Gastrointestinal Endoscopy - Articles in Press

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.

A retrograde-viewing device improves detection of adenomas in the colon: a prospective efficacy evaluation (with videos) - Corrected Proof

2009-12-17

Background: Colonoscopy may fail to detect neoplasia located on the proximal sides of haustral folds and flexures. The Third Eye Retroscope (TER) provides a simultaneous retrograde view that complements the forward view of a standard colonoscope.Objective: To evaluate the added benefit for polyp detection during colonoscopy of a retrograde-viewing device.Design: Open-label, prospective, multicenter study evaluating colonoscopy by using a TER in combination with a standard colonoscope.Setting: Eight U.S. sites, including university medical centers, ambulatory surgery centers, a community hospital, and a physician's office.Patients: A total of 249 patients (age range 55-80 years) presenting for screening or surveillance colonoscopy.Interventions: After cecal intubation, the disposable TER was inserted through the instrument channel of the colonoscope. During withdrawal, the forward and retrograde video images were observed simultaneously on a wide-screen monitor.Main Outcome Measurements: The number and sizes of lesions (adenomas and all polyps) detected with the standard colonoscope and the number and sizes of lesions found only because they were first detected with the TER.Results: In the 249 subjects, 257 polyps (including 136 adenomas) were identified with the colonoscope alone. The TER allowed detection of 34 additional polyps (a 13.2% increase; P < .0001) including 15 additional adenomas (an 11.0% increase; P < .0001). For lesions 6 mm or larger, the additional detection rates with the TER for all polyps and for adenomas were 18.2% and 25.0%, respectively. For lesions 10 mm or larger, the additional detection rates with the TER for all polyps and for adenomas were 30.8% and 33.3%, respectively. In 28 (11.2%) individuals, at least 1 additional polyp was found with the TER. In 8 (3.2%) patients, the polyp detected with the TER was the only one found. Every polyp that was detected with the TER was subsequently located with the colonoscope and removed. For all polyps and for adenomas, the additional detection rates for the TER were 9.7%/4.1% in the left colon (the splenic flexure to the rectum) and 16.5%/14.9% in the right colon (the cecum to the transverse colon), respectively.Limitations: There was no randomization or comparison with a separate control group.Conclusions: A retrograde-viewing device revealed areas that were hidden from the forward-viewing colonoscope and allowed detection of 13.2% additional polyps, including 11.0% additional adenomas. Additional detection rates with the TER for adenomas 6 mm or larger and 10 mm or larger were 25.0% and 33.3%, respectively. (Clinical trial registration number: NCT00657371.)

Endoscopic closure of gastrogastric fistulas by using a tissue apposition system (with videos) - Corrected Proof

Georg O. Spaun, Danny V. Martinec, Timothy J. Kennedy, Lee L. Swanström — 2009-12-17

Background: Gastrogastric fistulas (GGFs) are seen in 1.5% to 12.5% of patients after Roux-en-Y gastric bypass (RYGB) bariatric surgery, often leading to failure to lose adequate weight.Objective: The aim of this study was to assess the feasibility, safety, and percentage of successful primary endoluminal closures of GGFs by using a recently developed tissue apposition system in combination with local mucosectomy.Design: A feasibility and outcome study following institutional review board protocol.Setting: Tertiary referral teaching hospital, Legacy Health System, Portland, Oregon.Interventions: A combination of mucosectomy and nonresorbable tissue apposition is used to achieve a permanent closure of the GGF.Patients: Four patients with 5 GGFs after RYGB; the mean fistula diameter of was 18.6 mm (range 10-30 mm).Results: Primary closure rate (1 endoscopic session) of 5 GGFs was 100%. The mean procedure time was 88.5 minutes. One to 4 pairs of tissue anchors were used to close the fistulas. The mean time for performing mucosectomy was 21.6 minutes (range 8-42 minutes) and 39.6 minutes (range 12-58 minutes) for fistula closure. Estimated blood loss was on average 2 mL (range 0-5 mL). No complications were recorded. Early success (3 months), as evidenced by early satiety and weight loss, was noted for 3 of 4 patients. After 3 months, only the smallest fistula (10 mm) was still completely closed, and after 6 months, it also showed a pinhole opening.Conclusion: It was feasible to close all fistulas endoscopically without complications. Permanent closure of GGFs could not be achieved.

A diagnosis of an intraluminal carcinoid tumor of the bile duct by using cholangioscopy - Corrected Proof

2009-12-10

A 78-year-old man was seen after a 4-week history of intermittent right upper quadrant pain and 1 week of jaundice. A US scan revealed intrahepatic duct dilation and thickening of the common bile duct. ERCP revealed an ovoid filling defect in the common hepatic duct that measured approximately 2 cm and that was thought to be caused by a gallstone. An attempt at basket retrieval failed to remove the stone, and a plastic biliary stent was inserted. A second attempt to remove the stone at another ERCP also was unsuccessful, and he was referred to our unit for ERCP and cholangioscopy. Cholangiography confirmed the presence of a 2-cm filling defect in the common hepatic duct (A). Cholangioscopy with SpyGlass (Boston Scientific, Natick, Mass) revealed an exophytic mass arising from the bile duct mucosa (B) just distal to the bifurcation of the left and right hepatic ducts. Direct biopsy specimens were taken through the SpyGlass by using SpyBite (Boston Scientific) (C). The bile duct biopsy specimens showed a tumor composed of solid nests of monomorphic cells that stained strongly positive for chromogranin and synaptophysin (D) confirming the diagnosis of an endocrine tumor.

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.

A new fully covered stent with antimigration properties for the palliation of malignant dysphagia: a prospective cohort study - Corrected Proof

2009-12-09

Background: Fully covered stents are designed to resist tissue ingrowth that is often seen with partially covered stents. An issue with fully covered stents is the risk of migration.Objective: We aimed to determine efficacy, recurrent dysphagia, and complications of the SX–ELLA stent Esophageal HV, which is fully covered to resist tissue ingrowth and has an antimigration ring to withstand migration.Design: Prospective cohort study.Setting: Two tertiary referral centers.Patients: Forty-four patients with malignant esophageal strictures from inoperable or metastatic esophageal or gastric cardia cancer (n = 42) or lung cancer (n = 2).Interventions: Placement of an SX–ELLA stent.Main outcome measures: Functional outcome, recurrent dysphagia, complications, and survival.Results: Dysphagia improved from a median score of 3 (liquids only) before stent placement to 1 (ability to eat some solid food) 4 weeks later (P < .001). Twelve of 44 (Kaplan Meier analysis = 40%) patients developed 18 episodes of recurrent dysphagia of which 6 were caused by stent migration and 2 by tissue overgrowth. In total, 14 episodes of major complications developed in 10 of 44 (Kaplan Meier analysis = 29%) patients, 8 of which were caused by hemorrhage. After a median follow-up of 15 months, 39 patients had died (median survival 110 days), 5 (11%) from hemorrhage.Limitations: Nonrandomized study design.Conclusions: Dysphagia caused by esophageal cancer can be successfully palliated by placement of a new, fully covered esophageal stent (SX–ELLA). Although this single-wire braided stent with an antimigration ring is supposed to be less traumatic and to reduce migration, this was not substantiated in this study. Further improvements of stent features are needed to achieve the goals set for this study.

Endoscopic peritoneal access and insufflation: natural orifice transluminal endoscopic surgery - Corrected Proof

2009-12-09

Background: Diagnostic transgastric endoscopic peritoneoscopy is a safe model for exploration of the peritoneum. Endoscopic insufflation of the peritoneal cavity has not been validated in humans. We report here our experience with pneumoperitoneum established endoscopically with a laparoscopic insufflator.Design: Pneumoperitoneum was established with a laparoscopic insufflator through the biopsy channel of the gastroscope. Intra-abdominal pressure was measured with a transfascial Veress needle and compared with endoscopic values. The gastrotomy was used in the creation of the gastric pouch.Patients: Twenty patients undergoing laparoscopic Roux-en-Y gastric bypass participated in the study. Ten had undergone no previous surgery, whereas the other 10 patients had a history of abdominal procedures.Interventions: Diagnostic transgastric endoscopic peritoneoscopy was performed through a gastrotomy created endoscopically without laparoscopic visualization.Main Outcome Measurements: Diagnostic findings, operating times, and clinical course were recorded.Results: The average time for transgastric access was 9.6 minutes. This did not vary in patients with previous surgery (P = .3). Endoscopic insufflation was successful in all patients. The mean endoscopic and laparoscopic pressures were 9.80 and 9.75 mm Hg, respectively (P = .9). In no patients were there limitations to visualization of the abdomen. Adhesions were noted in 80% and 10% of patients with and without a history of surgery, respectively (P = .005). There were no complications related to transgastric passage of the endoscope or exploration of the peritoneal cavity.Conclusions: Although limited by the small sample size in this study, we believe that transgastric access may be considered as an alternative approach to peritoneal insufflation and provides a safe alternative for exploration of the abdomen. Endoscopic insufflation through the biopsy channel by using a laparoscopic insufflator seems to be an effective and safe method for establishing pneumoperitoneum.

Surgical gastrojejunostomy or endoscopic stent placement for the palliation of malignant gastric outlet obstruction (SUSTENT study): a multicenter randomized trial - Corrected Proof

2009-12-09

Background: Both gastrojejunostomy (GJJ) and stent placement are commonly used palliative treatments of obstructive symptoms caused by malignant gastric outlet obstruction (GOO).Objective: Compare GJJ and stent placement.Design: Multicenter, randomized trial.Setting: Twenty-one centers in The Netherlands.Patients: Patients with GOO.Interventions: GJJ and stent placement.Main Outcome Measurements: Outcomes were medical effects, quality of life, and costs. Analysis was by intent to treat.Results: Eighteen patients were randomized to GJJ and 21 to stent placement. Food intake improved more rapidly after stent placement than after GJJ (GOO Scoring System score ≥2: median 5 vs 8 days, respectively; P < .01) but long-term relief was better after GJJ, with more patients living more days with a GOO Scoring System score of 2 or more than after stent placement (72 vs 50 days, respectively; P = .05). More major complications (stent: 6 in 4 patients vs GJJ: 0; P = .02), recurrent obstructive symptoms (stent: 8 in 5 patients vs GJJ: 1 in 1 patient; P = .02), and reinterventions (stent: 10 in 7 patients vs GJJ: 2 in 2 patients; P < .01) were observed after stent placement compared with GJJ. When stent obstruction was not regarded as a major complication, no differences in complications were found (P = .4). There were also no differences in median survival (stent: 56 days vs GJJ: 78 days) and quality of life. Mean total costs of GJJ were higher compared with stent placement ($16,535 vs $11,720, respectively; P = .049 [comparing medians]). Because of the small study population, only initial hospital costs would have been statistically significant if the Bonferroni correction for multiple testing had been applied.Limitations: Relatively small patient population.Conclusions: Despite slow initial symptom improvement, GJJ was associated with better long-term results and is therefore the treatment of choice in patients with a life expectancy of 2 months or longer. Because stent placement was associated with better short-term outcomes, this treatment is preferable for patients expected to live less than 2 months. (Clinical trial registration number: ISRCTN 06702358.)

A new metal stent with a controlled-release system for palliation of malignant dysphagia: a prospective, multicenter study - Corrected Proof

2009-12-09

Background: Self-expanding metal stents are frequently used for the palliation of malignant dysphagia. Recently, a new stent design, the Evolution stent (Cook Medical, Limerick, Ireland), was developed. The stent has an internal and external silicone coating to resist tissue ingrowth and uncoated dual flanges on both ends to prevent migration. Its controlled-release system may allow full control and precise positioning of the stent.Objective: To determine the safety and clinical effectiveness of the Evolution stent for the palliation of dysphagia in patients with malignant strictures located in the esophagus (n = 33 [75%]) or gastric cardia (n = 11 [25%]).Methods: All patients who underwent placement of an esophageal Evolution stent from February to December 2008 received follow-up telephone calls 14 days after treatment and thereafter monthly until death. Data on technical and clinical outcome, complications, and recurrent dysphagia were collected.Results: A total of 44 patients (32 [73%] men, median age 74 years [range 48-91 years]) were treated with the Evolution stent. The median tumor length was 6 cm (range 1-11 cm). Stent placement was technically successful in 41 patients. Dysphagia improved from a median of 3 (ability to swallow liquids only) to 1 (ability to eat some solid foods) 4 weeks after stent placement. Major complications occurred in 4 (9%) patients, ie, pneumonia (3 patients) and hemorrhage (1 patient). Two (5%) patients died of pneumonia. Minor complications included gastroesophageal reflux and mild retrosternal pain in 11 (25%) and 4 (9%) patients, respectively. Recurrent dysphagia developed in 11 (25%) patients as a result of tissue ingrowth or overgrowth (6 patients; 14%), food impaction (3 patients; 7%), or stent migration (2 patients; 5%).Conclusions: The Evolution stent is safe and effective for the palliation of dysphagia from esophageal and gastric cardia cancer. Randomized trials are needed to compare this device with other stent designs.

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.

Intraductal electrohydraulic lithotripsy by using SpyGlass cholangioscopy through a colonoscope in a patient with Roux-en-Y hepaticojejunostomy - Corrected Proof

Todd H. Baron, Atif Saleem — 2009-11-18

The endoscopic approach to large bile duct stones may require the use of intraductal electrohydraulic lithotripsy (IEHL) performed under direct cholangioscopic visualization. In patients with Roux-en-Y biliary reconstruction after liver transplantation, endoscopic retrograde cholangiography is feasible using long-length endoscopes. We describe successful fragmentation of a large common hepatic duct stone by using cholangioscopy-guided IEHL delivered through a colonoscope in a patient with a Roux-en-Y hepaticojejunostomy.

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.

EUS-guided rendezvous for the treatment of pancreaticopleural fistula in a patient with chronic pancreatitis and pancreas pseudodivisum - Corrected Proof

Scott T. Cooper, Jane Malick, Kevin McGrath, Adam Slivka, Michael K. Sanders — 2009-11-05

Pancreatic duct (PD) disruption can result from acute and chronic pancreatitis, abdominal trauma, pancreatic malignancy, and surgery. Conservative management involves pancreatic rest with either hyperalimentation or nasojejunal feeding, initiation of somatostatin analogues, and/or pancreatic enzyme supplements. Unfortunately, medical therapy may be ineffective. Transpapillary stent placement is a safe and effective technique for managing ductal disruption. However, conventional stent placement may be difficult because of altered anatomy, PD strictures, and difficult cannulation. EUS-guided rendezvous has been reported for antegrade access to both the biliary duct and PD. We report a case of chronic pancreatitis with pancreas pseudodivisum complicated by ductal disruption and a pancreaticopleural fistula, subsequently treated with EUS-guided rendezvous and stent placement after failed conventional ERCP and medical therapy.

Sigmoid plasmacytoma mimicking colon cancer in a patient with multiple myeloma: case report and review of literature - Corrected Proof

2009-11-02

Colonic plasmacytomas are a rare manifestation of a myeloma malignancy, with fewer than 25 cases reported. We report such a case occurring in the sigmoid colon mimicking symptoms of colon cancer and review the literature. Awareness of this complication in patients with multiple myeloma is important in providing early diagnosis and treatment. We recommend prompt early colonoscopies for symptomatic patients with myeloma.

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.

Adult presentation of a congenital duodenal diaphragm - Corrected Proof

Damien Loh, Trevor Leese, Sven Anders — 2009-10-19

Congenital duodenal diaphragms usually present in infancy or childhood. Adult presentation is rare. We report a late presentation of duodenal diaphragm in a 43-year-old woman.

Endoscopic removal of dysfunctioning bands or rings after restrictive bariatric procedures - Corrected Proof

2009-09-14

Background: Intragastric band migrations or dysfunctions are common long-term complications of both vertical banded gastroplasty (VBG) and laparoscopic adjustable gastric banding (Lap-Band) that classically require surgical treatment.Objective: In this series, we describe the endoscopic removal of partially eroded Lap-Bands or Silastic rings and noneroded dysfunctioning rings after VBG.Design: Case series.Setting: A European, tertiary-care academic center.Patients: This study involved 13 patients—3 with eroded Lap-Bands, 4 with eroded Silastic rings, and 6 with refractory outlet stoma stenosis after VBG.Intervention: Endoscopic removal was performed within 1 or 2 sessions, according to the presence and extent of band erosion at presentation, including optional placement of a self-expandable plastic stent across the band, followed about 6 to 8 weeks later by extraction with transsection, if needed, by using a wire-cutting system.Main Outcome Measurements: Technical success and safety.Results: One failure was caused by huge adhesion formation around a Lap-Band on the lesser curvature of the stomach and the left liver lobe. Twelve of 13 endoscopic removals were successful in 1 (n = 2) and 2 (n = 10) sessions.Limitations: Highly selected patients (tertiary-case academic center).Conclusion: Endoscopic removal of dysfunctioning bands or rings is safe and feasible by the use of a 1- or 2-step endoscopic procedure.

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.