IU Indianapolis ScholarWorks :: Browsing by Author "Al-Haddad, Mohammad A."

Browsing by Author "Al-Haddad, Mohammad A."

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Biomarker Risk Score Algorithm and Preoperative Stratification of Patients with Pancreatic Cystic Lesions
(Wolters Kluwer, 2021) Yip-Schneider, Michele T.; Wu, Huangbing; Allison, Hannah R.; Easler, Jeffrey J.; Sherman, Stuart; Al-Haddad, Mohammad A.; Dewitt, John M.; Schmidt, C. Max; Surgery, School of Medicine
Background: Pancreatic cysts are incidentally detected in up to 13% of patients undergoing radiographic imaging. Of the most frequently encountered types, mucin-producing (mucinous) pancreatic cystic lesions may develop into pancreatic cancer, while nonmucinous ones have little or no malignant potential. Accurate preoperative diagnosis is critical for optimal management, but has been difficult to achieve, resulting in unnecessary major surgery. Here, we aim to develop an algorithm based on biomarker risk scores to improve risk stratification. Study design: Patients undergoing surgery and/or surveillance for a pancreatic cystic lesion, with diagnostic imaging and banked pancreatic cyst fluid, were enrolled in the study after informed consent (n = 163 surgical, 67 surveillance). Cyst fluid biomarkers with high specificity for distinguishing nonmucinous from mucinous pancreatic cysts (vascular endothelial growth factor [VEGF], glucose, carcinoembryonic antigen [CEA], amylase, cytology, and DNA mutation) were selected. Biomarker risk scores were used to design an algorithm to predict preoperative diagnosis. Performance was tested using surgical (retrospective) and surveillance (prospective) cohorts. Results: In the surgical cohort, the biomarker algorithm outperformed the preoperative clinical diagnosis in correctly predicting the final pathologic diagnosis (91% vs 73%; p < 0.000001). Specifically, nonmucinous serous cystic neoplasms (SCN) and mucinous cystic neoplasms (MCN) were correctly classified more frequently by the algorithm than clinical diagnosis (96% vs 30%; p < 0.000008 and 92% vs 69%; p = 0.04, respectively). In the surveillance cohort, the algorithm predicted a preoperative diagnosis with high confidence based on a high biomarker score and/or consistency with imaging from ≥1 follow-up visits. Conclusions: A biomarker risk score-based algorithm was able to correctly classify pancreatic cysts preoperatively. Importantly, this tool may improve initial and dynamic risk stratification, reducing overdiagnosis and underdiagnosis.
Design and validation of a therapeutic EUS training program using a live animal model: Taking training to the next level
(Wolters Kluwer, 2022) Sosa-Valencia, Leonardo; Huppertz, Jerôme; Wanert, Fanélie; Haberzetser, Francois; Swanström, Lee; Mangiavillano, Benedetto; Eisendrath, Pierre; Deprez, Pierre; Robles-Medranda, Carlos; Carrara, Silvia; Al-Haddad, Mohammad A.; Vilmann, Peter; Koch, Stephane; Larghi, Alberto; Khashab, Mouen; Medicine, School of Medicine
Background and objectives: EUS has evolved into a therapeutic modality for gastrointestinal disorders. Simulators, ex vivo models, and phantoms are the current teaching methods for therapeutic EUS (TEUS). We create and evaluate a high-fidelity simulated live animal model (HiFi SAM) for teaching endoscopists TEUS. Materials and methods: Designing a curriculum that uses HiFi SAM and enables trainees to perform realistic procedures with expert mentors. Results: Twenty-seven trainees participated in a 3-day program with 6 h of theoretical and 14 h of hands using life HiFi SAM. Eighteen experts participated. Twenty-two (20-25) TEUS were defined for each HiFi SAM, and 616 were performed in all. Of 616/264 (43%) were evaluated with a mean of 88 per course (ranging between 80 and 95). Ninety-one percent (240/264) of the procedures were completed successfully. In 24, success was not achieved due to technical and/or model problems. Student rating of HiFi SAM was: 71% excellent rating (scale 8-10) and 95% excellent/good. The HiFi SAM procedure evaluation was (scale 1-5): fine-needle biopsy: 4.79, radiofrequency: 4.76, common bile duct and gallbladder drainage: 4.75, cystic drainages: 4.72, neurolysis: 4.55, microbiopsy: 4.50, and hepatogastric drainage: 4.04, with an overall satisfaction rate of 4.56 (91%). A short survey showed: 83% would recommend absolutely (17% most likely), 33% think that ITEC training was sufficient for their practice, and 66% would like additional training, especially more practice in specific techniques rather than more clinical case discussion. Regarding impact on their practice, 66% of the trainees started a new procedure and/or noted improvement in previous ones. Conclusion: HiFi SAM is a complex model; however, experts and trainees are satisfied with the training this new curriculum provided.
The Dilemma of the Dilated Main Pancreatic Duct in the Distal Pancreatic Remnant After Proximal Pancreatectomy for IPMN
(Springer, 2019-08) Simpson, Rachel E.; Ceppa, Eugene P.; Wu, Howard H.; Akisik, Fatih; House, Michael G.; Zyromski, Nicholas J.; Nakeeb, Attila; Al-Haddad, Mohammad A.; DeWitt, John M.; Sherman, Stuart; Schmidt, C. Max; Surgery, School of Medicine
Objective(s) A dilated main pancreatic duct in the distal remnant after proximal pancreatectomy for intraductal papillary mucinous neoplasms (IPMN) poses a diagnostic dilemma. We sought to determine parameters predictive of remnant main-duct IPMN and malignancy during surveillance. Methods Three hundred seventeen patients underwent proximal pancreatectomy for IPMN (Indiana University, 1991–2016). Main-duct dilation included those ≥ 5 mm or “dilated” on radiographic reports. Statistics compared groups using Student’s T/Mann-Whitney U tests for continuous variables or chi-square/Fisher’s exact test for categorical variables with P < 0.05 considered significant. Results High-grade/invasive IPMN or adenocarcinoma at proximal pancreatectomy predicted malignant outcomes (100.0% malignant outcomes; P < 0.001) in remnant surveillance. Low/moderate-grade lesions revealed benign outcomes at last surveillance regardless of duct diameter. Twenty of 21 patients undergoing distal remnant reoperation had a dilated main duct. Seven had main-duct IPMN on remnant pathology; these patients had greater mean maximum main-duct diameter prior to reoperation (9.5 vs 6.2 mm, P = 0.072), but this did not reach statistical significance. Several features showed high sensitivity/specificity for remnant main-duct IPMN. Conclusions Remnant main-duct dilation after proximal pancreatectomy for IPMN remains a diagnostic dilemma. Several parameters show a promise in accurately diagnosing main-duct IPMN in the remnant.
DNA profile components predict malignant outcomes in select cases of intraductal papillary mucinous neoplasm with negative cytology
(Elsevier, 2018-10) Simpson, Rachel E.; Cockerill, Nathan J.; Yip-Schneider, Michele T.; Ceppa, Eugene P.; House, Michael G.; Zyromski, Nicholas J.; Nakeeb, Attila; Al-Haddad, Mohammad A.; Schmidt, C. Max; Surgery, School of Medicine
Predicting malignancy in intraductal papillary mucinous neoplasm remains challenging. Integrated molecular pathology combines pancreatic fluid DNA and clinical factors into a malignant potential score. We sought to determine the utility of DNA components alone in predicting high-grade dysplasia/invasive disease. Methods We reviewed prospectively the records from 1,106 patients with intraductal papillary mucinous neoplasm. We excluded non-intraductal papillary mucinous neoplasm cases and cases with definitive malignant cytology. A total 225 patients had 283 DNA profiles (98 followed by surgery, 185 followed by ≥23-month surveillance). High-grade dysplasia/invasive outcomes were high-grade dysplasia, intraductal papillary mucinous neoplasm-invasive, and adenocarcinoma on surgical pathology or mesenteric or vascular invasion, metastases, or biopsy with high-grade dysplasia or adenocarcinoma during surveillance. Results High-quantity DNA predicted (P = .004) high-grade dysplasia/invasive disease outcomes with sensitivity of 78.3%, but 52.7% specificity, indicating benign cases may exhibit high-quantity DNA. High clonality loss of heterozygosity of tumor suppressor genes was 98.0% specific, strongly predicted high-grade dysplasia/invasive disease but lacked sensitivity (20.0%). High-quantity DNA + high clonality loss of heterozygosity had 99.0% specificity for high-grade dysplasia/invasive disease. KRAS mutation alone did not predict high-grade dysplasia/invasive disease, but, when combined with high-quantity DNA (specificity 84.7%) and high clonality loss of heterozygosity (specificity 99.0%) strongly predicted high-grade dysplasia/invasive outcomes. Conclusion Certain DNA components are highly specific for high-grade dysplasia/invasive disease and may indicate aggressive lesions, requiring resection when cytology fails.
Effectiveness and safety of serial endoscopic ultrasound–guided celiac plexus block for chronic pancreatitis
(Thieme Open, 2015-02) Sey, Michael S. L.; Schmaltz, Leslie; Al-Haddad, Mohammad A.; DeWitt, John M.; Calley, Cynthia S. J.; Juan, Michelle; Lasisi, Femi; Sherman, Stuart; McHenry, Lee; Imperiale, Thomas F.; LeBlanc, Julia K.; Medicine, School of Medicine
Background and study aims: Endoscopic ultrasound – guided celiac plexus block (EUS-CPB) is an established treatment for pain in patients with chronic pancreatitis (CP), but the effectiveness and safety of repeated procedures are unknown. Our objective is to report our experience of repeated EUS-CPB procedures within a single patient. , Patients and methods: A prospectively maintained EUS database was retrospectively analyzed to identify patients who had undergone more than one EUS-CPB procedure over a 17-year period. The main outcome measures included number of EUS-CPB procedures for each patient, self-reported pain relief, duration of pain relief, and procedure-related adverse events. , Results: A total of 248 patients underwent more than one EUS-CPB procedure and were included in our study. Patients with known or suspected CP (N = 248) underwent a mean (SD) of 3.1 (1.6) EUS-CPB procedures. In 76 % of the patients with CP, the median (range) duration of the response to the first EUS-CPB procedure was 10 (1 – 54) weeks. Lack of pain relief after the initial EUS-CPB was associated with failure of the next EUS-CPB (OR 0.17, 95 %CI 0.06 – 0.54). Older age at first EUS-CPB and pain relief after the first EUS-CPB were significantly associated with pain relief after subsequent blocks (P = 0.026 and P = 0.002, respectively). Adverse events included peri-procedural hypoxia (n = 2) and hypotension (n = 1) and post-procedural orthostasis (n = 2) and diarrhea (n = 4). No major adverse events occurred., Conclusions: Repeated EUS-CPB procedures in a single patient appear to be safe. Response to the first EUS-CPB is associated with response to subsequent blocks.
Endoscopic ultrasound characteristics of pancreatic lymphoepithelial cysts: A case series from a large referral center.
(Wolters Kluwer, 2016) Dalal, Kunal S.; DeWitt, John M.; Sherman, Stuart; Cramer, Harvey M.; Tirkes, Temel; Al-Haddad, Mohammad A.; Department of Pathology and Laboratory Medicine, IU School of Medicine
BACKGROUND AND OBJECTIVES: Lymphoepithelial cysts (LECs) of the pancreas are benign lesions that can mimic cystic neoplasms on imaging. Endoscopic ultrasound (EUS) features have not been well described. We aimed to describe the clinical and EUS characteristics of LECs and the present outcomes of management at a high-volume referral center. MATERIALS AND METHODS: We identified patients who underwent EUS and were found to have LECs based on fine-needle aspiration (FNA) cytology or surgical pathology from existing databases. EUS features, imaging characteristics, and pathology results were described. RESULTS: Sixteen patients were found to have 17 LECs. The mean size was 33 mm ± 15 mm. Locations within the pancreas included 10 lesions in the tail, 3 in the body, 1 in the uncinate process; the remaining 3 were exophytic. Six lesions were anechoic, 6 were hypoechoic, and 5 had mixed echogenicity. Nine lesions had mixed solid/cystic components, 7 were purely cystic, and 1 was solid. Cyst fluid was thick or viscous in six cases and thin in three. Eleven patients had diagnostic cytopathology. Six patients ultimately underwent surgery due to symptoms, nondiagnostic FNA, or other clinical concerns for malignancy. CONCLUSIONS: Pancreatic LECs have variable morphology and echogenicity on EUS, but the appearance of a cyst with variable solid and cystic components combined with the appearance of thick, turbid, and viscous aspirate should raise suspicion for an LEC. The majority of patients with LECs at our center avoided surgery for LECs on the basis of diagnostic EUS-FNA.
Endoscopic Ultrasound Guided Treatment of Peristomal Varices
(Elsevier, 2023) Sarkis, Yara; Masuoka, Howard; Ghabril, Marwan; Gutta, Aditya; Al-Haddad, Mohammad A.; DeWitt, John M.; Medicine, School of Medicine
Background and aims The use of endoscopic ultrasound (EUS) for peristomal varices (PV) is limited to case reports. Methods Patients who underwent EUS-guided treatment of PV with cyanoacrylate (CYA) and/or coils between 04/2013 and 12/2019 were identified. All had failed previous therapies or had comorbidities precluding other options. Endoscopic technique, adverse events (AEs), rebleeding and repeat interventions were assessed. Results 20 patients (12 male, median: 62 years (IQR, 54.8-69.5) underwent initial EUS PV injection of CYA for secondary (n=19) or primary prophylaxis (n=1). Within 30 days, AEs occurred in 11 (55%) and 8 were mild. During a median 2.5 months (IQR, 2-8.5) follow-up, confirmed (n=6) or suspected (n=2) PV bleeding recurred; five of 8 recurrences were retreated with CYA and/or coils without AEs. After retreatment, PV bleeding recurred in two a median 6 months (IQR, 6-30) later. Conclusion EUS appears to be a safe and promising technique for treatment of PV.
EUS pancreatic function testing and dynamic pancreatic duct evaluation for the diagnosis of exocrine pancreatic insufficiency and chronic pancreatitis
(Elsevier, 2020) DeWitt, John M.; Al-Haddad, Mohammad A.; Easler, Jeffrey J.; Sherman, Stuart; Slaven, James; Gardner, Timothy B.; Medicine, School of Medicine
Background and Aims EUS and endoscopic pancreatic function tests (ePFTs) may be used to diagnose minimal- change chronic pancreatitis (MCCP). The impact of evaluation for exocrine pancreatic insufficiency (EPI) and real-time assessment of EUS changes after intravenous secretin on the clinical diagnosis of MCCP is unknown. Methods Patients with suspected MCCP underwent baseline EUS assessment of the pancreatic parenchyma and measurement of the main pancreatic duct (B-MPD) in the head, body, and tail. Human secretin 0.2 μg/kg IV was given followed 4, 8, and 12 minutes later by repeat MPD (S-MPD) measurements. Duodenal samples at 15, 30, and 45 minutes were aspirated for bicarbonate concentration. Endoscopists rated the percent clinical likelihood of CP: (1) before secretin; (2) after secretin but before aspiration; and (3) after bicarbonate results. Results 145 consecutive patients (mean age 44±13 years; 98F) were diagnosed with EPI (n=32; 22%). S-MPD/B-MPD ratios in the tail 4 and 8 minutes after secretin were higher in the group with normal exocrine function. Ratios at other times, locations and duodenal fluid volumes were similar between the 2 groups. A statistically significant change in the median percent likelihood of CP was noted after secretin in all groups. The sensitivity and specificity of EPI for the EUS diagnosis of CP (≥5 criteria) were 23.4% (95% CI, 12.3-38.0) and 78.6% (95% CI, 69.1-86.2), respectively. Conclusion Real-time EUS findings and ePFTs have a significant impact on the clinical assessment of MCCP. The diagnosis of EPI shows poor correlation with the EUS diagnosis of MCCP.
EUS-directed transgastric interventions in Roux-En-Y Gastric Bypass anatomy: a multicenter experience
(Elsevier, 2022-05) Ghandour, Bachir; Shinn, Brianna; Dawod, Qais M.; Fansa, Sima; El Chafic, Abdul Hamid; Irani, Shayan S.; Pawa, Rishi; Gutta, Aditya; Ichkhanian, Yervant; Paranandi, Bharat; Pawa, Swati; Al-Haddad, Mohammad A.; Zuchelli, Tobias; Huggett, Matthew T.; Bejjani, Michael; Sharaiha, Reem Z.; Kowalski, Thomas E.; Khashab, Mouen A.; Medicine, School of Medicine
Background and Aims Placement of a Lumen Apposing Metal Stent (LAMS) between the gastric pouch and the excluded stomach allows for EUS Guided Transgastric Interventions (EDGI) in patients with Roux-en-Y gastric bypass (RYGB). Although EUS guided transgastric ERCP (EDGE) outcomes have been reported, there is a paucity of data on other endoscopic interventions. We aimed to evaluate the outcomes and safety of EDGI. Methods This is a retrospective study involving 9 centers (8 USA, 1 Europe) and included patients with RYGB who underwent EDGI between 06/2015 and 09/2021. The primary outcome was the technical success of EDGI. Secondary outcomes included adverse events, length of hospital stay, and fistula follow-up and management. Results 54 EDGI procedures were performed in 47 patients (mean age 61yr, F 72%), most commonly for the evaluation of a pancreatic mass (n=16) and management of pancreatic fluid collections (n=10). A 20mm LAMS was utilized in 26 patients and a 15mm LAMS in 21, creating a gastrogastrostomy (GG) in 37 patients and jejunogastrostomy (JG) in 10. Most patients (n=30, 64%) underwent a dual-session EDGI, with a median interval of 17d between the 2 procedures. Single-session EDGI was performed in 17 patients, of whom 10 (59%) had anchoring of the LAMS. The most common interventions were diagnostic EUS (+/-FNA/B) (n=28) and EUS-guided cystgastrostomy (n=8). The mean procedural time was 97.6 ± 78.9 mins. Technical success was achieved in 52 (96%). AEs occurred in 5 (10.6%) patients, of which only 1 (2.1%) was graded as severe. Intraprocedural LAMS migration was the most common AE, occurring in 3 patients (6.4%), while delayed spontaneous LAMS migration occurred in 2 (4.3%). 4 of the 5 LAMS migration events were managed endoscopically, and one required surgical repair. LAMS anchoring was found to be protective against LAMS migration (p=0.001). The median duration of hospital stay was 2.1 ± 3.7d. Of the 17 patients who underwent objective fistula assessment endoscopically/radiologically after LAMS removal, 2 (11.7%) were found to have persistent fistulas. In one case the fistula was intentionally left open to assist with weight gain. The other fistula was successfully closed endoscopically. Conclusion EDGI is effective and safe for the diagnosis and management of pancreatobiliary and foregut disorders in RYGB patients. It is associated with high rates of technical success and low rates of severe AEs. LAMS migration is the most common AE with evidence that anchoring can be protective against its occurrence. Persistent fistulas may occur, but endoscopic closure seems effective.
EUS-guided Fine Needle Aspiration-based Clues to Mistaken or Uncertain Identity: Serous Pancreatic Cysts
(Elsevier, 2023) Yip-Schneider, Michele T.; Muraru, Rodica; Kim, Rachel C.; Wu, Howard H.; Sherman, Stuart; Gutta, Aditya; Al-Haddad, Mohammad A.; Dewitt, John M.; Schmidt, C. Max; Surgery, School of Medicine
Background/objectives: Pancreatic serous cystic neoplasms (SCN) present a diagnostic challenge given their increasing frequency of detection and benign nature yet relatively high rate of misdiagnosis. Here, imaging and analyses associated with EUS-guided fine-needle aspiration (EUS-FNA) are evaluated for their ability to provide a correct preoperative diagnosis of SCN. Methods: A surgical cohort with confirmed pathological diagnosis of SCN (n = 62) and a surveillance cohort with likely SCN (n = 31) were assessed for imaging (CT/MRI/EUS) and EUS-FNA-based analyses (cytology/DNA analysis for Von Hippel-Lindau [VHL] gene alterations/biomarkers). Results: In the surgical cohort, CT/MRI and EUS respectively predicted SCN in 4 of 58(7%) and 19 of 62(31%). Cyst fluid cytology and VHL alterations predicted SCN in 1 of 51(2%) and 5 of 21(24%), respectively. High specificity cyst fluid biomarkers (vascular endothelial growth factor [VEGF]/glucose/carcinoembryonic antigen [CEA]/amylase) correctly identified SCN in 25 of 27(93%). In the surveillance cohort, cyst fluid biomarkers predicted SCN in 12 of 12(100%) while VHL alterations identified SCN 3 of 10(30%). Conclusion: High specificity cyst fluid biomarkers provided the most sensitive means of diagnosing SCN preoperatively. To obtain a preoperative diagnosis of SCN at the highest level of certainty, a multidisciplinary approach should be taken to inform appropriate SCN management.

Browsing by Author "Al-Haddad, Mohammad A."

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