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Biomedical subjects

G B Haber

Publications and source records attributed to G B Haber.

At least 19 recordsLinked to original sources
PubMed1999

Same-day discharge after endoscopic biliary sphincterotomy: observations from a prospective multicenter complication study. The Multicenter Endoscopic Sphincterotomy (MESH) Study Group.

BACKGROUND: Same-day discharge after endoscopic biliary sphincterotomy (ES) is a common clinical practice, but there have been few data to guide appropriate selection of patients. Using a prospective, multicenter database of complications, we examined outcomes after same-day discharge as it was practiced by a variety of endoscopists and evaluated the ability of a multivariate risk factor analysis to predict which patients would require readmission for complications. METHODS: A 150-variable database was prospectively collected at time of ES, before discharge and again at 30 days in consecutive patients undergoing ES at 17 centers. Complications were defined by consensus criteria and included all specific adverse events directly or indirectly related to ES requiring more than 1 night of hospitalization. RESULTS: Six hundred fourteen (26%) of 2347 patients undergoing ES were discharged on the same day as the procedure, ranging from none at 6 centers to about 50% at 2 centers. After initial observation and release, readmission to the hospital for complications occurred in 35 (5.7%) of 614 same-day discharge patients (20 pancreatitis and 15 other complications, 3 severe). Of the same-day discharge patients, readmission was required for 14 (12.2%) of 115 who had at least one independently significant multivariate risk factor for overall complications (suspected sphincter of Oddi dysfunction, cirrhosis, difficult bile duct cannulation, precut sphincterotomy, or combined percutaneous-endoscopic procedure) versus 21 (4.2%) of 499 without a risk factor (odds ratio 3.1: 95% confidence interval [1.6, 6.3], p < 0.001). Of complications presenting within 24 hours after ES, only 44% presented within the first 2 hours, but 79% presented within 6 hours. CONCLUSIONS: Same-day discharge is widely utilized and relatively safe but results in a significant number of readmissions for complications. For patients at higher risk of complications, as indicated by the presence of at least one of five independent predictors, observation for 6 hours or overnight may reduce the need for readmission.

Adult↗
PubMed1998

Outcome in patients with bifurcation tumors who undergo unilateral versus bilateral hepatic duct drainage.

BACKGROUND: There is much controversy as to the importance of establishing drainage of both liver lobes in malignant hilar obstruction. The purpose of the present study was to compare survival data in patients with malignant hilar obstruction, stratified according to the Bismuth classification, who had cholangiography with filling of one or both hepatic ducts and subsequently endoscopic or percutaneous drainage of one or both ducts. METHODS: A retrospective review was performed for the time period from July 1990 to July 1995, and 224 patients were identified with a presumed diagnosis of a bifurcation tumor. All x-ray films were reviewed and 150 patients finally diagnosed as hilar tumor were classified according to Bismuth type I, II, or III. Type II and III patients were further subclassified with respect to contrast injection into a single or both hepatic duct systems and whether one or both sides were eventually drained. RESULTS: Data were obtained in 141 patients (4 patients still alive); there were 43 type I, 58 type II, and 40 type III. Type II and III patients were divided into three groups: group A, one lobe opacified with same lobe drained; group B, both lobes opacified with both lobes drained; and group C, both lobes opacified with one lobe drained. Overall median survival for type I, II, and III patients was 160, 131, and 62 days, respectively. Among type II and III patients the median survivals of groups A, B, and C were 145, 225, and 46 days, respectively. Survival was significantly longer in group A vs. group C (p < 0.001), group B vs. group C (p < 0.001, and group A + B (165 days) vs. group C p < 0.001). There was no difference in group A + B versus type I (p=0.90). In addition, when comparing single drain only (group A + C, 80 days) versus double drains (group B, 225 days), there was a significant survival advantage (p < 0.0001). CONCLUSION: In bifurcation tumors the best survival was noted in those with bilateral drainage, and the worst survival in those with cholangiographic opacification of both lobes but drainage of only one.

Adult↗
PubMed1997

A prospective study of the repeated use of sterilized papillotomes and retrieval baskets for ERCP: quality and cost analysis.

BACKGROUND: The impact on instrument quality and cost of the practice of reusing ERCP accessories has not been fully addressed. METHODS: Twenty-five new papillotomes and 15 new retrieval baskets were labeled and evaluated over time by staff blinded to the number of prior uses. Instruments were scored as to their function for the designated task. The cost of this practice was calculated from the purchase price of accessories and the costs of cleaning, sterilization, and disposal, and then compared with the estimated cost of a practice of one-time use of similar instruments. RESULTS: Twenty-five papillotomes were used 246 times (median 8; mean 9.8). Fifteen retrieval baskets were used 193 times (median 13; mean 12.9). The median survival of both papillotomes and baskets before being considered inadequate (score < 6 out of 10) was 9 uses. There were no complications attributable to using reused equipment. The projected yearly cost savings of using reusable versus disposable instruments was $94,095 for papillotomes and $61,809 for baskets, a 475% and 322% cost reduction, respectively. CONCLUSION: The papillotomes and baskets in this study could be reused reliably and safely multiple times, with considerable cost savings compared with the practice of using disposable instruments.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1997

Photodynamic therapy for the treatment of tumor ingrowth in expandable esophageal stents.

BACKGROUND AND STUDY AIMS: Tumor ingrowth through self-expanding metal stents presents a difficult problem for management. The techniques for treating tumor ingrowth have not yet been well described, and the optimal endoscopic approach is not clear. We have recently used photodynamic therapy (PDT) to treat tumor ingrowth through uncovered nitinol mesh stents. PATIENTS AND METHODS: Four patients (mean age 73) with obstructive adenocarcinomas of the distal esophagus had received self-expanding stents for palliation of their dysphagia. After stent placement, tumor ingrowth had caused progressive dysphagia in all of the patients; the dysphagia was graded on a scale from 0 (normal) to 4 (inability to swallow liquids). All of the patients received PDT treatment. RESULTS: After PDT, excellent palliation of the dysphagia was seen in all of the patients, with a mean improvement in the dysphagia score of 2.25 and a mean dysphagia-free interval of 92 days. There were no major complications. CONCLUSION: The use of PDT to treat tumor ingrowth through self-expanding metal esophageal stents is effective and safe.

Adenocarcinoma↗
PubMed1997

Watermelon stomach.

Watermelon stomach (WMS) is an uncommon cause of chronic gastrointestinal blood loss, which once suspected can often be easily diagnosed and endoscopically managed in most cases. The current review intends to heighten the gastroenterologist's awareness of this condition to avoid costly delays in its diagnosis. The characteristic endoscopic appearance of WMS and the other variants of gastric vascular ectasia (GVE) are described. The conditions often associated with WMS are reviewed, including the recently described occurrence of WMS in bone marrow transplant patients presenting with acute upper gastrointestinal hemorrhage. We have clearly differentiated GVE from portal hypertensive gastropathy. The biopsy findings, although usually not required for diagnosis, are discussed. The theories of pathogenesis of WMS are presented and their relation to the observed phenomena is explored. Finally, the management of GVE, which essentially involves endoscopic application of thermal ablation methods, and the newer developments in the field, such as argon plasma coagulation, are discussed.

Anemia, Iron-Deficiency↗
PubMed1997

Future of endoscopy in nonvariceal upper gastrointestinal bleeding. What remains to be done.

The centennial of the American Gastroenterological Association provides an occasion for a critical appraisal of past developments and future directions in endoscopy. The relevance of recent technologic advances in endoscopy must be questioned, and practical management issues need to be considered. New strategies are being developed that permit physicians to impact on the incidence and recurrence of bleeding peptic ulcers.

Costs and Cost Analysis↗
PubMed1996

Complications of endoscopic biliary sphincterotomy.

BACKGROUND: Endoscopic sphincterotomy is commonly used to remove bile-duct stones and to treat other problems. We prospectively investigated risk factors for complications of this procedure and their outcomes. METHODS: We studied complications that occurred within 30 days of endoscopic biliary sphincterotomy in consecutive patients treated at 17 institutions in the United States and Canada from 1992 through 1994. RESULTS: Of 2347 patients, 229 (9.8 percent) had a complication, including pancreatitis in 127 (5.4 percent) and hemorrhage in 48 (2.0 Percent). There were 55 deaths from all causes within 30 days; death was directly or indirectly related to the procedure in 10 cases. Of five significant risk factors for complications identified in a multivariate analysis, two were characteristics of the patients (suspected dysfunction of the sphincter of Oddi as an indication for the procedure and the presence of cirrhosis) and three were related to the endoscopic technique (difficulty in cannulating the bile duct achievement of access to the bile duct by "precut" sphincterotomy, and use of a combined percutaneous-endoscopic procedure). The overall risk of complications was not related to the patient's age, the number of coexisting illnesses, or the diameter of the bile duct. The rate of complications was highest when the indication for the procedure was suspected dysfunction of the sphincter of Oddi (21.7 percent) and lowest when the indication was removal of bile-duct stones within 30 days of laparoscopic cholecystectomy (4.9 percent). As compared with those who performed fewer procedures, endoscopists who performed more than one sphincterotomy per week had lower rates of all complications (8.4 percent vs. 11.1 percent, P=0.03) and severe complications (0.9 percent vs. 2.3 percent, P=0.01). CONCLUSIONS: The rate of complications after endoscopic biliary sphincterotomy can vary widely in different circumstances and is primarily related to the indication for the procedure and to endoscopic technique, rather than to the age or general medical condition of the patients.

Age Factors↗
PubMed1996

A prospective study of the safety of endoscopic therapy for choledocholithiasis in an outpatient population.

OBJECTIVE: Many centers routinely admit patients for observation after endoscopic therapy of choledocholithiasis although this is contrary to the current mandate for cost containment. The purpose of this study was to determine the safety, success, and complication rates of outpatient therapeutic ERCP in the management of choledocholithiasis. METHODS: Over a 4-month period, 97 consecutive outpatients undergoing endoscopic treatment for choledocholithiasis were enrolled in a prospective manner. Each subject was observed 1-3 h postprocedure before discharge with follow-up at 10 days. RESULTS: Successful endoscopic management of choledocholithiasis was achieved in 100% of patients. Complication rates were as follows: pancreatitis (2.1%), postsphincterotomy bleeding (3.2%), perforation (0%), and sepsis (0%). One patient required admission during the observation period, and two others with pancreatitis were readmitted within 24 h of discharge. There was no apparent adverse clinical outcome related to this policy. CONCLUSION: Endoscopic therapy of choledocholithiasis may be performed safely on an outpatient basis, realizing significant cost savings.

Ambulatory Surgical Procedures↗
PubMed1996

Transpapillary choledochoscopy.

This article reviews the current and future applications of peroral endoscopic choledochoscopy. As endoscopic technology has evolved with smaller, more durable miniscopes, the range of diagnostic and therapeutic uses has increased proportionately. The success of intraductal lithotripsy coupled with the advent of miniscopes that can be used through standard duodenoscopes will enable most endoscopists to remove almost all bile duct stones. Similarly, the accuracy of tissue sampling and tumor staging will be enhanced. The clinical impact of these developments are reviewed.

Endoscopy, Digestive System↗
PubMed1995

Endoscopic therapy of pancreatic stones.

This chapter provides an overview of the physiology of pancreatic exocrine function and the pathophysiology of pancreatic stone formation. The natural history and the clinical sequelae are reviewed. Potential pharmacologic intervention is addressed and a detailed description and analysis of the endoscopic management is outlined.

Animals↗
PubMed1994

Mucinous ductal ectasia: cholangiopancreatographic and endoscopic findings.

Mucinous ductal ectasia (MDE) is an uncommon disease characterized by a patulous duodenal papilla extruding mucus, and a pancreatogram showing dilation with amorphous filling defects, communication of the mass with the pancreatic duct, the mass usually being located in the head of the pancreas. We have recently treated three men and three women, mean age 66 years, with MDE. All had abdominal pain, while 33% had the clinical picture of pancreatic insufficiency. Three patients had recurrent pancreatitis, and three had biliary obstruction. Endoscopic retrograde cholangiopancreatography and imaging studies showed a patulous papilla draining mucus in six, pancreatic duct dilation in six, filling defects in six, and communication between the cystic mass and the pancreatic duct in five. A distinct finding not previously reported was a separate pancreatic and biliary orifice in two. Three patients had cancer, two cases being metastatic and one being found at surgery (not suspected preoperatively). Therapy included endoscopic biliary drainage in two, surgery in three, while one refused surgery. Of the operated patients, two underwent resection, one of whom had benign disease and the other cancer; both patients are doing well 14 and 32 months after surgery, respectively. One patient underwent pancreatojejunostomy without symptomatic relief, and developed cholangitis 18 months after surgery that was successfully treated with endoscopic drainage. The other two patients treated with biliary drainage died one and 13 months later, respectively. We conclude that MDE has characteristic pancreatographic and endoscopic findings, and that it is commonly associated with malignant degeneration. Surgical resection is the treatment of choice, since MDE is premalignant, and surgery may be curative when the malignancy is resectable.

Adenocarcinoma, Mucinous↗
PubMed1989

Pancreatoduodenal necrosis after endoscopic injection of cyanoacrylate to treat a bleeding duodenal ulcer: a case report.

N-butyl 2-cyanoacrylate monomer was injected at endoscopy in an attempt to control arterial bleeding from a duodenal ulcer crater. Segmental infarction of the duodenum and pancreatic head followed and necessitated pancreatoduodenectomy. Butyl 2-cyanoacrylate monomers have been used with angiography as embolization agents and with endoscopy to control variceal bleeding. To our knowledge, there are no reports of its use by endoscopic injection to stop arterial bleeding. Its potential for embolism in nonselective endoscopic injections may minimize the clinical application of butyl 2-cyanoacrylate monomers in the treatment of arterial gastrointestinal bleeding.

Cyanoacrylates↗
PubMed1987

Role of endoscopy in inflammatory bowel disease.

Over the past two decades, endoscopy has emerged as the single most important tool in the initial diagnosis and subsequent follow-up of inflammatory bowel disease. This article is an overview of the applicability of the various endoscopic procedures in the management of inflammatory bowel disease and its complications.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1984

Surgical complications of endoscopic sphincterotomy.

Endoscopic sphincterotomy (papillotomy) was performed in 289 patients for choledocholithiasis (250, of whom 223 had undergone cholecystectomy previously), papillary stenosis or spasm (32) and ampullary neoplasm (7). The complications encountered in 39 patients were hemorrhage (15 patients), perforation (4), hemorrhage and perforation (1), cholangitis (5), pancreatitis (11), impaction (1) and others (2). Laparotomy was required in seven of these patients for hemorrhage (two), perforation (two), hemorrhage and perforation (one), pancreatitis (one) and impaction (one). Bleeding required duodenotomy with an extension of the sphincterotomy incision to control hemorrhage, and a formal sutured sphincteroplasty. Perforation occurred at the junction of the distal bile duct and duodenum and was managed by mobilization of the duodenum, with T-tube drainage through the perforation, and sutured closure. A pancreatic abscess following pancreatitis required surgical drainage. An impacted Dormia basket with entrapped stone in the bile duct required duodenotomy for its removal. There was a high risk of perforation in those patients who did not have choledocholithiasis or who had had a previous Billroth II gastrectomy. There were two deaths but the overall complication rate of 2.4% is considered low, because many of the patients were elderly or debilitated.

Aged↗