Gastrointestinal Endoscopy - Articles in Press

Endoluminal bariatric techniques - Corrected Proof

2012-05-14

The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of new or emerging endoscopic technologies that have the potential to have an impact on the practice of GI endoscopy. Evidence-based methodology is used, with a MEDLINE literature search to identify pertinent preclinical and clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the “related articles” feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but in many cases, data from randomized, controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. For this review, the MEDLINE database was searched through January 2011 using the keywords “bariatric,” “endoscopic,” “intragastric balloon,” “duodenojejunal bypass sleeve,” and “transoral gastroplasty.” Reports on Emerging Technologies are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the Governing Board of the ASGE. These reports are scientific reviews provided solely for educational and informational purposes. Reports on Emerging Technologies are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.

Equipment for pediatric endoscopy - Corrected Proof

2012-05-14

The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used by performing a MEDLINE literature search to identify pertinent clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the “related articles” feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but in many cases, data from randomized, controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors.

Guidelines for endoscopy in pregnant and lactating women - Corrected Proof

2012-05-14

This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. This guideline updates a previously issued guideline on this topic. In preparing this guideline, we performed a search of the medical literature by using PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When few or no data exist from well-designed, prospective trials, emphasis was given to results from large series and reports from recognized experts. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time that the guidelines are drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations are based on reviewed studies and are graded on the strength of the supporting evidence (). The strength of individual recommendations is based on both the aggregate evidence quality and an assessment of the anticipated benefits and harms. Weaker recommendations are indicated by phrases such as “We suggest ….,” whereas stronger recommendations are typically stated as “We recommend….”

Phase I evaluation of TNFerade Biologic plus chemoradiotherapy before esophagectomy for locally advanced resectable esophageal cancer - Corrected Proof

2012-04-20

Background: Neoadjuvant chemoradiotherapy followed by surgery is the primary treatment option for patients with locally advanced esophageal cancer. This multicenter phase I trial examined intratumoral injection of TNFerade biologic, an adenoviral vector that expresses the human tumor necrosis factor-α gene, with chemoradiotherapy in locally advanced esophageal cancer. Objectives: To assess pathologic complete response (pCR), time to disease progression, progression-free survival, survival, and safety and tolerance in patients treated with preoperative chemoradiation combined with endoscopy or EUS-guided intratumoral injection of TNFerade biologic. Design/Intervention: Five weekly injections of TNFerade biologic, dose-escalated logarithmically from 4 × 108 to 4 × 1011 particle units (PU), were given in combination with cisplatin 75 mg/m2 and intravenous 5-fluorouracil 1000 mg/m2/d for 96 hours on days 1 and 29, and concurrent radiation therapy to 45 Gy. Surgery was performed 9 to 15 weeks after treatment. Setting: U.S. multicenter study. Patients: Patients with stage II and III esophageal cancer were enrolled. Main Outcome Measurements: Primary outcome measures were safety, feasibility, tolerability, and rate of pCR. Secondary outcome measures were overall survival (OS) and disease-free survival. Results: Twenty-four patients with a median age of 61 years were enrolled; 88% of the patients were men, 21% were stage II, and 79% were stage III. Six (29%) had a pCR, observed among 21 patients (20 who underwent esophagectomy and 1 at autopsy). Dose-limiting toxicities were not observed. The most frequent potentially related adverse events were fatigue (54%), fever (38%), nausea (29%), vomiting (21%), esophagitis (21%), and chills (21%). At the top dose of 4 × 1011 PU, thromboembolic events developed in 5 of 8 patients. The median OS was 47.8 months. The 3- and 5-year OS rates and disease-free survival rates were 54% and 41% and 38% and 38%, respectively. Limitations: We included primarily adenocarcinoma. Conclusions: Preoperative TNFerade, in combination with chemoradiotherapy, is active and safe at doses up to 4 × 1010 PU and is associated with long survival. This regimen warrants additional studies. (Clinical trial registration number: NCT00051480.)

Characterization of the pancreas in vivo using EUS spectrum analysis with electronic array echoendoscopes - Corrected Proof

2012-04-13

Background: Spectral analysis of the radiofrequency (RF) signals that underlie grayscale EUS images has been used to provide quantitative, objective information about tissue histology. Objective: Our purpose was to validate RF spectral analysis as a method to distinguish between chronic pancreatitis (CP) and pancreatic cancer (PC). Design and Setting: A prospective study of eligible patients was conducted to analyze the RF data obtained by using electronic array echoendoscopes. Patients: Pancreatic images were obtained by using electronic array echoendoscopes from 41 patients in a prospective study, including 15 patients with PC, 15 with CP, and 11 with a normal pancreas. Main Outcome Measurements: Midband fit, slope, intercept, correlation coefficient, and root mean square deviation from a linear regression of the calibrated power spectra were determined and compared among the groups. Results: Statistical analysis showed that significant differences were observable between groups for mean midband fit, intercept, and root mean square deviation (t test, P < .05). Discriminant analysis of these parameters was then performed to classify the data. For CP (n = 15) versus PC (n = 15), the same parameters provided 83% accuracy and an area under the curve of 0.83. Limitations: Moderate sample size and spatial averaging inherent in the technique. Conclusions: This study shows that mean spectral parameters of the backscattered signals obtained by using electronic array echoendoscopes can provide a noninvasive method to quantitatively discriminate between CP and PC.

Colonoscopy screening markedly reduces the occurrence of colon carcinomas and carcinoma-related death: a closed cohort study - Corrected Proof

2012-04-13

Background: Colonoscopy with a possible polypectomy is an efficient and preferred screening method to reduce the incidence of colorectal cancer (CRC). However, critics argue that, to date, a reduction of incidence and mortality from CRC has not been demonstrated in a population-based setting. Objective: To compare the incidence of and mortality from CRC among individuals screened by colonoscopy and non-screened individuals. Design: A closed cohort study. Setting: Population-based setting in a precisely defined area with a low level of population migration. Patients: This study involved 1912 screened and 20,774 control participants. Intervention: CRC cases in this closed cohort study were prospectively collected during the screening period of 1 year and the follow-up period of 6 years. Main Outcome Measurements: Follow-up data were corrected for negligible migration balance in the area. Tumor characteristics and risk or protective factors, age and sex, participation in general health screening examinations, history of CRC in a first-degree relative, smoking status, body mass index, frequency of sports activity, eating habits, and patients' professions were recorded. Results: Overall cancer incidence was significantly lower in the screened group compared with the non-screened group (adjusted odds ratio [OR] 0.31; 95% confidence interval [CI], 0.16-0.59; P < .001). Colon cancer–associated mortality also was clearly lower (adjusted OR 0.12; 95% CI, 0.01-0.93; P = .04). Risk factors such as lifestyle, smoking, and body mass index as well as family history were similar in both groups. Blue-collar workers had a higher incidence of CRC compared with professionals. The risk factors for CRC were a positive family history and smoking. Limitations: Number and ethnicity of the participants, non-randomized study. Conclusion: Colonoscopy with polypectomy significantly reduces CRC incidence and cancer-related mortality in the general population.

Characterization of buried glands before and after radiofrequency ablation by using 3-dimensional optical coherence tomography (with videos) - Corrected Proof

2012-04-09

Background: Radiofrequency ablation (RFA) is an endoscopic technique used to eradicate Barrett's esophagus (BE). However, such ablation can commonly lead to neosquamous epithelium overlying residual BE glands not visible by conventional endoscopy and may evade detection on random biopsy samples. Objective: To demonstrate the capability of endoscopic 3-dimensional optical coherence tomography (3D-OCT) for the identification and characterization of buried glands before and after RFA therapy. Design: Cross-sectional study. Setting: Single teaching hospital. Patients: Twenty-six male and 1 female white patients with BE undergoing RFA treatment. Interventions: 3D-OCT was performed at the gastroesophageal junction in 18 patients before attaining complete eradication of intestinal metaplasia (pre–CE-IM group) and in 16 patients after CE-IM (post–CE-IM group). Main Outcome Measurements: Prevalence, size, and location of buried glands relative to the squamocolumnar junction. Results: 3D-OCT provided an approximately 30 to 60 times larger field of view compared with jumbo and standard biopsy and sufficient imaging depth for detecting buried glands. Based on 3D-OCT results, buried glands were found in 72% of patients (13/18) in the pre–CE-IM group and 63% of patients (10/16) in the post–CE-IM group. The number (mean [standard deviation]) of buried glands per patient in the post–CE-IM group (7.1 [9.3]) was significantly lower compared with the pre–CE-IM group (34.4 [44.6]; P = .02). The buried gland size (P = .69) and distribution (P = .54) were not significantly different before and after CE-IM. Limitations: A single-center, cross-sectional study comparing patients at different time points in treatment. Lack of 1-to-1 coregistered histology for all OCT data sets obtained in vivo. Conclusion: Buried glands were frequently detected with 3D-OCT near the gastroesophageal junction before and after radiofrequency ablation.

Successful treatment of diffuse esophageal spasm by peroral endoscopic myotomy - Corrected Proof

2012-04-09

A 79-year-old woman was admitted to our hospital with dysphagia and chest pain that she had experienced for 20 years (Eckardt score: 7). A barium swallow examination showed a corkscrew appearance characteristic of diffuse esophageal spasm (DES) (A). Esophageal manometry showed simultaneous and multiple peaked contractions associated with more than 20% of wet swallows, whereas mean the simultaneous contraction amplitude was over 30 mm Hg (B). Therefore, the patient received a diagnosis of DES.

Use of the endoscopically applied hemostatic powder TC-325 in cancer-related upper GI hemorrhage: preliminary experience (with video) - Corrected Proof

Yen-I. Chen, Alan N. Barkun, Constantine Soulellis, Serge Mayrand, Peter Ghali — 2012-04-09

Upper GI hemorrhage is a common complication of gastroduodenal tumors. Bleeding from these neoplasms is generally difficult to control and is associated with high rebleeding rates. Current modalities for management include endoscopy, radiotherapy, interventional angiography, and surgery.

Endoscopic appearance of proximal colorectal neoplasms and potential implications for colonoscopy in cancer prevention - Corrected Proof

2012-04-09

Background: In everyday practice, the use of colonoscopy for the prevention of colorectal cancer (CRC) is less effective in the proximal than the distal colon. A potential explanation for this is that proximal neoplasms have a more subtle endoscopic appearance, making them more likely to be overlooked. Objective: To investigate the differences in endoscopic appearance, ie, diminutive size and nonpolypoid shape, of proximal compared with distal colorectal neoplasms. Design: Cross-sectional, single-center study. Setting: Endoscopists at the Maastricht University Medical Center in the Netherlands who were previously trained in the detection and classification of nonpolypoid colorectal lesions. Patients: Consecutive patients undergoing elective colonoscopy. Main Outcome Measurements: Endoscopic appearance, ie, diminutive size (<6 mm) or nonpolypoid shape (height less than half of the diameter) of colorectal adenomas and serrated polyps (SPs), with a focus on adenomas with advanced histology, ie, high-grade dysplasia or early CRC and SPs with dysplasia or large size. Results: We included 3720 consecutive patients with 2106 adenomas and 941 SPs. We found that in both men and women, proximal adenomas with high-grade dysplasia/early CRC (n = 181) were more likely to be diminutive or nonpolypoid than distal ones (76.3% vs 26.2%; odds ratio [OR] 9.24; 95% CI, 4.45-19.2; P < .001). Of the proximal adenomas, 84.4% were diminutive or nonpolypoid compared with 68.0% of the distal ones (OR 2.66; 95% CI, 2.14-3.29; P < .001). Likewise, large/dysplastic SPs in the proximal colon were more often nonpolypoid than distal ones (66.2% vs 27.8%; OR 5.51; 95% CI, 2.79-10.9; P < .001). Limitations: Inclusion of both symptomatic and asymptomatic patients. Conclusions: Proximal colorectal neoplasms with advanced histology frequently are small or have a nonpolypoid appearance. These findings support careful inspection of the proximal colon, if quality of cancer prevention with the use of colonoscopy is to be optimized.

Factors predicting perforation during endoscopic submucosal dissection for gastric cancer - Corrected Proof

2012-04-09

Background: Perforation is a common complication of endoscopic submucosal dissection (ESD), but little is known about the relevant risk factors. Objective: To investigate the risk factors for perforation. Design: Retrospective study. Setting: A cancer referral center. Patients: A total of 1795 early gastric tumors in 1500 patients treated by ESD from July 2002 to December 2010 were included in the analysis. Main Outcome Measurements: The associations between the incidence of perforation and patient and lesion characteristics were investigated. Results: Perforation during ESD occurred in 50 lesions (2.8%). Univariate analysis identified tumor location (upper, middle, or lower stomach), tumor diameter (≤20 or >20 mm), and treatment period (lesions treated in the first or second period) as predictors of perforation. Multivariate analysis identified tumor location (upper stomach), tumor diameter (>20 mm), and treatment period (first half) as independent risk factors for perforation. The odds ratios were 2.4 (95% CI, 1.3-4.7; P = .006) for lesions in the upper stomach and 1.9 (95% CI, 1.0-3.5; P = .04) for lesions larger than 20 mm. Perforation risks were 5.4% for lesions in the upper stomach and 4.4% for lesions larger than 20 mm. Three patients required emergency surgery, but the rest of the patients were successfully treated with endoscopic clipping. There was no perforation-related mortality. Limitations: Single-center, retrospective study design. Conclusions: Lesions in the upper stomach and lesions larger than 20 mm were independent risk factors for perforation during ESD. Patients should be made aware of the estimated high risks of these lesions before undergoing ESD.

High mortality of cocaine-related ischemic colitis: a hybrid cohort/case-control study - Corrected Proof

Moshen Elramah, Michael Einstein, Naoyo Mori, Nimish Vakil — 2012-04-09

Background: Isolated case reports describe bowel ischemia in cocaine users, and the optimal management of these patients remains uncertain. Design: Case-control study. Setting: Teaching hospitals. Patients: Patients hospitalized for colonic ischemia related to cocaine compared with noncocaine-related ischemic colitis. Cases were identified by using ICD-9 codes and laboratory urine toxicology tests. Patients were included if they had a confirmed diagnosis of bowel ischemia by CT, colonoscopy, angiography, or, in the case of emergency exploration, a pathology report showing bowel ischemia and a urine toxicology test that was positive for cocaine. Controls were individuals who met the same criteria but had no history of cocaine use and a urine test negative for cocaine. Charts were individually audited for accuracy of coding. Main Outcome Measurements: Mortality and its risk factors. Results: Patients with cocaine-related ischemia were significantly younger and had a significantly (P < .05) higher mortality rate than patients with ischemic colitis unrelated to cocaine (cocaine: 5/19 [26%] and noncocaine: 6/78 [7.7%]). The cause of death in all cases was septic shock caused by extensive bowel ischemia. Multivariate logistic regression analysis showed that cocaine-related ischemic colitis was a significant risk factor for mortality (odds ratio 5.77; 95% CI, 1.37-24.39) as was the need for surgical intervention (odds ratio 4.95; 95% CI, 1.22-20.12). Limitations: Retrospective design. Conclusions: Cocaine-related ischemic colitis has a high mortality. In young patients presenting with acute abdominal pain and/or rectal bleeding with evidence of bowel wall thickening or pneumatosis on imaging studies or colonoscopy, cocaine-related ischemia should be considered. Testing for cocaine use may help identify patients at high risk of sepsis and death.

Colon cancer with gastric invasion mimicking gastric submucosal tumor - Corrected Proof

Pin-Chao Wang, Chia-Chi Wang, Ching-Sheng Hsu, Chung-Tai Yue, Jiann-Hwa Chen — 2012-04-09

A 70-year-old woman presented to our outpatient department with several weeks of dull epigastric pain, belching, and early satiety. Physical examination revealed mild pallor and epigastric tenderness. Laboratory test results showed a leukocyte count of 14,400/mm3, hemoglobin of 10.7g/dL, and a positive fecal occult blood test. EGD disclosed an ovoid bulging mass at the posterior wall of the mid-gastric body (A, arrow) with intact overlying mucosa, a picture that suggested gastric submucosal tumor or external compression. CT showed a hypodense mass arising from the posterior greater curvature aspect of stomach (B, arrow), and extending to the adjacent colonic wall. EUS demonstrated a 4.5-cm exophytic dumbbell-shaped mass arising from the propria muscularis (C, arrow) with hyperechoic components (C, arrowheads); it was diagnosed as a GI stromal tumor. Colonoscopy found a stricture near the splenic flexure; biopsy specimens were negative for malignancy. During laparotomy, a 5-cm ill-defined tumor was found at the distal transverse colon with gastric invasion and regional lymph node involvement. Left hemicolectomy with lymph node dissection was performed, and pathology showed the tumor to be adenocarcinoma. (D, arrow, H&E. orig. mag. ×10). The final diagnosis was colon cancer with gastric invasion and lymph node involvement. She is currently receiving adjuvant chemotherapy and being followed in our oncology department.

Endoscopic submucosal dissection of early gastric neoplasia with a water jet–assisted knife: a Western, single-center experience - Corrected Proof

2012-04-09

Background: Endoscopic submucosal dissection (ESD) of early gastric neoplasia has not yet been established in Western countries because of a lack of data and the difficult, time-consuming, and hazardous nature of the method. Some of the technical limitations may be overcome by use of a water jet–assisted knife, which allows a combination of a high-pressure water jet and electrosurgical interventions. Objective: To evaluate the efficacy and safety of water jet–assisted ESD (WESD) with a water jet–assisted knife in selected patients with early gastric neoplasia. Design: Single-center, prospective study. Patients: This study involved 29 consecutive patients (13 female; median age 61 years; age range 35-93 years) with early gastric neoplasia that met the expanded criteria of the Japanese Gastric Cancer Association. Histology of biopsies had shown gastric adenocarcinoma in 21 cases, adenoma in 8 case, and suspicion of a GI stromal tumor in 1 case. The median maximal diameter of the lesions was 20 mm (range 10-40 mm). Intervention: All procedures were done with patients under sedation with propofol. The water jet–assisted knife was used for setting coagulation markers around the neoplastic lesions, then for circumferential incision and dissection in combination with repeated submucosal injection of saline solution with a water jet system. Bleeding was treated with diathermia by use of the water jet–assisted knife or hemostatic forceps in case of failure or larger vessels. Clips were used for closure of perforations. Main Outcome Measurements: Complete resection of neoplasia, procedure time, complication and recurrence rates. Results: According to endoscopic criteria, complete resection of the targeted area could be achieved in all cases, with an en bloc resection rate of 90%. The median procedure duration was 74 minutes (range 15-402 minutes). Exchange of the device was needed in only 10 cases because of severe bleeding from larger vessels, which could be managed by use of hemostatic forceps. The 30-day morbidity rate was 4 of 30 (13.8%) because of postprocedure pain in 3 cases and delayed bleeding in 1 case. A 93-year-old patient died the night after WESD without evidence of a procedure-related complication. Histology of the resected specimens showed adenocarcinoma in 20 cases, adenoma in 7, no neoplasia in 2, and a plasmacytoma in 1. Complete resection (R0) was histologically confirmed in 18 of 28 patients (64.3%) with resected neoplastic specimens. A horizontal or vertical neoplasia-free margin could not be confirmed in 9 cases and 1 case, respectively. Complete local remission of neoplasia was achieved in 25 of 28 patients (89.3%) who were followed over a median period of 22 months (range 6-44 months). In 1 patient, a metachronous gastric adenocarcinoma was identified 54 weeks after initial WESD. Limitations: Noncontrolled study with a limited number of patients. Conclusion: The use of a water jet–assisted knife simplifies ESD because exchange of devices is rarely needed. WESD promises to be effective and safe. The study demonstrates that the high rates of en bloc resection of early gastric neoplasia reported in Asia can be reproduced in Western referral centers. However, histology may not always confirm complete resection of horizontal tumor margins. In spite of the unfavorable histology results, the high rate of complete local remission of neoplasia promises that surgical treatment of early gastric neoplasia can be avoided in the majority of cases.

Endoscopic lumen restoration for obstructive aphagia: outcomes of a 25-year experience - Corrected Proof

H. Worth Boyce, David S. Estores, Joy Gaziano, Tapan Padhya, Janet Runk — 2012-04-09

Background: After chemoradiation therapy for head/neck cancer, some patients develop strictures that progress to complete pharyngoesophageal occlusion. Total lumen occlusion is less often due to other conditions. Enteral access (enterostomy tube) and good nutritional status tend to minimize the significance of dysphagia and therefore may mask recognition of impending complete lumen occlusion. Objective: Review outcomes of a 25-year experience with endoscopic lumen restoration (ELR) in 30 patients. Design: Retrospective, case review study. Setting: Two tertiary-care referral centers. Patients: This study involved 30 consecutive patients referred for obstructive aphagia due to complete lumen occlusion, primarily after chemoradiation therapy for head/neck cancer. Intervention: Antegrade and retrograde endoscopy with tri-plane fluoroscopy for penetrating the occluded segment, serial retrograde and antegrade dilations, plus swallowing rehabilitation therapy. Main Outcome Measurements: Restoration of lumen patency, swallowing function, and removal of enteral feeding tube. Results: ELR was successful in 30 patients in 31 of 33 attempts (93%). Return to soft to regular diet was achieved in 15 of 30 patients (50%), and fluids to pureed food with partial percutaneous endoscopic gastrostomy nutrition was achieved in 5 of 30 patients (17%). Ten of 30 patients (33%) were considered unsafe for oral feeding because of oropharyngeal neuromotor deficits. Complications occurred in 5 of 30 patients (17%), with no prolonged sequelae, deaths, or surgery, but two stents were placed for anastomotic fistulas. The median duration of follow-up was 22.75 months. Limitations: Retrospective, case review study. Conclusion: ELR by using tri-plane fluoroscopic guidance with antegrade and retrograde endoscopy and serial dilations allows lumen restoration and swallowing to some degree in a majority of patients. Engagement of a core team of specialists can provide optimal restoration of swallowing function.

Comparison of partially covered nitinol stents with partially covered stainless stents as a historical control in a multicenter study of distal malignant biliary obstruction: the WATCH study - Corrected Proof

2012-04-09

Background: Covered self-expandable metal stents (CSEMSs) were developed to prevent tumor ingrowth, but stent migration is one of the problems with CSEMSs. Objective: To evaluate a new, commercially available CSEMS with flared ends and low axial force compared with a commercially available CSEMS without the anti-migration system and high axial force. Design: Multicenter, prospective study with a historical cohort. Setting: Twenty Japanese referral centers. Patients: This study involved patients with unresectable distal malignant biliary obstruction. Intervention: Placement of a new, commercially available, partially covered SEMS. Main Outcome Measurements: Recurrent biliary obstruction rate, time to recurrent biliary obstruction, stent-related complications, survival. Results: Between April 2009 and March 2010, 141 patients underwent partially covered nitinol stent placement, and between May 2001 and January 2007, 138 patients underwent placement of partially covered stainless stents as a historical control. The silicone cover of the partially covered nitinol stents prevented tumor ingrowth. There were no significant differences in survival (229 vs 219 days; P = .250) or the rate of recurrent biliary obstruction (33% vs 38%; P = .385) between partially covered nitinol stents and partially covered stainless stents. Stent migration was less frequent (8% vs 17%; P = .019), and time to recurrent biliary obstruction was significantly longer (373 vs 285 days; P = .007) with partially covered nitinol stents. Stent removal was successful in 26 of 27 patients (96%). Limitations: Nonrandomized, controlled trial. Conclusion: Partially covered nitinol stents with an anti-migration system and less axial force demonstrated longer time to recurrent biliary obstruction with no tumor ingrowth and less stent migration. (Clinical trial registration number: UMIN000002293.)

Efficacy and safety of self-expandable metal stents for biliary decompression in patients receiving neoadjuvant therapy for pancreatic cancer: a prospective study - Corrected Proof

A. Aziz Aadam, Douglas B. Evans, Abdul Khan, Young Oh, Kulwinder Dua — 2012-04-09

Background: Increasing numbers of patients with resectable pancreatic cancer are receiving neoadjuvant therapy. Biliary drainage with plastic stents during this period can be associated with recurrent episodes of stent occlusion resulting in unplanned ERCPs and interruptions in therapy. Objective: To evaluate the efficacy and safety of self-expandable metal stents (SEMSs) during the neoadjuvant period for resectable pancreatic cancer. Design: Patients with proven pancreatic adenocarcinoma with biliary obstruction underwent placement of SEMSs, and data on stent patency and complication rates were collected prospectively. Setting: Tertiary-care referral center. Patients: This study involved 55 patients with resectable and borderline resectable pancreatic duct adenocarcinoma who were recruited between March 2009 and December 2010. Intervention: SEMSs were placed for biliary decompression. The shortest length of stent required to bridge the stricture was used so as to leave enough of the normal bile duct above the stent available for subsequent surgical anastomosis. Endoscopic reintervention was performed in those with stent malfunction. Stents were not removed before surgery. Main Outcome Measurements: Stent patency rate during the neoadjuvant period, stent malfunction rate, and complication rates. Information on stent-related difficulties, if any, during surgery. Results: Fifty-five patients were recruited (29 men, 26 women; age, mean [± SD] 65.9 ± 11 years; resectable 23, borderline resectable 32). Median time for neoadjuvant therapy and restaging before surgery was 104 days (range 70-260 days). At the median time of 104 days, 88% of SEMSs remained patent. By 260 days, stent malfunction occurred in 15% of patients. These included stent occlusion in 13% and stent migration in 2%. SEMS malfunction occurred in 3 of 27 patients (11%) who ultimately underwent pancreaticoduodenectomy and in 5 of 21 patients (24%) with disease progression (P = not significant). The presence of SEMSs did not interfere with pancreaticoduodenectomy in any patients who underwent surgery. Limitations: Nonrandomized study. Conclusion: SEMSs are effective and safe in achieving durable biliary drainage in patients with pancreatic cancer receiving neoadjuvant therapy. It is not necessary to remove SEMSs before surgery if the shortest length of stent required to bridge the stricture is used.

Applying a natural language processing tool to electronic health records to assess performance on colonoscopy quality measures - Corrected Proof

2012-04-06

Background: Gastroenterology specialty societies have advocated that providers routinely assess their performance on colonoscopy quality measures. Such routine measurement has been hampered by the costs and time required to manually review colonoscopy and pathology reports. Natural language processing (NLP) is a field of computer science in which programs are trained to extract relevant information from text reports in an automated fashion. Objective: To demonstrate the efficiency and potential of NLP-based colonoscopy quality measurement. Design: In a cross-sectional study design, we used a previously validated NLP program to analyze colonoscopy reports and associated pathology notes. The resulting data were used to generate provider performance on colonoscopy quality measures. Setting: Nine hospitals in the University of Pittsburgh Medical Center health care system. Patients: Study sample consisted of the 24,157 colonoscopy reports and associated pathology reports from 2008 to 2009. Main Outcome Measurements: Provider performance on 7 quality measures. Results: Performance on the colonoscopy quality measures was generally poor, and there was a wide range of performance. For example, across hospitals, the adequacy of preparation was noted overall in only 45.7% of procedures (range 14.6%-86.1% across 9 hospitals), cecal landmarks were documented in 62.7% of procedures (range 11.6%-90.0%), and the adenoma detection rate was 25.2% (range 14.9%-33.9%). Limitations: Our quality assessment was limited to a single health care system in western Pennsylvania. Conclusions: Our study illustrates how NLP can mine free-text data in electronic records to measure and report on the quality of care. Even within a single academic hospital system, there is considerable variation in the performance on colonoscopy quality measures, demonstrating the need for better methods to regularly and efficiently assess quality.

Fully covered self-expandable metal stents in biliary strictures caused by chronic pancreatitis not responding to plastic stenting: a prospective study with 2 years of follow-up - Corrected Proof

2012-04-01

Parenchymal fibrosis in chronic pancreatitis (CP) may induce stricturing of the common bile duct. The prevalence of CP-related benign biliary stricture (BBS) ranges between 3% and 46%. A durable drainage is needed if the stricture results in persistent increase in liver function test (LFT) results, jaundice, and cholangitis. If left untreated, symptomatic BBS can lead to secondary biliary cirrhosis.

Duodenal involvement of mantle cell lymphoma observed by magnified endoscopy with narrow-band imaging - Corrected Proof

2012-04-01

A 67-year-old man with mantle cell lymphoma (MCL) in remission for 3 years underwent follow-up positron emission tomography-computed tomography that showed cervical and abdominal lymph node enlargement. EGD was performed, and on duodenoscopy, multiple polypoid lesions of varying sizes were observed (A). Magnified chromoendoscopy with crystal violet staining of the smaller lesions showed a concentric circled structure and dilatation of the surrounding villi (B), and narrow-band imaging revealed looped and elongated microvessels on the surface of the lesions (C). The same endoscopic findings were emphasized on the surface of the larger lesions (D). Endoscopic biopsy specimens taken from the small lesions showed infiltration of neoplastic lymphoid cells (E), which were positive for CyclinD1 (F), CD20, and Bcl-1 but negative for CD3, CD5, and CD10. The patient received a diagnosis of MCL involving the duodenum, and chemotherapy with bendamustine was begun.

Submucosal tumors of the esophagogastric junction originating from the muscularis propria layer: a large study of endoscopic submucosal dissection (with video) - Corrected Proof

2012-03-29

Background: Given the high morbidity and mortality rates for surgery and the diminishment of quality of life caused by operative resection of the gastric cardia, a minor invasive treatment without loss of curability is desirable for submucosal tumors (SMTs) of the esophagogastric junction (EGJ). Endoscopic submucosal dissection (ESD) has been used successfully for the removal of esophageal or gastric SMTs; however, the EGJ has been regarded as a difficult location for ESD because of its narrow lumen and sharp angle. Objective: To evaluate the clinical impact of ESD for SMTs of the EGJ arising from the muscularis propria layer. Design: Single-center, prospective study. Setting: Academic medical center. Patients: 143 patients with 143 SMTs of the EGJ originating from the muscularis propria layer. Interventions: ESD. Main Outcome Measurements: Complications, en bloc resection rate, local recurrence, and distant metastases. Results: The average maximum diameter of the lesions was 17.6 mm (range 5 - 50 mm). The en bloc resection rate was 94.4% (135/143). All en bloc resection lesions showed both lateral and deep tumor-free margins, including 20 GI stromal tumors. Perforations occurred in 6 patients (4.2%, 6/143), and metal clips were used to occlude the defect. Four pneumoperitoneum and 2 pneumothorax caused by perforations were resolved with nonsurgical treatment. Local recurrence and distant metastasis have not occurred during a 2-year follow-up. Limitations: Single-center, short follow-up. Conclusions: ESD appears to be a safe, feasible, and effective procedure for providing accurate histopathologic evaluations, as well as curative treatments for SMTs of the EGJ originating from the muscularis propria layer.

A rare cause of chronic halitosis: gastric-colic fistulae - Corrected Proof

2012-03-29

A 32-year-old woman presented to the Gastroenterology Department with a 1-year history of fetid belching, halitosis, and diffuse abdominal pain. She had a history of morbid obesity and had undergone laparoscopic adjustable gastric banding, Lap-Band (Allergan, Irvine, California) 7 years before, although the band had to be endoscopically removed (AMI Gastric Band Cutter; Agency for Medical Innovation GmbH, Götzis, Austria) 4 years later because of intragastric migration. Subsequently, the patient had an uncomplicated full-term pregnancy; however, after delivery, the described digestive symptoms developed, which persisted until the present. Physical examination was unremarkable except for obesity. EGD showed a thick and cloudy liquid in the stomach, even though the patient had fasted for several hours. After aspiration, endoscopy revealed a fistulous opening at the gastric fundus (), which when entered with the endoscope was seen to communicate with the colon; fecal content was observed (). An upper GI series with water-soluble contrast confirmed the presence of a gastrocolic fistula (), and an abdominal CT showed a double-exit fistula, with communication between the gastric fundus and the transverse and descending colon, without abscess formation. Surgical correction was performed with complete resolution of symptoms.

The learning curve, accuracy, and interobserver agreement of endoscope-based confocal laser endomicroscopy for the differentiation of colorectal lesions - Corrected Proof

Teaco Kuiper, Ralf Kiesslich, Cyriel Ponsioen, Paul Fockens, Evelien Dekker — 2012-03-29

Background: The endoscope-based confocal laser endomicroscopy (eCLE) system allows in vivo imaging of colorectal epithelium. Little is known about the learning curve for accurate interpretation of confocal images acquired with eCLE. Objective: To determine the learning curve of eCLE, its diagnostic accuracy, and the intra- and interobserver agreement for the differentiation of colorectal lesions. Design: Post hoc assessment of selected eCLE images. Setting: Academic centers. Patients: This study involved colonoscopic images from 47 patients. Main Outcome Measurements: Learning curve of eCLE, accuracy, and intraobserver and interobserver agreement. Methods: Three endoscopists received a short introduction to eCLE before evaluating 90 images. Observers assessed all eCLE images by using the Mainz classification. After each set of 30 images, the accuracy of each observer was assessed. The same procedure was repeated 6 months later by using the same set of images. Limitations: Post hoc assessment. Results: There were no significant changes between the first set of 30 images and the 2 consecutive sets (P = .08 and P = .180, respectively). The overall accuracy was 85.6%, 95.6%, and 92.2% for each observer. The κ values of the intraobserver agreement were 0.68, 0.84, and 0.77 for each observer. The κ value for interobserver agreement was 0.73 during the first and 0.72 during the second assessment. Conclusions: Accurate post hoc interpretation of eCLE confocal images can be learned quickly. High diagnostic accuracy was achieved by all 3 observers during the initial stage of the assessment, which remained high thereafter. Intra- and interobserver agreement was substantial for all 3 observers. Future studies should focus on the real-time assessment of eCLE images.

Lymphogranuloma venereum proctitis - Corrected Proof

Scott E. Cunningham, Mark D. Johnson, Jeffrey T. Laczek — 2012-03-29

A 58-year-old man with HIV of 20 years' duration presented with 6 months of hematochezia and rectal pain. His HIV infection had been well controlled on antiretroviral therapy, and a recent viral load was undetectable; his CD4 count was 429 cells/mm. Colonoscopy showed multiple rectal ulcers that had a thick white exudate with surrounding erythema. Small ulcers were noted in the proximal rectum (); the ulcers became larger and more confluent in the distal rectum (). Biopsy specimens demonstrated an active destructive colitis without a viral cytopathic effect (). Viral cultures were negative for herpes simplex virus and cytomegalovirus. Rectal swab specimens were positive for Chlamydia on nucleic acid amplification testing (NAAT) and negative for gonorrhea. He was treated with azithromycin 1g orally, but his symptoms did not improve. He was then treated for lymphogranuloma venereum (LGV) proctitis with doxycycline 100 mg orally twice daily for 21 days. His symptoms resolved, and subsequent serotype testing performed at the Centers for Disease Control and Prevention obtained of rectal mucosa swab yielded LGV serotype L2. Repeat sigmoidoscopy 2 months later revealed resolution of the ulcers.

Endoscopic hole and clipping technique: a novel technique for closing the wide orifice of a postoperative fistula - Corrected Proof

Hyung Hun Kim, Seun Ja Park, Moo In Park, Won Moon — 2012-03-29

Background: Endoscopic clipping for closing a fistula created by surgery is often difficult because of the combination of a wide orifice and fibrosis. Creating holes for prongs of a clip may constitute a new endoscopic clipping technique for closing the wide orifice of a fistula. Objective: To assess the feasibility of performing the endoscopic hole and clipping technique (EHCT). Design: Experimental pilot study. Setting: Tertiary-care referral center. Patient: This study involved 1 patient who underwent EHCT. Interventions: EHCT was performed. Main Outcome Measurements: Technical success and procedural complications of EHCT. Results: Immediately after the procedure, drainage decreased dramatically and finally decreased to 0 mL/d. There was no evidence of a leak on fluoroscopic examination, and upon 4-month follow-up, we found that no symptoms had developed in the patient. Limitations: Single-patient pilot study. Conclusions: EHCT is very simple and efficient. EHCT can be applied as a means of closing the orifice of a postoperative fistula that is not easily managed by simple endoscopic clipping.

Advanced endoscopic imaging: from the top of the fold to the single bacterium - Corrected Proof

2012-03-22

A 71-year-old man underwent surveillance colonoscopy. He had had Clostridium difficile colitis, which was treated with metronidazole 2 weeks before the current examination. The patient was free of symptoms, and stool samples were negative for C difficile toxin at the time of endoscopy. High-resolution endoscopy (EG-3870 CIK, Pentax, Tokyo, Japan) showed mild mucosal edema and erythema in the rectum and sigmoid colon. From the descending colon proximal to the terminal ileum, no macroscopic signs of inflammation were visible (A). After administration of 3 mL intravenous fluorescein 10% (Alcon Laboratories, Fort Worth, TX), endomicroscopy was performed in the descending colon. Endoscopic histology revealed large, irregular, dilated crypt openings and mild crypt abnormalities. In addition, multiple white focal spots within the colonic epithelium were recorded that were highly suggestive of intramucosal bacteria (B, arrows). Biopsy samples were obtained from the same region previously evaluated by using endomicroscopy and subsequently incubated with phosphate-buffered saline solution. Afterward, a 5% solution of fluorescein-labeled eubacterial oligonucleotide probe EUB-338 was added, and the biopsy specimen was subsequently imaged by using the endomicroscopy system. Ex-vivo imaging confirmed the presence of bacteria within the colonic epithelium (C, arrows). To verify this finding, fluorescent in-situ hybridization with the Cy3-labeled universal eubacterial oligonucleotide probe EUB-338 was performed. Bright red fluorescence on fluorescent in situ hybridization testing additionally confirmed the presence of intramucosal bacteria (D).

Duodenal perforation due to plastic stent migration successfully treated by endoscopy - Corrected Proof

Varayu Prachayakul, Pitulak Aswakul, Udom Kachintorn — 2012-03-22

A 73-year-old woman with unresectable cholangiocarcinoma underwent ERCP and self-expandable metal stent (SEMS) placement for biliary drainage. The stent expansion proved insufficient, and she experienced ascending cholangitis a week later. A plastic stent was then inserted through the original SEMS, but she was admitted again because of progressive jaundice with low-grade fever. Preparations were made for the plastic stent exchange with a second SEMS placed with the patient under general anesthesia. Endoscopic views showed downward migration of the plastic stent; the tip of stent had migrated through the duodenal wall, and there was a 0.5-cm ulcer at the site of perforation (). Fluoroscopy confirmed a distally migrated stent with its tip protruding about 1 cm outside the duodenal wall (). Using minimal air insufflation, we grasped the plastic stent with a foreign body forceps near the ampulla and threaded back into the common bile duct. The perforation was immediately closed with metal clips (, and no free air was seen at fluoroscopy (). The plastic stent was then removed with the same forceps, and a second SEMS was deployed inside the original SEMS with satisfactory drainage, although it did not fully expand because of malignant in-growth (). The patient was discharged without procedure-related complications 5 days later.

Diagnostic yield and safety of jumbo biopsy forceps in patients with subepithelial lesions of the upper and lower GI tract - Corrected Proof

2012-03-19

Background: EUS-FNA often fails to make a definitive diagnosis in the evaluation of subepithelial lesions. The addition of jumbo biopsy forceps has the potential to improve diagnostic yield, but published series are limited. Objective: To assess the likelihood of definitive diagnosis for subepithelial lesions by using jumbo biopsy forceps during EUS examination. Design: Pooled retrospective analysis. Setting: 6 tertiary referral centers. Patients: All patients having undergone EUS examination for a subepithelial lesion in which jumbo biopsy forceps were used for tissue acquisition. Main Outcome Measurements: Diagnostic yield of jumbo biopsy forceps use, complication rates, and comparison of diagnostic yield with that of EUS-FNA. Results: A total of 129 patients underwent EUS with jumbo biopsy forceps; 31 patients (24%) had simultaneous EUS-FNA. The lesion locations were stomach (n = 98), esophagus (n = 14), duodenum (n = 11), colon (n = 5), and jejunum (n = 1). The average lesion size was 14.9 mm ± 9.3 mm. Overall, definitive diagnosis was obtained in 87 of 129 patients (67.4%) by using either method. A definitive diagnosis was provided by jumbo biopsy forceps use in 76 of 129 patients (58.9%) and by FNA in 14 of 31 patients (45.1%) (P = .175). The results in third-layer lesions were definitive with jumbo biopsy forceps in 56 of 86 lesions (65.1%) and with FNA in 6 of 16 lesions (37.5%) (P = .047). For fourth-layer lesions, the results with jumbo biopsy forceps were definitive in 10 of 25 (40.0%) and with FNA in 8 of 14 (57.1%) (P = .330). Forty-five of 129 patients (34.9%) experienced significant bleeding after biopsy with jumbo forceps and required some form of endoscopic hemostasis. Limitations: Retrospective study. Conclusions: Jumbo forceps are a useful tool for the definitive diagnosis of subepithelial lesions. The greatest benefit appears to be with third-layer (submucosal) lesions. The risk of bleeding is significant.

Failure to recognize serrated polyposis syndrome in a cohort with large sessile colorectal polyps - Corrected Proof

Krishna C. Vemulapalli, Douglas K. Rex — 2012-03-19

Background: Serrated polyposis syndrome (SPS) is a rare condition of multiple serrated colorectal polyps and cancers. Colorectal cancer risk is increased in SPS. Objective: We determined the prevalence of SPS in a cohort of patients with large (≥2 cm) sessile colorectal polyps and the rate at which the diagnosis was made by the clinicians. Design: Review of patient care database. The 2010 World Health Organization (WHO) criteria were used to identify cases of SPS. Setting: Tertiary academic center. Patients: 529 consecutive patients referred for endoscopic resection of a sessile colorectal polyp ≥2 cm. Main Outcome Measurements: Prevalence of SPS in the cohort and frequency with which the referring physician and the endoscopist recognized SPS. Results: Of the 529 patients, 20 (4%) met the WHO criteria for SPS. Only 1 of these cases was suspected by a referring physician. Twelve cases (60%) were either diagnosed or suspected by the endoscopist at our center. Compared with all other patients without SPS, those with SPS were more likely to have an index lesion (the lesion that led to referral) that was serrated (60% vs 3.8%), to have a cecal or ascending colon index lesion (70% vs 45%), and to be current smokers (42% vs 15%). Including the first colonoscopy to remove the index lesion and 26 follow-up colonoscopies, the endoscopist at our center removed 183 serrated polyps from the 20 patients with SPS; of those polyps, 68 were >1 cm. Three patients were referred for surgical resection of involved colon. Eighteen of the 20 patients with SPS met the WHO criterion of 5 serrated polyps proximal to the sigmoid, of which 2 are >1 cm. Failure to recognize SPS by the referring physician was at least partly related to unrecognized serrated lesions. Failure to recognize SPS by the endoscopist at our institution was the result of not systematically applying WHO criteria to the polyp findings. Limitations: Retrospective study. Conclusions: SPS was common in a cohort of patients with large sessile colorectal polyps, and it was frequently unrecognized. These data suggest the need for better detection of serrated lesions, better awareness of SPS, and more consistent application of SPS criteria to the polyp findings of individual patients.

Knowledge of quality performance measures associated with endoscopy among gastroenterology trainees and the impact of a Web-based intervention - Corrected Proof

Jennifer S. Thompson, Benjamin Lebwohl, Sapna Syngal, Fay Kastrinos — 2012-03-15

Background: Knowledge of quality measures in endoscopy among trainees is unknown. Objective: To assess knowledge of endoscopy-related quality indicators among U.S. trainees and determine whether it improves with a Web-based intervention. Design: Randomized, controlled study. Setting: Multicenter. Participants: This study involved trainees identified from the American Society for Gastrointestinal Endoscopy membership database. Intervention: Participants were invited to complete an 18-question online test. Respondents were randomized to receive a Web-based tutorial (intervention) or not. The test was readministered 6 weeks after randomization to determine the intervention's impact. Main Outcome Measurements: Baseline knowledge of endoscopy-related quality indicators and impact of the tutorial. Results: A total of 347 of 1220 trainees (28%) completed the test; the mean percentage of correct responses was 55%. For screening colonoscopy, 44% knew the adenoma detection rate benchmark, 42% identified the cecal intubation rate goal, and 74% knew the recommended minimum withdrawal time. A total of 208 of 347 trainees (59%) completed the second test; baseline scores were similar for the tutorial (n = 106) and no tutorial (n = 102) groups (56.4% vs 56.9%, respectively). Scores improved after intervention for the tutorial group (65%, P = .003) but remained unchanged in the no tutorial group. On multivariate analysis, each additional year in training (odds ratio [OR] 2.3; 95% confidence interval [CI], 1.5-3.4), training at an academic institution (OR 2.6; 95% CI, 1.1-6.3), and receiving the tutorial (OR 3.2; 95% CI, 1.7-5.9) were associated with scores in the upper tertile. Limitations: Low response rate. Conclusion: Knowledge of endoscopy-related quality performance measures is low among trainees but can improve with a Web-based tutorial. Gastroenterology training programs may need to incorporate a formal didactic curriculum to supplement practice-based learning of quality standards in endoscopy.

Endoscopic treatment of congenital duodenal membrane - Corrected Proof

2012-03-15

Congenital duodenal membrane is an anomaly characterized by luminal GI obstruction and consists of a diaphragm with multiple central or peripheral openings. The clinical presentation depends on the size of the fenestrations of the diaphragm. In cases of severe stenosis, vomiting and abdominal distention are the presenting symptons.

An unusual cause of lower GI bleeding in a young woman: metastatic gestational choriocarcinoma - Corrected Proof

2012-03-15

A 31-year-old woman was referred to our department for massive lower GI bleeding. She had undergone a cesarean section 1 month previously because of fetal distress at 8 months of pregnancy. At 6 months of pregnancy she had had a vaginal bleed that spontaneously subsided. During the cesarean section she had greater than expected blood loss, for which the cause could not be ascertained. After delivery, she had a low-grade fever for 20 days, which was empirically treated as enteric fever, and she then experienced massive lower GI bleeding.

Acute abdominal pain in systemic lupus erythematosus - Corrected Proof

Raj Majithia, Grishma Joy, John Liang, Kevin Olden — 2012-03-12

A 28-year-old woman with a history of systemic lupus erythematosus and antiphospholipid antibody syndrome presented with acute, severe, left-sided abdominal pain, hematemesis, and hematochezia. On physical examination, there was significant left-sided abdominal tenderness with guarding. Laboratory test analysis revealed leukocytosis of 30,800/mm3 (normal 4000-10,8000/mm3), anemia with a hemoglobin of 9.6 g/dL (12-16 g/dL), elevated C-reactive protein level of 140 mg/dL (<3 mg/dL), and a normal serum lactate level of 1.1 mmol/L (<2 mmol/L). An abdominal CT scan, performed without contrast, disclosed thickened proximal small bowel loops in the left upper quadrant, consistent with enteritis (arrows, A). EGD revealed erythematous and edematous mucosa oozing blood in the second portion of the duodenum, suggestive of enteritis (B). Biopsies were done with a standard forceps, and pathology revealed several small vessels with fibrinoid necrosis and thrombosis, confirming the diagnosis of lupus vasculitic enteritis (arrows, C). Three doses of methylprednisolone (1000 mg over 2 hours) and one dose of cyclophosphamide (1000 mg) were given and led to clinical remission of her GI symptoms.

Placement of a covered stent for palliation of a cavitated colon cancer by using a novel over-the-scope technique (with video) - Corrected Proof

2012-03-09

Covered self-expandable metal stents (SEMSs) dedicated for colonic use are unavailable in the United States. Closure of colonic fistulae and leaks is feasible using covered esophageal SEMSs, but their short-length, non–through-the-scope (TTS) delivery systems are difficult to pass through tortuous anatomy. We describe a novel over-the-scope (OTS) technique to place an esophageal partially covered SEMS (PC-SEMS) in the colon.

Prevalence of missed adenomas in patients with inadequate bowel preparation on screening colonoscopy - Corrected Proof

2012-03-01

Background: The prevalence of missed polyps in patients with inadequate bowel preparation on screening colonoscopy is unknown. Objective: To determine the prevalence of missed adenomas in average-risk patients presenting for screening colonoscopy who are found to have inadequate bowel preparation. Design: Retrospective chart review. Endoscopy and pathology reports were examined to determine the characteristics of polyps. Data from repeat colonoscopies were collected through 2010. Setting: Outpatient endoscopy center at an academic medical center. Patients: This study involved patients who underwent outpatient average-risk screening colonoscopy between 2004 and 2009 documented to have inadequate bowel preparation and who had colonoscopy to the cecum. Main Outcome Measurements: Initial adenoma detection rate and adenoma detection rate on follow-up examination. Results: Inadequate bowel preparation was reported on 373 patients, with an initial adenoma detection rate of 25.7%. Of 133 patients who underwent repeat colonoscopy, 33.8% had at least 1 adenoma detected, and 18.0% had high-risk states detected (≥3 adenomas, 1 adenoma ≥1 cm, or any adenoma with villous features or high-grade dysplasia). Per-adenoma miss rate was 47.9%. Among patients with at least 1 adenoma on repeat colonoscopy, 31.1% had no polyps on initial colonoscopy; mean time between colonoscopies was 340 days. Among patients with high-risk states, 25.0% had no polyps seen on initial colonoscopy; mean time between colonoscopies was 271 days. Limitations: Retrospective design. Conclusion: Adenomas and high-risk lesions were frequently detected on repeat colonoscopy in patients with inadequate bowel preparation on initial screening colonoscopy, suggesting that these lesions were likely missed on initial colonoscopy.

A case of oropharyngeal squamous papilloma in which endoscopic resection was performed - Corrected Proof

2012-02-27

A 56-year-old woman was referred to Hokkaido University Hospital for endoscopic resection of a tumor in the oropharynx. Further endoscopic examination revealed a lesion with a characteristic verrucous appearance reminiscent of papillomatous warts seen on the skin and esophagus (A). Magnified narrow-band imaging showed that microvessels in the lesion were not dilated (B). The lesion was diagnosed as an oropharyngeal squamous papilloma. Endoscopic resection was selected as treatment. Written informed consent was obtained after we explained the advantages and risks and before we initiated treatment.

Variceal transection of esophageal varix using the ESD method: new treatment technique for esophageal varix (with video) - Corrected Proof

2012-02-27

Standard treatments for esophageal varices are endoscopic injection sclerotherapy (EIS) and endoscopic variceal ligation (EVL). However, EIS or EVL for varices with paraesophageal veins and perforating shunt veins cannot be performed because of the risk of sclerosant leakage. The recurrence rate of EVL caused by perforating veins is very high. Almost all circumference esophageal cancer on esophageal varices with thick paraesophageal perforating veins can be treated by resecting the cancer en bloc after transecting the esophageal varix with simultaneous endoscopic submucosal dissection (ESD).

First report of celiac plexus block for refractory abdominal pain secondary to peripancreatic colon cancer metastasis - Corrected Proof

Mehmet Bektas, Muslim Atiq, Manoop S. Bhutani — 2012-02-10

Intractable abdominal pain is common in carcinoma of the pancreas. EUS-guided celiac plexus block (CPB) and neurolysis (CPN) have been performed successfully to reduce chronic abdominal pain in patients with pancreatic cancer or chronic pancreatitis. We present the first case of effective pain relief after CPB for intractable abdominal pain related to peripancreatic colon cancer metastasis.

Esophageal leiomyomatosis presenting as achalasia diagnosed by high-resolution manometry and endoscopic core biopsy - Corrected Proof

David A. Katzka, Thomas C. Smyrk, Heather J. Chial, Mark D. Topazian — 2012-02-10

Esophageal leiomyomatosis is a rare disorder characterized by hamartomatous proliferation of the esophageal muscularis propria and leiomyomata in the esophageal wall. This condition may be sporadic or familial, an isolated disease or associated with Alport's syndrome, and include leiomyomata within and outside of the GI tract. It presents with chronic dysphagia and may present anatomically with focal stricture or diffuse esophageal involvement, often diagnosed at surgery. Esophageal leiomyomatosis rarely has been reported to cause “pseudoachalasia” by barium studies and by descriptive manometric data only. This is the first case to confirm a manometric pattern of achalasia on high-resolution manometry and establish the diagnosis preoperatively by endoscopic esophageal core biopsy.

Successful EUS-guided FNA through a colonic stent array for diagnosis of an extraluminal pelvic malignancy causing colonic obstruction - Corrected Proof

2012-01-30

A 63-year-old man presented with new-onset constipation and abdominal pain. The patient had a history of high-grade T1 bladder cancer, for which he underwent a radical cystoprostatectomy with creation of an ileoneobladder approximately 3 years earlier, followed by a complex surgical revision. The patient had no surgical changes in the rectum or colon. A CT scan demonstrated a short segment of rectosigmoid thickening but no evidence of diverticulitis or mass. Colonoscopy revealed stenosis at the rectosigmoid colon, which was traversed with a pediatric colonoscope. The colonic mucosa in this region was normal appearing, and no mass, inflammation, or diverticula were present. Mucosal biopsies showed normal results.

Temporary placement of a fully covered metal stent to tamponade bleeding from endoscopic papillary balloon dilation - Corrected Proof

Florence Aslinia, Lauren Hawkins, Peter Darwin, Eric Goldberg — 2012-01-27

Endoscopic papillary balloon dilatation (EPBD) after endoscopic sphincterotomy (ES) is an effective technique to remove large common bile duct (CBD) stones. Although the bleeding risk from EPBD is low, hemorrhage can be intraampullary and thus challenging to visualize and treat. Fully covered metal stents have been used to tamponade hemorrhage from ES and even esophageal varices. We describe 2 cases in which fully covered metal stents were successfully used to treat intraductal bleeding secondary to EPBD.

Anastomotic stenosis after pancreaticoduodenectomy: an endoscopic solution - Corrected Proof

Johanna A.M.G. Tol, Jeroen M. Jansen, Sandra C. Donkervoort — 2012-01-27

Obstruction of the gastrojejunostomy (GJJ) after pancreaticoduodenectomy is often caused by malignant tumor ingrowth. Patients present with nausea and vomiting suggestive of gastric outlet obstruction (GOO). GOO may require surgical treatment, which is associated with relief of symptoms in 72% of patients but with the risk of morbidity.

Combined endoscopic-interventional radiologic approach for the treatment of bleeding gastric varices in the setting of a large splenorenal shunt - Corrected Proof

2012-01-20

Endoscopic cyanoacrylate (glue) injection is an effective therapy for bleeding gastric varices (GV) but may result in life-threatening embolic complications. The risk of glue-related embolism is heightened if a large gastro/splenorenal shunt (SRS) is present. Techniques that minimize the risk of glue embolization via the SRS would significantly enhance the safety of the procedure.

Contrast-enhanced US-guided ERCP for treatment of common bile duct stones in pregnancy - Corrected Proof

Manuela Götzberger, Matthias Pichler, Veit Gülberg — 2012-01-20

Usually, ERCP for the treatment of common bile duct stones (CBDS) is performed under fluoroscopic control. However, the exposure to x-rays raises a problem in pregnant women because radiation is a possible risk for fetal disorders. For pregnant patients with symptomatic CBDS, current guidelines recommend treatment by ERCP but with minimal exposure to radiation. Recently, the first experience in intraductal application of a US contrast agent during ERCP or percutaneous transhepatic cholangiography was reported. We report a case of contrast-enhanced US-guided ERCP for the treatment of CBDS in pregnancy.

Treatment of Epstein-Barr virus–associated gastric carcinoma with endoscopic submucosal dissection - Corrected Proof

2011-12-26

Epstein-Barr virus (EBV) is a herpes virus that was originally identified in a human Burkitt lymphoma cell line. A small portion of EBV-infected individuals develop hematopoietic, epithelial, and mesenchymal tumors. The endoscopic features of EBV-associated gastric carcinoma (EBV-GC) have not been well-documented, and there have been no case reports regarding endoscopic submucosal dissection (ESD). Here, we present a case of EBV-GC that was treated with ESD.

Simultaneous EUS-guided transbulbar pancreaticobiliary drainage (with video) - Corrected Proof

Winoah A. Henry, Vikesh K. Singh, Anthony N. Kalloo, Mouen A. Khashab — 2011-12-26

Failure to achieve access to the bile duct and/or the main pancreatic duct (MPD) during ERCP occurs because of either failed cannulation or an inaccessible papilla from altered anatomy or proximal duodenal obstruction caused by tumor invasion. Percutaneous transhepatic biliary drainage or surgical interventions are often required in these cases, but they are associated with significant morbidity. Recently, EUS-guided drainage through either a transluminal approach or a transpapillary rendezvous approach has been reported as a safe alternative technique for biliary and pancreatic ductal drainage (, available online at www/giejournal.org). Here we report the first case of successful simultaneous EUS-guided transbulbar drainage of obstructed biliary and pancreatic ducts.

EUS-guided coil and glue for bleeding rectal varix - Corrected Proof

Frank Weilert, Janak N. Shah, Fernando P. Marson, Kenneth F. Binmoeller — 2011-12-16

Rectal varices are usually caused by portal hypertension but also may result from mesenteric venous obstruction, heart failure, vascular anomalies, and adhesions. We present the first case of EUS-guided therapy with embolization coil and glue injection for rectal variceal bleeding.

Cantaloupe melon–like stomach - Corrected Proof

2011-12-12

A 27-year-old woman with no significant medical history came to our hospital because of recent onset of dyspepsia. Physical examinations, blood tests, and abdominal US revealed no significant abnormal findings. EGD showed an abundance of white longitudinal protuberances, which spread all over the patient's stomach ().

Jaundice and abdominal pain in a patient with hemobilia secondary to a right hepatic artery subsegmental arteriovenous malformation - Corrected Proof

Kondal Kyanam Kabir Baig, Horacio D'Agostino, Tony E. Yusuf — 2011-12-09

Hemobilia is an uncommon cause of GI bleeding. Jaundice, melena, and abdominal pain are common at presentation. All 3 symptoms are present in about 40% of patients. The most common causes of hemobilia include liver biopsy, trauma, gallstones, cholecystitis, vascular lesions, and malignancy.

Endoscopic treatment of paraesophageal abscess in eosinophilic esophagitis after chest trauma - Corrected Proof

2011-12-09

A 19-year-old man was admitted with dysphagia, retrosternal pain, and fever after he was hit on the breastbone during an assault 10 days before. He experienced progressive chest pain despite treatment with a proton pump inhibitor. Laboratory test analyses showed signs of inflammation, with a leucocyte count of 11,400/mm3 (normal 4.0-10.0 mm3) and C-reactive protein level of 201.8 mg/L (normal < 8 mg/L). CT revealed a 12-cm, paraesophageal abscess, with enlarged mediastinal and infradiaphragmatic lymph nodes and mediastinitis (). Upper endoscopy indicated a 7-cm–long narrowing of the esophagus with a pus-draining fistula located 30 cm from the teeth (). Endoscopic fistulotomy was performed along a guidewire. The cavity was generously rinsed with saline solution, and a nasogastric tube was inserted; proton pump inhibitor therapy, antibiotics, and parenteral nutrition were initiated. The patient's clinical condition improved rapidly, and CT 5 days later demonstrated abscess reduction. Microbiologic examination revealed group G streptococci. No other endoscopic interventions were needed.