Gastrointestinal Endoscopy

2010-03-01

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2010-03-01

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2010-03-01

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2010-03-01

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2010-03-01

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2010-03-01

ERCP cannulation and sphincterotomy devices

2010-03-01

The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, with a MEDLINE literature search to identify pertinent clinical studies on the topic, and a MAUDE (Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the “related articles” feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but, in many cases, data from randomized controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors.

A lexicon for endoscopic adverse events: report of an ASGE workshop

2010-03-01

Patients and practitioners expect that their endoscopy procedures will go smoothly and according to plan. There are several reasons why they may be disappointed. The procedure may fail technically (eg, incomplete colonoscopy, failed biliary cannulation). It may seem to be successful technically but turn out to be clinically unhelpful (eg, a diagnosis missed, an unsuccessful treatment), or there may be an early relapse (eg, stent dysfunction). In addition, some patients and relatives may be disappointed by a lack of courtesy and poor communication, even when everything otherwise works well.

A new metal stent with a controlled-release system for palliation of malignant dysphagia: a prospective, multicenter study

2009-12-09

Background: Self-expanding metal stents are frequently used for the palliation of malignant dysphagia. Recently, a new stent design, the Evolution stent (Cook Medical, Limerick, Ireland), was developed. The stent has an internal and external silicone coating to resist tissue ingrowth and uncoated dual flanges on both ends to prevent migration. Its controlled-release system may allow full control and precise positioning of the stent.Objective: To determine the safety and clinical effectiveness of the Evolution stent for the palliation of dysphagia in patients with malignant strictures located in the esophagus (n = 33 [75%]) or gastric cardia (n = 11 [25%]).Methods: All patients who underwent placement of an esophageal Evolution stent from February to December 2008 received follow-up telephone calls 14 days after treatment and thereafter monthly until death. Data on technical and clinical outcome, complications, and recurrent dysphagia were collected.Results: A total of 44 patients (32 [73%] men, median age 74 years [range 48-91 years]) were treated with the Evolution stent. The median tumor length was 6 cm (range 1-11 cm). Stent placement was technically successful in 41 patients. Dysphagia improved from a median of 3 (ability to swallow liquids only) to 1 (ability to eat some solid foods) 4 weeks after stent placement. Major complications occurred in 4 (9%) patients, ie, pneumonia (3 patients) and hemorrhage (1 patient). Two (5%) patients died of pneumonia. Minor complications included gastroesophageal reflux and mild retrosternal pain in 11 (25%) and 4 (9%) patients, respectively. Recurrent dysphagia developed in 11 (25%) patients as a result of tissue ingrowth or overgrowth (6 patients; 14%), food impaction (3 patients; 7%), or stent migration (2 patients; 5%).Conclusions: The Evolution stent is safe and effective for the palliation of dysphagia from esophageal and gastric cardia cancer. Randomized trials are needed to compare this device with other stent designs.

Effectiveness of asynchronous tele-endoscopy

2010-03-01

Background: Asynchronous tele-endoscopy can improve access and quality of patient care. This is the first published evaluation of the diagnostic accuracy of highly compressed digital video in GI endoscopy.Objective: To determine whether asynchronous tele-endoscopy using highly compressed video can accurately document and diagnose lesions in the upper GI tract.Design: Local endoscopists performed 50 elective upper GI endoscopies. A high-quality DV compressed video (25 megabits per second [Mbps], 720 × 480 pixels) and highly compressed MPEG-1 video (2.0 Mbps, 352 × 240 pixels) were simultaneously captured. Five endoscopists asynchronously reviewed 20 compressed digital videos (100 case reviews) for endoscopic diagnoses. In addition, demonstration technique and image quality were rated on a Likert scale. Concordance between local and asynchronous endoscopists for major and minor endoscopic findings was evaluated. An independent panel classified discrepancies as caused by image quality, endoscopic technique, or interobserver variability through comparison of the 2 forms of digital video.Results: Although asynchronous endoscopists rated the image quality of highly compressed video as diagnostic in 85% of cases, only 18% of studies yielded the same clinical diagnoses. There was high discordance for both major (kappa = 0.38, 95% CI, 0.19-0.57) and minor findings (kappa = −0.29, 95% CI, −0.43 to −0.15). Interobserver reporting was responsible for 90% of variability in contrast to only 4.9% for poor image quality.Conclusions: The findings suggest that the diagnostic accuracy of low-bandwidth, low-resolution, highly compressed video is well tolerated and comparable to the current standard. Interobserver reporting variability accounted for most of the poor correlation. Improved synoptic documentation is required for effective communication among endoscopists.

Endoscopic removal of dysfunctioning bands or rings after restrictive bariatric procedures

2009-09-14

Background: Intragastric band migrations or dysfunctions are common long-term complications of both vertical banded gastroplasty (VBG) and laparoscopic adjustable gastric banding (Lap-Band) that classically require surgical treatment.Objective: In this series, we describe the endoscopic removal of partially eroded Lap-Bands or Silastic rings and noneroded dysfunctioning rings after VBG.Design: Case series.Setting: A European, tertiary-care academic center.Patients: This study involved 13 patients—3 with eroded Lap-Bands, 4 with eroded Silastic rings, and 6 with refractory outlet stoma stenosis after VBG.Intervention: Endoscopic removal was performed within 1 or 2 sessions, according to the presence and extent of band erosion at presentation, including optional placement of a self-expandable plastic stent across the band, followed about 6 to 8 weeks later by extraction with transsection, if needed, by using a wire-cutting system.Main Outcome Measurements: Technical success and safety.Results: One failure was caused by huge adhesion formation around a Lap-Band on the lesser curvature of the stomach and the left liver lobe. Twelve of 13 endoscopic removals were successful in 1 (n = 2) and 2 (n = 10) sessions.Limitations: Highly selected patients (tertiary-case academic center).Conclusion: Endoscopic removal of dysfunctioning bands or rings is safe and feasible by the use of a 1- or 2-step endoscopic procedure.

Endoscopic removal of dysfunctioning rings or bands after restrictive bariatric procedures

John M. Morton — 2010-03-01

I want to congratulate the authors on their innovative work regarding the complementary use of endoscopy for remedial bariatric surgery. As obesity continues to progress, and the only effective and enduring treatment for it continues to increase in use, bariatric surgery will inevitably encounter significant success but also potential complications. This study demonstrates the need and documented potential for GI surgeons and gastroenterologists to work together. Through a collaborative paradigm, we can partner toward providing optimal care for the bariatric patient. Blero et al describe a case series of postoperative bariatric surgery patients who sustained complications of surgical foreign body (SFB) migrations, which were treated endoscopically. Their case series describes a thoughtful, tiered, and safe approach to dealing with these complications.

Magnifying narrow-band imaging versus magnifying white-light imaging for the differential diagnosis of gastric small depressive lesions: a prospective study

2010-03-01

Background: The accurate diagnosis of gastric small depressive lesions (SDLs), including gastritis and cancerous lesions, is difficult with conventional endoscopy when using white-light imaging (WLI). Narrow-band imaging (NBI) is expected to make a more accurate diagnosis of gastric SDLs than WLI because it provides better visualization of the mucosal surface and microvascular architecture when combined with magnifying endoscopy.Objective: To compare the real-time diagnostic accuracy of magnifying WLI and magnifying NBI for gastric SDLs.Design: Prospective study.Setting: National Cancer Center Hospital East, Kashiwa, Japan.Patients: Fifty-seven lesions in 53 consecutive patients were analyzed: 30 cancers and 27 benign lesions.Interventions: If previously undiagnosed gastric SDLs smaller than 10 mm were identified during an endoscopic examination, magnifying observation with both WLI and NBI was performed for each SDL. Endoscopic diagnosis of SDLs was made by each method on site.Main Outcome Measurements: The diagnostic accuracy and the time required for diagnosis.Results: The diagnostic accuracy was significantly higher for NBI than for WLI (79% vs 44%; P = .0001), as was its sensitivity (70% vs 33%; P = .0005). The diagnostic specificity of NBI (89%) was higher than that of WLI (67%), but the difference was not statistically significant. The time required for the diagnosis was equivalent with both methods.Limitations: Single-center study, small sample size.Conclusions: Adding NBI to the WLI examination is essential for making an accurate diagnosis of gastric SDLs compared with magnifying WLI alone. (UMIN Clinical Trials Registry identification number C000000421)

Endoscopic peritoneal access and insufflation: natural orifice transluminal endoscopic surgery

2009-12-09

Background: Diagnostic transgastric endoscopic peritoneoscopy is a safe model for exploration of the peritoneum. Endoscopic insufflation of the peritoneal cavity has not been validated in humans. We report here our experience with pneumoperitoneum established endoscopically with a laparoscopic insufflator.Design: Pneumoperitoneum was established with a laparoscopic insufflator through the biopsy channel of the gastroscope. Intra-abdominal pressure was measured with a transfascial Veress needle and compared with endoscopic values. The gastrotomy was used in the creation of the gastric pouch.Patients: Twenty patients undergoing laparoscopic Roux-en-Y gastric bypass participated in the study. Ten had undergone no previous surgery, whereas the other 10 patients had a history of abdominal procedures.Interventions: Diagnostic transgastric endoscopic peritoneoscopy was performed through a gastrotomy created endoscopically without laparoscopic visualization.Main Outcome Measurements: Diagnostic findings, operating times, and clinical course were recorded.Results: The average time for transgastric access was 9.6 minutes. This did not vary in patients with previous surgery (P = .3). Endoscopic insufflation was successful in all patients. The mean endoscopic and laparoscopic pressures were 9.80 and 9.75 mm Hg, respectively (P = .9). In no patients were there limitations to visualization of the abdomen. Adhesions were noted in 80% and 10% of patients with and without a history of surgery, respectively (P = .005). There were no complications related to transgastric passage of the endoscope or exploration of the peritoneal cavity.Conclusions: Although limited by the small sample size in this study, we believe that transgastric access may be considered as an alternative approach to peritoneal insufflation and provides a safe alternative for exploration of the abdomen. Endoscopic insufflation through the biopsy channel by using a laparoscopic insufflator seems to be an effective and safe method for establishing pneumoperitoneum.

Surgical gastrojejunostomy or endoscopic stent placement for the palliation of malignant gastric outlet obstruction (SUSTENT study): a multicenter randomized trial

2009-12-09

Background: Both gastrojejunostomy (GJJ) and stent placement are commonly used palliative treatments of obstructive symptoms caused by malignant gastric outlet obstruction (GOO).Objective: Compare GJJ and stent placement.Design: Multicenter, randomized trial.Setting: Twenty-one centers in The Netherlands.Patients: Patients with GOO.Interventions: GJJ and stent placement.Main Outcome Measurements: Outcomes were medical effects, quality of life, and costs. Analysis was by intent to treat.Results: Eighteen patients were randomized to GJJ and 21 to stent placement. Food intake improved more rapidly after stent placement than after GJJ (GOO Scoring System score ≥2: median 5 vs 8 days, respectively; P < .01) but long-term relief was better after GJJ, with more patients living more days with a GOO Scoring System score of 2 or more than after stent placement (72 vs 50 days, respectively; P = .05). More major complications (stent: 6 in 4 patients vs GJJ: 0; P = .02), recurrent obstructive symptoms (stent: 8 in 5 patients vs GJJ: 1 in 1 patient; P = .02), and reinterventions (stent: 10 in 7 patients vs GJJ: 2 in 2 patients; P < .01) were observed after stent placement compared with GJJ. When stent obstruction was not regarded as a major complication, no differences in complications were found (P = .4). There were also no differences in median survival (stent: 56 days vs GJJ: 78 days) and quality of life. Mean total costs of GJJ were higher compared with stent placement ($16,535 vs $11,720, respectively; P = .049 [comparing medians]). Because of the small study population, only initial hospital costs would have been statistically significant if the Bonferroni correction for multiple testing had been applied.Limitations: Relatively small patient population.Conclusions: Despite slow initial symptom improvement, GJJ was associated with better long-term results and is therefore the treatment of choice in patients with a life expectancy of 2 months or longer. Because stent placement was associated with better short-term outcomes, this treatment is preferable for patients expected to live less than 2 months. (Clinical trial registration number: ISRCTN 06702358.)

Impact of EUS-guided FNA on management of gastric carcinoma

Hazem Hassan, Peter Vilmann, Vijay Sharma — 2010-03-01

Background: EUS is an integral part of the pretherapeutic evaluation program for patients with upper GI cancer.Objective: To evaluate the impact of EUS-guided FNA on the clinical management of patients with gastric cancer.Design: The study included patients with confirmed gastric carcinoma who were referred to the Department of Surgical Gastroenterology, Gentofte Hospital, Copenhagen University, Copenhagen, Denmark, during a 6-year period (2001-2007).Setting: The patients underwent standard pretherapeutic evaluation. If no signs of incurability were detected, the patients were offered EUS and EUS-guided FNA. EUS-guided FNA was performed when lymph nodes or lesions were considered to be distant metastases. A board of surgeons was asked to evaluate the management of the patients after the results obtained by EUS-guided FNA were revealed.Patients: This study involved 234 patients with gastric carcinoma.Intervention: EUS-guided FNA.Main Outcome Measurements: Number of patients with distant metastasis diagnosed by EUS-guided FNA, with the avoidance of unnecessary surgery.Results: A total of 81 consecutive patients underwent EUS-guided FNA. Ninety-nine lesions were targeted, and 61 (62%) of these lesions were found to be malignant. In 38 of 81 patients (42%) distant metastases were confirmed by EUS-guided FNA. As judged by the board of surgeons, EUS-guided FNA changed the management plan in 34 of 234 patients (15%).Limitation: The positive EUS-guided FNA diagnoses were not surgically verified.Conclusion: EUS-guided FNA is a very important modality and should be integrated as a routine procedure in the preoperative staging algorithm of gastric cancer.

Endoscopic treatment of postorthotopic liver transplantation anastomotic biliary strictures with maximal stent therapy (with video)

2010-03-01

Background: The optimal endoscopic protocol for treating postorthotopic liver transplantation (OLT) anastomotic biliary strictures (ABSs) has not been established.Objective: To review the technique and outcomes of endoscopic retrograde cholangiopancreatography (ERCP) with maximal stenting for post-OLT ABSs at our institution.Design: Retrospective study.Setting: Tertiary-care center.Patients: Eighty-three patients with a diagnosis of ABS.Interventions: ERCP with balloon dilation and maximal stenting.Main Outcome Measurements: Stricture resolution, stricture recurrence, and complication rates.Results: Of 83 patients, 69 completed treatment, of whom 65 (94%) achieved resolution and 4 (6%) required hepaticojejunostomy (HJ). The remaining 14 patients who did not achieve a study endpoint were excluded (9 deaths or redo OLT unrelated to biliary disease, and 5 without follow-up). Comparing the resolution group and the HJ group, there were, respectively, 8.0 and 3.5 total stents (P = .021), 2.5 and 1.3 stents per ERCP (P = .018) (maximum = 9), 4.2 and 2.8 ERCPs (P = .15), and 20 and 22 months from OLT to ABS diagnosis (P = .19). There were 2 cases of ERCP pancreatitis (0.7%) and 2 cases of periprocedural bacteremia of 286 total ERCPs and no episodes of cholangitis caused by stent occlusion. In a median follow-up of 11 months (range 0-39), 2 (3%) patients had ABS recurrence that was successfully re-treated with ERCP. A multivariate Cox model demonstrated that treatment success was directly related to the number of stents used in total and per ERCP.Limitations: Retrospective study, single endoscopist.Conclusions: Our maximal stenting protocol for ABSs is effective, safe, rarely associated with ABS recurrence, and conducive to less frequent stent exchange and therefore fewer ERCPs compared with conventional treatment.

EUS-guided gold fiducial insertion for image-guided radiation therapy of pancreatic cancer: 50 successful cases without fluoroscopy

2010-03-01

Background: Image-guided radiation therapy (IGRT) accurately delivers a high dose of potentially tumoricidal radiation to its target while sparing adjacent healthy tissue. Application of IGRT to unresectable pancreatic cancer requires the use of fiducials to track the precise location of the tumor. Fiducial markers have been successfully placed endoscopically.Objective: To determine the feasibility of EUS-guided gold fiducial placement for IGRT.Design: Prospective case series.Setting: Tertiary medical center.Patients: Consecutively referred patients with locally advanced unresectable pancreatic adenocarcinoma for EUS–guided insertion of gold fiducials from December 2006 to February 2009.Interventions: Under only EUS guidance, fiducial markers were deployed into or near the tumor by using a 19-gauge needle. In most cases, a sterile water injection technique was used to insert the fiducials. Fluoroscopy was not used in any case.Main Outcome Measurements: Successful placement of an adequate number of fiducials to proceed with IGRT as determined by CT.Results: Fifty-seven consecutive patients were included. Fifty cases (88%) were successful. Of the cases in which fiducial placement was attempted and follow-up was adequate, 94% (50 of 53) of cases were successful.Limitations: Single-center, nonrandomized study.Conclusions: EUS-guided fine-needle insertion was safe and effective in delivering gold fiducial markers for image-guided radiation therapy. Fluoroscopy was not required for successful fiducial placement.

Multicenter comparison of the interobserver agreement of standard EUS scoring and Rosemont classification scoring for diagnosis of chronic pancreatitis

2010-03-01

Background: EUS has less than optimal interobserver agreement for the diagnosis of chronic pancreatitis. The newly developed Rosemont consensus scoring system includes weighted criteria and stricter definitions for individual features.Objective: The primary aim was to compare the interobserver agreement of standard and Rosemont scoring.Setting: Multiple tertiary-care institutions.Intervention: Fifty EUS videos were interpreted by 14 experts. Each expert interpreted the videos on two occasions: First, the videos were read by using standard scoring (9 criteria). Second, after viewing a presentation of the Rosemont classification, the same experts re-read the videos by using Rosemont scoring.Main Outcome Measurements: Fleiss' kappa (K) statistics are reported with 95% confidence intervals (CI).Results: The interobserver agreement was “substantial” (K = 0.65 [95% CI, 0.52-0.77]) for Rosemont scoring and “moderate” (K = 0.54 [95% CI, 0.44-0.66]) for standard scoring; however, the difference was not statistically significant (P = 0.12).Limitations: The sample size does not allow detection of differences in K of <0.25.Conclusion: Use of the Rosemont classification did not significantly increase interobserver agreement for EUS diagnosis of chronic pancreatitis compared with standard scoring.

Endoscopic dilation of dominant stenoses in primary sclerosing cholangitis: outcome after long-term treatment

2010-03-01

Background: Primary sclerosing cholangitis is characterized by progressive fibrotic inflammation and obliteration of intra- and/or extrahepatic bile ducts. Total or subtotal stenoses of major bile ducts are associated with reduced survival.Objective: To evaluate the outcome after long-term endoscopic treatment.Design: Prospective, single-center study.Setting: Tertiary care academic medical center.Patients: A total of 171 patients treated with ursodeoxycholic acid were followed for as long as 20 years. At entry, 20 patients had dominant stenoses, and during a median follow-up period of 7.1 years, dominant stenosis developed in another 77.Interventions: Ninety-six patients with dominant stenoses were treated by repeated balloon dilation; 5 patients with complete obstruction with bacterial cholangitis were stented.Main Outcome Measurements: Survival free of liver transplantation, number of procedures, complications.Results: In total, 500 balloon dilations were performed and 5 stents were placed. Complications were pancreatitis (2.2%), bacterial cholangitis (1.4%), and bile duct perforation (0.2%); there were no deaths. Repeated endoscopic interventions allowed the preservation of a functioning common bile duct and of at least 1 hepatic duct up to 2 cm above the bifurcation in all patients. Progression of intrahepatic bile duct and liver disease led to the need for liver transplantation in 22 of 96 patients. Five years after the first dilation of a dominant stenosis, the survival free of liver transplantation rate was 81%, and after 10 years, it was 52%.Limitations: Single-center study, no control group, primary end-stage liver disease excluded.Conclusion: Repeated endoscopic balloon dilations of dominant stenoses allow the preservation of a functioning common bile duct for many years.

Double-balloon endoscopy as the primary method for small-bowel video capsule endoscope retrieval

2010-03-01

Background: Capsule retention in the small bowel is a known complication of small-bowel video capsule endoscopy. Surgery is the most frequently used method of capsule retrieval.Objective: To determine the incidence and causes of capsule retention and to describe double-balloon endoscopy (DBE) as the primary technique used for capsule retrieval.Design: Retrospective analysis of all video capsule studies was performed at our center, and evaluation of the outcome of DBE was the first method used to retrieve entrapped video capsules.Setting: Tertiary referral center.Patients: A total of 904 patients who underwent small-bowel video capsule endoscopy.Interventions: Capsule retrieval by DBE.Main Outcome Measurements: The number of patients in whom capsule retention occurred and the number of patients in whom an entrapped capsule could be retrieved by using DBE.Results: Capsule retention occurred in 8 patients (incidence 0.88%; 95% CI, 0.41%-1.80%) and caused acute small-bowel obstruction in 6 patients. All retained capsules were successfully removed during DBE. Five patients underwent elective surgery to treat the underlying cause of capsule retention. One patient required emergency surgery because of multiple small-bowel perforations.Limitations: Retrospective design.Conclusions: In our series, the incidence of capsule retention was low. DBE is a reliable method for removing retained capsules and might prevent unnecessary surgery. If surgery is required, preoperative capsule retrieval allows preoperative diagnosis, adequate staging in case of malignancy, and optimal surgical planning.

Impact of experience with a retrograde-viewing device on adenoma detection rates and withdrawal times during colonoscopy: the Third Eye Retroscope study group

2010-03-01

Background: Colonoscopy has been adopted as the preferred method to screen for colorectal neoplasia in the United States. However, lesions can be missed because of numerous factors, including location on the proximal aspect of folds or flexures, where they may be difficult to detect with the forward-viewing colonoscope. The Third Eye Retroscope (TER) is a disposable device that is passed through the instrument channel of a standard colonoscope to provide a retrograde view that complements the forward view of the colonoscope during withdrawal.Objective: To evaluate whether experience with the TER affects polyp detection rates and procedure times in experienced endoscopists who had not previously used the equipment.Design, Setting, Patients: This was an open-label, prospective, multicenter study at 9 U.S. sites, involving 298 patients presenting for colonoscopy, evaluating the use of the TER in combination with a standard colonoscope.Interventions: After cecal intubation, the TER was inserted through the instrument channel of the colonoscope. During withdrawal, the forward and retrograde video images were observed simultaneously on a wide-screen monitor.Main Outcome Measurements: Primary outcome measures were the number and size of adenomas and all polyps detected with the standard colonoscope and with the colonoscope combined with the TER. Secondary outcome measures were withdrawal phase time and total procedure time. Each endoscopist examined 20 subjects, divided into quartiles according to the order of their procedures, and results were compared among quartiles.Results: Overall, 182 polyps were detected with the colonoscope and 27 additional polyps with the TER, a 14.8% increase (P < .001). A total of 100 adenomas were detected with the colonoscope and 16 more with the TER, a 16.0% increase (P < .001). For procedures performed after each endoscopist had completed 15 procedures while using the TER, the mean additional detection rates with the TER were 17.0% for all polyps (P < .001) and 25.0% for adenomas (P < .001). For lesions 6 mm or larger, the overall additional detection rates with the TER for all polyps and for adenomas were 23.2% and 24.3%, respectively. For lesions 10 mm or larger, the overall additional detection rates with the TER for all polyps and for adenomas were 22.6% and 19.0%, respectively. The mean withdrawal times in the first and fourth quartiles were 10.6 and 9.2 minutes, respectively (P = .044).Limitations: There was no randomization or separate control group. The endoscopists judged whether each lesion could have been detected with the colonscope alone by using their standard technique.Conclusions: Polyp detection rates improved significantly with the TER, especially after 15 procedures, when the mean additional detection rate for adenomas was 25.0%. Additional detection rates with the TER for medium-size and large adenomas were greater than for smaller lesions. These results suggest that, compared with a colonoscope alone, a retrograde-viewing device can increase detection rates for clinically significant adenomas without detriment to procedure time or procedure complications. (Clinical trial registration number: NCT00969124.)

A retrograde-viewing device improves detection of adenomas in the colon: a prospective efficacy evaluation (with videos)

2009-12-17

Background: Colonoscopy may fail to detect neoplasia located on the proximal sides of haustral folds and flexures. The Third Eye Retroscope (TER) provides a simultaneous retrograde view that complements the forward view of a standard colonoscope.Objective: To evaluate the added benefit for polyp detection during colonoscopy of a retrograde-viewing device.Design: Open-label, prospective, multicenter study evaluating colonoscopy by using a TER in combination with a standard colonoscope.Setting: Eight U.S. sites, including university medical centers, ambulatory surgery centers, a community hospital, and a physician's office.Patients: A total of 249 patients (age range 55-80 years) presenting for screening or surveillance colonoscopy.Interventions: After cecal intubation, the disposable TER was inserted through the instrument channel of the colonoscope. During withdrawal, the forward and retrograde video images were observed simultaneously on a wide-screen monitor.Main Outcome Measurements: The number and sizes of lesions (adenomas and all polyps) detected with the standard colonoscope and the number and sizes of lesions found only because they were first detected with the TER.Results: In the 249 subjects, 257 polyps (including 136 adenomas) were identified with the colonoscope alone. The TER allowed detection of 34 additional polyps (a 13.2% increase; P < .0001) including 15 additional adenomas (an 11.0% increase; P < .0001). For lesions 6 mm or larger, the additional detection rates with the TER for all polyps and for adenomas were 18.2% and 25.0%, respectively. For lesions 10 mm or larger, the additional detection rates with the TER for all polyps and for adenomas were 30.8% and 33.3%, respectively. In 28 (11.2%) individuals, at least 1 additional polyp was found with the TER. In 8 (3.2%) patients, the polyp detected with the TER was the only one found. Every polyp that was detected with the TER was subsequently located with the colonoscope and removed. For all polyps and for adenomas, the additional detection rates for the TER were 9.7%/4.1% in the left colon (the splenic flexure to the rectum) and 16.5%/14.9% in the right colon (the cecum to the transverse colon), respectively.Limitations: There was no randomization or comparison with a separate control group.Conclusions: A retrograde-viewing device revealed areas that were hidden from the forward-viewing colonoscope and allowed detection of 13.2% additional polyps, including 11.0% additional adenomas. Additional detection rates with the TER for adenomas 6 mm or larger and 10 mm or larger were 25.0% and 33.3%, respectively. (Clinical trial registration number: NCT00657371.)

Adenoma detection and retroscopy

James S. Barthel — 2010-03-01

Four interdependent technical variables govern polyp detection rates: (1) instrument angle of view, (2) withdrawal time, (3) bowel preparation quality, and (4) tip deflection technique.

Endoscopic placement of self-expandable metal stents for malignant colonic obstruction: long-term outcomes and complication factors

Aaron J. Small, Nayantara Coelho-Prabhu, Todd H. Baron — 2010-03-01

Background: Self-expandable metal stents (SEMSs) are used for colonic obstruction palliatively and preoperatively.Objective: Determine long-term efficacy, incidence of complications, and risk factors of SEMS placement for colonic obstruction.Design: Retrospective review of SEMSs placed for malignant colorectal obstruction from 1999 to 2008.Setting: Tertiary-care center.Patients: This study involved 168 patients who underwent SEMS placement for palliation and 65 patients who underwent SEMS placement as a “bridge to surgery.”Intervention: Colonic SEMS placement.Main Outcome Measurements: Stricture location, stent-induced complications, time to adverse events, need for reintervention.Results: Technical and immediate clinical success rates were 96% and 99% in the palliative group and 95% and 98% in the preoperative group. Forty-one patients (24.4%) in the palliative group had complications including perforation (9%), occlusion (9%), migration (5%), and erosion/ulcer (2%). Mean stent patency was 145 days in the palliative group. One hundred eight of 122 patients (88.5%) were free of obstruction from implantation until death. Preoperatively placed stents remained in situ for a mean of 25.4 days and remained patent until surgery in 73.8% of patients. Complications were present preoperatively in 23.1% of patients; 94% underwent elective colectomy. Univariate analysis identified males, complete obstruction, stent diameter ≤22 mm, stricture dilation during SEMS insertion, and operator experience as significant risk factors for complication. In the palliative group, intraluminal lesions (27% vs 19%), bevacizumab (35% vs 23%), and distal colon placement of the stent (27% vs 13%) were also associated with higher complication rates as compared to extraluminal lesions, patients not treated with bevacizumab, and stents in the proximal colon, respectively. Bevacizumab therapy nearly tripled the risk of perforation.Limitations: Retrospective analysis, single institution.Conclusion: Colorectal SEMS placement is relatively safe and effective but with a complication rate of nearly 25%. Patient characteristics and technical variables appear to affect the outcome of SEMS therapy.

One-day bowel preparation with polyethylene glycol 3350: an effective regimen for colonoscopy in children

2010-03-01

Background: Polyethylene glycol (PEG) 3350 is commonly used and has been proven safe and effective for the treatment of chronic constipation and as a 4-day bowel preparation in children. A 1-day PEG 3350 bowel preparation regimen has been recently developed for adults; however, data regarding its use in children are lacking.Objective: To evaluate the safety and effectiveness of a 1-day PEG 3350 regimen for bowel preparation in children before colonoscopy.Design: Retrospective review.Setting: Tertiary-care center.Patients: This study involved all children prescribed a 1-day PEG 3350 bowel preparation regimen before colonoscopy at our center in 2008.Intervention: We reviewed medical records of patients (≤18 years of age) who underwent colonoscopy during 2008 and received the 1-day bowel preparation regimen.Main Outcome Measurements: Adequate preparation for colonoscopy, success of colonoscopy, and factors associated with inadequate bowel preparation.Results: Inclusion criteria were met by 272 patients. The median age of the children receiving the 1-day PEG 3350 preparation regimen was 13.7 years (range 1.08-17.92 years). Fifty-two percent were male; 48% were female. The most common indications for colonoscopy included abdominal pain (65%), bloody stools (29%), diarrhea (21%), and weight loss (18%). The 1-day bowel preparation regimen was effective in 253 patients (93%). The indication for colonoscopy, the age of the child, or a history of constipation did not significantly alter the success rate of colonoscopy.Limitations: A retrospective study at one tertiary-care center.Conclusion: The 1-day PEG 3350 bowel preparation regimen is safe and effective and should be considered for use as preparation for colonoscopy in children.

Healing of a bleeding solitary rectal ulcer with multiple sessions of argon plasma

Sanjay Kumar Somani, Arindam Ghosh, Gurcharan Avasthi, Richa Goyal, Puneet Gupta — 2010-03-01

Background: Solitary rectal ulcer syndrome (SRUS) is an uncommon disorder of evacuation. Management of bleeding ulcers is usually unsatisfactory with conventional treatments. Argon plasma coagulation (APC) has been reported in case reports to control bleeding; however, it has not been shown to result in ulcer healing.Objective: To investigate the efficacy and safety of APC in controlling bleeding from SRUS and to study its efficacy in eventual healing of ulcers.Design: A randomized, controlled trial of the management of 24 consecutive patients with SRUS.Setting: The gastroenterology unit at 2 tertiary care hospitals.Patients: Twenty-four patients with bleeding SRUS.Main Outcome Measurements: Control of bleeding and endoscopic healing of SRUS.Methods: Twenty-four patients with bleeding SRUS, whose diagnoses were based on clinical, colonoscopic, and histologic findings, were randomized to receive either standard care only (12 patients, biofeedback therapy [BT] group) or multiple sessions of APC in addition to BT (12 patients, APC group). All patients were advised to intake a high level of fluids and fibers, laxatives, biofeedback, and behavior modification therapy in addition to the treatment. Patients were followed to determine whether ulcers healed.Results: Twenty-four patients with symptoms that lasted 12.6 ± 4.8 months were included. Bleeding was controlled in all 12 patients in the APC group, but only in 5 of 12 patients in BT group. We also made the following observations about healing of the ulcers: 8 of 12 patients in the APC group had complete healing of their ulcers after 4 to 8 sessions, whereas in the BT group, ulcers healed in only 2 of 12 patients.Conclusions: APC controls the bleeding in patients with SRUS and also improves the healing of these ulcers.

Gastric transmural pressure measurements in vivo: implications for natural orifice transluminal endoscopic surgery (NOTES)

David J. Desilets, Timothy J. Mader, John R. Romanelli, David B. Earle — 2010-03-01

Background: The success of natural orifice surgery depends on a reliable, secure closure of the opening in the gut. Forces that might be exerted on the gastric wall to disrupt closure have not been measured in humans or animals.Objective: To determine how transmural gastric pressure gradients vary under different experimental conditions.Design: In vivo porcine model.Setting: Animal laboratory.Patients: Eleven laboratory pigs.Interventions: Pressure transducers were placed in the abdomen and stomachs of the test animals. Simultaneous pressure measurements were obtained to determine the stresses applied to the gastric wall during various maneuvers.Main Outcome Measurements: Continuous intra-abdominal and intragastric pressures in vivo. Transgastric pressure gradients (ΔP) were computed in real time by subtracting gastric pressure from abdominal pressure.Results: In all cases, the measured gastric pressures were nearly identical to those measured in the abdominal cavity because the stomach is entirely contained within the abdomen. The transmural gastric pressure gradients were near zero during a variety of experimental conditions.Limitation: Anesthetized animal model, not engaged in usual activities. Relatively low pressures generated during a cough sequence and a Valsalva maneuver compared with reported values in the literature.Conclusion: Estimates of gastric pressures that must be tolerated by gastric closure devices after natural orifice transluminal endoscopic surgery procedures have been greatly overestimated. Absolute gastric pressure is counteracted by external (intra-abdominal) pressure such that the net transmural gastric pressure gradient remains near zero under a variety of conditions.

Succinylated gelatin substantially increases en bloc resection size in colonic EMR: a randomized, blinded trial in a porcine model

2010-03-01

Background: Succinylated gelatin (SG) is an inexpensive colloid that may combine ease of use with the advantages of a colloid to potentially increase EMR specimen size, leading to a higher rate of en bloc resection.Objective: To evaluate the safety, efficacy, and impact on EMR specimen size of SG as a submucosal (SM) injectant in comparison with normal saline solution (NS).Design: Randomized, blinded, controlled trial conducted with Animal Ethics Committee approval.Setting: Academic hospital.Subjects: Ten swine.Interventions: Sixty EMRs (30 using SG vs 30 using NS as 3 paired experiments per animal) of the largest possible en bloc snare resection of normal colonic mucosa after SM injection of a fixed volume of either SG or NS.Main Outcome Measurements: EMR specimen size, duration of SM cushion, duration of procedure, ratio of vertical elevation to lateral spread of injectant, ease of resection, adverse effects, perforation, histopathology of EMR sites in colectomy specimens at necropsy (for inflammatory cell content, depth of ulceration, and vascular or ischemic changes).Results: The mean subject weight was 53 kg. The mean EMR specimen dimensions and surface area were significantly larger with SG (length 37 vs 31 mm, P = .031; width 32 vs 26 mm, P = .022; surface area 9.5 cm2 vs 6.7 cm2, P = .044, respectively). The median SM cushion duration was 60 minutes with SG versus 15 minutes with NS (P = .005). The median procedure duration with SG was 2.6 minutes vs 2.5 minutes with NS (P = .515). The ratio of vertical elevation to lateral spread of injectant (mean score on a 3-point scale) was 3 with SG versus 2 with NS (P = .228). Ease of resection score (mean score on a 10-point scale) was 8 with SG versus 7 with NS (P = .216). There were no systemic adverse effects, hypersensitivity reactions, or bleeding episodes. There were 2 perforations (treated with clips) with SG and 1 with NS (P = 1.0). Blinded histopathologist assessment of necropsy colectomy specimens did not identify any significant differences between SG and NS EMR sites.Limitations: Animal study.Conclusions: SG is safe and results in a 42% increased surface area for en bloc EMR. Given its other favorable properties, it represents a significant step toward defining the ideal EMR solution.

Continuing Medical Education Exam: March 2010

2010-03-01

Endoscopic sedation training in gastroenterology fellowship

Tyler M. Berzin — 2010-03-01

Sedation in endoscopy has recently been much debated, yet it is not usually a topic formally addressed during fellowship. Recommendations recently published in a consensus statement will inevitably steer changes in sedation practices. In this month's Fellows' Corner, Dr. Tyler Berzin, a gastroenterology fellow at Beth Israel Deaconess Medical Center, experienced in the study of endoscopic sedation, summarizes the key elements stirring the propofol controversy and offers advice on training in the safe administration of anesthesia.

A new fully covered stent with antimigration properties for the palliation of malignant dysphagia: a prospective cohort study

2009-12-09

Background: Fully covered stents are designed to resist tissue ingrowth that is often seen with partially covered stents. An issue with fully covered stents is the risk of migration.Objective: We aimed to determine efficacy, recurrent dysphagia, and complications of the SX–ELLA stent Esophageal HV, which is fully covered to resist tissue ingrowth and has an antimigration ring to withstand migration.Design: Prospective cohort study.Setting: Two tertiary referral centers.Patients: Forty-four patients with malignant esophageal strictures from inoperable or metastatic esophageal or gastric cardia cancer (n = 42) or lung cancer (n = 2).Interventions: Placement of an SX–ELLA stent.Main outcome measures: Functional outcome, recurrent dysphagia, complications, and survival.Results: Dysphagia improved from a median score of 3 (liquids only) before stent placement to 1 (ability to eat some solid food) 4 weeks later (P < .001). Twelve of 44 (Kaplan Meier analysis = 40%) patients developed 18 episodes of recurrent dysphagia of which 6 were caused by stent migration and 2 by tissue overgrowth. In total, 14 episodes of major complications developed in 10 of 44 (Kaplan Meier analysis = 29%) patients, 8 of which were caused by hemorrhage. After a median follow-up of 15 months, 39 patients had died (median survival 110 days), 5 (11%) from hemorrhage.Limitations: Nonrandomized study design.Conclusions: Dysphagia caused by esophageal cancer can be successfully palliated by placement of a new, fully covered esophageal stent (SX–ELLA). Although this single-wire braided stent with an antimigration ring is supposed to be less traumatic and to reduce migration, this was not substantiated in this study. Further improvements of stent features are needed to achieve the goals set for this study.

Endoscopic closure of gastrogastric fistulas by using a tissue apposition system (with videos)

Georg O. Spaun, Danny V. Martinec, Timothy J. Kennedy, Lee L. Swanström — 2009-12-17

Background: Gastrogastric fistulas (GGFs) are seen in 1.5% to 12.5% of patients after Roux-en-Y gastric bypass (RYGB) bariatric surgery, often leading to failure to lose adequate weight.Objective: The aim of this study was to assess the feasibility, safety, and percentage of successful primary endoluminal closures of GGFs by using a recently developed tissue apposition system in combination with local mucosectomy.Design: A feasibility and outcome study following institutional review board protocol.Setting: Tertiary referral teaching hospital, Legacy Health System, Portland, Oregon.Interventions: A combination of mucosectomy and nonresorbable tissue apposition is used to achieve a permanent closure of the GGF.Patients: Four patients with 5 GGFs after RYGB; the mean fistula diameter of was 18.6 mm (range 10-30 mm).Results: Primary closure rate (1 endoscopic session) of 5 GGFs was 100%. The mean procedure time was 88.5 minutes. One to 4 pairs of tissue anchors were used to close the fistulas. The mean time for performing mucosectomy was 21.6 minutes (range 8-42 minutes) and 39.6 minutes (range 12-58 minutes) for fistula closure. Estimated blood loss was on average 2 mL (range 0-5 mL). No complications were recorded. Early success (3 months), as evidenced by early satiety and weight loss, was noted for 3 of 4 patients. After 3 months, only the smallest fistula (10 mm) was still completely closed, and after 6 months, it also showed a pinhole opening.Conclusion: It was feasible to close all fistulas endoscopically without complications. Permanent closure of GGFs could not be achieved.

A novel method for performing multiple wire insertions during endoscopic cyst gastrostomy

John A. Evans, Jason D. Conway, Girish Mishra — 2010-03-01

Background: Endoscopic cyst gastrostomy is effective in the management of uncomplicated pancreatic pseudocysts. A challenging aspect of the procedure is the insertion and confirmation of at least 2 guidewires into the cyst. Many technical procedures to accomplish the wire insertion have been described but are complicated.Objective: We describe the use of a simple commercially available catheter that allows multiple wires to be inserted into a pancreatic pseudocyst as an efficient and simple means of performing a cyst gastrostomy.Design: Case series.Setting: Academic referral center.Patients: Four consecutive patients undergoing EUS-guided cyst gastrostomy.Interventions: A Haber ramp was used as the means for the introduction of multiple wires into a pancreatic pseudocyst.Main Outcome Measurements: Technical success without loss of wire access during the cyst gastrostomy.Results: Four patients underwent successful pancreatic cyst gastrostomy. There was no loss of wire access during the procedure. There were no intraprocedure or postprocedure complications.Limitations: Small patient population.Conclusions: The use of the Haber ramp provides a simple and efficient means for introducing, ensuring, and maintaining wire access during the creation of an endoscopic cyst gastrostomy.

A novel device for endoscopic submucosal dissection that combines water-jet submucosal hydrodissection and elevation with electrocautery: initial experience in a porcine model

2010-03-01

Background: Endoscopic submucosal dissection requires a high degree of endoscopic skill and specifically designed dissecting instruments.Objective: To describe the technique for endoscopic submucosal dissection when using the ERBE Hybrid Knife, which combines an ultrafine high-pressure water jet with an electrocautery needle.Design: Descriptive study (ex vivo and in vivo porcine esophagus, stomach, and colon).Interventions: The only instrument used for the dissection was the ERBE Hybrid Knife. The high-pressure water jet was used at a pressure between 45 and 60 bar for creating submucosal fluid elevation. After this, circumferential mucosal incisions and submucosal dissection were performed with the FORCED COAG and ENDOCUT D modes of the same device. The water jet was used intermittently during the dissection process.Main Outcome Measurements: At the end of the in vivo experiments, animals were killed and the organs removed for evaluation.Results: Multiple endoscopic submucosal dissection procedures were successfully performed. It was possible to create submucosal fluid cushions rapidly. Repeated fluid injections during dissection were easily facilitated with the same device. All ex vivo gastric endoscopic submucosal dissections of 50 × 40-mm lesions were completed within 10 minutes. In the in vivo studies, the mean size of the gastric and colonic specimens was 3.7 ± 2.1 × 2.3 ± 1 cm, and the dissections were completed within 8 minutes. No thermal injury was observed on the serosa, and no perforations were detected.Conclusions: Endoscopic submucosal dissection can be safely and effectively achieved in a porcine model with the ERBE Hybrid Knife and should be considered a suitable device for this procedure in humans.

Multiple liver metastases from a rectal carcinoid tumor

2010-03-01

A 52-year-old man was referred to our hospital for evaluation of a positive fecal occult blood test. He had a 3-month history of right upper abdominal discomfort. On physical examination, there was a palm-sized, palpably hard liver below the right costal margin. Colonoscopy showed a lobulated polypoid lesion in the rectum, 6 cm from the anal verge, with multiple erosions and shallow ulcers covering the mucosal surface of the tumor (A). EUS revealed a hypoechoic, submucosal mass, which was 3.0 cm in diameter, protruding into the lumen and invading the serosa (B).

Intermittent hemorrhage from biliary varices caused by portal biliopathy after pancreatoduodenectomy successfully treated with trans-ileocolic vein obliteration

2010-03-01

A 78-year-old woman had intermittent melena requiring transfusions of 1 to 2 units of blood per month. Two years earlier, she had pancreatic cancer and had undergone pancreatoduodenectomy. Evaluation including enteroscopy did not reveal the cause of the bleeding. A CT demonstrated extrahepatic portal obstruction with complicated collateral vessels around the choledochoduodenostomy; vessels were clearly shown by portal venography. No recurrent tumor was found. We suspected portal hypertension as the primary cause of the bleeding, and splenectomy was performed to decompress the portal system; the melena recurred. EGD was performed again, and upon advancement of the endoscope to the choledochoduodenostomy, a reddish spot was found on the choledochal mucosa near the anastomosis (A), which we thought was a sign of portal biliopathy. Therefore, we ablated the varices by using argon plasma coagulation. However, brisk bleeding occurred, and we managed to establish only transient hemostasis by injection of hypertonic saline-epinephrine solution. To attain permanent hemostasis, we performed trans-ileocolic vein obliteration with N-butyl-2-cyanoacrylate (B, C). Hepatopetal portal flow was established through other collateral vessels, and no signs of liver failure were noted. Five days after trans-ileocolic vein obliteration, EGD disclosed white, thrombosed varices (D). The patient was discharged and remains well 6 months later.

A diagnosis of an intraluminal carcinoid tumor of the bile duct by using cholangioscopy

2009-12-10

A 78-year-old man was seen after a 4-week history of intermittent right upper quadrant pain and 1 week of jaundice. A US scan revealed intrahepatic duct dilation and thickening of the common bile duct. ERCP revealed an ovoid filling defect in the common hepatic duct that measured approximately 2 cm and that was thought to be caused by a gallstone. An attempt at basket retrieval failed to remove the stone, and a plastic biliary stent was inserted. A second attempt to remove the stone at another ERCP also was unsuccessful, and he was referred to our unit for ERCP and cholangioscopy. Cholangiography confirmed the presence of a 2-cm filling defect in the common hepatic duct (A). Cholangioscopy with SpyGlass (Boston Scientific, Natick, Mass) revealed an exophytic mass arising from the bile duct mucosa (B) just distal to the bifurcation of the left and right hepatic ducts. Direct biopsy specimens were taken through the SpyGlass by using SpyBite (Boston Scientific) (C). The bile duct biopsy specimens showed a tumor composed of solid nests of monomorphic cells that stained strongly positive for chromogranin and synaptophysin (D) confirming the diagnosis of an endocrine tumor.

Complete double-balloon enteroscopy: from A 2 E

Evin J. McCabe, Gregory B. Haber, Aman Ali, Sam M. Nourani — 2010-03-01

A 62-year-old male with CREST syndrome presented for retrograde double-balloon enteroscopy via the anus for ongoing obscure occult bleeding. A push enteroscopy and anterograde oral double-balloon enteroscopy 2 months earlier had revealed a few jejunal angiectasias, which were ablated with argon plasma coagulation. During the current examination, the therapeutic double-balloon enteroscope (EN-450T5; Fujinon, Saitama, Japan) with a diameter of 9.4 mm was passed via the anus and colon, through the ileocecal valve, and up the small bowel. A concentric narrowing was then approached (A). Initially, this narrowing was thought to be a stricture, but on traversal the enteroscope entered the stomach, confirming that the ring was the pyloric channel. The enteroscope was advanced to the proximal stomach, where the gastroesophageal junction was seen (B). Then the enteroscope was passed into the lower esophagus (C), and the enteroscope location was confirmed via fluoroscopy (D). On withdrawal, approximately 8 angiectasias in the duodenum and jejunum were identified and ablated with argon plasma coagulation. This is the only case of complete traversal of the small bowel via the anal route in a patient with unaltered anatomy at our institution. We have performed over 600 double-balloon enteroscopies, to date, 25% via the anal approach.

Successful outcomes of endoscopic resection for gastric adenomas and early cancers located on the pyloric ring (with video)

2010-03-01

Background: Endoscopic resection is difficult to perform in patients who have gastric neoplasms located on the pyloric ring, especially for lesions that extend from the pyloric area to the duodenal bulb, where it is difficult to retroflex the endoscope, and the risk of perforation is increased.Objective: To assess the results of endoscopic resection of early gastric neoplasms located on the pyloric ring.Design: Case series.Setting: Tertiary-care referral center.Patients: This study involved 16 patients with 5 gastric adenomas and 11 early cancers that were located on the pyloric ring.Interventions: After a retroflexion trial within the duodenum for evaluation of tumor extension from the pyloric area to the duodenal bulb, en bloc resection was attempted. Endoscopic submucosal dissection was attempted at the duodenal bulb with an endoscope retroflexed for cases of duodenal invasion.Main Outcome Measurements: The curative resection rate, en bloc resection rate, and complications were determined.Results: The success rate of retroflexion within the duodenum was 88% (14 of 16). The curative resection rate was 81.3% (13 of 16), and the en bloc resection rate was 75% (12 of 16). En bloc resection was possible for 3 of 4 (75%) cases of duodenal bulb extension. Major procedure-related complications were not encountered.Limitations: Small number of patients.Conclusion: Endoscopic resection appears to be a feasible and effective treatment for early gastric neoplasms located on the pyloric ring, including lesions that extend from the pyloric area to the duodenal bulb.

Fiducial placement for stereotactic radiation by using EUS: feasibility when using a marker compatible with a standard 22-gauge needle

2010-03-01

Background: Stereotactic radiation by using fiducial markers permits higher doses of radiation while reducing the exposure of uninvolved, adjacent structures. EUS has been used to deploy fiducials, although a 19-gauge needle has traditionally been required.Objective: To report a new technique and the feasibility of deploying a fiducial compatible with a 22-gauge needle under EUS guidance.Design: Single-center, case series.Setting: Tertiary care referral center.Patients: Thirteen patients with primary or metastatic cancer referred for stereotactic radiation.Interventions: EUS-guided placement of a single fiducial marker that is compatible with a 22-gauge EUS-FNA needle.Main Outcome Measurements: Technical success and complications.Results: Thirteen patients referred for EUS-guided placement of a fiducial marker were identified in the endoscopic database. Targeted lesions measured 27 ± 13 mm (range 8-50) × 21 ± 10 mm (range 6-42). All fiducials were successfully deployed, 9 using a transgastric and 4 using a transduodenal approach. There were no EUS-associated complications. Two patients did not proceed to radiation therapy as a result of interval peritoneal metastasis. However, all fiducials were visible on the roentogram. Eleven of 13 patients (85%) required placement of 1 fiducial, whereas 2 patients (15%) required 2 fiducials.Limitations: Uncontrolled feasibility study with limited sample size and follow-up.Conclusion: EUS-guided placement of a fiducial using a 22-gauge needle is technically feasible and may permit greater access compared with the 19-gauge needle technique.

EUS-guided cholecystoenterostomy with single-step placement of a 7F double-pigtail plastic stent in patients who are unsuitable for cholecystectomy: a pilot study (with video)

2010-03-01

Background: Although the definitive therapy of acute cholecystitis is cholecystectomy, nonsurgical treatment such as percutaneous cholecystostomy could be indicated in patients who are unsuitable candidates for cholecystectomy. EUS-guided cholecystoenterostomy with a plastic stent and/or nasobiliary drainage has been proposed as an alternative effective treatment for these patients.Objective: We conducted this study to evaluate the technical feasibility, safety, usefulness, and follow-up results of EUS-guided cholecystoenterostomy with single-step placement of a plastic stent for patients with acute cholecystitis who are unsuitable candidates for cholecystectomy.Design: A prospective feasibility study with a case series.Setting: Tertiary teaching hospital.Patients: Eight consecutive patients diagnosed with acute cholecystitis who were poor candidates for surgery.Interventions: EUS-guided cholecystoenterostomy with single-step placement of a 7F double-pigtail plastic stent.Main Outcome Measurements: Technical success, clinical resolution of acute cholecystitis, procedure-related complications, and recurrence of cholecystitis.Results: Technical success and clinical resolution were achieved in all patients (100% [8/8] as intent to treat). A transduodenal approach was used for 7 patients and a transgastric approach for 1 patient. One patient showed self-limited pneumoperitoneum, and bile peritonitis occurred in 1 patient. One patient showed distal stent migration without bile leakage 3 weeks after stent insertion. During follow-up periods (median 186 days; range 22-300 days), cholecystitis did not recur in any patients.Limitations: Small number of patients.Conclusion: EUS-guided cholecystoenterostomy with single-step placement of a 7F double-pigtail plastic stent may be a feasible and useful alternative in patients with acute cholecystitis who are unsuitable candidates for cholecystectomy.

Single-balloon enteroscopy effectively enables diagnostic and therapeutic retrograde cholangiography in patients with surgically altered anatomy

2010-03-01

Background: In patients with surgically altered anatomy, ERCP is often unsuccessful. Single-balloon enteroscopy (SBE) enables deep intubation of the small bowel, permitting diagnostic and therapeutic ERCP in this subset of patients.Objective: To determine the effectiveness of SBE in performing endoscopic retrograde cholangiography (ERC) in patients with surgically altered anatomy.Design: Case series.Setting: Large quaternary-care center.Patients: Thirteen patients (11 women) underwent 16 SBE procedures with ERCP. Patient anatomy consisted of Whipple (n = 3), hepaticojejunostomy (n = 3), Billroth II (n = 1), and Roux-en-Y (n = 9).Interventions: Patients with surgically altered anatomy in whom standard ERCP techniques had failed or were not possible underwent ERC by using SBE with initial therapeutic intent.Main Outcome Measurements: Success rates of diagnostic ERC and therapeutic ERC in those patients who required biliary intervention. Procedure-related complications were also assessed.Results: Diagnostic ERC was successful 12 (92.3%) of 13 patients and in 13 (81.3%) of 16 cases. Therapeutic ERC was required in 10 patients in whom diagnostic ERC was first accomplished, and therapeutic ERC was successful in 9 (90%) of 10 patients. Biliary interventions included balloon dilation (n = 4), stone extraction (n = 2), sphincterotomy (n = 4), removal of a surgically placed stent (n = 3), and stenting (n = 2). Two patients developed pancreatitis after therapeutic ERC. Median follow-up was 53 days (range 22-522 days). Overall procedural success in an intent-to-treat analysis by case was 75%.Limitation: Single-center experience.Conclusion: SBE enables diagnostic and therapeutic ERC in most patients with altered anatomy. SBE-assisted therapeutic ERC may be associated with an increased risk of pancreatitis. Improvement of the available equipment is necessary to perform more efficient and effective biliary interventions.

Intraductal electrohydraulic lithotripsy by using SpyGlass cholangioscopy through a colonoscope in a patient with Roux-en-Y hepaticojejunostomy

Todd H. Baron, Atif Saleem — 2009-11-18

The endoscopic approach to large bile duct stones may require the use of intraductal electrohydraulic lithotripsy (IEHL) performed under direct cholangioscopic visualization. In patients with Roux-en-Y biliary reconstruction after liver transplantation, endoscopic retrograde cholangiography is feasible using long-length endoscopes. We describe successful fragmentation of a large common hepatic duct stone by using cholangioscopy-guided IEHL delivered through a colonoscope in a patient with a Roux-en-Y hepaticojejunostomy.

EUS-guided rendezvous for the treatment of pancreaticopleural fistula in a patient with chronic pancreatitis and pancreas pseudodivisum

Scott T. Cooper, Jane Malick, Kevin McGrath, Adam Slivka, Michael K. Sanders — 2009-11-05

Pancreatic duct (PD) disruption can result from acute and chronic pancreatitis, abdominal trauma, pancreatic malignancy, and surgery. Conservative management involves pancreatic rest with either hyperalimentation or nasojejunal feeding, initiation of somatostatin analogues, and/or pancreatic enzyme supplements. Unfortunately, medical therapy may be ineffective. Transpapillary stent placement is a safe and effective technique for managing ductal disruption. However, conventional stent placement may be difficult because of altered anatomy, PD strictures, and difficult cannulation. EUS-guided rendezvous has been reported for antegrade access to both the biliary duct and PD. We report a case of chronic pancreatitis with pancreas pseudodivisum complicated by ductal disruption and a pancreaticopleural fistula, subsequently treated with EUS-guided rendezvous and stent placement after failed conventional ERCP and medical therapy.

Adult presentation of a congenital duodenal diaphragm

Damien Loh, Trevor Leese, Sven Anders — 2009-10-19

Congenital duodenal diaphragms usually present in infancy or childhood. Adult presentation is rare. We report a late presentation of duodenal diaphragm in a 43-year-old woman.

Sigmoid plasmacytoma mimicking colon cancer in a patient with multiple myeloma: case report and review of literature

2009-11-02

Colonic plasmacytomas are a rare manifestation of a myeloma malignancy, with fewer than 25 cases reported. We report such a case occurring in the sigmoid colon mimicking symptoms of colon cancer and review the literature. Awareness of this complication in patients with multiple myeloma is important in providing early diagnosis and treatment. We recommend prompt early colonoscopies for symptomatic patients with myeloma.

Isolated proximal black esophagus: etiology and the role of tissue biopsy

Grigoriy E. Gurvits, James G. Robilotti — 2010-03-01

To the Editor: We read with interest the article by Neumann et al on proximal black esophagus, in which they describe proximal acute necrotizing esophagitis in a patient who underwent cardiac catheterization for acute myocardial infarction. Their case is consistent with our recently published analysis. Black esophagus is thought to occur from a combination of hemodynamic compromise, transient gastric outlet obstruction with backflow injury, and altered mucosal barrier systems. Predilection to the distal esophagus is almost universal (97.5%), and only 2 reported cases describe isolated involvement of the middle third of the organ. Vascular supply to the cervical esophagus is derived from the descending branches of the inferior thyroid arteries, with additional variable blood supply from other branches. The mechanism of isolated injury to the cervical esophagus may be related to a selective embolic event or mechanical trauma from accidental cannulation of a thyrocervical trunk, compromising blood supply, both possible complications of a cardiac catheterization.

Biopsy or no biopsy after EUS examination of lesions suspicious for GI stromal tumors

Yucel Ustundag, Mehmet Cindoruk — 2010-03-01

To the Editor: We read with interest the retrospective study by Hoda et al in which approximately 30% of the submucosal lesions were considered GI stromal tumors (GISTs). They also indicated that EUS-guided FNA revealed an 83.9% diagnostic potential for a suspected upper GIST. However, diagnosis after FNA was reported to be definite in 61.6% of cases. The other 22.3% of cases were only possibly a GIST because there was no criterion standard surgical data to prove the results of FNA. Thus, we believe that the authors cannot claim that EUS-guided FNA is a good method to use for diagnosis of a possible GIST, which was proved in only 60% of suspected cases in their series. Moreover, they even suggest that biopsy sampling with jumbo forceps of the ulcerated area of a submucosal mass after negative results with FNA increased the diagnostic ability of the procedure by an additional 4%. However, most of these patients were possibly admitted with bleeding. Severe bleeding may occur from central ulceration, a submucosal vessel, or a Dieulafoy lesion in gastric GISTs. When we consider such patients admitted with bleeding from a gastric lesion suspicious for GIST, surgery after negative FNA results could be a more reasonable alternative instead of a repeat biopsy by using jumbo forceps. Furthermore, in cases suspicious for GIST with negative c-kit expression, analysis for mutated platelet-derived growth factor receptor antigen expression in biopsy samples could be a valuable method to enhance the diagnosis.

Response

Katherine M. Hoda, Sarah A. Rodriguez, Douglas O. Faigel — 2010-03-01

We thank Drs. Ustundag and Cindoruk for their interest in our article. We recognize that, without an external criterion standard, we cannot calculate the sensitivity or specificity of EUS-guided FNA for GI stromal tumors (GISTs). However, in the majority (>60%), a very specific diagnosis can be made, and in nearly all cases, a diagnosis of at least a spindle cell neoplasm can be made. Endoscopic appearance alone, including the presence of ulcerations, is inadequate to distinguish the etiology of one subepithelial mass from another. EUS features may be suggestive but not definitive. Clinical factors such as tumor location (eg, GISTs are rare in the esophagus) and medical history (especially of malignancies) may also be useful. Severe bleeding from an ulcerated mass may require immediate treatment, including surgery, if bleeding cannot be adequately controlled. In our experience, bleeding is self-limited, allowing a diagnostic evaluation. In many cases, these bleeding tumors are not GISTs, and the etiology may prompt nonsurgical treatment, especially for lymphomas and metastases. In the case of large and/or symptomatic GISTs, a preoperative diagnosis allows neoadjuvant therapy with imatinib mesylate. We rarely perform a second endoscopy to perform a biopsy of the ulcerated portion of the mass, but do this at the time of the EUS, especially if in-room cytology is nondiagnostic. Finally, regarding gain-of-function mutations in the platelet-derived growth factor receptor α (PDGRFα) genes, although this seems to be important in the pathogenesis of a small number of c-kit negative tumors, it is not specific for GIST. Unlike testing for c-kit, which is done with immunohistochemical stains against CD-117, testing for PDGRFα requires DNA mutational analysis that is not widely available. As a practical matter, PDGRFα mutational analysis is reserved for selected patients with CCD-117–negative spindle cell tumors that are also negative on immunohistochemical staining for leiomyomas and neural tumors (schwannomas).

EUS-guided FNA for GI stromal tumors: caveat lector

Eduardo B. da Silveira, Everson L. Artifon, Ruel T. Garcia — 2010-03-01

To the Editor: GIE recently addressed EUS-guided tissue sampling in GI stromal tumors (GISTs) in 2 separate articles aimed at determining the diagnostic yield of this technique. Although similar in their retrospective designs, the investigations differed in a few methodological aspects that deserve some comments because they could explain the significant discrepancies in the results.

Response

Douglas O. Faigel, Katherine M. Hoda, Sarah A. Rodriguez — 2010-03-01

In his letter entitled “Caveat lector,” Dr da Silveira states that there are significant discrepancies between our paper, a recent publication by Sepe et al, and an abstract by O'Neil et al, which is commented on by two of the abstract's authors (Al-Haddad and Dewitt) in an editorial regarding our article.

Effective hemostasis with multiple hemoclips and endoloops for GI bleeding

2010-03-01

To the Editor: We read with interest the article by Rácz et al on endoscopic hemostasis of a bleeding gastric ulcer with a combination of multiple hemoclips and endoloops.

Response

István Rácz, Tibor Kárász, Hussam Saleh — 2010-03-01

We appreciate the comment of Matsushita et al, and we have read their experience with the handcrafted 2-channel endoscope, allowing the use of combined forceps/snare techniques for polypectomy. We also recognize that combining multiple hemoclips with endoloops may be useful for the management of postpolypectomy colon hemorrhage, as reported by Uno et al. The optimal endoscopic hemostasis for peptic ulcer bleeding in patients with high-risk lesions is still unclear. Meta-analyses have repeatedly evaluated injection, thermocoagulation, clips, or combinations of these and have indicated the superiority of combination therapy and clips to stop active bleeding and to avoid rebleeding. However, endoloops have never been mentioned. Since our first successful case, we have successfully applied the combined clip-loop intervention in another 16 patients with actively bleeding gastric ulcers not responding to conventional endotherapy and also in 4 cases with nonbleeding visible vessels. After the ulcer margins were grasped with 3 to 4 clips, 1 endoloop was usually enough to snare and fix the clips, thus covering the ulcer bases. Rebleeding was avoided in all cases, and no complications occurred.

Rectal perforation caused by colonoscopic retroflexion

2010-03-01

To the Editor: We read with interest the article by Quallick and Brown on rectal perforation during colonoscopic retroflexion. Because of the limited amount of data, we present our experience with 1 analogous case among 18,000 colonoscopies performed in our department.

Gastrointestinal Endoscopy

Contents

Editors

Focus On…

ASGE Update

In Upcoming Issues…

Information for readers

ERCP cannulation and sphincterotomy devices

A lexicon for endoscopic adverse events: report of an ASGE workshop

A new metal stent with a controlled-release system for palliation of malignant dysphagia: a prospective, multicenter study

Effectiveness of asynchronous tele-endoscopy

Endoscopic removal of dysfunctioning bands or rings after restrictive bariatric procedures

Endoscopic removal of dysfunctioning rings or bands after restrictive bariatric procedures

Magnifying narrow-band imaging versus magnifying white-light imaging for the differential diagnosis of gastric small depressive lesions: a prospective study

Endoscopic peritoneal access and insufflation: natural orifice transluminal endoscopic surgery

Surgical gastrojejunostomy or endoscopic stent placement for the palliation of malignant gastric outlet obstruction (SUSTENT study): a multicenter randomized trial

Impact of EUS-guided FNA on management of gastric carcinoma

Endoscopic treatment of postorthotopic liver transplantation anastomotic biliary strictures with maximal stent therapy (with video)

EUS-guided gold fiducial insertion for image-guided radiation therapy of pancreatic cancer: 50 successful cases without fluoroscopy

Multicenter comparison of the interobserver agreement of standard EUS scoring and Rosemont classification scoring for diagnosis of chronic pancreatitis

Endoscopic dilation of dominant stenoses in primary sclerosing cholangitis: outcome after long-term treatment

Double-balloon endoscopy as the primary method for small-bowel video capsule endoscope retrieval

Impact of experience with a retrograde-viewing device on adenoma detection rates and withdrawal times during colonoscopy: the Third Eye Retroscope study group

A retrograde-viewing device improves detection of adenomas in the colon: a prospective efficacy evaluation (with videos)

Adenoma detection and retroscopy

Endoscopic placement of self-expandable metal stents for malignant colonic obstruction: long-term outcomes and complication factors

One-day bowel preparation with polyethylene glycol 3350: an effective regimen for colonoscopy in children

Healing of a bleeding solitary rectal ulcer with multiple sessions of argon plasma

Gastric transmural pressure measurements in vivo: implications for natural orifice transluminal endoscopic surgery (NOTES)

Succinylated gelatin substantially increases en bloc resection size in colonic EMR: a randomized, blinded trial in a porcine model

Continuing Medical Education Exam: March 2010

Endoscopic sedation training in gastroenterology fellowship

A new fully covered stent with antimigration properties for the palliation of malignant dysphagia: a prospective cohort study

Endoscopic closure of gastrogastric fistulas by using a tissue apposition system (with videos)

A novel method for performing multiple wire insertions during endoscopic cyst gastrostomy

A novel device for endoscopic submucosal dissection that combines water-jet submucosal hydrodissection and elevation with electrocautery: initial experience in a porcine model

Multiple liver metastases from a rectal carcinoid tumor

Intermittent hemorrhage from biliary varices caused by portal biliopathy after pancreatoduodenectomy successfully treated with trans-ileocolic vein obliteration

A diagnosis of an intraluminal carcinoid tumor of the bile duct by using cholangioscopy

Complete double-balloon enteroscopy: from A 2 E

Successful outcomes of endoscopic resection for gastric adenomas and early cancers located on the pyloric ring (with video)

Fiducial placement for stereotactic radiation by using EUS: feasibility when using a marker compatible with a standard 22-gauge needle

EUS-guided cholecystoenterostomy with single-step placement of a 7F double-pigtail plastic stent in patients who are unsuitable for cholecystectomy: a pilot study (with video)

Single-balloon enteroscopy effectively enables diagnostic and therapeutic retrograde cholangiography in patients with surgically altered anatomy

Intraductal electrohydraulic lithotripsy by using SpyGlass cholangioscopy through a colonoscope in a patient with Roux-en-Y hepaticojejunostomy

EUS-guided rendezvous for the treatment of pancreaticopleural fistula in a patient with chronic pancreatitis and pancreas pseudodivisum

Adult presentation of a congenital duodenal diaphragm

Sigmoid plasmacytoma mimicking colon cancer in a patient with multiple myeloma: case report and review of literature

Isolated proximal black esophagus: etiology and the role of tissue biopsy

Biopsy or no biopsy after EUS examination of lesions suspicious for GI stromal tumors

Response

EUS-guided FNA for GI stromal tumors: caveat lector

Response

Effective hemostasis with multiple hemoclips and endoloops for GI bleeding

Response

Rectal perforation caused by colonoscopic retroflexion