<i>Background and Aim</i>. Spiral enteroscopy (SE) is a new small bowel endoscopic technique. Our aim is to review the diagnostic and therapeutic yield, safety of SE, and the predictive role of prior capsule endoscopy (CE) at an academic center. <i>Methods</i>. A retrospective review of patients undergoing SE after prior CE between 2008 and 2013 was performed. Capsule location index (CLI) was defined as the fraction of total small bowel transit time when the lesion was seen on CE. <i>Results</i>. A total of 174 SEs were performed: antegrade (147) and retrograde (27). Abnormalities on SE were detected in 65% patients. The procedure was safe in patients with surgically altered bowel anatomy (<svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" style="vertical-align:-0.2063894pt" id="M1" height="8.54217pt" version="1.1" viewBox="-0.0498162 -8.33578 34.8136 8.54217" width="34.8136pt"><g transform="matrix(.013,0,0,-0.013,0,0)"><path id="g50-111" d="M504 89L488 119C453 85 428 69 416 69C408 69 405 75 412 102L462 304C492 438 460 451 436 451S388 441 356 423C311 397 229 336 170 256H168L189 340C208 418 200 451 177 451C144 451 82 413 24 352L40 322C65 345 98 369 108 369C114 369 119 363 112 335L28 -3L36 -12C54 -3 83 4 112 10C125 73 138 122 153 174C205 258 328 382 376 382C395 382 399 369 384 305L330 93C312 25 323 -12 351 -12C378 -12 439 21 504 89Z"/></g><g transform="matrix(.013,0,0,-0.013,10.332,0)"><path id="g54-34" d="M556 331V384H55V331H556ZM556 140V193H55V140H556Z"/></g><g transform="matrix(.013,0,0,-0.013,21.95,0)"><path id="g50-50" d="M389 0V32C297 38 291 46 291 118V635C234 613 175 595 109 583V556L161 554C203 552 207 547 207 497V118C207 46 201 38 110 32V0H389Z"/></g><g transform="matrix(.013,0,0,-0.013,28.281,0)"><path id="g50-51" d="M414 144C384 79 371 75 317 75H135L276 221C367 316 408 376 408 465C408 570 327 635 237 635C179 635 131 609 100 575L42 494L67 471C94 510 138 565 205 565C277 565 321 517 321 435C321 348 258 270 195 195C146 137 88 81 33 26V0H411C423 44 433 88 446 135L414 144Z"/></g></svg>). The diagnostic yield of antegrade SE decreased with increasing CLI range. The diagnostic yield of retrograde SE decreased on decreasing CLI range. A CLI cutoff of 0.6 was derived that determined the initial route of SE. Vascular ectasias seen on CE were detected in 83% cases on SE; <svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" style="vertical-align:-3.32502pt" id="M2" height="11.6608pt" version="1.1" viewBox="-0.0498162 -8.33578 45.37 11.6608" width="45.37pt"><g transform="matrix(.013,0,0,-0.013,0,0)"><path id="g50-113" d="M573 302C573 402 527 451 414 451C386 451 343 446 313 437L330 513L320 522C295 508 261 484 243 463L230 415C194 400 159 383 126 359L131 330C159 344 187 357 222 368L109 -147C96 -204 80 -214 18 -223L13 -255L256 -244L259 -212L236 -210C184 -205 180 -195 191 -141L219 -1C240 -10 268 -12 284 -12C352 4 431 48 484 104C543 166 573 240 573 302ZM481 290C481 165 381 37 305 37C280 37 249 56 235 71L302 395C328 399 353 402 372 402C427 402 481 378 481 290Z"/></g><g transform="matrix(.013,0,0,-0.013,11.438,0)"><path id="g54-91" d="M530 -6V57L144 261V263L530 468V530L81 290V234L530 -6Z"/></g><g transform="matrix(.013,0,0,-0.013,23.056,0)"><path id="g50-49" d="M245 635C92 635 37 457 37 312C37 149 91 -12 244 -12C395 -12 449 166 449 312C449 469 395 635 245 635ZM243 598C332 598 358 454 358 312C358 173 334 26 245 26C158 26 128 174 128 313S152 598 243 598Z"/></g><g transform="matrix(.013,0,0,-0.013,29.387,0)"><path id="g50-47" d="M117 -12C153 -12 178 12 178 50C178 84 153 110 118 110C84 110 59 84 59 50C59 12 84 -12 117 -12Z"/></g><g transform="matrix(.013,0,0,-0.013,32.468,0)"><path id="g50-49" d="M245 635C92 635 37 457 37 312C37 149 91 -12 244 -12C395 -12 449 166 449 312C449 469 395 635 245 635ZM243 598C332 598 358 454 358 312C358 173 334 26 245 26C158 26 128 174 128 313S152 598 243 598Z"/></g><g transform="matrix(.013,0,0,-0.013,38.799,0)"><path id="g50-50" d="M389 0V32C297 38 291 46 291 118V635C234 613 175 595 109 583V556L161 554C203 552 207 547 207 497V118C207 46 201 38 110 32V0H389Z"/></g></svg>. <i>Conclusions</i>. SE is safe with a high diagnostic and therapeutic yield. CLI is predictive of the success of SE and determines the best route of SE. The type of small bowel pathology targeted by SE may affect its utility and yield.

Rohan Mandaliya

Jason Korenblit

Brendan O&#x2019;Hare

Anastasia Shnitser

Ramalinga Kedika

Rebecca Matro

Dina Halegoua-De Marzio

Anthony Infantolino

Mitchell Conn

Spiral Enteroscopy Utilizing Capsule Location Index for Achieving High Diagnostic and Therapeutic Yield

<i>Objective</i>. Endobronchial ultrasound (EBUS) utility in diagnosis  in malignant and granulomatous mediastinal disease has been well demonstrated. We propose to examine the role of EBUS transbronchial needle aspiration (EBUS-TBNA) in the diagnosis of subacute pulmonary histoplasmosis (SPH) with mediastinal lymphadenopathy in an area where histoplasmosis is endemic. <i>Methods</i>. A retrospective review was performed in a single academic institution between 2009 and 2012 of patients referred for EBUS-TBNA who had radiographic imaging and clinical symptomatology suspicious for SPH. Seven patients were reviewed. TBNA results showing granulomatous disease with areas of necrosis in the appropriate clinical setting were considered to be adequate for the diagnosis of SPH when alternative diagnosis was excluded. Patients underwent further clinical follow-up of 12 months to determine the final diagnosis. <i>Results</i>. All seven patients were felt to have SPH diagnosis reached by a combination of clinical presentation, EBUS-TBNA results, fungal serologies, and antigen testing. None of the patients needed further invasive procedures. <i>Conclusions</i>. EBUS-TBNA is a minimally invasive tool that can be used to support a diagnosis of SPH in patients with a high degree of clinical suspicion. EBUS-TBNA should be considered as an adjunctive diagnostic procedure for patients with SPH in an appropriate clinical setting.

Katarine von Lang Egressy

Mohammed Mohammed

J. Scott Ferguson

The Use of Endobronchial Ultrasound in the Diagnosis of Subacute Pulmonary Histoplasmosis

<i>Background</i>. There has been a growing use of both capsule endoscopy (CE) and double balloon enteroscopy (DBE) to diagnose and treat patients with obscure gastrointestinal blood loss and suspected small bowel pathology. <i>Aim</i>. To compare and correlate sequential CE and DBE findings in a large series of patients at two tertiary level hospitals in Wisconsin. <i>Methods</i>. An IRB approved retrospective study of patients who underwent sequential CE and DBE, at two separate tertiary care academic centers from May 2007 to December 2011, was performed. <i>Results</i>. 
116 patients were included in the study. The mean age &#xb1; SD was 66.6 &#xb1; 13.2 years. There were 56&#x25; males and 43.9&#x25; females. Measure of agreement between prior capsule and DBE findings was performed using kappa statistics, which gave kappa value of 0.396 with <svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" style="vertical-align:-0.6370001pt" id="M1" height="9.2729pt" version="1.1" viewBox="-0.0498162 -8.6359 51.1027 9.2729" width="51.1027pt"><g transform="matrix(.013,0,0,-0.013,0,0)"><path id="g113-81" d="M600 480C600 590 528 650 384 650H143L137 622C222 614 225 607 210 531L130 127C113 41 106 36 23 28L17 0H294L300 28C204 36 195 42 212 127L243 284L314 263C327 263 339 263 352 264C465 271 600 337 600 480ZM508 481C508 351 402 304 329 304C289 304 265 311 250 317L295 559C302 594 310 606 323 611C335 616 350 619 367 619C455 619 508 573 508 481Z"/></g><g transform="matrix(.013,0,0,-0.013,11.658,0)"><path id="g117-91" d="M512 -3V55L134 254V256L512 456V514L75 281V230L512 -3Z"/></g><g transform="matrix(.013,0,0,-0.013,22.921,0)"><path id="g113-49" d="M241 635C89 635 35 457 35 312C35 153 89 -12 240 -12C390 -12 443 166 443 312C443 466 390 635 241 635ZM238 602C329 602 354 454 354 312C354 172 330 22 240 22C152 22 124 173 124 313S148 602 238 602Z"/></g><g transform="matrix(.013,0,0,-0.013,29.161,0)"><path id="g113-47" d="M113 -12C146 -12 170 11 170 46C170 78 146 103 114 103S58 78 58 46C58 11 82 -12 113 -12Z"/></g><g transform="matrix(.013,0,0,-0.013,32.125,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,38.365,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,44.605,0)"><path id="g113-50" d="M384 0V27C293 34 287 42 287 114V635C232 613 172 594 109 583V559L157 557C201 555 205 550 205 499V114C205 42 199 34 109 27V0H384Z"/></g></svg>. Also contingency coefficient was calculated and was found to be 0.732 (<svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" style="vertical-align:-0.6370001pt" id="M2" height="9.2729pt" version="1.1" viewBox="-0.0498162 -8.6359 51.1027 9.2729" width="51.1027pt"><g transform="matrix(.013,0,0,-0.013,0,0)"><use xlink:href="#g113-81"/></g><g transform="matrix(.013,0,0,-0.013,11.658,0)"><use xlink:href="#g117-91"/></g><g transform="matrix(.013,0,0,-0.013,22.921,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,29.161,0)"><use xlink:href="#g113-47"/></g><g transform="matrix(.013,0,0,-0.013,32.125,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,38.365,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,44.605,0)"><use xlink:href="#g113-50"/></g></svg>). <i>Conclusions</i>. Our study showed good overall agreement between DBE and CE. Findings of angioectasia had maximum agreement of 69&#x25;.

Amandeep S. Kalra

Andrew J. Walker

Mark E. Benson

Anurag Soni

Nalini M. Guda

Mehak Misha

Deepak V. Gopal

Comparison of Capsule Endoscopy Findings to Subsequent Double Balloon Enteroscopy: A Dual Center Experience

<i>Objective</i>. A new sclerosing agent for hemorrhoids, aluminum potassium sulfate and tannic acid (ALTA), is attracting attention as a curative treatment for internal hemorrhoids without resection.  The outcome and safety of ALTA sclerotherapy using an endoscope were investigated in the present study. <i>Materials and Methods</i>. Subjects comprised 83 internal hemorrhoid patients (61 males and 22 females).  An endoscope was inserted and retroflexed in the rectum, and a 1st-step injection was applied to the upper parts of the hemorrhoids.  The retroflexed scope was returned to the normal position, and 2nd&#x2013;4th-step injections were applied to the middle and lower parts of the hemorrhoids under direct vision.  The effects of endoscopic ALTA sclerotherapy were determined by evaluating the condition of the hemorrhoids using an anoscope and interviewing the patient 28 days after the treatment. <i>Results</i>. A cure, improvement, and failure were observed in 54 (65.1&#x25;), 27 (32.5&#x25;), and 2 (2.4&#x25;) patients, respectively, treated with ALTA.  Complications developed in 4 patients (mild fever in 3 and hematuria in 1).  Recurrence occurred in 9.6&#x25;.  <i>Conclusions</i>. The results of the present study suggest that endoscopic ALTA has the potential to become a useful and minimally invasive approach for ALTA sclerotherapy.

Yuichi Tomiki

Seigo Ono

Jun Aoki

Rina Takahashi

Shun Ishiyama

Kiichi Sugimoto

Yukihiro Yaginuma

Yutaka Kojima

Michitoshi Goto

Atsushi Okuzawa

Kazuhiro Sakamoto

Treatment of Internal Hemorrhoids by Endoscopic Sclerotherapy with Aluminum Potassium Sulfate and Tannic Acid

<i>Background</i>. Improved detection of adenomatous polyps using i-SCAN has mixed results in small studies. Utility of i-SCAN as a primary surveillance modality for colorectal cancer screening during colonoscopy is uncertain. <i>Aim</i>. Comparing high definition white light endoscopy (HDWLE) to i-SCAN in their ability to detect adenomas during colonoscopy. <i>Methods</i>. Prospective cohort study of 1936 average risk patients who had a screening colonoscopy at an ambulatory procedure center. Patients underwent colonoscopy with high definition white light endoscopy withdrawal versus i-SCAN withdrawal during endoscopic screening exam. Primary outcome measurement was adenoma detection rate for i-SCAN versus high definition white light endoscopy. Secondary measurements included polyp size, pathology, and morphology. <i>Results</i>. 1007 patients underwent colonoscopy with i-SCAN and 929 with HDWLE. 618 adenomas were detected in the i-SCAN group compared to 402 in the HDWLE group <svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" style="vertical-align:-3.42947pt" id="M1" height="12.7178pt" version="1.1" viewBox="-0.0498162 -9.28833 53.5559 12.7178" width="53.5559pt"><g transform="matrix(.013,0,0,-0.013,0,0)"><path id="g113-41" d="M300 -147C201 -63 143 98 143 270S200 602 300 686L282 710C136 610 70 450 70 271V270C70 89 136 -72 282 -170L300 -147Z"/></g><g transform="matrix(.013,0,0,-0.013,4.498,0)"><path id="g113-113" d="M570 304C570 398 525 448 414 448C385 448 343 445 312 434L329 511L321 518C297 504 262 482 244 460L233 411C195 397 159 381 128 358L135 332C160 347 189 360 224 373L111 -147C97 -210 84 -218 17 -231L13 -257L254 -247L259 -218L233 -216C183 -212 177 -202 189 -142L218 -1C238 -10 266 -12 283 -12C351 3 429 48 483 105C543 168 570 242 570 304ZM482 289C482 161 380 33 304 33C278 33 248 51 233 69L303 396C326 400 352 403 369 403C428 403 482 380 482 289Z"/></g><g transform="matrix(.013,0,0,-0.013,15.84,0)"><path id="g117-91" d="M512 -3V55L134 254V256L512 456V514L75 281V230L512 -3Z"/></g><g transform="matrix(.013,0,0,-0.013,27.103,0)"><path id="g113-49" d="M241 635C89 635 35 457 35 312C35 153 89 -12 240 -12C390 -12 443 166 443 312C443 466 390 635 241 635ZM238 602C329 602 354 454 354 312C354 172 330 22 240 22C152 22 124 173 124 313S148 602 238 602Z"/></g><g transform="matrix(.013,0,0,-0.013,33.343,0)"><path id="g113-47" d="M113 -12C146 -12 170 11 170 46C170 78 146 103 114 103S58 78 58 46C58 11 82 -12 113 -12Z"/></g><g transform="matrix(.013,0,0,-0.013,36.307,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,42.547,0)"><path id="g113-50" d="M384 0V27C293 34 287 42 287 114V635C232 613 172 594 109 583V559L157 557C201 555 205 550 205 499V114C205 42 199 34 109 27V0H384Z"/></g><g transform="matrix(.013,0,0,-0.013,48.787,0)"><path id="g113-42" d="M275 270C275 450 212 609 64 710L45 686C145 604 203 442 203 270S147 -63 45 -147L64 -170C213 -68 275 89 275 270Z"/></g></svg>. More advanced adenomas (&#x2265;10&#x2009;mm) were found by i-SCAN, 79 versus 47 <svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" style="vertical-align:-3.42947pt" id="M2" height="12.7178pt" version="1.1" viewBox="-0.0498162 -9.28833 59.8193 12.7178" width="59.8193pt"><g transform="matrix(.013,0,0,-0.013,0,0)"><use xlink:href="#g113-41"/></g><g transform="matrix(.013,0,0,-0.013,4.498,0)"><use xlink:href="#g113-113"/></g><g transform="matrix(.013,0,0,-0.013,15.84,0)"><path id="g117-34" d="M535 323V373H52V323H535ZM535 138V188H52V138H535Z"/></g><g transform="matrix(.013,0,0,-0.013,27.103,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,33.343,0)"><use xlink:href="#g113-47"/></g><g transform="matrix(.013,0,0,-0.013,36.307,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,42.547,0)"><path id="g113-51" d="M412 140C382 77 369 73 315 73H129L270 222C362 320 402 379 402 466C402 571 322 635 234 635C177 635 130 609 99 576L42 495L64 475C90 514 133 568 201 568C274 568 318 519 318 435C318 349 255 267 193 193C144 135 87 78 32 23V0H405C417 45 427 89 440 131L412 140Z"/></g><g transform="matrix(.013,0,0,-0.013,48.787,0)"><use xlink:href="#g113-50"/></g><g transform="matrix(.013,0,0,-0.013,55.027,0)"><use xlink:href="#g113-42"/></g></svg> and based upon histology alone 37 versus 18 <svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" style="vertical-align:-3.42947pt" id="M3" height="12.7178pt" version="1.1" viewBox="-0.0498162 -9.28833 59.8193 12.7178" width="59.8193pt"><g transform="matrix(.013,0,0,-0.013,0,0)"><use xlink:href="#g113-41"/></g><g transform="matrix(.013,0,0,-0.013,4.498,0)"><use xlink:href="#g113-113"/></g><g transform="matrix(.013,0,0,-0.013,15.84,0)"><use xlink:href="#g117-34"/></g><g transform="matrix(.013,0,0,-0.013,27.103,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,33.343,0)"><use xlink:href="#g113-47"/></g><g transform="matrix(.013,0,0,-0.013,36.307,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,42.547,0)"><use xlink:href="#g113-51"/></g><g transform="matrix(.013,0,0,-0.013,48.787,0)"><path id="g113-57" d="M249 635C141 635 70 555 70 471C70 401 114 353 179 316C143 294 106 267 90 252C68 231 45 202 45 157C45 50 130 -12 237 -12C322 -12 435 52 435 169C435 256 372 304 303 343C349 374 375 398 383 407C401 429 411 458 411 487C411 569 344 635 249 635ZM238 603C285 603 337 567 337 482C337 422 310 385 276 358C205 393 145 426 145 500C145 552 179 603 238 603ZM248 20C183 20 125 70 125 163C125 218 158 268 206 300C284 261 355 217 355 143C355 66 308 20 248 20Z"/></g><g transform="matrix(.013,0,0,-0.013,55.027,0)"><use xlink:href="#g113-42"/></g></svg>. <i>Conclusions</i>. i-SCAN detected significantly more adenomas and advanced adenomas compared to high definition white light endoscopy.

Erik A. Bowman

Patrick R. Pfau

Arnab Mitra

Mark Reichelderfer

Benjamin S. Hall

High Definition Colonoscopy Combined with i-SCAN Imaging Technology Is Superior in the Detection of Adenomas and Advanced Lesions Compared to High Definition Colonoscopy Alone

<i>Objective</i>. To reevaluate the long-term effectiveness and safety of laparoscopy in benign ovarian pathology. <i>Materials and Methods</i>. 1522 women with benign adnexal cysts, laparoscopically treated in the 3rd Department of Ob/Gyn, General University hospital &#x201c;Attikon&#x201d; and &#x201c;Lito&#x201d; Maternity Hospital between July 1998 and December 2006, were included. <i>Results</i>. The diagnosis in 1222 (80,6&#x25;) cases was endometriosis of the ovary, 60 (4&#x25;) hydrosalpinx, 51 (3,3&#x25;) serous cystadenomas, 44 (2,9&#x25;) dermoid ovarian cyst, 38 (2,5&#x25;) borderline tumors, 35 (2,3&#x25;) unruptured follicles, and 33 (2,2&#x25;) paraovarian cysts. In 174 cases (11,5&#x25;) laparoscopy was converted to laparotomy due to technical difficulties or suspicion of cancer. In particular, laparotomy was performed in 119 (8&#x25;) women due to severe adhesions and 18 (1,2&#x25;) women due to bleeding that could not be controlled safely by laparoscopy. In 36 (2,4&#x25;) 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.<i> Conclusions</i>. 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

D. Kassanos

Laparoscopic Treatment of 1522 Adnexal Masses: An 8-Year Experience

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Diagnostic and Therapeutic Endoscopy