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Tissue-engineered extracellular matrix populated with autologous pluripotent cells can result in de-novo organogenesis, but the technique is complex, not widely available, and has not yet been used to repair large oesophageal defects in human beings. We aimed to use readily available stents and extracellular matrix to regenerate the oesophagus in vivo in a human being to re-establish swallowing function. In a patient aged 24 years, we endoscopically placed a readily available, fully covered, self-expanding, metal stent (diameter 18 mm, length 120 mm) to bridge a 5 cm full-thickness oesophageal segment destroyed by a mediastinal abscess and leading to direct communication between the hypopharynx and the mediastinum. A commercially available extracellular matrix was used to cover the stent and was sprayed with autologous platelet-rich plasma adhesive gel. The sternocleidomastoid muscle was placed over the matrix. After 4 weeks, stent removal was needed due to stent migration, and was replaced with three stents telescopically aligned to improve anchoring. The stents were removed after 3·5 years and the oesophagus was assessed by endoscopy, biopsy, endoscopic ultrasonography, and high-resolution impedance manometry. After stent removal we saw full-thickness regeneration of the oesophagus with stratified squamous epithelium, a normal five-layer wall, and peristaltic motility with bolus transit. 4 years after stent removal, the patient was eating a normal diet and maintaining a steady weight. Maintenance of the structural morphology of the oesophagus with off-the-shelf non-biological scaffold and stimulation of regeneration with commercially available extracellular matrix led to de-novo structural and functional regeneration of the oesophagus. None.

Background Prior to withdrawing the EUS-FNA needle from the lesion, the stopcock of the suction syringe is closed to reduce contamination. Residual negative pressure (RNP) may persist in the needle despite closing the stopcock. Aims To determine whether neutralizing RNP before withdrawing the needle will improve the cytology yield. Methods Bench-top testing was done to confirm the presence of RNP followed by a prospective, randomized, cross-over study on patients with pancreas mass. Ten milliliters of suction was applied to the FNA needle. Before withdrawing the needle from the lesion, the stopcock was closed. Based on randomization, the first pass was done with the stopcock either attached to the needle (S+) or disconnected (S−) to allow air to enter and neutralize RNP and accordingly the second pass was crossed over to S+ or S−. On-site cytopathologist was blinded to S+/S−. Results Bench tests confirmed the presence of RNP which was successfully neutralized by disconnecting the syringe (S−) from the needle. Sixty patients were enrolled, 120 samples analyzed. S+ samples showed significantly greater GI tract contamination compared to S− samples (16.7 vs. 6.7 %, p  = 0.03). Of the 53 patients confirmed to have pancreas adenocarcinoma, FNA using S− approach was positive in 49 (93 %) compared to 40 using the S+ approach (76 %, p  = 0.02). Conclusions Despite closing the stopcock of the suction syringe, RNP is present in the FNA needle. Neutralizing RNP prior to withdrawing the needle from the target lesion significantly decreased GI tract contamination of the sample thereby improving the FNA cytology yield. Clinical Trials Registration Number NCT01995474.

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is essential to the management of pancreaticobiliary disease. ERCP in critically ill patients is often performed at the bedside but this is logistically and technically challenging. There is minimal data on performing ERCP in critically ill patients outside of the intensive care unit (ICU). The primary aims of this study are to report the 1) technical success and 2) safety of ERCP in critically ill patients performed in the endoscopy suite. Methods: We queried our institutional endoscopy database to identify all ICU patients who underwent ERCP at a single academic medical center from 04/01/2010 to 11/30/2017. Only patients admitted to the ICU prior to the ERCP were included. The electronic medical record was utilized to abstract patient demographics, ERCP indications and technical outcomes, type of anesthesia, patient hemodynamics, laboratory values, and mortality. Results: Of 7,218 ERCPs performed during the study period, 260 ERCPs (3.6%) were performed in 231 ICU patients (mean age 61y; 53% male; Table 1). Most ERCPs (n=258; 99%) performed in ICU patients occurred in the endoscopy suite; these 258 ERCPs comprised our study cohort. A majority (n=189; 73%) of ERCPs occurred in patients with evidence of clinical sepsis. The most common indications were: cholangitis (50%), post-liver transplant cholestasis (15%) and bile leak (10%). Deep cannulation of the duct of interest was achieved in 95% of all cases and 94% of native papillae cases. Over half (60%) of ERCPs were performed in the prone position. All ERCPs were performed with anesthesiology assistance, most with general anesthesia (n=154, 60%). Among patients requiring general anesthesia, 57% were intubated in the endoscopy suite immediately prior to ERCP and 5 (2%) were intubated during the ERCP. Of the 44 patients (17%) on vasopressors prior to ERCP, 25 (10%) required either a dose escalation or addition of a new vasopressor; 10 patients (4%) began vasopressors during ERCP. Adverse events occurred in 9% (n=23), with post-ERCP pancreatitis being most frequent (4%). No patients died during or within 24 hours of ERCP. Mortality at 30 days was 16% (n=40), all attributed to underlying disease. Conclusion: Critically ill patients can safely and effectively undergo ERCP in the endoscopy suite with anesthesiology assistance. While the vast majority of cases are successful, providers must be prepared to provide advanced cardiopulmonary support.