Diagnostic and Therapeutic Endoscopy https://www.hindawi.com The latest articles from Hindawi © 2017 , Hindawi Limited . All rights reserved. The Role of EUS-BD in the Management of Malignant Biliary Obstruction: The Indonesian Perspective Wed, 18 Oct 2017 09:44:13 +0000 http://www.hindawi.com/journals/dte/2017/4856276/ Aims. To evaluate the success rate and related factors of endoscopic ultrasound guided-biliary drainage (EUS-BD). Material and Methods. We conducted a retrospective study among 24 patients with malignant biliary obstruction who underwent EUS-BD after failed ERCP from January 2015 to December 2016 in a tertiary health center. The bilirubin levels before and after the procedure were used to define the clinical success rate, while the stent deployment was used to define the technical success rate. We placed either transluminal biliary stents or transpapillary biliary stents. Results. Among 24 patients, choledochoduodenostomy technique was conducted in 23 patients (95.8%) and hepaticogastrostomy technique in 1 patient (4.2%). Transluminal stent placement was conducted in 23 patients, while transpapillary stent placement was conducted in 1 patient. The clinical success rate was 78.2% (18) in choledochoduodenostomy route and 100% (1) in hepaticogastrostomy route. EUS-BD was 2.37 times and 2.11 times more likely to be successful in reducing the bilirubin level in patients with tumor of the head of pancreas and periampullary tumor, respectively, but not in cholangiocarcinoma. Conclusions. EUS-BD is an effective and efficient procedure to achieve biliary drainage among patients with malignant biliary obstruction after ERCP failure. Dadang Makmun, Achmad Fauzi, Murdani Abdullah, and Ari Fahrial Syam Copyright © 2017 Dadang Makmun et al. All rights reserved. Comparison of the Diagnostic Yield of EUS Needles for Liver Biopsy: Ex Vivo Study Wed, 13 Sep 2017 07:50:51 +0000 http://www.hindawi.com/journals/dte/2017/1497831/ Background and Aims. EUS-guided liver biopsy is an emerging method of liver tissue acquisition which is safe and had been shown to produce excellent histological yield. There is limited data comparing the diagnostic yield of different FNA needles. We aimed to compare the diagnostic performance of four commercially available 19-gauge FNA needles. Methods. Four FNA needles and one percutaneous needle were used to perform liver biopsies on two human cadaveric livers: Cook Echotip Procore™, Olympus EZ Shot 2™, Boston Scientific Expect Slimline™, Covidien SharkCore™, and an 18-gauge percutaneous needle (TruCore™, Argon Medical Devices). Each needle obtained biopsies by three, six, and nine complete back-and-forth motions of the needle (“throw”) with a fanning technique. The combined lengths of specimen fragments and the total number of complete portal tracts (CPT) were measured by a blinded pathologist. One-way analysis of variance (ANOVA) and Bonferroni correction were used for statistical analysis. Results. A total of 52 liver biopsies were performed. The Covidien SharkCore needle had significantly greater number of CPT compared to other FNA needles. The number of “throws” did not impact the number of CPT significantly. There was no statistically significant difference in mean total specimen length between each FNA needle type. Conclusion. The Covidien SharkCore needle produced superior histological specimen by capturing more CPT, possibly due to its unique needle design. Woo Jung Lee, Lance T. Uradomo, Yang Zhang, William Twaddell, and Peter Darwin Copyright © 2017 Woo Jung Lee et al. All rights reserved. Extended Cystogastrostomy with Hydrogen Peroxide Irrigation Facilitates Endoscopic Pancreatic Necrosectomy Tue, 05 Sep 2017 08:12:50 +0000 http://www.hindawi.com/journals/dte/2017/7145803/ Introduction. Walled-off pancreatic necrosis (WOPN) is a major complication of acute pancreatitis. We hypothesized that an extended (2 cm) cystogastrostomy opening combined with hydrogen peroxide irrigation can increase the success of endoscopic necrosectomy and decrease the number of required endoscopic interventions. The aim of the study is to assess the safety and feasibility of the technique in the management of WOPN. Methods. This is a retrospective chart review of all cases that underwent EUS with extended cystogastrostomy and hydrogen peroxide irrigation prior to necrosectomy in a tertiary referral medical center. Clinical success was defined as complete resolution of the cyst cavity or a cyst cavity less than 2 cm in size on follow-up imaging. Results. 19 patients satisfied the inclusion criteria. The mean size of the walled-off cavity was  cm. Technical success of the procedure was 100%. The median number of necrosectomy sessions was 2 (range 1 to 7). Cavity resolution was noted in 18 out of 19 patients resulting in a clinical success of 94.7%. The median follow-up period was 12 months. The adverse events rate in our cohort was 15.7%. Conclusion. Extended cystogastrostomy coupled with hydrogen peroxide irrigation of WOPN cavity is safe and feasible. Mohamed O. Othman, Sherif Elhanafi, Mohammed Saadi, Christine Yu, and Brian R. Davis Copyright © 2017 Mohamed O. Othman et al. All rights reserved. Use of 4-Fr versus 6-Fr Nasobiliary Catheter for Biliary Drainage: A Prospective, Multicenter, Randomized, Controlled Study Wed, 19 Apr 2017 08:15:25 +0000 http://www.hindawi.com/journals/dte/2017/7156719/ Background and Aim. Endoscopic nasobiliary drainage (NBD) effects according to diameter remain unclear. We aimed to assess the drainage effects of the 4-Fr and 6-Fr NBD catheters. Methods. This prospective, multicenter, randomized, controlled study was conducted at Hiroshima University Hospital and related facilities within Hiroshima Prefecture. Endoscopic retrograde cholangiopancreatography (ERCP) in 246 patients revealed acute cholangitis, obstructive jaundice, and/or extrahepatic cholestasis; 4-Fr or 6-Fr NBD catheters were randomly allocated and placed in these patients. The primary endpoint was the efficacy of NBD based on the technical success rate and clinical success (rates of change in blood test and amount of bile output). Secondary endpoints included the spontaneous catheter displacement rate and nasal discomfort. Results. The technical success rate and clinical success did not differ significantly between groups. No spontaneous catheter displacement was noted in either group. Nasal discomfort due to catheter placement was significantly lower in the 4-Fr group versus the 6-Fr group (24 h after ERCP: 2.4 versus 3.5 cm, ; 48 h after ERCP: 2.2 versus 3.1 cm, ). Conclusion. The 4-Fr NBD catheter was not inferior to 6-Fr NBD catheter in terms of clinical success; the 4-Fr NBD catheter was useful to reduce nasal discomfort. Tomofumi Tsuboi, Masahiro Serikawa, Tamito Sasaki, Yasutaka Ishii, Yoshifumi Fujimoto, Atsushi Yamaguchi, Takashi Ishigaki, Akinori Shimizu, Keisuke Kurihara, Yumiko Tatsukawa, Eisuke Miyaki, and Kazuaki Chayama Copyright © 2017 Tomofumi Tsuboi et al. All rights reserved. Endoscopic Submucosal Dissection Outcomes for Gastroesophageal Tumors in Low Volume Units: A Multicenter Survey Mon, 07 Nov 2016 08:47:44 +0000 http://www.hindawi.com/journals/dte/2016/5670564/ Background and Aims. Endoscopic submucosal dissection (ESD) outcomes have traditionally been reported from high volume centers in East Asia. Data from low volume centers in other parts of Asia remain sparse. Methods. A retrospective survey with a structured questionnaire of 5 tertiary centers in 3 countries in South East Asia was conducted. Details of training and clinical outcomes of ESD cases, with follow-up data from these centers, were analyzed. Results. Seven endoscopists from the 5 centers performed a total of 35 cases of ESD in the upper gastrointestinal tract (UGIT) over a 6-year duration. Details of the lesions excised were as follows: median size was 20 mm, morphologically 20 (68.6%) were flat/depressed and 6 (17.1%) were submucosal, and histologically 27 (77.1%) were neoplastic. The median duration of ESD procedures was 105 minutes, with an en-bloc resection rate of 91.4%. There was 1 (2.9%) case of delayed bleeding, but no perforation nor mortality in any of the cases. The recurrence rate after ESD was 5.7%. A prolonged ESD duration was influenced by a larger size of lesion (25 mm, ) but not by factors related to the training experience of endoscopists. Conclusions. ESD in the UGIT is feasible and safe in low volume centers in Asia. Ahmad Najib Azmi, Christopher J. L. Khor, Khek-Yu Ho, Rapat Pittayanon, Rungsun Rerknimitr, Thawee Ratanachu-ek, Doreen S. C. Koay, Jianyi Calvin Koh, Shiaw-Hooi Ho, Khean-Lee Goh, and Sanjiv Mahadeva Copyright © 2016 Ahmad Najib Azmi et al. All rights reserved. Therapeutic Endoscopy Can Be Performed Safely in an Ambulatory Surgical Center: A Multicenter, Prospective Study Thu, 20 Oct 2016 09:51:27 +0000 http://www.hindawi.com/journals/dte/2016/7168280/ Background. Even amongst experienced endoscopists, endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound with fine needle aspiration (EUS-FNA) carry a potential risk for complications. These procedures are typically performed in a hospital-based endoscopy unit with general anesthesia. Aims. The goal of our study was to evaluate the feasibility of ERCP and EUS-FNA in an ambulatory surgical center (ASC). Methods. From June to November of 2014, we prospectively enrolled consecutive subjects undergoing ERCP and/or EUS-FNA in an ASC. An anesthesiologist, who was not involved in our study group, screened all subjects prior to their scheduled procedure. In order to monitor for adverse events (AE), all subjects received a telephone call at day 1 and 30 days after procedure. Results. 375 subjects (98 inpatients and 277 from an ASC) were enrolled. In the total population, a high proportion of subjects underwent procedures for neoplasms (21 (23.3%) inpatients versus 44 (17.1%) from an ASC) and for sphincter of Oddi dysfunction (SOD) (27 (27.5%) versus 48 (17.3%)) and had the American Society for Anesthesiologists (ASA) class ≥III (75 (76.5%) versus 140 (50.5%)) and high-risk features (17 (17.3%) versus 75 (27.1%)). Overall ERCP-related AE (10 (13.2%) versus 12 (7.5%), ), pancreatitis (7 (9.2%) versus 11 (6.9%), ), and hemorrhage (3.9% versus 0.6%, ) were not different between inpatients and ASC subjects. There was also no difference between inpatients and ASC subjects’ EUS-related AE (1 (4.5%) versus 4 (3.4%), ), pancreatitis (1 (4.5%) versus 3 (2.6%), ), and hemorrhage (0% versus 1 (0.9%), ). Conclusions. ERCP and EUS can be performed in a higher risk population under the supervision of anesthesia in ASCs. Overall, the AE are equivalent between inpatients and ASC subjects. Shaffer R. S. Mok, Henry C. Ho, John P. Gaughan, and Adam B. Elfant Copyright © 2016 Shaffer R. S. Mok et al. All rights reserved. Endoscopic Ultrasound Guided Rendezvous Drainage of Biliary Obstruction Using a New Flexible 19-Gauge Fine Needle Aspiration Needle Sun, 16 Oct 2016 11:20:41 +0000 http://www.hindawi.com/journals/dte/2016/3125962/ Background and Aim. A successful endoscopic ultrasound guided rendezvous (EUS-RV) biliary drainage is dependent on accurate puncture of the bile duct and precise guide wire manipulation across the ampulla of Vater. We aim to study the feasibility of using a flexible 19-gauge fine aspiration needle in the performance of EUS-RV biliary drainage. Method. This is a retrospective case series of EUS-RV biliary drainage procedures at a single center. Patients who failed ERCP during the same session for benign or malignant biliary obstruction underwent EUS-RV using a flexible, nitinol covered, 19-gauge needle for biliary access and guide wire manipulation. Result. 24 patients underwent EUS-RV biliary drainage via extrahepatic access while 1 attempt was via intrahepatic access. The technical success rate was 80%, including 83.3% of cases via extrahepatic access. There was no significant difference in success rate of inpatient and outpatient procedures, benign or malignant indications, or type of guide wire used. Adverse events included mild pancreatitis (3 patients) and cholangitis (1 patient). Conclusion. A flexible 19-gauge needle for biliary access can be safe and effective when used to perform EUS-RV biliary drainage. Direct comparison between the nitinol needle and conventional metal needles in the performance of EUS guided biliary drainage is needed. Zhouwen Tang, Efehi Igbinomwanhia, Sherif Elhanafi, and Mohamed O. Othman Copyright © 2016 Zhouwen Tang et al. All rights reserved. Long-Term Endoscopic Follow-Up of Patients with Chronic Radiation Proctopathy after Brachytherapy for Prostate Cancer Thu, 09 Jun 2016 09:19:51 +0000 http://www.hindawi.com/journals/dte/2016/1414090/ Background. Chronic radiation proctopathy (CRP) is late toxicity and associated with morbidity. Aim. To investigate the predictors of prognosis in patients with CRP after brachytherapy (BT). Methods. One hundred four patients with prostate cancer were treated with BT or BT followed by external-beam radiotherapy (BT + EBRT). We retrospectively investigated the 5-year incidence of rectal bleeding and endoscopic findings of CRP using the Vienna Rectoscopy Score (VRS). Twenty patients with VRS ≥ 1 were divided into the improved VRS group without treatment, unchanged VRS group, and treated group. The parameters associated with alteration of VRS were analyzed. Results. The incidence of rectal bleeding was 24%. The risk of rectal bleeding was higher in patients treated with BT + EBRT compared to those treated with BT (). The incidence of superficial microulceration was higher in the improved VRS group than in the unchanged VRS group (). The incidence of multiple confluent telangiectasia or superficial ulcers > 1 cm2 was higher in the treated group than in both the improved and unchanged VRS groups (). Conclusions. Patients treated with BT + EBRT have a high risk of CRP. Endoscopic findings were useful for prognostic prediction of CRP. Masahiro Ohtani, Hiroyuki Suto, Takuto Nosaka, Yasushi Saito, Yoshihiko Ozaki, Ryoko Hayama, Tatsushi Naito, Kazuto Takahashi, Kazuya Ofuji, Hidetaka Matsuda, Katsushi Hiramatsu, Tomoyuki Nemoto, Hiroki Shioura, Hirohiko Kimura, Yoshitaka Aoki, Osamu Yokoyama, and Yasunari Nakamoto Copyright © 2016 Masahiro Ohtani et al. All rights reserved. Efficacy of the Ovesco Clip for Closure of Endoscope Related Perforations Mon, 16 May 2016 12:24:13 +0000 http://www.hindawi.com/journals/dte/2016/9371878/ Aim. To study the efficacy and other treatment outcomes of Ovesco clip closure of iatrogenic perforation. Methods. Retrospective study from 3 tertiary-care hospitals in Thailand. Patients with iatrogenic perforation who underwent immediate endoscopic closure by Ovesco clip were included. Patients’ demographic data, perforation size, number of Ovesco clips used, fasting day, length of hospital stay, success rates, and complication rate were recorded. Technical success was defined as closure achievement during endoscopic procedure and clinical success was defined as the patient can be discharged without the need of additional surgical or radiological intervention. Results. There were 6 iatrogenic perforations in 2 male and 4 female patients. The median age was 59 years (range 39–78 years). The locations of perforation were 5 duodenal walls and 1 rectosigmoid junction. The median perforation size was 13 mm (range 10–40 mm). The technical success was 100% and the clinical success was 83.3%. The success rates per locations were 100% in colon and 80% in duodenum, respectively. The median fasting time was 5 days (range 1–10 days) and the median length of hospital stay was 10 days (range 2–22 days). There was no mortality in any. Conclusion. Ovesco clip seems to be an effective and safe tool for a closure of iatrogenic perforation. Phonthep Angsuwatcharakon, Piyapan Prueksapanich, Pradermchai Kongkam, Thawee Rattanachu-ek, Jaksin Sottisuporn, and Rungsun Rerknimitr Copyright © 2016 Phonthep Angsuwatcharakon et al. All rights reserved. Analysis of Non-Small Bowel Lesions Detected by Capsule Endoscopy in Patients with Potential Small Bowel Bleeding Tue, 22 Mar 2016 13:49:24 +0000 http://www.hindawi.com/journals/dte/2016/9063293/ Gastrointestinal (GI) bleeding cases in whom source cannot be identified after conventional upper and lower GI endoscopy are defined as potential small bowel bleeding. We aimed to search for lesions in the reach of conventional endoscopy in patients to whom video capsule endoscopy (VCE) had been applied for potential small bowel bleeding. 114 patients who had VCE evaluation for potential small bowel bleeding between January 2009 and August 2015 were retrospectively evaluated. Mean age of the patients was 55 ± 17 years. Female/male ratio is 39/75. In 58 patients (50.9%) bleeding lesion could be determined. Among these 58 patients 8 patients’ lesions were in the reach of conventional endoscopes. Overall these 8 patients comprised 7% of patients in whom VCE was performed for potential small bowel bleeding. Among these 8 patients 5 had colonic lesions (4 angiodysplasia, 1 ulcerated polypoid cecal lesion), 2 had gastric lesions (1 GAVE, 1 anastomotic bleeding), and 1 patient had a bleeding lesion in the duodenal bulbus. Although capsule endoscopy is usually performed for potential small bowel bleeding gastroenterologists should always keep in mind that these patients may be suffering from bleeding from non-small bowel segments and should carefully review images captured from non-small bowel areas. Fatma Ebru Akin, Oyku Tayfur Yurekli, Aylin Demirezer Bolat, Mustafa Tahtacı, Huseyin Koseoglu, Eyup Selvi, Naciye Semnur Buyukasik, and Osman Ersoy Copyright © 2016 Fatma Ebru Akin et al. All rights reserved. Improved Bowel Preparation with Multimedia Education in a Predominantly African-American Population: A Randomized Study Tue, 23 Feb 2016 09:50:30 +0000 http://www.hindawi.com/journals/dte/2016/2072401/ Background and Aim. Inadequate bowel preparation is a major impediment in colonoscopy quality outcomes. Aim of this study was to evaluate the role of multimedia education (MME) in improving bowel preparation quality and adenoma detection rate. Methods. This was an IRB-approved prospective randomized study that enrolled 111 adult patients undergoing outpatient screening or surveillance colonoscopy. After receiving standard colonoscopy instructions, the patients were randomized into MME group () and control group (). The MME group received comprehensive multimedia education including an audio-visual program, a visual aid, and a brochure. Demographics, quality of bowel preparation, and colonoscopy findings were recorded. Results. MME group had a significantly better bowel preparation in the entire colon (OR 2.65, 95% CI 1.16–6.09) and on the right side of the colon (OR 2.74, 95% CI 1.12–6.71) as compared to control group (). Large polyps (>1 cm) were found more frequently in the MME group (11/31, 35.5% versus 0/13; ). More polyps and adenomas were detected in MME group (57 versus 39 and 31 versus 13, resp.) but the difference failed to reach statistical significance. Conclusion. MME can lead to significant improvement in the quality of bowel preparation and large adenoma detection in a predominantly African-American population. Shashank Garg, Mohit Girotra, Lakshya Chandra, Vipin Verma, Sumanjit Kaur, Allawy Allawy, Alessandra Secco, Rohit Anand, and Sudhir K. Dutta Copyright © 2016 Shashank Garg et al. All rights reserved. Spiral Enteroscopy Utilizing Capsule Location Index for Achieving High Diagnostic and Therapeutic Yield Thu, 19 Nov 2015 07:10:16 +0000 http://www.hindawi.com/journals/dte/2015/793516/ Background and Aim. 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. Methods. 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. Results. 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 (). 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; . Conclusions. 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’Hare, Anastasia Shnitser, Ramalinga Kedika, Rebecca Matro, Dina Halegoua-De Marzio, Anthony Infantolino, and Mitchell Conn Copyright © 2015 Rohan Mandaliya et al. All rights reserved. The Use of Endobronchial Ultrasound in the Diagnosis of Subacute Pulmonary Histoplasmosis Mon, 12 Oct 2015 10:58:25 +0000 http://www.hindawi.com/journals/dte/2015/510863/ Objective. 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. Methods. 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. Results. 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. Conclusions. 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, and J. Scott Ferguson Copyright © 2015 Katarine von Lang Egressy et al. All rights reserved. Comparison of Capsule Endoscopy Findings to Subsequent Double Balloon Enteroscopy: A Dual Center Experience Tue, 01 Sep 2015 08:26:38 +0000 http://www.hindawi.com/journals/dte/2015/438757/ Background. 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. Aim. To compare and correlate sequential CE and DBE findings in a large series of patients at two tertiary level hospitals in Wisconsin. Methods. 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. Results. 116 patients were included in the study. The mean age ± SD was 66.6 ± 13.2 years. There were 56% males and 43.9% females. Measure of agreement between prior capsule and DBE findings was performed using kappa statistics, which gave kappa value of 0.396 with . Also contingency coefficient was calculated and was found to be 0.732 (). Conclusions. Our study showed good overall agreement between DBE and CE. Findings of angioectasia had maximum agreement of 69%. Amandeep S. Kalra, Andrew J. Walker, Mark E. Benson, Anurag Soni, Nalini M. Guda, Mehak Misha, and Deepak V. Gopal Copyright © 2015 Amandeep S. Kalra et al. All rights reserved. Treatment of Internal Hemorrhoids by Endoscopic Sclerotherapy with Aluminum Potassium Sulfate and Tannic Acid Sun, 12 Jul 2015 09:42:40 +0000 http://www.hindawi.com/journals/dte/2015/517690/ Objective. 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. Materials and Methods. 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–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. Results. A cure, improvement, and failure were observed in 54 (65.1%), 27 (32.5%), and 2 (2.4%) patients, respectively, treated with ALTA. Complications developed in 4 patients (mild fever in 3 and hematuria in 1). Recurrence occurred in 9.6%. Conclusions. 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, and Kazuhiro Sakamoto Copyright © 2015 Yuichi Tomiki et al. All rights reserved. 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 Thu, 18 Jun 2015 11:43:16 +0000 http://www.hindawi.com/journals/dte/2015/167406/ Background. 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. Aim. Comparing high definition white light endoscopy (HDWLE) to i-SCAN in their ability to detect adenomas during colonoscopy. Methods. 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. Results. 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 . More advanced adenomas (≥10 mm) were found by i-SCAN, 79 versus 47 and based upon histology alone 37 versus 18 . Conclusions. 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, Deepak V. Gopal, Benjamin S. Hall, and Mark E. Benson Copyright © 2015 Erik A. Bowman et al. 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.