Giant laterally spreading tumors of the duodenum: endoscopic resection outcomes, limitations, and caveats.
Gastrointest Endosc. 2012 Feb 3;
Authors: Fanning SB, Bourke MJ, Williams SJ, Chung A, Kariyawasam VC
Abstract
BACKGROUND: Giant hemicircumferential and greater nonampullary duodenal adenomas or laterally spreading tumors (LSTs) may be amenable to safe endoscopic resection, but little data exists on outcomes or risk stratification. DESIGN: We interrogated a prospectively maintained database of all patients who underwent endoscopic resection between January 2008 and November 2010. The resection technique was standardized. Major complications were defined as perforation, bleeding requiring readmission with hemoglobin drop of more than 20 g/L, or other substantial deviations from the usual clinical course. Outcomes were analyzed in 2 groups: giant lesions (>30 mm) and conventional duodenal polyps (<30 mm in diameter). Statistical evaluation was performed by using a χ(2) test. RESULTS: A total of 50 nonampullary duodenal polyps and LSTs were resected from 46 patients (23 men, mean age 59.4 years, range 35-83 years). Nineteen were giant hemicircumferential and greater LSTs (mean size 40.5 mm, range 30-80 mm), and 31 were less than 30 mm in diameter (mean size 14.5 mm, range 5-25 mm). Intraprocedural bleeding occurred more frequently in giant lesions (57.8% vs 19.3%, P = .005) and was treated with a combination of soft coagulation and endoscopic clips with hemostasis achieved in all cases. Major complications, mostly bleeding related, occurred in 5 patients (26.3%) with giant lesions and 1 patient (3.2%) with a smaller lesion (P = .014). There were no deaths. LIMITATION: Retrospective observational study in a tertiary center. CONCLUSIONS: Endoscopic resection of giant nonampullary duodenal LSTs is a successful treatment. However, it is hazardous and associated with significantly higher complication rates, primarily bleeding, when compared with conventional duodenal polypectomy. Safer and more effective hemostatic tools are required in this high-risk location.
PMID: 22305507 [PubMed - as supplied by publisher]
New 10F soft and pliable polyurethane stents decrease the migration rate compared with conventional 10F polyethylene stents in hilar biliary obstruction: results of a pilot study.
Gastrointest Endosc. 2012 Jan 31;
Authors: Cheon YK, Oh HC, Cho YD, Lee TY, Shim CS
Abstract
BACKGROUND: Migration of biliary stents is a well-documented problem that can result in a variety of complications. The newly designed polyurethane (PU) stent, which is made of a soft and pliable material, may prevent distal and proximal stent migration. OBJECTIVE: To compare the migration rate of the PU stent with that of the conventional polyethylene stent (PE). DESIGN: Prospective, comparative, randomized trial. SETTING: Tertiary academic medical centers. PATIENTS: Fifty patients with a hilar stricture who had not undergone a previous drainage procedure. INTERVENTION: In patients with hilar stricture, random assignment of either a PU stent or PE stent. MAIN OUTCOME MEASUREMENT: The rate of early proximal or distal migration before stent occlusion. RESULTS: Overall and distal migration rates were significantly lower in the PU group than in the PE group (4.5% vs 29%, P = .032 and 4.5% vs 26.1%, P = .049, respectively). There was no significant difference between the migration rate in benign and malignant biliary strictures (5.9% vs 21.4%, P = .167). Sex, stent length, preprocedure bilirubin level, and Bismuth type were not associated with migration rate in either the PU or PE group. Median stent patency was 148 days (range 36-224 days) in the PU group and 151 days (range 40-241 days) in the PE group (P = .891). LIMITATIONS: Small sample size. CONCLUSIONS: Use of the new PU stent, which is soft and pliable, decreased distal migration. The PU stent patency rates appear similar, but this study is not powered to demonstrate equivalency of patency.
PMID: 22301338 [PubMed - as supplied by publisher]
Diagnostic yield of colonoscopy to evaluate melena after a nondiagnostic EGD.
Gastrointest Endosc. 2012 Jan 31;
Authors: Etzel JP, Williams JL, Jiang Z, Lieberman DA, Knigge K, Faigel DO
Abstract
BACKGROUND: Melena can be caused by bleeding from lower GI sources. Colonoscopy is frequently used to investigate melena after a nondiagnostic EGD. OBJECTIVE: To determine the diagnostic yield and rate of therapeutic intervention during colonoscopy in patients with melena and a nondiagnostic EGD. DESIGN: Retrospective case-control study. SETTING: Community and academic centers over a diverse geographic area in the United States. PATIENTS: This study involved patients in the Clinical Outcomes Research Initiative database with a colonoscopy performed to investigate melena within 30 days of a nondiagnostic EGD for the same indication. A control group had colonoscopies performed for average-risk screening. MAIN OUTCOME MEASUREMENTS: The endoscopic finding of a suspected bleeding source defined as right-sided arteriovenous malformation, colitis, polyp ≥ 20 mm, tumor, or ulcer. Rate of therapeutic intervention during colonoscopy. RESULTS: Colonoscopy found a suspected bleeding source in 4.8% of patients with melena, more frequently than in the control group (odds ratio [OR] 2.17; 95% confidence interval [CI], 1.65-2.86; P < .0001). The rate of therapeutic intervention during melena-related colonoscopy was 1.7%. Patients with melena were more likely to have a colon tumor (OR 2.87; 95% CI, 1.82-5.51; P < .0001) than were control patients. LIMITATIONS: Retrospective design, conclusions being dependent on the accuracy of database input, and lack of pertinent clinical data (eg, hemoglobin). CONCLUSION: The diagnostic yield of colonoscopy to investigate melena after nondiagnostic EGD is low. The need for therapeutic intervention during colonoscopy for this indication is very low. This population should undergo colonoscopy because they are at increased risk of colorectal cancer. Colonoscopy can potentially be performed electively in stable patients without continued bleeding.
PMID: 22301339 [PubMed - as supplied by publisher]
Laparoscopy-assisted versus balloon enteroscopy-assisted ERCP in bariatric post-Roux-en-Y gastric bypass patients.
Gastrointest Endosc. 2012 Jan 31;
Authors: Schreiner MA, Chang L, Gluck M, Irani S, Gan SI, Brandabur JJ, Thirlby R, Moonka R, Kozarek RA, Ross AS
Abstract
BACKGROUND: Data on balloon enteroscopy-assisted ERCP (BEA-ERCP) versus laparoscopy-assisted ERCP (LA-ERCP) in post-Roux-en-Y gastric bypass (RYGB) patients are lacking. OBJECTIVES: To compare BEA-ERCP with LA-ERCP in post-RYGB patients and to identify factors that predict therapeutic success with BEA-ERCP. DESIGN: Retrospective chart review. SETTING: A single North American tertiary referral center. PATIENTS: The review included 56 bariatric post-RYGB patients who underwent ERCP. INTERVENTIONS: BEA-ERCP or LA-ERCP. MAIN OUTCOME MEASUREMENTS: Cannulation rate, therapeutic success, hospital stay, complications, procedure duration, endoscopist time, and cost. RESULTS: A total of 32 patients underwent BEA-ERCP, and 24 underwent LA-ERCP. LA-ERCP was superior to BEA-ERCP in papilla identification (100% vs 72%, P = .005), cannulation rate (100% vs 59%, P < .001), and therapeutic success (100% vs 59%, P < .001). The total procedure time was shorter (P < .001) and endoscopist time was longer (P = .006) for BEA-ERCP. There was no difference in postprocedure hospital stay (P = .127) or complication rate (P = .392) between the 2 groups. In the BEA-ERCP group, in patients having a Roux limb + biliopancreatic (from ligament of Treitz to jejunojejunal anastomosis), a limb length less than 150 cm was associated with therapeutic success. Starting with BEA-ERCP and continuing with LA-ERCP after a failed BEA-ERCP saved $1015 compared with starting with LA-ERCP. LIMITATIONS: Single center, retrospective study. CONCLUSIONS: In centers with expertise in deep enteroscopy and ERCP, post-RYGB patients with a Roux + ligament of Treitz to jejunojejunal anastomosis limb length less than 150 cm should first be offered deep enteroscopy-assisted ERCP. In patients with Roux + ligament of Treitz to jejunojejunal anastomosis (LTJJ) limb length 150 cm or longer, LA-ERCP should be the preferred approach because of the lack of need for a second procedure, equivalent morbidity and hospital stay, decreased endoscopist time, and decreased cost.
PMID: 22301340 [PubMed - as supplied by publisher]
Endoscopic submucosal dissection for pig esophagus by using photocrosslinkable chitosan hydrogel as submucosal fluid cushion.
Gastrointest Endosc. 2012 Jan 31;
Authors: Kumano I, Ishihara M, Nakamura S, Kishimoto S, Fujita M, Hattori H, Horio T, Tanaka Y, Hase K, Maehara T
Abstract
BACKGROUND: Hypertonic saline solution (HS) as a submucosal fluid cushion (SFC) for endoscopic submucosal dissection (ESD) has several disadvantages, including a short effect duration and increased risk of bleeding and perforation. Photocrosslinkable chitosan hydrogel in DMEM/F12 medium (PCH) can be converted into an insoluble hydrogel by UV irradiation for 30 seconds. OBJECTIVE: To evaluate the feasibility, usefulness, and safety of PCH as an SFC for ESD of esophagi, compared with HS and sodium hyaluronate (SH). DESIGN: Survival animal study. SETTINGS: Research laboratory study of 24 pig models in vivo. INTERVENTIONS: Twenty-four pigs were used in the 2 steps: First, ESD of the esophagus was performed with PCH, SH, or HS (each n = 6) as an SFC, and the effects of these agents on wound healing were examined endoscopically and histologically. Second, in vivo degradation of PCH (n = 3) and HS (n = 3) was examined in independent pig esophagi. MAIN OUTCOME MEASUREMENTS: Outcome measurements included feasibility and safety of PCH-assisted ESD of esophagus, gross and histologic evidence of the treated esophagus, biodegradation of injected PCH, and clinical tolerance by the animals. RESULT: PCH injection led to a longer-lasting elevation with clearer margins compared with SH and HS, thus enabling precise ESD along the margins of the elevated mucosa without complications such as bleeding and perforation. The aspects of wound repair after PCH-assisted ESD were similar to those of SH- and HS-assisted ESDs. Biodegradation of PCH was confirmed to be almost completed within 8 weeks on the basis of endoscopic and histologic observations. LIMITATIONS: In vivo animal model study. CONCLUSION: PCH permits more reliable ESD of the esophagus without complications than do SH and HS. Furthermore, the applied PCH appeared to be completely biodegraded within 8 weeks. Thus, PCH is a promising agent as an SFC in ESD of the esophagus.
PMID: 22301341 [PubMed - as supplied by publisher]
Vital-dye enhanced fluorescence imaging of GI mucosa: metaplasia, neoplasia, inflammation.
Gastrointest Endosc. 2012 Jan 31;
Authors: Thekkek N, Muldoon T, Polydorides AD, Maru DM, Harpaz N, Harris MT, Hofstettor W, Hiotis SP, Kim SA, Ky AJ, Anandasabapathy S, Richards-Kortum R
Abstract
BACKGROUND: Confocal endomicroscopy has revolutionized endoscopy by offering subcellular images of the GI epithelium; however, the field of view is limited. Multiscale endoscopy platforms that use widefield imaging are needed to better direct the placement of high-resolution probes. DESIGN: Feasibility study. OBJECTIVE: This study evaluated the feasibility of a single agent, proflavine hemisulfate, as a contrast medium during both widefield and high-resolution imaging to characterize the morphologic changes associated with a variety of GI conditions. SETTING: The University of Texas MD Anderson Cancer Center, Houston, Texas, and Mount Sinai Medical Center, New York, New York. PATIENTS, INTERVENTIONS, AND MAIN OUTCOME MEASUREMENTS: Resected specimens were obtained from 15 patients undergoing EMR, esophagectomy, or colectomy. Proflavine hemisulfate, a vital fluorescent dye, was applied topically. The specimens were imaged with a widefield multispectral microscope and a high-resolution microendoscope. The images were compared with histopathologic examination. RESULTS: Widefield fluorescence imaging enhanced visualization of morphology, including the presence and spatial distribution of glands, glandular distortion, atrophy, and crowding. High-resolution imaging of widefield abnormal areas revealed that neoplastic progression corresponded to glandular heterogeneity and nuclear crowding in dysplasia, with glandular effacement in carcinoma. These widefield and high-resolution image features correlated well with the histopathologic features. LIMITATIONS: This imaging approach must be validated in vivo with a larger sample size. CONCLUSIONS: Multiscale proflavine-enhanced fluorescence imaging can delineate epithelial changes in a variety of GI conditions. Distorted glandular features seen with widefield imaging could serve as a critical bridge to high-resolution probe placement. An endoscopic platform combining the two modalities with a single vital dye may facilitate point-of-care decision making by providing real-time, in vivo diagnoses.
PMID: 22301343 [PubMed - as supplied by publisher]
Intraductal aspiration: a promising new tissue-sampling technique for the diagnosis of suspected malignant biliary strictures.
Gastrointest Endosc. 2012 Jan 31;
Authors: Curcio G, Traina M, Mocciaro F, Liotta R, Gentile R, Tarantino I, Barresi L, Granata A, Tuzzolino F, Gridelli B
Abstract
BACKGROUND: Brushing is the most commonly used technique for biliary sampling at ERCP, despite its limited sensitivity. OBJECTIVE: To evaluate intraductal aspiration (IDA) as a new combined endoscopic technique for cytodiagnosis, its cellular adequacy, diagnostic accuracy for cancer detection, feasibility, and safety. DESIGN: Prospective, observational study. SETTING: Single tertiary referral center. MAIN OUTCOME MEASUREMENTS: IDA cellular adequacy, diagnostic accuracy for cancer detection, feasibility, and safety. PATIENTS AND METHODS: From April 2009 to September 2010, 42 consecutive patients with suspected malignant biliary stricture underwent ERCP, with tissue sampling obtained with IDA. IDA included performance of standard brushing in all patients. After standard brushing, to perform IDA, we removed the brush from its catheter and used the tip of the catheter as a scraping device. The tip was scraped back and forth across the stricture at least 10 times. The catheter and a suction line were connected to a specimen trap to obtain intraductal aspiration of fluids and samplings. RESULTS: Our cytopathologists found adequate cellular yield in 39 of the 42 IDA samples (92.8%) versus 15 of the 42 brushing samples (35.7%) (P < .001). IDA showed a significantly higher sensitivity than brushing (89% vs 78% for adequate samples and 89% vs 37% for all samples) and provided significantly superior cellular adequacy (92.8% vs 35.7%). LIMITATIONS: Observational study, small number of patients. CONCLUSIONS: IDA significantly improves brushing cellular adequacy and has high sensitivity for cancer detection. It was also safe, simple, rapid, and applicable during routine diagnostic ERCP, with no additional costs.
PMID: 22301344 [PubMed - as supplied by publisher]
Dose-dependent depth of tissue injury with carbon dioxide cryotherapy in porcine GI tract.
Gastrointest Endosc. 2012 Jan 31;
Authors: Shin EJ, Amateau SK, Kim Y, Gabrielson KL, Montgomery EA, Khashab MA, Chandrasekhara V, Rolshud D, Giday SA, Canto MI
Abstract
BACKGROUND: Cryotherapy is a method of endoscopic mucosal ablation that involves delivery of a cryogen to result in tissue destruction by extreme low temperature. Its effects are influenced by the dosage of cryogen and thawing of ice. There are limited data on the tissue effects of multiple freeze and thaw cycles of carbon dioxide (CO(2)) cryotherapy on GI tissues. OBJECTIVE: To investigate the extent of tissue injury due to escalating doses of CO(2) cryotherapy on the esophagus, stomach, and colon of pigs. DESIGN: Animal experiment. INTERVENTION: Varying doses of CO(2) cryotherapy with increasing number of freeze-thaw cycles were applied to each site. The animals were allowed to survive for 48 hours. MAIN OUTCOME MEASUREMENTS: Depth of tissue injury assessed in blinded fashion by varying doses of cryotherapy on a defined area of porcine esophagus, stomach, and colon. RESULTS: There was a dose-dependent relationship of CO(2) cryogen and depth of injury (P = .0001 and P = .002, respectively). In the stomach, the dose-response relationship was significant (P = .007), but the average grades of injury across the various doses were lower when compared with the esophagus at comparable cryogen doses (P = .0004). The estimated depth of tissue injury from the mucosal surface in the porcine esophagus and colon tissue ranged from 1.2 to 2.5 mm and 1.3 to 2.5 mm, respectively. LIMITATIONS: The study was performed in a normal porcine model. CONCLUSION: There was a dose-dependent relationship between the dose of CO(2) cryotherapy and the depth of tissue injury in the porcine esophagus, stomach, and colon.
PMID: 22301345 [PubMed - as supplied by publisher]
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