Intraprocedural quality in endoscopic retrograde cholangiopancreatography: a meta-analysis

OBJECTIVES

In 2006, the American College of Gastroenterology (ACG)/the American Society for Gastrointestinal Endoscopy (ASGE) Taskforce on Quality in Endoscopy published quality indicators for the major gastrointestinal procedures. Our primary aim was to use the published literature to assess current endoscopic retrograde cholangiopancreatography (ERCP) intraprocedural performance and compare it to the targets set by the ACG/ASGE taskforce. Our secondary aim was to determine whether performance varies across different health-care settings (academic and community), study designs (prospective and retrospective), and trainee participation.

METHODS

A PubMed and EMBASE literature search from 1/1/2006 to 2/1/2013 was conducted. Articles were selected based on title, abstract, full text, and reporting of success rates for the intraprocedural quality indicators. Success rates, represented as numerical proportions, were collected from each study. For each success rate, a standard error and a 95% confidence interval (CI) was calculated. A random-effects meta-analysis model was used to weight each study, and a cumulative, weighted success rate (or effect size) for each indicator was determined. Random-effects meta-regression was then used to examine the impact of study setting, design, and trainee involvement on each quality indicator.

RESULTS

A total of 8,005 articles were initially retrieved. Following the application of predefined criteria, 52 articles remained. The cumulative, weighted bile duct cannulation success rate was 89.3% (95% CI 0.866-0.919); pancreatic duct cannulation was 85.0% (95% CI 0.813-0.886); precut utilization rate was 10.5% (95% CI 0.087-0.123); common bile duct stone extraction rate was 88.3% (95% CI 0.825-0.941); and the rate of successful biliary stenting below the common bile duct bifurcation was 97.5% (95% CI 0.967-0.984). Subgroup analysis with meta-regression showed no statistically significant differences between academic and community settings, prospective and retrospective study designs, and trainee participation on success across bile duct cannulation, precut utilization, and common bile duct stone extraction (insufficient observations/variance for pancreatic duct cannulation and biliary stent placement).

CONCLUSIONS

ERCP intraprocedural quality is in good standing. On the basis of this analysis, the two targets that could be potentially revised are precut utilization and biliary stenting. This analysis was confined to the published literature and therefore, in general, reflects the ERCP performance of institutions, primarily academic, that are conducting clinical research. Thus, it is difficult to generalize this performance assessment to the broader ERCP community as a whole.

Post-colonoscopy appendicitis: A case report and systematic review

Colonoscopy is a widely used diagnostic and therapeutic modality with a relatively low morbidity. However, given the large volume of procedures performed, awareness of the infrequent complications is essential. Perforation is an established complication of colonoscopy, and can range from 0.2%-3% depending on the series, population and modality of colonoscopy. Acute appendicitis after colonoscopy is an extremely rare event, and a cause-effect relationship between the colonoscopy and the appendicitis is not well documented. In addition, awareness of this condition can aid in prompt diagnosis. Relatively mild symptoms and exclusion of bowel perforation by contrast studies do not exclude appendicitis from the differential diagnosis for post-colonoscopy pain. In addition to the difficult diagnosis inherent to postcolonoscopy appendicitis, treatment strategies have varied greatly. This paper reviews these approaches. We also expand upon prior articles by giving guidance for the role of nonoperative management in these patients. This case and review of the literature will help to create awareness about this complication, and guide optimal treatment of pericolonoscopy appendicitis.

Transvaginal organ extraction: potential for broad clinical application

BACKGROUND

Natural orifice transluminal endoscopic surgery procedures have evolved over the past few years. A transvaginal approach is a promising alternative for intraperitoneal procedures. Our objective was to evaluate the safety and feasibility of transvaginal organ extraction.

METHODS

This institutional review board-approved protocol involved retrospective review of an ongoing prospective study. Female subjects who presented to our hospital for elective cholecystectomy, appendectomy, or sleeve gastrectomy were offered participation in the study. Eligible patients met the following criteria: age between 18 and 75, diagnosis of gallbladder disease, acute appendicitis, or morbid obesity who desired surgical treatment. A hybrid transvaginal natural orifice approach was used in this series.

RESULTS

Thirty-four women underwent transvaginal organ extraction between September 2007 and January 2012. The mean age was 40 ± 12.1 years (range 23-63 years). The mean body mass index was 27 ± 6.4 kg/m(2) (range 16-43 kg/m(2)). All patients had an American Society of Anesthesiologists classification of two or below. The mean operative time for cholecystectomy, appendectomy, and sleeve gastrectomy was 90, 71, and 135 min, respectively. There were no conversions to open operation and no intraoperative complications. The mean hospital stay was 2 days for all cases. Patients were followed for a mean of 24 months (range 1-61 months). There were two pregnancies and two successful vaginal deliveries. Six patients (18 %) had minor complaints of spotting or heavy menses in the immediate postoperative period that resolved with conservative measures. There were no abdominal wall complications. There were no long-term complications and no mortalities.

CONCLUSIONS

This initial experience suggests that this surgical approach is safe, does not increase length of stay, and has no long-term vaginal complications. Given this attractive profile, a transvaginal approach may prove to be a superior mode of organ extraction, although randomized studies and long-term follow-up are needed.

Role of (18)F-fluorodeoxyglucose positron emission tomography/computed tomography in diagnosis and management of pancreatic cancer; comparison with multidetector row computed tomography, magnetic resonance imaging and endoscopic ultrasonography

OBJECTIVES

We aimed to analyze the contribution of (18)F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) imaging to the diagnosis and management of pancreatic cancer compared with multidetector row computed tomography (MDCT), magnetic resonance imaging (MRI) and endoscopic ultrasonography (EUS).

MATERIAL AND METHODS

We retrospectively scanned the data of 52 patients who were referred for FDG PET/CT imaging for evaluation of pancreatic lesions greater than 10mm. The diagnostic performances of 4 imaging methods and the impact of PET/CT on the management of pancreatic cancer were defined.

RESULTS

Pancreatic adenocarcinoma was diagnosed in 33 of 52 patients (63%), 15 patients had benign diseases of pancreas (29%), and 4 patients were normal (8%). Sensitivity and NPV of EUS and PET/CT were equal (100%) and higher than MDCT and MRI. Specificity, PPV and NPV of PET/CT were significantly higher than MDCT. However, sensitivities of two imaging methods were not significantly different. There was no significant difference between PET/CT and MRI and EUS for these values. When the cut-off value of SUVmax was 3.2, the most effective sensitivity and specificity values were obtained. PET/CT contributed to the management of pancreatic cancer in 30% of patients.

CONCLUSION

FDG PET/CT is a valuable imaging method for the diagnosis and management of pancreatic cancer, especially when applied along with EUS as first line diagnostic tools.

Enteroscopy in small bowel Crohn’s disease: A review

Crohn’s disease (CD) is a chronic inflammatory condition of the gastrointestinal tract resulting in inflammation, stricturing and fistulae secondary to transmural inflammation. Diagnosis relies on clinical history, abnormal laboratory parameters, characteristic radiologic and endoscopic changes within the gastrointestinal tract and most importantly a supportive histology. The article is intended mainly for the general gastroenterologist and for other interested physicians. Management of small bowel CD has been suboptimal and limited due to the inaccessibility of the small bowel. Enteroscopy has had a significant renaissance recently, thereby extending the reach of the endoscopist, aiding diagnosis and enabling therapeutic interventions in the small bowel. Radiologic imaging is used as the first line modality to visualise the small bowel. If the clinical suspicion is high, wireless capsule endoscopy (WCE) is used to rule out superficial and early disease, despite the above investigations being normal. This is followed by push enteroscopy or device assisted enteroscopy (DAE) as is appropriate. This approach has been found to be the most cost effective and least invasive. DAE includes balloon-assisted enteroscopy, [double balloon enteroscopy (DBE), single balloon enteroscopy (SBE) and more recently spiral enteroscopy (SE)]. This review is not going to cover the various other indications of enteroscopy, radiological small bowel investigations nor WCE and limited only to enteroscopy in small bowel Crohn’s. These excluded topics already have comprehensive reviews. Evidence available from randomized controlled trials comparing the various modalities is limited and at best regarded as Grade C or D (based on expert opinion). The evidence suggests that all three DAE modalities have comparable insertion depths, diagnostic and therapeutic efficacies and complication rates, though most favour DBE due to higher rates of total enteroscopy. SE is quicker than DBE, but lower complete enteroscopy rates. SBE has quicker procedural times and is evolving but the least available DAE today. Larger prospective randomised controlled trial’s in the future could help us understand some unanswered areas including the role of BAE in small bowel screening and comparative studies between the main types of enteroscopy in small bowel CD.

Small bowel necrosis as a consequence of spontaneous deflation and migration of an air-filled intragastric balloon - a potentially life-threatening complication

Intragastric balloon placement is a common method of treatment of obesity and is often used by non-surgical teams in endoscopy departments. The likelihood of spontaneous intragastric balloon damage is a well-known phenomenon. We describe a patient who was disqualified from surgical obesity treatment and in whom intragastric fluid-filled balloons had already been inserted twice and removed due to their intolerance. Therefore we qualified this patient for placement of the air-filled balloon Heliosphere BAG. Two months after the planned check-up, he arrived at the surgery department complaining of nausea and vomiting and due to symptoms of ileus diagnosed with an X-ray and ultrasound examination we qualified him for emergency surgery. We would like to emphasise the following issues: the necessity of air-filled balloon removal according to the producer's instructions and multidisciplinary specialist team care along with appropriate diagnostic tools in every case of intragastric balloon insertion.

Clinical comparison of single- versus double-balloon enteroscopy

AIM: To compare the clinical application value of single balloon enteroscopy (SBE) and double balloon enteroscopy (DBE).

METHODS: Clinical data for 720 subjects who underwent enteroscopy (510 cases of SBE and 210 cases of DBE) from January 2007 to September 2012 were retrospectively analyzed. Procedure duration, intubation depth, diagnostic yield and endoscopic treatment rate were compared between the two groups.

RESULTS: No significant difference was found between the two groups in procedure duration (SBE 54.41 min ± 11.742 min vs DBE 54.94 min ± 12.315 min for the oral approach, SBE 64.71 min ± 12.359 min vs DBE 65.81 min ± 13.995 min for the anal approach), intubation depth (SBE 235.12 cm ± 87.831 cm vs DBE 219.94 cm ± 68.226 cm for the oral approach, SBE 187.75 cm ± 67.037 cm vs DBE 172.37 cm ± 81.808 cm for the anal approach), diagnostic yield (SBE 77.05% vs DBE 75.67% for the oral approach, SBE 70.18% vs DBE 76.77% for the anal approach) or endoscopic treatment rate (SBE 46.58% vs DBE 48.85% for the oral approach, SBE 35.32% vs DBE 33.33% for the anal approach).

CONCLUSION: SBE and DBE have comparable performance and diagnostic yield in the evaluation of the small bowel. SBE is an effective method for the diagnosis and treatment of small bowel diseases.

Is there an optimal surgery time after endoscopic resection in early gastric cancer?

BACKGROUND

The patients with early gastric cancer who have undergone incomplete endoscopic resection (ER) generally need additional surgery because of the possibility of lymph node metastasis. The aim of study was to evaluate the optimal time interval from ER to additive surgery by evaluating the effect of time interval on the surgical and oncological outcomes.

METHODS

We analyzed 154 patients who underwent additive gastrectomy after incomplete ER at Severance and Gangnam Severance Hospitals. The time interval point, at which operative time and estimated intraoperative blood loss (EBL) of the earlier operation group and the later operation group showed the greatest disparities, was evaluated. The patients were divided into 2 groups according to the time interval point, as the earlier operation group (group A) and the later operation group (group B). We retrospectively evaluated the clinicopathological characteristics and surgical and oncological outcomes.

RESULTS

The greatest difference between operative time and EBL was in the groups who underwent operation before and after 29 days. Of the 154 patients, 78 were in group A (≤29 days) and 76 in group B (>29 days). There were no differences in the clinicopathological characteristics and oncological outcomes except for tumor size. The operative time and EBL were significantly longer and more in group A compared with group B.

CONCLUSIONS

The time interval between ER and additive surgery is associated with surgical outcomes. Additive surgery at about 1 month after ER may be optimal for better surgical outcomes without affecting the oncological outcomes.

Efficacy of plastic stent placement inside bile ducts for the treatment of unresectable malignant hilar obstruction (with videos)

BACKGROUND

Recent reports have addressed the utility of plastic stent (PS) placement inside bile ducts for treating biliary obstructions. Here, we evaluated the utility and safety of PS placement inside bile ducts for treating unresectable malignant hilar biliary obstruction.

METHODS

We conducted a retrospective study of 27 patients with unresectable malignant hilar biliary obstruction who underwent intraductal modified PS placement. We modified the PS, by cutting off the distal end to facilitate insertion through the papilla of Vater, and attached a nylon thread to the distal end for removal. We evaluated complications, the time to recurrent biliary obstruction (TRBO), and removability.

RESULTS

Bilateral stenting was performed in nine of the 27 patients. Mild acute pancreatitis occurred in one patient (4%). Recurrent biliary obstruction (RBO) occurred in 16 patients (59%), with a median TRBO of 190 days (95% confidence interval: 174-205 days). Reintervention was necessary in 13 of the 16 patients (81%) with RBO, and we were able to remove the initial stents in all the patients who required reintervention.

CONCLUSIONS

A relatively long stent patency period (>6 months) and removability make placement of a modified PS inside bile ducts a viable treatment for unresectable malignant hilar biliary obstruction.

Grasper type scissors for endoscopic submucosal dissection of gastric epithelial neoplasia

AIM

To evaluate the efficacy and safety of grasper type scissors (GTS) for endoscopic submucosal dissection (ESD) of gastric epithelial neoplasia.

METHODS

The study was performed by 4 endoscopists in 4 institutions affiliated to The Catholic University of Korea. ESD was performed in 76 consecutive patients with gastric epithelial neoplasia by using the GTS (37 patients) or the hook knife plus coagrasper (HKC) (39 patients). The complete resection rate, complication rate, total time elapsed and elapsed time per square centimeter of the dissected specimen were analyzed between the GTS and HKC group.

RESULTS

The mean age of the GTS group was 62.3 ± 11.4 years and mean age of the HKC group was 65.6 ± 10.1 years. Differentiated adenocarcinoma was found in 32.4% in the GTS group and 33.3% in the HKC group. The procedures were performed without interruption in every case in both groups. The en bloc resection rates of both groups were 100%. The total time elapsed during the procedure was 44.54 ± 21.72 min in the GTS group and 43.77 ± 21.84 min in the HKC group (P = 0.88) and the time elapsed per square centimeter of the resected lesion was 7.53 ± 6.35 min/cm(2) in the GTS group and 6.92 ± 5.93 min/cm(2) in the HKC group (P = 0.66). The overall complication rate was not significantly different between the two groups.

CONCLUSION

GTS is a safe and effective device for ESD compared with HKC. ESD can be performed with GTS alone, which can reduce the costs for ESD.

Review of the use of intralesional steroid injections in the management of ileocolonic Crohn's strictures

Most patients with Crohn's disease present with either terminal ileal or colonic disease, with 70% requiring surgery by 10 years after diagnosis. Recurrent stricturing at the anastomotic site is common, often symptomatic and can require re-operation with its inherent risks. Balloon dilation has been shown to provide good symptom relief from such strictures. However, repeat dilations may be required, and further surgical intervention to an anastomotic stricture is needed in up to 30% of cases. Injection of corticosteroids has been suggested as an adjunct to dilation in order to improve outcomes. This paper reviews the current literature on the use of intralesional steroid injections following endoscopic balloon dilation of anastomotic and de novo Crohn's strictures. There have been only two randomised placebo controlled trials and five small non-controlled or retrospective studies. Study numbers vary from 10 to 29 patients. The two randomised trials conflict in their conclusions and numbers are small in these studies. Currently therefore, no firm support can be given to the routine use of intralesional steroid injections.

EUS access to the biliary tree

EUS-guided biliary access procedures can target the gallbladder or the bile duct for drainage in selected cases. EUS-guided gallbladder drainage offers comparable results to percutaneous cholecystostomy in high-surgical risk patients with acute cholecystitis refractory to medical treatment. The procedure is not yet widely available. Novel lumen-apposing stents may improve long-term outcomes, resulting in rapid dissemination. EUS access to the bile duct is coupled with ERCP techniques into a hybrid procedure, endosono-cholangiopancreatography (ESCP). ESCP admits six variant approaches to bile duct drainage based on the combination of two access routes (intrahepatic and extrahepatic) with three drainage routes: transmural, retrograde transpapillary and antegrade transpapillary. A thousand ESCP cases have been reported to date with good outcomes. When the expertise is available, ESCP is increasingly replacing percutaneous transhepatic biliary drainage to provide biliary drainage in patients in whom ERCP is not feasible, predominantly in the setting of palliation, but not limited to it.

Review article on current applications and future concepts of capsule endoscopy

Since the advent of capsule endoscopy (CE) more than one decade has passed. During this time, extensive efforts have been made to proof the relevance of CE for diagnosis of various disease entities within the esophagus, small bowel, and colon. To date, the most common indications for CE are obscure gastrointestinal bleeding, Crohn's disease, polyposis syndromes and evaluation of patients with complicated celiac disease. In this review we will focus on the current clinical applications of CE for imaging of the esophagus, small bowel and colon and will additionally give an outlook on future concepts and developments of CE.

Systematic review of the diagnosis of gastric premalignant conditions and neoplasia with high-resolution endoscopic technologies

AIM. The aim of the article is to systematically review the current evidence on the diagnostic use of narrow band imaging (NBI), flexible spectral imaging color enhancement (FICE) and endoscopic image enhancement technology i-scan endoscopies for gastric precancerous and cancerous lesions. MATERIALS AND METHODS. Original manuscripts were searched in PubMed until October 2012. Pertinent data were collected and pooled diagnostic accuracy measures were estimated when possible. RESULTs. In total, 38 studies were evaluated. Thirty-one studies were included for NBI and 7 studies for FICE assessment in this systematic review. No article was found meeting inclusion criteria for i-scan endoscopy. The most defined and evaluated outcomes were cancer-related (n = 26). Quality Assessment of Diagnostic Accuracy Studies score varied from 9 to 12 (out of 14). Only few studies assessed the interobserver reliability. On a patient level analysis, NBI's pooled sensitivity, specificity and diagnostic odds ratio were 0.67 (95% CI: 0.61-0.73), 0.81 (95% CI: 0.76-0.85) and 22.71 (95% CI: 12.53-41.1), respectively for diagnosing normal mucosa; 0.86 (95% CI: 0.82-0.90), 0.77 (95% CI: 0.73-0.80) and 17.01 (95% CI: 1.4-207.2) for intestinal metaplasia and 0.90 (95% CI: 0.84-0.94), 0.83 (95% CI: 0.80-0.86) and 47.61 (95% CI: 4.61-491.34) for dysplasia. Owing to the insufficient data and different definitions, we could not aggregate the results for FICE. CONCLUSION. Gastric pattern descriptions have been proposed for NBI and FICE studies by gathering all descriptions in one single description. The classification systems varied between studies, a single description of gastric mucosal features with HR--scopes or at least per technology--will have to be agreed on.

Intussusception secondary to anaphylactic reaction to salmon roe (ikura)

Anaphylactic food reaction often involves gastrointestinal symptoms, such as vomiting and abdominal pain, but to date, there have been no publications documenting the association between food hypersensitivity and intussusception. Herein is reported the case of a 2-year-old boy with intussusception accompanied by anaphylactic food reaction. The patient without known allergies complained of severe abdominal pain following ingestion of salmon roe for the first time. Dyspnea, wheezing and generalized urticaria also developed. Subsequently, he had stools containing jelly-like blood with mucus. At hospital arrival, physical examination identified an abdominal mass in the right lower quadrant; imaging confirmed the diagnosis of colo-colic intussusception. This patient was successfully treated with enema and no pathological findings were identified via radiology. Laboratory results supported the presence of IgE-mediated allergy to salmon roe in the present patient. To our knowledge, this is the first report to describe the possible association between intussusception and a hypersensitive food reaction.

Emphysematous Cholecystitis Resulting in Secondary Biliary Cirrhosis: A Rare Complication of Endoscopic Retrograde Cholangiopancreatography

A 48-year-old female developed acute emphysematous cholecystitis after an endoscopic retrograde cholangiopancreatography (ERCP) for evaluation of sphincter of Oddi dysfunction. Cholecystectomy was performed 2 days later. Cultures grew Clostridium perfringens. The patient received broad-spectrum antibiotics but developed recurrent cholangitic abscesses and intra- and extra-hepatic biliary necrosis. She was managed by percutaneous transhepatic biliary drains. For next 3 years, patient had recurrent episodes of biliary obstruction, cholangitis, and sepsis, resulting in secondary biliary cirrhosis requiring a liver transplantation. Emphysematous cholecystitis is a rare complication of ERCP. Prompt diagnosis and surgical management can prevent further spread of infection to biliary tree.

Radiofrequency ablation for refractory gastric antral vascular ectasia (with video)

BACKGROUND

Gastric antral vascular ectasia (GAVE) is a cause of upper GI bleeding and chronic anemia. Although upper endoscopy with argon plasma coagulation (APC) is an accepted therapy for GAVE, many patients continue to bleed and remain transfusion dependent after therapy. Radiofrequency ablation (RFA) may provide an alternative therapeutic option for GAVE.

OBJECTIVE

To determine the efficacy and safety of RFA for patients with GAVE who remain transfusion dependent after APC treatment.

DESIGN

Open-label prospective cohort study of patients with GAVE refractory to APC.

SETTING

Academic tertiary referral center.

PATIENTS

GAVE patients with previous failed APC therapy, chronic anemia, and transfusion dependence.

INTERVENTIONS

Endoscopic RFA to the gastric antrum using the HALO(90) ULTRA ablation catheter until transfusion independence is achieved or a maximum of 4 sessions are performed.

MAIN OUTCOME MEASUREMENTS

Transfusion requirements before and after RFA. Secondary outcomes are hemoglobin before and 6 months after RFA completion, number of RFA sessions, and complications.

RESULTS

Twenty-one patients underwent at least 1 RFA session with ablation of GAVE lesions. At 6 months after completion of the course of RFA therapy, 18 of 21 patients (86%) were transfusion independent. Mean hemoglobin increased from 7.8 to 10.2 in responders (n = 18). Two adverse events occurred (minor acute bleeding and superficial ulceration); both resolved without intervention.

LIMITATIONS

Single-center, single-operator, and nonrandomized design.

CONCLUSIONS

RFA is safe and effective for treating patients with refractory GAVE after attempted APC.

Long term outcome of acute pancreatitis in Italy: results of a multicentre study

BACKGROUND

In Italy, no long-term studies regarding the natural history of acute pancreatitis have been carried out.

AIM

To report the results of a follow-up on a large series of patients hospitalised for pancreatitis.

METHODS

Data of 631 patients admitted to 35 Italian hospitals were retrospectively evaluated 51.7±8.4 months after discharge.

RESULTS

The average recovery time after mild or severe pancreatitis was 28.2 and 53.4 days respectively. Fourteen sequelae were not resolved and 9 cases required late surgical intervention. Eighty patients (12.7%) had a second hospital admission. Of the patients with mild biliary pancreatitis, 67.9% underwent a cholecystectomy. The overall incidence of relapse was 12.7%. Mortality was 9.8% and no death was related to pancreatitis. Three patients died from carcinoma of the pancreas.

CONCLUSION

Reported recovery time after an attack of pancreatitis was longer than expected in the mild forms. The treatment of sequelae was delayed beyond one year after discharge. The incidence of relapse of biliary pancreatitis in patients not undergoing a cholecystectomy was low, due to endoscopic treatment. Mortality from pancreatic-related causes is low, but there is an association with malignant pancreatic or ampullary tumours not diagnosed during the acute phase of the illness.

Double-balloon enteroscopy in the elderly with obscure gastrointestinal bleeding: safety and feasibility

BACKGROUND

Double-balloon enteroscopy (DBE) is a novel endoscopic procedure to access the small bowel. There is paucity of data on its use in the elderly.

OBJECTIVE

The aim of this study was to assess the utility of DBE in patients with obscure gastrointestinal bleeding (OGB) in terms of safety and feasibility.

MATERIALS AND METHODS

A prospective review of consecutive patients who underwent DBE for OGB was conducted. Data were collected on demographics, dose of sedation/analgesia, diagnostic yield, and management and complications. Patients were divided into group 1, age of at least 70 years, and group 2, age less than 70 years.

RESULTS

A total of 148 DBE procedures were carried out for OGB. Group 1 (age≥70 years) comprised 27% (n=40) of the cohort with a mean age of 77 years (range 70-83 years). The mean age in group 2 (n=108) was 54 years, 44% women. The diagnostic yield in group 1 was 53 versus 35% in group 2 (P=0.06). Subsequent management was altered more frequently in group 1 (50 vs. 28%, P=0.01, odds ratio 2.6, 95% confidence interval 1.2-5.5). Sedation requirement was less in the elderly (median dose of midazolam, group 1: 4.5 mg versus group 2: 6 mg, P<0.001; fentanyl, group 1: 50 mcg vs. group 2: 75 mcg, P<0.001). There was no significant difference in complications between the two groups (0/40 vs. 1/108, P=0.54). On logistic regression, increasing age (P=0.008) was associated with a higher yield with DBE in all patients.

CONCLUSION

DBE is safe, has a high diagnostic yield and has a positive impact on patient management in the elderly.

Deep enteroscopy: which technique will survive?

The advent of deep enteroscopy (DE) has dramatically changed diagnostic and therapeutic approaches to small bowel diseases. Unlike capsule endoscopy, which is unable to obtain biopsies or treat a disease, DE techniques have diagnostic and therapeutic capabilities. Double-balloon enteroscopy (DBE) was introduced in 2001, and single-balloon enteroscopy (SBE) and spiral enteroscopy (SE) were subsequently developed for small bowel investigation. In published reports comparing these different enteroscopy techniques, most comparative parameters (depth of insertion, complications, learning curve, diagnostic yield, and therapeutic yield) were comparable among DBE, SBE, and SE. However, the procedure duration appears to be shorter for SE than for DBE and SBE. The rate of complete enteroscopy is clearly superior for DBE, compared with SE and SBE. Because these results do not indicate an increase in diagnostic or therapeutic yield, the clinical impact of complete enteroscopy remains controversial. According to previous studies, the three DE methods seem to be equally effective and safe in the clinical setting. Although larger randomized controlled trials are needed to evaluate the procedural characteristics and clinical impact, the selection of an enteroscopic technique should be based on availability and the endoscopist's experience.

Endoscopic treatment for early foregut neuroendocrine tumors

Foregut neuroendocrine tumors (NETs) include those arising in the esophagus, stomach, pancreas, and duodenum and seem to have a broad range of clinical behavior from benign to metastatic. Several factors including the advent of screening endoscopy may be related to increased incidence of gastrointestinal NETs; thus, many foregut NETs are diagnosed at an early stage. Early foregut NETs, such as those of the stomach and duodenum, can be managed with endoscopic treatment because of a low frequency of lymph node and distant metastases. However, controversy continues concerning the optimal management of early foregut NETs due to a lack of controlled prospective studies. Several issues such as indications, technical issues, and outcomes of endoscopic treatment for early foregut NETs are reviewed based on some published studies.

Endoscopic Ultrasound-Fine Needle Aspiration versus Core Biopsy for the Diagnosis of Subepithelial Tumors

Subepithelial lesions are frequently encountered and remain a diagnostic challenge. Imaging of subepithelial lesions using endoscopic ultrasound (EUS) can be helpful in narrowing the differential diagnosis of the lesion; however, definitive diagnosis typically requires tissue. Many methods for acquiring tissue exist including EUS-guided fine needle aspiration, Trucut biopsy, and fine needle biopsy. Obtaining adequate tissue is important for cytologic and histologic exams including immunohistochemical stains, thus a great deal of effort has been made to increase tissue acquisition in order to improve diagnostic yield in subepithelial lesions.

Treatment with valsartan reduces TGF-β1 expression and collagen fiber content in the portal vein of rats with portal hypertensive gastropathy

AIM: To investigate the effect of treatment with valsartan on portal vein lesions in rats with portal hypertensive gastropathy (PHG).

METHODS: Forty-eight SD rats were randomly divided into a sham operation group, a PHG model group, a valsartan prevention group, a normal dose valsartan group, and a double dose valsartan group. Partial portal vein ligation was used to induce PHG. Portal venous pressure (PVP) and heart rate (HR) were measured. Immunohistochemistry was used to detect TGF-β1 protein expression in the portal vein, and Masson's trichrome technique was used to determine the content of collagen fibers.

RESULTS: The PVP decreased significantly in the normal dose valsartan group, double dose valsartan group and prevention group compared with the model group (13.32 cmH₂O ± 0.96 cmH₂O vs 9.54 cmH₂O ± 0.80 cmH₂O, 9.04 cmH₂O ± 0.96 cmH₂O, 8.30 cmH₂O ± 0.41 cmH₂O, all P < 0.01). TGF-β1 expression and collagen fiber content were significantly higher in the model group than in the sham operation group (8.51 ± 1.42 vs 5.73 ± 0.87, 2.01 ± 1.25 vs 0.82 ± 0.54); however, TGF-β1 expression and collagen fiber content were significantly lower in the valsartan normal dose group, double dose group and prevention group than in the model group (6.54 ± 1.09, 6.45 ± 1.37, 6.42 ± 1.98 vs 8.51 ± 1.42; 0.92 ± 0.53, 1.09 ± 0.40, 1.03 ± 0.36 vs 2.01 ± 1.25, all P < 0.05).

CONCLUSION: TGF-β1 expression and collagen fiber content in the portal vein increase in rats with PHG. Treatment with valsartan can not only reduce portal pressure and TGF-β1 expression in the portal vein but also decrease collagen synthesis.

Endoscopic ultrasonography for gastrointestinal submucosal lesions

Advances in endoscopic imaging technology have led to the detection of more cases of gastrointestinal submucosal lesions (SMLs). Endoscopic ultrasonography (EUS) was previously known as the best imaging procedure to characterize SMLs. However, the progress of endoscopic submucosal dissection (ESD) has raised some new questions concerning the role of EUS in the diagnosis of SMLs. What is the diagnostic accuracy of EUS for SMLs? How is the nature of SMLs determined? How is the layer of origin identified? What is the preoperative value of EUS for ESD? In this review, we will discuss the endosonographic features of SMLs, the diagnostic accuracy of EUS, the ability of EUS to distinguish benign and malignant SMLs, the value of EUS-guided fine-needle aspiration (FNA), and the value of EUS in clinical surveillance.

Radiofrequency ablation for early oesophageal squamous neoplasia: Outcomes form United Kingdom registry

AIM: To report outcomes on patients undergoing radiofrequency ablation (RFA) for early oesophageal squamous neoplasia from a National Registry.

METHODS: A Prospective cohort study from 8 tertiary referral centres in the United Kingdom. Patients with squamous high grade dysplasia (HGD) and early squamous cell carcinoma (ESCC) confined to the mucosa were treated. Visible lesions were removed by endoscopic mucosal resection (EMR) before RFA. Following initial RFA treatment, patients were followed up 3 monthly. Residual flat dysplasia was treated with RFA until complete reversal dysplasia (CR-D) was achieved or progression to invasive Squamous cell cancer defined as infiltration into the submucosa layer or beyond. The main outcome measures were CR-D at 12 mo from start of treatment, long term durability, progression to cancer and adverse events.

RESULTS: Twenty patients with squamous HGD/ESCC completed treatment protocol. Five patients (25%) had EMR before starting RFA treatment. CR-D was 50% at 12 mo with a median of 1 RFA treatment, mean 1.5 (range 1-3). Two further patients achieved CR-D with repeat RFA after this time. Eighty per cent with CR-D remain dysplasia free at latest biopsy, with median follow up 24 mo (IQR 17-54). Six of 20 patients (30%) progressed to invasive cancer at 1 year. Four patients (20%) required endoscopic dilatations for symptomatic structuring after treatment. Two of these patients have required serial dilatations thereafter for symptomatic dysphagia with a median of 4 dilatations per patient. The other 2 patients required only a single dilatation to achieve an adequate symptomatic response. One patient developed cancer during follow up after end of treatment protocol.

CONCLUSION: The role of RFA in these patients remains unclear. In our series 50% patients responded at 12 mo. These figures are lower than limited published data.

New concepts in vocal fold imaging: a review

OBJECTIVE

To review new imaging technology potentially useful in the clinical practice of laryngology.

HYPOTHESIS

Narrow band imaging, iScan (Pentax Medical Company, Montvale, NJ), optical computed tomography, and confocal microscopy have potential value for enhancing diagnosis of laryngeal pathology.

DESIGN

Literature review.

METHODS

Literature search of computer databases including MEDLINE and PubMed.

RESULTS

A review of 50 articles suggests that new imaging technologies may enhance clinical diagnostic capabilities.

CONCLUSION

The probable value of new imaging technologies suggests that further research is needed to refine these technologies and define their clinical efficacy.

Review on novel concepts of columnar lined esophagus

BACKGROUND

Columnar lined esophagus (CLE) is a marker for gastroesophageal reflux and associates with an increased cancer risk among those with Barrett's esophagus. Recent studies fostered the development of integrated CLE concepts.

METHODS

Using PubMed, we conducted a review of studies on novel histopathological concepts of nondysplastic CLE.

RESULTS

Two histopathological concepts-the squamo-oxyntic gap (SOG) and the dilated distal esophagus (DDE), currently model our novel understanding of CLE. As a consequence of reflux, SOG interposes between the squamous lined esophagus and the oxyntic mucosa of the proximal stomach. Thus the SOG describes the histopathology of CLE within the tubular esophagus and the DDE, which is known to develop at the cost of a shortened lower esophageal sphincter and foster increased acid gastric reflux. Histopathological studies of the lower end of the esophagus indicate, that the DDE is reflux damaged, dilated, gastric type folds forming esophagus and cannot be differentiated from proximal stomach by endoscopy. While the endoscopically visible squamocolumnar junction (SCJ) defines the proximal limit of the SOG, the assessment of the distal limit requires the histopathology of measured multilevel biopsies. Within the SOG, CLE types distribute along a distinct zonation with intestinal metaplasia (IM; Barrett's esophagus) and/or cardiac mucosa (CM) at the SCJ and oxyntocardiac mucosa (OCM) within the distal portion of the SOG. The zonation follows the pH-gradient across the distal esophagus. Diagnosis of SOG and DDE includes endoscopy, histopathology of measured multi-level biopsies from the distal esophagus, function, and radiologic tests. CM and OCM do not require treatment and are surveilled in 5 year intervals, unless they associate with life quality impairing symptoms, which demand medical or surgical therapy. In the presence of an increased cancer risk profile, it is justified to consider radiofrequency ablation (RFA) of IM within clinical studies in order to prevent the progression to dysplasia and cancer. Dysplasia justifies RFA ± endoscopic resection.

CONCLUSIONS

SOG and DDE represent novel concepts fusing the morphological and functional aspects of CLE. Future studies should examine the impact of SOG and DDE for monitoring and management of gastroesophageal reflux disease (GERD).

The effect of ursodeoxycholic acid in liver functional restoration of patients with obstructive jaundice after endoscopic treatment: a prospective, randomized, and controlled study

BACKGROUND

In patients with obstructive jaundice, multi-organ dysfunction may develop.

METHODS/DESIGN

This trial is a prospective, open-label, randomized, and controlled study with the objective to evaluate the effect of ursodeoxycholic acid in liver functional restoration in patients with obstructive jaundice after endoscopic treatment. The aim of this study is to evaluate the effect of ursodeoxycholic acid in liver functional restoration of patients with obstructive jaundice after endoscopic treatment. The hypothesis of this trial is that patients with obstructive jaundice, in which will be administered UDCA, in the early phase after endoscopic intervention will have better and faster functional restoration of the liver than patients in the control group.Patients with obstructive jaundice, randomly, will be divided into two groups: (A) test group in which will be administered ursodeoxycholic acid twenty-four hours after endoscopic procedure and will last fourteen days, and (B) control group.Serum-testing will include determination of bilirubin, alanine transaminase, aspartate transaminase, gama-glutamil transpeptidase, alkaline phosphatase, albumin, and cholesterol levels. These parameters will be determined one day prior endoscopic procedure, and on the third, fifth, seventh, tenth, twelfth and fourteenth days after endoscopic intervention.

DISCUSSION

This trial is a prospective, open-label, randomized, and controlled study to asses the effect of ursodeoxycholic acid in liver functional restoration of patients with obstructive jaundice in the early phase after endoscopic treatment.

Pure NOTES transvaginal appendectomy with gasless laparoscopy

BACKGROUND

The vagina is the most widely used approach to natural orifice transluminal endoscopic surgery. However, a gas leak can significantly affect transvaginal operations during pneumoperitoneum laparoscopy. We tried to establish the proper technique for transvaginal appendectomy under gasless laparoscopy.

MATERIALS AND METHODS

Five patients with chronic appendicitis were selected to receive gasless laparoscopic transvaginal appendectomy with concurrent vaginal hysterectomy. An abdominal wall-lifting device was applied after removal of the uterus, and the appendix was removed transvaginally. Clinical data such as operative duration, bleeding volume, morbidity, and hospital stay duration were analyzed.

RESULTS

All procedures were performed successfully, without intraoperative or major postoperative complications. The appendectomy portion of the procedure took approximately 20-30 minutes, with minimal blood loss. All patients were discharged, scar-free, 3 d after surgery.

CONCLUSIONS

Transvaginal appendectomy with gasless laparoscopy after vaginal hysterectomy appears to be a feasible and safe modification of established techniques, with acceptable outcomes.

Hemostatic Efficacy of a Traditional Medicinal Plant Extract (Ankaferd Blood Stopper) in Bleeding Control

The aim of this study is to assess the in vivo hemostatic effect of Ankaferd Blood Stopper (ABS) on rats using a tail bleeding model. Wistar rats were randomized into 4 groups of 9 each: group 1, control, no pretreatment, irrigated with saline; group 2, no pretreatment, irrigated with ABS; group 3, control, heparin pretreatment, irrigated with saline; and group 4, heparin pretreatment, irrigated with ABS. To control bleeding, compressive dressings were placed after instilling 1 mL of either ABS or saline to the bleeding area. Without heparin pretreatment, ABS shortened hemostasis time by 1.57 minutes and reduced the amount of bleeding by 0.85 g. With heparin pretreatment, ABS shortened hemostasis time by 3.29 minutes and reduced the amount of bleeding by 1.32 g. The ABS was more effective than saline irrigation for treating tail tip bleeding in rats, with or without heparin pretreatment, while also using a compressive dressing.

In vivo imaging of intestinal helminths by capsule endoscopy

This review examines the use of digestive endoscopy to visualize intestinal helminths. The infections caused by these parasites are responsible for high levels of morbidity and mortality. These helminths can be visualized using gastroduodenal endoscopy, endoscopic retrograde cholangiopancreatography, and colonoscopy. Endoscopic examination of the small bowel is limited by its considerable length and its distance from the mouth and anus. Since capsule endoscopy (CE) was first reported in 2000, it has been established as a noninvasive modality for the investigation of the gastrointestinal tract. CE is used as a first-line tool for imaging various small-bowel diseases, mainly obscure gastrointestinal bleeding and Crohn's disease. Since the Food and Drug Administration (FDA) approved CE in 2001, the indications for its use have expanded widely. For example, CE can be used to visualize the in vivo kinetics of intestinal helminths. If the current trends in technological development continue, CE will become more widely used to facilitate the diagnosis and treatment of helminth infections in the near future.

Diagnostic utility of small-caliber and conventional endoscopes for gastric cancer and analysis of endoscopic false-negative gastric cancers

AIM: To analyze the diagnostic utility of a small-caliber endoscope (SC-E) and clinicopathological features of false-negative gastric cancers (FN-GCs).

METHODS: A total of 21638 esophagogastroduodenoscopy (EGD) gastric cancer (GC) screening examinations were analyzed. Secondary endoscopic examinations (n = 3352) were excluded because most secondary examinations tended to be included in the conventional endoscopy (C-E) group. Detection rates of GCs and FN-GCs were compared between SC-E and C-E groups. FN-GC was defined as GC performed with EGD within the past 3 years without GC detection. Macroscopic types, histopathological characteristics and locations of FN-GCs were compared with firstly found-gastric cancers (FF-GCs) in detail.

RESULTS: SC-E cases (n = 6657) and C-E cases (n = 11644), a total of 18301 cases, were analyzed. GCs were detected in 16 (0.24%) SC-E cases and 40 C-E (0.34%) cases (P = 0.23) and there were 4 FN-GCs (0.06%) in SC-E and 13 (0.11%) in C-E (P = 0.27), with no significant difference. FN-GCs/GCs ratio between SC-E and C-E groups was not significantly different (P = 0.75). The comparison of endoscopic macroscopic types of FN-GCs tended to be a less advanced type (P = 0.02). Histopathologically, 70.6% of FN-GCs were differentiated and 29.4% undifferentiated type. On the other hand, 43.0% of FF-GCs were differentiated and 53.8% undifferentiated type, so FN-GCs tended to be more differentiated type (P = 0.048).

CONCLUSION: The diagnostic utility of SC-E for the detection of GCs and FN-GCs was not inferior to that of C-E. Careful observation for superficially depressed type lesions in the upper lesser curvature region is needed to decrease FN-GCs.

Use of enhancement algorithm to suppress reflections in 3-D reconstructed capsule endoscopy images

In capsule endoscopy (CE), there is research to develop hardware that enables ‘‘real’’ three-dimensional (3-D) video. However, it should not be forgotten that ‘‘true’’ 3-D requires dual video images. Inclusion of two cameras within the shell of a capsule endoscope though might be unwieldy at present. Therefore, in an attempt to approximate a 3-D reconstruction of the digestive tract surface, a software that recovers information-using gradual variation of shading-from monocular two-dimensional CE images has been proposed. Light reflections on the surface of the digestive tract are still a significant problem. Therefore, a phantom model and simulator has been constructed in an attempt to check the validity of a highlight suppression algorithm. Our results confirm that 3-D representation software performs better with simultaneous application of a highlight reduction algorithm. Furthermore, 3-D representation follows a good approximation of the real distance to the lumen surface.

Confocal laser endomicroscopy in inflammatory bowel diseases: dream or reality?

Confocal laser endomicroscopy (CLE) is a newly introduced procedure that provide real-time, high-resolution imaging of the gastrointestinal mucosa during endoscopy, allowing the visualization of the pathology of the mucosal epithelium with its cellular and subcellular structures. Recently, the use of CLE was reported in the study of colonic mucosa in patients with inflammatory bowel diseases and in particular in patients affected by ulcerative colitis. CLE has the potential to have an important role in management of inflammatory bowel diseases (IBD) patients as it can be used to assess the grading of colitis and in detection of microscopic colitis in endoscopically silent segments. Moreover, CLE can be used in surveillance programs especially in high-risk patients. Finally, CLE has been effectively used in diagnosing a biliary dysplasia/neoplasia in patients with primary sclerosing cholangitis, a pathological condition frequently associated with IBD, with a coexisting bile duct stricture.

Epidemiology of esophageal cancer

Esophageal cancer (EsC) is one of the least studied and deadliest cancers worldwide because of its extremely aggressive nature and poor survival rate. It ranks sixth among all cancers in mortality. In retrospective studies of EsC, smoking, hot tea drinking, red meat consumption, poor oral health, low intake of fresh fruit and vegetables, and low socioeconomic status have been associated with a higher risk of esophageal squamous cell carcinoma. Barrett's esophagus is clearly recognized as a risk factor for EsC, and dysplasia remains the only factor useful for identifying patients at increased risk, for the development of esophageal adenocarcinoma in clinical practice. Here, we investigated the epidemiologic patterns and causes of EsC. Using population based cancer data from the Surveillance, Epidemiology and End Results Program of the United States; we generated the most up-to-date stage distribution and 5-year relative survival by stage at diagnosis for 1998-2009. Special note should be given to the fact that esophageal cancer, mainly adenocarcinoma, is one of the very few cancers that is contributing to increasing death rates (20%) among males in the United States. To further explore the mechanism of development of EsC will hopefully decrease the incidence of EsC and improve outcomes.

Laparoscopic-endoscopic cooperative surgery for gastric submucosal tumors

AIM: To assess the feasibility, safety, and advantages of minimally invasive laparoscopic-endoscopic cooperative surgery (LECS) for gastric submucosal tumors (SMT).

METHODS: We retrospectively analyzed 101 consecutive patients, who had undergone partial, proximal, or distal gastrectomy using LECS for gastric SMT at Peking Union Medical College Hospital from June 2006 to April 2013. All patients were followed up by visit or telephone. Clinical data, surgical approach, pathological features such as the size, location, and pathological type of each tumor; and follow-up results were analyzed. The feasibility, safety and effectiveness of LECS for gastric SMT were evaluated, especially for patients with tumors located near the cardia or pylorus.

RESULTS: The 101 patients included 43 (42.6%) men and 58 (57.4%) women, with mean age of 51.2 ± 13.1 years (range, 14-76 years). The most common symptom was belching. Almost all (n = 97) patients underwent surgery with preservation of the cardia and pylorus, with the other four patients undergoing proximal or distal gastrectomy. The mean distance from the lesion to the cardia or pylorus was 3.4 ± 1.3 cm, and the minimum distance from the tumor edge to the cardia was 1.5 cm. Tumor pathology included gastrointestinal stromal tumor in 78 patients, leiomyoma in 13, carcinoid tumors in three, ectopic pancreas in three, lipoma in two, glomus tumor in one, and inflammatory pseudotumor in one. Tumor size ranged from 1 to 8.2 cm, with 65 (64.4%) lesions < 2 cm, 32 (31.7%) > 2 cm, and four > 5 cm. Sixty-six lesions (65.3%) were located in the fundus, 21 (20.8%) in the body, 10 (9.9%) in the antrum, three (3.0%) in the cardia, and one (1.0%) in the pylorus. During a median follow-up of 28 mo (range, 1-69 mo), none of these patients experienced recurrence or metastasis. The three patients who underwent proximal gastrectomy experienced symptoms of regurgitation and belching.

CONCLUSION: Laparoscopic-endoscopic cooperative surgery is feasible and safe for patients with gastric submucosal tumor. Endoscopic intraoperative localization and support can help preserve the cardia and pylorus during surgery.

Osseous metaplasia in a juvenile polyp: a rare case report in India

Osseous metaplasia is a phenomenon which is described in a variety of tissue types with respect to both neoplastic and non-neoplastic conditions. In the gastrointestinal tract, osseous metaplasia (heterotopic bone formation) is rarely detected. Most of the reported cases were associated with malignant lesions. Here, we are reporting a rare case of a juvenile rectal polyp in a 14 years male, which showed osseous metaplasia on histological examination. This feature is a striking phenomenon on histological examination.

Outpatient endoscopic retrograde cholangiopancreatography: Safety and efficacy of anesthetic management with a natural airway in 653 consecutive procedures

Background:

Endoscopic retrograde cholangiopancreatography (ERCP) is a unique diagnostic and therapeutic procedure performed in high risk patients in prone/semi-prone position. Propofol based deep sedation has emerged as the method of choice however, the ability to predict possible complications is yet un-explored.

Aims:

The present study aimed to evaluate known high risk-factors for general anesthesia (American Society of Anesthesiologists (ASA) status, body mass index (BMI), and Mallampati class) for their ability to affect outcomes in ERCP patients.

Study Design:

Retrospective data of 653 patients who underwent ERCP during a period of 26 months at university hospital of Pennsylvania was reviewed. Patient-specific and procedure specific data was extracted. Desaturation was defined by fall of pulse oximeter saturation below 95% and its relation to patient specific high risk-factors was analyzed.

Results:

Only 45 patients had transient de-saturation below 95% without any residual sequlae. No statistically significant relation between desaturation episodes and patients higher ASA status or BMI or modified Mallampati (MMP) class was found. Despite 60% patients being ASA III/IV none required emergency intubation or procedural interruption. Optimal oxygenation and airway patency was maintained with high degree of success using simple airway maneuvers or conduit devices (nasal/oral trumpet) with oxygen supplementation in all patients.

Conclusions:

Unlike general anesthesia, pre-operative patient ASA status, higher MMP or increasing BMI does not bear relation with likelihood of patients desaturating during ERCP. In presence of vigilant apnea monitoring and careful dose titration of maintenance anesthetics with airway conduits, general anesthesia, emergency intubations, and procedure interruptions can be avoided.

Endoscopic assessment of the small bowel

BACKGROUND

Small bowel imaging and endoscopy in IBD have undergone a tremendous change and advancement in the recent years. Modalities shifted from gastroscopy, colonoscopy and small bowel follow through to ileocolonoscopy, CT or MR enteroscopy, wireless video capsule endoscopy and balloon-assisted enteroscopy.

METHODS

We reviewed the present role of endoscopy in assessing the small bowel in the context of IBD.

RESULTS

Endoscopy has a major role in the diagnosis of IBD, in the assessment of its extent, treatment of complications, assessment of the success of various medications and as a predictor of disease course. Wireless capsule endoscopy (WCE) is a relatively new tool allowing direct, patient-friendly visualization of the entire small bowel mucosa. It has gained a substantial role in the evaluation of patients with suspected Crohn's disease (CD) and indeterminate colitis. WCE has a high positive predictive value in patients with suspected CD, when one uses more than two of the International Conference on Capsule Endoscopy criteria, and not less important a very high negative predictive value in patients with suspected CD. Its role in patients with known CD, in the assessment of their disease activity and extent, assessment of postsurgical small bowel recurrence and evaluation of mucosal healing is still unclear. Balloon-assisted enteroscopy has established its role as a complementary tool in cases where there is a need for biopsy or treatment (dilatation of strictures).

CONCLUSIONS

The present review summarizes the role of endoscopy in the assessment of the small bowel in the context of IBD.

Percutaneous closure of catheter enterotomy: feasibility determination in vivo

AIM

To determine whether a catheter enterotomy can be percutaneously sealed with a commercially available vascular closure implant.

MATERIAL AND METHODS

The study was performed using a porcine model of small intestinal obstruction. Preliminary experiments were performed to allow an informed choice between two of the most promising commercially available alternatives: A multipronged metal clip (StarClose®) and a resorbable anchored polymer plate (FemoSeal®). Thereafter closure of seven enterotomies was attempted with the most suitable implant. The deployment procedure was subjectively analyzed. The sealed enterotomies were visually evaluated and hydrostatically tested.

RESULTS

StarClose was rejected for formal assessment because it was both difficult to deploy and could not ensure a watertight seal. The conventional method for deploying FemoSeal was found to be inappropriate for percutaneously closing enterotomies. However an improvised accessory allowed all seven enterotomies to be successfully sealed with the implant using a modified procedure that involved only one additional step. After closure, six of the seven enterotomies tolerated intraluminal pressure up to 65 mm Hg.

CONCLUSION

FemoSeal has the potential to serve as an implant for percutaneous closure of catheter enterotomies if the deployment tool can be appropriately modified.

New platforms and devices in colonoscopy

Gastrointestinal endoscopy is a rapidly evolving field. Techniques in endoscopy continue to become more sophisticated, as do the devices and platforms, particularly in colonoscopy and endoscopic resection. This article reviews new platforms for endoscopic imaging of the colon, and discusses new endoscopic accessories and developments in endoscopic resection.