Biomedical subjects
T H Baron
Publications and source records attributed to T H Baron.
Acute necrotizing pancreatitis.
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Endoscopic transgastric irrigation tube placement via PEG for debridement of organized pancreatic necrosis.
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Proximal migration of a pancreatic duct stent: endoscopic retrieval using interventional cardiology accessories.
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Treatment of a radiation-induced sigmoid stricture with an expandable metal stent.
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Evaluation and endoscopic palliation of cholangiocarcinoma. Management of cholangiocarcinoma.
Patients with a cholangiocarcinoma usually develop symptoms of biliary obstruction which dominate the course of their illness. At presentation, the diagnosis may be difficult to establish due to the desmoplastic nature of this tumor. Location and extent of the tumor, however, are more effectively evaluated by current radiologic techniques. Following these staging procedures, most patients are found to be unsuitable for curative resection. Therefore, establishing effective biliary drainage to relieve symptoms of obstruction becomes the most critical therapeutic goal in these patients. In the past, surgical biliary bypass procedures were advocated, but were associated with high perioperative morbidity and mortality rates. Endoscopic biliary stenting produces quick and effective relief of symptoms from biliary obstruction due to cholangiocarcinoma. Initially, successful biliary drainage is possible in most patients. However, subsequent stent occlusion or spread of tumor into nonstentable intrahepatic ducts leads to recurrent jaundice. Local therapies including (192)Ir brachytherapy and photodynamic therapy may prevent or postpone these problems.
Stenotrophomonas (Xanthomonas) maltophilia infection in necrotizing pancreatitis.
CONCLUSION: Although the therapy of infected pancreatic collections or organized pancreatic necrosis remains surgical, we have demonstrated that infected organized pancreatic necrosis can be treated endoscopically. BACKGROUND: Stenotrophomonas (Xanthomonas) maltophilia has been increasingly recognized as a nosocomial pathogen associated with meningitis, pneumonia, conjunctivitis, soft tissue infections, endocarditis, and urinary tract infections. This organism is consistently resistant to imipenem, a drug commonly employed in patients with necrotizing pancreatitis to prevent local and systemic infections. METHODS AND RESULTS: We report the first case of infected pancreatic necrosis by S. (X.) maltophilia. Our patient was treated successfully with endoscopic drainage of the pancreatic fluid collection and appropriate antibiogram-based antibiotic therapy. Endoscopic drainage has emerged as one of the treatment modalities for pancreatic fluid collections.
Pancreas divisum: implications for diagnostic and therapeutic pancreatography.
OBJECTIVE: The purpose of our study was to determine the prevalence, distribution, and clinical significance of pancreatic ductal changes due to pancreatitis on ERCP in patients with pancreas divisum. MATERIALS AND METHODS: From January 1993 through December 1997, 1714 patients underwent 2469 ERCP studies. Ninety-four patients (5.5%) had pancreas divisum. Retrospective review of the spot radiographs was performed to establish the presence and location of pancreatitis. Clinical indications for and therapy during ERCP were correlated with radiographic findings. RESULTS: Of the 94 patients with pancreas divisum, 54 (57%) had radiographic evidence of pancreatitis. Of these 54 patients, 44 had at least one episode of clinically documented pancreatitis, seven had recurrent abdominal pain, and three underwent ERCP for biliary indications. In 76% of the 54 patients with radiographic evidence of pancreatitis, only the dorsal system showed irreversible inflammatory change (p < .0001). Acute recurrent pancreatitis was the most common indication for ERCP in divisum patients and was statistically more common than in pancreatitis patients with normal anatomy (p < .0001). Sixty-two (66%) of the 94 patients with pancreas divisum underwent endoscopic pancreatic intervention, most commonly minor papilla sphincterotomy or stenting or both. Eleven patients with clinically documented pancreatitis had no abnormalities revealed by ERCP. CONCLUSION: In our population of patients referred for ERCP and found to have pancreas divisum, the prevalence of pancreatitis was very high and usually was limited to a dorsal distribution.
Organized pancreatic necrosis: endoscopic, radiologic, and pathologic features of a distinct clinical entity.
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Surgical gastrostomy placement as access for diagnostic and therapeutic ERCP.
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How many times can you reuse a "single-use" sphincterotome? A prospective evaluation.
BACKGROUND: The decreasing reimbursement for endoscopic supplies has prompted evaluation of reuse of "single use" items. METHODS: Over a 12.5-month period, numbered sphincterotomes were used for sphincterotomy or as a diagnostic catheter in all patients undergoing endoscopic retrograde cholangiopancreatography. Before first use and after each subsequent use, the resistance of the sphincterotome was measured with an ohmmeter. After each use, the sphincterotome was thoroughly cleaned and gas sterilized. Sphincterotomes that could not be adequately cleaned or would not function properly were discarded. The endoscopist was blinded to the number of prior uses of the sphincterotome. RESULTS: During the study period, 80 sphincterotomes were used 290 times, including use in 162 sphincterotomies. The median number of uses before discarding was 3 and ranged from 0 to 10. The single most common reason for discarding the sphincterotome was breakage of the wire to the handle which occurred after 1 to 9 uses. The sphincterotome did not cut inappropriately in any patient, and no complications were linked to reuse. Equipment costs to our unit were reduced $21,000 by reuse. CONCLUSIONS: "Single use" sphincterotomes can be safely reused multiple times without compromising their use as a diagnostic or therapeutic device.
Transmural drainage of pancreatic fluid collections without electrocautery using the Seldinger technique.
BACKGROUND: Complications of endoscopic transmural drainage of pancreatic fluid collections arise from entry through the gastrointestinal wall. We describe transmural drainage of these collections using the Seldinger technique without electrocautery. METHODS: From January 1995 to September 1997, we attempted endoscopic transmural drainage of 94 consecutive pancreatic fluid collections without EUS guidance (needle-knife entry in 51, Seldinger entry technique in 43). Success of entry and complications were compared. RESULTS: Successful entry was achieved in 95.3% using the Seldinger technique and 92.1% using the needle-knife entry technique (p = NS). Complications of bleeding and perforation were seen in 4.6% of patients in the Seldinger group and 15.7% in the needle-knife entry group. CONCLUSIONS: The Seldinger technique of endoscopic transmural drainage of pancreatic fluid collections appears effective and safer than entry using the needle-knife. Collections as small as 3 cm in diameter can be entered using the Seldinger technique without EUS guidance.
Endoscopic transgastric drainage of a retroperitoneal lymphocele.
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Expandable metal stents for the treatment of colonic obstruction: techniques and outcomes.
BACKGROUND: Acute left-sided colonic obstruction is a surgical emergency whose management is controversial. Because experience using expandable metal stents for relief of this type of obstruction is limited, we evaluated their effectiveness, feasibility, safety, and outcome. METHODS: Twenty-five patients with acute colorectal obstruction underwent placement of various metal stents under fluoroscopic and endoscopic guidance. On an intent-to-treat basis, stents were placed for decompression before one-stage surgical resection in 10 patients and palliatively in 15 patients. Two preoperative patients had unresectable malignant disease, and stents were left for palliation resulting in 17 palliative and 10 preoperative patients for analysis. RESULTS: Stent placement was technically successful in 94% of patients. Overall effectiveness in relieving obstruction was 85% (palliative 82%, preoperative 90%). In the palliative group, stent duration ranged from 2 to 64 weeks (mean 17.3 weeks). Major complications occurred in 7 patients (30%). CONCLUSIONS: Expandable metal stents are a feasible, effective adjunct and alternative to surgery for acute colorectal obstruction.
Palliation of malignant gastric and small intestinal strictures with self-expandable metal stents.
BACKGROUND: Malignant gastrointestinal obstruction is a common preterminal event that is often treated surgically. The use of self-expandable stents to treat malignant gastric and small intestinal strictures is limited. We evaluated the feasibility, effectiveness, safety and outcome of self-expandable metal stents in providing palliative care for patients with inoperable malignant strictures of the stomach and small intestine. METHODS: Eleven consecutive patients with complete or near complete gastric or small intestinal obstruction were treated palliatively with self-expandable metal stents. Contrast radiographs were taken before and after insertion in all patients to confirm patency. Nineteen stents were placed using biliary guidewires and catheters under endoscopic and fluoroscopic guidance. Diets were modified as needed. Success was defined both technically and clinically. RESULTS: Technical and clinical success with improvement in the patient's oral diet was achieved in ten patients (91%). The one failure was caused by severe anastomotic angulation and distal luminal obstruction. During the follow-up of 5 to 294 days (mean 77 days) there were no major complications except that the stents occluded in four patients. CONCLUSION: Palliation of malignant gastric and small intestinal strictures with self-expandable metal stents is a feasible, effective, and safe alternative to operation.
Practical imaging in acute pancreatitis.
Pancreatitis may be acute or chronic, mild or severe. In patients with acute pancreatitis the optimal imaging test is dynamic intravenous and oral contrast enhanced computed tomography (CECT). Serial CECTs are useful to monitor disease progression and to assess intraabdominal complications in patients with severe acute pancreatitis. CECT is helpful in planning the approach (endoscopic transmural versus percutaneous) for pancreatic drainage. Computed tomography or ultrasound-guided aspiration of pancreatic collections is safe, sensitive, and specific and has become a routine procedure used to screen for infected necrosis. When pancreatic drainage is contemplated, magnetic resonance imaging is useful for identifying residual necrotic debris within the collection. Patients with mild acute pancreatitis usually require no cross-sectional imaging study other than ultrasound screening for gallstones, if gallstone pancreatitis is suspected clinically. In patients with chronic pancreatitis, screening for complications such as superimposed acute pancreatitis or development of pancreatic pseudocysts may be performed with CECT or ultrasound.
Pancreatic fluid collections: diagnosis and endoscopic management.
Pancreatitis may be acute or chronic, mild or severe. Acute necrotizing pancreatitis remains the most serious form of acute pancreatitis and accounts for the majority of complications. Although there is an established nomenclature for pancreatitis and pancreatic fluid collections, such as pancreatic pseudocysts, it is not widely understood or recognized by gastroenterologists. Because the management options for the treatment of pancreatic fluid collections continues to evolve with an increased use of endoscopic therapy, gastroenterologists will be increasingly called on to treat patients with pancreatitis and its complications. This article addresses and summarizes pancreatic fluid collections and their management, with an emphasis on endoscopic drainage.
The diagnosis and management of fluid collections associated with pancreatitis.
Pancreatitis may be acute or chronic, mild or severe. Acute necrotizing pancreatitis remains the most serious form of acute pancreatitis and accounts for the majority of complications. Although there is an established nomenclature for pancreatitis and pancreatic fluid collections, such as pancreatic pseudocysts, it is not widely understood or recognized by physicians, including gastroenterologists. Because nonspecialists will be increasingly called upon to treat and appropriately refer patients with pancreatitis and its complications for more specialized care, it is important to understand the evolving treatment options for managing these patients. This article addresses and summarizes pancreatitis and its complications, particularly pancreatic collections.