Michael Gluck - Academia.edu (original) (raw)

Papers by Michael Gluck

Research paper thumbnail of Risks and Benefits of Colonoscopy in Patients 90 y or Older, Compared With Younger Patients

Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association, Jan 8, 2015

Although the numbers of medical procedures performed on extremely elderly patients (90 y or older... more Although the numbers of medical procedures performed on extremely elderly patients (90 y or older, nonagenarians) is increasing, there are no data on the performance, diagnostic yield, or safety of colonoscopy for these patients. We compared the performance and safety of diagnostic colonoscopy, as well as lesions detected, in nonagenarians compared to patients 75-79 y old. In a retrospective study, we compared data from 76 extremely elderly patients (90 y or older) with data from 140 very elderly patients (75-79 y old, controls), all of whom underwent diagnostic colonoscopy from January 2010 through March 2013 at Virginia Mason Medical Center. All colonoscopies were performed by 15 endoscopists. We compared rates of colonoscopy completion, bowel preparation quality, diagnostic yield, and adverse events. In extremely elderly patients, more colonoscopies were performed under general anesthesia, compared with controls (P<.001). When extremely elderly patients underwent colonoscopies...

Research paper thumbnail of A quarantine process for the resolution of duodenoscope-associated transmission of multidrug-resistant Escherichia coli

Gastrointestinal endoscopy, Jan 16, 2015

Because of their complex design, duodenoscopes have been long recognized to be difficult to fully... more Because of their complex design, duodenoscopes have been long recognized to be difficult to fully disinfect and may play a role in transmission of bacteria between patients. Recent reports of duodenoscope-associated carbapenem-resistant enterobacteriaceae transmission have confirmed these suspicions. An outbreak of a multidrug resistant strain of Escherichia coli was recently reported at our institution. Herein we report the results of our investigation and the process improvements that we deployed in an effort to contain the outbreak. A full investigation into the environment, endoscopists, infection control practices, high-level disinfection process as well as endoscopes was undertaken in conjunction with the local county health authority and the Centers for Disease Control and Prevention. Duodenoscopes were cultured and quarantined for 48 hours until negative cultures were obtained. Ergonomic changes were made to the endoscope reprocessing area, duodenoscopes were returned for ro...

Research paper thumbnail of Disparities in prevalence, location, and shape characteristics of colorectal neoplasia between South Korean and U.S. patients

Gastrointestinal endoscopy, Jan 27, 2015

Colon cancer screening is being introduced in many countries, but standard Western screening appr... more Colon cancer screening is being introduced in many countries, but standard Western screening approaches may not be appropriate for Asian societies if differences in colon cancer epidemiology exist. Comparative analysis of colorectal neoplasia patterns in South Korean and Western subjects has implications for appropriate screening approaches in non-Western societies. The results of concurrent screening colonoscopies performed in average-risk patients 50 to 69 years old in 2 teaching hospitals, Kyung Hee University Hospital (Seoul, South Korea) and Virginia Mason Medical Center (Seattle, Wash), were compared with respect to prevalence, histologic features, anatomic distribution, and shape characteristics of colorectal neoplasia. The U.S. (n = 3460) and South Korean (n = 2193) cohorts were similar with regard to the prevalence of adenomas (28.5% vs 29.8%, respectively, P = .312) and advanced neoplasia (6.4% vs 5.4%, respectively, P = .102), but the proportion of proximal adenomas was g...

Research paper thumbnail of Findings of diagnostic colonoscopy in young adults versus findings of screening colonoscopy in patients aged 50 to 54 years: a comparative study stratified by symptom category

Gastrointestinal endoscopy, Jan 2, 2015

The threshold for diagnostic colonoscopy in symptomatic patients aged <50 years remains contro... more The threshold for diagnostic colonoscopy in symptomatic patients aged <50 years remains controversial. Previous studies on the prevalence of neoplasia or other serious pathology in young patients mostly have been uncontrolled, providing only limited data on the risk associated with specific symptoms. To compare colonoscopy findings in patients aged <50 years who have various symptoms (diagnostic cohort) against those of concurrent patients aged 50 to 54 years who are asymptomatic (screening cohort). Retrospective controlled cohort study. Teaching hospital. Symptomatic patients aged between 18 and 49 years and asymptomatic patients aged between 50 and 54 years. Colonoscopy. Prevalence of advanced neoplasia. During the study period, 1638 patients underwent colonoscopy in the screening cohort (mean [± standard deviation{SD}] age 51.7 ± 1.4 years) and 1266 underwent colonoscopy in the diagnostic cohort (40.4 ± 8.0 years). Despite the age difference, the prevalence of advanced neop...

Research paper thumbnail of Survival and clinical outcome after endoscopic duodenal stent placement for malignant gastric outlet obstruction: comparison of pancreatic cancer and nonpancreatic cancer

Gastrointestinal Endoscopy, 2015

Data on endoscopic stenting of malignant gastric outlet obstruction (GOO) are based on studies pr... more Data on endoscopic stenting of malignant gastric outlet obstruction (GOO) are based on studies predominantly involving patients with pancreatic adenocarcinoma. To compare survival and clinical outcome after stent placement for GOO due to pancreatic cancer compared with nonpancreatic cancer. Retrospective study. Single tertiary hospital. A total of 292 patients with malignant GOO. Stent placement. Post-stent placement survival and clinical outcome. In 196 patients with pancreatic cancer and 96 with nonpancreatic cancer, median post-stent placement survival was similar (2.7 months in pancreatic cancer vs 2.4 months in nonpancreatic cancer). Overall survival was shorter in patients with pancreatic cancer (13.7 vs 17.1 months; P = .004). Clinical success rates at 2 months (71% vs 91%) and reintervention rates (30% vs 23%) were comparable. Post-stent placement chemotherapy and the absence of distant metastasis were associated with better post-stent placement survival in both groups (pancreatic cancer: chemotherapy vs no chemotherapy, 5.4 vs 1.5 months, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001; metastasis vs no metastasis, 1.8 vs 4.6, P = .005; nonpancreatic cancer: chemotherapy vs no chemotherapy, 9.2 vs 1.8, P = .001; metastasis vs no metastasis, 2.1 vs 6.1, P = .009). Retrospective study. In this large series of patients undergoing stent placement for malignant GOO in North America, we observed no difference in post-stent placement survival despite better overall survival in patients with nonpancreatic cancer. GOO is a marker for poor survival in malignancy, regardless of the type. Chemotherapy and the absence of distant metastasis were associated with better post-stent placement survival in both groups.

Research paper thumbnail of Endoscopic Retrograde Cholangiopancreatography-Associated AmpC Escherichia coli Outbreak

Infection control and hospital epidemiology, Jan 30, 2015

BACKGROUND We identified an outbreak of AmpC-producing Escherichia coli infections resistant to t... more BACKGROUND We identified an outbreak of AmpC-producing Escherichia coli infections resistant to third-generation cephalosporins and carbapenems (CR) among 7 patients who had undergone endoscopic retrograde cholangiopancreatography at hospital A during November 2012-August 2013. Gene sequencing revealed a shared novel mutation in a bla CMY gene and a distinctive fumC/ fimH typing profile. OBJECTIVE To determine the extent and epidemiologic characteristics of the outbreak, identify potential sources of transmission, design and implement infection control measures, and determine the association between the CR E. coli and AmpC E. coli circulating at hospital A. METHODS We reviewed laboratory, medical, and endoscopy reports, and endoscope reprocessing procedures. We obtained cultures from endoscopes after reprocessing as well as environmental samples and conducted pulsed-field gel electrophoresis and gene sequencing on phenotypic AmpC isolates from patients and endoscopes. Cases were tho...

Research paper thumbnail of Fecal microbiota transplant for treatment of Clostridium difficile infection in immunocompromised patients

The American journal of gastroenterology, 2014

Patients who are immunocompromised (IC) are at increased risk of Clostridium difficile infection ... more Patients who are immunocompromised (IC) are at increased risk of Clostridium difficile infection (CDI), which has increased to epidemic proportions over the past decade. Fecal microbiota transplantation (FMT) appears effective for the treatment of CDI, although there is concern that IC patients may be at increased risk of having adverse events (AEs) related to FMT. This study describes the multicenter experience of FMT in IC patients. A multicenter retrospective series was performed on the use of FMT in IC patients with CDI that was recurrent, refractory, or severe. We aimed to describe rates of CDI cure after FMT as well as AEs experienced by IC patients after FMT. A 32-item questionnaire soliciting demographic and pre- and post-FMT data was completed for 99 patients at 16 centers, of whom 80 were eligible for inclusion. Outcomes included (i) rates of CDI cure after FMT, (ii) serious adverse events (SAEs) such as death or hospitalization within 12 weeks of FMT, (iii) infection with...

Research paper thumbnail of Endoscopic treatment of nonstricture-related benign biliary diseases using covered self-expandable metal stents

Endoscopy, Jan 18, 2014

Background and study aims: Nonstricture benign biliary diseases (BBDs) such as leaks, perforation... more Background and study aims: Nonstricture benign biliary diseases (BBDs) such as leaks, perforations, and bleeding, have been traditionally managed by placement of one or more plastic stents. Emerging data support the use of covered, self-expandable, metal stents (CSEMSs). The aim of this study was to assess the outcomes of endoscopic temporary placement of CSEMS in patients with nonstricture BBD. Patients and methods: This was a retrospective study of CSEMS placement for BBD between May 2005 and August 2013 at two tertiary care centers. The main outcome measures were resolution of perforation, bleeding, leak, and adverse events related to CSEMS treatment. Results: A total of 87 patients were included (median age 62 years [range 18 - 86]). Indications for stent placement were bile leaks (n = 35, 40 %), bleeding (n = 27, 31 %), perforation (n = 18, 21 %), and other conditions (n = 7, 8 %). Fully and partially covered 8 - 10-mm diameter CSEMS were placed and subsequently removed in all ...

Research paper thumbnail of Pancreaticocolonic Fistulas Secondary to Severe Acute Pancreatitis Treated by Percutaneous Drainage: Successful Nonsurgical Outcomes in a Single-center Case Series

Journal of Vascular and Interventional Radiology, 2013

Purpose: Pancreaticocolonic fistulas (PCFs) are uncommon complications of acute necrotizing pancr... more Purpose: Pancreaticocolonic fistulas (PCFs) are uncommon complications of acute necrotizing pancreatitis (ANP). Studies advocating primary surgical treatment showed severe morbidity and mortality with nonsurgical treatment, with survival rates of approximately 50%. However, a nonsurgical treatment scheme with primary percutaneous drainage and other interventions may show improved outcomes. This retrospective single-center study describes the presentation, diagnosis, course, treatment strategy, and outcome of successfully treated PCFs, with an emphasis on nonsurgical interventions.

Research paper thumbnail of Dual Modality Drainage for Symptomatic Walled-Off Pancreatic Necrosis Reduces Length of Hospitalization, Radiological Procedures, and Number of Endoscopies Compared to Standard Percutaneous Drainage

Journal of Gastrointestinal Surgery, 2012

Symptomatic walled-off pancreatic necrosis (WOPN) treated with dual modality endoscopic and percu... more Symptomatic walled-off pancreatic necrosis (WOPN) treated with dual modality endoscopic and percutaneous drainage (DMD) has been shown to decrease length of hospitalization (LOH) and use of radiological resources in comparison to standard percutaneous drainage (SPD). The aim of this study is to demonstrate that as the cohort of DMD and SPD patients expand, the original conclusions are durable. The database of patients receiving treatment for WOPN between January 2006 and April 2011 was analyzed retrospectively. One hundred two patients with symptomatic WOPN who had no previous drainage procedures were evaluated: 49 with DMD and 46 with SPD; 7 were excluded due to a salvage procedure. Patient characteristics including age, sex, etiology of pancreatitis, and severity of disease based on computed tomographic severity index were indistinguishable between the two cohorts. The DMD cohort had shorter LOH, time until removal of percutaneous drains, fewer CT scans, drain studies, and endoscopic retrograde cholangiopancreatography (ERCPs; p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05 for all). There were 12 identifiable complications during DMD, which were successfully treated without the need for surgery. The 30-day mortality in DMD was 4% (one multi-system organ failure and one out of the hospital with congestive heart failure). Three patients receiving SPD had surgery, and three (7%) died in the hospital. DMD for symptomatic WOPN reduces LOH, radiological procedures, and number of ERCPs compared to SPD.

Research paper thumbnail of A Twenty-year Experience With Endoscopic Therapy for Symptomatic Primary Sclerosing Cholangitis

Journal of Clinical Gastroenterology, 2008

The current study presents 1 tertiary endoscopy center&amp;amp;amp;amp;amp;amp;amp;amp;amp;am... more The current study presents 1 tertiary endoscopy center&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s 20-year experience using endoscopic therapy to treat patients with symptomatic primary sclerosing cholangitis (PSC). Endoscopic therapy for patients with PSC and dominant strictures has been used for more than 20 years, but there is concern that instrumenting a sclerotic biliary tree induces risks that outweigh anticipated benefits. In this retrospective chart review, 117 patients with PSC were identified using ICD-9 codes. Patients had a mean age of 47 years (range: 15 to 86 y). Mean duration of follow-up was 8 years (range: 2 to 20 y). Of the 117 identified patients, 106 underwent endoscopic retrograde cholangiopancreatography on one or more occasions (for a total of 317 endoscopic retrograde cholangiopancreatographies), and a subset of 84 patients received endoscopic therapy for treatment of dominant strictures and/or deteriorating clinical status. Actual survival for endoscopically treated patients was compared with predicted survival using the Mayo Clinic natural history model for PSC. Our chart review revealed 23 recognized complications among the 317 procedures performed (7.3%), and no procedure-related deaths. Observed patient survival at years 3 and 4 was significantly higher than that predicted by the Mayo Clinic natural history model for PSC (P=0.021). Patients with PSC who have a deteriorating clinical course benefited from endoscopic therapy to provide drainage of bile ducts, removal of stones, and/or temporary relief from obstructions, with acceptable procedure-related complications and higher than expected 3-year and 4-year survival.

Research paper thumbnail of Multiple esophageal rings: histology, EUS, and manometric findings

American Journal of Gastroenterology, 2001

Methods: Subjects were 26 healthy adults with no history of gastrointestinal disease or symptoms.... more Methods: Subjects were 26 healthy adults with no history of gastrointestinal disease or symptoms. Esophageal pH was recorded for 24 hours on 2 separate occasions, 7 days apart. Recordings began at 8:00 at which time subjects ingested a placebo, followed by standardized meals at 9:00, 12:00 and 18:00. Data were analyzed for each hour of the recording period and results for each subject were means from the 2 separate recording periods. Results: At least 1 subject experienced esophageal pHϽ4 (acid reflux) during each hour of the recording period. 46% of subjects had esophageal pHϽ4 during the 1st hour, 65% during the 2nd hour, and Ͼ85% during hours 11:00-22:00. All 26 subjects experienced acid reflux between 18:00-20:00. During the night (0:00-6:00), 38% of subjects had acid reflux. Of these, maximal % time esophageal pHϽ4 was 42%/hr; number of reflux episodes, 10/hr; mean duration of reflux episodes, 8 minutes; and mean esophageal acid concentration, 12mM. Median values for esophageal acidity during the nocturnal period were comparable to values during the daytime period. Conclusions: Data from esophageal pH recordings can be analyzed to provide precise quantitation of acidity and characterize the patterns of esophageal acid exposure over time in individual subjects. These data indicate that as many as 38% of healthy subjects experience substantial nocturnal esophageal reflux and that the extent of nocturnal acid reflux in these normal subjects parallels acid reflux occurring during daytime hours.

Research paper thumbnail of Preventing migration of fully covered esophageal stents with an over-the-scope clip device (with videos)

Gastrointestinal Endoscopy, 2014

Research paper thumbnail of Chronic iron deficiency anemia caused by small-bowel lipoma

Gastrointestinal Endoscopy, 2014

Research paper thumbnail of Endoscopic evaluation and treatment of rectal hemorrhage after prostate biopsy

Gastrointestinal Endoscopy, 2001

Research paper thumbnail of Reusable biopsy forceps: A prospective evaluation of cleaning, function, adequacy of tissue specimen, and durability

Gastrointestinal Endoscopy, 2001

There are conflicting data regarding the functionality, adequacy of biopsy specimens, and ultimat... more There are conflicting data regarding the functionality, adequacy of biopsy specimens, and ultimate cost efficacy of reusable biopsy forceps when compared to their one-time-use counterparts. In fact, 2 recently published studies comparing disposable forceps to reusable ones suggested malfunction or actual breakage after 12 to 25 uses, rendering onetime-use forceps generally more cost-effective. In contrast, in a prospective cost evaluation, another group of investigators obtained over 300 biopsy sessions per forceps. 9 Each biopsy forceps had a mean life span of 3 years and was repaired a mean of 3 times. These investigators found that total costs (purchase, repair, reprocessing) were 25% of disposable device costs and that purchase of the latter would lead to an additional $78,377 in endoscopy unit costs yearly. Previously published data demonstrated that reusable biopsy forceps were cost-effective in our endoscopy unit, but the large number of forceps available (>100) and their uncertain age at study onset precluded assessment of durability. 4 Form and function were not vigorously assessed or the actual size of the specimen measured. Finally, when comparing cost data, one-time-use biopsy forceps had just been introduced and their price has since been substantially reduced. Accordingly, the form and function of a reusable forceps until malfunction or breakage were prospectively evaluated.

Research paper thumbnail of Dual-modality drainage of infected and symptomatic walled-off pancreatic necrosis: long-term clinical outcomes

Gastrointestinal Endoscopy, 2013

Management options for symptomatic and infected walled-off pancreatic necrosis (WOPN) have evolve... more Management options for symptomatic and infected walled-off pancreatic necrosis (WOPN) have evolved over the past decade from open surgical necrosectomy to more minimally invasive approaches. We reported the use of a combined percutaneous and endoscopic approach (dual modality drainage [DMD]) for the treatment of symptomatic and infected WOPN, with good short-term outcomes in a small cohort of patients. To describe the long-term outcomes of 117 patients with symptomatic and infected WOPN treated by DMD. Review of a prospective, internal review board-approved database. Single, North American, tertiary-care center. All patients with symptomatic and infected WOPN treated by DMD at our institution between 2007 and 2012. DMD of symptomatic and infected WOPN. Disease-related mortality, pancreaticocutaneous fistula formation, need for early and late surgical intervention, procedure-related adverse events. A total of 117 patients underwent DMD for symptomatic and infected WOPN. A total of 103 have completed treatment, with all percutaneous drains removed. Ten patients are still undergoing treatment, and 4 patients died with percutaneous drains in place (3.4% disease-related mortality). For the patients completing therapy, the median duration of follow-up was 749.5 days. No patients required surgical necrosectomy or surgical treatment of DMD-related adverse events; 3 patients required late surgery for pain (n = 2) and gastric outlet obstruction (n = 1). There were no procedure-related deaths. In patients who have completed treatment, percutaneous drains have been removed in 100%; no patients have developed pancreaticocutaneous fistulas. Single-center design, lack of a comparison group. DMD for symptomatic and infected WOPN results in favorable clinical outcomes; complete avoidance of pancreaticocutaneous fistulae, surgical necrosectomy, and major procedure-related adverse events, while maintaining single-digit disease-related mortality.

Research paper thumbnail of Spontaneous intramural rupture of the esophagus: Clinical presentation and endoscopic findings

Gastrointestinal Endoscopy, 2002

Research paper thumbnail of Sp606 Endoscopic Management of Severe Bleeding Encountered at/after Drainage of Pancreatic Fluid Collections

Gastrointestinal Endoscopy, 2013

endoscopy is extremely useful to detect non-polypoid neoplasia and is now recommended by the AGA,... more endoscopy is extremely useful to detect non-polypoid neoplasia and is now recommended by the AGA, the British Society for Gastroenterology and the Australian Cancer Council. However, video descriptions of imageenhanced endoscopy for detection of IBD-related neoplasia are rare. We present several illustrative examples. The detection, diagnosis and treatment of all dysplasiapolypoid and non-polypoid -is important in patients with IBD. Early detection can save lives. The video provides important information on the recommended technique to screen for dysplasia in patients with IBD and, more importantly, examples of the difficult to find flat and depressed neoplasms.

Research paper thumbnail of A concern with use of the “push technique” in patients with multiple esophageal rings

Gastrointestinal Endoscopy, 2001

methodology adopted by several investigators in other medical specialties. [3][4][5][6][7][8] Mor... more methodology adopted by several investigators in other medical specialties. [3][4][5][6][7][8] More importantly, the 2 reports 2,10 with the lowest publication rates cited by Dr. von Elm were not published at the time of submission and acceptance of our manuscript. Our results support these current investigations in surgery and in pharmacology and they confirm that the publication rate for endoscopy abstracts is low compared with other medical subspecialties.

Research paper thumbnail of Risks and Benefits of Colonoscopy in Patients 90 y or Older, Compared With Younger Patients

Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association, Jan 8, 2015

Although the numbers of medical procedures performed on extremely elderly patients (90 y or older... more Although the numbers of medical procedures performed on extremely elderly patients (90 y or older, nonagenarians) is increasing, there are no data on the performance, diagnostic yield, or safety of colonoscopy for these patients. We compared the performance and safety of diagnostic colonoscopy, as well as lesions detected, in nonagenarians compared to patients 75-79 y old. In a retrospective study, we compared data from 76 extremely elderly patients (90 y or older) with data from 140 very elderly patients (75-79 y old, controls), all of whom underwent diagnostic colonoscopy from January 2010 through March 2013 at Virginia Mason Medical Center. All colonoscopies were performed by 15 endoscopists. We compared rates of colonoscopy completion, bowel preparation quality, diagnostic yield, and adverse events. In extremely elderly patients, more colonoscopies were performed under general anesthesia, compared with controls (P<.001). When extremely elderly patients underwent colonoscopies...

Research paper thumbnail of A quarantine process for the resolution of duodenoscope-associated transmission of multidrug-resistant Escherichia coli

Gastrointestinal endoscopy, Jan 16, 2015

Because of their complex design, duodenoscopes have been long recognized to be difficult to fully... more Because of their complex design, duodenoscopes have been long recognized to be difficult to fully disinfect and may play a role in transmission of bacteria between patients. Recent reports of duodenoscope-associated carbapenem-resistant enterobacteriaceae transmission have confirmed these suspicions. An outbreak of a multidrug resistant strain of Escherichia coli was recently reported at our institution. Herein we report the results of our investigation and the process improvements that we deployed in an effort to contain the outbreak. A full investigation into the environment, endoscopists, infection control practices, high-level disinfection process as well as endoscopes was undertaken in conjunction with the local county health authority and the Centers for Disease Control and Prevention. Duodenoscopes were cultured and quarantined for 48 hours until negative cultures were obtained. Ergonomic changes were made to the endoscope reprocessing area, duodenoscopes were returned for ro...

Research paper thumbnail of Disparities in prevalence, location, and shape characteristics of colorectal neoplasia between South Korean and U.S. patients

Gastrointestinal endoscopy, Jan 27, 2015

Colon cancer screening is being introduced in many countries, but standard Western screening appr... more Colon cancer screening is being introduced in many countries, but standard Western screening approaches may not be appropriate for Asian societies if differences in colon cancer epidemiology exist. Comparative analysis of colorectal neoplasia patterns in South Korean and Western subjects has implications for appropriate screening approaches in non-Western societies. The results of concurrent screening colonoscopies performed in average-risk patients 50 to 69 years old in 2 teaching hospitals, Kyung Hee University Hospital (Seoul, South Korea) and Virginia Mason Medical Center (Seattle, Wash), were compared with respect to prevalence, histologic features, anatomic distribution, and shape characteristics of colorectal neoplasia. The U.S. (n = 3460) and South Korean (n = 2193) cohorts were similar with regard to the prevalence of adenomas (28.5% vs 29.8%, respectively, P = .312) and advanced neoplasia (6.4% vs 5.4%, respectively, P = .102), but the proportion of proximal adenomas was g...

Research paper thumbnail of Findings of diagnostic colonoscopy in young adults versus findings of screening colonoscopy in patients aged 50 to 54 years: a comparative study stratified by symptom category

Gastrointestinal endoscopy, Jan 2, 2015

The threshold for diagnostic colonoscopy in symptomatic patients aged <50 years remains contro... more The threshold for diagnostic colonoscopy in symptomatic patients aged <50 years remains controversial. Previous studies on the prevalence of neoplasia or other serious pathology in young patients mostly have been uncontrolled, providing only limited data on the risk associated with specific symptoms. To compare colonoscopy findings in patients aged <50 years who have various symptoms (diagnostic cohort) against those of concurrent patients aged 50 to 54 years who are asymptomatic (screening cohort). Retrospective controlled cohort study. Teaching hospital. Symptomatic patients aged between 18 and 49 years and asymptomatic patients aged between 50 and 54 years. Colonoscopy. Prevalence of advanced neoplasia. During the study period, 1638 patients underwent colonoscopy in the screening cohort (mean [± standard deviation{SD}] age 51.7 ± 1.4 years) and 1266 underwent colonoscopy in the diagnostic cohort (40.4 ± 8.0 years). Despite the age difference, the prevalence of advanced neop...

Research paper thumbnail of Survival and clinical outcome after endoscopic duodenal stent placement for malignant gastric outlet obstruction: comparison of pancreatic cancer and nonpancreatic cancer

Gastrointestinal Endoscopy, 2015

Data on endoscopic stenting of malignant gastric outlet obstruction (GOO) are based on studies pr... more Data on endoscopic stenting of malignant gastric outlet obstruction (GOO) are based on studies predominantly involving patients with pancreatic adenocarcinoma. To compare survival and clinical outcome after stent placement for GOO due to pancreatic cancer compared with nonpancreatic cancer. Retrospective study. Single tertiary hospital. A total of 292 patients with malignant GOO. Stent placement. Post-stent placement survival and clinical outcome. In 196 patients with pancreatic cancer and 96 with nonpancreatic cancer, median post-stent placement survival was similar (2.7 months in pancreatic cancer vs 2.4 months in nonpancreatic cancer). Overall survival was shorter in patients with pancreatic cancer (13.7 vs 17.1 months; P = .004). Clinical success rates at 2 months (71% vs 91%) and reintervention rates (30% vs 23%) were comparable. Post-stent placement chemotherapy and the absence of distant metastasis were associated with better post-stent placement survival in both groups (pancreatic cancer: chemotherapy vs no chemotherapy, 5.4 vs 1.5 months, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001; metastasis vs no metastasis, 1.8 vs 4.6, P = .005; nonpancreatic cancer: chemotherapy vs no chemotherapy, 9.2 vs 1.8, P = .001; metastasis vs no metastasis, 2.1 vs 6.1, P = .009). Retrospective study. In this large series of patients undergoing stent placement for malignant GOO in North America, we observed no difference in post-stent placement survival despite better overall survival in patients with nonpancreatic cancer. GOO is a marker for poor survival in malignancy, regardless of the type. Chemotherapy and the absence of distant metastasis were associated with better post-stent placement survival in both groups.

Research paper thumbnail of Endoscopic Retrograde Cholangiopancreatography-Associated AmpC Escherichia coli Outbreak

Infection control and hospital epidemiology, Jan 30, 2015

BACKGROUND We identified an outbreak of AmpC-producing Escherichia coli infections resistant to t... more BACKGROUND We identified an outbreak of AmpC-producing Escherichia coli infections resistant to third-generation cephalosporins and carbapenems (CR) among 7 patients who had undergone endoscopic retrograde cholangiopancreatography at hospital A during November 2012-August 2013. Gene sequencing revealed a shared novel mutation in a bla CMY gene and a distinctive fumC/ fimH typing profile. OBJECTIVE To determine the extent and epidemiologic characteristics of the outbreak, identify potential sources of transmission, design and implement infection control measures, and determine the association between the CR E. coli and AmpC E. coli circulating at hospital A. METHODS We reviewed laboratory, medical, and endoscopy reports, and endoscope reprocessing procedures. We obtained cultures from endoscopes after reprocessing as well as environmental samples and conducted pulsed-field gel electrophoresis and gene sequencing on phenotypic AmpC isolates from patients and endoscopes. Cases were tho...

Research paper thumbnail of Fecal microbiota transplant for treatment of Clostridium difficile infection in immunocompromised patients

The American journal of gastroenterology, 2014

Patients who are immunocompromised (IC) are at increased risk of Clostridium difficile infection ... more Patients who are immunocompromised (IC) are at increased risk of Clostridium difficile infection (CDI), which has increased to epidemic proportions over the past decade. Fecal microbiota transplantation (FMT) appears effective for the treatment of CDI, although there is concern that IC patients may be at increased risk of having adverse events (AEs) related to FMT. This study describes the multicenter experience of FMT in IC patients. A multicenter retrospective series was performed on the use of FMT in IC patients with CDI that was recurrent, refractory, or severe. We aimed to describe rates of CDI cure after FMT as well as AEs experienced by IC patients after FMT. A 32-item questionnaire soliciting demographic and pre- and post-FMT data was completed for 99 patients at 16 centers, of whom 80 were eligible for inclusion. Outcomes included (i) rates of CDI cure after FMT, (ii) serious adverse events (SAEs) such as death or hospitalization within 12 weeks of FMT, (iii) infection with...

Research paper thumbnail of Endoscopic treatment of nonstricture-related benign biliary diseases using covered self-expandable metal stents

Endoscopy, Jan 18, 2014

Background and study aims: Nonstricture benign biliary diseases (BBDs) such as leaks, perforation... more Background and study aims: Nonstricture benign biliary diseases (BBDs) such as leaks, perforations, and bleeding, have been traditionally managed by placement of one or more plastic stents. Emerging data support the use of covered, self-expandable, metal stents (CSEMSs). The aim of this study was to assess the outcomes of endoscopic temporary placement of CSEMS in patients with nonstricture BBD. Patients and methods: This was a retrospective study of CSEMS placement for BBD between May 2005 and August 2013 at two tertiary care centers. The main outcome measures were resolution of perforation, bleeding, leak, and adverse events related to CSEMS treatment. Results: A total of 87 patients were included (median age 62 years [range 18 - 86]). Indications for stent placement were bile leaks (n = 35, 40 %), bleeding (n = 27, 31 %), perforation (n = 18, 21 %), and other conditions (n = 7, 8 %). Fully and partially covered 8 - 10-mm diameter CSEMS were placed and subsequently removed in all ...

Research paper thumbnail of Pancreaticocolonic Fistulas Secondary to Severe Acute Pancreatitis Treated by Percutaneous Drainage: Successful Nonsurgical Outcomes in a Single-center Case Series

Journal of Vascular and Interventional Radiology, 2013

Purpose: Pancreaticocolonic fistulas (PCFs) are uncommon complications of acute necrotizing pancr... more Purpose: Pancreaticocolonic fistulas (PCFs) are uncommon complications of acute necrotizing pancreatitis (ANP). Studies advocating primary surgical treatment showed severe morbidity and mortality with nonsurgical treatment, with survival rates of approximately 50%. However, a nonsurgical treatment scheme with primary percutaneous drainage and other interventions may show improved outcomes. This retrospective single-center study describes the presentation, diagnosis, course, treatment strategy, and outcome of successfully treated PCFs, with an emphasis on nonsurgical interventions.

Research paper thumbnail of Dual Modality Drainage for Symptomatic Walled-Off Pancreatic Necrosis Reduces Length of Hospitalization, Radiological Procedures, and Number of Endoscopies Compared to Standard Percutaneous Drainage

Journal of Gastrointestinal Surgery, 2012

Symptomatic walled-off pancreatic necrosis (WOPN) treated with dual modality endoscopic and percu... more Symptomatic walled-off pancreatic necrosis (WOPN) treated with dual modality endoscopic and percutaneous drainage (DMD) has been shown to decrease length of hospitalization (LOH) and use of radiological resources in comparison to standard percutaneous drainage (SPD). The aim of this study is to demonstrate that as the cohort of DMD and SPD patients expand, the original conclusions are durable. The database of patients receiving treatment for WOPN between January 2006 and April 2011 was analyzed retrospectively. One hundred two patients with symptomatic WOPN who had no previous drainage procedures were evaluated: 49 with DMD and 46 with SPD; 7 were excluded due to a salvage procedure. Patient characteristics including age, sex, etiology of pancreatitis, and severity of disease based on computed tomographic severity index were indistinguishable between the two cohorts. The DMD cohort had shorter LOH, time until removal of percutaneous drains, fewer CT scans, drain studies, and endoscopic retrograde cholangiopancreatography (ERCPs; p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05 for all). There were 12 identifiable complications during DMD, which were successfully treated without the need for surgery. The 30-day mortality in DMD was 4% (one multi-system organ failure and one out of the hospital with congestive heart failure). Three patients receiving SPD had surgery, and three (7%) died in the hospital. DMD for symptomatic WOPN reduces LOH, radiological procedures, and number of ERCPs compared to SPD.

Research paper thumbnail of A Twenty-year Experience With Endoscopic Therapy for Symptomatic Primary Sclerosing Cholangitis

Journal of Clinical Gastroenterology, 2008

The current study presents 1 tertiary endoscopy center&amp;amp;amp;amp;amp;amp;amp;amp;amp;am... more The current study presents 1 tertiary endoscopy center&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s 20-year experience using endoscopic therapy to treat patients with symptomatic primary sclerosing cholangitis (PSC). Endoscopic therapy for patients with PSC and dominant strictures has been used for more than 20 years, but there is concern that instrumenting a sclerotic biliary tree induces risks that outweigh anticipated benefits. In this retrospective chart review, 117 patients with PSC were identified using ICD-9 codes. Patients had a mean age of 47 years (range: 15 to 86 y). Mean duration of follow-up was 8 years (range: 2 to 20 y). Of the 117 identified patients, 106 underwent endoscopic retrograde cholangiopancreatography on one or more occasions (for a total of 317 endoscopic retrograde cholangiopancreatographies), and a subset of 84 patients received endoscopic therapy for treatment of dominant strictures and/or deteriorating clinical status. Actual survival for endoscopically treated patients was compared with predicted survival using the Mayo Clinic natural history model for PSC. Our chart review revealed 23 recognized complications among the 317 procedures performed (7.3%), and no procedure-related deaths. Observed patient survival at years 3 and 4 was significantly higher than that predicted by the Mayo Clinic natural history model for PSC (P=0.021). Patients with PSC who have a deteriorating clinical course benefited from endoscopic therapy to provide drainage of bile ducts, removal of stones, and/or temporary relief from obstructions, with acceptable procedure-related complications and higher than expected 3-year and 4-year survival.

Research paper thumbnail of Multiple esophageal rings: histology, EUS, and manometric findings

American Journal of Gastroenterology, 2001

Methods: Subjects were 26 healthy adults with no history of gastrointestinal disease or symptoms.... more Methods: Subjects were 26 healthy adults with no history of gastrointestinal disease or symptoms. Esophageal pH was recorded for 24 hours on 2 separate occasions, 7 days apart. Recordings began at 8:00 at which time subjects ingested a placebo, followed by standardized meals at 9:00, 12:00 and 18:00. Data were analyzed for each hour of the recording period and results for each subject were means from the 2 separate recording periods. Results: At least 1 subject experienced esophageal pHϽ4 (acid reflux) during each hour of the recording period. 46% of subjects had esophageal pHϽ4 during the 1st hour, 65% during the 2nd hour, and Ͼ85% during hours 11:00-22:00. All 26 subjects experienced acid reflux between 18:00-20:00. During the night (0:00-6:00), 38% of subjects had acid reflux. Of these, maximal % time esophageal pHϽ4 was 42%/hr; number of reflux episodes, 10/hr; mean duration of reflux episodes, 8 minutes; and mean esophageal acid concentration, 12mM. Median values for esophageal acidity during the nocturnal period were comparable to values during the daytime period. Conclusions: Data from esophageal pH recordings can be analyzed to provide precise quantitation of acidity and characterize the patterns of esophageal acid exposure over time in individual subjects. These data indicate that as many as 38% of healthy subjects experience substantial nocturnal esophageal reflux and that the extent of nocturnal acid reflux in these normal subjects parallels acid reflux occurring during daytime hours.

Research paper thumbnail of Preventing migration of fully covered esophageal stents with an over-the-scope clip device (with videos)

Gastrointestinal Endoscopy, 2014

Research paper thumbnail of Chronic iron deficiency anemia caused by small-bowel lipoma

Gastrointestinal Endoscopy, 2014

Research paper thumbnail of Endoscopic evaluation and treatment of rectal hemorrhage after prostate biopsy

Gastrointestinal Endoscopy, 2001

Research paper thumbnail of Reusable biopsy forceps: A prospective evaluation of cleaning, function, adequacy of tissue specimen, and durability

Gastrointestinal Endoscopy, 2001

There are conflicting data regarding the functionality, adequacy of biopsy specimens, and ultimat... more There are conflicting data regarding the functionality, adequacy of biopsy specimens, and ultimate cost efficacy of reusable biopsy forceps when compared to their one-time-use counterparts. In fact, 2 recently published studies comparing disposable forceps to reusable ones suggested malfunction or actual breakage after 12 to 25 uses, rendering onetime-use forceps generally more cost-effective. In contrast, in a prospective cost evaluation, another group of investigators obtained over 300 biopsy sessions per forceps. 9 Each biopsy forceps had a mean life span of 3 years and was repaired a mean of 3 times. These investigators found that total costs (purchase, repair, reprocessing) were 25% of disposable device costs and that purchase of the latter would lead to an additional $78,377 in endoscopy unit costs yearly. Previously published data demonstrated that reusable biopsy forceps were cost-effective in our endoscopy unit, but the large number of forceps available (>100) and their uncertain age at study onset precluded assessment of durability. 4 Form and function were not vigorously assessed or the actual size of the specimen measured. Finally, when comparing cost data, one-time-use biopsy forceps had just been introduced and their price has since been substantially reduced. Accordingly, the form and function of a reusable forceps until malfunction or breakage were prospectively evaluated.

Research paper thumbnail of Dual-modality drainage of infected and symptomatic walled-off pancreatic necrosis: long-term clinical outcomes

Gastrointestinal Endoscopy, 2013

Management options for symptomatic and infected walled-off pancreatic necrosis (WOPN) have evolve... more Management options for symptomatic and infected walled-off pancreatic necrosis (WOPN) have evolved over the past decade from open surgical necrosectomy to more minimally invasive approaches. We reported the use of a combined percutaneous and endoscopic approach (dual modality drainage [DMD]) for the treatment of symptomatic and infected WOPN, with good short-term outcomes in a small cohort of patients. To describe the long-term outcomes of 117 patients with symptomatic and infected WOPN treated by DMD. Review of a prospective, internal review board-approved database. Single, North American, tertiary-care center. All patients with symptomatic and infected WOPN treated by DMD at our institution between 2007 and 2012. DMD of symptomatic and infected WOPN. Disease-related mortality, pancreaticocutaneous fistula formation, need for early and late surgical intervention, procedure-related adverse events. A total of 117 patients underwent DMD for symptomatic and infected WOPN. A total of 103 have completed treatment, with all percutaneous drains removed. Ten patients are still undergoing treatment, and 4 patients died with percutaneous drains in place (3.4% disease-related mortality). For the patients completing therapy, the median duration of follow-up was 749.5 days. No patients required surgical necrosectomy or surgical treatment of DMD-related adverse events; 3 patients required late surgery for pain (n = 2) and gastric outlet obstruction (n = 1). There were no procedure-related deaths. In patients who have completed treatment, percutaneous drains have been removed in 100%; no patients have developed pancreaticocutaneous fistulas. Single-center design, lack of a comparison group. DMD for symptomatic and infected WOPN results in favorable clinical outcomes; complete avoidance of pancreaticocutaneous fistulae, surgical necrosectomy, and major procedure-related adverse events, while maintaining single-digit disease-related mortality.

Research paper thumbnail of Spontaneous intramural rupture of the esophagus: Clinical presentation and endoscopic findings

Gastrointestinal Endoscopy, 2002

Research paper thumbnail of Sp606 Endoscopic Management of Severe Bleeding Encountered at/after Drainage of Pancreatic Fluid Collections

Gastrointestinal Endoscopy, 2013

endoscopy is extremely useful to detect non-polypoid neoplasia and is now recommended by the AGA,... more endoscopy is extremely useful to detect non-polypoid neoplasia and is now recommended by the AGA, the British Society for Gastroenterology and the Australian Cancer Council. However, video descriptions of imageenhanced endoscopy for detection of IBD-related neoplasia are rare. We present several illustrative examples. The detection, diagnosis and treatment of all dysplasiapolypoid and non-polypoid -is important in patients with IBD. Early detection can save lives. The video provides important information on the recommended technique to screen for dysplasia in patients with IBD and, more importantly, examples of the difficult to find flat and depressed neoplasms.

Research paper thumbnail of A concern with use of the “push technique” in patients with multiple esophageal rings

Gastrointestinal Endoscopy, 2001

methodology adopted by several investigators in other medical specialties. [3][4][5][6][7][8] Mor... more methodology adopted by several investigators in other medical specialties. [3][4][5][6][7][8] More importantly, the 2 reports 2,10 with the lowest publication rates cited by Dr. von Elm were not published at the time of submission and acceptance of our manuscript. Our results support these current investigations in surgery and in pharmacology and they confirm that the publication rate for endoscopy abstracts is low compared with other medical subspecialties.