- Email: [email protected]
Abstracts from Around the World
CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2008;6:956 –957
ABSTRACTS FROM AROUND THE WORLD Visit CGH online at www.cghjournal.org to link to these articles and additional papers of interest.
Barretts and Dysplasia: Improved Visualization With Narrow Band Imaging Wolfsen HC, Crook JE, Krishna M, et al. Prospective, controlled tandem endoscopy study of narrow band imaging for dysplasia detection in Barrett’s esophagus. Gastroenterology 2008;135: 24 –31.
Summary. Narrow band imaging (NBI) is becoming widely available. Via traditional endoscopes, this imaging technique may enhance the visualization of abnormal mucosa such as Barrett’s esophagus (BE), and thus could improve the detection of dysplasia in BE. Prospective blinded tandem endoscopy was performed in 65 patients with BE and dysplasia at a tertiary care center. Standard endoscopy was first used to detect visible lesions followed by NBI. NBI detected higher grades of dysplasia, and directed biopsies with NBI also detected dysplasia in more patients (57%) compared with standard resolution endoscopy (43%). More biopsies were also required using standard imaging as compared to NBI (8.5 vs 4.7). Editor’s comment. NBI more often led to the detection of dysplasia and higher grades of dysplasia with fewer biopsy samples. While dysplasia was found more commonly, it may be difficult to prove this technique has an improved outcome; however, currently, the best surrogate marker we have for the development of cancer is dysplasia. The investigative team was relatively experienced with this technique. Knowing the slope of the learning curve for this technique is crucial to determine if the findings are widely generalizable to a community setting. If confirmed, this technique may be an improvement to our current screening strategies. ............................................................
Amazing! Ramos CA, Murakami A, Galvão M, et al. NOTES transvaginal video-assisted cholecystectomy: first series Endoscopy 2008;40: 572–575.
Summary. Natural orifice transluminal endoscopic therapy or NOTES is currently the rage. This study suggests such visionary procedures may not be that far away. This study demonstrated the feasibility of transvaginal cholecystectomy. Of 60 eligible patients, 53% accepted this approach vs standard laparoscopic cholecystectomy. The laparoscopic ports included first a puncture through an umbilical incision followed by pneumoperitoneum. A trocar was inserted and the pelvis examined for any abnormalities such as adhesions which may prohibit this
approach. The uterus was then retracted followed by placement of a 12 mm trocar through the posterior vaginal fornix to the peritoneal cavity. A 2 mm incision was made in the right upper quadrant to manipulate the gallbladder for dissection of Calot’s triangle for gallbladder resection and with ultimate removal through the vaginal fornix. Operative time ranged from 18 to 50 minutes (mean 38 minutes). Intraoperative cholangiography was used in 3 cases showing no abnormalities. In only 1 case (3%) was conversion to laparoscopic cholecystectomy required. All patients were discharged within 6 hours of the procedure. Patients were able to return to normal daily activities within 24 hours and requirement for pain medicines was minimal. Editor’s comment. While still preliminary, the results here are quite impressive. The operating time was minimal, postoperative analgesia was infrequent, conversion to open cholecystectomy were very rare and no complications were seen. With any new technique, comparison to the current standard must be done. The presence of fewer abdominal scars is not a solid end point for NOTES. Look for additional novel approaches and appropriate end point assessments before we hop on the NOTES bandwagon. Nevertheless, let’s not let the trains pass us by. ............................................................
Prevention of Variceal Rebleeding in Cirrhosis: 2 Is Better Than 1 Gonzalez R, Zamora J, Gomez-Camarero J, et al. Meta-analysis: combination endoscopic and drug therapy to prevent variceal rebleeding in cirrhosis. Ann Intern Med 2008;149:109 –122.
Summary. Both endoscopic therapy and beta-blockers prevent rebleeding from esophageal varices. Whether combination therapy is superior to either therapy alone is not well established. Twenty-three trials met inclusion for this meta-analysis. Combination therapy reduced overall rebleeding better than either therapy alone, and similar findings were established for variceal rebleeding and recurrence. However, no difference in overall mortality was observed between combination and single therapy. Injection sclerotherapy and banding were equivalent. Editor’s comment. Variceal bleeding and rebleeding have high mortality rates. Endoscopic variceal banding is now well accepted, although many will use this as primary therapy, reserving beta blocker therapy for primary prevention. This well done meta-analysis suggests that combination therapy is, in fact, superior to either therapy alone. Therefore, for the patient under-
September 2008
going variceal obliteration following endoscopic treatment, beta blocker therapy should be used concurrently. ............................................................
Better Characterizing Autoimmune Hepatitis Overlap Syndromes Al-Chalabi T, Portmann BC, Bernal W, et al. Autoimmune hepatitis overlap syndromes: an evaluation of treatment response, long-term outcome and survival. Aliment Pharmacol Ther 2008;28:209 –220.
Summary. Autoimmune hepatitis (AIH) may overlap both primary sclerosing cholangitis (PSC) and primary biliary cirrhosis (PBC). However, the response to treatment and long-term outcome of these overlap syndromes compared to AIH are little known. Two hundred thirtyeight consecutive patients with AIH retrospectively obtained from a database were compared with 10 consecutive patients with PBC/AIH and 16 with PSC/AIH. The median duration of follow-up was 11 years (range 1–35) for patients with AIH. All patients were treated with Prednisone and Azathioprine with subsequent discontinuation of steroids if possible. Most PSC overlap patients were male. Laboratory parameters showed higher levels of AST in patients with AIH compared with overlap syndromes. Jaundice was the most common presentation in patients with AIH and PSC overlap whereas malaise and lethargy were more frequent in the PBC overlap patients. Over 85% of patients with PSC/AIH and 96% of patients with AIH had a good initial response to therapy compared with 75% of patients with PBC overlap. Survival was shortest in patients with AIH/PSC and best in those with AIH. Editor’s comment. This study provides useful information to better characterize the presentation, response to therapy, and long-term outcome of both AIH and overlap syndromes with PSC and PBC. Patients with PSC have the poorest survival while those with PBC have a poorer response to standard immunosuppressive therapy. ............................................................
IgG4-related Biliary Disease Mimicking Cancer: A Capricious Disease Erdogan D, Kloek JJ, ten Kate FJW, et al. Immunoglobulin G4-related sclerosing cholangitis in patients resected for presumed malignant bile duct strictures. Br J Surg 2008;95:727– 734.
Summary. Increasingly, there is recognition that biliary tract disease resembling primary sclerosing cholangitis (PSC) may be associated with autoimmune pancreatitis. In some patients, biliary disease may resemble either PSC or cholangiocarcinoma. This retrospective study identified 185 patients over an 11-year period that had undergone resection for suspicion of hilar cholan-
ABSTRACTS FROM AROUND THE WORLD
957
giocarcinoma. The paraffin embedded tissue blocks were recut and a variety of stains performed including for IgG4– the sine qua non of IgG4-related disease. A benign bile duct stricture was found in 32 (17.3%). Of these, 15 had features of an autoimmune like disease and showed moderate to severe lymphoplasmacytic infiltration and in 2 of these abundant IgG4 –positive plasma cell infiltrates were seen around the bile ducts. Editor’s comment. Diagnosing hilar cholangiocarcinoma by routine endoscopic methods is difficult. This series should cause pause that in some patients with whom endoscopic sampling does not diagnose cancer, the possibility of an IgG4-related sclerosing cholangitis should be considered. This series further suggests that of benign strictures, autoimmune-like disease may be found in approximately half. When suspected, one should obtain blood studies for IgG4 which may be elevated in this disease. Also, biopsy of the lesions with IgG4 staining may also make a definitive diagnosis. This entity is important to diagnose given its favorable response to corticosteroid therapy.
Additional Papers of Interest Ganz RA, Overholt BF, Sharma VK, et al. Circumferential ablation of Barrett’s esophagus that contains highgrade dysplasia: a U.S. multicenter registry. Gastrointest Endosc 2008;68:35– 40. Herth FJF, Annema JT, Eberhardt R, et al. Endobronchial ultrasound with transbronchial needle aspiration for restaging the mediastinum in lung cancer. J Clin Oncol 2008;26:3346 –3350. Marmo R, Koch M, Cipolletta L, et al. Predictive factors of mortality from nonvariceal upper gastrointestinal hemorrhage: a multicenter study. Am J Gastroenterol 2008;103:1639 –1647. Foschi D, Lazzaroni M, Sangaletti O, et al. Effects of intramural administration of Botulinum Toxin A on gastric emptying and eating capacity in obese patients. Dig Liver Dis 2008;40:667– 672. Kamm MA, Lichtenstein GR, Sandborn WJ, et al. Randomised trial of once- or twice-daily MMX mesalazine for maintenance of remission in ulcerative colitis. Gut 2008;57:893–902. van Roest MHG, Gouw ASH, Peeters PMJG, et al. Results of pancreaticoduodenectomy in patients with periampullary adenocarcinoma. Perineural growth more important prognostic factor than tumor localization. Ann Surg 2008;248:97–103. Morisco F, Pagliaro L, Caporaso N, et al. Consensus recommendations for managing asymptomatic persistent non-virus non-alcohol related elevation of aminotransferase levels. Suggestions for diagnostic procedures and monitoring. Dig Liver Dis 2008;40:585–598.
ABSTRACTS FROM AROUND THE WORLD Visit CGH online at www.cghjournal.org to link to these articles and additional papers of interest.
Barretts and Dysplasia: Improved Visualization With Narrow Band Imaging Wolfsen HC, Crook JE, Krishna M, et al. Prospective, controlled tandem endoscopy study of narrow band imaging for dysplasia detection in Barrett’s esophagus. Gastroenterology 2008;135: 24 –31.
Summary. Narrow band imaging (NBI) is becoming widely available. Via traditional endoscopes, this imaging technique may enhance the visualization of abnormal mucosa such as Barrett’s esophagus (BE), and thus could improve the detection of dysplasia in BE. Prospective blinded tandem endoscopy was performed in 65 patients with BE and dysplasia at a tertiary care center. Standard endoscopy was first used to detect visible lesions followed by NBI. NBI detected higher grades of dysplasia, and directed biopsies with NBI also detected dysplasia in more patients (57%) compared with standard resolution endoscopy (43%). More biopsies were also required using standard imaging as compared to NBI (8.5 vs 4.7). Editor’s comment. NBI more often led to the detection of dysplasia and higher grades of dysplasia with fewer biopsy samples. While dysplasia was found more commonly, it may be difficult to prove this technique has an improved outcome; however, currently, the best surrogate marker we have for the development of cancer is dysplasia. The investigative team was relatively experienced with this technique. Knowing the slope of the learning curve for this technique is crucial to determine if the findings are widely generalizable to a community setting. If confirmed, this technique may be an improvement to our current screening strategies. ............................................................
Amazing! Ramos CA, Murakami A, Galvão M, et al. NOTES transvaginal video-assisted cholecystectomy: first series Endoscopy 2008;40: 572–575.
Summary. Natural orifice transluminal endoscopic therapy or NOTES is currently the rage. This study suggests such visionary procedures may not be that far away. This study demonstrated the feasibility of transvaginal cholecystectomy. Of 60 eligible patients, 53% accepted this approach vs standard laparoscopic cholecystectomy. The laparoscopic ports included first a puncture through an umbilical incision followed by pneumoperitoneum. A trocar was inserted and the pelvis examined for any abnormalities such as adhesions which may prohibit this
approach. The uterus was then retracted followed by placement of a 12 mm trocar through the posterior vaginal fornix to the peritoneal cavity. A 2 mm incision was made in the right upper quadrant to manipulate the gallbladder for dissection of Calot’s triangle for gallbladder resection and with ultimate removal through the vaginal fornix. Operative time ranged from 18 to 50 minutes (mean 38 minutes). Intraoperative cholangiography was used in 3 cases showing no abnormalities. In only 1 case (3%) was conversion to laparoscopic cholecystectomy required. All patients were discharged within 6 hours of the procedure. Patients were able to return to normal daily activities within 24 hours and requirement for pain medicines was minimal. Editor’s comment. While still preliminary, the results here are quite impressive. The operating time was minimal, postoperative analgesia was infrequent, conversion to open cholecystectomy were very rare and no complications were seen. With any new technique, comparison to the current standard must be done. The presence of fewer abdominal scars is not a solid end point for NOTES. Look for additional novel approaches and appropriate end point assessments before we hop on the NOTES bandwagon. Nevertheless, let’s not let the trains pass us by. ............................................................
Prevention of Variceal Rebleeding in Cirrhosis: 2 Is Better Than 1 Gonzalez R, Zamora J, Gomez-Camarero J, et al. Meta-analysis: combination endoscopic and drug therapy to prevent variceal rebleeding in cirrhosis. Ann Intern Med 2008;149:109 –122.
Summary. Both endoscopic therapy and beta-blockers prevent rebleeding from esophageal varices. Whether combination therapy is superior to either therapy alone is not well established. Twenty-three trials met inclusion for this meta-analysis. Combination therapy reduced overall rebleeding better than either therapy alone, and similar findings were established for variceal rebleeding and recurrence. However, no difference in overall mortality was observed between combination and single therapy. Injection sclerotherapy and banding were equivalent. Editor’s comment. Variceal bleeding and rebleeding have high mortality rates. Endoscopic variceal banding is now well accepted, although many will use this as primary therapy, reserving beta blocker therapy for primary prevention. This well done meta-analysis suggests that combination therapy is, in fact, superior to either therapy alone. Therefore, for the patient under-
September 2008
going variceal obliteration following endoscopic treatment, beta blocker therapy should be used concurrently. ............................................................
Better Characterizing Autoimmune Hepatitis Overlap Syndromes Al-Chalabi T, Portmann BC, Bernal W, et al. Autoimmune hepatitis overlap syndromes: an evaluation of treatment response, long-term outcome and survival. Aliment Pharmacol Ther 2008;28:209 –220.
Summary. Autoimmune hepatitis (AIH) may overlap both primary sclerosing cholangitis (PSC) and primary biliary cirrhosis (PBC). However, the response to treatment and long-term outcome of these overlap syndromes compared to AIH are little known. Two hundred thirtyeight consecutive patients with AIH retrospectively obtained from a database were compared with 10 consecutive patients with PBC/AIH and 16 with PSC/AIH. The median duration of follow-up was 11 years (range 1–35) for patients with AIH. All patients were treated with Prednisone and Azathioprine with subsequent discontinuation of steroids if possible. Most PSC overlap patients were male. Laboratory parameters showed higher levels of AST in patients with AIH compared with overlap syndromes. Jaundice was the most common presentation in patients with AIH and PSC overlap whereas malaise and lethargy were more frequent in the PBC overlap patients. Over 85% of patients with PSC/AIH and 96% of patients with AIH had a good initial response to therapy compared with 75% of patients with PBC overlap. Survival was shortest in patients with AIH/PSC and best in those with AIH. Editor’s comment. This study provides useful information to better characterize the presentation, response to therapy, and long-term outcome of both AIH and overlap syndromes with PSC and PBC. Patients with PSC have the poorest survival while those with PBC have a poorer response to standard immunosuppressive therapy. ............................................................
IgG4-related Biliary Disease Mimicking Cancer: A Capricious Disease Erdogan D, Kloek JJ, ten Kate FJW, et al. Immunoglobulin G4-related sclerosing cholangitis in patients resected for presumed malignant bile duct strictures. Br J Surg 2008;95:727– 734.
Summary. Increasingly, there is recognition that biliary tract disease resembling primary sclerosing cholangitis (PSC) may be associated with autoimmune pancreatitis. In some patients, biliary disease may resemble either PSC or cholangiocarcinoma. This retrospective study identified 185 patients over an 11-year period that had undergone resection for suspicion of hilar cholan-
ABSTRACTS FROM AROUND THE WORLD
957
giocarcinoma. The paraffin embedded tissue blocks were recut and a variety of stains performed including for IgG4– the sine qua non of IgG4-related disease. A benign bile duct stricture was found in 32 (17.3%). Of these, 15 had features of an autoimmune like disease and showed moderate to severe lymphoplasmacytic infiltration and in 2 of these abundant IgG4 –positive plasma cell infiltrates were seen around the bile ducts. Editor’s comment. Diagnosing hilar cholangiocarcinoma by routine endoscopic methods is difficult. This series should cause pause that in some patients with whom endoscopic sampling does not diagnose cancer, the possibility of an IgG4-related sclerosing cholangitis should be considered. This series further suggests that of benign strictures, autoimmune-like disease may be found in approximately half. When suspected, one should obtain blood studies for IgG4 which may be elevated in this disease. Also, biopsy of the lesions with IgG4 staining may also make a definitive diagnosis. This entity is important to diagnose given its favorable response to corticosteroid therapy.
Additional Papers of Interest Ganz RA, Overholt BF, Sharma VK, et al. Circumferential ablation of Barrett’s esophagus that contains highgrade dysplasia: a U.S. multicenter registry. Gastrointest Endosc 2008;68:35– 40. Herth FJF, Annema JT, Eberhardt R, et al. Endobronchial ultrasound with transbronchial needle aspiration for restaging the mediastinum in lung cancer. J Clin Oncol 2008;26:3346 –3350. Marmo R, Koch M, Cipolletta L, et al. Predictive factors of mortality from nonvariceal upper gastrointestinal hemorrhage: a multicenter study. Am J Gastroenterol 2008;103:1639 –1647. Foschi D, Lazzaroni M, Sangaletti O, et al. Effects of intramural administration of Botulinum Toxin A on gastric emptying and eating capacity in obese patients. Dig Liver Dis 2008;40:667– 672. Kamm MA, Lichtenstein GR, Sandborn WJ, et al. Randomised trial of once- or twice-daily MMX mesalazine for maintenance of remission in ulcerative colitis. Gut 2008;57:893–902. van Roest MHG, Gouw ASH, Peeters PMJG, et al. Results of pancreaticoduodenectomy in patients with periampullary adenocarcinoma. Perineural growth more important prognostic factor than tumor localization. Ann Surg 2008;248:97–103. Morisco F, Pagliaro L, Caporaso N, et al. Consensus recommendations for managing asymptomatic persistent non-virus non-alcohol related elevation of aminotransferase levels. Suggestions for diagnostic procedures and monitoring. Dig Liver Dis 2008;40:585–598.