Update on Endoscopic Research Presented at 2007 Digestive Disease Week
Update on Endoscopic Research Presented at 2007 Digestive Disease Week
Prepared by Gastroenterology fellows from New York City and Boston area training programs.
Edited by Jonathan Cohen, MD, New York University School of Medicine
| Topic | Reporter Name |
|---|---|
| The New Frontier of Colonoscopic Imaging | Jason N. Rogart, Yale University School of Medicine |
| Contemporary Approaches to Small Bowel Imaging | Jonathan A. Erber, SUNY Downstate Medical Center |
| New Therapeutic Endoscopic Technologies | Gina Sam, New York University School of Medicine |
| Risk Factors for Colorectal Cancer Screening and Surveillance | Alissa Mark, Stony Brook University Hospital |
| Outcomes of EMR and ESD | Satish Nagula, MSKCC |
| Biliary Imaging and Therapy | Tamas Gorda, New York Presbyterian Hospital |
| Innovations in Endoscopic Ultrasound | Malini Sahu, New York University School of Medicine |
| Minimizing Risks for the Patient and Endoscopist | Shahzad Iqbal, Methodist Hospital |
| Advances in Endoscopic Ultrasound | Shasin Shah, UMDNJ |
| Benign Esophageal Disorders | Tamas Gorda, New York Presbyterian Hospital |
| New Technology: NOTES | Micheal Schmidt, New York Presbyterian Hospital |
| Issues in Colonic Polyps | Alejandra Castillo-Roth, SUNY Downstate |
| Endoscopic Diganosis and Treatment of Esophageal Cancer or High Grade Dysplasia | Edmond Bouassaf, SUNY Downstate |
| Improving the Quality of Pediatric Endoscopy | Orhan Artay, Cleveland Clinic |
| Advances in Pancreatic ERCP | Diego Kuperschmit, Beth Israel Hospital |
| Improving Quality in Endoscopic Training and Practice | Shahzad Iqbal, Methodist Hospital |
| Endoscopic Ultrasound | Diego Kuperschmit, Beth Israel Hospital |
| Non-Variceal Upper GI Bleeding | Alejandra Castillo-Roth, SUNY Downstate |
| Advances in Endoscopic Diagnosis and Imaging | Caroline Loeser, Yale |
| Advances in Biliary Imaging and Therapies | Shasin Shah, UMDNJ |
| Late Breaking Abstracts | Shanti Eswaran, New York Presbyterian Hospital |
| ASGE Plenary session | Shahzad Iqbal/ Kiranmaye Tiriveedhi, Methodist Hospital |
Section 1: The New Frontier of Colonoscopic Imaging
This session consisted of six abstracts presented by groups representing four different countries, and included research on Narrow Band Imaging (NBI), Autofluorescence Imaging (AFI), high resolution / high definition imaging systems, wide-angle colonoscopes, and chromoendoscopy. The theme throughout was the use of new imaging technology to increase adenoma detection during colonoscopy, and thereby decrease adenoma miss rates, which have been reported to be as high as 26%.
Performance of High-Definition Colonoscopy for the Detection of Colonic Polyps
This presentation by Shenoy and Friedenberg from Temple University retrospectively reviewed more than 300 colonoscopies performed with an old monochrome system (Pentax), standard resolution colonoscopes (Olympus 160 series), and the new high resolution/definition colonoscopes which also have a wider 170 degree viewing angle (Olympus 180 series with Exera Series II processors). The results showed no difference in the diagnostic yield for adenomas between all 3 systems. The bowel prep quality, however, was better in the monochrome group, possibly offsetting potential advantages in the high resolution arm. The other major limitation is that this was not a prospective, randomized study.
Surface Visualization at CT Colonography Simulated Optical Colonoscopy: Wide Angle Colonoscopy and Retrograde Viewing Auxiliary Imaging Devices
This research from St. Mark’s Hospital, presented by East, used customized CT colonography (CTC) software to evaluate the theoretical effect of increasing the viewing angle afforded by colonoscopes, including retrograde views (as may be achieved by, e.g., the Third Eye Retroscope, presented at DDW 2006). They reviewed 20 previously performed CTC scans with simulated viewing angles of 90°, 120°, 140°, and 170°, as well as 140° and 170° with retrograde viewing capability. Not surprisingly, the percentage of the colonic surface visualized increased progressively with wider viewing angles (peak 92% with 170°) and was the highest when retrograde visualization was included (99%). Similarly, the total number of “missed areas” was lowest with the widest angles of view, as were the total number of “large” missed areas.
Optimal Withdrawal Time at Colonoscopy: Evidence-Based Guidelines
The aim of this study presented by Simmons from the Mayo Clinic was to characterize the optimal withdrawal time needed to achieve the ASGE/ACG recommended adenoma detection rates during screening examinations of 25% in men and 15% in women older than age 50. 9528 colonoscopies performed by 43 endoscopists during a one year period were retrospectively reviewed for polyp detection rates and withdrawal times. Polyps were found in 45%. A random sample of 50 polyps was found to be comprised of 56% adenomas. It was therefore calculated that polyp detection rates of 45% for men and 27% for women would correspond to the above-mentioned recommended adenoma detection rates. In the 9528 colonoscopy records reviewed, these polyp detection rates correlated to withdrawal times of 6 minutes in men and 4.3 minutes in women. It is not clear from this study whether differences in withdrawal time accounted for some of the decreased adenoma detection rate observed in women.
Narrow Band Imaging Improves Adenoma Detection in Patients at High Risk for Adenomas: A Randomized Trial
The aim of this study, again from the group at St. Mark’s Hospital, was to compare NBI to high resolution- high definition white light (WLE) in detecting adenomas in a selected group of patients at increased risk for adenomas, including those with a history of colorectal cancer, 3 or more adenomas or one advanced adenoma on prior colonoscopy, or fecal occult blood test positive. Data from 91 patients was reported. After insertion to the cecum, patients were randomized to either WLE or NBI for withdrawal. There were significantly more men in the WLE group, but otherwise no difference between groups, including in bowel prep score and withdrawal time. There was no statistical difference in the number of patients in which at least one adenoma was found or in which advanced adenomas were identified; however, overall, there were statistically more adenomas and more polyps found in the NBI group. There was also a trend toward finding more flat adenomas in the NBI group.
Endoscopic Trimodality Imaging (ETMI) for the Detection and Classification of Colonic Polyps
The aim of this study presented by Van Den Broek from Amsterdam was to evaluate whether a tri-modality imaging system can increase the adenoma detection rate, as well as accurately characterize polyps as neoplastic or non-neoplastic. The system consisted of a prototype instrument combining high resolution white light endoscopy (WLE), autofluorescence imaging (AFI), and narrow band imaging (NBI). After cecal intubation, 100 patients were randomized to segmental withdrawal with either WLE or AFI first, and then re-examined with the alternate technology (cross-over). There was no statistical difference in the additional adenomas detected with the second technology, suggesting that AFI does not increase adenoma detection rate. When evaluating the Kudo pit patterns of all polyps with NBI alone, the sensitivity, specificity, and accuracy for predicting adenoma on histology was 81%, 70%, and 75% respectively. AFI alone (pink/purple color suggests neoplasia) showed a higher sensitivity (92%) but a high false positive rate, with resulting low specificity and accuracy (31% and 61% respectively). Combining the two strategies- i.e. AFI followed by NBI if positive – resulted in the highest accuracy rate (79%), with sensitivity and specificities of 88% and 71% respectively.
Evaluation of the Diagnostic Accuracy Rate of Minute Colonic Adenomas: High-Resolution Magnifying Chromoendoscopy vs. Histopathology of a Biopsy Forceps Specimen
This prospective study presented by Tamura from Kochi, Japan identified 255 adenomas 3mm or smaller. High resolution magnifying chromoendoscopy with 0.2% indigo carmine was used to identify type III Kudo pit patterns, which in previous studies has been shown to correspond to adenoma on histology. They were then resected with biopsy forceps and separated into two groups- half were placed directly in fixative (20% buffered formalin), while the other half were flattened using the forceps before being placed in fixative. Adenoma was diagnosed histologically in 100% of the “flattened” group vs. Only 85% of the un-flattened group. From this latter group, the 19 specimens initially diagnosed as non-neoplastic were fully sectioned (i.e. The complete paraffin wax blocks) and reexamined, and 17/19 (89%) were reclassified as adenomas. The authors concluded that high magnification chromoendoscopy is more accurate than standard histopathology in the evaluation of very small colon polyps.Section 2: Contemporary Approaches to Small Bowel Imaging
This session reviewed data on two new balloon guided small bowel endoscopes, the technique of stricture dilatation for Small intestinal Crohn’s disease, complications of double balloon enteroscopy, as well as long term outcomes from Small bowel Pillcam® Endoscopy. The session revealed that the methods of examining the small bowel are expanding and ability to deliver endoscopic therapy there increasing. More head to head comparisons will be required in coming years of these various modalities.
Complications of Double Balloon Enteroscopy: A Report of 2367 Procedures
Mensink and colleagues presented retrospective data on complications of Double Balloon Enteroscopy (DBE), which was a multi-center, multi-national survey. They reviewed the complication rates of both diagnostic and therapeutic DBE (use of argon plasma coagulation (APC), polypectomy with snare, injection of fluid other than ink for marking, foreign body retrieval, and balloon dilation). Fourteen centers across 4-continents were asked to participate via standard questioner; 10 out of 14-centers responded (71%). A total of 40 complications were reported out of 2,362 procedures (2001 to 2003); 13/1728 diagnostic (0.8%), 27/412 therapeutic (4.3%). Complications were ranked as minor (21, 0.9%), moderate (6, 0.3%), or severe (13, 0.5%). There were no fatal complications. There were 7 cases of acute pancreatitis reported, 6 after diagnostic (0.3%) and 1 after therapeutic (0.2%). A more detailed analysis from 7 centers on 31 complications after therapeutic DBE was elaborated on: 12 episodes of bleeding (5-minor, 7-moderate) out of a total of 364 polypectomies (complication rate CR 3.3%), no perforation; 3-cases of perforation out of 253 APC’s (CR 1.2%); 2-cases of perforation out of 70-balloon dilatations (CR 2.9%). They concluded that the most common complication after diagnostic DBE was acute pancreatitis, and that the complication rate after therapeutic DBE is high compared to interventional colonoscopy.
New Balloon-Guided Technique for Deep Small Intestine Endoscopy with Standard Endoscopes
Adler and colleagues, presented data on a novel push-pull balloon guided endoscopy (BGE). The BGE is a disposable sleeve that is FDA and CE approved. It can be mounted on any standard endoscope, with an inflatable balloon at the tip of the endoscope that acts as a stabilizer and a second balloon that can be advanced ahead of the endoscope and when inflated acts as a pulling device. It has a stand alone air supply. Their preliminary study evaluated the safety and efficacy of this device. They performed 9 BGE procedures, 7-peroral intubations, using the Olympus PCF-160AL pediatric colonoscope and SIF-140 enteroscope, and the Fuji EC-250WL5 colonoscope and EG-250CT5 therapeutic gastroscope. The scopes were advanced in all patients up to 2-meters past the pylorus; procedure times were between 30-60 minutes; there were no reported complications. In one patient a diagnosis of mid small bowel Crohn’s disease was made. In two other cases, biopsies from the proximal jejunum were obtained. Two retrograde procedures were performed and the IC valve intubated with subsequent enteroscopy; they reported time to the IC valve as similar to standard colonoscopy. They conclude that BGE is safe and enables enteroscopy with standard endoscopes. This presents an interesting alternative to purchase of a free-standing double balloon enteroscopy system, though direct comparisons will be important.
Clinical Utility of the Olympus Single Balloon Enteroscope: The Initial U.S. Experience
A variation on balloon guided enteroscopy was also discussed by John Dumot and colleagues. They presented there data on the use of a single balloon enteroscopy, the Olympus XSIF-Q160Y (200cm length, 9.2mm OD, 2.8mm working channel) was coupled with a 132cm long, 13.2mm OD overtube with an inflatable anchoring balloon at its distal tip. Fluoroscopy was used intermittently. Patients who were candidates for deep small bowel enteroscopy were enrolled. Twenty procedures were performed (9-male, mean age 65.9); indications included obscure-occult GIB (8), obscure-overt GIB (6), iron deficiency anemia (2), polyps (2), mass (1), and enteritis (1). Nineteen procedures were performed anterograde; 19/20 successfully sedated with midazolam and an opioid. Mean procedure time was 54.5 +/- 18min. The scope reached the ileum in 5/19 (26%) using the anterograde approach; the remainder reached the mid to distal jejunum. There was no significant difference between procedure time and depth of insertion (jejunum 57.7 +/- 20.66 min versus ileum 46.0 +/- 4.2 min, p=0.20). The overall diagnostic yield was 60%; findings included AVM’s (7), duodenitis (1), enteritis (1), polyps (1), and anastamotic ulcer (1).
Small Bowel Tumors Detected By Video Capsule Endoscopy (VCE): Preliminary Data from the ECEG (European Capsule Endoscopy Group) Database
Emanuele Rondonotti and colleagues presented their retrospective data from the European Capsule Endoscopy Group database (ECEG) on small bowel tumors. The database encompassed 17-centers across 6-European countries. Out of 3,031 VCE’s, 74 (32-female, 42-male; mean age 59 +/- 14.7 years) with small bowel tumor were identified (2.4%). Indications included obscure GI bleeding in 67 (90.5%): obscure-occult in 39.2%, obscure overt in 32.4%, and previous overt in 18.9%; abdominal pain in 4 (5.5%); search for primary neoplasm in 3 patients with liver metastases (4%). Seventeen patients (23%) underwent VCE as the third test after a negative pan-endoscopy; 57 patients (62.2%) had at least one further exam of the SB before VCE. Findings included polyps in 67.7%, ulcers in 12.1%, stenoses in 10.8%, fresh blood in 6.7%, and cobble-stoning in 2.8%. Lesions were single in 87.6% of cases: 63.1%, located in the jejunum, 32.3% in the ileum, and 4.6% in the duodenum. Multiple lesions were seen in 9.4%. Capsule retentions occurred in 10.9%, and surgically removed in all. GIST’s were the most common primary neoplasm found, 66/74 (36.6%), followed by carcinoids 16.6%, adenocarcinoma 13.6%, and other 33.2%. Eight tumors were metastatic: 5 melanoma, 1 colon, 1 HCC, and 1 seminoma. After VCE, 32 patients were operated and 34 underwent another diagnostic examination before surgery; 4 patients underwent chemotherapy.
They concluded that the prevalence of small bowel tumors in patients undergoing VCE is 2.4%, most commonly GIST. The most common indication was obscure GI bleeding. Tumors frequently appear polypoid. Treatment was surgery in 93% of cases.
Long-Term Impact of Capsule Endoscopy in Patients with Iron Deficiency Anemia
Barrett Levesque from UCSF, presented outcomes data on patients undergoing Capsule Endoscopy (CE) for iron deficiency. Their abstract attempted to compare outcomes of 80-patients with iron deficiency anemia (Fe-def) with a control group of 81-patients that had overt GI bleeding between 2/2002-11/2005. They used a standardized telephone interview to determine the subsequent need for diagnostic or therapeutic interventions and resolution of anemia. Outcomes from 48-Fe-def patients (67% male, mean age 65 +/- 5-years) and 27-overt GI bleeders (78% male, mean age 67 +/- 14 years) were analyzed. Forty percent (19/48) of Fe-def patients, compared to 97% (26/27) of overt bleeders required transfusions post-CE. (p=0.001). CE findings did not differ between the two groups. Average follow-up time post-CE was 23 +/- 15 months (range 4-56) for the Fe-def group and 24 +/- 14 months (range 2-55) for controls.
Post-CE, 75% (36/48) of Fe-def patients underwent further procedures: EGD (19), Double balloon enteroscopy (DBE) (14), push enteroscopy (2), or repeat CE (1).
Findings included: 1) DBE - normal 50% (7/14), AVM 43% (6/14), Ulcer (1/14); 2) EGD/Colonoscopy - normal 63% (13/19), AVM 10% (2/19), Varices (1/19), gastritis/erosion (1/19), Zenker’s (1/19), and GAVE (1/19); 3) enteroscopy - normal 50% (1/2), and ulcer 50% (1/2). Forty four percent (13/36) had therapeutic interventions including cautery (12) and surgery (3). Post-CE, 9 (19%) Fe-def and 12 (44%) controls died due to non-bleeding causes (mean time of 13 +/- 7 and 20 +/-9 months. (p=0.01).
Seventy five percent (9/12) of patients in the Fe-def cohort with significant follow-up findings and subsequent therapeutic interventions were no longer anemic. Among Fe-def patients with positive CE but without significant follow-up findings, and in those with normal CE, only 14% (2/24) and 17% (2/12) respectively were still anemic. Their conclusions were that the diagnostic yield of CE in patients with Fe-def anemia was equivalent to patients with overt GIB. Second, positive findings on CE, when confirmed by additional diagnostic studies such as DBE, often led to successful therapeutic interventions; lastly, most Fe-def patients with normal CE were no longer anemic after an average of two years of follow-up.
Endoscopic Balloon Dilation Therapy for Small Intestinal Strictures with Crohn’s Disease Using Double Balloon Endoscopy
Sunada and colleagues discussed their experience with dilating small bowel strictures due to Crohn’s disease. Eighteen patients (14 men, 4 women; median age 37.5, range 20-57), with obstructive symptoms or evidence of small intestinal stenoses, underwent double balloon enteroscopy (DBE) followed by endoscopic balloon dilation therapy. The CRE wire guided balloon dilator (Boston Scientific, USA), was used under direct vision with the Fuji DBE (EN-450T5; 2.8 mm working channel). Evaluation of the stricture, by both endoscopy and contrast imaging was performed immediately before the dilatation.
With difficult cases, a small caliber-tip transparent hood was used to localize the orifice of the stricture. Twenty seven dilatations (from 10-20 mm) were performed in 18-patients (additional dilation procedures were necessary in 5 patients). The sites included the duodenum (1), jejunum (2), mid intestine (2), ileum (12), ileocolonic anastomosis (2), and ileoileal anastomosis (1). Perforation requiring surgery occurred in 1 patient. Two patients required surgery despite successful dilatation therapy due to the recurrence of a complicated stricture in one, and an ileal bladder fistula in the other. Fifteen patients were doing well on average after 11-months of follow-up (maximum 48-months). They conclude that balloon dilatation of small bowel strictures due to Crohn’s disease using DBE is safe and efficacious.Section 3: New Therapeutic Endoscopic Technologies
This section included a number of intriguing innovations to facilitate ESD with either better or safer dissection techniques using water jets, or with articulating arms using dual endoscopes in an overtube. The papers also included advancing therapeutic capability into the third space of the esophageal submucosa and arming endoscopists with a much simpler tool for performing suturing using existing scopes for a variety of potential indications both within and outside the lumen.
A New Biomimetic Adhesive for Therapeutic Capsule Endoscope Applications in the Gastrointestinal Tract
Glass et al reported on the development of a new type of material as an adhesive for robotic pill cameras in the GI tract. The adhesive is based on the idea from the feet of beetles capable of adhering to surfaces by secretion of oil from food micro-fibers. Patterned micro pillar polymer arrays are coated with a viscous oil to stick to the micro-villi of the small intestine. Testing in the labs on porcine small intestine has shown that this material has five times the adhesive power compared to non-patterned materials. This adhesive material would assist in developing new endoscopic devices. Such technology might provide a useful step in the ultimate development of capsules with therapeutic capability.
The Use of Waterjet Technology in Gastrointestinal Endoscopy: An Experimental Study of Two New Techniques for Endoscopic Submucosal Dissection
Endoscopic Mucosal Dissection (ESD) is a technique that enables resection of superficial neoplastic lesions, but this procedure has a high morbidity and is technically difficult. Lepilliez et al.reports on Waterjet (WJ), a new surgical device that is being investigated in many areas of medicine. The purpose of this study was to determine the application of WJ in ESD using 2 new techniques. The study included 12 pigs and three techniques were used, technique A, B and C. Technique A involved manually injecting saline into the submucosal layer and ESD was performed using the IT-knife. Technique B involved using partial WJ; saline solution was injected with the WJ and ESD was performed using IT-knife. Technique C, total WJ, involved using saline injected with the WJ an ESD was done using a catheter prototype. In conclusion, performing ESD with complete WJ system allowed for faster dissection times and was an easier method to learn and perform.
The New Approach for the Difficult Cases in Early Gastric Cancer Treatment-Development of Double Scope-ESD Method
Morita et al reports on the development of a new device and technique, a double scope ESD (D-ESD) using a large, flexible double lumen overtube. 10 patients were enrolled in the study who had differentiated intramucosal early gastric cancer (EGC) based on biopsy and EUS and who had lesions that were difficult to remove using conventional endoscopy for the following reasons: 1) Large lesion (>50mm) 2) Difficult location (>30mm lesion at the greater curvature of the body) 3) Severe fibrosis due to ulcer scar. The D-ESD was performed using 2 endoscopes. First, the N260 (Olympus) small diameter gastroscope was used to visualize, lift and catch the lesion. The second endoscope employed was the Q260J (Olympus) with a waterjet feature and this was used to dissect and cut out the lesion. Mucosal dissection was performed using an IT knife. The mean procedure time was 58 minutes and all patients had complete resection without bleeding and perforation. Waterjet enabled the detection of minor areas of bleeding and cleared the view. Importantly, no injuries to the hypopharynx or esophagus from using this large overtube were reported. In conclusion, they observed that D-ESD can provide assistance with ESD in difficult cases of EGC.
Submucosal Endoscopic Esophageal Myotomy: A Novel Experimental Approach for the Treatment of Achalasia
Pasricha et al. presented a novel endoscopic technique for performing myotomy.
The approach for the treatment of achalasia is to decrease lower esophageal pressure. Myotomy is most effective for achalasia with symptomatic relief in 80-90% for up to 10 years. The problem is that myotomy is an invasive procedure with multiple risks and is expensive. The purpose of this study was to determine if it is feasible to perform a myotomy endoscopically. This survival study involved 4 pigs. 5cm above LES a submucosal injection was performed and a small incision with a needle knife was made. A balloon was used under the mucosa to expand the space and the scope then entered the space. The circular muscle was then cut with a needle knife. Finally the scope was withdrawn into the esophageal lumen and the defect on the mucosal side was closed with standard clips. One pig was sacrificed immediately for what was reported as unrelated respiratory distress. One week post myotomy, the other 3 pigs tolerated the procedure and in all pigs the LES pressure was decreased.
Early Clinical Experience with A New Simple Flexible Endoscopic Suturing Method for Intra-Luminal and Transgastric Surgery (NOTES)
Park et al. presented their work with a stitching device called the T-TAG which allows stitching of an incision without removing the endoscope. This is a device using a metal tag attached to 3.0 polypropylene thread which is passed through the endoscopic accessory channel. The endoscopist uses this accessory to place 2 stitches and then tie the stitches together. In contrast to prior and commercially available endoscopic stitching methods, this technique uses a standard 9 mm diameter scope with a 2.8 mm working accessory channel and does not require an overtube. The authors presented some of their early experience with this devise to perform stiching in various clinical scenarios both in survival pigs and in human experience, such as perforated duodenal ulcer, anastamotic leak, and acute bleeding.
Effectiveness of Endoscopic Submucosal Dissection Using Flush Knife for Esophageal Cancers
In order to perform ESD more safely and efficiently, Toyonaga et al. developed a waterjet short needle Knife (flushknife) with Fujinon. This flushknife has a tip portion with five projection lengths 1, 1.5, 2, 2.5, 3 mm that can emit a jet of water from the tip of the sheath. 62 lesions in 52 patients (54 intramucosal cancers, 8 submucosal cancers) were treated with flushknife between March 2005 and October 2006. The lesion was marked using a 1mm flushknife with forced coagulation mode of 20W and performed the mucosal incision of the entire circumference using the different lengths of flushknife. Enbloc resection was performed in 61 cases (98.4%). Complete resection was performed in 61 cases (98.4%). The median size of specimen was 45mm and tumors was 23mm. The median time to procedure was 45 minutes. There were no perforations and bleeding was stopped using hemostatic forceps. This study concluded that the flushknife enables complete resection rate and low complications. Shortening the tip of the needle knife enabled small and sharp markings for safer ESD.Section 4: Risk Factors for Colorectal Cancer Screening and Surveillance
This session consisted of 6 abstracts related to colorectal cancer screening and surveillance.
Autofluorescence Endoscopy Improves Detection of Adenomas in Patients with Familial Colorectal Cancer: Preliminary Results of a Back-to-Back Colonoscopy Study
The aim of this study presented by Ramsoekh was to compare the sensitivity of autofluoescence endoscopy (AFE) to white light endoscopy (WLE) in diagnosing colorectal neoplasia in patients belonging to HNPCC or familial CRC families. AFE is capable of detecting adenomatous lesions that are not seen with WLE by exposing the mucosa to shorter wavelengths of light. Thirty consecutive asymptomatic patients, mean age of 52 years old, were examined first with WLE, followed immediately by AFE performed by a second endoscopist who was unaware of the results of the previous examination. Twelve patients had no abnormalities detected and 18 patients were found to have a total of 31 adenomas. WLE identified 16 adenomas. AFE detected all but one of the lesions seen with WLE and additionally found 15 more adenomas, thereby significantly increasing the detection rate (p<0.001). The 15 additionally detected lesions included flat, small and sessile adenomas. The sensitivity of AFE for detecting adenomas was calculated to be 97% and the specificity was 59%. For WLE the sensitivity and specificity was 52% and 71% respectively. The investigators concluded that AFE significantly improves the detection of colorectal neoplasia in patients with HNPCC or familial colorectal cancer, especially in the detection of small or flat lesions.
The effect of gender and obesity on colorectal polyp prevalence in an asymptomatic ethnically diverse screening population
Lam et al. evaluated the effect of gender and obesity on polyp prevalence in a diverse population. The investigators prospectively enrolled 581 average-risk patients referred for screening colonoscopy, calculated each individual’s body mass index (BMI), classified them as normal (BMI 18-24.9), overweight (BMI 25-29.9) or obese (BMI >30), and assessed the association between gender and adenomas and advanced neoplasms of any size for each BMI category. 52% of the patients were Hispanic, 26% Asian, 14.1% Black, and 7.2% were Caucasian. 61% of the enrollees were women with no gender difference in the mean age or BMI. The total prevalence of adenomas was 14.5%. Overall, women had a lower prevalence of adenomas and advanced neoplasms compared with men. Among the 203 people with normal BMI, women had a significantly lower prevalence of adenomas (7.3% vs. 21.3%) and advanced carcinomas (5.7%vs. 17.5%) when compared to men. However, the prevalence of adenomas and advanced carcinomas in the overweight and obese women was comparable to that of men. The positive correlation of adenomas with BMI was significant for women, but not for men. They concluded that in this asymptomatic, ethnically diverse population, the prevalence of adenomas and advanced neoplasms was significantly lower in normal weight woman compared to men; however this gender difference was lost in the overweight and obese groups.
Racial variability in secular trends in the incidence of proximal colon cancer- results from a national cancer registry
Vandana Singh presented this study which investigated the specific incidence rates of colorectal cancer in different races. The investigators analyzed the Surveillance, Epidemiology and End-Results database of the National Cancer Institute and identified all patients with microscopically confirmed invasive first primary colorectal cancer between 1973 and 2003. Gender, race and sub-site specific age adjusted incidence rates were calculated using Jointpoint trend analysis software to estimate annual percentage change. Proximal colon cancers were defined as those arising in or proximal to the splenic flexure. They found that overall colon cancer rates have declined from 1973 to 2003 in both whites and blacks. While in white men and women, proximal colon cancer rates have declined proportionately, in blacks, particularly men, there has been a significant rise in incidence rates from the mid-nineties. They concluded that the incidence of proximal colon cancer is rising in the black population which must be considered for future colorectal cancer screening strategies and epidemiological research.
The Optimal Surveillance for Colon Polyps with High Grade Dysplasia (HGD): Not All Adenomas are Equal
The aim of this study by Rudraraju et al. was to evaluate the recurrence rate of polyps or cancer in patients having polypectomy for high grade dysplasia (HGD) compared to individuals with no polyps and simple adenomas. The investigators conducted a retrospective cohort study of 90 patients with HGD matched for age, gender, race, year of index colonoscopy and polyp size to 90 patients with simple adenomatous polyps and 90 patients with normal colonoscopy. The HGD group was subdivided into 3 groups based on histology; tubular, villous or tubulovillous. Incidence of advanced polyps (defined as adenomas >1 cm, villous histology, HGD or cancer) was documented. 5.5% of the normal colonoscopy group, 16.6% of the simple adenoma group and 25.8% of the HGD had at least 1 advanced polyp on surveillance. In the HGD subgroups advanced polyps were found in 20.3 %(13/64) of the tubular group, 45.5%(10/23) of the villous group and none(0/2) of the tubulovillous group. For subjects that developed advanced polyps the median time to advanced polyp was 34.8 months in the normal group, 36.6 in the simple adenoma group and 6.4 months for the HGD group. The investigators concluded that advanced adenomas and colon cancer occur more frequently in patients with colon polyps containing HGD and subsequently the surveillance interval for patients with HGD polyps should be narrowed.
Screening Colonoscopy, Colorectal Cancer and Gender: An Unfair Deal for the Fair Sex?
Gurkirpal Singh et al. conducted this comparison of the effectiveness of screening colonoscopy in women compared to men. The investigators conducted a retrospective, case-control study in the California Medicaid program. Cases of newly diagnosed CRC were age, gender and time matched with 10 controls. The protective effect of negative colonoscopy compared to no screening was estimated by conditional logistic regression. A total of 604,961 colonoscopies were studied. The adjusted relative risk for CRC after a negative colonoscopy (compared with no screening) was 0.55. The risk for right sided tumors following a negative colonoscopy was much higher than that for left sided tumors. The relative risk for CRC following negative colonoscopy was much higher for women (RR 0.66) compared to men (RR 0.35). The protective effect of colonoscopy for left sided tumors was high, and similar in men and women. The protection for right-sided CRC was dramatically lower in women (RR for CRC 0.81) compared to men (RR 0.38). The researchers concluded that while screening colonoscopy is effective in preventing colorectal cancer, this protection is much less in women than men. The decreased benefit is likely explained by poor recognition of right sided lesions in women due to lower completion rates.
Assessing the Prevalence and Risk Factors for Advanced Colonic Neoplasia in Asymptomatic, Average-risk Women, 50-59 Years of Age
The aim of this study by Zaidman et al. was to identify risk factors in the development of advanced colonic neoplasia in order to risk stratify individuals to guide optimal resource utilization for colon cancer screening. They conducted a retrospective cohort study of consecutive asymptomatic women 50-59 years old, who underwent screening colonoscopy. Colonoscopy and pathology reports were reviewed to obtain patient’s age and number, size, and histology of polyps found. Telephone and mailed surveys were conducted to obtain data regarding tobacco use, alcohol and coffee consumption, history of diabetes and cholecystectomy. Advanced neoplasia was defined as tubular adenoma 1cm or larger, any villous histology, high grade dysplasia or cancer. 1,116 patients underwent screening during the 13 month study period. 275 patients were women between the ages of 50 and 59. The overall prevalence of colorectal neoplasia in this group was 26%. 19% had non-advanced neoplasia and 6% had advanced neoplasia. Women with diabetes had a significantly increased rate of colonic neoplasia and advanced neoplasia. Women in the 50-54 year age group had significantly decreased risk of colonic neoplasia compare with women age 55-59(19% vs. 33%). Women in the 50-54 year age group without diabetes had a 4% prevalence of advanced neoplasia which is similar to that of average risk patients age 40-49 in whom screening colonoscopy is not currently recommended. The investigators concluded that Diabetes increases the risk of advanced colonic neoplasia independent of BMI and women in the 50-54 year age group without diabetes have the lowest risk for advanced neoplasia and therefore may defer colonoscopy until after age 55.Section 5: Outcomes of EMR and ESD
This session consisted of several studies looking at the outcomes of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) for the management of large colonic polyps, early stage gastric cancer, and early stage esophageal cancer. Important data about safety, minimizing bleeding complications, and long term efficacy were presented.
The Results of Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection of Gastric Tumors Over 15 Years
Dr. Wan Jung Kim presented this study which reviewed the EMR and ESD experience for gastric lesions at a single institution. EMR was performed on 790 lesions, 130 (16.5%) were greater than 20mm, and high grade dysplasia/adenocarcinoma was seen in 465 lesions (59%). ESD was performed on 422 lesions, 190 (45%) were greater than 20mm, and 318 lesions (75%) were either high grade dysplasia or adenocarcinoma. For lesions larger than 20mm, complete en-bloc resection was successful in 48% of the EMR cases, and in 80% of the ESD cases. Recurrence occurred in 13 (4.5%) lesions in the EMR group (mean follow-up 85 months), and in 1 (0.5%) lesion in the ESD group at 19 months. Although EMR and ESD for similar size lesions were not compared in a controlled fashion in this paper, the researchers concluded that ESD allows for complete en-bloc resection of larger gastric lesions with a likely lower recurrence rate, although follow-up time is significantly shorter in the ESD group.
Immunohistochemistry Panel of Early Gastric Cancer Can Predict Recurrence After Endoscopic Mucosal Resection
Dr. Fabio Y. Hondo presented the paper examining local recurrence after curative endoscopic mucosal resection for early gastric cancer. This study examined both clinical and histopathological parameters in 22 patients who had complete resection of early gastric cancer by EMR. Five patients had local recurrence (22.7%). Based on mucin immunoexpression, the tumors were classified as intestinal, gastric or mixed. Neither gender, EMR technique, location of tumor, or piecemeal (vs. En bloc) resection were statistically associated with recurrence. The mixed phenotype was seen in 4/5 of the recurrent tumors, and is thus associated with a higher probability of recurrence after EMR.
Evaluation of Complication Rate and Safety of Endoscopic Submucosal Dissection
Dr. Young Dae Kim presented this retrospective review of 511 cases of endoscopic mucosal dissection (ESD). Perforations occurred in 10 cases (1.95%), 9 were managed with endoscopic clipping and antibiotics, one patient required surgery. Any bleeding that was encountered during the ESD was controlled endoscopically. After ESD was complete, 25 cases (5%) required transfusions, and 2 cases (0.4%) required surgery for ongoing bleeding. Strictures occurred in 5 cases (1%) in the esophagus, at the esophagogastric junction, or at the pylorus. Overall, 0.58% of the total cases required surgery to manage complications. The study group concluded that ESD is a comparatively safe endoscopic therapy for the management of early gastric cancer, early esophageal cancer, gastric adenomas and submucosal tumors.
Successful Complete CURE En-Bloc Resection of Large Colonic Polyps by Endoscopic Mucosal or Submucosal Resection
Dr. Srinivas R. Puli presented this meta-analysis of the published literature on the endoscopic removal of large colonic polyps with EMR/ESD techniques. A total of 7 studies (407 cases) were included in the analysis. The mean polyp size was 23mm, and there was a total of 114 successful en-bloc resections. Using a random-effects model, the pooled proportion of successful complete en-bloc resection was 48%. EMR & ESD are potential alternatives to surgery for the removal of large colonic polyps, but the study investigators suggest an improvement in EMR/ESD technique is needed to improve the en-bloc resection rate.
Effect on Proton Pump Inhibitor or H2 Receptor Antagonist on Prevention of Bleeding from the Ulcer After Endoscopic Submucosal Dissection of Early Gastric Cancer: A Prospective Randomized Controlled Trial
Dr. Noriya Uedo presented the results of this single-center randomized controlled trial comparing the use of a proton pump inhibitor (PPI) or H2 Receptor Antagonist (H2RA) in the prevention of bleeding after ESD for early gastric cancer. A total of 143 patients were enrolled, and received either rabeprazole 20 mg or cimetidine 800mg 1 day prior to the procedure, and continued for 8 weeks after ESD. Bleeding was defined as hematemesis or melena with at least a 2 g/dl decrease in hemoglobin. Bleeding occurred in 4 patients in the PPI group and in 11 patients in the H2RA group. Multivariate analysis revealed that the use H2 receptor antagonists, tumor size exceeding 2 cm, and an ulcer present in the tumor were each independent predictors for bleeding. The investigators concluded that although this study was limited in size, PPI appeared more effective than h2ras in the prevention of bleeding after ESD.
Long Term Results and Risk Factor Analysis for Recurrence in 349 Patients with High Grade Dysplasia and Mucosal Adenocarcinoma in Barrett’s Esophagus
Dr. Oliver Pech reported the results of this single-center prospective study which investigated the efficacy of endoscopic therapy for high grade dysplasia or mucosal adenocarcinoma (BC) arising in a Barrett’s esophagus. A total of 349 patients were enrolled, 61 with HGD and 288 with BC. Endoscopic mucosal resection was performed in 279 patients (2.1 resections/pt), photodynamic therapy (PDT) in 55 patients, and 13 patients received both treatments. Complete response was initially seen in 337 patients (96%), and metachronous lesions/recurrences were seen in 74 patients (21.5%). These were successfully retreated, for an overall complete response rate of 95.5%. Twelve patients required surgery after failure of endoscopic therapy. None of the patients in the study have died from Barrett’s neoplasia at an average follow-up of 64 months. Major complications were only reported in 2 patients (0.6%). Multivariate analysis revealed long segment Barrett’s esophagus, multifocal neoplasia, piecemeal resection are independent predictors for recurrence. This study illustrates the high efficacy and safety of endoscopic therapy for the durable treatment of HGD or mucosal adenocarcinoma in patients with Barrett’s esophagus. These data provide strong support for the endoscopic approach to HGD in Barrett’s.
Section 6: Biliary Imaging and Therapy
This session included some thought provoking papers looking at the optimal use of ERCP as a first line approach in suspected stone disease, EUS guided biliary access, innovations in the management of large stones, improved diagnosis of malignant strictures, and ERCP based therapy for cholangiocarcinoma.
Cost-effectiveness of MRCP in the evaluation of suspected biliary obstruction
In this prospective multi-center randomized effectiveness study comparing an ERCP first to an MRCP first approach in patients with an intermediate probability of biliary obstruction [based on laboratory and ultrasound (US) data)], Da Silveira et al found a total cost savings with the ERCP first approach. However, indirect costs were greater with the ERCP first approach. Ultrasound findings such as CBD and intrahepatic ductal dilatation were positive predictors of additional procedures and increased indirect cost in the ERCP group, while the presence of a CBD stone or chronic pancreatitis were negative predictors. In the MRCP first group, the presence of elevated bilirubin, CBD stone or ampullary lesion on US were associated with a greater number of additional tests and hence increased indirect cost. The authors conclude that these specific US findings may be used to further stratify resource utilization.
An interim analysis of EUS vs. ERCP guided biliary therapeutic intervention
Artifon et al presented a randomized prospective study comparing the efficacy of EUS guided biliary access and stone retrieval with ERCP in patients with a single sub-cm stone identified by MRCP. Patients with duodenal diverticuli were excluded. Pre-cut with needle-knife sphincterotomy was performed in 1 and 2 patients in the two groups. In a series of 16 and 17 patients in the two groups they found no difference between the success rate, the duration and the complications (bleeding, pancreatitis) associated with the procedure. All patients needed the MRCP to rule out multiple stones which was an exclusion for the EUS approach in this study. The main theoretical advantage postulated was the possibility of avoiding fluoroscopy. These were not patients with failed ERCP access and the ultimate role for this alternative approach for first line biliary access and stone extraction is uncertain.
Biliary stone extraction (BSE) guided by direct visualization using the new Spyglass™ Direct Visualization System
Stevens et al presented the efficacy of the Spyglass™ Direct Visualization System (DVS) cholangioscope in removing large stones (15+10mm) that were not retrieved with conventional bile stone extraction techniques. This technology represents an improvement to the standard cholangioscope in that it requires only one operator and allows for four-way tip deflection. The 15 patients enrolled in the study had on average undergone three previous ERCP attempts. Spyglass DVS delivered lithotripsy was successful in retrieving all stones in 11 of 13 (85%) cases in who the procedure could be attempted (61% in one and 23% in two treatment session).
Large balloon sphincteroplasty along with or without sphincterotomy in patients with large extrahepatic bile duct stones—multi center study
Yoo et al examined the success rate and risks associated with large balloon sphincteroplasty for stones measuring 16.1+5.4 mm in 166 patients. In the majority of cases (77%) sphincteroplasty was combined with sphincterotomy and when necessary endoscopic mechanical lithotripsy was also performed. Using a 15 to 18 mm balloon for an average dilation time of 1 minute the overall success rate was 83%. However, the rate of complications was 6.6%, including two cases of death one due to perforation and the other from massive bleeding. Their multivariate analysis could not identify clear risk factors for complications. The high stone clearance needs to be weighed along with the sobering severe complication possibility and comparisons with existing strategies such as EHL and laser lithotripsy appear warranted before widespread adoption of large balloon dilation occurs.
Optical Coherence Tomography (OCT) in the evaluation of biliary strictures
A rotating OCT probe introduced through standard ERCP catheter channels was used in this study by Arvanitakis et al to evaluate biliary strictures. Of the 32 patients with previously identified biliary strictures satisfactory images were obtained in 30 patients (in two patients the strictures were too tight to introduce the probe). Two OCT criteria (vascular pattern and unrecognizable layers) were compared to the sensitivity and specificity of a brushings/biopsy only strategy and to a combination of both modalities. A combination of at least one abnormal OCT pattern along with brush/biopsy results had an 83% sensitivity in diagnosing malignancy. The authors concluded that in the majority of cases OCT is feasible during conventional ERCP and a combination of OCT findings with brushings/biopsy results may improve sensitivity.
Photodynamic therapy (PDT) in unresectable cholangiocarcinoma
In this single-center case control study Kahaleh et al. compared the mortality benefit of plastic stenting alone to plastic stenting combined with PDT in patients with unresectable cholangiocarcinoma. Kaplan-Meier analysis showed an improved survival in the PDT group, with a significant difference in mortality at 3 and 6 months. A trend towards lower mortality was seen at 12 months but the difference was not significant. In a multivariate analysis the authors point out that in addition to PDT, the number of ERCP sessions (3 in the PDT group and 2 in the stent-only group) was also significant. Given this 3 and 6 month mortality benefit and the fact that number of ERCP sessions was also associated with longer survival, a randomized trial, possibly including metal stenting with and without PDT seems warranted.Section 7: Innovations in Endoscopic Ultrasound
In this topic forum, several papers were presented exploring the utility of EUS in diagnosing mediatstinal lymph nodes, biopsy parenchymal lung masses, providing prognostic information regarding the malignant potential of cysts, and in diagnosing pancreatic cancer in cases of chronic pancreatitis, and even obtaining information about unresectable tumors to help predict response to chemotherapy.
A Prospective Double Blind Comparison of Endoscopic Ultrasound, Endobronchial Ultrasound, and Bronchoscopic Fine Needle Aspiration for Malignant Mediastinal Lymph Nodes
EUS is the preferred modality for staging the posterior mediastinum in lung cancer. Wallace et al. performed this study to compare the accuracy of 3 major endoscopic methods for mediastinal lymph nodes staging in lung cancer patients, including EUS-FNA, EBUS-FNA, bronchoscopy-FNA. 138 patients were included and underwent all three diagnostic modalities. They concluded that EUS and EBUS are both superior to bronchoscopic FNA for detection of malignant mediastinal lymph nodes. Bronchoscopic FNA had no incremental yield compared to the combination of EUS and EBUS. Additionally, EUS and EBUS had near-complete “mediastinoscopy” in patients with lung tumors and enlarged mediastinal lymph nodes.
Prediction of the Chemotherapeutic Efficacy for Advanced Pancreatic Cancer By Focused DNA Array Analysis Using Endoscopic Ultrasound Guided Fine Needle Aspiration
Patients with unresectable pancreatic cancer have a dismal prognosis, due to the poor efficacy of chemotherapy in this cancer. Ashida et al. examined the usefulness of Focused DNA Array (FDA) analysis using the pancreatic cancer tissue obtained by EUS guided FNA biopsy for the prediction of chemotherapeutic effect. Tissue from 21 unresectable pancreatic cancers were analyzed (DNA and RNA studied), and treated with Gemcitabine, to see their responsiveness to the chemotherapy. These authors found that the tissues that underwent Focused DNA Analysis had many genes that helped predict the efficacy of different chemotherapies (like 5 FU, cisplatin, Gemcitabine) and different molecular targeting agents. The gene analysis using a sample taken by EUS-FNA might be useful to predict the chemotherapeutic efficacy and success for patients with unresectable pancreatic cancer.
Pancreatic Cyst Fluid DNA Analysis Detects Malignant Cysts: Final Report of the Panda Study.
PANDA is a 2 year prospective multi-center study investigating the role of pancreatic cyst (PC) fluid DNA analysis in detecting malignancy. Of 391 patients enrolled, 124 reached final pathologic diagnosis. Khalid et al. showed that a detailed pancreatic cyst aspirate DNA analysis is helpful in detecting malignant pancreatic cysts. Elevated amount of good quality DNA and high amplitude mutations are associated with malignancy. Very high amounts of mutated DNA and mutational sequence of k-ras followed by allelic loss is very specific for malignant pancreatic cysts. Pancreatic cyst fluid CEA level distinguished mucinous from non-mucinous cysts with accuracy. High amplitude and k-ras mutations are very specific for mucinous pancreatic cysts.
Endoscopic Ultrasound Guided Fine Needle Aspiration (EUS-FNA) of Masses located in the lung parenchyma: Diagnostic Yield and Safety.
EUS-FNA is known to be a safe technique for biopsying mediastinal lymphadenopathy. In this study, Vazquez-Sequeiros prospectively assessed the diagnostic yield and safety of EUS-FNA in lung parenchyma masses. 21 patients had EUS-FNA through the esophagus, of a lung mass that was not accessible by other means. Cells were obtained from all but one patient, for diagnosis. One patient did develop a large pneumothorax in the first 24 hours, requiring chest tube placement. There were no other complications. EUS-FNA in this paper was an accurate and fairly safe technique to achieve a tissue diagnosis in patients with a primary lung mass accessible for transesophageal-transpleural FNA.
Digital Image Analysis (DIA) of EUS Images Accurately Differentiates Pancreatic Cancer from Chronic Pancreatitis.
Changes in chronic pancreatitis decreases the accuracy of EUS in diagnosing pancreatic cancer. Das et al. performed a quantitative analysis of texture parameters of EUS images to evaluate if DIA can reliably distinguish pancreatic cancer from chronic pancreatitis. They showed that DIA of texture features of EUS images is highly accurate in differentiating pancreatic cancer from chronic pancreatitis and normal tissue, with performance characteristics similar to aspiration cytology. If real time application of DNA achieves similar results, this technology can potentially reduce the need for tissue acquisition.
Contrast EUS Versus EUS Sono-Elastography in the Differentiation of Atypical Pancreatic Masses.
The differentiation of inflammatory lesions from malignant tumors in the pancreas by non-invasive means is a challenge. The goal of Deprez. et al. in this study was to prospectively compare the results of contrast EUS versus sono-elastography EUS in patients presenting with atypical masses on imaging. 18 patients were included, and EUS-FNA provided accurate diagnosis in all but one. This study showed that in patients with unclear pancreatic masses, contrast EUS with Sonovue and sono elastography had similar sensitivity in detecting the presence of malignant tumor. Contrast EUS however, performed better in terms of specificity and differentiation of adenocarcinoma versus neuroendocrine tumors. These techniques may be interesting adjuncts to EUS and EUS-FNA, to characterize pancreatic masses.
Section 8: Minimizing Risks for the Patient and Endoscopist
The papers in this topic fora covered a wide range of endoscopic complications with the focus on adverse event prevention. This included supplemental O2 for cardiopulmonary complications, risk factors for post-polypectomy bleeding, the impact of untreated pneumonia upon survival after PEG placement, and renal toxicity of colonoscopy preps. This session also considered occupation musculoskeletal injuries facing endoscopists.
Does Routine Use of Supplemental Oxygen During Endoscopy Really Reduce the Risk of Cardiopulmonary Complications?
The data presented in this paper was collected from the Clinical Outcomes Research Initiative National Endoscopic Database. Endoscopists were categorized as routine users if they used O2 during >90% of endoscopic procedures. After adjusting for age and ASA class, cardiopulomary complications (CPC) occurred more likely during colonoscopy among routine users of O2 as compared to non-routine users. However, no difference was found during EGD. Healthy patients tend to had fewer CPC with non-routine O2 use, while sicker patients (ASA III, IV, V) tend to had fewer CPC with routine O2 use. Hence, routine use of O2 was associated with fewer CPC only in less healthy patients (ASA class III, IV, V).
Bowel Cleansing Prior to Colonoscopy (C): Evidence for Renal Toxicity in a Randomized, Prospective Trial Using Oral Sodium Phosphate (OSP) and Polyethylene Glycol (PEG)
These investigators used urinary N-acetyl-D-glucosamidase (NAG) as an early marker of renal tubular damage due to calcium phosphate deposition in the renal tubules caused by OSP. 55 patients undergoing elective colonoscopy were randomized to receive OPS, PEG, or a dual prep. Blood and urine were collected 1-week before, on the day and 1-week after the test. The % change in serum creatinine was significantly higher after OSP and dual prep than after PEG. While serum PO4 increased significantly after both OPS and dual prep but not after PEG, this was accompanied by an increase in mean urinary NAG only after OPS but not after the dual prep or PEG.
Improvements in Sedation Practice Do Not Translate to Better Endoscopic Outcomes. A Re- Audit of a Large UK Teaching Hospital's Endoscopic Practice Following Substantial Reductions in Sedation Doses
This was a re-audit done 12 months post-implementation of a proposed safer sedation practice, to assess it's impact on endoscopic outcomes. Sedation practice was improved with overall much lower mean midazolam dose. However, the use of reversal agents, overall post-procedure mortality (PPM) and sedated patients PPM were all similar. Furthermore, overall poor outcomes in sedated patients (i.e. either/or PPM/Reversal/Immediate Complications) were no different. Thus, with the implementation of safer sedation practice, despite substantial reductions in midazolam dosage, no improvement in objective endpoints were realized.
Resuming Anticoagulation After Colonoscopic Polypectomy: Does It Increase the Risk of Delayed Post-Polypectomy Bleeding?
The aim of this study was to identify factors associated with the risk of delayed post-polypectomy bleeding. Of the total 4592 patients, 41 patients [0.9%] developed delayed severe post-polypectomy bleeding [cases], and 132 patients were selected as controls who didn’t develop post-polypectomy bleeding. Anticoagulation following polypectomy and polyp diameter were strongly associated with increased risk of delayed post-polypectomy bleeding. For every 1 mm increase in polyp diameter, the risk of hemorrhage increased by 9%. However, hypertension and aspirin use did not increase the risk.
Prevalence and Impact of Musculoskeletal Injury Among Endoscopists: A Controlled Study
These authors administered a 45-questionnaire survey to all gastroenterologists and hepatologists and to a similar group of non-procedure-oriented internal medicine specialists and subspecialists across the three Mayo Clinic sites. The frequency of any musculoskeletal injury was higher in the GI group. The most common sites were thumb, hand, back and neck. There was no significant association between volume of endoscopy or years doing endoscopy and injury. There were no significant differences in medical care seeking or short- or long-term disability between the GI and non-GI groups. However, more in the GI group lost days of work compared to the non-GI group as a result of the injury. Most of the GI group had made at least one modification in their endoscopic practice to reduce injury risk. Thus, musculoskeletal injury occurs more commonly among GI than non-procedure-oriented internal medicine specialists despite similar age and levels of physical activity and fewer years in practice. This difference, however, did not translate into greater health care utilization of long term disability, suggesting the severity of the injury that occurs might not be great. Still, this survey suggests that more attention to occupational injury prevention among gastrointestinal endoscopists is required.
Effective Treatment of Prevalent Pneumonia Reduces in-Hospital Mortality in Patients Undergoing Percutaneous Endoscopic Gastrostomy (PEG)
After identifying active pneumonia as a predictive factor for early mortality in a retrospective analysis, the investigators analyzed in a second period prospectively, if effective treatment of preexisting pneumonia could reduce the early mortality rates after PEG procedures. While PEGs were placed as soon as requested by the physician in the 1st period, it was postponed in the 2nd period if patients had active pneumonia. The in-hospital mortality rate dropped form 18% in the 1st period to 7% in the 2nd period (P = 0.03). This paper provided evidence that active pneumonia at the time of PEG placement is a risk factor for early mortality post- PEG, and appears to be a risk that can be prevented by judicious delay to treat the pneumonia first.
Section 9: Advances in Endoscopic Ultrasound
This topic fora included a series of papers detailing a variety of novel therapeutic capabilities of EUS. A number of papers utilized FNA needle puncture to lavage and apply treatments such as ethanol and radiopaque marker materials, and chemotherapeutic agents to target cysts, nodes, or tumors. EUS direct access was described to provide drainage to the pancreaticobiliary ducts and even pelvic abscesses.
Endoscopic Ultrasonography- Guided Interstitial Implantation of Iodine 125 Seeds Combined with Chemotherapy in the Treatment of Unresectable Abdominal Carcinoma: A prospective study
In this study presented by J. Lin et al., 28 patients with unresectable abdominal cancers (twenty-five advanced pancreatic, and three metastatic) received EUS guided iodine seed implants. Measured outcomes were tumor size, quality of life and pain scores before and after brachytherapy. Placement of the I-125 seeds was technically successful in all patients with an average number of 10 seeds being placed per patient. The mean radioactivity per seed was 0.708 --0.014 mci. Patients were followed up to 14 months (mean 5.4 months) and were found to have a median survival time is 9.4 months. Results showed three cases of partial remission (10.7%), ten cases (35.7%) subsequently developed progressive cancer and eight of them died. Twelve patients (42.9%) had stable disease and three were lost to follow-up. Visual analog pain scores were significantly reduced at one week and one month after brachytherapy. Other than mild fever within 24 hours in 52.9% patients, no other complications were noted. This study demonstrates how EUS-guided interstitial implantation of iodine 125 seeds is technically feasible and can be used for the treatment of various abdominal carcinomas.
Endoscopic Ultrasound (EUS)-Guided Implantation of Radio-Opaque Marker into Mediastinal and Retroperitoneal Lymph Nodes is Safe and Effective.
In this study, Magno et al. used Tantalum. a long-lasting inert metal, to opacify mediastinal and retroperitoneal lymph nodes in a porcine model. Six pigs were enrolled in the study. Using EUS guidance, the lymph nodes were identified and injected with tantalum using a 19 or 22 gauge Echo-Tip needle under fluoroscopic guidance.
Fluoroscopy was repeated at 1, 2 and 4 weeks followed by necropsy and histologic evaluation. Follow up at all intervals demonstrated residual tantalum at the injection site without local infection, inflammation or necrosis of adjacent tissue. The authors conclude that this form of “tagging” lymph nodes may help in radiation planning.
Ethanol Pancreatic Injection of Cysts (EPIC): Preliminary Results of a Prospective Multicenter, Randomized, Double Blinded Study
In this multi-center study, Dewitt et al. randomized 39 patients with pancreatic cystic lesions between 1 and 5cm in size and 0 to 4 septations to EUS guided aspiration and five-minute lavage with either saline or 80% ethanol. (The patient and physician were blinded to the study drug). Thirty-two of the cystic lesions were mucinous, 4 were non-mucinous and 3 were pseudocysts. Cysts were located in the head (17), body (15) and tail (7). Twenty-three patients initially received ethanol, and 16 initially received saline. Repeat EUS was performed at 3 months to re-measure the size of the cyst, for CEA analysis, amylase and cytology and for cross over drug administration. At the three-month EUS exam, patients received ethanol lavage regardless of initial lavage (18 from ethanol group and 12 from saline group). Symptom diaries were recorded after each examination. CT scans were repeated every 3 to 6 months. Three patients had abdominal pain, one with pancreatitis after the second lavage. Two patients underwent surgery, one of which had an IPMN in the tail and was found to have 50 to 75% epithelial ablation while the second post surgical evaluation showed 100% epithelial ablation of a mucinous cystadenoma in the uncinate process. Follow up CT scan of the remaining patients after the second ethanol lavage showed complete resolution of 5 suspected mucinous tumors and 1 pseudocyst. The authors concluded that EUS guided ethanol lavage is safe and feasible with few complications and may lead to histologic epithelial ablation in a subset of patients.
New Treatment of Pancreatic Cystic Tumors: EUS-Guided ethanol lavage followed by Paclitaxel Injection.
H. Oh, et al. evaluated the safety and effectiveness of ethanol lavage followed by paclitaxel injection with EUS guidance for the treatment of pancreatic cystic tumors.
They enrolled ten patients (mean age 53) with presumed pancreatic cystic tumors excluding patients with pseudocysts, cystadenocarcinoma, and cysts with main pancreatic duct communication. With EUS guidance, cystic fluid was aspirated and then lavaged with ethanol for 3 to 5 minutes. The ethanol was then aspirated after which palliate diluted in saline (3-18 mg) was injected into the cyst. The authors used CT scan measurements for residual cyst dimensions. The median size of cysts was 23.5 mm (18-50 mm) and median follow-up was 6.5 months (3-23 months). The presumed diagnosis before treatment was mucinous cystic neoplasm in 5, serous cystadenoma in 3, and lymphangioma in 2. After EUS-guided treatment, three had no residual cyst while three had partially resolved cysts, one had a persistent cyst. Complications included vague abdominal pain in one patient that lasted three months, and focal pancreatitis in another which was treated conservatively. No patients underwent surgical resection.
EUS-Guided Pancreatic and Biliary Ductal Drainage (EUS-PBD) A First line Strategy after Unsuccessful ERCP drainage.
M. Miranda et al. enrolled 41 of the 58 patients who had failed ERCPs for biliary or pancreatic duct drainage from November 2003 to Nov 2006 out of a total of 2514 ERCPs performed. Using therapeutic Pentax and Olympus Echo-endoscopes, 19 or 22 G needles and guidewires, along with fluoroscopy, the authors planned pancreatic ductal drainage in 4 patients and biliary drainage in 37. Three patients from this were excluded due to technical difficulties (intervening vessels, ascites). Of the remaining 38 patients, the authors obtained ductograms in 37/38,ductal with guidewire access in 34, and stent placement in 30, of which 16 were metal and 14 were 7F plastic stents. Drainage was successful in (79%). Resolution of abdominal pain and jaundice was successful in 63% Complications occurred in 7/38 (18.4%), ranging from 4 mild (bile leaks that settled in 3-7 days), to severe in 3 severe (pseudocyst, biloma & hemoperitoneum, 1 death). Technical success rate increased significantly over the three-year study from 50 to 70% while complications decreased significantly from 38% in year 1 to 18% in year 3. The authors conclude that although this has a high rate of complications (near 20%) EUS-PBD may be a feasible alternative to PTC.
EUS guided Drainage of Pelvic Abscess.
S. Varadarajulu et al. evaluated the role of EUS drainage of pelvic abscesses in poor surgical candidates who were not technically amenable to ultrasound or CT guided drainage. This was a 1-year study. Excluded patients included those with rectocele, multi-loculated, or abscesses by the right or transverse colon. Seven patients were included and received prophylactic antibiotics. A linear echoendosope identified the abscess. Two had luminal compression. A 19-gauge needle was used to puncture into the lesion. Following this a .035-inch guide wire was placed so that the tract could be dilated with a 4.5 Fr cannula. Following this, a 10Fr single pigtail catheter was placed into the abscess. The catheter was flushed every 6 hours with 100cc of saline. The patient’s body position was changed every 72 hours. Oral antibiotics were continued. Repeat CT scan was performed. Catheter was removed based on follow up CT scan. Technical success was achieved in 100% of patients without complications. Abscess resolution occurred in 100% at a mean of 6 days and no recurrence was present in any case at 3 months. One patient died due to pulmonary edema 48 hours after the procedure. The authors concluded that EUS guided drainage of abscess is minimally invasive, safe and feasible.
Section 10: Benign Esophageal Disorders
This section highlighted such topics as the utility of capsule endoscopy in screening and surveillance of esophageal varices, treatment of esophageal varices, endoscopic GERD therapy and treatment of symptomatic esophageal (Schatzki’s) rings.
Cost Effectiveness of String Capsule Endoscopy for Screening and Surveillance of Esophageal Varices
Stypho et al. built a Markov model of a hypothetical cohort of patients with compensated cirrhosis followed over a ten year period to evaluate four screening strategies: no screening for varices versus screening with either EGD, standard capsule endoscopy or string capsule endoscopy (SCE). No screening was both the most expensive and least effective approach. EGD was most effective but also the most expensive. Of the two capsule based approached, the SCE was less expensive but equally effective.
Esophageal Capsule Endoscopy (pillcam ESO) Is Comparable to Traditional Endoscopy for Detection of Esophageal Varices-An International Multi-Center Trial
De Franchis et al. presented the results of a multicenter trial comparing esophageal capsule endoscopy to EGD in the detection of esophageal varices. 285 patients underwent an examination with pillcam Eso, followed by EGD for verification. The endoscopists reading the capsule findings were blinded to the EGD results. Only two patients were unable to tolerate the capsule exam (one due to vomiting the other due to a stricture). 3 cases (~1%) of medium to large varices were missed on capsule endoscopy. In 82% of the cases there was a complete agreement and in 93% of the cases there was an overall agreement with regards to treatment decision. The authors concluded that the pillcam Eso is effective and depending on cost and patient preference should be considered as a screening strategy.
Meta-Analysis: Pharmacotherapy Is As Effective As Endoscopic Therapy in the Secondary Prevention of Esophageal Variceal Bleeding
A meta-analysis of secondary prophylaxis in 26 published studies representing 2268 patients comparing medical therapy (beta blockers + nitrates) to endoscopic therapy (sclerotherapy or band ligation) alone or in combination with medical therapy was presented by Ravipati et al. Outcomes examined were all cause rebleeding, rebleeding from varices, all cause mortality and mortality due to bleeding. Medical therapy was as effective in reducing rebleeding rate and all cause mortality as endoscopic therapy (either band ligation or sclerotherapy) alone. A combination of medical therapy and endoscopic therapy was more effective then endoscopic intervention alone.
Endoscopic Treatment of Esophageal Varices in Cirrhotic Patients: Band Ligation Versus Cyanoacrylate Injection
Santos et al compared the effectiveness, mortality and complication rate of band ligation (EBL) to cyanoacrylate injection (CI) in patients with severe liver disease with medium to large varices, with red spots presenting for either primary or secondary prophylaxis. Effectiveness after an average of 3 sessions was 90 % in the EBL group and 80% in the CI group. There was no significant difference in mortality or rebleeding, although bleeding related deaths (5 vs 22%) and procedure related deaths (0 vs 11%) were higher in the CI group. There were significantly higher numbers of minor complications in the CI group (retrosternal pain and dysphagia).
Endoscopic Full-Thickness Plication for GERD: 6-Month Follow-Up to a Multi-Center Sham-Controlled Trial
Rothstein et al. provided follow up data on patients who received the Plicator™ device for symptomatic GERD as part of a previous sham-controlled trial. The device allows the placement of a transmural suture at the GEJ. Six months after the placement of the Plicator™ device in 148 patients in 14 centers they noted a significant reduction in symptoms scores and quality of life scores as compared to baseline symptoms off medical therapy. Over half of the patients were able to eliminate PPI therapy and nearly a fourth achieved ph normalization 6 months after treatment.
A Randomized, Prospective Trial of Electrosurgical Incision Followed By Rabeprazole Versus Bougie Dilation Followed By Rabeprazole of Symptomatic Esophageal (Schatzki’s) Rings
Wills et al. compared the efficacy of using a 52-54 French Maloney dilator to electrosurgical incision by a needle knife in 50 consecutive patients with Schatzki’s rings. All patients were also taking rabeprazole for the duration of the study. The symptom free period was significantly longer in the incision group (7.9 months vs 5.8 months). Patients were followed a total of 12 months. GERD symptoms improved significantly compared to baseline in both groups at all time points through the 12 months follow up (except at the 12 month time point in the incision group). There was no difference in GERD symptoms or dysphagia symptoms between the two groups.
Section 11: New Technology: NOTES
The New Technology: NOTES forum on Monday explored the latest advances in expanding the toolkit for NOTES procedures as well as addressing issues of patient acceptance and what is required to move the field forward in the years to come.
The Development and Testing of a Toolbox for NOTES
This study was presented by Paul Swain. He noted that devices have been the limiting factor in NOTES procedures to date, and he presented a series of new tools to address various functional needs. These included a closing device consisting of a t-tag applier with knotting element, a bipolar forceps for improved hemostasis control, a multiple clip applier to be used in ligation, a spray dissector to decrease tissue injury versus current approaches, a "hybrid" endoscopic trocar to decrease the need for instrument changes, and articulating devices for improved manipulation. Swain noted that all of these devices may have utility in laparoscopic surgery as well as NOTES.
Cosmetic Issues of NOTES: A Rationale for Further Research and Investments
This study was presented by Monica Hagen. She presented data from polls and interviews with 292 people to gauge their interest in "scarless" surgery. Her data suggested that while people were satisfied with the scars they had from prior surgeries, they favored not having scars from future surgeries and were willing to accept a 21% increased risk of complications to obtain a "scarless" result. When the population was divided by age, it showed that the oldest group (50-75 years old) was most favorable to "scarless" surgery and would actually accept a 31% increased risk of complications. There were no differences when the group was divided by gender.
Short-Term Survival Outcomes Following Transvaginal NOTES Cholecystectomy Using Magnetically Anchored Instruments
This paper was presented by Daniel J. Scott. He described the insertion of instruments attached to magnets via a transvaginal access port, followed by anchoring of the devices using external magnets using a porcine model. Functions performed with this technique included retraction of the gallbladder and dissection, which was performed by pressing on the abdomen with the external magnet. Scott reported an average operative time of 4.4 hours with post-operative analysis showing no bacterial peritonitis, few adhesions and no leaks with a well-healed vaginotomy at 14 day necropsy. As a future goal, Scott suggested that magnetic positioning of a camera would be of great benefit to advancing the field.
Transcolonic Ventral Wall Hernia Mesh Fixation in a Porcine Model
This study was presented by Derek G. Fong. His team's hypothesis was that a NOTES abdominal wall hernia repair is preferable to laparoscopic repair in that it reduces the risk of incisional hernia (there were 105,000 in the U.S. in 2003) and increases the quality of repair. This feasibility study involved delivery of mesh to the peritoneal cavity using a tube system with pusher shaft, followed by alignment of the mesh using magnetic retraction before t-tags were used to sew the mesh into place. Necropsy demonstrated successful peritonealization of the mesh in 5 of 5 pigs, but only 10 of 12 sutures placed were "successful," and only 2 of 12 penetrated the anterior fascia.
A Pilot Comparison of Adhesion Formation Following Colonic Perforation and Repair in a Porcine Model: Transgastric (NOTES), Laparoscopic, Or Open Surgical Technique
This study was presented by Binh H. Pham. Given the concern that increased frequency of NOTES procedures may lead to iatrogenesis such as perforation, 3 groups of 5 pigs had a sigmoid perforation created. Each group then underwent surgical closure by 1 of the 3 techniques. Necropsy showed that the pigs who underwent a NOTES procedure had fewer overall adhesions, and any adhesions present were narrower than those seen in pigs who had the laparoscopic or open procedure.
Robotic Manipulator for Natural Orifice Transluminal Endoscopic Surgery
This study was presented by Khek-Yu Ho. His group created prototype “slave” manipulator which reproduces upper limb actions using sensors attached to the endoscopist. The design was based on a crab claw, includes a grasper on the left and a hook on the right, and has 9 degrees of freedom with a slot for an endoscope. Using an Erlangen model, a simulated EMR was performed using the device in a porcine model after it was placed using an overtube. Limitations demonstrated by the study include a delay in action due to computation and the use of cables, a lack of tactile feedback and device size.
"State-of-the-Art Lecture: NOTES: Where We Are, Where We Are Going" was presented by Robert H. Hawes to conclude the session. After giving a brief history of NOTES, he described the 3 drivers of the technique as less invasive access, a plateau in laparoscopic development, and the potential disruption of laparoscopic surgery. Hawes suggested that NOTES development will take place either through a "Big Bang" or hybrid GI-surgery model, and he shared concerns including putting practice before science, treating before data is available, acting on appearance versus substance, and corporate-driven versus academic-driven progress. To address these issues, he advocated a team-based approach which put science first and acted via prospective IRB-approved studies. While there have been many advances in the field to date, he looked forward to the creation of a registry for NOTES procedures, as well as further research with device development, a search for expanded uses of NOTES, a "rocket booster" procedure to propel the field into widely-accepted use, and the determination of optimal access to the procedure site.
Section 12: Issues in Colonic Polyps
This topic forum included papers on a wide range of topics from clinical practice patterns in management of large polyps, observer variability in pathological interpretation of polyps, technical methods of improving cecal intubation and adenoma detection using standard endoscope technology.
Assessment of Pathologic Interpretation of Colorectal Polyps by General Pathologist in Community Practice.
Bernard Denis presented this study. The slides of 300 polyps were reviewed by general pathologist (P1) and by expert GI academic pathologist (P2). The overall agreement between P1 and P2 in reference to the type of polyp and degree of dysplasia was only 40.3%. Significant impact on clinical management was seen in half of the cases.
Treatment of Large and Giant Colorectal Polyps in the Real World.
Bernard Denis presented this retrospective review of the management of 325 large polyps (≥ 20 cm) showed that surgical removal was performed in one of four patients. EMR was used only in 8.6% of the cases. Factors that determined referral to surgery are: sessile or flat shape of the adenoma; its size; its proximal or rectal location; its malignancy; and the lack of referral to an expert endoscopist.
Endoscopic Resection Is As Effective As Surgical Resection in Managing Malignant Colorectal Polyps – Analysis of Data from National Cancer Registry.
Ananya Das presented retrospective comparison of endoscopic (581 patients) versus surgical (7640 patients) management of malignant colorectal polyps showed equivalent long term survival. Variable associated with favorable prognosis were less depth of invasion, rectal location, tubular histology, and younger age at diagnosis.
Polyp Detection Rate Is Improved with Position Changes During Colonoscope Withdrawal: A Randomized, Crossover Trial, Mid-Point Analysis.
James E. East from St. Mark’s hospital [UK] presented this study. The analysis of the data in 64 patients showed that changing position during colonoscopy: supine during transverse colon examination and right lateral during examination of splenic flexure and descending colon significantly increased detection rate of polyps.
Small Caliber Overtube-Assisted Colonoscopy in Patients with Incomplete Colonoscopy Using Standard Endoscopes.
Shai Friedland presented this retrospective review of 35 patients with history of unsuccessful regular colonoscopy by GI attendings who underwent colonoscopy with a novel system using a 9mm enteroscope and a low-friction 60cm-long overtube (modified double balloon endoscope overtube). Showed 94% success rate, median time to cecum was 7min; median time to complete colonoscopy was 15min, including at least one snare-polypectomy in 8 patients.
Colonoscopy Screening in Asymptomatic VA Octogenarians: Our “Control Access” Program and the Case for Profiling.
Rozina Mithani. conducted this study to assess a policy of approving screening colonoscopy in VA patients ≥80 years old only if the primary care physician was willing to document that the patient was healthy enough to undergo the procedure and expected to live >5 years. This strategy was able to avoid unnecessary CRC screening in 60% of these patients and no CRC was missed after a mean follow up of 29 months.Section 13: Endoscopic Diagnosis and Treatment of Esophageal Cancer or High Grade Dysplasia
This topic forum combined presentation of a new therapy [cryotherapy], a study of complications of complete EMR resection of HGD and early Barrett’s cancers, and 2 studies of radiofrequency ablation for dysplastic and non-dysplastic Barrett’s epithelium. On the squamous side, a paper proved NBI to be a major step forward in detection of head and neck as well as esophageal cancers, and a large series of ESD for esophageal cancer.
Multi-center Prospective Randomized Controlled Study On the Detection and Diagnosis of Superficial Squamous Cell Carcinoma By Back-to-Back Endoscopic Examination of Narrowband Imaging and White Light Observation.
Manabu Muto presented the results of this multi-center randomized prospective controlled study to compare the detection rates of superficial cancer, (i.e squamous cell carcinoma of the esophagus (ESCC) and the head-and-neck region (HNSCC)), between NBI and white light observation (WLO). 320 patients with ESCC were assigned to NBI followed by WLO (162) or to WLO followed by NBI (158). Histological confirmation was used as the gold standard. NBI had a statistically significant better detection rate than WLO for superficial HNSCC [15 fold increase] and ESCC [2 fold increase].
Endoscopic Submucosal Dissection for Superficial Esophageal Squamous Cell Carcinoma (SCC) and Adenocarcinoma.
Tsuneo Oyama et al conducted this study in order to clarify the use of a novel method of ESD using a hook knife for the resection of superficial esophageal cancer. 207 cases (197 SCC, 10 adenocarcinoma) of superficial esophageal cancer were resected.
The median size of the resected specimen was 37 mm (8-76 mm) and that of the cancer was 23 mm (2-64 mm). The complete resection rate, defined as en bloc resection with negative lateral and vertical margins, was 94.2% (195/207). There were no perforations and the local recurrence rate was 1%. Therefore, ESD with hook knife is safe and useful for superficial esophageal cancer.
Preliminary Results of Cryotherapy Ablation for Esophageal High Grade Dysplasia (HGD) or Intra-Mucosal Cancer (IMC) in High Risk Non-Surgical Patients
John Dumot et al. conducted this pilot, single center, non-randomized study to assess the safety and efficacy of cryotherapy, using low pressure liquid nitrogen spray, for BE or squamous cell (SC) associated HGD or IMC. 32 patients were enrolled and 20 completed therapy. A complete response, defined as the absence of BE and dysplasia on surveillance, was seen in 7/16 patients with HGD and 1/ 4 patients with IMC ablation. A Partial Response, defined as focal residual BE without dysplasia, was seen in 8/16 patients with HGD and 2/4 patients with IMC ablation. The overall success rate was 94% (15/16) for HGD and 75% (3/4) for IMC ablation. There was 1 gastric perforation. They concluded that endoscopic cryotherapy ablation with low pressure liquid nitrogen spray is effective in HGD and IMC in high risk patients. Control of gastric distension during the procedure is important to avoid gastric complications.
Novel Combined Modality Therapy for Barrett's Esophagus Containing High-Grade Dysplasia: Endoscopic Mucosal Resection Followed By Circumferential and Focal Ablation Using the HALO System.
Roos E. Pouw et al. conducted this study is to assess the safety and efficacy of EMR followed by radiofrequency ablation using the HALO System in patients with BE (<10 cm) containing HGD or EMC. Six weeks following EMR, circumferential ablation (CA) was done with the balloon-based HALO 360 System followed by secondary focal ablation with the endoscope-mounted HALO 90 System at 2 month intervals thereafter as needed to treat residual Barrett’s areas. Complete histological and endoscopic elimination of dysplasia and IM occurred in 12/13 patients (92%) after a mean of 1.5 CA sessions and 2.5 FA follow up sessions. 284 total follow-up biopsies revealed no cases of buried Barrett’s glands. Complications included one acute bleeding treated with hemoclip and one stenosis which resolved with dilation. These results compare favorably with other regimens, such as radical EMR, PDT, or APC.
Complications of Endoscopic Mucosal Resection (EMR) in 122 Early Barrett's Cancers
Jelle Haringsma et al. presented the results and complications of endoscopic mucosal resection using the cap technique in a series of 102 patients with HGN and IMC between. A total of 122 EMR’s were performed. En-bloc resection was feasible in 38 (31%) lesions and complete resection of the Barrett's segment was performed in 12 patients (10%). Complications included 2 perforations, 2 stenoses and 1 moderate post-procedural bleed. All complications were treated endoscopically. They concluded that EMR offers improved diagnosis and staging of early Barrett's cancer and carries an acceptable complication risk.
Frequency of Buried Barrett's Metaplasia After BÂRRX Ablation for Intestinal Metaplasia with Or Without Dysplasia
Jose Hernandez et al presented the interim analysis of a prospective trial to assess the frequency of buried Barrett's metaplasia (BBM) following BÂRRX radiofrequency ablation in 25 patients with BE (3 with dysplasia [12 Joules/cm2] and 22 with no dysplasia [10 J/cm2]). At three-month Follow up, 2 out of 20 patients had buried Barrett's and underwent re-ablation at 12 months with resulting absent residual Barrett’s or buried Barrett’s. A total of 6 patients completed 12 month follow up; 5 patients had no Barrett’s, 1 patient had residual Barrett’s and none had buried Barrett’s. Of note, the 2 cases of buried Barrett’s both occurred following the lower dose ablation energy of 10 J/cm2 used for non-dysplastic Barrett’s. These preliminary data suggest that buried Barrett’s occurs at lower rates after BARRX Ablation as compared to other BE ablative therapies (14.8-51.1%). Nonetheless, the possibility of buried Barrett's metaplasia after ablation, especially at the lower ablation dose, should necessitate diligent follow-up surveillance biopsies.
Section 14: Improving the Quality of Pediatric Endoscopy
There were six papers on a range of clinical topics discussed at this session. These included negative studies of multimedia assisted informed consent and magnetic guided colonoscopy, a study of propofol sedation in community vs. academic training centers, a small descriptive study of the utility of rectal ultrasound in evaluating perianal disease in children, and two studies of eosinophilic esophagitis.
Use of an interactive multimedia presentation to improve patient understanding of endoscopic procedures and to standardize the informed consent process
This case was presented by Melissa B. Wanzer from the Women and Children’s Hospital of Buffalo. This was a prospective study investigating the benefit of implementing a multimedia presentation during the informed consent process. Traditionally, barriers in informed consent consist of foreign accents, English not a primary language, difficult to understand medical language, various levels of education, inconsistent communication, and different learning styles. 50 parents/guardians were recruited in this study. 25 consisted of the control group and 25 were placed in the experimental group subjected to the multimedia presentation. Results of this study revealed that anxiety was not statistically decreased in the experimental group compared to the control group. Increased understanding was not supported in the experimental group. Physician perception of patient understanding, inverse correlation of anxiety with patient understanding, and increased perceived understanding with increased patient satisfaction were all supported by this study.
Rectal EUS is a useful imaging modality in children
This study was presented by Deborah R. Flomenhoft form the University of Kentucky. Rectal ultrasound is described as a safe, convenient, and reliable method to assess perianal disease. Two scopes are traditionally used, the radial scanning endoscope and the linear scanning endoscope (allows for biopsy). 17 examinations were performed using the radial scanning endoscope in 11 patients (10 with Crohn’s disease, 1 with an abnormal MRI) between the ages of 7 and 18 years. 3/11 of the patients had confirmed fistulizing disease one week later under general anesthesia. This study showed that EUS is a safe and reliable method to help guide treatment decisions in patients with perianal complaints.
Randomized control trial of magnetic positioning device assisted pediatric colonoscopy: a pilot and feasibility study
This study was presented by James P. Franciosi of the Children’s Hospital of Philadelphia. The proposed hypothesis of this study was that MPD assisted colonoscopy can help the endoscopist navigate through loops, decrease the total time of the procedure, and increase the number of completed procedures. A completed procedure was defined as reaching the cecum. N= 18 for the standard colonoscopy arm, N = 20 for the MPD arm. 94% of the SC group completed the colonoscopy, 95% of the MPD group completed the procedure. The average time to completion in the SC and MPD group was 12 minutes and 16.5 minutes respectively. This study showed that there was not a statistically significant difference in completion time or number of completed procedures between the MPD group and the standard colonoscopy group.
Efficiency of propofol for pediatric endoscopy: a comparison of hospital settings
This study was presented by Jennifer R. Lightdale of the Children’s Hospital of Boston. Propofol is a known anesthetic, but not an analgesic. The aim of this study was to determine if there is a difference in procedure efficiency with use of propofol in a community hospital setting versus a fellowship training center. Pre-procedure, procedure, recovery and total times were measured. It was found that the total time was not significantly different in the two clinical settings, although pre-procedure time was found to be faster in the community hospital based setting, and recovery time was found to be faster in the fellowship training center. Interestingly, 14% of patients in the community hospital were intubated versus 34% in the fellowship training center.
Healing of erosive esophagitis (ee) and improvement in symptoms of gastroesophageal reflux disease (gerd) in 1-and 2- year old children after esomeprazole treatment
The aim of this study by Tolia et al.was to determine the efficacy of 8 week therapy on esomeprazole in children ages 1 through 2 years with endoscopically proven EE. These patients also underwent evaluation via the Physician Global Assessment of GERD symptoms test. N = 9 patients who were taking 5 mg of esomeprazole daily, N = 4 patients who were taking 10 mg of esomeprazole daily. The study showed that all 13 patients had full resolution of EE at the end of 8 weeks on therapy.
Histopathologic variability and clinical findings in children with eosinophilic esophagitis
This study was presented by Ameesh Shah from Children’s Memorial Hospital, Northwestern University. The aims of this study were to analyze the variability in histopathology in children with eosinophilic esophagitis, and to determine differences in the density of eosinophils from biopsies obtained from either the distal or mid esophagus. Diagnostic criteria for EE was > 15 eosinophils per high power field in patients treated with 8 weeks of PPI therapy. It was found that by obtaining at least 3 biopsies, sensitivity was 97 %. There was also less histologic variability in patients with positive pH studies versus those with negative studies. Finally, although the concentration of eosinophils was greater in distal biopsies compared to mid esophageal biopsies, it was not statistically significant.
Section 15: Advances in Pancreatic ERCP
This topic forum included 2 studies on prevention of post-ERCP pancreatitis, one with two types of pancreatic duct stents and the other pharmacologic. Neither stent proved more effective than the other in preventing clinical pancreatitis; nor did the pharmacological prophylaxis reduce clinical pancreatitis. There were 2 articles on autoimmune pancreatitis, one on analysis of pancreatic juice in IPMT evaluation, and one paper on an intraductal method of secretin stimulation test for chronic pancreatitis.
Post ERCP Pancreatitis: Differences in Outcomes Between 3 Fr Long Pigtail and Modified Short 5 Fr Geenen Stents: A Randomized Controlled Trial
Guda et al presented this study evaluating the placement of either a 3 Fr single pigtail unflanged long stent versus a short 5 Fr modified Geenen stent (no inner flange) in 136 “high risk pts” (those undergoing ERCP for suspected sphincter of Oddi dysfunction (SOD), idiopathic recurrent pancreatitis (ARP), prior history of post ERCP pancreatitis (PEP)). Majority of these procedures were for either ARP (53.2%) or suspected SOD (41.1%). Outcome measures included: 1) incidence of PEP (abdominal pain and greater than 3 fold elevation of amylase and/lipase and or abnormal imaging) 2) spontaneous migration of stent, 3) stent induced ductal injury where possible in patients undergoing repeat ERCP. The authors concluded that there were no differences in the incidence of PEP in the 3 Fr pigtail or 5 Fr modified stent groups. Stent migration rates at 24 hours were significantly higher in the 5Fr group suggesting that short (trans sphincteric stenting) immediately post procedure is of significant importance. 5 Fr stents were easier to deploy. No ductal injuries were seen in their cohort
Intraductal Secretin Stimulation Test: What is the Proper Collection Time?
This study by Aziz et al. evaluated the proper collection time for the intraductal secretin test (idst) in the evaluation of chronic pancreatitis. The results of 68 idst’s were evaluated. Pure pancreatic juice (PPJ) was collected after an IV injection of 16 μg of synthetic secretin using a triple lumen manometry catheter. The parameters evaluated were the peak secretory flow rate (SFR), time of peak SFR, max bicarbonate concentration (BC) and time of max BC. The final clinical diagnosis of CP was established or excluded by the first 20 min collection period (for both SFR and BC) in all pts. The first 20-minute collection period during IDST was sufficient time for diagnosing or excluding CP in all pts in this series.
Pancreatic Duct lavage: Cytology Without Secretin Injection for the Diagnosis of Branch duct Type Intraductal Papillary Mucinous Neoplasm of the Pancreas
Sai et al. retrospectively evaluated the usefulness of pancreatic duct lavage cytology using an originally made coaxial double-lumen cytology catheter in the diagnosis of branch duct-type IPMN of the pancreas in 14 patients that subsequently underwent surgical resection. More than 30 ml of pancreatic duct lavage fluid was obtained from each patient. The sensitivity, specificity, positive and negative predictive value of the cytologic diagnosis of malignant IPMN was 75%, 80%, 60%, and 89%, respectively. No complications were reported. The authors concluded that pancreatic duct lavage cytology using an originally made coaxial double-lumen cytology catheter could be useful in the diagnosis of branch duct type IPMN of the pancreas.
Clinicopathological Features of Autoimmune pancreatitis (AIP) with and Without Systemic Extrapancreatic Lesions
Nishino et al studied the clinicopathological similarities and differences between AIP with and without systemic extrapancreatic lesions. 34 AIP patients were divided into 2 groups according to whether extrapancreatic lesions were present based on the clinical, morphological, and histological findings: a group with systemic extrapancreatic lesions and a group with involvement of the pancreas alone with or without intrapancreatic duct stenosis. The grade of igg4-immunoreactive plasma cells in the pancreas, bile duct were scored from 0 (none) to 4 (most severe). The serum igg4 level (mg/dl) was significantly higher in the group with systemic extrapancreatic lesions (p = 0.03). Igg4-positive plasma cell infiltration score was significantly higher in the group with systemic extrapancreatic lesions, in both the pancreas (p = 0.04) and the bile duct (p = 0.02). The authors concluded that the serum igg4 levels and igg4-positive plasma cell scores in the pancreas and bile duct were significantly higher in the AIP patients with systemic extrapancreatic lesions than in the AIP patients with lesions confined to the pancreas.
Clinical Factors Predictive of Spontaneous Remission Or Relapse in Cases of Autoimmune Pancreatitis
Kubota et al presented this evaluation of endoscopic and clinicopathological findings predictive of spontaneous remission or relapse in cases of AIP in twenty patients. 12 patients were administered steroids and the other 8 showed spontaneous remission. The endoscopic and immunohistochemical findings in the duodenal papilla using igg4 antibodies in the patients were retrospectively reviewed. Fourteen patients (70%) showed positivity for igg4 in the duodenal papilla. Multivariate analysis revealed, igg4 negativity of the duodenal papilla as the only significant independent factor predictive of spontaneous remission in these cases of AIP (OR = 1.395, p = 0.0304). The authors concluded that AIP patients showing negative staining of the duodenal papilla for igg4 have a high likelihood of spontaneous remission, AIP patients with diffuse pancreatic swelling are at a higher risk for relapse after initial steroid administration, and also at a higher risk for complicating choledochlithiasis.
Prophylaxis of Post-ERCP Pancreatitis: A Randomized, Placebo Controlled Trial Using Intravenous Infusion of Semapimod, a Mitogen Activated Protein Kinases Inhibitor
This study by van Westerloo et al. evaluated the use of Semapimod to determine if it reduces the incidence post ERCP hyperamylasemia and pancreatitis. Semapimod is a synthetic guanylhydrazone that inhibits the mitogen-activated protein kinase (MAPK) pathway, macrophage activation and the production of several inflammatory cytokines. This study was randomized, double blinded, and performed at tertiary referral center. A total of 242 patients were studied. The authors concluded that a single dose of 50 milligrams of intravenous semapimod one hour pre ERCP is safe and exerts a biological effect demonstrated by a statistically significant reduction of the incidence of hyperamylasemia and levels of post ERCP amylase but did not show a statistical difference in preventing post ERCP pancreatitis.
Section 16: Improving Quality in Endoscopic Training and Practice
This session included a number of thought provoking papers looking at the required numbers of supervised colonoscopies for reaching technical competence, the amount of training available to surgical endoscopists coupled with practice patterns in non-gastroenterology endoscopy. The effects of narrowband imaging on adenoma detection and upon learning to better detect polyps on standard examinations was presented. The other theme was looking at the time and financial impact of endoscopy on the endoscopy unit and hospitals. Specifically topic included assessing the downstream revenue of some of the more complex endoscopic procedures previously considered to be financial drains, and closely analyzing the time flow components in a unit in an effort to identify ways to improve efficiency. Two sedation regimens aimed at safe sedation with rapid recovery were also compared.
Adequate Level of Training for Technical Competence in Colonoscopy: A Prospective Multicenter Evaluation of the Learning Curve
This study evaluated the adequate level of training for technical competence in colonoscopy. Acquisition of competence (success rate) was evaluated based on completion rate (>90%), and cecal intubation time (<20 minutes). During 6 months, 3,752 diagnostic colonoscopic procedures of 14 first-year GI fellowships in 11 tertiary care academic centers were evaluated. The success rate significantly improved over the consecutive blocks of 50 cases: (66.6%, 78.6%, 92%, 94.2%, and 97.1%). In addition, time to cecal intubation decreased significantly from 14.2 to 9.8 minutes after 150 procedures. With logistic regression analysis, prolonged cecal intubation (>20 minutes) was affected by the following factors: older patient age, female gender, lower body mass index, poor bowel preparation, poor ASA status, and lower case volume. This data indicated that technical competence in colonoscopy generally requires experience of more than 150 cases.
Randomized Controlled Trial of Patient Controlled Sedation for Colonoscopy: Entonox Versus Patient Maintained Target Controlled Propofol
This study compared patient controlled Entonox inhalation with patient-maintained target-controlled Propofol infusion for colonoscopy in terms of analgesic efficacy, psychomotor recovery, and patient and endoscopist satisfaction. Patients in the entonox group inhaled this gas for 60 seconds before the procedure and then as needed during the endoscopy. Patients in propofol group were administered drug with target value of 1 μg/ml loading dose and then allowed to sedate themselves using a PCA handset. 50 patients were randomized to each arm. There was no difference in two groups in pre-procedure anxiety scores, pain during the procedure, completion rates, time to cecum, total colonoscopy time and endoscopist patient and nurse satisfaction. The depth of sedation was higher in propofol group. Despite this deeper sedation with propofol, both methods proved safe and effective for colonoscopy, providing good patient satisfaction and allowed for early discharge.
Heavily Weighted Endoscopic Procedures: Do the Dollars Make Sense?
This study examined the revenue generated at single tertiary care center from 77 patients undergoing EUS, ERCP, EMR or enteral stenting as their initial encounter over a 5 months period. Financial records were reviewed for all hospital services following the initial visit. All charges, revenue, total cost and net income to the medical center were recorded as well as professional fees collected only for clinic visits and GI procedures. These heavily weighted procedures, while themselves losing money for the hospital, generated large profits resulting from downstream revenues. Such financial benefits have not previously been quantified or appreciated, but are likely limited to facilities with the capacity to provide the resulting radiologic and surgical services which follow these endoscopic procedures.
Surgeons Are Doing More Endoscopic Procedures: Are They Being Appropriately Trained?
This study was done in Alberta to assess the total number of endoscopic procedures performed by gastroenterologists (gis), surgeons, and residents in GI and surgery programs. Alberta physician billing data from January 1, 1994 to December 31, 2002 was used to determine the number of endoscopies done by gis and surgeons in large (>100,000 persons) and small (<100,000 persons) communities. The number of egd’s and Cx performed by all GI fellows and surgery residents completing their training in 2004-2006, at one of the two teaching centers in Alberta, was also determined. In large communities, gis performed the majority of procedures; however, in smaller communities, surgeons performed @ double the number of both egd’s and colonoscopies. All GI fellows exceeded ASGE recommended number of egds and Cx during their training. However, none of the 10 surgery residents met the ASGE recommended number of egds, and only 2 of 12 surgery residents achieved achieved this for Cx. No objective measurements of competency for fellows and surgical residents were reported. During the 8 year study period, the proportion of endoscopic procedures performed by surgeons in small communities compared to gis increased dramatically. The combination of increased reliance on surgeons to perform endoscopic procedures in small communities with the limited experience during training for these providers raises important questions about the training guidelines for non-gastroenterologist endoscopists, and the general need for objective competency assessment of trainees.
Evaluation of the Efficiency of a Tertiary Care Academic Endoscopy Unit
This study evaluated the efficiency of an endoscopy suite by measuring the time of different components of the patient flow for 400 consecutive patients undergoing an endoscopic procedure in a single unit. The flow was divided into pre-procedure segments (arrival time, prep room, procedure room, sedation), the procedure itself, and post-procedure segments (transport to recovery, recovery complete, and discharge). Pre, intra, and post procedure time intervals were compared , and the effect of trainee involvement was assessed as compared to procedures performed by an attending only. Of the total mean patient time of 184 minutes at the endoscopy unit only 17/184 (9.2%) was actual procedure time. Although the mean length of procedure was longer when fellows participated [20.6 vs 16.0 minutes (p = 0.0021)], total time spent per patient at the endoscopy unit was not affected. With significantly more time spent before and after the procedures than during the endoscopies themselves, the authors concluded that improvements in efficiency ought to focus on these aspects of flow within the unit.
Narrow Band Imaging (NBI) Influences the Learning Curve for Conventional Endoscopy - Final Results of a Prospective Randomized Study in the Detection of Colorectal Adenomas
This study evaluated the use of Narrow Band Imaging (NBI) in polyp and adenoma detection in a mixed population of screening and non-screening indication colonoscopies. This was a randomized comparison of white light vs NBI colonoscopy in 401 consecutive individuals referred for diagnostic examinations. There was no significant difference overall in adenoma detection rate between the NBI and the conventional white light groups [22.7% vs. 16.7% (p = 0.129)]. While this study did not aim to evaluate the effects of performing NBI colonoscopy on performance of conventional colonoscopy, they did observe a significant improvement in the adenoma detection rate for white light colonoscopy between the first and last 100 cases of the study. There was also an initial significant difference in adenoma detection rates [(NBI 26% vs. controls 8%, p = 0.015) during the first 100 cases only. Unlike other studies including one presented at this meeting, flat adenomas were not found more frequently in the NBI group. Instead, NBI detected significantly more hyperplastic polyps than did conventional colonoscopy [28.3% vs. 11.66%, (p < 0.001)]. The authors concluded that NBI may have a training effect on the adenoma detection rate for standard white light colonoscopy.
Section 17: Endoscopic Ultrasound
In this section, papers were presented on an array of EUS applications in clinical practice, including reproducibility of accuracy for lung cancer staging in community practices, assessment of perianal disease in patients with Crohn’s disease, assessment of new cytologic markers for pancreatic cancer, assessment of mediastinal granulomatous disease. There was also a paper looking at the clinical relevance of the finding of mild chronic pancreatitis on EUS, and the feasibility and results of recording published quality measures in EUS.
Implementation of EUS-FNA for Lung Cancer Staging
This study presented by Annema evaluated if less experienced investigators could reproduce the published accuracy of EUS-FNA for mediastinal staging of lung cancer as obtained by experts. Chest physicians and gastroenterologists (with no or limited EUS experience) participated in a dedicated EUS training for lung cancer staging for 3 months on 36 patients. After completion of the training, consecutive patients with (suspected) lung cancer - all candidates for surgical staging - underwent EUS-FNA. Results of the five test centers were compared with that of the single expert center. A total of 321 patients were evaluated, 196 in the test centers and 125 in the expert center. There was no statistical difference of lymph node metastasis detected or tumor invasion between the two sites. The authors concluded that for EUS-FNA in lung cancer staging - physicians with limited or no prior EUS experience can obtain results comparable to that of expert investigators.
Immunostaining As Adjunct to Cytologic Assessment of Endoscopic Ultrasound Guided Fine Needle Aspiration (EUS-FNA) Specimens for Diagnosis of Pancreatic Adenocarcinoma
Ludwig et al. evaluated the feasibility of using novel markers in the diagnosis of pancreatic cancer with EUS-FNA specimens. The authors identified 5 markers that are differentially expressed in pancreatic cancer with reported specificity exceeding 90%. These markers included 14-3-3σ, Maspin, Fascin, CEACAM6 and Mesothelin. In part 1 of the study they immunostained surgical specimens of patients with pancreatic adenocarcinoma, chronic pancreatitis, and normal pancreas. In part 2 they studied cell blocks of EUS-FNA specimens of different patients with the same diagnosis as part 1. In part 3 they evaluated direct smears of EUS-FNA specimens of patients with pancreatic cancer and chronic pancreatitis. Of the novel immunomarkers identified and reported based on SAGE analysis, 14-3-3 σ and mesothelin appeared most promising as potential adjunct to cytology for diagnosis of pancreatic cancer from EUS-FNA specimens.
Rectal Endoscopic Ultrasound in the Management of Rectal and Perianal Complaints of Crohn's Disease Patients
Mardini presented the authors experience in utilizing EUS as the initial study to assess and manage perianal and rectal complaints among patients with Crohn's disease [CD]. A total of 31 CD patients underwent 36 EUS exam for a variety of indications mostly from suspected fistula/abscess or rectal pain. Management decisions were based on the EUS findings, including using immunomodulators and / or infliximab, seton placement, and reassurance. None required additional assessment beyond what was determined on EUS findings. EUS was also used to perform follow up and assess resolution of fistulas in some patients. The authors concluded that EUS should be considered in all Crohn's disease patients with rectal and perianal complaints. It can be used alone and lead to significant changes in the management plan.
Non Malignant Mediastinal Adenopathy: Can EUS-FNA Differentiate Tuberculosis and Sarcoidosis?
This study presented by Fritscher-Ravens evaluated the usefulness of EUS FNA of mediastinal adenopathy to differentiate between TB and sarcoidosis. They prospectively studied 52 patients with mediastinal adenopathy with no suspicion of lung cancer on CT. EUS FNA was performed in all cases. Cytology revealed epitheloid-cell granulomas on a dirty background suggestive of tuberculosis in 22 patients and sarcoidosis with epitheloid-cell granulomas on a clear background in 26. Accuracy for cytology in TB was: 82% with culture positive results in 46%. Accuracy for TB, when cytology and culture results were combined was 100%. The accuracy for sarcoidosis was 95%. The authors concluded that EUS-FNA of posterior mediastinal lymphadenopathy in patients with difficult differential diagnosis of sarcoidosis and tuberculosis seems to be a powerful tool, once cytology is combined with additional sampling for bacteriology.
Long-Term Outcome of Endosonographically Detected Minimum Criteria for Chronic Pancreatitis (MCCP) When Conventional Imaging and Functional Testing Are Normal
Catalano presented this study evaluating the true sensitivity of EUS in detecting early CP and followed patients diagnosed with MCCP on EUS and determined how many would definitely develop CP. Patients were evaluated retrospectively, and patients with mild criteria on EUS (1-2 features) for chronic pancreatitis were included with negative ERCP, CT, and if available, secretin test for chronic pancreatitis. 37 patients were included in the study. Over 6 years, 20 had worsening CP by EUS (including 14 moderate disease, 6 severe disease), 18 had abnormal CT scan suggesting CP, and 16 had abnormal secretin function testing. The authors concluded that EUS is a very sensitive modality in the diagnosis of early chronic pancreatitis in those with unexplained abdominal pain or pancreatitis.
Assessment of Quality for Endoscopic Ultrasonography: A Review of 5453 Cases Using the ASGE-ACG Quality Indicators
This study by Coe et al. proposed to define the prevalence of the pre- and intra-procedure quality indicators in their endoscopic ultrasound (EUS) cases and to identify areas for improvement within their practice. They reviewed a 10 year period of EUS procedures and each of the published pre- and intra-procedure EUS quality indictors were measured. The prevalence of each indictor was determined. They identified four areas for quality improvement; visualization of the celiac axis in esophageal cancer, visualization of the entire pancreas in suspected pancreatic disease and documentation of submucosal tumor wall layer and echogenicity. Such efforts to put published quality measures into use by assessing actual procedure outcomes represent an important step towards achieving the goal of using these measures to effect improved endoscopic quality.
Section 18: Non-Variceal Upper GI Bleeding
This topic fora included papers dealing with management principles ranging from choice of hemostasis technique—clips vs. coagulation, testing of physical principles of thermocoagulation hemostasis, and use of PPI drips following hemostasis. Papers on predictors of need for hemostasis, outcome of GI bleeding in the elderly, and effects on outcome of MI complicating upper GI bleeding were also presented.
Bolus versus Continuous High-Dose Omeprazole Infusion Combined With Endoscopic Hemostasis in Peptic Ulcer Bleeding. A Randomized, Multicenter, Italian Study
Angelo Andriulli presented this paper which found no difference in the rate of recurrent bleeding, need for blood transfusion, length of hospital stay, or mortality between continues infusion of PPI (Omeprazol or Pantoprazol) and daily single intravenous dose of PPI (Omeprazol or Pantoprazol) in 369 patients randomized to either arm after endoscopic hemostasis. This was a double blind study that included individuals with ulcer bleeding with either active bleeding or non-bleeding visible vessels. The rebleeding rates, while equivalent in the two groups, were low at 8% and 9%. The effect of continuous vs bolus IV vs oral PPI among individuals with adherent clots not getting endoscopic hemostasis remains to be determined.
The Prognosis of Upper GI Bleeding in very Elderly Patients is the Same as That of Younger Ones: Results of French Prospective Multicenter Study of The ANGH Group
Stephane Nahon presented this prospective study of 3253 consecutive patients presenting in 53 French hospitals with upper GI bleeding. The elderly patients (≥75years) in this study were more likely to take aspirin, costicosteroids, vitamin K antagonist, anti-platelet agents and significantly require more blood transfusion. The cause of bleeding was more commonly peptic ulcer, erosive gastritis and esophagitis in the older group; while portal hypertensive gastropathy, esophageal and gastric varices were more common in the younger patients. However, no differences were seen in the rates of complications and mortality between the two groups.
Assessment of Endoscopic Features and Outcomes in Patients with Non-variceal Upper Gastrointestinal Hemorrhage (UGIH) Complicated by Myocardial Infarction (MI).
In this study presented by Constantinos P. Anastassiades, individuals with non-variceal upper GI bleeding complicated by MI were compared with controls without MI but matched for age and cardiovascular risk. The comparison between case and control groups did not show any significant difference in reference to demographic characteristics, hemoglobin levels at admission and blood transfusion requirements, cause of bleeding and rate of re-bleeding, in-patient mortality and mortality at 3 months. But significant increase in length of hospital stay and ICU stay, as well as trend toward increased development of acute renal failure was seen in the MI group.
Hemoclips versus Thermocoagulation for the Treatment of Non-Variceal Upper Gastrointestinal Bleeding; A Meta-Analysis.
Joseph J. Sung presented the results of this meta-analysis. The analysis of 6 trials, including a total of 179 patients in the hemoclip group and 205 patients in the thermocoagulation group, showed significantly lower rates of rebleeding in the hemoclip group. However, no differences were observed in terms of initial hemostasis rates, final hemostasis, need for surgery or mortality between the two groups.
Physician Clinical Decision-Making and Triage is a More Accurate Predictor of Need for Endoscopic Therapy (ET) than Clinical Rockall Score (crs) and Blatchford Score (BS) in patients with Acute Upper GI Hemorrhage (UGIH).
Farees T. Farooq presented this retrospective analysis of data in 195 patients with acute UGIH showed that physicians’ clinical decision-making was more accurate in predicting need for ET than crs and BS, given the low specificity of both scores. The clinical decision making, as measured by triage to ICU vs non-ICU had an accuracy of 69% in predicting the need for hemostasis at endoscopy.
Optimizing Bipolar Electrocoagulation (BEPC) for Endoscopic Hemostasis: Assessment of Factors Influencing Energy Delivery and Coagulation Depth.
Loren A. Laine conducted this characterization of BEPC and Gold probe (GP) using different settings. The results demonstrated that only increasing duration increases depth of coagulation; increasing force of application doesn’t increase coagulation depth alone, but does increase coagulation depth and cavitation only when using GP. Force and duration affected energy delivery. However, increasing power alone did not increase energy delivery or coagulation depth. Tamponade (40g of force) was required with BPEC to seal vessels of the size of feeding ulcers. These experiments provide evidence to support recommended hemostasis practice in non-variceal ulcer bleeding to apply tamponade at relatively low power over a relatively long duration.
Section 19: Advances in Endoscopic Diagnosis and Imaging
In this session, many exciting new modalities and technologies were presented. They ranged from advances in optical imaging, imaging using specific markers, devices to facilitate small and large bowel scope passage for diagnosis and therapy, a combination of high resolution optics and a dramatically smaller diameter fiber, and probe based endocytoscopy.
Endoscopic Molecular Imaging of Gastrointestinal Neoplasm: A Pilot Study
Manabu Muto presented this study. Through endocystocopy, a molecular probe to p53 was used to evaluate esophageal cancer ex vivo. Immunohistochemistry (IHC) staining was positive for p53 in the esophageal cancer but not in normal tissue. At the tumor margin, there was demarcation between normal epithelium and cancer using the p53 probe. In another experiment, cell lines mutant for p53 were injected into mice to establish a xenograft. The tumor surface was exposed and IHC to p53 was applied. P53 was positive in mutant and negative in wild type.
Novel Method of Enteroscopy using Endo-easetm Discovery SB Overtube
Paul A. Akerman presented this paper. Endo-easetm is a raised spiral overtube with variable stiffness which fits over a pediatric colonoscope and allows for deep enteroscopy by rotation and pleating the small bowel over the overtube. Twenty-seven patients were evaluated for obscure GI hemorrhage and enteroscopy with this overtube was possible in all but 2. The average depth of insertion was 165.5cm, procedure time 39 minutes, and the source of GI bleed identified in 9/27 patients. Complications included throat pain and superficial mucosal trauma. Future goals described included decreasing the diameter of the tube, automation, and total enteroscopy of the small intestine.
Novel Ultrathin Scanning Fiber Endoscope for Cholangioscopy and Pancreatoscopy
Eric J. Seibel presented this paper. They described a prototype scanning fiber endoscope which is a 1.6mm high resolution flexible fiber with a 13 mm rigid tip followed by a highly flexible shaft. The scanning fiber allows full color, 70-1000 field-of-view, high resolution with magnification, and fluorescence endoscopy. The scanning fiber endoscope can allow rapid and direct visualization of previously difficult to access areas such as the pancreatic duct. It has the potential for laser diagnostics for detecting dysplasia and for assisting in interventions.
A Multi-Center Randomized Comparison of the Endocapsule: Olympus Inc. And the pillcamtm SB:Given Imaging in Patients with Obscure GI Bleeding.
David R. Cave presented this partially blinded (images revealed which technology used) randomized multi-center prospective trial comparing the Olympus capsule with an early version of the Given capsule. The goal was to show non-inferiority. The capsules were ingested 40 minutes apart on the same day. Both were safe with similar diagnostic yield. Both capsules missed lesions. The Olympus capsule was rated higher in image quality.
Spirus Endo-easetm: Multi-Center Experience with a New Colonoscopy Assist Device.
Daniel Cantero presented this paper describing the use of the Endo-easetm spiral overtube within the colon. Seven centers used the Endo-easetm for colonoscopy (most for screening) in 168 patients. Eleven percent could not be performed due to discomfort, anatomy, or poor prep. The cecum was reached in 98% of the cases with a mean time of 10.3 minutes. Mean withdrawal time was 7.7 minutes There were no adverse events other than minor mucosal changes.
In vivo Histopathology via Standard Endoscopes? First Results of a New High-Resolution Miniprobe-Based Confocal Microscope.
Valentin Becker presented this study. Using the confocal endomicroscopy miniprobe and 1% IV fluoroscein, 6 patients were evaluated with suspected IBD, gastritis, Barrett’s esophagus, etc. Cytological features corresponded with histopathology – crypts, villi, goblet cells, inflammation, red blood cells within capillaries could all be seen. The confocal endomicroscope has a limited field of view so a method of video mosaicing was developed which allows the images to appear somewhat fused together to resemble a static image more closely resembling a pathologic slide.Section 20: Advances in Biliary Imaging and Therapies
This topic forum presented several papers on such topics on advances in choledochosopy, novel usage of temporary covered self-expanding metal stents (SEMS), covered vs uncovered SEMS, use of removable biliary SEMS for benign strictures, an assessment of sphincterotomy alone vs. cholecystectomy plus endotherapy for choledocholithiasis, and the use of propofol sedation for ERCP.
SPYGLASS Cholangioscopy (SGC): Preliminary Clinical Experience in 3 Tertiary Care Centers.
Lo et al. reported on their technical experience with SPYGLASS, a disposable, single operator cholangioscope made by Boston Scientific. In their study, they performed 55 procedures on patients who otherwise would have qualified for cholangioscopy. Indications for using Spyglass were for directing biopsies, examining strictures, facilitating EHL and to visualize filling defects. The authors were universally able to cannulate over a guide wire. Visualized pathology seen included mucus, stones, ulcers, strictures and sludge. Spyglass was able to confirm strictures, disputed suspected pathology, examine intrahepatic and common hepatic duct in all patients. On a scale of 1 to 5, the authors gave their experience a 3 and felt it was easier than traditional choledocoscopy for single operator use, had better tip deflection, allowed for easier passage of wire or probes but not as good in terms of brightness or for visualization which however improved with irrigation. In only 1/22 did the optical fibers break.
Temporary Access Fistulas (TAF) Using Covered Self Expandable Metal Stents (csems): A Feasible Tool for Interventional Pancreaticobiliary Endoscopy.
M. Miranda et al. reported their experience with placing (csems) to create Temporary Access Fistulas (tafs) for endoscopic intervention such as stent insertion, enteroscopy, stone removal, balloon dilation, and rendezvous EUS-ERCP. Seven male pts had TAFS, 3 biliary and 4 pancreatic. Biliary pathology for these patients who had failed more traditional approaches i.e. PTC, ERCP, etc. included Roux-en-Y with benign intrahepatic stricture or residual common bile duct stone, and post liver transplant anastomotic transection. Miranda was able to place two 6 cm covered metal wall stents through mature tracts by over the wire exchange of 7Fr plastic stents initially placed under EUS guidance from stomach into left liver duct. A total of 8 interventions were performed throug tafs but in only 1/3 was therapy accomplished. In ¾ of cases of failed pancreatic necrocystectomy by traditional methods, EUS guided placement of csems using 10F double pigtails thru the csems into target areas were identified with transgastric endoscopy. For the pancreatic cases, a total of 7 interventions were performed through tafs on 5 repeat sessions, direct endoscopic irrigation/necrosectomy & catheter replacement. Csems were removed without complications at a mean of 16.7 wks. Complications included migration in one and technical problems in two others. The procedure was successful in 3 out of the 4 pancreatic cases. The authors concluded from this dramatic though limited experience that placing and removing csems through tafs is feasible and safe. No comparisons to alternative techniques such as interventional radiology procedures were made, and while this paper showed proof of principle, there were not that many cases from which to characterize accurate complication rates.
A Randomized Trial Comparing the Covered and Uncovered Wallstent in palliation of Malignant Distal Biliary Obstruction: Interim Analysis.
Telford et al. prospectively randomized non-operative patients who had malignant biliary obstruction to either covered or uncovered Wallstents. The primary outcomes were time to stent obstruction and time to death. Serious adverse events were also recorded. 100 patients were randomized at 4 sites from Oct 2002 to May 2006. The patients and interviewers were blinded to stent assignment. 84% had pancreatic cancer. 51 received covered stents, 10 of which obstructed, while 7 of 49 uncovered stents obstructed. The average time to stent obstruction or death was not statistically different in the two groups (217 days vs. 236 days). A total of 118 serious adverse events occurred in 49 patients. However, there was no statistical difference between the two groups (20 in covered, 29 in uncovered) Four occurrences of cholecystitis occurred, two patients in each group. Four patients were noted to have a migrated stent; all were in the covered stent group. Based on the interim analysis of 100 patients, the authors showed there was no difference in primary or secondary outcomes or complications between covered and uncovered metal Wallstents when placed for malignant biliary obstruction.
Temporary Placement of Covered Self-Expandable Metal Stents in Benign Biliary Strictures: Long Term Results
Kahaleh presented this analysis of the long-term efficacy and safety of covered metal stents for benign biliary strictures. They enrolled 79 patients (40 to 70 y.o) with benign biliary strictures. Of these, 32 were due to chronic pancreatitis, 24 due to stone disease, 16 post OLT, 3 post-op, 3 AIP, and 1 PSC. In patients who still had gallbladders, stents were placed below the cystic duct. Removal was based on normalization of liver function tests, resolution of symptoms and decompression of biliary tree by imaging. All patients received a sphincterotomy. The CSEMS were later removed with a snare or rat tooth forceps. CSEMS were subsequently removed from 65 of the 79 patients. Resolution of the stricture was confirmed in 59 out of 65 cases (90%) after a median follow-up time post removal of 12 months. Of the remaining six patients, three developed strictures in the uncovered proximal portion of the stent and three failed therapy. Complications included post-ERCP pancreatitis (2), post-sphincterotomy bleeding (1) and pain requiring CSEMS removal (2), stent migration in the duodenum (2), in three patients, spontaneous migration and expulsion of the CSEMS was observed with resolution of the stricture; and in six cases, proximal migration resulted in tissue in-growth in the distal uncovered portion of the stent, and finally bile leak in 1 patient. Two patients developed cholecystitis in the setting of cholelithiasis; both underwent cholecystectomy. Of the 14 patients who did not undergo CSEMS removal during the study period, three were lost from follow-up, one developed hepatocellular carcinoma, three developed pancreatic cancer, two developed duodenal edema preventing removal and five died from unrelated causes. The authors concluded that temporary metal stents offer an alternative to surgery for benign biliary strictures.
Endoscopic Sphincterotomy Versus Surgery As a Primary Treatment for Patients with Common Bile Duct Calculi: A Meta-Analysis of Randomized Controlled Trials.
This paper by A. Kaza et al. was a meta-analysis from randomized controlled studies obtained from a Medline search from 1996 to 2006 to determine if there was, in fact, a morbidity/mortality benefit of either ES or cholecystectomy in patient with bile duct stones. They included only randomized controlled studies enrolling adult subjects and comparing surgery versus endoscopic treatment were included and found 5 trials with a total of 666 patients (263 males, 403 females, age range: 50 - 80 yrs). Follow up ranged from 18 months to 5 years. Primary failure (risk of retained stones) was higher with the ES than Surgical Treatment (ST). Risk of major complications (acute cholecystitis, biliary pancreatitis or cholangitis) was slightly higher with ES than ST. The risk of minor complications was lower with ES. Procedure-related mortality was equal in both groups Duration of hospital stay was longer in the in the surgery group Biliary complications were more common in the ES group during the follow-up period. Overall, 28% of the patients in the ES group subsequently required a cholecystectomy. All-cause mortality was higher in the ES group. For every 4 patients treated ES compared to surgery, biliary events occurred in approximately 25%, the authors concluded that ES alone is associated with increase risk of primary treatment failure and recurrent biliary complication compared to surgery.
Is Deep Sedation with Propofol Safe During ERCP?
J. Linder et al. analyzed 2113 ERCPs performed prospectively from 1996 to 2006 using various types of sedation. They evaluated sedation related complications, reason for conversion from deep sedation to general anesthesia, and primary reasons for general anesthesia. 438 (21%) were performed after nurse administered intravenous sedation with narcotic and midazolam. Anesthesia personnel provided deep sedation with propofol (DSP) during 1533(73%) procedures. 5 intraoperative ERCPs were performed and the remaining (6%) had GETA during ERCP. There was 1 death 24 hr after ERCP using RN administered sedation. There was 1 case of pneumonia following ERCP with general anesthesia. 4 patients experienced mild potential sedation related complications after DSP. Nine patients were converted from deep sedation to general anestheisa. There were no adverse events following DSP cases converted to general anesthesia. Common reasons for planned GETA were obesity, expected lengthy or complicated procedures, and pregnancy. The authors concluded that deep sedation is safe for ERCP with few adverse events and when needed in rare circumstances, can easily be converted to general anesthesia.
Section 21: Late-breaking abstracts
PillCam colon capsule endoscopy compared to colonoscopy in detection of colon polyps and cancers. Interim analysis of a prospective multi-center trial.
In pilot studies, PillCam colon capsule endoscopy (PCCE) has been shown to be feasible and able to demonstrate colon polyps and cancers. The PillCam is similar to a regular capsule endoscopy, but it is slightly longer, with a two sided camera, and has a longer operating time of 9-10 hours. Because of the potential of being performed outside of the endoscopy suite or hospital, use of PCCE may improve CRC screening compliance rates and meet the demand for screening colonoscopies. Fernandez-Urien et al presented their report on the interim analysis to assess the yield of PCCE in detecting polyps and other pathologies in comparison to traditional colonoscopy. The study looked at safety, accuracy, and transit time in patients age >50 years or those under 50 years with an increased risk of CRC. Patients went through a traditional PEG colon preparation and ingested the capsule in the morning, followed by prokinetic agents and additional small doses of laxatives. A subsequent colonoscopy served as the “gold standard” after excretion of the capsule. Eighty-four patients, mean age 60 (23-84) years, were included and analyzed for this interim analysis. No adverse effects were recorded. Fifty-nine patients (70%) had a polyp of any size and 38 (45%) had significant findings (at least one polyp ≥6 mm or ≥3 polyps of any size). The sensitivity and specificity of PCCE was 76% and 76%, respectively, for all polyps and 79% and 78% for significant findings. The NPV for all lesions was 58% and for significant findings was of 82%. Six polyps were detected only by PCCE, though it was difficult to assess whether or not these polyps were true or false positives. This interim data is encouraging for PCCE as an emerging non-invasive technology. It needs further validation and improved sensitivity, however, as the current NPV is too low to be acceptable as a screening tool. In addition, colonic preparation is still necessary and arguably more important for this technique compared to traditional colonoscopy.
Endoscopic Tri-Modal Imaging improves the detection of high-grade dysplasia (HGD) and early cancer (EC) in Barrett’s esophagus; an international multi-center study
Standard endoscopy and random biopsy have a poor sensitivity for detection of dysplasia in Barrett’s esophagus (BE). Autofluorescence imaging (AFI) has been shown to increase this sensitivity at the expense of a relatively high false positive rate, but this may be reduced by the addition of NBI detailed inspection of AFI-suspicious lesions. That AFI and NBI require separate endoscopy systems has limited this application. In this international multi-center study, Curvers et prospectively evaluated Endoscopic Tri-Modal Imaging (ETMI), a new endoscopy system that incorporates high-resolution white light endoscopy (HRE), AFI and NBI in a single device with magnification in the HRE and NBI mode. 84 BE patients were examined with the ETMI system. The esophagus was first inspected with HRE followed by AFI for the detection of additional lesions. All lesions detected with HRE and/or AFI were subsequently inspected by NBI using the optical zoom mode of the system for the presence of abnormal mucosal and/or microvascular patterns. Biopsies were obtained according to the Seattle protocol. The investigators found that the addition of AFI increased the detection rate of HGD/EC from 53% to 90%. The addition of NBI decreased the false positive rate of AFI from 81% to 26%. These promising results will need to be confirmed with planned randomized cross-over trials.
Section 22: ASGE Plenary session:
Narrow Band Imaging (NBI) for Colonoscopic Surveillance in Hereditary Non-Polyposis Colorectal Cancer (HNPCC) Syndrome: A Back-to-Back Study
Patients who met revised Amsterdam II or genetic criteria for HNPCC were examined twice from the cecum to sigmoid-descending junction, first with high definition white light, and then with NBI. 61 patients (mean age 48yrs; male 26%) from MLH1/MSH2/MLH6 positive families were examined by one of the three endoscopists, each with over 100 cases experience, with a minimum extubation time of 6 minutes for each pass. 28% of patients had at least one adenoma after white light alone vs. 43% after white light and NBI (P = 0.003). The proportion of flat adenomas was higher in NBI pass, P = 0.02. The median extubation time was longer in the NBI pass by 29 seconds, P < 0.001. Hence, the use of NBI after meticulous HDTV white light examination and polyp removal almost doubled the yield of adenomas in the right colon. NBI looks promising as a tool to improve adenoma detection in HNPCC surveillance.
A New Benchmark in the Colorectal Neoplasm Miss Rate During Colonoscopy: Results of a Randomized Controlled Trial of Wide Angle View (170°) Colonoscopy Comparing Narrow Band Imaging and White Light
This study evaluated the colonoscopic polyp miss rate, and compared NBI to white light by using current colonoscope with wide angle (170°) view and high resolution. 240 patients were randomized to standard white light (n = 121) or NBI (n = 119) during the first withdrawal. The patients then immediately underwent a second examination by the same endoscopist using white light. There was overall 11% miss rate for neoplasm of any size, 3% for neoplasms ≥6 mm, and 0% for neoplasms ≥10 mm. There was no significant difference of missed lesions between the NBI and white light. Patient demographics, procedure indications and quality of bowel preparation were similar between groups. Mean withdrawal time was 8 and 6 minutes in the white light arm and 9 and 7 minutes in the NBI arm, for the first and second withdrawal, respectively. Hence, using currently available colonoscopy with wide angle of view (170°) and high resolution, the colorectal neoplasm miss rate was significantly lower than previously published rates. However, NBI did not significantly improve the miss rate compared to white light.
Rate of Advanced Pathologic Features in 6-9 mm Polyps in Patients Referred for Colonoscopy Screening
David Lieberman presented the results of this analysis of the CORI database to evaluate the histology and therby the clinical significance of 6-9 mm polyps. CORI is a national endoscopic data repository. It was searched to identify asymptomatic patients referred for screening colonoscopy (average-risk, family history or FOBT/flexible sigmoidoscopy positive) to 21 sites where all pathology results were reported in the database. In patients undergoing colon screening, the largest polyp(s) was 6-9 mm in 8.9% of exams—1137 cases. Adenomas with advanced features (villous, high-grade dysplasia, invasive cancer) were found in 5.3%, including adenoma with high-grade dysplasia or cancer in 1.0%. Therefore, adenomas of this size can harbor significant pathology. Advanced lesions were somewhat more common in men, in the distal colon, and in individuals 60 years and older. If a primary goal of colon screening is the detection and removal of advanced neoplasia to prevent cancer, then these data support the recommendation that most patients with polyps 6-9 mm undergo colonoscopy with polypectomy.
Systemic Inflammation and Physiologic Burden of Transgastric Natural Orifice Translumenal Endoscopic Surgery (NOTES) Peritoneoscopy: A Controlled, Prospective Comparison between NOTES and Laparoscopy
This study was a prospective, controlled trial that compared the physiologic stress induced by NOTES and laparoscopy. Ten anesthetized 40 kg female swine underwent transgastric NOTES peritoneoscopy (n = 6) or diagnostic laparoscopy (DL, n = 4). Plasma levels of IL-1, IL-6 and TNF-α were determined. Animals underwent sacrifice and laparotomy on post-operative day 14. Additional swine (n = 2) underwent nonsurvival procedures simulating gastric perforation with diffuse peritonitis to serve as positive controls for cytokine assays. Post-operative hyperinflammatory surge of TNF-α was similar in all groups. IL-1 and IL-6 were undetectable in all groups. Hence, physiologic stress induced by transgastric NOTES is similar to that of laparoscopy. Moreover, a non-significant, but persistent decrease in TNF-α levels beyond post-operative day 14 was noted in NOTES animals when compared to DL animals. However, the clinical effects of this post-operative immunosuppression are unclear.
Randomized Multicenter Controlled Study of Endoscopic and Surgical Closure of a 4-cm Gaping Wide Colon Perforation in a Porcine Model
Recent studies report the rate of colonic perforation during colonoscopy is about 1 in 1000. Most of these being 1 to 2 cm in size rarely up to 4 cm. Management of choice has been early surgery in indicated cases. Even in best centers 50% have peritonitis by the time surgery is done. Alternatively, immediate endoscopic approach may be effective if the perforation is recognized immediately. The aim of this study was to evaluate if endoscopic closure of a gaping colonic perforation is feasible. This was a randomized 2 week multicenter study in porcine model. A 4cm gaping linear perforation was made in the animal’s colon at 18cm from anus. All animals received antibiotics. The 36 animals included in the study were randomized to endoscopic closure vs surgical closure. The endoscopic closure was performed using T-tag sutures +clips/sutures. After statistical analysis there was no difference in the incidence of peritonitis at 2 weeks between the two groups. The surgical closure group had more distant adhesions compared to the endoscopic closure group. There was no difference between the two groups in terms of healing both macro and microscopically. In summary, endoscopic closure of colonic perforation is feasible if recognized immediately, is as good as surgery in preventing peritonitis and better than surgery in limiting distant adhesions as shown in this study. Immediate endoscopic closure of colonic perforation is probably an effective alternative to surgery.
Endoscopic Therapy is as Effective as Surgical Resection in Managing Patients with Early Esophageal Cancer - Analysis of Data from a National Cancer Registry
Up to 20% of esophageal cancers are early and surgical resection has been the standard of care for such patients. However, in US reports of endoscopic therapy for esophageal cancer have been limited. This study was done to compare endoscopic therapy to surgical resection in early esophageal cancer management by analyzing NCI database. The SEER database with 18 cancer registries was analyzed. Only stage 0 and I first primary esophageal cancers which were confirmed microscopically were included. 742 patients were included (84% had non-squamous cancers, most of which were adenocarcinomas). 13.3% underwent endoscopic therapy and the rest underwent surgical therapy. 3% from endoscopic group developed recurrence but were retreated endoscopically. 0% developed recurrence among the surgically treated group. In conclusion from this study, endoscopic therapy of early esophageal cancer is as effective as surgical resection in regards to long term cancer free survival.
Immediate capsule endoscopy or mesenteric angiogram in patients with acute overt obscure gastrointestinal bleeding: Interim results of a prospective randomized trial
This a prospective randomized trial conducted in Hong Kong . The aim of this study was to compare capsule endoscopy to 3 vessel mesenteric angiogram in patients with active acute obscure gastrointestinal bleeding. Consecutive patients with melena or hematochezia associated with a significant drop in hemoglobin, normal upper and lower endoscopy were included. Patients were randomized in 1:1 ratio in computer generated block of 10 to undergo small bowel capsule endoscopy vs three vessel mesenteric angiogram. All patients were followed for 12 months for rebleeding. The overall diagnostic yield was 55% in the capsule endoscopy group vs 9.5% in the mesenteric angiogram group.