A large multicenter cohort on the use of full-thickness resection device for difficult colonic lesions.

BACKGROUND: Introduction of the full-thickness resection device (FTRD) has allowed endoscopic resection of difficult lesions such as those with deep wall origin/infiltration or those located in difficult anatomic locations. The aim of this study is to assess the outcomes of the FTRD among its early users in the USA. METHODS: Patients who underwent endoscopic full-thickness resection (EFTR) for lower gastrointestinal tract lesions using the FTRD at 26 US tertiary care centers between 10/2017 and 12/2018 were included. Primary outcome was R0 resection rate. Secondary outcomes included rate of technical success (en bloc resection), achievement of histologic full-thickness resection (FTR), and adverse events (AE). RESULTS: A total of 95 patients (mean age 65.5 ± 12.6 year, 38.9% F) were included. The most common indication, for use of FTRD, was resection of difficult adenomas (non-lifting, recurrent, residual, or involving appendiceal orifice/diverticular opening) (66.3%), followed by adenocarcinomas (22.1%), and subepithelial tumors (SET) (11.6%). Lesions were located in the proximal colon (61.1%), distal colon (18.9%), or rectum (20%). Mean lesion diameter was 15.5 ± 6.4 mm and 61.1% had a prior resection attempt. The mean total procedure time was 59.7 ± 31.8 min. R0 resection was achieved in 82.7% while technical success was achieved in 84.2%. Histologically FTR was demonstrated in 88.1% of patients. There were five clinical AE (5.3%) with 2 (2.1%) requiring surgical intervention. CONCLUSIONS: Results from this first US multicenter study suggest that EFTR with the FTRD is a technically feasible, safe, and effective technique for resecting difficult colonic lesions.

The Status of SEMS Versus Plastic Stents for Benign Biliary Strictures.

PURPOSE OF REVIEW: Benign biliary strictures can be treated with plastic stents and self-expandable metal stents (SEMS). This review article delineates the latest scientific evidence for their usage. RECENT FINDINGS: Despite evolving literature on both type of stents as treatment modalities of benign biliary strictures, which encompass mainly anastomotic strictures and strictures related to chronic pancreatitis, no final conclusions can be drawn regarding the superiority of a particular stent. SEMS tend to have higher stricture resolution rates and fewer procedural requirements which are partly offset by higher stent migration and stricture recurrence rates compared with plastic stents. Additional studies focusing on new SEMS types with anti-migration features as well as cost-effectiveness calculations are necessary for clinical decision-making when treating patients with benign biliary strictures.

Covered self-expandable metal stents in pancreatic malignancy regardless of resectability: a new concept validated by a decision analysis.

BACKGROUND AND STUDY AIMS: The current treatment model for the management of malignant biliary obstruction is to place a plastic stent for unstaged pancreatic cancer. In patients with unresectable disease but a life expectancy of more than 6 months, self-expandable metal stents (SEMS) are favored because of their more prolonged patency. We analyzed the efficacy and cost-effectiveness of covered SEMS (CSEMS) in patients with pancreatic cancer and distal biliary obstruction without regard to surgical resectability. PATIENTS AND METHODS: Between March 2001 and March 2005, 101 consecutive patients with obstructive jaundice secondary to pancreatic cancer underwent placement of a CSEMS. Patients with resectable tumor were offered pancreaticoduodenectomy. A model was developed to compare the costs of CSEMS and polyethylene and DoubleLayer stents. RESULTS: A total of 21 patients underwent staging laparoscopy, of whom 16 had a resection (76%). The 85 patients who did not have a resection had a mean survival of 5.9 months (range 1-25 months) and a mean CSEMS patency duration of 5.5 months (range 1-16 months). Life-table analysis demonstrated CSEMS patency rates of 97% at 3 months, 85% at 6 months, and 68% at 12 months. In a cost model that accounted for polyethylene and DoubleLayer stent malfunction and surgical resections, initial CSEMS placement (3177 euros per patient) was a less costly intervention than either DoubleLayer stent placement (3224 euros per patient) or polyethylene stent placement with revision (3570 euros per patient). CONCLUSIONS: Covered SEMS are an effective treatment for distal biliary obstructions caused by pancreatic carcinoma. Their prolonged patency and removability makes them an attractive option for biliary decompression, regardless of resectability. The strategy of initial covered SEMS placement might be the most cost-effective strategy in these patients.

Endoscopic ultrasound drainage of pancreatic pseudocyst: a prospective comparison with conventional endoscopic drainage.

BACKGROUND AND STUDY AIMS: Pancreatic pseudocysts are a complication in up to 20% of patients with pancreatitis. Endoscopic management of pseudocysts by a conventional transenteric technique, i. e. conventional transmural drainage (CTD), or by endoscopic ultrasound-guided drainage (EUD), is well described. Our aim was to prospectively compare the short-term and long-term results of CTD and EUD in the management of pseudocysts. PATIENTS AND METHODS: A total of 99 consecutive patients underwent endoscopic management of pancreatic pseudocysts according to this predetermined treatment algorithm: patients with bulging lesions without obvious portal hypertension underwent CTD; all remaining patients underwent EUD. Patients were followed prospectively, with cross-sectional imaging during clinic visits. We compared short-term and long-term results (effectiveness and complications) at 1 and 6 months post procedure. RESULTS: 46 patients (37 men) underwent EUD and 53 patients (39 men) had CTD. The mean age of the entire group was 50 +/- 13 years. There were no significant differences between the two groups regarding short-term success (93% vs. 94%) or long-term success (84% vs. 91%); 68 of the 99 patients completed 6 months of follow-up. Complications occurred in 19% of EUD vs. 18% of CTD patients, and consisted of bleeding in three, infection of the collection in eight, stent migration into the pseudocyst in three, and pneumoperitoneum in five. All complications but one could be managed conservatively. CONCLUSIONS: No clear differences in efficacy or safety were observed between conventional and EUS-guided cystenterostomy. The choice of technique is likely best predicated by individual patient presentation and local expertise.

Drainage of gallbladder fossa fluid collections with endoprosthesis placement under endoscopic ultrasound guidance: a preliminary report of two cases.

Collections of fluid in the gallbladder fossa can be detected by ultrasound in as many as 29% of patients following cholecystectomy. Traditionally, persistent collections are treated by percutaneous drainage and bile duct decompression. We present two cases of persistent gallbladder fossa fluid collections which were refractory to bile duct decompression but which were successfully drained by endoscopic ultrasound-guided endoprosthesis placement. Under endoscopic ultrasound (EUS) control, a 19-gauge needle was inserted through the duodenal wall into the gallbladder fossa fluid collection. A guide wire was coiled within the collection, and an endoprosthesis was placed over the wire. Endoprosthesis insertion was successful in both cases, resulting in rapid symptomatic and radiographic improvement. EUS-guided drainage offers a minimally invasive alternative to percutaneous treatment of persistent gallbladder fossa fluid collections following cholecystectomy.

Observation of a subsurface oil-rich layer in the open ocean.

A layer of water at a depth of 200 meters containing 3 to 12 milligrams per liter of oil was found during February and March 1978 over a distance of 800 nautical miles in the southwest North Atlantic and the eastern Caribbean. The geochemistry and carbon-14 activity of the oil shows it to be a weathered crude, probably from a submarine seep. Although the dimensions of the oily layer were not determined, conservative estimates indicate that more than I megaton could have been present.

Determining what heroin means to heroin addicts.

For purposes of treatment, description, typological and psychological instrumentation, agreement judgements were obtained from 20 heroin addicts and 51 normal controls on data matrices constructed from sentences obtained from the heroin addicts. Correlations demonstrate controls are similar to one another and qualitatively different from addicts. Multidimensional scaling techniques and perspective summary maps demonstrate these differences and provide the technology for developing a typology of addicts for future studies. Heroin addicts have an inability to tolerate frustration, a depressive core, a negative sense of identity and a sense of futility and isolation. Heroin addicts deviate from normals at well beyond the p less than .001 level of significance in using heroin to handle problems that normals handle in other ways. For treatment of the addict, the drug must be withdrawn and new ways of coping with old needs must be taught. This matrix qualitatively demonstrates and pinpoints the deficiencies and excesses of the addict which need treatment. The epidemiology of drug use relating narcotics, delinquency, and social policy has been well documented (Chein, 1964). One major problem posed by narcotic addition is the problem of getting people to stay off drugs (withdrawal). Another major problem is the alleviation of the human misery that motivates drug use (rehabilitation). (Jaffee, 1970, Chein, 1964). In addition to the above, a problem of recent importance has been the key question of whether or not the Vietnam addicts differ basically from addicts socialized in the drug culture in the united States. (Walsh, 1971). Numerous investigators have discussed personality and addiction (Chein, 1964; Eddy, 1965, Jaffee, 1970) usually from the vantage point of the investigators. This study attempted to describe the personalities of heroin addicts from the vantage point of the addicts using instruments borrowed from descriptive semantics. (Goodenough, 1967; Stefflre, Reich, Wendell, 1967). The purpose of the pilot study was to: 1) determine where heroin positioned in the conceptual frames of reference of heroin addicts and non-addicted control subjects, 2) to establish a classification procedure for determining subtypes of heroin addicts, and 3) to demonstrate the usefulness of a linguistically based instrument in application in clinical psychiatry.