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Biomedical subjects

Stuart Sherman

Publications and source records attributed to Stuart Sherman.

At least 55 records · Page 3Linked to original sources
PubMed2003

Effects of droperidol on the pancreatic and biliary sphincters.

BACKGROUND: Performance of sphincter of Oddi manometry at ERCP is technically demanding and requires that the patient be well sedated. Droperidol is frequently administered when adequate sedation cannot be achieved with a benzodiazepine and meperidine. This study examined the effects of droperidol on the biliary and pancreatic sphincters. METHODS: A total of 31 patients were prospectively evaluated by sphincter of Oddi manometry in the conventional retrograde fashion. Manometry was initially performed with intravenous administration of diazepam alone, diazepam plus meperidine or midazolam plus meperidine. Manometry was then repeated 5 minutes after droperidol was administered. RESULTS: The basal pressure of the biliary sphincter and of the pancreatic sphincter were not significantly altered by droperidol. Concordance (normal vs. abnormal) between the basal sphincter pressure before and after droperidol was seen in 30 patients (97%). Droperidol also did not lead to a difference in phasic wave amplitude, duration, or frequency. Thirteen manometry tracings (42%) were judged as being qualitatively better after droperidol, whereas two (6.5%; </= p 0.001) were qualitatively better before droperidol administration. CONCLUSIONS: Droperidol does not significantly affect sphincter of Oddi manometric parameters. It appears that it can be added to the armamentarium of agents needed for performance of sphincter of Oddi manometry. However, further study is needed to determine whether recent safety concerns with droperidol use are valid.

Adjuvants, Anesthesia↗
PubMed2003

EUS-FNA of recurrent postoperative extraluminal and metastatic malignancy.

BACKGROUND: EUS-guided FNA is safe and accurate for the diagnosis of benign or malignant neoplasia and lymphadenopathy; however, its role in the diagnosis of recurrent malignancy is not well described. METHODS: A prospectively updated EUS-guided FNA cytology database was used to identify patients in whom a diagnosis of postoperative, recurrent, extraluminal, or metastatic malignancy was made over a 5-year period. Only patients with a positive EUS-guided FNA were included in the analysis. All had undergone surgery for the primary malignancy and were in clinical and/or radiographic remission before the initial suspicion of tumor recurrence. RESULTS: Twenty-one patients underwent EUS-guided FNA of 21 lesions (19 masses, 2 lymph nodes) because of a suspicion of recurrent malignancy based on CT (n = 17) or EUS (n = 4) findings. Median time from the initial diagnosis to recurrence was 26 months (range 5-276 months). Lesions were located in the pancreas (9 patients), mediastinum (7), liver (3), perigastric region (1), and liver hilum (1). EUS-guided FNA (mean number of needle passes, 4.5; range 2-8) obtained diagnostic material for recurrent malignancy in all patients as follows: esophageal (6 patients), renal cell (6), pancreatic (2), breast (2), colon (2), bile duct (1), Ewing's sarcoma (1), and lung (1) cancer. No complication was encountered. Transgastric EUS-guided FNA (4 patients), distal, or transesophageal EUS-FNA (2) proximal to a surgical anastomosis was required to confirm recurrence in all 6 patients with esophageal cancer. The initial cytologic diagnosis of recurrent malignancy was made by EUS in 20 of 21 (95%) patients. One patient with recurrent breast cancer had CT-guided FNA of a right lung mass preceding EUS-guided FNA of an AP window lymph node. CONCLUSIONS: EUS-guided FNA can detect and safely diagnose recurrent malignancy in the mediastinum, retroperitoneum, and liver. When possible, correlation between EUS-guided FNA cytology and original tumor histopathology/cytology, or the use of immunostaining to confirm the diagnosis, is recommended.

Adenocarcinoma↗
PubMed2003

Clinical utility of stent cytology for the diagnosis of pancreaticobiliary neoplasms.

OBJECTIVE: ERCP is frequently the technique of choice for the diagnosis and palliative treatment of pancreaticobiliary neoplasms. The sensitivity of tissue sampling techniques has been disappointing. Two small series have reported a high diagnostic yield from cytological examination of cellular debris from removed biliary stents. The aim of this study was to determine the clinical utility of stent cytology for the diagnosis of biliary and pancreatic neoplasia. METHODS: Patients who had biliary or pancreatic stents removed at ERCP and evaluated cytologically were the subjects of this study. Stents were scraped and washed, and the cellular debris was examined cytologically and recorded as positive, atypical, or negative. Patient demographics, ductal stricture, and stent characteristics were recorded. RESULTS: Between January, 1994 and January, 2001 a total of 126 biliary stents from 101 patients (61 male, 40 female, mean age 62 yr) and 29 pancreatic stents from 19 patients (seven male, 12 female, mean age 58 yr) were examined. The sensitivity, specificity, positive predictive value, and negative predictive value of biliary and pancreatic stents for the diagnosis of neoplasia were: 11%, 100%, 100%, 53%, and 25%, 100%, 100%, 77.8%, respectively. The sensitivity improved slightly if all degrees of atypia were considered positive for neoplasia. The mean duration of stent placement was 93.6 days for biliary stents and 43.5 days for pancreatic stents. CONCLUSIONS: Biliary and pancreatic stent cytology has limited clinical utility in the diagnosis of pancreaticobiliary neoplasia, owing to poor sensitivity. In addition, the time lag between stent placement and removal for cytologic examination further limits its contribution to patient management.

Adult↗
PubMed2003

Endoscopic ultrasound-guided fine needle aspiration cytology of solid liver lesions: a large single-center experience.

OBJECTIVES: The aim of this study was to report the sensitivity, cytological diagnoses, endoscopic ultrasound (EUS) features, complications, clinical impact, and long term follow-up of a large single-center experience with endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of benign and malignant solid liver lesions. METHODS: A database of cytologic specimens from EUS-FNA was reviewed to identify all hepatic lesions aspirated between January, 1997, and July, 2002. Procedural indications, prior radiographic data, patient demographics, EUS examination results, complications, and follow-up data were obtained and recorded. RESULTS: EUS-FNA of 77 liver lesions in 77 patients was performed without complications. Of these 77 lesions, 45 (58%) were diagnostic for malignancy, 25 (33%) were benign, and seven (9%) were nondiagnostic. A total of 22 lesions were confirmed as negative for malignancy by follow-up (mean 762 days, range 512-1556 days) or intraoperative examination; however, seven lesions could not be classified as benign or malignant. Depending on the status of the seven unclassified lesions, sensitivity of EUS-FNA for the diagnosis of malignancy ranged from 82 to 94%. When compared with benign lesions, EUS features predictive of malignant hepatic masses were the presence of regular outer margins (60% vs 27%; p = 0.02) and the detection of two or more lesions (38% vs 9%; p = 0.03). Of the 42 patients with malignancy identified by EUS-FNA and other available imaging records, EUS detected the malignancy in 41% of patients with previously negative examinations. For the 45 subjects with cytology positive for malignancy, EUS-FNA changed management in 86% of subjects. CONCLUSION: EUS-FNA of the liver is a safe and sensitive procedure that can have a significant impact on patient management. Prospective studies comparing the accuracy and complication rate of EUS-FNA and percutaneous fine needle aspiration (P-FNA) for the diagnosis of liver tumors are needed.

Aged↗
PubMed2002

Sphincter of Oddi (pancreatic) hypertension and recurrent pancreatitis.

Major papilla pancreatic sphincter dysfunction, a variant of sphincter of Oddi dysfunction, causes pancreatitis and pancreatic-type pain. The gold standard for diagnosis is sphincter of Oddi manometry, most commonly performed at endoscopic retrograde cholangiopancreatography (ERCP). Noninvasive testing, such as secretin-stimulated transabdominal or endoscopic ultrasound assessment of pancreatic duct diameter, is less reliable and has relatively low sensitivity. Two thirds of patients with biliary sphincter of Oddi dysfunction have elevated pancreatic basal sphincter pressure. To maximize the diagnostic yield of sphincter of Oddi dysfunction, both the biliary and pancreatic sphincter pressures should be measured. Patients with sphincter of Oddi dysfunction may respond to biliary sphincterotomy alone, but evaluation of their pancreatic sphincter is warranted if symptoms persist after biliary therapy alone. Whether both biliary and pancreatic sphincters should be treated at the first ERCP session is controversial. Biliary and pancreatic endoscopic sphincterotomies are associated with two- to fourfold increased incidence of pancreatitis following the procedure in patients with pancreatic sphincter hypertension. Prophylactic pancreatic duct stenting reduces the frequency and severity of complications by greater than 50%.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed2002

Clinical utility of EUS-guided fine-needle aspiration of mediastinal masses in the absence of known pulmonary malignancy.

BACKGROUND: Mediastinal masses represent a diagnostic challenge because of their proximity to numerous critical structures, difficulty of access for tissue sampling, and myriad potential pathologic etiologies. A large, single-center experience with EUS-guided fine-needle aspiration (EUS-FNA) in the diagnosis of non-lung cancer-related mediastinal masses is presented. METHODS: An EUS database was reviewed and all cases of mediastinal mass or lymphadenopathy encountered between 1994 and 1999 were included. Final diagnoses were determined by EUS-FNA cytology and clinical follow-up. RESULTS: Forty-nine patients were identified (27 women, 22 men; mean age 58.1 years, range 30-89 years). A malignant process was diagnosed in 22 cases (45%) and a benign process in 24 (49%). The EUS-FNA specimen was nondiagnostic in 3 cases (6%). An accurate diagnosis was made in 46 of the 49 patients (94%). No complication was noted. CONCLUSIONS: EUS-FNA is a minimally invasive technique that facilitates detection and tissue sampling of mediastinal masses. It is a safe procedure that can be performed with the patient under conscious sedation in an outpatient setting.

Adult↗
PubMed2002

Biliary tract complications after orthotopic liver transplantation with choledochocholedochostomy anastomosis: endoscopic findings and results of therapy.

BACKGROUND: Biliary tract complications are a continuing source of morbidity after orthotopic liver transplantation. This is a retrospective examination of experience with ERCP in patients with biliary tract complications after orthotopic liver transplantation to determine type and frequency of complications and outcome after endoscopic therapy. METHODS: From May 1988 to August 1999, orthotopic liver transplantation was performed 408 times; 4 additional patients who underwent orthotopic liver transplantation at another hospital were also followed. The records of 367 patients who underwent choledochocholedochostomy were reviewed. Of these, 121 underwent 325 ERCPs; 226 ERCPs were performed because of acute problems (typically cholestasis with or without cholangitis), and 99 were for reevaluation of the bile duct, stent change, or stent removal. Three patients underwent ERCP because of pancreatic problems. RESULTS: A biliary complication was identified in 24.5% of patients (90 of 367) and more than 1 complication in 32%. At ERCP, 37 patients (30.5%) had biliary stones; 9 further patients (7.4%) had only sludge. Stones were completely cleared at the initial or a subsequent ERCP. Strictures were found in 55 patients (45.5%), either at the anastomosis (n = 43) or at another site(s) in the donor duct (n = 12). Balloon or bougie dilation followed by stent insertion was performed in 54 patients. Endoscopic therapy was successful in 91% of patients with biliary strictures. A biliary leak/fistulae was found in 22 patients (18.1%) and endoscopic therapy, when attempted, was successful in all. Eight patients had possible sphincter of Oddi dysfunction based on dilated recipient and donor ducts together with elevated liver enzymes. After sphincterotomy, the liver enzymes returned to normal in only one of these patients. Three patients had blood clots in the biliary tree. CONCLUSION: When biliary tract complications are suspected after orthotopic liver transplantation, ERCP identifies biliary abnormalities if present and offers multiple therapeutic options. Endoscopic therapy is usually successful but multiple procedures are often necessary, especially when treating strictures.

Adolescent↗
PubMed2002

Hereditary pancreatitis: clinical presentation, ERCP findings, and outcome of endoscopic therapy.

BACKGROUND: Hereditary pancreatitis (HP) is an autosomal dominant disorder characterized by the onset of recurrent attacks of acute pancreatitis in childhood and frequent progression to chronic pancreatitis. There are limited data on the role of diagnostic and therapeutic ERCP in patients with HP. The aims of this study were to describe the clinical presentation and findings on pancreatography and to evaluate the role of endoscopic and surgical intervention in patients with HP. METHODS: Twenty-seven consecutive patients with HP were referred for ERCP at two centers in the midwest United States. Medical records and pancreatograms were reviewed. RESULTS: Pancreatography was abnormal in all patients. The majority (70%) had severe (Cambridge Grade III) changes of chronic pancreatitis. Nineteen (70%) patients underwent endoscopic therapy and 8 (30%) surgical intervention. After endoscopic therapy (mean follow-up 32 months), 50% were symptom free, 38% had moderate improvement, and 12% had no or transient improvement in symptoms. After surgery (mean follow-up 32 months), 38% were symptom-free, 25% had moderate improvement, and 12% had transient improvement in symptoms. Two patients treated surgically died of pancreatic cancer. CONCLUSIONS: In the short-term, improving drainage of the pancreatic ductal system by endoscopic means effectively relieves pain and reduces the number of attacks of pancreatitis in the majority of patients with HP.

Acute Disease↗
PubMed2002

Microbiology of bile in patients with cholangitis or cholestasis with and without plastic biliary endoprosthesis.

BACKGROUND: Cholangitis is a frequent complication of biliary stents. Empiric antibiotic selection is primarily based on bile cultures obtained from patients undergoing surgery and few data are available with respect to ERCP and biliary stents. This study analyzed the microbiology of bile and the antibiotic sensitivities of the organisms identified in patients presenting with clinical cholangitis or cholestasis. METHODS: All bile cultures collected during ERCP from January 1994 to January 2000 were identified by using an ERCP database. RESULTS: One hundred eighty cultures from 160 patients (mean age 55 years, range 6-94 years) were identified. Sixty-nine specimens were collected at ERCPs performed in patients with no biliary stent in place (group 1). One hundred eleven specimens were obtained from patients with a biliary stent in situ (group 2). The primary diagnoses for patients in groups 1 and 2 were as follows, respectively: malignant bile duct obstruction (25 and 85), choledocholithiasis (16 and 2), benign biliary strictures (6 and 18), acquired immunodeficiency syndrome (8 and 0), and miscellaneous (14 and 6). There were 38 positive bile cultures in group 1 (55%) and 109 positive cultures in group 2 (98%; p < 0.05). A higher frequency of polymicrobial infections (90%) was found in group 2 patients (vs. group 1, 45%; p < 0.001). Escherichia coli was the most common organism found in group 1 (17%); Enterococcus the most common in group 2 (31%). Among patients with positive bile cultures, bacteremia was more frequent in group 2 patients (46% vs. 21%; p < 0.05). Ciprofloxacin and cefiriaxone were the most effective antibiotics against identified gram-negative bacilli, and vancomycin against Enterococci. CONCLUSION: In patients with cholangitis associated with biliary obstruction, the antibiotic selected initially should be active against gram-negative bacilli. Use of quinolones is recommended because these agents effectively penetrate an obstructed biliary tree and can be administered orally. Enterococci and polymicrobial infections are found more commonly in patients with a biliary stent than those without a stent. Pending definitive biliary decompression, patients with sepsis and those who do not quickly respond to treatment with a quinolone may benefit from the addition of antibiotic coverage against gram-positive organisms, targeted against Enterococci.

Adolescent↗
PubMed2002

Facilitation of pancreatic duct cannulation using a new synthetic porcine secretin.

OBJECTIVES: Cannulation of the pancreatic duct at ERCP can represent a technical challenge, even to experienced pancreaticobiliary endoscopists. Secretin is a polypeptide hormone that increases the volume and bicarbonate content of pancreatic secretions. We report our single center experience in the use of a new synthetic porcine secretin (sPS) for the facilitation of cannulation of either the major or minor pancreatic orifice during ERCP. METHODS: Patients presenting for a variety of indications were enrolled. If identification or cannulation of the desired pancreatic duct was difficult, 0.2 microg/kg of sPS was administered i.v. Cannulation success or failure was recorded. RESULTS: Between March, 1999, and May, 2000, a total of 25 patients (seven men and 18 women) were enrolled. The most frequent indication (15 of 25 cases) was facilitation of dorsal pancreatic duct cannulation in patients with pancreas divisum. The overall rate of successful cannulation secretin administration was 24 of 25 cases (96%). No adverse events directly attributable to secretin were observed. CONCLUSIONS: The results of this study show that sPS is safe and efficacious in faciliting cannulation of either the major or minor pancreatic orifice at ERCP in the subset of patients who represent cannulation difficulties. Once commercially available, sPS can be added to the armamentarium of techniques to facilitate ERP.

Adult↗