Half-dose rabeprazole has an equal efficacy to standard-dose rabeprazole on endoscopic submucosal dissection-induced ulcer

BACKGROUND

Although endoscopic submucosal dissection (ESD)-induced ulcers heal faster and recur less often than non-iatrogenic gastric ulcers, the optimal dosage and duration of proton pump inhibitor treatment for ESD-induced ulcers remain unclear.

AIMS

To evaluate the efficacy of half-dose rabeprazole on endoscopic submucosal dissection-induced ulcer compared with standard dose rabeprazole.

METHODS

The study was a prospective randomized controlled double-blind trial at a single tertiary hospital. A total of 80 patients who underwent ESD for gastric neoplasia were enrolled. Of these patients, 10 were not followed to completion. Final analysis included the remaining 70 patients. Rabeprazole 20 or 10 mg, depending on randomization, was given orally for 4 weeks after ESD.

RESULTS

Of the 70 patients, 45 (64 %) were men, and the median age was 65.2 ± 9.7 years. The mean ESD-induced ulcer area was 673 mm(2). No significant differences in ulcer area reduction ratio (p = 0.49) or ulcer-related symptoms (p = 0.91) were observed between the two groups at 4 weeks after ESD.

CONCLUSION

For ESD-induced ulcers, treatment with 10 mg of rabeprazole daily produces a similar outcome as 20 mg of rabeprazole with regard to healing efficacy and symptom resolution.

Adenoma-like and non-adenoma-like dysplasia-associated lesion or mass in ulcerative colitis

Ulcerative colitis (UC) patients have an increased risk of colorectal cancer. UC has two general patterns of dysplasia, which are commonly classified as adenoma-like dysplasia-associated lesion or mass (DALM) and non-adenoma-like DALM. The latter has a high risk of concurrent malignancy and often requires a colectomy. Unfortunately, non-adenoma-like DALMs sometimes have endoscopic features similar to those of adenoma-like DALMs. Therefore, new endoscopic techniques to distinguish between these two kinds of DALM have been proposed.

Oesophageal cancer--an overview

Oesophageal carcinoma is one of the most virulent malignant diseases and a major cause of cancer-related deaths worldwide. Diagnosis and accuracy of pretreatment staging have substantially improved throughout the past three decades. Therapy is challenging and the optimal approach is still debated. Oesophagectomy is considered to be the procedure of choice in patients with operable oesophageal cancer. Endoscopic measures and limited surgical procedures provide an alternative in patients with early carcinomas confined to the oesophageal mucosa. Chemotherapy and radiotherapy or concurrent chemoradiotherapy are also frequently applied, either as definitive treatment or as neoadjuvant therapy within multimodal approaches. The question of whether multimodal treatment offers improved results has been the focus of many studies since the 1990s. Although results are discordant and even some meta-analyses remain inconclusive, it is now widely accepted that multimodal therapy leads to a modest survival benefit. The role of minimally invasive oesophagectomy is not yet defined. Endoscopic stent insertion, radiotherapy and other palliative measures provide relief of tumour-related symptoms in advanced, unresectable tumour stages.

The surgical management of Rapunzel syndrome: a case series and literature review

BACKGROUND/PURPOSE

The surgical removal of a trichobezoar is the rare end complication of the psychiatric disorders trichotillomania and trichophagia. The more severe form of the disease is termed Rapunzel syndrome, where the bezoar extends from the gastric body beyond the pylorus into the duodenum. Traditional therapy has included endoscopy, often with subsequent laparotomy, and associated psychiatric intervention. We present the largest and most recent series of patients with trichobezoars managed in a single institution.

METHODS

A retrospective review of all cases of trichobezoar at our institution from 2003 to 2011 was performed. Demographic data, presenting complaints, imaging, surgical treatment, and subsequent management were collected.

RESULTS

All 7 patients were female, ages 5 to 23 years (mean, 11.5 years). Although multiple imaging modalities were necessary for preoperative diagnosis, most patients were accurately diagnosed without endoscopic evaluation (85%). All patients required an exploratory laparotomy for definitive treatment. At laparotomy, 5 patients were found to have postpyloric extension of the trichobezoar (71%). One of 7 patients had a wound infection postoperatively. There were no other surgical complications or recurrences requiring further exploration.

CONCLUSIONS

Our series of trichobezoar patients appear to have a high rate of Rapunzel syndrome, and perhaps postpyloric extension should be considered the rule rather than the exception. Our series demonstrates that diagnosis can be established with a thorough history combined with radiography, and treatment should be a combination of laparoscopy and/or laparotomy with psychiatric consultation.

Effectiveness of unsedated transnasal endoscopy with white-light, flexible spectral imaging color enhancement, and lugol staining for esophageal cancer screening in high-risk patients

BACKGROUND AND AIMS

Transnasal endoscopy (TNE) has been proposed to screen for esophageal squamous cell cancer (ESCC) in Asia. This study aimed to assess the feasibility and tolerance of Brazilian patients to undergo unsedated TNE for screening, the prevalence of ESCC in this population, and the effectiveness of white-light endoscopy (WLE) and digital chromoendoscopy [flexible spectral imaging color enhancement (FICE)] to diagnose esophageal neoplasia.

PATIENTS AND METHODS

This was a diagnostic test study that enrolled patients with head and neck squamous cell cancer (HNSCC) referred to ESCC screening. Patients' tolerance was rated by a numeric pain intensity scale. Interventions included unsedated TNE with WLE and FICE examination of the esophagus, in a tandem manner with blinded operators, followed by lugol chromoscopy. Performance of WLE and FICE for neoplasia detection was compared with the reference standard (lugol chromoscopy plus histology).

RESULTS

A total of 106 patients were recruited. TNE was feasible in 99.1%, and 92% of the patients rated the discomfort as absent or minimal. Thirteen ESCC were detected (12.3%), with 10 early cancers (77%). The tests showed an excellent performance and there was no difference between WLE (sensitivity 92.3%, specificity 98.9%, accuracy 98.1%, area under curve 0.995) and FICE (sensitivity 100%, specificity 98.9%, accuracy 99%, area under curve 0.956) for esophageal neoplasia detection.

CONCLUSIONS

Unsedated TNE is a feasible, well accepted, and efficient diagnostic tool for the screening of ESCC. The elevated rate of esophageal neoplasia strengthens the recommendations to screen patients with HNSCC. The yields of WLE and FICE were similar for ESCC detection.

Endoscopic ultrasonography in tandem with endoscopic retrograde cholangiopancreatography in the management of suspected distal obstructive jaundice

GOALS

To examine the benefits and feasibility of endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) in tandem for distal obstructive jaundice.

MATERIALS AND METHODS

From September 2007 to August 2012, patients with suspected distal obstructive jaundice were randomized to single-session EUS-ERCP (group A), EUS, and ERCP in different sessions (group B), and an ERCP-only procedure (group C). Data were prospectively collected on the following parameters: ERCP-avoided, duration of procedure, the dose of propofol, complications, and diagnostic yield.

RESULTS

A total of 180 patients were divided randomly into 60 patients in group A, 60 in group B, and 60 in group C. A total of four therapeutic ERCP were canceled after EUS. The ERCP procedural time in group A was shorter, although not significantly different from that in group B (group A vs. group B: 41.24±7.57 vs. 43.38±6.57 min; P>0.05), but both were significantly less than that in group C (group C: 49.12±7.46 min; P<0.05). The total procedural time did not differ significantly between group A and group B (70.05±15.35 vs. 73.70±15.12 min; P>0.05), nor were there significant differences in the dose of propofol between them (group A vs. group B: 357.11±115.86 vs. 369.55±133.86 mg; P>0.05). In all, 22 anesthetic complications and 21 endoscopic complications occurred without significant differences among the three groups (P>0.05).

CONCLUSION

As a triaging or a screening tool, diagnostic EUS gives added benefit to therapeutic ERCP. EUS and ERCP in a tandem approach are safe and feasible in patients with suspected distal obstructive jaundice.

Surgical treatment of gastric gastrointestinal stromal tumor

Gastrointestinal stromal tumor is the most common mesenchymal tumor in the gastrointestinal tract and is most frequently developed in the stomach in the form of submucosal tumor. The incidence of gastric gastrointestinal stromal tumor is estimated to be as high as 25% of the population when all small and asymptomatic tumors are included. Because gastric gastrointestinal stromal tumor is not completely distinguished from other submucosal tumors, a surgical excisional biopsy is recommended for tumors >2 cm. The surgical principles of gastrointestinal stromal tumor are composed of an R0 resection with a normal mucosa margin, no systemic lymph node dissection, and avoidance of perforation, which results in peritoneal seeding even in cases with otherwise low risk profiles. Laparoscopic surgery has been indicated for gastrointestinal stromal tumors <5 cm, and the indication for laparoscopic surgery is expanded to larger tumors if the above mentioned surgical principles can be maintained. A simple exogastric resection and various transgastric resection techniques are used for gastrointestinal stromal tumors in favorable locations (the fundus, body, greater curvature side). For a lesion at the gastroesophageal junction in the posterior wall of the stomach, enucleation techniques have been tried preserve the organ's function. Those methods have a theoretical risk of seeding a ruptured tumor, but this risk has not been evaluated by well-designed clinical trials. While some clinical trials are still on-going, neoadjuvant imatinib is suggested when marginally unresectable or multiorgan resection is anticipated to reduce the extent of surgery and the chance of incomplete resection, rupture or bleeding.

Clinical application of liver stiffness measurement using transient elastography in chronic liver disease from longitudinal perspectives

Accurate determination of the presence and degree of fibrosis in liver is of great importance, because the prognosis and management strategies for chronic liver disease depend mainly on these factors. To date, liver biopsy (LB) remains the "gold standard" for assessing the severity of liver fibrosis; however, LB is often limited by its invasiveness, sampling error, and intra/inter-observer variability in histological interpretation. Furthermore, repeated LB examinations within a short time interval are indeed ineligible in a real clinical practice. Thus, due to the pressing need for non-invasive surrogates for liver fibrosis, transient elastography (TE), as a novel ultrasound based technology, has allowed a noninvasive measurement of liver stiffness and has gained in popularity over recent years. In the past few years, additional roles for transient TE beyond the initial purpose of a non-invasive surrogate for LB have included the prediction of the most two critical consequences of fibrosis progression: the development of portal hypertension-related complications and hepatocellular carcinoma. This indicates that the role of transient TE is not merely limited to reducing the need for LB, but transient TE can enable the establishment of tailored management strategies by providing more detailed prognostic information. In particular, under the concept in which the clinical course of liver fibrosis is dynamic and bidirectional, especially when appropriate intervention is commenced, transient TE can be used to track the dynamic changes in fibrotic burden during antiviral or antifibrotic treatment. This review discussed extended applications of transient TE in prediction of the development of real clinical endpoints from a longitudinal perspective.

Conventional endoscopic retrograde cholangiopancreaticography vs the Olympus V-scope system

AIM

To compare the new Olympus V-scope (VS) to conventional endoscopic retrograde cholangiopancreaticography (ERCP).

METHODS

Forty-nine patients with previous endoscopic papillotomy who were admitted for interventional ERCP for one of several reasons were included in this single-centre, prospective randomized study. Consecutive patients were randomized to either the VS group or to the conventional ERCP group. ERCP-naïve patients who had not undergone papillotomy were excluded. The main study parameters were interventional examination time, X-ray time and dose, and premedication dose (all given below as the median, range) and were investigated in addition to each patient's clinical outcome and complications. Subjective scores to assess each procedure were also provided by the physicians and endoscopy assistants who carried out the procedures. A statistical analysis was carried out using the Wilcoxon rank-sum test.

RESULTS

Twenty-five patients with 50 interventions were examined with the VS ERCP technique, and 24 patients with 47 interventions were examined using the conventional ERCP technique. There were no significant differences between the two groups regarding the age, sex, indications, degree of ERCP difficulty, or interventions performed. The main study parameters in the VS group showed a nonsignificant trend towards a shorter interventional examination time (29 min, 5-50 min vs 31 min, 7-90 min, P = 0.28), shorter X-ray time (5.8 min, 0.6-14.1 min vs 6.1 min, 1.6-18.8 min, P = 0.48), and lower X-ray dose (1351 cGy/m(2), 159-5039 cGy/m(2) vs 1296 cGy/m(2), 202.2-6421 cGy/m(2), P = 0.34). A nonsignificant trend towards fewer adverse events occurred in the VS group as compared with the conventional ERCP group (cholangitis: 12% vs 16%, P = 0.12; pain: 4% vs 12.5%, P = 0.33; post-ERCP pancreatitis: 4% vs 12.5%, P = 0.14). In addition, there were no statistically significant differences in assessment by the physicians and endoscopy assistants using subjective questionnaires.

CONCLUSION

ERCP using the short-guidewire V-system did not significantly improve ERCP performance or patient outcomes, but it may reduce and simplify the ERCP procedure in difficult settings.

Is Helicobacter pylori Infection the Primary Cause of Duodenal Ulceration or a Secondary Factor? A Review of the Evidence

Helicobacter pylori (H. pylori) has a role in the multifactorial etiology of peptic ulcer disease. A link between H. pylori infection and duodenal ulcer disease is now established. Other contributing factors and their interaction with the organism may initiate the ulcerative process. The fact that eradication of H. pylori infection leads to a long-term cure in the majority of duodenal ulcer patients and the fact that the prevalence of infection is higher in ulcer patients than in the normal population are cogent arguments in favor of it being the primary cause of the ulceration. Against this concept there are issues that need explanation such as the reason why only a minority of infected persons develop duodenal ulceration when infection with H. pylori is widespread. There is evidence that H. pylori infection has been prevalent for several centuries, yet duodenal ulceration became common at the beginning of the twentieth century. The prevalence of duodenal ulceration is not higher in countries with a high prevalence of H. pylori infection. This paper debate puts forth the point of view of two groups of workers in this field whether H. pylori infection is the primary cause of duodenal ulcer disease or a secondary factor.

Optimisation of Radiation Exposure to Gastroenterologists and Patients during Therapeutic ERCP

This study intended to optimize the radiation doses for gastroenterologists and patients during therapeutic endoscopic retrograde cholangiopancreatography (ERCP) and to compare the doses based on available data obtained by other researchers. A total of 153 patients were studied in two Gastroenterology Departments, (group A, 111; group B, 42). Thermoluminescent dosimeters (TLD) were used to measure the staff and patients entrance surface air kerma (ESAK) at different body sites. The mean ESAK and effective doses per procedure were estimated to be 68.75 mGy and 2.74 mSv, respectively. Staff was exposed to a heterogonous doses. The third examiner (trainee) was exposed to a high dose compared with other examiners because no shield was located to protect him from stray radiation. Patients and examiners doses were lower compared to the lowest values found in previous studies taking into consideration the heterogeneity of patients and equipment. Staff doses during ERCP are within the safety limit in the light of the current practice.

Metaplastic ossification in a juvenile rectal polyp: a rare histological finding

An osseous metaplasia is a phenomenon which has been described in a wide variety of tissue types with respect to both neoplastic and non-neoplastic conditions. However, an osseous metaplasia is exceedingly rare in colonic polyps. We are herein representing a case of osseous metaplasia in a juvenile rectal polyp in a six year old boy, with review of the literature on the suggested mechanisms of its aetiology.

Short-type single balloon enteroscope for endoscopic retrograde cholangiopancreatography with altered gastrointestinal anatomy

AIM

To evaluate the effectiveness of a short-type single-balloon-enteroscope (SBE) for endoscopic retrograde cholangiopancreatography (ERCP) in patients with a reconstructed intestine.

METHODS

Short-type SBE was developed to perform ERCP in postoperative patients with a reconstructed intestine. Short-type SBE is a direct-viewing endoscope with the following specifications: working length, 1520 mm; total length, 1840 mm; channel diameter, 3.2 mm. In addition, short-type SBE has a water-jet channel. The study group comprised 22 patients who underwent 31 sessions of short-type SBE-assisted ERCP from June 2011 through May 2012. Reconstruction was performed by Billroth-II (B-II) gastrectomy in 6 patients (8 sessions), Roux-en-Y (R-Y) gastrectomy in 14 patients (21 sessions), and R-Y hepaticojejunostomy in 2 patients (2 sessions). We retrospectively studied the rate of reaching the blind end (papilla of Vater or choledochojejunal anastomosis), mean time required to reach the blind end, diagnostic success rate (defined as the rate of successfully imaging the bile and pancreatic ducts), therapeutic success rate (defined as the rate of successfully completing endoscopic treatment), mean procedure time, and complications.

RESULTS

Among the 31 sessions of ERCP, the rate of reaching the blind end was 88% in B-II gastrectomy, 91% in R-Y gastrectomy, and 100% in R-Y hepaticojejunostomy. The mean time required to reach the papilla was 18.3 min in B-II gastrectomy, 21.1 min in R-Y gastrectomy, and 32.5 min in R-Y hepaticojejunostomy. The diagnostic success rates in all patients and those with an intact papilla were respectively 86% and 86% in B-II gastrectomy, 90% and 87% in R-Y gastrectomy, and 100% in R-Y hepaticojejunostomy. The therapeutic success rates in all patients and those with an intact papilla were respectively 100% and 100% in B-II gastrectomy, 94% and 92% in R-Y gastrectomy, and 100% in R-Y hepaticojejunostomy. Because the channel diameter was 3.2 mm, stone extraction could be performed with a wire-guided basket in 12 sessions, and wire-guided intraductal ultrasonography could be performed in 8 sessions. As for complications, hyperamylasemia (defined as a rise in serum amylase levels to more than 3 times the upper limit of normal) occurred in 1 patient (7 sessions) with a B-II gastrectomy and 4 patients (19 sessions) with an R-Y gastrectomy. After ERCP in patients with an R-Y gastrectomy, 2 patients (19 sessions) had pancreatitis, 1 patient (21 sessions) had gastrointestinal perforation, and 1 patient (19 sessions) had papillary bleeding. Pancreatitis and bleeding were both mild. Gastrointestinal perforation improved after conservative treatment.

CONCLUSION

Short-type SBE is effective for ERCP in patients with a reconstructed intestine and allows most conventional ERCP devices to be used.

Screening for precancerous lesions of upper gastrointestinal tract: from the endoscopists' viewpoint

Upper gastrointestinal tract cancers are one of the most important leading causes of cancer death worldwide. Diagnosis at late stages always brings about poor outcome of these malignancies. The early detection of precancerous or early cancerous lesions of gastrointestinal tract is therefore of utmost importance to improve the overall outcome and maintain a good quality of life of patients. The desire of endoscopists to visualize the invisibles under conventional white-light endoscopy has accelerated the advancements in endoscopy technologies. Nowadays, image-enhanced endoscopy which utilizes optical- or dye-based contrasting techniques has been widely applied in endoscopic screening program of gastrointestinal tract malignancies. These contrasting endoscopic technologies not only improve the visualization of early foci missed by conventional endoscopy, but also gain the insight of histopathology and tumor invasiveness, that is so-called optical biopsy. Here, we will review the application of advanced endoscopy technique in screening program of upper gastrointestinal tract cancers.

Outcomes of endoscopic-ultrasound-guided cholangiopancreatography: a literature review

Endoscopic retrograde cholangiopancreatography (ERCP) can fail in 3–10% of the cases even in experienced hands. Although percutaneous transhepatic cholangiography (PTC) and surgery are the traditional alternatives, there are morbidity and mortality associated with both. In this paper, we have discussed the efficacy and safety of endoscopic-ultrasound-guided cholangiopancreatography (EUS-CP) in decompression of biliary and pancreatic ducts. The overall technical and clinical success rates are around 90% for biliary and 70% for pancreatic duct drainage. The overall EUS-CP complication rate is around 15%. EUS-CP is, however, a technically challenging procedure and should be performed by an experienced endoscopist skilled in both EUS and ERCP. Same session EUS-CP as failed initial ERCP is practical and may result in avoidance of additional procedures. With increasing availability of endoscopists trained in both ERCP and EUS, the role of EUS-CP is likely to grow in clinical practice.

Detection of active bleeding from gastric antral vascular ectasia by capsule endoscopy

Gastric antral vascular ectasia (GAVE) has been recognized as one of the important causes of occult and obscure gastrointestinal bleeding. The diagnosis is typically made based on the characteristic endoscopic features, including longitudinal row of flat, reddish stripes radiating from the pylorus into the antrum that resemble the stripes on a watermelon. These appearances, however, can easily be misinterpreted as moderate to severe gastritis. Although it is believed that capsule endoscopy (CE) is not helpful for the study of the stomach with its large lumen, GAVE can be more likely to be detected at CE rather than conventional endoscopy. CE can be regarded as “physiologic” endoscopy, without the need for gastric inflation and subsequent compression of the vasculature. The blood flow of the ecstatic vessels may be diminished in an inflated stomach. Therefore, GAVE may be prominent in CE. We herein describe a case of active bleeding from GAVE detected by CE and would like to emphasize a possibility that CE can improve diagnostic yields for GAVE.

Recurrent acute pancreatitis and massive hemorrhagic ascites secondary to a duodenal duplication in a child: a case report

Introduction

Duodenal duplication is a rare congenital malformation and has been reported as a rare cause of recurrent acute pancreatitis. Hemorrhagic ascites has been reported in only one case of duodenal duplication.

Case presentation

An 11-year-old Chinese girl presented with abdominal pain, hematemesis and dark stools. On admission, an abdominal examination revealed a moderately distended abdomen with diffuse tenderness. Biochemical investigations showed increased serum levels of amylase, lipase, and urine amylase. An abdominal computed tomography scan and magnetic resonance imaging scan revealed an enlarged and heterogeneous pancreas with poorly delineated borders. There was a cystic lesion measuring 25mm × 48mm × 28mm, located between the descending portion of her duodenum and the head of her pancreas. There were massive effusion signals in her abdominal cavity. An exploratory laparotomy was performed. A tubular cyst measuring 32mm × 52mm × 30mm was found in the second part of the duodenum, next to the head of her pancreas. The anterior wall of the duplication cyst was resected and anastomosis of the remaining cyst to the duodenum was performed for drainage. Histopathological examination of the excised cyst wall showed duodenal mucosa, submucosa and muscle coats, indicative of a duodenal duplication.

Conclusions

It is important to be aware of duodenal duplication when evaluating a patient with recurrent acute pancreatitis accompanied by massive hemorrhagic ascites.

A new approach: endoscopic submucosal dissection using the Clutch Cutter® for early stage digestive tract tumors

Endoscopic submucosal dissection (ESD) is accepted as minimally invasive therapy for early stage digestive tract tumors. It has allowed the achievement of histologically curative en-bloc resection of early stage digestive tract tumors regardless of size, including the resection of previously non-resectable tumors. Although numerous electrosurgical knives have been developed for ESD, technical difficulties and high complication rates (bleeding and perforation) have limited their use worldwide. Furthermore, conventional ESD usually needs several devices for each session. We developed the Clutch Cutter® (CC), which can grasp and incise the targeted tissue using electrosurgical current, to resolve such ESD-related problems. The ESD procedure using the CC is as follows: after marking using the CC and the injection of a solution into the submucosa, the lesion is separated from the surrounding normal mucosa by complete incision around the lesion using the CC. A piece of submucosal tissue is grasped and cut with the CC using electrosurgical current to achieve submucosal exfoliation. Intraoperative bleeding is also treated by the CC. Reported clinical studies showed that ESD using the CC is a safe, simple, easy-to-learn, technically efficient (en-bloc resection rate 100%), and a single-device method for the dissection of early stage digestive tract tumors. This new approach is promising to become the worldwide method of choice for early stage digestive tract tumors because it is technically simple and safe to perform.

Endoscopic and surgical resection of T1a/T1b esophageal neoplasms: A systematic review

AIM: To investigate potential therapeutic recommendations for endoscopic and surgical resection of T1a/T1b esophageal neoplasms.

METHODS: A thorough search of electronic databases MEDLINE, Embase, Pubmed and Cochrane Library, from 1997 up to January 2011 was performed. An analysis was carried out, pooling the effects of outcomes of 4241 patients enrolled in 80 retrospective studies. For comparisons across studies, each reporting on only one endoscopic method, we used a random effects meta-regression of the log-odds of the outcome of treatment in each study. “Neural networks” as a data mining technique was employed in order to establish a prediction model of lymph node status in superficial submucosal esophageal carcinoma. Another data mining technique, the “feature selection and root cause analysis”, was used to identify the most important predictors of local recurrence and metachronous cancer development in endoscopically resected patients, and lymph node positivity in squamous carcinoma (SCC) and adenocarcinoma (ADC) separately in surgically resected patients.

RESULTS: Endoscopically resected patients: Low grade dysplasia was observed in 4% of patients, high grade dysplasia in 14.6%, carcinoma in situ in 19%, mucosal cancer in 54%, and submucosal cancer in 16% of patients. There were no significant differences between endoscopic mucosal resection and endoscopic submucosal dissection (ESD) for the following parameters: complications, patients submitted to surgery, positive margins, lymph node positivity, local recurrence and metachronous cancer. With regard to piecemeal resection, ESD performed better since the number of cases was significantly less [coefficient: -7.709438, 95%CI: (-11.03803, -4.380844), P < 0.001]; hence local recurrence rates were significantly lower [coefficient: -4.033528, 95%CI: (-6.151498, -1.915559), P < 0.01]. A higher rate of esophageal stenosis was observed following ESD [coefficient: 7.322266, 95%CI: (3.810146, 10.83439), P < 0.001]. A significantly greater number of SCC patients were submitted to surgery (log-odds, ADC: -2.1206 ± 0.6249 vs SCC: 4.1356 ± 0.4038, P < 0.05). The odds for re-classification of tumor stage after endoscopic resection were 53% and 39% for ADC and SCC, respectively. Local tumor recurrence was best predicted by grade 3 differentiation and piecemeal resection, metachronous cancer development by the carcinoma in situ component, and lymph node positivity by lymphovascular invasion. With regard to surgically resected patients: Significant differences in patients with positive lymph nodes were observed between ADC and SCC [coefficient: 1.889569, 95%CI: (0.3945146, 3.384624), P < 0.01). In contrast, lymphovascular and microvascular invasion and grade 3 patients between histologic types were comparable, the respective rank order of the predictors of lymph node positivity was: Grade 3, lymphovascular invasion (L+), microvascular invasion (V+), submucosal (Sm) 3 invasion, Sm2 invasion and Sm1 invasion. Histologic type (ADC/SCC) was not included in the model. The best predictors for SCC lymph node positivity were Sm3 invasion and (V+). For ADC, the most important predictor was (L+).

CONCLUSION: Local tumor recurrence is predicted by grade 3, metachronous cancer by the carcinoma in-situ component, and lymph node positivity by L+. T1b cancer should be treated with surgical resection.

Endoscopic ultrasonography guided biliary drainage: Summary of consortium meeting, May 7th, 2011, Chicago

Endoscopic retrograde cholangiopancreatography (ERCP) has become the preferred procedure for biliary or pancreatic drainage in various pancreatico-biliary disorders. With a success rate of more than 90%, ERCP may not achieve biliary or pancreatic drainage in cases with altered anatomy or with tumors obstructing access to the duodenum. In the past those failures were typically managed exclusively by percutaneous approaches by interventional radiologists or surgical intervention. The morbidity associated was significant especially in those patients with advanced malignancy, seeking minimally invasive interventions and improved quality of life. With the advent of biliary drainage via endoscopic ultrasound (EUS) guidance, EUS guided biliary drainage has been used more frequently within the last decade in different countries. As with any novel advanced endoscopic procedure that encompasses various approaches, advanced endoscopists all over the world have innovated and adopted diverse EUS guided biliary and pancreatic drainage techniques. This diversity has resulted in variations and improvements in EUS Guided biliary and pancreatic drainage; and over the years has led to an extensive nomenclature. The diversity of techniques, nomenclature and recent progress in our intrumentation has led to a dedicated meeting on May 7^th, 2011 during Digestive Disease Week 2011. More than 40 advanced endoscopists from United States, Brazil, Mexico, Venezuela, Colombia, Italy, France, Austria, Germany, Spain, Japan, China, South Korea and India attended this pivotal meeting. The meeting covered improved EUS guided biliary access and drainage procedures, terminology, nomenclature, training and credentialing; as well as emerging devices for EUS guided biliary drainage. This paper summarizes the meeting’s agenda and the conclusions generated by the creation of this consortium group.

Challenges in diagnosing mesenteric ischemia

Early identification of acute mesenteric ischemia (AMI) is challenging. The wide variability in clinical presentation challenges providers to make an early accurate diagnosis. Despite major diagnostic and treatment advances over the past decades, mortality remains high. Arterial embolus and superior mesenteric artery thrombosis are common causes of AMI. Non-occlusive causes are less common, but vasculitis may be important, especially in younger people. Because of the unclear clinical presentation and non-specific laboratory findings, low clinical suspicion may lead to loss of valuable time. During this diagnostic delay, progression of ischemia to transmural bowel infarction with peritonitis and septicemia may further worsen patient outcomes. Several diagnostic modalities are used to assess possible AMI. Multi-detector row computed tomographic angiography is the current gold standard. Although computed tomographic angiography leads to an accurate diagnosis in many cases, early detection is a persistent problem. Because early diagnosis is vital to commence treatment, new diagnostic strategies are needed. A non-invasive simple biochemical test would be ideal to increase clinical suspicion of AMI and would improve patient selection for radiographic evaluation. Thus, AMI could be diagnosed earlier with follow-up computed tomographic angiography or high spatial magnetic resonance imaging. Experimental in vitro and in vivo studies show promise for alpha glutathione S transferase and intestinal fatty acid binding protein as markers for AMI. Future research must confirm the clinical utility of these biochemical markers in the diagnosis of mesenteric ischemia.

A Case-Control Study of Esomeprazole Plus Rebamipide vs. Omeprazole Plus Rebamipide on Post-ESD Gastric Ulcers

Objectives

Endoscopic submucosal dissection (ESD) is useful for treating gastric tumors. Several trials have shown the efficacy of 4 or 8 weeks of proton pump inhibitor (PPI) administration for post-ESD ulcers. However, if the size of the post-ESD ulcer is larger than predicted, PPI administration alone might not be sufficient for the ulcer to heal within 4 weeks. There is no report about the efficacy of post-ESD gastric ulcers by esomeprazole. We examined retrospectively the efficacy of a combination therapy of esomeprazole plus rebamipide, a mucosal-protective antiulcer drug, on the acceleration of post-ESD ulcer healing comparing with omeprazole plus rebamipide.

Methods:

We reviewed the medical records of patients who underwent ESD for gastric neoplasia. We conducted a case-control study to compare the healing rates within 4 weeks effected by esomeprazole plus rebamipide (group E) and omeprazole plus rebamipide (group O). The sizes of the artificial ulcers were divided into normal-sized or large-sized.

Results:

The baseline characteristics did not differ significantly between the two groups except age and sex. Stage S1 disease was observed in 27.6% and 38.7% of patients after 4 weeks of treatment in the group E and O, respectively. In large-sized artificial ulcers, the healing rate of stage S1 in group E is significantly higher than that in group O in 4 weeks.(25% VS 0%:P = 0.02)

Conclusions:

The safety and efficacy profiles of esomeprazole plus rebamipide and omeprazole and rebamipide are similar for the treatment of ESD-induced ulcers. In large-sized ulcers, esomeprazole plus rebamipide promotes ulcer healing.

Microscopic polyangiitis complicated with ileal involvement detected by double-balloon endoscopy: a case report

BACKGROUND

Microscopic polyangiitis is characterized by pauci-immune, necrotizing small-vessel vasculitis and an anti-neutrophil cytoplasmic antibody-associated vasculitis. Although gastrointestinal involvement in microscopic polyangiitis is not rare, endoscopic observation of it is extremely rare. To the best of our knowledge, this is the first case report of small intestinal involvement in microscopic polyangiitis detected and followed up by double-balloon endoscopy.

CASE PRESENTATION

A 70-year-old Japanese woman was transferred to our hospital for close examination of suspected small intestinal lymphoma. Retrograde double-balloon endoscopy revealed various forms of ulcers with redness and edema in the ileum. Histological findings suggested ischemic changes. Because mononeuritis multiplex and a fever spike appeared later, vasculitis was suspected. The perinuclear anti-neutrophil cytoplasmic antibody titer was elevated. Nerve biopsy results suggested vasculitis. From these findings, microscopic polyangiitis was diagnosed. It was suggested that microscopic polyangiitis caused the intestinal involvement. Intravenous pulse cyclophosphamide and oral predonisolone were started. After treatment, perinuclear anti-neutrophil cytoplasmic antibodies decreased to the normal range. Retrograde double-balloon endoscopy after treatment showed ulcer scars and no ulcer.

CONCLUSION

The cause of gastrointestinal involvement in microscopic polyangiitis is ischemia due to vasculitis. It is difficult to diagnose small-vessel vasculitis by endoscopic biopsy. Although histological evidence of microscopic polyangiitis is important, the treatment should not be delayed by repeating the biopsy, because such delay can result in adverse sequela.This case report shows that microscopic polyangiitis should be considered as a differential diagnosis when small intestinal changes like those in the present case are observed by endoscopy.

Update on Ophthalmic Oncology 2012: Advances in Retinoblastoma and Uveal Melanoma

PURPOSE

The purpose of this article was to review the major advances in both translational and clinical research in 2 diseases, retinoblastoma and uveal melanoma, from November 2011 through October 2012.

DESIGN

Literature Review.

METHODS

A MEDLINE search was performed using the search terms "retinoblastoma" and "uveal melanoma." All relevant articles were reviewed, and articles with the most clinical relevance were reported.

RESULTS

In retinoblastoma, new clinical data are emerging every year regarding the safety and efficacy of intra-arterial chemotherapy as well as other even newer modalities such as intravitreal chemotherapy. Globe salvage rates for eyes without vitreous seeding approach 100% and are increasing to 80% for those with seeds with new methods of treatment. In uveal melanoma, our understanding of the genetic pathways underlying this disease is improving each day and leading to the initiation of clinical trials for adjuvant therapy and metastatic disease.

CONCLUSIONS

Ocular oncology is a small but dynamic field in which our knowledge is increasing every day. Exciting data emerged in the fields of both retinoblastoma and uveal melanoma this year.

Video capsule endoscopy of the small bowel

PURPOSE OF REVIEW

Small bowel capsule endoscopy (SBCE) was introduced 13 years ago by Given Imaging (Yokneam, Israel). It has become one of the most important investigational tools of the small bowel. The capsule is swallowed with water after a 12 h fast, propelled via peristalsis through the gastrointestinal tract and excreted naturally. A nonvideo patency capsule was developed to confirm functional patency of the gastrointestinal tract.

RECENT FINDINGS

Four additional companies have introduced competitive small bowel video capsules, some of which are Food and Drug Admistration (FDA) approved. Due to the easiness of the procedure, SBCE has become a first-line tool to detect small bowel abnormalities. The main indications for SBCE include obscure gastrointestinal bleeding, suspected Crohn's disease, small bowel tumors and practically any abnormal small bowel imaging. New indications are emerging like small bowel motility and monitoring of drug therapy and mucosal healing. The present review will describe the available capsules in the market, the procedure itself, present indications and future expectations. It will focus on the PillCam SB of Given Imaging as it is the one on which most of the literature is written.

SUMMARY

Over the past 10 years, SBCE has become a routine, first-line investigational tool of many small bowel pathologies.

Recent trends in the endoscopic management of variceal bleeding in children

Variceal bleeding results in significant morbidity and mortality in both children and adults. The guidelines for the management of variceal bleeding are well established in adults but not in children as there have been insufficient pediatric studies of this disorder. In addition, the adult guidelines for treatment of variceal bleeding cannot be applied directly to children as the etiology and natural course of this disease differs between children and adults. Examples of recommended treatments in children include endoscopic variceal ligation as secondary prophylaxis for biliary atresia whereas a meso-Rex shunt operation for extrahepatic portal vein obstruction. In this review, we discuss prophylaxis options and some technical aspects of endoscopic management for variceal bleeding in children.

Endoscopic resection (endoscopic submucosal dissection/endoscopic mucosal resection) for superficial Barrett's esophageal cancer

Recently developed endoscopic resection (endoscopic submucosal dissection [ESD]/ endoscopic mucosal resection) has dramatically changed the therapeutic approach for Barrett's esophageal cancer. The rationale for endoscopic resection is that lesions confined to the mucosal layer have negligible risk for developing lymph node metastasis and can be successfully eradicated by endoscopic treatment as a curative treatment with minimal invasiveness. According to some reports that analyzed the rate of lymph-node involvement relative to the depth of mucosal or submucosal tumor infiltration, endoscopic resection is clearly indicated for intramucosal carcinoma and might be extended to lesions with invasion into the submucosa (<200 μm, sm1) because of the low risk for lymph node metastasis. Most Japanese experts recommend ESD for Barrett's esophageal cancer after accurate diagnosis of the margin of cancer using narrow band imaging with magnifying endoscopy because of its high curative rate. However, few studies have evaluated the long-term outcomes of endoscopic resection for Barrett's esophageal cancer in Japan. Further investigations should be conducted to establish endoscopic resection for Barrett's esophageal cancer.

Endoscopic ultrasound-guided choledochoduodenostomy and duodenal stenting in patients with unresectable periampullary cancer: one-step procedure by using linear echoendoscope

OBJECTIVE

Describe a case series of endoscopic ultrasound (EUS)-guided choledochoduodenostomy (EUS-CD) associated with duodenal self-expandable metal stents (SEMS) placement using solely the linear echoendoscope in seven patients with obstructive jaundice and duodenal obstruction due to unresectable periampullary cancer.

MATERIAL AND METHODS

EUS-CD in the first portion of the duodenum, associated with duodenal SEMS placement was performed in seven patients with unresectable periampullary cancer with obstructive jaundice and invasive duodenal obstruction. Laboratory tests and clinical follow-up were performed until patient's death. The procedure was performed by an experienced endoscopist under conscious sedation. The puncture position was chosen based on EUS evaluation, at the common bile duct (CBD) above the tumor, through the distal part of the duodenal bulb. After that, the needle was withdrawn and a wire-guided needle knife was used to enlarge the site puncture in the duodenal wall. Then, a partially covered SEMS was passed over the guide, through the choledochoduodenal fistula. Duodenal SEMS placement was performed during the same endoscopic procedure.

RESULTS

The procedure was performed in seven patients, ranging between 34 and 86 years. Technical success of EUS-CD, by the stent placement, occurred in 100% of the cases. There were no early complications. Duodenal SEMS placement was effective in 100% of the cases that remained alive after a follow-up of 7 and 30 days.

CONCLUSION

The results suggest therapeutic EUS one-step procedure drainage as an alternative for these patients, with good clinical success, feasible technique and safety.

Evaluation of the small bowel in inflammatory bowel disease

Crohn's disease is a chronic inflammatory bowel disease (IBD) that can affect the entire GI tract, and adequate visualization of the small bowel is imperative for both diagnosis and management. Magnetic resonance and computed tomography enterography have gradually replaced barium-based studies. Magnetic resonance enterography has the distinct advantage of avoiding ionizing radiation to which many patients with IBD are overexposed. Endoscopy-based techniques, including capsule endoscopy and device-assisted enteroscopy, allow direct visualization of the small bowel mucosa. Deep enteroscopy has the additional benefit of allowing sampling of the mucosa for histological analysis. Small intestine contrast ultrasound is rapidly gaining credence as an excellent, radiation-free imaging technique, but is not available in all countries. Other imaging modalities, such as positron emission tomography and leucocyte scintigraphy, continue to be studied and may have a role in specific circumstances. This review summarizes the evidence for the various techniques for evaluating the small bowel in IBD.

Management of complications associated with endoscopic submucosal dissection/ endoscopic mucosal resection for esophageal cancer

Endoscopic resection of early esophageal cancer (EEC) is an established therapy in Japan and is increasingly becoming accepted and used regularly in other countries. Endoscopic submucosal dissection (ESD), an application of conventional endoscopic mucosal resection (EMR), has been developed to allow the resection of larger lesions in an en bloc manner; the earliest results so far have been promising even in EEC. ESD allows precise assessment of the histopathological curability of resected specimens, reducing local recurrence. However, ESD has relatively high complication rates; notification of perforation risk is essential especially in the esophagus. Bleeding during ESD can be managed by endoscopic closure with endoclips, and delayed bleeding is rare. Esophageal stricture following semicircular or complete circular esophageal ESD was relatively frequent even when treated by multiple pre-emptive endoscopic balloon dilation. Endoscopic triamcinolone injection, temporal stenting and innovative transplantation of autologous tissue-engineered epithelial cell sheets have shown promising results for the prevention of luminal stricture following semicircular esophageal ESD. In cases of circumferential ESD, however, giving oral prednisolone can offer a unique treatment option for the prevention of intractable post-procedural stricture of the esophagus.

Role of antisecretory agents for gastric endoscopic submucosal dissection

Gastric endoscopic submucosal dissection (ESD) causes artificial gastric ulcers and there is no consensus regarding the optimal perioperative management in terms of prevention of intra- or postoperative bleeding and promotion of healing. Traditionally, 8-week administration of proton pump inhibitors (PPI) and mucosal protective agents were used in the same way as for peptic ulcer management. However, recent studies have revealed that prior use of PPI might reduce intraoperative bleeding or early-phase postoperative bleeding, and combination of histamine-2 receptor antagonist (H2RA), and second-look endoscopy might have a similar effect on postoperative bleeding to PPI. Additionally, the advantage of PPI over H2RA is not proven and the optimal duration of PPI may be shortened until 2 weeks when the deteriorating factors for ESD ulcer are excluded. Furthermore, mucosal protective agents may facilitate ulcer healing. Further studies are needed to determine the optimal treatment protocol before and after ESD for both prevention of bleeding complication and promotion of ulcer healing, by using available antisecretory agents and mucosal protective agents.

Complications of gastric endoscopic submucosal dissection

Endoscopic resection is now a widely accepted treatment for early gastric cancer, having a negligible risk of lymph-node metastasis. Endoscopic submucosal dissection (ESD) is a relatively new endoscopic resection method developed in the mid-1990 s that facilitates en-bloc resection even in patients with large or ulcerative lesions difficult to resect using conventional endoscopic mucosal resection (EMR). However, compared to EMR, ESD requires a longer procedure time and a higher level of technical expertise, in addition to having a slightly greater risk of complications. Endoscopists must be aware of not only the risk factors for, and incidence of, complications, but also how to effectively treat such complications. Perforation and bleeding are the major complications associated with gastric ESD. The perforation and delayed bleeding rates have been reported to range from 1.2% to 5.2% and 0% to 15.6%, respectively, and can usually be managed with appropriate endoscopic treatment. Immediate bleeding during gastric ESD is quite common and controlling such bleeding, which is primarily achieved by carrying out electrocautery, plays a critical role in the successful completion of ESD.

The role of colonoscopy in evaluating hematochezia: a population-based study in a large consortium of endoscopy practices

BACKGROUND

Data on the role of colonoscopy in hematochezia are almost exclusively derived from clinical experience in tertiary care practice.

OBJECTIVE

To characterize the patient population who received colonoscopy for hematochezia in a consortium of diverse gastroenterology practices.

DESIGN

Retrospective analysis.

SETTING

Clinical Outcomes Research Initiative Database, 2002 to 2008.

PATIENTS

Adults undergoing colonoscopy for the indication of hematochezia.

MAIN OUTCOME MEASUREMENTS

Demographics, comorbidity, practice setting, adverse events, and colonoscopy procedure characteristics and findings. Age-stratified analyses and analyses of inpatient- versus outpatient-performed colonoscopies were also performed.

RESULTS

A total of 966,536 colonoscopies were performed during the study period, 76,186 (7.9%) were performed for evaluation of hematochezia. The majority of patients were white non-Hispanic men younger than 60 years old who underwent colonoscopy at a community practice site (79.1%) and had a low-risk American Society of Anesthesiologists (ASA) score (81.5%), in whom colonoscopy reached the cecum (94.8%), and serious adverse events were rare. Colonoscopy findings were hemorrhoids (64.4%), diverticulosis (38.6%), and polyp or multiple polyps (38.8%). From the overall cohort, 38.3% were 60 years of age and older. The older age cohort had significantly more white non-Hispanic females, high-risk ASA scores, incomplete colonoscopies, and unplanned events. Colonoscopy findings demonstrated significantly higher rates of diverticulosis, polyp or multiple polyps, mucosal abnormality/colitis, tumor, and solitary ulcer (P < .0001). There were 3941 (5.2%) who underwent inpatient-performed colonoscopy. One third of this cohort (32.6%) was defined as having a high ASA score.

LIMITATIONS

Retrospective database review.

CONCLUSIONS

These results describe patient populations and characterize colonoscopy findings in individuals presenting with hematochezia primarily in a community practice setting.

Is narrow band imaging superior to high-definition white light endoscopy in the assessment of diminutive colorectal polyps?

BACKGROUND AND AIM

Diminutive polyps measuring ≤ 5 mm in size constitute 80% of polyps in the colon. We prospectively assessed the performance of high-definition white light endoscopy (hWLE) and narrow band imaging (NBI) in differentiating diminutive colorectal polyps.

METHODS

In this prospective, multicenter study, videos of 50 diminutive polyps (31 hyperplastic, 19 adenomatous) in hWLE followed by NBI (total 100 videos) were initially obtained and placed in random order into five separate folders (each folder 20 videos). Eight endoscopists were then invited to predict the histology (each endoscopist 100 videos, 800 video assessments in all). Polyps were classified into types 1-3 (hyperplastic) and type 4 (adenoma). Feedback on individual performance was given after each folder (20 videos) was assessed.

RESULTS

The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy in differentiating hyperplastic from adenomatous polyps by hWLE (400 videos) and NBI (400 videos) were 67.8%, 90.7%, 81.7%, 82.1%, and 82.0%; and 82.2%, 81.5%, 73.1%, 88.2%, and 81.8%, respectively. In the pretest and post-test analysis, the accuracy with NBI improved markedly from 68.8% to 91.3% (P = 0.001) compared with hWLE, 76.3-78.8% (P = 0.850). Overall, the interobserver agreement was 0.46 for hWLE (moderate) and 0.64 for NBI (good).

CONCLUSIONS

NBI was as accurate as hWLE in differentiating diminutive colorectal polyps. Once a learning curve was reached, NBI achieved significantly higher accuracies with good interobserver agreement. Using a simplified classification, a didactic learning session and feedback on performance, diminutive colorectal polyps could be predicted with high accuracies with NBI.

The current state of diagnosis and treatment for early gastric cancer

The prognosis for gastric cancer depends on its stage; so, detection in the early stage of disease is important, when complete and curative removal is possible. Accurate diagnosis can be facilitated by a sound understanding of the basic findings of white light endoscopy of early gastric cancer, and diagnosis can be refined further by the combined use of other imaging modalities such as image-enhanced endoscopy including chromoendoscopy and endoscopic ultrasonography. Minimally invasive endoscopic treatment has come to be the preferred therapeutic approach for early gastric cancer. In addition to conventional endoscopic mucosal resection, a new technique known as endoscopic submucosal dissection (ESD) has spread rapidly worldwide. Indeed, strategies for ESD have been established, devices developed, its indications expanded, and its safety and long-term results extensively reported. Some unique combination therapies involving endoscopy and surgical treatment have also been reported. It is anticipated that the number of patients undergoing endoscopic therapy will continue to increase, and the ongoing developments in endoscopic treatment are expected not only to improve gastric cancer prognosis but also to maintain good quality of life after treatment.

Diagnostic value of EUS elastography in detection of gastrointestinal submucosal tumors

AIM: To summarize the real-time EUS elastographic patterns of gastrointestinal submucosal tumors (SMTs) and investigate the potential use of EUS elatography for the differentiation between benign and malignant conditions.

METHODS: Thirty-four patients who underwent EUS at our department for SMT between January 2009 and October 2011 were enrolled, and real-time elastography was carried out during conventional EUS examination. Elastographic images were scored 1 to 5 based on the elastographic pattern. The final diagnosis was made based on the histopathology of specimens resected by surgery or endoscopy.

RESULTS: The 34 lesions were finally diagnosed as leiomyoma (n = 6), lipoma (n = 1), liposarcoma (n = 1), neurilemmoma (n = 1), or gastrointestinal stromal tumors (GISTs) (n = 25). Among the 25 GIST cases with pathological results, 12 were low-risk GISTs, 7 were moderate-risk GISTs, and 6 were high-risk GISTs. The elatographic patterns of benign SMTs tended to be type Ⅰ, Ⅱ or Ⅲ. All moderate-/high-risk GIST showed an elatographic pattern of type IV. There was a significant difference in elastographic pattern between benign and malignant lesions (P < 0.001). The sensitivity, specificity and accuracy of real-time EUS elastography in the evaluation of malignant lesions were 92.86%, 95.00% and 94.12%, respectively. There was no significant difference in elastographic pattern between GISTs and leiomyoma.

CONCLUSION: There is an apparent difference in elastographic pattern between benign and malignant lesions of upper gastrointestinal SMTs. Real-time EUS elastography may be a promising method for the differentiation of benign and malignant lesions of upper gastrointestinal SMTs.

Colonoscopy practice in lagos, Nigeria: a report of an audit

Background. Colonoscopy effectiveness depends on the quality of the examination. Community-based report of quality of colonoscopy practice in a developing country will help in determining standard and also serve as a stimulus for improvement in service. Aim. To review the quality of colonoscopy practice and document pattern of colonic disease including polyp detection rate in Lagos, Nigeria. Method. A protocol that captured the patients' demographics, indication, and some quality indices of colonoscopy was developed and sent to all the identified colonoscopy units in Lagos to complete for all procedures performed between January 2011 and June 2012. All data were collated and analyzed. The quality indices studied were compared with guideline standard. Results. Twelve colonoscopy centers were identified but only nine centers responded. The gastroenterologist/endoscopists were physicians (3) and surgeons (5). Six hundred and seven colonoscopy procedures were performed during this period (M : F = 333 : 179) while the sex was not disclosed in 95 subjects. The examination indications were lower GI bleeding (24.2%), altered bowel habits (9.2%), lower abdominal pain (9.1%), screening for CRC (4.3%) and unspecified (46.8%). Conscious sedation was generally used while bowel preparation (good in 81.4%) was done with low residue diet and stimulant laxatives. Caecal intubation rate was 81.2%. Common endoscopic findings were haemorrhoids (43.2%), polyps/masses (13.4%), diverticulosis (11.1%), and no abnormality (23.4%). Polyp was detected in 6.8% of cases. Conclusion. Colonoscopy utilization is low, and the quality of practice is suboptimal; although limited resources could partly explain this, however it is not clear if the low rate of polyp detection is due to missed lesions or low population incidence.

Food impaction in older age: Think about an eosinophilic esophagitis

Eosinophilic esophagitis is an inflammatory condition of esophagus. It is generally seen in childhood and young population. Men are more commonly affected than women. However, it is not common in an advanced age. Eosinophilic esophagitis decreases the ability of the esophagus to stretch and accommodation against foods. Therefore, the major symptom in adults with eosinophilic esophagitis is difficulty in swallowing solid food (dysphagia). Specifically, the food gets stuck in the esophagus after it is swallowed. Less common symptoms include heartburn and chest pain. Because of this, it may be incorrectly diagnosed as a gastroesophageal reflux disease. Here, we reported a case presented with food impaction at advanced age. As a conclusion, eosinophilic esophagitis is a rare entity that must be remembered in advance aged patients presenting with food impaction.

Factors influencing quality of bowel preparation for colonoscopy

Recent technological advances in colonoscopy have led to improvements in both image enhancement and procedural performance. However, the utility of these technological advancements remain dependent on the quality of bowel preparation during colonoscopy. Poor bowel preparation has been shown to be associated with lower quality indicators of colonoscopy performance, such as reduced cecal intubation rates, increased patient discomfort and lower adenoma detection. The most popular bowel preparation regimes currently used are based on either Polyethylene glycol-electrolyte, a non-absorbable solution, or aqueous sodium phosphate, a low-volume hyperosmotic solution. Statements from various international societies and several reviews have suggested that the efficacy of bowel preparation regimes based on both purgatives are similar, although patients’ compliance with these regimes may differ somewhat. Many studies have now shown that factors other than the type of bowel preparation regime used, can influence the quality of bowel preparation among adult patients undergoing colonoscopy. These factors can be broadly categorized as either patient-related or procedure-related. Studies from both Asia and the West have identified patient-related factors such as an increased age, male gender, presence of co-morbidity and socio-economic status of patients to be associated with poor bowel preparation among adults undergoing routine out-patient colonoscopy. Additionally, procedure-related factors such as adherence to bowel preparation instructions, timing of bowel purgative administration and appointment waiting times for colonoscopy are recognized to influence the quality of colon cleansing. Knowledge of these factors should aid clinicians in modifying bowel preparation regimes accordingly, such that the quality of colonoscopy performance and delivery of service to patients can be optimised.

Mucosal healing effect of mesalazine granules in naproxen-induced small bowel enteropathy

AIM

To investigate the effect of mesalazine granules on small intestinal injury induced by naproxen using capsule endoscopy (CE).

METHODS

This was a single center, non-randomized, open-label, uncontrolled pilot study, using the PillCam SB CE system with RAPID 5 software. The Lewis Index Score (LIS) for small bowel injury was investigated to evaluate the severity of mucosal injury. Arthropathy patients with at least one month history of daily naproxen use of 1000 mg and proton pump inhibitor co-therapy were screened. Patients with a minimum LIS of 135 were eligible to enter the 4-wk treatment phase of the study. During this treatment period, 3 × 1000 mg/d mesalazine granules were added to ongoing therapies of 1000 mg/d naproxen and 20 mg/d omeprazole. At the end of the 4-wk combined treatment period, a second small bowel CE was performed to re-evaluate the enteropathy according to the LIS results. The primary objective of this study was to assess the mucosal changes after 4 wk of mesalazine treatment.

RESULTS

A total of 18 patients (16 females), ranging in age from 46 to 78 years (mean age 60.3 years) were screened, all had been taking 1000 mg/d naproxen for at least one month. Eight patients were excluded from the mesalazine therapeutic phase of the study for the following reasons: the screening CE showed normal small bowel mucosa or only insignificant damages (LIS < 135) in five patients, the screening esophagogastroduodenoscopy revealed gastric ulcer in one patient, capsule technical failure and incomplete CE due to poor small bowel cleanliness in two patients. Ten patients (9 female, mean age 56.2 years) whose initial LIS reached mild and moderate-to-severe enteropathy grades (between 135 and 790 and ≥ 790) entered the 4-wk therapeutic phase and a repeat CE was performed. When comparing the change in LIS from baseline to end of treatment in all patients, a marked decrease was seen (mean LIS: 1236.4 ± 821.9 vs 925.2 ± 543.4, P = 0.271). Moreover, a significant difference between pre- and post-treatment mean total LIS was detected in 7 patients who had moderate-to-severe enteropathy gradings at the inclusion CE (mean LIS: 1615 ± 672 vs 1064 ± 424, P = 0.033).

CONCLUSION

According to the small bowel CE evaluation mesalazine granules significantly attenuated mucosal injuries in patients with moderate-to-severe enteropathies induced by naproxen.

Ampulla dilation with different sized balloons to remove common bile duct stones

AIM: To assess the outcomes of ampulla dilation with different sized balloons to remove common bile duct (CBD) stones.

METHODS: Patients (n = 208) were divided into five groups based on the largest CBD stone size of < 5, 6-8, 8-12, 12-14, and > 14 mm. Patients underwent limited endoscopic sphincterotomy (EST) alone or limited EST followed by endoscopic papillary balloon dilation with 8, 10, 12 and 14 mm balloons, such that the size of each balloon did not exceed the size of the CBD. Short- and long-term outcomes, such as post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, perforation, bleeding, and pneumobilia were compared among the five groups.

RESULTS: The overall rate of successful stone removal in all groups was 100%, and all patients were cured. Eight (3.85%) patients had post-ERCP pancreatitis, none had perforations, and 6 (2.9%) had bleeding requiring transfusion. There were no significant differences in early complication rates among the five groups. We observed significant correlations between increased balloon size and the short- and long-term rates of post-ERCP pneumobilia. Post-ERCP pancreatitis and bleeding correlated significantly with age, with post-ERCP pancreatitis occurring more frequently in patients aged < 60 years, and bleeding occurring more frequently in patients aged > 70 years. We observed a significant correlation between patient age and the diameter of the largest CBD stone, with stones > 12 mm occurring more frequently in patients > 60 years old.

CONCLUSION: Choosing a balloon size based on the largest stone diameter is safe and effective for removing CBD stones. Balloon size should not exceed 15 mm.

Gastroenteropancreatic neuroendocrine tumors: role of imaging in diagnosis and management

Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are a heterogeneous group of neoplasms that arise from cells of the diffuse neuroendocrine system and are characterized by a wide spectrum of clinical manifestations. All NETs are potentially malignant but differ in their biologic characteristics and the probability of metastatic disease. The pathologic classification of these tumors relies on their proliferation and differentiation. In the past decades, several nomenclatures have been proposed to stratify neuroendocrine tumors, but the World Health Organization classification is the one that is most widely accepted and used. The diagnosis of neuroendocrine tumor relies on clinical manifestation, laboratory parameters, imaging features, and tissue biomarkers in a biopsy specimen. With improved understanding of the natural history and lesion biology, management of GEP-NETs has also evolved. Although surgery remains the only potentially curative therapy for patients with primary GEP-NETs, other available treatments include chemotherapy, interferon, somatostatin analogs, and targeted therapies. Recent improvements in both morphologic and functional imaging methods have contributed immensely to patient care. Morphologic imaging with contrast agent-enhanced multidetector computed tomography and magnetic resonance imaging is most widely used for initial evaluation and staging of disease in these patients, whereas functional imaging techniques are useful both for detection and prognostic evaluation and can change treatment planning.

Prophecy about post-endoscopic retrograde cholangiopancreatography pancreatitis: From divination to science

One unresolved issue of endoscopic retrograde cholangiopancreatography (ERCP) is post-ERCP pancreatitis (PEP), which occurs in up to 40% of patients. Identification of risk factors for PEP is especially important in the field of ERCP practice because it may assist physicians in taking protective measures in situations with high risk. A decade ago, Freeman et al meticulously evaluated a large number of potentially relevant risk factors for PEP, which can be divided into patient-related and procedure-related issues. In this commentary, we summarize this classic article and reevaluate the risk factors for PEP from the current point of view. This is followed by assessment of strategies for prevention of PEP that can be divided into mechanical and pharmacologic methods.

Sedation methods can determine performance of endoscopic submucosal dissection in patients with gastric neoplasia

BACKGROUND

Although proper sedation is mandatory for endoscopic procedures such as endoscopic submucosal dissection (ESD), there is no research investigating the effects of sedation on ESD performance and complications. We aimed to evaluate the relationship among sedation methods, clinical outcomes, and complications after ESD for gastric neoplasia.

METHODS

We retrospectively reviewed clinical data of 1,367 patients with 1,485 lesions who had undergone ESD for gastric adenoma or early gastric cancer at our tertiary teaching hospital in Seoul, Korea, between January 2008 and May 2011. Of these, 1,035 lesions in 958 patients were included in the intermittent midazolam/propofol injection by endoscopists (IMIE) group, and 450 lesions in 409 patients were included in the continuous propofol infusion with opioid administration by anesthesiologists (CPIA) group.

RESULTS

En bloc resection and complete resection rates were higher in the CPIA group than in the IMIE group (CPIA vs. IMIE; en bloc resection, 99.8 and 95.0 %, P < 0.001; complete resection, 94.2 and 88.3 %, P < 0.001). Duration of procedure was shorter in the CPIA group than in the IMIE group (CPIA vs. IMIE; 48.2 ± 32.5 and 57.6 ± 41.3 min, P < 0.001). In multivariate analysis, sedation method was an independent factor associated with en bloc resection and complete resection. Additionally, sedation with CPIA was not a risk factor for bleeding (P = 0.403) or perforation (P = 0.474); however, aspiration pneumonia developed more frequently in patients sedated with CPIA (CPIA vs. IMIE, 4.4 and 1.5 %, P = 0.002).

CONCLUSIONS

Sedation with CPIA can improve ESD performance.

Consecutive versus separate sessions of endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) for symptomatic choledocholithiasis

BACKGROUND

Common bile duct (CBD) stones are a potentially life-threatening medical condition. Patients with proven CBD stones should undergo stone extraction. The aim of this study was to evaluate whether performing endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) for symptomatic CBD stones in a single session reduces complications related to postponing treatment due to separate EUS and ERCP sessions, and to assess the safety in both options.

METHODS

A total of 151 patients with EUS-proven CBD stones, with subsequent ERCP, treated in our department between January 2005 and December 2011 were included. Complications related to the procedures or sedation and complications due to the CBD stones when EUS and ERCP were not performed in a single session were assessed and compared to complications when the two procedures were performed in one session.

RESULTS

In total, 149 patients of the 151 (98.7 %) had a successful ERCP. Four (5 %) patients in the separate-session group (B) had a major complication compared to none in the single-session group (A) (p > 0.05). Group B received 14 % more midazolam during ERCP than group A (p < 0.05). No sedation-related complications were noted in either group. Eleven of the 80 patients in group B (13.8 %) experienced complications while waiting for ERCP compared to none in group A (p = 0.001, OR = 2.17, CI = 1.06-4.

CONCLUSIONS

EUS and ERCP done in a single session proved to be safe, with no increase in sedation- or procedure-related complications. Postponing treatment for symptomatic CBD stones exposes the patient to biliary complications, especially cholangitis.