Hanada, Yuri

Abstract Background and study aims In patients with inflammatory bowel disease (IBD), endoscopically visible lesions with distinct borders can be considered for endoscopic resection. The role of endoscopic submucosal dissection (ESD) for these lesions is not well defined because of a paucity of data. We aimed to evaluate the outcomes of colorectal ESD of dysplastic lesions in patients with IBD across centers in the United States. Patients and methods This was a retrospective analysis of consecutive patients with IBD who were referred for ESD of dysplastic colorectal lesions at nine centers. The primary endpoints were the rates of en bloc resection and complete (R0) resection. The secondary endpoints were the rates of adverse events and lesion recurrence. Results A total of 45 dysplastic lesions (median size 30mm, interquartile range [IQR] 23 to 42 mm) in 41 patients were included. Submucosal fibrosis was observed in 73 %. En bloc resection was achieved in 43 of 45 lesions (96 %) and R0 resection in 34 of 45 lesions (76 %). Intraprocedural perforation occurred in one patient (2.4 %) and was treated successfully with clip placement. Delayed bleeding occurred in four patients (9.8 %). No severe intraprocedural bleeding or delayed perforation occurred. During a median follow-up of 18 months (IQR 13 to 37 months), local recurrence occurred in one case (2.6 %). Metachronous lesions were identified in 11 patients (31 %). Conclusions ESD, when performed by experts, is safe and effective for large, dysplastic colorectal lesions in patients with IBD. Despite the high prevalence of submucosal fibrosis, en bloc resection was achieved in nearly all patients with IBD undergoing ESD. Careful endoscopic surveillance is necessary to monitor for local recurrence and metachronous lesions after ESD.

Abstract Background Dysphagia is the most common symptom in advanced esophageal cancer patients. Esophageal stent placement (SP) is a common palliation method but can be associated with significant morbidity. Limited data exist regarding the ability of spray cryotherapy (SC) prolong time to SP. Methods A Mayo Clinic (Rochester, MN) patient database was reviewed for cases with a SC indication of esophageal cancer palliation from 2007–2019. Procedures were performed using a liquid nitrogen SC system to apply 2–5 separate 20 second freeze and 60 second thaw cycles based on tumor characteristics. Primary outcome was time to subsequent palliative SP. Results Of 56 patients (71.4% male, mean age 77.8 ± 10.2 years) who underwent a total of 199 SC sessions (mean 3.6 ± 2.7, range 1–12 per patient), 41 had adenocarcinoma and 15 squamous cell carcinoma (SCC). Overall, 13 patients underwent subsequent SP within a mean duration of 15.7 ± 11.0 months over a mean follow-up duration of 25.6 ± 29.4 months. Treatment did produce stenosis in 16 patients, who required dilation within a mean period of 193.1 ± 294.1 days; notably, 10 patients had a history of preceding malignant strictures requiring dilation. Two patients experienced bleeding requiring transfusion, whereas 1 experienced perforation at the start of SC. Prior chemotherapy and/or radiation was not associated with developing an SC-related complication (risk ratio (RR) 1.5; 95% CI 0.6–3.7, P > 0.4). Conclusions SC appears to be an effective and safe modality to palliate esophageal cancer in appropriate candidates. Majority of patients who undergo SC avoid the need for future SP. If patients eventually require SP, they are able to, on average, defer stenting for >1 year from SC initiation.

BACKGROUND: Acute ileitis is most classically associated with inflammatory bowel disease. However, several infections can also cause inflammation or obstruction of the terminal ileum. Clinical presentation is usually acute and characterized by abdominal pain of the right abdomen. CASE REPORT: We report the case of a healthy 24 year-old man who presented with a two month history of right lower quadrant pain, nausea and emesis after returning from a trip to South Africa. Over the subsequent two months, he had continued symptoms and an ileocecal obstruction was demonstrated both on cross-sectional imaging and on colonoscopy. A stool pathogen panel was positive for Campylobacter jejuni, and he completed an empiric three-day course of azithromycin. Endoscopic biopsies were negative for histologic features of inflammatory bowel disease. After three hospitalizations for recurrent obstruction, an ileocecal resection was performed. The resection specimen revealed marked eosinophilia within the muscularis propria and submucosal fibrosis. The patient made an uneventful recovery following his surgery. CONCLUSION: Although inflammatory bowel disease should be excluded during the workup of terminal ileitis, this case illustrates the importance of including infections and post-infectious sequelae in the differential, especially in otherwise healthy patients with recent travel history.

INTRODUCTION: Non-variceal upper gastrointestinal hemorrhage is traditionally managed with mechanical devices, thermal coagulation, or injection therapy. However, due to specific lesion characteristics, certain cases may not be easily or effectively managed by these methods, in which case either a novel therapy or repurposing of an existing technique could be considered. Here, we present a case of gastric antral vascular ectasia (GAVE) addressed with cryotherapy. CASE DESCRIPTION/METHODS: An 82 year old man with CAD s/p CABG, AS s/p AVR, symptomatic AVB s/p PPM, HTN, and BPH presented to his primary care provider Clinic with chronic, symptomatic, transfusion-dependent iron-deficiency anemia with a hemoglobin nadir of 6.7 g/dL from 12.2 g/dL four months prior. The patient also reported possible melena, though stool appearance was obscured by oral iron supplementation. He underwent diagnostic EGD, which identified severe GAVE with mild associated bleeding throughout the entire stomach. This was therapeutically managed with APC, but given the severity and diffuse nature of the GAVE (Figure 1), the patient was referred for cryotherapy. Medically, the patient was recommended to initiate PPI therapy and continue iron supplementation. Three sessions occurring at 1 month intervals were completed, followed by one session 3 months out. By the third session, the patient no longer required transfusional support to maintain appropriate hemoglobin levels. On endoscopic follow-up 6 months out (one year from initial EGD), the GAVE had improved in severity (Figure 2). DISCUSSION: The current treatment of GAVE primarily involves argon plasma coagulation, which is limited by its inability to treat large areas of mucosa in an efficient manner. However, data supporting the use of cryotherapy as a safe and effective treatment for GAVE are emerging. Patients with diffuse, extensive mucosal gastrointestinal lesions should be referred to a tertiary care center to assess cryotherapy candidacy.

Abstract Background and study aims The preferred management of bleeding esophageal varices includes endoscopic band ligation. Endoscopic ligation devices (ELDs) are expensive and designed for single use, limiting their uptake in developing countries. We aimed to assess the efficacy of reprocessing ELDs using terminal microbial cultures and adenosine triphosphate (ATP) testing. Materials and methods ELDs were recovered after clinical use and their components (cap, handle, and cord) were subjected to reprocessing. This included manual cleaning, automated high-level disinfection (HLD), and drying with forced air. Using sterile technique, ELD components were sampled for ATP at three stages: before manual cleaning, after manual cleaning, and after HLD. Components were sent to an external laboratory for culturing. Cultures were interpreted as positive upon identification of Gram-negative bacilli. Results A total of 14 clinically used ELDs were studied, and 189 ATP tests and 41 cultures were evaluated. Overall, 95 % (39/41) of components and 86 % (12/14) of ELDs were culture-negative or did not yield Gram-negative bacilli. Two components (5 %; one handle and one cord) harbored Gram-negative bacilli in quantities of 1 CFU per component. There was no apparent correlation between ATP at any juncture of reprocessing and terminal cultures. Conclusions Reprocessing of ELDs is effective, resulting in infrequent and minimal microbial contamination. Microbial culturing can be used to ensure adequacy of ELD reprocessing if pursued. Until reusable ELDs are commercially available, continued efforts to better define the adequacy and long-term effects of reprocessing ELDs are needed.

Abstract Background. The objectives of this study were to estimate the incidence and evaluate risk factors for development of minocycline-induced cutaneous hyperpigmentation in patients with orthopedic infections. Methods. Patients with orthopedic infections evaluated at Mayo Clinic (Rochester, MN) and treated with minocycline from 1 January 2002 to 31 December 2011 were retrospectively identified. Long-term minocycline suppression was defined as daily minocycline use for at least 3 months. A proportional hazards model was used to evaluate potential risk factors. Results. Of 291 patients receiving long-term minocycline suppression, 54% (156 of 291) developed hyperpigmentation after a mean follow-up of 4.8 years (range, 0.3–13.2 years); 88% involved blue-gray pigmentation of normal skin that appeared most commonly in the lower (75%) and upper extremities (44%). The mean duration of minocycline therapy before hyperpigmentation was 1.5 years (range, 0.1–9 years) with a mean cumulative dosage of 107.3 g (range, 8.6–657 g). Notable risk factors include a history of vitamin D deficiency (relative risk [RR], 6.29; 95% confidence interval [CI], 1.91–15.27; P = .0052), presence of a shoulder prosthesis (RR, 3.2; 95% CI, 1.23–6.56; P = .0062), noncirrhotic liver pathology (RR, 3.63; 95% CI, 1.11–8.75; P = .0359), and use of a concurrent medication also known to cause hyperpigmentation (RR, 4.75; 95% CI, 1.83–10.1; P = .0029). Conclusions. Hyperpigmentation associated with the use of long-term minocycline suppression in patients with orthopedic infections is common.