Endoscopy, Pancreas, & Biliary Tract

BERLIN – Roux-en-Y gastric bypass surgery can reverse type 2 diabetes in up to 73% of patients – even in those with long-standing disease.

Disease remission even occurred in 38% of those who had diabetes for longer than 8 years, with all who were taking insulin able to discontinue the medication, Dr. Sarah Steven said at the annual meeting of the European Association for the Study of Diabetes.

Dr. Steven, of Newcastle (England) University, presented a retrospective study of 73 patients with type 2 diabetes who underwent gastric bypass surgery with the Roux-en-Y technique.

Most (46) were women; the group’s median age was 49 years. Their median disease duration was 5 years, although the range was wide, from 1 month to 19 years.

She did not give a median follow-up time, but did say that it was a minimum of 3 months.

Overall, they were obese, with a median body mass index of 50 kg/m². Their median preoperative hemoglobin A_1c was 7.1%. Criteria for reversal was a postoperative HbA_1c of 6%.

At baseline, all of the patients were taking metformin and 12 were also on insulin. Other medications included sulphonylurea, thiazolidinedione, glucagon-like peptide-1 agonist, and dipeptidyl peptidase-4 inhibitor.

Diabetes reversal occurred in 79% of those with short-duration disease (up to 4 years); 73% of the patients were able to discontinue all diabetes medications. *Diabetes reversed in 38% of those who had the disease longer than 8 years; 21% of that group no longer needed any antidiabetic medication.

The amount of weight lost was significantly associated with disease reversal. Reversal occurred in 50% of the group that lost fewer than 10 kg/m²; in 73% of those that lost 10-15 kg/m²; and in 76% of those who lost more than 15 kg/m².

In the group with long disease duration, the mean weight loss in those whose diabetes reversed was 34 kg/m², compared with 21 kg/m² in those whose diabetes did not.

Weight loss also significantly influenced the individual ability to successfully withdraw from diabetes medications. About a quarter (27%) of those who lost fewer than 10 kg no longer needed the drugs. However, 67% of those who lost 10-15 kg/m² and 50% of those who lost more than 15 kg/m² no longer needed any of the medications.

"The reversal of type 2 diabetes seems to depend on the degree of weight loss," Dr. Steven said. "Individuals with long-term diabetes are likely to have gained more weight than those with short-term – this is in part due to the natural history of the disease and is compounded by the use of medications and insulin therapy.

"It’s hypothesized that these individuals may need to lose more weight to reach the target weight that will normalize their glucose levels."

The benefit of weight loss is most likely tied to improved beta cell functioning, Dr. Steven suggested.

"There is good in vitro evidence that saturated fatty acids are particularly detrimental to beta cells, inhibiting acute insulin secretion and inducing apoptosis," she said.

"Autopsy studies have shown that beta cells continue replication and neogenesis [in type 2 diabetes]," Dr. Steven continued. "So it’s at least theoretically possible that beta cell function could be regained at any stage of the disease upon removal of the toxic environment."

*CORRECTION 10/26/12: This article misstated the percentage of long-term diabetes patients (having the disease more than 8 years)who experienced disease reversal. Diabetes reversed in 38% of this population.

BERLIN – Roux-en-Y gastric bypass surgery can reverse type 2 diabetes in up to 73% of patients – even in those with long-standing disease.

Disease remission even occurred in 38% of those who had diabetes for longer than 8 years, with all who were taking insulin able to discontinue the medication, Dr. Sarah Steven said at the annual meeting of the European Association for the Study of Diabetes.

Dr. Steven, of Newcastle (England) University, presented a retrospective study of 73 patients with type 2 diabetes who underwent gastric bypass surgery with the Roux-en-Y technique.

Most (46) were women; the group’s median age was 49 years. Their median disease duration was 5 years, although the range was wide, from 1 month to 19 years.

She did not give a median follow-up time, but did say that it was a minimum of 3 months.

Overall, they were obese, with a median body mass index of 50 kg/m². Their median preoperative hemoglobin A_1c was 7.1%. Criteria for reversal was a postoperative HbA_1c of 6%.

At baseline, all of the patients were taking metformin and 12 were also on insulin. Other medications included sulphonylurea, thiazolidinedione, glucagon-like peptide-1 agonist, and dipeptidyl peptidase-4 inhibitor.

Diabetes reversal occurred in 79% of those with short-duration disease (up to 4 years); 73% of the patients were able to discontinue all diabetes medications. *Diabetes reversed in 38% of those who had the disease longer than 8 years; 21% of that group no longer needed any antidiabetic medication.

The amount of weight lost was significantly associated with disease reversal. Reversal occurred in 50% of the group that lost fewer than 10 kg/m²; in 73% of those that lost 10-15 kg/m²; and in 76% of those who lost more than 15 kg/m².

In the group with long disease duration, the mean weight loss in those whose diabetes reversed was 34 kg/m², compared with 21 kg/m² in those whose diabetes did not.

Weight loss also significantly influenced the individual ability to successfully withdraw from diabetes medications. About a quarter (27%) of those who lost fewer than 10 kg no longer needed the drugs. However, 67% of those who lost 10-15 kg/m² and 50% of those who lost more than 15 kg/m² no longer needed any of the medications.

"The reversal of type 2 diabetes seems to depend on the degree of weight loss," Dr. Steven said. "Individuals with long-term diabetes are likely to have gained more weight than those with short-term – this is in part due to the natural history of the disease and is compounded by the use of medications and insulin therapy.

"It’s hypothesized that these individuals may need to lose more weight to reach the target weight that will normalize their glucose levels."

The benefit of weight loss is most likely tied to improved beta cell functioning, Dr. Steven suggested.

"There is good in vitro evidence that saturated fatty acids are particularly detrimental to beta cells, inhibiting acute insulin secretion and inducing apoptosis," she said.

"Autopsy studies have shown that beta cells continue replication and neogenesis [in type 2 diabetes]," Dr. Steven continued. "So it’s at least theoretically possible that beta cell function could be regained at any stage of the disease upon removal of the toxic environment."

*CORRECTION 10/26/12: This article misstated the percentage of long-term diabetes patients (having the disease more than 8 years)who experienced disease reversal. Diabetes reversed in 38% of this population.

BERLIN – Roux-en-Y gastric bypass surgery can reverse type 2 diabetes in up to 73% of patients – even in those with long-standing disease.

Disease remission even occurred in 38% of those who had diabetes for longer than 8 years, with all who were taking insulin able to discontinue the medication, Dr. Sarah Steven said at the annual meeting of the European Association for the Study of Diabetes.

Dr. Steven, of Newcastle (England) University, presented a retrospective study of 73 patients with type 2 diabetes who underwent gastric bypass surgery with the Roux-en-Y technique.

Most (46) were women; the group’s median age was 49 years. Their median disease duration was 5 years, although the range was wide, from 1 month to 19 years.

She did not give a median follow-up time, but did say that it was a minimum of 3 months.

Overall, they were obese, with a median body mass index of 50 kg/m². Their median preoperative hemoglobin A_1c was 7.1%. Criteria for reversal was a postoperative HbA_1c of 6%.

At baseline, all of the patients were taking metformin and 12 were also on insulin. Other medications included sulphonylurea, thiazolidinedione, glucagon-like peptide-1 agonist, and dipeptidyl peptidase-4 inhibitor.

Diabetes reversal occurred in 79% of those with short-duration disease (up to 4 years); 73% of the patients were able to discontinue all diabetes medications. *Diabetes reversed in 38% of those who had the disease longer than 8 years; 21% of that group no longer needed any antidiabetic medication.

The amount of weight lost was significantly associated with disease reversal. Reversal occurred in 50% of the group that lost fewer than 10 kg/m²; in 73% of those that lost 10-15 kg/m²; and in 76% of those who lost more than 15 kg/m².

In the group with long disease duration, the mean weight loss in those whose diabetes reversed was 34 kg/m², compared with 21 kg/m² in those whose diabetes did not.

Weight loss also significantly influenced the individual ability to successfully withdraw from diabetes medications. About a quarter (27%) of those who lost fewer than 10 kg no longer needed the drugs. However, 67% of those who lost 10-15 kg/m² and 50% of those who lost more than 15 kg/m² no longer needed any of the medications.

"The reversal of type 2 diabetes seems to depend on the degree of weight loss," Dr. Steven said. "Individuals with long-term diabetes are likely to have gained more weight than those with short-term – this is in part due to the natural history of the disease and is compounded by the use of medications and insulin therapy.

"It’s hypothesized that these individuals may need to lose more weight to reach the target weight that will normalize their glucose levels."

The benefit of weight loss is most likely tied to improved beta cell functioning, Dr. Steven suggested.

"There is good in vitro evidence that saturated fatty acids are particularly detrimental to beta cells, inhibiting acute insulin secretion and inducing apoptosis," she said.

"Autopsy studies have shown that beta cells continue replication and neogenesis [in type 2 diabetes]," Dr. Steven continued. "So it’s at least theoretically possible that beta cell function could be regained at any stage of the disease upon removal of the toxic environment."

*CORRECTION 10/26/12: This article misstated the percentage of long-term diabetes patients (having the disease more than 8 years)who experienced disease reversal. Diabetes reversed in 38% of this population.

BERLIN – Roux-en-Y gastric bypass surgery can reverse type 2 diabetes in up to 73% of patients – even in those with long-standing disease.

Disease remission even occurred in 38% of those who had diabetes for longer than 8 years, with all who were taking insulin able to discontinue the medication, Dr. Sarah Steven said at the annual meeting of the European Associations for the Study of Diabetes.

Dr. Steven, of Newcastle (England) University, presented a retrospective study of 73 patients with type 2 diabetes who underwent gastric bypass surgery with the Roux-en-Y technique. Most (46) were women; the group’s median age was 49 years. Their median disease duration was 5 years, although the range was wide, from 1 month to 19 years. She did not give a median follow-up time, but did say that it was a minimum of 3 months.

Overall, they were obese, with a median body mass index of 50 kg/m². Their median preoperative hemoglobin A_1c was 7.1%. Criteria for reversal was a postoperative HbA_1c of 6%.

At baseline, all of the patients were taking metformin and 12 were also on insulin. Other medications included sulphonylurea, thiazolidinedione, glucagon-like peptide-1 agonist, and dipeptidyl peptidase-4 inhibitor.

Diabetes reversal occurred in 79% of those with short-duration disease (up to 4 years); 73% of the patients were able to discontinue all diabetes medications. *Diabetes reversed in 38% of those who had the disease longer than 8 years; 21% of that group no longer needed any antidiabetic medication.

The amount of weight lost was significantly associated with disease reversal. Reversal occurred in 50% of the group that lost fewer than 10 kg/m²; in 73% of those that lost 10-15 kg/m²; and in 76% of those who lost more than 15 kg/m².

In the group with long disease duration, the mean weight loss in those whose diabetes reversed was 34 kg/m², compared with 21 kg/m² in those whose diabetes did not.

Weight loss also significantly influenced the individual ability to successfully withdraw from diabetes medications. About a quarter (27%) of those who lost fewer than 10 kg no longer needed the drugs. However, 67% of those who lost 10-15 kg/m² and 50% of those who lost more than 15 kg/m² no longer needed any of the medications.

"The reversal of type 2 diabetes seems to depend on the degree of weight loss," Dr. Steven said. "Individuals with long-term diabetes are likely to have gained more weight than those with short-term – this is in part due to the natural history of the disease and is compounded by the use of medications and insulin therapy. It’s hypothesized that these individuals may need to lose more weight to reach the target weight that will normalize their glucose levels."

The benefit of weight loss is most likely tied to improved beta cell functioning, Dr. Steven suggested. "There is good in vitro evidence that saturated fatty acids are particularly detrimental to beta cells, inhibiting acute insulin secretion and inducing apoptosis. Autopsy studies have shown that beta cells continue replication and neogenesis [in type 2 diabetes], so it’s at least theoretically possible that beta cell function could be regained at any stage of the disease upon removal of the toxic environment."

Dr. Steven did not disclose any financial relationships.

*CORRECTION 10/26/12: This article misstated the percentage of long-term diabetes patients (having the disease more than 8 years) who experienced disease reversal. Diabetes reversed in 38% of this population.

BERLIN – Roux-en-Y gastric bypass surgery can reverse type 2 diabetes in up to 73% of patients – even in those with long-standing disease.

Disease remission even occurred in 38% of those who had diabetes for longer than 8 years, with all who were taking insulin able to discontinue the medication, Dr. Sarah Steven said at the annual meeting of the European Associations for the Study of Diabetes.

Dr. Steven, of Newcastle (England) University, presented a retrospective study of 73 patients with type 2 diabetes who underwent gastric bypass surgery with the Roux-en-Y technique. Most (46) were women; the group’s median age was 49 years. Their median disease duration was 5 years, although the range was wide, from 1 month to 19 years. She did not give a median follow-up time, but did say that it was a minimum of 3 months.

Overall, they were obese, with a median body mass index of 50 kg/m². Their median preoperative hemoglobin A_1c was 7.1%. Criteria for reversal was a postoperative HbA_1c of 6%.

At baseline, all of the patients were taking metformin and 12 were also on insulin. Other medications included sulphonylurea, thiazolidinedione, glucagon-like peptide-1 agonist, and dipeptidyl peptidase-4 inhibitor.

Diabetes reversal occurred in 79% of those with short-duration disease (up to 4 years); 73% of the patients were able to discontinue all diabetes medications. *Diabetes reversed in 38% of those who had the disease longer than 8 years; 21% of that group no longer needed any antidiabetic medication.

The amount of weight lost was significantly associated with disease reversal. Reversal occurred in 50% of the group that lost fewer than 10 kg/m²; in 73% of those that lost 10-15 kg/m²; and in 76% of those who lost more than 15 kg/m².

In the group with long disease duration, the mean weight loss in those whose diabetes reversed was 34 kg/m², compared with 21 kg/m² in those whose diabetes did not.

Weight loss also significantly influenced the individual ability to successfully withdraw from diabetes medications. About a quarter (27%) of those who lost fewer than 10 kg no longer needed the drugs. However, 67% of those who lost 10-15 kg/m² and 50% of those who lost more than 15 kg/m² no longer needed any of the medications.

"The reversal of type 2 diabetes seems to depend on the degree of weight loss," Dr. Steven said. "Individuals with long-term diabetes are likely to have gained more weight than those with short-term – this is in part due to the natural history of the disease and is compounded by the use of medications and insulin therapy. It’s hypothesized that these individuals may need to lose more weight to reach the target weight that will normalize their glucose levels."

The benefit of weight loss is most likely tied to improved beta cell functioning, Dr. Steven suggested. "There is good in vitro evidence that saturated fatty acids are particularly detrimental to beta cells, inhibiting acute insulin secretion and inducing apoptosis. Autopsy studies have shown that beta cells continue replication and neogenesis [in type 2 diabetes], so it’s at least theoretically possible that beta cell function could be regained at any stage of the disease upon removal of the toxic environment."

Dr. Steven did not disclose any financial relationships.

*CORRECTION 10/26/12: This article misstated the percentage of long-term diabetes patients (having the disease more than 8 years) who experienced disease reversal. Diabetes reversed in 38% of this population.

BERLIN – Roux-en-Y gastric bypass surgery can reverse type 2 diabetes in up to 73% of patients – even in those with long-standing disease.

Disease remission even occurred in 38% of those who had diabetes for longer than 8 years, with all who were taking insulin able to discontinue the medication, Dr. Sarah Steven said at the annual meeting of the European Associations for the Study of Diabetes.

Dr. Steven, of Newcastle (England) University, presented a retrospective study of 73 patients with type 2 diabetes who underwent gastric bypass surgery with the Roux-en-Y technique. Most (46) were women; the group’s median age was 49 years. Their median disease duration was 5 years, although the range was wide, from 1 month to 19 years. She did not give a median follow-up time, but did say that it was a minimum of 3 months.

Overall, they were obese, with a median body mass index of 50 kg/m². Their median preoperative hemoglobin A_1c was 7.1%. Criteria for reversal was a postoperative HbA_1c of 6%.

At baseline, all of the patients were taking metformin and 12 were also on insulin. Other medications included sulphonylurea, thiazolidinedione, glucagon-like peptide-1 agonist, and dipeptidyl peptidase-4 inhibitor.

Diabetes reversal occurred in 79% of those with short-duration disease (up to 4 years); 73% of the patients were able to discontinue all diabetes medications. *Diabetes reversed in 38% of those who had the disease longer than 8 years; 21% of that group no longer needed any antidiabetic medication.

The amount of weight lost was significantly associated with disease reversal. Reversal occurred in 50% of the group that lost fewer than 10 kg/m²; in 73% of those that lost 10-15 kg/m²; and in 76% of those who lost more than 15 kg/m².

In the group with long disease duration, the mean weight loss in those whose diabetes reversed was 34 kg/m², compared with 21 kg/m² in those whose diabetes did not.

Weight loss also significantly influenced the individual ability to successfully withdraw from diabetes medications. About a quarter (27%) of those who lost fewer than 10 kg no longer needed the drugs. However, 67% of those who lost 10-15 kg/m² and 50% of those who lost more than 15 kg/m² no longer needed any of the medications.

"The reversal of type 2 diabetes seems to depend on the degree of weight loss," Dr. Steven said. "Individuals with long-term diabetes are likely to have gained more weight than those with short-term – this is in part due to the natural history of the disease and is compounded by the use of medications and insulin therapy. It’s hypothesized that these individuals may need to lose more weight to reach the target weight that will normalize their glucose levels."

The benefit of weight loss is most likely tied to improved beta cell functioning, Dr. Steven suggested. "There is good in vitro evidence that saturated fatty acids are particularly detrimental to beta cells, inhibiting acute insulin secretion and inducing apoptosis. Autopsy studies have shown that beta cells continue replication and neogenesis [in type 2 diabetes], so it’s at least theoretically possible that beta cell function could be regained at any stage of the disease upon removal of the toxic environment."

Dr. Steven did not disclose any financial relationships.

*CORRECTION 10/26/12: This article misstated the percentage of long-term diabetes patients (having the disease more than 8 years) who experienced disease reversal. Diabetes reversed in 38% of this population.

Deciding not to resume warfarin therapy after an episode of gastrointestinal bleeding raises the risk of thrombosis by a factor of 10 and the risk of death threefold, according to a retrospective cohort study published online September 17 in Archives of Internal Medicine.

"For many patients who have experienced gastrointestinal bleeding, the benefits of resuming warfarin therapy will outweigh the risks," said Daniel M. Witt, Pharm.D., of the clinical pharmacy anticoagulation service at Kaiser Permanente of Colorado, Aurora, and his associates.

"Surprisingly little is known about warfarin therapy and resumption" following a GI bleed, and there is no consensus as to the optimal timing or the risks of restarting anticoagulation. Dr. Witt and his colleagues used Kaiser’s administrative and clinical databases to study the incidence of thrombosis, recurrent bleeding episodes, and death from any cause in 442 adults who presented to a hospital or emergency department with warfarin-associated GI bleeding in 2005-2009 and who were followed for 90 days.

The mean patient age was 74 years, and the study population was equally comprised of men and women. Half of the study subjects were taking warfarin to prevent atrial fibrillation–related stroke or systemic embolization. One-quarter of patients used it to treat or prevent a second venous thrombosis, 10% were on it to prevent thromboembolic complications from prosthetic heart valves, and the remainder took it for other indications.

After an index GI bleed, 260 patients (59%) resumed warfarin therapy, usually within a week. The median time to resumption of warfarin was 4 days. In 41 of these patients, warfarin therapy was never suspended. It was suspended and never resumed in the remaining 182 patients.

During the 90-day follow-up, 11 patients (2.5%) had a thrombotic event. There were six arterial events, including five strokes and one systemic embolus, and five venous events, including three pulmonary embolisms and two deep vein thromboses (DVTs).

The rate of thrombotic events was 0.4% among the patients who resumed warfarin therapy (one DVT), compared with 5.5% among those who did not resume warfarin (five strokes, one systemic embolus, three pulmonary embolisms, and one DVT), a significant difference, the investigators said (Arch. Intern. Med. 2012 [doi:10.1001/archinternmed.2012.5261]).

"Patients who either never interrupted warfarin therapy or resumed therapy within 14 days of the index GI bleed experienced no thromboses," they added.

GI bleeding recurred in 36 patients (8.4%) overall. A numerically higher proportion of patients who resumed warfarin therapy had recurrent GI bleeding (10%) than those who did not resume warfarin (5.5%), but this difference was not statistically significant.

In addition, a multivariable analysis that accounted for numerous possible confounders – including patient age, sex, propensity for complications; the INR at admission; acute treatment for the GI bleed; and location of GI bleed – also showed that the risk for rebleeding was not significantly greater in patients who resumed warfarin therapy than in those who did not.

Moreover, recurrent GI bleeding was never fatal. Fatal strokes did occur, however, in three patients with atrial fibrillation whose warfarin therapy was withdrawn and never resumed, Dr. Witt and his associates said.

A total of 52 patients (12%) died during follow-up. The most common cause of death was related to malignancy (29% of deaths), infection (19% of deaths), or cardiac disease (17%).

Resumption of warfarin therapy was strongly associated with a threefold decrease in the risk of death from any cause.

The investigators also performed a post hoc analysis excluding all patients who died within 1 week of the index GI bleed to rule out those who may not have had an opportunity to resume warfarin therapy. In this analysis, the strong association between resumption of warfarin and decreased mortality persisted.

Mortality was lowest among patients who resumed warfarin therapy within 15-90 days of the index GI bleed, the researchers said.

"Our results provide some guidance regarding the optimal timing of warfarin therapy resumption following GI bleeding, but clinical judgment remains a critical factor in this difficult decision," they noted.

This study was funded by CSL Behring. Dr. Witt’s associates, but not Dr. Witt, reported ties to numerous industry sources.

Deciding not to resume warfarin therapy after an episode of gastrointestinal bleeding raises the risk of thrombosis by a factor of 10 and the risk of death threefold, according to a retrospective cohort study published online September 17 in Archives of Internal Medicine.

"For many patients who have experienced gastrointestinal bleeding, the benefits of resuming warfarin therapy will outweigh the risks," said Daniel M. Witt, Pharm.D., of the clinical pharmacy anticoagulation service at Kaiser Permanente of Colorado, Aurora, and his associates.

"Surprisingly little is known about warfarin therapy and resumption" following a GI bleed, and there is no consensus as to the optimal timing or the risks of restarting anticoagulation. Dr. Witt and his colleagues used Kaiser’s administrative and clinical databases to study the incidence of thrombosis, recurrent bleeding episodes, and death from any cause in 442 adults who presented to a hospital or emergency department with warfarin-associated GI bleeding in 2005-2009 and who were followed for 90 days.

The mean patient age was 74 years, and the study population was equally comprised of men and women. Half of the study subjects were taking warfarin to prevent atrial fibrillation–related stroke or systemic embolization. One-quarter of patients used it to treat or prevent a second venous thrombosis, 10% were on it to prevent thromboembolic complications from prosthetic heart valves, and the remainder took it for other indications.

After an index GI bleed, 260 patients (59%) resumed warfarin therapy, usually within a week. The median time to resumption of warfarin was 4 days. In 41 of these patients, warfarin therapy was never suspended. It was suspended and never resumed in the remaining 182 patients.

During the 90-day follow-up, 11 patients (2.5%) had a thrombotic event. There were six arterial events, including five strokes and one systemic embolus, and five venous events, including three pulmonary embolisms and two deep vein thromboses (DVTs).

The rate of thrombotic events was 0.4% among the patients who resumed warfarin therapy (one DVT), compared with 5.5% among those who did not resume warfarin (five strokes, one systemic embolus, three pulmonary embolisms, and one DVT), a significant difference, the investigators said (Arch. Intern. Med. 2012 [doi:10.1001/archinternmed.2012.5261]).

"Patients who either never interrupted warfarin therapy or resumed therapy within 14 days of the index GI bleed experienced no thromboses," they added.

GI bleeding recurred in 36 patients (8.4%) overall. A numerically higher proportion of patients who resumed warfarin therapy had recurrent GI bleeding (10%) than those who did not resume warfarin (5.5%), but this difference was not statistically significant.

In addition, a multivariable analysis that accounted for numerous possible confounders – including patient age, sex, propensity for complications; the INR at admission; acute treatment for the GI bleed; and location of GI bleed – also showed that the risk for rebleeding was not significantly greater in patients who resumed warfarin therapy than in those who did not.

Moreover, recurrent GI bleeding was never fatal. Fatal strokes did occur, however, in three patients with atrial fibrillation whose warfarin therapy was withdrawn and never resumed, Dr. Witt and his associates said.

A total of 52 patients (12%) died during follow-up. The most common cause of death was related to malignancy (29% of deaths), infection (19% of deaths), or cardiac disease (17%).

Resumption of warfarin therapy was strongly associated with a threefold decrease in the risk of death from any cause.

The investigators also performed a post hoc analysis excluding all patients who died within 1 week of the index GI bleed to rule out those who may not have had an opportunity to resume warfarin therapy. In this analysis, the strong association between resumption of warfarin and decreased mortality persisted.

Mortality was lowest among patients who resumed warfarin therapy within 15-90 days of the index GI bleed, the researchers said.

"Our results provide some guidance regarding the optimal timing of warfarin therapy resumption following GI bleeding, but clinical judgment remains a critical factor in this difficult decision," they noted.

This study was funded by CSL Behring. Dr. Witt’s associates, but not Dr. Witt, reported ties to numerous industry sources.

Deciding not to resume warfarin therapy after an episode of gastrointestinal bleeding raises the risk of thrombosis by a factor of 10 and the risk of death threefold, according to a retrospective cohort study published online September 17 in Archives of Internal Medicine.

"For many patients who have experienced gastrointestinal bleeding, the benefits of resuming warfarin therapy will outweigh the risks," said Daniel M. Witt, Pharm.D., of the clinical pharmacy anticoagulation service at Kaiser Permanente of Colorado, Aurora, and his associates.

"Surprisingly little is known about warfarin therapy and resumption" following a GI bleed, and there is no consensus as to the optimal timing or the risks of restarting anticoagulation. Dr. Witt and his colleagues used Kaiser’s administrative and clinical databases to study the incidence of thrombosis, recurrent bleeding episodes, and death from any cause in 442 adults who presented to a hospital or emergency department with warfarin-associated GI bleeding in 2005-2009 and who were followed for 90 days.

The mean patient age was 74 years, and the study population was equally comprised of men and women. Half of the study subjects were taking warfarin to prevent atrial fibrillation–related stroke or systemic embolization. One-quarter of patients used it to treat or prevent a second venous thrombosis, 10% were on it to prevent thromboembolic complications from prosthetic heart valves, and the remainder took it for other indications.

After an index GI bleed, 260 patients (59%) resumed warfarin therapy, usually within a week. The median time to resumption of warfarin was 4 days. In 41 of these patients, warfarin therapy was never suspended. It was suspended and never resumed in the remaining 182 patients.

During the 90-day follow-up, 11 patients (2.5%) had a thrombotic event. There were six arterial events, including five strokes and one systemic embolus, and five venous events, including three pulmonary embolisms and two deep vein thromboses (DVTs).

The rate of thrombotic events was 0.4% among the patients who resumed warfarin therapy (one DVT), compared with 5.5% among those who did not resume warfarin (five strokes, one systemic embolus, three pulmonary embolisms, and one DVT), a significant difference, the investigators said (Arch. Intern. Med. 2012 [doi:10.1001/archinternmed.2012.5261]).

"Patients who either never interrupted warfarin therapy or resumed therapy within 14 days of the index GI bleed experienced no thromboses," they added.

GI bleeding recurred in 36 patients (8.4%) overall. A numerically higher proportion of patients who resumed warfarin therapy had recurrent GI bleeding (10%) than those who did not resume warfarin (5.5%), but this difference was not statistically significant.

In addition, a multivariable analysis that accounted for numerous possible confounders – including patient age, sex, propensity for complications; the INR at admission; acute treatment for the GI bleed; and location of GI bleed – also showed that the risk for rebleeding was not significantly greater in patients who resumed warfarin therapy than in those who did not.

Moreover, recurrent GI bleeding was never fatal. Fatal strokes did occur, however, in three patients with atrial fibrillation whose warfarin therapy was withdrawn and never resumed, Dr. Witt and his associates said.

A total of 52 patients (12%) died during follow-up. The most common cause of death was related to malignancy (29% of deaths), infection (19% of deaths), or cardiac disease (17%).

Resumption of warfarin therapy was strongly associated with a threefold decrease in the risk of death from any cause.

The investigators also performed a post hoc analysis excluding all patients who died within 1 week of the index GI bleed to rule out those who may not have had an opportunity to resume warfarin therapy. In this analysis, the strong association between resumption of warfarin and decreased mortality persisted.

Mortality was lowest among patients who resumed warfarin therapy within 15-90 days of the index GI bleed, the researchers said.

"Our results provide some guidance regarding the optimal timing of warfarin therapy resumption following GI bleeding, but clinical judgment remains a critical factor in this difficult decision," they noted.

This study was funded by CSL Behring. Dr. Witt’s associates, but not Dr. Witt, reported ties to numerous industry sources.

A policy of regular ultrasound exams for small gallbladder polyps and resection on only larger ones could catch five more gallbladder cancers per year and save more than $200,000.

A retrospective study also found that 50% of gallbladder polyps were not followed at all, setting the stage for the rare – but potentially dangerous – cancers to develop, Dr. Giuseppe Garcea and his colleagues wrote in the Aug. 20 online issue of Archives of Surgery.

Nevit Dilmen/WikimediaCommons

"All gallbladder polyps represent potentially premalignant disease and require discussion at a hepatobiliary multidisciplinary team meeting because this would enhance and standardize the management of this condition," wrote Dr. Garcea of the University Hospitals of Leicester (England).

The investigators reviewed the records of 986 patients with confirmed gallbladder polyps who were followed up for a median period of 39 months. The patients’ median age was 57 years.

About half of the polyps were detected by ultrasound after a complaint of upper abdominal pain, thought to have been caused by gallstones. The rest were found incidentally. Most of the findings were of single polyps (62%), but 24% of the lesions occurred in groups of three or more.

Specialist consultation was uncommon, with only 5% of cases discussed at a hepatobiliary multidisciplinary meeting. Half of the patients were not followed at all for changes in polyp morphology. Follow-up was more common in patients seen by a specialist than in those who were not (60% vs.10%).

Although 23% of the patients had an increased number of polyps over the follow-up period, only 7% of these lesions increased in size. Those polyps that did get larger were also significantly larger at presentation than those with a stable size (7 mm vs. 5 mm).

Surgery was performed on 134 patients. Histologic examination showed that in almost half of the gallbladders, the only abnormality was cholesterolosis or cholesterol polyps; 94% of the gallbladders had benign conditions. A malignant or potentially malignant pathology occurred in just five patients, with one polyp showing signs of malignant differentiation.

Polyps that were found to be malignant or potentially malignant during follow-up had also been significantly larger than nonmalignant polyps at presentation (median, 10 mm vs. 5 mm). All of the malignant polyps had also become larger during the follow-up period. A baseline size of more than 10 mm and increases in size during follow-up were the best predictors of malignant polyps (Arch. Surg. 2012 Aug. 20 [doi:10.1001/archsurg.2012.1948]).

Based on an incidence of 504 cases per 100,000 people in the United Kingdom, the authors pegged the annual socioeconomic cost of gallbladder surgery at about U.S. $78 million each year. They constructed a mathematical model assuming biannual ultrasound follow-up, and a 20-year expected life span after age at diagnosis. The model predicted that ultrasound surveillance would catch five patients with gallbladder cancer every year and save U.S. $507,986 per year in associated costs.

In the very young patients, however, "an argument may be made for prophylactic cholecystectomy even with polyps less than 10 mm, because the long protracted follow-up involved would be impractical and probably unsustainable," the investigators said.

To maximize effectiveness and financial gains, they determined that polyps sized 5-10 mm should be followed, and those larger than 10 mm should be removed. No study has determined the likelihood of a 5- to 10-mm polyp becoming malignant, they said, but because the risks associated with ultrasound surveillance and any subsequent gallbladder surgery are so small, they concluded that regular follow-up would still be cost effective.

Neither Dr. Garcea nor any of his coauthors reported any financial conflicts.

A policy of regular ultrasound exams for small gallbladder polyps and resection on only larger ones could catch five more gallbladder cancers per year and save more than $200,000.

A retrospective study also found that 50% of gallbladder polyps were not followed at all, setting the stage for the rare – but potentially dangerous – cancers to develop, Dr. Giuseppe Garcea and his colleagues wrote in the Aug. 20 online issue of Archives of Surgery.

Nevit Dilmen/WikimediaCommons

"All gallbladder polyps represent potentially premalignant disease and require discussion at a hepatobiliary multidisciplinary team meeting because this would enhance and standardize the management of this condition," wrote Dr. Garcea of the University Hospitals of Leicester (England).

The investigators reviewed the records of 986 patients with confirmed gallbladder polyps who were followed up for a median period of 39 months. The patients’ median age was 57 years.

About half of the polyps were detected by ultrasound after a complaint of upper abdominal pain, thought to have been caused by gallstones. The rest were found incidentally. Most of the findings were of single polyps (62%), but 24% of the lesions occurred in groups of three or more.

Specialist consultation was uncommon, with only 5% of cases discussed at a hepatobiliary multidisciplinary meeting. Half of the patients were not followed at all for changes in polyp morphology. Follow-up was more common in patients seen by a specialist than in those who were not (60% vs.10%).

Although 23% of the patients had an increased number of polyps over the follow-up period, only 7% of these lesions increased in size. Those polyps that did get larger were also significantly larger at presentation than those with a stable size (7 mm vs. 5 mm).

Surgery was performed on 134 patients. Histologic examination showed that in almost half of the gallbladders, the only abnormality was cholesterolosis or cholesterol polyps; 94% of the gallbladders had benign conditions. A malignant or potentially malignant pathology occurred in just five patients, with one polyp showing signs of malignant differentiation.

Polyps that were found to be malignant or potentially malignant during follow-up had also been significantly larger than nonmalignant polyps at presentation (median, 10 mm vs. 5 mm). All of the malignant polyps had also become larger during the follow-up period. A baseline size of more than 10 mm and increases in size during follow-up were the best predictors of malignant polyps (Arch. Surg. 2012 Aug. 20 [doi:10.1001/archsurg.2012.1948]).

Based on an incidence of 504 cases per 100,000 people in the United Kingdom, the authors pegged the annual socioeconomic cost of gallbladder surgery at about U.S. $78 million each year. They constructed a mathematical model assuming biannual ultrasound follow-up, and a 20-year expected life span after age at diagnosis. The model predicted that ultrasound surveillance would catch five patients with gallbladder cancer every year and save U.S. $507,986 per year in associated costs.

In the very young patients, however, "an argument may be made for prophylactic cholecystectomy even with polyps less than 10 mm, because the long protracted follow-up involved would be impractical and probably unsustainable," the investigators said.

To maximize effectiveness and financial gains, they determined that polyps sized 5-10 mm should be followed, and those larger than 10 mm should be removed. No study has determined the likelihood of a 5- to 10-mm polyp becoming malignant, they said, but because the risks associated with ultrasound surveillance and any subsequent gallbladder surgery are so small, they concluded that regular follow-up would still be cost effective.

Neither Dr. Garcea nor any of his coauthors reported any financial conflicts.

A policy of regular ultrasound exams for small gallbladder polyps and resection on only larger ones could catch five more gallbladder cancers per year and save more than $200,000.

A retrospective study also found that 50% of gallbladder polyps were not followed at all, setting the stage for the rare – but potentially dangerous – cancers to develop, Dr. Giuseppe Garcea and his colleagues wrote in the Aug. 20 online issue of Archives of Surgery.

Nevit Dilmen/WikimediaCommons

"All gallbladder polyps represent potentially premalignant disease and require discussion at a hepatobiliary multidisciplinary team meeting because this would enhance and standardize the management of this condition," wrote Dr. Garcea of the University Hospitals of Leicester (England).

The investigators reviewed the records of 986 patients with confirmed gallbladder polyps who were followed up for a median period of 39 months. The patients’ median age was 57 years.

About half of the polyps were detected by ultrasound after a complaint of upper abdominal pain, thought to have been caused by gallstones. The rest were found incidentally. Most of the findings were of single polyps (62%), but 24% of the lesions occurred in groups of three or more.

Specialist consultation was uncommon, with only 5% of cases discussed at a hepatobiliary multidisciplinary meeting. Half of the patients were not followed at all for changes in polyp morphology. Follow-up was more common in patients seen by a specialist than in those who were not (60% vs.10%).

Although 23% of the patients had an increased number of polyps over the follow-up period, only 7% of these lesions increased in size. Those polyps that did get larger were also significantly larger at presentation than those with a stable size (7 mm vs. 5 mm).

Surgery was performed on 134 patients. Histologic examination showed that in almost half of the gallbladders, the only abnormality was cholesterolosis or cholesterol polyps; 94% of the gallbladders had benign conditions. A malignant or potentially malignant pathology occurred in just five patients, with one polyp showing signs of malignant differentiation.

Polyps that were found to be malignant or potentially malignant during follow-up had also been significantly larger than nonmalignant polyps at presentation (median, 10 mm vs. 5 mm). All of the malignant polyps had also become larger during the follow-up period. A baseline size of more than 10 mm and increases in size during follow-up were the best predictors of malignant polyps (Arch. Surg. 2012 Aug. 20 [doi:10.1001/archsurg.2012.1948]).

Based on an incidence of 504 cases per 100,000 people in the United Kingdom, the authors pegged the annual socioeconomic cost of gallbladder surgery at about U.S. $78 million each year. They constructed a mathematical model assuming biannual ultrasound follow-up, and a 20-year expected life span after age at diagnosis. The model predicted that ultrasound surveillance would catch five patients with gallbladder cancer every year and save U.S. $507,986 per year in associated costs.

In the very young patients, however, "an argument may be made for prophylactic cholecystectomy even with polyps less than 10 mm, because the long protracted follow-up involved would be impractical and probably unsustainable," the investigators said.

To maximize effectiveness and financial gains, they determined that polyps sized 5-10 mm should be followed, and those larger than 10 mm should be removed. No study has determined the likelihood of a 5- to 10-mm polyp becoming malignant, they said, but because the risks associated with ultrasound surveillance and any subsequent gallbladder surgery are so small, they concluded that regular follow-up would still be cost effective.

Neither Dr. Garcea nor any of his coauthors reported any financial conflicts.

Adults with no polyps at baseline colonoscopy and average risk for colorectal cancer can still wait 10 years until their next colonoscopy, according to updated surveillance guidelines from the U.S. Multi-Society Task Force on Colorectal Cancer. The guidelines were published in the September issue of Gastroenterology.

New concerns, including the risk of interval colorectal cancer (CRC), the risk of proximal colorectal cancer, and the role of serrated polyps in carcinogenesis prompted an update to the guidelines, which were last revised in 2006, according to lead author Dr. David A. Lieberman of Oregon Health and Science University, Portland, and his colleagues.

The task force is composed of GI specialists representing the three major GI professional organizations: the American Gastroenterological Association (AGA) Institute, American College of Gastroenterology (ACG), and American Society for Gastrointestinal Endoscopy (ASGE).

Overall, the recommendations have not changed, but the task force reviewed the most recent literature and found additional evidence to support several categories of surveillance and screening intervals for adults with average risk of CRC at the time of a baseline screening.

Recommendations supported by new evidence include a 10-year interval for individuals with no polyps, and a 5- to 10-year interval for those with one or two tubular adenomas less than 10 mm in size. New evidence also supports a 3-year interval for patients with 3-10 tubular adenomas of any size, and also 3 years for patients with one or more tubular adenomas 10 mm or larger. In addition, data reported since 2006 support a 3-year surveillance interval for patients with one or more villous adenomas.

Recommendations that remain unchanged without additional evidence are a 10-year surveillance interval for individuals with hyperplastic polyps in the rectum or sigmoid, an interval of less than 3 years for those with more than 10 adenomas, and an interval of 3 years in cases of an adenoma with high-grade dysplasia.

In addition, serrated lesions are now included as part of the surveillance schedule after a baseline colonoscopy. Individuals with one or more sessile serrated polyps less than 10 mm in size and no dysplasia should be rescreened after 5 years. Those with one or more sessile serrated polyps 10 mm or larger, or any sessile serrated polyp with dysplasia, or a traditional serrated adenoma should be rescreened after 3 years.

Individuals with serrated polyposis syndrome (SPS) should be rescreened after 1 year. Serrated polyposis syndrome is defined as meeting one of three criteria (in agreement with the World Health Organization definition): at least five serrated polyps proximal to the sigmoid, with at least two measuring 10 mm or larger; any serrated polyps proximal to the sigmoid in patients with a family history of SPS; and more than 20 serrated polyps of any size throughout the colon.

The authors noted that the quality of the evidence supporting the current guidelines is low, and will require updates. "There are no longitudinal studies available on which to base surveillance intervals after resection," they said.

In addition, given new evidence about the increased risk of colonoscopy with advancing age, surveillance and screening should be discontinued when the risks outweigh the benefits, according to the guidelines. "The United States Preventive Services Task Forces determined that screening should not be continued after age 85 years because risk could exceed potential benefit," the task force noted. "It is the opinion of the MSTF that the decision to continue surveillance should be individualized, based on an assessment of benefit, risk, and co-morbidities."

However, "the guidelines are dynamic, and will be revised in the future, based on new evidence. This new evidence should include information about the quality of the baseline examinations," the authors said. "The task force recommends that all endoscopists monitor key quality indicators as part of a colonoscopy screening and surveillance program," they noted.

Lead author Dr. David Lieberman has served on the advisory boards of Given Imaging and Exact Sciences.

Adults with no polyps at baseline colonoscopy and average risk for colorectal cancer can still wait 10 years until their next colonoscopy, according to updated surveillance guidelines from the U.S. Multi-Society Task Force on Colorectal Cancer. The guidelines were published in the September issue of Gastroenterology.

New concerns, including the risk of interval colorectal cancer (CRC), the risk of proximal colorectal cancer, and the role of serrated polyps in carcinogenesis prompted an update to the guidelines, which were last revised in 2006, according to lead author Dr. David A. Lieberman of Oregon Health and Science University, Portland, and his colleagues.

The task force is composed of GI specialists representing the three major GI professional organizations: the American Gastroenterological Association (AGA) Institute, American College of Gastroenterology (ACG), and American Society for Gastrointestinal Endoscopy (ASGE).

Overall, the recommendations have not changed, but the task force reviewed the most recent literature and found additional evidence to support several categories of surveillance and screening intervals for adults with average risk of CRC at the time of a baseline screening.

Recommendations supported by new evidence include a 10-year interval for individuals with no polyps, and a 5- to 10-year interval for those with one or two tubular adenomas less than 10 mm in size. New evidence also supports a 3-year interval for patients with 3-10 tubular adenomas of any size, and also 3 years for patients with one or more tubular adenomas 10 mm or larger. In addition, data reported since 2006 support a 3-year surveillance interval for patients with one or more villous adenomas.

Recommendations that remain unchanged without additional evidence are a 10-year surveillance interval for individuals with hyperplastic polyps in the rectum or sigmoid, an interval of less than 3 years for those with more than 10 adenomas, and an interval of 3 years in cases of an adenoma with high-grade dysplasia.

In addition, serrated lesions are now included as part of the surveillance schedule after a baseline colonoscopy. Individuals with one or more sessile serrated polyps less than 10 mm in size and no dysplasia should be rescreened after 5 years. Those with one or more sessile serrated polyps 10 mm or larger, or any sessile serrated polyp with dysplasia, or a traditional serrated adenoma should be rescreened after 3 years.

Individuals with serrated polyposis syndrome (SPS) should be rescreened after 1 year. Serrated polyposis syndrome is defined as meeting one of three criteria (in agreement with the World Health Organization definition): at least five serrated polyps proximal to the sigmoid, with at least two measuring 10 mm or larger; any serrated polyps proximal to the sigmoid in patients with a family history of SPS; and more than 20 serrated polyps of any size throughout the colon.

The authors noted that the quality of the evidence supporting the current guidelines is low, and will require updates. "There are no longitudinal studies available on which to base surveillance intervals after resection," they said.

In addition, given new evidence about the increased risk of colonoscopy with advancing age, surveillance and screening should be discontinued when the risks outweigh the benefits, according to the guidelines. "The United States Preventive Services Task Forces determined that screening should not be continued after age 85 years because risk could exceed potential benefit," the task force noted. "It is the opinion of the MSTF that the decision to continue surveillance should be individualized, based on an assessment of benefit, risk, and co-morbidities."

However, "the guidelines are dynamic, and will be revised in the future, based on new evidence. This new evidence should include information about the quality of the baseline examinations," the authors said. "The task force recommends that all endoscopists monitor key quality indicators as part of a colonoscopy screening and surveillance program," they noted.

Lead author Dr. David Lieberman has served on the advisory boards of Given Imaging and Exact Sciences.

Adults with no polyps at baseline colonoscopy and average risk for colorectal cancer can still wait 10 years until their next colonoscopy, according to updated surveillance guidelines from the U.S. Multi-Society Task Force on Colorectal Cancer. The guidelines were published in the September issue of Gastroenterology.

New concerns, including the risk of interval colorectal cancer (CRC), the risk of proximal colorectal cancer, and the role of serrated polyps in carcinogenesis prompted an update to the guidelines, which were last revised in 2006, according to lead author Dr. David A. Lieberman of Oregon Health and Science University, Portland, and his colleagues.

The task force is composed of GI specialists representing the three major GI professional organizations: the American Gastroenterological Association (AGA) Institute, American College of Gastroenterology (ACG), and American Society for Gastrointestinal Endoscopy (ASGE).

Overall, the recommendations have not changed, but the task force reviewed the most recent literature and found additional evidence to support several categories of surveillance and screening intervals for adults with average risk of CRC at the time of a baseline screening.

Recommendations supported by new evidence include a 10-year interval for individuals with no polyps, and a 5- to 10-year interval for those with one or two tubular adenomas less than 10 mm in size. New evidence also supports a 3-year interval for patients with 3-10 tubular adenomas of any size, and also 3 years for patients with one or more tubular adenomas 10 mm or larger. In addition, data reported since 2006 support a 3-year surveillance interval for patients with one or more villous adenomas.

Recommendations that remain unchanged without additional evidence are a 10-year surveillance interval for individuals with hyperplastic polyps in the rectum or sigmoid, an interval of less than 3 years for those with more than 10 adenomas, and an interval of 3 years in cases of an adenoma with high-grade dysplasia.

In addition, serrated lesions are now included as part of the surveillance schedule after a baseline colonoscopy. Individuals with one or more sessile serrated polyps less than 10 mm in size and no dysplasia should be rescreened after 5 years. Those with one or more sessile serrated polyps 10 mm or larger, or any sessile serrated polyp with dysplasia, or a traditional serrated adenoma should be rescreened after 3 years.

Individuals with serrated polyposis syndrome (SPS) should be rescreened after 1 year. Serrated polyposis syndrome is defined as meeting one of three criteria (in agreement with the World Health Organization definition): at least five serrated polyps proximal to the sigmoid, with at least two measuring 10 mm or larger; any serrated polyps proximal to the sigmoid in patients with a family history of SPS; and more than 20 serrated polyps of any size throughout the colon.

The authors noted that the quality of the evidence supporting the current guidelines is low, and will require updates. "There are no longitudinal studies available on which to base surveillance intervals after resection," they said.

In addition, given new evidence about the increased risk of colonoscopy with advancing age, surveillance and screening should be discontinued when the risks outweigh the benefits, according to the guidelines. "The United States Preventive Services Task Forces determined that screening should not be continued after age 85 years because risk could exceed potential benefit," the task force noted. "It is the opinion of the MSTF that the decision to continue surveillance should be individualized, based on an assessment of benefit, risk, and co-morbidities."

However, "the guidelines are dynamic, and will be revised in the future, based on new evidence. This new evidence should include information about the quality of the baseline examinations," the authors said. "The task force recommends that all endoscopists monitor key quality indicators as part of a colonoscopy screening and surveillance program," they noted.

Lead author Dr. David Lieberman has served on the advisory boards of Given Imaging and Exact Sciences.

Endoscopic findings alone are not sufficient to diagnose eosinophilic esophagitis and instead, biopsies are needed, reported Ms. Hannah P. Kim and her colleagues in the September issue of Clinical Gastroenterology and Hepatology.

Indeed, while findings like rings, strictures, and linear furrows ought to raise suspicion, a meta-analysis of more than 4,600 patients confirms that "low sensitivity and variable predictive values make them inadequate both for the diagnosis of EoE [eosinophilic esophagitis] and for the decision of whether or not to obtain biopsies."

Ms. Kim of the Center for Esophageal Diseases and Swallowing at the University of North Carolina, Chapel Hill, and her colleagues analyzed data from 80 articles and 20 abstracts that included a total of 4,678 patients with EoE and 2,742 patients without, who served as controls.

The studies were culled from PubMed, EMBASE, and gastroenterology meetings. All studies included in the analysis had more than 10 patients with EoE and provided information on the associated endoscopic findings. The mean age of participants ranged from 6 years to 55 years in the different studies.

In an analysis, the authors found that the overall pooled prevalence of esophageal rings in the sample was 44%. For strictures, the prevalence was 21%, and for linear furrows, 48% (Clin. Gastroenterol. Hepatol. 2012 [doi:10.1016/j.cgh.2012.04.019]).

Narrow-caliber esophagus findings had a pooled prevalence of only 9% of the total sample, while the presence of white plaques or exudates was 27%. Visible pallor or decreased vasculature on endoscopy was seen in 41% of patients, and erosive esophagitis in 17%.

"The endoscopic examination was normal in 17% of cases," added the authors.

They also found a difference in prevalence according to age of patients. For example, rings and strictures were more prevalent in adults (57% and 25%, respectively) than in children (11% and 8%; P less than .05 for each).

"On the other hand, white plaques and pallor or decreased vasculature were more prevalent in children (36% and 58%) than in adults (19% and 18%; P less than .05 for each)."

Finally, Ms. Kim and her associates assessed the overall sensitivity, specificity, pooled positive predictive value (PPV), and pooled negative predictive value (NPV) for each of the assessed endoscopic characteristics.

For rings, the overall sensitivity was 48%, the specificity was 91%, the PPV was 64%, and NPV was 84%. Strictures had an overall sensitivity of 15%, specificity of 95%, PPV of 51%, and NPV of 76%.

"The operating characteristics were slightly higher for linear furrows, with a sensitivity of 40%, specificity 95%, PPV 73%, and NPV 83%," wrote the authors.

And for the endoscopic finding of pallor and/or decreased vasculature, sensitivity was 43%, specificity 90%, PPV 65%, and NPV 79%.

"In contrast to the low sensitivity of individual endoscopic findings, when examining the presence of at least one endoscopic finding, an abnormal endoscopy had a sensitivity of 87%, specificity of 47%, PPV of 42%, and NPV of 89%," the authors added.

"Although endoscopic features of EoE such as esophageal rings, linear furrows, and white plaques or exudates are often considered to be typical features of EoE, these are not always identified by endoscopists," wrote the researchers.

And while most patients with EoE have abnormal findings on upper endoscopy examinations, "the sensitivity values of individual endoscopic findings were modest, and although the specificity values were higher, the predictive values were inadequate for diagnostic purposes."

"Esophageal biopsies should be obtained from all patients who present with symptoms of EoE, regardless of the endoscopic appearance of the esophagus."

The authors stated that the study was supported by grants from the National Institutes of Health and the Doris Duke Charitable Foundation. They stated that they had no individual disclosures.

Endoscopic findings alone are not sufficient to diagnose eosinophilic esophagitis and instead, biopsies are needed, reported Ms. Hannah P. Kim and her colleagues in the September issue of Clinical Gastroenterology and Hepatology.

Indeed, while findings like rings, strictures, and linear furrows ought to raise suspicion, a meta-analysis of more than 4,600 patients confirms that "low sensitivity and variable predictive values make them inadequate both for the diagnosis of EoE [eosinophilic esophagitis] and for the decision of whether or not to obtain biopsies."

Ms. Kim of the Center for Esophageal Diseases and Swallowing at the University of North Carolina, Chapel Hill, and her colleagues analyzed data from 80 articles and 20 abstracts that included a total of 4,678 patients with EoE and 2,742 patients without, who served as controls.

The studies were culled from PubMed, EMBASE, and gastroenterology meetings. All studies included in the analysis had more than 10 patients with EoE and provided information on the associated endoscopic findings. The mean age of participants ranged from 6 years to 55 years in the different studies.

In an analysis, the authors found that the overall pooled prevalence of esophageal rings in the sample was 44%. For strictures, the prevalence was 21%, and for linear furrows, 48% (Clin. Gastroenterol. Hepatol. 2012 [doi:10.1016/j.cgh.2012.04.019]).

Narrow-caliber esophagus findings had a pooled prevalence of only 9% of the total sample, while the presence of white plaques or exudates was 27%. Visible pallor or decreased vasculature on endoscopy was seen in 41% of patients, and erosive esophagitis in 17%.

"The endoscopic examination was normal in 17% of cases," added the authors.

They also found a difference in prevalence according to age of patients. For example, rings and strictures were more prevalent in adults (57% and 25%, respectively) than in children (11% and 8%; P less than .05 for each).

"On the other hand, white plaques and pallor or decreased vasculature were more prevalent in children (36% and 58%) than in adults (19% and 18%; P less than .05 for each)."

Finally, Ms. Kim and her associates assessed the overall sensitivity, specificity, pooled positive predictive value (PPV), and pooled negative predictive value (NPV) for each of the assessed endoscopic characteristics.

For rings, the overall sensitivity was 48%, the specificity was 91%, the PPV was 64%, and NPV was 84%. Strictures had an overall sensitivity of 15%, specificity of 95%, PPV of 51%, and NPV of 76%.

"The operating characteristics were slightly higher for linear furrows, with a sensitivity of 40%, specificity 95%, PPV 73%, and NPV 83%," wrote the authors.

And for the endoscopic finding of pallor and/or decreased vasculature, sensitivity was 43%, specificity 90%, PPV 65%, and NPV 79%.

"In contrast to the low sensitivity of individual endoscopic findings, when examining the presence of at least one endoscopic finding, an abnormal endoscopy had a sensitivity of 87%, specificity of 47%, PPV of 42%, and NPV of 89%," the authors added.

"Although endoscopic features of EoE such as esophageal rings, linear furrows, and white plaques or exudates are often considered to be typical features of EoE, these are not always identified by endoscopists," wrote the researchers.

And while most patients with EoE have abnormal findings on upper endoscopy examinations, "the sensitivity values of individual endoscopic findings were modest, and although the specificity values were higher, the predictive values were inadequate for diagnostic purposes."

"Esophageal biopsies should be obtained from all patients who present with symptoms of EoE, regardless of the endoscopic appearance of the esophagus."

The authors stated that the study was supported by grants from the National Institutes of Health and the Doris Duke Charitable Foundation. They stated that they had no individual disclosures.

Endoscopic findings alone are not sufficient to diagnose eosinophilic esophagitis and instead, biopsies are needed, reported Ms. Hannah P. Kim and her colleagues in the September issue of Clinical Gastroenterology and Hepatology.

Indeed, while findings like rings, strictures, and linear furrows ought to raise suspicion, a meta-analysis of more than 4,600 patients confirms that "low sensitivity and variable predictive values make them inadequate both for the diagnosis of EoE [eosinophilic esophagitis] and for the decision of whether or not to obtain biopsies."

Ms. Kim of the Center for Esophageal Diseases and Swallowing at the University of North Carolina, Chapel Hill, and her colleagues analyzed data from 80 articles and 20 abstracts that included a total of 4,678 patients with EoE and 2,742 patients without, who served as controls.

The studies were culled from PubMed, EMBASE, and gastroenterology meetings. All studies included in the analysis had more than 10 patients with EoE and provided information on the associated endoscopic findings. The mean age of participants ranged from 6 years to 55 years in the different studies.

In an analysis, the authors found that the overall pooled prevalence of esophageal rings in the sample was 44%. For strictures, the prevalence was 21%, and for linear furrows, 48% (Clin. Gastroenterol. Hepatol. 2012 [doi:10.1016/j.cgh.2012.04.019]).

Narrow-caliber esophagus findings had a pooled prevalence of only 9% of the total sample, while the presence of white plaques or exudates was 27%. Visible pallor or decreased vasculature on endoscopy was seen in 41% of patients, and erosive esophagitis in 17%.

"The endoscopic examination was normal in 17% of cases," added the authors.

They also found a difference in prevalence according to age of patients. For example, rings and strictures were more prevalent in adults (57% and 25%, respectively) than in children (11% and 8%; P less than .05 for each).

"On the other hand, white plaques and pallor or decreased vasculature were more prevalent in children (36% and 58%) than in adults (19% and 18%; P less than .05 for each)."

Finally, Ms. Kim and her associates assessed the overall sensitivity, specificity, pooled positive predictive value (PPV), and pooled negative predictive value (NPV) for each of the assessed endoscopic characteristics.

For rings, the overall sensitivity was 48%, the specificity was 91%, the PPV was 64%, and NPV was 84%. Strictures had an overall sensitivity of 15%, specificity of 95%, PPV of 51%, and NPV of 76%.

"The operating characteristics were slightly higher for linear furrows, with a sensitivity of 40%, specificity 95%, PPV 73%, and NPV 83%," wrote the authors.

And for the endoscopic finding of pallor and/or decreased vasculature, sensitivity was 43%, specificity 90%, PPV 65%, and NPV 79%.

"In contrast to the low sensitivity of individual endoscopic findings, when examining the presence of at least one endoscopic finding, an abnormal endoscopy had a sensitivity of 87%, specificity of 47%, PPV of 42%, and NPV of 89%," the authors added.

"Although endoscopic features of EoE such as esophageal rings, linear furrows, and white plaques or exudates are often considered to be typical features of EoE, these are not always identified by endoscopists," wrote the researchers.

And while most patients with EoE have abnormal findings on upper endoscopy examinations, "the sensitivity values of individual endoscopic findings were modest, and although the specificity values were higher, the predictive values were inadequate for diagnostic purposes."

"Esophageal biopsies should be obtained from all patients who present with symptoms of EoE, regardless of the endoscopic appearance of the esophagus."

The authors stated that the study was supported by grants from the National Institutes of Health and the Doris Duke Charitable Foundation. They stated that they had no individual disclosures.

A novel robotic system designed to perform endoscopic submucosal dissection of early gastric neoplasia was safe and effective in a five-patient trial, reported Soo Jay Phee, Ph.D., and colleagues in Clinical Gastroenterology and Hepatology.

Indeed, the first human study of the robotic device showed that it achieved clear margins, no cases of major bleeding or perforation, and discharge within hours for several of the patients.

Dr. Phee of the School of Mechanical and Aerospace Engineering at Nanyang Technological University in Singapore and first author Dr. D. Nageshwar Reddy of the Asian Institute of Gastroenterology in Somajiguda, India, enrolled five patients from two centers in India and one in Hong Kong.

Only patients with gastric neoplasia limited to the mucosa, confirmed by biopsy and histopathology, were included.

All patients underwent endoscopic submucosal dissection with the assistance of a novel device called the Master and Slave Transluminal Endoscopic Robot (MASTER). The MASTER device has been described previously (Gastrointest. Endoscopy 2010;72:593-9).

According to the authors, the device is controlled by two operators, "one responsible for the steering of the endoscope while the other would be performing the submucosal dissection with the two robotic arms."

The investigators added, "The open edge of the mucosa with the tumor was grasped by one of the robotic arms to retract the mucosa and enhance exposure of the submucosa, while submucosal dissection was completed with the other L hook arm" (Clin. Gastroenterol. Hepatol. 2012 October [doi:10.1016/j.cgh.2012.05.019]).

All procedures were performed under general anesthesia and with ventilation by naso- or orotracheal intubation. All operators trained on porcine models prior to the study.

In the case of the first patient, a 41-year-old man with a 2-cm adenocarcinoma in the body of the stomach, "the submucosal dissection with the robotic system was successfully done in 19 minutes," reported the authors.

There was no bleeding for perforation, and histopathology of the specimen after retrieval showed intramucosal well-differentiated adenocarcinoma with clear resection margins. The patient was discharged after 12 hours.

The second case, a 60-year-old man, was found to have a 1.5-cm mucosal adenocarcinoma in the gastric antrum. "The submucosal dissection was completed in only 5 minutes," wrote the authors, with no complications, and clear margins on histopathology. The patient was discharged in 6 hours.

Similarly, the third patient (a 39-year-old man) had a 2-cm sessile lesion in the gastric antrum. Submucosal dissection with the MASTER was completed in 3 minutes, with no complications, clear margins, and discharge from the hospital 4 hours later.

The longest procedure was done in a 51-year-old woman with a 3-cm early gastric cancer; this procedure took 50 minutes. She had no major bleeding or perforation, had clear margins on histopathology, and had a 3-day hospital stay.

Finally, a 50-year-old man with a 2.5-cm sessile polypoid in the inferior wall of the prepyloric canal underwent a 16-minute dissection. "Severe bleeding was encountered during the procedure and required exchange of the MASTER-mounted endoscope for a waterjet endoscope to stop the bleeding with coagulation grapser," wrote the authors.

"The pathology showed hyperplastic polyp with clear margins. He was discharged from hospital on day 3 after the procedure."

At 30 days’ follow-up, no complications were reported by any of the patients, and the follow-up endoscopy showed "complete healing" of the resection site. At 6 months, the three patients with data available were "doing well," according to the authors.

The study was supported by a MedTech Seeding Fund from the National University of Singapore. The authors reported having no other relevant financial disclosures.

A novel robotic system designed to perform endoscopic submucosal dissection of early gastric neoplasia was safe and effective in a five-patient trial, reported Soo Jay Phee, Ph.D., and colleagues in Clinical Gastroenterology and Hepatology.

Indeed, the first human study of the robotic device showed that it achieved clear margins, no cases of major bleeding or perforation, and discharge within hours for several of the patients.

Dr. Phee of the School of Mechanical and Aerospace Engineering at Nanyang Technological University in Singapore and first author Dr. D. Nageshwar Reddy of the Asian Institute of Gastroenterology in Somajiguda, India, enrolled five patients from two centers in India and one in Hong Kong.

Only patients with gastric neoplasia limited to the mucosa, confirmed by biopsy and histopathology, were included.

All patients underwent endoscopic submucosal dissection with the assistance of a novel device called the Master and Slave Transluminal Endoscopic Robot (MASTER). The MASTER device has been described previously (Gastrointest. Endoscopy 2010;72:593-9).

According to the authors, the device is controlled by two operators, "one responsible for the steering of the endoscope while the other would be performing the submucosal dissection with the two robotic arms."

The investigators added, "The open edge of the mucosa with the tumor was grasped by one of the robotic arms to retract the mucosa and enhance exposure of the submucosa, while submucosal dissection was completed with the other L hook arm" (Clin. Gastroenterol. Hepatol. 2012 October [doi:10.1016/j.cgh.2012.05.019]).

All procedures were performed under general anesthesia and with ventilation by naso- or orotracheal intubation. All operators trained on porcine models prior to the study.

In the case of the first patient, a 41-year-old man with a 2-cm adenocarcinoma in the body of the stomach, "the submucosal dissection with the robotic system was successfully done in 19 minutes," reported the authors.

There was no bleeding for perforation, and histopathology of the specimen after retrieval showed intramucosal well-differentiated adenocarcinoma with clear resection margins. The patient was discharged after 12 hours.

The second case, a 60-year-old man, was found to have a 1.5-cm mucosal adenocarcinoma in the gastric antrum. "The submucosal dissection was completed in only 5 minutes," wrote the authors, with no complications, and clear margins on histopathology. The patient was discharged in 6 hours.

Similarly, the third patient (a 39-year-old man) had a 2-cm sessile lesion in the gastric antrum. Submucosal dissection with the MASTER was completed in 3 minutes, with no complications, clear margins, and discharge from the hospital 4 hours later.

The longest procedure was done in a 51-year-old woman with a 3-cm early gastric cancer; this procedure took 50 minutes. She had no major bleeding or perforation, had clear margins on histopathology, and had a 3-day hospital stay.

Finally, a 50-year-old man with a 2.5-cm sessile polypoid in the inferior wall of the prepyloric canal underwent a 16-minute dissection. "Severe bleeding was encountered during the procedure and required exchange of the MASTER-mounted endoscope for a waterjet endoscope to stop the bleeding with coagulation grapser," wrote the authors.

"The pathology showed hyperplastic polyp with clear margins. He was discharged from hospital on day 3 after the procedure."

At 30 days’ follow-up, no complications were reported by any of the patients, and the follow-up endoscopy showed "complete healing" of the resection site. At 6 months, the three patients with data available were "doing well," according to the authors.

The study was supported by a MedTech Seeding Fund from the National University of Singapore. The authors reported having no other relevant financial disclosures.

A novel robotic system designed to perform endoscopic submucosal dissection of early gastric neoplasia was safe and effective in a five-patient trial, reported Soo Jay Phee, Ph.D., and colleagues in Clinical Gastroenterology and Hepatology.

Indeed, the first human study of the robotic device showed that it achieved clear margins, no cases of major bleeding or perforation, and discharge within hours for several of the patients.

Dr. Phee of the School of Mechanical and Aerospace Engineering at Nanyang Technological University in Singapore and first author Dr. D. Nageshwar Reddy of the Asian Institute of Gastroenterology in Somajiguda, India, enrolled five patients from two centers in India and one in Hong Kong.

Only patients with gastric neoplasia limited to the mucosa, confirmed by biopsy and histopathology, were included.

All patients underwent endoscopic submucosal dissection with the assistance of a novel device called the Master and Slave Transluminal Endoscopic Robot (MASTER). The MASTER device has been described previously (Gastrointest. Endoscopy 2010;72:593-9).

According to the authors, the device is controlled by two operators, "one responsible for the steering of the endoscope while the other would be performing the submucosal dissection with the two robotic arms."

The investigators added, "The open edge of the mucosa with the tumor was grasped by one of the robotic arms to retract the mucosa and enhance exposure of the submucosa, while submucosal dissection was completed with the other L hook arm" (Clin. Gastroenterol. Hepatol. 2012 October [doi:10.1016/j.cgh.2012.05.019]).

All procedures were performed under general anesthesia and with ventilation by naso- or orotracheal intubation. All operators trained on porcine models prior to the study.

In the case of the first patient, a 41-year-old man with a 2-cm adenocarcinoma in the body of the stomach, "the submucosal dissection with the robotic system was successfully done in 19 minutes," reported the authors.

There was no bleeding for perforation, and histopathology of the specimen after retrieval showed intramucosal well-differentiated adenocarcinoma with clear resection margins. The patient was discharged after 12 hours.

The second case, a 60-year-old man, was found to have a 1.5-cm mucosal adenocarcinoma in the gastric antrum. "The submucosal dissection was completed in only 5 minutes," wrote the authors, with no complications, and clear margins on histopathology. The patient was discharged in 6 hours.

Similarly, the third patient (a 39-year-old man) had a 2-cm sessile lesion in the gastric antrum. Submucosal dissection with the MASTER was completed in 3 minutes, with no complications, clear margins, and discharge from the hospital 4 hours later.

The longest procedure was done in a 51-year-old woman with a 3-cm early gastric cancer; this procedure took 50 minutes. She had no major bleeding or perforation, had clear margins on histopathology, and had a 3-day hospital stay.

Finally, a 50-year-old man with a 2.5-cm sessile polypoid in the inferior wall of the prepyloric canal underwent a 16-minute dissection. "Severe bleeding was encountered during the procedure and required exchange of the MASTER-mounted endoscope for a waterjet endoscope to stop the bleeding with coagulation grapser," wrote the authors.

"The pathology showed hyperplastic polyp with clear margins. He was discharged from hospital on day 3 after the procedure."

At 30 days’ follow-up, no complications were reported by any of the patients, and the follow-up endoscopy showed "complete healing" of the resection site. At 6 months, the three patients with data available were "doing well," according to the authors.

The study was supported by a MedTech Seeding Fund from the National University of Singapore. The authors reported having no other relevant financial disclosures.

When treating choledocholithiasis, a shorter duration of endoscopic papillary balloon dilation increases, rather than decreases, the risk of postprocedure pancreatitis, reported Dr. Wei-Chih Liao and his colleagues in Clinical Gastroenterology and Hepatology.

"This meta-analysis contradicts the common belief that pancreatitis results from direct pancreatic duct compression during balloon dilation, and thus dilation duration should be short," he and his colleagues wrote. On the contrary, "[endoscopic papillary balloon dilation] with an adequate duration (around 5 minutes) has lower complication rates than the current standard of endoscopic sphincterotomy, and may be used as the first-line treatment for bile duct stones."

Dr. Liao, of the National Taiwan University College of Medicine, Taipei, conducted a systematic review of Medline, the Cochrane databases, and clinicaltrials.gov to identify randomized controlled trials of endoscopic papillary balloon dilation (EPBD), endoscopic sphincteroplasty, endoscopic balloon sphincter dilation, and endoscopic balloon dilation. Studies were excluded if dilation duration was not clearly reported.

Overall, 12 studies were included in the analysis: 11 compared EPBD with endoscopic sphincterotomy (EST); 4 compared short-duration EPBD (1 minute or less) with EST; and 7 looked at long-duration EPBD (more than 1 minute) versus EST.

Only one study compared long-duration EPBD with short-duration EPBD, they wrote (Clin. Gastroenterol. Hepatol. 2012 [doi: 10.1016/j.cgh.2012.05.017]).

First, the authors looked at the risk of pancreatitis when comparing EST to short-duration EPBD. They found that the latter had a significantly higher pancreatitis risk, with a pooled odds ratio of 3.87 for developing pancreatitis post procedure, compared with EST (95% confidence interval, 1.08-13.84).

However, long-duration EPBD did not pose a significantly higher risk compared with EST (OR, 1.14; 95% CI, 0.56-2.35).

Similarly, looking at overall complications, the researchers noted a trend toward a higher overall complication rate in short-duration EPBD compared with EST (OR, 1.71; 95% CI, 0.67-4.35). "By contrast, long EPBD seemed to have a lower overall complication rate (pooled OR, 0.61; 95% CI, 0.36-1.04)," wrote the authors.

The researchers also calculated the regression coefficient of dilation duration, and found it to be –0.69, "meaning that every 1-minute increase in dilation duration up to 3 minutes was associated with a 49.8% (95% CI, –9.4% –77.0%) reduction in OR," they wrote.

The finding was similar for overall complications, with every 1-minute increase in dilation duration up to 5 minutes associated with a 45.1% reduction in OR.

In an attempt to explain the findings, Dr. Liao noted that recent evidence suggests that EPBD with dilation duration of 1 minute or less "carries a higher risk of inadequate sphincter loosening, which increases the risks of pancreatitis and failed stone extraction."

"An inadequately loosened sphincter from short-duration EPBD may limit volume expansion of its encircled contents as in a compartment syndrome, thus [worsening] compression of the pancreatic duct from post-EPBD edema and [increasing] pancreatitis risk."

The researchers added that the longest reported EPBD duration is 5 minutes.

"It is unknown whether dilation duration longer than 5 minutes may further reduce pancreatitis risk, but the degree of sphincter loosening can only increase to a certain point. ... Further studies on EPBD with different durations will be helpful to corroborate our findings and determine the optimal duration."

The study was funded by grants from the Royal Society, London; the National Science Council, Taiwan; and the National Taiwan University Hospital, Taipei. The authors stated that they had no individual conflicts to disclose.

When treating choledocholithiasis, a shorter duration of endoscopic papillary balloon dilation increases, rather than decreases, the risk of postprocedure pancreatitis, reported Dr. Wei-Chih Liao and his colleagues in Clinical Gastroenterology and Hepatology.

"This meta-analysis contradicts the common belief that pancreatitis results from direct pancreatic duct compression during balloon dilation, and thus dilation duration should be short," he and his colleagues wrote. On the contrary, "[endoscopic papillary balloon dilation] with an adequate duration (around 5 minutes) has lower complication rates than the current standard of endoscopic sphincterotomy, and may be used as the first-line treatment for bile duct stones."

Dr. Liao, of the National Taiwan University College of Medicine, Taipei, conducted a systematic review of Medline, the Cochrane databases, and clinicaltrials.gov to identify randomized controlled trials of endoscopic papillary balloon dilation (EPBD), endoscopic sphincteroplasty, endoscopic balloon sphincter dilation, and endoscopic balloon dilation. Studies were excluded if dilation duration was not clearly reported.

Overall, 12 studies were included in the analysis: 11 compared EPBD with endoscopic sphincterotomy (EST); 4 compared short-duration EPBD (1 minute or less) with EST; and 7 looked at long-duration EPBD (more than 1 minute) versus EST.

Only one study compared long-duration EPBD with short-duration EPBD, they wrote (Clin. Gastroenterol. Hepatol. 2012 [doi: 10.1016/j.cgh.2012.05.017]).

First, the authors looked at the risk of pancreatitis when comparing EST to short-duration EPBD. They found that the latter had a significantly higher pancreatitis risk, with a pooled odds ratio of 3.87 for developing pancreatitis post procedure, compared with EST (95% confidence interval, 1.08-13.84).

However, long-duration EPBD did not pose a significantly higher risk compared with EST (OR, 1.14; 95% CI, 0.56-2.35).

Similarly, looking at overall complications, the researchers noted a trend toward a higher overall complication rate in short-duration EPBD compared with EST (OR, 1.71; 95% CI, 0.67-4.35). "By contrast, long EPBD seemed to have a lower overall complication rate (pooled OR, 0.61; 95% CI, 0.36-1.04)," wrote the authors.

The researchers also calculated the regression coefficient of dilation duration, and found it to be –0.69, "meaning that every 1-minute increase in dilation duration up to 3 minutes was associated with a 49.8% (95% CI, –9.4% –77.0%) reduction in OR," they wrote.

The finding was similar for overall complications, with every 1-minute increase in dilation duration up to 5 minutes associated with a 45.1% reduction in OR.

In an attempt to explain the findings, Dr. Liao noted that recent evidence suggests that EPBD with dilation duration of 1 minute or less "carries a higher risk of inadequate sphincter loosening, which increases the risks of pancreatitis and failed stone extraction."

"An inadequately loosened sphincter from short-duration EPBD may limit volume expansion of its encircled contents as in a compartment syndrome, thus [worsening] compression of the pancreatic duct from post-EPBD edema and [increasing] pancreatitis risk."

The researchers added that the longest reported EPBD duration is 5 minutes.

"It is unknown whether dilation duration longer than 5 minutes may further reduce pancreatitis risk, but the degree of sphincter loosening can only increase to a certain point. ... Further studies on EPBD with different durations will be helpful to corroborate our findings and determine the optimal duration."

The study was funded by grants from the Royal Society, London; the National Science Council, Taiwan; and the National Taiwan University Hospital, Taipei. The authors stated that they had no individual conflicts to disclose.

When treating choledocholithiasis, a shorter duration of endoscopic papillary balloon dilation increases, rather than decreases, the risk of postprocedure pancreatitis, reported Dr. Wei-Chih Liao and his colleagues in Clinical Gastroenterology and Hepatology.

"This meta-analysis contradicts the common belief that pancreatitis results from direct pancreatic duct compression during balloon dilation, and thus dilation duration should be short," he and his colleagues wrote. On the contrary, "[endoscopic papillary balloon dilation] with an adequate duration (around 5 minutes) has lower complication rates than the current standard of endoscopic sphincterotomy, and may be used as the first-line treatment for bile duct stones."

Dr. Liao, of the National Taiwan University College of Medicine, Taipei, conducted a systematic review of Medline, the Cochrane databases, and clinicaltrials.gov to identify randomized controlled trials of endoscopic papillary balloon dilation (EPBD), endoscopic sphincteroplasty, endoscopic balloon sphincter dilation, and endoscopic balloon dilation. Studies were excluded if dilation duration was not clearly reported.

Overall, 12 studies were included in the analysis: 11 compared EPBD with endoscopic sphincterotomy (EST); 4 compared short-duration EPBD (1 minute or less) with EST; and 7 looked at long-duration EPBD (more than 1 minute) versus EST.

Only one study compared long-duration EPBD with short-duration EPBD, they wrote (Clin. Gastroenterol. Hepatol. 2012 [doi: 10.1016/j.cgh.2012.05.017]).

First, the authors looked at the risk of pancreatitis when comparing EST to short-duration EPBD. They found that the latter had a significantly higher pancreatitis risk, with a pooled odds ratio of 3.87 for developing pancreatitis post procedure, compared with EST (95% confidence interval, 1.08-13.84).

However, long-duration EPBD did not pose a significantly higher risk compared with EST (OR, 1.14; 95% CI, 0.56-2.35).

Similarly, looking at overall complications, the researchers noted a trend toward a higher overall complication rate in short-duration EPBD compared with EST (OR, 1.71; 95% CI, 0.67-4.35). "By contrast, long EPBD seemed to have a lower overall complication rate (pooled OR, 0.61; 95% CI, 0.36-1.04)," wrote the authors.

The researchers also calculated the regression coefficient of dilation duration, and found it to be –0.69, "meaning that every 1-minute increase in dilation duration up to 3 minutes was associated with a 49.8% (95% CI, –9.4% –77.0%) reduction in OR," they wrote.

The finding was similar for overall complications, with every 1-minute increase in dilation duration up to 5 minutes associated with a 45.1% reduction in OR.

In an attempt to explain the findings, Dr. Liao noted that recent evidence suggests that EPBD with dilation duration of 1 minute or less "carries a higher risk of inadequate sphincter loosening, which increases the risks of pancreatitis and failed stone extraction."

"An inadequately loosened sphincter from short-duration EPBD may limit volume expansion of its encircled contents as in a compartment syndrome, thus [worsening] compression of the pancreatic duct from post-EPBD edema and [increasing] pancreatitis risk."

The researchers added that the longest reported EPBD duration is 5 minutes.

"It is unknown whether dilation duration longer than 5 minutes may further reduce pancreatitis risk, but the degree of sphincter loosening can only increase to a certain point. ... Further studies on EPBD with different durations will be helpful to corroborate our findings and determine the optimal duration."

The study was funded by grants from the Royal Society, London; the National Science Council, Taiwan; and the National Taiwan University Hospital, Taipei. The authors stated that they had no individual conflicts to disclose.

Bariatric surgery reduced the incidence of type 2 diabetes by 78% compared with usual care at 15 years in a prospective, case-matched study of more than 3,000 obese adults.

This significant risk reduction was seen with all types of bariatric surgery and regardless of baseline body mass index. And, it occurred despite the fact that the matching process unexpectedly resulted in the bariatric surgery group having a higher mean body weight and more severe risk factors at baseline than the controls.

The impact of bariatric surgery was even greater, with an 87% risk reduction, for those with impaired fasting glucose at baseline, said Dr. Lena M.S. Carlsson of the Sahlgrenska Academy at the University of Gothenburg, Sweden, and her associates (N. Engl. J. Med. 2012;367:695-704).

© Sean Locke/iStockphoto.com

"Our data indicate that bariatric surgery has a preventive effect on incident type 2 diabetes, particularly in participants with impaired fasting glucose. In contrast, baseline BMI did not influence the preventive effect of bariatric surgery on type 2 diabetes, implying that anthropometric data are not useful in the selection of candidates for bariatric surgery, whereas data on impaired fasting glucose may be helpful," the authors wrote.

The finding comes from the Swedish Obese Subjects (SOS) trial, which included 1,658 patients who chose to undergo bariatric surgery and 1,771 matched controls. All patients in both groups entered the study with the intention of losing weight. None had diabetes at baseline.

In the bariatric surgery group, the types of procedures were banding in 311, vertical banded gastroplasty in 1,140, and gastric bypass in 207. Patients in the control group received the customary treatment for obesity at their primary health care centers, which in Sweden ranges from advanced lifestyle modification – including recommendations regarding eating behavior, food selection, energy intake, and physical activity – to no treatment. About half (54%) of the controls reported receiving professional guidance in attempts to lose weight.

There were several significant differences between groups at baseline. The bariatric surgery group weighed an average of 6 kg more than did the controls, and had a greater mean BMI (42.4 vs. 40.2 kg/m²). They also had higher mean blood pressures and total cholesterol and triglyceride levels, and were more likely to smoke and to be less active.

After adjustment for follow-up of less than 15 years and for death, the 15-year participation rate was 54%. At 15 years, the bariatric surgery group had lost 31 kg after 1 year, but then regained weight, so the average loss at 10 and 15 years was about 20 kg. The control group never lost or gained more than 3 kg over the entire study period, regardless of whether they had professional help.

During the follow-up, type 2 diabetes developed in 110 of the bariatric surgery patients and in 392 controls, corresponding to incidence rates of 6.8 and 28.4 cases per 1,000 person-years, respectively (P less than .001). The unadjusted hazard ratio was 0.22, which dropped to 0.17 following multivariate adjustments. Aside from treatment group, other strong univariate predictors of diabetes outcome were baseline blood glucose and the presence or absence of impaired fasting glucose, Dr. Carlsson and her associates reported.

In a sensitivity analysis performed to account for the low participation rate, the impact of treatment on the incidence of type 2 diabetes was at least as strong after 2 years and 10 years of follow-up as after 15 years. All types of bariatric surgery were associated with a reduced incidence of diabetes, with no significant differences among them. There were also no differences by receipt of professional weight-loss assistance, or by BMI at baseline, the investigators noted.

A total of 3 patients (0.2%) died within 90 days of surgery, and 245 patients in the surgery group (15%) reported at least one complication. Of those, 46 (2.8%) were serious enough to require a reoperation.

The risk reduction seen among those with impaired fasting glucose was at least twice as large as the risk reduction achieved with lifestyle interventions in large, long-term trials of moderately obese people with prediabetes (Lancet 2006;368:1673-9, Lancet 2009;374:1677-86, and Lancet 2008;371:1783-9), the investigators noted.

The ongoing SOS study is supported by grants from the Swedish Research Council, the Swedish Foundation for Strategic Research to the Sahlgrenska Center for Cardiovascular and Metabolic Research, the Swedish federal government, the VINNOVA-VINNMER program, and the Wenner-Gren Foundations. The SOS study has previously been supported by grants to one of the authors from Hoffmann-La Roche, AstraZeneca, and other companies. Dr. Carlsson reported receiving consulting fees from AstraZeneca and owning stock in Sahltech. Other coinvestigators also had financial disclosures.

Bariatric surgery reduced the incidence of type 2 diabetes by 78% compared with usual care at 15 years in a prospective, case-matched study of more than 3,000 obese adults.

This significant risk reduction was seen with all types of bariatric surgery and regardless of baseline body mass index. And, it occurred despite the fact that the matching process unexpectedly resulted in the bariatric surgery group having a higher mean body weight and more severe risk factors at baseline than the controls.

The impact of bariatric surgery was even greater, with an 87% risk reduction, for those with impaired fasting glucose at baseline, said Dr. Lena M.S. Carlsson of the Sahlgrenska Academy at the University of Gothenburg, Sweden, and her associates (N. Engl. J. Med. 2012;367:695-704).

© Sean Locke/iStockphoto.com

"Our data indicate that bariatric surgery has a preventive effect on incident type 2 diabetes, particularly in participants with impaired fasting glucose. In contrast, baseline BMI did not influence the preventive effect of bariatric surgery on type 2 diabetes, implying that anthropometric data are not useful in the selection of candidates for bariatric surgery, whereas data on impaired fasting glucose may be helpful," the authors wrote.

The finding comes from the Swedish Obese Subjects (SOS) trial, which included 1,658 patients who chose to undergo bariatric surgery and 1,771 matched controls. All patients in both groups entered the study with the intention of losing weight. None had diabetes at baseline.

In the bariatric surgery group, the types of procedures were banding in 311, vertical banded gastroplasty in 1,140, and gastric bypass in 207. Patients in the control group received the customary treatment for obesity at their primary health care centers, which in Sweden ranges from advanced lifestyle modification – including recommendations regarding eating behavior, food selection, energy intake, and physical activity – to no treatment. About half (54%) of the controls reported receiving professional guidance in attempts to lose weight.

There were several significant differences between groups at baseline. The bariatric surgery group weighed an average of 6 kg more than did the controls, and had a greater mean BMI (42.4 vs. 40.2 kg/m²). They also had higher mean blood pressures and total cholesterol and triglyceride levels, and were more likely to smoke and to be less active.

After adjustment for follow-up of less than 15 years and for death, the 15-year participation rate was 54%. At 15 years, the bariatric surgery group had lost 31 kg after 1 year, but then regained weight, so the average loss at 10 and 15 years was about 20 kg. The control group never lost or gained more than 3 kg over the entire study period, regardless of whether they had professional help.

During the follow-up, type 2 diabetes developed in 110 of the bariatric surgery patients and in 392 controls, corresponding to incidence rates of 6.8 and 28.4 cases per 1,000 person-years, respectively (P less than .001). The unadjusted hazard ratio was 0.22, which dropped to 0.17 following multivariate adjustments. Aside from treatment group, other strong univariate predictors of diabetes outcome were baseline blood glucose and the presence or absence of impaired fasting glucose, Dr. Carlsson and her associates reported.

In a sensitivity analysis performed to account for the low participation rate, the impact of treatment on the incidence of type 2 diabetes was at least as strong after 2 years and 10 years of follow-up as after 15 years. All types of bariatric surgery were associated with a reduced incidence of diabetes, with no significant differences among them. There were also no differences by receipt of professional weight-loss assistance, or by BMI at baseline, the investigators noted.

A total of 3 patients (0.2%) died within 90 days of surgery, and 245 patients in the surgery group (15%) reported at least one complication. Of those, 46 (2.8%) were serious enough to require a reoperation.

The risk reduction seen among those with impaired fasting glucose was at least twice as large as the risk reduction achieved with lifestyle interventions in large, long-term trials of moderately obese people with prediabetes (Lancet 2006;368:1673-9, Lancet 2009;374:1677-86, and Lancet 2008;371:1783-9), the investigators noted.

The ongoing SOS study is supported by grants from the Swedish Research Council, the Swedish Foundation for Strategic Research to the Sahlgrenska Center for Cardiovascular and Metabolic Research, the Swedish federal government, the VINNOVA-VINNMER program, and the Wenner-Gren Foundations. The SOS study has previously been supported by grants to one of the authors from Hoffmann-La Roche, AstraZeneca, and other companies. Dr. Carlsson reported receiving consulting fees from AstraZeneca and owning stock in Sahltech. Other coinvestigators also had financial disclosures.

Bariatric surgery reduced the incidence of type 2 diabetes by 78% compared with usual care at 15 years in a prospective, case-matched study of more than 3,000 obese adults.

This significant risk reduction was seen with all types of bariatric surgery and regardless of baseline body mass index. And, it occurred despite the fact that the matching process unexpectedly resulted in the bariatric surgery group having a higher mean body weight and more severe risk factors at baseline than the controls.

The impact of bariatric surgery was even greater, with an 87% risk reduction, for those with impaired fasting glucose at baseline, said Dr. Lena M.S. Carlsson of the Sahlgrenska Academy at the University of Gothenburg, Sweden, and her associates (N. Engl. J. Med. 2012;367:695-704).

© Sean Locke/iStockphoto.com

"Our data indicate that bariatric surgery has a preventive effect on incident type 2 diabetes, particularly in participants with impaired fasting glucose. In contrast, baseline BMI did not influence the preventive effect of bariatric surgery on type 2 diabetes, implying that anthropometric data are not useful in the selection of candidates for bariatric surgery, whereas data on impaired fasting glucose may be helpful," the authors wrote.

The finding comes from the Swedish Obese Subjects (SOS) trial, which included 1,658 patients who chose to undergo bariatric surgery and 1,771 matched controls. All patients in both groups entered the study with the intention of losing weight. None had diabetes at baseline.

In the bariatric surgery group, the types of procedures were banding in 311, vertical banded gastroplasty in 1,140, and gastric bypass in 207. Patients in the control group received the customary treatment for obesity at their primary health care centers, which in Sweden ranges from advanced lifestyle modification – including recommendations regarding eating behavior, food selection, energy intake, and physical activity – to no treatment. About half (54%) of the controls reported receiving professional guidance in attempts to lose weight.

There were several significant differences between groups at baseline. The bariatric surgery group weighed an average of 6 kg more than did the controls, and had a greater mean BMI (42.4 vs. 40.2 kg/m²). They also had higher mean blood pressures and total cholesterol and triglyceride levels, and were more likely to smoke and to be less active.

After adjustment for follow-up of less than 15 years and for death, the 15-year participation rate was 54%. At 15 years, the bariatric surgery group had lost 31 kg after 1 year, but then regained weight, so the average loss at 10 and 15 years was about 20 kg. The control group never lost or gained more than 3 kg over the entire study period, regardless of whether they had professional help.

During the follow-up, type 2 diabetes developed in 110 of the bariatric surgery patients and in 392 controls, corresponding to incidence rates of 6.8 and 28.4 cases per 1,000 person-years, respectively (P less than .001). The unadjusted hazard ratio was 0.22, which dropped to 0.17 following multivariate adjustments. Aside from treatment group, other strong univariate predictors of diabetes outcome were baseline blood glucose and the presence or absence of impaired fasting glucose, Dr. Carlsson and her associates reported.

In a sensitivity analysis performed to account for the low participation rate, the impact of treatment on the incidence of type 2 diabetes was at least as strong after 2 years and 10 years of follow-up as after 15 years. All types of bariatric surgery were associated with a reduced incidence of diabetes, with no significant differences among them. There were also no differences by receipt of professional weight-loss assistance, or by BMI at baseline, the investigators noted.

A total of 3 patients (0.2%) died within 90 days of surgery, and 245 patients in the surgery group (15%) reported at least one complication. Of those, 46 (2.8%) were serious enough to require a reoperation.

The risk reduction seen among those with impaired fasting glucose was at least twice as large as the risk reduction achieved with lifestyle interventions in large, long-term trials of moderately obese people with prediabetes (Lancet 2006;368:1673-9, Lancet 2009;374:1677-86, and Lancet 2008;371:1783-9), the investigators noted.

The ongoing SOS study is supported by grants from the Swedish Research Council, the Swedish Foundation for Strategic Research to the Sahlgrenska Center for Cardiovascular and Metabolic Research, the Swedish federal government, the VINNOVA-VINNMER program, and the Wenner-Gren Foundations. The SOS study has previously been supported by grants to one of the authors from Hoffmann-La Roche, AstraZeneca, and other companies. Dr. Carlsson reported receiving consulting fees from AstraZeneca and owning stock in Sahltech. Other coinvestigators also had financial disclosures.