Gastrointestinal Endoscopy - Articles in Press

Prophylaxis of post-ERCP pancreatitis: a practice survey - Corrected Proof

2010-03-12

Background: Prophylactic pancreatic stenting is widely used by expert biliary endoscopists to prevent post-ERCP pancreatitis (PEP); nonsteroidal anti-inflammatory drugs (NSAIDs) are thought to prevent PEP.Objective: To assess the use of pancreatic stenting and NSAIDs for PEP prophylaxis among endoscopists and its determinants.Design: A survey was distributed to 467 endoscopists attending a course on therapeutic digestive endoscopy.Intervention: Completed surveys were collected from 141 endoscopists performing ERCP in 29 countries (answer rate 30.2%); practices were most often located in community hospitals with an annual hospital volume of ≤500 ERCPs (in Belgium, Spain, Italy, and France in about half of cases). For all conditions listed, including needle-knife precut, previous PEP, suspected sphincter of Oddi dysfunction, and ampullectomy, less than half of the endoscopists reported attempting prophylactic pancreatic stenting in ≥75% of cases. Thirty (21.3%) survey respondents did not perform prophylactic pancreatic stenting in any circumstance; this was mainly ascribed to lack of experience. Measurement of PEP incidence and an annual hospital volume of >500 ERCPs were independently associated with the use of prophylactic pancreatic stenting (P = .005 and P = .030, respectively). Most survey respondents (n = 118, 83.7%) did not use NSAIDs for PEP prophylaxis. This was mainly ascribed to lack of scientific evidence of its benefits.Main Outcome Measurements: Proportion of cases in which pancreatic stenting is attempted during ERCP; reasons for not using prophylactic pancreatic stenting or NSAIDs.Limitations: Survey, not an audit of practice.Conclusions: Despite scientific evidence of its benefits, use of prophylactic pancreatic stenting is not as widely adopted as previously thought; use of NSAIDs for PEP prophylaxis is marginal.

Combined endoclip and endoloop treatment for delayed postpolypectomy hemorrhage - Corrected Proof

Kun-Ching Chou, Hsu-Heng Yen — 2010-03-12

Colonoscopic polypectomy is a widely used method for management of precancerous polyps. Bleeding is the most common complication after polypectomy, with a reported rate of 0.3% to 6%. The most commonly used endoscopic hemostasis techniques are injection therapy and endoclip therapy. We report herein the case of a 40-year-old man with delayed postpolypectomy bleeding that failed to respond to conventional techniques, requiring the combined application of endoclips and endoloops to achieve hemostasis. This is, to our knowledge, the first report of using these techniques to treat difficult delayed postpolypectomy hemorrhage.

Esophageal inflammatory myofibroblastic tumor sampled by EUS-FNA - Corrected Proof

2010-03-12

A 39-year-old woman with renal failure scheduled for a transplantation presented with progressive dysphagia. She underwent EUS for evaluation of a subepithelial esophageal mass that had been identified by endoscopy. EUS revealed a 3.2 × 2.5-cm hypoechoic, circumscribed mass centered within the muscularis propria (). To exclude malignancy, the lesion was sampled by FNA. Cytologic preparations contained cellular fragments composed of haphazardly arranged, slightly atypical spindled cells admixed with numerous lymphocytes (). A cell block showed cellular fragments of spindled cells with occasional larger epithelioid cells. The cells were immunoreactive with antibodies to smooth muscle actin and not with antibodies to desmin, S100 protein, CD34, and CD117 (c-kit). A diagnosis of “spindle cell proliferation, favor smooth muscle neoplasm” was rendered.

Peroral cholangioscopy in Roux-en-Y hepaticojejunostomy anatomy by using the SpyGlass Direct Visualization System (with video) - Corrected Proof

Shanshan Mou, Irving Waxman, Jennifer Chennat — 2010-03-12

Choledochal cysts are a rare congenital anomaly resulting in dilation of the intra- or extrahepatic bile ducts. Malignant transformation is a potential long-term complication that requires surveillance even after surgical resection.

Treatment of radiation-induced hemorrhagic gastritis with endoscopic band ligation - Corrected Proof

2010-03-12

Radiation-induced gastritis is an infrequent cause of upper GI bleeding. We present a case of hemorrhagic gastritis induced by adjuvant external radiotherapy for resected gastric cancer that was successfully treated with endoscopic band ligation (EBL).

Giant laterally spreading tumors of the papilla: endoscopic features, resection technique, and outcome (with videos) - Corrected Proof

Andrew D. Hopper, Michael J. Bourke, Stephen J. Williams, Michael P. Swan — 2010-03-12

Background: Successful endoscopic treatment of conventional papillary adenomas is well described. However, many authors recommend surgical resection for larger lesions with extrapapillary extension.Objective: To describe the classification, technique, and outcome for the endoscopic resection of giant laterally spreading tumors of the papilla (LST-P).Design: Single-center case series.Settings: Tertiary referral academic gastroenterology unit.Patients: Patients referred for endoscopic treatment of LST-P.Intervention: Pre-resection staging and single-session endoscopic removal of papillary adenomas. For those classified as LST-P (>30 mm, extending beyond the papilla onto the duodenal wall and involving as much as two thirds of the duodenal circumference), a standardized single-session EMR technique was used.Main Outcome Measurements: Technical success, complications, and adenoma recurrence for single-session removal of LST-P. Outcomes were compared with those of conventional ampullary adenoma resection during the same period.Results: Twenty-five patients with ampullary adenomas were referred. In 10 patients identified with LST-P (mean age 70.2 years; adenoma size 30-80 mm), combination EMR and papillectomy was performed in a single session. The median admission duration was 1 night (range 0-35). Complications included bleeding (30%) and cholecystitis (10%), with no cases of pancreatitis or perforation. Adenoma recurrence at 3 months was found in 1 patient (10%). Complication and recurrence rates in smaller (<30 mm) ampullary adenoma resections were not significantly different.Limitations: A relatively uncommon entity and thus small sample size.Conclusions: Endoscopic resection of carefully staged LST-P is a viable therapeutic alternative to surgery. In experienced hands, the outcomes are comparable to those for conventional ampullary adenomas.

Postpolypectomy bleeding in patients undergoing colonoscopy on uninterrupted clopidogrel therapy - Corrected Proof

Mandeep Singh, Nilesh Mehta, Uma K. Murthy, Vivek Kaul, Asma Arif, Nancy Newman — 2010-03-12

Background: The risk of postpolypectomy bleeding (PPB) in patients undergoing colonoscopy on uninterrupted clopidogrel therapy has not been established.Objective: To assess the PPB rate and outcome and identify risk factors associated with PPB in patients taking clopidogrel.Design: Single-center, retrospective study. Demographics, clinical parameters, polyp characteristics, polypectomy techniques, and postpolypectomy events in the groups were compared by univariate analysis. Stepwise logistic regression analyses identified independent risk factors associated with PPB.Setting: Veterans Affairs Medical Center.Patients: A total of 142 patients (375 polypectomies) taking clopidogrel (cases) and 1243 patients (3226 polypectomies) not taking clopidogrel (controls).Interventions: None.Main Outcome Measurements: Postpolypectomy bleeding, hospitalization, and mortality.Results: The immediate (intraprocedural) bleeding rate was similar in the 2 groups (2.1% vs 2.1%). Delayed (postprocedural) PPB rate was higher in the group taking clopidogrel (3.5% vs 1.0%, P = .02). Delayed bleeding of significance requiring hospitalization and transfusion/intervention was also higher in patients taking clopidogrel (2.1% vs 0.4%, P = .04). The length of hospital stay and interventions for PPB were comparable between the 2 groups. There was no mortality. Concomitant use of clopidogrel and aspirin/other nonsteroidal anti-inflammatory drugs (odds ratio 3.7; 95% CI, 1.6-8.5) and the number of polyps removed (OR 1.3; 95% CI, 1.2-1.4) were the only significant risk factors associated with PPB. Clopidogrel alone was not an independent risk factor for PPB.Limitations: Retrospective study and small number of patients with PPB.Conclusions: The PPB rate is significantly higher in patients undergoing polypectomy while taking clopidogrel and concomitant aspirin/nonsteroidal anti-inflammatory drugs; however, the risk is small and the outcome is favorable. Routine cessation of clopidogrel in patients before colonoscopy/polypectomy is not necessary.

Pancreatitis, panniculitis, polyarthritis syndrome successfully treated with EUS-guided cyst-gastrostomy - Corrected Proof

Michael D. Harris, Juan Carlos Bucobo, Jonathan M. Buscaglia — 2010-03-12

Acute pancreatitis can be complicated by extrapancreatic manifestations of disease. One such complication that infrequently occurs, however, is pancreatic panniculitis, or pancreatitis-associated fat necrosis in the subcutaneous and visceral tissue. Approximately 100 cases of pancreatic panniculitis have been reported in the medical literature, and when associated with polyarthritis, the condition can be termed PPP syndrome. We describe a rare case in which endoscopic therapy was used in the successful treatment of PPP syndrome.

Evaluation of endoscopy in localizing transgastric access for natural orifice transluminal endoscopic surgery in humans - Corrected Proof

2010-03-12

Background: To date, transgastric access in humans for natural orifice transluminal endoscopic surgery (NOTES) has been poorly evaluated.Objective: To compare endoscopic visualization of the transgastric access point with the laparoscopically defined ideal entrance to the peritoneal cavity.Design: Prospective pilot study in humans.Setting: Single tertiary-care center.Patients: This study involved 31 patients referred for laparoscopic cholecystectomy.Intervention: Access points were marked by endoscopy alone, endoscopy combined with diaphanoscopy, and endoscopy after pneumoperitoneum. Points were correlated with a laparoscopically visualized, previously defined ideal access area.Main Outcome Measurements: To choose the appropriate access point within the laparoscopically defined ideal access area to the peritoneal cavity away from major vessels and adjacent organs, by using endoscopy and to establish landmarks for the endoscopist, look for a learning curve, and identify potential problems.Results: The percentage of access points within the laparoscopically defined ideal area was 35.5% with endoscopy alone, 13.8% using the diaphanoscopy method, and 45.2% after transcutaneous pneumoperitoneum. A safe access point (≥3 cm from major gastric vessels) could be achieved with the 3 techniques in 83.9%, 65.5%, and 87.1 % of patients, respectively. A positive learning curve for endoscopic localization was identified before (P = .008) and after (P = .014) pneumoperitoneum. Virtual complications were greater in obese patients.Limitations: This was a small pilot study with hypothetical complications and problems, because actual transgastric access was not performed. The criteria for an ideal access area were very strict.Conclusion: Endoscopy, especially with the use of pneumoperitoneum, can reliably locate a safe transgastric entrance point. However, the endoscopically chosen site correlates poorly with the ideal laparoscopically determined site for transgastric access.

Diagnostic utility of EUS-guided FNA in patients with gastric submucosal tumors - Corrected Proof

2010-03-12

Background: Submucosal tumors (SMTs) comprise both benign and malignant lesions, and most of the gastric lesions tend to be malignant. The addition of EUS-guided FNA (EUS-FNA) has the potential to improve this distinction, but published series are limited.Objective: To evaluate the yield of EUS-FNA in gastric SMTs with referral to a criterion standard final diagnosis.Design: Retrospective study.Setting: Tertiary-care referral center.Patients: This study involved 141 consecutive patients with gastric SMTs, who underwent EUS-FNA from January 2000 to December 2008. Immunohistochemical staining with c-kit, CD34, actin, and S-100 antibodies was done if a spindle cell tumor was found. Based on FNA sample adequacy, and whether a specific diagnosis could be established, EUS-FNA results were categorized as diagnostic, suggestive, or nondiagnostic. The criterion standards for final diagnosis were the surgical histopathological results or the follow-up course for malignant, inoperable cases.Intervention: EUS-FNA.Main Outcome Measurements: Diagnostic yield of EUS-FNA and factors related to sampling adequacy for cytological and immunohistochemical evaluation.Results: A total of 141 patients (52% female, mean age 56.7 years) underwent EUS-FNA (range 1-5 passes). The overall results of EUS-FNA were diagnostic, suggestive, and nondiagnostic in 43.3%, 39%, and 17.7% of cases, respectively. Adequate specimens were obtained in 83% of cases, and 69 cases (48.9%) had a definitive final diagnosis. The most common gastric SMT was GI stromal tumor (59.5%). EUS-FNA results were 95.6% accurate (95% confidence interval [CI], 87.5%-99%) for the final diagnosis and 94.2% (95% CI, 85.6%-98.1%) accurate for differentiating potentially malignant lesions. A heterogeneous echo pattern was the only independent predictor for sampling adequacy (adjusted odds ratio 6.15; P = .002). There were no procedure-related complications.Limitations: Possibility of selection bias.Conclusion: EUS-FNA is an accurate method for diagnosis of gastric SMTs and for differentiating malignant lesions.

EUS-guided therapeutic interventions for uncommon benign pancreaticobiliary disorders by using a newly developed forward-viewing echoendoscope (with videos) - Corrected Proof

2010-03-08

Interventional pancreaticobiliary EUS is a rapidly growing field. We present our experience using the newly developed forward-viewing linear echoendoscope (FV-EUS) to provide access and therapy in two patients with uncommon benign pancreaticobiliary disorders who had previous failed ERCPs.

Unusual duodenal polyp and GI bleeding: a word of caution! (with video) - Corrected Proof

Ammar Al Jajeh, Swati Pawa, Omar S. Khokhar, Firas H. Al-Kawas — 2010-03-02

Aortoduodenal fistulae are the most frequent aortoenteric fistulae. They may be primary, caused by spontaneous communication between an aortic aneurysm and an intestinal loop, or secondary, caused by surgical repair of aneurysms with prosthetic implants. An aortoduodenal fistula is a life-threatening complication of aortic graft surgery and a rare cause of upper GI bleeding. Upper endoscopy with evaluation of the distal duodenum is an important investigative procedure for early diagnosis. A high index of suspicion is needed because the period during which this procedure may be performed is brief, and a prompt diagnosis will lead to a timely surgical intervention.

Double-balloon enteroscopy in the elderly: safety, findings, and diagnostic and therapeutic success - Corrected Proof

2010-03-02

Background: Double-balloon enteroscopy (DBE) is an important tool in the evaluation and management of small-bowel disease. Limited data are available on the safety, findings, and outcomes of DBE in elderly patients.Objective: To determine the safety and efficacy of DBE in elderly patients.Design: Single-center, retrospective analysis of prospectively collected database.Setting: Open-access, tertiary care referral center.Patients: A total of 176 patients undergoing DBE (216 procedures) for evaluation of small-bowel disease between August 2007 and August 2008.Interventions: Argon plasma coagulation of bleeding small-bowel lesions.Main Outcome Measurements: DBE complication rate, diagnostic/therapeutic success of DBE.Methods: An age cutoff of 75 years and older was used to designate patients as elderly. Data on complications, indications, findings, and diagnostic and therapeutic success of DBE were compared between age groups.Results: The mean age of patients was 66 ± 16.4 years (range 20-95 years). DBE was performed in 185 patients, including 60 patients age 75 years and older and 110 patients younger than age 75. An overall complication rate of 0.9% was seen for DBE in this study, with no significant difference between age groups. No major complications were observed in elderly patients. Elderly patients were more likely to have angioectasias (39% vs 23%; P = .01) and were more likely to require endoscopic therapy during DBE (46.8% vs 29.2%; P = .01).Limitations: Single-center, retrospective study.Conclusions: DBE is safe in elderly patients. Elderly patients are more likely to have angioectasias and to require endoscopic therapy during DBE.

Endoscopic therapy of small-bowel polyps by double-balloon enteroscopy in patients with Peutz-Jeghers syndrome - Corrected Proof

2010-02-26

Background: Peutz-Jeghers syndrome (PJS) is a hereditary disorder characterized by mucocutaneous pigmentations and hamartomatous polyps mainly in the small bowel. These polyps may cause complications such as intussusception.Objective: To assess therapeutic efficacy and safety of double-balloon enteroscopy (DBE) for detection and treatment of small-bowel polyps in patients with PJS.Design: Prospective cohort study.Setting: Tertiary-care referral center.Patients: This study involved 13 patients with PJS, defined as a proven STK11 gene mutation or according to international diagnostic criteria.Intervention: DBE with enteroscopic removal of pedunculated polyps of ≥10 mm.Main Outcome Measurements: Location, number and size of small-bowel polyps, polypectomy data, and complications and long-term complications associated with development of small-intestine polyps.Results: Thirteen patients with PJS (8 male, mean age 31 years) underwent 29 DBE procedures. Ten patients (77%) had a history of partial small-bowel resection because of small-bowel polyps. Small-bowel polyps were found in all 13 patients. The majority of polyps (94%) were located in the proximal jejunum. A total of 82 polyps of ≥10 mm were detected, and 79 (96%) were endoscopically removed without complications. After the introduction of DBE, no small-intestine-polyp-related complications occurred during a follow-up period of 356 person-months.Limitations: Small number of patients.Conclusion: DBE is clinically useful and safe for diagnosis and therapy of small-bowel polyps in patients with PJS, even in patients with a history of extensive abdominal surgery. DBE may decrease the need for laparotomy in patients with PJS.

Presacral myelolypoma: diagnosis by EUS-FNA and Trucut biopsy - Corrected Proof

Kanwar R.S. Gill, Muhammad K. Hasan, David M. Menke, Michael B. Wallace — 2010-02-26

A 71-year-old woman presented with cramping bilateral lower quadrant abdominal pain. An abdominal CT scan suggested the presence of presacral masses, and pelvic magnetic resonance imaging (MRI) showed 3 well circumscribed, lobulated, fat-containing masses inferiorly from S2 to S3 (A). No extension into the presacral cortex or neural foramina was evident. The imaging features were thought to represent presacral myelolipoma, extramedullary hematopoiesis, or liposarcoma. A rectal radial Olympus EUS confirmed the finding of 3 hyperechoic masses, which corresponded to the MRI findings (B). Subsequently, a linear Olympus EUS was done with FNA by using a 22-gauge needle for 2 passes and an EUS-guided Trucut for biopsy of the presacral masses. Levofloxacin was given during the procedure. Pathology specimens were consistent with extramedullary hematopoiesis versus myelolipoma (C), but myeloperoxidase stain confirmed the diagnosis of myelolipoma (D). Flow cytometery was negative for lymphoma.

First human case of esophagus-tracheal fistula closure by using a cardiac septal occluder (with video) - Corrected Proof

2010-02-25

Clinically relevant anastomotic leaks occur in approximately 4% to 20% of cases after upper GI surgery and can result in a fistula in the trachea or the main bronchus. Esophagotracheal fistulas are rare but life threatening. The mortality rate is very high, as high as 80%, and the treatment must be immediate to avoid severe complications and fatal events. We report the first case of successful treatment of a postsurgical esophagotracheal fistula by using an occluder device commonly adopted to close cardiac septal defects.

Leaks and endoscopic assessment of break of integrity after NOTES gastrotomy: the LEAKING study, a prospective, randomized, controlled trial - Corrected Proof

2010-02-25

Background: Gastric leak testing after natural orifice transluminal endoscopic surgery (NOTES) gastrotomy closure may help reduce the risk of leaks after transgastric procedures.Objective: To develop a novel endoscopy-based system to determine the presence of a leak after NOTES gastrotomy and to compare this system prospectively with radiographic leak testing.Design: Prospective, randomized, controlled trial.Setting: Academic Medical Center laboratory.Subjects: Fifty swine.Intervention: During the pretrial phase, an endoscopic system for the measurement of intragastric pressure was developed. In the trial phase, swine with a NOTES gastrotomy were randomized to endoscopic versus radiographic leak testing. If a leak was demonstrated, the gastrotomy was reclosed by using a second-generation prototype T-anchor system. The primary outcome was leak detection after gastrotomy closure. The secondary outcome variables included necropsy findings, peritoneal fluid analysis, histologic examination, and clinical outcome.Results: Fourteen swine were included in the pretrial phase and 36 in the randomized trial. Swine were survived for a mean of 9 days postoperatively. Endoscopic pressure monitoring demonstrated a reproducible change in intragastric pressure with insufflation; r = 0.735, P = .001 and r = 0.769, P ≤ .000 for the total and maximum pressures, respectively. Post-peritoneoscopy, there was a detectable and significant decrease in the mean total and mean maximum pressures versus baseline (P = .006 and P = .009). There was no significant difference between the radiologic and endoscopic arms in leak detection rate (4/18 vs 3/18, respectively, P = .500). Clinical outcomes and mean weight gain were equivalent. There was 1 operative abdominal wall injury and no deaths.Limitations: Animal study.Conclusion: Endoscopic pressure monitoring was reproducible, demonstrated the presence of gastric leak, and was as reliable as contrast-based radiographic leak testing.

Photodynamic diagnosis of endoscopically invisible flat dysplasia in patients with ulcerative colitis by visualization using local 5-aminolevulinic acid–induced photosensitization - Corrected Proof

2010-02-22

Clinical treatments for patients with ulcerative colitis (UC) are rapidly advancing because of the development of several immunomodulators and biological agents. An important issue in the clinical management of patients with UC is colitis-associated cancer or dysplasia (CC/D), which can be fatal.

A case of small-bowel intussusception caused by intestinal lipomatosis: preoperative diagnosis and reduction of intussusception with double-balloon enteroscopy - Corrected Proof

2010-02-22

Given that approximately 50% of adult small-bowel intussusception cases are caused by malignant disorders, the existence of malignancy must be excluded. However, conventional diagnostic methods such as US and CT cannot distinguish benign from malignant causes, which is an important distinction to make before surgery.

Accuracy of EUS in the evaluation of small gastric subepithelial lesions - Corrected Proof

Cetin Karaca, Brian G. Turner, Sevdenur Cizginer, David Forcione, William Brugge — 2010-02-22

Background: EUS combined with endoluminal resection techniques is increasingly used to provide a definitive diagnosis of small gastric subepithelial lesions seen on standard upper endoscopy.Objective: To evaluate the accuracy of EUS in diagnosing small gastric subepithelial lesions by using histology as the criterion standard.Design: A retrospective study.Setting: Academic tertiary care center.Patients: A total of 22 patients (15 women, mean age 62.2 years) with an endoscopically resected gastric subepithelial lesion were included in this 3-year retrospective study.Main Outcome Measurements: The size, echogenicity, the layer of origin, and presumptive diagnosis were determined by EUS. The diagnostic accuracy of EUS was determined by using histology as the criterion standard.Results: The mean size of the 22 lesions was 13.6 mm (range 8-20 mm). An endoscopic cap band mucosectomy device was used to resect 16 (72.7%) lesions, whereas 6 (27.3%) were resected with a saline solution–assisted and snare technique. Using histology as a criterion standard, we found that the accuracy of the EUS diagnosis was 10 of 22 (45.5%). EUS alone had an accuracy rate of 30.8% and 66.7%, respectively, in the diagnosis of neoplastic and non-neoplastic lesions.Limitations: A single-center, retrospective analysis.Conclusion: EUS imaging had a low accuracy rate in the diagnosis of gastric subepithelial lesions, and endoscopic submucosal resection should be performed to provide a histologic diagnosis. Resection of small subepithelial lesions of 20 mm or less can be accomplished en bloc with an endoscopic cap band mucosectomy device.

A case of nonampullary duodenal adenoma treated by endoscopic submucosal dissection (with video) - Corrected Proof

Philip Wai-yan Chiu, Anthony Yun-bunTeoh, Enders Kwok-wai Ng — 2010-02-22

A 73-year-old man with a history of acute pancreatitis in 2007 presented with epigastric pain of a few months' duration. Upper endoscopy revealed a 1.5-cm sessile polypoid lesion in the first part of the inferior wall of the duodenum, and narrow-band imaging–magnifying endoscopy revealed irregular pits with a tortuous subepithelial capillary network (). A biopsy confirmed this lesion to be a villous adenoma with mild dysplasia. EUS revealed that this lesion was limited to the mucosa, and endoscopic submucosal dissection (ESD) was performed by using the Hook Knife and the Triangle Tip Knife (Olympus Co Ltd, Tokyo, Japan) (, available online at www.giejournal.org). The operating time was 50 minutes. A small perforation was encountered during the ESD procedure that was closed with endoclips (EZ 90 clips; Olympus Co Ltd) (). After the procedure, 20 mg of esomeprazole administered intravenously every 12 hours was prescribed, and the patient was discharged 7 days after the procedure. Pathology confirmed the sessile polyp to be a tubular adenoma with focal epithelial dysplasia and no invasion to the submucosa. The resected margins were clear, and follow-up endoscopy 12 months after the ESD showed no recurrence.

Nasoenteral feeding tube placement by nurses using an electromagnetic guidance system (with video) - Corrected Proof

Elisabeth M.H. Mathus-Vliegen, Ann Duflou, Marcel B.W. Spanier, Paul Fockens — 2010-02-19

Background: The early institution of feeding in patients who need postpyloric feeding tubes is often hampered by a limited availability of endoscopists experienced in safe tube positioning.Objective: To test the feasibility of having nurses place postpyloric feeding tubes by using a universal path finding system device.Design: Prospective study.Setting: Academic hospital.Patients: The success rate and learning curve of a senior nurse placing postpyloric feeding tubes in 50 patients was studied, followed by a study in 160 patients on the success rates and learning curves of 4 inexperienced nurses instructed by the senior nurse. Finally, the success rate of postpyloric feeding tube placement by the senior nurse in 50 critically ill patients was investigated.Intervention: Postpyloric feeding tube positioning by nurses using an electromagnetic universal path-finding system device enabling them to follow the path of the tip of the feeding tube on a monitor screen.Main Outcome Measurements: Success was defined by postpyloric positioning of the feeding tube. The ultimate aim was to reach at least the duodenojejunal flexure.Results: In the first part, the senior nurse was successful in 72% of cases. There was a clear learning curve. In the second part, the 4 newly instructed nurses had a success rate of 89.4% without an evident learning curve. In the third part, successful feeding tube positioning was achieved in 78% of critically ill patients. Of the 217 successfully positioned tubes, 74% reached at least the duodenojejunal flexure. In half of the unsuccessful cases, an explanation for the failure was found at endoscopy. No complications were seen.Limitations: The generalization to less-specialized hospitals should be investigated.Conclusion: Postpyloric positioning of feeding tubes by nurses at the bedside without endoscopy is feasible and safe. Nurses may take over some of the tasks of doctors in a time of high endoscopic needs.

Esophageal dilation in eosinophilic esophagitis: safety and predictors of clinical response and complications - Corrected Proof

2010-02-19

Background: Esophageal strictures resulting from eosinophilic esophagitis present management challenges, and high rates of rents and perforation have been reported.Objective: To assess the safety of esophageal dilation in eosinophilic esophagitis and to characterize predictors of both clinical response and complications of the procedure.Design: Retrospective study of the University of North Carolina eosinophilic esophagitis database.Setting: Tertiary care referral center.Patients: Cases of eosinophilic esophagitis were defined as per consensus guidelines.Intervention: Dilation with either Savary or through-the-scope balloon techniques.Main Outcome Measurements: Complications (deep mucosal rents, contained or free perforation, and chest pain requiring medical attention or hospitalization) and the global clinical symptom response.Results: Of 130 eosinophilic esophagitis cases identified, 70 dilations (12 Savary, 58 balloon) were performed in 36 patients. Esophageal size improved from 12 to 16 mm (P < .001), with an overall symptom response rate of 83%. The only predictor of clinical response was final dilation diameter. There were 5 complications (7%): 2 deep mucosal rents and 3 episodes of chest pain. There were no perforations. There was one hospitalization for chest pain. All complications occurred in patients being treated with topical steroids, who underwent balloon dilation. Complications were associated with younger age (23 vs 42; P = .02) and more dilations (4 vs 1.7; P = .009).Limitations: Single center, retrospective study.Conclusions: Esophageal dilation can be performed in eosinophilic esophagitis with low rates of tears, chest pain, and hospitalization. No perforations were found in our database. The effectiveness of dilation was best when a larger esophageal caliber was achieved, but patients undergoing more procedures was associated with complications.

Natural orifice transluminal endoscopic surgery versus laparoscopic surgery for inadvertent colon injury repair: feasibility, risk of abdominal adhesions, and peritoneal contamination in a porcine survival model - Corrected Proof

2010-02-19

Background: Adhesions are common after conventional surgery; natural orifice transluminal endoscopic surgery (NOTES) avoids peritoneal disruption and may reduce adhesions.Objectives: To determine whether adhesions (and peritoneal contamination) are less common with NOTES transgastric colon injury and repair (TGCR) than with laparoscopic colon repair (LCR).Design/Setting: Porcine survival study.Interventions: After colon preparation and administration of antibiotics, forty 25-kg male pigs were randomly assigned to either TGCR or LCR. TGCR involved an endoscopic gastrotomy (needle-knife plus balloon dilation), CO2 pneumoperitoneum, and a 2-cm needle-knife transmural incision of spiral colon. Colotomies were repaired with clips; gastrotomies were closed with clips and a detachable snare.Main Outcome Measurements: Adhesions were assessed at necropsy at 21 days; biopsy specimens were blindly reviewed. A 9-point adhesion score (density/vascularity, width, and extent) was averaged from 3 reviewers. Peritoneal lavage was sent for cell count and culture.Results: Two of 20 TGCR pigs died immediately (unrecognized preoperative autopsy-proven pneumonia). The median procedure times were 70.5 and 19.0 minutes for TGCR and LCR, respectively; weight gains were 7.1 and 8.2 kg, respectively. The median adhesion scores were 4.3 and 3.7, respectively (P = .26); subscores were similar (1.9, 1.5, 1.3 vs 1.7, 1.1, 1.0, respectively (P = .3-.6)). Peritoneal lavage bacterial growth was nonsignificantly lower after TGCR than after LCR (38.9% vs 60.0%, respectively; P = .30); administration of intragastric antibiotics did not decrease contamination. Three TGCR (vs no LCR) pigs had histologic peritonitis.Limitations: Animal model, colon prepped, injury immediately recognized.Conclusion: NOTES colon repair is feasible after transmural injury. Adhesions, histologic peritonitis, and contamination were similar to those with laparoscopy and were not helped by intragastric antibiotics.

A novel double-endoloop technique for natural orifice transluminal endoscopic surgery gastric access site closure - Corrected Proof

2010-02-19

Background: Effective and safe access site closure is critical for clinical application of natural orifice transluminal endoscopic surgery.Objective: The current study evaluated a simple novel technique of gastrotomy closure.Design: Feasibility study with a survival animal model.Setting: Animal laboratory.Subjects: Ten female domestic pigs.Interventions: Endoscopic closure of a gastrotomy incision was evaluated in 10 pigs in a survival study. A standard double-channel endoscope was advanced into the peritoneal cavity through an incision made by a needle-knife and an 18-mm dilation balloon. After peritoneoscopy and salpingectomy, gastric closure was performed by using an endoscopic grasper and sequential application of 2 endoloops. After a follow-up period of 1 to 3 weeks, the pigs were killed for postmortem examination.Main Outcome Measurements: Feasibility, efficiency, and safety of a novel closure technique.Results: Correct positioning and delivery of endoloops was achieved in all animals in a median time of 17 minutes (range 13-25 minutes). All animals survived without complications. Postmortem examination demonstrated patent full-thickness gastric closure without any evidence of infection.Limitations: Feasibility study with a small number of subjects in a porcine model.Conclusion: Double endoloop technique represents a novel, simple, safe, and efficient means of gastric access site closure in natural orifice transluminal endoscopic surgery.

High diagnostic and clinical impact of small-bowel capsule endoscopy in patients with hereditary hemorrhagic telangiectasia with overt digestive bleeding and/or severe anemia - Corrected Proof

2010-02-19

Background: Patients with hereditary hemorrhagic telangiectasia (HHT) often present with recurrent anemia because of epistaxis or GI bleeding in relation to telangiectases mostly located in the stomach or small bowel. Capsule endoscopy is considered a major diagnostic tool for small-bowel diseases, but the impact of capsule endoscopy imaging on patient management in HHT is poorly understood.Objective: To clarify the contribution of capsule endoscopy in selected patients with HHT.Design: Prospective, descriptive study.Setting: Multicenter, two university hospital tertiary-care centers, from January 2003 to June 2007.Patients: This study involved 30 patients with HHT and severe anemia (hemoglobin <9 g/dL; normal: 11-15 g/dL) and minimal epistaxis or moderate anemia but overt GI bleeding.Intervention: Capsule endoscopy investigation.Main Outcome Measurements: Clinical characteristics and capsule endoscopy results and their clinical consequences.Results: Capsule endoscopy detected gastric and small-bowel telangiectases in 14 (46.7%) and 26 (86.7%) cases, respectively. Active bleeding was present in 36.7% of cases. Diffuse telangiectases were detected in 42.3% without correlation with age, sex, or type of HHT mutation. Further investigations were carried out as a consequence of the capsule endoscopy results in 67% of cases. Treatment, consisting mostly of endoscopic argon plasma coagulation, was scheduled in 46.7% of patients.Limitations: Our population was essentially composed of patients with the ALK1 mutation.Conclusion: This study shows that there is a high diagnostic yield for capsule endoscopy in selected patients with HHT. Capsule endoscopy makes possible precise mapping of lesions and has a considerable impact on the management of these selected patients by using a predefined algorithm: a limited number of accessible lesions is suitable for endoscopic treatment, whereas innumerable diffuse lesions require a medical approach. We suggest that capsule endoscopy could be a first-line, noninvasive, digestive tract examination in selected patients with HHT.

Left gastric pseudoaneurysmal hemorrhage: a rare endoscopic detection - Corrected Proof

Mark Marilley, Rupali Prabhukhot, Matthew Astin, Karl Chiang — 2010-02-16

A 37-year-old woman with a 20-year history of binge vodka use and alcoholic chronic pancreatitis with a pseudocyst presented with 4 episodes of bright red hematemesis, a pulse rate of 111 beats per minute, blood pressure of 85/51, and left upper quadrant tenderness. Her hemoglobin was 6.6 g/dL (13.0-18.0 g/dL), hematocrit 21% (40%-52%), platelet count 204k (150k-450k), and international normalized ratio was 1.2. She was resuscitated with intravenous fluids and 3 units packed red blood cells. Infusions of esomeprazole and octreotide were initiated. Upon transfer to our facility, emergent gastroscopy revealed a pulsating bulge in the proximal body of the stomach with a red spot in the center (). A pseudoaneurysm communicating with gastric lumen was suspected. Emergent spiral contrast-enhanced CT demonstrated a 3.0 × 4.5 × 2.8-cm pseudoaneurysm abutting the pancreatic body and posterior curvature of stomach with partial thrombosis (). An initial celiac arteriogram demonstrated a large pseudoaneurysm that appeared to arise from the splenic artery (). The patient underwent splenic artery coil embolization after which the pseudoaneurysm was seen arising from a terminal branch of the left gastric artery (). This branch was then successfully coil embolized (). There were no additional feeder vessels.

A large single-center experience of EUS-guided FNA of the left and right adrenal glands: diagnostic utility and impact on patient management - Corrected Proof

2010-02-16

Background: EUS-guided FNA of the left and right adrenals has been described, but data are very limited.Objectives: Our primary objective was to determine the impact of the diagnostic utility of EUS-guided FNA of adrenal glands on patient management. Our secondary objective was to determine predictors of malignant adrenal involvement.Study Design: Observational study.Setting: Tertiary referral center.Patients: Patients with enlarged adrenal(s) on abdominal imaging underwent EUS-guided FNA. The left adrenal (n = 54) was sampled via the transgastric approach and the right adrenal (n = 5) via a transduodenal approach.Results: Fifty-nine patients (63% men, median age 65 years) were evaluated. The median adrenal gland size was 25 × 17 mm. Adrenal tissue adequate for interpretation was obtained in all of the patients. EUS-guided FNA confirmed malignancy in 22 (37%) patients. Based on size (≥30 mm) alone, EUS had an accuracy of 68%. Patients with malignant cytology had higher standard uptake value scores on positron-emission tomography compared with patients with benign adrenal masses (P < .001). Malignant masses were more likely to have an altered adrenal gland shape compared with benign masses (crude odds ratio [OR] 12.0; P < .001). On multivariable analysis, altered adrenal gland shape was a significant predictor of malignancy (adjusted OR 7.94; P = .015), whereas a size of 30 mm or larger (adjusted OR 1.30; P = .774) and hypoechoic nature (adjusted OR 12.05; P = .148) were not. All patients except 2 with malignant cytology were treated with systemic therapy without the need for additional invasive biopsies or surgery. No immediate complications were encountered.Limitations: Lack of surgical criterion standard; 1 experienced endosonographer.Conclusions: EUS-guided FNA of the adrenal glands is a minimally invasive and safe approach that documents or excludes malignant involvement. EUS-guided FNA should be the first next test to evaluate enlarged adrenal glands because it directs therapy and affects patient management.

Intestinal Mycobacterium avium complex infection initially misdiagnosed and mistreated as Whipple disease - Corrected Proof

Mitchell S. Cappell, Mihaela Batke, Mitul Amin — 2010-02-08

A 34-year-old male with no known HIV risk factors and no known prior immunodeficiency syndrome presented to a community hospital in February 2009 with profound diarrhea manifesting as 15 watery, nonbloody bowel movements per day, weight loss, abdominal discomfort, and progressive fatigue during the prior 2 months. He denied fevers or arthralgias. EGD revealed tan-gray, coarsely-granular-to-nodular duodenal mucosa. Endoscopic duodenal biopsies revealed macrophages containing intensely periodic-acid-Schiff (PAS)–positive material. The patient was erroneously diagnosed as having Whipple disease and was treated with ceftriaxone, without performance of an acid-fast stain of duodenal biopsy specimens.

Transcecostomal colonic stent placement after US-guided percutaneous cecostomy - Corrected Proof

2010-02-08

Colorectal stenting for the treatment of malignant large-bowel obstruction is useful for palliation or as a bridge to surgery. It is more difficult to position a stent in the right-sided colon by using a retrograde placement method via the rectum compared with the distal colon. Herein, we present a case involving the successful antegrade placement of a stent in the ascending colon after US-guided percutaneous cecostomy.

A gastric moonscape: lymph node penetration from subsequent Burkitt lymphoma after treatment of Hodgkin's lymphoma - Corrected Proof

Nicola Patuto, Bruno M. Strebel, Anja M. Schmitt, Radu Tutuian — 2010-02-08

A 63-year-old man presented to the emergency department with malaise, fatigue, decreased appetite, and weight loss of 7 kg over the previous 2 months. One week prior to admission he had orthostatic dizziness with repetitive falls, and he noted dark, tarry stools. Thirty years earlier he was diagnosed as having Hodgkin's lymphoma grade IIb (mixed pattern with nodular sclerosis), for which he underwent splenectomy, followed by mantle-field radiation and chemotherapy with cyclophosphamide, vinblastine, procarbazine, and prednisone (COPP regimen). Physical examination results were normal (blood pressure 110/65 mm Hg, heart rate 90/minute) with the exception of bilaterally enlarged inguinal lymph nodes. Further most important findings included normocytic anemia with a hemoglobin of 7.7 g/dL (normal 11-14 g/dL), a white blood cell count of 12,000/mm3 (3900-10,700/mm3), and normal chest and abdominal radiographs.

Massive abdominal venous cavernous transformation diagnosed by use of EUS - Corrected Proof

Patrick J. McDevitt, Matthew Moyer, Abraham Mathew — 2009-12-09

EUS has enjoyed much success in the diagnosis of GI tract pathology since its inception in 1980. Since then, accepted indications and uses have continually expanded, including inventions such as FNA for the tissue diagnosis and staging of several upper GI malignancies. Because of the unique physics of US imaging (especially at short distances in which resolution is exquisite), EUS often can offer a definitive view of a lesion when other imaging modalities are unable to reveal, or sufficiently characterize, a lesion. This case describes the superiority of EUS for diagnosis of an abdominal mass thought to be a malignancy on CT and magnetic resonance imaging (MRI) radiography.

Prevalence and predictors of recurrent neoplasia after ablation of Barrett's esophagus - Corrected Proof

2009-12-04

Background: The incidence and risk factors for recurrence of dysplasia after ablation of Barrett's esophagus (BE) have not been well defined.Objective: To determine the rate and predictors of dysplasia/neoplasia recurrence after photodynamic therapy (PDT) in BE.Setting: Retrospective analysis of a prospective cohort of BE patients seen at a specialized BE unit.Methods: Patients underwent a standard protocol assessment with esophagogastroduodenoscopy and 4-quadrant biopsies every centimeter at 3-month intervals after ablation. Recurrence was defined as the appearance of any grade of dysplasia or neoplasia after 2 consecutive endoscopies without dysplasia. Entry histology, demographics, length of BE, presence and length of diaphragmatic hernia, EMR, stricture formation, nonsteroidal anti-inflammatory drug use, smoking, and the presence of nondysplastic BE or squamous epithelium were assessed for univariate associations. Time-to-recurrence analysis was done by using Cox proportional hazards regression. A multivariate model was constructed to establish independent associations with recurrence.Results: A total of 363 patients underwent PDT with or without EMR. Of these, 261 patients were included in the final analysis (44 lost to follow-up, 46 had residual dysplasia, and 12 had no dysplasia at baseline). Indication for ablation was low-grade dysplasia (53 patients, 20%), high-grade dysplasia (152 patients, 58%), and intramucosal cancer (56 patients, 21%). Median follow-up was 36 months (interquartile range 18-79 months). Recurrence occurred in 45 patients. Median time to recurrence was 17 months (interquartile range 8-45 months). Significant predictors of recurrence on the multivariate model were older age (hazard ratio [HR] 1.04, P=.029), presence of residual nondysplastic BE (HR 2.88, P=.012), and a history of smoking (HR 2.68, P=.048).Limitations: Possibility of missing prevalent dysplasia despite aggressive surveillance.Conclusion: Recurrence of dysplasia/neoplasia after PDT ablation is associated with advanced age, smoking, and residual BE.

A randomized comparison of a new flexible bipolar hemostasis forceps designed principally for NOTES versus a conventional surgical laparoscopic bipolar forceps for intra-abdominal vessel sealing in a porcine model - Corrected Proof

2009-11-30

Background: Current devices for hemostasis in flexible endoscopy are inferior to methods used during open or laparoscopic surgery and might be ineffective for natural orifice transluminal endoscopic surgery.Objective: To compare new flexible bipolar forceps (FBF), designed principally for natural orifice transluminal endoscopic surgery, with laparoscopic bipolar forceps (LBF) for hemostasis of intra-abdominal porcine arteries.Setting: Surgical laboratories in Europe and the United States.Design and Interventions: New FBF for hemostasis (3.7-mm diameter), featuring electrode isolation, were compared with rigid 5-mm LBF (ERBE BiClamp LAP forceps) at recommended settings. A porcine model of acute hemostasis was prepared by suturing the uterine horns and cecum to the abdominal wall, exposing uterine arteries, ovarian pedicles, cecal mesenteric bundles, and the inferior mesenteric artery. This allowed access to 10 vessels in each pig by transabdominal laparoscopic devices or a transgastric double-channel gastroscope. Vessels were measured, coagulated at 4 and more points, and transected. Blood pressure was increased to more than 200 mm Hg for 10 minutes by administering phenylephrine. Delayed bleeding was identified.Main Outcome Measurements: In 7 pigs, a total of 65 vessels (1.5-6.0 mm) were randomly allocated to FBF (n = 32) or LBF (n = 33). Successful hemostasis both before and after blood pressure increase was equivalent between the 2 groups (before: 88% FBF vs 88% LBF, not significant [NS]; after: 97% FBF vs 94% LBF, NS). With FBF, the number of seals per vessel was 4.8 vs 4.4 with LBF (NS). The energy used to create FBF seals was 19.8 J vs 38.2 J for LBF (P < .05).Limitations: Results from porcine studies may not reflect patient outcomes.Conclusions: In a porcine model, transgastric FBF endoscopic hemostasis was as effective as conventional laparoscopic hemostasis using LBF across a wide range of vessels.

Instant control of fundal variceal bleeding with a folkloric medicinal plant extract: Ankaferd Blood Stopper - Corrected Proof

Ilyas Tuncer, Levent Doganay, Oguzhan Ozturk — 2009-11-18

Variceal bleeding is one of the fatal complications of portal hypertension. As many as 33% of the patients with cirrhosis have gastric varices, and one fourth of them will bleed within 2 years. Gastric variceal bleeding, compared with bleeding from esophageal varices, has a poorer prognosis, is associated to more blood loss, and has higher rebleeding and mortality rates.

Peroral direct cholangioscopic-guided selective intrahepatic duct stent placement with an ultraslim endoscope - Corrected Proof

Irving Waxman, Jennifer Chennat, Vani Konda — 2009-11-18

Recent advances in endoscopic and catheter-based technology have enabled better and more robust systems for cholangioscopy. Since our initial report on the feasibility of using an ultraslim upper endoscope for peroral direct cholangioscopy (PDCS), reports describing the therapeutic applications have been described. In this case report, we describe the first through-the-scope, direct, cholangioscopic, selective biliary stent placement performed by using an ultraslim endoscope.

Endoscopic transgastric drainage of a postoperative intra-abdominal abscess after colon surgery - Corrected Proof

Martin D. Zielinski, Robert R. Cima, Todd H. Baron — 2009-11-18

Approaches to postoperative intra-abdominal abscesses have focused on percutaneous or surgical drainage; however, surgical procedures are associated with high mortality rates and there are anatomic locations that are not accessible via percutaneous techniques. Transmural endoscopic drainage of pancreatic and nonpancreatic fluid collections have been reported. We describe a patient with an intra-abdominal abscess causing sepsis after colon surgery that was successfully drained by using endoscopic transmural therapy.

Endoscopic hemostasis in a case of bleeding from Zenker's diverticulum - Corrected Proof

Michael S. Flicker, H. Christian Weber — 2009-11-18

Ulceration inside a Zenker's diverticulum (ZD) is an exceedingly rare cause of bleeding. Although the true pathogenesis of formation of a ZD remains elusive, its location between the inferior pharyngeal constrictor muscle and the cricopharyngeus muscle was identified by Killian in the early 20th century. Five previous cases of bleeding from ZD have been reported in the literature. Here, we describe a case of bleeding from an ulcer in the base of a ZD presenting with suspected hemoptysis and successful hemostasis by endoscopic placement of a hemoclip.

Effect of the BioEnterics intragastric balloon on weight, insulin resistance, and liver steatosis in obese patients - Corrected Proof

2009-10-28

Background: In obese patients, positioning of the BioEnterics intragastric balloon (BIB) proved beneficial for weight loss, but the effect of the device on ameliorating some components of the metabolic syndrome associated with obesity remains uncertain.Objective: To evaluate the effectiveness of BIB insertion on weight control and amelioration of components of the metabolic syndrome.Design: A prospective intervention study performed at baseline, 6 months after BIB insertion, and after a mean (standard deviation [SD]) of 21 (3) months (range 14-26) of follow-up.Setting: Division of Gastroenterology and Endoscopic Unit, “Casa Sollievo della Sofferenza” Hospital.Patients: One hundred thirty obese patients with a mean (SD) weight of 118 (24) kg and mean (SD) body mass index (BMI) of 43 (8) kg/m2.Interventions: Positioning of BIB.Main Outcome Measurements: Anthropometric and laboratory parameters.Results: Overall, the mean (SD) weight and BMI decreased by 13.2 (8.2) kg and 5.1 (3.2) kg/m2, respectively, compared with baseline. The mean glycemia, insulinemia, Homeostasis Model Assessment index, triglyceridemia, and alanine aminotransferase levels were significantly reduced. In the 91 responders (BMI decrease of ≥3.5 kg/m2), the mean (SD) weight and BMI decreased by 16.4 (6.3) kg and 6.4 (2.3) kg/m2, respectively, and severe liver steatosis decreased from 52% to 4% (P < .0001). On multivariate analysis, severe steatosis and the Homeostasis Model Assessment index were predictive of the response to BIB: odds ratios of 6.71 (95% CI, 2.23-20.19) and 3.18 (95% CI, 1.20-8.42). After a median follow-up of 22 months after BIB removal, 50% of responders maintained or continued to lose weight.Limitations: No sham-treated patients were included as comparative controls.Conclusions: Treatment was effective in inducing weight loss, improving liver steatosis, and restoring some components of the metabolic syndrome.

REMOVED: Amplatzer septal occluder for endoscopic treatment of the “sump syndrome” after choledochoduodenostomy: a new technique - Corrected Proof

Christian Ell, Christoph Boosfeld, Rolf Henrich, Thomas Rabenstein — 2006-11-10

This article has been removed, consistent with Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). The Publisher apologizes for any inconvenience this may cause.