Propofol vs traditional sedatives for sedation in endoscopy: A systematic review and meta-analysis

BACKGROUND

Propofol is commonly used for sedation during endoscopic procedures. Data suggests its superiority to traditional sedatives used in endoscopy including benzodiazepines and opioids with more rapid onset of action and improved post-procedure recovery times for patients. However, Propofol requires administration by trained healthcare providers, has a narrow therapeutic index, lacks an antidote and increases risks of cardio-pulmonary complications.

AIM

To compare, through a systematic review of the literature and meta-analysis, sedation with propofol to traditional sedatives with or without propofol during endoscopic procedures.

METHODS

A literature search was performed using MEDLINE, Scopus, EMBASE, the Cochrane Library, Scopus, LILACS, BVS, Cochrane Central Register of Controlled Trials, and The Cumulative Index to Nursing and Allied Health Literature databases. The last search in the literature was performed on March, 2019 with no restriction regarding the idiom or the year of publication. Only randomized clinical trials with full texts published were included. We divided sedation therapies to the following groups: (1) Propofol versus benzodiazepines and/or opiate sedatives; (2) Propofol versus Propofol with benzodiazepine and/or opioids; and (3) Propofol with adjunctive benzodiazepine and opioid versus benzodiazepine and opioid. The following outcomes were addressed: Adverse events, patient satisfaction with type of sedation, endoscopists satisfaction with sedation administered, dose of propofol administered and time to recovery post procedure. Meta-analysis was performed using RevMan5 software version 5.39.

RESULTS

A total of 23 clinical trials were included (n = 3854) from the initial search of 6410 articles. For Group I (Propofol vs benzodiazepine and/or opioids): The incidence of bradycardia was not statistically different between both sedation arms (RD: -0.01, 95%CI: -0.03-+0.01, I 2: 22%). In 10 studies, the incidence of hypotension was not statistically difference between sedation arms (RD: 0.01, 95%CI: -0.02-+0.04, I 2: 0%). Oxygen desaturation was higher in the propofol group but not statistically different between groups (RD: -0.03, 95%CI: -0.06-+0.00, I 2: 25%). Patients were more satisfied with their sedation in the benzodiazepine + opioid group compared to those with monotherapy propofol sedation (MD: +0.89, 95%CI: +0.62-+1.17, I 2: 39%). The recovery time after the procedure showed high heterogeneity even after outlier withdrawal, there was no statistical difference between both arms (MD: -15.15, 95%CI: -31.85-+1.56, I 2: 99%). For Group II (Propofol vs propofol with benzodiazepine and/or opioids): Bradycardia had a tendency to occur in the Propofol group with benzodiazepine and/or opioid-associated (RD: -0.08, 95%CI: -0.13--0.02, I 2: 59%). There was no statistical difference in the incidence of bradycardia (RD: -0.00, 95%CI: -0.08-+0.08, I 2: 85%), desaturation (RD: -0.00, 95%CI: -0.03-+0.02, I 2: 44%) or recovery time (MD: -2.04, 95%CI: -6.96-+2.88, I 2: 97%) between sedation arms. The total dose of propofol was higher in the propofol group with benzodiazepine and/or opiates but with high heterogeneity. (MD: 70.36, 95%CI: +53.11-+87.60, I 2: 61%). For Group III (Propofol with benzodiazepine and opioid vs benzodiazepine and opioid): Bradycardia and hypotension was not statistically significant between groups (RD: -0.00, 95%CI: -0.002-+0.02, I 2: 3%; RD: 0.04, 95%CI: -0.05-+0.13, I 2: 77%). Desaturation was evaluated in two articles and was higher in the propofol + benzodiazepine + opioid group, but with high heterogeneity (RD: 0.15, 95%CI: 0.08-+0.22, I 2: 95%).

CONCLUSION

This meta-analysis suggests that the use of propofol alone or in combination with traditional adjunctive sedatives is safe and does not result in an increase in negative outcomes in patients undergoing endoscopic procedures.

Submucosal tunnel endoscopy: Peroral endoscopic myotomy and peroral endoscopic tumor resection

Peroral endoscopic myotomy (POEM) is an innovative, minimally invasive, endoscopic treatment for esophageal achalasia and other esophageal motility disorders, emerged from the natural orifice transluminal endoscopic surgery procedures, and since the first human case performed by Inoue in 2008, showed exciting results in international level, with more than 4000 cases globally up to now. POEM showed superior characteristics than the standard 100-year-old surgical or laparoscopic Heller myotomy (LHM), not only for all types of esophageal achalasia [classical (I), vigorous (II), spastic (III), Chicago Classification], but also for advanced sigmoid type achalasia (S1 and S2), failed LHM, or other esophageal motility disorders (diffuse esophageal spasm, nutcracker esophagus or Jackhammer esophagus). POEM starts with a mucosal incision, followed by submucosal tunnel creation crossing the esophagogastric junction (EGJ) and myotomy. Finally the mucosal entry is closed with endoscopic clip placement. POEM permitted relatively free choice of myotomy length and localization. Although it is technically demanding procedure, POEM can be performed safely and achieves very good control of dysphagia and chest pain. Gastroesophageal reflux is the most common troublesome side effect, and is well controllable with proton pump inhibitors. Furthermore, POEM opened the era of submucosal tunnel endoscopy, with many other applications. Based on the same principles with POEM, in combination with new technological developments, such as endoscopic suturing, peroral endoscopic tumor resection (POET), is safely and effectively applied for challenging submucosal esophageal, EGJ and gastric cardia tumors (submucosal tumors), emerged from muscularis propria. POET showed up to know promising results, however, it is restricted to specialized centers. The present article reviews the recent data of POEM and POET and discussed controversial issues that need further study and future perspectives.

Characteristic endoscopic findings and risk factors for cytomegalovirus-associated colitis in patients with active ulcerative colitis

AIM: To identify characteristic endoscopic findings and risk factors for cytomegalovirus (CMV)-associated colitis in patients with active ulcerative colitis (UC).

METHODS: A total of 149 UC patients admitted to the Department of Gastroenterology, Nagoya University Hospital, from January 2004 to December 2013 with exacerbation of UC symptoms were enrolled in this retrospective study. All medical records, including colonoscopy results, were reviewed. CMV infection was determined by the presence of CMV antigen, CMV inclusion bodies in biopsy specimens, or positive specific immunohistochemical staining for CMV. Multivariate analysis was used to identify independent risk factors for CMV colitis.

RESULTS: Multivariate analysis indicated independent associations with the extent of disease (pancolitis) and use of > 400 mg corticosteroids for the previous 4 wk. In contrast, no association was seen with sex, age at UC diagnosis, immunomodulator use, or infliximab use. Punched-out ulceration was also significantly associated with CMV infection in patients with active UC (odds ratio = 12.672, 95%CI: 4.210-38.143).

CONCLUSION: Identification of a total corticosteroid dose > 400 mg for 4 wk, extensive colitis and a specific endoscopic finding of punched-out ulcer might facilitate the more rapid diagnosis and timely initiation of antiviral therapy for CMV-associated colitis in patients with active UC.

Single balloon enteroscopy: Technical aspects and clinical applications

The small bowel has long been considered a black box for endoscopists because of its long length and the presence of multiple complex loop. Most of the small bowel is inaccessible by traditional endoscopic means. In addition, radiographic studies have significant limitations with regard to diagnostic yield, and surgery is an invasive alternative. This limitation was overcome through the development of balloon enteroscopy that becomes established throughout the world for diagnostic and therapeutic examinations of the small bowel. The single-balloon enteroscope (SBE) system (Olympus, Tokyo, Japan) was introduced into the commercial market in 2007. Several study demonstrated its efficacy and safety. Early reports on the use of single-balloon enteroscopy have suggested a high diagnostic yield and similar therapeutic potential to that of the double-balloon endoscope. SBE is viable technique for in the management of small bowel disease. Technically, it is easy to perform, may be efficient, and in the literature data available, seems to provide high diagnostic and therapeutic yield.

Prospective postsurgical capsule endoscopy in patients with Crohn’s disease

AIM: To clarify the usefulness of postsurgical capsule endoscopy (CE) in the diagnosis of recurrent small bowel lesions of Crohn’s disease (CD).

METHODS: This prospective study included 19 patients who underwent ileocolectomy or partial ileal resection for CD. CE was performed 2-3 wk after surgery to check for the presence/absence and severity of lesions remaining in the small bowel, and for any recurrence at the anastomosed area. CE was repeated 6-8 mo after surgery and the findings were compared with those obtained shortly after surgery. The Lewis score (LS) was used to evaluate any inflammatory changes of the small bowel.

RESULTS: One patient was excluded from analysis because of insufficient endoscopy data at the initial CE. The total LS shortly after surgery was 428.3 on average (median, 174; range, 8-4264), and was ≥ 135 (active stage) in 78% (14 of 18) of the patients. When the remaining unresected small bowel was divided into 3 equal portions according to the transition time (proximal, middle, and distal tertiles), the mean LS was 286.6, 83.0, and 146.7, respectively, without any significant difference. Ulcerous lesions in the anastomosed area were observed in 83% of all patients. In 38% of the 13 patients who could undergo CE again after 6-8 mo, the total LS was higher by ≥ 100 than that recorded shortly after surgery, thus indicating a diagnosis of endoscopic progressive recurrence.

CONCLUSION: Our pilot study suggests that CE can be used to objectively evaluate the postoperative recurrence of small bowel lesions after surgery for CD.

Staple-line leak after sleve gastrectomy in obese patients: A hot topic in bariatric surgery

Laparoscopic sleeve gastrectomy is a surgical procedure that is being increasingly performed on obese patients. Among its complications, leaks are the most serious and life threatening. The placement of esophageal, covered, self-expandable metal stents in these cases has been performed by many authors but reports on the outcome of this procedure are limited and the technical aspects are not well defined. Stent migration is the main complication of the procedure and poses a challenge to the surgeon, with a limited number of options. Here we evaluate the technical and clinical outcome of a new, dedicated, self-expanding metal stent, comparing the advantages of this stent to those traditionally used to treat staple-line leak after sleeve gastrectomy. While published data are limited, they seem support the use of this kind of new stent as the best option for the stenting treatment of a staple-line leak after sleeve gastrectomy, over other kinds of stents. Further studies based on larger series are needed to better evaluate patient outcome.

Transnasal endoscopy: Technical considerations, advantages and limitations

Transnasal endoscopy (TNE) is an upper endoscopy method which is performed by the nasal route using a thin endoscope less than 6 mm in diameter. The primary goal of this method is to improve patient tolerance and convenience of the procedure. TNE can be performed without sedation and thus eliminates the risks associated with general anesthesia. In this way, TNE decreases the cost and total duration of endoscopic procedures, while maintaining the image quality of standard caliber endoscopes, providing good results for diagnostic purposes. However, the small working channel of the ultra-thin endoscope used for TNE makes it difficult to use for therapeutic procedures except in certain conditions which require a thinner endoscope. Biopsy is possible with special forceps less than 2 mm in diameter. Recently, TNE has been used for screening endoscopy in Far East Asia, including Japan. In most controlled studies, TNE was found to have better patient tolerance when compared to unsedated endoscopy. Nasal pain is the most significant symptom associated with endoscopic procedures but can be reduced with nasal pretreatment. Despite the potential advantage of TNE, it is not common in Western countries, usually due to a lack of training in the technique and a lack of awareness of its potential advantages. This paper briefly reviews the technical considerations as well as the potential advantages and limitations of TNE with ultra-thin scopes.

Does capsule endoscopy have an added value in patients with perianal disease and a negative work up for Crohn's disease?

AIM: To investigate the role of capsule endoscopy in patients with persistent perianal disease and negative conventional work up for Crohn’s disease (CD).

METHODS: Patients with perianal disease (abscesses, fistulas, recurrent fissures) were evaluated for underlying CD. Patients who had a negative work up, defined as a negative colonoscopy with a normal ileoscopy or a normal small bowel series or a normal CT/MR enterography, underwent a Pillcam study of the small bowel after signing informed consent. Patients using nonsteroidal anti-inflammatory drugs or who had a history of inflammatory bowel disease or rheumatic disease were excluded.

RESULTS: We recruited 26 patients aged 21-61 years (average 35.6 years), 17 males and 9 females. One case could not be evaluated since the capsule did not leave the stomach. In 6 of 25 (24%) patients with a negative standard work up for Crohn's disease, capsule endoscopy (CE) findings were consistent with Crohn's disease of the small bowel. Family history of CD, white blood cell, hemoglobin, erythrocyte sedimentation rate or C-reactive protein did not predict a diagnosis of CD. Capsule endoscopy findings led to a change in treatment.

CONCLUSION: In patients with perianal disease and a negative conventional work up to exclude CD, CE leads to incremental diagnostic yield of 24%.

Gastrointestinal stromal tumor of the stomach: How to manage?

Gastrointestinal stromal tumor (GIST) is one of the most common malignant mesenchymal tumors of the stomach. Prognosis of this disease is related to tumor size and mitotic activity and early diagnosis is the only way to improve it. Diagnosis of GIST always requires histological and immunohistochemical confirmation as no imaging modalities can diagnose it conclusively. Endoscopic forceps biopsy results are frequently negative. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is a technique which allows tissue samples to be obtained with minimal risks and is accurate in the diagnosis of GIST. From the point of view of the endoscopist, aggressive use of EUS-FNA is the only promising way to allow early diagnosis and early treatment of this disease.

Mucosal-incision assisted biopsy for suspected gastric gastrointestinal stromal tumors

To evaluate the diagnostic yield of the procedure, mucosal-incision assisted biopsy (MIAB), for the histological diagnosis of gastric gastrointestinal stromal tumor (GIST), we performed a retrospective review of the 27 patients with suspected gastric GIST who underwent MIAB in our hospitals. Tissue samples obtained by MIAB were sufficient to make a histological diagnosis (diagnostic MIAB) in 23 out of the 27 patients, where the lesions had intraluminal growth patterns. Alternatively, the samples were insufficient (non-diagnostic MIAB) in remaining 4 patients, three of whom had gastric submucosal tumor with extraluminal growth patterns. Although endoscopic ultrasound and fine needle aspiration is the gold standard for obtaining tissue specimens for histological and cytological analysis of suspected gastric GISTs, MIAB can be used as an alternative method for obtaining biopsy specimens of lesions with an intraluminal growth pattern.

Improved endoscopic retrograde cholangiopancreatography brush increases diagnostic yield of malignant biliary strictures

AIM

To determine if a new brush design could improve the diagnostic yield of biliary stricture brushings.

METHODS

Retrospective chart review was performed of all endoscopic retrograde cholangiopancreatography procedures with malignant biliary stricture brushing between January 2008 and October 2012. A standard wire-guided cytology brush was used prior to protocol implementation in July 2011, after which, a new 9 French wire-guided cytology brush (Infinity sampling device, US Endoscopy, Mentor, OH) was used for all cases. All specimens were reviewed by blinded pathologists who determined whether the sample was positive or negative for malignancy. Cellular yield was quantified by describing the number of cell clusters seen.

RESULTS

Thirty-two new brush cases were compared to 46 historical controls. Twenty-five of 32 (78%) cases in the new brush group showed abnormal cellular findings consistent with malignancy as compared to 17 of 46 (37%) in the historical control group (P = 0.0003). There was also a significant increase in the average number of cell clusters of all sizes (21.1 vs 9.9 clusters, P = 0.0007) in the new brush group compared to historical controls.

CONCLUSION

The use of a new brush design for brush cytology of biliary strictures shows increased diagnostic accuracy, likely due to improved cellular yield, as evidenced by an increase in number of cellular clusters obtained.

Risk factors for postoperative bleeding after gastric endoscopic submucosal dissection in patients under antithrombotics

AIM: To evaluate the risk factors for postoperative bleeding after gastric endoscopic submucosal dissection (ESD) based on the latest guidelines.

METHODS: A total of 262 gastric neoplasms were treated by ESD at our center during a 2-year period from October 2012. We analyzed the data of these cases retrospectively to identify the risk factors for post-ESD bleeding.

RESULTS: Of the 48 (18.3%) cases on antithrombotic treatment, 10 were still receiving antiplatelet drugs perioperatively, 13 were on heparin replacement after oral anticoagulant withdrawal, and the antithrombotic therapy was discontinued perioperatively in 25 cases. Postoperative bleeding occurred in 23 cases (8.8%). The postoperative bleeding rate in the heparin replacement group was 61.5%, significantly higher than that in the non-antithrombotic therapy group (6.1%). Univariate analysis identified history of antithrombotic drug use, heparin replacement, hemodialysis, cardiovascular disease, diabetes mellitus, elevated prothrombin time-international normalized ratio, and low hemoglobin level on admission as risk factors for post ESD bleeding. Multivariate analysis identified only heparin replacement (OR = 13.7, 95%CI: 1.2-151.3, P = 0.0329) as a significant risk factor for post-ESD bleeding.

CONCLUSION: Continued administration of antiplatelet agents, based on the guidelines, was not a risk factor for postoperative bleeding after gastric ESD; however, heparin replacement, which is recommended after withdrawal of oral anticoagulants, was identified as a significant risk factor.

Management of bleeding and artificial gastric ulcers associated with endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD), an endoscopic procedure for the treatment of gastric epithelial neoplasia without lymph node metastases, spread rapidly, primarily in Japan, starting in the late 1990s. ESD enables en bloc resection of lesions that are difficult to resect using conventional endoscopic mucosal resection (EMR). However, in comparison to EMR, ESD requires a high level of endoscopic competence and a longer resection time. Thus, ESD is associated with a higher risk of adverse events, including intraoperative and postoperative bleeding and gastrointestinal perforation. In particular, because of a higher incidence of intraoperative bleeding with mucosal incision and submucosal dissection, which are distinctive endoscopic procedures in ESD, a strategy for endoscopic hemostasis, mainly by thermo-coagulation hemostasis using hemostatic forceps, is important. In addition, because of iatrogenic artificial ulcers that always form after ESD, endoscopic hemostasis and appropriate pharmacotherapy during the healing process are essential.

Efficacy and safety of endoscopic prophylactic treatment with undiluted cyanoacrylate for gastric varices

AIM: To evaluate the efficacy and safety of undiluted N-butyl-2 cyanoacrylate plus methacryloxysulfolane (NBCM) as a prophylactic treatment for gastric varices (GV) bleeding.

METHODS: This prospective study was conducted at a single tertiary-care teaching hospital between October 2009 and March 2013. Patients with portal hypertension (PH) and GV, with no active gastrointestinal bleeding, were enrolled in primary prophylactic treatment with NBCM injection without lipiodol dilution. Initial diagnosis of GV was based on endoscopy and confirmed with endosonography (EUS); the same procedure was used after treatment to confirm eradication of GV. After puncturing the GV with a regular injection needle, 1 mL of undiluted NBCM was injected intranasally into GV. The injection was repeated as necessary to achieve eradication or until a maximum total volume of 3 mL of NBCM had been injected. Patients were followed clinically and evaluated with endoscopy at 3, 6 and 12 mo. Later follow-ups were performed yearly. The main outcome measures were efficacy (GV eradication), safety (adverse events related to cyanoacrylate injection), recurrence, bleeding from GV and mortality related to GV treatment.

RESULTS: A total of 20 patients (15 male) with PH and GV were enrolled in the study and treated with undiluted NBCM injection. Only 2 (10%) patients had no esophageal varices (EV); 18 (90%) patients were treated with endoscopic band ligation to eradicate EV before inclusion in the study. The patients were followed clinically and endoscopically for a median of 31 mo (range: 6-40 mo). Eradication of GV was observed in all patients (13 patients were treated with 1 session and 7 patients with 2 sessions), with a maximum injected volume of 2 mL NBCM. One patient had GV recurrence, confirmed by EUS, at 6-mo follow-up, and another had late recurrence with GV bleeding after 35 mo of follow-up; overall, GV recurrence was observed in 2 patients (10%), after 6 and 35 mo of follow-up, and GV bleeding rate was 5% (1 patient). Mild epigastric pain was reported by 3 patients (15%). No mortality or major complications, including embolism, or damage to equipment were observed.

CONCLUSION: Endoscopic injection with NBCM, without lipiodol, may be a safe and effective treatment for primary prophylaxis of gastric variceal bleeding.

Narrow-band imaging observation of colorectal lesions using NICE classification to avoid discarding significant lesions

AIM: To assess the risk of failing to detect diminutive and small colorectal cancers with the “resect and discard” policy.

METHODS: Patients who received colonoscopy and polypectomy were recruited in the retrospective study. Probable histology of the polyps was predicted by six colonoscopists by the use of NICE classification. The incidence of diminutive and small colorectal cancers and their endoscopic features were assessed.

RESULTS: In total, we found 681 cases of diminutive (1-5 mm) lesions in 402 patients and 197 cases of small (6-9 mm) lesions in 151 patients. Based on pathology of the diminutive and small polyps, 105 and 18 were non-neoplastic polyps, 557 and 154 were low-grade adenomas, 18 and 24 were high-grade adenomas or intramucosal/submucosal (SM) scanty invasive carcinomas, 1 and 1 were SM-d carcinoma, respectively. The endoscopic features of invasive cancer were classified as NICE type 3 endoscopically.

CONCLUSION: The risk of failing to detect diminutive and small colorectal invasive cancer with the “resect and discard” strategy might be avoided through the use of narrow-band imaging observation with the NICE classification scheme and magnifying endoscopy.

Prevalence and clinical features of colonic diverticulosis in a Middle Eastern population

AIM: To determine the prevalence, location, associations and clinical features of colonic-diverticulosis and its role as a cause of lower-gastroenterology-bleeding.

METHODS: We retrospectively reviewed the medical records of 3649 consecutive patients who underwent a colonoscopy for all indications between 2007 and 2011 at King Khalid University Hospital, Riyadh, Saudi Arabia. The demographic data were collected retrospectively through the hospital’s information system, electronic file system, endoscopic e-reports, and manual review of the files by two research assistants. The demographic information included the age, sex, comorbidities and indication for the colonoscopy. The association among colonic polyps, comorbidities and diverticular disease was also measured.

RESULTS: A total of 270 patients out of 3649 were diagnosed with colonic diverticulosis, with a prevalence of 7.4%. The mean age was 60.82 years ± 0.833, (range 12-110). Females comprised 38.89% (95%CI: 33-44.7) of the study population. The major symptoms were rectal bleeding in 33.6%, abdominal pain in 19.3%, constipation in 12.8% and anemia in 6%. Diverticula were predominantly left-sided (sigmoid and descending colon) in 62%, right-sided in 13% and in multiple locations in 25%. There was an association between the presence of diverticulosis and adenomatous polyps (P-value < 0.001), hypertension (P-value < 0.0001) and diabetes mellitus (P-value < 0.0016). Diverticular disease was the second most common cause of lower gastrointestinal bleeding, in 33.6% (95%CI: 27.7-39.4), after internal hemorrhoids, in 44.6% (95%CI: 40.3-48.9). On multivariable logistic regression, hypertension (OR = 2.30; 95%CI: 1.29-4.10), rectal bleeding (OR = 2.57; 95%CI: 1.50-4.38), and per year increment in age (OR = 1.05; 95%CI: 1.03-1.07) were associated with diverticulosis but not with bleeding diverticular disease. Limitations: A small proportion of the patients included had colonoscopies performed as a screening test.

CONCLUSION: Colonic-diverticulosis was found to have a low prevalence, be predominantly left-sided and associated with adenomatous-polyps. Age, hypertension and rectal bleeding predict the presence of diverticular disease.

Management of abdominal and pelvic abscess in Crohn's disease

Patients with Crohn's disease may develop an abdominal or pelvic abscess during the course of their illness. This process results from transmural inflammation and penetration of the bowel wall, which in turn leads to a contained perforation and subsequent abscess formation. Management of patients with Crohn's related intra-abdominal and pelvic abscesses is challenging and requires the expertise of multiple specialties working in concert. Treatment usually consists of percutaneous abscess drainage (PAD) under guidance of computed tomography in addition to antibiotics. PAD allows for drainage of infection and avoidance of a two-stage surgical procedure in most cases. It is unclear if PAD can be considered a definitive treatment without the need for future surgery. The use of immune suppressive agents such as anti-tumor necrosis factor-α in this setting may be hazardous and their appropriate use is controversial. This article discusses the management of spontaneous abdominal and pelvic abscesses in Crohn's disease.

Management of gastric subepithelial tumors: The role of endoscopy

With the wide use of esophagogastroduodenoscopy, the incidence of gastric subepithelial tumor (SET) diagnosis has increased. While the management of large or symptomatic gastric SETs is obvious, treatment of small (≤ 3 cm) asymptomatic gastric SETs remains inconclusive. Moreover, the presence of gastrointestinal stromal tumors with malignant potential is of concern, and endoscopic treatment of gastric SETs remains a subject of debate. Recently, numerous studies have demonstrated the feasibility of endoscopic treatment of gastric SETs, and have proposed various endoscopic procedures including endoscopic submucosal dissection, endoscopic muscularis dissection, endoscopic enucleation, endoscopic submucosal tunnel dissection, endoscopic full-thickness resection, and a hybrid approach (the combination of endoscopy and laparoscopy). In this review article, we discuss current endoscopic treatments for gastric SETs as well as the advantages and limitations of this type of therapy. Finally, we predict the availability of newly developed endoscopic treatments for gastric SETs.

Assessment of disease activity in inflammatory bowel diseases: Non-invasive biomarkers and endoscopic scores

Inflammatory bowel diseases (IBD) comprise two major forms: Crohn's disease and ulcerative colitis. The diagnosis of IBD is based on clinical symptoms combined with results found in endoscopic and radiological examinations. In addition, the discovery of biomarkers has significantly improved the diagnosis and management of IBD. Several potential genetic, serological, fecal, microbial, histological and immunological biomarkers have been proposed for IBD, and they have been evaluated for clinical routine and clinical trials. Ileocolonoscopy, especially with biopsy collection, has been considered the standard method to diagnose IBD and to assess clinical activity of the disease, but it is limited to the colon and terminal ileum and is considered invasive. For this reason, non-invasive biomarkers are necessary for this type of chronic inflammatory disease, which affects mostly young individuals, as they are expected to have a long follow-up.

Examining the whole bowel, double balloon enteroscopy: Indications, diagnostic yield and complications

Double balloon enteroscopy (DBE) is an advanced type of endoscopic procedure which brings the advantage of reaching the whole small bowel using anterograde or the retrograde route. This procedure is both diagnostic and interventional for a variety of small intestinal diseases, such as vascular lesions, tumors, polyps and involvement of inflammatory bowel diseases. Main indication is the diagnosis and treatment of mid-gastrointestinal bleeding according to the recent published data all over the world. The complication rates seem to be higher than conventional procedures but growing experience is lowering them and improving the procedure to be safe and well tolerated. This review is about the technique, indications, diagnostic importance and complications of DBE according to the literature growing since 2001.

Biodegradable stent for the treatment of a colonic stricture in Crohn’s disease

Biodegradable polydioxanone stents were developed for the treatment of refractory benign esophageal strictures but have been suggested as a new therapeutic option for intestinal strictures. The primary advantage of biodegradable stents over self-expandable metallic stents is that removal is not required. There are, however, few data available on their use in the small or large bowel. We herein describe the case of a 33-year-old patient with long-standing Crohn’s disease (CD) who developed a fibrotic stricture of the sigmoid too long to be amenable to balloon dilation. The use of a biodegradable polydioxanone stent was chosen to avoid surgery. Combined endoscopic and fluoroscopic placement of the stent was technically simple, safe and clinically successful, and no recurrence of obstructive symptoms occurred during a 16-mo follow-up. Further studies are needed to evaluate the long-term efficacy and safety of biodegradable stents in the treatment of intestinal strictures, particularly in the context of CD.

Endoscopic ultrasound-guided biliary intervention in patients with surgically altered anatomy

AIM

To evaluate the efficacy of endoscopic ultrasound guided biliary drainage (EUS-BD) in patients with surgically altered anatomies.

METHODS

We performed a search of the MEDLINE database for studies published between 2001 to July 2014 reporting on EUS-BD in patients with surgically altered anatomy using the terms "EUS drainage" and "altered anatomy". All relevant articles were accessed in full text. A manual search of the reference lists of relevant retrieved articles was also performed. Only full-text English papers were included. Data regarding age, gender, diagnosis, method of EUS-BD and intervention, type of altered anatomy, technical success, clinical success, and complications were extracted and collected. Anatomic alterations were categorized as: group 1, Billroth I; group 2, Billroth II; group 4, Roux-en-Y with gastric bypass; and group 3, all other types.

RESULTS

Twenty three articles identified in the literature search, three reports were from the same group with different numbers of cases. In total, 101 cases of EUS-BD in patients with altered anatomy were identified. Twenty-seven cases had no information and were excluded. Seventy four cases were included for analysis. Data of EUS-BD in patients categorized as group 1, 2 and 4 were limited with 2, 3 and 6 cases with EUS-BD done respectively. Thirty four cases with EUS-BD were reported in group 3. The pooled technical success, clinical success, and complication rates of all reports with available data were 89.18%, 91.07% and 17.5%, respectively. The results are similar to the reported outcomes of EUS-BD in general, however, with limited data of EUS-BD in patients with altered anatomy rendered it difficult to draw a firm conclusion.

CONCLUSION

EUS-BD may be an option for patients with altered anatomy after a failed endoscopic-retrograde-cholangiography in centers with expertise in EUS-BD procedures in a research setting.

Intentional ingestions of foreign objects among prisoners: A review

The intentional ingestion of foreign objects (IIFO) is described more commonly in prison populations than in the general population, with an estimated annual incidence of 1 in 1900 inmates in our state correctional facilities. Incidents often involve ingestion of small metal objects (e.g., paperclips, razor blades) or other commonly available items like pens or eating utensils. Despite ingestion of relatively sharp objects, most episodes can be clinically managed with either observation or endoscopy. Surgery should be reserved for those with signs or symptoms of gastrointestinal perforation or obstruction. For those with a history of IIFO, efforts should focus on prevention of recurrence as subsequent episodes are associated with higher morbidity, significant healthcare and security costs. The pattern of IIFO is often repetitive, with escalation both in frequency of ingestions and in number of items ingested. Little is known about successful prevention strategies, but efforts to monitor patients and provide psychiatric care are potential best-practice strategies. This article aims to provide state-of-the art review on the topic, followed by a set of basic recommendations.

Colon capsule endoscopy: Advantages, limitations and expectations. Which novelties?

Since the first reports almost ten years ago, wireless capsule endoscopy has gained new fields of application. Colon capsule endoscopy represents a new diagnostic technology for colonic exploration. Clinical trials have shown that colon capsule endoscopy is feasible, accurate and safe in patients suffering from colonic diseases and might be a valid alternative to conventional colonoscopy in selected cases such as patients refusing conventional colonoscopy or with contraindications to colonoscopy or when colonoscopy is incomplete. Despite the enthusiasm surrounding this new technique, few clinical and randomized controlled trials are to be found in the current literature, leading to heterogeneous or controversial results. Upcoming studies are needed to prove the substantial utility of colon capsule endoscopy for colon cancer screening, especially in a low prevalence of disease population, and for other indications such as inflammatory bowel disease. Possible perspectives are critically analysed and reported in this paper.

Management of iatrogenic colorectal perforation: From surgery to endoscopy

Iatrogenic colon perforation is one the most pernicious complications for patients undergoing endoscopic screening or therapy. It is a serious but rare complication of colonoscopy. However, with the expansion of the indications for endoscopic therapies for gastrointestinal diseases, the frequency of colorectal perforation has increased. The management of iatrogenic colorectal perforation is still a challenge for many endoscopists. The methods for treating this complication vary, including conservative treatment, surgical treatment, laparoscopy and endoscopy. In this review, we highlight the etiology, recognition and treatment of colorectal iatrogenic perforation. Specifically, we shed light on the endoscopic management of this rare complication.