Gastrointestinal Endoscopy

2010-09-01

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2010-09-01

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2010-09-01

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2010-09-01

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2010-09-01

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2010-09-01

Minimum staffing requirements for the performance of GI endoscopy

2010-06-28

This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. In preparing this guideline, a search of the medical literature was performed by using PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time the guidelines are drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice.This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient's condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines.

The role of endoscopy in the management of obscure GI bleeding

2010-09-01

This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. In preparing this guideline, we performed a search of the medical literature by using PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time the guidelines were drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations are based on reviewed studies and are graded on the strength of the supporting evidence (). The strength of individual recommendations is based both upon the aggregate evidence quality and an assessment of the anticipated benefits and harms. Weaker recommendations are indicated by phrases such as “we suggest,” whereas stronger recommendations are typically stated as “we recommend.”This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient's condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines.

Prevalence and risk of colorectal neoplasms in asymptomatic, average-risk screenees 40 to 49 years of age

2010-07-20

Background: A paucity of information exists regarding colorectal neoplasm in asymptomatic, average-risk individuals 40 to 49 years of age.Objective: To evaluate the prevalence and risk factors of colorectal neoplasms in those in their 40s.Design: Cross-sectional study.Setting: Results offered to subjects of a health care provider that offers screening services as part of an employer-provided wellness program.Patients: A consecutive series of 1761 asymptomatic, average-risk screenees 40 to 59 years of age.Intervention: First screening colonoscopy.Results: The prevalence of overall colorectal neoplasm in subjects of ages 40 to 44 years, 45 to 49 years, 50 to 54 years, and 55 to 59 years increased significantly with increasing age (13.7%, 20.2%, 21.0%, and 23.8%, respectively; P < .001). The prevalence of advanced adenomas in subjects of ages 40 to 44 years, 45 to 49 years, 50 to 54 years, and 55 to 59 years increased significantly with age (1.9%, 3.0%, 3.2%, and 5.9%, respectively; P = .004). Multivariate analysis of data from the 40- to 49-year age group identified an increased risk of colorectal neoplasm associated with ages 45 years and older (odds ratio [OR], 1.68; 95% CI, 1.20-2.35), male sex (OR, 1.76; 95% CI, 1.15-2.69), presence of abdominal obesity (OR, 1.57; 95% CI, 1.12-2.21), and metabolic syndrome (OR, 1.56; 95% CI, 1.03-2.35), whereas for advanced adenomas, abdominal obesity (OR, 2.37; 95% CI, 1.06-5.27) and metabolic syndrome (OR, 2.83; 95% CI, 1.23-6.53) were the independent risk factors.Limitations: Single-center study and the cohort composed of ethnic Korean subjects who lived in the same geographic region.Conclusion: In average-risk individuals 40 to 49 years of age, men with abdominal obesity or metabolic syndrome might benefit from screening colonoscopy starting at 45 years of age to detect colorectal neoplasm.

Biopsy depth after radiofrequency ablation of dysplastic Barrett's esophagus

2010-07-05

Background: After endoscopic radiofrequency ablation (RFA) of dysplastic Barrett's esophagus (BE), endoscopic biopsy samples are obtained to assess response to therapy. Whether these biopsies are of adequate depth to assess efficacy is unknown.Objective: To compare the depth of endoscopic biopsy samples after RFA with those of untreated controls and to determine the prevalence of subepithelial structures in endoscopic biopsy fragments.Design: Secondary analysis of the AIM Dysplasia Trial, a multicenter, randomized, sham-controlled study.Setting: Nineteen treatment centers.Patients: Subjects with dysplastic BE, either status post RFA or ablation naïve (sham).Main Outcome Measurements: The proportion of biopsy samples demonstrating subepithelial structures, stratified by tissue type (columnar vs squamous) in sham- and RFA-treated subjects.Results: A total of 5648 biopsy fragments were analyzed from 113 subjects (78 RFA, 35 sham; mean 50.0 fragments per subject). Most fragments (4653, 82.4%) contained subepithelium. Squamous biopsy samples from RFA and sham subjects demonstrated subepithelium at similar rates (78.4% vs 79.1%, respectively, P = not significant [NS]). Columnar biopsy samples from RFA and sham subjects also included subepithelium at similar rates (99.0% vs 98.8%, respectively, P = NS). Regardless of treatment assignment, more columnar than squamous biopsy samples demonstrated subepithelium (98.8% vs 78.5%, P < .001).Limitations: Biopsy samples were not individually mounted.Conclusions: In both squamous and columnar tissue, endoscopic biopsy samples after RFA were as likely to demonstrate subepithelium as untreated controls. Almost 80% of all biopsy samples were adequate to evaluate for subsquamous intestinal metaplasia. The primary determinant of biopsy depth is the type of epithelium that underwent biopsy, with squamous less likely to yield subepithelium than columnar. Biopsy samples after RFA appear to be of adequate depth to assess response to therapy. (Clinical trial registration number NCT00282672.)

Short-term safety and efficacy of the Trans-oral Endoscopic Restrictive Implant System for the treatment of obesity

2010-06-11

Background: Medical treatment of obesity often fails, and surgical treatment, although successful, is aggressive.Objective: To evaluate the short-term safety and efficacy of an endoscopic restrictive implant procedure in the treatment of obesity.Design: Prospective, observational study.Setting: Tertiary-care referral hospital in The Netherlands.Patients: This study involved 13 patients with body mass indexes of between 40 and 50 kg/m2 or between 35 and 40 kg/m2 with obesity-related comorbidities.Intervention: A new transoral endoscopic restrictive implant procedure in the treatment of obesity.Main Outcome Measurements: Safety of the procedure, percentage of excess weight loss, change in body mass index.Results: In 1 patient, the procedure was abandoned after a gastric perforation related to stapler malfunctioning. In 2 patients, pneumoperitoneum was detected. This was desufflated with a percutaneous hollow needle in one patient and treated conservatively in the other. After these complications, technical adjustments were made in the procedure, and no subsequent procedural complications were seen. At 3 months postprocedure, patients obtained a median excess weight loss of 28%. Median body mass index decreased from 42.1 to 37.9 kg/m2.Limitations: Small number of patients.Conclusion: Preliminary results of this transoral endoscopic restrictive implant system for the treatment of obesity showed successful placement in 12 of 13 patients. Procedural complications occurred in 3 patients. Weight loss was comparable to that of laparoscopic gastric band placement. Further long-term studies are under way.

Endoscopic therapy of obesity: a new paradigm in bariatric care

Christopher C. Thompson — 2010-09-01

Obesity is a complex metabolic disease that carries a severe toll of comorbid illness. Over the past few decades, obesity has evolved into a global epidemic, and it is now more prevalent than malnutrition from hunger. Obesity has been defined and categorized by a series of National Institutes of Health consensus conferences, which, in large part, have also dictated the management of this condition. Heretofore, patients were determined to be surgery-eligible only if they were obesity class III (body mass index [BMI] >40 kg/m2) or obesity class II (BMI 35-39.9 kg/m2) with significant associated comorbid illness. Although it is clear that increasing BMI is associated with a higher burden of comorbid illness, stringent application of these well-rounded BMI categories in determining which patients are eligible for treatment leaves many without effective therapeutic options. For patients who do not meet these criteria, lifestyle modification and medications have been recommended; however, these have been of limited effectiveness and durability, with high rates of attrition. Alternatively, surgical intervention is effective and provides durable results for many patients but with a substantially higher risk profile. Although the current system was established to limit risk for patients with lower disease burdens while providing the benefit of surgical alternatives to those with a higher disease burden, it has not been able to adequately address the burgeoning epidemic.

Lymph node metastasis from intestinal-type early gastric cancer: experience in a single institution and reassessment of the extended criteria for endoscopic submucosal dissection

2010-06-16

Background: Given the increasing use of endoscopic resection as a therapeutic modality for cases of early gastric cancer (EGC), it is very important to define strict criteria for the use of endoscopic mucosal resection and endoscopic submucosal dissection. To date, the criteria are almost entirely based on Japanese literature evaluating the risk of lymph node (LN) metastasis in patients with EGC.Objective: To analyze our own experience with the factors affecting LN metastasis and to reappraise the extended criteria for endoscopic submucosal dissection.Design: Retrospective, single-center study.Setting: University teaching hospital.Patients: This study involved 478 patients who underwent gastrectomy with LN dissection (n = 270, mucosal [m] EGC; n = 208, submucosal [sm] EGC).Intervention: Gastrectomy with LN dissection.Main Outcome Measurements: LN metastasis.Results: Overall, 12.6% (60/478) of patients with EGCs presented with LN metastasis (mEGC, 3.0% [8/270], smEGC, 25.0% [52/208]). Increased size, macroscopic type (elevated), depth of invasion, and lymphovascular invasion were associated with LN metastasis. In 270 cases of mEGC, there was no relationship between clinicopathologic features and LN metastasis. In the smEGC group, size, depth of invasion, and lymphovascular emboli were associated with an increased risk of LN metastasis. Significantly, LN metastasis was noted in EGCs falling within established extended endoscopic submucosal dissection criteria, that is, intestinal-type mucosal cancer of any size without ulcer and no lymphovascular emboli (2/146 [1.4%]) or ≤3 cm with no lymphovascular emboli and irrespective of the presence of ulceration (2/126 [1.6%]) or intestinal-type submucosal cancer (sm1, <500 μm) without lymphovascular invasion and measuring ≤3 cm in size (3/20 [15.0%]).Limitations: Retrospective review of a single-center study.Conclusion: We recommend that more centers survey their experiences of LN metastasis in cases of EGC to refine the criteria for endoscopic submucosal dissection as a therapeutic modality of intestinal-type EGC.

Split-dose bowel preparation for colonoscopy and residual gastric fluid volume: an observational study

2010-06-21

Background: Split-dose bowel preparations for colonoscopy are more effective and better tolerated than preparations given entirely the day or evening before the procedure; however, some resistance to split-dose preparation stems from concerns about an increased risk of aspiration with same-day preparation.Objective: We sought to evaluate residual gastric volumes in patients after split-dose bowel preparations.Design: Prospective measurement of residual gastric volumes in patients undergoing same-day EGD and colonoscopy after split-dose bowel preparations, patients undergoing EGD alone, or patients undergoing EGD and colonoscopy after bowel preparation given entirely the evening before the procedure.Setting: Tertiary care hospital–based endoscopy unit.Patients: This study involved 712 patients, including 254 in the split-dose bowel preparation group, 411 in the EGD-only group, and 47 in the evening-before-procedure bowel preparation group.Intervention: Measurement of residual gastric volume before endoscopic procedures.Main Outcome Measurements: Residual gastric volume.Results: The mean residual gastric volume in patients receiving split-dose bowel preparation (19.7 mL) was higher than in patients undergoing EGD alone (14.6 mL) but not different from that in patients receiving bowel preparation the evening before the procedure (20.2 mL). Within the split-dose preparation group, there was no association between the interval from last actual fluid ingestion and procedure start time and the residual gastric volume. The range of residual gastric volumes between study arms was similar.Limitations: Nonrandomized study. The number of inpatients undergoing split-dose bowel preparation was small.Conclusion: These data support the safety of split-dose bowel preparation for outpatients undergoing colonoscopy.

Magnifying endoscopy with narrow-band imaging achieves superior accuracy in the differential diagnosis of superficial gastric lesions identified with white-light endoscopy: a prospective study

2010-07-05

Background: Conventional, white-light imaging endoscopy (WLE) results in a significant number of misdiagnoses in early gastric cancer. Magnifying endoscopy combined with narrow-band imaging (ME-NBI) is more accurate in the diagnosis of gastric cancer when the diagnostic triad of the disappearance of fine mucosal structure, microvascular dilation, and heterogeneity is used.Objective: The aim of the present study was to evaluate the superiority of ME-NBI in the differential diagnosis of superficial gastric lesions identified with conventional WLE.Design: Prospective, comparative study.Setting: Single academic center.Patients: This study involved patients who underwent WLE and ME-NBI for surveying synchronous or metachronous cancers because they had a high risk of gastric cancer.Intervention: Patients with superficial gastric lesions that were diagnosed by WLE as cancer or non-cancer with a slight suspicion of cancer were prospectively enrolled in the study. ME-NBI was used to further characterize lesions picked up with WLE.Main Outcome Measurements: Sensitivity and specificity for the diagnosis of gastric cancer, with pathology as the criterion standard.Results: A total of 201 lesions (mean diameter [± SD] 7.0 ± 4.0 mm) from 111 patients (98 men, 13 women; mean age 66.3 years) were evaluated. Fourteen of the 201 lesions were pathologically proven as gastric cancer; the others were noncancerous lesions. The sensitivity and specificity for ME-NBI diagnosis with the use of the triad (92.9% and 94.7%, respectively) were significantly better than for WLE (42.9% and 61.0%, respectively; P < .0001).Limitations: Single center and a highly selected population at high risk for gastric cancer.Conclusion: ME-NBI achieved superior accuracy in the differential diagnosis of superficial gastric lesions identified with WLE. Thus, ME-NBI may increase the diagnostic value of endoscopy in a population at high risk of gastric cancer.

Endoscopic magnetic gastroenteric anastomosis for palliation of malignant gastric outlet obstruction: a prospective multicenter study

2010-07-26

Background: Palliation of malignant gastric outlet obstruction remains challenging. Although there are 2 established treatment options, ie, surgical gastrojejunostomy and endoscopic duodenal stent insertion, there is an ongoing search for a technique that would combine the safety and rapid effect of duodenal stent placement with the long-term efficacy and low reintervention rate of a surgical gastrojejunostomy.Objective: To investigate the safety and success rate of endoscopic creation of a gastroenteric anastomosis formed by magnetic compression and stent placement.Design: Prospective, multicenter cohort study.Setting: Four referral centers.Patients: The expected number of patients with symptomatic malignant gastric outlet obstruction to be included at the participating hospitals during a year was 40. Because of a serious adverse device event, the study was terminated after inclusion of 18 patients.Intervention: Creation of an endoscopic gastroenteric anastomosis by using the Cook Magnetic Anastomosis Device with transanastomotic deployment of a self-expandable stent.Main Outcome Measurements: Primary endpoints were safety and success rate associated with the creation of an endoscopic gastrojejunostomy by using a magnetic anastomotic device with transanastomotic deployment of a self-expandable stent.Results: Because of a serious adverse event, the study was terminated prematurely. A success rate of 66.7% (12 of 18 patients) was achieved; 1 serious adverse event (stent perforation) occurred leading to the death of the patient. Three patients (25%) experienced an adverse device effect (stent migration).Limitations: Small sample size, lack of a control group.Conclusion: Endoscopic creation of a gastroenteric anastomosis by magnetic compression is feasible and safe; however, the necessity of a stent led to serious morbidity and even mortality in this study. The current system can therefore not be recommended for clinical use.

Endoscopic pancreatic sphincterotomy and stenting for preoperative prophylaxis of pancreatic fistula after distal pancreatectomy

Bernhard Rieder, Daniel Krampulz, Jost Adolf, Albrecht Pfeiffer — 2010-07-05

Background: Pancreatic fistula (PF) is the most common postoperative complication after distal pancreatectomy (DP). Endoscopic pancreatic sphincterotomy and drainage have been shown to be an effective treatment for PF. Recently, preoperative endoscopic pancreatic stenting was proposed to prevent PF, but there are no controlled trials so far.Objective: We investigated whether preoperative pancreatic sphincterotomy and stenting could prevent the development of PF in patients with DP.Design: Nonrandomized cohort study with a prospective endoscopic intervention group and a retrospective control group.Setting: Single-center academic teaching hospital.Patients: Preoperative endoscopic pancreatic sphincterotomy and stenting were intended to prevent PF after DP in 25 patients between July 2004 and October 2008. The incidence of PF was compared with that in a control group of 23 patients who underwent DP between January 2001 and March 2004 without preoperative endoscopic intervention.Interventions: Pancreatic sphincterotomy and stenting.Main Outcome Measurement: PF rate.Results: Overall, a cohort of 48 patients underwent DP between January 2001 and October 2008. In all 25 patients who underwent preoperative endoscopic pancreatic intervention, sphincterotomy was successfully performed, and stenting of the pancreatic duct was successful in 23 patients. PF developed in none of the 25 patients in the endoscopic intervention group. In the 23 patients without preoperative endoscopic intervention, a PF developed in 5 patients (22%) (P = .02).Limitations: Nonrandomized design, retrospective control group.Conclusions: Preoperative pancreatic sphincterotomy and stenting were a feasible and safe procedure in this series. Prophylactic preoperative endoscopic intervention may decrease PF rates after DP.

Distal pancreatectomy: another indication for prophylactic pancreatic stenting?

Jean-Marc Dumonceau — 2010-09-01

Distal pancreatectomy (DP), the removal of the left portion of the pancreas, is less frequently performed than pancreatic head resection. It is mostly done to resect rare pancreatic tumors and, less frequently, to treat complicated chronic pancreatitis. After DP, the whole bile duct and the cephalic portion of the main pancreatic duct remain unaffected so that the pancreatic remnant is usually simply closed (by hand sewing or by using a stapler) with a percutaneous drain left close to the transected pancreas. A pancreaticojejunostomy is performed in a minority of cases. Both DP and pancreatic head resection currently carry an acceptable mortality rate in high-volume centers, but morbidity remains extremely high. Pancreatic fistula is the most frequent serious complication after DP, with an incidence of 32% in a recent meta-analysis that totaled 479 patients. Although postoperative pancreatic fistulae (POPFs) may resolve spontaneously, they are associated with hospital readmissions in a majority of cases (mean of 1.7 readmissions per patient in a recent study) because they often cause other complications, including sterile intra-abdominal collections, abscesses, and wound disruptions. Management of POPFs requires multiple medical interventions such as repeated CT scans, percutaneous drainage, and visits for months after surgery, the total average cost of which was equal to that of an uncomplicated DP in a recent study. Therefore, strategies to prevent POPFs are needed and can even be costly and cost-effective at the same time.

Biliary stent placement is associated with post-ERCP pancreatitis

C. Mel Wilcox, Milind Phadnis, Shyam Varadarajulu — 2010-07-15

Background: A variety of factors have been linked to post-ERCP pancreatitis. However, the role of biliary stenting has not been well studied.Objective: To evaluate the relationship between biliary stenting and post-ERCP pancreatitis.Design: Prospective study of all patients undergoing ERCP with biliary stenting over a 7.5-year period. All patients had follow-up at 24 to 48 hours after the procedure and at 1 month.Setting: A single-center tertiary referral academic medical center.Patients: Consecutive patients undergoing ERCP over a 7.5-year period.Interventions: Endoscopic therapy based on the indication for and findings of ERCP.Main Outcome Measurements: The rate of post-ERCP pancreatitis.Results: A total of 3499 patients underwent ERCP with bile duct stent placement of a native papilla performed in 660: 544 (83%) 10F and 116 (17%) 7F. The most common indication for stent placement was pancreaticobiliary malignancy in 250 patients (37%). The overall rate of pancreatitis for the entire cohort was 3.17%. Multivariate analysis identified 6 factors that were associated with pancreatitis: previous ERCP pancreatitis (odds ratio [OR], 2.44; 95% CI, 1.31-4.55), age (OR, 2.30; 95% CI, 1.44-3.67), history of acute pancreatitis (OR, 1.78; 95% CI, 1.12-2.88), pancreatic sphincterotomy (OR, 2.30, 95% CI, 1.43-3.70), suspected sphincter of Oddi dysfunction (OR, 3.91; 95% CI, 2.36-6.46), and bile duct stenting (OR, 1.72; 95% CI, 1.03-2.88). The rates of pancreatitis were not significantly different based on performing sphincterotomy before stent placement, stent type, stent length, stent size, or indication.Limitations: Single-center study.Conclusions: Bile duct stent placement is an independent predictor for pancreatitis, and pancreatitis is not related to performing sphincterotomy before stenting or to stent characteristics.

Endotherapy of postoperative biliary strictures with multiple stents: results after more than 10 years of follow-up

2010-07-14

Background: Endoscopic dilation of postoperative biliary strictures with increasing numbers of stents was first described by our group in 2001 with promising results after a long-term follow-up (mean 4 years).Objective: To verify results of endoscopic treatment of postoperative biliary strictures at a very-long-term follow-up.Design: Single center, follow-up study.Setting: Tertiary-care, academic referral center.Patients: A group of 42 patients from our 2001 study, who had undergone endoscopic dilation of postoperative biliary strictures with the multiple endoscopic stenting technique, underwent systematic follow-up. The last telephone follow-up was done in September 2009.Intervention: Clinical conditions and the occurrence of new biliary symptoms during the follow-up period were assessed, and results of the most recent liver function tests and abdominal US were recovered.Main Outcome Measurements: Occurrence of cholangitis and liver function test evaluation during the follow-up period.Results: Of the 40 patients who were alive at the end of the study published in 2001, 5 (12.5%) died of unrelated causes after a mean of 6.7 years (range 3-13.3 years) from the end of treatment, without further biliary symptoms. The overall mean follow-up time for the remaining 35 patients (87.5%) was 13.7 years (range 11.7-19.8 years). Seven patients (20%) experienced recurrent acute cholangitis after a mean of 6.8 years (range 3.1-11.7 years) from the end of treatment. All 7 of these patients underwent ERCP. Four of the 7 patients had postoperative biliary stricture recurrence (n = 4/35, 11.4%) that was retreated endoscopically with placement of stents, and the other 3 patients had common bile duct stones (n = 3/35, 8.6%) that were extracted. No stricture or bile duct stone recurrences after retreatment were recorded after a mean follow-up period of a further 7.1 years (range 2.5-12.1 years). Twenty-eight patients remained asymptomatic with normal liver function test results and abdominal US results after a mean follow-up period of 13.7 years (range 11.7-19.8 years).Limitations: Telephone follow-up.Conclusion: Results of multiple endoscopic stenting for postoperative biliary strictures remain excellent even after a very-long-term follow-up. The stricture recurrence rate is low, and recurrences can be retreated endoscopically.

Low symptomatic premature stent occlusion of multiple plastic stents for benign biliary strictures: comparing standard and prolonged stent change intervals

2010-07-20

Background: Benign biliary strictures are typically managed endoscopically whereby an increasing size or number of plastic stents is placed at ERCP. Stents are often changed every 3 to 4 months based on the known median patency of a single biliary stent, but patency data for multiple biliary stents are lacking.Objective: To assess the incidence of occlusion-free survival of multiple plastic biliary stents and the rate of premature occlusion if left in longer than 6 months.Design: Retrospective.Setting: Tertiary-care medical center (Charleston, SC).Patients: Consecutive patients who received multiple plastic stents for benign nonhilar biliary strictures from 1994 to 2008 were identified.Interventions: Exchange of multiple plastic biliary stents within 6 months (group 1) or 6 months or longer (group 2) after placement.Main Outcome Measurements: Symptomatic stent occlusion.Results: Seventy-nine patients with nonhilar extrahepatic benign biliary stricture underwent 125 ERCPs with multiple plastic biliary stents. Stents were scheduled for removal/exchange within 6 months in 52 patients (86 ERCPs) compared with after 6 months in 22 patients (26 ERCPs). The median interval between multiple stent placement and removal/exchange was 90 days for group 1 and 242 days for group 2. Premature stent occlusion occurred in 4 of 52 (7.7%) patients in group 1 versus 1 of 22 (4.5%) in group 2, with significantly longer occlusion-free survival in group 2 (log-rank P < .0001).Limitations: Retrospective study at a single tertiary referral center.Conclusion: Multiple plastic biliary stents for benign nonhilar strictures were associated with a low rate of premature symptomatic stent occlusion at more than 6 months and a longer occlusion-free survival.

Bulb biopsies for the diagnosis of celiac disease in pediatric patients

2010-07-14

Background: Celiac disease (CD) is a gluten-dependent enteropathy. The current standard for diagnosing CD involves obtaining 4 biopsy samples from the descending duodenum. It has been suggested that duodenal bulb biopsies may also be useful.Objective: To assess the utility of bulbar biopsies for the diagnosis of CD in pediatric patients.Design: Prospective study.Setting: Single center.Patients: Forty-seven consecutively enrolled pediatric patients with celiac serologies and a clinical suspicion of CD.Interventions: All patients underwent EGD, and 4 biopsy samples were obtained from the duodenal bulb and 4 from the descending duodenum of each child.Main Outcome Measurements: The pathologist blindly reported the Marsh histological grade for the diagnosis of CD of the bulb and descending duodenum.Results: The diagnosis of CD was histologically confirmed in 89.4% (42/47) of the cases of biopsy samples obtained from the descending duodenum and in all 47 obtained from the bulb. In 35 patients (74.5%), histology was the same in the bulb and duodenum; in 11 (23.4%) cases, the grade of atrophy was higher in the bulb than in the descending duodenum, and 5 (10.6%) had bulb histology positive for CD but negative duodenal findings. One child (2.1%) had a higher histological grade in the duodenum than in the bulb. The diagnostic gain with bulbar biopsies was 10.6%.Limitations: Small sample and absence of a comparison group (asymptomatic children with normal CD antibodies).Conclusions: We suggest examining 4 biopsy samples from the duodenal bulb and 4 from the descending duodenum to improve diagnostic accuracy of CD.

Not everything is celiac disease

Eric Hassall — 2010-09-01

In this issue of the Gastrointestinal Endoscopy, Mangiavillano et al remind us that the lesion of celiac disease is patchy and suggest that the diagnosis can be missed if biopsy samples from the duodenal bulb are not taken. They report their single-center, prospective study in 47 children with “clinical and serological indicators of the disease.” Each patient underwent EGD with 4 biopsy specimens obtained from the duodenal bulb and 4 from the descending duodenum. One pathologist read the biopsy results blinded to the clinical data.

Differentiating adenomas from hyperplastic colorectal polyps: narrow-band imaging can be learned in 20 minutes

Meghana Raghavendra, David G. Hewett, Douglas K. Rex — 2010-06-21

Background: Colonoscopy with narrow-band imaging can allow real-time determination of polyp histology.Objective: To determine whether physicians with varying levels of experience can learn and apply endoscopic criteria to distinguish between adenomas and hyperplastic polyps.Design: Prospective observational study.Setting: University teaching hospital.Participants: This study involved 37 physicians (medical residents, N = 12; gastroenterology fellows, N = 12; and gastroenterology faculty, N = 13).Intervention: Small-group, 20-minute, didactic teaching sessions in which the endoscopic criteria for determining polyp histology by using narrow-band imaging were described and demonstrated.Main Outcome Measurements: Learning outcomes were evaluated by using written pretests and posttests in which participants scored pathologically verified, high-definition polyp photographs as adenomas or hyperplastic polyps.Results: The mean overall scores increased significantly from 47.6% correct on the pretest to 90.8% correct on the posttest (P = .0001). The overall mean percentage of responses answered don't know was significantly lower on the posttest (0.6%) compared with the pretest (20.5%, P < .0001). After training, the level of agreement was substantial (κ = 0.69 for all participants, κ = 0.79 for fellows).Limitations: Our study did not assess for sustained improvement with time or in vivo accuracy of histological prediction during live colonoscopy. Further validation in a sample of community physicians is required.Conclusion: A short, didactic teaching session can achieve high accuracy and good interobserver agreement in the use of narrow-band imaging for determining the histology of colorectal polyps.

Narrow-band imaging for colorectal polyps: it can be taught but will it be used?

Brooks D. Cash — 2010-09-01

Colonoscopy remains the reference standard to which new technologies for colorectal cancer (CRC) screening must be compared. As newer CRC screening tests such as CT colonography (CTC) and capsule endoscopy have been developed and compared with colonoscopy, the realization that colonoscopy is an imperfect reference standard has been repeatedly brought to the fore. Concerns regarding the incomplete degree of colonoscopy protection and the emerging understanding of the importance of the serrated polyp pathway and nonpolypoid neoplasia continue to provide an impetus to improve the accuracy of colonoscopy. Currently available video endoscopy systems that allow us to see smaller polyps in finer detail than ever before are becoming standard equipment for many endoscopy suites. In addition, mucosal examination techniques that permit real-time histologic diagnosis are becoming more readily available and their potential is also beginning to become more evident. The most studied of these techniques is chromoendoscopy, involving the direct mucosal application of vital stains or dyes to the colonic mucosa and suspect lesions to facilitate examination of pit patterns based on criteria developed by Kudo et al.

Projected increased growth rate of anesthesia professional–delivered sedation for colonoscopy and EGD in the United States: 2009 to 2015

John M. Inadomi, Candace L. Gunnarsson, John A. Rizzo, Hai Fang — 2010-07-14

Background: Anesthesia professional–delivered sedation has become increasingly common when performing colonoscopy and EGD.Objective: To provide an estimate of anesthesia professional–participation rates in colonoscopy and EGD procedures and to examine rate changes over time and geographic variations for both procedures.Design: Retrospective sample design.Setting: National survey data from i3 Innovus for the period 2003 to 2007 on the use rate of anesthesia professionals in both procedures.Patients: A sample of 3688 observations included 3-digit zip code–level information on anesthesia professional use rates.Interventions: Data were linked to the Bureau of Health Professions' Area Resource File to control for sociodemographic factors and provider supply characteristics for anesthesia professional use rates.Main Outcome Measurements: Multivariable regression analyses were performed to identify factors predicting the use rate of anesthesia professionals in these procedures and to forecast use rates for the years 2009 to 2015.Results: For colonoscopy and EGD, anesthesia professional participation is projected to grow from 23.9% and 24.4% in 2007 to 53.4% and 52.9% by 2015, respectively. Average growth rates were highest in the northeast for colonoscopy (145.8%) and EGD (146.6%). Anesthesia professional use rates were significantly greater in areas having a higher percentage of older subjects (45 years and older), higher per capita income and lower unemployment rates, and higher per capita inpatient admissions and were significantly lower in areas having more per capita outpatient visits for both procedures.Limitations: Nonexperimental retrospective sample study design. Database sample may not be nationally representative. Market area characteristics were used to control for socioeconomic and demographic factors. However, there may remain some important market factors that we were unable to control.Conclusions: Anesthesia professional–delivered sedation is projected to grow substantially for both procedures.

Anatomic-manometric correlation of the upper esophageal sphincter: a concurrent US and manometry study

2010-06-25

Background: The pharyngoesophageal segment commonly referred to as the upper esophageal sphincter (UES) generates a high-pressure zone (HPZ) between the pharynx and the esophagus. However, the exact anatomical components of the UES-HPZ remain incompletely determined.Objective: To systematically define the US signature of various components of the pharyngoesophageal junction and to determine how these structures contribute to the development of the UES-HPZ.Design: Prospective, experimental study.Setting: Tertiary Academic Medical Center.Patients: This study involved 18 healthy volunteers.Intervention: We studied 5 participants by using a high-frequency US miniprobe (US-MP) and concurrent fluoroscopy and another 13 participants by using the US-MP and concurrent manometry.Main Outcome Measurements: Relative contribution of various muscles in the UES-HPZ.Results: Manometrically, the UES-HPZ had a median length of 4.0 cm (range 3.0-4.5 cm). A C-shaped muscle, believed to represent the cricopharyngeus muscle, was observed for a median length of 3.5 cm (range 2.0-4.0 cm). The oval configuration representing the esophageal contribution to the UES was seen in 10 of 13 participants (77%) at the distal HPZ (esophagus to UES transition zone). The flat configuration of the inferior constrictor muscle was noted in 7 of 13 participants (54%) at the proximal HPZ (UES to pharynx transition zone). There were 4 to 5 wall layers versus 3 layers in the distal and proximal HPZ, respectively. The mean (± SD) muscle thickness was relatively constant along the length of the UES-HPZ.Limitations: Air artifacts in the UES-HPZ.Conclusion: The configuration and layers of the UES-HPZ vary along its length. The upper esophagus is a significant contributor to the distal UES-HPZ.

Endoscopic submucosal dissection of gastric lesions by using a Master and Slave Transluminal Endoscopic Robot (MASTER)

2010-06-21

Background: Performing endoscopic submucosal dissection (ESD) by using standard endoscopy platforms is technically challenging because of the equipment's lack of dexterity.Objective: To explore the feasibility of using the Master and Slave Transluminal Endoscopic Robot (MASTER), a novel robotics-enhanced endosurgical system, to perform ESD.Design: ESD was performed on simulated gastric lesions in 5 Erlangen porcine stomach models (ex vivo) and 5 live pigs (in vivo). Performance of ESD by using the MASTER was compared with that using the insulation-tipped (IT) diathermic knife.Setting: SMART Laboratory, Advance Surgical Training Centre, National University Hospital, Singapore.Subjects: Five Erlangen porcine stomach models and 5 pigs, 5 to 7 months old, each weighing about 35 kg.Interventions: ESD.Main Outcome Measurements: Lesion resection time, grasper and hook efficacy grade, completeness of resection, and presence of procedure-related perforation.Results: In the Erlangen stomach models, 15 simulated lesions from the cardia, antrum, and body were removed en bloc (mean dimension, 37.4 × 26.5 mm) by electrocautery excision using the MASTER. The mean ESD time was 23.9 minutes (range 7-48 minutes). There was no difference in the dissection times of lesions at different locations (P = .449). In the live pigs, the MASTER took a mean of 16.2 minutes (range 3-29 minutes) to complete the ESD of 5 gastric lesions, whereas the IT diathermic knife took 18.6 minutes (range 9-34 minutes). There was no significant difference in the times taken (P = .708). All lesions were excised en bloc; the mean dimensions of lesions resected by the MASTER and the IT diathermic knife were 37.2 × 30.1 mm and 32.78 × 25.6 mm, respectively. The MASTER exhibited good grasping and cutting efficiency throughout. Surgical maneuvers were achieved with ease and precision. There was no incidence of excessive bleeding or stomach wall perforation.Limitations: Exploratory study with limited sample size.Conclusions: Performing ESD by using the MASTER is feasible.

Continuing Medical Education Exam: September 2010

2010-09-01

The benefits of a gastroenterology fellows club

Vinay Chandrasekhara — 2010-09-01

Many topics of benefit and interest to gastroenterology trainees may not be covered by the traditional gastroenterology training model. Gastroenterology fellows training at different programs in Baltimore, Maryland, started the Baltimore Gastroenterology Fellows Club to cover topics of common interest. Dr. Vinay Chandrasekhara shares with us the successful experience of this club with the hope of replicating this type of organization in other cities.

Erupted cysts in the cervical esophagus result in gastric inlet patches

Alexander Meining, Monther Bajbouj — 2010-09-01

Gastric inlet patches (GIPs) are composed of islands of heterotopic gastric columnar epithelium in the cervical esophagus. They are often found accidentally at upper endoscopy with a reported prevalence of approximately 1% to 5%. However, symptoms such as globus sensations and other laryngeal and pharyngeal disorders have also been linked to their presence. This can be confirmed by our previously reported findings that ablation of the heterotopic gastric mucosa by means of argon plasma coagulation leads to resolution of such symptoms in the majority of all treated patients, in contrast to those treated by a sham procedure. To date at our institution, there have been 41 patients treated. Among these, 37 (90.2%) were clinically followed. The overall success rate was 81% after a median follow-up of 21 months (range 3-54 months). Hence, ablation of the heterotopic mucosa appears to be beneficial for the majority of those patients.

Use of the front-view forward-array echoendoscope to evaluate right colonic subepithelial lesions

Thai Nguyen-Tang, Janak N. Shah, Andres Sanchez-Yague, Kenneth F. Binmoeller — 2010-06-21

Background: Endosonographic evaluation and sampling of right colonic subepithelial lesions is technically difficult.Objective: To evaluate the feasibility, safety, and tissue yield of a prototype front-view, forward-array, curved linear array echoendoscope in the evaluation and sampling of right colonic subepithelial lesions.Setting: Tertiary referral center.Design: Procedural and outcome data on all patients undergoing EUS evaluation of right-sided colonic and pericolonic lesions were collected during a 1-year study period.Main Outcome Measurements: Patient demographics, clinical indication, EUS findings, EUS-FNA yield, technical success, and procedural complications.Results: A total of 15 patients underwent EUS examination of right-sided colonic lesions with the prototype echoendoscope. The lesions were located in the cecum (n = 12) and the ascending colon (n = 3). The cecum was reached in all examinations within 10 minutes. Twelve patients had subepithelial lesions detected during colonoscopy. Findings included 6 extrinsic compressions from an adjacent normal structure, 1 calcified lymph node, 1 ovarian cyst, 1 prolapsed appendiceal orifice, 1 GI stromal tumor, 1 appendiceal mucocele, and 1 lymphoma. Two patients were evaluated for a pericolonic lesion seen on CT; findings included focal diverticulitis and a metastatic lymph node. In the patient evaluated for an infiltrative mass with previous nondiagnostic biopsies, colonic histoplasmosis was diagnosed. FNA was performed in 6 patients and provided diagnostic samples in 5 (83%). No procedure- or FNA-related complications were reported.Conclusions: Endosonographic evaluation and sampling of right-sided colonic subepithelial lesions with the prototype front-view, forward-array, curved linear array echoendoscope is feasible and safe. The yield of FNA is high, consistent with applications in the upper GI tract.

Initial evaluation of a novel, prototype, forward-viewing echoendoscope in a porcine arterial bleeding model (with video)

2010-07-14

Background: Real-time visualization of submucosal arterial flow at the base of an ulcer might improve endoscopic hemostasis by permitting more accurate assessment of the artery, precise targeting of therapy, and confirmation of vessel ablation.Objective: To evaluate the utility of a novel, forward-viewing echoendoscope in identifying bleeding submucosal arteries, guiding hemostatic therapy, and confirming cessation of flow through treated vessels.Design: In 7 pigs, a previously described porcine model for peptic ulcer hemorrhage was created by isolating the gastroepiploic and/or short gastric artery and tunneling it into the subserosal space at laparotomy.Setting: Animal research facility.Intervention: The prototype endoscope was used to image submucosal arterial flow. EUS guidance was then used to deliver endoscopic hemostatic therapy and assess treatment adequacy.Main Outcome Measurements: Identification of the target submucosal artery and successful delivery of EUS-guided endoscopic therapy, evidenced by cessation of Doppler flow through the target vessel.Results: Tunneled arteries were visualized endosonographically in all 7 cases. EUS-guided submucosal injection of epinephrine was successful in 2 of 2 cases. EUS-guided delivery of thermal hemostatic therapy was successful in 2 of 4 cases. Absence of flow through treated vessels was confirmed in cases in which EUS-guided therapy was successfully delivered.Limitations: Acute animal model.Conclusion: Proof of principle experiments in a porcine peptic ulcer hemorrhage model suggest that real-time sonographic imaging of submucosal arteries is feasible with a forward-viewing echoendoscope, and guided hemostatic therapy can be delivered.

Gastric perforations after ligation of GI stromal tumors in the gastric fundus

Sun Siyu, Wang Sheng, Wang Guoxin, Ge Nan, Liu Jingang — 2010-06-11

We report 2 cases of gastric perforation after endoscopic band ligation of small stromal tumors in the gastric fundus. Two female patients, one 39 years old and one 50 years old, were referred to our hospital for treatment of these lesions. EUS revealed both lesions to be of low echogenicity and to derive from the muscularis propria; one measured 4 × 3 mm and the other measured 5 × 3 mm ( and ). The diagnosis of stromal tumor was confirmed in each by deep tissue biopsy and immunohistochemical staining. Endoscopic ligation was performed by using an air-driven ligator of 10-mm diameter and after ligation, each lesion assumed a pseudopolypoid form (). EUS confirmed that the focus where the lesion was derived from the muscularis had been completely ligated (, T: ligated tumor, arrow: ligation point). Both patients complained of severe abdominal pain, one at 24 hours and one at 35 hours after the procedure. Upright abdominal plain films confirmed bilateral subphrenic free air, and both patients underwent emergent laparotomy. At operation, circular perforations of 2.0- to 2.5-cm diameter were found with gastric mucosa that appeared inverted. The perforations were oversewn and postoperative antibiotic prophylaxis and supportive treatment were given. Both patients recovered and were discharged from the hospital 10 to 12 days after surgery.

Endoscopic closure of a distal common bile duct perforation caused by papillary dilation with a large-diameter balloon (with video)

2010-06-11

A 66-year-old woman with a history of a Billroth II gastrectomy and common bile duct (CBD) stone removal after endoscopic sphincterotomy was admitted for recurrent CBD stones. Endoscopic retrograde cholangiography showed dilatation of the CBD with large stones. We performed endoscopic papillary balloon dilation with a large-diameter balloon (15 mm, 90 seconds) using a wire-guided balloon dilatation catheter (CRE; Boston Scientific, Natick, Mass; ). During stone removal with a Dormia basket, pneumoretroperitoneum was detected on fluoroscopy. Endoscopy showed a circumferential perforation of the distal CBD (). We immediately performed direct endoscopic closure of the perforation using hemoclips (Olympus, Tokyo, Japan; , , available online at www.giejournal.org), after which an endoscopic nasobiliary drainage catheter was inserted. After the procedure, a plain film of the abdomen showed air in the retroperitoneal space (). Conservative management was instituted, which included antibiotics and withholding oral intake. On the fifth day after perforation, cholangiography through the endoscopic nasobiliary drainage indicated no leakage from the CBD. On the tenth day, abdominal CT showed resolution of the pneumoperitoneum and absence of fluid collections (); oral feeding was started. The patient was discharged on the twelfth day after the procedure.

GI vasculitis associated with systemic lupus erythematosus

2010-06-11

A 19-year-old woman presented with a 1-week history of abdominal pain, nausea, vomiting, and watery diarrhea. She had no history of systemic disease and denied taking any medications. On admission, physical examination showed a slightly distended tender abdomen with hypoactive bowel sounds but no rebound tenderness. An initial abdominal plain film showed only a nonspecific bowel gas pattern without evidence of ileus. Colonoscopy was performed cautiously and revealed segmental submucosal edema in the sigmoid colon (). Biopsy specimens obtained from the sigmoid colon showed nonspecific inflammation. Abdominal CT 2 days after colonoscopy revealed intestinal wall thickening with the target sign (an enhancing inner and outer rim with hypoattenuation in the center) in several segments of bowel (, arrow) and prominent engorgement of mesenteric vessels with a palisade pattern (the comb sign; , arrows). Laboratory evaluation revealed leucopenia (leukocyte count 1.94 × 103/mm3 [normal 4.0-10.8 × 103/mm3]), anemia (hemoglobin 8.0 g/dL [12-16 g/dL]), low levels of complements (C3 32.3 mg/dL [90-180 mg/dL] and C4 7.5 mg/dL [10-40 mg/dL]) and positive serologic tests for antinuclear antibody with a homogenous pattern (1:800 [<1:40]) and anti-double-stranded DNA antibody. The patient was diagnosed with GI vasculitis caused by systemic lupus erythematosus and was treated with intravenous methylprednisolone (1 mg/kg/day). Her symptoms improved greatly within 3 days. A follow-up endoscopy 5 days later showed marked improvement of colonic edema (). On the ninth hospital day, she was discharged on a regimen of oral prednisolone and hydroxychloroquine.

Gone but not forgotten. “Bubble gum enema” containing hydrogen peroxide and causing life-threatening colitis

Rizwan Kibria, Syed A. Ali, Christopher J. Barde — 2010-06-11

A 61-year-old man was seen in consultation for rectal bleeding. He had constipation that was unresponsive to Milk of Magnesia (Bayer Health Care, Morristown, NJ) and docusate sodium and was given a “bubble gum” enema containing 90 mL each of hydrogen peroxide, sodium phosphate, and docusate sodium to relieve his constipation. One hour later, he developed severe abdominal pain and passed bloody bowel movements. Abdominal examination revealed tenderness in the left lower quadrant. The white blood cell count, which initially was in the normal range, rose to 24,000 u/L. Abdominal CT scan showed rectosigmoid wall thickening and inflammatory changes (). He was treated with parenteral fluids, levofloxacin, and metronidazole. Colonoscopy revealed friable mucosa with discrete ulcerations covered with yellowish-green pseudomembranes up to 40 centimeters from the anus; more proximally, the appearance of the mucosa improved but it still was erythematous (). Biopsy specimens showed focal acute ulcerations with congestion of lamina propria. He became asymptomatic on conservative therapy and was discharged. Colonoscopy 3 months later was unremarkable.

Can EUS-guided FNA distinguish between gallbladder cancer and xanthogranulomatous cholecystitis?

2010-07-14

Background: EUS-guided FNA (EUS-FNA) is a useful modality for sampling various targets, but its applicability to gallbladder (GB) mass lesions is limited.Objective: To determine the usefulness of EUS-FNA for diagnosing GB mass lesions.Design: Single-center, retrospective, case-series study.Setting: Tertiary-care referral center.Patients: This study involved 15 consecutive patients who underwent EUS-FNA of GB mass lesions. We punctured GB masses in patients with suspected xanthogranulomatous cholecystitis to distinguish them from malignancy, and in patients with unresectable GB carcinoma for pathological confirmation. The final diagnosis was based on surgical histopathological results or follow-up outcome.Interventions: EUS-FNA.Main Outcome Measurements: Evaluation of EUS-FNA sampling adequacy rate and diagnostic yield.Results: Xanthogranulomatous cholecystitis was suspected in 6 of the 15 patients. EUS-FNA revealed foam cells (n = 3), inflammatory cells (n = 1, proven by cholecystectomy), and GB carcinoma (n = 1), and the amount of the aspirate was insufficient in one case (xanthogranulomatous cholecystitis was later proven by extended hepatectomy). The mean follow-up period of the patients with xanthogranulomatous cholecystitis was 1177 days. Adenocarcinoma was confirmed by EUS-FNA in 8 of the 9 patients with suspected unresectable GB carcinoma, and the FNA was inconclusive in one. All 10 patients with GB carcinoma underwent chemotherapy. The overall sampling adequacy was 86.6%. The accuracy of EUS-FNA for detecting malignancy and for the final diagnosis was 93.3% (95% CI, 62.4%-99.9%) and 80% (95% CI, 54%-93.7%), respectively.Limitations: A small patient cohort and a retrospective design with potential selection bias.Conclusions: Malignant GB mass lesions can be safely and accurately differentiated by EUS-FNA. Thus, patients with xanthogranulomatous cholecystitis can avoid undue extensive surgery.

Large-diameter therapeutic channel duodenoscope to facilitate simultaneous deployment of side-by-side self-expandable metal stents in hilar cholangiocarcinoma

Atif Saleem, Todd H. Baron, Christopher J. Gostout — 2010-06-25

Background: Hilar cholangiocarcinoma (CC) is unresectable in 80% to 90% of cases. Placement of side-by-side bilateral self-expandable metal stents (SEMSs) can be technically challenging in these patients because deployment of the first stent can preclude passage of the second stent.Methods: Using a prototype large-diameter therapeutic channel (6-mm) duodenoscope, we positioned guidewires into the right and left intrahepatic systems. Two predeployed uncovered SEMSs with 7.5F delivery systems were passed side by side over each guidewire and deployed simultaneously.Design: Observational clinical feasibility study.Setting: Tertiary referral center.Results: This technique was attempted in 6 patients with malignant hilar biliary obstruction. Successful placement was achieved in all, with significant improvement in symptoms and cholestasis.Limitations: Small number of patients.Conclusion: This simple technique using a prototype large-diameter therapeutic channel duodenoscope facilitates placement of bilateral side-by-side hilar SEMSs.

Initial performance profile of a new 6F self-expanding metal stent for palliation of malignant hilar biliary obstruction

Jennifer Chennat, Irving Waxman — 2010-06-28

Background: A 6F endoscopic biliary self-expanding metal stent (SEMS) has been newly introduced for intended simultaneous side-by-side bilateral deployment in hilar malignant obstruction.Objective: To report our initial experience with the Zilver 635 biliary SEMS.Design: Retrospective chart review.Setting: Tertiary referral medical center.Patients: Sixteen consecutive malignant hilar biliary obstruction patients.Interventions: Endoscopic palliative treatment of malignant biliary obstruction with the Zilver 635 SEMS from December 2008 to January 2010.Main Outcome Measurements: Technical/functional success rates, early complications (within 30 days of stent placement), early/late stent occlusion, and biliary reintervention rates.Results: A total of 49 Zilver SEMSs were placed in 16 patients (mean age 61 years, 6 men) for Bismuth type II (n = 4), III (n = 5), and IV (n = 7) lesions. Twelve had cholangiocarcinoma, 2 had metastatic colon cancer, 1 had lung cancer, and 1 had pancreatic cancer. The technical success rate was 100%. Side-by-side simultaneous bilateral stent deployment was required and was achieved successfully in 10 cases. Additional transpapillary stents were placed for potential future biliary access. The 30-day mortality rate was 0%. There were 1 early (6%) and 3 late (19%) stent occlusions. Successful overall biliary drainage was 75%.Limitations: Small sample size, uncontrolled retrospective study.Conclusions: Malignant hilar biliary obstruction endoscopic palliation with the Zilver 635 SEMS offers acceptable initial feasibility, safety, and efficacy profiles. The current design facilitates smaller bile duct negotiation and more precise intrahepatic placement. Expanding available lengths would allow transpapillary bridged bilateral SEMS placement for future reobstructed biliary access. Further long-term studies are required for comparative outcomes with other current SEMS technology.

Characterization of intra-abdominal lesions of undetermined origin by contrast-enhanced harmonic EUS (with videos)

2010-06-21

Background: The diagnosis of intra-abdominal lesions of undetermined origin is often a challenge for endoscopists and radiologists.Objective: To evaluate the microvasculature of benign and malignant intra-abdominal lesions by contrast-enhanced harmonic EUS (CEH-EUS) and to investigate its usefulness for discriminating between malignant and benign lesions.Design: The vascularity of intra-abdominal lesions of undetermined origin was observed by using CEH-EUS. The lesions were classified according to their vascular patterns. The effectiveness of CEH-EUS in differentiating malignant from benign lesions was evaluated.Setting: Kinki University School of Medicine, Osaka, Japan.Patients: Forty-three patients, each with a lesion of undetermined origin, were evaluated prospectively by CEH-EUS between March 2007 and March 2009.Interventions: CEH-EUS was performed by using a prototype echoendoscope and the extended pure harmonic detection mode (a specific mode for contrast harmonic imaging).Main Outcome Measurements: The lesions were categorized by 2 physicians as having no, homogeneous, or heterogeneous enhancement. A consensus was reached for each case offline. How the benign and malignant groups differed in terms of their enhancement patterns was examined.Results: The κ coefficient of the interobserver agreement test was 0.953 (P < .001). Of the 27 malignant lesions, 26 (96.3%) exhibited heterogeneous enhancement. The 1 remaining malignant lesion (3.7%) showed homogeneous enhancement. Of the 16 benign lesions, none displayed heterogeneous enhancement, and 12 (75%) and 4 (25%) exhibited homogeneous and no enhancement, respectively. The malignant and benign lesion groups differed significantly in terms of homogeneous and heterogeneous enhancement (P < .001). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy with which CEH-EUS differentiated malignant from benign lesions were 96.3%, 100%, 100%, 94.1%, and 97.6%, respectively.Limitations: A single medical unit with a limited number of patients.Conclusions: CEH-EUS depicted the microvasculature of intra-abdominal lesions of undetermined origin very clearly and may be useful for characterizing such lesions.

In vivo visualization of trophozoites in patients with amoebic colitis by using a newly developed endocytoscope

2010-06-25

Background: The endocytoscopy system (ECS) is a new method to provide real-time super-magnifying microscopic imaging in vivo. Routine diagnosis of amebic colitis requires multiple tests that are both time consuming and costly.Objective: To determine the feasibility of ECS to directly detect the amebic parasites in vivo.Design: Prospective, single-center, pilot study.Setting: Tertiary-care university hospital.Patients: This study involved 5 patients who were suspected to have amebic colitis by conventional colonoscopy in our institute.Interventions: A super-magnifying ECS with 450 × magnification.Main Outcome Measurements: We compared ECS findings with those of conventional methods—serum antibody tests and histology of colon biopsy specimens.Results: We successfully visualized the amebic trophozoites in all 5 cases. In contrast, 3 specimens had positive results on serology, and 3 had positive histology results on hematoxylin and eosin staining.Limitations: Pilot study with a limited number of patients. Findings were compared only with serology and histology findings.Conclusions: ECS would be a useful tool for the prompt diagnosis of amebic colitis via the real-time in vivo visualization of amebic trophozoites.

Endoscopic treatment of a recalcitrant esophageal fistula with new tools: stents, Surgisis, and nitinol staples (with video)

2010-03-22

Intrathoracic esophageal anastomotic leaks are a feared complication of esophageal surgery. Beyond surgical drainage, therapeutic endoscopic intervention is increasingly indicated to effect closure of acute perforations, leaks, and fistulae. Conventional endoscopic clips and self-expanding stents are in the front line of endoscopic therapy, but even with these standard approaches, healing may remain elusive. This case report describes the use of two complementary secondary closure methods, Surgisis Soft Tissue Graft (Cook Biotech Inc, West Lafayette, IN) and the Over-The-Scope-Clipping system (OTSC system; Ovesco Endoscopy GmbH, Tuebingen, Germany) to resolve a recalcitrant esophageal fistula.

Esophageal anthracosis complicated by mediastinal tuberculous lymphadenitis presenting as submucosal tumor

2010-04-26

Anthracosis is a black pigment discoloration located mainly in the bronchi because of inhalation of dust or particulates. Extrapulmonary anthracosis that includes the esophagus is very rare, and its etiology is not well established. We present a case of esophageal anthracosis presenting as a submucosal tumor (SMT) complicated by mediastinal tuberculous lymphadenitis.

Spiral enteroscopy-assisted pancreatoscopy for the diagnosis of obscure overt bleeding in a patient with surgically altered anatomy

Mark Wilkinson, Satish Nagula, Jonathan M. Buscaglia — 2010-04-26

Pseudoaneurysm formation of the peripancreatic arteries is a rare but well-described complication of chronic pancreatitis. Angiography and arterial embolization are valuable means of diagnosis and treatment for bleeding peripancreatic pseudoaneurysms. We present a case of obscure overt GI bleeding as a complication of coil migration after embolization of a bleeding gastroduodenal artery (GDA) pseudoaneurysm. Spiral enteroscopy-assisted pancreatoscopy was used to establish the site of bleeding in this patient with a prior lateral pancreaticojejunostomy.

Repeated enteral stent fracture in patient with benign duodenal stricture

Nicholas Stern, Howard Smart — 2010-03-29

Self-expanding metal stents (SEMSs) are now widely used for palliation of malignant stricturing in the pyloric region as well as other parts of the GI tract. There is limited literature about the benefits in benign gastric outlet obstruction.

Reduction of ileoileal intussusception by using double-balloon endoscopy in Peutz-Jeghers syndrome (with video)

2010-03-15

Until only a few years ago, primary surgical resection and intraoperative endoscopy with polypectomy were the only means available for treating polyps in the small intestine in patients with Peutz-Jeghers syndrome (PJS). With the introduction of double-balloon endoscopy (DBE), however, endoscopic polypectomy has become available. However, in the case of intussusception in PJS, surgical intervention is still usually required. We describe our experience with successful reduction of an ileoileal intussusception followed by endoscopic resection of the responsible polyp by using DBE in a patient with PJS.

Jejunal capillary hemangioma treated by using double-balloon endoscopy (with video)

2010-05-24

Vascular tumors of the small bowel are rare, accounting for only 5% to 10% of all benign tumors of the small intestine. The main presenting symptom of capillary hemangioma is bleeding. In most cases, partial resections of the small bowel are necessary. Here, we report a rare case of capillary hemangioma of the small bowel treated by endoscopic mucosal resection by using double-balloon endoscopy (DBE).

Endoscopic-assisted closure of a chronic colocutaneous fistula

2010-04-26

In the absence of such factors as distal obstruction, a complete rosette of mucosa at the external opening, foreign body, malignancy, inflammatory bowel disease, or epithelialization of the tract, conservative management should allow healing of a postoperative, anastomotic, enterocutaneous fistula. Chronic or high-output fistulae usually require surgical correction. We describe the combined use of endoscopic clips and fibrin glue in the closure of a chronic colocutaneous fistula.

Endoscopic treatment of pseudocystocolonic fistula with fibrin glue

Jukka Karvonen, Risto Gullichsen, Paulina Salminen, Juha M. Grönroos — 2010-04-26

Pseudocysts are common complications of acute pancreatitis, whereas subsequent colonic complications such as necrosis, stenosis, and fistula associated with pseudocysts are rare. External pancreatic fistulas and other GI fistulas have been treated successfully with fibrin glue. A case of endoscopically glued pseudocystocolonic fistula is presented herein.

Successful management of a difficult case of radiation proctopathy with Ankaferd BloodStopper: a novel indication (with video)

Ali Shorbagi, Bülent Sivri — 2010-04-26

A 70-year-old female patient who underwent surgery for rectal cancer at another center in February 2007 presented to our department a year later with rectal bleeding. She had received adjuvant chemoradiotherapy after surgery. A left-sided colonoscopy revealed actively bleeding telangiectasia up to 25 cm from the anal verge. The patient was initially started on a course of mesalazine enema at a dose of 4 g/day; however, this treatment was not tolerated, and citing an increase in symptoms, the patient decided to discontinue therapy. Continued bleeding with marked decrease in hematocrit prompted hospitalization followed by erythrocyte suspension transfusion. She was referred for endoscopic therapy with argon plasma coagulation; however, the profuse nature of the bleeding did not allow for accurate targeting of the bleeding telangiectasia, and despite two separate sessions of “blind” coagulation, the patient's symptoms persisted. The patient vehemently refused the option of surgery and was subsequently informed about a not-yet-approved option of the “off-label” use of Ankaferd BloodStopper (ABS), a unique medicinal plant extract that gained health ministerial approval in Turkey for the management of external hemorrhage and dental surgery bleeding, to achieve hemostasis. There is an increasing number of reports on the off-label use of ABS in several clinical settings.

Confocal laser endomicroscopy in Barrett's esophagus and endoscopically inapparent Barrett's neoplasia: a prospective, randomized, double-blind, controlled, crossover trial

Kerry B. Dunbar, Marcia I. Canto — 2010-09-01

We read with interest the editorial by Dr. Joo-Ha Hwang in reference to our article published in Gastrointestinal Endoscopy October 2009. The editorial mentions a false-positive rate for suspected dysplasia of 64.3% using endomicroscopy (EM).

“Locked” pancreatic duct-wire technique for biliary cannulation

Shyam Menon, Neil C. Fisher — 2010-09-01

De Tejada et al has tried to address an important question pertaining to biliary cannulation at ERCP by using a “double-guidewire” technique (DGT) with a well designed randomized trial. However, some of their conclusions may be a reflection of the study design and interventional parameters and need to be addressed. First, a multicenter trial raises issues about the diversity of experience among operators, and therefore a breakdown of procedures (successes/failures) per center would be useful. Second, it would be helpful to clarify whether “short” wires were used in any of the centers either within the study protocol or for “salvage” ERCPs once the defined end point had been reached, because use of a “locked” short wire could potentially facilitate a DGT approach. Third, despite the total volume of contrast injected into the pancreatic duct being similar in both groups (single vs double guidewire), the authors did not take into account the fact that the double-guidewire group had more instrumentation of the pancreatic duct. Finally, the design of the study should perhaps have ensured that the patients in the double-guidewire group had a pancreatic stent inserted after the procedure. The higher rates of hyperamylasemia and pancreatitis in this group may be a reflection of failure to insert a prophylactic stent, and this can not be considered to be standard practice.

Response

Alberto Herreros De Tejada, Jose L. Calleja, Luis E. Abreu — 2010-09-01

We thank Drs Menon and Fisher for their interest in our article about the double-guidewire technique (DGT). One of the main advantages of a multicenter trial is to include a large number of subjects, perhaps increasing the generalization of the results. In our study, there were no statistically significant differences in primary success rates (common bile duct [CBD] cannulation rates within 15 attempts by using DGT) nor in ERCP-related pancreatitis rates with regard to the recruiting center. One of the limitations in the intention to analyze differences between centers was the reduced number of patients per group and hospital. As we discussed in our article, the small number of enrolled patients was probably the result of using a strict definition of cannulation attempt and difficult CBD cannulation, in comparison with prior studies.

Using an overtube for cholangioscopy

Jacobo Dib — 2010-09-01

I read with interest the report “Overtube use in gastrointestinal endoscopy,” prepared by the ASGE (American Society for Gastrointestinal Endoscopy) Technology Committee. It came to my attention that you did not mention an article recently published in the journal about the use of an overtube balloon assisted cholangioscopy using an ultra-slim upper endoscope, previously published as an abstract in 2008. In this study, peroral cholangioscopy was successfully performed in 10 of 12 patients without complications with the use of an upper endoscope with an outer diameter between 5.2 and 6 mm. By means of the use of the overtube, under direct visualization, there is no need to use a guidewire to maintain access to the bile duct during the procedure. Thus, this indication for the use of an overtube in GI endoscopy should be added to all of the others described in your article.

Response

William M. Tierney — 2010-09-01

The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee respects Dr Dib's comment regarding our recent article “Status Evaluation Report (SER) on Overtube Use in Gastrointestinal Endoscopy.” One of the major roles of this committee is to provide an update on a variety of established and evolving endoscopic technologies to ASGE members as a means to enhance their ability to provide state-of-the-art care. The ASGE Technology Committee does adhere to a described systematic review process and selects the most appropriate references available at the time of document drafting. Unfortunately, there will be occasional publications on the topic that appear in peer review publications in the interval between drafting and submission to GIE and final publication in GIE. The literature search deadline is always noted at the beginning of every SER or Report on Emerging Technology. The publication by Choi et al on the use of an adapted small-bowel enteroscopy overtube to facilitate choledochoscopy with an ultrathin endoscope was not included because it was published in peer review format after the drafting of the technology review. The indications for overtube use listed in the SER include a list of general application categories along with some representative examples in each category. The use of the overtube in the report by Choi et al is essentially a means of reducing endoscope looping. Indeed, the concept of using overtube devices to facilitate cholangioscopy and pancreatoscopy is likely to be an area of future device development. We applaud Dr Dib for taking the time to provide feedback on the overtube SER and extend an assurance that the committee will continue to work toward the goal of helping ASGE members in their mission to provide first-rate care for their patients.

Does the selective use of metoclopramide improve the completion rate of small-bowel capsule endoscopy?

Reena Sidhu, Kaye Drew, David S. Sanders, Ruchit Sood, Mark E. McAlindon — 2010-09-01

Postgate et al recently showed that the use of purgatives and metoclopramide had no effect on transit times or completion rates for capsule endoscopy. Several studies have, in fact, investigated factors that may influence completion rates of capsule endoscopy, but there remains a lack of a consensus on the optimal preparation. Furthermore, there have been concerns about the theoretical risk of increasing the rate of missed pathology when drugs affecting the small-bowel transit time are used routinely. We would like to share our experience in this area, which is contrary to the findings of Postgate et al.

Response

Edward J. Despott, Aymer Postgate, Chris Fraser — 2010-09-01

We read with interest the letter from Sidhu et al on the use of metoclopramide for capsule endoscopes retained in the stomach 30 minutes after swallowing. We recognize along with the Sheffield group that this is common practice within many capsule endoscopy (CE) units to try to reduce the risk of an incomplete procedure since delayed gastric emptying is a recognized risk factor.

Ongoing colorectal cancer risk despite surveillance colonoscopy: the Polyp Prevention Trial Continued Follow-up Study

Andreas Stang, Thomas Seufferlein — 2010-09-01

Leung et al recently reported interesting results of the continued follow-up study (CFS) of patients enrolled in the Polyp Prevention Trial (PPT). However, we believe that they provided an arbitrary estimate of the beneficial effect of removal of adenoma by colonoscopy on the subsequent colorectal cancer (CRC) risk by their method. Leung et al compared the observed incidence of CRC of a subcohort of the CFS patients with the expected incidence derived from CRC rates from the Surveillance, Epidemiology, and End Results (SEER) program. The corresponding SEER rates were used for each gender, 5-year age group, and 4-year calendar period. The estimated standardized incidence ratio (IR) was 0.64 (95% confidence interval, 0.28-1.06).

Problems with combining esophagogastroduodenoscopy and colonoscopy to analyze risks of transient hypoxia from procedures in patients with risk factors for obstructive sleep apnea: a call for stratifying risks according to individual procedures

Mitchell S. Cappell — 2010-09-01

Obstructive sleep apnea is increasingly being diagnosed, and its cardiopulmonary risks are being increasingly elucidated, but the risks of GI endoscopy in patients with obstructive sleep apnea is previously unstudied. Thus the article by Khiani et al related to this subject is particularly welcomed and important. Khiani et al show no significant difference in the rates of transient hypoxia between relatively high-risk and relatively low-risk groups for obstructive sleep apnea. I have 2 comments about this article. First, the authors analyze patients at relatively high risk of obstructive sleep apnea but exclude patients with diagnosed obstructive sleep apnea and 2 other significant cardiopulmonary conditions, chronic obstructive pulmonary disease and congestive heart failure. Thus, their conclusion of an insignificantly increased risk of transient hypoxia during GI endoscopy pertains only to a population with some risk factors for obstructive sleep apnea, but not to the population with diagnosed obstructive sleep apnea, which is the population precisely at greatest theoretical risk of transient hypoxia from endoscopy. Their high-risk patients encompassed 39% of all outpatients undergoing endoscopy and thus likely comprised mostly patients without (undiagnosed) obstructive sleep apnea, as the prevalence of obstructive sleep apnea—whether diagnosed or undiagnosed—is estimated at 5% or less of the adult population. Second, the theoretical risks of transient hypoxia from GI endoscopy appear to be much greater for EGD than for colonoscopy because of potentially direct impingement of the airway, laryngeal irritation, or microaspiration during esophageal intubation during EGD. Only 25.8% of the total number of analyzed patients underwent only EGD. They combined EGD and colonoscopy in their statistical analysis of procedure risks. This combined analysis is not recommended in general because these procedures have different procedure indications, are often performed by endoscopists with different levels of training (ie, in many hospitals EGDs are performed exclusively by gastroenterologists, whereas colonoscopies are performed by gastroenterologists or surgeons), and have a different spectrum and distribution of complications. This combined analysis is particularly problematic when examining transient hypoxia because of the greater theoretical risk of this complication in EGD than in colonoscopy. I congratulate Khiani et al on their important study, but further studies are required, particularly on pulmonary complications of EGD in patients with diagnosed obstructive sleep apnea.

Response

Vijay Khiani, Amitabh Chak — 2010-09-01

We greatly appreciate Dr Cappell's insights and discussion of the strengths and weaknesses of our study. Obstructive sleep apnea is a condition that deserves attention in patients undergoing endoscopy. In particular, there are an increasing number of patients with undiagnosed obstructive sleep apnea who are undergoing endoscopy. While Dr Cappell is correct in stating that the overall prevalence of diagnosed obstructive sleep apnea may be around 3% to 7%, it has been estimated that the overall prevalence of obstructive sleep apnea in the U.S. population is approximately 20% with approximately 90% of all obstructive sleep apnea being undiagnosed. This is an under-recognized disease. Because there is a lack of literature on the percentage of patients at high risk for obstructive sleep apnea who present for endoscopy, a major aim of our study was to determine what proportion of patients presenting for endoscopy at our institution might have undiagnosed sleep apnea and whether the failure to recognize sleep apnea was leading to sedation-related complications. The Berlin Questionnaire is a validated questionnaire for assessing the risk of obstructive sleep apnea with a sensitivity range of 0.69 to 0.87 and a specificity range of 0.77 to 0.95. Therefore, about 80% of the patients in our high-risk group had undiagnosed obstructive sleep apnea. Patients with known pulmonary conditions such as congestive heart failure and chronic obstructive pulmonary disease were excluded to minimize confounding variables leading to cardiovascular complications in the study population. Patients with diagnosed sleep apnea were also deliberately excluded from our study because endoscopists often change sedation practices in patients with known sleep apnea. Our study did examine patients undergoing EGD, colonoscopy, or both. The majority of these patients did undergo colonoscopy. Overall, there was no significant difference in transient hypoxia between the high-risk and low-risk groups. We did not power our study for subset analysis and completely agree with Dr Cappell that it would be useful to perform further studies examining differences in subsets. Dr Cappell makes an excellent point about taking a closer look at the risk of transient hypoxia in patients with a known diagnosis of obstructive sleep apnea who are undergoing an EGD in particular.

Errata

2010-09-01

1. In the article entitled “Endoscopic treatment of postorthotopic liver transplantation anastomotic biliary strictures with maximal stent therapy (with video)” by James H. Tabibian et al (Gastrointest Endosc 2010;71:505-12), in Table 4, the study on the last line, Tabibian et al, contains information from the current study and should not refer to the study in reference 22.

Gastrointestinal Endoscopy

Contents

Editors

Focus on…

ASGE update

In upcoming issues…

Information for readers

Minimum staffing requirements for the performance of GI endoscopy

The role of endoscopy in the management of obscure GI bleeding

Prevalence and risk of colorectal neoplasms in asymptomatic, average-risk screenees 40 to 49 years of age

Biopsy depth after radiofrequency ablation of dysplastic Barrett's esophagus

Short-term safety and efficacy of the Trans-oral Endoscopic Restrictive Implant System for the treatment of obesity

Endoscopic therapy of obesity: a new paradigm in bariatric care

Lymph node metastasis from intestinal-type early gastric cancer: experience in a single institution and reassessment of the extended criteria for endoscopic submucosal dissection

Split-dose bowel preparation for colonoscopy and residual gastric fluid volume: an observational study

Magnifying endoscopy with narrow-band imaging achieves superior accuracy in the differential diagnosis of superficial gastric lesions identified with white-light endoscopy: a prospective study

Endoscopic magnetic gastroenteric anastomosis for palliation of malignant gastric outlet obstruction: a prospective multicenter study

Endoscopic pancreatic sphincterotomy and stenting for preoperative prophylaxis of pancreatic fistula after distal pancreatectomy

Distal pancreatectomy: another indication for prophylactic pancreatic stenting?

Biliary stent placement is associated with post-ERCP pancreatitis

Endotherapy of postoperative biliary strictures with multiple stents: results after more than 10 years of follow-up

Low symptomatic premature stent occlusion of multiple plastic stents for benign biliary strictures: comparing standard and prolonged stent change intervals

Bulb biopsies for the diagnosis of celiac disease in pediatric patients

Not everything is celiac disease

Differentiating adenomas from hyperplastic colorectal polyps: narrow-band imaging can be learned in 20 minutes

Narrow-band imaging for colorectal polyps: it can be taught but will it be used?

Projected increased growth rate of anesthesia professional–delivered sedation for colonoscopy and EGD in the United States: 2009 to 2015

Anatomic-manometric correlation of the upper esophageal sphincter: a concurrent US and manometry study

Endoscopic submucosal dissection of gastric lesions by using a Master and Slave Transluminal Endoscopic Robot (MASTER)

Continuing Medical Education Exam: September 2010

The benefits of a gastroenterology fellows club

Erupted cysts in the cervical esophagus result in gastric inlet patches

Use of the front-view forward-array echoendoscope to evaluate right colonic subepithelial lesions

Initial evaluation of a novel, prototype, forward-viewing echoendoscope in a porcine arterial bleeding model (with video)

Gastric perforations after ligation of GI stromal tumors in the gastric fundus

Endoscopic closure of a distal common bile duct perforation caused by papillary dilation with a large-diameter balloon (with video)

GI vasculitis associated with systemic lupus erythematosus

Gone but not forgotten. “Bubble gum enema” containing hydrogen peroxide and causing life-threatening colitis

Can EUS-guided FNA distinguish between gallbladder cancer and xanthogranulomatous cholecystitis?

Large-diameter therapeutic channel duodenoscope to facilitate simultaneous deployment of side-by-side self-expandable metal stents in hilar cholangiocarcinoma

Initial performance profile of a new 6F self-expanding metal stent for palliation of malignant hilar biliary obstruction

Characterization of intra-abdominal lesions of undetermined origin by contrast-enhanced harmonic EUS (with videos)

In vivo visualization of trophozoites in patients with amoebic colitis by using a newly developed endocytoscope

Endoscopic treatment of a recalcitrant esophageal fistula with new tools: stents, Surgisis, and nitinol staples (with video)

Esophageal anthracosis complicated by mediastinal tuberculous lymphadenitis presenting as submucosal tumor

Spiral enteroscopy-assisted pancreatoscopy for the diagnosis of obscure overt bleeding in a patient with surgically altered anatomy

Repeated enteral stent fracture in patient with benign duodenal stricture

Reduction of ileoileal intussusception by using double-balloon endoscopy in Peutz-Jeghers syndrome (with video)

Jejunal capillary hemangioma treated by using double-balloon endoscopy (with video)

Endoscopic-assisted closure of a chronic colocutaneous fistula

Endoscopic treatment of pseudocystocolonic fistula with fibrin glue

Successful management of a difficult case of radiation proctopathy with Ankaferd BloodStopper: a novel indication (with video)

Confocal laser endomicroscopy in Barrett's esophagus and endoscopically inapparent Barrett's neoplasia: a prospective, randomized, double-blind, controlled, crossover trial

“Locked” pancreatic duct-wire technique for biliary cannulation

Response

Using an overtube for cholangioscopy

Response

Does the selective use of metoclopramide improve the completion rate of small-bowel capsule endoscopy?

Response

Ongoing colorectal cancer risk despite surveillance colonoscopy: the Polyp Prevention Trial Continued Follow-up Study

Problems with combining esophagogastroduodenoscopy and colonoscopy to analyze risks of transient hypoxia from procedures in patients with risk factors for obstructive sleep apnea: a call for stratifying risks according to individual procedures

Response

Errata