An endoscopic approach to therapy for spontaneous esophageal rupture.

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Timing of esophageal stent placement and outcomes in patients with esophageal perforation: a single-center experience.

BACKGROUND: Endoscopic treatment for esophageal perforation with stenting is an alternative to surgery. There is no data on the impact of timing of esophageal stent placement and outcomes in patients with esophageal perforation. OBJECTIVE: To determine the significance of timing of esophageal stent placement on short-term (30-day complications) and long-term clinical outcomes of patients with esophageal perforation. METHODS: Patients with esophageal perforations who underwent endoscopic treatment with stenting from 2007 to 2012 at the Cleveland Clinic were included for the study. Main outcomes measurements were impact of time to esophageal stent placement on 30-day complications and long-term outcomes. RESULTS: A total of 20 patients (males 40 % and females 60 %) were included. Mean age was 72.5 ± 10 years. The most common etiology for perforation was iatrogenic after endoscopy procedure in 10 (50 %) patients. The stent was in place for a median of 24.6 days in our cohort. Eight patients (40 %) had stent placement within 24 h, while the remaining 12 patients (60 %) had stent placement after 24 h. The mortality rate due to perforation related causes was 10 % (2/20) in our study. The 30-day complication rate was 10 %; 1 with stent migration and the other with chest pain. The 30-day readmission rates excluding patients who died during the initial hospitalization were 10 %. On long-term follow-up, 30 % complication rates were encountered; 3 (15 %) stent migrations, 2 (10 %) patients presented with hematemesis, and 1 (5 %) with chest pain. The timing of stent placement (within 24 h or later) did not impact the risk of complications (Odds Ratio [OR] 1.13, 95 % confidence interval 0.1-8.9, P = 0.91). CONCLUSIONS: Endoscopic stent placement is safe and effective for treating esophageal perforations. However, the timing of stent placement on outcomes remains unclear.

Factors associated with 30-day readmission and long-term efficacy of enteral stent placement for malignancy.

BACKGROUND: Readmissions to the hospital within 30 days of discharge (30-day readmission rate) may impact stent use in palliative treatment of cancer. OBJECTIVE: Our objective was to investigate the incidence of readmission and factors predicting readmissions and long-term outcomes in patients with self-expanding metal stents (SEMS) placed for malignant obstruction. METHODS: Retrospective analysis of all patients who underwent placement of SEMS from 2007 to 2012 for malignant esophageal, gastroduodenal, and colonic obstruction. Incidence and variables associated with 30-day readmission and long-term outcomes were determined. RESULTS: A total of 191 patients underwent stent placement. The 30-day readmission rate was 17.3 % (N = 33). Readmissions were for stent-related complications in 7.3 % (N = 14) and non-stent-related complications in 9.9 % (N = 19). Stent placement was technically successful in 185 of 191 (96.9 %) and clinically successful in 170 of 191 (89.0 %) patients. On long-term follow-up, 32 (16.8 %) patients needed re-intervention. The mean stent patency was 142 days. Readmission within 30 days was independently associated with development of early complications (<7 days) following stent placement (odds ratio [OR] 5.90; 95 % confidence interval [CI] 2.04­17.1), while the stent location did not impact readmission risk. On Cox regression analysis, American Society of Anesthesiologists physical classification (OR 1.36; 95 % CI 1.02­1.87) and stent location in the esophagus (OR 1.82; 95 % CI 1.10­3.02) were independently associated with long-term mortality. CONCLUSIONS: Early complications following stent placement increase the risk of 30-day readmission. SEMS is efficacious long-term for palliation of malignant gastrointestinal obstruction.

Limited scleroderma with pauci-immune glomerulonephritis in the presence of renal cell carcinoma.

Connective tissue disorders increase the risk of malignancy; conversely, they may manifest as rheumatological paraneoplastic syndromes due to an underlying malignancy. We describe the case of a patient with limited scleroderma whose rapid disease progression coincided with the discovery of a renal tumor. A woman, age 75 years, presented with a 3-month history of progressive difficulty grasping objects, unsteadiness, dyspnea, xerostomia, xerophthalmia, and significant weight loss. She had a 10-year history of gastroesophageal reflux and Raynaud's phenomenon. Pertinent physical examination findings included facial telangiectasias, bibasilar inspiratory rales, sclerodactyly, and absent pinprick and vibratory sensation in her toes. She also had swelling and tenderness in several metacarpophalangeal and interphalangeal joints and in both ankles. A renal mass was demonstrated on abdominal computed tomography. A left partial nephrectomy was performed, confirming an unclassified type of renal cell carcinoma, along with a focal proliferative crescentic pauci-immune glomerulonephritis. Medical therapy with rituximab, pulse methylprednisolone, and prednisone led to improvement in her symptoms. The patient's presentation is consistent with a rapid progression of pre-existing limited scleroderma with the development of new rheumatological symptoms, including vasculitis. We propose that this progression was secondary to paraneoplastic stimulation by the renal cell carcinoma. Clinicians should consider looking for a malignancy in patients with connective tissue disorders who present with a myriad of new symptoms.

Conservative management of renal masses in the elderly: our experience.

OBJECTIVES: To analyse a group of patients with clinically and radiologically detected renal neoplasms who were conservatively treated for various reasons. The patients were followed-up radiologically and intervened only if symptomatic. The natural progression of these masses and also a brief review of the literature is done. METHODS: The series was collected retrospectively from the case-notes of patients coded for renal neoplasms. Of the 13 patients followed up conservatively, eight were deferred surgery in view of their age (mean age-83.25 years), one patient had a single kidney, two were unwilling for surgery and two had severe co-morbidities which made them unfit for surgery. RESULTS: The mean age at diagnosis was 80.4 years (median-82; range 66-88). Seven females and six males were followed up for a mean and median follow-up of 38.38 and 34 months respectively (range-19 to 105 months). Six patients died during follow-up (mean-41.57 months). The average longest dimension at diagnosis and when last reviewed were 5.01 cm and 5.57 cm. However, only one of these died due to metastasis which developed during follow-up and two had to be angio-embolised for hematuria. The average rate of growth along the longitudinal dimension was 0.17 cm/year while the average change in volume was 11.97 cc/year. CONCLUSIONS: Malignant renal neoplasms grow at a relatively slow rate. Without tumour growth the risk of metastasis appears limited. Thus expectant management can be considered as an alternative for a selected group of patients who are either unwilling or unfit or high risk for surgery.