Faculty Bibliography

A case of a biliopleural fistula with a biloma occurring after superselective hepatic transarterial chemoembolization ablation of a metastatic hepatic carcinoid is described. The presentation was complicated by choledocholithiasis. The biloma was successfully treated with endoscopic drainage.

The gastrointestinal tract is the largest neuroendocrine system in the body. Carcinoid tumors are amine precursor uptake decarboxylase (APUD) omas that arise from enterochromaffin cells throughout the gut. These tumors secrete discrete bioactive substances producing characteristic immunohistochemical patterns. Most tumors are asymptomatic and detected at late stages. Hepatic metastases are commonly responsible for carcinoid syndrome. The small bowel is the most common location of carcinoids. Computed tomography scan and magnetic resonance imaging are useful in the detection of these tumors. The measurement of bioactive amines is the initial diagnostic test. Various treatment options, including somatostatin analogs, interferon, chemotherapy, surgery, hepatic artery chemoembolization, and surgery have emerged in the past two decades. However, the incidence and prevalence of carcinoid tumors has increased, while mean survival time has not changed significantly. The lack of standardized classification, federal support, and an incomplete understanding of the complications of this disease are some of the impediments to progress in treatment.

BACKGROUND: Development of persistent gastrocutaneous fistula and leakage after the removal of a PEG tube is a well-known complication. Various treatments including medications to alter gastric pH, prokinetic agents, endoscopic clipping/suturing, electric and chemical cauterization, argon plasma coagulation, and fibrin sealant, have been used with variable success. Although surgical closure is the current treatment of choice, most of the elderly patients are poor surgical candidates because of multiple comorbid conditions. OBJECTIVE: We describe a method of endoscopic suturing of a gastrocutaneous fistula that is a safe and cost-effective alternative to surgical closure. DESIGN: Individual case. SETTING: Community hospital. PATIENT: One elderly patient. INTERVENTIONS: By using a trocar, we placed multiple, long monofilament sutures from the skin around the gastrocutaneous fistula in criss-cross fashion. Gastric ends of these sutures were pulled from the stomach with a snare under endoscopic visualization. Suture knots were made at the gastric end of the sutures and then were pulled back from the cutaneous side. Multiple biopsy specimens were obtained from both ends of the fistula to promote granulation tissue. Final knots were made at skin level to obliterate the fistula. RESULT: Our procedure resulted in complete closure of a large, persistently leaking gastrocutaneous fistula in an elderly patient within 7 days. The patient tolerated the optimal rate of enteral nutrition without further leakage. LIMITATION: Only 1 patient. CONCLUSION: We believe that this method of endoscopic suturing along with de-epithelialization of the fistula tract for persistent gastrocutaneous fistula is a safe and cost-effective alternative to surgical closure.

OBJECTIVES: Persistent leakage from a gastrocutaneous fistula (GCF) created for the purpose of percutaneous endoscopic gastrostomy (PEG) tube placement is a common problem in elderly patients. Conservative methods often prove unsuccessful and surgical closure is usually not performed because of poor surgical risk. With advances in endoscopic technology, several nonsurgical approaches have emerged. These new methods have been reported in the past as case reports. The purpose of this study is to report a case series of eleven elderly patients with persistent leakage from gastrocutaneous fistulas who underwent combined electrochemical cautery and endoscopic clip placement. METHODS: Eleven patients had failed conservative therapy and were deemed unsuitable candidates for surgical closure. Electric and chemical cauterization was used to de-epithelialize the fistulous tract. The edges of the internal orifice of the gastrocutaneous fistula were approximated using endoclips during an esophagogastroduodenoscopy. Patients were observed postprocedure for leakage. RESULTS: This procedure resulted in complete closure of the gastrocutaneous fistula in nine patients (82%). One patient had partial closure of the fistula which was sealed using a new PEG tube. CONCLUSION: Gastrocutaneous fistula is a common complication in elderly patients after removal of gastrostomy tubes. Simple endoscopic procedures have shown promising results in the treatment of this complication.

Colorectal cancer (CRC), is the second-leading cause of cancer-related deaths in the USA, affecting both men and women. Current projections show little or no change since the publication of a morbidity and mortality study in 2005. The projected number of new cases for 2008 is 154,000, and the projected number of CRC cancer deaths for 2008 is 53,000. The standard diagnostic paradigm is based on histopathology of either biopsy or surgical specimens. This article suggests a new paradigm for colon cancer diagnosis and staging using matrix-assisted laser desorption/ionization imaging mass spectrometry (MALDI IMS or IMS). IMS may identify potential tumors in normal tissue of cancer patients and predict those cancer patients who are at risk for recurrent cancer