Effect of a Combination of Omeprazole Plus Sustained Release Baclofen Versus Omeprazole Alone on Symptoms of Patients with Gastroesophageal Reflux Disease (GERD)

Previous studies have reported the efficacy of baclofen in the treatment of Gastroesophageal Reflux Diseases (GERD). The objective of present study is to evaluate the effect of co-administration of omeprazole 20 mg/d plus sustained Release baclofen (SR baclofen) vs. omeprazole 20 mg/d plus placebo on alleviation of symptoms in patients with a diagnosis of GERD. A prospective, double blind, placebo controlled trial included 60 patients with diagnosis of GERD have been done. Patients were randomly selected to receive either SR baclofen or a placebo in addition to omeprazole 20 mg/d for a period of 2 weeks. Patients were questioned regarding heartburn, regurgitation, chest pain and hoarseness at the base line and after 2 weeks. All patients tolerated the medications and no patients failed to complete the study due to adverse drug reactions. A total of 53 patients completed the study, 25 in SR baclofen and 28 in placebo group. After 2 weeks, 1 patient (4%) in SR baclofen group reported heartburn and regurgitation. However 13(46.4%) and 15 (53.6%) of patients in the placebo group had heartburn and regurgitation respectively. The analysis of the data shows that there is a significant difference between the two groups in heartburn and regurgitation (p < 0.0001, p < 0.0001 respectively). Statistical analysis revealed a significant difference in two groups regarding total GERD score (p <0.0001). The results of the present study suggest that a combination of SR baclofen and omeprazole may be a more effective treatment for heartburn and regurgitation than omeprazole alone.

Texture and color based image segmentation and pathology detection in capsule endoscopy videos

This paper presents an in-depth study of several approaches to exploratory analysis of wireless capsule endoscopy images (WCE). It is demonstrated that versatile texture and color based descriptors of image regions corresponding to various anomalies of the gastrointestinal tract allows their accurate detection of pathologies in a sequence of WCE frames. Moreover, through classification of single pixels described by texture features of their neighborhood, the images can be segmented into homogeneous areas well matched to the image content. For both, detection and segmentation tasks the same procedure is applied which consists of features calculation, relevant feature subset selection and classification stages. This general three-stage framework is realized using various recognition strategies. In particular, the performance of the developed Vector Supported Convex Hull classification algorithm is compared against Support Vector Machines run in configuration with two different feature selection methods.

Present and future status of flexible spectral imaging color enhancement and blue laser imaging technology

The usefulness of flexible spectral imaging color enhancement (FICE) has been reported for evaluating the esophagus, stomach, and small and large intestine. Higher contrast is shown between cancer and the surrounding mucosa in the esophagus and stomach and may facilitate the detection of gastric cancers missed by white light imaging alone. The surface patterns of gastric mucosa are clearly visualized in non-malignant areas but are irregular and blurred in malignant areas, leading to clear demarcation. Capsule endoscopy with FICE detects angiodysplasia and erosions of the small intestine. The surface and vascular pattern with FICE is useful for the differential diagnosis of colorectal polyps. However, FICE remains somewhat poor at visualizing mucosal microvasculature on a tumor surface. Narrow-band imaging (NBI) is dark in observing whole gastric mucosa and poor at visualizing mucosal microstructure. Blue laser imaging (BLI) has the potential to resolve these limitations. Narrow-band laser light combined with white light shows irregular microvessels on both differentiated and undifferentiated gastric cancer similar to those using NBI. In addition, irregular surface patterns including minute white zones are clearly seen on the uneven surface of differentiated lesions, resulting in exclusion of undifferentiated lesions. Using both distant and close-up views, a high contrast between green intestinal metaplasia and brown gastric cancer may lead to early detection of gastric cancers and determination of a demarcation line. BLI produces high-contrast images in esophageal cancer with clear vision of intrapapillary capillary loops and also predicts the histopathological diagnosis and depth of invasion in colorectal neoplasms.

Basic technique in endoscopic ultrasound-guided fine needle aspiration for solid lesions: What needle is the best?

Basic technique for endoscopic ultrasound (EUS) of solid lesions has developed during 30 years of EUS, as endoscopes and accessory equipment, particularly needles, have been developed. Systematic high-quality examinations require understanding and planning. Needles used for EUS-guided fine needle aspiration (FNA) have gone through many improvements; some 18 characteristics of any needle are presented and these come under consideration whenever choosing the best needle for each procedure. The bright future of EUS and FNA for solid lesions currently still leaves much room for continued developments.

Prognositic factors and clinicopathologic characteristics of small gastrointestinal stromal tumor of the stomach: a retrospective analysis of 31 cases in one center

Objective

To analyze the clinicopathologic characteristics and prognostic factors of small gastrointestinal stromal tumor (GIST) of the stomach.

Methods

A total of 31 small gastric GIST patients, including 10 males and 21 females, with a median age of 58 years (37-81 years), who underwent surgery at any time from 1999 to 2012 were included in this study. The clinical records of the patients were analyzed retrospectively.

Results

Abdominal discomfort and pain (10 cases, 32.3%, respectively) were the two most common complaints among the patients. All patients received surgery, 11 received gastric wedge resection, 11 received subtotal gastrectomy, 5 received laparoscopic gastric wedge resection, and 4 received endoscopic submucosal dissection. No severe adverse complication was observed. A total of 29 patients (93.5%) were followed up. During the follow-up, 2 patients were found to exhibit tumor recurrence, and 1 patient had liver metastases. One patient died of tumor progression, while another died of another malignant tumor. Median progression free survival (PFS) time was 120.3 months, and median overall survival (OS) time was 130.4 months.

Conclusion

Small gastric GIST has better prognosis. Surgery is the best choice for therapy. Micro-invasive procedures are safe and effective for elective patients. Tumor necrosis, tumor bleeding, and muscle invasion are potential prognostic factors of small gastric GIST.

Single balloon enteroscopy for diagnosis and treatment of small intestinal diseases

AIM: To evaluate the value of single balloon enteroscopy (SBE) in the diagnosis and treatment of small intestinal diseases.

METHODS: A total of 406 patients (255 males and 151 females) with suspected or confirmed small intestinal diseases underwent 629 SBE examinations (356 via the oral approach and 273 via the anal approach). A total of 292 cases (139 patients) underwent endoscopic therapy.

RESULTS: Of all the 406 cases, 300 were diagnosed with small intestinal diseases, and the diagnostic yield was 73.9% (300/406). The procedure time was 54.18 min ± 11.870 min for the oral approach, and 64.53 min ± 11.821 min for the anal approach. The intubation depth was 236.47 cm ± 90.397 cm for the oral approach, and 184.18 cm ± 65.716 cm for the anal approach. The main lesions were Peutz-Jeghers syndrome (119 cases), small intestinal inflammatory changes (45 cases), small intestinal ulcer (23 cases), Crohn's disease (23 cases), carcinoma of the small intestine (17 cases), small intestinal stromal tumors (15 cases), small bowel polyps (13 cases), and Meckel's diverticulum (10 cases). A total of 139 patients underwent 292 endoscopic therapies, of whom 112 underwent the resection of polyps, 9 underwent endoscopic hemostatic therapy, 16 underwent small intestinal stent implantation, and 2 underwent foreign body removal.

CONCLUSION: SBE has a high diagnostic yield in small intestinal diseases and can be used therapeutically, representing a safe and reliable method for diagnosis and treatment of intestinal diseases.

Two surgical procedures for esophagogastric variceal bleeding in patients with portal hypertension

AIM: To determine the clinical value of a splenorenal shunt plus pericardial devascularization (PCVD) in portal hypertension (PHT) patients with variceal bleeding.

METHODS: From January 2008 to November 2012, 290 patients with cirrhotic portal hypertension were treated surgically in our department for the prevention of gastroesophageal variceal bleeding: 207 patients received a routine PCVD procedure (PCVD group), and 83 patients received a PCVD plus a splenorenal shunt procedure (combined group). Changes in hemodynamic parameters, rebleeding, encephalopathy, portal vein thrombosis, and mortality were analyzed.

RESULTS: The free portal pressure decreased to 21.43 ± 4.35 mmHg in the combined group compared with 24.61 ± 5.42 mmHg in the PCVD group (P < 0.05). The changes in hemodynamic parameters were more significant in the combined group (P < 0.05). The long-term rebleeding rate was 7.22% in the combined group, which was lower than that in the PCVD group (14.93%), (P < 0.05).

CONCLUSION: Devascularization plus splenorenal shunt is an effective and safe strategy to control esophagogastric variceal bleeding in PHT. It should be recommended as a first-line treatment for preventing bleeding in PHT patients when surgical interventions are considered.

Magnetic resonance evaluations of biliary malignancy and condition at high-risk for biliary malignancy: Current status

Tumors of the biliary tree are relatively rare; but their incidence is rising worldwide. There are several known risk factors for bile duct cancers, and these are seem to be associated with chronic inflammation of the biliary epithelium. Herein, 2 risk factors have been discussed, primary sclerosing cholangitis and reflux of pancreatic juice into the bile duct, as seen in such as an abnormal union of the pancreatic-biliary junction because magnetic resonance imaging (MRI) is used widely and effectively in the diagnosis of these diseases. When biliary disease is suspected, MRI can often help differentiate between benignity and malignancy, stage tumors, select surgical candidates and guide surgical planning. MRI has many advantages over other modalities. Therefore, MRI is a reliable noninvasive imaging tool for diagnosis and pre-surgical evaluation of bile duct tumors. Nowadays remarkable technical advances in magnetic resonance technology have expanded the clinical applications of MRI in case of biliary diseases. In this article, it is also discussed how recent developments in MRI contributes to the diagnosis of the bile duct cancer and the evaluation of patients with risk factors affecting bile duct cancer.

Appropriateness, endoscopic findings and contributive yield of pediatric gastrointestinal endoscopy

AIM

To determine the predictability of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and American Society for Gastrointestinal Endoscopy (ASGE) guideline with regard to appropriate endoscopic practice in children, positive endoscopic findings and contributive yield in clinical practice.

METHODS

This was a descriptive, retrospective analysis, conducted at the Department of Paediatrics, University Malaya Medical Centre, Malaysia. All children who had esophagogastroduodenoscopy (EGD) and colonoscopy from January 2008 to June 2011 were included. An endoscopy was considered appropriate when its indication complied with the NASPGHAN and ASGE guideline. All endoscopic findings were classified as either positive (presence of any endoscopic or histologic abnormality) or negative (no or minor abnormality, normal histology); effecting a positive contributive (a change in therapeutic decisions or prognostic consequences) or non-contributive yield (no therapeutic or prognostic consequences).

RESULTS

Overall, 76% of the 345 procedures (231 EGD alone, 26 colonoscopy alone, 44 combined EGD and colonoscopy) performed in 301 children (median age 7.0 years, range 3 months to 18 years) had a positive endoscopic finding. Based on the NASPGHAN and ASGE guideline, 99.7% of the procedures performed were considered as appropriate. The only inappropriate procedure (0.3%) was in a child who had EGD for assessment of the healing of gastric ulcer following therapy in the absence of any symptoms. The overall positive contributive yield for a change in diagnosis and/or management was 44%. The presence of a positive endoscopic finding was more likely to effect a change in the therapeutic plan than an alteration of the initial diagnosis. A total of 20 (5.8%) adverse events were noted, most were minor and none was fatal.

CONCLUSION

The NASPGHAN and ASGE guideline is more likely to predict a positive endoscopic finding but is less sensitive to effect a change in the initial clinical diagnosis or the subsequent therapeutic plan.

Clinically detected gastroenteropancreatic neuroendocrine tumors are on the rise: Epidemiological changes in Germany

AIM: To study the epidemiologic changes of gastroenteropancreatic neuroendocrine tumors (GEP-NET) in Germany, we analyzed two time periods 1976-1988 and 1998-2006.

METHODS: We evaluated epidemiological data of GEP-NET from the former East German National Cancer Registry (DDR Krebsregister, 1976-1988) and its successor, the Joint Cancer Registry (GKR, 1998-2006), which was founded after German reunification. Due to a particularly substantial database the epidemiological data from the federal states of Mecklenburg-Western Pomerania, Saxony, Brandenburg and Thuringia, covering a population of more than 10.8 million people, were analyzed. Survival probabilities were calculated using life table analysis. In addition, GEP-NET patients were evaluated for one or more second (non-GEP-NET) primary malignancies.

RESULTS: A total of 2821 GEP neuroendocrine neoplasms were identified in the two registries. The overall incidence increased significantly between 1976 and 2006 from 0.31 (per 100.000 inhabitants per year) to 2.27 for men and from 0.57 to 2.38 for women. In the later period studied (2004-2006), the small intestine was the most common site. Neuroendocrine (NE) neoplasms of the small intestine showed the largest absolute increase in incidence, while rectal NE neoplasms exhibited the greatest relative increase. Only the incidence of appendiceal NET in women showed little change between 1976 and 2006. Overall survival of patients varied for sex, tumor site and the two periods studied but improved significantly over time. Interestingly, about 20% of the GEP-NET patients developed one or more second malignancies. Their most common location was the gastrointestinal tract. GEP-NET patients without second malignancies fared better than those with one or more of them.

CONCLUSION: The number of detected GEP-NET increased about 5-fold in Germany between 1976 and 2006. At the same time, their anatomic distribution changed, and the survival of GEP-NET patients improved significantly. Second malignancies are common and influence the overall survival of GEP-NET patients. Thus, GEP-NET warrant our attention as well as intensive research on their tumorigenesis.

Endoscopic lithotripsy for gastric bezoars by Nd:YAG laser-ignited mini-explosive technique

Until now, there still has no standard treatment option to deal with gastric bezoars. This respective study was conducted to evaluate the safety and efficiency of Nd:YAG laser-ignited mini-explosive technique for the treatment of gastric bezoars. Two hundred sixty patients with 285 gastric bezoars were treated by endoscopic lithotripsy with Nd:YAG laser-ignited mini-explosive technique. Among the 260 patients, the 284 gastric bezoars of the 259 patients completely disappeared, with the cure rate of 99.6% after 1-2 treatments at 2-4 weeks follow-up. Only one patient, who was cured by surgery, had gastric perforation during the explosion. No intraoperative or delayed complications was found in the other 259 patients. The endoscopic lithotripsy with Nd:YAG laser-ignited mini-explosive technique is an effective, safe, and promising alternative for gastric bezoars.

Follow-up intervals for precancerous colorectal conditions

Colorectal cancer screening is useful not only in detecting colorectal cancer at an early stage, but also in finding people with precancerous conditions. Proper interference in precancerous patients is good for reducing the occurrence of cancer. The precancerous conditions vary from patient to patient, so is the risk of malignant transformation. However, the lack of clear definition and classification for precancerous colorectal conditions in China makes standard treatment and follow-up management of these people difficult. This review summarizes basic definition and classification for precancerous colorectal conditions, clarifies different risks among people, and introduces the latest progress in follow-up intervals worldwide.

Double balloon enteroscopy vs capsule endoscopy for obscure gastrointestinal bleeding: A Meta-analysis

AIM: To compare the diagnostic value of double balloon enteroscopy versus capsule endoscopy in obscure gastrointestinal bleeding to help choose the optimal diagnostic strategy for this clinical condition.

METHODS: A comprehensive literature search was performed in PubMed, Medline, Vip database, Wanfang database, China National Knowledge Infrastructure database (CNKI) and Chinese Biomedical Literature database (CBM) of randomized controlled clinical trial using double balloon enteroscopy and capsule endoscopy for the diagnosis of obscure gastrointestinal bleeding dating from January 2003 to January 2013. Data of included studies were extracted and their quality evaluated independently by two reviewers. RevMan5 software was used for Meta-analysis.

RESULTS: Based on inclusion criteria, 13 prospective randomized controlled clinical studies were included in this study. Meta-analysis showed no significant difference in the diagnostic rate between double balloon enteroscopy and capsule endoscopy for obscure gastrointestinal bleeding. Subgroup analysis showed that the diagnostic rate had no significant difference between enteroscopy in patients with positive results in previous capsule endoscopy and enteroscopy in unselected patients.

CONCLUSION: Double balloon enteroscopy and capsule endoscopy have similar diagnostic results in patients with obscure gastrointestinal bleeding, and enteroscopy after capsule endoscopy can not improve the diagnostic rate.

Stents for benign and malignant esophageal strictures

This paper presents commentaries on endotherapy for esophageal perforation/leaks; treatment of esophageal perforation; whether esophageal stents should be used for treating benign esophageal strictures; what determines the optimal stenting period in benign esophageal strictures/leaks; how to choose an esophageal stent; how a new fistula secondary to an esophageal stent should be treated; which strategy should be adopted when a fistula of a cervical anastomosis occurs; intralesional steroids for refractory esophageal strictures; balloon and bougie dilators for esophageal strictures and predictors of response to dilation; whether refractory strictures from different etiologies respond differently to endotherapy; surgical therapy of benign esophageal strictures; and whether stenoses following severe esophageal burns should be treated by esophageal resection or esophageal bypass.

Giant rectal villous adenoma: Surgical approach with rectal eversion and perianal coloanal anastomosis

INTRODUCTION

Colorectal cancer is an important cause of death. Most cases of colon and rectal cancer arise from a preexisting adenomatous polyp. However, if colorectal polyps are very large or not accessible for endoscopic ablation, or if they cannot be removed without an increased risk of perforation, surgical procedures are required.

PRESENTATION OF CASE

The case of a patient with a giant villous adenoma of the rectum is described. The patient had diarrhea for 2 years associated with asthenia. Colonoscopy revealed a sessile lesion in the rectum measuring 14cm in the largest diameter. Rectal eversion technique was used, resecting the lesion under direct visibility and an external coloanal anastomosis was performed. Surgery was satisfactory and the resection margins were free.

DISCUSSION

Removal of these polyps should be performed aiming to reduce the incidence of colorectal cancer, as well as to control local and systemic symptoms, such as diarrhea and fluid and electrolyte disorders, mainly in villous adenomas. Various surgical techniques are proposed, but in extensive circumferential lesions of the rectum they are difficult to apply. The rectal stump eversion technique was described by Maunsell (1892), for rectal cancer.

CONCLUSION

Eversion of the rectal stump and external coloanal anastomosis may be a good surgical alternative for resecting giant rectal adenomas.

Gastrointestinal bleeding in patients with ventricular assist devices: what every cardiac nurse should know

Patients with end-stage heart failure are increasingly being treated with implantation of a long-term ventricular assist device. As the use of these devices has grown, health care providers have been faced with managing clinically significant gastrointestinal bleeding in this population. Gastrointestinal bleeding is not uncommon and is reported to occur in 13% to 44% of patients treated with ventricular assist devices. Interestingly, because patients with ventricular assist devices are housed on units accustomed to managing the device, cardiac nurses are often asked about the management of gastrointestinal bleeding. This article describes the possible causes of, the array of diagnostic procedures for, and treatments for this complication. It is critical to develop an understanding of this topic so cardiac nurses can partner with other subspecialty groups to manage this population.

[Does endoscopist fatigue play a role in incomplete colonoscopies and detection of polypoid lesions?]

INTRODUCTION

Nowadays, the possible effect of endoscopist fatigue on the results of colonoscopies is under discussion. We aimed to analyze possible differences in cecal intubation and the polyp and adenoma detection rate, depending on whether colonoscopies were performed at the beginning or at the end of the daily endoscopy session and to analyze the influence of the queue position on the detection rate.

PATIENTS AND METHODS

A retrospective study was performed with 1,000 ambulatory and consecutive colonoscopies, divided into 2 groups: «early» and «late» procedures. A total of 95 colonoscopies were excluded due to poor colon cleansing. After confirming that patient characteristics were homogenous in the two groups, we compared the frequency of complete colonoscopies and the polyp and adenoma detection rate. Possible differences between the 2 groups in the polyp detection rate according to the colonoscopy schedule were analyzed.

RESULTS

The overall polyp and adenoma detection rates were 44.2 and 30.5%, respectively, with no significant differences among 13 different endoscopists; polyps: p = 0.21; adenomas: p=0.63. No significant differences were found between the «early group» (n= 532) and the «late group» (n = 373) in the rates of complete colonoscopies [97.2 vs 99.4% (p=0.92)], the polyp detection rate [45.9 vs 41.8% (p=0.23)], the adenoma detection rate [30.8 vs 30% (p=0.80)] or the serrated adenoma rate [2.1% vs 1.6% (p=0.62)]. The lesion detection rate did not vary in relation to the «queue position»: polyps [p = 0.60, and adenomas: p = 0.83.

CONCLUSIONS

In our series, endoscopist fatigue at the end of the day had no influence on the complete colonoscopy rate or on the polyp and adenoma detection rate. There were no differences in the number of polypoid lesions detected according to the timing of the colonoscopy schedule.

Endoscopic papillary large balloon dilation for the removal of bile duct stones

Endoscopic papillary large balloon dilation (EPLBD) with endoscopic sphincterotomy (EST) has been widely used as the alternative to EST along with endoscopic mechanical lithotripsy (EML) for the removal of large or difficult bile duct stones. Furthermore, EPLBD without EST was recently introduced as its simplified alternative technique. Thus, we systematically searched PubMed, Medline, the Cochrane Library and EMBASE, and analyzed all gathered data of EPLBD with and without EST, respectively, by using a single standardized definition, reviewing relevant literatures, published between 2003 and June 2013, where it was performed with large-diameter balloons (12-20 mm). The outcomes, including the initial success rate, the rate of needs for EML, and the overall success rate, and adverse events were assessed in each and compared between both of two procedures: “EPLBD with EST” and “EPLBD without EST”. A total of 2511 procedures from 30 published articles were included in EPLBD with EST, while a total of 413 procedures from 3 published articles were included in EPLBD without EST. In the results of outcomes, the overall success rate was 96.5% in EPLBD with EST and 97.2% in EPLBD without EST, showing no significant difference between both of them. The initial success rate (84.0% vs 76.2%, P < 0.001) and the success rate of EPLBD without EML (83.2% vs 76.7%, P = 0.001) was significantly higher, while the rate of use of EML was significantly lower (14.1% vs 21.6%, P < 0.001), in EPLBD with EST. The rate of overall adverse events, pancreatitis, bleeding, perforation, other adverse events, surgery for adverse events, and fatal adverse events were 8.3%, 2.4%, 3.6%, 0.6%, 1.7%, 0.2% and 0.2% in EPLBD with EST and 7.0%, 3.9%, 1.9%, 0.5%, 0.7%, 0% and 0% in EPLBD without EST, respectively, showing no significant difference between both of them. In conclusion, recent accumulated results of EPLBD with or even without EST suggest that it is a safe and effective procedure for the removal of large or difficult bile duct stones without any additional risk of severe adverse events, when performed under appropriate guidelines.

Assessment of the diagnostic performance and interobserver variability of endocytoscopy in Barrett’s esophagus: A pilot ex-vivo study

AIM: To investigate a classification of endocytoscopy (ECS) images in Barrett’s esophagus (BE) and evaluate its diagnostic performance and interobserver variability.

METHODS: ECS was applied to surveillance endoscopic mucosal resection (EMR) specimens of BE ex-vivo. The mucosal surface of specimen was stained with 1% methylene blue and surveyed with a catheter-type endocytoscope. We selected still images that were most representative of the endoscopically suspect lesion and matched with the final histopathological diagnosis to accomplish accurate correlation. The diagnostic performance and inter-observer variability of the new classification scheme were assessed in a blinded fashion by physicians with expertise in both BE and ECS and inexperienced physicians with no prior exposure to ECS.

RESULTS: Three staff physicians and 22 gastroenterology fellows classified eight randomly assigned unknown still ECS pictures (two images per each classification) into one of four histopathologic categories as follows: (1) BEC1-squamous epithelium; (2) BEC2-BE without dysplasia; (3) BEC3-BE with dysplasia; and (4) BEC4-esophageal adenocarcinoma (EAC) in BE. Accuracy of diagnosis in staff physicians and clinical fellows were, respectively, 100% and 99.4% for BEC1, 95.8% and 83.0% for BEC2, 91.7% and 83.0% for BEC3, and 95.8% and 98.3% for BEC4. Interobserver agreement of the faculty physicians and fellows in classifying each category were 0.932 and 0.897, respectively.

CONCLUSION: This is the first study to investigate classification system of ECS in BE. This ex-vivo pilot study demonstrated acceptable diagnostic accuracy and excellent interobserver agreement.

Clinical practice of endoscopic submucosal dissection for early colorectal neoplasms by a colonoscopist with limited gastric experience

Objectives. Endoscopic submucosal dissection (ESD) for early colorectal neoplasms is regarded as a difficult technique and should commence after receiving the experiences of ESD in the stomach. The implementation of colorectal ESD in countries where early gastric cancer is uncommon might therefore be difficult. The aim is to delineate the feasibility and the learning curve of colorectal ESD performed by a colonoscopist with limited experience of gastric ESD. Methods. The first fifty cases of colorectal ESD, which were performed by a single colonoscopist between July 2010 and April 2013, were enrolled. Results. The mean of age was 64 (±9.204) years with mean size of neoplasm at 33 (±12.63) mm. The mean of procedure time was 70.5 (±48.9) min. The rates of en bloc resection, R0 resection, and curative resection were 86%, 86%, and 82%, respectively. Three patients had immediate perforation, but no patient developed delayed perforation or delayed bleeding. Conclusion. Our result disclosed that it is feasible for colorectal ESD to be performed by a colonoscopist with little experience of gastric ESD through satisfactory training and adequate case selection.

Update on the pathogenesis and clinical treatment of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a clinically common chronic disease which seriously lowers patient's quality of life. Despite many studies on GERD, there has been no consensus regarding its pathogenesis. Various treatments have been developed and used for clinical purposes based on the traditional Chinese and Western medicine theories. This paper summarizes the recent progress in understanding the pathogenesis and clinical treatment of GERD.

Severe acute pancreatitis complicated with gastrointestinal dysfunction: Pathogenesis, diagnosis and treatment

Severe acute pancreatitis (SAP) is often associated with gastrointestinal dysfunction, leading to gastrointestinal motility disorders and even gastrointestinal failure, which has an important effect on SAP progression and prognosis, directly influences the outcome of treatment, is an important cause of death in patients with SAP, and moreover, has been one of the important prognostic factors for SAP. This review aims to discuss the pathophysiology, pathogenesis, diagnosis and treatment of SAP with gastrointestinal dysfunction.

Clinical value of double balloon endoscopy in small intestinal diseases

AIM: To evaluate the diagnostic and therapeutic value and safety of double balloon endoscopy (DBE) in small intestinal diseases.

METHODS: A retrospective analysis of 123 patients who underwent DBE under conscious sedation anesthesia with suspected small intestinal diseases from January 2009 to February 2013 was performed. Oral and anal DBE was performed in 52 and 55 patients, respectively, while 16 patients underwent a combination of both approaches. Endoscopic tissue biopsy of suspicious lesions was performed routinely.

RESULTS: The overall diagnostic yield of DBE was 75.6% (93/123), with nonspecific intestinal inflammations in 37 patients and Crohn's diseases in 17 patients. There were benign or malignant tumors in 13 patients, including small intestine adenocarcinoma in 5 patients, stromal tumors and lymphomas in 3, lipomas in 2, and polyps in 11 (including inflammatory polyps in 8 and Peutz-Jeghers syndrome in 3), vascular diseases in 6 (including vascular malformations in 4 and angiotelectasia in 2), ulcers in 4 and other lesions in 5 (including lymphangiectasia, small intestinal diverticulum, Behcet's disease, entericintussusception and portal hypertensive enteropathy). In addition, there were three cases of external compressive lesions. The overall therapeutic yield of DBE was 9.8% (12/123), including endoscopic snare and electric coagulation or cutting in all polyps and clipping (with a titanium clip) in one case of vascular malformation with active bleeding. There were no severe complications such as bleeding, perforation, and pancreatitis.

CONCLUSION: DBE is a method with high diagnostic value, safety and reliability for small intestinal diseases, and can be used for endoscopic treatment.

Prevalence, correlates and outcomes of gastric antral vascular ectasia in systemic sclerosis: a EUSTAR case-control study

OBJECTIVE

To estimate the prevalence, determine the subgroups at risk, and the outcomes of patients with systemic sclerosis (SSc) and gastric antral vascular ectasia (GAVE).

METHODS

We queried the European League Against Rheumatism Scleroderma Trials and Research (EUSTAR) network for the recruitment of patients with SSc-GAVE. Each case was matched for cutaneous subset and disease duration with 2 controls with SSc recruited from the same center, evaluated at the time the index case made the diagnosis of GAVE. SSc characteristics were recorded at the time GAVE occurred and the last observation was collected to define the outcomes.

RESULTS

Forty-nine patients with SSc and GAVE were included (24 with diffuse cutaneous SSc) and compared to 93 controls with SSc. The prevalence of GAVE was estimated at about 1% of patients with SSc. By multivariate analysis, patients with SSc-GAVE more frequently exhibited a diminished (< 75%) DLCO value (OR 12.8; 95% CI 1.9-82.8) despite less frequent pulmonary fibrosis (OR 0.2; 95% CI 0.1-0.6). GAVE was also associated with the presence of anti-RNA-polymerase III antibodies (OR 4.6; 95% CI 1.2-21.1). SSc-GAVE was associated with anemia (82%) requiring blood transfusion (45%). Therapeutic endoscopic procedures were performed in 45% of patients with GAVE. After a median followup of 30 months (range 1-113 months), survival was similar in patients with SSc-GAVE compared to controls, but a higher number of scleroderma renal crisis cases occurred (12% vs 2%; p = 0.01).

CONCLUSION

GAVE is rare and associated with a vascular phenotype, including anti-RNA-polymerase III antibodies, and a high risk of renal crisis. Anemia, usually requiring blood transfusions, is a common complication.

Metabolic and inflammatory responses after ERCP

BACKGROUND

We aim to evaluate the metabolic and inflammatory responses after ERCP procedure in patients who have common bile duct stones.

METHODS

Between September 2009 and October 2010, we studied prospectively 50 patients who diagnosed with common bile duct stones. Our study was included patients who had previously been suspected with common biliary duct stone via radiological and biochemical examinations. We investigated parameters of pro-inflammatory cytokines (IL-1β, IL-6, Il-8, IL-12, IFN-γ, TNF-α), anti inflammatory cytokines (IL-4, IL-10, IL-13), stress hormones (ACTH, cortisol, growth hormone, aldosterone) and acute phase reactant (CRP). All venous blood samples were taken firstly 1hr before endoscopic intervention as a control. After ERCP procedure, venous blood samples were taken two more times, the first in 1hr, the second in 24 hours.

RESULTS

We performed ERCP successfully to 50 patients due to common bile duct stones. All of them had higher serum cytokine levels (p<0.01) after an hour and 24 hours later ERCP than before endoscopic intervention except IL-13 level. A significant increase (p<0,01) was found in ACTH, cortisol, GH and aldosterone levels 1 hour and 24 hours after ERCP, except GH level (p>0.05). CRP level was significiantly increased 1 hour and 24 hours after ERCP.

CONCLUSION

ERCP procedure is a kind of invasive attempt as known, also causes, with its effects, systemically inflammatory response in the body. This response, mostly not staying at the local stage, becomes systemic inflammatory response. Therefore, before ERCP is performed, the applications of other non-invasive methods of diagnosis are strongly advised.

An update on the management of implanted cardiac devices during electrosurgical procedures

To date, the major guidelines for the management of implanted cardiac devices during electrosurgical procedures have come from 1 of several major medical societies.These most recent guidelines are from the ACCF/AHA in 2009, a combined consensus statement from the Heart Rhythm Society and the American Society of Anesthesiologists in 2011, as well as an update from the ASGE in 2007. Tables 1 and 2 summarize the most recent recommendations by society. Further studies are needed so that data can be available for the specialty societies to unify consensus on guidelines on the proper management of patients with implanted cardiac devices.

Molecular imaging in gastroenterology

Molecular imaging is a novel field in gastroenterology that uses fluorescently labelled probes to specifically highlight neoplastic lesions on the basis of their molecular signature. The development of molecular imaging has been driven by the need to improve endoscopic diagnosis and by progress in targeted therapies in gastrointestinal oncology to provide individualized treatment, which coincides with progress in endoscopy techniques and further miniaturization of detection devices. Different exogenous molecular probes for imaging include labelled antibodies, oligopeptides, affibodies(™) (Affibody AB, Bromma, Sweden), aptamers and activatable probes. Molecular imaging has been evaluated in two major indications: many trials have studied molecular imaging as a red flag technique to improve detection of lesions in wide-field imaging; on the other hand, microscopic analysis has been investigated for in vivo characterization of the molecular fingerprint of tumours with the ultimate goal of assessing the likelihood of response to targeted therapy. This Review focusses on the applications of molecular imaging that have immediate potential for translational science or imminent transition into clinical practice of gastrointestinal endoscopy.

Wireless capsule endoscopy

Over the last decade, WCE has established itself as a valuable test for imaging the small intestine. It is a safe and relatively easy procedure to perform that can provide valuable information in the diagnosis of small-bowel conditions. Its applications still remain limited within the esophagus and colon. Future developments may include improving visualization within the esophagus and developing technologies that may allow manipulation of the capsule within the GI tract and biopsy capabilities.

Experiences with endoscopic interventions for variceal bleeding in children with portal hypertension: a single center study

PURPOSE

The aim of this study was to compare the efficacy and safety of band ligation and injection sclerotherapy in the endoscopic treatment of children with variceal bleeding.

METHODS

The study population included 55 children, all of whom were treated at the time of endoscopic diagnosis of esophageal varices at Asan Medical Center, Seoul, Korea, between January 1994 and January 2011. The primary outcomes included initial success rates and duration of hemostasis after endoscopic management (band ligation vs. injectionsclerotherapy).

RESULTS

The mean age was 6.7±5.2 years and the mean follow-up time was 5.4±3.7 years. The most common cause of esophageal varices was biliary atresia. Of 55 children with acute variceal bleeding, 39 had band ligation and 16 had injection sclerotherapy. No differences between groups were observed in terms of the size, location, and presence of red color sign. The success rates of band ligation and sclerotherapy in the control of acute bleeding episodes were 89.7% and 87.5%. The mean duration of hemostasis after endoscopic intervention was 13.2±25.1 months. After one year, 19 of 39 patients (48.7%) treated with band ligation and 7 of 16 patients (43.8%) with injection sclerotherapy had experienced rebleeding episodes. Complications after the procedures were observed in 10.3% and 18.8% of children treated with band ligation and injection sclerotherapy.

CONCLUSION

The results of our current study suggest that band ligation and injection sclerotherapy are equally efficient treatments for the control of acute variceal bleeding and prevention of rebleeding.

Evaluation of 4 three-dimensional representation algorithms in capsule endoscopy images

AIM: To evaluate the three-dimensional (3-D) representation performance of 4 publicly available Shape-from-Shading (SfS) algorithms in small-bowel capsule endoscopy (SBCE).

METHODS: SfS techniques recover the shape of objects using the gradual variation of shading. There are 4 publicly available SfS algorithms. To the best of our knowledge, no comparative study with images obtained during clinical SBCE has been performed to date. Three experienced reviewers were asked to evaluate 54 two-dimensional (2-D) images (categories: protrusion/inflammation/vascular) transformed to 3-D by the aforementioned SfS 3-D algorithms. The best algorithm was selected and inter-rater agreement was calculated.

RESULTS: Four publicly available SfS algorithms were compared. Tsai’s SfS algorithm outperformed the rest (selected as best performing in 45/54 SBCE images), followed by Ciuti’s algorithm (best performing in 7/54 images) and Torreão’s (in 1/54 images). In 26/54 images; Tsai’s algorithm was unanimously selected as the best performing 3-D representation SfS software. Tsai’s 3-D algorithm superiority was independent of lesion category (protrusion/inflammatory/vascular; P = 0.678) and/or CE system used to obtain the 2-D images (MiroCam^®/PillCam^®; P = 0.558). Lastly, the inter-observer agreement was good (kappa = 0.55).

CONCLUSION: 3-D representation software offers a plausible alternative for 3-D representation of conventional capsule endoscopy images (until optics technology matures enough to allow hardware enabled-“real” 3-D reconstruction of the gastrointestinal tract).

Endoscopic mucosal imaging of gastrointestinal neoplasia in 2013

The holy grail of gastrointestinal endoscopy consists of the detection, in vivo characterization, and endoscopic removal of early or premalignant mucosal lesions. While our ability to achieve this goal has improved substantially since the development of the modern video-endoscope, inadequate visual inspection, errors of interpretation, and lesion subtlety all contribute to the continued suboptimal detection and assessment of early neoplasia. A myriad of new technologies has thus emerged that may help resolve these shortcomings; high magnification endoscopes, as well as the techniques of dye-based and virtual chromoendoscopy, are now widely available, while confocal laser endomicroscopy and endocystoscopy, optical coherence tomography, and autofluorescence imaging are generally applicable only in a research setting. Such technologies can be broadly categorized according to whether they potentially afford endoscopists improved detection, or real-time characterization, of mucosal lesions. Enhanced detection of otherwise "invisible" lesions, such as a flat area of intramucosal adenocarcinoma within Barrett's esophagus, carries the potential of an endoscopic cure prior to the development into a more advanced or metastatic disease. The ability to characterize a lesion to achieve an in vivo diagnosis, such as a colonic polyp, potentially affords endoscopists the ability to decide which lesions require removal and which can be safely left behind or discarded without histological assessment. Furthermore targeted biopsies, such as in the surveillance of chronic colitis, may prove to be more accurate and efficacious than the current protocol of random biopsies. An important caveat in the discussion of developing technologies in early cancer detection is the fundamental importance of a health-care system that promotes screening programs to recruit at-risk individuals. The ideal tool to optimize the use of endoscopy in population screening would be a panel of reliable biomarkers (blood, stool, or urine) that could effectively select a high-risk group, thus reducing the indiscriminate use of an expensive technology. The following review summarizes the current endoscopic imaging techniques available, and in development, for the early identification of gastrointestinal neoplasia.

Cryptogenic multifocal ulcerous stenosing enteritis: a review of the literature

Cryptogenic multifocal ulcerous stenosing enteritis (CMUSE) is an extremely rare illness characterised by chronic or relapsing subileus status resulting from multiple small intestinal fibrous strictures and multiple shallow ulcers of the small bowel. The etiology is unknown and pathogenesis is not fully understood. Therapy with systemic glucocorticosteroids is the treatment of choice. However, most patients develop corticosteroid dependence. Deep enteroscopy enables precise diagnostic work, possible endoscopic treatment of stenoses; may obviate the need for surgery and prevent excessive small bowel resections.

High-throughput mutation profiling identifies novel molecular dysregulation in high-grade intraepithelial neoplasia and early gastric cancers

BACKGROUND

There is still no widely accepted molecular marker available to distinguish between gastric high-grade intraepithelial neoplasia (HG-IEN) and invasive early gastric cancer (EGC).

METHODS

HG-IEN and EGC lesions coexisting in the same patient were manually microdissected from a series of 15 gastrectomies for EGC; 40 ng DNA was used for multiplex PCR amplification using the Ion AmpliSeq Cancer Panel, which explores the mutational status of hotspot regions in 50 cancer-associated genes.

RESULTS

Of the 15 EGCs, 12 presented at least one somatic mutation among the 50 investigated genes, and 6 of these showed multiple driver gene somatic mutations. TP53 mutations were observed in 9 cases; APC mutations were identified in 3 cases; and ATM and STK11 were mutated in 2 cases. Seven HG-IEN lesions shared an identical mutational profile with the EGC from the same patient; 13 mutations observed in APC, ATM, FGFR3, PIK3CA, RB1, STK11, and TP53 genes were shared by both HG-IEN and ECG lesions. CDKN2A, IDH2, MET, and RET mutations were observed only in EGC. TP53 deregulation was further investigated in an independent series of 75 biopsies corresponding to all the phenotypic lesions occurring in the EGC carcinogenetic cascade. p53 nuclear immunoreaction progressively increased along with the dedifferentiation of the lesions (P < 0.001). Overall, 18 of 20 p53-positive lesions showed a TP53 mutated gene.

DISCUSSION

Our results support the molecular similarity between HG-IEN and EGC and suggest a relevant role for TP53 in the progression to the invasive phenotype and the use of immunohistochemistry as a surrogate to detect TP53 gene mutations.

Hybridization-based detection of Helicobacter pylori at human body temperature using advanced locked nucleic acid (LNA) probes

The understanding of the human microbiome and its influence upon human life has long been a subject of study. Hence, methods that allow the direct detection and visualization of microorganisms and microbial consortia (e.g. biofilms) within the human body would be invaluable. In here, we assessed the possibility of developing a variant of fluorescence in situ hybridization (FISH), named fluorescence in vivo hybridization (FIVH), for the detection of Helicobacter pylori. Using oligonucleotide variations comprising locked nucleic acids (LNA) and 2’-O-methyl RNAs (2’OMe) with two types of backbone linkages (phosphate or phosphorothioate), we were able to successfully identify two probes that hybridize at 37 °C with high specificity and sensitivity for H. pylori, both in pure cultures and in gastric biopsies. Furthermore, the use of this type of probes implied that toxic compounds typically used in FISH were either found to be unnecessary or could be replaced by a non-toxic substitute. We show here for the first time that the use of advanced LNA probes in FIVH conditions provides an accurate, simple and fast method for H. pylori detection and location, which could be used in the future for potential in vivo applications either for this microorganism or for others.

Mechanical Evaluation of Articulating Instruments and Cross-Handed Manipulation in Laparoendoscopic Single-Site Surgery

Background. Laparoendoscopic single-site surgery (LESS) is limited by loss of triangulation and internal instruments conflict. To overcome these difficulties, some concepts have been introduced, namely, articulating instruments and cross-handed manipulation, which causes the right hand to control the left instrument tip and vice versa. The aim of this study was to compare task performance with different approaches based on a mechanical evaluation platform. Methods. A LESS mechanical evaluation platform was set up to investigate the performance of 2 tasks (suture pass-through rings and clip-cut) with 3 different settings: uncrossed manipulation with straight instruments (group A, the control group), uncrossed manipulation with articulating instruments (group B), and cross-handed manipulation with articulating instruments (group C). The operation time and average load required for accomplishment of the standard tasks were measured. Results. Group A presented significantly better time scores than group B, and group C consumed the longest time to accomplish the 2 tasks ( P < .05). Comparing of average load required to perform the suture pass-through rings task, it differed significantly between dominant and nondominant hand in all groups ( P < .01) and was less in group A and group B than group C in dominant hand ( P < .01), while it was almost the same in all groups in the nondominant hand. In terms of average load requirement to accomplish clip-cut task, it was almost equal not only between group A and B but also between dominant and nondominant hand while the increase reached statistical significance when comparing group C with other groups ( P < .05). Conclusions. Compared with conventional devices and maneuvering techniques, articulating instruments and cross-handed manipulation are associated with longer operation time and higher workload. Instruments with better maneuverability should be developed in the future for LESS.

Implications of acquired environmental enteric dysfunction for growth and stunting in infants and children living in low- and middle-income countries

Changes in small bowel function early in infancy in developing countries are increasingly being demonstrated, probably accompanied by altered mucosal architecture in most individuals, including reduced enterocyte mass and evidence of immune activation and inflammation in the mucosa. These alterations appear to be the result of factors of uncertain nature in the environment, and may be a cause of growth faltering and stunting in young children. For these reasons, this constellation of findings is being referred to as environmental enteropathy, or as we propose herein, environmental enteric dysfunction. If the causes were known and effective interventions were available, strategies and policies to intervene at--or possibly before--birth could be developed and promoted in order to prevent subsequent malnutrition and recurrent infection, which are known to interact in a cyclical and synergistic manner in a downward clinical course often ending in death. Resources would be mobilized and applied differently, and the emphasis would change from treatment to prevention. In order to move in this highly desired direction, investments in research will be required to establish the criteria to assess environmental enteric dysfunction, determine its predictive value for growth faltering and stunting, identify the causes, and propose and test potential interventions. The concepts and tools are available. What is required is the decision to move forward along this pathway to better health for infants and children in low-income countries.

Pharmacological challenges in chronic pancreatitis

Drug absorption in patients with chronic pancreatitis might be affected by the pathophysiology of the disease. The exocrine pancreatic insufficiency is associated with changes in gastrointestinal intraluminal pH, motility disorder, bacterial overgrowth and changed pancreatic gland secretion. Together these factors can result in malabsorption and may also affect the efficacy of pharmacological intervention. The lifestyle of chronic pancreatitis patients may also contribute to gastrointestinal changes. Many patients limit their food intake because of the pain caused by eating and in some cases food intake is more or less substituted with alcohol, tobacco and coffee. Alcohol and drug interaction are known to influence the pharmacokinetics by altering either drug absorption or by affecting liver metabolism. Since patients suffering from chronic pancreatitis experience severe pain, opioids are often prescribed as pain treatment. Opioids have intrinsic effects on gastrointestinal motility and hence can modify the absorption of other drugs taken at the same time. Furthermore, the increased fluid absorption caused by opioids will decrease water available for drug dissolution and may hereby affect absorption of the drug. As stated above many factors can influence drug absorption and metabolism in patients with chronic pancreatitis. The factors may not have clinical relevance, but may explain inter-individual variations in responses to a given drug, in patients with chronic pancreatitis.

Endoscopic management of complications of chronic pancreatitis

Pseudocysts and biliary obstructions will affect approximately one third of patients with chronic pancreatitis (CP). For CP-related, uncomplicated, pancreatic pseudocysts (PPC), endoscopy is the first-choice therapeutic option. Recent advances have focused on endosonography-guided PPC transmural drainage, which tends to replace the conventional, duodenoscope-based coma immediately approach. Ancillary material is being tested to facilitate the endosonography-guided procedure. In this review, the most adequate techniques depending on PPC characteristics are presented along with supporting evidence. For CP-related biliary obstructions, endoscopy and surgery are valid therapeutic options. Patient co-morbidities (e.g., portal cavernoma) and expected patient compliance to repeat endoscopic procedures are important factors when selecting the most adapted option. Malignancy should be reasonably ruled out before embarking on the endoscopic treatment of presumed CP-related biliary strictures. In endoscopy, the gold standard technique consists of placing simultaneous, multiple, side-by-side, plastic stents for a one-year period. Fully covered self-expandable metal stents are challenging this method and have provided 50% mid-term success.

Fiber bundle endocytoscopy

Endocytoscopy is an optical biopsy technique which uses a miniaturized camera to capture white light microscopy images through an endoscope. We have developed an alternative design that instead relays images to an external camera via a coherent fiber bundle. In this paper we characterize the device and demonstrate microscopy of porcine tissue ex vivo. One advantage of our approach is the ease with which other bundle-compatible imaging modalities can be deployed simultaneously. We show this by acquiring quasi-simultaneous endocytoscopy and fluorescence confocal endomicroscopy images through a single fiber bundle. This opens up possibilities for multi-modal endomicroscopy, combining white light and fluorescence imaging.

New progress in endoscopic treatment of esophageal diseases

The technique of endoscopic submucosal dissection (ESD), which was developed for en bloc resection of large lesions in the stomach, has been widely accepted for the treatment of the entire gastrointestinal tract. Many minimally invasive endoscopic therapies based on ESD have been developed recently. Endoscopic submucosal excavation, submucosal tunneling endoscopic resection and laparoscopic-endoscopic cooperative surgery have been used to remove submucosal tumors, especially tumors which originate from the muscularis propria of the digestive tract. Peroral endoscopic myotomy has recently been described as a scarless and less invasive surgical myotomy option for the treatment of achalasia. Patients benefit from minimally invasive endoscopic therapy. This article, in the highlight topic series, provides detailed information on the indications and treatments for esophageal diseases.