Diagnostic and Therapeutic Endoscopy

Endoscopic Management of Nonlifting Colon Polyps

Tue, 14 May 2013 17:57:09 +0000

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.

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

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).

Multicenter Randomized Trial of 10-French versus 11.5-French Plastic Stents for Malignant Biliary Obstruction

Thu, 02 May 2013 11:25:59 +0000

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.

Advanced Endoscopic Imaging

Thu, 04 Apr 2013 09:15:59 +0000

Efficacy, Safety, and Long-Term Follow-Up Results of EUS-Guided Transmural Drainage for Pancreatic Pseudocyst

Sun, 10 Mar 2013 14:15:15 +0000

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.

The Current State of Diagnosis and Treatment for Early Gastric Cancer

Tomoyuki Yada, Chizu Yokoi, and Naomi Uemura — Thu, 28 Feb 2013 07:25:57 +0000

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.

Colonoscopy Practice in Lagos, Nigeria: A Report of an Audit

C. A. Onyekwere, J. N. Odiagah, O. O. Ogunleye, C. Chibututu, and O. A. Lesi — Wed, 27 Feb 2013 16:28:30 +0000

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

Endoscopic Ultrasound-Guided Oncologic Therapy for Pancreatic Cancer

Rei Suzuki, Atsushi Irisawa, and Manoop S. Bhutani — Sun, 24 Feb 2013 10:45:49 +0000

Since the development of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in the early 1990s, its application has been extended to various diseases. For pancreatic cancer, EUS-FNA can obtain specimens from the tumor itself with fewer complications than other methods. Interventional EUS enables various therapeutic options: local ablation, brachytherapy, placement of fiducial markers for radiotherapy, and direct injection of antitumor agents into cancer. This paper will focus on EUS-guided oncologic therapy for pancreatic cancer.

Endomicroscopy of the Pancreaticobiliary System

Thu, 14 Feb 2013 17:39:25 +0000

It is often difficult to accurately differentiate between benign and malignant pancreaticobiliary strictures, and some are interpreted as indeterminate despite ERCP, EUS, or radiological imaging techniques, thereby making it difficult for the clinician to make appropriate management decisions. Probe-based confocal laser endomicroscopy (pCLE) is an innovative imaging tool integrating real-time in vivo imaging of these difficult-to-interpret strictures in the pancreaticobiliary system during endoscopy. Recent studies of endomicroscopy have shown a promising role with improved accuracy in distinguishing these lesions, thus paving the way for future research addressing improving precise interpretation, training, and long long-term impact.

Narrow Band Imaging with Magnification Can Pick Up Esophageal Squamous Cell Carcinoma More Efficiently Than Lugol Chromoendoscopy in Patients after Chemoradiotherapy

Tue, 12 Feb 2013 15:44:13 +0000

Aim. Little is known about the usefulness of narrow band imaging (NBI) for surveillance of patients after chemoradiotherapy for esophageal neoplasia. Its usefulness in detecting esophageal squamous cell carcinoma (SCC) or high-grade intraepithelial neoplasia (HGIN) in these patients was retrospectively compared to Lugol chromoendoscopy. Patients and Methods. We assessed the diagnostic ability of NBI with magnification based on the biopsy specimens obtained from iodine-unstained lesions. Seventy-two iodine-unstained lesions were biopsied and consecutively enrolled for this study. The lesions were divided into NBI positive and NBI negative. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of NBI with magnification and PPV of Lugol chromoendoscopy was calculated using histological assessment as a gold standard. Results. Forty-six endoscopic examinations using NBI with magnification followed by Lugol chromoendoscopy were performed to 28 patients. The prevalence of SCC and HGIN was 21.4%. Sensitivity, specificity, PPV, NPV, and accuracy of NBI were 100.0%, 98.5%, 85.7%, 100%, and 98.6%, respectively. On the contrary, PPV of Lugol chromoendoscopy were 8.3%. Compared to Lugol chromoendoscopy, NBI with magnification showed equal sensitivity and significantly higher PPV (). Conclusion. NBI with magnification would be able to pick up esophageal neoplasia more efficiently than Lugol chromoendoscopy in patients after chemoradiotherapy.

Endomicroscopic Imaging of COX-2 Activity in Murine Sporadic and Colitis-Associated Colorectal Cancer

Sebastian Foersch, Clemens Neufert, Markus F. Neurath, and Maximilian J. Waldner — Tue, 15 Jan 2013 10:22:55 +0000

Although several studies propose a chemopreventive effect of aspirin for colorectal cancer (CRC) development, the general use of aspirin cannot be recommended due to its adverse side effects. As the protective effect of aspirin has been associated with an increased expression of COX-2, molecular imaging of COX-2, for instance, during confocal endomicroscopy could enable the identification of patients who would possibly benefit from aspirin treatment. In this pilot trial, we used a COX-2-specific fluorescent probe for detection of colitis-associated and sporadic CRC in mice using confocal microscopy. Following the injection of the COX-2 probe into tumor-bearing APCmin mice or mice exposed to the AOM + DSS model of colitis-associated cancer, the tumor-specific upregulation of COX-2 could be validated with in vivo fluorescence imaging. Subsequent confocal imaging of tumor tissue showed an increased number of COX-2 expressing cells when compared to the normal mucosa of healthy controls. COX-2-expression was detectable with subcellular resolution in tumor cells and infiltrating stroma cells. These findings pose a proof of concept and suggest the use of CLE for the detection of COX-2 expression during colorectal cancer surveillance endoscopy. This could improve early detection and stratification of chemoprevention in patients with CRC.

Endoscopic Ultrasound-Guided Celiac Plexus Neurolysis in Pancreatic Cancer: A Prospective Pilot Study of Safety Using 10 mL versus 20 mL Alcohol

Tue, 08 Jan 2013 16:08:29 +0000

Background. The dose of alcohol used in EUS-CPN is not standardized. The objective was to compare the safety of 20 mL alcohol versus 10 mL alcohol during EUS-CPN for patients with pancreatic cancer-related pain. Methods. 20 patients were selected to receive 10 mL or 20 mL of alcohol during EUS-CPN. Followup was done at baseline, 24 hours, and weekly. Health-related quality of life (HRQoL) was assessed at baseline, week 2, week 4, and every 4 weeks thereafter until pain returned. Results. There were no major complications in both groups. Minor self-limited adverse effects were seen in 6 (30%) subjects and included lightheadedness in 1 (5%), transient diarrhea in 2 (10%), and transient nausea and vomiting in 3. Pain relief was similar in both groups: 80% in the 10 mL group and 100% in the 20 mL group (). The mean (± SD) duration of pain relief in the 10 mL and 20 mL groups was and weeks, respectively. 30% of patients in each group had complete pain relief. Conclusions. EUS-CPN using 20 mL of alcohol is safe. Similar clinical outcomes were seen in both groups. Further investigations to confirm these findings are warranted.

NBI and NBI Combined with Magnifying Colonoscopy

Sun, 09 Dec 2012 08:10:06 +0000

Although magnifying chromoendoscopy had been a reliable diagnostic tool, narrow-band imaging (NBI) has been developed in Japan since 1999 and has now replaced the major role of chromoendoscopy because of its convenience and simplicity. In this paper, we principally describe the efficacy of magnifying chromoendoscopy and magnifying colonoscopy with NBI for detection, histological prediction, estimation of the depth of early colorectal cancer, and future prospects. Although some meta-analyses have concluded that NBI is not superior to white light imaging for detection of adenomatous polyps in screening colonoscopy, NBI with magnification colonoscopy is useful for histological prediction, or for estimating the depth of invasion. To standardize these diagnostic strategies, we will focus on the NBI International Colorectal Endoscopic (NICE) classification proposed for use by endoscopists with or without a magnifying endoscope. However, more prospective research is needed to prove that this classification can be applied with satisfactory availability, feasibility, and reliability. In the future, NBI might contribute to the evaluation of real-time histological prediction during colonoscopy, which has substantial benefits for both reducing the risk of polypectomy and saving the cost of histological evaluation by resecting and discarding diminutive adenomatous polyps (resect and discard strategy).

Diagnosis of Early Gastric Cancer by Magnifying Endoscopy with NBI from Viewpoint of Histological Imaging: Mucosal Patterning in terms of White Zone Visibility and Its Relationship to Histology

Kazuyoshi Yagi, Yujiro Nozawa, Shinsaku Endou, and Atsuo Nakamura — Mon, 03 Dec 2012 15:44:39 +0000

The diagnosis of early gastric cancer by magnifying endoscopy with NBI is based on two components: microvascular pattern and mucosal pattern. Mucosal patterns are characterized by a whitish edge, which has been named the white zone. Some cancerous areas showing a distinct white zone form clear mucosal patterns, whereas others showing a nondistinct white zone do not form mucosal patterns. The aim of the present study was to clarify the histological differences between these two types of area. In transverse sections of gastric epithelium, the lengths of intervening parts in areas showing a distinct white zone, a nondistinct white zone, and an invisible white zone were measured, and the depths of the crypts in these three types of area were also measured. The intervening parts in areas with a nondistinct or invisible white zone were shorter than those in areas with a distinct white zone (), and the crypts in the former areas were shallower than those in the latter (). Areas in which the intervening part were long and the crypts deep tended to show a distinct white zone, whereas areas with short intervening parts or shallow crypts tended to show a nondistinct or non-visible white zone.

Use of i-scan Endoscopic Image Enhancement Technology in Clinical Practice to Assist in Diagnostic and Therapeutic Endoscopy: A Case Series and Review of the Literature

Sun, 02 Dec 2012 15:40:37 +0000

Background. i-scan is a software-driven technology that allows modifications of sharpness, hue, and contrast to enhance mucosal imaging. It uses postimage acquisition software with real-time mapping technology embedded in the endoscopic processor. Aims. To review applications of i-scan technology in clinical endoscopic practice. Methods. This is a case series of 20 consecutive patients who underwent endoscopic procedures where i-scan image enhancement algorithms were applied. The main outcome measures were to compare mucosal lesions with high-definition white light endoscopy (HD-WLE) and i-scan image enhancement for the application of diagnostic sampling and therapy. Results. 13 cases involving the upper GI tract and 7 cases of the lower GI tract are included. For upper GI tract pathology i-scan assisted in diagnosis or therapy of Barrett’s esophagus with dysplasia, esophageal adenocarcinoma, HSV esophagitis, gastric MALT lymphoma, gastric antral intestinal metaplasia with dysplasia, duodenal follicular lymphoma, and a flat duodenal adenoma. For lower GI tract pathology i-scan assisted in diagnosis or therapy of right-sided serrated adenomas, flat tubular adenoma, rectal adenocarcinoma, anal squamous cell cancer, solitary rectal ulcer, and radiation proctitis. Conclusions. i-scan imaging provides detailed topography of mucosal surfaces and delineates lesion edges, which can directly impact endoscopic management.

The Learning Curve of Gastric Intestinal Metaplasia Interpretation on the Images Obtained by Probe-Based Confocal Laser Endomicroscopy

Sat, 01 Dec 2012 15:44:01 +0000

Background. Reading the results of gastric intestinal metaplasia (GIM) with probe-based confocal laser endomicroscopy (pCLE) by the expert was excellent. There is a lack of study on the learning curve for GIM interpretation. Therefore, we conducted a study to explore the learning curve in the beginners. Material and Method. Five GI fellows who had no experience in GIM interpretation had been trained with a set of 10 pCLE video clips of GIM and non-GIM until they were able to interpret correctly. Then they were asked to interpret another 80 video clips of GIM and non-GIM. The sensitivity, specificity, accuracy, PPV, NPV, and interobserver agreement on each session were analyzed. Results. Within 2 sessions, all beginners can achieve 80% accuracy with substantial to almost perfect level of interobserver agreement. The sensitivities and specificities among all interpreters were not different statistically. Four out of five interpreters can maintain their high quality of reading skill. Conclusion. After a short session of training on GIM interpretation of pCLE images, the beginners can achieve a high level of reading accuracy with at least substantial level of interobserver agreement. Once they achieve the high reading accuracy, almost all can maintain their high quality of reading skill.

Endoscopic Color Doppler Ultrasonography for Esophagogastric Varices

Takahiro Sato and Katsu Yamazaki — Thu, 29 Nov 2012 09:29:03 +0000

Esophagogastric varices are considered to be the most common complication in patients with portal hypertension. Endoscopic ultrasonography not only visualizes the surface of the varices but also provides detailed information about their internal structure. The direction of blood flow can be determined and its velocity measured only via endoscopic color Doppler ultrasonography (ECDUS). This can show graphically esophageal varices, paraesophageal veins, and passageways in esophageal variceal patients and gastric varices, perigastric collateral veins in gastric variceal patients. It is important to evaluate the hemodynamics of the portal venous system when treating the esophago-gastric varices. ECDUS is a useful modality for the evaluation of the detailed hemodynamics and the therapeutic effects of esophago-gastric varices.

A Review of Machine-Vision-Based Analysis of Wireless Capsule Endoscopy Video

Yingju Chen and Jeongkyu Lee — Tue, 13 Nov 2012 12:02:18 +0000

Wireless capsule endoscopy (WCE) enables a physician to diagnose a patient's digestive system without surgical procedures. However, it takes 1-2 hours for a gastroenterologist to examine the video. To speed up the review process, a number of analysis techniques based on machine vision have been proposed by computer science researchers. In order to train a machine to understand the semantics of an image, the image contents need to be translated into numerical form first. The numerical form of the image is known as image abstraction. The process of selecting relevant image features is often determined by the modality of medical images and the nature of the diagnoses. For example, there are radiographic projection-based images (e.g., X-rays and PET scans), tomography-based images (e.g., MRT and CT scans), and photography-based images (e.g., endoscopy, dermatology, and microscopic histology). Each modality imposes unique image-dependent restrictions for automatic and medically meaningful image abstraction processes. In this paper, we review the current development of machine-vision-based analysis of WCE video, focusing on the research that identifies specific gastrointestinal (GI) pathology and methods of shot boundary detection.

Contrast-Enhanced Harmonic Endoscopic Ultrasonography in Pancreatic Diseases

Can Xu, Zhaoshen Li, and Michael Wallace — Thu, 01 Nov 2012 14:51:34 +0000

Endoscopic ultrasonography (EUS) is the most sensitive imaging method for diagnosis of pancreatic tumors. However, it still has limits in the differentiation between pancreatic cancers and inflammatory tumor-like masses. A novel technology, contrast-enhanced harmonic EUS (CH-EUS), has been developed recently. It can visualize both parenchymal perfusion and microvasculature in pancreas without Doppler-related artifacts. Therefore, it is superior to EUS and CT in detecting small pancreatic masses and differential diagnosis of pancreatic masses. CH-EUS could be used for adequate sampling of pancreatic tumors and may predict the pathological features of the pancreatic solid lesions but still cannot replace EUS-FNA now.

Accuracy and Quality Assessment of EUS-FNA: A Single-Center Large Cohort of Biopsies

Wed, 31 Oct 2012 13:43:50 +0000

Introduction. Thorough quality control (QC) study with systemic monitoring and evaluation is crucial to optimizing the effectiveness of EUS-FNA. Methods. Retrospective analysis was composed of investigating consecutive patient files that underwent EUS-FNA. QC specifically focused on diagnostic accuracy, impacts on preexisting diagnoses, and case management. Results. 268 patient files were evaluated. EUS-FNA cytology helped establish accurate diagnoses in 92.54% (248/268) of patients. Sensitivity, specificity, PPV, NPV, and accuracy were 83%, 100%, 100%, 91.6%, and 94%, respectively. The most common biopsy site was the pancreas (68%). The most accurate location for EUS-FNA was the esophagus, 13/13 (100%), followed by the pancreas (89.6%). EUS-FNA was least informative for abdominal lymph nodes (70.5%). After FNA and followup, eight false negatives for tumors were found (3%), while 7.5% of samples still lacked a definitive diagnosis. Discussion. QC suggests that the diagnostic accuracy of EUS-FNA might be improved further by (1) taking more FNA passes from suspected lesions, (2) optimizing needle selection (3) having an experienced echo-endoscopist available during the learning curve, and (4) having a cytologist present during the procedure. QC also identified remediable reporting errors. In conclusion, QC study is valuable in identifying weaknesses and thereby augmenting the effectiveness of EUS-FNA.

Comparison of Narrowband Imaging with Autofluorescence Imaging for Endoscopic Visualization of Superficial Squamous Cell Carcinoma Lesions of the Esophagus

Tue, 30 Oct 2012 09:08:12 +0000

Aim. To compare narrowband imaging (NBI) and autofluorescence imaging (AFI) endoscopic visualization for identifying superficial esophageal squamous cell carcinoma (SCC). Methods. Twenty-four patients with superficial esophageal carcinomas diagnosed at previous hospitals were enrolled in this study. Lesions were initially detected using white-light endoscopy and then observed with both NBI and AFI. Endoscopic images documented each method, and three endoscopists experienced in esophageal imaging retrospectively reviewed respective images of histologically confirmed esophageal SCCs. Images were assessed for quality in identifying superficial SCCs and rated as excellent, fair, or poor by the three reviewers with interobserver agreement calculated using kappa (κ) statistics. Results. Thirty-one lesions histologically confirmed as superficial esophageal SCCs were detected in 24 patients. NBI images of 27 lesions (87%) were rated as excellent, three as fair, and one as poor compared to AFI images of 19 lesions (61%) rated as excellent, 10 as fair and two as poor (). Moderate interobserver agreement (, 95% CI 0.24–0.60) resulted in NBI while fair agreement (, 95% CI 0.18–0.51) was achieved using AFI. Conclusion. NBI may be more effective than AFI for visualization of esophageal SCC.

Consensus of the Present and Prospects on Endoscopic Diagnosis and Treatment in East Asian Countries

Wed, 10 Oct 2012 15:01:24 +0000

Background and Aim. New diagnostic or therapeutic methods in endoscopy have been used. Current clinical application of these procedures is not well known. The aim of this study is to investigate the present situation on endoscopic diagnosis and treatment of gastrointestinal disorders in East Asian countries. Method. A representative member from the International Gastrointestinal Consensus Symposium Committee provided a questionnaire to physicians in China, Indonesia, Japan, Korea, the Philippines, and Thailand. Results. In total, 514 physicians including gastroenterologists, surgeons, and general practitioners enrolled. The most frequently occurring disorder as the origin of upper gastrointestinal bleeding is gastric ulcer. Capsule endoscopy is selected as the first choice for the diagnosis of small intestine bleeding. The second choice was double-balloon endoscopy or angiography. For patients with gastric adenoma, the number of physicians who choose endoscopic mucosal resection is larger than those selecting endoscopic submucosal dissection (ESD) in China, Indonesia, the Philippines, and Thailand. ESD is chosen first in Japan and Korea. Conclusion. New instruments or techniques on endoscopy have not come into wide use yet, and there is diversity in the situation on it in Asian countries. We should unify the endoscopic diagnostic criteria or treated strategy in patients with GI disease.

Management of Complications during Gastric Endoscopic Submucosal Dissection

Dong Wook Lee and Seong Woo Jeon — Wed, 03 Oct 2012 15:42:31 +0000

Popularity of endoscopic submucosal dissection (ESD) has shown an increase during the last decade, and may, for the time being, be the most important technique in treatment of early gastrointestinal cancer or a premalignant lesion. This technique has advantages in the aspect of en bloc resection, which enables evaluation of the completeness of resection and other pathologic characteristics; however, it has limitation in terms of complications, compared to endoscopic mucosal resection (EMR). Bleeding and perforation are the most common complications encountered during the procedure. These complications can cause embarrassment for the endoscopist and hamper performance of the procedure, which can result in an incomplete resection. To overcome these obstacles during performance of the procedure, we should be familiar with management of complications. In particular, beginners who start performing ESD should have full knowledge of and be in good handling of the method of hemostasis using hemoclips or electrocoagulation for management of complications. Various methods, procedures, and equipment are under development, which will provide us with powerful tools for achievement of successful ESD without complications in the near future.

Digital Chromoendoscopy for Diagnosis of Diminutive Colorectal Lesions

Wed, 03 Oct 2012 08:59:21 +0000

Introduction. To compare the accuracy of digital and real-time chromoendoscopy for the differential diagnosis of diminutive (<5 mm) neoplastic and nonneoplastic colorectal lesions. Materials and Methods. This is a prospective randomized study comparing the Fujinon intelligent color enhancement (FICE) system (65 patients/95 lesions) and indigo carmine (69 patients/120 lesions) in the analysis of capillary meshwork and pit pattern, respectively. All lesions were less than 5 mm in diameter, and magnification was used in both groups. Histopathology was the gold standard examination. Results. Of 215 colorectal lesions, 153 (71.2%) were adenomas, and 62 were hyperplastic polyps (28.8%). Morphological analysis revealed 132 (61.4%) superficial lesions, with 7 (3.3%) depressed lesions, and 83 (38.6%) protruding lesions. Vascular meshwork analysis using FICE and magnification resulted in 91.7% sensitivity, 95.7% specificity, and 92.6% accuracy in differentiating neoplastic from nonneoplastic lesions. Pit pattern analysis with indigo carmine and magnification showed 96.5% sensitivity, 88.2% specificity, and 94.2% accuracy for the same purpose. Conclusion. Both magnifying virtual chromoendoscopy and indigo carmine chromoendoscopy showed high accuracy in the histopathological diagnosis of colorectal lesions less than 5 mm in diameter.

Carbon Dioxide Insufflation in Colonoscopy Is Safe: A Prospective Trial of 347 Patients

M. Geyer, U. Guller, and Ch. Beglinger — Sat, 29 Sep 2012 02:39:23 +0000

Available evidence suggests that the use of CO2 insufflation in endoscopy is more comfortable for the patient. The safety of CO2 use in colonoscopy remains contentious, particularly in sedated patients. The objective of the present prospective trial was to assess the safety of CO2 colonoscopies. Methods. 109 patients from our previous randomized CO2 colonoscopy study and an additional 238 subsequent consecutive unselected patients who had a routine colonoscopy performed in a private practice were enrolled from April 2008 through September 2008. All but 2 patients were sedated. All patients were routinely monitored with transcutaneous CO2 measurement. Volumes of CO2 administered were correlated with capnographic measurements from transcutaneous monitoring. Results. Of the 347 patients examined, 57% were women; mean (SD) age of participants was of 60.2 years (12.8). Mean propofol dosage was 136 mg (64 mg). Mean CO2 values were 34.7 mm Hg (5.3) at baseline, 38.9 mm Hg (5.5) upon reaching the ileum, and 36.9 mm Hg (5.0) at examination's end. Mean maximum increase of CO2 was 4.5 mm Hg (3.6). No correlation was observed between volume of CO2 administered and increase in level of CO2 (correlation coefficient: 0.01; P value: 0.84). No complications were observed. Conclusions. The present prospective study, which was based on one of the largest sedated patient sample reported to date in this setting, provides compelling evidence that CO2 insufflation in colonoscopy is safe and unassociated with relevant increases in transcutaneously measured levels of CO2.

Current Clinical Applications of Magnifying Endoscopy with Narrow Band Imaging in the Stomach

Hai-Yan Li, Zhi-Zheng Ge, Mitsuhiro Fujishiro, and Xiao-Bo Li — Sun, 16 Sep 2012 10:59:48 +0000

Narrow band imaging (NBI), in conjunction with magnifying endoscopy (ME), has arisen more and more attention in the area of advanced endoscopy. By enhancing the mucosal microvascular architecture and surface pattern, it is feasible to use ME-NBI to identify subtle changes associated with gastric inflammation, atrophy, intestinal metaplasia, and early gastric cancer. The new technique thus plays a valuable role in therapeutic decision-making, endoscopic treatment process, postoperative evaluation, and follow-up examination. To date, many criteria or evaluation method of ME-NBI has been proposed. This paper aims to summarize the various diagnosing classifications and the current clinical applications of ME-NBI in the stomach.

Bringing Top-End Endoscopy to Regional Australia: Hurdles and Benefits

J. Van Den Bogaerde and D. Sorrentino — Sun, 09 Sep 2012 14:00:22 +0000

This paper focuses on recent experience in setting up an endoscopy unit in a large regional hospital. The mix of endoscopy in three smaller hospitals, draining into the large hospital endoscopy unit, has enabled the authors to comment on practical and achievable steps towards creating best practice endoscopy in the regional setting. The challenges of using what is available from an infrastructural equipment and personnel setting are discussed. In a fast moving field such as endoscopy, new techniques have an important role to play, and some are indeed cost effective and have been shown to improve patient care. Some of the new techniques and technologies are easily applicable to smaller endoscopy units and can be easily integrated into the practice of working endoscopists. Cost effectiveness and patient care should always be the final arbiter of what is essential, as opposed to what is nice to have. Close cooperation between referral and peripheral centers should also guide these decisions.

Proton Pump Inhibitor Therapy before and after Endoscopic Submucosal Dissection: A Review

Wed, 18 Jul 2012 11:26:59 +0000

Endoscopic submucosal dissection (ESD) is a novel endoscopic procedure first developed in the 1990s which enables en bloc resection of gastric neoplastic lesions that are difficult to resect via conventional endoscopic mucosal resection. However, given that ESD increases the risk of intra- and post-ESD delayed bleeding and that platelet aggregation and coagulation in artificial ulcers after ESD strongly depend on intragastric pH, faster and stronger acid inhibition via proton pump inhibitors (PPIs) and histamine 2-receptor antagonists (H2RAs) as well as endoscopic hemostasis by thermocoagulation during ESD have been used to prevent ESD-related bleeding. Because PPIs more potently inhibit acid secretion than H2RAs, they are often the first-line drugs employed in ESD treatment. However, acid inhibition after the initial infusion of a PPI is weaker in the early phase than that achievable with H2RAs; further, PPI effectiveness can vary depending on genetic differences in CYP2C19. Therefore, optimal acid inhibition may require tailored treatment based on CYP2C19 genotype when ESD is performed, with a concomitant infusion of PPI and H2RA possibly most effective for patients with the rapid metabolizer CYP2C19 genotype, while PPI alone may be sufficient for those with the intermediate or poor metabolizer genotypes.

Preventive Role of Wire-Guided Cannulation to Reduce Hyperamylasemia and Pancreatitis Following Endoscopic Retrograde Cholangiopancreatography

Sun, 15 Jul 2012 10:10:15 +0000

Background and Study Aims. The usefulness of wire-guided cannulation for avoiding hyperamylasemia and pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP) is conflicting, and therefore we designed this study to determine whether wire-guided cannulation reduces the rate of post-ERCP hyperamylasemia and pancreatitis and compare its efficacy to conventional method. Patients and Methods. Seven hundred and forty-eight patients with hepatobiliary diseases consecutively underwent diagnostic or therapeutic ERCP at the unit of Taleghani referral hospital in Tehran. Among them, 546 patients were eligible for wire-guided cannulation and underwent this procedure and others underwent sphincterotome biliary cannulation using contrast injection as the conventional method. Results. Patients in the two groups were comparable in terms of gender and age. Successful biliary cannulation was achieved similary in the guidewire and conventional group (89.2% versus 86.4%) that in 5.4% and 14.1% of them it was difficultly performed, respectively (𝑃=0.003). The main pancreatic duct was more visualized in 99.0% of patients in conventional group in comparison with 79.0% in another group (𝑃<0.001). Multivariate regression analysis showed that wire-guided cannulation had a protective role for post-ERCP hyperamylasemia (OR: 0.336, 95% CI: 0.181–0.623, 𝑃<0.001). However, there were no significant differences between the two groups in rates of other procedure-related complications, such as, pancreatitis, bleeding, and perforation. Conclusion. The use of guidewire cannulation in comparison with conventional method can be accompanied with lower post-ERCP hyperamylasemia, and therefore selection of this cannulation technique especially in high-risk group is recommended.

Successful Treatment of Early-Stage Jejunum Adenocarcinoma by Endoscopic Mucosal Resection Using Double-Balloon Endoscopy: A Case Report

Tue, 10 Jul 2012 13:42:10 +0000

Small bowel adenocarcinoma (SBA) has generally been considered to have a poor prognosis because of nonspecific presentations and difficulties in detection of the disease. The advent of capsule endoscopy (CE) and double-balloon endoscopy (DBE) makes it possible to access to the small intestine for endoscopic interventions. We describe a successful case of early jejunum adenocarcinoma completely resected by endoscopic mucosal resection (EMR) using double-balloon endoscopy (DBE). Early diagnosis and EMR using new technologies such as CE and DBE may improve the recognition of this disease that, at present, has a poor prognosis.