Gastric electrical stimulation for the treatment of obesity: from entrainment to bezoars-a functional review

GROWING WORLDWIDE OBESITY EPIDEMIC HAS PROMPTED THE DEVELOPMENT OF TWO MAIN TREATMENT STREAMS: (a) conservative approaches and (b) invasive techniques. However, only invasive surgical methods have delivered significant and sustainable benefits. Therefore, contemporary research exploration has focused on the development of minimally invasive gastric manipulation methods featuring a safe but reliable and long-term sustainable weight loss effect similar to the one delivered by bariatric surgeries. This antiobesity approach is based on placing external devices in the stomach ranging from electrodes for gastric electrical stimulation to temporary intraluminal bezoars for gastric volume displacement for a predetermined amount of time. The present paper examines the evolution of these techniques from invasively implantable units to completely noninvasive patient-controllable implements, from a functional, rather than from the traditional, parametric point of view. Comparative discussion over the available pilot and clinical studies related to gastric electrical stimulation outlines the promises and the fallacies of this concept as a reliable alternative anti-obesity strategy.

Continuous quality improvement of colorectal cancer screening

Quality assurance is a key issue in colorectal cancer screening, because effective screening is able to improve primary prevention of the cancer. The quality measure may be described in terms: how well the screening test tells who truly has a disease (sensitivity) and who truly does not have a disease (specificity). This paper raises concerns about identification of the optimal screening test for colorectal cancer. Colonoscopy vs flexible sigmoidoscopy in colorectal cancer screening has been a source of ongoing debate. A multicentre randomised controlled trial comparing flexible sigmoidoscopy with usual care showed that flexible sigmoidoscopy screening is able to diminish the incidence of distal and proximal colorectal cancer, and also mortality related to the distal colorectal cancer. However, colonoscopy provides a more complete examination and remains the more sensitive exam than flexible sigmoidoscopy. Moreover, colonoscopy with polypectomy significantly reduces colorectal cancer incidence and colorectal cancer-related mortality in the general population. The article considers the relative merits of both methods and stresses an ethical aspect of patient’s involvement in decision-making. Patients should be informed not only about tests tolerability and risk of endoscopy complications, but also that different screening tests for bowel cancer have different strength to exclude colonic cancer and polyps. The authorities calculate effectiveness and costs of the screening tests, but patients may not be interested in statistics regarding flexible sigmoidoscopy screening and from an ethical point of view, they have the right to chose colonoscopy, which is able to exclude a cancer and precancerous lesions in the whole large bowel.

Acute recurrent pancreatitis secondary to the rare association of a duodenal duplication cyst and a pancreas divisum

Duodenal duplication cysts are rare congenital anomalies that can cause acute pancreatitis. Pancreas divisum is also a congenital anomaly, often discovered incidentally, but is considered a possible cause of acute pancreatitis. We report the case of the combination of both anomalies causing recurrent episodes of acute pancreatitis in a young man. Endoscopic treatment by partial excision of the cyst with a polypectomy snare and sphincterotomy of the minor papilla was successful.

The efficacy of i-SCAN for detecting reflux esophagitis: a prospective randomized controlled trial

New imaging technologies have been applied in endoscopy to improve the detection and differentiation of subtle mucosal changes using a digital contrast method. Among them, i-SCAN technology is the most recently developed image-enhancing technology. We investigated whether i-SCAN could improve the detection rate of reflux esophagitis. Interobserver agreement between endoscopists was compared with conventional white light (WL) endoscopic examination. We performed a prospective randomized controlled trial. A consecutive series of 514 subjects that underwent an esophagogastroduodenoscopy for health inspection were enrolled and randomized into the i-SCAN group (n = 246) and WL group (n = 268). An esophagogastroduodenoscopy with video recording was used for detecting reflux esophagitis, and reflux esophagitis were categorized by the modified Los Angeles (LA) classification. The total number of reflux esophagitis identified by WL and i-SCAN was 58 (21.7%) and 74 (30.1%), respectively. The diagnostic yield of reflux esophagitis was significantly higher (P = 0.034) in the i-SCAN group (30.1%) as compared to the WL group (21.6%). Using the modified LA classification, the detection rate of minimal changes was significantly higher (P = 0.017) in the i-SCAN group (11.8%) as compared to the WL group (5.6%), but the detection rates of LA-A and LA-B were not significantly different between the two groups (P = 0.897 and P = 0.311, respectively). After comparison of the interobserver agreement using randomly selected video clips, the i-SCAN group showed better agreement than the WL group (Kappa value, 0.793 vs. 0.473). Compared to WL endoscopy, applying i-SCAN in daily practice can improve the diagnostic yield of reflux esophagitis by detecting more minimal changes in the squamo-columnar junction of the esophagus and can improve the interobserver agreement of the modified Los Angeles classification.

Suture marker lesion detection in the colon by self-stabilizing and unmodified capsule endoscopes: pilot study in acute canine models

BACKGROUND

Capsule endoscopy is a noninvasive method for examining the small intestine. Recently, this method has been used to visualize the colon. However, the capsule often tumbles in the wider colon lumen, resulting in potentially missed pathology. In addition, the capsule does not have the ability to distend collapsed segments of the organ. Self-stabilizing capsule endoscopy is a new method of visualizing the colon without tumbling and with the ability to passively distend colon walls.

OBJECTIVE

To quantitatively compare the detection rate of intraluminal suture marker lesions for colonoscopy by using a custom-modified, self-stabilizing capsule endoscope (SCE); an unmodified capsule endoscope (CE) of the same brand; and a standard colonoscope.

DESIGN

Four mongrel dogs underwent laparotomy and the implantation of 5 to 8 suture markers to approximate colon lesions. Each dog had both capsule endoscopy and self-stabilizing capsule endoscopy, administered consecutively in random order. In each case, the capsule was inserted endoscopically into the proximal lumen of the colon followed by pharmacologically induced colon peristalsis to propel it distally through the colon. Blinded standard colonoscopy was performed by an experienced gastroenterologist after the capsule endoscopies.

SETTING

Experimental study in a live canine model.

SUBJECTS

Four dogs.

INTERVENTION

Laparotomy, capsule endoscopy, colonoscopy.

MAIN OUTCOME MEASUREMENTS

Comparison of the marker detection rate of the SCE to that of the unmodified MiroCam CE and a colonoscope.

RESULTS

The average percentages of the marker detection rate for unmodified capsule endoscopy, self-stabilizing capsule endoscopy, and colonoscopy, respectively, were 31.1%, 86%, and 100% (P < .01), with both self-stabilizing capsule endoscopy and colonoscopy performing significantly better than the unmodified capsule endoscopy.

LIMITATIONS

Acute canine model, suture markings poorly representative of epithelial polyps, limited number of animals.

CONCLUSION

The proposed self-stabilizing capsule endoscope delivered a significant improvement in detection rates of colon suture markings when compared with the unmodified capsule endoscope.

Transumbilical single-incision laparoscopic splenectomy plus pericardial devascularization using conventional instruments: initial experience of 5 cases

PURPOSE

Laparoendoscopic single-site surgery (LESS) has been proposed for several intra-abdominal surgical interventions. However, application of the LESS technique in portal hypertension is still in its infancy. We report in this article a new technique of LESS splenectomy plus pericardial devascularization with conventional laparoscopic instruments in patients with portal hypertension.

PATIENTS AND METHODS

From January 2010 to April 2012, LESS splenectomy plus pericardial devascularization was performed on 5 patients with portal hypertension. Surgical techniques and short-term outcomes were summarized and analyzed retrospectively.

RESULTS

All the operations were successful with a mean operative duration of 252 minutes (range, 220-270 minutes), intraoperative blood loss of 290 mL (range, 250-350 mL), and hospital stay of 8.2 days (range, 7-9 days). No intraoperative or postoperative complications were recorded. The umbilical incision healed well with a satisfactory cosmetic effect.

CONCLUSIONS

LESS splenectomy plus pericardial devascularization is feasible when performed by experienced laparoscopic surgeons and may offer safety comparable to that of the conventional laparoscopic operation.

Gastroesophageal reflux in critically ill children: a review

Gastroesophageal reflux (GER) is very common in children due to immaturity of the antireflux barrier. In critically ill patients there is also a high incidence due to a partial or complete loss of pressure of the lower esophageal sphincter though other factors, such as the use of nasogastric tubes, treatment with adrenergic agonists, bronchodilators, or opiates and mechanical ventilation, can further increase the risk of GER. Vomiting and regurgitation are the most common manifestations in infants and are considered pathological when they have repercussions on the nutritional status. In critically ill children, damage to the esophageal mucosa predisposes to digestive tract hemorrhage and nosocomial pneumonia secondary to repeated microaspiration. GER is mainly alkaline in children, as is also the case in critically ill pediatric patients. pH-metry combined with multichannel intraluminal impedance is therefore the technique of choice for diagnosis. The proton pump inhibitors are the drugs of choice for the treatment of GER because they have a greater effect, longer duration of action, and a good safety profile.

Can endoscopic submucosal dissection be safely performed in a smaller specialized clinic?

AIM

To investigate whether endoscopic submucosal dissection (ESD) can be safely performed at small clinics, such as the Shirakawa Clinic.

METHODS

One thousand forty-seven ESDs to treat gastrointestinal tumors were performed at the Shirakawa Clinic from April 2006 to March 2011. The efficacy, technical feasibility and associated complications of the procedures were assessed. The ESD procedures were performed by five endoscopists. Sedation was induced with propofol for esophagogastorduodenal ESD.

RESULTS

One thousand forty-seven ESDs were performed to treat 64 patients with esophageal cancer (E), 850 patients with gastric tumors (G: 764 patients with cancer, 82 patients with adenomas and four others), four patients with duodenal cancer (D) and 129 patients with colorectal tumors (C: 94 patients with cancer, 21 patients with adenomas and 14 others). The en bloc resection rate was 94.3% (E: 96.9%, G: 95.8%, D: 100%, C: 79.8%). The median operation time was 46 min (range: 4-360 min) and the mean size of the resected specimens was 18 mm (range: 2-150 mm). No mortal complications were observed in association with the ESD procedures. Perforation occurred in 12 cases (1.1%, E: 1 case, G: 9 cases, D: 1 case, C: 1 case) and postoperative bleeding occurred in 53 cases (5.1%, G: 51 cases, D: 1 case, C: 1 case); however, no case required either emergency surgery or blood transfusion. All of the perforations and postperative bleedings were resolved by endoscopic clipping or hemostasis. The other problematic complication observed was pneumonia, which was treated with conservative therapy.

CONCLUSION

ESD can be safely performed in a clinic with established therapeutic methods and medical services to address potential complications.

Endoscopic ultrasound evaluation in the surgical treatment of duodenal and peri-ampullary adenomas

AIM: To investigate endoscopic ultrasound (EUS) for predicting depth of mucosal invasion and to analyze outcomes following endoscopic and transduodenal resection.

METHODS: Records of 111 patients seen at our institution from November 1999 to July 2011 with the post-operative pathological diagnosis of benign ampullary and duodenal adenomas were reviewed. Records of patients who underwent preoperative EUS for diagnostic purposes were identified. The accuracy of EUS in predicting the absence of muscular invasion was assessed by comparing EUS reports to the final surgical pathological results. In addition, the incidence of the post-operative complications over a period of 30 d and the subsequent long-term outcome (recurrence) over a period of 30 mo associated with endoscopic and transduodenal surgical resection was recorded, compared and analyzed.

RESULTS: Among 111 patients with benign ampullary and duodenal adenomas, 47 underwent preoperative EUS for 29 peri-ampullary lesions and 18 duodenal lesions. In addition, computed tomography was performed in 18 patients, endoscopic retrograde cholangio-pancreatography in 10 patients and esophagogastroduodenoscopy in 22 patients. There were 43 patients with sporadic adenomas and 4 patients with familial adenomatous polyposis (FAP)/other polyposis syndromes. In 38 (81%, P < 0.05) patients, EUS reliably identified absence of submucosal and muscularis invasion. In 4 cases, EUS underestimated submucosal invasion that was proven by pathology. In the other 5 patients, EUS predicted muscularis invasion which could not be demonstrated in the resected specimen. EUS predicted tumor muscularis invasion with a specificity of 88% and negative predictive value of 90% (P < 0.05). Types of resection performed included endoscopic resection in 22 cases, partial duodenectomy in 9 cases, transduodenal ampullectomy with sphincteroplasty in 10 cases and pancreaticoduodenectomy in 6 cases. The main post-operative final pathological results included villous adenoma (n = 5), adenoma (n = 8), tubulovillous adenoma (n = 10), tubular adenoma (n = 20) and hyperplastic polyp (n = 2). Among the 47 patients who underwent resection, 8 (17%, 5 of which corresponded to surgical resection) developed post-procedural complications which included retroperitoneal hematoma, intra-abdominal abscess, wound infection, delayed gastric emptying and prolonged ileus. After median follow-up of 20 mo there were 6 local recurrences (13%, median follow-up = 20 mo) 4 of which were in patients with FAP.

CONCLUSION: EUS accurately predicts the depth of mucosal invasion in suspected benign ampullary and duodenal adenomas. These patients can safely undergo endoscopic or local resection.

Advanced endoscopic technologies for colorectal cancer screening

Colorectal cancer is the third most common cancer in men and the second most common cancer in women worldwide. Diagnosing colorectal has been increasingly successful due to advances in technology. Flexible endoscopy is considered to be an effective method for early diagnosis and treatment of gastrointestinal cancer, making it a popular choice for screening programs. However, millions of people who may benefit from endoscopic colorectal cancer screening fail to have the procedure performed. Main reasons include psychological barriers due to the indignity of the procedure, fear of procedure related pain, bowel preparation discomfort, and potential need for sedation. Therefore, an urgent need for new technologies addressing these issues clearly exists. In this review, we discuss a set of advanced endoscopic technologies for colorectal cancer screening that are either already available or close to clinical trial. In particular, we focus on visual-inspection-only advanced flexible colonoscopes, interventional colonoscopes with alternative propulsion mechanisms, wireless capsule colonoscopy, and technologies for intraprocedural bowel cleansing. Many of these devices have the potential to reduce exam related patient discomfort, obviate the need for sedation, increase diagnostic yield, reduce learning curves, improve access to screening, and possibly avert the need for a bowel preparation.

Minimally invasive surgery using intraoperative real-time capsule endoscopy for small bowel lesions

BACKGROUND

The small bowel has been considered the "black box" of gastroenterology. Identifying the exact site of small bowel hemorrhage is often difficult, thus complicating surgical treatment. We report two cases of small bowel bleeding lesions that were successfully managed by intraoperative real-time capsule endoscopy and minimally invasive surgery.

METHODS

We developed a double-lumen tube similar to, but thinner and longer than, the Miller-Abbott tube. We insert the tube nasally, 3 or 4 days preoperatively, such that its balloon tip reaches the anus by the operative day. During surgery, the endoscopic capsule is connected to the balloon tip of the tube that protrudes from the anus. An assistant pulls on the nasal end of the tube, bringing the balloon tip and capsule back into the bowel. Capsule endoscopic images are displayed in a real-time video format.

RESULTS

We employed this procedure in two patients with repeated melena. Various examinations including gastroendoscopy and total colonoscopy showed bleeding confined to the small bowel, but the exact lesion site was unknown. Minimally invasive surgery was successfully performed in both patients: open minilaparotomy in one and laparoscopy in the other. The small bowel and capsule endoscope were easily controlled during minilaparotomy, and real-time capsule endoscopic images clearly identified the bleeding lesion. Control of the small bowel was more difficult in the laparoscopic case; however, real-time capsule endoscopic images identified a small tumor that was successfully resected.

CONCLUSIONS

Intraoperative capsule endoscopy combined with the tube provides surgeons real-time images indicating the exact site of lesions. The tube also helps surgeons control the position of the capsule endoscope and enables suction of intraluminal fluid or inflation of the lumen to allow clearer views during the operation. We conclude that combined use of capsule endoscopy and the tube facilitates management of bleeding lesions in the small bowel.

Clinical significance of heterotopic gastric mucosal patch of the proximal esophagus

Heterotopic gastric mucosa of the proximal esophagus (HGMPE), also referred to as “inlet patch” or “cervical inlet patch”, is a salmon colored patch that is usually located just distal to the upper esophageal sphincter. HGMPE is uncommon with endoscopic studies reporting a prevalence ranging from less than one percent to 18%. Most HGMPE are asymptomatic and are detected incidentally during endoscopy for evaluations of other gastrointestinal complaints. Most consider HGMPE as clinically irrelevant entity. The clinical significance of HGMPE is mainly acid related or neoplastic transformation. The reported prevalence of laryngopharyngeal reflux symptoms varies from less than 20% to as high as 73.1%. However, most of these symptoms are mild. Clinically significant acid related complications such as bleeding, ulcerations, structure and fistulization have been reported. Although rare, dysplastic changes and malignancies in association with HGMPE have also been reported. Associations with Barrett’s esophagus have also been reported but the findings so far have been conflicting. There are still many areas that are unknown or not well understood and these include the natural history of HGMPE, risk factors for complications, role of Helicobacter pylori infection and factors associated with malignant transformations. Follow-up may need to be considered for patients with complications of HGMPE and surveillance if biopsies show intestinal metaplasia or dysplastic changes. Despite the overall low incidence of clinically relevant manifestations reported in the literature, HGMPE is a clinically significant entity but further researches are required to better understand its clinical significance.

Imaging of focal autoimmune pancreatitis and differentiating it from pancreatic cancer

Autoimmune pancreatitis (AIP) is an inflammatory disorder of pancreas. Two types have been identified: the diffuse and the focal or mass forming. Clinical presentation of AIP overlaps that of pancreatic cancer (PC). Sometimes serum IgG4 and CA 19-9 levels are unable to differentiate AIP from PC. Various series have shown that 5%–21% of resected pancreatic masses for suspected malignancy turned out to be AIP. Accurate diagnosis of focal AIP can avoid unnecessary surgeries. This paper elaborates the various imaging modalities useful in differentiating focal AIP from PC.

Use of anesthesia on the rise in gastrointestinal endoscopy

Conscious sedation has been the standard of care for many years for gastrointestinal endoscopic procedures. As procedures have become more complex and lengthy, additional medications became essential for adequate sedation. Often time's deep sedation is required for procedures such as endoscopic retrograde cholangiography which necessitates higher doses of narcotics and benzodiazepines or even use of other medications such as ketamine. Given its pharmacologic properties, propofol was rapidly adopted worldwide to gastrointestinal endoscopy for complex procedures and more recently to routine upper and lower endoscopy. Many studies have shown superiority for both the physician and patient compared to standard sedation. Nevertheless, its use remains highly controversial. A number of studies worldwide show that propofol can be given safely by endoscopists or nurses when well trained. Despite this wealth of data, at many centers its use has been prohibited unless administered by anesthesiology. In this commentary, we review the use of anesthesia support for endoscopy in the United States based on recent data and its implications for gastroenterologists worldwide.

Anesthetic management of the SRSTM endoscopic stapling system for gastro-esophageal reflux disease

The SRS^TM Endoscopic Stapling System (Medigus, Tel Aviv, Israel) is a new tool capable of creating a totally endoscopic fundoplication, combined with an endoscope, endoscopic ultrasound and a surgical stapler. SRS^TM endoscopic stapling for gastro-esophageal reflux disease is a minimally invasive, outpatient procedure, which requires general anesthesia with positive-pressure ventilation. Keeping the patient on positive end-expiratory pressure (PEEP) may minimize the pressure gradient between the esophagus and the mediastinum, as well as help to prevent air from leaking around the screws and causing pneumomediastinum. In addition, in patients with hiatal hernia, higher PEEP levels may be required to increase intra-thoracic pressure and to force the stomach to slide into the abdomen for ease of endoscopy. We advise smoother emergence from anesthesia, taking precautions for retching, postoperative nausea and vomiting (PONV), while coughing and gagging during extubation and PONV may affect the success of the procedure. Total intravenous anesthesia with propofol and remifentanil seems to be a good choice for these reasons.

Internal frontier: the pathophysiology of the small intestine

Even though the small intestine occupies a major portion of the abdominal space and is essential for life, in most pathology textbooks any chapter on small intestinal diseases, especially in human beings, is typically shorter than those for other gastrointestinal organs. Clinical and experimental investigations of the small intestine in various clinical situations, such as nutrition management, obesity interventions, and emergency care, have elucidated several important biological problems associated with the small intestine, the last frontier of gastroenterology. In this issue, a review by Professor Basson and his team at Michigan State University sheds light on the changes in the human small intestine under various conditions based on their clinical and surgical experience. With the advent of recent innovations in enteroscopy, a form of endoscopy used to examine deep within the small intestine, the issue that they highlighted, i.e., mucosal adaptation and atrophy of the human small intestine, has emerged as a major and manageable challenge for gastroenterologists in general, including the readers of the World Journal of Gastroenterology.

[A case of intrahepatic cholangiocarcinoma associated with Type IV choledochal cyst]

Anomalous union of the pancreaticobiliary duct (AUPBD) is a congenital anomaly that is defined as a junction of the bile duct and pancreatic duct outside the duodenal wall. This anomaly results in a loss of normal sphincteric mechanisms at the pancreaticobiliary junction. As a result, regurgitation of pancreatic juice into the biliary system develops and causes choledochal cysts, choledocholithiasis, cholangitis, pancreatitis and malignancy of the biliary tract. Gallbladder cancer or common bile duct cancer associated with AUPBD and choledochal cysts have been frequently reported. But, intrahepatic cholangiocarcinoma associated with this condition has been only rarely reported. Here, we report a case of intrahepatic cholangiocarcinoma associated with AUPBD and choledochal cyst.

Gastric gastrointestinal stromal tumor smaller than 20 mm with liver metastasis

There have been no reports of gastric gastrointestinal stromal tumors (GISTs) <20 mm with distant metastasis. We report a case of a 15-mm gastric GIST with liver metastasis 1 year after surgical resection of the primary lesion. A 35-year-old man underwent routine esophagogastroduodenoscopy in July 2009. A submucosal tumor (SMT) <20 mm was incidentally detected at the posterior wall of the gastric body. Endoscopic ultrasound (EUS) indicated that it was a gastrointestinal mesenchymal tumor, including GIST, leiomyoma or schwannoma. He did not accept regular follow-up for this gastric SMT, therefore local laparoscopic excision was carried out in October 2009. The final pathological diagnosis after surgery was GIST, 15 mm in size, and a mitotic rate of 7/50 high-power fields, which did not indicate a high metastatic risk. The patient was followed up regularly without adjuvant chemotherapy. At 1 year after surgery, a space-occupying lesion ~15 mm was detected in the left lobe of the liver by abdominal ultrasound, where no mass lesion had been observed before surgery. To make a definite diagnosis of the hepatic mass lesion, EUS-guided fine-needle aspiration was performed, which demonstrated a metastatic liver tumor from a gastric GIST. Although this was a rare case, we should keep in mind that gastric GISTs do have a chance of malignant behavior, even if <20 mm.

Esophageal bezoar formation due to solidification of enteral feed administered through a malpositioned nasogastric tube: case report and review of the literature

Enteral feeding is now standard and routine practice in intensive care. The use of a nasogastric tube for enteral feeding is generally considered to be safe, but tubes with small bores can sometimes lead to aspiration or passage clogging when malpositioned in sedated patients who are on long-term mechanical ventilation. Thus, accurate confirmation of correct placement is mandatory in such patients. This is not always the case, but this faulty practice can lead to serious complications in the absence of potential bezoar-forming medicines or gastrointestinal pathology. We present here one such interesting case of a patient who developed esophageal bezoar due to a malpositioned nasogastric tube for administering a casein-containing feed. In addition, we present a review of the literature.

Comparison of hemodynamic and inflammatory changes between transoral and transthoracic thoracoscopic surgery

BACKGROUND

Natural orifice transluminal endoscopy has been developed for abdominal surgical procedures. The aim of this study was to compare the surgical outcome between a novel transoral approach and a standard transthoracic approach for the thoracic cavity in a canine model.

METHODS

Twenty-eight dogs were assigned to transoral (n = 14) or standard thoracoscopy (n = 14). Each group underwent thoracic exploration, pre-determined surgical lung biopsy, and pericardial window creation. Blood draws were obtained before surgery and at postoperative days 1, 3, 7, and 14. Operative time, complications, laboratory parameters, hemodynamic parameters, and inflammatory parameters were compared between the two procedures. The animals were monitored for two weeks and necropsy were performed for surgical outcome evaluation.

RESULTS

The thoracic procedures were successfully performed in all of the dogs, with the exception of one animal in the transoral group. There were no serious acute or delayed complications related to surgery. There was no difference between the two surgical groups for each of the hemodynamic parameters that were evaluated. Regarding the immunological impact of the surgeries, transoral thoracoscopy was associated with significant elevations in interleukin 6 and c-reactive protein levels on postoperative days 1 and 3, respectively, when compared with the standard thoracoscopy. All dogs recovered well, without signs of mediastinitis or thoracic infection. Necropsy revealed absence of infection, no injury to vital organs, and confirmed the success of the novel procedure.

CONCLUSIONS

This study suggests that both techniques were comparable with respect to procedure success rate, hemodynamic impact, and inflammatory changes. Furthermore, there was no difference in the incidence of postoperative discomfort between groups.

A resected perivascular epithelioid cell tumor (PEComa) of the pancreas diagnosed using endoscopic ultrasound-guided fine-needle aspiration

Primary perivascular epithelioid cell tumors (PEComas) of the pancreas are extremely rare. We herein report our experience with a patient who had a primary PEComa of the pancreas that was diagnosed by the preoperative histopathological examination of a biopsy specimen obtained by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). The patient was a 43-year-old woman whose chief complaint was abdominal pain. Imaging studies revealed a pancreatic tumor. Gastrointestinal stromal tumor (GIST), solid pseudopapillary tumor and neuroendocrine tumor were considered in the differential diagnosis. A histopathological examination of a specimen of the tumor obtained using EUS-FNA showed spindle-shaped tumor cells with enlarged nuclei and eosinophilic cytoplasm. The tumor cells proliferated in a sheet-like fashion and stained positive for the melanoma-associated antigen HMB-45. A PEComa was thus diagnosed. If an adequate tumor specimen can be obtained using EUS-FNA, immunostaining may facilitate the diagnosis of extremely rare diseases and therefore assist in deciding the treatment policy.

Prospective feasibility study on the use of multiband mucosectomy for endoscopic resection of early squamous neoplasia in the esophagus

BACKGROUND AND STUDY AIMS

Endoscopic resection for esophageal squamous high-grade intraepithelial neoplasia (HGIN) or intramucosal cancer (esophageal squamous cell carcinoma [ESCC]) with the endoscopic resection cap technique is technically difficult, and requires submucosal lifting and multiple snares for piecemeal resections. Multiband mucosectomy (MBM) is an easy-to-use endoscopic resection technique and may be the modality of choice in China, where ESCC is extremely prevalent. The aim of the current study was to prospectively evaluate MBM for piecemeal endoscopic resection of squamous neoplasia of the esophagus.

METHODS

Patients with HGIN/ESCC and no signs of submucosal invasion or metastatic disease were included in the study. Lesions were delineated using electrocoagulation and resected using the MBM technique. Endpoints were procedure time, endoscopic radicality, complications, histology of the endoscopic resection specimens, and absence of HGIN/ESCC at the endoscopic resection scar during follow-up.

RESULTS

A total of 41 patients (26 male; mean age 61 years) underwent MBM; all lesions were visible with white light endoscopy (median length 5 cm, interquartile range [IQR] 4 - 6 cm; median circumferential extent 42 %, IQR 25 - 50 %). Median procedure time was 12 minutes (IQR 8 - 24 minutes). Median number of resections was 5 (IQR 3 - 6). Endoscopic complete resection was achieved in all lesions. There was one perforation, which was treated by application of clips. No other complications were observed. The worst histology was ESCC (n = 19), HGIN (n = 17), middle grade intraepithelial neoplasia (n = 4), and normal squamous epithelium (n = 1). Endoscopic follow-up at 3 months showed HGIN at the endoscopic resection scar in two patients, which was effectively treated endoscopically, and showed normal squamous epithelium in all patients at final follow-up (median 15 months, IQR 12 - 24 months).

CONCLUSION

This first prospective study on MBM for piecemeal endoscopic resection of early esophageal squamous neoplasia showed that MBM was effective for the complete removal of lesions with short procedure time, few complications, effective histological assessment of resected specimens, and durable treatment effect.

Topical anesthesia for transnasal esophagogastroduodenoscopy: spray, applicator, or both?

BACKGROUND AND AIM

Transnasal esophagogastroduodenoscopy (EGD) has become widely accepted in Japan. Better performance and compliance for the procedure are expected with appropriate nasal anesthesia.We aimed to elucidate the effectiveness, the safety and the compliance of nasal anesthesia for transnasal EGD.

METHODS

Subjects were 372 asymptomatic patients examined by transnasal EGD for gastric cancer screening. They were pretreated with topical anesthesia either with a nasal spray method (Spr group, n = 127), cotton-tipped applicator method (Cot group, n = 115), or both (Com group, n = 130). Lidocaine (4%) was applied with atomizer in the Spr method, whereas a cotton-tipped applicator soaked in 4% lidocaine was placed in the nasal cavity for 5 min in the Cot method. After transnasal EGD, each subject rated procedure-related discomfort according to visual analogue scales. In subjects who had prior experience of transoral EGD, tolerance against EGD was compared between transnasal and transoral routes.

RESULTS

There were no severe adverse events related to topical anesthesia.Transnasal EGD was completed in 94.9% of the patients.Age, gender or insertion failure rate were not different among Spr, Cot and Com groups. Pain scores for anesthesia and examination were significantly lower in the Spr group, whereas the pain score for insertion was not different among the three groups.The rate of patients who deemed transnasal EGD to be more tolerable than transoral EGD was highest in the Spr group.

CONCLUSIONS

Topical nasal spray seems to be appropriate for topical anesthesia in transnasal EGD.

Long-term outcomes of Roux-en-Y and Billroth-I reconstruction after laparoscopic distal gastrectomy

BACKGROUND

Laparoscopic distal gastrectomy (LDG) is an established procedure for the treatment of early gastric cancer. Roux-en-Y (R-Y) or Billroth-I (B-I) reconstruction is generally performed after LDG in Japan. The aim of this retrospective cohort study was to compare the effectiveness of R-Y and B-I reconstructions and thereby determine which has better clinical outcomes.

METHODS

We analyzed data from 172 patients with gastric cancer who underwent LDG. Reconstruction was done by R-Y in 83 patients and B-I in 89. All patients were followed up for 5 years. Evaluated variables included symptoms, nutritional status, endoscopic findings, gallstone formation, and later gastrointestinal complications.

RESULTS

Scores for the amount of residue in the gastric stump, remnant gastritis, and bile reflux, calculated according to the "residue, gastritis, bile" scoring system, were significantly lower in the R-Y group (score 0 vs. 1 and more; p = 0.027, <0.001, and <0.001, respectively). The proportion of patients with reflux esophagitis was significantly lower in the R-Y group (p < 0.001). Relative values (postoperative 5 years/preoperative) for body weight, serum albumin level, and total cholesterol level were similar in the two groups (p = 0.59, 0.56, and 0.34, respectively). Gallstone formation did not differ between the groups (p = 0.57). As for later complications, the incidence of gastrointestinal ulcer was 4.5 % in the B-I group, and that of ileus was 3.6 % in the R-Y group, but differences between the groups were not significant (p = 0.12, 0.11, respectively).

CONCLUSIONS

As compared with B-I, R-Y was associated with lower long-term incidences of both bile reflux into the gastric remnant and reflux esophagitis.

Endoscopic diagnosis and management of ampullary lesions

Most (>95%) ampullary lesions are adenomas or adenocarcinomas. Side viewing endoscopy, endoscopic ultrasound, and endoscopic retrograde cholangiopancreatography are complementary procedures that have an important role in the diagnosis, staging, and treatment of ampullary lesions. Here the authors review their epidemiology and discuss the evidence for endoscopic modalities, with an emphasis on techniques for endoscopic resection. Although endoscopic papillectomy represents one of the highest-risk endoscopic interventions, it has largely replaced surgical modalities for the treatment of adenomatous lesions. Appropriate patient selection and use of preventive maneuvers will minimize the likelihood of persistent or recurrent lesions and postprocedure complications.

Determination of chemical composition of gallbladder stones and their association with induction of cholangiocarcinoma

Gallstone disease is a major surgical problem in many populations; it is probably related to diet, especially excessive consumption of meat. The objective of this study was to determine the chemical composition of gallstones and their association with neoplastic changes including cholangiocarcinomas in cholecystectomised patients. The chemical composition of gallstones from 40 patients (8 males and 32 females) was analyzed. This is a prospective study performed in Baquba teaching hospital in the period from 1/10/2012 to 1/1/2013 in which we collected the gallstones for the patients who underwent cholecystectomy, whether open or laparoscopic. The stones were classified according to their chemical composition as a mixed stones (MS), and examined using a stone analysis set (chemical qualitative method) for calcium, magnesium, phosphate, uric acid and oxalate which was used reagent for qualitative determination of main individual components of stones. The results of this study showed the highest incidence of gallstones in the age group 40-49 was 13 cases followed by 11, 8 and 4 cases for age groups 30-39, 50-59, 20-29 and 60 and above, respectively. The chemical analysis showed the majority of gallstones were mixed, 38 containing calcium followed by 37 cases with uric acid, 28 with magnesium, and 25 and 22 stones with oxalate and phosphate, respectively. Microscopically, we confirmed neoplastic changes (17.5%) as cholangiocarcinomas (CCCs) (7.55%) and dysplastic cells of carcinoma in situ in 4 (10%), 31 (77.5%) cases were chronic cholecystitis and 2 (5%) cases were acute cholecystitis with empyema out of bile duct disorders patients. In conclusion, majority of cases had mixed gallstones that involved five and four of inorganic chemicals of calcium, magnesium and phosphate, the highest incidence of gallstones in age group 40-49 years old was 13 cases, and neoplastic changes were confirmed (17.5%) including CCCs, (7.5%) and dysplastic cells of carcinoma in situ (10%), while 31 (77.5%) cases were chronic cholecystitis.

Progress in molecular imaging in endoscopy and endomicroscopy for cancer imaging

Imaging is an essential tool for effective cancer management. Endoscopes are important medical instruments for performing in vivo imaging in hollow organs. Early detection of cancer can be achieved with surveillance using endoscopy, and has been shown to reduce mortality and to improve outcomes. Recently, great advancements have been made in endoscopic instruments, including new developments in optical designs, light sources, optical fibers, miniature scanners, and multimodal systems, allowing for improved resolution, greater tissue penetration, and multispectral imaging. In addition, progress has been made in the development of highly-specific optical probes, allowing for improved specificity for molecular targets. Integration of these new endoscopic instruments with molecular probes provides a unique opportunity for significantly improving patient outcomes and has potential to further improve early detection, image guided therapy, targeted therapy, and personalized medicine. This work summarizes current and evolving endoscopic technologies, and provides an overview of various promising optical molecular probes.

Mesenteric air embolism following enteroscopic small bowel tattooing procedure

Double balloon enteroscopy (DBE) is a revolutionary procedure in which the entire small bowel can be visualized endoscopically. DBE has the advantage of both diagnostic and therapeutic capabilities in the setting of small bowel neoplasms and vascular malformations. We present a unique case of a 76-year-old female who underwent small bowel DBE tattoo marking of a distal small bowel tumor complicated by development of severe abdominal pain postprocedure secondary to bowel air embolism into the mesenteric veins. Mesenteric air can be seen after other endoscopic procedures such as biopsy, mucosal clip placement and polypectomy, or following a colonoscopy. Mesenteric air embolism following small bowel tattooing procedure has not been previously reported in the literature. Mesenteric air when present may be attributed to mesenteric ischemia and can subject the patient to unnecessary surgical intervention if misdiagnosed. Thus, this report holds significance for the radiologist as computed tomography (CT) findings of mesenteric air embolism must be evaluated in the context of appropriate clinical history before treatment decisions are made.

Confocal Laser Endomicroscopy: Applications in Clinical and Translational Science—A Comprehensive Review

Confocal laser endomicroscopy (CLE) is a novel tool in the endoscopist’s armamentarium. It allows on-site histological information. The ability of gastroenterologists to interpret such microscopic information has been demonstrated in multiple studies from the upper and lower gastrointestinal tract. Recently, the field of application has expanded to provide hepatobiliary and intra-abdominal CLE imaging. CLE allows “smart,” targeted biopsies and is able to guide endoscopic interventions. But CLE is also translational in its approach and permits functional imaging that significantly impacts on our understanding of gastrointestinal diseases. Molecular imaging with CLE allows detection and characterization of lesions and may even be used for prediction of response to targeted therapy. This paper provides a comprehensive review over current applications of CLE in clinical applications and translational science.

Clinical outcomes for anaplastic pancreatic cancer: a population-based study

BACKGROUND

Anaplastic pancreatic cancer (APC) is a rare subtype of pancreatic ductal adenocarcinoma (PDA) that can carry a worse overall survival (OS) when compared with other variants. However, the presence of osteoclast-like giant cells (OCGCs) in APC specimens can predict improved OS. The aim of this study was to evaluate the OS of patients with APC (with and without OCGCs) compared with patients with other subtypes of PDA using a population-based registry.

STUDY DESIGN

We identified all patients in the Surveillance, Epidemiology and End Results (SEER) database with pathologically confirmed APC and PDA diagnosed between 1988 and 2008. Overall survival was evaluated using Kaplan-Meier and Cox proportional hazard regression.

RESULTS

The study cohort included 5,859 (94.3%) patients with PDA and 353 (5.7%) with APC. Overall survival for all patients with APC was significantly worse than for patients with PDA (hazard ratio [HR] = 1.9; 95% CI, 1.7-2.1; p < 0.001); however, in the subgroup of resected patients, APC (n = 81) had similar OS to PDA (n = 3,517) (HR = 0.9; 95% CI, 0.7-1.2; p = 0.37). Patients with APC tumors with OCGCs (n = 11) demonstrated improved OS when compared with all other APC variants without OCGCs (n = 342) (HR = 0.3; 95% CI, 0.1-0.7; p = 0.004), but this survival difference was not observed in the subgroup of resected patients (HR = 0.5; 95% CI, 0.2-1.4; p = 0.18).

CONCLUSIONS

Anaplastic pancreatic cancer is a rare malignancy with poor OS. The diagnosis of APC with OCGCs is predictive of improved OS compared with other patients with APC. This survival benefit, however, is not observed in patients with resected disease.

Needs analysis for developing a virtual-reality NOTES simulator

INTRODUCTION AND STUDY AIM: Natural orifice translumenal endoscopic surgery (NOTES) is an emerging surgical technique that requires a cautious adoption approach to ensure patient safety. High-fidelity virtual-reality-based simulators allow development of new surgical procedures and tools and train medical personnel without risk to human patients. As part of a project funded by the National Institutes of Health, we are developing the virtual transluminal endoscopic surgery trainer (VTEST) for this purpose. The objective of this study is to conduct a structured needs analysis to identify the design parameters for such a virtual-reality-based simulator for NOTES.

METHODS

A 30-point questionnaire was distributed at the 2011 National Orifice Surgery Consortium for Assessment and Research meeting to obtain responses from experts. Ordinal logistic regression and the Wilcoxon rank-sum test were used for analysis.

RESULTS

A total of 22 NOTES experts participated in the study. Cholecystectomy (CE, 68 %) followed by appendectomy (AE, 63 %) (CE vs AE, p = 0.0521) was selected as the first choice for simulation. Flexible (FL, 47 %) and hybrid (HY, 47 %) approaches were equally favorable compared with rigid (RI, 6 %) with p < 0.001 for both FL versus RI and HY versus RI. The transvaginal approach was preferred 3 to 1 to the transgastric. Most participants preferred two-channel (2C) scopes (65 %) compared with single (1C) or three (3C) or more channels with p < 0.001 for both 2C versus 1C and 2C versus 3C. The importance of force feedback and the utility of a virtual NOTES simulator in training and testing new tools for NOTES were rated very high by the participants.

CONCLUSION

Our study reinforces the importance of developing a virtual NOTES simulator and clearly presents expert preferences. The results of this analysis will direct our initial development of the VTEST platform.

First Pillcam Colon 2 capsule images of Whipple's disease: Case report and review of the literature

Whipple's disease is a rare chronic systemic infection determined by the Gram-positive bacillus Tropheryma whipplei. The infection usually mainly involves the small bowel, but sometimes other organs are affected as well. Since the current standard clinical and biological tests are nonspecific, diagnosis is very difficult and relies on histopathology. Here we present the case of a 52-year-old man with chronic diarrhea and weight loss whose symptoms had been evolving for 2 years and whose diagnosis came unexpectedly after capsule examination. Diagnosis was confirmed by the histopathologic examination of endoscopic biopsy samples, and treatment with co-trimoxazole resulted in remission of symptoms. We present the first images of Whipple's disease obtained with the Pillcam Colon 2 video capsule system.

Hepatocellular carcinoma with obstructive jaundice: endoscopic and percutaneous biliary drainage

Among patients with later stage hepatocellular carcinoma (HCC), only 1-12% manifest obstructive jaundice as the initial complaint. Endoscopic retrograde biliary drainage (ERBD) and percutaneous transhepatic biliary drainage (PTBD) are the two main non-surgical treatment options for obstructive jaundice in patients with HCC. ERBD is usually the first-line treatment because of its low hemorrhage risk. Some have reported that the successful drainage rate ranges from 72 to 100%. Mean stent patency time and mean survival range from 1.0 to 15.9 and 2.8 to 12.3 months, respectively. PTBD is often an important second-line treatment when ERBD is impossible. With regard to materials, metallic stents offer the benefit of longer patency than plastic stents. The dominant effect of biliary drainage suggests that successful jaundice therapy could enhance anti-cancer treatment by increasing life expectancy, decreasing mortality, or both. We present an overview of the efficacy of endoscopic and percutaneous drainage for obstructive jaundice in patients with HCC who are not candidates for surgical resection and summarize the current indications and outcomes of reported clinical use.

Guidewire-assisted cannulation of the common bile duct for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis

BACKGROUND

Cannulation techniques have been recognized to be important in causing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, considerable controversy exists about the usefulness of the guidewire-assisted cannulation technique for the prevention of PEP.

OBJECTIVES

To systematically review evidence from randomised controlled trials (RCTs) assessing the effectiveness and safety of the guidewire-assisted cannulation technique compared to the conventional contrast-assisted cannulation technique for the prevention of PEP.

SEARCH METHODS

We searched CENTRAL (The Cochrane Library), MEDLINE, EMBASE, and CINAHL databases and major conference proceedings, up to February 2012, using the Cochrane Upper Gastrointestinal and Pancreatic Diseases model with no language restrictions.

SELECTION CRITERIA

RCTs comparing the guidewire-assisted cannulation technique versus the contrast-assisted cannulation technique in patients undergoing ERCP.

DATA COLLECTION AND ANALYSIS

Two review authors conducted study selection, data extraction and methodological quality assessment independently. Using intention-to-treat analysis with random-effects models, we combined dichotomous data to obtain risk ratios (RR) with 95% confidence intervals (CI). We assessed heterogeneity using the Chi² test (P < 0.15) and I² statistic (> 25%). To explore sources of heterogeneity, we conducted a priori subgroup analyses according to trial design, publication type, risk of bias, use of precut sphincterotomy, inadvertent guidewire insertion or contrast injection of the pancreatic duct (PD), use of a PD stent, cannulation device, and trainee involvement in cannulation. To assess the robustness of our results we carried out sensitivity analyses using different summary statistics (RR versus odds ratio (OR)) and meta-analytic models (fixed-effect versus random-effects), and per protocol analysis.

MAIN RESULTS

Twelve RCTs comprising 3450 participants were included. There was statistical heterogeneity among trials for the outcome of PEP (P = 0.04, I² = 45%). The guidewire-assisted cannulation technique significantly reduced PEP compared to the contrast-assisted cannulation technique (RR 0.51, 95% CI 0.32 to 0.82). In addition, the guidewire-assisted cannulation technique was associated with greater primary cannulation success (RR 1.07, 95% CI 1.00 to 1.15), less precut sphincterotomy (RR 0.75, 95% CI 0.60 to 0.95), and no increase in other ERCP-related complications. Subgroup analyses indicated that this significant risk reduction in PEP with the guidewire-assisted cannulation technique existed only in 'non-crossover' trials (RR 0.22, 95% CI 0.12 to 0.42). The results were robust in sensitivity analyses.

AUTHORS' CONCLUSIONS

Compared with the contrast-assisted cannulation technique, the guidewire-assisted cannulation technique increases the primary cannulation rate and reduces the risk of PEP, and it appears to be the most appropriate first-line cannulation technique.

Postprocedural combined treatment using the coagulation plus artery-selective clipping (2C) method for the prevention of delayed bleeding after ESD

BACKGROUND

The incidence of delayed bleeding after endoscopic submucosal dissection (ESD) for gastric neoplasms is reported to be approximately 5 %. We examined whether postprocedural combined treatment using the coagulation plus artery-selective clipping (2C) method is a useful measure for preventing delayed bleeding after ESD.

METHODS

A total of 234 gastric epithelial neoplasms were treated from June 2007 to May 2012. Post-ESD coagulation (PEC) and clipping for part of the vessels was performed for 154 lesions from June 2007 to June 2010. A total of 80 lesions were treated using the 2C method from July 2010 to May 2012. During ESD, the locations of the arteries were recorded on a schematic diagram of the lesion. Arteries were defined as regions of arterial bleeding that required coagulation or apparent arteries in which preventive coagulation was performed. When ESD was completed, soft coagulation was performed for arteries in the resection area using hemostatic forceps, followed by arterial clipping for additional strength. Coagulation also was performed continuously for visible vessels in the resection area. This was a retrospective study. The incidence rates of delayed bleeding after ESD, as evidenced by hematemesis or melena, or the presence of anemia (decline in Hb >2 g/dl) that required emergency endoscopy were recorded.

RESULTS

Delayed bleeding occurred in 7 (4.5 %) of the 154 cases treated using PEC and in 1 (1.3 %) of the 80 cases treated using the 2C method. The mean time required for the 2C method was 15.0 ± 7.0 min (range, 5-44 min). The mean number of clippings per lesion was 3.8 ± 2.8 (range, 0-13). Almost all clips fell off within 2 months of the procedure.

CONCLUSIONS

Coagulation plus artery-selective clipping (the 2C method) of post-ESD ulcers might effectively reduce the incidence of delayed bleeding after ESD for gastric neoplasms.

Bronchoesophageal fistula

Bronchoesophageal fistula (BEF) is an undesirable consequence of esophageal cancer. A BEF is encountered in 5% to 15% of patients with esophageal cancer. It is generally a life-threatening complication because of the development of recurrent pulmonary infection and sepsis. We present a case with esophageal cancer and acquired BEF. The fistula allowed herniation of the esophageal wall into the endobronchial lumen, causing significant obstruction of the airway lumen, findings not reported previously.

Initial experience with EUS-guided cholangiopancreatography for biliary and pancreatic duct drainage: a Spanish national survey

BACKGROUND

EUS-guided cholangiopancreatography (ESCP) allows transmural access to biliopancreatic ducts when ERCP fails. Data regarding technical details, safety, and outcomes of ESCP are still unknown.

OBJECTIVE

To evaluate outcomes of ESCP in community and referral centers at the initial development phase of this procedure, to identify the ESCP stages with higher risk of failure, and to evaluate the influence on outcomes of factors related to the endoscopist.

DESIGN

Multicenter retrospective study.

SETTING

Public health system hospitals with experience in ESCP in Spain.

PATIENTS

A total of 125 patients underwent ESCP in 19 hospitals, with an experience of <20 procedures.

INTERVENTION

ESCP.

MAIN OUTCOME MEASUREMENTS

Technical success and complication rates in the initial phase of implantation of ESCP are described. The influence of technical characteristics and endoscopist features on outcomes was analyzed.

RESULTS

A total of 125 patients from 19 hospitals were included. Biliary ESCP was performed in 106 patients and pancreatic ESCP was performed in 19. Technical success was achieved in 84 patients (67.2%) followed by clinical success in 79 (63.2%). Complications occurred in 29 patients (23.2%). Unsuccessful manipulation of the guidewire was responsible for 68.2% of technical failures, and 58.6% of complications were related to problems with the transmural fistula.

LIMITATIONS

Retrospective study.

CONCLUSION

Outcomes of ESCP during its implantation stage reached a technical success rate of 67.2%, with a complication rate of 23.2%. Intraductal manipulation of the guidewire seems to be the most difficult stage of the procedure.

Chromoendoscopy and Advanced Imaging Technologies for Surveillance of Patients with IBD

Inflammatory bowel disease patients with long-standing colitis have an increased risk of colorectal cancer. The high rate of interval colitis-associated cancers among patients who adhere to a nontargeted, random biopsy surveillance strategy underlies the need for improved methods of early dysplasia detection. Compelling evidence supports the efficacy of chromoendoscopy for increasing the detection rate of dysplasia; however, this technology is currently underutilized in the clinical setting. Other contrast-based technologies-including confocal laser endomicroscopy (Pentax), endocytoscopy, multiband imaging, i-scan (Pentax), and molecular-targeted techniques-show promise in the detection of dysplasia in patients with inflammatory bowel disease. The strategies currently available for identifying patients with dysplasia or colitis-associated cancers remain inadequate and need to demonstrate both cost and time efficiency before they can be adopted in community-based practices.

Flexible imaging color enhancement improves visibility of transnasal endoscopic images in diagnosing esophageal varices: a multicenter prospective blinded study

OBJECTIVE

To clarify the usefulness of transnasal esophagogastroduodenoscope (N-EGD) with all flexible imaging color enhancement (FICE) patterns (0-9) for the diagnosis of esophageal varices (EV).

METHODS

A total of 50 patients with EV were examined during the same period by N-EGD without sedation and by peroral endoscopy (O-EGD) with sedation. The visibility of treatment scars, microvessels, recurrent EV and red color sign (RCS) were measured. Visibility was evaluated by five blinded observers (poor-good: 0-10), and the effect of both endoscopic examinations on the cardiorespiratory function of the patients was measured.

RESULTS

The image scores for O-EGD and N-EGD with ordinary mode and N-EGD with FICE were 7.3 ± 1.2, 6.1 ± 1.0 and 6.9 ± 1.0 for treatment scars; 7.2 ± 1.4, 6.2 ± 1.2 and 7.3 ± 1.0 for microvessels; 7.2 ± 1.2, 6.1 ± 1.0 and 7.1 ± 1.0 for recurrent EV and 7.2 ± 1.3, 6.1 ± 1.3, and 7.2 ± 1.2 for RCS, respectively (intraclass correlation coefficients > 0.6). When FICE patterns 2, 6 and 9 were used, visibility was much improved. Ten minutes after insertion, the double product values in the N-EGD with the FICE group were significantly better (P < 0.05).

CONCLUSIONS

N-EGD with FICE is very useful for the diagnosis of EV and can improve the visibility of N-EGD on each lesion to the same level as that of O-EGD. N-EGD with FICE does not require sedation and may reduce the risk of hepatic encephalopathy.

Lemmel's syndrome as a rare cause of obstructive jaundice

Obstructive jaundice is a frequent symptom most frequently resulting from choledocolithiasis or pancreatico-biliary and periampullary tumors. If duodenal diverticula are frequently asymptomatic, they can occasionally present with obstructive jaundice in the absence of lithiasis or another obstructing lesion such as a tumor in a presentation called Lemmel's syndrome. We herein present a 70-year-old male with obstructive jaundice secondary to a periampullary duodenal diverticulum associated with hepatic abscess. Endoscopic sphincterotomy associated with percutaneous abscess drainage released patient from all symptoms. Lemmel's syndrome as a rare cause of obstructive jaundice should be known in order to avoid mismanagement and therapeutic delay.