Endoscopic ultrasound-guided transmural gallbladder drainage in malignant obstruction using a novel lumen-apposing stent: a case series (with video).

Background and aims Current endoscopic methods of biliary decompression in malignant pancreatic neoplasms are often limited by anatomical and technical challenges. In this case series, we report our experience with endoscopic ultrasound (EUS)-guided placement of an electrocautery-enhanced, lumen-apposing self-expandable metallic stent (LAMS) via transmural gallbladder drainage. Methods This is a retrospective case series of nine patients (five male, mean age 63.1 years) who underwent EUS-guided LAMS placement for malignant, obstructive jaundice in the pancreatic head. All nine cases were performed by an experienced interventional endoscopist at a single, tertiary medical center. We review the technical and clinical success rates as well as the incidence of procedural adverse events across the nine patients. Results LAMS placement was technically successful in all cases and there were no procedural adverse events. Seven of nine (77.78 %) patients showed clinical and laboratory improvement immediately following the procedure. One case required re-intervention with interventional radiology guided biliary drain placement. The mean fluoroscopy time was 1.02 minutes. Conclusions EUS-guided LAMS placement for transmural gallbladder drainage in malignant obstruction appears to be a safe and effective technique, allowing patients to proceed to surgery, chemotherapy, or hospice care.

Enhanced Recovery in Mild Acute Pancreatitis: A Randomized Controlled Trial.

OBJECTIVES: Acute pancreatitis (AP) is a leading cause of hospitalization for a gastrointestinal illness in the United States. We hypothesized that enhanced recovery approaches may lead to earlier time to refeeding in patients with AP. METHODS: We performed a double-blind, randomized controlled trial of patients admitted with mild AP from July 2016 to April 2017 at a tertiary medical center. Participants were randomly assigned to receive either enhanced recovery consisting of nonopioid analgesia, patient-directed oral intake, and early ambulation versus standard treatment with opioid analgesia and physician-directed diet. Primary study end point was time to oral refeeding on an intent-to-treat basis. Secondary end points included differences in pancreatitis activity scores, morphine equivalents, length of stay, and 30-day readmissions. RESULTS: Forty-six participants enrolled. Median age was 53.1 years, and 54.3% were female. There was significant reduction in time to successful oral refeeding in the enhanced recovery versus standard treatment group (median, 13.8 vs 124.8 hours, P < 0.001). Pancreatitis activity scores trended lower at 48 to 96 hours among patients assigned to enhanced recovery (mean, 43.6 vs. 58.9, P = 0.32). No differences found in length of stay or 30-day readmissions. CONCLUSION: In this randomized controlled trial, enhanced recovery was safe and effective in promoting earlier time to refeeding in patients hospitalized with AP.

Cachexia, and not obesity, prior to pancreatic cancer diagnosis worsens survival and is negated by chemotherapy.

BACKGROUND: Although advanced pancreatic ductal adenocarcinoma (PDAC) is characterized by progressive weight loss and nutritional deterioration, the effect of cancer cachexia and body mass index (BMI) at diagnosis on survival remains unclear. METHODS: We retrospectively evaluated a prospectively collected internal cancer registry of PDAC cases from 2006-2014 at the Kaiser Permanente Medical Center. Cancer cachexia was defined as weight loss greater than 5% over the 6 months prior to diagnosis. Multivariate cox proportional hazards regression was used to assess the influence of cachexia on survival. To evaluate effect measure modification of this relationship, we performed additional analyses stratified by race, BMI class, stage, receipt of surgery and receipt of chemotherapy. We tested for heterogeneity by fitting models with an interaction term for cachexia and the modifying variable. RESULTS: Of the 977 patients, 611 (63%) were identified with cachexia. Cachexia in PDAC patients was prevalent across all stages of disease and BMI classes. Patients with cachexia had lower survival (median 4.3 months, IQR 1.7-10.0) compared to those without cachexia (median 5.2 months, IQR 2.0-10.6), log-rank P=0.03. In this analysis BMI at diagnosis was not associated with survival. In the multivariate Cox regression, cachexia was independently associated with decreased overall survival (HR 1.24, CI: 1.06-1.45, P=0.01). However, the effect of cachexia on survival outcomes was modified by receipt of chemotherapy. Cachectic patients who did not receive chemotherapy had a 40% increase in risk of death compared to non-cachectic patients (HR 1.40, CI: 1.12-1.75), while those receiving chemotherapy were unaffected by cachexia (HR 1.04, CI: 0.82-1.32, Pinteraction=0.01). CONCLUSIONS: In the largest cohort of pancreatic cancer patients examined to date, cachexia and not obesity is independently associated with worse survival in PDA and its effect is negated by systemic chemotherapy.

Impact of Integrated Health Care Delivery on Racial and Ethnic Disparities in Pancreatic Cancer.

OBJECTIVES: The objective of this study was to evaluate whether disparities in pancreatic cancer diagnosis, treatment, and survival are reduced in an integrated health system. METHODS: We conducted a retrospective study (2006-2014) among patients with pancreatic cancer from Kaiser Permanente Southern California. Racial ethnic groups included non-Hispanic whites (NHW), non-Hispanic blacks (NHB), Hispanics, and Asians. We used multivariable and Cox regression analyses to evaluate disparities in diagnosis and treatment utilization (oncology care, surgery, time to surgery, chemotherapy) and overall survival, respectively. RESULTS: Among 2103 patients, 54% were diagnosed with stage IV disease, 80% received oncology consultation, 20% received surgery with mean time to surgery 27 days (standard deviation, 36.8), 50.4% received chemotherapy. Mean overall survival was 8.6 months (standard deviation, 11.5). There were no differences in odds of stage IV diagnosis, oncology consultation, surgery, or time to surgery by racial ethnic group. Asians were more likely to receive chemotherapy (odds ratio, 1.59; 95% confidence interval [CI], 1.09-2.32) compared to NHW. NHB (hazard ratio, 0.78; 95% CI, 0.67-0.91) and Asians (hazard ratio, 0.81; 95% CI, 0.66-1.00) had improved survival compared to NHW. CONCLUSIONS: Minorities were not disadvantaged in pancreatic cancer care. Improved health care coordination may improve current disparities.

Influence of Statins and Cholesterol on Mortality Among Patients With Pancreatic Cancer.

Background: Recent studies have suggested associations between statins and enhanced survival among patients with pancreatic ductal adenocarcinoma (PDAC). However, the relationship between statins, cholesterol, and survival remains unclear. Methods: We conducted a retrospective cohort study on 2142 PDAC patients in a regional integrated healthcare system from 2006 to 2014. Electronic pharmacy records were used to abstract information on the type, length, and dosage of statin exposures starting in the year prior to diagnosis. The cumulative and individual effects of simvastatin, lovastatin, atorvastatin, pravastatin, and rosuvastatin on mortality were assessed using Cox proportional hazards regression. Statins were evaluated as any use (pre- and postdiagnosis as a time-dependent variable) and baseline use (prediagnosis only). We also evaluated whether low-density lipoprotein (LDL) cholesterol, measured at various time windows prior to diagnosis, had an independent influence on survival. Additional analyses were performed to examine whether cholesterol mediated the relationship between statins and mortality. All models included age, race, stage, surgery, gemcitabine-based chemotherapy, and the Charlson comorbidity index as covariates. Results: Any (hazard ratio [HR] = 0.87, 95% confidence interval [CI] = 0.79 to 0.97) and baseline (HR = 0.88, 95% CI = 0.79 to 0.98) statin use were both associated with a decreased risk in mortality. When assessing individual statins, we found reduced mortality among simvastatin (HR = 0.87, 95% CI = 0.77 to 0.98) and atorvastatin (HR = 0.58, 95% CI = 0.46 to 0.72) users. Cholesterol was not associated with mortality and did not mediate any relationships between statins and survival. Conclusions: Statin use rather than cholesterol level was associated with lower mortality risk in patients with pancreatic cancer. Statins appear to improve survival through a lipid-independent mechanism.

Risk of Gastric Cancer Among Patients With Intestinal Metaplasia of the Stomach in a US Integrated Health Care System.

BACKGROUND & AIMS: Gastric intestinal metaplasia (GIM) is a common finding from routine endoscopies. Although GIM is an early step in gastric carcinogenesis, there is controversy regarding routine surveillance of patients with GIM in regions with a low prevalence of gastric cancer. We aimed to determine the incidence of gastric cancer among patients with GIM and risk factors for gastric cancer. METHODS: We performed a retrospective cohort study of patients from the Kaiser Permanente Southern California region diagnosed with GIM from 2000 through 2011. GIM was identified by a keyword search of pathology reports; gastric cancer cases were identified by cross-reference with an internal cancer registry. The incidence of gastric cancer in patients with GIM (n = 923; median age at diagnosis, 68 y) was compared with that of an age- and sex-matched reference population (controls). Risk factors such as ethnicity, smoking status, history of Helicobacter pylori infection, and family history of gastric cancer were evaluated by individual Cox proportional hazards regression. We then performed a second case-cohort study to evaluate the risk of gastric cancer based on the location and extent of GIM. The median duration of follow-up evaluation was 4.6 years (interquartile range, 3.0-6.7 y). RESULTS: We identified 25 patients with GIM who developed gastric cancers. Seventeen cases of cancer were diagnosed at the same time as the diagnosis of GIM. Eight cases of cancer were identified within a median time period of 4.6 years after a diagnosis of GIM (interquartile range, 2-5.7 y). The overall incidence rate for the cohort was 1.72 (95% confidence interval, 0.74-3.39). Among the risk factors evaluated, only family history (hazard ratio, 3.8; 95% confidence interval, 1.5-9.7; P = .012) and extent of GIM (odds ratio, 9.4; 95% confidence interval, 1.8-50.4) increased the risk for gastric cancer. The incidence rate for gastric cancer in patients with a positive family history was 8.12 (95% confidence interval, 1.67-23.73). CONCLUSIONS: In an analysis of patients with GIM listed in the Kaiser Permanente Southern California database, 2.7% were diagnosed with gastric cancer; almost 70% of cases of gastric cancer were detected at the time of GIM diagnosis. Family history and extensive metaplasia were associated with an increased risk of subsequent gastric cancer. Targeted surveillance of patients with these criteria could increase early detection of gastric cancer.