Gastrointestinal Endoscopy

2010-02-01

Editors

2010-02-01

Focus On…

2010-02-01

ASGE Update

2010-02-01

In Upcoming Issues…

2010-02-01

Information for readers

2010-02-01

Imaging of subsquamous Barrett's epithelium with ultrahigh-resolution optical coherence tomography: a histologic correlation study

2009-10-21

Background: Optical coherence tomography (OCT) is being developed as a potentially valuable method for high-resolution cross-sectional imaging of the esophageal mucosal and submucosal layers. One potential application of OCT imaging is to identify subsquamous Barrett's epithelium in patients who have undergone ablative therapy, which is not visible on standard endoscopic examination. However, histologic correlation confirming the ability of OCT to image subsquamous Barrett's epithelium has yet to be performed.Design: Histologic correlation study.Objective: To perform histologic correlation of ultrahigh-resolution optical coherence tomography (UHR-OCT) imaging for identification of subsquamous Barrett's epithelium.Setting: Academic Medical Center (University of Washington, Seattle, WA).Patients: Fourteen patients with pathologic biopsy specimens, proven to be high-grade dysplasia or adenocarcinoma underwent esophagectomy.Interventions: UHR-OCT imaging was performed on ex vivo esophagectomy specimens immediately after resection.Main Outcome Measurements: Correlation of UHR-OCT images with histologic images.Results: Subsquamous Barrett's epithelium was clearly identified by using UHR-OCT images and was confirmed by corresponding histology.Limitations: Difficulty distinguishing some subsquamous Barrett's glands from blood vessels in ex vivo tissue (because of the lack of blood flow) in some cases. Imaging was performed with a bench-top system.Conclusions: Results from this study demonstrate that UHR-OCT imaging is capable of identifying subsquamous Barrett's epithelium.

Optical coherence tomography in Barrett's esophagus: the road to clinical utility

Anne F. Peery, Nicholas J. Shaheen — 2010-02-01

Will gastroenterologists ever push the “OCT button” on their endoscopes to obtain clinically actionable images?

Does Barrett's esophagus respond to chemoradiation therapy for adenocarcinoma of the esophagus?

2009-12-09

Background: Adenocarcinoma of the esophagus is frequently associated with Barrett's esophagus (BE). The response of esophageal adenocarcinoma to chemoradiation therapy is well described; however, the effect of chemoradiation on tumor-associated BE has not been specifically reported.Objective: To determine the response of tumor-associated BE to chemoradiation therapy.Design: Retrospective cohort study.Setting: A single National Cancer Institute Comprehensive Cancer Care Center experience.Patients: The study cohort consisted of 43 patients with stage I to IVA esophageal adenocarcinoma associated with BE who received either neoadjuvant or definitive chemoradiation therapy and underwent either esophagectomy or surveillance at our institution.Main Outcome Measurement: The presence and extent of BE after chemoradiation therapy of esophageal adenocarcinoma associated with endoscopically documented pretreatment BE.Results: BE persisted after chemoradiation therapy in 93% (40/43) of cases (95% CI, 83%-99%). Twenty-seven patients received neoadjuvant chemoradiation therapy before esophagectomy. Persistent BE was detected in all 27 surgical specimens (100%). In 59% (16/27) of the cases, there was complete pathologic tumor response. Sixteen patients received definitive chemoradiation therapy. Persistent pretreatment BE was identified in 88% (14/16) by surveillance endoscopy (95% CI, 60%-98%). The mean length of BE before and after chemoradiation was 6.6 cm and 5.8 cm, respectively (P = .38).Limitations: Retrospective design, small sample size, and single-site data collection.Conclusions: Chemoradiation therapy of esophageal adenocarcinoma does not eliminate tumor-associated BE, nor does it affect the length of the BE segment.

A second-look endoscopy after endoscopic submucosal dissection for gastric epithelial neoplasm may be unnecessary: a retrospective analysis of postendoscopic submucosal dissection bleeding

2009-11-18

Background: Endoscopic submucosal dissection (ESD) is one of the curative endoluminal surgical procedures for gastric epithelial neoplasms. There has been little research on bleeding after gastric ESD.Objective: To investigate cases of post-ESD bleeding and to verify whether a second-look endoscopy after ESD is effective in the prevention of delayed bleeding.Design: A retrospective study with consecutive data.Setting: A single tertiary referral center.Subjects: A total of 454 gastric epithelial neoplasms (386 early gastric cancers and 68 gastric adenomas).Interventions: ESD and second-look endoscopy.Main Outcome Measurements: Predictors on post-ESD bleeding by univariate analysis, incidence of post–ESD bleedings, and the timing of those before and after second-look endoscopy.Results: Post–ESD bleeding occurred in 26 (5.7%) lesions. Gross type (flat or depressed type) was the only factor influencing post-ESD bleeding. All cases of post-ESD bleeding occurred within 14 days after ESD (median 2; range 0-14), and bleeding tended to occur from the lower and upper stomach earlier and later, respectively. In 19 lesions with delayed bleeding more than 24 hours after ESD, the maximum delayed bleeding rates before and after the second-look endoscopy were 2.8% and 2.5%, respectively.Limitations: A retrospective, single-center analysis.Conclusions: A second-look endoscopy after gastric ESD may contribute little to the prevention of delayed bleeding.

Periductal hypoechoic sign: an endosonographic finding associated with pancreatic malignancy

2009-11-18

Background: Despite advances in imaging, differentiating benign from malignant causes of pancreatic duct dilation is difficult.Objective: The aim of our study was to assess the accuracy of the periductal hypoechoic sign (PHS), defined as patchy hypoechoic areas adjacent to a dilated pancreatic duct, for the diagnosis of pancreatic malignancy.Design: Single-center, retrospective analysis.Setting: Tertiary care university hospital.Patients: All patients who underwent EUS from 2006 to 2008 for evaluation of pancreatic pathology were identified. Those with pancreatic duct dilation of 4 mm or more in the head of the pancreas or 3 mm or more in the body or tail were included. Digitally recorded EUS images were analyzed for PHS by 1 endoscopist blinded to final results. The final diagnosis was based on pathology results or clinical follow-up.Results: During the study period, 84 of 427 patients who underwent EUS for pancreas pathology had dilated pancreatic ducts. Of these, 42 patients had benign disease and 42 had pancreatic malignancy. The PHS was noted in 31 (73.8%) of 42 patients with malignancy compared with 6 (14.3%) of 42 patients with benign disease (P < .001). The PHS had a sensitivity of 73.8%, a specificity of 85.7%, and an accuracy of 79.8% for the diagnosis of pancreatic malignancy. After adjusting for age, patients with the PHS were 17 times more likely to have a malignancy (odds ratio 16.66; 95% CI, 5.01-55.44). Pancreatic duct diameter or dilation of both bile and pancreatic ducts were not predictive of malignancy.Limitation: A retrospective design.Conclusions: The PHS was an accurate and independent predictor of pancreatic malignancy in patients with a dilated pancreatic duct.

What the heck is this new periductal hypoechoic sign?

John Affronti — 2010-02-01

What the heck is that thing? … I dunno! This is starting to sound like a Saturday Night Live skit that Steve Martin and Bill Murray used to do. In this month's issue of GIE, Sawhney et al describe a previously undefined sign that they demonstrate with EUS in patients suspected of having pancreatic cancer. They report that this new periductal hypoechoic sign (PHS) is associated with the finding of malignancy in patients who have a dilated pancreatic duct. Why has this finding only come to our attention now after more than 20 years of performing EUS on thousands of patients? What exactly are we seeing here? Moreover, is this sign really helpful in the clinical management of these patients? As is often the case with discoveries, science, and medicine, the more we see, the more questions we have. Or, in the lyrics of Don Henley, cofounder of the Eagles, “The more I know the less I understand.”

Survival in patients with pancreatic cancer after the diagnosis of malignant ascites or liver metastases by EUS-FNA

2009-11-18

Background: The expected survival after the EUS-FNA diagnosis of malignant ascites or liver metastases from pancreatic cancer is not known.Objective: To report overall and 1-year survival in these patients.Design: Retrospective cohort series.Setting: Tertiary referral hospital.Patients: Consecutive subjects with newly diagnosed pancreatic cancer from June 1998 and March 2008 in whom EUS-FNA of the liver or ascitic fluid confirmed hepatic metastases or malignant ascites.Interventions: Calculation of survival after diagnosis by using the Social Security Death Index.Main Outcome Measurements: Survival after EUS-FNA diagnosis of stage IV pancreatic cancer.Results: EUS-FNA identified liver metastases and malignant ascites from primary pancreatic cancer in 75 and 13 patients, respectively, and all 88 died during follow-up. For all 88 patients, the 1-year survival rate and median survival were 3.4% (95% CI, 1.1%-10.4%) and 82 days (range 2-754 days), respectively. The 1-year survival rates for those with liver metastases (4.0% [95% CI, 1.3%-12.1%]) and for those with malignant ascites (0% [95% CI, 0-24.7%]) were similar (P = 1.0). The median survival for patients with liver metastases of 83 days (range 2-754 days) was similar to that for those with malignant ascites (64 days; range 2-153 days) (P = .13). No clinical variable considered predicted survival of more than, less than, or 3 months.Limitations: Retrospective series with variable treatment for malignancy.Conclusions: In patients with pancreatic cancer, identification of malignant ascites or liver metastases by EUS-FNA is associated with a very poor prognosis.

Needle-knife sphincterotomy: factors predicting its use and the relationship with post-ERCP pancreatitis (with video)

2009-12-09

Background: In the absence of precut needle-knife sphincterotomy (NKS), failure of biliary cannulation may occur in up to 10% of cases. There are few prospective evaluations of the safety and efficacy of NKS, and studies of its early use in difficult cannulation have been inconclusive. Whether precut NKS after failure of primary biliary cannulation is independently associated with post-ERCP pancreatitis (PEP) remains controversial.Objective: To examine the relationship between NKS and PEP.Design: Analysis of prospectively collected data from two randomized trials of ERCP techniques, with PEP as the primary endpoint measure.Setting: Tertiary-care academic medical center.Patients: This study involved 732 patients from two successive, prospective, randomized trials of naïve papilla cannulation between November 2001 and April 2006. Patients with pancreatic or ampullary cancer were excluded.Intervention: Naïve papilla cannulation, NKS, primary guidewire versus contrast-assisted cannulation, and glyceryl trinitrate patch versus placebo.Main Outcome Measurements: PEP and procedure-related complications.Results: NKS was performed in 94 of 732 patients (12.8%) and was successful in achieving bile duct access in 80 of 94 patients (85%). Cannulation success in the entire group was 717 of 732 patients (97.7%). The overall frequency of PEP following NKS was 14.9% (14 of 94 patients) compared with 6.1% (39 of 638 patients) without NKS (P < .001). The incidence of PEP increased with an increasing number of attempts at cannulating the papilla. Pancreatic stents were inserted in 22 patients, 5 of whom developed pancreatitis. In multivariate analysis, independent predictors of PEP were as follow: female sex (odds ratio [OR] = 3.5, P = .028), suspected sphincter of Oddi dysfunction (SOD) (OR = 9.7, P < .001), partial pancreatic drainage (OR = 4.8, P = .011), 10 to 14 attempts at papilla cannulation (OR = 4.4, P = .031), and ≥15 attempts at papilla cannulation (OR = 9.4, P = .013). NKS was not an independent predictor of PEP. There were no perforations, no major bleeding, and no cases of severe pancreatitis in the NKS group.Limitations: Nonrandomized for NKS intervention.Conclusions: The number of attempts at cannulating the papilla is independently associated with PEP, and the risk increases with an increasing number of attempts. NKS is not an independent predictor of PEP.

Needle-knife sphincterotomy and post-ERCP pancreatitis: time to lower the threshold for the needle?

Tony C.K. Tham, Jo Vandervoort — 2010-02-01

Earlier use of needle-knife sphincterotomy (ie, lowering the threshold) for cases of difficult cannulation may ameliorate the occurrence of post-ERCP pancreatitis.

Difficult biliary cannulation: use of physician-controlled wire-guided cannulation over a pancreatic duct stent to reduce the rate of precut sphincterotomy (with video)

2009-11-19

Background: Successful cannulation of the common bile duct (CBD) remains the benchmark for ERCP. Use of a pancreatic duct (PD) stent to facilitate biliary cannulation has been described, although the majority of patients require precut sphincterotomy to achieve CBD cannulation.Objective: To report the performance characteristics of using a PD stent in conjunction with physician-controlled wire-guided cannulation (WGC) to facilitate bile duct cannulation.Design: Retrospective cohort.Setting: Two tertiary care, academic medical centers.Patients: All undergoing ERCP with native papillae.Intervention: In cases of difficult biliary access in which the PD is cannulated, a pancreatic stent is placed. After this, physician-controlled WGC is attempted by using the PD stent to direct the sphincterotome into the biliary orifice. If cannulation is unsuccessful after several minutes, a precut sphincterotomy is performed over the PD stent or the procedure is terminated.Main Outcome Measurements: Frequency of successful bile duct cannulation and precut sphincterotomy.Results: A total of 2345 ERCPs were identified, 1544 with native papillae. Among these, CBD and PD cannulation failed in 16 (1.0%) patients, whereas 76 (4.9%) patients received a PD stent to facilitate biliary cannulation. Successful cannulation was achieved in 71 (93.4%) of 76 patients, 60 (78.9%) of whom did not require precut sphincterotomy. Complications included mild post-ERCP pancreatitis in 4 (5.3%) and aspiration in 1 (1.3%). Precut sphincterotomy was complicated by hemorrhage, controlled during the procedure in 2 (13.3%) of 15.Conclusions: Physician-controlled WGC over a PD stent facilitates biliary cannulation while maintaining a low rate of precut sphincterotomy.

Indications and detection, completion, and retention rates of small-bowel capsule endoscopy: a systematic review

Zhuan Liao, Rui Gao, Can Xu, Zhao-Shen Li — 2010-02-01

Background: Capsule endoscopy (CE) has been widely used in clinical practice.Objective: To provide systematically pooled results on the indications and detection, completion, and retention rates of small-bowel CE.Design: A systematic review.Main Outcome Measurements: We searched the PubMed database (2000-2008) for original articles relevant to small-bowel CE for the evaluation of patients with small-bowel signs and symptoms. Data on the total number of capsule procedures, the distribution of different indications for the procedures, the percentages of procedures with positive detection (detection rate), complete examination (completion rate), or capsule retention (retention rate) were extracted and/or calculated, respectively. In addition, the detection, completion, and retention rates were also extracted and/or calculated in relation to indications such as obscure GI bleeding (OGIB), definite or suspected Crohn's disease (CD), and neoplastic lesions.Results: A total of 227 English-language original articles involving 22,840 procedures were included. OGIB was the most common indication (66.0%), followed by the indication of only clinical symptoms reported (10.6%), and definite or suspected CD (10.4%). The pooled detection rates were 59.4%; 60.5%, 55.3%, and 55.9%, respectively, for overall, OGIB, CD, and neoplastic lesions. Angiodysplasia was the most common reason (50.0%) for OGIB. The pooled completion rate was 83.5%, with the rates being 83.6%, 85.4%, and 84.2%, respectively, for the 3 indications. The pooled retention rates were 1.4%, 1.2%, 2.6%, and 2.1%, respectively, for overall and the 3 indications.Limitations: Inclusion and exclusion criteria were loosely defined.Conclusions: The pooled detection, completion, and retention rates are acceptable for total procedures. OGIB is the most common indication for small-bowel CE, with a high detection rate and low retention rate. In addition, angiodysplasia is the most common finding in patients with OGIB. A relatively high retention rate is associated with definite or suspected CD and neoplasms.

Safety and efficacy of double-balloon enteroscopy in pediatric patients

2009-11-16

Background: Although double-balloon enteroscopy (DBE) is performed increasingly often in adults, few findings are available on the use of DBE in pediatric patients in the published literature.Objectives: The aim of our study was to evaluate the safety and efficacy of DBE in pediatric patients.Design: A retrospective database review.Setting and Patients: A database analysis was performed on all pediatric patients (18 years old or younger) who underwent DBE at the Jichi Medical University Hospital between September 2000 and October 2008 selected from a total of 825 patients.Main Outcome Measurements: Clinical utility and safety of DBE in pediatric patients.Results: A total of 92 procedures were performed in 48 patients (27 male, 21 female) with a median age (range) of 12.2 (4-18) years. DBE was performed with the patients under general anesthesia in 43 procedures and under moderate sedation in 49 procedures. The most common indication for DBE was treatment of a stricture of a biliary anastomosis after living-donor liver transplantation with establishment of Roux-en-Y hepaticojejunostomy (23 patients). Endoscopic retrograde cholangiography using DBE was performed, and endoscopic therapy could be performed successfully in 13 (56%) patients. The second most common indication was obscure GI bleeding (10 patients); the lesions responsible for the bleeding were found in 7 (70%) patients. Other indications included surveillance and treatment of hereditary polyposis syndromes (5 patients), abdominal pain (4 patients), and inflammatory bowel disease (2 patients). The overall diagnostic yield was 65% (31 of the 48 patients). Postpolypectomy bleeding occurred in 1 case, but no other complications such as perforation and pancreatitis were observed.Limitations: Small number of patients, participation bias, and single center's experience.Conclusions: DBE is a safe and clinically useful endoscopic procedure in pediatric patients.

Balloon by balloon, inch by inch

Petar Mamula — 2010-02-01

Several important aspects of double-balloon endoscopy that are unique to the pediatric population—training; type of sedation used; comparison to experience in adults in terms of safety, technical difficulties, and procedure time and success; and the lack of instruments designed specifically for children, a factor that is very often the case in pediatric endoscopy—deserve further analysis.

Training and transfer of colonoscopy skills: a multinational, randomized, blinded, controlled trial of simulator versus bedside training

2009-11-04

Background: The Olympus colonoscopy simulator provides a high-fidelity training platform designed to develop knowledge and skills in colonoscopy. It has the potential to shorten the learning process to competency.Objective: To investigate the efficacy of the simulator in training novices in colonoscopy by comparing training outcomes from simulator training with those of standard patient-based training.Design: Multinational, multicenter, single-blind, randomized, controlled trial.Setting: Four academic endoscopy centers in the United Kingdom, Italy, and The Netherlands.Participants and Intervention: This study included 36 novice colonoscopists who were randomized to 16 hours of simulator training (subjects) or patient-based training (controls). Participants completed 3 simulator cases before and after training. Three live cases were assessed after training by blinded experts.Main Outcome Measurements: Automatically recorded performance metrics for the simulator cases and blinded expert assessment of live cases using Direct Observation of Procedural Skills and Global Score sheets.Results: Simulator training significantly improved performance on simulated cases compared with patient-based training. Subjects had higher completion rates (P=.001) and shorter completion times (P < .001) and demonstrated superior technical skill (reduced simulated pain scores, correct use of abdominal pressure, and loop management). On live colonoscopy, there were no significant differences between the 2 groups.Limitations: Assessment tools for live colonoscopies may lack sensitivity to discriminate between the skills of relative novices.Conclusion: Performance of novices trained on the colonoscopy simulator matched the performance of those with standard patient-based colonoscopy training, and novices in the simulator group demonstrated superior technical skills on simulated cases. The simulator should be considered as a tool for developing knowledge and skills prior to clinical practice.

Computers for colonoscopy training: where do they fit in?

Jonathan Cohen — 2010-02-01

Virtual reality colonoscopy simulators may enhance the learning process, improve patient comfort, and reduce the time required for labor-intensive expert supervision.

Time-gated fluorescence spectroscopy improves endoscopic detection of low-grade dysplasia in ulcerative colitis

2009-12-09

Background: Dysplasia in ulcerative colitis is frequently missed with 4-quadrant biopsies. An experimental setup recording delayed fluorescence spectra simultaneously with white light endoscopy was recently developed.Objective: We compared detection of invisible flat intraepithelial neoplasia with protoporphyrin IX fluorescence and standard 4-quadrant biopsies.Design: Prospective, crossover design without randomization of the order of procedures.Setting: Gastroenterology Department, Humboldt University, Charité, Berlin, Germany.Patients: Forty-two patients with extensive ulcerative colitis of more than 10 years' duration were included.Interventions: Colonoscopy with 4-quadrant biopsies and targeted biopsies of macroscopic lesions and time-gated fluorescence–guided colonoscopy were performed 2 weeks apart by 2 blinded endoscopists. Three independent pathologists examined the biopsy specimens.Main Outcome Measurements: The primary outcome criterion was detection rate of invisible flat intraepithelial neoplasia.Results: Invisible flat intraepithelial neoplasia was detected in 3 (7%) patients by white light 4-quadrant biopsies and in 10 (24%) patients by fluorescence-guided endoscopy (P = .02). The sensitivity and specificity for differentiating patients with and without dysplasia were 100% and 81%, respectively. Dysplastic and nondysplastic mucosa could be discriminated with a sensitivity and specificity of 73% and 81%, respectively.Limitations: The trial was not randomized.Conclusion: The detection rate of intraepithelial neoplasia in patients with ulcerative colitis can be improved by fluorescence-guided colonoscopy.

Colonoscopy training in gastroenterology fellowships: determining competence

2009-08-03

Background: Although 140 colonoscopies is the recommended minimal requirement for gastroenterology fellows, it is unclear whether this minimum is a surrogate for competence.Objective: To assess whether 140 colonoscopies is an adequate threshold to determine ≥90% colonoscopy performance independence.Design: Retrospective analysis on a database constructed for quality control/improvement.Setting: Gastroenterology fellowship training program at a veterans hospital.Patients: Consecutive patients who underwent colonoscopy primarily for symptoms, previous polyps, or family history of cancer (a minority were performed for screening only) from April 2007 to September 2008. This study involved 11 gastroenterology fellows who performed 770 colonoscopies during 18 individual month-long rotations.Intervention: Assessment of various procedure-related parameters.Main Outcome Measurements: Determining when ≥90% independence in colonoscopy performance was reached.Results: Total colonoscopy time, time to cecal intubation, withdrawal time, and independent completion rates all significantly improved when first and third years of training were compared (P < .001 for all comparisons). The adenoma detection rate did not change between years of training. Independent completion was achieved in ≥90% of cases for all fellows after 500 colonoscopies, whereas no fellow reached a ≥90% independent colonoscopy completion rate after 140 colonoscopies.Limitations: Number of participants, single center.Conclusions: Becoming a competent colonoscopist requires repeated practice. Our study suggests that, although there is variability between a trainee's ability to become colonoscopy independent, 500 colonoscopies are likely required to ensure reliable (≥90%) independent completion rates. Competency requires more than a single parameter.

North of 100 and south of 500: where does the “sweet spot” of colonoscopic competence lie?

John J. Vargo — 2010-02-01

Those who speak most of progress measure it by quantity and not by quality.—George Santayana

Characterization of forces applied by endoscopists during colonoscopy by using a wireless colonoscopy force monitor

2009-11-18

Background: To perform a colonoscopy, the endoscopist maneuvers the colonoscope through a series of loops by applying force to the insertion tube. Colonoscopy insertion techniques are operator dependent but have never been comprehensively quantified.Objective: To determine whether the Colonoscopy Force Monitor (CFM), a device that continually measures force applied to the insertion tube, can identify different force application patterns among experienced endoscopists.Design: Observational study of 6 experienced endoscopists performing routine diagnostic and therapeutic colonoscopy in 30 patients.Setting: Outpatient ambulatory endoscopy center.Patients: Adult male and female patients between 30 and 75 years of age undergoing routine colonoscopy.Interventions: CFM monitoring of force applied to the colonoscope insertion tube during colonoscopy.Main Outcome Measurements: Maximum and mean linear and torque force, time derivative of force, combined linear and torque vector force, and total manipulation time.Results: The CFM demonstrates differences among endoscopists for maximum and average push/pull and mean torque forces, time derivatives of force, combined push/torque force vector, and total manipulation time. Endoscopists could be grouped by force application patterns.Limitations: Only experienced endoscopists using conscious sedation in the patients were studied. Sample size was 30 patients.Conclusions: This study demonstrates that CFM allows continuous force monitoring, characterization, and display of similarities and differences in endoscopic technique. CFM has the potential to facilitate training by enabling trainees to assess, compare, and quantify their techniques and progress.

Variations between endoscopists in rates of detection of colorectal neoplasia and their impact on a regional screening program based on colonoscopy after fecal occult blood testing

2009-11-18

Background: There are few data about the performance variability among endoscopists participating to nationwide or regionwide colorectal cancer screening programs.Objective: To assess the variability of neoplasia detection rates among endoscopists participating in a regional colorectal cancer screening program based on colonoscopy after biennial fecal occult blood testing (FOBT).Design: Two rounds of colonoscopy were performed: round 1 took place in 2003 and 2004, and round 2 took place in 2005 and 2006. Secondary analysis of colonoscopy findings from the first 2 rounds was performed by using data drawn from all endoscopists who performed more than 30 colonoscopies in each round. Detection rates were adjusted for patient age and sex, and logistic regression analyses were conducted including these 2 variables and round number (1 or 2).Setting: District of Ille-et-Vilaine in Brittany (population >900,000) between 2003 and 2007.Main Outcome Measurements: The per-endoscopist adjusted rates of colonoscopies with at least 1, 2, or 3 adenomas, 1 adenoma 10 mm or larger, or a cancer.Results: Among the 18 endoscopists who performed 3462 colonoscopies, the adjusted detection rates were in the following ranges: at least 1 adenoma, 25.4% to 46.8%; 2 adenomas, 5.1% to 21.7%; 3 adenomas, 2.7% to 12.4%; 1 adenoma 10 mm or larger, 14.2% to 28.0%; and cancer, 6.3% to 16.4%. Multivariate analyses showed that the endoscopist was not an independent predictor of cancer detection, but was an independent predictor of detecting adenomas, regardless of category; the R2 of the models ranged from 6% to 13% only.Limitations: Other factors known to influence colorectal neoplasia occurrence and withdrawal time could not be taken into account.Conclusions: In a screening program with a high compliance rate with colonoscopy after FOBT, interendoscopist variability had no effect on cancer detection, but did influence identification of adenomas. The clinical impact of such findings merits further evaluation.

The best screening test for colorectal cancer is the one that gets done well

James E. Allison — 2010-02-01

When all patients eligible for screening are screened with colonoscopy, the fraction with no colorectal neoplasia is consistent, ranging from 75% to 83%; thus, most patients screened with colonoscopy will have neither adenomas nor cancers.

Image-guided biopsy in the esophagus through comprehensive optical frequency domain imaging and laser marking: a study in living swine

2009-11-02

Background: Random biopsy esophageal surveillance can be subject to sampling errors, resulting in diagnostic uncertainty. Optical frequency domain imaging (OFDI) is a high-speed, 3-dimensional endoscopic microscopy technique. When deployed through a balloon-centering catheter, OFDI can automatically image the entire distal esophagus (6.0 cm length) in approximately 2 minutes.Objective: To test a new platform for guided biopsy that allows the operator to select target regions of interest on an OFDI dataset, and then use a laser to mark the esophagus at corresponding locations. The specific goals include determining the optimal laser parameters, testing the accuracy of the laser marking process, evaluating the endoscopic visibility of the laser marks, and assessing the amount of mucosal damage produced by the laser.Design: Experimental study conducted in 5 swine in vivo.Setting: Massachusetts General Hospital.Main Outcome Measurements: Success rate, including endoscopic visibility of laser marks and accuracy of the laser marking process for selected target sites, and extent of the thermal damage caused by the laser marks.Results: All of the laser-induced marks were visible by endoscopy. Target locations were correctly marked with a success rate of 97.07% (95% confidence interval, 89.8%-99.7%). Thermal damage was limited to the superficial layers of the mucosa and was observed to partially heal within 2 days.Limitations: An animal study with artificially placed targets to simulate pathology.Conclusions: The study demonstrates that laser marking of esophageal sites identified in comprehensive OFDI datasets is feasible and can be performed with sufficient accuracy, precision, and visibility to guide biopsy in vivo.

Somewhere over the rainbow

Michael B. Wallace — 2010-02-01

A major potential for optical frequency domain imaging, and particularly its mapping system, is to directly guide endoscopic ablation.

Face and construct validity of a computer-based virtual reality simulator for ERCP

2009-11-18

Background: Currently, little evidence supports computer-based simulation for ERCP training.Objective: To determine face and construct validity of a computer-based simulator for ERCP and assess its perceived utility as a training tool.Design: Novice and expert endoscopists completed 2 simulated ERCP cases by using the GI Mentor II.Setting: Virtual Education and Surgical Simulation Laboratory, Medical College of Georgia.Main Outcome Measurements: Outcomes included times to complete the procedure, reach the papilla, and use fluoroscopy; attempts to cannulate the papilla, pancreatic duct, and common bile duct; and number of contrast injections and complications. Subjects assessed simulator graphics, procedural accuracy, difficulty, haptics, overall realism, and training potential.Results: Only when performance data from cases A and B were combined did the GI Mentor II differentiate novices and experts based on times to complete the procedure, reach the papilla, and use fluoroscopy. Across skill levels, overall opinions were similar regarding graphics (moderately realistic), accuracy (similar to clinical ERCP), difficulty (similar to clinical ERCP), overall realism (moderately realistic), and haptics. Most participants (92%) claimed that the simulator has definite training potential or should be required for training.Limitations: Small sample size, single institution.Conclusions: The GI Mentor II demonstrated construct validity for ERCP based on select metrics. Most subjects thought that the simulated graphics, procedural accuracy, and overall realism exhibit face validity. Subjects deemed it a useful training tool. Study repetition involving more participants and cases may help confirm results and establish the simulator's ability to differentiate skill levels based on ERCP-specific metrics.

Continuing Medical Education Exam: February 2010

2010-02-01

Population-based prevalence estimates of history of colonoscopy or sigmoidoscopy: review and analysis of recent trends

Christian Stock, Ulrike Haug, Hermann Brenner — 2009-10-21

Background: Lower GI endoscopy, such as colonoscopy or sigmoidoscopy, is thought to have a substantial impact on colorectal cancer incidence and mortality through detection and removal of precancerous lesions and early cancers. We aimed to review prevalence estimates of history of colonoscopy or sigmoidoscopy in the general population and to analyze recent trends.Methods: A systematic review of the medical literature, including MEDLINE (1966 to August 2008) and EMBASE (1980 to August 2008), was undertaken, supplemented by searches of the European Health Interview & Health Examination Surveys database and bibliographies. Detailed age-specific and sex-specific prevalence estimates from the United States were obtained from the Behavioral Risk Factor Surveillance System surveys 2002, 2004, and 2006.Results: The search yielded 55 studies that met our inclusion criteria. The majority of the reports (43) originated from the United States. Other countries of origin included Australia (2), Austria (2), Canada (5), France (1), Germany (1), and Greece (1). Estimates from the United States were generally increasing over time up to 56% (2006) for lifetime use of colonoscopy or sigmoidoscopy in people aged 50 years and older. Analysis of national survey data showed higher prevalences among men aged 55 years and older than for women of the same age. Prevalences were highest for people aged 70 to 79 years.Conclusion: Data from outside the United States were extremely limited. Prevalence estimates from the United States indicate that a considerable and increasing proportion of the population at risk has had at least 1 colonoscopy or sigmoidoscopy in their lives, although differences between age and sex groups persist. Prevalences of previous colonoscopy or sigmoidoscopy need to be taken into account in the interpretation of time trends in, and variation across, populations of colorectal cancer incidence and mortality.

Management of major postsurgical gastroesophageal intrathoracic leaks with an endoscopic vacuum-assisted closure system

2009-11-02

Background: Endoscopic treatment options for postsurgical intrathoracic leaks include injection of fibrin glue, clip application, and stent placement. Endoscopic vacuum-assisted closure (E-VAC) may be an effective treatment option.Objective: To demonstrate that E-VAC is an effective endoscopic treatment option for closure of major intrathoracic postsurgical leaks.Design and Setting: A prospective, single-center study at an academic medical center.Patients: Eight consecutive patients with major intrathoracic postsurgical leaks.Interventions: Endoscopic placement of transnasal draining tubes, armed with a size-adjusted sponge at their distal end, in the necrotic anastomotic cavities, followed by continuous suction. Sponge and drainage were changed twice weekly. Patients were followed-up for 193 ± 137 days.Main Outcome Measurement: Successful leak closure.Results: Successful closure of leaks was achieved in 7 of 8 patients (88%) after a mean of 23 ± 8 days. A median of 7 endoscopic interventions was necessary. No major treatment-associated short-term or long-term (follow-up, 193 ± 137 days) complications were noted.Limitations: Small sample size, single-center study, and lack of randomization.Conclusion: E-VAC is an effective endoscopic treatment modality for major postsurgical intrathoracic leaks. (This study is registered at Clinicaltrials.gov, identifier NCT00876551.)

Endoluminal management of anastomotic dehiscence after esophagectomy: an increasing quiver of options reflects the difficulty in realizing a definitive therapy

Thomas Murphy, Blair A. Jobe — 2010-02-01

Intrathoracic leakage after esophagogastrectomy is a dreaded and morbid complication that can be associated with a prolonged hospitalization and high mortality rate. The presentation and subsequent management of an intrathoracic leak depends on the defect size and location within the gastric conduit or the esophagogastric anastomosis. Therefore, in the initial management, it is important to define whether intrathoracic leakage is secondary to (1) gastric conduit necrosis, (2) conduit staple line dehiscence, or (3) esophagogastric anastomosis dehiscence. Gastric conduit necrosis presents early in the perioperative interval and manifests with profound systemic sepsis requiring immediate surgical intervention. Staple line and esophagogastric anastomosis dehiscence, which occur early in the perioperative period, are also associated with a high degree of intrathoracic contamination and systemic sepsis and may require surgical intervention. However, late intrathoracic leakage arising from an isolated and limited defect within the staple line or anastomosis may be associated with little or no intrathoracic contamination and can be managed nonoperatively if adequate drainage can be achieved, infection treated, and enteral nutrition established. However, because no consensus for optimal treatment has been formulated, the appropriate treatment is usually individualized to the scenario encountered, and there is a high degree of variability among providers.

Transgastric endoluminal gastrojejunostomy: technical development from bench to animal study (with video)

2009-12-11

Background: Gastrojejunal anastomosis is commonly performed for palliative management of malignant gastric outlet obstruction and bariatric surgery. Natural orifice transluminal endoscopic surgery revolutionized the surgical approach to intra-abdominal surgery. This study explored the possibility of performing gastrojejunostomy (GJ) by using a hybrid natural orifice transluminal endoscopic surgery approach.Objective: To develop a surgical technique for the performance of transgastric endoscopic GJ (TGEJ) in a porcine model.Design: Prospective series of animal experiments.Setting: University hospital animal laboratory.Animals: Thirteen female domestic pigs.Interventions: With the animals under general anesthesia, the endoscope is passed through the gastrotomy and a segment of small bowel is retrieved into the stomach. An enterotomy is then created, and an EndoGIA stapler is introduced through an intragastric port and passed between the small bowel and stomach wall. A GJ is formed after firing of the EndoGIA stapler. The pigs are allowed to resume their diet 1 day after the operation and are allowed to survive for 2 weeks before they are euthanized. The patency of the GJ is confirmed with a repeat endoscopy, contrast study, and postmortem examination.Results: A total of 13 TEGJs were performed, 11 of which were successful. The mean operative time was 53.6 ± 45.7 minutes. The mean time for gastrotomy was 4.7 minutes, and that for GJ was 42.5 minutes. One TEGJ was converted to open surgery because of malpositioning of the intragastric port, and the other failed because the enterotomy was too extensive. Ten of 11 pigs survived for 2 weeks, and endoscopic examination with contrast study confirmed that all the gastrojejunostomies were patent. On postmortem examination, the average size of the GJ was 30 mm.Limitations: The length between duodenojejunal flexure and the site chosen to perform the GJ could not be determined.Conclusions: TEGJ is technically feasible with a patent and sizable anastomosis.

Eosinophilic esophagitis misdiagnosed twice as esophageal candidiasis

Javier Molina Infante, Lucia Ferrando Lamana — 2010-02-01

A 56-year-old man with no previous allergic or medical history was referred because of esophageal candidiasis and persistent dysphagia despite standard treatment with fluconazole. Endoscopy revealed multiple white mucosal plaquelike lesions throughout the length of the esophagus suggestive of esophageal candidiasis, but esophageal biopsy samples showed an intense intraepithelial eosinophilic infiltration (165 eosinophils per high-power field (Eo/HPF). After a 2-month course of 20 mg rabeprazole twice daily without clinical improvement, follow-up endoscopy disclosed corrugation, white papules, and a cobblestone-like mucosa in the upper esophagus (A); subtle linear furrows, luminal narrowing and pinpoint white spots in the mid esophagus (B); and erythema, mucosal fragility, and confluent exudative white plaques in the distal esophagus (C). Biopsies confirmed the diagnosis of eosinophilic esophagitis and revealed different degrees of eosinophilic infiltration along the segments of the esophagus (upper esophagus 12 Eo/HPF, mid esophagus 56 Eo/HPF, and distal esophagus 89 Eo/HPF). Whitish plaques were pathologically associated with the densest areas of eosinophilic infiltration (D) and flat disrupted fragments from the surface strata contained eosinophils, which interestingly resembled histopathologic findings of esophageal candidiasis and macroscopic plaques at endoscopy (E).

Endoscopic management of multiple colonic fistulae secondary to acute pancreatitis (with video)

Soon Oh Hwang, Tae Hoon Lee, Jin Woo Park, Sang-Heum Park, Sun-Joo Kim — 2010-02-01

A 29-year-old man was transferred to our hospital for management of acute pancreatitis. His medical history was unremarkable except for binge drinking. On physical examination, moderate tenderness of the epigastrium was noted, and initial laboratory test results revealed serum amylase and lipase concentrations of 450 IU/L (normal 60-160 IU/L) and 120 U/L (0-60 U/L), respectively. Abdominal CT scanning disclosed peripancreatic fatty infiltration and fluid collections involving the pancreatic body and tail (arrowheads) (A). The patient was given nothing by mouth as treatment of pancreatitis. One week after the abdominal CT scan, there was improvement of the pancreatitis and pseudocyst; however, complicated cystic lesions showing air-bubble–like densities were still present in the pancreatic tail, and a retroperitoneocolonic fistula was suspected (arrowheads) (B). A virtual colonoscopy was performed, showing the fistula tract (white arrow) on the splenic flexure of the colon (left), and multiple retroperitoneocolonic fistulae secondary to acute pancreatitis were diagnosed. A small hole can be seen on the same lesion (right). (C, D). Cap-assisted colonoscopy was then performed to evaluate the fistulae; multiple fistula holes (one large hole and several small holes) were found in the splenic flexure of the colon (E). We performed multiple hemoclippings and Greenplast (Green Cross, Young-in, Korea) sprayings (endoscopic glue injection) to close the fistula holes (, available online at www.giejournal.org). After treatment, the patient had no abdominal pain or signs of infection. There were no complications in the following 2 months during which the patient was under outpatient observation.

Colonic invasion of malignant peritoneal mesothelioma

2009-11-13

A 56-year-old woman presented with a several-week history of low-grade fever and diarrhea. For 4 years, she had been treated for malignant peritoneal mesothelioma with monthly or bimonthly intravenous vinorelbine ditartrate (30 mg/m2) followed by intraperitoneal cisplatin (100 mg/m2). A barium contrast enema showed a large mass in the mid-transverse colon (A), which was confirmed at colonoscopy (B). Biopsy specimens taken from the lesion revealed sarcomatous tissue with spindle cells (C). Immunostaining revealed the tissue to be carcinoembryonic antigen negative but calretinin positive (D), thereby supporting a diagnosis of malignant peritoneal mesothelioma. This patient had no evidence of asbestos exposure, and the cause for the mesothelioma was unknown.

Autofluorescence imaging of a diminutive, depressed-type early colon cancer invaded to the submucosal layer

2009-11-18

A 61-year-old woman with a positive fecal occult blood study result underwent a colonoscopy that indicated an early cancer in her sigmoid colon. She was then referred to our hospital for further evaluation. Colonoscopic re-evaluation of the lesion was done using an autofluorescence imaging system consisting of an image processor (XCV-260HP; Olympus Medical Systems, Tokyo, Japan), a light source (XCLV-260HP, Olympus), and a colonoscope with 2 charged, coupled devices for white light imaging and autofluorescence imaging modes (XCF-Q240FZI, Olympus). Autofluorescence imaging revealed a 5-mm green area surrounded by magenta mucosa (A). White light imaging (B) and chromoendoscopy with 0.4% indigo carmine (C) revealed a depressed-type lesion colored similarly to the surrounding mucosa. EUS revealed a minute tumor that invaded down to the submucosa. The lesion was diagnosed as an early colon cancer invading into the submucosa, and sigmoidectomy was performed. Histologic examination (D, H&E, orig. mag. × 7.5) of the resected specimen revealed a moderately differentiated adenocarcinoma invading into the submucosa (submucosal invasion [SM] 150 μm). The cancer was more depressed than the surrounding mucosa, whereas the surrounding submucosal layer was relatively thick. Thus, a green image of a lesion surrounded by a magenta mucosa on autofluorescence imaging may be representative of the depressed-type colon cancer.

Fulminant amebic colitis mimicking pseudomembranous colitis

Ja Seol Koo, Won Suk Choi, Dae Won Park — 2009-10-28

A 53-year-old man was referred with a 7-day history of diffuse abdominal pain and watery diarrhea. He had been diagnosed as having schizophrenia two years previously and had been treated in a long-term-care hospital. He had not traveled to the tropics in recent years. On examination, his abdomen was distended and had signs of peritonitis. A fecal occult blood test result was positive. Sigmoidoscopy demonstrated erythematous mucosa with numerous raised, whitish-yellow plaques throughout the rectosigmoid colon, an appearance that suggested pseudomembranous colitis (A). After sigmoidoscopy, a chest film showed subdiaphragmatic intraperitoneal air. Exploratory laparotomy was performed urgently, and a cecal perforation with a gangrenous appendix was found. The appendix and cecum were resected and an ileostomy created. Histologic examination of the resected colon demonstrated trophozoites of Entamoeba histolytica in the appendiceal wall (B, H&E, orig. mag. ×400). Stool examinations for Clostridium difficile toxin and culture were negative. The patient was treated with antibiotics including metronidazole for 14 days, and he recovered without further difficulty.

Percutaneous transesophageal gastrostomy tube placement: an alternative to percutaneous endoscopic gastrostomy in patients with intra-abdominal metastasis

Ashwani Kumar Singal, Alexander A. Dekovich, Alda L. Tam, Michael J. Wallace — 2010-02-01

Background: PEG/jejunostomy (PEG/J) is often placed in patients with metastatic gastric cancer for palliating bowel obstruction or for feeding. However, PEG/J placement may not always be possible for many reasons.Objective: We wish to bring attention to the percutaneous transesophageal gastrostomy/jejunostomy (PTEG/J) as a viable alternative to nasogastric decompression in patients who are not candidates for PEG/J. PTEG/J is a largely unknown technique in the United States that designed to gain access to the stomach and proximal small bowel in these patients. We describe the use of PTEG/J in 3 patients with metastatic gastric cancer by using resources and techniques readily available in a well-stocked interventional radiology suite.Patients: In the first case, percutaneous transesophageal gastrostomy (PTEG) was placed for palliation of intractable nausea and vomiting in a 37-year-woman with diffuse gastric cancer and peritoneal carcinomatosis. In the second case, PTEG was extended into the jejunum for feeding a 60-year-old woman with metastatic gastric cancer. In the third case, PTEG extending into the jejunum was placed in a 69-year-old man for palliation of bowel obstruction caused by metastatic gastric cancer and peritoneal carcinomatosis.Methods: After adequate sedation is administered, a 22 × 4-mm balloon catheter is passed into the esophagus over a guidewire just below the thoracic inlet. The balloon is ruptured with a needle passed through the neck under US guidance. A guidewire is then passed through the needle into the balloon and carried into the stomach or proximal small bowel by advancing the balloon catheter. The track is then dilated over the guidewire and a pigtail 45-cm-long 14F nephrostomy tube then passed into the stomach or into the proximal small bowel over the guidewire. The catheter is secured by suturing to the skin of the neck.Results: PTEG/J was effective in achieving palliation or feeding in our patients. No complications occurred.Conclusions: PTEG/J is a safe and effective alternative to standard percutaneous gastrostomy/jejunostomy tube placement for decompression of bowel obstruction or feeding in appropriately selected patients.

A case of intraductal papillary mucinous neoplasm of the pancreas rupturing both the stomach and duodenum

2009-11-18

Background: Intraductal papillary mucinous neoplasm (IPMN) of the pancreas may extend to other organs. However, it is rare for a histopathologically benign IPMN to rupture other organs, particularly multiple organs. There has been no report of a benign IPMN rupturing both the stomach and duodenum.Objective: We experienced a very rare case and make personal remarks based on bibliographical consideration.Design: Case report.Setting: National Defense Medical College.Patient: A patient with IPMN.Intervention: EGD, ERCP, and pancreatoduodenectomy.Conclusions: We report a case of benign IPMN of the pancreas extending to two adjacent organs. A 77-year-old male who was diagnosed as having IPMN by CT, MRI, upper GIF, and ERCP underwent pancreatoduodenectomy for a mass of 4.2 cm in diameter. Pathological examinations revealed that the IPMN was composed of adenoma. Intraluminal nodular growth was observed in the duodenal gland tissue, and abnormal growth was observed in the fistula to the stomach. According to a literature review based on PubMed data up until March 2009, it is rare for a benign IPMN to penetrate two adjacent organs.

EUS-guided hepaticogastrostomy with a fully covered metal stent as the biliary diversion technique for an occluded biliary metal stent after a failed ERCP (with videos)

2010-02-01

Background: Percutaneous transhepatic biliary drainage (PTBD) may be the last resort for an occluded biliary metal stent when the ERCP was unsuccessful.Objective: Because an EUS-guided biliary drainage has been proposed as an effective alternative for PTBD after a failed ERCP, we conducted this study to determine the feasibility and usefulness of an EUS-guided hepaticogastrostomy (EUS-HG) with a fully covered self-expandable metal stent (FCSEMS) for an occluded biliary metal stent after a failed ERCP.Design: A case study.Setting: A tertiary referral center.Patients and Interventions: Five patients who had an occluded biliary metal stent inserted after a hilar bilateral metal stent or a combined duodenal and biliary metal stent insertion and for whom reinterventional ERCP was unsuccessful underwent an EUS-HG with an FCSEMS for alternative PTBD.Main Outcome Measurements: Technical and functional success, procedural complications, reinterventional rate after EUS-HG with an FCSEMS, and short-term stent patency.Results: In all 5 patients, an EUS-HG with an FCSEMS was technically successful. No procedural complications, such as bile peritonitis, cholangitis, and pneumoperitoneum, were observed. Functional success was also 100% (5/5). During the follow-up period (median 152 days, range 64-184 days), no late complications, such as stent migration and occlusion, were observed. Thus, no biliary reintervention was performed during the follow-up period.Limitations: A small series of patients without a control group.Conclusions: The EUS-HG with an FCSEMS may be feasible, effective, and an alternative PTBD for an occluded biliary metal stent after a failed ERCP.

Autoimmune pancreatitis presenting with IgG4-positive multiple gastric polyps

2009-10-21

Autoimmune pancreatitis (AIP) occurs in association with a variety of multiorgan pathologies. AIP coexists most often with sclerosing cholangitis, and involvement of the lachrymal gland, salivary gland, thyroid gland, lymph nodes, and retroperitoneum has been reported, although these are less common. It has been reported that gastric ulcers are associated with AIP, even though these are actually rare. We encountered a case of IgG4-positive multiple inflammatory gastric polyps in a patient with AIP. We believe that there are no similar previous reports, so we present our findings as a case report.

Spiral-enteroscopy–assisted enteral stent placement for palliation of malignant small-bowel obstruction (with video)

Anne Marie Lennon, Vinay Chandrasekhara, Eun Ji Shin, Patrick I. Okolo — 2009-11-09

Management of patients with small-bowel obstruction distal to the third part of the duodenum can be challenging. These patients are often poor surgical candidates, and placement of a self-expanding metal stent (SEMS) can be technically demanding. We report on 2 consecutive patients, referred with small-bowel obstruction to a tertiary-care institution, who had successful placement of SEMS by using spiral enteroscopy.

EUS-guided drainage of an isolated primary tubercular prostatic abscess

2009-11-02

Prostatic abscess occurs infrequently. The genitourinary tract is a common site of involvement in extrapulmonary tuberculosis. However, primary prostatic tuberculosis is very rare, and tubercular abscess in the prostate gland is extremely uncommon unless the patient is immunocompromised. Prostatic imaging studies, such as transrectal US (TRUS) and magnetic resonance imaging (MRI) are important in the diagnosis and management of prostatic abscess. Although surgical drainage is the mainstay in the treatment of prostatic abscess, the best method of drainage remains somewhat controversial. TRUS-guided needle aspiration or drainage is the most widely used technique, with fairly good success. Failure of this method usually requires surgical drainage. Although there are a few case reports of tubercular prostatic abscess in the medical literature, all were described in AIDS patients. EUS-guided transrectal drainage of deep pelvic abscesses is described in the medical literature, but, to our knowledge, this is the first report of EUS-guided aspiration and drainage of a prostatic abscess after failed TRUS-guided aspiration.

Occult adenocarcinoma after esophagectomy for Barrett's high-grade dysplasia

Fergal Donnellan, Gavin C. Harewood, Stephen E. Patchett — 2010-02-01

To the Editor: We read with interest the article by Wang et al, which reported rates of T1a and T1b adenocarcinoma of 45% and 7%, respectively, among patients with high-grade dysplasia/intramucosal adenocarcinoma in the setting of Barrett's esophagus. A recent retrospective review of 17 patients with high-grade dysplasia/intramucosal adenocarcinoma in Barrett's esophagus undergoing esophagectomy at our institution between January 2003 and December 2008 showed T1a and T1b adenocarcinoma in 6 (35%) and 4 (24%) patients, respectively. These findings provide further evidence that the rate of submucosal invasive adenocarcinoma (T1b) in these patients is lower than 40%.

Previous experience and long-term follow-up of Schatzki's rings treated with electrosurgical incision

Moises Guelrud — 2010-02-01

To the Editor: I read with interest the article by Wills et al, comparing electrosurgical incision and bougie dilation for the treatment of Schatzki's ring, and the letter to the editor by Minocha. In 1987, we published a series of 17 patients with severe intermittent dysphagia due to Schatzki's ring. All patients underwent an endoscopic electrosurgical radial incision of the ring with a needle-knife sphincterotome. The incision was successfully accomplished with immediate relief of dysphagia in all patients. Fourteen patients remained asymptomatic with a mean follow-up of 46 months. Three patients required a second incision, and they remained asymptomatic for more than 24 months. There was one mild bleeding episode. We concluded that electrosurgical incision of the Schatzki's ring is an effective therapeutic modality in selected patients.

The mucosal pattern in the non-neoplastic gastric mucosa by using magnifying narrow-band imaging endoscopy significantly correlates with gastric cancer risk

2010-02-01

To the Editor: Recently, we showed that mucosal patterns seen with magnifying narrow band imaging (NBI) in an uninvolved gastric corpus could be divided into the following categories: normal/small (round pits with regular subepithelial capillary networks), type 1 (slightly enlarged round pits with unclear or irregular subepithelial capillary networks), type 2 (obviously enlarged oval or prolonged pits with increased density of irregular vessels), and type 3 (well-demarcated oval or tubulovillous pits with clearly visible coiled or wavy vessels). These patterns clearly distinguish Helicobacter pylori–related histological and serological severity of atrophic gastritis.

EUS-guided celiac plexus block for chronic pancreatitis: a placebo-controlled trial should be the first priority

Anand V. Sahai, Jonathan Wyse — 2010-02-01

To the Editor: In their recent report, Leblanc et al cite our work, comparing central and unilateral celiac plexus blow or celiac plexus neurolysis (CPB/CPN). The citation implies that we found bilateral injection superior in chronic pancreatitis (CP) patients. This is false. In CP patients, we found no benefit for any CPB method (central or bilateral). In fact, the only predictor of “no response” was CP.

Response

2010-02-01

We thank Drs Sahai and Wyse for their comments on our article, which describes no difference in pain relief with 1 versus 2 injections during EUS-celiac plexus block (CPB) in patients with pain caused by chronic pancreatitis. They express the need for a placebo-controlled trial, and we agree with their position, as stated in our concluding remarks.

Prospective randomized trial comparing EUS and EGD for transmural drainage of pancreatic pseudocysts: a need for a large randomized study

Bryan Sauer, Michel Kahaleh — 2010-02-01

To the Editor: We commend Varadarajulu et al for performing a randomized, controlled trial comparing EGD-guided versus EUS-guided drainage of pseudocysts. Clearly, more randomized, controlled trials are needed in advanced endoscopy to evaluate efficacy and safety. However, we would like to express several concerns with the report of Varadarajulu et al.

Response

Shyam Varadarajulu — 2010-02-01

I respond to the comments of Drs Sauer and Kahaleh on our randomized trial comparing EUS and EGD for transmural drainage of pancreatic pseudocysts. First, regarding the choice of endoscopes, in patients randomized for drainage by EGD after ERCP, a search for a definitive luminal compression in the duodenum and stomach was undertaken using the duodenoscope. If none was seen, the duodenoscope was exchanged for a double-channel gastroscope.

Improve anorectal examination by the cap-assisted colonoscopy method

Yuk Tong Lee — 2010-02-01

To the Editor: Quallick and Brown presented their study of 39,054 consecutive colonoscopy cases and reported 4 cases of rectal perforation during rectal retroflexion (0.1 case per 1000). Unfortunately, the authors did not record the success rate of their retroflexion technique and the rectal findings. If the success rate is taken as approximately 95%, as reported by the authors, it means that approximately 2000 patients in this cohort would have failed the retroflexion rectal examination, and the rectum may not have been appropriately examined, although the value of rectal retroflexion, as compared with forward examination, in detecting significant rectal findings has been questioned. Apart from colonoscopic rectal retroflexion, various techniques, such as rigid rectoscopy and video proctoscopy, have been suggested as being useful in detecting lesions around the anorectal region. I present an easy way to examine the anorectal region during colonoscopy to prevent failure of rectal inspection and to avoid complications.

Gastrointestinal Endoscopy

Contents

Editors

Focus On…

ASGE Update

In Upcoming Issues…

Information for readers

Imaging of subsquamous Barrett's epithelium with ultrahigh-resolution optical coherence tomography: a histologic correlation study

Optical coherence tomography in Barrett's esophagus: the road to clinical utility

Does Barrett's esophagus respond to chemoradiation therapy for adenocarcinoma of the esophagus?

A second-look endoscopy after endoscopic submucosal dissection for gastric epithelial neoplasm may be unnecessary: a retrospective analysis of postendoscopic submucosal dissection bleeding

Periductal hypoechoic sign: an endosonographic finding associated with pancreatic malignancy

What the heck is this new periductal hypoechoic sign?

Survival in patients with pancreatic cancer after the diagnosis of malignant ascites or liver metastases by EUS-FNA

Needle-knife sphincterotomy: factors predicting its use and the relationship with post-ERCP pancreatitis (with video)

Needle-knife sphincterotomy and post-ERCP pancreatitis: time to lower the threshold for the needle?

Difficult biliary cannulation: use of physician-controlled wire-guided cannulation over a pancreatic duct stent to reduce the rate of precut sphincterotomy (with video)

Indications and detection, completion, and retention rates of small-bowel capsule endoscopy: a systematic review

Safety and efficacy of double-balloon enteroscopy in pediatric patients

Balloon by balloon, inch by inch

Training and transfer of colonoscopy skills: a multinational, randomized, blinded, controlled trial of simulator versus bedside training

Computers for colonoscopy training: where do they fit in?

Time-gated fluorescence spectroscopy improves endoscopic detection of low-grade dysplasia in ulcerative colitis

Colonoscopy training in gastroenterology fellowships: determining competence

North of 100 and south of 500: where does the “sweet spot” of colonoscopic competence lie?

Characterization of forces applied by endoscopists during colonoscopy by using a wireless colonoscopy force monitor

Variations between endoscopists in rates of detection of colorectal neoplasia and their impact on a regional screening program based on colonoscopy after fecal occult blood testing

The best screening test for colorectal cancer is the one that gets done well

Image-guided biopsy in the esophagus through comprehensive optical frequency domain imaging and laser marking: a study in living swine

Somewhere over the rainbow

Face and construct validity of a computer-based virtual reality simulator for ERCP

Continuing Medical Education Exam: February 2010

Population-based prevalence estimates of history of colonoscopy or sigmoidoscopy: review and analysis of recent trends

Management of major postsurgical gastroesophageal intrathoracic leaks with an endoscopic vacuum-assisted closure system

Endoluminal management of anastomotic dehiscence after esophagectomy: an increasing quiver of options reflects the difficulty in realizing a definitive therapy

Transgastric endoluminal gastrojejunostomy: technical development from bench to animal study (with video)

Eosinophilic esophagitis misdiagnosed twice as esophageal candidiasis

Endoscopic management of multiple colonic fistulae secondary to acute pancreatitis (with video)

Colonic invasion of malignant peritoneal mesothelioma

Autofluorescence imaging of a diminutive, depressed-type early colon cancer invaded to the submucosal layer

Fulminant amebic colitis mimicking pseudomembranous colitis

Percutaneous transesophageal gastrostomy tube placement: an alternative to percutaneous endoscopic gastrostomy in patients with intra-abdominal metastasis

A case of intraductal papillary mucinous neoplasm of the pancreas rupturing both the stomach and duodenum

EUS-guided hepaticogastrostomy with a fully covered metal stent as the biliary diversion technique for an occluded biliary metal stent after a failed ERCP (with videos)

Autoimmune pancreatitis presenting with IgG4-positive multiple gastric polyps

Spiral-enteroscopy–assisted enteral stent placement for palliation of malignant small-bowel obstruction (with video)

EUS-guided drainage of an isolated primary tubercular prostatic abscess

Occult adenocarcinoma after esophagectomy for Barrett's high-grade dysplasia

Previous experience and long-term follow-up of Schatzki's rings treated with electrosurgical incision

The mucosal pattern in the non-neoplastic gastric mucosa by using magnifying narrow-band imaging endoscopy significantly correlates with gastric cancer risk

EUS-guided celiac plexus block for chronic pancreatitis: a placebo-controlled trial should be the first priority

Response

Prospective randomized trial comparing EUS and EGD for transmural drainage of pancreatic pseudocysts: a need for a large randomized study

Response

Improve anorectal examination by the cap-assisted colonoscopy method