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Todd H Baron

Publications and source records attributed to Todd H Baron.

At least 73 records · Page 4Linked to original sources
PubMed2005

ASGE guideline: complications of EUS.

This is one of a series of statements discussing the utilization of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of experts. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement and revision needed to clarify aspects of this statement and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to the recommendations.

Autonomic Nerve Block↗
PubMed2005

A randomized trial of endoscopic biliary sphincterotomy using pure-cut versus combined cut and coagulation waveforms.

BACKGROUND & AIMS: Endoscopic biliary sphincterotomy has complication rates of 5%-12%. The output from the electrosurgical generator may influence the degree of coagulation and the rapidity of the incision, and thus rates of pancreatitis, hemorrhage, and perforation. Some modern generators incorporate feedback control to standardize output and automate the alternating cut and coagulation modes. Our aim was to compare 2 feedback-controlled generators, one with constant pure cutting-type output and the other with an alternating cut and coagulation mode. METHODS: In this multicenter randomized study, 133 patients were assigned to the alternating cut/coag output and 134 patients were assigned to constant pure-cut output. Patients were stratified by their risk for pancreatitis. RESULTS: The overall pancreatitis rate was 1.5%, including 3 patients in the cut/coag group and 1 patient in the pure-cut group (P>.05). There were 11 poorly controlled (zipper) incisions in the pure-cut group and none in the cut/coag group (P=.02). The incision was completed in all patients without stalling. Immediate hemorrhage occurred in 35 pure-cut patients and 8 cut/coag patients output (P=.002). There were no episodes of clinically significant bleeding, delayed bleeding, or perforation. CONCLUSIONS: Biliary sphincterotomy using feedback-controlled generators results in dependable progression of incision with a low pancreatitis rate. Control of the incision is improved subjectively with the cut/coagulation output, but this did not translate into a difference in clinically significant complications.

Adult↗
PubMed2005

Expandable metal biliary stents before pancreaticoduodenectomy for pancreatic cancer: a Monte-Carlo decision analysis.

BACKGROUND & AIMS: Endoscopic placement of plastic or self-expandable metal biliary stents (SEMS) relieves obstructive jaundice from pancreatic cancer. Short-length, distally placed SEMS do not preclude subsequent pancreaticoduodenectomy. We sought to determine whether SEMS placement in patients whose surgical status is uncertain is cost-effective for management of obstructive jaundice. METHODS: A Markov model was constructed to evaluate costs and outcomes associated with endoscopic biliary stenting for obstructive jaundice. Strategies evaluated were: (1) initial plastic stent with plastic stents for subsequent occlusions in nonsurgical candidates after staging (plastic followed-up by [f/u] plastic), (2) initial plastic with subsequent SEMS (plastic f/u metal), (3) initial short-length SEMS with subsequent plastic (metal f/u plastic), and (4) initial short-length SEMS with subsequent expandable metal stent (metal f/u metal). Published stent occlusion rates, ERCP complication rates and outcomes, cholangitis rates and outcomes, pancreatic cancer mortality rates, and Whipple complication rates were used. Costs were based on 2004 Medicare standard allowable charges and were accrued until all patients reached an absorbing health state (death or pancreaticoduodenectomy) or 24 cycles (24 mo) ended. RESULTS: Average costs per patient from Monte Carlo simulation were: (1) metal f/u metal, $19,935; (2) plastic f/u metal, 20,157 dollars; (3) metal f/u plastic, 20,871 dollars; and (4) plastic f/u plastic, 20,878 dollars. For initial plastic stents to be preferred over short-length metal stents, 70% or more of pancreatic cancers would need to be potentially resectable by pancreaticoduodenectomy. CONCLUSIONS: In patients undergoing ERCP before definitive cancer staging, short-length SEMS is the preferred initial cost-minimizing strategy.

Bile Ducts↗
PubMed2005

Technology insight: Enteral stenting and new technology.

Self-expandable metal stents (SEMS) have gained acceptance for use in the gastrointestinal tract in order to relieve malignant luminal obstruction. In the upper gastrointestinal tract SEMS are used as an alternative to surgical bypass for palliation of malignant gastric-outlet obstruction. In the colon, SEMS are used to avoid colostomy during palliation and as a bridge to surgery for left-sided colonic obstruction. Enteral SEMS appear to be cost effective. This article reviews the latest in stent technology as well as the outcomes following their placement.

Constriction, Pathologic↗
PubMed2005

Outcome following endoscopic transmural drainage of pancreatic fluid collections in outpatients.

OBJECTIVE: To evaluate the performance of endoscopic transmural drainage of pancreatic fluid collections (PFCs) in outpatients. PATIENTS AND METHODS: We retrospectively reviewed 19 consecutive outpatient cases in 18 patients who underwent attempted endoscopic transmural drainage of PFCs by a single endoscopist at the Mayo Clinic in Rochester, MN, over a 5-year period (October 1998 to October 2003). All drainages were performed without EUS-guided entry, using an aspiration needle and no cautery. Two 10-Fr stents were placed after dilation of the entry site. RESULTS: The study group consisted of 12 men and 6 women (median age, 48 years; range, 28-79 years), with 14 cases of pseudocysts and 5 cases of pancreatic necrosis. Transmural drainage approaches included 13 transgastric, 5 transduodenal, and 1 combined transgastric/transpapillary. Drainage was established in 16 of 19 (84%) cases. Hospitalization was noted in 6 of 19 (32%) cases, with median hospitalization duration of 1.5 days (range, 1-19 days). Three patients were hospitalized for overnight observation only. In all instances, the decision to hospitalize was made while the patient was still in recovery. No deaths occurred. Follow-up imaging was available in 15 of 16 (94%) cases in which drainage was established, demonstrating PFC resolution in all 15. CONCLUSIONS: Endoscopic transmural drainage of PFCs can be performed safely and effectively in selected outpatients. It is our opinion that outpatient drainage of PFCs be considered only by experienced therapeutic endoscopists with readily available inpatient facilities. Future studies should seek to identify predictors of hospitalization and address cost-effectiveness.

Adult↗
PubMed2005

A retrospective comparison of outcomes using three different precut needle knife techniques for biliary cannulation.

GOALS: To assess the outcome differences following different precut biliary sphincterotomy needle-knife techniques. BACKGROUND: Precut biliary needle-knife sphincterotomy (NKS) allows biliary access when standard cannulation techniques fail. Little comparative data exist on the outcome of precut NKS. STUDY: Retrospective comparison of outcome differences of three NKS techniques performed by three pancreaticobiliary endoscopists at a tertiary referral center. RESULTS: A total of 139 consecutive biliary NKS were performed. In 44 cases (technique A), NKS was performed using a precut fistulotomy technique avoiding the papillary orifice, with pure cutting current, and occasional pancreatic duct (PD) stenting (6 of 44). In 47 cases (technique B), NKS was performed starting from the papillary orifice cutting upward with blended current, and no PD stenting. In 48 cases (technique C), NKS was performed as B but using pure cutting current and frequent PD stenting (15 of 48). NKS was successful in 95.5%, 95.7%, and 89.6% at initial endoscopic retrograde cholangiopancreatography and 100%, 97.8%, and 95.6% after a second endoscopic retrograde cholangiopancreatography. Total complications were not significantly different between the three groups; however, a lower incidence of pancreatitis occurred using technique A compared with techniques B and C (not significant). CONCLUSIONS: NKS techniques result in a high success rate of biliary cannulation with a similar overall complication rate. Avoiding cutting at the papillary orifice may reduce the risk of pancreatitis. When cutting at the papillary orifice, pancreatic duct stenting, pure cutting current, or both may reduce the incidence of pancreatitis.

Biliary Tract Diseases↗
PubMed2005

Pilot study to assess patient outcomes following endoscopic application of photodynamic therapy for advanced cholangiocarcinoma.

BACKGROUND: Photodynamic therapy (PDT) has demonstrated promise in the palliative treatment of advanced cholangiocarcinoma. The aim of this pilot study was to assess the outcome in patients with non-resectable cholangiocarcinoma following endoscopic application of PDT directly into the biliary tract. METHODS: In patients with advanced cholangiocarcinoma, endoscopic retrograde cholangiopancreatography (ERCP) was performed to define the proximal and distal extent of intraductal tumor. Sodium porfimer was administered intravenously to all patients. Forty-eight hours later, a commercially available cylindrical diffusing laser fiber (1-2.5 cm in length, OptiGuide) designed for esophageal use was advanced across the biliary strictures. Laser light was applied at a power of 400 mW/cm fiber for a total energy of 180 J/cm(2) using an argon-pumped tunable dye laser. Patients received endoscopic PDT every 3 months provided they maintained a favorable performance status. Plastic biliary stents were replaced immediately following light application and were maintained in all patients. RESULTS: Using a preloaded catheter, adequate positioning of the laser fiber was achieved in all patients. Eight patients with advanced cholangiocarcinoma received a total of 19 PDT treatments, range 1-5 treatments/patient. All eight patients were followed until death; mean follow-up was 9.8 months. Median survival from the date of the first PDT treatment was 276 days, which compares favorably with published series that have reported median survival times between 45 and 127 days for patients with bismuth type III and IV tumors treated with stenting alone. CONCLUSIONS: Endoscopic application of PDT demonstrates promise in prolonging survival in patients with advanced cholangiocarcinoma. Additional randomized clinical trials using commercially available fibers are needed to fully evaluate both the optimum frequency and treatment interval of endoscopic PDT in the management of advanced cholangiocarcinoma.

Adult↗
PubMed2005

Biochemical analysis of pancreatic fluid collections predicts bacterial infection.

BACKGROUND AND AIMS: Despite our understanding of the pathophysiology of different types of pancreatic fluid collections (PFC), few studies have attempted to correlate the biochemical analysis of PFC contents with clinical and radiological characteristics. The aim of this study was to assess the predictive value of fluid analysis for discerning collection type (pseudocyst vs acute fluid collection with necrosis), presence of infection or communication with the pancreatic duct in the setting of acute and chronic pancreatitis. METHODS: Pancreatic fluid from 34 consecutive patients undergoing endotherapy of PFC was prospectively analyzed for seven variables: lactate dehydrogenase (LDH), total protein, albumin, glucose, amylase, lipase and specific gravity. RESULTS: In multivariate analysis, adjusting for age and gender, high intracystic levels of protein (OR 6.2; 95% CI 1.3-37.0), LDH (OR 6.8 [2.3-38.3]), and albumin (OR 7.8 [1.3-67.4]), and low levels of glucose (OR 0.2 [0.03-0.9]) predicted the presence of PFC infection. The optimal threshold value for protein was 1000 g/dL, which achieved a sensitivity of 73% and specificity of 75% for detecting infection; the optimal cut-off for LDH was 1000 U/L (sensitivity 64%, specificity 85%), and the cut-off for albumin was 500 g/dL (sensitivity 75%, specificity 85%). There were no statistically significant differences in biochemical fluid analysis with respect to fluid collection type (pseudocysts vs acute fluid collection with necrosis) and the presence of pancreatic duct communication. CONCLUSIONS: Biochemical analysis of PFC fluid is clinically helpful in detecting fluid infection in patients with bacteria on Gram stain or positive fluid cultures. Our findings fail to support the utility of fluid analysis in characterizing cyst type, and we caution against its use in distinguishing pseudocysts from acute fluid collection with necrosis.

Acute Disease↗
PubMed2005

Hemobilia caused by cytomegalovirus cholangiopathy.

A 57-yr-old male on long-term steroid therapy presented with hematemesis, fever, and a retroperitoneal fluid collection. Hemobilia was diagnosed, but the cause was not identified by ERCP, computed tomography, or angiography. Peroral cholangioscopy revealed multiple biliary ulcers. Cholangioscopic biopsies diagnosed cytomegalovirus (CMV) infection. Intravenous ganciclovir therapy was initiated, and was associated with cessation of bleeding. Biliary CMV disease is rare in HIV-negative persons, but should be considered in a patient with unexplained hemobilia. Cholangioscopy may be useful for diagnosis.

Antiviral Agents↗
PubMed2005

A prospective, randomized, double-blind, placebo-controlled trial of endoscopic steroid injection therapy for recalcitrant esophageal peptic strictures.

BACKGROUND AND AIMS: The aim of the study was to examine whether endoscopic intralesional corticosteroid injection into recalcitrant peptic esophageal strictures reduces the need for repeat stricture dilation. METHODS: Patients with a peptic esophageal stricture and recurrent dysphagia having had at least one dilation in the preceding 18 months were enrolled in a prospective randomized, double-blind study comparing steroid and sham injection. After endoscopic confirmation of recurrent stricture, patients were randomized to receive either 0.5 cc/quadrant triamcinolone (40 mg/cc) or sham injection into the stricture followed by balloon dilation of the stricture. Patients were stratified by the number of dilations required in the preceding 18 months, severity of dysphagia, the presence of esophagitis, stricture severity, and prior therapy with a proton-pump inhibitor. Patients and their physicians were blinded to the type of intervention received. Baseline dysphagia questionnaires were completed. Post-procedurally all patients were placed on a standardized proton-pump inhibitor regimen and standardized telephone follow-up questionnaires were completed at 1 wk and at 1, 3, 6, 9, and 12 months. The original sample-size calculation of 60 patients could not be met in a timely fashion because of a low incidence of recalcitrant peptic stricture patients. RESULTS: A total of 30 patients were enrolled, 15 in the steroid group (10 men, mean age 66 yr) and 15 in the sham group (11 M, mean age 67 yr). Patients were followed for 1 yr, unless they underwent an antireflux operation or died. Two patients, one per group, died of non-esophageal causes at 1 and 12 months. Four patients had fundoplication, two in each group, unrelated to stricture or dysphagia. Two patients in the steroid group (13%) and nine in the sham group (60%) required repeat dilation (p= 0.011). CONCLUSIONS: In patients with recalcitrant peptic esophageal stricture, steroid injection into the stricture combined with acid suppression significantly diminishes both the need for repeat dilation and the average time to repeat dilation compared to sham injection and acid suppression alone.

Aged↗
PubMed2005

Direct percutaneous endoscopic jejunostomy: outcomes in 307 consecutive attempts.

BACKGROUND: Clinical utilization of direct percutaneous endoscopic jejunostomy (DPEJ) is increasing. However, little data exist regarding important clinical outcomes with DPEJ. OBJECTIVE: To describe the indications, success, and complications of DPEJ in a large cohort of >300 consecutive attempted DPEJ cases at our institution. METHODS: Institutional databases identified 316 consecutive attempted DPEJ placements between January 1996 and August 2004. The medical records of consenting patients were abstracted for demographics, indication, success, complications, and follow-up. A scheme for classifying complication severity was designed. RESULTS: Three hundred and seven attempts at DPEJ were made on 286 patients. Of these, 209 succeeded (68%). The most common indications for DPEJ included resectable distal esophageal cancer, other malignancies causing obstruction, gastroparesis, prior esophageal or gastric resection, and high aspiration risk. Overall, 81 adverse events (AEs) were associated with DPEJ placement or removal in 69 (22.5%) cases. There were 14 serious AEs, 20 moderate AEs, and 47 mild AEs. Serious AEs included 7 bowel perforations, 3 jejunal volvuli, 3 major bleeds, and 1 aspiration. The only death was due to profound jejunal mesenteric bleeding after an unsuccessful trocar pass. Moderate AEs included 9 chronic enterocutaneous fistulae. Many of the 47 mild AEs were site infections requiring oral antibiotics (23) or persistent site pain (14). CONCLUSIONS: DPEJ was associated with a moderate or severe complication in approximately 10% of cases. While DPEJ is a useful technique to gain enteral access that obviates the need for surgery and is more reliable than percutaneous gastrostomy with jejunal extension, patients and physicians should be aware of the risks involved.

Adult↗
PubMed2004

Assessment of the predictors of response to glucagon in the setting of acute esophageal food bolus impaction.

Esophageal food impactions are frequently seen in endoscopic practice. Glucagon is known to relax the lower esophageal sphincter and has been used with variable success to treat food impactions. We retrieved clinical information of all patients with acute food impactions who attended the emergency room from 1975 to 2000 from the Mayo diagnostic database. Data were abstracted on age, sex, body mass index, relevant prior medical history, food type ingested (meat, bread, vegetable, or other), duration of symptoms at presentation, dosage (in mg) of glucagon, outcome including success of glucagon or spontaneous passage, and endoscopic findings. A total of 222 cases of food impaction were identified, of whom 106 patients (48%) received glucagon, average 1 mg. In glucagon responders, meat was less likely to be the offending food type, accounting for 70% (glucagon responders) vs. 90% (in nonresponders) ( p = 0.03), while responders were less likely to have esophageal rings/strictures detected on subsequent EGD compared with nonresponders, 0% (glucagon responders) vs. 31% (nonresponders) ( p = 0.05). In the patients that did not receive glucagon, spontaneous resolvers had a shorter duration of symptoms at presentation, 3.3 h vs. 12.4 h ( p = 0.07) and were less likely to have an organic esophageal obstruction detected on EGD, 0% vs. 21%. There were no significant differences between the resolvers and nonresolvers in terms of age, gender, BMI, and prior medical history. Conservative management of acute food bolus obstruction, either with or without glucagon, is most successful in the absence of a fixed esophageal obstruction. An impacted meat bolus is more likely to require intervention for removal than other food types. These clinical predictors should be considered before administration of glucagon.

Acute Disease↗