Noncirrhotic Portal Hypertension Secondary to Nodular Regenerative Hyperplasia Postrenal Transplant.

Noncirrhotic portal hypertension (NCPH) is a well-known clinical entity, but often underdiagnosed. One of the common causes of NCPH is nodular regenerative hyperplasia (NRH) that presents as nodularity with features of portal hypertension and thus often diagnosed as cirrhosis. Although NRH has no histologic fibrosis, the liver synthetic function remains intact; thus, clinical diagnosis is essential because management may differ from cirrhosis. We were asked to consult in this series of 4 patients who had new-onset ascites after kidney transplantation and were diagnosed with NCPH from NRH.

Fluoroscopic gastric peroral endoscopic pyloromyotomy (G-POEM) in patients with a failed gastric electrical stimulator.

BACKGROUND: Gastric electrical stimulators (GESs) have been used to treat refractory gastroparesis in patients who fail initial therapies such as dietary modifications, control of psychological stressors and pharmacologic treatment. More recently, gastric peroral endoscopic pyloromyotomy (G-POEM) has emerged as a novel endoscopic technique to treat refractory gastroparesis. We present a case series of patients with refractory gastroparesis who failed treatment with an implanted GES that were safely treated with G-POEM performed under fluoroscopy as a salvage therapy. METHODS: Cases of G-POEM performed on patients with refractory gastroparesis who failed treatment with a GES were retrospectively reviewed. All G-POEM procedures were performed under fluoroscopic guidance with the GES still in place. Gastroparesis Cardinal Symptoms Index (GCSI) and gastric emptying scintigraphy were assessed before and after the procedure. Patients were followed up for up to 18 months post procedure. RESULTS: Five patients underwent G-POEM after failing treatment with a GES. Under fluoroscopy, the GES and their leads were visualized in different parts of the stomach. One GES lead was observed at the antrum near the myotomy site. All procedures were successfully completed without complications. Patients' GCSI decreased by an average of 62% 1 month post procedure. Patients also had notable improvements in gastric emptying 2 months post procedure. CONCLUSION: In patients with refractory gastroparesis who have failed treatment with a GES, G-POEM can be safe and effective without removing the GES. To visualize the GES and avoid cutting GES leads during myotomy, the procedure should be performed under fluoroscopy.

The efficacy of rapid on-site evaluation during endoscopic ultrasound-guided fine needle aspiration of pancreatic masses.

BACKGROUND: Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) has become the preferred method to diagnose pancreatic masses due to its minimally invasive approach and diagnostic accuracy. Many studies have shown that rapid on-site evaluation (ROSE) improves diagnostic yield by 10-30%; however, more recent studies have demonstrated effective diagnostic accuracy rates without ROSE. Our study aims to examine whether the current standard of performing ROSE after each FNA pass adds diagnostic value during EUS-guided FNA of pancreatic masses. METHODS: We conducted a retrospective case series on patients who underwent EUS-guided FNA of pancreatic masses between February 2011 and October 2014. All cases were performed by one of three endoscopists at Emory University Hospital. Patient demographics, radiologic details of pancreatic masses and pathology reports of the biopsied pancreatic masses were examined. RESULTS: A total of 184 procedures performed in 171 patients were reviewed. The final pathology reports of the biopsied pancreatic masses showed 128 (70%) with confirmed malignancy. Only 64 (50%) of these 128 cases initially showed malignant cells during ROSE. Among these 64 cases, 23% required 5 or more FNA passes to first detect malignant cells. CONCLUSIONS: The use of ROSE during EUS-guided FNA of pancreatic masses may increase the diagnostic yield, since malignant cells were often detected during later FNA passes that would otherwise be missed if tissue sampling stopped prematurely. In addition, sample preparation for ROSE may be suboptimal, since malignant cells were only detected in 50% of cases.

Safety and efficacy of single-balloon enteroscopy in management of gastrointestinal bleeding in patients with a left ventricular assist device.

Background and study aims Left ventricular assist devices (LVADs) are currently the standard of care in treatment of patients with end-stage heart failure waiting for heart transplant as well as destination therapy for non-transplant candidates. However, patients with LVADs are at increased risk of gastrointestinal bleeding due to the device's unique effects on hemodynamics. A major source of gastrointestinal bleeding in these patients are gastrointestinal angioectasias located within the small bowel that can only be reached with deep enteroscopy. The goal of our study was to determine the safety and efficacy of single-balloon enteroscopy (SBE) in treating gastrointestinal bleeding in patients with LVADs. Patients and methods We present a retrospective case series performed on patients with LVADs who underwent SBE to treat episodes of gastrointestinal bleeding. All procedures were performed at Emory University Hospital by a single endoscopist. Patient demographics, diagnosis and treatment of gastrointestinal bleeding, episodes of re-bleeding, and procedure-related complications were examined. Results A total of 27 SBE procedures performed in 14 patients were reviewed. SBE was performed in an antegrade approach in 89 % (24/27) of cases. Deep intubation was achieved in all antegrade procedures, with the distal jejunum reached in 79 % (19/24) of cases. The diagnostic yield was 78 %. There were no reported complications associated with the procedures. Conclusions SBE is a safe and effective modality to manage gastrointestinal bleeding in patients with LVADs.

The effect of antifibrinolytic prophylaxis on postoperative outcomes in patients undergoing cardiac operations.

Antifibrinolytic agents such as aprotinin and epsilon aminocaproic acid limit postoperative bleeding and blood transfusion in patients undergoing cardiac operations using cardiopulmonary bypass (CPB). Recent evidence suggests that these agents have adverse side effects that influence operative mortality and morbidity. We studied postoperative bleeding, transfusion rates, and operative outcomes in our patients in order to assess the efficacy of these agents during cardiac operations requiring CPB. We reviewed records of 520 patients undergoing a variety of cardiac operations between January 2005 and May 2009. We measured multiple variables including pre-operative risk factors, antifibrinolytic agent used, and outcomes of operation, such as measures of bleeding and blood transfusion, as well as serious operative morbidity and mortality. Postoperative bleeding rates varied significantly between patients receiving aprotinin and those receiving aminocaproic acid (P < 0.05). There was an associated 12% decrease in operative site bleeding in aprotinin-treated patients compared with aminocaproic acid. There was no significant difference in the transfusion rates of packed red blood cells between patients receiving aminocaproic acid or aprotinin (P > 0.05), though individuals in the aprotinin group did receive FFP more frequently than patients in the aminocaproic acid group (P < 0.05). There was no significant difference in morbidity and mortality rates between patients in either drug group (P > 0.05). Our study shows that aprotinin is more effective at controlling operative site bleeding than aminocaproic acid. Reduced operative site bleeding did not portend better outcome or differences in transfusion requirements. Aminocaproic acid remains a safe and cost-effective option for antifibrinolytic prophylaxis because of unavailability of aprotinin.