John C. Fang

Well-differentiated esophageal liposarcomas are exceptionally rare tumors that are incompletely characterized in the literature. We report a case of an 80-year-old man presenting with an obstructive esophageal liposarcoma that was resected using endoscopic submucosal dissection (ESD) and extracted in fragments due to its large size. At 6-month follow-up, the patient reported resolution of presenting dysphagia with accompanying esophagogastroduodenoscopy notable for no tumor recurrence. This case highlights the efficacy of ESD in the resection of a giant esophageal liposarcoma and the diagnostic challenge of differentiating malignant and benign esophageal tumors preoperatively.

Purpose:Familial adenomatous polyposis (FAP) confers a significant risk of colorectal/duodenal cancer. Encapsulated rapamycin (eRapa) has demonstrated promise as FAP chemoprevention in early clinical studies. Patients and Methods:Thirty patients with FAP enrolled to three dosing regimens of eRapa (0.5 mg): cohort 1—every other day, cohort 2—daily every other week, or cohort 3—daily. The primary endpoints were safety/tolerability, pharmacokinetics, and percentage change from baseline (PCFB) in colorectal polyp burden (CPB) at 6 months. Secondary endpoints included PCFB total (TPB) and duodenal (DPB) polyp burden and change in International Society for Gastrointestinal Hereditary Tumors stage and Spigelman score at 6 and 12 months. Results:Twenty nine of thirty patients (97%) completed the 12-month study with predictable bioavailability. Low-grade adverse events were frequent but most pronounced in daily dosing. Two patients discontinued treatment related to toxicity. Cohort 1 had the largest decrease median PCFB CPB, DPB, and TPB at 6 months: −39.4 % (IQR, 108.9; P = 0.28), −33.33 % (IQR, 90; P = 0.04), and −38.6 % (IQR, 88.5; P = 0.26), respectively. At 12 months, cohort 2 had the largest decrease median PCFB CPB and TPB: −29.3 % (IQR, 67.6; P = 0.37) and −26.3 % (IQR, 49.5; P = 0.29), respectively. Intermittent dosing cohorts (1 and 2) reduced DPB at 6 months (P = 0.04) and improved TPB at 12 months (P = 0.05) compared with daily dosing. Conclusions:eRapa was safe, tolerable, and showed preliminary efficacy for FAP chemoprevention. The 0.5 mg daily every-other-week schedule will be evaluated in an upcoming phase III trial.

Supplementary Table 1. Representativeness of Study Participants.

Purpose: Familial adenomatous polyposis (FAP) confers a significant risk of colorectal/duodenal cancer. Encapsulated rapamycin (eRapa) has demonstrated promise as FAP chemoprevention in early clinical studies. Patients and Methods: Thirty patients with FAP enrolled to three dosing regimens of eRapa (0.5 mg): cohort 1—every other day, cohort 2—daily every other week, or cohort 3—daily. The primary endpoints were safety/tolerability, pharmacokinetics, and percentage change from baseline (PCFB) in colorectal polyp burden (CPB) at 6 months. Secondary endpoints included PCFB total (TPB) and duodenal (DPB) polyp burden and change in International Society for Gastrointestinal Hereditary Tumors stage and Spigelman score at 6 and 12 months. Results: Twenty nine of thirty patients (97%) completed the 12-month study with predictable bioavailability. Low-grade adverse events were frequent but most pronounced in daily dosing. Two patients discontinued treatment related to toxicity. Cohort 1 had the largest decrease median PCFB CPB, DPB, and TPB at 6 months: −39.4 % (IQR, 108.9; P = 0.28), −33.33 % (IQR, 90; P = 0.04), and −38.6 % (IQR, 88.5; P = 0.26), respectively. At 12 months, cohort 2 had the largest decrease median PCFB CPB and TPB: −29.3 % (IQR, 67.6; P = 0.37) and −26.3 % (IQR, 49.5; P = 0.29), respectively. Intermittent dosing cohorts (1 and 2) reduced DPB at 6 months (P = 0.04) and improved TPB at 12 months (P = 0.05) compared with daily dosing. Conclusions: eRapa was safe, tolerable, and showed preliminary efficacy for FAP chemoprevention. The 0.5 mg daily every-other-week schedule will be evaluated in an upcoming phase III trial.

Background: Colonoscopy is a diagnostic and therapeutic procedure that reduces colorectal cancer incidence and mortality but requires adequate bowel cleansing for high-quality examination. Past studies have suggested cirrhosis as a risk factor for worse bowel preparation. Methods: We carried out a match-controlled retrospective study evaluating patients with and without cirrhosis who underwent outpatient screening colonoscopies to assess the effect of cirrhosis and portal hypertension complications on preparation quality and endoscopic measures. We also did a subgroup analysis excluding patients with obesity. Results: We examined 1464 patients with cirrhosis and matched controls. Cirrhotic patients had lower mean Boston Bowel Preparation Scale (BBPS) scores and slower cecal intubation times. We found a single point increase in the Model for End-stage Liver Disease (MELD) score, as well as ascites, hepatic encephalopathy, and variceal hemorrhage were all associated with a longer cecal intubation time. Subgroup analysis excluding patients with obesity again found a significantly lower BBPS score and longer cecal intubation time while also finding a 24% drop in polyp detection. Conclusions: Patients with cirrhosis have worse BBPS scores and longer cecal intubation times. Nonobese cirrhotic patients additionally have a lower polyp detection rate. Portal hypertension complications were associated with worsened preparation quality and longer cecal intubation times. Each incremental increase in MELD score lengthened cecal intubation time. These findings support a more aggressive bowel preparation strategy for patients with cirrhosis, especially patients with severe disease or portal hypertension complications.

Background and Aims: We compared the safety and outcomes of percutaneous jejunostomy tubes placed endoscopically (PEJ), fluoroscopically by interventional radiology (IR-jejunostomy), and open jejunostomy placed surgically (surgical jejunostomy). Methods: Using the Nationwide Readmissions Database, we identified hospitalized patients who underwent a jejunostomy from 2016 to 2019. Selected patients were divided into 3 cohorts: PEJ, IR-jejunostomy, and surgical jejunostomy. Adjusted odds ratios (OR) for adverse events were calculated using multivariable logistic regression analysis. Results: A total of 6022 (65.2±9.8 y) surgical jejunostomy patients, 3715 (63.6±11.0 y) endoscopic jejunostomy patients, and 14,912 (64.8±11.6 y) IR-jejunostomy patients were identified. Compared with surgery, PEJ patients were 32% less likely to experience postprocedure complications (OR: 0.68; 95% CI: 0.58-0.79, PPPPPPP=0.001); and for hemorrhage requiring blood transfusion 0.71 (95% CI: 0.56-0.91; P=0.005) and 0.75 (95% CI: 0.61-0.91; P=0.003). Conclusions: Endoscopic placement of percutaneous jejunostomy tubes (PEJ) in inpatients is associated with significantly lower risks of adverse events and mortality compared with IR and surgical jejunostomy.

Article: A comprehensive intervention to enhance inpatient colon preparation quality for colonoscopy - Minerva Gastroenterology 2021 Apr 01 - Minerva Medica - Journals

Background: Percutaneous jejunal enteral access can be obtained with percutaneous endoscopic gastric jejunostomy (PEGJ) and direct percutaneous endoscopic jejunostomy (DPEJ) tubes. PEGJ may not be feasible in patients with previous gastric resection (PGR) and DPEJ may be the only option. Our aim is to determine if DPEJ tubes can be placed successfully in patients with history of gastrointestinal (GI) surgery and if success rates are comparable to DPEJ or PEGJ in those without prior GI surgery.Methods: We reviewed all tube placements performed from 2010 to present. Procedures were performed using a pediatric colonoscope. Previous upper GI surgery was defined as PGR or esophagectomy with gastric pull‐up. Adverse events (AEs) were graded per American Society for Gastrointestinal Endoscopy criteria. Mild events included unplanned medical consultation or hospitalization <3 days, and moderate events included repeat endoscopy without surgical intervention.Results: Successful placement rates were high regardless of GI surgical history. Patients receiving a DPEJ with a history of GI surgery were significantly less likely to experience an AE compared with those receiving DPEJ with no history and compared with PEGJ patients with or without a history.Conclusions: DPEJ placement in patients with previous upper GI surgery has very high success rate. It is associated with lower AE rates than patients receiving DPEJ without previous gastric surgery, or PEGJ regardless of previous gastric surgery. Patients with a history of upper GI surgery requiring enteral access may benefit from DPEJ over PEGJ placement considering its very high success rate and lower incidence of AEs.