The role of a novel self-expanding metal stent in variceal bleeding: a multicenter Australian and New Zealand experience.

Background and study aims Refractory variceal bleeding is associated with high mortality in patients with chronic liver disease. A fully-covered self-expanding metal stent (SEMS) has been reported to have excellent rates of technical success and initial bleeding control; however, studies to date are small and limited to Europe and Asia. Our aim was to evaluate the efficacy and safety of this SEMS for control of refractory variceal bleeding (VB). Patients and methods A retrospective analysis was undertaken of all patients who received the SX-ELLA Danis SEMS for management of VB at 9 tertiary centers across Australia and New Zealand. A total of 32 SEMS had been deployed in 30 patients (median age 53.3). Results Technical success of SEMS placement was achieved in 100 % of cases, resulting in immediate control of bleeding across 31 of 32 cases (96.9 %). Re-bleeding with SEMS in situ occurred in three of 32 cases (9.4 %). Mean SEMS in-dwelling time was 6.4 days. Delayed SEMS migration occurred in 6.3 % of cases. Interventional radiological therapy for management of varices within 6 weeks was performed in 12 of 30 patients (40 %). Death with SEMS in situ occurred in seven of 30 patients (23.3 %). Seven-day bleeding-related mortality was 16.7 %, 14-day mortality 23.3 %, and 6-week mortality 33.3 %. Three of 30 patients (10 %) received orthotopic liver transplantation following SEMS insertion, including two patients within 6 weeks. Conclusions SX-Danis Ella SEMS is highly effective for immediate control of refractory VB and bridging to definitive therapy because it has excellent technical success rates, appears to be relatively easy to use, and has low rates of serious adverse events.

To investigate outcomes in endoscopic management of early oesophageal adenocarcinoma in Barrett oesophagus: experience at three Australian tertiary centres.

BACKGROUND: Barrett oesophagus is a known precursor of oesophageal adenocarcinoma (EAC). Early EAC includes T1a (invasion into mucosa) and T1b (invasion into submucosa but not muscularis propria). Endoscopic mucosal resection (EMR) provides accurate histological staging and definitive treatment for early EAC. Post EMR, the remaining Barrett is eradicated with radiofrequency ablation (RFA). However, there is a paucity of long-term Australian data. AIM: To investigate the efficacy and long-term outcomes of EMR and RFA in the management of early EAC. METHODS: Retrospective analysis of patients early EAC treated endoscopically at three Western Australian tertiary centres, with at least 12-months follow up, over the past 10 years. RESULTS: Sixty-seven patients with early EAC (61 T1a and 6 T1b) were treated with EMR. Complete Barrett eradication was done by EMR in 31 of 67 patients whereas 36/67 patients underwent RFA for residual Barrett. EMR changed pinch biopsy histology from HGD (n = 33), HGD suspicious for IMC (n = 5) and LGD (n = 1) to early EAC in 58.2% (n = 39) patients. During a mean follow up of 37.2 months (interquartile range: 20, 56), complete remission of dysplasia and intestinal metaplasia was seen in 97% (n = 65) and 89.5% (n = 60) patients. One patient with T1b EAC underwent oesophagectomy. No cases developed metachronous EAC, progression to invasive adenocarcinoma or development of nodal/distant metastasis. Complications were endoscopically treated haematemesis (n = 1) and strictures (n = 16) requiring dilatations. Three patients died due to causes unrelated to IMC. CONCLUSION: EMR in conjunction with RFA is an effective and safe management for early EAC. EMR provides accurate staging and has low complication rates.

Benign biliary strictures: prevalence, impact, and management strategies.

Benign biliary strictures (BBSs) may form from chronic inflammatory pancreaticobiliary pathologies, postoperative bile-duct injury, or at biliary anastomoses following liver transplantation. Treatment aims to relieve symptoms of biliary obstruction, maintain long-term drainage, and preserve liver function. Endoscopic therapy, including stricture dilatation and stenting, is effective in most cases and the first-line treatment of BBS. Radiological and surgical therapies are reserved for patients whose strictures are refractory to endoscopic interventions. Response to treatment is dependent upon the technique and accessories used, as well as stricture etiology. In this review, we discuss the various BBS etiologies and their management strategies.

A recurrent, ischaemic ileocolonic anastomosis ulcer refractory to surgery treated with hyperbaric oxygen.

A 54-year-old male had undergone right hemicolectomy and ileo-colonic anastomosis for carcinoma-in-situ found at colonoscopy. Eighteen months later, he presented with a lower gastrointestinal bleed from an anastomotic ulcer, treated with resection of the anastomotic site and ileo-sigmoid anastomosis. In the ensuing 12 months, he had three episodes of haematochezia. Colonoscopy revealed a 12 mm anastomotic ulcer necessitating a further colonic resection and re-anastomosis. Two-years later, he presented with iron deficiency anaemia. He preferred expectant management and received ten iron-infusions over the subsequent four years. Thereafter, he developed painless haematochezia. Colonoscopy showed a 15 mm linear ulcer with mild ooze at the anastomosis. Histology was consistent with an ischaemic ulcer; there was no evidence of recurrence of carcinoma-in-situ. The ulcer remained refractory to endoscopic and medical treatment, as seen at three follow-up colonoscopies. Hyperbaric oxygen treatment (HBOT) was offered and he received 30 sessions over six weeks. Colonoscopy at HBOT completion revealed healing of the ulcer. The patient had no further overt bleeding and serum ferritin has continued to rise spontaneously over 12 months follow-up.

Management of pancreatic collections with a novel endoscopically placed fully covered self-expandable metal stent: a national experience (with videos).

BACKGROUND: Recent medical literature on novel lumen-apposing stents for the treatment of pancreatic fluid collections (PFCs) is limited by small numbers, solo operators, and single-center experience. OBJECTIVE: To evaluate a recently developed lumen-apposing, fully covered self-expandable metal stent (FCSEMS) in the management of PFCs. DESIGN: Retrospective case series. SETTING: Thirteen tertiary and private health care centers across Australia. PATIENTS: Forty-seven patients (median age 51 years) who underwent endoscopic management of PFCs. INTERVENTION: Insertion of FCSEMS after PFC puncture under EUS guidance. A subgroup of 9 patients underwent direct endoscopic necrosectomy. MAIN OUTCOME MEASUREMENTS: Technical and clinical success rate, adverse event rate. RESULTS: The technical success rate was 53 of 54 patients (98.1%), and the initial clinical success rate was 36 of 47 (76.6%), which was sustained for more than 6 months in 34 of 36 (94.4%). Early adverse events included 4 cases (7.4%) of stent migration during direct endoscopic necrosectomy, 4 cases (7.4%) of sepsis, 1 case (1.9%) of bleeding, and 1 case (1.9%) of stent migration into the fistula tract. Late adverse events were 6 (11.1%) spontaneous stent migrations, 3 (5.6%) recurrent stent occlusions, 3 (5.6%) tissue ingrowth/overgrowth, and 2 (3.7%) bleeding into PFC. The majority of stents inserted (48 of 54, 88.9%) and removed (31 of 35, 88.6%) in our study were described by the operator as superior to pigtail stents with regard to ease of use. LIMITATIONS: Retrospective study. CONCLUSION: Although FCSEMSs are technically easier to insert and remove compared with traditional pigtail stents, there are significant limitations to the widespread use of FCSEMSs in the management of PFCs. These include cost, adverse events, and lower-than-expected resolution rates.

Diagnostic performance of EUS for chronic pancreatitis: a comparison with histopathology.

BACKGROUND: EUS has been proposed as a minimally invasive and accurate test to detect chronic pancreatitis (CP). OBJECTIVE: To investigate the correlation between EUS criteria and histopathology grading in patients with presumed CP. DESIGN: Retrospective study. SETTING AND PATIENTS: Patients who received pancreatic surgery according to presumed CP from the Medical University of South Carolina surgical database between 1995 and 2003 were identified and included if EUS was performed within 1 year before surgery. The number of EUS criteria for CP was compared with a histologic fibrosis score (FS). MAIN OUTCOME MEASUREMENTS: Sensitivity and specificity of number of EUS criteria compared with FS. RESULTS: Seventy-one patients were identified (38 women). Median FS was 7 (range, 0-12). Of the patients with calcifications: calcifications were detected by EUS in 30 (42%), 14 (47%) had calcifications missed by other imaging modalities, and 28 (93%) were confirmed to have abnormal histology (FS > or = 2). Of the patients without calcifications: in the 41 patients without calcifications on EUS, 36 (88%) had FS > or = 2; median FS was 5 (range, 0-12); the correlation between the number of EUS criteria and FS was low but statistically significant (r = 0.40; P = .01). Three or more EUS criteria provided the best balance of sensitivity (83.3%) and specificity (80.0%) for predicting abnormal histology. LIMITATIONS: Retrospective study. All patients were believed to need surgery. CONCLUSIONS: A threshold of 3 or more EUS criteria provides the best balance of sensitivity and specificity for histologic pancreatic fibrosis. Calcifications seen by EUS but missed by other imaging are common in this group of patients.

Clinically significant small-bowel pathology identified by double-balloon enteroscopy but missed by capsule endoscopy.

BACKGROUND: Capsule endoscopy (CE) is increasingly being used to investigate the small bowel for various indications, including obscure GI bleeding (OGB). However, false negatives have been described. Double-balloon enteroscopy (DBE) is a new endoscopic technique developed to potentially view the entire small intestine while allowing therapeutic options to be carried out when appropriate. OBJECTIVE: We described 4 patients with small-bowel pathology missed on CE but detected by DBE. DESIGN: Descriptive retrospective study. All patients underwent CE followed by DBE. SETTING: Single-center tertiary referral hospital. PATIENTS: Four patients were included. Three patients had OGB that required blood transfusions. One patient with celiac disease, compliant on a strict gluten-free diet for 5 months, presented with persistent weight loss and abdominal pain. INTERVENTIONS: DBE followed by surgical exploration and resection of small-bowel pathology. MAIN OUTCOME MEASUREMENTS: Successful identification of pathology missed by CE. Definitive treatment of small-bowel pathology by surgical resection. RESULTS: CE did not identify the small-bowel pathology in all 4 patients. The 3 patients with OGB had small-bowel masses found by DBE. Two of these were GI stromal tumors and one was an adenocarcinoma. The patient with celiac disease had a malignant ulcer, confirmed to be a lymphoma after surgical resection. LIMITATIONS: Retrospective study and small sample size. CONCLUSIONS: CE and DBE are complementary investigations. If there is a high index of suspicion of small-bowel pathology despite a negative CE, DBE should be performed.

Fecal incontinence related to pregnancy.

Fecal incontinence related to pregnancy is an underreported and debilitating physical problem that has psychosocial ramifications. Disruption of the external and internal anal sphincters, which may occur during vaginal delivery, is the most common etiologic factor. Endoanal ultrasound is a minimally invasive, simple, and accurate diagnostic tool used to confirm and guide management of sphincter complex disruption.

The effect of erythromycin on video capsule endoscopy intestinal-transit time.

BACKGROUND: Video capsule endoscopy (VCE) will fail to reach the cecum in 20% of patients within the 8-hour battery life. The use of prokinetics to improve VCE completion rates to the cecum remains unclear. The objective of this study was to determine whether erythromycin increases the completion rate of VCE to the cecum without adversely affecting image quality. METHODS: This was a prospective, randomized, single-blinded control trial at St. Vincent's Hospital, Melbourne, Australia. A total of 86 consecutive patients referred for VCE were considered for entry; 45 patients met the entry criteria. These 45 patients were prospectively randomized to no erythromycin (controls, n = 23) or 250 mg erythromycin (n = 22). Two gastroenterologists, who were unaware of which group the patients were randomized into, reported all VCEs. The number of VCEs that reached the cecum within the 8-hour study period, gastric emptying time (GET), and small-bowel transit time (SBTT) were calculated for each group. RESULTS: There was no significant difference in the number of VCEs that reached the cecum (32% failed to reach the cecum in the erythromycin group compared with 22% in the control group), GET, or SBTT between the two groups. Image quality was not adversely affected by the use of erythromycin. The dose and the preparation of erythromycin used in this study may have possibly had an effect on GET and SBTT. CONCLUSIONS: The use of erythromycin did not significantly increase the likelihood of the capsule reaching the cecum or affect the degree of visible peristalsis or the interpretation of capsule findings.

Prospective study of the clinical impact of EUS.

BACKGROUND: Studies on the clinical impact of EUS are lacking. The aim of this study was to examine the impact of EUS on the management plans by referring doctors and patient outcomes. METHODS: Consecutive patients undergoing EUS between August 2002 and June 2004 were prospectively studied. Referring doctors were given a pre-EUS questionnaire that asked about provisional diagnosis and management plan. A post-EUS questionnaire was sent 6 weeks after the procedure. RESULTS: A total of 330 patients were examined, and completed questionnaires were received in 70%. EUS-guided FNA was performed in 69 (30%) patients. EUS resulted in a change in diagnosis and management in 26% and 48% of cases, respectively. Thirty-nine of the latter patients (33%) avoided unnecessary surgery. In 50% of cases, additional investigations were avoided. Doctors reported EUS as very or moderately useful in 210 patients (91%). Doctors of 223 patients (97%) reported that they would use EUS again. CONCLUSIONS: The use of EUS had a significant clinical impact on patients. EUS resulted in a change of diagnosis in a fourth of patients and a change in management in half of patients studied.

Capsule endoscopy vs. push enteroscopy and enteroclysis in suspected small-bowel Crohn's disease.

BACKGROUND: The diagnosis of small-bowel Crohn's disease sometimes is difficult and may be missed by conventional imaging studies. Capsule endoscopy might identify small-bowel disease undetected by other investigations. METHODS: Patients with or without known Crohn's disease who were suspected to have small-bowel Crohn's disease were prospectively evaluated with push enteroscopy, enteroclysis, and capsule endoscopy. Each examiner was blinded to results of other investigations. Referring doctors were required to complete questionnaires before and after the investigations. RESULTS: Twenty-two patients were known to have Crohn's disease (Group 1), and 21 were suspected to have small-bowel Crohn's disease (Group 2). In Group 1, capsule endoscopy detected more erosions than the other two investigations (p < 0.001). In Group 2, a new diagnosis of Crohn's disease was made in two patients, but there was no significant difference in yield compared with the other two investigations. Referring physicians rated the usefulness of capsule endoscopy as 4.4 on a scale of 5. Capsule endoscopy changed management for 30 patients (70%). CONCLUSIONS: Capsule endoscopy has a higher yield than push enteroscopy and enteroclysis in patients with known Crohn's disease when small-bowel mucosal disease is suspected, and this leads to a change in management in the majority of these patients.

Clinical and endoscopic features of eosinophilic esophagitis in adults.

BACKGROUND: Eosinophilic esophagitis in adults is regarded as unusual, being diagnosed mostly in young men presenting with dysphagia. Mucosal furrows are a sentinel endoscopic feature. This study examined the demographic and clinical profile of adults with eosinophilic esophagitis seen from 1981 to 2002. METHODS: All patients from an Australian provincial city (population 198,000) with otherwise unexplained eosinophilic inflammation of the squamous epithelium (>/=30 eosinophils per high-power field) were included in a retrospective review. RESULTS: A diagnosis of eosinophilic esophagitis was made in 31 patients (24 men, 7 women; mean age 34 years, range 14-77 years). The diagnosis was made in 19 (61%) of the 31 patients during the most recent 2 years (none between 1981 and 1994 vs. 12 between 1995-2000 vs. 19 between 2000-2001). Esophageal mucosal furrows were present in 30 (97%), a finding infrequently recognized before 2001. Dysphagia was documented in 26 (89%). Symptoms had been present for long periods before diagnosis (mean 54 months; range 0-180 months), and diagnosis was delayed in 7 (mean 81 months, range 20-144 months) because sentinel features were overlooked at endoscopy. Strictures, often evident only as a result of mucosal shearing during dilation, were present in 17 (57%). Esophageal dilation preformed in 17 (mean 3.4 dilations per patient, range 1-13) consistently relieved symptoms; tears were recorded in 13 (87%), but no serious complication resulted. CONCLUSIONS: Eosinophilic esophagitis in adults of all ages is more common than recognized. Mucosal furrows are easily overlooked at endoscopy although this finding is an important clue to diagnosis. Strictures, a frequent consequence, can be safely managed by dilation.

Initial experience with capsule endoscopy at a major referral hospital.

OBJECTIVES: To determine the utility of capsule endoscopy in patients referred for investigation of suspected disease of the small intestine. DESIGN AND SETTING: Single centre, prospective, cohort study from 4 July 2001 to 8 September 2002. PATIENTS: Sixty consecutive patients who underwent capsule endoscopy for investigation of suspected disease of the small intestine. MAIN OUTCOME MEASURES: Abnormal findings at capsule endoscopy. RESULTS: Examination of the entire small bowel was achieved in 46/60 patients (77%). Thirty-two of 47 patients (68%) referred with obscure gastrointestinal bleeding had positive findings. Seven of nine patients (78%) referred for investigation of suspected Crohn's disease had small bowel erosions or ulcers consistent with Crohn's disease. The capsule was not passed in one patient. CONCLUSION: Capsule endoscopy is a novel, minimally invasive and useful tool for the investigation of the small intestine.