Gastrointestinal Endoscopy

Principles of training in GI endoscopy

2011-12-09

This document, prepared by the American Society for Gastrointestinal Endoscopy Committee on Training, was undertaken to provide general guidelines for endoscopy training and written primarily for individuals involved in teaching endoscopic procedures to fellows/trainees. This updates the previous Principles of Training document. Research in objective evaluation of procedural skills makes revision of the guidelines at this time highly appropriate.

Validation of the Prague C & M criteria for the endoscopic grading of Barrett's esophagus by gastroenterology trainees: a multicenter study

2012-02-01

Background: The Prague C & M criteria, developed for the endoscopic grading of Barrett's esophagus (BE), (C = circumferential length, M = maximal length) were previously validated among a panel of 29 expert endoscopists with a special interest in BE. Its performance among gastroenterology trainees is unknown. Objective: To test interobserver agreement among gastroenterology trainees for the Prague C & M criteria, identification of the gastroesophageal junction (GEJ) and the diaphragmatic hiatus. Design: A prospective study. Setting: Two tertiary referral centers. Patients and Interventions: Standardized endoscopic videos were used. Main Outcome Measurements: Interobserver agreement. Results: Eighteen high-quality videos (normal esophagus, short and long lengths of BE, equally distributed) were independently evaluated by 18 gastroenterology trainees (year 1, n = 5; year 2, n = 6; year 3, n = 7) after administration of a formal teaching module by an expert endoscopist. Overall intraclass correlation coefficients for assessment of the C and M extent of the endoscopic BE segment above the GEJ were 0.94 (95% CI, 0.89-0.98) and 0.96 (95% CI, 0.94-0.98), respectively. The overall intraclass correlation coefficients for GEJ and diaphragmatic hiatus location recognition were 0.92 (0.86-0.96) and 0.90 (0.82-0.95), respectively. The year of training did not affect interobserver agreement. Limitations: The use of videos for endoscopic evaluation. Conclusion: After standardized teaching, the Prague C & M criteria have high overall validity among gastroenterology trainees irrespective of the level of training for endoscopic evaluation of visualized BE lengths as well as key endoscopic landmarks.

Diagnostic accuracy of EUS in differentiating mucosal versus submucosal invasion of superficial esophageal cancers: a systematic review and meta-analysis

2011-11-24

Background: The prognosis of esophageal cancer (EC) depends on the depth of tumor invasion and lymph node metastasis. EC limited to the mucosa (T1a) can be treated effectively with minimally invasive endoscopic therapy, whereas submucosal (T1b) EC carries relatively high risk of lymph node metastasis and requires surgical resection. Objective: To determine the diagnostic accuracy of EUS in differentiating T1a EC from T1b EC. Design: We performed a comprehensive search of MEDLINE, SCOPUS, Cochrane, and CINAHL Plus databases to identify studies in which results of EUS-based staging of EC were compared with the results of histopathology of EMR or surgically resected esophageal lesions. DerSimonian-Laird random-effects model was used to estimate the pooled sensitivity, specificity, and likelihood ratio, and a summary receiver operating characteristic (SROC) curve was created. Setting: Meta-analysis of 19 international studies. Patients: Total of 1019 patients with superficial EC (SEC). Interventions: EUS and EMR or surgical resection of SEC. Main Outcome Measurements: Sensitivity and specificity of EUS in accurately staging SEC. Results: The pooled sensitivity, specificity, and positive and negative likelihood ratio of EUS for T1a staging were 0.85 (95% CI, 0.82-0.88), 0.87 (95% CI, 0.84-0.90), 6.62 (95% CI, 3.61-12.12), and 0.20 (95% CI, 0.14-0.30), respectively. For T1b staging, these results were 0.86 (95% CI, 0.82-0.89), 0.86 (95% CI, 0.83-0.89), 5.13 (95% CI, 3.36-7.82), and 0.17 (95% CI, 0.09-0.30), respectively. The area under the curve was at least 0.93 for both mucosal and submucosal lesions. Limitations: Heterogeneity was present among the studies. Conclusion: Overall EUS has good accuracy (area under the curve ≥0.93) in staging SECs. Heterogeneity among the included studies suggests that multiple factors including the location and type of lesion, method and frequency of EUS probe, and the experience of the endosonographer can affect the diagnostic accuracy of EUS.

Strategies for training in diagnostic upper endoscopy: a prospective, randomized trial

2011-12-09

Background: Training simulators have been used for decades with success; however, a standardized educational strategy for diagnostic EGD is still lacking. Objective: Development of a training strategy for diagnostic upper endoscopy. Study design: Prospective, randomized trial. Settings: A total of 28 medical and surgical residents without endoscopic experience were enrolled. Basic skills evaluations were performed following a structured program involving theoretical lectures and a hands-on course in diagnostic EGD. Subsequently, stratified randomization to clinical plus simulator training (group 1, n = 10), clinical training only (group 2, n = 9), or simulator training only (group 3, n = 9) was performed. Ten sessions of simulator training were conducted for groups 1 and 3 during the 4-month program. Group 2 underwent standard training in endoscopy without supplemental simulator training. The final evaluation was performed on the simulator and by observation of 3 clinical cases. Skills and procedural times were recorded by blinded and unblinded evaluators. Main Outcome Measurements: Time to reach the duodenum, pylorus, or esophagus. Results: All trainees demonstrated a significant reduction in procedure time during a simple manual skills test (P < .05) and significantly better skills scores (P = .006, P = .042 and P = .017) in the simulator independent of the training strategy. Group 1 showed shorter times to intubate the esophagus (61 ± 26 seconds vs 85 ± 30 seconds and 95 ± 36 seconds) and the pylorus (183 ± 65 seconds vs 207 ± 61 seconds and 247 ± 66 seconds) during the clinical evaluation. Blinded assessment of EGD skills showed significantly better results for group 1 compared with group 3. Blinded and unblinded evaluations were not statistically different. Limitations: Small sample size. Conclusions: Structured simulator training supplementing clinical training in upper endoscopy appears to be superior to clinical training alone. Simulator training alone does not seem to be sufficient to improve endoscopic skills.

Ain't nothing like the real thing? Simulators in endoscopy training

Harry R. Aslanian — 2012-02-01

Ende et al present a well-conducted study of training techniques in diagnostic upper endoscopy. Twenty-eight medical and surgical residents with no previous endoscopic experience underwent didactic (6 hours) and hands-on (4 hours) teaching and were randomized into 3 groups of combined simulator and clinical training or clinical or simulator training alone. A 4-month training period included ten 2-hour sessions of proctored simulator training, with each type of simulator used equally: mechanical (plastic model), explanted animal model (compactEASIE), and computerized (Simbionix). The groups using clinical training performed a mean of 24 EGDs.

Mortality from nonulcer bleeding is similar to that of ulcer bleeding in high-risk patients with nonvariceal hemorrhage: a prospective database study in Italy

2011-10-17

Background: Nonulcer causes of bleeding are often regarded as minor, ie, associated with a lower risk of mortality. Objective: To assess the risk of death from nonulcer causes of upper GI bleeding (UGIB). Design: Secondary analysis of prospectively collected data from 3 national databases. Settings: Community and teaching hospitals. Patients: Consecutive patients admitted for acute nonvariceal UGIB. Interventions: Early endoscopy, medical and endoscopic treatment as appropriate. Main Outcome Measurements: Thirty-day mortality, recurrent bleeding, and need for surgery. Results: A total of 3207 patients (65.8% male), mean (standard deviation) age 68.3 (16.4) years, were analyzed. Overall mortality was 4.45% (143 patients). According to the source of bleeding, mortality was 9.8% for neoplasia, 4.8% for Mallory-Weiss tears, 4.8% for vascular lesions, 4.4% for gastroduodenal erosions, 4.4% for duodenal ulcer, and 3.1% for gastric ulcer. Frequency of death was not different among benign endoscopic diagnoses (overall P = .567). Risk of death was significantly higher in patients with neoplasia compared with benign conditions (odds ratio 2.50; 95% CI, 1.32-4.46; P < .0001). Gastric or duodenal ulcer significantly increased the risk of death, but this was not related to the presence of high-risk stigmata (P = .368). The strongest predictor of mortality for all causes of nonvariceal UGIB was the overall physical status of the patient measured with the American Society of Anesthesiologists score (1-2 vs 3-4, P < .001). Limitations: No data on the American Society of Anesthesiologists class score in the Prometeo study. Conclusions: Nonulcer causes of nonvariceal UGIB have a risk of death, similar to bleeding peptic ulcers in the clinical context of a high-risk patient.

Nonvariceal upper GI bleeding: it's not just about peptic ulcers

Vipul Jairath, Alan N. Barkun — 2012-02-01

Nonvariceal upper GI bleeding (NVUGIB) is one of the most common conditions faced by practicing gastroenterologists and endoscopists, carrying considerable morbidity, mortality, and a health economic burden. There have been a number of advances in the evidence-based approach to the management of the patient with NVUGIB over the past decade, most notably the optimal use of endoscopic therapy and high-dose proton pump inhibition, resulting in the dissemination of international best evidence-based practice guidelines. Subsequently, in the past few years, we have been provided with a plethora of detailed “real-life” outcome data from multicenter observational registries of upper GI bleeding, originating from Italy, Canada, and the United Kingdom, enabling us to examine both how well guidelines are adhered to and serving to highlight both improvements and deficiencies in aspects of care.

Endoscopic submucosal dissection for treatment of gastric subepithelial tumors (with video)

2011-10-28

Background: Endoscopic submucosal dissection (ESD) is a well-accepted method for removing superficial mucosal tumors; however, there is limited data on the use of this method for removing subepithelial tumors. Objective: To investigate the efficacy, safety, and outcome of ESD for gastric subepithelial tumors and determine factors related to treatment success. Design: Retrospective analysis of a prospectively maintained database. Setting: Single tertiary academic center. Patients and Interventions: From April 2007 to November 2010, 37 patients with gastric subepithelial tumors were treated with ESD. Main Outcome Measurements: Macroscopically and microscopically complete en block resection rate (R0), complication rate, and endosonographic features predictive of R0 resection. Results: The median tumor diameter was 25.0 mm, (range 10-60 mm, IQR 17-37). The overall rate of R0 resections was 81.1% (30/37, 95%CI: 61.8-90.2%), including 100% (15/15, 95%CI: 78.2-100.0%) of tumors from the submucosa and 68.2% (15/22, 95%CI: 45.1-86.1%) of tumors from the muscularis propria. Seventeen patients had a final diagnosis of gastrointestinal stromal tumor. The severe complication (perforation) rate was 5.4% (2/37, 95%CI: 0.0-9.5%). One patient required surgery; the other was treated conservatively. No recurrence was observed in patients with R0 resections at a median follow up of 21.0 months (IQR 11-35). Successful R0 resections were predicted by the observation of no, or only narrow, tumor connections with the underlying muscle layer during EUS (OR=35.0, 95%CI: 3.7-334.4, p=0.001). Limitations: Single-center, retrospective analysis, short follow-up. Conclusions: ESD is an effective and relatively safe method for removing gastric subepithelial tumors. Endoscopic ultrasonography findings can predict complete tumor resections.

Use of self-expandable stents in the treatment of bariatric surgery leaks: a systematic review and meta-analysis

Srinivas R. Puli, Inbar S. Spofford, Christopher C. Thompson — 2011-11-03

Background: Bariatric surgery leaks can result in significant morbidity and mortality. Endoscopic placement of self-expandable stents (SESs) is emerging as a less-invasive alternative to surgery for the treatment of leaks. Objective: To evaluate the success of SESs in the treatment of bariatric surgery leaks. Design: Studies using SESs in the management of bariatric surgery leaks were selected. Success of SES treatment was defined as radiographic evidence of leak closure after stent removal. Articles were searched in MEDLINE, PubMed, Ovid, and Cochrane Register of Controlled Trials. Pooled proportions were calculated by using fixed- and random-effects models. Publication bias was calculated by using the Begg-Mazumdar and Harbord bias estimators. Results: A total of 189 relevant articles were reviewed of which 7 studies (67 patients with leaks) met inclusion criteria. The pooled proportion of successful leak closures by using SESs was 87.77% (95% CI, 79.39%-94.19%). The pooled proportion of successful endoscopic stent removal was 91.57% (95% CI, 84.22%-96.77%). Stent migration was noted in 16.94% (95% CI, 9.32%-26.27%). Test of heterogeneity gave a P value >.10. There was no publication bias. Limitations: Small retrospective studies, different types of stents used. Conclusion: Endoscopic placement of SESs is a minimally invasive, safe, and effective alternative in the management of leaks after bariatric surgery. The use of SESs can minimize the need for surgical revision and improve patient outcomes.

Endoscopic stenting is not as effective for palliation of colorectal obstruction in patients with advanced gastric cancer as emergency surgery

2011-12-12

Background: Although self-expandable metal stent (SEMS) insertion has been shown to be an effective therapy for palliation of obstruction from colorectal malignancy, the clinical efficacy of SEMS insertion in the palliation of colorectal obstruction from an extracolonic malignancy (ECM) has not been extensively evaluated. Objective: The aim of this study was to evaluate the clinical outcomes and complications of SEMSs compared with those of emergency surgery for relief of colorectal obstruction in patients with advanced gastric cancer (AGC). Design: Retrospective study. Patients: From January 2000 to December 2009, patients with AGC who were treated with SEMSs (N = 111) or emergency surgery (N = 69) for palliation of malignant colorectal obstruction were included. Intervention: SEMS insertion or surgery. Results: Although acute complications and stoma formations were lower in the SEMS group than in the surgery group, the clinical efficacy of SEMSs was inferior to emergency surgery (technical success, 73.9% vs 94.2%, P = .001; clinical success, 54.1% vs 75.4%, P = .005). SEMS-related complications occurred in 64.5%, including reobstruction (36.8%), stent migration (10.5%), perforation (13.2%), and bleeding (3.9%). The median duration of patency was not statistically different between the patients who underwent SEMS insertion and those who underwent emergency surgery (117 days vs 183 days, P = .105). Patients with fewer than 2 obstructive sites or less than 2 years to obstructive symptom onset after diagnosis of AGC showed better clinical outcomes after endoscopic stenting. Limitations: Retrospective and single-center study. Conclusions: SEMS insertion seems to be less effective than emergency surgery for the palliation of colorectal obstruction in patients with AGC. Further study is necessary to define those patients with ECM who may benefit from SEMS insertion.

Endoscopic intrapyloric injection of botulinum toxin A in the treatment of children with gastroparesis: a retrospective, open-label study

Leonel Rodriguez, Rachel Rosen, Michael Manfredi, Samuel Nurko — 2012-02-01

Background: Botulinum toxin A has been used in children to treat spastic disorders and recently for GI conditions. Open-label studies in adults with gastroparesis have reported an improvement in symptoms and gastric emptying after endoscopic intrapyloric botulinum injections (IPBIs), although placebo-controlled trials have shown conflicting results. Only a single case report of IPBI is available in children. Objective: To determine the long-term clinical outcomes and predictive factors for IPBI response in children with gastroparesis refractory to medical therapy. Design: Retrospective review. Setting: Single tertiary care center. Patients: Children with refractory gastroparesis symptoms undergoing IPBIs. Interventions: IPBIs. Main Outcome Measurements: Clinical improvement and predictive factors for response. Results: A total of 70 injections were given to 47 patients (mean age 9.98 ± 6.5 years; 23 female patients) with follow-up in 45 patients. IPBI failed in 15 patients and was successful in 30 patients. The median duration of response to the first IPBI was 3.0 months (95% CI, 1.2-4.8). A total of 29 patients received a single IPBI, and 18 received multiple IPBIs. Older age and vomiting predicted response to initial IPBI, and male sex predicted response to repeat IPBI. Only 1 patient reported exacerbation of vomiting after IPBI resolving within a week. Limitations: The open-label and retrospective nature of the study. Conclusion: IPBI is safe and may be effective in the management of children with symptoms of gastroparesis. Subgroups identifying who responded to the first IPBI include older patients and those presenting with vomiting, whereas male patients responded better to repeat IPBIs.

High yield of same-session EUS-guided liver biopsy by 19-gauge FNA needle in patients undergoing EUS to exclude biliary obstruction

2012-02-01

Background: EUS-guided liver biopsy by Trucut yields variable specimen adequacy at high cost, limiting its utility. A modified EUS-guided technique with reliable adequacy could be a viable alternative to standard techniques in cost-effective clinical settings. Objective: To describe our experience with EUS-guided liver biopsy by 19-gauge FNA, non-Trucut, needle in a cost-effective setting: patients with abnormal liver test results of unclear etiology referred for EUS to exclude biliary obstruction in whom an unrevealing EUS would have prompted a next-step liver biopsy by the referring physician. Design: Prospective case series. Setting: Tertiary-care teaching hospital. Patients: Consecutive patients with abnormal liver tests referred for EUS. Interventions: EUS-guided liver biopsy by 19-gauge FNA needle (non-Trucut). Main Outcome Measurements: Diagnostic yield, specimen adequacy, and complications. An adequate specimen was defined as a length of 15 mm or longer and 6 or more complete portal tracts (CPTs). Results: Between July 2008 and July 2011, 22 of 31 consecutive patients meeting inclusion criteria underwent unrevealing EUS with same-session EUS-guided liver biopsy by 19-gauge FNA needle. A median of 2 FNA passes (range 1-3) yielded a median specimen length of 36.9 mm (range 2-184.6 mm) with a median of 9 CPTs (range 1-73 CPTs). EUS-guided liver biopsies yielded a histologic diagnosis and adequate specimens in 20 of 22 patients (91%). Expanded experience led to improved specimen adequacy. There were no complications. Limitation: Small study size. Conclusions: EUS-guided liver biopsy by using a 19-gauge FNA needle appears to be feasible and safe and provides excellent diagnostic yield and specimen adequacy.

EUS-guided FNA for diagnosis of solid pancreatic neoplasms: a meta-analysis

2012-02-01

Background: Preoperative diagnosis of solid pancreatic lesions remains challenging despite advancement in imaging technologies. EUS has the benefit of being a minimally invasive, well-tolerated procedure, although results are operator-dependent. The addition of FNA (EUS-guided FNA) provides samples for cytopathologic analysis, a major advantage over other imaging techniques. Objective: To determine the diagnostic accuracy of EUS-FNA for pancreatic cancer. Design: This is a meta-analysis of published studies assessing the diagnostic capability of EUS-FNA. Relevant studies were identified via MEDLINE and were included if they used a reference standard of definitive surgical histology or clinical follow-up of at least 6 months. Main Outcome Measurements: Data from selected studies were analyzed by using test accuracy meta-analysis software, providing a pooled value for sensitivity, specificity, diagnostic odds ratio, and summary receiver operating characteristic curve. Cytology results were classified as inadequate, benign, atypical, suspicious, or malignant. Predefined subgroup analysis was performed. Results: Thirty-three studies published between 1997 and 2009 were included, with a total number of 4984 patients. The pooled sensitivity for malignant cytology was 85% (95% confidence interval [CI], 84-86), and pooled specificity was 98% (95% CI, 0.97-0.99). If atypical and suspicious cytology results were included to determine true neoplasms, the sensitivity increased to 91% (95% CI, 90-92); however, the specificity was reduced to 94% (95% CI, 93-96). The diagnostic accuracy of EUS-FNA was enhanced in prospective, multicenter studies. Limitation: Publication bias was not a significant determinant of pooled accuracy. Conclusion: This meta-analysis demonstrates that EUS-FNA is a highly accurate diagnostic test for solid neoplasms of the pancreas and should be considered when algorithms for investigating solid pancreatic lesions are being planned.

EUS or percutaneously guided intratumoral TNFerade biologic with 5-fluorouracil and radiotherapy for first-line treatment of locally advanced pancreatic cancer: a phase I/II study

2012-02-01

Background: TNFeradeBiologic (AdGVEGR.TNF.11D) is a replication-deficient adenoviral vector that expresses tumor necrosis factor-α (TNF-α) under the control of the Egr-1 promoter, which is inducible by chemotherapy and radiation. Objective: This study was conducted to determine the maximal tolerated dose of TNFeradeBiologic with standard chemoradiotherapy and preliminary activity and safety of the combination in the treatment of locally advanced pancreatic cancer (LAPC). Design: TNFeradeBiologic was injected into locally advanced pancreatic carcinomas by using EUS or percutaneous administration once a week for 5 weeks together with 50.4 Gy radiation and 5-fluorouracil (5-FU) 200 mg/m2 daily over 5.5 weeks. Dose levels from 4 × 109 to 1 × 1012 particle units (PU) were studied. Setting: Multicentered, academic institutions. Patients: Fifty patients with LAPC were treated. Interventions: Doses of TNFerade Biologic were administered to patients. Main Outcome Measurements: Toleration of TNFerade Biologic was measured through toxicity and tumor response, by using the criteria of the Response Evaluation Criteria in Solid Tumors and the World Health Organization, and was reviewed by a central radiology facility. Overall survival and progression-free survival were also measured. Results: Dose-limiting toxicities of pancreatitis and cholangitis were observed in 3 patients at the 1 × 1012 PU dose, making 4 × 1011 PU the maximum tolerated dose. One complete response, 3 partial responses, and 12 patients with stable disease were noted. Seven patients eventually went to surgery, 6 had clear margins, and 3 survived >24 months. Limitations: This is a Phase1/2 non-randomized study. Conclusions: Intratumoral delivery of TNFerade Biologic by EUS with fine-needle viral injection or percutaneously, combined with chemoradiation, shows promise in the treatment of LAPC. There appeared to be better clinical outcome at the maximal tolerated dose than at lower doses. The dose of 4 ×1011 PU TNFerade Biologic was generally well tolerated, with encouraging indications of activity, and will be tested in the randomized phase of this study. Delivery of TNFerade Biologic did not interfere with subsequent surgical resection.

Guidewire biliary cannulation does not reduce post-ERCP pancreatitis compared with the contrast injection technique in low-risk and high-risk patients

2011-11-11

Background: Guidewire (GW) cannulation can reduce the risk of post-ERCP pancreatitis (PEP) by avoiding the opacification of the main pancreatic duct. Objective: To compare the effects of conventional contrast ERCP and GW cannulation of the common bile duct on the rate of PEP in low- and high-risk patients. Design: Prospective, comparative-intervention single-center study. Setting: Tertiary referral center. Patients: Patients with biliary disease with an intact papilla were prospectively examined by ERCP. Interventions: Biliary cannulation using a sphincterotome with contrast injection (ConI) or a hydrophilic GW without contrast injection. Main Outcome Measurements: Pancreatitis rate in the GW group and the contrast injection (ConI) group. Results: PEP occurred in 60 of 1249 patients (4.8%), 35 of 678 (5.2%) in the GW group and 25 of 571 (4.4%) in the ConI group (not significant). The overall rate of PEP was significantly higher in high-risk patients (12.2%) than in low-risk patients (3.5%) (P < .001), but was similar for the 2 techniques within each of these 2 groups. In patients with unintended main pancreatic duct (MPD) cannulation or opacification, the rate of PEP was not significantly different with the GW (15.2%) and ConI (8.4%) techniques but was associated with a significantly higher rate of pancreatitis (11.9%) than in patients in whom the contrast medium or GW did not enter the MPD (3.5%) (P < .001). Multivariate analysis indicated that more than 10 papillary cannulation attempts, MPD cannulation or opacification, suspected sphincter of Oddi dysfunction, and precut methods were significant risk factors independently associated with PEP. Limitations: Lack of randomization. Conclusions: For selective cannulation of the CBD, the risk of inducing PEP is similar with the ConI and GW techniques in high-risk and low-risk patients. Any manipulation of the MPD must be considered a high-risk factor for PEP, such as multiple attempts on the papilla or use of the precut method.

Diagnostic accuracy of conventional and cholangioscopy-guided sampling of indeterminate biliary lesions at the time of ERCP: a prospective, long-term follow-up study

2012-02-01

Background: The diagnostic accuracy of cholangioscopy-guided sampling has not been rigorously evaluated. Objective: To prospectively evaluate the accuracy of cholangioscopy-guided mini-forceps sampling and compare it with standard cytology brushings and forceps biopsies for the tissue diagnosis of indeterminate biliary lesions. Design: Prospective, long-term follow-up, paired design cohort study. Setting: Tertiary center. Patients: Patients undergoing cholangioscopy for the evaluation of indeterminate biliary lesions. Interventions: Each patient underwent triple sampling with cholangioscopy-guided mini-forceps, cytology brushing, and standard forceps. Main Outcome Measurements: Diagnostic accuracy of each sampling method compared with the patient final status (cancer vs no cancer). Results: A total of 26 patients (17 cancer positive/9 cancer negative) were enrolled. The mean follow-up in the patients with no cancer was 21.78 (SD ±6.78) months. The procedure was technically successful in all cases (100%). Sample quality was adequate in 25 of 26 (96.2%) of the cytology brushings, in 26 of 26 (100%) of the standard forceps biopsies, and in 25 of 26 (96.2%) of the mini-forceps biopsies. The sensitivity, accuracy, and negative predictive values were 5.9%, 38.5%, and 36% for standard cytology brushings; 29.4%, 53.8%, and 42.8% for standard forceps biopsies; and 76.5%, 84.6%, and 69.2% for mini-forceps biopsies, respectively. When comparing the 3 methods of sampling, mini-forceps biopsy provided significantly better sensitivity and overall accuracy compared with standard cytology brushing (P < .0001) and standard forceps biopsy (P = .0215). Limitations: Potential for selection bias. Conclusions: Cholangioscopy-guided biopsies of indeterminate biliary lesions have significantly higher accuracy compared with ERCP-guided cytology brushings and standard forceps biopsies, but negative findings on mini-forceps biopsy cannot rule out malignancy with a high degree of certainty. (Clinical trial registration number: NCT01227382.)

Comparison of EUS-guided rendezvous and precut papillotomy techniques for biliary access (with videos)

Vinay Dhir, Suryaprakash Bhandari, Mukta Bapat, Amit Maydeo — 2012-02-01

Background: Precut papillotomy after failed bile duct cannulation is associated with an increased risk of pancreatitis. EUS-guided rendezvous drainage is a novel alternative technique, but there are no data comparing this approach with precut papillotomy. Objective: To evaluate the safety and efficacy of EUS-guided rendezvous drainage of the bile duct and compare its outcome with that of precut papillotomy. Design: Retrospective study. Setting: Tertiary care referral center. Patients: Consecutive patients with distal bile duct obstruction, in whom selective cannulation of the bile duct at ERCP failed after 5 attempts with a guidewire and sphincterotome, underwent an EUS-guided rendezvous procedure. The outcomes were compared with those in a historical cohort of patients who underwent precut papillotomy. Interventions: Patients in whom selective cannulation failed underwent EUS-guided rendezvous drainage by use of the short wire technique or precut papillotomy by use of the Erlangen papillotome. At EUS, after the extrahepatic bile duct was punctured with a 19-gauge needle, a hydrophilic angled-tip guidewire 260 cm long was passed in an antegrade manner across the papilla into the duodenum. The echoendoscope was then exchanged for a duodenoscope, which was introduced alongside the EUS-placed guidewire. The transpapillary guidewire was retrieved through its biopsy channel, and accessories were passed over the wire to perform the requisite endotherapy. Main Outcome Measures: Comparison of the rates of technical success and complications between patients treated by the EUS-guided rendezvous and those treated by precut papillotomy techniques. Treatment success was defined as completion of the requisite endotherapy in one treatment session. Results: Treatment success was significantly higher for the EUS-guided rendezvous (57/58 patients) than for those undergoing precut papillotomy technique (130/144 patients) (98.3% vs 90.3%; P = .03). There was no significant difference in the rate of procedural complications between the EUS and precut papillotomy techniques (3.4% vs 6.9%, P = .27). Limitations: Retrospective nonrandomized study design; highly selective patient cohort. Conclusions: In this study, the EUS-guided rendezvous technique was found to be superior to precut papillotomy for single-session biliary access. Prospective randomized trials are needed to confirm these preliminary but promising findings.

EUS-guided biliary rendezvous: EUS to the rescue

Won Jae Yoon, William R. Brugge — 2012-02-01

We all recollect with joy when we performed our first selective cannulation by ERCP. We also know the frustration when ERCP does not provide us with access to the biliary tree. The use of facilitated cannulation techniques such as needle-knife sphincterotomy brings fear to many endoscopists. The memories of complications associated with gaining biliary access have stimulated many innovations in new biliary access techniques.

A multicenter, prospective, randomized study of selective bile duct cannulation performed by multiple endoscopists: the BIDMEN study

2012-02-01

Background: Wire-guided cannulation (WGC) with a sphincterotome (S) for selective bile duct cannulation (SBDC) has been reported to have a higher success rate and lower incidence of post-ERCP pancreatitis (PEP) than conventional methods in some randomized, controlled trials (RCTs) that were both single center and limited to only a few endoscopists. Objective: To estimate the difference in SBDC according to the method and catheter used in a multicenter and multiendoscopist study. Design: A prospective, multicenter RCT with a 2 × 2 factorial design. Setting: Fifteen referral endoscopy units. Patients: In total, 400 consecutive patients with naive papillae who were candidates for ERCP were enrolled and randomized. Interventions: Patients were assigned to 4 groups according to combined catheter (S or catheter [C]) and method (with/without guidewire [GW]). Main Outcome Measurements: Success rate of SBDC performed in 10 minutes, SBDC time, fluoroscopy time, and incidence of complications. Results: There was no significant difference in the SBDC success rate between the groups with and without GW, between C and S, or among the 4 groups (C+GW, C, S+GW, S). WGC had a tendency to significantly shorten cannulation and fluoroscopy times only in approximately 70% of patients in this study in whom SBDC was achieved in 10 minutes or less (P = .036 and .00004, respectively). All 4 groups resulted in similar outcomes in PEP (4%, 5.9%, 2%, and 2.1%, respectively). Limitations: Non–double-blind study. Conclusions: WGC appears to significantly shorten cannulation and fluoroscopy times. However, neither the method nor type of catheter used resulted in significant differences in either SBDC success rate or incidence of PEP in this RCT. (Clinical trial registration number: UMIN000002572.)

Blinded nonrandomized comparative study of gastric examination with a magnetically guided capsule endoscope and standard videoendoscope

2011-12-12

Background: Passive video capsule endoscopy is the criterion standard for small-bowel exploration but cannot be used for the large gastric cavity. We report the first blinded comparative clinical trial in humans comparing a magnetically guided capsule endoscope (MGCE) and a conventional high-definition gastroscope. Objective: To assess the potential of gastric examination with a guided capsule. Design: Blinded, nonrandomized comparative study. Setting: Single endoscopy center. Methods: The trial involved 61 patients included in a blinded capsule and gastroscopy comparative study. MGCE examination was performed 24 hours after patients had undergone gastroscopy. To remove food residue or mucus, patients drank 900 mL of water in 2 portions. Then to provide the air-water interface required by the guidance system, they drank 400 mL of water at 35°C. Results: Visualization of the gastric pylorus, antrum, body, fundus, and cardia was evaluated as complete in 88.5%, 86.9%, 93.4%, 85.2%, and 88.5% of patients, respectively. Of gastric lesions, 58.3% were detected by both gastroscopy and MGCE at immediate assessment and review of recorded data. Capsule examination missed 14 findings and gastroscopy missed 31 findings seen with MGCE. Overall diagnostic yield was similar for both modalities. Limitation: Pilot study. Conclusions: Diagnostic results were similar for the 2 methods. After some technical difficulties related to gastric expansion or presence of mucus had been overcome, this study opened a new field for noninvasive gastric examination in countries where high gastric cancer incidence demands a screening tool.

Endoscopic band ligation for colonic diverticular hemorrhage

2011-09-26

Background: The number of sample cases of colonic diverticular hemorrhage treated with endoscopic band ligation (EBL) has been small to date. Objective: To elucidate the safety and efficacy of EBL for colonic diverticular hemorrhage. Design: Retrospective study. Setting: General hospital. Patients: A total of 29 patients with 31 colonic diverticula with stigmata of recent hemorrhage (SRH). Interventions: Urgent colonoscopy was performed after bowel preparation. When diverticula with SRH were identified, marking with hemoclips was done near the diverticula. The endoscope was removed and reinserted after a band-ligator device was attached to the tip of endoscope. At first, EBL was attempted. In patients who could not be treated with EBL, epinephrine injection or endoscopic clipping was performed. Main Outcome Measurements: Procedure time, rate of hemostasis and rebleeding, complications. Results: The mean procedure time was 47 ± 19 minutes. EBL was successfully completed in 27 colonic diverticula (87%); except in 3 diverticula with a small orifice and large dome and 1 diverticula in which the orifice was too large. Early rebleeding after EBL occurred in 3 of 27 cases (11%). Although 2 cases of sigmoid rebleeding could be managed by repeat EBL or conservatively, right hemicolectomy was performed in 1 ascending diverticulum, in which the bleeding source was not identified on repeat colonoscopy. Scar formation at previously banded diverticula was identified in 7 of 11 patients who underwent follow-up colonoscopy. There were no complications after EBL in any of the patients. Limitations: Retrospective study. Conclusions: EBL is a safe and effective treatment for colonic diverticular hemorrhage, and colonic diverticula resolve after EBL.

The ins and outs of diverticular bleeding

Dennis M. Jensen — 2012-02-01

I have several goals in this editorial. The first is to compliment Dr. Ishii and his colleagues for their interest in diverticular hemorrhage and for reporting a large cumulative experience of patients with definitive diverticular hemorrhage from Japan. The diagnosis of definitive diverticular hemorrhage made during urgent colonoscopy is based on finding major stigmata of recent hemorrhage (SRH) in a diverticulum (ie, active bleeding, a nonbleeding visible vessel, or an adherent clot), as my CURE Hemostasis Research Group previously reported. The second goal is to review the vascular anatomy of colonic diverticula and provide some insight on blood flow related to SRH of diverticular hemorrhage with Doppler US probe, which is very useful in risk stratification, deciding where to treat, and documenting complete endoscopic hemostasis. The third is to clarify several misconceptions about diverticular hemorrhage that are common in the medical-surgical literature. The last is to offer colonoscopists some practical recommendations about colonoscopic diagnosis and hemostasis of patients with severe hematochezia and a presumed diagnosis of diverticular hemorrhage. For a critical review of the topic and as an evidence-based approach, these are important for both the readers of the current report and reviewers of future articles about severe hematochezia and how the diagnosis of diverticular hemorrhage is made and treated.

Unsedated colonoscopy: an option for some but not for all

2012-02-01

Background: The increasing request for colonoscopy in clinical practice, coupled with the lack of time, has led to a renewed interest in unsedated procedures. Objective: To evaluate the acceptability of unsedated colonoscopy and to characterize the subset of patients more likely to undergo and complete the procedure without sedation and/or analgesia. Design: Prospective, population study. Setting: Nonacademic community hospital, 6-month observation period. Patients: Adult outpatients referred for colonoscopy were offered unsedated procedure, with the possibility of on-demand sedation. Interventions: Demographics, clinical features, and endoscopy outcomes were recorded. Data were analyzed by stepwise logistic regression analysis, and odds ratio (OR) and 95% confidence interval (CI) are given for significant variables. Main Outcome Measurements: Unsedated colonoscopy acceptance rate. Factors significantly associated with acceptance and completion of unsedated procedures. Results: The acceptance rate for unsedated colonoscopy was 56.2% of 964 consecutive evaluated patients. The cecal intubation rate in unsedated patients was 81.6% and increased to 97.3% with the option of on-demand sedation. At multivariate analysis, factors significantly associated with the acceptance were no previous colonoscopy (OR 1.52; 95% CI, 1.10-2.11), absent/low level of anxiety (OR 3.82; 95% CI, 2.71-5.38), and no concern about the examination (OR 1.80; 95% CI, 1.17-2.77). Fear of procedure-related pain was inversely associated with acceptance (OR 0.28; 95% CI, 0.17-0.35). Factors associated to drug-free colonoscopy completion were absence of preprocedure anxiety (OR 1.87; 95% CI, 1.08-3.21) and male sex (OR 3.59; 95% CI, 2.13-6.05). Limitations: Single-center study. Conclusion: The acceptance rate of unsedated colonoscopy is clinically relevant, and the procedure can be completed without sedation in the majority of patients. Subject-related factors may help to identify patients willing to undergo and potentially complete unsedated procedures.

Continuing Medical Education Exam: February 2012

2012-02-01

Endoscopic mucosal ablation: a new argon plasma coagulation/injection technique to assist complete resection of recurrent, fibrotic colon polyps (with video)

Zacharias P. Tsiamoulos, Leonidas A. Bourikas, Brian P. Saunders — 2011-12-09

Background: Incomplete piecemeal EMR of large, sessile/flat colon polyps results in polyp recurrence, with massive submucosal scarring making subsequent attempts at endoscopic resection problematic. Objective: We report our experience with a new endoscopic mucosal ablation (EMA) technique that can be used to complement the eradication of recurrent fibrotic colon polyps. Design: Single-center, retrospective case series. Setting: Tertiary-care referral academic endoscopy unit. Patients: This study involved consecutive patients referred for endoscopic excision of recurrent benign colon polyps with severe submucosal fibrosis (>30% of the entire lesion). Intervention: Application of high-power argon plasma coagulation (APC), preceded by injection of a submucosal fluid cushion (normal saline/diluted adrenaline and/or sodium hyaluronate solution) to protect the muscle layer, was performed to augment further piecemeal EMR and polyp eradication. Main Outcome Measurements: Technical safety and success, complication and recurrence rates. Results: Fourteen patients (mean age 73 years; 9 men, 5 women) with 15 recurrent colon adenomas (mean polyp size 30 mm, 9 proximal/6 distal) were included. EMA with a mean APC power setting of 55 W was applied. Complete polyp eradication was achieved in 9 of 11 patients (82%) at first or second completed follow-up. One patient needed laparoscopic colectomy because of cancer, and 1 underwent transanal endoscopic microsurgery for benign massive recurrence. The other 3 patients with small, easily treatable recurrence (≤3 mm) were followed by 1-year-surveillance. No perforations and no postpolypectomy syndrome were reported. Limitations: Single-center, nonrandomized case series with short duration follow-up. Conclusion: EMA appears to be a safe and easily applicable technique to assist the complete eradication of recurrent fibrotic colon polyps.

In vivo histologic imaging of the muscularis propria and myenteric neurons with probe-based confocal laser endomicroscopy in porcine models (with videos)

2012-02-01

Background: The submucosal tunneling technique enables us to endoscopically access deeper tissue layers. Use of probe-based confocal laser endomicroscopy (pCLE) provides optical histologic imaging on the site. Objective: To determine the technical feasibility of ex vivo and in vivo pCLE imaging of the muscularis propria and myenteric neurons by using submucosal endoscopy with a mucosal flap safety valve (SEMF). Design: Acute porcine model study. Setting: Animal laboratory. Intervention: Two ex vivo and 6 in vivo porcine models were used. A submucosal space was created with SEMF, and a neuronal molecular probe was topically applied onto the muscularis. Confocal imaging of the stained muscularis was performed by using pCLE. The selected sites were sampled, and the histopathology of the sites was analyzed. Main Outcome Measurements: The two main outcome measures were the procedural success rate of submucosal access and the correlation between pCLE and histologic images. Results: Submucosal access to the pCLE study site was successful in all attempts (100%; 17/17 sites). The muscularis propria was visualized with pCLE in the ex vivo and in vivo porcine models in 83.3% of sites (20/24), and the neuron-like cells were identified in 41.7% of sites (10/24). Limitations: Animal experiment. Conclusion: The muscularis propria and myenteric neurons could be selectively visualized with pCLE in vivo.

An endoscopic wireless gastrostimulator (with video)

2012-02-01

Background: Gastric electric stimulation (GES) at a high-frequency, low-energy setting is an option for treating refractory gastroparesis. The currently available commercial stimulator, the Enterra neurostimulator (Medtronic Inc, Minneapolis, MN), however, requires surgical implantation and is powered by a nonrechargeable battery. Objective: To develop and test a miniature wireless GES device for endoscopic implantation in an experimental model. Design: In-vivo gastric signals were recorded and measured in a nonsurvival swine model (n = 2; 110-lb animals). Intervention: An endoscopically placed, wireless GES device was inserted into the stomach through an overtube; the two GES electrodes were endoscopically attached to the gastric mucosa and secured with endoclips to permit stimulation. Main Outcome Measurements: Stable electrogastrogram measures were observed during GES stimulation. Results: Electrogastrogram recordings demonstrated that gastric slow waves became more regular and of constant amplitudes when stomach tissues were stimulated, in comparison with no stimulation. The frequency-to-amplitude ratio also changed significantly with stimulation. Limitation: Nonsurvival pig studies. Conclusion: Gastric electric stimulation is feasible by our endoscopically implanted, wireless GES device.

Initial design of a novel suction enteroscope for endoscopic locomotion in the small bowel (with video)

Mihir S. Wagh, Roberto Montane — 2011-12-02

Background: The upper GI tract and the colon are readily accessible endoscopically, but the small intestine is relatively difficult to evaluate. Objective: To demonstrate the feasibility of using suction as a means of locomotion and to assess the initial design of a suction enteroscope. Design: Feasibility study. Setting: Animal laboratory. Intervention: Various prototype suction devices designed in our laboratory were tested in swine small intestine in a force test station. For in vivo experiments in live anesthetized animals, two suction devices (1 fixed tip and 1 movable tip) were attached to the outside of the endoscope. By creating suction in the fixed tip, the endoscope was anchored while the movable tip was advanced. Suction was then applied to the extended tip to attach it to the distal bowel. Suction on the fixed tip was then released and the movable tip with suction pulled back, resulting in advancement of the endoscope. These steps were sequentially repeated. Intestinal segments were sent for pathologic assessment after testing. Results: Force generated ranged from 0.278 to 4.74 N with 64.3 to 88 kPa vacuum pressure. A linear relationship was seen between the pull force and vacuum pressures and tip surface area. During in vivo experiments, the endoscope was advanced in 25-cm segmental increments with sequential suction-and-release maneuvers. No significant bowel trauma was seen on pathology and necropsy. Limitation: The enteroscopy system requires further refinement. Conclusion: A novel suction enteroscope was designed and tested. Suction tip characteristics played a critical role impacting the functionality of this enteroscopy system.

Gastric involvement by mantle cell lymphoma observed by magnified endoscopy with narrow-band imaging

2012-02-01

An 83-year-old man was admitted to our hospital because of tarry stools. EGD showed a reddish gastric erosion with a linear ulcerated scar (). Magnified endoscopy with narrow-band imaging revealed the area around the scar to have an altered microsurface structure with a lack of epithelium and some abnormal microvessels without caliber changes (, arrows). Endoscopic mucosal biopsy specimens taken from the lesion showed diffuse proliferation of medium-sized abnormal lymphoid cells with dense nuclei (), and immunohistochemical analysis was positive for cyclin D1, CD5, CD20, Bcl-1, and Bcl-2 but negative for CD3 and CD10. Therefore, we speculated that this endoscopic finding represented an abnormal aggregation of lymphoid tissue. When the abdominal CT scan showed multiple enlarged cervical and abdominal lymph nodes, with a maximum diameter of 5 cm, the patient was diagnosed as having gastric involvement of mantle cell lymphoma. Bone marrow aspiration revealed an aggregation of monocytes positive for cyclin D1, CD3, CD5, and Bcl-2 but negative for CD10, which was compatible with mantle cell lymphoma. Chemotherapy with pirarubicin, cyclophosphamide, vincristine, prednisolone, and rituximab was given for 5 months, after which the gastric lesion and lymph node swelling improved (). The patient has been in remission clinically and on repeat CT and EGD for 1 year.

Unusual presentation of MALT lymphoma as diffuse gastric erythema

Chien-Huan Chen, Rish Pai — 2012-02-01

A 59-year-old white man was admitted with sudden onset of dysphagia, nausea, and vomiting. He had no abdominal pain, fever, night sweats, or weight loss. Physical examination and basic blood tests showed normal results. EGD revealed multiple distal esophageal ulcers ( ) and Candida esophagitis. The stomach and duodenum were unremarkable. There was no evidence of HIV, cytomegalovirus, or herpes simplex virus infection. His symptoms improved with acid suppression and antifungal therapy. EGD 2 months later revealed a normal esophagus and diffuse erythema in the gastric fundus and body resembling portal hypertensive gastropathy ( ). Gastric biopsy, however, showed MALT lymphoma ( ) with strong CD20 immunohistochemistry staining, but no evidence of Helicobacter pylori infection. A 10-day course of omeprazole, bismuth, metronidazole, and tetracycline was given because IgG serologies were positive for H pylori, and a urea breath test was negative 6 weeks later. EGD 10 weeks after H pylori eradication revealed worsening erythema of stomach ( ), and a repeat biopsy showed persistent gastric MALT lymphoma. He ultimately received radiation therapy and at follow-up was in remission.

Ischemic colitis with diverticular sparing

Jochim S. Terhaar sive Droste, Stijn J.B. Van Weyenberg — 2011-12-12

A 78-year-old man presented with a 2-day history of abdominal pain and diarrhea mixed with blood. On physical examination, his temperature was 37.6°C, blood pressure was 110/65 mm Hg, and pulse rate was irregular at 70 beats per minute. His abdomen was slightly distended with normal bowel sounds and without rebound tenderness or peritoneal guarding. The hemoglobin level was normal. Colonoscopy revealed erythema with ulcers throughout the sigmoid colon and multiple diverticula that were all surrounded by normal-appearing mucosa ( and ); the rectum and descending colon were normal. Biopsy specimens of the erythematous mucosa showed edema, inflammatory infiltration of the lamina propria, and intravascular platelet thrombi, all consistent with acute ischemic colitis. Biopsy specimens of the mucosa surrounding the diverticula revealed normal mucosa. The patient recovered quickly, without specific therapy.

Complete closure of a colonic bleeding diverticulum using endoscopic hemoclip and band ligation

2011-12-12

A 66-year-old woman visited our emergency department after having 6 episodes of hematochezia. Initial laboratory data included a Hb level of 12.1g/dL (normal range, 12-16 g/dL), white blood cell count of 7900/mm3 (4000-10,000/mm3), and platelet count of 374,000/mm3 (130,000-450,000/mm3). Colonoscopy revealed diverticulosis from the sigmoid to ascending colon. After extensive washing and instillation of water in the general area of diverticulosis, a 0.4-cm diverticulum was visualized 36 cm from the anal verge, with fresh blood trickling out; no visible vessel was seen. The bleeding site was clipped by using a hemoclip ( ). Despite what we believed to be good placement of the hemoclip, we could not achieve hemostasis ( ). Because of ongoing bleeding, the lesion was gently aspirated into the ligator device (MD-48709; Akita Sumitomo Bakelite Co, Ltd, Tokyo, Japan) ( ), and an elastic band was placed around its base ( ). Hemostasis was achieved, and the patient was discharged from the hospital 2 days later. No further bleeding and no adverse effects were noted throughout the hospital course or during subsequent outpatient follow-up.

Weck clip migration into the rectum

Abhitabh Patil, Srinadh Komanduri — 2012-02-01

A 70-year-old man was referred for further evaluation of a submucosal rectal nodule ( ), discovered incidentally on routine colonoscopy. Three years before the procedure, the patient underwent an uncomplicated robot-assisted laparoscopic prostatectomy for localized prostate cancer. Careful endoscopic inspection revealed a penetrating foreign body–type lesion (). Snare extraction of the lesion revealed an eroded hemostatic Weck clip. The unused Weck clips are shown ().

Use of a forward-viewing echoendoscope for evaluation of GI submucosal lesions

David L. Diehl, Amit S. Johal, Viet-Nhan H. Nguyen, Hashem J. Hashem — 2012-02-01

EUS has earned a secure position as a very useful procedure to investigate GI submucosal lesions (SMLs). Interrogation of these lesions with EUS allows differentiation between extrinsic impressions of nearby organs from true masses under the mucosal layer. In addition, the echoendoscopic appearance frequently suggests the correct diagnosis, and, if needed, FNA can be done for cytologic diagnosis. Precise measurement of the size of the lesion can be done, and serial EUS examinations can determine whether there is growth of the lesion.

Early additional endoscopic submucosal dissection in patients with positive lateral resection margins after initial endoscopic submucosal dissection for early gastric cancer

2012-02-01

Endoscopic submucosal dissection (ESD) has become the standard treatment for early gastric cancer (EGC). Compared with EMR, ESD resects larger tumors en bloc, thereby permitting more precise pathologic assessment compared with piecemeal EMR. These features serve to justify the expanded use of ESD in patients with EGCs without clinical evidence of lymph node metastasis. Approximately 5% to 10% of patients undergoing ESD have incomplete resections, as follows: the presence of tumor in the resection margin and deep submucosal or lymphovascular invasion in the resected specimen. In these cases, gastrectomy has usually been performed for secondary treatment. Given the complications and consequent decrease in quality of life after surgery and recent advances in the ESD technique, early additional ESD may be another treatment option. There have been no reports of the usefulness of early additional ESD. We report the usefulness of early additional ESD in patients with positive lateral resection margins after initial ESD for EGCs.

Fistulization in the GI tract in acute pancreatitis

2011-12-12

Severe acute pancreatitis is known to be complicated by fistulization into the neighboring organs, but reports of such patients are scarce. Pancreatocolonic fistulae are the most common, whereas pancreatogastric fistulae are the rarest. The majority of these fistulae are found after necrosectomy, and the diagnosis is rarely made preoperatively. The aim of this study was to retrospectively analyze the clinical presentation, profile, course, and outcome of patients with acute pancreatitis with GI fistulae presenting at our institution.

Diagnostic and therapeutic peroral direct cholangioscopy in patients with altered GI anatomy (with videos)

2011-12-12

Peroral cholangioscopy (POCS) by using the mother-baby system was developed for the diagnosis of biliary diseases. Since then, peroral fiberoptic cholangioscopy and, recently, video cholangioscopy have been increasingly used not only for diagnosis but also for therapeutic interventions in bile duct pathology.

Duodenal bulb nodularity: an endoscopic sign of cow's milk protein allergy in infants?

Abdulrahman Al-Hussaini, Mosa Khormi, Mosa Fagih — 2012-02-01

To our knowledge, the endoscopic and histologic descriptions of children with cow's milk protein allergy (CMPA) are limited to case descriptions of children with food allergy and lymphoid nodularity of the duodenal bulb. Reports of intestinal lymphonodular hyperplasia (LNH) in children usually refer to colonic or ileal LNH, and we are unaware of any reports on the significance of duodenal LNH in infants. We report an association between LNH of the duodenal bulb and CMPA in infants with previous diagnoses of gastroesophageal reflux (GER) who subsequently experienced hematemesis and required upper endoscopy.

A case of upper GI “pseudobleeding”

Joachim Guntau, Guntram Lock — 2011-04-15

An 82-year-old male patient with severe dyspnea and decompensated left heart failure was admitted for aortic and mitral valve replacement to the cardiothoracic surgery department of our hospital.

Fully endoscopic removal of migrated mesh after laparoscopic fundoplication eroded into the gastroesophageal junction: a case report (with video)

2011-06-16

Diaphragmatic crural mesh reinforcement significantly reduces recurrence after laparoscopic hiatal hernia repair. Complications, including esophageal mesh erosion and stenosis requiring surgical resection, are known. Endoscopic removal of migrated intraluminal mesh has been described. We report the successful endoscopic retrieval of migrated intraluminal mesh followed by stenting.

Endoscopic full-thickness resection of a gastric subepithelial tumor by using the submucosal tunnel technique with the patient under conscious sedation (with video)

2011-06-16

Recently, several investigators have reported the feasibility of endoscopic full-thickness resection (EFTR) of gastric lesions with a hybrid technique involving laparoscopic assistance and general anesthesia in humans. Here, we present a case of EFTR by using the submucosal tunnel technique in a patient with a gastric subepithelial tumor, with the patient under conscious sedation.

EUS-guided fistulization of postoperative colorectal stenosis in an infant with Hirschsprung's disease: a new technique

2011-05-30

Hirschsprung's disease may be treated by surgical resection of the aganglionic portion of the colon. Benign stricture of the anastomosis can occur and may be treated by surgery or endoscopic dilations. In this case we describe a feasible and effective technique of EUS-guided fistulization of complete postoperative colorectal stenosis in a case of Hirschsprung's disease.

A gigantic ectopic pancreatic lesion in the upper body of the stomach

2012-02-01

Endoscopy and radiography lead to the correct diagnosis in most patients with ectopic pancreas. Gastric lesions are found at the antrum in 85% to 95% of patients, either on the posterior or anterior wall, most commonly along the greater curvature. The most common characteristic gross feature is a central depression, which corresponds to a ductal orifice. Histopathologic diagnosis is straightforward when pancreatic acini, ducts, islets of Langerhans, and intervening connective tissue are present. Here we report a case of a large, ectopic, pancreatic mass, about 7 cm in size, which was incidentally found in an unusual location during screening gastroscopy. To our knowledge, this is the first description of such a large, ectopic, pancreatic lesion in an unusual location.

Direct percutaneous endoscopic jejunostomy tube placement using double-balloon enteroscopy

Klaus Mönkemüller, Klaus Vormbrock, Marco Kassalik, Aytekin Sancar — 2012-02-01

The advent of the double-balloon enteroscope (DBE) has increased our ability to navigate the small bowel and perform small bowel as well as biliary tract interventions in patients with complex postsurgical anatomy. Herein we present a case of successful DBE-assisted placement of a direct percutaneous endoscopic jejunostomy (DPEJ).

Erratum

2012-02-01

In the article, “Outcomes of T1b esophageal adenocarcinoma patients,” by Tian et al., which appeared in the December 2011 issue of GIE (Gastronintest Endosc 2011;74:1201-6), there was an error in the Abstract and in the list of abbreviations. The correct version of each follows.

2012-02-01

Editors

2012-02-01

Focus on…

2012-02-01

ASGE Update

2012-02-01

In upcoming issues…

2012-02-01

Information for readers

2012-02-01

Gastrointestinal Endoscopy

Principles of training in GI endoscopy

Validation of the Prague C & M criteria for the endoscopic grading of Barrett's esophagus by gastroenterology trainees: a multicenter study

Diagnostic accuracy of EUS in differentiating mucosal versus submucosal invasion of superficial esophageal cancers: a systematic review and meta-analysis

Strategies for training in diagnostic upper endoscopy: a prospective, randomized trial

Ain't nothing like the real thing? Simulators in endoscopy training

Mortality from nonulcer bleeding is similar to that of ulcer bleeding in high-risk patients with nonvariceal hemorrhage: a prospective database study in Italy

Nonvariceal upper GI bleeding: it's not just about peptic ulcers

Endoscopic submucosal dissection for treatment of gastric subepithelial tumors (with video)

Use of self-expandable stents in the treatment of bariatric surgery leaks: a systematic review and meta-analysis

Endoscopic stenting is not as effective for palliation of colorectal obstruction in patients with advanced gastric cancer as emergency surgery

Endoscopic intrapyloric injection of botulinum toxin A in the treatment of children with gastroparesis: a retrospective, open-label study

High yield of same-session EUS-guided liver biopsy by 19-gauge FNA needle in patients undergoing EUS to exclude biliary obstruction

EUS-guided FNA for diagnosis of solid pancreatic neoplasms: a meta-analysis

EUS or percutaneously guided intratumoral TNFerade biologic with 5-fluorouracil and radiotherapy for first-line treatment of locally advanced pancreatic cancer: a phase I/II study

Guidewire biliary cannulation does not reduce post-ERCP pancreatitis compared with the contrast injection technique in low-risk and high-risk patients

Diagnostic accuracy of conventional and cholangioscopy-guided sampling of indeterminate biliary lesions at the time of ERCP: a prospective, long-term follow-up study

Comparison of EUS-guided rendezvous and precut papillotomy techniques for biliary access (with videos)

EUS-guided biliary rendezvous: EUS to the rescue

A multicenter, prospective, randomized study of selective bile duct cannulation performed by multiple endoscopists: the BIDMEN study

Blinded nonrandomized comparative study of gastric examination with a magnetically guided capsule endoscope and standard videoendoscope

Endoscopic band ligation for colonic diverticular hemorrhage

The ins and outs of diverticular bleeding

Unsedated colonoscopy: an option for some but not for all

Continuing Medical Education Exam: February 2012

Endoscopic mucosal ablation: a new argon plasma coagulation/injection technique to assist complete resection of recurrent, fibrotic colon polyps (with video)

In vivo histologic imaging of the muscularis propria and myenteric neurons with probe-based confocal laser endomicroscopy in porcine models (with videos)

An endoscopic wireless gastrostimulator (with video)

Initial design of a novel suction enteroscope for endoscopic locomotion in the small bowel (with video)

Gastric involvement by mantle cell lymphoma observed by magnified endoscopy with narrow-band imaging

Unusual presentation of MALT lymphoma as diffuse gastric erythema

Ischemic colitis with diverticular sparing

Complete closure of a colonic bleeding diverticulum using endoscopic hemoclip and band ligation

Weck clip migration into the rectum

Use of a forward-viewing echoendoscope for evaluation of GI submucosal lesions

Early additional endoscopic submucosal dissection in patients with positive lateral resection margins after initial endoscopic submucosal dissection for early gastric cancer

Fistulization in the GI tract in acute pancreatitis

Diagnostic and therapeutic peroral direct cholangioscopy in patients with altered GI anatomy (with videos)

Duodenal bulb nodularity: an endoscopic sign of cow's milk protein allergy in infants?

A case of upper GI “pseudobleeding”

Fully endoscopic removal of migrated mesh after laparoscopic fundoplication eroded into the gastroesophageal junction: a case report (with video)

Endoscopic full-thickness resection of a gastric subepithelial tumor by using the submucosal tunnel technique with the patient under conscious sedation (with video)

EUS-guided fistulization of postoperative colorectal stenosis in an infant with Hirschsprung's disease: a new technique

A gigantic ectopic pancreatic lesion in the upper body of the stomach

Direct percutaneous endoscopic jejunostomy tube placement using double-balloon enteroscopy

Erratum

Contents

Editors

Focus on…

ASGE Update

In upcoming issues…

Information for readers