoring greater than or equal to 75% pass the exam and can print a CME certificate. Persons scoring less than 75% cannot print a CME certificate; however, they can retake the exam. Exams can be saved to be accessed at a later date. You may create a free personal account to save and return to your work in progress, as well as save and track your completed activities so that you may print a certificate at any time. The complete articles, detailed instructions for completion, as well as past Journal CME activities can also be found at this site.
Target Audience This activity is designed for physicians who are involved with providing patient care and who wish to advance their current knowledge of clinical medicine.
Learning Objectives As a result of completing this activity, participating physicians will be able to: 1. To assess the differences in outcome of surgical and endoscopic management of malignant gastric outlet obstruction. 2. To explain the utility of EUS-guided FNA in the management of gastric cancer. 3. To demonstrate the long-term outcome of endoscopic dilation of dominant biliary stenosis in primary sclerosing cholangitis. 4. To review the outcome of endoscopic placement of self-expandable metal stents (SEMS) in patients with malignant colonic obstruction.
Continuing Medical Education The American Society for Gastrointestinal Endoscopy (ASGE) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The ASGE designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit ™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Activity Start Date: March 1, 2010 Activity Expiration Date: March 31, 2012
Disclosures Disclosure information for authors of the articles can be found with the article in the abstract section. All disclosure information for GIE editors can be found online at http://www.giejournal.org/content/conflictofinterest. CME editors, and their disclosures, are as follows: G. S. Raju, MD FASGE (Associate Editor for Journal CME): Jeffrey H. Lee, MD (CME Editor): Consulting/Advisory/Speaking: Wyeth, Olympus Disclosed no relevant financial relationships. Research Support: ConMed Raquel E. Davila, MD (CME Editor): William Ross, MD (CME Editor): Disclosed no relevant financial relationships. Consulting/Advisory/Speaking: Boston Scientific, Olympus All CME activities, including their associated articles are copyrighted by the ASGE. Minimum Online System Requirements: 486 Pentium 1 level computer (PC or Macintosh) Windows 95, 98, 2000, NT or Mac OS Netscape 4.x or Microsoft Internet Explorer 4.x and above 16 MB RAM 56.6K modem
596 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 3 : 2010
Shou-Jiang Tang, MD (CME Editor): Consulting/Advisory/Speaking: Olympus America Other Financial: Ethicon Endo-Surgery, licensing agreement for magnetic anchoring and guidance sysytem; Patents pending for magnetic anchoring and guidance system
www.giejournal.org
CME ACTIVITY
Continuing Medical Education Questions: March 2010 QUESTION 1 OBJECTIVE: To assess the differences in outcome of surgical and endoscopic management of malignant gastric outlet obstruction.
What are the management options for gastric outlet obstruction? Question 1: A 68-year-old man with metastatic pancreatic cancer on chemotherapy and narcotics for pain control is admitted with nausea and emesis of stale food. His functional status is limited to walking a few steps in the house, and his life expectancy is just a few weeks. He has patent biliary metal stent with normal serum bilirubin. He prefers endoscopic stent insertion to gastrojejunostomy for palliation of gastric outlet obstruction.
What are the advantages of stent insertion compared with surgery in the management of this patient?
Possible answers: (A-D) A. B. C. D.
Better survival rate Earlier resumption of oral intake Lower complication rate Lower reintervention rate
Look-up: Jeurnink S, Steyerberg EW, van Hooft JE, et al. Surgical gastrojejunostomy or endoscopic stent placement for the palliation of malignant gastric outlet obstruction (SUSTENT Study): a multicenter randomized trial. Gastrointest Endosc 2010;71:490-9.
QUESTION 2 OBJECTIVE: To explain the utility of EUS-guided FNA in the management of gastric cancer.
What is the utility of EUS-guided FNA in gastric cancer? Question 2:
Possible answers: (A-D)
A 55-year-old South American man with a previous history of peptic ulcer disease is seen with acute upper GI bleeding. Esophagogastroduodenoscopy shows an ulcerated mass in the cardia of the stomach. EUS shows a 25 mm x 37 mm solid mass in the stomach invading through the serosa, as well as 1 subcarinal and 5 perigastric lymph nodes. Which of the following management options could be determined by the results of EUS-guided FNA of the subcarinal lymph node?
A. B. C. D.
Palliative care for inoperable, metastatic gastric cancer Gastrectomy with extended lymphadenectomy Preoperative chemotherapy Staging laparoscopy
Look-up: Hassan H, Vilmann P, Sharma V. Impact of EUS-guided FNA on management of gastric carcinoma. Gastrointest Endosc 2010;71:500-4.
www.giejournal.org
Volume 71, No. 3 : 2010 GASTROINTESTINAL ENDOSCOPY
596.e1
CME Exam
QUESTION 3 OBJECTIVE: To demonstrate the long-term outcome of endoscopic dilation of dominant biliary stenosis in primary sclerosing cholangitis.
Endoscopic dilation of dominant biliary stenoses in primary sclerosing cholangitis Question 3: A 40-year-old man with primary sclerosing cholangitis (PSC) and jaundice is referred to you for endoscopic management of biliary obstruction. He denies fever or rigors. His serum bilirubin is 2.5 mg/dL. His referring doctor sends you a copy of his recent cholangiogram (Fig. 1). Which of the following is the best management option in this patient?
Possible answers: (A-D) A. B. C. D.
Endoscopic biliary sphincterotomy (EBS) alone EBS ⫹ balloon dilation of stricture EBS ⫹ plastic stent insertion for 3-6 months EBS ⫹ metal stent insertion
Figure 1.
Look-up: Gotthardt D, Rudolph G, Klöters-Plachky P, et al. Endoscopic dilatation of dominant stenoses in primary sclerosing cholangitis: outcome after long-term treatment. Gastrointest Endosc 2010;71:527-34.
QUESTION 4 OBJECTIVE: To review the outcome of endoscopic placement of self-expandable metal stents (SEMS) in patients with malignant colonic obstruction.
What is the outcome of endoscopic insertion of SEMS for malignant colonic obstruction? Question 4: An 82-year old male with metastatic rectal cancer presents with colonic obstruction. CT scan shows a rectal mass with obstruction. The patient has severe coronary artery disease, chronic obstructive pulmonary disease, and chronic renal insufficiency. After you are able to traverse the endoscope through the stricture with some difficulty, you decide to insert a 25 mm self-expandable metal stent (SEMS).
Which of the following factors is associated with increased complications after placing a SEMS in this patient?
Possible answers: (A-D) A. B. C. D.
Age of patient Sex of patient Severity of obstruction Size of stent
Look-up: Small AJ, Coelho-Prabhu N, Baron TH. Endoscopic placement of self-expandable metal stents for malignant colonic obstruction: long-term outcomes and complication factors. Gastrointest Endosc 2010;71:560-72.
596.e2 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 3 : 2010
www.giejournal.org
CME ACTIVITY
Continuing Medical Education Answers: March 2010 QUESTION 1 CORRECT RESPONSE: B Rationale for correct response: The most common cause of nausea and emesis in patients with advanced pancreatic cancer is gastric outlet obstruction. One should also consider the possibility of narcotic-induced gastroparesis. The clinical situation presented is challenging. One should carefully balance the benefits of resumption of oral intake against the serious risks of complications associated with stent insertion. To date, published reports have established that stent placement is a viable alternative to surgery with comparable results. Which option to pursue was largely dictated by local expertise and whether biliary decompression had to be addressed at the same time. A randomized control trial by Jeurnink et al provides some guidance on the management of patients with malignant gastric outlet obstruction. When anticipated survival is limited to 8 weeks or less, stent placement leads to a faster improvement in oral intake as reflected by a GOSS score of 2 or greater in a median of 5 days versus 8 days in the surgical group. However, that benefit is lost because of the significantly higher complication and reintervention rates in the stent group. Survival in both groups was comparable.1 Take-home message: Consider stents in patients with an expected life span limited to a few weeks and surgery in patients with a life span lasting several weeks. REFERENCE: 1. Jeurnink S, Steyerberg EW, van Hooft JE, et al. Surgical gastrojejunostomy or endoscopic stent placement for the palliation of malignant gastric outlet obstruction (SUSTENT Study): a multicenter randomized trial. Gastrointest Endosc 2010;71:490-9.
QUESTION 2 CORRECT RESPONSE: A Rationale for correct response: EUS is useful in the staging of gastric cancer with a high accuracy for determining T stage1,2; however, no studies to date have shown a direct impact of EUS and EUS-guided FNA on patient management. Recently, EUS has been mostly used for selecting superficial gastric cancers that may be amenable to endoscopic resection, and for determining T and N stage before enrollment of patients in clinical trials studying neoadjuvant therapy. In a prospective study, 234 patients with gastric cancer underwent extensive preoperative evaluation including EUS. Eighty-one patients underwent EUSguided FNA of suspicious lesions in distant lymph nodes or solid organs. Distant metastases were confirmed by EUS-FNA in 38 of the 81 patients (42%). The large majority of distant metastases were found in mediastinal lymph nodes, and the majority of primary tumors were located in the cardia of the stomach. CT identified 4 of 6 liver metastases later confirmed by EUS-FNA. All patients who were identified with metastatic disease were considered inoperable and were referred for palliative treatment. Subsequently, EUS and EUS-FNA changed the management in 15% of study patients (34/234). Take-home message: EUS-guided FNA in gastric cancer staging is useful in identifying distant metastases and in sparing patients with inoperable cancer from undergoing unnecessary surgery. REFERENCES: 1. Puli SR, Reddy JB, Bechtold ML, et al. How good is endoscopic ultrasound for TNM staging for gastric cancers? A meta-analysis and systematic review. World J Gastroenterol 2008;14:4011-9. 2. Hassan H, Vilmann P, Sharma V. Impact of EUS-guided FNA on management of gastric carcinoma. Gastrointest Endosc 2010;71:500-4.
QUESTION 3 CORRECT RESPONSE: B Rationale for correct response: The management of choice in patients with jaundice and dominant biliary stricture in patients with PSC is balloon dilation. Prolonged plastic stent insertion leads to stent occlusion and worsening of the biliary strictures. There is no role for metal stent insertion in benign strictures of PSC. www.giejournal.org
Volume 71, No. 3 : 2010 GASTROINTESTINAL ENDOSCOPY
596.e3
CME Answers
Review of a prospective study of 171 patients spanning over 20 years from an academic center in Germany provides several insights on the management of dominant stenosis of bile ducts1: 1. Repeated balloon dilation of dominant biliary strictures: ● Ninety-six patients with dominant stenoses were treated by repeated balloon dilatations (a total of 500 balloon dilations, mean 5.2 per patient). ● Technique of dilation - Repeated dilation at 4 week intervals: ● Main bile duct stenosis was dilated to 8 mm ● Hepatic duct stenosis was dilated to 6 mm to 8 mm. ● Surveillance ERCP at yearly intervals in patients with main bile duct stenosis and at 2-year intervals in those without narrowing of the common duct or when alkaline phosphatase or gammaglutamyl transferase increased by 20 % or more. 2. Biliary stent insertion for 2 weeks in those with bacterial cholangitis and complete obstruction. 3. Outcome: Five years after the first dilatation of a dominant stenosis, survival free of liver transplantation was 81 %, and after 10 years it was 52 %. Repeated endoscopic balloon dilatation of dominant stenosis allows the preservation of a functioning common bile duct, improves cholestasis over many years, and prolongs survival free of liver transplantation.1-3 Take-home message: Repeated endoscopic balloon dilation of dominant stenosis preserves the function of common bile duct, improves cholestasis over many years, and prolongs survival free of liver transplantation. REFERENCES: 1. Gotthardt D, Rudolph G, Kloeters-Plachky P, et al. Endoscopic dilatation of dominant stenoses in primary sclerosing cholangitis: outcome after long-time treatment. Gastrointest Endosc 2010;71:527-34. 2. Baluyut AR, Sherman S, Lehman GA, et al. Impact of endoscopic therapy on the survival of patients with primary sclerosing cholangitis. Gastrointest Endosc 2001;53:308-12. 3. Stiehl A, Rudolph G, Klöters-Plachky P, et al. Development of dominant bile duct stenoses in patients with primary sclerosing cholangitis treated with ursodeoxycholic acid: outcome after endoscopic treatment. J Hepatol 2002;36:151-6.
QUESTION 4 CORRECT RESPONSE: B Rationale for correct response: Endoscopists play a critical role in the fight against colon cancer, by preventing colorectal cancer by endoscopic removal of polyps, staging local spread by EUS, and relieving colonic obstruction by endoscopic stent insertion. Self-expandable metal stents are used to relieve colonic obstruction under two clinical circumstances: ● Palliation in patients with widespread disease and limited life span. ● Preoperative “bridge to surgery” in selected patients to perform single-stage resection and reanastomosis. The technical and clinical success rates of endoscopic placement of self-expandable metal stents (SEMS) for malignant colorectal obstruction are high. In a study involving 233 patients with malignant colonic obstruction who underwent SEMS placement for palliation or as “bridge to surgery,” the technical and clinical success rates were 95% and 99%, respectively. The stents were patent for 145 days in the palliative group.1 Complications occurred in about a quarter of patients. Factors associated with high stent complication rates include the following (Univariate analysis)1: Demography and nature of obstruction
Technical factors
1. Males 2. Complete obstruction 3. Intraluminal lesion
1. 2. 3. 4.
Stricture dilation before stent insertion Stent diameter ⬍22 mm Operator experience Use of bevacizumab
Take-home message: Although placement of SEMS for the treatment of colorectal obstruction is feasible and safe, demographic, tumor, and technical factors should be considered to bring a desirable outcome. REFERENCE: 1. Small AJ, Coelho-Prabhu N, Baron TH. Endoscopic placement of self-expandable metal stents for malignant colonic obstruction: long-term outcomes and complication factors. Gastrointest Endosc 2010;71:560-72.
596.e4 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 3 : 2010
www.giejournal.org
CME Answers
EVALUATION PAGE, GIE Please complete the following questions in order to complete the process for earning your CME. Assessment of change in knowledge, skills and/or practice In general, this activity (check all that apply): □ Yes □ Yes □ Yes
Reinforced by existing knowledge and/or skills. Increased by knowledge. Will positively impact my practice.
□ No □ No □ No
Please specify any changes you plan to implement in your practice as a result of this activity:
Overall Evaluation of Activity
Strongly agree
Agree
Disagree
□ □ □
□ □ □
□ □ □
1. The overall educational value of this activity is excellent. 2. I would recommend this activity to a colleague. 3. I am interested in participating in future journal CME activities. Did you perceive commercial bias in this activity?
www.giejournal.org
□
Yes
□
No
Volume 71, No. 3 : 2010 GASTROINTESTINAL ENDOSCOPY
596.e5
CME ACTIVITY
Continuing Medical Education Exam: March 2010 Raquel E. Davila, MD, Jeffrey H. Lee, MD, William Ross, MD, Shou-Jiang Tang, MD, Co-Editors, CME Section G. S. Raju, MD, Editor, CME Section Glenn M. Eisen, MD, MPH, Editor-in-Chief, Gastrointestinal Endoscopy
Instructions: The GIE: Gastrointestinal Endoscopy CME Activity can now be completed entirely on-line. To complete this CME activity, you will need to do the following: 1. Read the following articles that have been designated for CME in this issue: Jeurnink S, Steyerberg EW, van Hooft JE, et al. Surgical gastrojejunostomy or endoscopic stent placement for the palliation of malignant gastric outlet obstruction (SUSTENT Study): a multicenter randomized trial. Gastrointest Endosc 2010;71:490-9. Hassan H, Vilmann P, Sharma V. Impact of EUS-guided FNA on management of gastric carcinoma. Gastrointest Endosc 2010;71:500-4. Gotthardt D, Rudolph G, Klöters-Plachky P, et al. Endoscopic dilatation of dominant stenoses in primary sclerosing cholangitis: outcome after long-term treatment. Gastrointest Endosc 2010;71:527-34. Small AJ, Coelho-Prabhu N, Baron TH. Endoscopic placement of self-expandable metal stents for malignant colonic obstruction: long-term outcomes and complication factors. Gastrointest Endosc 2010;71:560-72. 2. Log-in on-line to complete a single exam with multiple choice questions followed by a brief post-test evaluation. Visit the Journal’s Web site at www.asge.org (members) or www.giejournal.org (nonmembers). 3. Persons scoring greater than or equal to 75% pass the exam and can print a CME certificate. Persons scoring less than 75% cannot print a CME certificate; however, they can retake the exam. Exams can be saved to be accessed at a later date. You may create a free personal account to save and return to your work in progress, as well as save and track your completed activities so that you may print a certificate at any time. The complete articles, detailed instructions for completion, as well as past Journal CME activities can also be found at this site.
Target Audience This activity is designed for physicians who are involved with providing patient care and who wish to advance their current knowledge of clinical medicine.
Learning Objectives As a result of completing this activity, participating physicians will be able to: 1. To assess the differences in outcome of surgical and endoscopic management of malignant gastric outlet obstruction. 2. To explain the utility of EUS-guided FNA in the management of gastric cancer. 3. To demonstrate the long-term outcome of endoscopic dilation of dominant biliary stenosis in primary sclerosing cholangitis. 4. To review the outcome of endoscopic placement of self-expandable metal stents (SEMS) in patients with malignant colonic obstruction.
Continuing Medical Education The American Society for Gastrointestinal Endoscopy (ASGE) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The ASGE designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit ™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Activity Start Date: March 1, 2010 Activity Expiration Date: March 31, 2012
Disclosures Disclosure information for authors of the articles can be found with the article in the abstract section. All disclosure information for GIE editors can be found online at http://www.giejournal.org/content/conflictofinterest. CME editors, and their disclosures, are as follows: G. S. Raju, MD FASGE (Associate Editor for Journal CME): Jeffrey H. Lee, MD (CME Editor): Consulting/Advisory/Speaking: Wyeth, Olympus Disclosed no relevant financial relationships. Research Support: ConMed Raquel E. Davila, MD (CME Editor): William Ross, MD (CME Editor): Disclosed no relevant financial relationships. Consulting/Advisory/Speaking: Boston Scientific, Olympus All CME activities, including their associated articles are copyrighted by the ASGE. Minimum Online System Requirements: 486 Pentium 1 level computer (PC or Macintosh) Windows 95, 98, 2000, NT or Mac OS Netscape 4.x or Microsoft Internet Explorer 4.x and above 16 MB RAM 56.6K modem
596 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 3 : 2010
Shou-Jiang Tang, MD (CME Editor): Consulting/Advisory/Speaking: Olympus America Other Financial: Ethicon Endo-Surgery, licensing agreement for magnetic anchoring and guidance sysytem; Patents pending for magnetic anchoring and guidance system
www.giejournal.org
CME ACTIVITY
Continuing Medical Education Questions: March 2010 QUESTION 1 OBJECTIVE: To assess the differences in outcome of surgical and endoscopic management of malignant gastric outlet obstruction.
What are the management options for gastric outlet obstruction? Question 1: A 68-year-old man with metastatic pancreatic cancer on chemotherapy and narcotics for pain control is admitted with nausea and emesis of stale food. His functional status is limited to walking a few steps in the house, and his life expectancy is just a few weeks. He has patent biliary metal stent with normal serum bilirubin. He prefers endoscopic stent insertion to gastrojejunostomy for palliation of gastric outlet obstruction.
What are the advantages of stent insertion compared with surgery in the management of this patient?
Possible answers: (A-D) A. B. C. D.
Better survival rate Earlier resumption of oral intake Lower complication rate Lower reintervention rate
Look-up: Jeurnink S, Steyerberg EW, van Hooft JE, et al. Surgical gastrojejunostomy or endoscopic stent placement for the palliation of malignant gastric outlet obstruction (SUSTENT Study): a multicenter randomized trial. Gastrointest Endosc 2010;71:490-9.
QUESTION 2 OBJECTIVE: To explain the utility of EUS-guided FNA in the management of gastric cancer.
What is the utility of EUS-guided FNA in gastric cancer? Question 2:
Possible answers: (A-D)
A 55-year-old South American man with a previous history of peptic ulcer disease is seen with acute upper GI bleeding. Esophagogastroduodenoscopy shows an ulcerated mass in the cardia of the stomach. EUS shows a 25 mm x 37 mm solid mass in the stomach invading through the serosa, as well as 1 subcarinal and 5 perigastric lymph nodes. Which of the following management options could be determined by the results of EUS-guided FNA of the subcarinal lymph node?
A. B. C. D.
Palliative care for inoperable, metastatic gastric cancer Gastrectomy with extended lymphadenectomy Preoperative chemotherapy Staging laparoscopy
Look-up: Hassan H, Vilmann P, Sharma V. Impact of EUS-guided FNA on management of gastric carcinoma. Gastrointest Endosc 2010;71:500-4.
www.giejournal.org
Volume 71, No. 3 : 2010 GASTROINTESTINAL ENDOSCOPY
596.e1
CME Exam
QUESTION 3 OBJECTIVE: To demonstrate the long-term outcome of endoscopic dilation of dominant biliary stenosis in primary sclerosing cholangitis.
Endoscopic dilation of dominant biliary stenoses in primary sclerosing cholangitis Question 3: A 40-year-old man with primary sclerosing cholangitis (PSC) and jaundice is referred to you for endoscopic management of biliary obstruction. He denies fever or rigors. His serum bilirubin is 2.5 mg/dL. His referring doctor sends you a copy of his recent cholangiogram (Fig. 1). Which of the following is the best management option in this patient?
Possible answers: (A-D) A. B. C. D.
Endoscopic biliary sphincterotomy (EBS) alone EBS ⫹ balloon dilation of stricture EBS ⫹ plastic stent insertion for 3-6 months EBS ⫹ metal stent insertion
Figure 1.
Look-up: Gotthardt D, Rudolph G, Klöters-Plachky P, et al. Endoscopic dilatation of dominant stenoses in primary sclerosing cholangitis: outcome after long-term treatment. Gastrointest Endosc 2010;71:527-34.
QUESTION 4 OBJECTIVE: To review the outcome of endoscopic placement of self-expandable metal stents (SEMS) in patients with malignant colonic obstruction.
What is the outcome of endoscopic insertion of SEMS for malignant colonic obstruction? Question 4: An 82-year old male with metastatic rectal cancer presents with colonic obstruction. CT scan shows a rectal mass with obstruction. The patient has severe coronary artery disease, chronic obstructive pulmonary disease, and chronic renal insufficiency. After you are able to traverse the endoscope through the stricture with some difficulty, you decide to insert a 25 mm self-expandable metal stent (SEMS).
Which of the following factors is associated with increased complications after placing a SEMS in this patient?
Possible answers: (A-D) A. B. C. D.
Age of patient Sex of patient Severity of obstruction Size of stent
Look-up: Small AJ, Coelho-Prabhu N, Baron TH. Endoscopic placement of self-expandable metal stents for malignant colonic obstruction: long-term outcomes and complication factors. Gastrointest Endosc 2010;71:560-72.
596.e2 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 3 : 2010
www.giejournal.org
CME ACTIVITY
Continuing Medical Education Answers: March 2010 QUESTION 1 CORRECT RESPONSE: B Rationale for correct response: The most common cause of nausea and emesis in patients with advanced pancreatic cancer is gastric outlet obstruction. One should also consider the possibility of narcotic-induced gastroparesis. The clinical situation presented is challenging. One should carefully balance the benefits of resumption of oral intake against the serious risks of complications associated with stent insertion. To date, published reports have established that stent placement is a viable alternative to surgery with comparable results. Which option to pursue was largely dictated by local expertise and whether biliary decompression had to be addressed at the same time. A randomized control trial by Jeurnink et al provides some guidance on the management of patients with malignant gastric outlet obstruction. When anticipated survival is limited to 8 weeks or less, stent placement leads to a faster improvement in oral intake as reflected by a GOSS score of 2 or greater in a median of 5 days versus 8 days in the surgical group. However, that benefit is lost because of the significantly higher complication and reintervention rates in the stent group. Survival in both groups was comparable.1 Take-home message: Consider stents in patients with an expected life span limited to a few weeks and surgery in patients with a life span lasting several weeks. REFERENCE: 1. Jeurnink S, Steyerberg EW, van Hooft JE, et al. Surgical gastrojejunostomy or endoscopic stent placement for the palliation of malignant gastric outlet obstruction (SUSTENT Study): a multicenter randomized trial. Gastrointest Endosc 2010;71:490-9.
QUESTION 2 CORRECT RESPONSE: A Rationale for correct response: EUS is useful in the staging of gastric cancer with a high accuracy for determining T stage1,2; however, no studies to date have shown a direct impact of EUS and EUS-guided FNA on patient management. Recently, EUS has been mostly used for selecting superficial gastric cancers that may be amenable to endoscopic resection, and for determining T and N stage before enrollment of patients in clinical trials studying neoadjuvant therapy. In a prospective study, 234 patients with gastric cancer underwent extensive preoperative evaluation including EUS. Eighty-one patients underwent EUSguided FNA of suspicious lesions in distant lymph nodes or solid organs. Distant metastases were confirmed by EUS-FNA in 38 of the 81 patients (42%). The large majority of distant metastases were found in mediastinal lymph nodes, and the majority of primary tumors were located in the cardia of the stomach. CT identified 4 of 6 liver metastases later confirmed by EUS-FNA. All patients who were identified with metastatic disease were considered inoperable and were referred for palliative treatment. Subsequently, EUS and EUS-FNA changed the management in 15% of study patients (34/234). Take-home message: EUS-guided FNA in gastric cancer staging is useful in identifying distant metastases and in sparing patients with inoperable cancer from undergoing unnecessary surgery. REFERENCES: 1. Puli SR, Reddy JB, Bechtold ML, et al. How good is endoscopic ultrasound for TNM staging for gastric cancers? A meta-analysis and systematic review. World J Gastroenterol 2008;14:4011-9. 2. Hassan H, Vilmann P, Sharma V. Impact of EUS-guided FNA on management of gastric carcinoma. Gastrointest Endosc 2010;71:500-4.
QUESTION 3 CORRECT RESPONSE: B Rationale for correct response: The management of choice in patients with jaundice and dominant biliary stricture in patients with PSC is balloon dilation. Prolonged plastic stent insertion leads to stent occlusion and worsening of the biliary strictures. There is no role for metal stent insertion in benign strictures of PSC. www.giejournal.org
Volume 71, No. 3 : 2010 GASTROINTESTINAL ENDOSCOPY
596.e3
CME Answers
Review of a prospective study of 171 patients spanning over 20 years from an academic center in Germany provides several insights on the management of dominant stenosis of bile ducts1: 1. Repeated balloon dilation of dominant biliary strictures: ● Ninety-six patients with dominant stenoses were treated by repeated balloon dilatations (a total of 500 balloon dilations, mean 5.2 per patient). ● Technique of dilation - Repeated dilation at 4 week intervals: ● Main bile duct stenosis was dilated to 8 mm ● Hepatic duct stenosis was dilated to 6 mm to 8 mm. ● Surveillance ERCP at yearly intervals in patients with main bile duct stenosis and at 2-year intervals in those without narrowing of the common duct or when alkaline phosphatase or gammaglutamyl transferase increased by 20 % or more. 2. Biliary stent insertion for 2 weeks in those with bacterial cholangitis and complete obstruction. 3. Outcome: Five years after the first dilatation of a dominant stenosis, survival free of liver transplantation was 81 %, and after 10 years it was 52 %. Repeated endoscopic balloon dilatation of dominant stenosis allows the preservation of a functioning common bile duct, improves cholestasis over many years, and prolongs survival free of liver transplantation.1-3 Take-home message: Repeated endoscopic balloon dilation of dominant stenosis preserves the function of common bile duct, improves cholestasis over many years, and prolongs survival free of liver transplantation. REFERENCES: 1. Gotthardt D, Rudolph G, Kloeters-Plachky P, et al. Endoscopic dilatation of dominant stenoses in primary sclerosing cholangitis: outcome after long-time treatment. Gastrointest Endosc 2010;71:527-34. 2. Baluyut AR, Sherman S, Lehman GA, et al. Impact of endoscopic therapy on the survival of patients with primary sclerosing cholangitis. Gastrointest Endosc 2001;53:308-12. 3. Stiehl A, Rudolph G, Klöters-Plachky P, et al. Development of dominant bile duct stenoses in patients with primary sclerosing cholangitis treated with ursodeoxycholic acid: outcome after endoscopic treatment. J Hepatol 2002;36:151-6.
QUESTION 4 CORRECT RESPONSE: B Rationale for correct response: Endoscopists play a critical role in the fight against colon cancer, by preventing colorectal cancer by endoscopic removal of polyps, staging local spread by EUS, and relieving colonic obstruction by endoscopic stent insertion. Self-expandable metal stents are used to relieve colonic obstruction under two clinical circumstances: ● Palliation in patients with widespread disease and limited life span. ● Preoperative “bridge to surgery” in selected patients to perform single-stage resection and reanastomosis. The technical and clinical success rates of endoscopic placement of self-expandable metal stents (SEMS) for malignant colorectal obstruction are high. In a study involving 233 patients with malignant colonic obstruction who underwent SEMS placement for palliation or as “bridge to surgery,” the technical and clinical success rates were 95% and 99%, respectively. The stents were patent for 145 days in the palliative group.1 Complications occurred in about a quarter of patients. Factors associated with high stent complication rates include the following (Univariate analysis)1: Demography and nature of obstruction
Technical factors
1. Males 2. Complete obstruction 3. Intraluminal lesion
1. 2. 3. 4.
Stricture dilation before stent insertion Stent diameter ⬍22 mm Operator experience Use of bevacizumab
Take-home message: Although placement of SEMS for the treatment of colorectal obstruction is feasible and safe, demographic, tumor, and technical factors should be considered to bring a desirable outcome. REFERENCE: 1. Small AJ, Coelho-Prabhu N, Baron TH. Endoscopic placement of self-expandable metal stents for malignant colonic obstruction: long-term outcomes and complication factors. Gastrointest Endosc 2010;71:560-72.
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