Gastrointestinal Endoscopy

Emerging technologies for endoscopic hemostasis

2012-03-26

The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of emerging endoscopic technologies that have the potential to affect the practice of GI endoscopy. Evidence-based methodology is used, with MEDLINE and PubMed literature searches to identify pertinent clinical studies on the topic. Because many topics have a limited number of peer-reviewed articles, abstracts from scientific meetings are used to supplement the review. The reports focus on the current status of the technologies, areas in need of further research, and barriers to incorporation into the mainstream practice of GI endoscopy.

Circumferential location predicts the risk of high-grade dysplasia and early adenocarcinoma in short-segment Barrett's esophagus

2012-03-02

Background: Whether early Barrett's neoplasia has a predilection for particular spatial locations in shorter segment disease is currently unknown. Anatomic factors may play a role in lesion location because of differing levels of mucosal acid exposure. Objective: To identify high-risk lesion locations, which has important implications for surveillance strategies. Design: We interrogated a prospectively maintained database of patients who underwent endoscopic resection (ER) for Barrett’s neoplasia at 2 Australian tertiary centers. Lesions targeted for ER were characterized and their location in the distal esophagus was noted as on a clock face. A Z test of proportions was used to test for deviation from uniformity in the distribution of lesions. Setting: Two Australian tertiary centers. Patients: Patients who underwent ER for Barrett’s neoplasia. Main Outcome Measurements: Lesion location in the distal oesophagus, resected specimen histology. Results: A total of 146 consecutive patients had ER for biopsy-proven high-grade dysplasia or esophageal adenocarcinoma. A total of 75 patients had Barrett's segment length of 5 cm or less and a visible lesion. Five patients had 2 visible lesions giving a total of 80 lesions. ER of 66 lesions (82.5%) led to the identification of advanced pathology: 37 high-grade dysplasia (46%), 24 mucosal adenocarcinoma (30%), 5 submucosal adenocarcinoma (6%). Of a total of 80 lesions, 43 (53.8%) (95% CI, 42.9%-64.7%) were centered within the 2- to 5-o'clock arc, comprising 25% of the circumference. This area also accounted for 36 (54.5%) of the 66 lesions with advanced histology (95% CI, 42.5%-66.5%). All confidence intervals lie wholly above the 25% expected in a uniform circular distribution (P < .05). Limitations: Observational study in a tertiary center. Conclusions: In Barrett's maximal segments of 5 cm or less, the 2- to 5-o'clock arc, accounts for approximately 50% of macroscopically visible lesions and associated early neoplasia. This finding has important implications for surveillance strategies.

Feasibility, safety, acceptability, and yield of office-based, screening transnasal esophagoscopy (with video)

2012-03-19

Background: Endoscopic screening for esophageal neoplasia can identify patients eligible for early intervention for precancerous lesions. Unsedated transnasal esophagoscopy may provide an efficient and accurate endoscopic assessment with fewer risks and less cost, compared with conventional upper endoscopy. Objective: To assess the feasibility, safety, acceptability, and yield of unsedated transnasal esophagoscopy in a primary care population. Design: Multicenter, prospective, cross-sectional study. Setting: Two outpatient tertiary-care centers. Patients: This study involved a general medical clinic population aged between 40 and 85 years. Intervention: Unsedated, office-based transnasal esophagoscopy. Main Outcome Measurements: Procedure yield; completeness of examination; procedure length; adverse events and complications; choking, gagging, pain, or anxiety during the examination; and overall tolerability. Results: A total of 426 participants (mean [± standard deviation] age 55.8 ± 9.5 years; 43% male) enrolled in the study, and 422 (99%) completed the examination. Mean (± standard deviation) examination time was 3.7 ± 1.8 minutes. There were no serious adverse events, and 12 participants (2.8%) reported minor complications. Participants reported minimal choking, gagging, pain, or anxiety. The examination was well-tolerated by most participants. Overall, 38% of participants had an esophageal finding that changed management (34% erosive esophagitis, 4% Barrett's esophagus). Limitations: Nonrandomized study, tertiary-care centers only, self-selected population with a large proportion reporting esophageal symptoms. Conclusion: Unsedated transnasal esophagoscopy is a feasible, safe, and well-tolerated method to screen for esophageal disease in a primary care population. Endoscopic findings are common in this patient population.

Randomized crossover study comparing efficacy of transnasal endoscopy with that of standard endoscopy to detect Barrett's esophagus

2012-03-15

Background: Unsedated transnasal endoscopy (TNE) may be safer and less expensive than standard endoscopy (SE) for detecting Barrett's esophagus (BE). Emerging technologies require robust evaluation before routine use. Objective: To evaluate the sensitivity, specificity, and acceptability of TNE in diagnosing BE compared with those of SE. Design: Prospective, randomized, crossover study. Setting: Single, tertiary-care referral center. Patients: This study enrolled consecutive patients with BE or those referred for diagnostic assessment. Intervention: All patients underwent TNE followed by SE or the reverse. Spielberger State-Trait Anxiety Inventory short-form questionnaires, a visual analogue scale, and a single question addressing preference for endoscopy type were administered. Main Outcome Measurements: Diagnostic accuracy and tolerability of TNE were compared with those of SE. Results: Of 95 patients randomized, 82 completed the study. We correctly diagnosed 48 of 49 BE cases by TNE for endoscopic findings of columnar lined esophagus compared with the criterion standard, SE, giving a sensitivity and specificity of 0.98 and 1.00, respectively. The BE median length was 3 cm (interquartile range [IQR] 1-5 cm) with SE and 3 cm (IQR 2-4 cm) with TNE, giving high correlations between the two modalities (R2 = 0.97; P < .001). The sensitivity and specificity for detecting intestinal metaplasia by TNE compared with those by SE was 0.91 and 1.00, respectively. The mean (± standard deviation) post-endoscopy Spielberger State-Trait Anxiety Inventory short-form score for TNE (30.0 ± 1.10 standard error of the mean [SEM]) was lower than that for SE (30.7 ± 1.29 SEM), (P = .054). The visual analogue scale scores were no different (P = .07). The majority of patients (59%) expressed a preference for TNE. Limitations: This is a small study, with limited generalizability, a high prevalence of patients with BE, differential drop-out between the two procedures, and use of sedation. Conclusion: TNE is an accurate and well-tolerated method for diagnosing BE compared with SE. TNE warrants further evaluation as a screening tool for BE.

Ultrathin transnasal endoscopy without sedation: the straight skinny

Douglas G. Adler — 2012-05-01

The modern era has seen an explosive increase in the incidence of esophageal adenocarcinoma, most cases of which are believed to be related to an antecedent history of Barrett's esophagus (BE). As of this writing, screening of the general population for the presence of BE is not advocated, although it is believed that BE is present in a significant portion of the population at any given time. Arguments in favor of routine screening of the general population for BE include its strong association with GERD, which is known to be clinically widespread, and its treatability with radiofrequency ablation. Arguments against screening the general population include the significant costs of such a program, especially for those who require surveillance examinations once BE is found, and the fact that most patients who have BE will never develop esophageal adenocarcinoma.

Usefulness of endoscopic radial incision and cutting method for refractory esophagogastric anastomotic stricture (with video)

2012-05-01

Background: There is no effective treatment for gastroesophageal anastomotic strictures that are refractory to repeated endoscopic balloon dilation (EBD). However, EBD is still selected worldwide to manage such refractory strictures. To relieve the symptoms of dysphagia and keep a wide lumen, we developed a new incisional treatment, radial incision and cutting (RIC). Objective: To evaluate the efficacy and safety of the RIC method for the treatment of refractory anastomotic strictures. Design: Retrospective cohort study. Setting: National Cancer Center and University Hospital. Patients: This study involved 54 consecutive patients with refractory anastomotic stricture after esophagogastric surgery. Intervention: RIC. Main Outcome Measurements: The safety and clinical success of RIC and the long-term patency after RIC compared with those of continued EBD. Results: The median procedure time of RIC was 14 minutes (range, 4–40 minutes). No serious adverse events associated with RIC were observed. Immediately after RIC, 81.3% (26/32) of patients were able to eat solid food without symptoms of dysphagia. As a short-term effect, the dysphagia improved after RIC in 93.8% (30/32) of the patients. As a long-term effect, 63% (17/27) and 62% (13/21) of patients were able to eat solid food 6 and 12 months after RIC, respectively. The 6-month and 12-month patency rates were significantly different between the RIC group and the continued EBD group (65.3% vs 19.8%, P < .005; 61.5% vs 19.8%, P < .005). Limitations: Nonrandomized retrospective study. Conclusions: RIC is an effective and safe method. The demonstration of the validity of this method may place RIC as a new medical treatment for patients with refractory stricture after surgical resection for esophagogastric diseases.

Evaluation of GI bleeding after implantation of left ventricular assist device

2012-02-17

Background: Left ventricular assist devices (LVADs) have revolutionized the management of end-stage heart failure (ESHF). However, unexpectedly high rates of GI bleeding (GIB) have been described, and etiology and outcome remain unclear. Objective: To determine the prevalence, etiology, and outcome of GIB in LVAD recipients. Design: Retrospective case series. Setting: Tertiary care academic university hospital. Patients: 154 ESHF patients (55.4 years, 122 men/32 women) with LVADs implanted over a 10-year period. Main outcome measurements: Overt or occult GIB prompting endoscopic evaluation ≥7 days after LVAD implantation. Results: Over a mean of 0.9 ± 0.1 years of follow-up, 29 patients (19%) experienced 44 GIB episodes. Patients with GIB were older and received anticoagulation therapy before devices were implanted (P ≤ .02 for each). GIB was overt (n = 31) rather than occult (n = 13), and most patients presented with melena (n = 22, 50%); hemodynamic instability was observed in 13.6%. Each bleeding episode required 2.1 ± 0.1 diagnostic or therapeutic procedures, and a source was localized in 71%. Upper endoscopy provided the highest diagnostic yield; peptic bleeding (n = 14) and vascular malformations (n = 8) dominated the findings. Endoscopy was safe and well tolerated. Overall mortality was 35%, none directly from GIB. Limitation: Retrospective design. Conclusions: Rates of GIB with LVADs are higher than that seen in other patient populations, including those receiving anticoagulation and antiplatelet therapy. GIB episodes are mostly overt and predominantly from the upper GI tract. Endoscopy is safe in the LVAD population.

Mucosal barrier defects in gastric intestinal metaplasia: in vivo evaluation by confocal endomicroscopy

Rui Ji, Xiu-Li Zuo, Tao Yu, Xiao-Meng Gu, Zhen Li, Cheng-Jun Zhou, Yan-Qing Li — 2012-02-13

Background: Helicobacter pylori infection and intestinal metaplasia (IM) are associated with gastric cancer. An impaired gastric mucosal barrier could be involved in this carcinogenesis. Objective: To evaluate laser confocal laser endomicroscopy (CLE) for in vivo functional imaging of mucosal barrier defects in patients with IM. Design: Prospective, controlled study. Setting: A tertiary-care academic center. Patients: This study involved patients with IM of the gastric mucosa who underwent CLE for surveillance. Interventions: Specific IM mucosa and non-IM mucosa in patients were identified by CLE, and targeted biopsy samples were taken for histopathology and electron microscopy. Main Outcome Measurements: Post-CLE assessment of paracellular fluorescein leakage was devised and validated by electron microscopy. We also evaluated the effect of H pylori eradication on the mucosal barrier. Results: Forty-two patients were included. Of non-IM samples, the paracellular permeability was significantly increased in H pylori–positive samples compared with H pylori–negative controls (54 ± 31% vs 3 ± 6%, P < .05). Of IM samples, the permeability was significantly increased in both H pylori–negative and H pylori–positive samples (67 ± 34% and 72 ± 28% vs 3 ± 6%, both P < .05). The results of post-CLE assessment correlated well with the electron microscopy findings (R2 0.834, P < .0001). After the eradication of H pylori, the paracellular barrier dysfunction of non-IM mucosa was significantly improved as shown by electron microscopy and CLE (both P < .001). However, there was no significant change in IM mucosa. Limitations: Single-center study. Conclusions: CLE allows functional imaging of mucosal barrier defects. Gastric IM is associated with an impaired paracellular barrier irrespective of H pylori eradication.

Effect of the introducer technique compared with the pull technique on the peristomal infection rate in PEG: a meta-analysis

2012-02-27

Background: Peristomal infection is a main complication of PEG. The pull technique appears to be associated with higher infection rates compared with the introducer technique, although published results are controversial. Objective: To determine which technique is associated with a higher risk of infection. Design: Systematic review and meta-analysis. Setting: Studies reporting rates of peristomal infection after PEG performed by either the pull or introducer technique. Patients: This study involved 2336 patients from 6 comparative and 10 observational studies. Intervention: Public MEDLINE (National Library of Medicine journal articles database), Excerpta Medica Database, Cochrane Central Register of Controlled Trials, and Latin American and Caribbean Center on Health Sciences Information databases and proceedings of two meetings, Digestive Disease Week and United European Gastroenterology Week, were searched. Both comparative and observational studies were included and analyzed separately. Main Outcome Measurements: Effect measures from each comparative study were reported as the odds ratio (OR). The pooled effect was then calculated. The infection rate in each observational study was also calculated, and a summary effect was then determined. Results: In comparative studies, the risk of infection was significantly higher with the pull technique (OR 13.0; 95% confidence interval [CI], 4.6-36.8; P < .0001). Similarly, observational studies also reported higher infection rates with the pull technique (10.7%; 95% CI, 4.9-21.8 with the pull technique vs 0.9%; 95% CI, 0.2-4.5 with the introducer technique). Limitations: Few studies were available for inclusion, and there was a high risk of bias among the comparative studies. Conclusion: The pull technique appears to be associated with a significantly higher risk of infection compared with the introducer technique.

Long-term outcomes associated with pancreatic extracorporeal shock wave lithotripsy for chronic calcific pancreatitis

2012-03-09

Background: Most outcomes data on pancreatic extracorporeal shock wave lithotripsy (P-ESWL) for chronic calcific pancreatitis (CCP) are based on studies with <4 years' follow-up, and U.S. long-term studies are lacking. Objective: To report long-term P-ESWL outcomes for CCP and to assess whether smoking or alcohol use influences P-ESWL outcomes. Design: Cross-sectional study, retrospective chart review. Setting: Virginia Mason Medical Center, Seattle, Washington. Patients: This study involved 120 patients who underwent P-ESWL and ERCP for CCP and completed an outcomes questionnaire. Intervention: P-ESWL and ERCP, outcomes survey. Main Outcome Measurements: Pain, quality of life, narcotics use, diabetes status, pancreatic enzyme requirement, repeat P-ESWL, repeat ERCP, surgery. Results: A total of 120 patients underwent P-ESWL followed by ERCP (mean ± standard deviation [SD] follow-up 4.3 [± 3.7] years) and completed a survey. The mean (± SD) before-P-ESWL pain score was 7.9 (± 2.6) compared with 2.9 (± 2.6) after P-ESWL (P < .001). Improved pain was reported by 102 patients (85%); 60 (50%) reported complete pain relief and no narcotic use. The mean (± SD) before-P-ESWL quality-of-life score was 3.7 (± 2.4) compared with 7.3 (± 2.7) after P-ESWL (P < .001). In patients with ≥4 years' follow-up, repeat procedures included P-ESWL (29%), ERCP (84%), and surgery (16%). Smokers who quit smoking after P-ESWL had improved narcotic requirements compared with those who continued smoking (95% vs 67%; P = .014), and a trend suggested a decreased need for repeat ERCPs (68% vs 84%; P = .071). Limitations: Single center, retrospective, recall bias, nonvalidated pain and quality-of-life scales. Conclusion: P-ESWL as the initial therapy for CCP may lead to more lifetime procedures; however, partial pain relief in 85%, complete pain relief with no narcotic use in 50%, and avoidance of surgery in 84% of patients may be achieved. Quitting smoking after P-ESWL may improve outcomes.

Diagnostic yield of EUS-guided FNA and cytology in suspected tubercular intra-abdominal lymphadenopathy

2012-03-15

Background: Intra-abdominal lymphadenopathy is a common diagnostic challenge faced by clinicians. In the absence of palpable peripheral nodes, tissue is usually obtained from the abdominal nodes by image-guided biopsy or surgery. We speculate that EUS-guided FNA (EUS-FNA) avoids the morbidity of a laparotomy and might be equally effective. Objective: To evaluate the role of EUS-FNA in abdominal lymphadenopathy. Design: Prospective study conducted over 42 months. Setting: Tertiary care center in New Delhi, India. Patients: Patients with abdominal lymphadenopathy in whom image-guided node biopsy failed were considered for EUS-FNA. Intervention: A total of 3 passes were performed at each site. Slides were prepared per protocol and sent for cytopathologic evaluation. Results: A total of 142 patients were enrolled, but only 130 (91.5%) underwent FNA. The mean lymph node size was 22 ± 3.2 mm; 71.8% of the nodes were hypoechoic (n = 102), and 28.1% were heterogeneous with an anechoic center (n = 40). In 120 patients (84.5%), the lymph nodes were intra-abdominal only, and in 22 patients (15.5%), they were both intra-abdominal and mediastinal in location. Main Outcome Measurement: EUS-FNA was successful in establishing a diagnosis in 90.8% of these patients; 76.1% were found to have tuberculosis, 7.04% sarcoidosis, 6.33% Hodgkin's lymphoma, and 0.74% non-Hodgkin's lymphoma. Limitations: In 8.4% patients, nodes were inaccessible because of their retropancreatic location. Conclusions: EUS-FNA is a safe, accurate, and minimally invasive modality for diagnosing the cause of abdominal lymphadenopathy. In highly endemic areas, tuberculosis is the most common cause.

Prospective, randomized, back-to-back trial evaluating the usefulness of i-SCAN in screening colonoscopy

2012-03-01

Background: The newly developed i-SCAN application can theoretically maximize the effectiveness of colonoscopy. However, the practical usefulness of the i-SCAN application during screening colonoscopy has not been assessed. Objective: To assess the efficacy of the i-SCAN application during screening colonoscopy. Design: A prospective, randomized trial that used a modified, back-to-back colonoscopy. Setting: Academic hospital. Patients: This study involved 389 asymptomatic, consecutive, average-risk patients who underwent screening colonoscopy. Intervention: The patients were randomized to the first withdrawal with either conventional high-definition white light (HDWL group; n = 119), i-SCAN contrast/surface enhancement (CE/SE) mode (i-SCAN1 group; n = 115), or i-SCAN CE/SE/tone enhancement-colorectal mode (i-SCAN2 group; n = 118). All patients underwent a second examination with HDWL as the criterion standard. Main Outcome Measurements: The primary outcome measurement was the adenoma detection rate and adenoma miss rate. The secondary outcome measurement was the accuracy of the histologic prediction of neoplastic and nonneoplastic polyps. Results: The adenoma detection rates during the first withdrawal of HDWL, i-SCAN1, and i-SCAN2 were 31.9%, 36.5%, and 33.1%, respectively (P = .742), and the adenoma miss rates of each group were 22.9%, 19.3%, and 15.9%, respectively (P = .513). Based on the multivariate analysis, the application of i-SCAN was not associated with an improvement in adenoma detection and the prevention of missed polyps. However, the prediction of neoplastic and nonneoplastic colorectal lesions was more precise in the i-SCAN2 group compared with the HDWL group (accuracy 79.3% vs 75.5%, P = .029; sensitivity 86.5% vs 72.6%, P = .020; and specificity 91.4% vs 80.6%, P = .040). Limitations: Single-center trial. Conclusion: i-SCAN during the screening colonoscopy may fail to improve adenoma detection and the prevention of missed polyps, but i-SCAN appears to be effective for real-time histologic prediction of polyps compared with conventional HDWL colonoscopy. (Clinical trial registration number: NCT01417611.)

Prevalence of advanced histological features in diminutive and small colon polyps

2012-03-12

Background: Investigators have proposed “predict, resect, and discard” strategies for diminutive (≤5 mm) or small (6-9 mm) polyps to reduce screening colonoscopy costs. Advanced histological features such as villous histology, high-grade dysplasia, and/or cancer in these polyps could deter adoption of these strategies. Objective: Determine the prevalence of advanced histological features in diminutive and small colon polyps. Design: Retrospective analysis of data from 3 prospective clinical trials. Setting: Two tertiary-care referral centers. Patients: This study involved patients undergoing screening or surveillance colonoscopy. Intervention: The location, size, and morphology of each polyp detected was documented. Each polyp was then resected, placed in a unique specimen jar, and sent for histopathological evaluation. Main Outcome Measurements: Rates of advanced histological features (villous histology, high-grade dysplasia, and cancer). Results: A total of 2361 polyps were detected, removed, and retrieved. Both diminutive and small polyps had a lower frequency of any advanced histological features compared with large polyps (0.5% and 1.5%, respectively vs 15.0%; P < .001 for both comparisons). Polyps <10 mm in size had a lower frequency of advanced histology compared with polyps ≥10 mm (0.8% vs 15.0%; P < .001). During sensitivity analysis, the frequency of advanced histological features varied from 0.2% to 0.7% within diminutive polyps, 1.5% to 3.6% within small polyps, and 0.8% to 1.2% within polyps <10 mm. Limitations: Retrospective analysis from tertiary-care referral centers; predominantly white, male, veteran patient population resulting in limited generalizability of results. Conclusion: The prevalence of advanced histological features in colon polyps ≤5 mm is very low (0.5%). This has important implications for the potential practice of “predicting, resecting, and discarding” diminutive colon polyps.

Randomized trial of standard versus magnetic endoscope imaging colonoscopes for unsedated colonoscopy

2012-03-02

Background: Unsedated colonoscopy has potential benefits, including decreased costs and decreased risks. Objective: To determine whether patient comfort during unsedated colonoscopy can be improved through the use of a magnetic endoscopic imaging (MEI) colonoscope compared with a standard colonoscope. Design: Prospective, patient-blinded, randomized, controlled trial. Setting: San Francisco Veterans Affairs Medical Center. Patients: Veterans undergoing outpatient screening or surveillance colonoscopy. Interventions: Use of a standard or MEI colonoscope during unsedated colonoscopy. Main Outcome Measurement: The primary outcome variable was patient perception of pain using a 7-point scale. The secondary endpoint was patient willingness to undergo a future unsedated colonoscopy. Results: Of the 160 patients enrolled, 140 completed an unsedated colonoscopy in the study protocol. In a per-protocol analysis, the mean and median pain score was 3.12 (standard deviation 1.22) and 4 (interquartile range 2-4) for the standard colonoscope group and 3.06 (standard deviation 1.13) and 3 (interquartile range 2-4) for the MEI group, where 3 was mild pain (P = not significant). Overall, 80% of subjects were willing to undergo a future unsedated colonoscopy for screening or surveillance. In an intention-to-treat analysis, 80% of subjects (64/80) in the standard colonoscope arm and 79% in the MEI arm (63/80) were willing to undergo a future unsedated colonoscopy (P = not significant). Limitations: Single-center study of mostly male veterans. Conclusions: This patient-blinded, randomized, controlled trial did not demonstrate any difference in patient perception of pain or willingness to undergo unsedated examinations when using the MEI versus the conventional colonoscope. Unsedated colonoscopy is generally feasible and well tolerated and is associated with high patient satisfaction rates.

Magnetic endoscope imaging colonoscope: a new modality for hypothesis testing in unsedated colonoscopy

Felix W. Leung — 2012-05-01

Magnetic endoscope imaging (MEI) provides nonfluoroscopic real-time feedback for colonoscopy configuration. Uncontrolled, nonrandomized MEI observations documented loop formation as the major cause of discomfort (defined as demand for self-administered pain medications). A total of 650 demands were recorded in 102 patients when the colonoscope tip was in the sigmoid colon (77%), descending colon (7%), splenic flexure (6%), transverse colon (5%), and proximal colon (4%). Of all pain episodes, 90% coincided with either looping (79%) or straightening (11%) of the colonoscope shaft and presumed overinsufflation (9%). The N-sigmoid spiral loop was associated with the majority of pain episodes (56%). Looping was both more frequent (P = .0002) and less well tolerated in women than in men (P = .014). An earlier randomized, controlled trial (RCT) in patients receiving self-administered sedation showed that real-time MEI feedback significantly improved colonoscopy performance. Loops were straightened or managed effectively, resulting in quicker intubation times (12 minutes vs 15 minutes in a trainee, 8 minutes vs 9 minutes in an experienced colonoscopist) and higher completion rate (100% vs 89% in a trainee, 100% vs 91% in an experienced colonoscopist). The amount of sedation medication and the pain (0-100 scale) scores did not differ in examinations performed by a trainee (29 vs 30) or experienced colonoscopist (29 vs 25). A subsequent RCT comparing the use of MEI and non-MEI colonoscopes in sedated patients revealed that for the experienced colonoscopist, no significant difference was observed in the intubation time (5 minutes vs 5 minutes), colonoscopy completion rate (95% vs 93%), or pain score (0-10 scale) (5 vs 4). In another RCT, a consecutive series of outpatients were randomly allocated to examination with (imager group) or without (standard group) the use of MEI. Sedation was given on demand. Pain was graded by category on the day after the examination. The proportion of colonoscopies performed without sedation was similar when comparing imager and standard groups and experienced and inexperienced colonoscopists, altogether 367 of 419 colonoscopies (88%). The cecal intubation rate was higher in the imager group (190/212, 90%) than in the standard group (153/207, 74%) (P < .001), both collectively and separately for experienced and inexperienced colonoscopists. A pain-reducing effect of the use of MEI with colonoscopy was shown only when performed by experienced colonoscopists, with severe pain in 10 of 137 patients (7.3%) in the imager group and 21 of 132 patients (16%) in the standard group (P = .03). In a recent RCT of patients receiving on-demand sedation, 810 consecutive patients (MEI, 419; standard, 391) were evaluated. For inexperienced endoscopists, the cecal intubation rate was significantly higher in the MEI group (78% vs 56%, P = .02) but not for experienced endoscopists (94% vs 96%). Inexperienced endoscopists required less assistance from a senior colleague when they used MEI (19% vs 40%, P = .02). The mean time to reach the cecum was comparable (14 minutes vs 15 minutes, P = .67). Severe pain was experienced by 43 patients (13%) in the MEI group compared with 53 patients (17%) in the standard group (P = .15). For inexperienced endoscopists, there was a 40% reduction in the number of patients with severe pain in the MEI group compared with the standard group, but this did not reach statistical significance (P = .29). More women (24%) than men (7%) experienced severe pain in the MEI group (P = .001). The corresponding figures for the standard group were 18% and 6%, respectively (P = .001). There was no sex-specific, statistically significant difference between the MEI and standard groups. Further, there was no difference in the use of sedation or analgesics between the study groups. Another RCT of MEI (n = 490) versus a control without MEI (n = 510) in sedated patients showed that time to cecal intubation did not differ between the groups (8 minutes vs 9 minutes), but the duration of abdominal compression was significantly shorter in the MEI group (without compression: 55% vs 45%; <1 minute of compression: 19% vs 18%; 1-3 minutes of compression: 14% vs 24%; >3 minutes of compression: 13% vs 13%; P = .002).

Endoscopic mucosal resection with an over-the-counter hyaluronate preparation

Shai Friedland, Shivangi Kothari, Ann Chen, Walter Park, Subhas Banerjee — 2012-03-02

Background: Hyaluronic acid (HA) provides a long-lasting and distinct mucosal elevation for EMR, but expense and inconvenience have limited its adoption. Objective: To evaluate the safety and efficacy of an over-the-counter 0.15% HA preparation for EMR. Design: Retrospective study. Setting: Veterans Administration Hospital and university hospital. Patients: 30 patients with a total of 32 colonic lesions and 1 duodenal lesion. Intervention: EMR by using HA. Main Outcome Measurements: En bloc resection rate and complications. Results: EMR was successful in all cases. En bloc resection was achieved in 26 of the 28 lesions up to 25 mm in diameter. Two lesions, both with fibrosis from prior attempted resection, had trace residual tissue necessitating cauterization with argon plasma. Five lesions measuring 30 mm to 60 mm all required piecemeal resection. There was one complication, a postpolypectomy bleed. Limitations: Small number of patients and retrospective design. Conclusions: EMR may be performed safely and effectively by using an inexpensive, over-the-counter 0.15% HA preparation. Further studies are needed to verify the results of this study and to compare the safety and efficacy of this HA preparation with saline solution.

Duration and severity of primary sclerosing cholangitis is not associated with risk of neoplastic changes in the colon in patients with ulcerative colitis

2012-03-12

Background: Annual surveillance colonoscopy to detect colon cancer is recommended for patients with primary sclerosing cholangitis (PSC) and ulcerative colitis (UC). Limited data currently support these recommendations. Objective: To study whether a relationship exists between the severity and duration of PSC and the risk of colon cancer and dysplasia (colon neoplasia). Design: Retrospective, longitudinal study. Setting: Tertiary-care referral center. Patients: Information pertaining to duration of PSC, UC, requirement for orthotopic liver transplantation, and time to diagnosis of colon neoplasia was obtained for patients with PSC and UC. Patients were evaluated and followed-up from 1985 to 2011 at a single institution. Main Outcome Measurements: Association between the severity and duration of PSC-UC and the time of occurrence of colon neoplasia. Results: Of 167 patients with a combined diagnosis of PSC-UC, 55 had colonic neoplasia on colonoscopy. Colonic neoplasia occurred more frequently within 2 years of a combined diagnosis of PSC-UC (6.6/100 patient-years of follow-up) than after 8 years from PSC-UC (2.7/100 patient-years of follow-up). On proportional hazards analysis, older age at PSC diagnosis (hazard ratio 1.23 for every 5 years; 95% confidence interval, 1.03-1.34; P = .014) increased the risk of colon neoplasia. Limitations: Retrospective study. Conclusion: In this study, the severity of PSC was not significantly associated with the risk of colon neoplasia. Patients with PSC and UC have a high risk of colon neoplasia soon after the coexistence of the two diseases is discovered. Older age at PSC diagnosis increases this risk.

Left atrial appendage ligation with single transthoracic port assistance: a study of survival assessment in a porcine model (with videos)

2012-03-02

Background: Left atrial appendage (LAA) exclusion is a well-known procedure for the prevention of stroke in high-risk patients with atrial fibrillation and contraindication to long-term oral anticoagulant therapy. Objective: To evaluate a natural orifice transluminal endoscopic surgery (NOTES) approach for LAA ligation. Design: In 4 acute and 6 survival pigs, we performed LAA by using a forward-viewing, single-channel gastroscope and an operative thoracoscope with a 3-mm working channel (introduced through an 8-mm single transthoracic port). Setting: Animal laboratory. Interventions: The gastroscope was introduced in the thoracic cavity through an esophageal submucosal tunnel. An end loop introduced through the gastroscope was used to legate the LAA. In the survival experiments, the esophageal mucosa was closed using hemoclips. Main Outcome Measurements: The time, safety, and feasibility of the procedure were recorded. In the survival experiments, endoscopy and postmortem examination were performed on postoperative day 14. Results: Creation of a submucosal tunnel and esophagotomy were safely performed in all animals without incidents. The mean time for esophagotomy was 17.0 ± 6.3 minutes. Pericardial dissection and LAA ligation were performed in all animals but 1. The mean time for LAA ligation was 34.4 ± 19.1 minutes. No adverse events occurred during the survival period. Endoscopy showed complete esophageal closure. Postmortem examination revealed pleural adhesions on the site of pericardial dissection, and the LAA was fibrotic with the endoloop in place. Limitations: Animal study. Conclusions: LAA ligation with single transthoracic trocar assistance is feasible and may be an alternative to anticoagulant therapy or to permanent intracardiac implants in patients with atrial fibrillation.

Dose-dependent depth of tissue injury with carbon dioxide cryotherapy in porcine GI tract

2012-02-10

Background: Cryotherapy is a method of endoscopic mucosal ablation that involves delivery of a cryogen to result in tissue destruction by extreme low temperature. Its effects are influenced by the dosage of cryogen and thawing of ice. There are limited data on the tissue effects of multiple freeze and thaw cycles of carbon dioxide (CO2) cryotherapy on GI tissues. Objective: To investigate the extent of tissue injury due to escalating doses of CO2 cryotherapy on the esophagus, stomach, and colon of pigs. Design: Animal experiment. Intervention: Varying doses of CO2 cryotherapy with increasing number of freeze-thaw cycles were applied to each site. The animals were allowed to survive for 48 hours. Main Outcome Measurements: Depth of tissue injury assessed in blinded fashion by varying doses of cryotherapy on a defined area of porcine esophagus, stomach, and colon. Results: There was a dose-dependent relationship of CO2 cryogen and depth of injury (P = .0001 and P = .002, respectively). In the stomach, the dose-response relationship was significant (P = .007), but the average grades of injury across the various doses were lower when compared with the esophagus at comparable cryogen doses (P = .0004). The estimated depth of tissue injury from the mucosal surface in the porcine esophagus and colon tissue ranged from 1.2 to 2.5 mm and 1.3 to 2.5 mm, respectively. Limitations: The study was performed in a normal porcine model. Conclusion: There was a dose-dependent relationship between the dose of CO2 cryotherapy and the depth of tissue injury in the porcine esophagus, stomach, and colon.

Continuing Medical Education Exam: May 2012

2012-05-01

Teaching the endoscopic and paraendoscopic skills of gastroenterology

Amnon Sonnenberg — 2012-05-01

Fellowship is the last step in training for the majority of gastroenterologists. This is the time when they acquire advanced knowledge of gastroenterology and also endoscopic skills before embarking on an independent career. This is also the time to develop or refine other skills necessary to become a good doctor, effective communicator, and team member. However, the latter skill set does not lend itself to straightforward teaching. Dr. Amnon Sonnenberg, in this month's Fellows' Corner, argues that it is possible to acquire those skills only if the trainee is willing to have an open mind.

An unsolved conundrum: the ideal follow-up strategy after curative surgery for colorectal cancer

Piriyah Sinclair, Anjana Singh, Amjid A. Riaz, Alla Amin — 2012-05-01

One million people receive a diagnosis of colorectal cancer (CRC) annually worldwide. Approximately two-thirds of CRC cases are suitable for curative surgery. Metastatic disease will develop in 30% to 40% of CRC patients, and 50% will die of CRC recurrence. Consequently, after resection, patients are entered into a follow-up regimen to detect recurrence and metachronous lesions at a stage at which further curative surgery is possible.

Feasibility of placing a modified fully covered self-expandable metal stent above the papilla to minimize stent-induced bile duct injury in patients with refractory benign biliary strictures (with videos)

2012-03-09

Background: Endoscopic placement of fully covered self-expandable metal stents (FCSEMS) has been attempted to manage benign biliary strictures, but currently available FCSEMSs may be associated with unintended complications, including de novo strictures, in patients with normal life expectancy. Objective: To evaluate the feasibility of an intraductally placed modified FCSEMS to minimize stent-induced bile duct injury in patients with benign biliary strictures. Design: Prospective observational clinical feasibility study. Setting: Tertiary-care academic center. Patients: This study involved 21 patients with symptomatic benign biliary strictures in whom conventional endoscopic management failed. Intervention: Strictured segments were 15 mm above the ampulla of Vater. The modified FCSEMS has convex margins, a lasso, and an anti-migrating waist on the central portion. Stents were placed entirely above the papilla and removed after 3 to 5 months. Main Outcome Measurements: Success, complications, removability, midterm outcome. Results: FCSEMSs were successfully placed inside the bile duct in all patients. No episodes of pancreatitis, cholangitis, or sepsis were noted during the stenting period. Stent migration occurred in 4 patients (19.0%), but 3 were asymptomatic during follow-up. All stents were removed successfully with rat-tooth forceps without complications. Post-stenting cholangiograms showed improvement of strictures in 20 of 21 patients, without de novo focal stricture. The clinical success rate was 95.2%, with one recurrent stricture. Limitations: The small number and lack of comparison with other types of FCSEMSs. Conclusion: Temporary intraductal placement of a newly modified FCSEMS effectively improved strictures and prevented potential stent-induced complications in patients with benign biliary strictures. Controlled large-scale trials are needed to confirm the long-term efficacy.

“Underwater” EMR without submucosal injection for large sessile colorectal polyps (with video)

Kenneth F. Binmoeller, Frank Weilert, Janak Shah, Yasser Bhat, Steve Kane — 2012-02-27

Background: Submucosal injection is widely performed before EMR of large sessile colorectal polyps to facilitate resection and decrease perforation risk. We developed a novel method of water immersion (“underwater”) EMR (UEMR) that eliminates submucosal injection. Objective: To evaluate the feasibility and outcomes of UEMR without submucosal injection for large sessile colorectal polyps. Design: Prospective, observational study. Setting: Single, tertiary-care referral center. Intervention: The standardized EMR technique involves full water immersion for the entire procedure and piecemeal resection with a 15-mm “duck bill” snare. Main Outcome Measurements: Complete resection, bleeding, perforation, postpolypectomy syndrome, residual or recurrence adenoma. Results: Sixty patients with 62 large sessile colorectal polyps underwent UEMR. The mean/median polyp size was 34/30 mm, and the mean/median resection time was 21/18 minutes. Histology revealed the following: tubular adenoma (n = 22), tubulovillous adenoma (n = 19), villous adenoma (n = 4), serrated adenoma (n = 11), and high-grade dysplasia/carcinoma in situ (n = 6). The mean/median interval until a follow-up colonoscopy in 54 patients (90%) was 20.4/15.2 weeks. One of 54 patients (2%) had an adenoma smaller than 5 mm outside of the postresection scar, consistent with a residual lesion missed on index UEMR. Complications: There was no perforation or postpolypectomy syndrome. Delayed bleeding occurred in 3 patients and was managed conservatively. Limitations: Limited follow-up; single-center, single-endoscopist, uncontrolled study. Conclusions: The underwater resection technique enables complete removal of large sessile colorectal polyps without submucosal injection. The technique was safe in a large patient cohort, and the early recurrence rate appears low. Use of a water interface for UEMR has potential advantages that deserve further study.

Injectable drug-eluting elastomeric polymer: a novel submucosal injection material

Richard T. Tran, Michael Palmer, Shou-Jiang Tang, Thomas L. Abell, Jian Yang — 2012-02-10

Background: Biodegradable hydrogels can deliver therapeutic payloads with great potentials in EMR and endoscopic submucosal dissection (ESD) to yield improvements in efficacy and foster mucosal regeneration. Objective: To assess the efficacy of an injectable drug-eluting elastomeric polymer (iDEEP) as a submucosal injection material. Design: Comparative study of 3 different solutions by using material characterization tests and ex vivo and in vivo porcine models. Setting: Academic hospital. Interventions: Thirty gastric submucosal cushions were achieved with saline solution (0.9%), sodium hyaluronate (0.4%), and iDEEP (n = 10) in ex vivo porcine stomachs. Four porcine gastric submucosal cushions were then created in vivo by using iDEEP. Main Outcome Measurements: Maximum injection pressure, rebamipide release rate, submucosal elevation duration, and assessment of in vivo efficacy by en bloc resection. Results: No significant difference in injection pressures between iDEEP (28.9 ± 0.3 psi) and sodium hyaluronate (29.5 ± 0.4 psi, P > .05) was observed. iDEEP gels displayed a controlled release of rebamipide up to 2 weeks in vitro. The elevation height of iDEEP (5.7 ± 0.5 mm) was higher than that of saline solution (2.8 ± 0.2 mm, P < .01) and sodium hyaluronate (4.2 ± 0.2 mm, P < .05). All EMR procedures were successfully performed after injection of iDEEP, and a large gel cushion was noted after the resection procedure. Limitations: Benchtop, ex vivo, and nonsurvival pig study. Conclusions: A novel injection solution was evaluated for endoscopic resection. These results suggest that iDEEP may provide a significant step toward the realization of an ideal EMR and endoscopic submucosal dissection injection material.

Gastric necrosis caused by gastric banding

Andreia Albuquerque, Pedro Bastos, Guilherme Macedo — 2012-02-27

A 48-year-old woman, with a history of type 2 diabetes, stage 5 chronic kidney disease, and gastric banding that had been performed 8 months previously because of morbid obesity, was admitted with progressive vomiting over a period of 3 weeks, after stoma calibration. Upper endoscopy revealed ulceration and extensive gastric necrosis of the gastric body near the band impression (). Biopsy specimens were taken, and histology showed hemorrhagic gastric necrosis. Laparoscopic removal of the gastric band was performed with anterior gastric wall seromuscular suturing. During the surgical procedure, gastric necrosis was confirmed at the stenotic depression corresponding to the lap band.

Hepatobiliary cystadenoma of the liver prolapsing into the extrahepatic bile duct (with video)

2012-03-15

A 28-year-old woman was admitted to our hospital with upper abdominal pain. Palpebral conjunctivae showed slight icterus, and abdominal examination revealed a soft but slightly tender abdomen in the epigastric region without hepatomegaly. Laboratory data indicated obstructive jaundice without tumor marker elevation. US, CT (A), and magnetic resonance imaging (B) showed bilateral dilatation of the intrahepatic bile ducts and a cyst measuring 7.3 cm × 7.0 cm, with thin, internal, septal structures in segment IV of the liver. ERCP revealed a huge filling defect in the common bile duct (CBD) (C). EUS and intraductal US (D) revealed a multilocular cystic lesion in the CBD. Peroral videocholangioscopy showed a smooth surface of the cystic lesion (E) (, available online at www.giejournal.org). The patient underwent resection of the left medial section of the liver, with en bloc excision of the extrahepatic bile duct and gallbladder. A large, cystic mass with well-defined tumor margins was observed in the liver. The sausage-shaped mass prolapsed into the extrahepatic bile duct (F), and the cut surface of the resected specimen revealed septal formation and cystic spaces (G). The smooth-walled lining continued into the cystic mass in segment IV of the liver via segment IV of the bile duct. Histologic examination revealed multiple loculations lined by a columnar biliary epithelium with ovarian-like stroma (H [H&E, orig. mag. X4], I [H&E, orig. mag. X100]). The tumor was histologically diagnosed as hepatobiliary cystadenoma of the liver, with a part of the cyst prolapsing into the CBD.

“Doctor, I have a long, sausage-shaped lump in my abdomen”

Pietro Familiari, Cristina Hervoso, Ivo Boskoski, Guido Costamagna — 2012-03-05

An 88-year-old woman was admitted for postprandial epigastric pain, poor appetite, weight loss, and fever for the previous 6 weeks. On physical examination, a tubular mass was palpable in the upper abdomen; although painful, the mass was nontender. Liver biochemical and pancreatic enzyme test results were normal. CT (A and B) demonstrated significant dilation (4 cm) of the entire main pancreatic duct (asterisk), with severe atrophy of the pancreatic parenchyma (small arrows). Neither pancreatic nor duodenal masses were documented, and no bile duct dilation was seen. ERCP revealed an enlarged major papilla orifice with spontaneous outflow of mucus (C). Pancreatography (D) confirmed significant dilation of the main pancreatic duct and showed it to be filled with mucus, which was removed by using an extraction balloon. Pancreatic ductal side branches were dilated mainly in the body and tail of the gland (arrows). No strictures were identified. The diagnosis of intraductal papillary mucinous neoplasm was proposed. A 7F, nasopancreatic drainage tube was placed for saline solution flushing of the duct, after which the abdominal mass did not substantially change in size, although the patient's condition improved slightly after 3 days. The drain was removed, and the patient was discharged. Despite the fact that intraductal papillary mucinous neoplasm is a premalignant condition, surgery has not been scheduled for this patient because of her age and comorbid health conditions; clinical follow-up has been planned instead.

Inverted diverticulum or adenomatous lesion? Identification using confocal laser endomicroscopy

2012-05-01

A 59-year-old woman was seen for surveillance colonoscopy. She had no history of abdominal pain or rectal bleeding. Physical examination and results of laboratory investigations were unremarkable. High-resolution ileocolonoscopy revealed extensive diverticulosis in the sigmoid colon. Additionally, an 8-mm flat polyp with a central indentation and Kudo pit pattern II was found in the sigmoid colon (). The polypoid structure showed no change in its appearance after air insufflation or palpation with biopsy forceps. To characterize the lesion more intensively, 5 mL of 10% fluorescein were administered intravenously, and the probe-based confocal laser endomicroscopy system (Cellvizio; Mauna Kea Technologies, Paris, France) was inserted through the working channel of the endoscope and gently pushed against the polypoid structure. Fluorescein-guided endomicroscopy revealed tubular architecture and nondysplastic cells (B). The polyp was removed by snare polypectomy, and the in vivo diagnosis of tubular adenoma without high-grade intraepithelial neoplasia was confirmed on histopathological analysis (C).

Mediastinal abscess formation after EUS-guided FNA: are patients with sarcoidosis at increased risk?

Martin von Bartheld, Erik van der Heijden, Jouke Annema — 2012-02-27

Sarcoidosis is a disease of unknown etiology mostly affecting young adults and presenting with mediastinal or hilar lymphadenopathy in 85% of patients. Endoscopic US-guided FNA (EUS-FNA) and endobronchial US-guided transbronchial needle aspiration (EBUS-TBNA) of intrathoracic lymph nodes is increasingly used for the diagnosis of pulmonary sarcoidosis. Complications are rare—severe procedure-related infections have been reported in only 2 patients. One patient developed mediastinitis and another a mediastinal abscess after EUS-FNA. This case series describes 5 patients with suspected sarcoidosis who developed mediastinal abscesses after EUS-FNA, necessitating surgical treatment in 4 patients.

Endoscopic submucosal dissection of oropharyngeal carcinoma by using local lidocaine injection with the patient under conscious sedation

2011-08-12

A 69-year-old man was found to have early-stage oropharyngeal carcinoma by endoscopic examination (). Endoscopic submucosal dissection (ESD) was selected as the treatment. At first, we scheduled ESD with the patient under general anesthesia as previously reported. However, the patient had congestive heart failure and was determined to have general anesthesia risks. We therefore decided to perform ESD with the patient under conscious sedation. The cancer board of our hospital approved the treatment strategy, and written informed consent was obtained after explaining the advantages and risks before initiating treatment.

Flexible endoscopic septoplasty for bilobed Zenker's diverticulum

Marios Efthymiou, Spiro Raftopoulos, Norman Marcon — 2011-08-08

A 70-year-old male with a known diagnosis of bilobed Zenker's diverticulum and worsening dysphagia to solids was referred to our unit for flexible endoscopic septoplasty, having declined surgery. There was no regurgitation and no coughing or choking attacks, and he was maintaining stable weight.

A rare cause of esophageal strictures: Actinomyces

Vinay Chandrasekhara, Lanjing Zhang, Beth N.I. Floyd, Michael L. Kochman — 2011-08-08

Infectious esophagitis is associated with considerable morbidity and mortality. Bacteria are often looked at as colonizing organisms rather than true pathogens. Esophageal actinomycosis is a rarely described entity that, if undiagnosed, can lead to serious complications. We present a case of symptomatic Actinomyces infection within a radiation-induced esophageal stricture.

A case of two primary gastric malignancies: adenocarcinoma and squamous cell carcinoma of the stomach

2011-08-01

Gastric cancer is the second leading cause of death from cancer worldwide. Despite this fact, there has been an overall decrease in the incidence of gastric cancer over the past few decades. Therefore, it is important to understand the different histological manifestations of the disease. The most common form of gastric cancer is adenocarcinoma. In contrast, squamous cell carcinoma of the stomach is rare and has been described in numerous case reports. In addition, cases of primary gastric adenosquamous carcinoma also have been reported. We present a case of a woman with two gastric tumors in separate locations with different histological characteristics; one an adenocarcinoma, the other squamous cell carcinoma. To our knowledge there are no reported cases of two separate gastric primary tumors consisting of these two pathologic diagnoses.

Endoscopic “retroperitoneal fatpexy” of a large ERCP-related jejunal perforation by using a new over–the-scope clip device in Billroth II anatomy (with video)

2011-08-08

ERCP has a known perforation rate of 0.3% to 1.3%. We describe a jejunal perforation in Billroth II anatomy during ERCP that was sealed with an over-the-scope clip device and managed conservatively.

A first report of tumor cell implantation after EMR in a patient with rectosigmoid cancer

2011-07-18

After surgical resection, exfoliated colorectal cancer cells can implant on the suture line, resulting in tumor recurrence at this site. EMR is now widely accepted as a safe treatment for upper and lower GI neoplasms. We report the first case of tumor cell implantation from a rectosigmoid colon cancer at the EMR site of a synchronous rectal carcinoid.

Post-ERCP mortality and provider volume in England

Muhammad F. Dawwas, Richard M. Charnley, Manu K. Nayar, Kofi W. Oppong — 2012-05-01

We read with interest the study of post-ERCP mortality in England by Bodger et al. Although the nationwide scale and robust fatality ascertainment are incontestable strengths of this study, we believe it has a number of noteworthy limitations. First, it seems ironic that none of the 150 hospitals included in the analysis had a statistically significant divergent performance, not least because the 2004 National Confidential Enquiry into Patient Outcome and Death and British Society of Gastroenterology's (BSG) audit of ERCP have both highlighted concerns about the quality of the United Kingdom's ERCP practice. Furthermore, over the 18-month period of the study, only 13 of 1078 post-ERCP deaths within 30 days could be attributed to the procedure. This compares with 20 ERCP-related fatalities within the same time span that were reported to the BSG's ERCP audit in 2004, despite capturing only 20% of the total number of procedures performed nationally during a 6-month period. The authors' assertion that the overall proportion of procedure-related deaths (0.06%) was similar to that recently reported in a large single-center study in the United States discounts the fact that the center in question has some of the world's most experienced biliary endoscopists undertaking a higher proportion of benign case load than an average British hospital. Other shortcomings of the study include a flawed definition of a first ERCP (as first recorded procedure in the financial year), inference of the cause of death from discharge diagnosis codes, use of a crude risk-adjustment method (with comorbid disease being classified as either present or absent and center differences in procedure complexity not being taken into account), omission of analysis of mortality beyond 30 days, and, last but not least, the considerable proportion (93%) of clinicians who expressed concerns about incomplete capture of their local data. We believe these shortcomings undermine the authors' interpretation of the apparent lack of a significant ERCP volume-outcome association in their study as suggesting a “process under control”—an experience, we submit, not universally shared by biliary endoscopists in the United Kingdom. For now, therefore, we believe that the claim that ERCP provider volume does not influence postprocedure mortality remains unproven.

Response

2012-05-01

We thank Dawwas et al for their interest in our article. Their critique suggests some misunderstanding of both our principal aims and methodology. Without continuous and prospective capture of clinically rich datasets for all procedures performed by all providers, the exploration of institutional variation in post-ERCP outcomes with precise case-mix adjustment remains impossible. Voluntary audits are costly and time-consuming for staff, and they inevitably suffer from incomplete case-ascertainment and/or case numbers that are too low to allow statistically meaningful comparisons. We would agree that the general question of provider volume and ERCP outcomes is unresolved. Variation in outcome is likely, but can this be measured and proven? Hence, the primary focus of our work was to explore all-cause mortality at 30 days, both at the national level (to define real-world outcomes and simple predictors) and as a candidate indicator at the institutional level. By using linkage analysis of HES data, we find no “volume” effect in this particular mortality metric. The BSG audit was unable to explore institutional variation because only a sample of hospitals participated, and variation in sample sizes suggest highly variable case ascertainment. The NCEPOD report looks only at deaths, with no denominator of similarly treated patients who survive. We state clearly that it is not possible from routine HES data to distinguish reliably between procedure-related deaths and disease progression or unrelated comorbidity. For interest, we report the frequency of coding of specific procedural complications as final primary diagnosis among fatalities, but this does not imply that such data are complete.

Better stent function with chemotherapy: effects of chemotherapy or just a better prognosis?

2012-05-01

We read with great interest the article by Yoon et al on a retrospective, large-scale study of self-expandable metal stents (SEMSs) for malignant colorectal obstructions. In their analysis, no additional chemotherapy, as well as combined dilation and extracolonic origin of the tumor, was a predictive factor for long-term clinical SEMS failure in the palliative group.

Response

Jae Hee Cheon, Jin Young Yoon — 2012-05-01

We would like to thank Hamada et al for their interest in our study and valuable comments. We agree that competing risk analysis is considered a more appropriate statistical method than the Kaplan-Meier estimate for comparing the cumulative incidence function of long-term clinical self-expandable metal stent (SEMS) failure between additional chemotherapy and no additional chemotherapy groups.

Autoimmune pancreatitis presenting with gastric outlet obstruction

2012-05-01

Autoimmune pancreatitis (AIP) is an uncommon form of chronic pancreatitis associated with hypergammaglobulinemia and suggested autoimmunity as a pathogenetic mechanism. The most common presenting symptom in these patients is obstructive jaundice. We report a patient with AIP with unusual presenting features of gastric outlet obstruction and abdominal pain.

Duodenal web: complications and failure of endoscopic treatment

Arrigo Barabino, Serena Arrigo, Paolo Gandullia, Silvia Vignola — 2012-05-01

Endoscopic treatment of duodenal webs in newborns and children is an alternative option to surgery, although the experience is still limited. Recently we published in this journal a successful endoscopic incision of a duodenal web in an infant. Later we tried to repeat the operative procedure in a 20-month-old girl with chronic vomiting and failure to thrive. Upper GI radiographs were consistent with a perforated duodenal web. The first operative endoscopy was abandoned because of mild bleeding that occurred after the partial opening of the web. The hemorrhage spontaneously resolved. An exclusive milk diet was offered, and the child did not vomit. Three weeks later, operative endoscopy was repeated successfully, reaching the second duodenal segment with a gastroscope of an outer diameter of 8.6 mm. It is of note that the previous partial incision was entirely scarred. After the procedure the girl was able to tolerate a normal diet, but an upper GI series 2 months later showed no changes. Diagnostic endoscopy showed complete closure of the previous membranotomy with a little central aperture. A third operative endoscopy was then attempted, and complete incision of the web was obtained. To avoid possible closure of the opening by scars, 2 mucosal limbs of the membrane were also resected. At the end of the procedure moderate bleeding occurred, requiring intramucosal injection of adrenaline. A blood transfusion was needed. During the follow-up period the girl remained asymptomatic, but radiographs showed no modifications, and she eventually underwent surgical duodenojejunostomy. As previously described, the first 2 operative endoscopic procedures were followed by a transitory increase of pancreatic enzymes.

Recurrent esophageal web in Plummer-Vinson syndrome successfully treated with postdilation intralesional injection of mitomycin C

2012-05-01

In their article Seo et al reported an esophageal web resolved by endoscopic incision in a patient with Plummer-Vinson syndrome (PVS). We herein report an interesting case of recurrent esophageal web in a patient with PVS successfully treated with postdilation intralesional mitomycin C injection.

A single-center experience with spiral enteroscopy: a note of caution

2012-05-01

On the basis of our center's initial experience with spiral enteroscopy (SE), we would like to share a word of caution regarding its use in patients with small-bowel strictures and anastomoses.

2012-05-01

Editors

2012-05-01

Focus on…

2012-05-01

ASGE update

2012-05-01

In upcoming issues…

2012-05-01

Information for readers

2012-05-01

Gastrointestinal Endoscopy

Emerging technologies for endoscopic hemostasis

Circumferential location predicts the risk of high-grade dysplasia and early adenocarcinoma in short-segment Barrett's esophagus

Feasibility, safety, acceptability, and yield of office-based, screening transnasal esophagoscopy (with video)

Randomized crossover study comparing efficacy of transnasal endoscopy with that of standard endoscopy to detect Barrett's esophagus

Ultrathin transnasal endoscopy without sedation: the straight skinny

Usefulness of endoscopic radial incision and cutting method for refractory esophagogastric anastomotic stricture (with video)

Evaluation of GI bleeding after implantation of left ventricular assist device

Mucosal barrier defects in gastric intestinal metaplasia: in vivo evaluation by confocal endomicroscopy

Effect of the introducer technique compared with the pull technique on the peristomal infection rate in PEG: a meta-analysis

Long-term outcomes associated with pancreatic extracorporeal shock wave lithotripsy for chronic calcific pancreatitis

Diagnostic yield of EUS-guided FNA and cytology in suspected tubercular intra-abdominal lymphadenopathy

Prospective, randomized, back-to-back trial evaluating the usefulness of i-SCAN in screening colonoscopy

Prevalence of advanced histological features in diminutive and small colon polyps

Randomized trial of standard versus magnetic endoscope imaging colonoscopes for unsedated colonoscopy

Magnetic endoscope imaging colonoscope: a new modality for hypothesis testing in unsedated colonoscopy

Endoscopic mucosal resection with an over-the-counter hyaluronate preparation

Duration and severity of primary sclerosing cholangitis is not associated with risk of neoplastic changes in the colon in patients with ulcerative colitis

Left atrial appendage ligation with single transthoracic port assistance: a study of survival assessment in a porcine model (with videos)

Dose-dependent depth of tissue injury with carbon dioxide cryotherapy in porcine GI tract

Continuing Medical Education Exam: May 2012

Teaching the endoscopic and paraendoscopic skills of gastroenterology

An unsolved conundrum: the ideal follow-up strategy after curative surgery for colorectal cancer

Feasibility of placing a modified fully covered self-expandable metal stent above the papilla to minimize stent-induced bile duct injury in patients with refractory benign biliary strictures (with videos)

“Underwater” EMR without submucosal injection for large sessile colorectal polyps (with video)

Injectable drug-eluting elastomeric polymer: a novel submucosal injection material

Gastric necrosis caused by gastric banding

Hepatobiliary cystadenoma of the liver prolapsing into the extrahepatic bile duct (with video)

“Doctor, I have a long, sausage-shaped lump in my abdomen”

Inverted diverticulum or adenomatous lesion? Identification using confocal laser endomicroscopy

Mediastinal abscess formation after EUS-guided FNA: are patients with sarcoidosis at increased risk?

Endoscopic submucosal dissection of oropharyngeal carcinoma by using local lidocaine injection with the patient under conscious sedation

Flexible endoscopic septoplasty for bilobed Zenker's diverticulum

A rare cause of esophageal strictures: Actinomyces

A case of two primary gastric malignancies: adenocarcinoma and squamous cell carcinoma of the stomach

Endoscopic “retroperitoneal fatpexy” of a large ERCP-related jejunal perforation by using a new over–the-scope clip device in Billroth II anatomy (with video)

A first report of tumor cell implantation after EMR in a patient with rectosigmoid cancer

Post-ERCP mortality and provider volume in England

Response

Better stent function with chemotherapy: effects of chemotherapy or just a better prognosis?

Response

Autoimmune pancreatitis presenting with gastric outlet obstruction

Duodenal web: complications and failure of endoscopic treatment

Recurrent esophageal web in Plummer-Vinson syndrome successfully treated with postdilation intralesional injection of mitomycin C

A single-center experience with spiral enteroscopy: a note of caution

Contents

Editors

Focus on…

ASGE update

In upcoming issues…

Information for readers