Endoscopic suturing for the prevention of stent migration in benign upper gastrointestinal conditions: a comparative multicenter study.

BACKGROUND AND STUDY AIMS: Fully covered self-expandable metal stents (FCSEMSs) have increasingly been used in benign upper gastrointestinal (UGI) conditions; however, stent migration remains a major limitation. Endoscopic suture fixation (ESF) may prevent stent migration. The aims of this study were to compare the frequency of stent migration in patients who received endoscopic suturing for stent fixation (ESF group) compared with those who did not (NSF group) and to assess the impact of ESF on clinical outcome. PATIENTS AND METHODS: This was a retrospective study of patients who underwent FCSEMS placement for benign UGI diseases. Patients were divided into either the NSF or ESF group. Outcome variables, including stent migration, clinical success (resolution of underlying pathology), and adverse events, were compared. RESULTS: A total of 125 patients (44 in ESF group, 81 in NSF group; 56 benign strictures, 69 leaks/fistulas/perforations) underwent 224 stenting procedures. Stent migration was significantly more common in the NSF group (33 % vs. 16 %; P = 0.03). Time to stent migration was longer in the ESF group (P = 0.02). ESF appeared to protect against stent migration in patients with a history of stent migration (adjusted odds ratio [OR] 0.09; P = 0.002). ESF was also significantly associated with a higher rate of clinical success (60 % vs. 38 %; P = 0.03). Rates of adverse events were similar between the two groups. CONCLUSIONS: Endoscopic suturing for stent fixation is safe and associated with a decreased migration rate, particularly in patients with a prior history of stent migration. It may also improve clinical response, likely because of the reduction in stent migration.

Foregut and colonic perforations: practical measures to prevent and assess them.

Acute endoscopic perforations of the foregut and colon are rare but can have devastating consequences. There are several principles and practices that can lower the risk of perforation and guide the endoscopist in early assessment when they do occur. Mastery of these principles will lead to overall improved patient outcomes.

Nurse observation during colonoscopy increases polyp detection: a randomized prospective study.

OBJECTIVES: To determine whether a second observer during colonoscopy increases adenoma detection. METHODS: Consecutive patients undergoing screening colonoscopy were prospectively randomized to routine colonoscopy or physician and nurse observation during withdrawal. RESULTS: Of 502 patients, 249 were randomized to routine colonoscopy, and 253 to physician plus nurse observation during withdrawal. A total of 592 polyps were detected, 40 identified by the endoscopy nurse only. With nurse observation, 1.32 polyps and 0.82 adenomas were found per colonoscopy, vs. 1.03 polyps and 0.64 adenomas in the routine group, demonstrating a 1.29-fold and a 1.28-fold increase in the average number of polyps and of adenomas detected, respectively. The overall adenoma detection rate (ADR) was 44.1%, with trends toward increased ADR and all-polyp detection rate with nurse observation. CONCLUSIONS: Nurse observation during colonoscopy resulted in an increase in the number of polyps and adenomas found per colonoscopy, along with a trend toward improved overall ADR and all-polyp detection rate.

Targeted cyst wall puncture and aspiration during EUS-FNA increases the diagnostic yield of premalignant and malignant pancreatic cysts.

BACKGROUND: Characterization of pancreatic cysts by using EUS-FNA includes chemical and cytologic analysis. OBJECTIVE: To evaluate whether material obtained from FNA of the cyst wall increases diagnostic yield. DESIGN: Prospective series. SETTING: Tertiary referral center. PATIENTS: Consecutive patients with pancreatic cysts referred for EUS-FNA between March 2010 and March 2011. INTERVENTION: FNA was performed with aspiration of cyst fluid for carcinoembryonic antigen (CEA) and cytology, followed by cyst wall puncture (CWP). CWP is defined as puncturing the far wall of the cyst and moving the needle back and forth through the wall to sample the wall epithelium. MAIN OUTCOME MEASUREMENTS: The diagnostic yield for mucinous cystic pancreatic neoplasms by CEA and cytology obtained from cyst fluid compared with cytology obtained from CWP. CEA ≥192 ng/mL was considered mucinous. RESULTS: A total of 69 pancreatic cysts from 66 patients were included. Adequate amounts of fluid were aspirated for CEA, amylase, and cytology in 60 cysts (81%). Cellular material adequate for cytologic assessment from CWP was obtained in 56 cysts (81%). Ten (30%) of 33 cysts with CEA <192 ng/mL and negative results of cyst fluid cytology had a mucinous diagnosis from CWP; 6 of 9 (67%) cysts with an insufficient amount of fluid for CEA analysis and cyst fluid cytology had a mucinous diagnosis from CWP. Furthermore, 4 malignant cysts were independently diagnosed by CWP cytology. The incremental diagnostic yield of CWP for mucinous or malignant cysts was therefore 29% (20 of 69 cysts, P = .0001). An episode of pancreatitis (1.45%) occurred. LIMITATION: Lack of surgical criterion standard. CONCLUSIONS: CWP during EUS-FNA is a safe and effective technique for improving the diagnostic yield for premalignant and malignant pancreatic cysts.

Cyst wall puncture and aspiration during EUS-guided fine needle aspiration may increase the diagnostic yield of mucinous cysts of the pancreas.

BACKGROUND: Pancreatic cysts are common, however, their diagnosis and classification remains a challenge despite advances in cross-sectional imaging and endoscopic ultrasound with fine needle aspiration (EUS-FNA). OBJECTIVE: To determine the incremental yield of cytologic examination of material obtained from targeted fine needle aspiration ("puncture") of the cyst wall after aspiration of fluid for CEA. DESIGN: Retrospective consecutive series. PATIENTS AND SETTING: Consecutive patients undergoing EUS-FNA of a pancreatic cyst by 2 expert endoscopists at a single tertiary care center between January 2006 and June 2008. INTERVENTION: Standard EUS-FNA of pancreatic cysts was carried out, and after cyst fluid aspiration the cyst wall was punctured and aspirated (CWP) to obtain epithelium for cytologic analysis. MAIN OUTCOME MEASUREMENTS: The diagnostic yields of carcinoembryonic antigen (CEA) obtained from cyst fluid and of cytology obtained from CWP. CEA greater than192 ng/mL was considered diagnostic of a mucinous cyst. RESULTS: One hundred seven patients underwent EUS-FNA with CWP. Sixteen (31%) of 52 patients with CEA <192 ng/mL had cytology positive for mucinous epithelium, whereas 15 (47%) of 32 cysts with an insufficient amount of fluid for CEA analysis had positive cytology from CWP. The additional, cumulative diagnostic yield for mucinous cysts was therefore, 37%. Of 55 cysts diagnosed as mucinous, more (56%) were diagnosed by CWP cytology alone than by CEA (P<0.05). LIMITATIONS: Retrospective design and limited surgical pathology. CONCLUSIONS: Cyst wall puncture and aspiration during routine EUS-FNA may be a safe, easily applied, and inexpensive technique for improving the diagnostic yield for mucinous cysts of the pancreas.

Narrow band imaging to detect residual or recurrent neoplastic tissue during surveillance endoscopy.

BACKGROUND: There is little data on the prevalence of residual neoplastic tissue or the rate of endoscopically detected recurrence in patients with prior surgical or endoscopic resection of advanced neoplasia. AIMS: To compare standard white light with NBI for both the detection, as well as the differentiation, of residual or recurrent neoplastic tissue during real-time endoscopy. METHODS: A prospective study of 46 consecutive patients undergoing surveillance colonoscopy or upper endoscopy was conducted. Prior resection sites were examined first with white light and then with NBI. Main outcome measurements included the number of distinct lesions identified with white light, the number of additional lesions identified with NBI, and the overall accuracy of endoscopic diagnosis using white light alone or with NBI. RESULTS: Sixty discrete lesions were identified, 43 with white light alone, and an additional 17 with NBI. NBI identified more lesions per patient than white light alone (mean 1.33 vs. 0.96, p < 0.05) and there was a trend towards increased detection of neoplastic lesions. Recurrent/residual neoplasia was present in 14 patients (30%) and there was a trend towards increased detection with the addition of NBI. About 63% of lesions identified with white light appeared more extensive when examined with NBI. The diagnostic accuracy in predicting histology was equivalent for NBI and white light (87 vs. 88%), though there was a trend towards higher sensitivity for neoplastic lesions with NBI (88 vs. 69%, p = 0.16). CONCLUSIONS: A substantial number of patients undergoing surveillance endoscopy had residual or recurrent neoplastic tissue identified at the prior resection site. As NBI detected additional neoplastic lesions as well as demonstrated that lesions detected with white light were more extensive, adjunctive use of NBI for examining post-endoscopy resection sites should be studied in future, larger studies.

Fellow involvement may increase adenoma detection rates during colonoscopy.

BACKGROUND: Adenoma detection rate (ADR) is increasingly used as a quality indicator for screening/surveillance colonoscopy. Recent investigations to identify factors that affect ADR have focused on the technical aspects of the procedure or the equipment. OBJECTIVE: To assess whether gastroenterology (GI) fellow participation during colonoscopy affects ADR. METHODS: This is a retrospective study of data prospectively collected on 309 patients enrolled in a different study not involving polyp detection. In total, 126 colonoscopies were performed by a GI attending alone, and 183 by a GI fellow supervised by one of the same four GI attendings. RESULTS: The ADR was significantly higher when a fellow was involved (37% vs 23%, P < 0.01), as was the total number of adenomas detected (0.56 per patient vs 0.30 per patient, P < 0.05). The percentage of patients with two and three or more adenomas was also higher for fellows versus attendings alone (13.1% vs 5.6%, and 6% vs 1.6%, respectively; P < 0.05), though there was no difference in the detection of advanced adenomas (7.1% vs 5.6%, P = 0.16). The adenomas detected when fellows participated were smaller (mean size 4.4 mm vs 5.8 mm, P < 0.05), and more likely to be sessile (80.6% vs 64.9%, P < 0.05). There were no significant differences in the age, gender, indication for colonoscopy, or procedure time for the two groups. CONCLUSIONS: In this retrospective study, fellow involvement in colonoscopy may increase not only the ADR, but also the detection of more subtle adenomas. Further investigation into whether this is a "fellow effect," or simply a matter of more efficient visual scanning and recognition with two people, should be considered.

Narrow-band imaging without high magnification to differentiate polyps during real-time colonoscopy: improvement with experience.

BACKGROUND: There is no widely adopted, easily applied method for distinguishing between adenomatous and nonadenomatous polyps during real-time colonoscopy. OBJECTIVE: To compare white light (WL) with narrow-band imaging (NBI) for the differentiation of colorectal polyps in vivo and to assess for a learning curve. DESIGN: A prospective polyp series. PATIENTS AND SETTING: A total of 302 patients referred for colonoscopy, between August 2006 and July 2007, to a single tertiary-referral center in the United States. INTERVENTION: Standard WL colonoscopy was performed with Olympus 180-series colonoscopes. Each detected polyp was first characterized by WL and then by NBI. Modified Kudo pit pattern and vascular color intensity (VCI) were recorded, and the histology was predicted. Endoscopists were given feedback every 2 weeks. MAIN OUTCOME MEASUREMENTS: Overall accuracy and sensitivity and specificity of endoscopic diagnosis by using WL alone and with NBI, as well as improvement in endoscopists' performance. RESULTS: A total of 265 polyps were found in 131 patients. Diagnostic accuracy was 80% with NBI and 77% with WL (P = .35). NBI performed better than WL in diagnosing adenomas (sensitivity 80% vs 69%, P < .05). Nonadenomatous polyps were more likely to have a "light" VCI compared with adenomas (71% vs 29%, P < .001). During the second half of the study, NBI accuracy improved, from 74% to 87%, and outperformed an unchanged WL accuracy of 79% (P < .05). CONCLUSIONS: Overall, NBI was not more accurate than WL in differentiating colorectal polyps in vivo; however, once a learning curve was achieved, NBI performed significantly better. Further refinements of an NBI pit-pattern classification and VCI scale are needed before broad application to clinical decisions regarding the necessity of polypectomy.

Analysis of endoscopic management of occluded metal biliary stents at a single tertiary care center.

BACKGROUND: A significant number of self-expandable metal stents (SEMSs) placed to palliate malignant biliary obstruction will occlude. Few data exist as to what constitutes optimal management. OBJECTIVE: Our purpose was to review the management and outcomes of patients with biliary SEMS occlusion. DESIGN AND SETTING: Retrospective chart review at a single tertiary care hospital. PATIENTS: From January 1999 to October 2005, a total of 90 patients had SEMSs placed for malignant biliary obstruction, and 27 of these occluded. MAIN OUTCOME MEASUREMENTS: Technical success of treating SEMS occlusion, stent patency and need for reintervention, and incremental cost analysis. RESULTS: A total of 60 ERCPs were performed to treat SEMS occlusions in 27 patients. The success rate was 95%; however, 52% of patients eventually required more than 1 intervention. Placing a second SEMS through the existing SEMS (n = 14) provided the lowest reocclusion rate (43% vs 55% and 100%), the longest time to reintervention (172 days vs 66 and 43 days, P = .03), and a trend toward longer survival (285 days vs 188 and 194 days) compared with plastic stent and mechanical balloon cleaning, respectively. Incremental cost analysis showed both uncovered SEMSs and plastic stents to be cost effective strategies. LIMITATIONS: Small number of patients, retrospective study. CONCLUSIONS: Treatment of biliary SEMS occlusion with SEMS insertion provides for longer patency and survival, decreases the number of subsequent ERCPs by 50% compared with plastic stents, and is cost-effective.

Type I autoimmune hepatitis presenting with acute liver failure in the setting of wild mushroom ingestion.

Type I autoimmune hepatitis usually has an indolent presentation and course, and is classically thought of as a disease of young women, but can in fact occur across all age ranges. Although its etiology remains unclear, it is hypothesized that an environmental antigen may trigger the disease in a genetically susceptible individual. Here, we report the unusual case of a woman in her seventh decade who presented with acute liver failure as her initial manifestation of autoimmune hepatitis, and who had been a long-time ingestor of hand-picked, wild mushrooms.

Successful Multimodality Endoscopic Treatment of Gastric Outlet Obstruction Caused by an Impacted Gallstone (Bouveret's Syndrome).

Bouveret's syndrome is a rare condition of gastric outlet obstruction resulting from the migration of a gallstone through a choledochoduodenal fistula. Due to the large size of these stones and the difficult location in which they become impacted, endoscopic treatment is unsuccessful and most patients require surgery. We report the case of an elderly male who presented with nausea and hematemesis, and was found on CT scan and endoscopy to have an obstructing gallstone in his duodenal bulb. After several endoscopic sessions and the use of multiple instruments including a Holmium: YAG laser and electrohydraulic lithotripter, fragmentation and endoscopic removal of the stone were successful. We believe this to be the first case of Bouveret's syndrome successfully treated by endoscopy alone in the United States. We describe the difficulties encountered which necessitated varied and innovative therapeutic techniques.

Multiphoton imaging can be used for microscopic examination of intact human gastrointestinal mucosa ex vivo.

BACKGROUND & AIMS: The ability to observe cellular and subcellular detail during routine endoscopy is a major goal in the development of new endoscopic imaging techniques. Multiphoton microscopy, which relies on nonlinear infrared optical processes, has the potential to identify cellular details by excitation of endogenous fluorescent molecules. We examined the feasibility of using multiphoton microscopy to characterize mucosal histology in the human gastrointestinal tract. METHODS: A multiphoton microscope was used to determine the optimal excitation wavelength for examination of gastrointestinal mucosa. Fresh, unfixed, and unstained biopsy specimens obtained during routine endoscopy in human subjects then were examined by confocal microscopy and multiphoton microscopy. Multiphoton images also were compared with standard H&E images obtained from paired biopsy specimens. A prototype miniaturized multiphoton probe was used to examine intact rat colon. RESULTS: Peak multiphoton autofluorescence intensity was detected in mucosa excited at 735 nm. Multiphoton microscopic examination of unstained biopsy specimens revealed improved cellular detail relative to either unstained or stained specimens examined by confocal imaging. Resolution of structures such as epithelial nuclei, goblet cells, and interstitial fibers and cells was comparable with what was obtained using standard H&E histology. Similar findings were observed when using a prototype miniaturized multiphoton probe. CONCLUSIONS: Multiphoton microscopy can be used to examine gastrointestinal mucosa at the cellular level, without the need for fluorescent dyes. The construction of a multiphoton endomicroscope therefore could provide a practical means of performing virtual biopsies during the course of routine endoscopy, with advantages over currently available endomicroscopy technologies.