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Impact of Argon Plasma Coagulation on Three-Month Tumor Recurrence Rates Following Endoscopic Mucosal Resection of Colorectal Lateral Spreading Tumors
CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2011;9:184 –188
AGA These abstracts were presented at the Clinical Congress of Gastroenterology and Hepatology: Best Practices in 2011 in Miami, Florida, January 14 –15, 2011. Effect of Proton Pump Inhibitors on the Risk of Hip Fracture: Systematic Review and Synthesis L. Cardinal, U. Shankar, S. Sharma, W.M. Masood Purpose: The purpose of this research was to evaluate the association between exposure to proton pump inhibitors (PPIs) and the likelihood of hip fracture. Prior studies examining PPIs and various fractures have been widely discrepant in terms of study focus and duration of exposure. Studies looking at short duration of exposure have often shown minimal or no effect. We hypothesized that cumulative exposure would result in increased likelihood of hip fracture. We made the assumption that the association of hip fracture is related to alteration in bone structure. With this assumption and with consideration of the slow rate of bone turnover, we anticipated no effect in an early exposure window of unclear duration, followed by a graded increase in the risk. Methods: A highly sensitive search was performed for Medline, Embase, Google Scholar, CINHL, and LILAC through May 26, 2010. Multiple search terms including osteoporosis, fracture, hip fracture and PPI were used. Clinical studies related to PPI use and hip fracture were identified. Bibliographies of identified articles were reviewed for relevant articles. 8 observational studies met the inclusion criteria for the review. All adjusted Odds Ratios (OR) corresponding to ⭌ duration format were incorporated into the analysis and displayed visually. Relative weights for fracture number were also displayed. Results: Over 34,000 unique hip fractures were identified. The likelihood of hip fracture increased significantly at ⭌ 4 years of exposure, the OR ranging between 1.62 and 4.55. The OR showed no increased risk, and remained at approximately 1.0 up through the 3 year mark. Conclusion: The analysis supported the hypothesis that the duration of exposure to a PPI is associated with an increased likelihood of hip fracture. Endoscopic Treatment of Anastomotic Biliary Strictures After Living Donor Liver Transplantation: Outcomes After Maximal Stent Therapy Ting-Hui Hsieh, M. Edwyn Harrison, Michael D. Crowell, Kristin L. Mekeel, Bashar A. Aqel, Elizabeth J. Carey, Thomas J. Byrne, Hugo E. Vargas, David D. Douglas, Jorge Rakela, Kunam S. Reddy, Adyr A. Moss, and David C. Mulligan Background: Living-donor liver transplantation (LDLT) has emerged as a viable strategy in an era of extreme organ shortage. However, biliary strictures remain the Achilles’ heel of LDLT. The optimal endoscopic treatment for anastomotic biliary strictures (ABS) after LDLT is undefined. Aim: To determine the outcome of an aggressive endoscopic approach that uses endoscopic dilatation followed by maximal stent placement at a single tertiary– care academic medical center. Methods: We retrospectively reviewed our transplant database for all LDLT performed between March 2001 and September 2010. Demographic data was collected and treatment outcomes, including bile-duct patency, recurrence of stricture, need for surgical intervention, morbidity, and mortality were evaluated. Results: Of 106 LDLTs completed at our institution since 2001, 41 (38.7%) developed a biliary stricture after transplant; 38 patients had duct to duct anastomoses and are included in the analysis. The mean follow-up time is 54 months (range 2.5–97 months). Among them, 23 (60.5%) were male, 20 (52.6%) had bile leakage, and 6 required concomitant percutaneous transhepatic cholangiodrainage. The mean time to the development ABS after LDLT was 4 months. The mean time to stricture resolution was 6.6 months. The strictures took an average of 4.3 interventions and 7.9 stents to resolve. There was statistically significant improvement in biochemical markers after intervention, including aspartate transaminase (76 vs 39, P ⫽ .001), alanine transaminase (127.5 vs 45.5, P ⬍ .001), alkaline phosphatase (590 vs 260, P ⬍ .001) and total bilirubin (2.57 vs 1.73, P ⫽ .017). Eight patients (21%) had recurrent stricture after initial treatment. All recurrences were treated successfully endoscopically. All patients have been managed without surgical revision or retransplantation, resulting in 100% success by an intention-to-treat analysis. Conclusions: In our experience, aggressive endoscopy-based treatment with maximal stent placement strategy allows 100% resolution of all ABS after LDLT without the need for surgical intervention or re-transplantation. Hepatitis C Treatment Response in Liver Transplant Recipients Ranjith Wijeratne, Joshua Dworetzky, Alice Thomas, Amandeep Sahota, Alan J. Sheinbaum Background: Hepatitis C virus (HCV)–related end-stage liver disease is the leading indication for liver transplantation (LT). HCV recurrence after LT is universal leading to accelerated recurrence of cirrhosis. Therapeutic response to currently available regimen is reported lower compared to treatment of HCV in non LT patients. Objective: Evaluate the response of HCV treatment in LT recipients. Methods: It was a retrospective study in which medical records of subjects who underwent liver transplant for HCV related liver disease from September 1991 to August 2009 were reviewed.
Results: One hundred ninety-five subjects with HCV LT recipients charts were reviewed, 139 were excluded as there were not treated. Fifty-six subjects were treated with pegylated interferon and ribavirin standard dose. Mean age was 60 years, predominantly males (82%). Twenty-eight (50%) were white, 18 (32%) were Hispanic and 10 (18%) were African American. Average body mass index was 28, and genotype (GT) 1 was predominant (84%). Median METAVIR fibrosis score was 2. Overall sustained virological response (SVR) in this cohort was 32%. Hispanics and Whites had similar SVR rates (50%) but none of the African Americans achieved SVR and had 40% relapse rate. There were no deaths in subjects who achieved SVR whereas 4 died in non SVR group. Complications: SVR group: one subject underwent re-transplantation due to hepatic artery issues, 6 had acute cellular rejection (ACR) during treatment and one had chronic rejection. Overall, 16% received blood transfusions, 21% required erythropoietin respectively for anemia. Conclusion: SVR to pegylated interferon and ribavirin for recurrent HCV in LT recipients was modest in our experience (32%). HCV LT recipients should be offered treatment.
Table 1. Treatment Response According to Genotype GT-1 (n ⫽ 47) SVR No SVR Relapser Treatment intolerant
13 (28%) 17 (36%) 14 (30%) 3 (6%)
GT-2 (n ⫽ 2)
GT-3 (n ⫽ 7) 5 (71%)
1 (50%) 1 (50%)
2 (29%)
GT, genotype; SVR, sustained virological response.
Impact of Argon Plasma Coagulation on Three-Month Tumor Recurrence Rates Following Endoscopic Mucosal Resection of Colorectal Lateral Spreading Tumors William J. Salyers, Jr., Emily Christman, Ryan C. Butterfield, Juan Carlos Munoz Introduction: Endoscopic mucosal resection (EMR) may be considered for curative resection of superficial lateral spreading tumors (LST) of the colorectum in the absence of lymphatic invasion. LSTs measure ⬎10 mm in diameter, extend laterally with a low vertical axis, and are divided into 2 subtypes, granular (LST-G) and non-granular (LST-NG). The purpose of this study was to evaluate 3 month tumor recurrence rates based upon use of argon plasma coagulation (APC) following EMR. Methods: Charts of patients with colorectal lesions ⬎10 mm resected by EMR between May 1, 2007, and May 1, 2010, were examined retrospectively to identify patients with LSTs who had a follow-up endoscopy at least 12 weeks after the initial EMR. Endoscopic images were reviewed to identify LSTs which were then classified as either LST-G or LST-NG. Flat lesions ⬍10 mm, depressed tumors, and pedunculated polyps were excluded. A total of 19 patients met inclusion and exclusion criteria. Statistical analysis: Interactive effects of the predictive and response variables were analyzed using Fisher’s Exact Test for association and Pearson’s correlation coefficient. Linear regression was used with alpha⫽.1 to identify possible predictors of tumor recurrence after 3 months and complete tumor resection at the end of the study period. Results: No significant associations or correlations were identified between LST type and size or APC use and 3 month recurrence of LST. Mean age was 70.9 years with 11 (57.9) males and 8 (42.1) females. LST-G were the largest subtype of LST with 14 (73.7) LST-G and 5 (26.3) LST-NG resected. Tumor size was distributed evenly with 10 (52.6) LST ⬍20 mm and 9 (47.4) ⬎20 mm (Range ⫽ 10 mm– 40 mm). Lift and cut method of EMR was used in 18 (94.7) patients and suction banding method in 1 (5.3). Piecemeal resection was used in 14 (73.7) patients and en bloc resection in the remaining 5 (26.3) patients. APC was used following EMR in 9 (47.4) patients. There were no immediate complications in any patients. Pathology review revealed 9 (47.4) tubular adenomas, 5 (26.3) tubulovillous adenomas, 4 (21.1) adenomatous polyps with high-grade dysplasia, and 1 (5.3) intramucosal adenocarcinoma. Mean time to first follow-up endoscopy was 23.6 weeks (range ⫽ 12– 49 weeks) with mean total endoscopic follow-up 35.4 weeks (range ⫽ 12–92 weeks). Three month tumor recurrence occurred in 8 (42.1) patients. Following a maximum of up to 2 repeat EMRs, there was no evidence of LST recurrence in 16 (84.2) patients at the end of the study period. Conclusions: APC use following EMR does not appear to have a significant impact on 3 month recurrence rates of colorectal LSTs.
AGA These abstracts were presented at the Clinical Congress of Gastroenterology and Hepatology: Best Practices in 2011 in Miami, Florida, January 14 –15, 2011. Effect of Proton Pump Inhibitors on the Risk of Hip Fracture: Systematic Review and Synthesis L. Cardinal, U. Shankar, S. Sharma, W.M. Masood Purpose: The purpose of this research was to evaluate the association between exposure to proton pump inhibitors (PPIs) and the likelihood of hip fracture. Prior studies examining PPIs and various fractures have been widely discrepant in terms of study focus and duration of exposure. Studies looking at short duration of exposure have often shown minimal or no effect. We hypothesized that cumulative exposure would result in increased likelihood of hip fracture. We made the assumption that the association of hip fracture is related to alteration in bone structure. With this assumption and with consideration of the slow rate of bone turnover, we anticipated no effect in an early exposure window of unclear duration, followed by a graded increase in the risk. Methods: A highly sensitive search was performed for Medline, Embase, Google Scholar, CINHL, and LILAC through May 26, 2010. Multiple search terms including osteoporosis, fracture, hip fracture and PPI were used. Clinical studies related to PPI use and hip fracture were identified. Bibliographies of identified articles were reviewed for relevant articles. 8 observational studies met the inclusion criteria for the review. All adjusted Odds Ratios (OR) corresponding to ⭌ duration format were incorporated into the analysis and displayed visually. Relative weights for fracture number were also displayed. Results: Over 34,000 unique hip fractures were identified. The likelihood of hip fracture increased significantly at ⭌ 4 years of exposure, the OR ranging between 1.62 and 4.55. The OR showed no increased risk, and remained at approximately 1.0 up through the 3 year mark. Conclusion: The analysis supported the hypothesis that the duration of exposure to a PPI is associated with an increased likelihood of hip fracture. Endoscopic Treatment of Anastomotic Biliary Strictures After Living Donor Liver Transplantation: Outcomes After Maximal Stent Therapy Ting-Hui Hsieh, M. Edwyn Harrison, Michael D. Crowell, Kristin L. Mekeel, Bashar A. Aqel, Elizabeth J. Carey, Thomas J. Byrne, Hugo E. Vargas, David D. Douglas, Jorge Rakela, Kunam S. Reddy, Adyr A. Moss, and David C. Mulligan Background: Living-donor liver transplantation (LDLT) has emerged as a viable strategy in an era of extreme organ shortage. However, biliary strictures remain the Achilles’ heel of LDLT. The optimal endoscopic treatment for anastomotic biliary strictures (ABS) after LDLT is undefined. Aim: To determine the outcome of an aggressive endoscopic approach that uses endoscopic dilatation followed by maximal stent placement at a single tertiary– care academic medical center. Methods: We retrospectively reviewed our transplant database for all LDLT performed between March 2001 and September 2010. Demographic data was collected and treatment outcomes, including bile-duct patency, recurrence of stricture, need for surgical intervention, morbidity, and mortality were evaluated. Results: Of 106 LDLTs completed at our institution since 2001, 41 (38.7%) developed a biliary stricture after transplant; 38 patients had duct to duct anastomoses and are included in the analysis. The mean follow-up time is 54 months (range 2.5–97 months). Among them, 23 (60.5%) were male, 20 (52.6%) had bile leakage, and 6 required concomitant percutaneous transhepatic cholangiodrainage. The mean time to the development ABS after LDLT was 4 months. The mean time to stricture resolution was 6.6 months. The strictures took an average of 4.3 interventions and 7.9 stents to resolve. There was statistically significant improvement in biochemical markers after intervention, including aspartate transaminase (76 vs 39, P ⫽ .001), alanine transaminase (127.5 vs 45.5, P ⬍ .001), alkaline phosphatase (590 vs 260, P ⬍ .001) and total bilirubin (2.57 vs 1.73, P ⫽ .017). Eight patients (21%) had recurrent stricture after initial treatment. All recurrences were treated successfully endoscopically. All patients have been managed without surgical revision or retransplantation, resulting in 100% success by an intention-to-treat analysis. Conclusions: In our experience, aggressive endoscopy-based treatment with maximal stent placement strategy allows 100% resolution of all ABS after LDLT without the need for surgical intervention or re-transplantation. Hepatitis C Treatment Response in Liver Transplant Recipients Ranjith Wijeratne, Joshua Dworetzky, Alice Thomas, Amandeep Sahota, Alan J. Sheinbaum Background: Hepatitis C virus (HCV)–related end-stage liver disease is the leading indication for liver transplantation (LT). HCV recurrence after LT is universal leading to accelerated recurrence of cirrhosis. Therapeutic response to currently available regimen is reported lower compared to treatment of HCV in non LT patients. Objective: Evaluate the response of HCV treatment in LT recipients. Methods: It was a retrospective study in which medical records of subjects who underwent liver transplant for HCV related liver disease from September 1991 to August 2009 were reviewed.
Results: One hundred ninety-five subjects with HCV LT recipients charts were reviewed, 139 were excluded as there were not treated. Fifty-six subjects were treated with pegylated interferon and ribavirin standard dose. Mean age was 60 years, predominantly males (82%). Twenty-eight (50%) were white, 18 (32%) were Hispanic and 10 (18%) were African American. Average body mass index was 28, and genotype (GT) 1 was predominant (84%). Median METAVIR fibrosis score was 2. Overall sustained virological response (SVR) in this cohort was 32%. Hispanics and Whites had similar SVR rates (50%) but none of the African Americans achieved SVR and had 40% relapse rate. There were no deaths in subjects who achieved SVR whereas 4 died in non SVR group. Complications: SVR group: one subject underwent re-transplantation due to hepatic artery issues, 6 had acute cellular rejection (ACR) during treatment and one had chronic rejection. Overall, 16% received blood transfusions, 21% required erythropoietin respectively for anemia. Conclusion: SVR to pegylated interferon and ribavirin for recurrent HCV in LT recipients was modest in our experience (32%). HCV LT recipients should be offered treatment.
Table 1. Treatment Response According to Genotype GT-1 (n ⫽ 47) SVR No SVR Relapser Treatment intolerant
13 (28%) 17 (36%) 14 (30%) 3 (6%)
GT-2 (n ⫽ 2)
GT-3 (n ⫽ 7) 5 (71%)
1 (50%) 1 (50%)
2 (29%)
GT, genotype; SVR, sustained virological response.
Impact of Argon Plasma Coagulation on Three-Month Tumor Recurrence Rates Following Endoscopic Mucosal Resection of Colorectal Lateral Spreading Tumors William J. Salyers, Jr., Emily Christman, Ryan C. Butterfield, Juan Carlos Munoz Introduction: Endoscopic mucosal resection (EMR) may be considered for curative resection of superficial lateral spreading tumors (LST) of the colorectum in the absence of lymphatic invasion. LSTs measure ⬎10 mm in diameter, extend laterally with a low vertical axis, and are divided into 2 subtypes, granular (LST-G) and non-granular (LST-NG). The purpose of this study was to evaluate 3 month tumor recurrence rates based upon use of argon plasma coagulation (APC) following EMR. Methods: Charts of patients with colorectal lesions ⬎10 mm resected by EMR between May 1, 2007, and May 1, 2010, were examined retrospectively to identify patients with LSTs who had a follow-up endoscopy at least 12 weeks after the initial EMR. Endoscopic images were reviewed to identify LSTs which were then classified as either LST-G or LST-NG. Flat lesions ⬍10 mm, depressed tumors, and pedunculated polyps were excluded. A total of 19 patients met inclusion and exclusion criteria. Statistical analysis: Interactive effects of the predictive and response variables were analyzed using Fisher’s Exact Test for association and Pearson’s correlation coefficient. Linear regression was used with alpha⫽.1 to identify possible predictors of tumor recurrence after 3 months and complete tumor resection at the end of the study period. Results: No significant associations or correlations were identified between LST type and size or APC use and 3 month recurrence of LST. Mean age was 70.9 years with 11 (57.9) males and 8 (42.1) females. LST-G were the largest subtype of LST with 14 (73.7) LST-G and 5 (26.3) LST-NG resected. Tumor size was distributed evenly with 10 (52.6) LST ⬍20 mm and 9 (47.4) ⬎20 mm (Range ⫽ 10 mm– 40 mm). Lift and cut method of EMR was used in 18 (94.7) patients and suction banding method in 1 (5.3). Piecemeal resection was used in 14 (73.7) patients and en bloc resection in the remaining 5 (26.3) patients. APC was used following EMR in 9 (47.4) patients. There were no immediate complications in any patients. Pathology review revealed 9 (47.4) tubular adenomas, 5 (26.3) tubulovillous adenomas, 4 (21.1) adenomatous polyps with high-grade dysplasia, and 1 (5.3) intramucosal adenocarcinoma. Mean time to first follow-up endoscopy was 23.6 weeks (range ⫽ 12– 49 weeks) with mean total endoscopic follow-up 35.4 weeks (range ⫽ 12–92 weeks). Three month tumor recurrence occurred in 8 (42.1) patients. Following a maximum of up to 2 repeat EMRs, there was no evidence of LST recurrence in 16 (84.2) patients at the end of the study period. Conclusions: APC use following EMR does not appear to have a significant impact on 3 month recurrence rates of colorectal LSTs.