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R A Kozarek

Publications and source records attributed to R A Kozarek.

At least 19 recordsLinked to original sources
PubMed2000

Twenty cases of peristomal pyoderma gangrenosum: diagnostic implications and management.

HYPOTHESIS: Our experience with peristomal ulcers suggested that peristomal pyoderma gangrenosum (PPG) is an infrequent and usually unrecognized complication of inflammatory bowel disease. We hypothesized that a review of our experience with PPG would clarify the essentials of its diagnosis, evaluation, and treatment. DESIGN: A case series of 20 consecutive patients with PPG complicating inflammatory bowel disease were treated at our institution between 1986 and 1999. There were 15 women and 5 men. At the time of development of peristomal pyoderma, 10 of 20 patients had a diagnosis of Crohn disease (CD), while 9 had a diagnosis of ulcerative colitis (UC). One patient was diagnosed as having CD only after first developing PPG. MAIN OUTCOME MEASURE: Healing of PPG. INTERVENTIONS: All patients had failed local enterostomal care prior to referral. Debridements and/or stomal revisions were uniformly unsuccessful. Biopsies, when performed, did not provide clinically important information. Treatment was directed toward inflammatory bowel disease, with variable clinical responses to corticosteroids, metronidazole, cyclosporine, sulfasalazine, and infliximab. RESULTS: Ultimately, 13 patients had a diagnosis of CD. Of these patients, 12 (92%) of 13 developed PPG coincident with recurrent disease. Two patients had a remote history of proctocolectomy for UC and subsequent evaluation revealed CD. One patient developed PPG adjacent to a urinary Kock pouch after cystectomy; ultimately, a diagnosis of CD was made. No patients were lost to follow-up, but in 1 case of UC, no evaluation for latent CD was carried out. The final diagnosis was CD disease in 13 (65%) of 20 and UC in 7 (35%) of 20 patients. All PPG ulcers healed completely, within an average of 11.4 months (median, 8 months; range, 1-41 months). Ulcer resolution was achieved with medical therapy alone in 14 (70%) of 20 cases. Resection of active gastrointestinal CD resulted in healing in 5 (83%) of 6 cases. One case healed 2 months after conservative therapy only. CONCLUSIONS: This review of the largest reported series of PPG suggests the following: (1) PPG complicating inflammatory bowel disease is uncommon and often misdiagnosed by clinicians; (2) local wound care measures have little role in the healing of PPG; (3) PPG usually heralds active CD; (4) in patients with prior history of UC, PPG indicates CD until proven otherwise; (5) prolonged medical therapy (11 months), usually with immunosupression, is required for healing of PPG; and (6) if feasible, surgical resection of all active CD leads to the healing of PPG ulcers.

Adult↗
PubMed2000

Computed tomography severity index is a predictor of outcomes for severe pancreatitis.

BACKGROUND: In a small group of patients with acute pancreatitis, Balthazar and Ranson demonstrated the applicability of computed tomography (CT) criteria to predict mortality. Building upon their work with a larger group of patients with acute pancreatitis, we set out not only to demonstrate that the CT severity index can predict death, but also length of hospital stay and need for necrosectomy. METHODS: We reviewed all patients admitted to our hospital in the years 1992 to 1997 with a primary diagnosis of acute pancreatitis. Entrance criteria required that a CT scan had been performed during the hospitalization. The index CT scan was used to determine a CT severity index (the CTSI of Balthazar and Ranson). Outcomes measured were death, length of stay (LOS), and need for necrosectomy (NEC). Statistical analysis was performed using Fisher's exact and chi-square tests where appropriate. RESULTS: Between the years 1992 to 1997, 886 patients had 1,774 admissions for acute pancreatitis, of which 268 had a CT scan performed and were entered into our study. These 268 patients had a mean age of 57 years, a mean LOS of 16 days (1 to 118), and a mean CTSI of 3.9 (0 to 10). Overall mortality was 4% (n = 11). A CTSI >5 significantly correlated with death (P = 0.0005), prolonged hospital stay (P <0.0001), and need for necrosectomy (P <0.0001). Patients with a CTSI >5 were 8 times more likely to die, 17 times more likely to have a prolonged hospital course, and 10 times more likely to undergo necrosectomy than their counterparts with CT scores <5. CONCLUSIONS: These data show that the CTSI is an applicable and comparable predictor of outcomes in severe pancreatitis.

APACHE↗
PubMed2000

Overview of the problem: reprocessing versus disposal of endoscopic accessories.

The decision to reuse or not reuse endoscopic accessories appears simple on the surface. Further reflection, however, reveals that the decision to purchase reusable accessories or reuse disposable accessories is complex and controversial. This article clarifies key issues surrounding the use of disposable and reusable endoscopic accessories. Discussion includes the advantages and disadvantages of disposable and reusable accessories, the issues surrounding reprocessing of reusable equipment, and the issues surrounding the reuse of disposable accessories.

Disposable Equipment↗
PubMed1999

Recurrent pancreatitis in Gardner variant familial polyposis: etiology, diagnostic approach, and interventional results.

HYPOTHESIS: Pancreatitis arising from an obstructing ampullary neoplasm in patients with Gardner variant familial polyposis is an infrequently described clinical entity. We reviewed all patients with Gardner variant polyposis presenting with pancreatitis during a 12-year period in our institution, hoping to better define etiology and the appropriate diagnostic and interventional approach. METHODS: A retrospective record review (1986-1998) defined patient demographics, presenting features, initial and subsequent endoscopic retrograde cholangiopancreatography (ERCP) findings, subsequent treatments, and both immediate and long-term outcomes. Particular consideration was given to initial post-ERCP diagnosis and to endoscopic interventions undertaken at that time. We also looked at those patients who eventually required surgical intervention after long-term failure of medical and endoscopic therapy, the indications for surgery, final pathological characteristics, and follow-up results. RESULTS: Eight patients (6 women and 2 men), with a mean age of 42 years at initial presentation, were found. Each patient was known to have Gardner variant familial polyposis at the time of the initial bout of pancreatitis. All had undergone prior colectomy and 4 of 8 had undergone prior cholecystectomy. None were known to be taking medications or ingesting pancreatoxic substances. Five of 8 patients had obstructing focal or diffuse adenomatous disease involving the ampulla. Two of 8 patients had pancreatitis attributed to other causes (divisum, stones) and a single patient had no clear etiology. Three of 5 patients with ampullary adenomatous disease underwent pancreaticoduodenectomy for recurrent adenomatous encroachment and ampullary stenosis, despite repetitive snare resection and papillotomy. All of these patients had ampullary and other duodenal adenomas, and none had malignant disease. CONCLUSIONS: Patients presenting with pancreatitis in the setting of Gardner variant familial polyposis will frequently have an obstructing ampullary neoplasm, although additional etiologies should be sought. Initial endoscopic therapy affords transient relief but may not be definitive. The abnormal scarring and fibrosis (keloid formation, desmoid reaction) that characterize this disease likely play a large role in endoscopic or subsequent surgical failure. A significant number of these patients will go on to require surgical referral and intervention.

Adult↗
PubMed1999

In vitro and in vivo evaluation of a reusable double-channel sphincterotome.

BACKGROUND: To date, one reusable, double-channel sphincterotome has been approved by the Food and Drug Administration in the United States. Whether this device can be reprocessed easily and whether it is more durable than currently manufactured disposable sphincterotomes are uncertain. METHODS: Thirty double-channel, 20 mm, braided-wire sphincterotomes approved for multiple uses were studied in vitro/in vivo with regard to durability and sterilization. A cost analysis of reusable, disposable, and reprocessed disposable sphincterotomes was also carried out. RESULTS: Three of 10 sphincterotomes evaluated in vitro broke after 3, 4, and 8 uses. Electrical integrity was preserved after 10 uses in the remaining sphincterotomes. Nine sphincterotomes remained functional for at least 3 uses, five for 6 uses, and one for 10 uses. Culture results after inoculation demonstrated contamination with surviving organisms after manual cleaning and no growth after ethylene oxide sterilization. Sixty-one procedures were performed in vivo using 20 sphincterotomes (mean number of uses 3.1). No evidence of procedurally related infection occurred with reuse. Cost per use of this reusable sphincterotome was calculated to be $62.98; it became cost effective after 2.2 and 7.9 uses when compared with disposable and reprocessed, disposable sphincterotomes, respectively. CONCLUSIONS: This reusable sphincterotome proved to be safe, easily sterilized, and electrically intact after repeated use. In vivo, however, a progressive loss of function limited the mean number of uses to 3.1. In settings that preclude reuse of reprocessed disposable accessories, this reusable sphincterotome may provide a means to decrease costs associated with endoscopic retrograde cholangiopancreatography.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1999

Use of a double-channel duodenoscope for diagnostic and therapeutic ERCP.

BACKGROUND: A double-channel duodenoscope has the potential to shorten ERCP procedure time or improve procedure success rates because tasks can be done in parallel through variably situated accessory channels. METHODS: We prospectively evaluated a prototype double-channel duodenoscope in 102 patients, recording findings, procedural success, and potential advantages or problems associated with the instrument. RESULTS: Both channels were used in 79 cases (77%) and a single-channel in the remainder. Ninety-nine percent (101 of 102) of diagnostic and 95% (87 of 92) of therapeutic ERCPs were successful. Instrument advantages included decreased procedure time (23%), cannulation/procedural ease (16%), and miscellaneous (6%). Disadvantages were noted in 15% of the patients and were related to instrument diameter and diameter of the accessory channels. CONCLUSIONS: Additional study of second generation dual-channel duodenoscopes appears warranted.

Bile Duct Diseases↗
PubMed1999

ERCP economics.

Explore the source record for details and available documents.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1999

Reuse of disposable sphincterotomes for diagnostic and therapeutic ERCP: a one-year prospective study.

BACKGROUND: Although previous studies have documented that single-channel sphincterotomes can be sterilized and used up to 10 times, no studies have prospectively evaluated the reuse of disposable sphincterotomes. METHODS: Five- and six-French double-channel sphincterotomes marketed as one-time-use only were manually cleaned, sterilized with ethylene oxide, and used up to 10 times. Over a 1-year period, total number of uses as a cannulation or cutting device, reason for sphincterotome dysfunction, possible infectious complications were evaluated, and cost-savings associated with reuse were evaluated. RESULTS: The mean number of times sphincterotomes could be used in our institution was 3.4; a broken or stiff cutting wire was the main reason for discard. There were two infectious complications during the study period. Both were experienced by patients with unrelieved obstruction treated with new sphincterotomes. Contingent on the method used, total savings related to sphincterotome reuse was approximately $66,000. CONCLUSIONS: Double-channel sphincterotomes marketed as one-time-use items can be reused safely when properly cleaned. Reuse was associated with significant cost savings in our institution.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1999

Histological and anatomic changes in Barrett's esophagus after antireflux surgery.

OBJECTIVE: The best treatment approach for patients with documented Barrett's esophagus remains controversial. There is currently no well designed prospective study examining the effect of successful antireflux surgery on Barrett's esophagus. METHODS: Fourteen patients with histologically proven Barrett's esophagus underwent standard antireflux surgery followed by careful endoscopic, histological, and symptomatic follow-up beginning at 2-4 wk after surgery. Pre- and postoperative symptoms, patient functional assessment scores, lower esophageal sphincter pressure, and 24-h pH studies were compared, in addition to monitoring patients for evidence of squamous re-epithelialization and dysplasia. RESULTS: Patients demonstrated statistically significant improvement in symptoms, functional assessment scores, lower esophageal sphincter pressure, and 24-h pH assessments after antireflux surgery. Two patients had complete disappearance of short segments (2 and 3 cm) of Barrett's esophagus. Ten additional patients demonstrated evidence of squamous re-epithelialization, although biopsies often showed mixed components of squamous and columnar epithelium. No patients showed progression of dysplastic change, and four patients demonstrated the disappearance of low grade dysplasia throughout the period of the study. CONCLUSION: Successful antireflux surgery can produce at least partial squamous re-epithelialization in Barrett's metaplasia and stabilization or apparent improvement in dysplasia in some patients without the need for long term medication. Continued long term endoscopic and histologic follow-up is still required in all patients with Barrett's esophagus after antireflux surgery.

Adult↗
PubMed1999

In vitro evaluation of integrity and sterilization of single-use argon beam plasma coagulation probes.

OBJECTIVE: Argon plasma coagulation probes (APC) are currently marketed in the United States as single-use items, and may constitute a significant per-procedure expense. It is unknown whether these probes can be sterilized after endoscopic use and if electrical integrity can be maintained after reprocessing. METHODS: Ten probes (2.3 mm diameter, 220 cm length) manufactured by ERBE Inc., (Marietta, GA) were studied using the ERBE APC 300 at 60 watts. Baseline coagulation depth was measured by coagulating a piece of beefsteak for 60 s. Probes were contaminated with 10(6) Bacillus subtilis spores, cultured, and manually cleaned. Culturing involved introducing 10 cc sterile water through the probes; water was filtered, plated onto blood agar, and incubated for 48 h. After ethylene oxide (ETO), the probes were cultured to determine sterilization. Finally, the per-procedure cost of each probe was assessed. RESULTS: Ten of 10 probes completed 10 testing sessions. One probe split at the proximal end but remained functionally intact. Electrical integrity remained intact for all 10 sessions. All probes grew too numerous to count colonies of B. subtilis after inoculation and no B. subtilis was detected after ETO sterilization. Assuming 10 uses clinically, a total per-procedure equipment cost would approximate $24.00, whereas per-procedure probe cost would equal $42.66 if only five uses were obtained in vivo. CONCLUSIONS: The combination of manual cleaning and ETO sterilization consistently sterilized APC probes. Ninety percent of the probes showed no sign of physical deterioration and 100% maintained their electrical activity after 10 uses. APC probes can potentially be safely and effectively reused up to 10 times, and a significant procedural savings is possible with reuse.

Bacillus subtilis↗
PubMed1999

Complications and lessons learned from 10 years of expandable gastrointestinal prostheses.

Initially inserted percutaneously for malignant biliary stenoses, expandable gastrointestinal prostheses have evolved as primary treatment for malignant dysphagia and as an alternative to plastic prostheses for some types of obstructive jaundice. They are also in their infancy as a means to palliate unresectable obstructions of the gastric outlet, small bowel, and colorectum. Despite a decade of development, problems persist and include: maldeployment; inadequate expansion; ingrowth; overgrowth; erosion, and migration. This article outlines some of the problems noted and opportunities to improve this still-evolving technology.

Biliary Tract Neoplasms↗
PubMed1999

Basic research in endoscopy.

Endoscopic research includes Technologic Development, Facilitated Research in which endoscopy may simply be a means to an end (such as to gauge a response to a pharmacologic agent or obtain tissue which is used for genetic analysis); Translational Research which can be defined as the clinical evaluation of endoscopic techniques or technology as well as the delivery of basic science innovations to patients endoscopically; and Outcomes Research. Defining the barriers to endoscopic research is much more important than the distinction of whether the research is basic or clinical. These barriers are multifactorial and include inadequate infrastructure and training and lack of both funding and protected time at the divisional level. Governmental, GI Societal, and industry financial support will all be required as will training programme revisions. The latter may include training in areas such as outcomes, physics, or biomedical engineering; and should also entail a formal mentoring process, "seed money" early in the investigator's career and protected time.

Endoscopy, Gastrointestinal↗