Diagnostic and Therapeutic Endoscopy http://www.hindawi.com The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Laparoscopic Treatment of 1522 Adnexal Masses: An 8-Year Experience Wed, 11 Feb 2015 14:37:23 +0000 http://www.hindawi.com/journals/dte/2015/979162/ Objective. To reevaluate the long-term effectiveness and safety of laparoscopy in benign ovarian pathology. Materials and Methods. 1522 women with benign adnexal cysts, laparoscopically treated in the 3rd Department of Ob/Gyn, General University hospital “Attikon” and “Lito” Maternity Hospital between July 1998 and December 2006, were included. Results. The diagnosis in 1222 (80,6%) cases was endometriosis of the ovary, 60 (4%) hydrosalpinx, 51 (3,3%) serous cystadenomas, 44 (2,9%) dermoid ovarian cyst, 38 (2,5%) borderline tumors, 35 (2,3%) unruptured follicles, and 33 (2,2%) paraovarian cysts. In 174 cases (11,5%) laparoscopy was converted to laparotomy due to technical difficulties or suspicion of cancer. In particular, laparotomy was performed in 119 (8%) women due to severe adhesions and 18 (1,2%) women due to bleeding that could not be controlled safely by laparoscopy. In 36 (2,4%) women frozen section during operation revealed malignancy and laparoscopy was converted to laparotomy. A few operative complications were recorded like post-op fever, small hematomas at the trocar entries. Conclusions. Laparoscopic surgery seems to offer significant advantages such as reduced hospital stay, less adverse effects, better quality of life, and superior vision especially on surgical treatment of cases like endometriosis. I. Grammatikakis, P. Trompoukis, S. Zervoudis, C. Mavrelos, P. Economides, V. Tziortzioti, N. Evangelinakis, and D. Kassanos Copyright © 2015 I. Grammatikakis et al. All rights reserved. Increased Prevalence of Colorectal Polyp in Acromegaly Patients: A Case-Control Study Mon, 29 Dec 2014 00:10:12 +0000 http://www.hindawi.com/journals/dte/2014/152049/ An increase in the prevalence of colorectal polyps and cancer is reported in patients with acromegaly. This trial is designed to determine whether there is an increase in the prevalence of colorectal polyps/cancer in Turkish acromegaly patients. Sixty-six patients, who were under follow-up with the diagnosis of acromegaly and underwent total colonoscopic examination, were enrolled in the study. Sixty-five age- and gender-matched patients with nonspecific complaints were selected as control. The mean age of acromegalic patients was years of whom 27 (40.9%) were females. In 20 (30.3%) of the patients with acromegaly a total of 65 colorectal polyps were detected. Forty-seven (72.3%) of the polyps were detected at the rectosigmoid region. In 8 (12.3%) of the 65 control patients a total of 17 polyps were found. There was a statistically significant difference between the groups . At the logistic regression analysis we found that the risk for colon polyps increased 3.2-fold in the presence of acromegaly, irrespective of age and gender (OR: 3.191, 95% CI: 1.25–8.13). In conclusion, patients who were followed up with the diagnosis of acromegaly should be taken to the colonoscopic surveillance program and all polyps detected should be excised in order to protect them from colorectal cancer. Ali Riza Koksal, Meltem Ergun, Salih Boga, Huseyin Alkim, Mehmet Bayram, Yuksel Altuntas, Banu Ozguven Yilmaz, and Canan Alkim Copyright © 2014 Ali Riza Koksal et al. All rights reserved. Outcomes of the Use of Fully Covered Esophageal Self-Expandable Stent in the Management of Colorectal Anastomotic Strictures and Leaks Thu, 18 Dec 2014 06:38:25 +0000 http://www.hindawi.com/journals/dte/2014/187541/ Introduction. Colorectal anastomotic leak or stricture is a dreaded complication leading to significant morbidity and mortality. The novel use of self-expandable metal stents (SEMS) in the management of postoperative colorectal anastomotic leaks or strictures can avoid surgical reintervention. Methods. Retrospective study with particular attention to the indications, operative or postoperative complications, and clinical outcomes of SEMS placement for patients with either a colorectal anastomotic stricture or leak. Results. Eight patients had SEMS (WallFlex stent) for the management of postoperative colorectal anastomotic leak or stricture. Five had a colorectal anastomotic stricture and 3 had a colorectal anastomotic leak. Complete resolution of the anastomotic stricture or leak was achieved in all patients. Three had recurrence of the anastomotic stricture on 3-month flexible sigmoidoscopy follow-up after the initial stent was removed. Two of these patients had a stricture that was technically too difficult to place another stent. Stent migration was noted in 2 patients, one at day 3 and the other at day 14 after stent placement that required a larger 23 mm stent to be placed. Conclusions. The use of SEMS in the management of colorectal anastomotic leaks or strictures is feasible and is associated with high technical and clinical success rate. Chad J. Cooper, Angel Morales, and Mohamed O. Othman Copyright © 2014 Chad J. Cooper et al. All rights reserved. Late Complications following Endoscopic Sphincterotomy for Choledocholithiasis: A Swedish Population-Based Study Thu, 16 Oct 2014 07:11:06 +0000 http://www.hindawi.com/journals/dte/2014/745790/ In order to assess the risk of long-term complications following endoscopic sphincterotomy (ES) for common bile duct stones (CBDS), we conducted a cohort study. The study included 1,113 patients who underwent ES for CBDS in six different hospitals in central Sweden between 1977 and 1990. Through the use of the Swedish population registry, each patient was assigned five population-based controls matched for sex and age. Linkage to the Inpatient Registry yielded information on morbidity and mortality for the patients as well as for the controls. After one year of washout, there were 964 patients available for follow-up. The mean age was 70.6 years, 57% were women, and the mean length of follow-up was 8.9 years. The patients’ overall morbidity was significantly higher and we observed a tendency towards increased mortality as well. Recurrent CBDS was diagnosed in 4.1% of the patients. Acute cholangitis with a hazard ratio (HR) of 36 (95%CI 11–119.4) was associated with recurrent CBDS in 39% of the patients. HR for acute pancreatitis was 6.2 (95%CI 3.4–11.3) and only one patient had CBDS at the same time. In conclusion, we consider acute pancreatitis and cholangitis both as probable long-term complications after ES. A. Langerth, L. Brandt, A. Ekbom, and B.-M. Karlson Copyright © 2014 A. Langerth et al. All rights reserved. Interobserver Agreement for Single Operator Choledochoscopy Imaging: Can We Do Better? Wed, 08 Oct 2014 00:00:00 +0000 http://www.hindawi.com/journals/dte/2014/730731/ Background. The SpyGlass Direct Visualization System (Boston Scientific, Natick, MA) is routinely used during single operator choledochoscopy (SOC) to identify biliary lesions or strictures with a diagnostic accuracy up to 88%. The objective of this study was to determine the interobserver agreement (IOA) of modified scoring criteria for diagnosing biliary lesions/strictures. Methods. 27 SPY SOC video clips were reviewed and scored by 9 interventional endoscopists based on published criteria that included the presence and severity of surface structure, vasculature visualization, lesions, and findings. Results. Overall IOA was “slight” for all variables. The K statistics are as follows: surface (, SE = 0.02); vessels (, SE = 0.02); lesions (, SE = 0.02); findings (, SE = 0.03); and final diagnosis (, SE = 0.02). The IOA for “findings” and “final diagnosis” was also only “slight.” The final diagnosis was malignant (11), benign (11), and indeterminate (5). Conclusion. IOA using the modified criteria of SOC images was slight to almost poor. The average accuracy was less than 50%. These findings reaffirm that imaging criteria for benign and malignant biliary pathology need to be formally established and validated. Amrita Sethi, Theodore Doukides, Divyesh V. Sejpal, Douglas K. Pleskow, Adam Slivka, Douglas G. Adler, Raj J. Shah, Steven A. Edmundowicz, Takao Itoi, Bret T. Petersen, Frank G. Gress, Monica Gaidhane, and Michel Kahaleh Copyright © 2014 Amrita Sethi et al. All rights reserved. Factors Significantly Contributing to a Failed Conventional Endoscopic Stone Clearance in Patients with “Difficult” Choledecholithiasis: A Single-Center Experience Tue, 30 Sep 2014 13:16:32 +0000 http://www.hindawi.com/journals/dte/2014/861689/ The objective of this study is to retrospectively evaluate factors significantly contributing to a failed stone extraction (SE) in patients with difficult to extract bile duct stones (BDS). Patients and Methods. During a 10-year period 1390 patients with BDS underwent successfully endoscopic sphincterotomy. Endoscopic SE was graded as easy; relatively easy; difficult; and failed. Difficult SE was encountered in 221 patients while failed SE was encountered in 205. A retrospective analysis of the criteria governing the difficulty of endoscopic SE following the index endoscopic intervention was performed to evaluate their significance in determining failure of complete SE among patients with difficult to extract bile duct stones. Results. Age ≥ 85 years, periampullary diverticula, multiple CBD stones (>4), and diameter of CBD stones (≥15 mm) were all significant contributing factors to a failed SE in univariate statistical tests. In the definitive multivariate analysis age, multiple stones and diameter of stones were found to be the significant, independent contributors. Conclusion. Failed conventional endoscopic stone clearance in patients with difficult to extract BDS is more likely to occur in overage patients, in patients with multiple CBD stones >4, and in patients with CBD stone(s) diameter ≥15 mm. Emmanuel Christoforidis, Konstantinos Vasiliadis, Konstantinos Tsalis, Dimitrios Patridas, Konstantinos Blouhos, Manousos-Georgios Pramateftakis, Moysis Moysidis, and Charalampos Lazaridis Copyright © 2014 Emmanuel Christoforidis et al. All rights reserved. The Changing Pattern of Upper Gastrointestinal Disorders by Endoscopy: Data of the Last 40 Years Mon, 08 Sep 2014 00:00:00 +0000 http://www.hindawi.com/journals/dte/2014/262638/ Objectives. We have investigated the changes in the incidence of various diagnoses that have been made in the endoscopy unit throughout the last 40 years. Methods. In this study, changes in the incidence of endoscopic diagnosis in upper gastrointestinal system between 1970 and 2010 were evaluated. Their diagnosis, age, and gender data were entered into the Excel software. Results. Of the 52816 cases who underwent esophagogastroduodenoscopy in the 40-year time period, the mean age was 48.17 ± 16.27 (mean ± SD). Although overall more than half of the patients were male (54.3%), in 1995 and after a marked increase was seen in the proportion of female gender (51–55%). The presence of hiatal hernia, reflux esophagitis, and the number of Barrett’s esophaguses significantly increased. Erosive gastritis showed gradual increase, while the number of gastric ulcers decreased significantly. The presence of gastric and esophageal cancer significantly decreased. The number of duodenal ulcers significantly decreased. Conclusion. We detected that the incidences of esophagitis, Barrett’s esophagus, and erosive gastritis significantly increased while the incidences of gastric/duodenal ulcer and gastric/esophageal cancer decreased throughout the last 40 years. Erkan Caglar, Birol Baysal, and Ahmet Dobrucalı Copyright © 2014 Erkan Caglar et al. All rights reserved. Postcolonoscopy Followup Recommendations: Comparison with and without Use of Polyp Pathology Wed, 27 Aug 2014 13:12:44 +0000 http://www.hindawi.com/journals/dte/2014/683491/ Background. Appropriate recommendations for a followup exam after an index colonoscopy are an important quality indicator. Lack of knowledge of polyp pathology at the time of colonoscopy may be one reason that followup recommendations are not made. Aim. To describe and compare the accuracy of followup recommendations made at colonoscopy based on the size and number of polyps with recommendations made at a later date based on actual polyp pathology. Methods. All patients who underwent screening and surveillance colonoscopy from March, 2012, to August, 2012, were included. Surveillance recommendations from the endoscopy reports were graded as “accurate” or “not accurate” based on the postpolypectomy surveillance guidelines established by US Multisociety Task Force on Colon Cancer. Polyp pathology was then used to regrade the surveillance recommendations. Results. Followup recommendations were accurate in 759/884 (86%) of the study colonoscopies, based upon size and number of polyps with the assumption that all polyps were adenomatous. After incorporating actual polyp pathology, 717/884 (81%) colonoscopies had accurate recommendations. Conclusion. In our practice, the knowledge of actual polyp pathology does not change the surveillance recommendations made at the time of colonoscopy in the majority of patients. Shiva K. Ratuapli, Suryakanth R. Gurudu, Mary A. Atia, Michael D. Crowell, Sarah B. Umar, M. Edwyn Harrison, Jonathan A. Leighton, and Francisco C. Ramirez Copyright © 2014 Shiva K. Ratuapli et al. All rights reserved. Opioid Use Is Not Associated with Incomplete Wireless Capsule Endoscopy for Inpatient or Outpatient Procedures Tue, 19 Aug 2014 12:06:14 +0000 http://www.hindawi.com/journals/dte/2014/651259/ Objective. Wireless capsule endoscopy (WCE) is commonly used to directly visualize the small bowel. Opioids have variably been linked with incomplete studies and prolonged transit times in heterogeneous cohorts. We aimed to investigate the effect of opioid use on WCE for inpatient and outpatient cohorts. Methods. We performed a retrospective review of patients receiving WCE at our institution from April 2010 to March 2013. Demographic data, medical history, and WCE details were collected. Transit times were compared by log-rank analysis. Multivariable logistic regression and Cox proportional hazard models were utilized. Results. We performed 314 outpatient and 280 inpatient WCE that met study criteria. In the outpatient cohort, gastric transit time (GTT) was not significantly different between opioid and nonopioid users. Completion rates were similar as well (88% and 87%, ). In the inpatient cohort, GTT was significantly longer in patients receiving opioids than in patients not receiving opioids (44 versus 23 min, ), but completion rates were similar (71% versus 75%, ). Conclusion. Opioid use within 24 hours of WCE did not significantly affect completion rates for inpatients or outpatients. GTT was prolonged in inpatients receiving opioids but not in outpatients. Bryan Kleinman, Peter P. Stanich, Kavita Betkerur, Kyle Porter, and Marty M. Meyer Copyright © 2014 Bryan Kleinman et al. All rights reserved. Safety and Yield of Diagnostic ERCP in Liver Transplant Patients with Abnormal Liver Function Tests Wed, 09 Jul 2014 00:00:00 +0000 http://www.hindawi.com/journals/dte/2014/314927/ Background. Abnormal liver enzymes postorthotopic liver transplant (OLT) may indicate significant biliary pathology or organ rejection. There is very little known in the literature regarding the current role of diagnostic ERCP in this scenario. Aim. To review the utility of diagnostic ERCP in patients presenting with abnormal liver function tests in the setting of OLT. Methods. A retrospective review of diagnostic ERCPs in patients with OLT from 2002 to 2013 from a prospectively maintained, IRB approved database. Results. Of the 474 ERCPs performed in OLT patients, 210 (44.3%; 95% CI 39.8–48.8) were performed for abnormal liver function tests during the study period. Majority of patients were Caucasian (83.8%), male (62.4%) with median age of 55 years (IQR 48–62 years). Biliary cannulation was successful in 99.6% of cases and findings included stricture in 45 (21.4 %); biliary stones/sludge in 23 (11%); biliary dilation alone in 31 (14.8%); and normal in 91 (43.3%). Three (1.4%) patients developed mild, self-limiting pancreatitis; one patient (0.5%) developed cholangitis and two (1%) had postsphincterotomy bleeding. Multivariate analyses showed significant association between dilated ducts on imaging with a therapeutic outcome. Conclusion. Diagnostic ERCP in OLT patients presenting with liver function test abnormalities is safe and frequently therapeutic. Jayapal Ramesh, Nipun Reddy, Hwasoon Kim, Klaus Mönkemüller, Shyam Varadarajulu, Brendan McGuire, Derek DuBay, Devin Eckhoff, and C. Mel Wilcox Copyright © 2014 Jayapal Ramesh et al. All rights reserved. Capsule Endoscopy for Obscure Gastrointestinal Bleeding in Patients with Comorbid Rheumatic Diseases Sun, 06 Jul 2014 07:34:20 +0000 http://www.hindawi.com/journals/dte/2014/534345/ Background and Aim. We evaluated the association between patients with rheumatic diseases (RD) suffering from obscure gastrointestinal bleeding (OGIB) and positive capsule endoscopy (CE) findings. Methods. All CE procedures performed on patients with RD and OGIB were assessed from a large database at St. Paul’s Hospital (Vancouver, BC, Canada) between December 2001 and April 2011. A positive finding on CE was defined as any pathology, including ulcers/erosions, vascular lesions, and mass lesions, perceived to be the source of bleeding. Results. Of the 1133 CEs performed, 41 (4%) complete CEs were for OGIB in patients with RD. Of these, 54% presented with overt bleeding. Mean age was 66 years. Positive findings were seen in 61% of patients. Ulcerations/erosions (36%) and vascular lesions (36%) were the most common findings. Significant differences between the RD versus non-RD populations included: inpatient status, nonsteroidal anti-inflammatory drug (NSAIDs) use, oral steroid use, and mean Charlson index score (all ). Similar nonsignificant trends were seen between positive and negative CEs among the RD population. Conclusions. The correlation between RD and positive CE findings is likely influenced by ongoing anti-inflammatory drug use, poorer health status, and a predisposition for angiodysplastic lesions. Neal Shahidi, George Ou, Jessica Tong, Ricky Kwok, Cherry Galorport, Joanna K. Law, and Robert Enns Copyright © 2014 Neal Shahidi et al. All rights reserved. Status of the Gastric Mucosa with Endoscopically Diagnosed Gastrointestinal Stromal Tumor Wed, 02 Jul 2014 06:17:34 +0000 http://www.hindawi.com/journals/dte/2014/429761/ Background. Since gastrointestinal stromal tumor (GIST) is a mesenchymal submucosal tumor, the endosonographic, CT, and MRI features of gastric GISTs have been widely investigated. However, the GIST-bearing gastric mucosa status has not been reported. Objective. To characterize the GIST-bearing gastric mucosa status in terms of the degree of inflammation and atrophy, assessed endoscopically. Subjects and Methods. The subjects were 46 patients with submucosal tumors (histologically proven gastric GISTs) who had undergone upper gastrointestinal endoscopy in our hospital between April 2007 and September 2012. They were retrospectively evaluated regarding clinicopathological features, the endoscopically determined status of the entire gastric mucosa (presence or absence and degree of atrophy), presence or absence and severity of endoscopic gastritis/atrophy (A-B classification) at the GIST site, and presence or absence of H. pylori infection. Results. Twenty-three patients had no mucosal atrophy, but 17 and 6 had closed- and open-type atrophy, respectively. Twenty-six, 5, 12, 1, 1, and 1 patients had grades B0, B1, B2, B3, A0, and A1 gastritis/atrophy at the lesion site, respectively, with no grade A2 gastritis/atrophy. Conclusion. The results suggest that gastric GISTs tend to arise in the stomach wall with H. pylori-negative, nonatrophic mucosa or H. pylori-positive, mildly atrophic mucosa. Kouichi Nonaka, Shinichi Ban, Yoshimitsu Hiejima, Rei Narita, Michio Shimizu, Masayasu Aikawa, Ken Ohata, Nobuyuki Matsuhashi, Shin Arai, and Hiroto Kita Copyright © 2014 Kouichi Nonaka et al. All rights reserved. Increased Incidence of Benign Pancreatic Pathology following Pancreaticoduodenectomy for Presumed Malignancy over 10 Years despite Increased Use of Endoscopic Ultrasound Thu, 05 Jun 2014 06:30:55 +0000 http://www.hindawi.com/journals/dte/2014/701535/ Despite using imaging studies, tissue sampling, and serologic tests about 5–10% of surgeries done for presumed pancreatic malignancies will have benign findings on final pathology. Endoscopic ultrasound (EUS) is used with increasing frequency to study pancreatic masses. The aim of this study is to examine the effect of EUS on prevalence of benign diseases undergoing Whipple over the last decade. Patients who underwent Whipple procedure for presumed malignancy at Emory University Hospital from 1998 to 2011 were selected. Demographic data, history of smoking and drinking, history of diabetes and pancreatitis, imaging data, pathology reports, and tumor markers were extracted. 878 patients were found. 95 (10.82%) patients had benign disease. Prevalence of benign finding had increased over the recent years despite using more EUS. Logistic regression models showed that abdominal pain (OR: 5.829, 95% CI 2.681–12.674, ≤ 0.001) and alcohol abuse (OR: 3.221, CI 95%: 1.362–7.261, : 0.002) were predictors of benign diseases. Jaundice (OR: 0.221, 95% CI: 0.084–0.58, : 0.002), mass (OR: 0.145, 95% CI: 0.043–0.485, : 0.008), and ductal dilation (OR: 0.297, 95% CI 0.134–0.657, : 0.003) were associated with malignancy. Use of imaging studies, ERCP, and EUS has not decreased the percentage of benign findings after surgery for presumed pancreatic malignancy. Shadi S. Yarandi, Thomas Runge, Lei Wang, Zhijian Liu, Yueping Jiang, Saurabh Chawla, Kevin E. Woods, Steven Keilin, Field F. Willingham, Hong Xu, and Qiang Cai Copyright © 2014 Shadi S. Yarandi et al. All rights reserved. Is It Possible to Predict the Presence of Intestinal Angioectasias? Mon, 17 Mar 2014 07:32:23 +0000 http://www.hindawi.com/journals/dte/2014/461602/ Background and Aim. Angioectasias are the most common vascular anomalies found in the gastrointestinal tract. In small bowel (SB), they can cause obscure gastrointestinal bleeding (OGIB) and in this setting, small bowel capsule endoscopy (SBCE) is an important diagnostic tool. This study aimed to identify predictive factors for the presence of SB angioectasias, detected by SBCE. Methods. We retrospectively analyzed the results of 284 consecutive SBCE procedures between April 2006 and December 2012, whose indication was OGIB, of which 47 cases with SB angioectasias and 53 controls without vascular lesions were selected to enter the study. Demographic and clinical data were collected. Results. The mean age of subjects with angioectasias was significantly higher than in controls ; . The presence of SB angioectasias was significantly higher when the indication for the exam was overt OGIB versus occult OGIB (13/19 versus 34/81, . Hypertension and hypercholesterolemia were significantly associated with the presence of SB angioectasias (38/62 versus 9/38, and 28/47 versus 19/53, , resp.). Other studied factors were not associated with small bowel angioectasias. Conclusions. In patients with OGIB, overt bleeding, older age, hypercholesterolemia, and hypertension are predictive of the presence of SB angioectasias detected by SBCE, which may be used to increase the diagnostic yield of the SBCE procedure and to reduce the proportion of nondiagnostic examinations. Tiago Cúrdia Gonçalves, Joana Magalhães, Pedro Boal Carvalho, Maria João Moreira, Bruno Rosa, and José Cotter Copyright © 2014 Tiago Cúrdia Gonçalves et al. All rights reserved. Transpancreatic Precut Sphincterotomy for Biliary Access: The Relation of Sphincterotomy Size to Immediate Success Rate of Biliary Cannulation Mon, 10 Mar 2014 16:26:16 +0000 http://www.hindawi.com/journals/dte/2014/864082/ Background. Transpancreatic precut sphincterotomy (TPS) is an option for difficult common bile duct (CBD) access, and the reports are few, with immediate success rate varying from 60 to 96%. The description of relation between the size of TPS and the immediate success rate of CBD cannulation was not found in the literature. The Aim of the Study. To evaluate the relation of large TPS to immediate success rate of CBD cannulation. Methods. A retrospective analysis was performed in prospectively collected data of 20 patients. TPS was performed with traction papillotome in the main pancreatic duct (MPD) directing towards 11 o’clock. Needle knife (NK) was used to enlarge TPS in five patients, and the other 15 cases had large TPS from the beginning of sphincterotomy. Prophylactic pancreatic stent was inserted in 18 cases, with diclofenac given in 12 cases. Results. The immediate success rate of CBD cannulation was 90% and with an eventual success rate of 100%. The failure in one immediate CBD cannulation with large TPS was due to atypical location of CBD orifice, and the other failed immediate CBD cannulation was due to inadequate size of TPS. Complications included 3 cases of post-TPS bleeding and 3 cases of mild pancreatitis. Conclusion. TPS is an effective procedure in patients with difficult biliary access and can have high immediate success rate with large TPS. Lien-Fu Lin Copyright © 2014 Lien-Fu Lin. All rights reserved. Endoscopic Papillary Large Balloon Dilation Reduces the Need for Mechanical Lithotripsy in Patients with Large Bile Duct Stones: A Systematic Review and Meta-Analysis Thu, 06 Mar 2014 14:01:25 +0000 http://www.hindawi.com/journals/dte/2014/309618/ Background. Removal of large stones can be challenging and frequently requires the use of mechanical lithotripsy (ML). Endoscopic papillary large balloon dilation (EPLBD) following endoscopic sphincterotomy (ES) is a technique that appears to be safe and effective. However, data comparing ES + EPLBD with ES alone have not conclusively shown superiority of either technique. Objective. To assess comparative efficacies and rate of adverse events of these methods. Method. Studies were identified by searching nine medical databases for reports published between 1994 and 2013, using a reproducible search strategy. Only studies comparing ES and ES + EPLBD with regard to large bile duct stone extraction were included. Pooling was conducted by both fixed-effects and random-effects models. Risk ratio (RR) estimates with 95% confidence interval (CI) were calculated. Results. Seven studies (involving 902 patients) met the inclusion criteria; 3 of 7 studies were prospective trials. Of the 902 patients, 463 were in the ES + EPLBD group, whereas 439 underwent ES alone. There were no differences noted between the groups with regard to overall stone clearance (98% versus 95%, RR  =  1.01 [0.97, 1.05]; ) and stone clearance at the 1st session (87% versus 79%, RR = 1.11 [0.98, 1.25]; ). ES + EPLBD was associated with a reduced need for ML compared to ES alone (15% versus 32%; RR  =  0.49 [0.32, 0.74]; ) and was also associated with a reduction in the overall rate of adverse events (11% versus 18%; RR = 0.58 [0.41, 0.81]; ). Conclusions. ES + EPLBD has similar efficacy to ES alone while significantly reducing the need for ML. Further, ES + EPLBD appears to be safe, with a lower rate of adverse events than traditional ES. ES + EPLBD should be considered as a first-line technique in the management of large bile duct stones. Mohammad F. Madhoun, Sachin Wani, Sam Hong, William M. Tierney, and John T. Maple Copyright © 2014 Mohammad F. Madhoun et al. All rights reserved. Evaluation of Pharyngeal Function between No Bolus and Bolus Propofol Induced Sedation for Advanced Upper Endoscopy Mon, 03 Mar 2014 09:23:39 +0000 http://www.hindawi.com/journals/dte/2014/248097/ This study aimed to assess pharyngeal function between no bolus and bolus propofol induced sedation during gastric endoscopic submucosal dissection. A retrospective study was conducted involving consecutive gastric cancer patients. Patients in the no bolus group received a 3 mg/kg/h maintenance dose of propofol after the initiation of sedation without bolus injection. All patients in the bolus group received the same maintenance dose of propofol with bolus 0.5 mg/kg propofol injection. Pharyngeal functions were evaluated endoscopically for the first 5 min following the initial administration of propofol. Fourteen patients received no bolus propofol induction and 13 received bolus propofol induction. Motionless vocal cords were observed in 2 patients (14%) in the no bolus group and 3 (23%) in the bolus group. Trachea cartilage was not observed in the no bolus group but was apparent in 6 patients (46%) in the bolus group (). Scope stimulated pharyngeal reflex was observed in 11 patients (79%) in the no bolus group and in 3 (23%) in the bolus group (). Propofol induced sedation without bolus administration preserves pharyngeal function and may constitute a safer sedation method than with bolus. Shinsuke Kiriyama, Hiroshi Naitoh, Minoru Fukuchi, Takaharu Fukasawa, Kana Saito, Yuichi Tabe, Hayato Yamauchi, Tomonori Yoshida, and Hiroyuki Kuwano Copyright © 2014 Shinsuke Kiriyama et al. All rights reserved. Evaluation of Patient Satisfaction Using the EORTC IN-PATSAT32 Questionnaire and Surgical Outcome in Single-Port Surgery for Benign Adnexal Disease: Observational Comparison with Traditional Laparoscopy Mon, 25 Nov 2013 14:10:27 +0000 http://www.hindawi.com/journals/dte/2013/578392/ Laparoscopic surgery has been demonstrated as a valid approach in almost all gynaecologic procedures including malignant diseases. Benefits of the minimally invasive approach over traditional open surgery have been well demonstrated in terms of minimal perioperative morbidity and reduced postoperative pain and hospital stay duration, with consequent quick postoperative recovery (Medeiros et al. (2009)). Single-port surgery resurfaced in gynaecology surgery in recent years and renewed interest among other surgeons and within the industry to develop this field (Podolsky et al. (2009)). Patient satisfaction is emerging as an increasingly important measure of quality which represents a complex entity that is dependent on patient demographics, comorbidities, disease, and, to a large extent, patient expectations (Tomlinson and Ko (2006)). It can be broadly thought to refer to all relevant experiences and processes associated with health care delivery (Jackson et al. (2001)). In this study we aim to compare single-port surgery (SPS) with conventional laparoscopy in terms of patient satisfaction using the EORTC IN-PATSAT32 questionnaire. We also evaluate the main surgical outcomes of both minimally invasive approaches. Alessandro Buda, Marco Cuzzocrea, Luca Montanelli, Paolo Passoni, Lorena Bargossi, Romina Baldo, Luca Locatelli, and Rodolfo Milani Copyright © 2013 Alessandro Buda et al. All rights reserved. A Novel Opportunity in Minimally Invasive Colorectal Cancer Therapy: Defining a Role for Endoscopic Submucosal Dissection in the United States Wed, 06 Nov 2013 14:34:26 +0000 http://www.hindawi.com/journals/dte/2013/681783/ Colorectal cancer is the third most common cancer among both men and women in the United States and the second leading cause of cancer death. Endoscopic submucosal dissection (ESD) is an innovative advanced endoscopic therapy for superficial gastrointestinal neoplasms which is rapidly becoming standard of care particularly in Asia. ESD was first developed for the resection of early gastric cancers; yet ESD for colon tumors has gained increasing attention in recent years. The advantage of ESD over conventional endoscopic resection lies in its potential to achieve en bloc resection regardless of tumor size, leading to more precise histological evaluation and greater potential for cure. Selecting appropriate patients for this procedure involves identifying colorectal cancers with nul risk of lymph node spread. For colorectal ESD to engraft in the United States, the prevalence of such early stage lesions must be defined so that centers of excellence can be developed for high volume clinical practice to offer patients the safest and most efficacious outcomes. This review discusses the endoscopic staging of colorectal neoplasms, indications for colorectal ESD, and the epidemiology of early stage ESD-amenable colorectal cancer in America to better define an opportunity for this important minimally invasive therapy. Jonah Cohen Copyright © 2013 Jonah Cohen. All rights reserved. Peroral Endoscopic Myotomy for the Treatment of Achalasia: An Analysis Sun, 27 Oct 2013 14:50:40 +0000 http://www.hindawi.com/journals/dte/2013/389596/ Achalasia is a motility disorder of the esophagus, characterized by aperistalsis of the esophageal body and incomplete relaxation of the lower esophageal sphincter (LES). Treatment of achalasia is currently aimed at decreasing the resting pressure in the LES. Peroral endoscopic myotomy (POEM) is an emerging novel endoscopic procedure for the treatment of achalasia with initial data suggesting an acceptable safety profile, excellent short-term symptom resolution, low incidence of postprocedural gastroesophageal reflux (GER), and improvement in manometric outcomes. Further prospective randomized trials are required to evaluate the long-term effectiveness of this promising technique compared to other treatment modalities for achalasia. In this review we outline the technical aspects of POEM, summarize the available data on safety and outcomes, and suggest future directions for further advancement of this minimally invasive approach for the treatment of achalasia. Dennis Yang and Mihir S. Wagh Copyright © 2013 Dennis Yang and Mihir S. Wagh. All rights reserved. Narrow Band Imaging with Magnification Endoscopy for Celiac Disease: Results from a Prospective, Single-Center Study Tue, 06 Aug 2013 08:34:54 +0000 http://www.hindawi.com/journals/dte/2013/580526/ In celiac disease (CD), the intestinal lesions can be patchy and partial villous atrophy may elude detection at standard endoscopy (SE). Narrow Band Imaging (NBI) system in combination with a magnifying endoscope (ME) is a simple tool able to obtain targeted biopsy specimens. The aim of the study was to assess the correlation between NBI-ME and histology in CD diagnosis and to compare diagnostic accuracy between NBI-ME and SE in detecting villous abnormalities in CD. Forty-four consecutive patients with suspected CD undergoing upper gastrointestinal endoscopy have been prospectively evaluated. Utilizing both SE and NBI-ME, observed surface patterns were compared with histological results obtained from biopsy specimens using the k-Cohen agreement coefficient. NBI-ME identified partial villous atrophy in 12 patients in whom SE was normal, with sensitivity, specificity, and accuracy of 100%, 92.6%, and 95%, respectively. The overall agreement between NBI-ME and histology was significantly higher when compared with SE and histology (kappa score: 0.90 versus 0.46; ) in diagnosing CD. NBI-ME could help identify partial mucosal atrophy in the routine endoscopic practice, potentially reducing the need for blind biopsies. NBI-ME was superior to SE and can reliably predict in vivo the villous changes of CD. L. De Luca, L. Ricciardiello, M. B. L. Rocchi, M. T. Fabi, M. L. Bianchi, A. de Leone, S. Fiori, and D. Baroncini Copyright © 2013 L. De Luca et al. All rights reserved. Clinical Application and Outcomes of Over the Scope Clip Device: Initial US Experience in Humans Sun, 14 Jul 2013 09:56:40 +0000 http://www.hindawi.com/journals/dte/2013/381873/ Background. OTSCs are now available in the US for various indications. Methods. Retrospective review of OTSCs used from January 2011 to April 2012. Results. Twenty-four patients underwent placement of 28 OTSCs. Indications included postsurgical fistula, perforations, anastomotic leak, prophylactic closure after EMR, postpolypectomy bleeding, tracheoesophageal fistula, and jejunostomy site leak. Instruments used to grasp the tissue were dedicated (bidirectional forceps or tripronged device) and nondedicated devices (rat/alligator forceps or suction). Success was higher with nondedicated devices (12.5% versus 86.5%, ). Overall, OTSC was effective in 15/27 procedures. Defect closure was complete in 12/21. Mean followup was 2.9 months (1–8 m). Mean defect size was 10 mm (5–25 mm). A trend towards higher success was noted in defects <10 mm compared to defects >10 mm (90% versus 60%; ). No difference was noted in closure of fresh (<72 hrs) versus chronic defects (>1 month) (75% versus 67%). There were no complications. Conclusion. The OTSC provides a safe alternative to manage fistula, perforation, and bleeding. No significant difference was seen for closure of early fistula or perforations as compared to chronic fistula. Rat-tooth forceps or suction was superior to the dedicated devices. Vijay Jayaraman, Christoper Hammerle, Simon K. Lo, Laith Jamil, and Kapil Gupta Copyright © 2013 Vijay Jayaraman et al. All rights reserved. Intradiverticular Ampulla of Vater: Personal Experience at ERCP Thu, 27 Jun 2013 16:29:28 +0000 http://www.hindawi.com/journals/dte/2013/102571/ Introduction. Conflicting results have been reported about the true impact of intradiverticula ampulla (IA) on the technical success and complication rate of endoscopic retrograde cholangiopancreatography (ERCP). Patients. A total of 500 patients who underwent ERCP were divided into two groups according to the presence (group A, 81 patients) or absence (group B, 419 patients) of IA. Success rate, difficulty at cannulation, findings at ERCP, and procedure-related complications were retrospectively reviewed. Results. Successful cannulation was achieved in 100% of group A patients compared to 98% of group B patients (P = ns). There was a significant difference in the type of cannulation that was routinary in group B (), while requiring guidewire in group A (). Cholangitis (), microstones (), dilated common bile duct without stones (), stone recurrence (), and transient postprocedure hyperamylasemia () were more frequently observed in group A. There was no significant difference in complication rate between both groups. Conclusions. The finding of an IA at ERCP should not be considered a predictor for failed cannulation. IA is associated with post-ERCP transient hyperamylasemia and is a risk factor for biliary stone disease and its recurrence. Girolamo Geraci, Giuseppe Modica, Carmelo Sciumè, and Antonio Sciuto Copyright © 2013 Girolamo Geraci et al. All rights reserved. Diagnostic Yield and Safety of Endoscopic Ultrasound Guided Fine Needle Aspiration of Central Mediastinal Lung Masses Thu, 30 May 2013 10:24:18 +0000 http://www.hindawi.com/journals/dte/2013/150492/ Background and Aims. EUS-FNA is an accurate and safe technique to biopsy mediastinal lymph nodes. However, there are few data pertaining to the role of EUS-FNA to biopsy central lung masses. The aim of the study was to assess the diagnostic yield and safety of EUS-FNA of indeterminate central mediastinal lung masses. Methods. Design: Retrospective review of a prospectively maintained database; noncomparative. Setting: Tertiary referral center. From 10/2004 to 12/2010, all patients with a lung mass located within proximity to the esophagus were referred for EUS-FNA. Main Outcome Measurement: EUS-FNA diagnostic accuracy and safety. Results. 73 consecutive patients were included. EUS allowed detection in 62 (85%) patients with lack of visualization prohibiting FNA in 11 patients. Among sampled lesions, one patient (1/62 = 1.6%) had a benign lung mass (hamartoma), while the remaining 61 patients (61/62 = 98.4%) had a malignant mass (primary lung cancer: 55/61 = 90%; lung metastasis: 6/61 = 10%). The sensitivity, specificity, and accuracy of EUS-FNA were 96.7%, 100%, and 96.7%, respectively. The sensitivity was 80.8% when considering nonvisualized masses. One patient developed a pneumothorax (1/62 = 1.6%). Conclusions. EUS-FNA appears to be an accurate and safe technique for tissue diagnosis of central mediastinal lung masses. Enrique Vazquez-Sequeiros, Michael J. Levy, Manuel Van Domselaar, Fernando González-Panizo, Jose Ramon Foruny-Olcina, Daniel Boixeda-Miquel, Diego Juzgado-Lucas, and Agustin Albillos Copyright © 2013 Enrique Vazquez-Sequeiros et al. All rights reserved. Endoscopic Management of Nonlifting Colon Polyps Tue, 14 May 2013 17:57:09 +0000 http://www.hindawi.com/journals/dte/2013/412936/ Background and Study Aims. The nonlifting polyp sign of invasive colon cancer is considered highly sensitive and specific for cancer extending beyond the mid-submucosa. However, prior interventions can cause adenomas to become nonlifting due to fibrosis. It is unclear whether nonlifting adenomas can be successfully treated endoscopically. The aim of this study was to evaluate outcomes in a referral practice incorporating a standardized protocol of attempted endoscopic resection of nonlifting lesions previously treated by biopsy, polypectomy, surgery, or tattoo placement. Patients and Methods. Retrospective review of patients undergoing colonoscopy by one endoscopist at two hospitals found to have nonlifting lesions from prior interventions. Lesions with biopsy proven invasive cancer or definite endoscopic features of invasive cancer were excluded. Lesions ≥ 8 mm were routinely injected with saline prior to attempted endoscopic resection. Polypectomy was performed using a stiff snare, followed by argon plasma coagulation (APC) if necessary. Results. 26 patients each had a single nonlifting lesion with a history of prior intervention. Endoscopic resection was completed in 25 (96%). 22 required snare resection and APC. 1 patient had invasive cancer and was referred for surgery. The recurrence rate on follow-up colonoscopy was 26%. All of the recurrences were successfully treated endoscopically. There was 1 postprocedure bleed (4%), no perforations, and no other complications. Conclusions. The majority of adenomas that are nonlifting after prior interventions can be treated successfully and safely by a combination of piecemeal polypectomy and ablation. Although recurrence rates are high at 26%, these too can be successfully treated endoscopically. Shai Friedland, Andrew Shelton, Shivangi Kothari, Rajan Kochar, Ann Chen, and Subhas Banerjee Copyright © 2013 Shai Friedland et al. All rights reserved. Effectiveness and Safety of Endoscopic Treatment of Benign Biliary Strictures Using a New Fully Covered Self Expandable Metal Stent Sat, 11 May 2013 11:57:32 +0000 http://www.hindawi.com/journals/dte/2013/183513/ Background. In patients with benign biliary strictures, the use of fully covered self-expandable metal stents (SEMS) has been proposed as an alternative to plastic stenting, but high quality prospective data are sparse. This study was performed to evaluate the long-term effectiveness and safety of a new fully covered SEMS for benign biliary strictures. Methods. All consecutive patients with benign biliary strictures were treated with placement of a fully covered SEMS (WallFlex) for 6 months. Short- and long-term stricture resolution, adverse events, and ease of stent removal were recorded. Results. 23 patients were enrolled. Stricture etiology was chronic pancreatitis (14), postorthotopic liver transplant (4), idiopathic (4), and biliary stones (1). All ERCPs were technically successful. All stents were successfully removed. Short-term stricture resolution was seen in 22/23 (96%) patients. Long-term success was 15/18 (83.3%). All 3 failures were patients with biliary strictures in the setting of chronic calcific pancreatitis. Conclusions. The use of the new SEMS for the treatment of benign biliary strictures led to short-term stricture resolution in the vast majority of patients. Over a long-term followup the success rate appears favorable compared to historical results achieved with multiple plastic stenting, particularly in patients with chronic pancreatitis. The study was registered with ClinicalTrials.gov (NCT01238900). Mihir S. Wagh, Disaya Chavalitdhamrong, Koorosh Moezardalan, Shailendra S. Chauhan, Anand R. Gupte, Michael J. Nosler, Chris E. Forsmark, and Peter V. Draganov Copyright © 2013 Mihir S. Wagh et al. All rights reserved. Multicenter Randomized Trial of 10-French versus 11.5-French Plastic Stents for Malignant Biliary Obstruction Thu, 02 May 2013 11:25:59 +0000 http://www.hindawi.com/journals/dte/2013/891915/ Background. There is little prospective data on whether bigger plastic stents are better for patients with malignant biliary obstruction with jaundice. Goals. Multicenter prospective study to compare technical success, clinical response, stent occlusion, and patient survival in patients with malignant biliary obstruction randomized to 10-French or 11.5-French plastic stent. Study. Patients with malignant biliary obstruction were randomized to 10-French or 11.5-French biliary stents. Patients were prospectively assessed for stent occlusion, stent-related interventions, hospital stay, and change in bilirubin. Main outcome measurements included technical success, clinical response, rates of stent occlusion, and survival. Results. 234 patients (47 hilar and 187 common bile duct strictures) were randomized. Outcomes were similar for the 10-French and 11.5-French groups (technical success 99.1% versus 97.4%, ). Overall, median stent survival was 213 days, but there was no statistically significant difference in stent survival between 10-French and 11.5-French stents (149 versus 258 days, ). Stent survival was significantly longer when placed for common bile duct versus hilar strictures (231 versus 115 days, ). Conclusions. The theoretical advantage of improved bile flow for the 11.5-French stent does not translate into more prolonged patency, better clinical response, and longer patient survival than the 10-French stent. Mihir S. Wagh, Mario de Bellis, Evan L. Fogel, James T. Frakes, John F. Johanson, Tahir Qaseem, Douglas A. Howell, Glen A. Lehman, and Stuart Sherman Copyright © 2013 Mihir S. Wagh et al. All rights reserved. Advanced Endoscopic Imaging Thu, 04 Apr 2013 09:15:59 +0000 http://www.hindawi.com/journals/dte/2013/206839/ Helmut Neumann, Klaus Mönkemüller, Markus F. Neurath, Arthur Hoffman, and Charles Melbern Wilcox Copyright © 2013 Helmut Neumann et al. All rights reserved. Efficacy, Safety, and Long-Term Follow-Up Results of EUS-Guided Transmural Drainage for Pancreatic Pseudocyst Sun, 10 Mar 2013 14:15:15 +0000 http://www.hindawi.com/journals/dte/2013/924291/ Background and Aim. EUS-guided transmural drainage (EUS-GTD) is now considered a minimally invasive and effective alternative to surgery for drainage of symptomatic pancreatic pseudocysts. However, the technique is rather difficult, and sometimes serious complications occur to patients undergoing this procedure. We retrospectively evaluated efficacy, safety, and long-term follow-up results of EUS-GTD for pancreatic pseudocyst. Methods. Sixty-seven patients with pancreatic pseudocyst who underwent EUS-GTD from April 2000 to March 2011 were enrolled. We retrospectively evaluated (1) technical success, (2) clinical success, (3) adverse event of procedure, and (4) long-term follow-up results. Results. Total technical success rate was 88%. Ninety-one percent of external drainage, 79% of internal drainage, and 66% of puncture and aspiration only achieved clinical success. There was only one case with an adverse event, perforation (1.5%). The case required emergency operation. Total recurrence rate was 23.9%. Median follow-up period was 33.9 months. The recurrence rates in the cases of stent remaining, spontaneously dislodged, removed on schedule, external tube removal, and aspiration only were 10.0%, 12.5%, 42.9%, 50%, and 0%, respectively. Conclusion. EUS-GTD is a relatively safe and effective therapeutic method. However, further analysis should be done by larger series to determine the method of EUS-GTD for pancreatic pseudocyst. Shin Kato, Akio Katanuma, Hiroyuki Maguchi, Kuniyuki Takahashi, Manabu Osanai, Kei Yane, Toshifumi Kim, Maki Kaneko, Ryo Takaki, Kazuyuki Matsumoto, Tomoaki Matsumori, Katsushige Gon, and Akiko Tomonari Copyright © 2013 Shin Kato et al. All rights reserved. The Current State of Diagnosis and Treatment for Early Gastric Cancer Thu, 28 Feb 2013 07:25:57 +0000 http://www.hindawi.com/journals/dte/2013/241320/ The prognosis for gastric cancer depends on its stage; so, detection in the early stage of disease is important, when complete and curative removal is possible. Accurate diagnosis can be facilitated by a sound understanding of the basic findings of white light endoscopy of early gastric cancer, and diagnosis can be refined further by the combined use of other imaging modalities such as image-enhanced endoscopy including chromoendoscopy and endoscopic ultrasonography. Minimally invasive endoscopic treatment has come to be the preferred therapeutic approach for early gastric cancer. In addition to conventional endoscopic mucosal resection, a new technique known as endoscopic submucosal dissection (ESD) has spread rapidly worldwide. Indeed, strategies for ESD have been established, devices developed, its indications expanded, and its safety and long-term results extensively reported. Some unique combination therapies involving endoscopy and surgical treatment have also been reported. It is anticipated that the number of patients undergoing endoscopic therapy will continue to increase, and the ongoing developments in endoscopic treatment are expected not only to improve gastric cancer prognosis but also to maintain good quality of life after treatment. Tomoyuki Yada, Chizu Yokoi, and Naomi Uemura Copyright © 2013 Tomoyuki Yada et al. All rights reserved.