ERCP core curriculum.
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Bile Duct Diseases↗
Biomedical subjects
Jennifer J Telford
Publications and source records attributed to Jennifer J Telford.
Are patients with inflammatory bowel disease receiving optimal care?
OBJECTIVES: Guidelines have been published as a framework for therapy of patients with inflammatory bowel disease (IBD). The purpose of this study was to determine whether patients referred for a second opinion were receiving therapy in accordance with practice guidelines. METHODS: Patients with luminal IBD under the care of a gastroenterologist who sought a a second opinion at Brigham and Women's Hospital between January 2001 and April 2003 were enrolled in this study. Clinical information was obtained by direct patient interview at the time of initial patient visit and by a review of prior records. Data obtained included the diagnosis, clinical symptoms, prior medical therapy, preventive measures for metabolic bone disease, and colon-cancer screening. RESULTS: The study population consisted of 67 consecutive patients: 21 with ulcerative colitis, 44 with Crohn's disease and 2 in whom the diagnosis of IBD could not be confirmed. Of the 65 patients with confirmed IBD, 56 patients had symptoms of active disease and 9 were asymptomatic. All analyses were carried out on the 56 patients with active disease. Of the 33 patients treated with aminosalicylates, 21 (64%) were not receiving maximal doses. Nine of 12 (75%) patients with distal ulcerative colitis were not receiving rectal aminosalicylate therapy. Within 6 months of their clinic visit, 35 patients had received corticosteroid therapy, and 27 (77%) patients had been treated with corticosteroids for greater than 3 months. In 16 of 27 (59%) there was no attempt to start steroid sparing medications such as 6-mercaptopurine (6MP), azathioprine, or infliximab. Of the 11 patients treated with either 6MP or azathioprine, 9 (82%) were suboptimally dosed without an attempt to increase dosage. Of the 27 patients on prolonged corticosteroid therapy 21 (78%) received inadequate treatment to prevent metabolic bone disease. Three of 9 patients (33%) meeting indications for surveillance colonoscopy for dysplasia had not undergone colonoscopy at the appropriate interval. CONCLUSIONS: Patients with IBD often do not receive optimal medical therapy. In particular, there is suboptimal dosing of 5-ASA and immunomodulatory medications, prolonged use of corticosteroids, failure to use steroid-sparing agents, inadequate measures to prevent metabolic bone disease, and inadequate screening for colorectal cancer.
Adrenal Cortex Hormones↗
Management of ingested foreign bodies.
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Foreign Bodies↗
Impact of preoperative staging and chemoradiation versus postoperative chemoradiation on outcome in patients with rectal cancer: a decision analysis.
BACKGROUND: Although radical resection and postoperative chemoradiation have been the standard therapy for patients with rectal cancer, preoperative staging by local imaging and chemoradiation are widely used. We used a decision analysis to compare the two strategies for rectal cancer management. METHODS: We developed a decision model to compare survival outcomes after postoperative chemoradiation versus preoperative staging and chemoradiation in patients aged 70 years with resectable rectal cancer. In the postoperative chemoradiation strategy, patients undergo radical resection and receive postoperative chemoradiation. In the preoperative staging and chemoradiation strategy, patients with locally advanced cancer receive preoperative chemoradiation and radical resection, whereas those with amenable localized tumors undergo local excision. The cohorts of patients were entered into a Markov model incorporating age-adjusted and disease-specific mortality. Outcomes were evaluated by modeling 5-year disease-specific survival for preoperative chemoradiation as less than, equal to, or greater than that of postoperative chemoradiation. Base-case probabilities were derived from published data; the Surveillance, Epidemiology, and End Results (SEER) Program database; and U.S. Life Tables. One-way and two-way sensitivity analyses were performed. The outcome measures were life expectancy and quality-adjusted life expectancy. RESULTS: Life expectancy and quality-adjusted life expectancy were 9.72 and 8.72 years, respectively, in the postoperative chemoradiation strategy. In the preoperative staging and chemoradiation strategy, life expectancy was 9.36, 9.72, and 10.09 years and quality-adjusted life expectancy was 8.71, 9.04, and 9.37 years when 5-year disease-specific survival was less than, equal to, or greater than that of postoperative chemoradiation, respectively. The decision model was sensitive to differences in the long-term toxicity of pre- and postoperative chemoradiation. When the 5-year disease-specific survival for patients after pre- or postoperative chemoradiation was equal, the decision model was sensitive to surgical mortality and to the probability of residual lymph node disease after local excision. CONCLUSION: If efficacy and toxicity after preoperative chemoradiation are equal to or better than that after postoperative chemoradiation in patients with locally advanced rectal cancer, then preoperative staging to select patients appropriate for preoperative chemoradiation is beneficial.
Adult↗
Palliation of patients with malignant gastric outlet obstruction with the enteral Wallstent: outcomes from a multicenter study.
BACKGROUND: Endoscopic placement of self-expandable metallic stents for palliation of patients with malignant gastric outlet obstruction is safe and feasible. METHODS: Patients with malignant gastric outlet obstruction undergoing enteral stent insertion were identified from endoscopy databases. Duration of oral intake after stent insertion was calculated by using the log-rank test. Factors associated with duration of oral intake were assessed by using Cox multivariable regression analysis. RESULTS: A total of 176 patients (mean age 65 [14] years) treated at 4 centers from 1996 to 2003 were identified. Obstruction was caused by cancer of the pancreas in 84, the stomach in 20, the bile duct in 15, the major duodenal papilla in 8, another primary site in 16, and metastases in 33. The site of obstruction was the duodenum in 125, the distal stomach in 17, the stomach and the duodenum in 18, and surgical anastomosis in 16 patients. Stent deployment was technically successful in 173. Complications occurred in 14 patients. Seventeen patients were lost to follow-up. Of the remaining 159 patients, 133 resumed oral intake for a median time of 146 days: 95% CI [65, 202]. On regression analysis, chemotherapy after stent placement was associated with prolonged duration of oral intake (hazard ratio 0.41: 95% CI [0.23, 0.72]). CONCLUSIONS: After enteral stent insertion for malignant gastric outlet obstruction, 84% of patients resumed oral intake for a median time of 146 days. Chemotherapy after enteral stent insertion was independently associated with prolongation of oral intake.
Aged↗
Analysis of cystic fibrosis gener product (CFTR) function in patients with pancreas divisum and recurrent acute pancreatitis.
BACKGROUND: The mechanism by which pancreas divisum may lead to recurrent episodes of acute pancreatitis in a subset of individuals is unknown. Abnormalities of the cystic fibrosis gene product (CFTR) have been implicated in the genesis of idiopathic chronic pancreatitis. The aim of this study was to determine if CFTR function is abnormal in patients with pancreas divisum and recurrent acute pancreatitis (PD/RAP). METHODS: A total of 69 healthy control subjects, 12 patients with PD/RAP, 16 obligate heterozygotes with a single CFTR mutation, and 95 patients with cystic fibrosis were enrolled. CFTR function was analyzed by nasal transepithelial potential difference testing in vivo. The outcomes of the PD/RAP patients following endoscopic and surgical treatments were concomitantly analyzed. FINDINGS: Direct measurement of CFTR function in nasal epithelium in response to isoproterenol demonstrated that the values for PD/RAP were intermediate between those observed for healthy controls and cystic fibrosis patients. The median value was 13 mV for PD/RAP subjects, which was statistically different from healthy controls (22 mV, p= 0.001) and cystic fibrosis pancreatic sufficient (-1 mV, p < 0.0001) and pancreatic insufficient (-3 mV, p < 0.0001) patients. INTERPRETATIONS: These results suggest a link between CFTR dysfunction and recurrent acute pancreatitis in patients with pancreas divisum and may explain why a subset of patients with pancreas divisum develops recurrent acute pancreatitis.
Acute Disease↗
The role of ERCP and pancreatoscopy in cystic and intraductal tumors.
ERCP and pancreatoscopy may establish a diagnosis of IPMT and differentiate it from a pseudocyst or cystic neoplasm of the pancreas. These techniques may also assess risk of malignancy, extent of disease, allow tissue sampling, and provide therapeutic intervention.
Adenocarcinoma, Mucinous↗
Pancreatic stent placement for duct disruption.
BACKGROUND: The aim of this study was to identify predictors of outcome after pancreatic duct stent placement for duct disruption. METHODS: Patients were identified from endoscopy databases. Disruption was defined by extravasation of contrast from the pancreatic duct during endoscopic retrograde pancreatography. Data collected included demographic information, imaging studies, management before and outcome after stent placement. Success was defined as resolution of the disruption clinically, on radiologic imaging, and/or at endoscopic retrograde pancreatography. RESULTS: Forty-three patients (23 women, 20 men; mean age 57 years, [SD] 15.2 years) were studied. The etiology of pancreatic duct disruption was acute pancreatitis in 24, chronic pancreatitis in 9, operative injury in 7, and trauma in 3 patients. In 25 patients there was resolution of the disruption, whereas stent therapy was unsuccessful in 16 and the outcome was indeterminate in 2 patients. On univariate analysis, stent positioned to bridge the disruption (p = 0.04) and longer duration of stent therapy (p = 0.002) were associated with a successful outcome. Female gender (p = 0.05) and acute pancreatitis (p = 0.05) were associated with a lack of success. On multivariate analysis, only the bridging stent position remained correlated to outcome. Complications occurred in 4 patients. CONCLUSIONS: A bridging stent is associated with a successful outcome after pancreatic duct stent placement for duct disruption.
Acute Disease↗