[Anesthesia in gastrointestinal endoscopy: peroral endoscopic myotomy]

Idiopathic achalasia is a motility disorder of the esophagus characterized by a dysfunction of the lower esophageal sphincter, which typically manifests as dysphagia. Peroral endoscopic myotomy (POEM) is an interventional endoscopic procedure for achalasia, which was introduced in 2010. Although results from randomized studies comparing short-term and long-term safety and efficacy are yet to be published, POEM is regarded to be less invasive than the standard treatment of achalasia (laparoscopic Heller myotomy). POEM is the first endoscopic procedure routinely performed with the patient under general anesthesia. During the preoperative assessment particular attention must be paid to the specific fasting intervals and the risk of aspiration during induction of anesthesia. For the purpose of temporary surgical access, the integrity of the esophageal wall is deliberately interrupted to create a long submucosal tunnel. As a result, unwanted fistulas can arise between the esophageal lumen, the mediastinum, the pleura or the intraperitoneal cavity. Endoscopically insufflated CO₂ may escape into these surrounding compartments with subsequent systemic CO₂ accumulation, capnomediastinum, tension capnoperitoneum or pneumothorax. As a result substantial cardiorespiratory instability can arise. Thus, the attending anesthesiologist must be familiar with these typical complications and with specific emergency measures, such as compensatory hyperventilation, percutaneous needle decompression and thoracic drainage. The POEM procedure is a therapeutic innovation and interdisciplinary challenge. However, anesthesia standards of care have not yet been specified. The aim of this review is therefore to outline some clinical recommendations for the daily clinical practice based on existing evidence.

Proton acceleration by irradiation of isolated spheres with an intense laser pulse

We report on experiments irradiating isolated plastic spheres with a peak laser intensity of 2-3×10^{20}Wcm^{-2}. With a laser focal spot size of 10 μm full width half maximum (FWHM) the sphere diameter was varied between 520 nm and 19.3 μm. Maximum proton energies of ∼25 MeV are achieved for targets matching the focal spot size of 10 μm in diameter or being slightly smaller. For smaller spheres the kinetic energy distributions of protons become nonmonotonic, indicating a change in the accelerating mechanism from ambipolar expansion towards a regime dominated by effects caused by Coulomb repulsion of ions. The energy conversion efficiency from laser energy to proton kinetic energy is optimized when the target diameter matches the laser focal spot size with efficiencies reaching the percent level. The change of proton acceleration efficiency with target size can be attributed to the reduced cross-sectional overlap of subfocus targets with the laser. Reported experimental observations are in line with 3D3V particle in cell simulations. They make use of well-defined targets and point out pathways for future applications and experiments.

Endoscopic ultrasound-guided drainage of abdominal fluid collections after pancreatic surgery: Efficacy and long-term follow-up

BACKGROUND/PURPOSE

Endoscopic ultrasound-guided drainage (EUS-GD) of postoperative abdominal fluid collections (POFC) following pancreatic surgery is used as an alternative or complement to percutaneous drainage (PD) procedure. The present single-center retrospective study evaluates its efficacy and safety.

METHOD

We included consecutive cases with POFC treated by EUS-GD between September 2009 and November 2014 in our department. Technical success, long-term clinical success, recurrence rate and need for surgery were analyzed.

RESULTS

24 procedures in 20 patients (95 % after pancreatic resection) were assessed. Indications for surgery included tumors/lesions located in the pancreas (15/20), chronic pancreatitis (3/20) and duodenal adenoma not completely resectable endoscopically (2/20). EUS-GD was performed within a median of 30 days (IQR: 8.25) for a median fluid collection size of 72.5 mm (IQR: 46.25), requiring a mean of 1.2 sessions with placement of a mean of 2.1 plastic stents (7 Fr/10 Fr) per patient for a mean of 89 days (IQR: 127). Microbiology of aspirated fluid revealed positive cultures in 13 patients, mostly polymicrobial, isolated positive for fungal and 3 multidrug-resistant gram negative (MRGN) in 4 cases. An additional transpapillary drainage was inserted in 1/20 patients. 4/20 patients received PD, mostly before EUS-GD. Technical and clinical success was achieved in 20/20 (100 %) and 18/20 (90 %) patients, respectively, while 2 patients required re-operation. During follow-up (median 630 days after stent removal, range: 45 - 2160), recurrence occurred in 1/18 (5.5 %) patient that was referred for surgery. No death or severe adverse events were noted.

CONCLUSION

EUS-GD is an effective, minimally invasive and safe method for therapy of POFC after pancreatic surgery offering long-term remission in about 95 % of cases.

Feasibility of a colon capsule overnight procedure followed by colonoscopy

BACKGROUND AND AIM

Due to limited acceptance of colonoscopy as diagnostic and screening test alternatives are warranted. Colon capsule endoscopy (CCE) has been shown to be a possible filter test, but because of logistical issues a second bowel preparation is usually required, if consecutive colonoscopy is needed. We therefore evaluated the feasibility of a single bowel preparation for both overnight CCE and (therapeutical) colonoscopy thereafter.

METHODS

Patients from two university hospitals referred to undergo colonoscopy were prospectively included in a dual centre feasibility study. A polyethylene glycol (PEG) based bowel preparation-schedule with ingestion of a colon capsule endoscopy (CCE) at 10pm and subsequent colonoscopy at about 12am on the next day was investigated. The first generation PillCam colon capsule was used with 4 different preparation protocols containing several prokinetics in different compositions (i. e. metoclopramide, erythromycin, sennosoides). The main endpoint was the proportion of patients who completed both CCE and colonoscopy; secondary endpoints were capsule transit times, amount of colon seen on CCE, bowel cleanliness, sensitivity and specifity of CCE and patients' acceptance.

RESULTS

50 patients between 18 and 75 years were included. The sequence of overnight colon capsule endoscopy and colonoscopy was successfully completed in all but one (one refused colonoscopy). The capsule was excreted during recording time in 86 % of examinations, visualization of the complete colon was possible in 60 %, but adequate colon preparation was achieved in only 45 % irrespective of the regimen used. The preparation regimen consisting of a PEG-solution, erythromycin as prokinetic drug followed by PEG-solution as boost showed the largest proportion of adequate preparations. Overall sensitivity and specificity of CCE for polyps of any size were 65 % and 76 %, respectively. 26 of 30 patients (86.7 %) returned the subjective assessment questionnaire. 23 patients (88 %) reported mild to no discomfort or embarrassment during CCE, whereas 15 patients (58 %) did during the preparation procedure. Drinking the purgative solution was the most inconvenient step in 84 % of cases, drinking the boosts during CCE the second inconvenient step (60 %).

CONCLUSION

Overnight CCE-procedure followed by direct capsule-reading is feasible and safe and might avoid repetitive bowel preparation for subsequent colonoscopy. The bowel preparation needs to be improved.

Long-term follow-up in patients with indeterminate Barrett esophagus

BACKGROUND

Barrett esophagus (BE) is a major risk factor for adenocarcinoma of the distal esophagus. Reliable detection of BE during upper endoscopy is therefore mandatory. According to most guidelines, diagnosis of BE requires both endoscopy and histology for confirmation. However, since adenocarcinomas were also described in patients with indeterminate BE, i.e. endoscopic visible columnar metaplasia but no histological confirmation of goblet cells or vice versa, debate has risen on the risk of malignancy and the need for endoscopic surveillance in such patients.

PATIENTS AND METHODS

The study was aimed to assess long-term follow-up data on 209 patients with indeterminate BE (on histopathology or endoscopy) initially examined between 1999 and 2000. Patients or referring physicians were contacted concerning the most recent endoscopic and histopathological results.

RESULTS

Follow-up data could be assessed in 149/209 patients (65.1%) after a mean follow-up period of 9.4 years (SD ±2.4 years). Neoplasia was not reported for any patient. The previous endoscopic-histopathological diagnoses could be confirmed in 3 patients only. In the group with endoscopic diagnosis of BE but no histopathological confirmation, BE was described histopathologically in 1 patient during follow-up.

CONCLUSION

Persistence of indeterminate BE is poor during long-term follow up. The risk of cancer appears to be negligible. Hence, surveillance of these patients appears equivocal.

[Implementing an Organised Colorectal Cancer Screening Programme in Germany: Opportunities and Challenges]

BACKGROUND

Each year in Germany, about 65,000 people are diagnosed with colorectal cancer (CRC) and more than 25,000 people die of the disease. The majority of these cases could be avoided by a more effective screening programme. Recently, a law came into force that offers a great opportunity in this regard. It calls for introducing an organised CRC screening programme in Germany, which includes an invitation system as well as further measures for quality assurance and programme evaluation. To realise this opportunity, challenges of implementation need to be considered. The aim of this review article is to elaborate the challenges of an organised CRC screening in Germany in order to derive the need for action regarding successful implementation.

METHODS

This review article is based on a selective literature search, including current guidelines and recommendations.

RESULTS AND CONCLUSION

In the context of CRC screening, but also by colonoscopies performed for other indications (e.g., due to symptoms), precancerous lesions (adenomas) are detected and removed in a relevant proportion of the target population, which requires a surveillance examination after 3 or 5 years according to current recommendations. Therefore, an efficient invitation system for CRC screening should be designed to allow for a flexible interval depending on previous findings, which differs from mammography screening with its fixed interval. A prerequisite would be the standardised documentation of all colonoscopies irrespective of the indication, given that a substantial proportion of colonoscopies in Germany are performed outside of the screening program. Still, the work load regarding documentation could be less than for mammography screening. Another challenge in terms of organisation results from the parallel offer of 2 different screening tools (colonoscopy and faecal occult blood test). To realise the potential of an organised CRC screening, it seems important to devote sufficient time and resources for developing an efficient and feasible concept, while there might be interim options to avoid further delay regarding the initial invitation of the target population. Given that expertise from, amongst others, gastroenterology, epidemiology, clinical chemistry and health communication is required, an interdisciplinary approach appears essential.

Peroral endoscopic myotomy for achalasia

BACKGROUND

Treatment of achalasia is complicated by symptom recurrence and a significant risk for severe complications. Endoscopic myotomy was developed in the search for a highly efficacious treatment with lower risks. Since its introduction in 2010, several centers have adopted the technique and published excellent short-term results of open label series. Randomized trials with long-term endpoint comparing per-oral endoscopic myotomy (POEM) with the established treatments such as balloon dilation and surgical myotomy are now warranted, before POEM can be regarded as the routine clinical care for achalasia patients.

PURPOSE

This review describes the development, technical aspects, efficacy, and complications of POEM.

[A 44-year-old woman with hereditary nonpolyposis colon carcinoma: screening examinations for non-colonic tumors]

A 44-year-old woman presented in March 2010 for surveillance esophagogastroduodenoscopy (EGD). In October 2004, rectal cancer had been diagnosed and treated by resection of the rectum with adjuvant chemotherapy. A diagnosis of hereditary nonpolyposis colon carcinoma (HNPCC) was established on the basis of the Amsterdam II criteria. Due to a lack of clear guidelines we decided to perform annual systematic surveillance examinations of the stomach and the most frequent tumor manifestations. Until 2009, extracolonic tumors were not observed in the patient. In March 2010, EGD showed a discrete erosive lesion in the gastric antrum, which was biopsied. Most notably, the histopathological examination revealed a poorly differentiated mucinous adenocarcinoma. Due to the poor differentiation, we decided against technically possible, endoscopic resection. The patient underwent subtotal gastrectomy and is still doing fine 28 months after surgery. This case prompted us to evaluate our surveillance approach in HNPCC patients and to review the literature.

Progress in endoscopy: areas of current interest and topics to watch out for

The past few years have seen a shift in focus for endoscopy research. For example, there has been a halt in the apparent revolution of natural orifice transluminal surgery (NOTES), which was long considered the most important innovation in flexible endoscopy. Other trends such as endoscopic histology are slowing down and not progressing into clinical practice. In general, the quality of endoscopic research needs to be improved, particularly in the field of diagnostics and imaging 1. Nevertheless, progress in some areas continues, albeit at a slower pace than we might like. In this review the areas of current interest are reviewed with reference to the most relevant areas of progress in recent years.

Endoscopic ultrasound for differential diagnosis of duodenal lesions

PURPOSE

Duodenal tumors are rare and require a different management from that of esophagogastric neoplasia. The present study retrospectively analyses the endoscopic ultrasound (EUS) features of duodenal tumors of both epithelial and subepithelial origin.

MATERIALS AND METHODS

During a 12 year period, all duodenal tumors with histologic confirmation by surgery or biopsy were collected including endoscopic and endosonographic images. EUS images were analyzed for specific features (echogenicity, wall layer structure and relation, outer margins) to possibly distinguish epithelial (polyps and carcinoma versus lymphoma) and subepithelial (tumor type) tumors.

RESULTS

53/80 cases had histologic confirmation (mean age 53.1 ± 11.4 years, m:f = 33:20), 31 were epithelial (13 adenomas, 12 carcinomas, 6 lymphomas) and 22 subepithelial (11 GISTs, 7 Brunneromas, 1 lipoma, 3 NETs). EUS did not recognize carcinomas in 2/13 adenomas. EUS features suggesting carcinoma were loss of wall layers and irregular margins. 5/6 lymphomas showed inhomogeneous thickening with layers partially recognizable. Tumor type of subepithelial lesions correlated with echogenicity: GIST tumors were mostly (62.5 %) hypocheoic with the 3 malignant cases being characterized by heterogeneous echopattern with irregular outer margins. Of the hyperechoic lesions, lipomas had a homogeneous whitish appearance, while NET and Brunneromas were less hyperechoic. In the latter, the endoscopic aspect was also helpful for differential diagnosis. Accuracy of combined endoscopic/EUS imaging for all duodenal lesions was 84.9 % (45/53). No procedural complications occurred among all patients that received EUS examinations.

CONCLUSION

EUS contributes to the differential diagnosis of epithelial lesions known to be malignant; in subepithelial tumors, tissue confirmation is still required.

Staging and outcome depending on surgical treatment in adenocarcinomas of the oesophagogastric junction

BACKGROUND

Owing to controversial staging and classification of adenocarcinoma of the oesophago-gastric junction (AOG) before surgery, the choice of appropriate surgical approach remains problematic. In a retrospective study, preoperative staging of AOG and the impact of preoperative misclassification on outcome were analysed.

METHODS

Data from patients with AOG were analysed from a prospectively collected database with regard to surgical treatment, preoperative and postoperative staging, and outcome.

RESULTS

One-hundred and thirty patients with Siewert types I and II AOG who did not have neoadjuvant treatment were included in the study: 41 patients with an AOG type I who underwent oesophagectomy, 51 patients with an AOG staged before surgery as type I who underwent oesophagectomy but in whom the final histology showed a type II tumour, and 38 patients whose tumours were staged as AOG type II before and after operation who underwent gastrectomy. Among patients who had an oesophagectomy, lymph node metastases (P = 0.022), tumour relapse (P = 0.009) and recurrent distant metastases (P = 0.028) were significantly more frequent in patients with AOG type II; those with AOG type II had shorter overall survival than those with type I tumours (P = 0.024). Among those with AOG type II, recurrence-free survival was significantly shorter after oesophagectomy compared with extended gastrectomy (P = 0.019). Thoracoabdominal oesophagectomy had a favourable influence on outcome compared with the transhiatal approach.

CONCLUSION

Accurate preoperative staging of AOG and appropriate surgical therapy are crucial for outcome. AOG type II is a more aggressive tumour with higher recurrence rates than AOG type I. These patients therefore benefit from more radical surgical treatment.

CO₂ versus air insufflation for private practice routine colonoscopy: results of a randomized double blind trial

BACKGROUND

Pain and bloating following colonoscopy are an underestimated problem, with 30 - 60 % of patients complaining of such symptoms. The use of CO₂ has been shown to significantly decrease pain after colonoscopy in academic hospital-based studies. The aim of the present study was to evaluate whether such an effect can also be seen during private practice routine colonoscopy.

PATIENTS AND METHODS

In a prospective double-blind randomized trial, one experienced colonoscopist (> 12,000 examinations) used either air or CO₂ insufflation for diagnostic or screening colonoscopy in consecutive patients presenting for diagnostic and screening colonoscopy in private practice. Outcome parameters were occurrence and duration of pain and bloating after colonoscopy based on a patient questionnaire.

RESULTS

Of 180 randomized patients, 156 replies were analyzed (43.3 % male, mean age 61.7 ± 9.7 years). There were no significant differences between the two groups with respect to age and sex distribution, indication, sedation, examination times and polypectomy rates. Both pain and abdominal bloating were significantly lower in the CO₂ group. Abdominal pain and bloating in the CO₂ vs. air group were absent in 84.4 vs. 64.6 % (p = 0.005) and 66.2 vs. 32.9 % (p < 0.001). Moderate/strong symptoms were also significantly lower with CO₂.

CONCLUSIONS

The use of CO₂ appears to be as effective in daily routine in private practice colonoscopy as reported in previous hospital-based studies.

[Highlights in gastroenterology 2011]

«Gastro-Highlights», an annual symposium dedicated to continuing education, took place at the University Hospital Zürich for the sixteenth time this autumn. In this well-attended event, major new findings in the fields of gastroenterology and hepatology that were published in the past year or recently presented at the «Digestive Disease Week (DDW)» were summarized for practising gastroenterologists and internists.

Effectiveness of a novel endoscopy training concept

BACKGROUND AND STUDY AIMS

Training standards in gastrointestinal endoscopy are poorly defined even though different simulators are increasingly used for skills training. In 2001 a new training concept called "GATE--gastroenterological education-training endoscopy" was established, which provides a combination of background theory, video demonstrations, and simulator training. We aimed to evaluate the acceptance and training effect of this training model.

METHODS

In total, 98 physicians participating in four training courses were included. Data were collected on baseline characteristics, acceptance (5-point Likert scale), and pre- and post-course knowledge through a structured questionnaire (A-type and Pick-N multiple choice questions). A total of 13 trainees were randomly selected for additional simulator assessment of training effects on manual skills (5-point Likert scale).

RESULTS

A total of 78 trainees (80%) provided complete data sets. The evaluation showed a positive acceptance of the training program (value 1 and 2, Likert scale); for example, 88% of participants suggested the inclusion of the GATE course as an obligatory part of endoscopic education. There was a significant improvement in theoretical knowledge in the post-test set compared with the pre-test set (mean 3.27 ±1.30 vs. 1.69 ±1.01 points; P<0.001). The training effect on practical skill showed a significant reduction in time needed for a procedure (445 ±189 s vs. 274 ±129 s; P<0.01). The mean assessment rating for practical skills improved from 3.05 ±0.65 at baseline to 2.52 ±0.59 on Likert scale ( P=0.085).

CONCLUSIONS

The integrated GATE training improved theoretical knowledge and manual skill. The GATE courses have been accredited by the German Society of Gastroenterology, underlining the demand for implementing preclinical training courses in endoscopic training.

UEGW 2010 Report. Putting endoscopy into perspective

The 18th United European Gastroenterology Week (UEGW), held in Barcelona in October 2010, marked a return to the traditional "stand-alone" UEGW meeting after the previous year's combined congress format of GASTRO 2009. Various abstracts on endoscopic subjects were presented, providing a unique opportunity for those interested in gastrointestinal endoscopy to not only become acquainted with the latest advancements and research in the field, but also to meet and exchange experiences with colleagues from all over the world. This report will focus mainly on oral presentations, with a few selected poster presentations, which will be reviewed briefly in the context of recent literature in the respective fields of gastrointestinal endoscopy.

[Highlights in gastroenterology 2010]

This summer saw the fifteenth edition of «Gastro-Highlights», a well-attended symposium dedicated to continuing education that takes place each year at the University Hospital in Zurich. Major new findings in the fields of gastroenterology and hepatology that were achieved in the past year and were recently presented at the «Digestive Disease Week (DDW)» were summarized here for practising gastroenterologists and internists.

Neuroendocrine tumors of the stomach (gastric carcinoids) are on the rise: small tumors, small problems?

Well differentiated neuroendocrine tumors (NETs) of the stomach (gastric carcinoid tumors) are observed more often, with a tenfold increase in the US in the last 30 - 35 years, and the prognosis has improved greatly in that time. Nowadays most carcinoids of the stomach are diagnosed at an early stage. Four types of gastric NETs have been proposed and recognition of the type is important for defining the diagnostic approach and treatment. Often gastric NETs (especially type 1) are found incidentally during a gastroscopy performed for other reasons; most of these NETs are smaller than 20 mm in size. Conservative management and endoscopic surveillance is adequate for well differentiated, multifocal gastric carcinoids (type 1 or type 2 gastric NETs) that are less than 10 - 20 mm in diameter, unless they show angioinvasion, infiltrate the muscular wall, or have a proliferation rate above 2 %. Endoscopic ultrasound is the method of choice to determine tumor size and depth of infiltration. It is essential to distinguish between multifocal (types 1 and 2) and unifocal type 3 or type 4 gastric NETs, since surgery is indicated for type 3 gastric NETs larger than 10 mm in diameter and for poorly differentiated (localized) neuroendocrine gastric carcinomas (type 4 gastric NET). For optimal management, the type, biology, and stage of the tumor as well as the individual situation of the patient must be considered. Most patients with well differentiated gastric NETs can be treated conservatively and be followed up with endoscopic surveillance.

Probe-based confocal laser endomicroscopy compared with standard four-quadrant biopsy for evaluation of neoplasia in Barrett's esophagus

BACKGROUND AND STUDY AIMS

Surveillance of Barrett's esophagus includes endoscopic inspection with biopsy of suspicious lesions followed by four-quadrant biopsy of the remaining mucosa. We assessed the ability of probe-based confocal laser endomicroscopy (pCLE) to replace biopsy in the endoscopic evaluation of patients with Barrett's esophagus in a prospective and controlled setting.

PATIENTS AND METHODS

A total of 68 patients who were referred for endoscopic assessment of Barrett's esophagus were included across three centers. pCLE recordings were interpreted live during the examination as well as in a blinded manner at least 3 months after endoscopy. pCLE diagnosis of neoplasia based on pre-defined criteria was compared with histopathology from suspicious as well as four-quadrant biopsies.

RESULTS

A total of 670 pairs of biopsies and pCLE video sequences were available for analysis, with neoplasia (high-grade dysplasia or cancer) being histologically diagnosed in 8.3 %. Specificity and negative predictive value of pCLE in excluding neoplasia was 0.97 (90 %CI 0.95 - 0.98) and 0.93 (0.91 - 0.95) for the blinded evaluation, and 0.95 (0.90 - 0.98) and 0.92 (0.90 - 0.94) for the on-site assessment. Positive predictive values (PPVs) and sensitivity were rather poor for both settings (46 %/28 % [blinded] and 18 %/12 % [on-site], respectively).

CONCLUSIONS

pCLE can be regarded as non-inferior to endoscopic biopsy in excluding neoplasia of Barrett's esophagus mucosa. However, due to its low PPV and sensitivity, pCLE may currently not replace standard biopsy techniques for the diagnosis of Barrett's esophagus and associated neoplasia. Further technical development of pCLE and a better understanding of its role in relation to other imaging technologies are necessary.

Transluminal endoscopic necrosectomy after acute pancreatitis: a multicentre study with long-term follow-up (the GEPARD Study)

BACKGROUND

As with endoscopic transmural drainage of peripancreatic fluid collections, the same transluminal access can be expanded to introduce an endoscope through the gastrointestinal wall into the retroperitoneum and remove infected pancreatic necroses under direct visual control. This study reports the first large series with long-term follow-up.

METHODS

Data for all patients undergoing transluminal endoscopic removal of (peri)pancreatic necroses between 1999 and 2005 in six different centres were collected retrospectively, and the patients were followed up prospectively until 2008. The initial patient and treatment outcome data were recorded, as were long-term results.

RESULTS

Ninety-three patients (63 men, 30 women; mean age 57 years) underwent a mean of six interventions starting at a mean of 43 days after an attack of severe acute pancreatitis. After establishment of transluminal access to the necrotic cavity and subsequent endoscopic necrosectomy, initial clinical success was obtained in 80% of the patients, with a 26% complication and a 7.5% mortality rate at 30 days. After a mean follow-up period of 43 months, 84% of the initially successfully treated patients had sustained clinical improvement, with 10% receiving further endoscopic and 4% receiving surgical treatment for recurrent cavities; 16% suffered recurrent pancreatitis.

CONCLUSIONS

Direct transluminal endoscopic removal of pancreatic necroses is associated with good long-term maintenance of the high initial efficacy; complications can occur, with an associated mortality of around 7.5%. Further studies are necessary in order to optimise endotherapy and define its role in relation to surgery in the clinical management of such patients.

UEGW Report 2008: putting endoscopy into perspective

The 16th United European Gastroenterology Week (UEGW), which was held in Vienna in October 2008, provided the opportunity for those interested in gastrointestinal endoscopy to be informed of the experience of colleagues throughout the world and to become acquainted with the latest advancements and research in the field. Many of these abstracts focused on innovations and new techniques, and numerous others concentrated on topics with an impact on everyday clinical practice. This report attempts to highlight mostly oral presentations but also a few selected poster presentations, and each will be briefly reviewed in the light of recent publications in the respective fields of gastrointestinal endoscopy.

Long-term follow-up of percutaneous transhepatic biliary drainage (PTBD) in patients with benign bilioenterostomy stricture

BACKGROUND AND AIMS

Anastomotic strictures are well-known complications after bilioenterostomy. Endoscopic procedures are usually not possible in patients with a bilioenterostomy. Hence, percutaneous transhepatic biliary drainage (PTBD) has become the treatment of choice for the management of these patients. The main goal of the present study was to analyze the long-term follow-up of PTBD in such patients.

METHODS AND PATIENTS

Between January 1996 and December 2006, 44 patients with benign anastomotic stricture after bilioenterostomy were identified by an analysis of the PTBD database, hospital charts, and cholangiograms.

RESULTS

In 27/44 patients the percutaneous transhepatic biliary drain was successfully removed after 19.9 +/- 16.1 months (treatment success in 61.4 %). During a mean follow-up of 53.7 +/- 28.4 months after removal of the drain, no evidence was found of recurrent strictures in these patients. Ten out of 44 patients carry permanent drains (22.6 % of patients with ongoing treatment, mean follow-up 46.4 +/- 54.7 months) without the option for further surgery owing to concomitant disease (n = 2) or because they refused further surgery (n = 8). In 7 out of 44 patients (16 %) PTBD treatment was deemed to have failed and the patients underwent repeat operation.

CONCLUSIONS

PTBD should be considered the treatment of choice in patients with benign anastomotic stricture after bilioenterostomy, especially after stricturing of a hepatojejunostomy.

[Impact of the body mass index on the prognosis and complication rate after surgical resection of cancers at the oesophagogastric junction]

BACKGROUND

An elevated body mass index (BMI) is associated with an increased incidence of cancer at the gastro-oesophageal junction. Less is known about the postoperative complication rate and prognosis in relation to the BMI.

PATIENTS AND METHODS

We investigated 108 patients with cancer of the cardia and a BMI below (group 1, n = 56) or above (group 2, n = 52) 25 kg / m (2), who were operated from 2000 to 2006 in our department. According to the Siewert classification, the tumours were subdivided into 3 types. Patients with type I cancers (n = 26) received a transthoracic oesophageal resection with gastric pull up. Patients with type II (n = 61) or type III (n = 21) cancers underwent an extended gastrectomy. The complication rates and survival were analysed.

RESULTS

The complications were pulmonary (respiratory insufficiency n = 12, pneumonia n = 12, bronchitis n = 7, pulmonary embolism n = 2), surgical (anastomotic leakage n = 7, abscesses n = 8, bleeding n = 2, chylus fistula n = 1), or functional (dysphagia n = 5, nausea n = 5, heart burn n = 4, delayed enteral passage n = 6, vomiting n = 9). Patients of group 2 showed more delayed enteral passages (5 vs. 1) and more vomiting (7 vs. 2) than those of group 1. The median stay in the intensive care unit was shorter in group 1 than in group 2 (3 vs. 5 days) (p = 0.021). Overall hospitalisation was 14 days in the mean in both groups. We found no significant difference in the postoperative mortality of 6.5 % (n = 7) between the two groups. Overall survival after a follow-up of 42 months was 34 % (group 1) and 25 % (group 2). The difference did not reach statistical significance (p = 0.961). Patients with an elevated BMI show slightly more complications than those with a lower BMI.

CONCLUSIONS

Our data show that patients with elevated BMI have slightly more complications and an identical long term survival as patients with normal body weight.

Miniprobe confocal laser microscopy for the detection of invisible neoplasia in patients with Barrett's oesophagus

OBJECTIVE

The biggest challenge in endoscopic surveillance of Barrett's oesophagus is better detection of neoplasia in mucosa of normal macroscopic appearance. We evaluated in vivo miniprobe confocal laser microscopy (CLM) for the detection of invisible Barrett's neoplasia.

DESIGN

Prospective two-centre trial in two phases: phase I to establish criteria of Barrett's neoplasia and phase II to test these criteria.

PATIENTS AND INTERVENTION

296 biopsy sites in 38 consecutive patients with Barrett's oesophagus (mean age 62.1 years, 89.5% men, median length of the Barrett's oesophagus, 3 cm) were examined with standard high-resolution endoscopy and by miniprobe CLM, with precise matching of CLM recordings to biopsy sites. CLM image criteria for normal versus neoplastic Barrett's oesophagus were established from 95 biopsies of 15 patients (phase I); these criteria were then prospectively tested on 201 biopsies from the remaining patients without visible focal changes (phase II). All 201 CLM video recordings from phase II cases were randomised and blindly evaluated by two gastroenterologists.

MAIN OUTCOME MEASURE

The primary endpoints were accuracy values in diagnosing HGIN or early carcinoma (EC) on a per-biopsy basis. Secondary endpoints included inter-observer agreement.

RESULTS

All initially defined miniprobe CLM criteria (phase I) were significantly more frequently detected in HGIN/EC sites compared with sites with no or low grade neoplasia (phase II). In a per-biopsy analysis, sensitivity and specificity for two independent investigators were 75.0% and 88.8%, and 75.0% and 91.0%, respectively, translating at best into a positive predictive value of 44.4% and a negative predictive value of 98.8%. Inter-observer agreement was good (kappa 0.6).

CONCLUSION

Miniprobe CLM showed a high negative predictive value for the diagnosis of endoscopically invisible neoplasia in Barrett's oesophagus; sensitivity, however, has still to be improved.

Critical reappraisal of current surveillance strategies for Barrett's esophagus: analysis of a large German Barrett's database

Endoscopic surveillance is recommended for patients with Barrett's esophagus (BE). Based on a large database, gathered from predominantly community-based practices in Germany, we aimed to investigate the time-course of malignant progression and apply these findings to current clinical practice. Data of 1438 patients with BE from a large German BE database were analyzed. Patients with at least one follow-up endoscopy/biopsy were included. Detection of 'malignant Barrett' (either high-grade intra-epithelial neoplasia or invasive adenocarcinoma) was considered as study end-point. Of 1438 patients with BE, 57 patients had low-grade intra-epithelial neoplasia (LG-IN) on initial biopsy and 1381 exhibited non-neoplastic BE. 'Malignant Barrett' was detected in 28 cases (1.9%) during a median follow-up period of 24 months (1-255), accounting for an incidence of 0.95% per patient year of follow-up. The frequency of 'malignant Barrett' was significantly higher (P < 0.001, chi(2)-test) in the LG-IN group (n = 11, 19.3%) compared with the non-neoplastic BE group (n = 17, 1.2%). In the non-neoplastic BE group, 'malignant Barrett' was predominantly found during re-endoscopy within the first year of follow-up (12 of 17; 70.6%), in contrast to the LG-IN group, in which 'malignant Barrett' was observed predominantly after a time exceeding 12 months (8 of 11, 72.7%; P = 0.05, Fisher's exact test). Initial endoscopic evaluations seem to play the most crucial role in managing BE. After 1 year of follow-up, endoscopic surveillance should be focused on patients with LG-IN. In patients with repeatedly proven non-neoplastic BE, elongation of the follow-up intervals to the upper limit of current guidelines, that is, 5 years, might be justified.

Endoscopy in Barrett's oesophagus: adherence to standards and neoplasia detection in the community practice versus hospital setting

OBJECTIVE

Potential process differences between hospital and community-based endoscopy for Barrett's oesophagus have not been examined. We aimed at comparing adherence to guidelines and neoplasia detection rates in medical centres (MC) and community practices (CP).

DESIGN

Retrospective analysis.

SETTING

All histologically confirmed Barrett cases seen over a 3-year period in six MC and 19 CP covering a third of all upper gastrointestinal endoscopies (n = 126,000) performed annually in Berlin, Germany.

MAIN OUTCOME MEASURE

Rate of relevant neoplasia (high-grade intraepithelial neoplasia or more) in both settings in relation to adherence to standards.

RESULTS

Of 1317 Barrett cases, 66% were seen in CP. CP patients had a shorter mean Barrett length (2.6 cm vs. 3.8 cm; P < 0.001) with fewer biopsies taken during an examination (2.5 vs. 4.1 for Barrett length <or=2 cm; P < 0.001). CPs also provided fewer complete esophagogastroduodenoscopy documentation (25.1% vs. 57.8%, P < 0.001). Neoplasias were found more commonly in MCs compared to CPs (9.2% vs. 0.8%; P < 0.001). However, on exclusion of all referred patients with known neoplasia (65%) or those examined for other reasons (27.5%), the detection rate at MCs decreased to 1.3%, not different from the one seen at CPs (0.8%, P = 0.43). Only 13% were found during surveillance, but 57% were diagnosed at an early stage.

CONCLUSIONS

Referral bias and not better adherence to guidelines could explain the higher neoplasia prevalence in Barrett's oesophagus at hospital centres. Despite a generally poor adherence to guidelines, most neoplasias found were at an early and potentially curable stage.

A novel and practicable ERCP training system with simulated fluoroscopy

INTRODUCTION

Simulators facilitate the acquisition of technical skills for endoscopy. Here, we describe the development, introduction, and first evaluation of a novel generation of mechanical endoscopic retrograde cholangiopancreatography (ERCP) simulation models with simulated fluoroscopy, the X-Vision ERCP Training System.

METHODS

A custom-made modular ERCP simulation system was built with the use of universally obtainable materials and tools. The trainee controls ERCP activities on two screens: the aspect of the papilla and duodenum is shown on the conventional endoscopy monitor, and the trainee's actions in the equivalents of the pancreaticobiliary ducts are shown on the viewing screen of the model. Thereby, the latter screen serves as a substitute for fluoroscopy. Currently, four different models are available, allowing simulation of selective cannulation of the pancreatic or bile duct, intubation of differently arranged papillae, stent placement, and sphincterotomy of a biopapilla. The X-Vision ERCP Training System was first used during an ERCP course attended by 26 endoscopists. Trainees were supervised by an ERCP expert and an experienced ERCP nurse at each training model. The training system was evaluated by the participants and experts using a specific questionnaire.

RESULTS

During the course there were no technical problems related to the X-Vision ERCP Training System. After sphincterotomy the organic papillae could easily be exchanged within less than 15 seconds. Overall, the X-Vision ERCP Training System achieved favorable results in all categories assessed.

CONCLUSION

The new X-Vision ERCP Training System is simple and effective. A first evaluation in the context of an ERCP course showed impressive results.

The new scopes--broadening the colonoscopy marketplace

Colonoscopy has been established as a screening tool for colorectal cancer and precursors in some countries. Efforts to improve instrument performance as well as patient comfort, safety and compliance have led to modifications of existing endoscopes as well as to the development of new scopes with different working mechanisms, including the colon capsule. While the former have not substantially changed performance, the true value of new scopes - partially single use and/or self propelling - can not be fully assessed, since they are either still under development and/or tested only in animals and in small groups of patients or volunteers. The colon capsule holds promise but has a too complicated preparatory regimen and too low a sensitivity at the moment. Future developments and further studies will show which of these techniques may complement or even replace traditional screening colonoscopy.

A prospective randomised study on narrow-band imaging versus conventional colonoscopy for adenoma detection: does narrow-band imaging induce a learning effect?

BACKGROUND AND AIMS

Colonoscopy is an established method of colorectal cancer screening, but has an adenoma miss rate of 10-20%. Detection rates are expected to improve with optimised visualisation methods. This prospective randomised study evaluated narrow-band imaging (NBI), a new technique that may enhance image contrast in colon adenoma detection.

METHODS

Eligible patients presenting for diagnostic colonoscopy were randomly assigned to undergo wide-angle colonoscopy using either conventional high-resolution imaging or NBI during instrument withdrawal. The primary outcome parameter was the difference in the adenoma detection rate between the two techniques.

RESULTS

A total of 401 patients were included (mean age 59.4 years, 52.6% men). Adenomas were detected more frequently in the NBI group (23%) than in the control group (17%) with a number of 17 colonoscopies needed to find one additional adenoma patient; however, the difference was not statistically significant (p = 0.129). When the two techniques were compared in consecutive subgroups of 100 study patients, adenoma rates in the NBI group remained fairly stable, whereas these rates steadily increased in the control group (8%, 15%, 17%, and 26.5%, respectively). Significant differences in the first 100 cases (26.5% versus 8%; p = 0.02) could not be maintained in the last 100 cases (25.5% versus 26.5%, p = 0.91).

CONCLUSIONS

The increased adenoma detection rate means of NBI colonoscopy were statistically not significant. It remains speculative as to whether the increasing adenoma rate in the conventional group may have been caused by a training effect of better polyp recognition on NBI.