Low-dose pulsed vs standard pulsed fluoroscopy during ERCP to reduce radiation without change in image quality: Prospective randomized study.

Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) poses the risk of radiation exposure (RE) to patients and staff and increases the risk of adverse biological effects such as cataracts, sterility, and cancer. Newer fluoroscopy equipment (C-Arm) provides options to limit radiation in the form of lower radiation dose and frame rate or time-limited "pulsed" settings. However, the impact of lower settings on image quality has not been assessed, and no standard protocol exists for fluoroscopy settings used during ERCP. Patients and methods This was a single-center, double-blind, prospective randomized study of consecutive adult patients undergoing standard-of-care ERCP at a tertiary academic medical center. Patients were randomized into two groups: 1) standard-dose pulsed and 2) low-dose pulsed. Pulsed mode (8 fps) was defined as x-ray exposure either in the manufacturer standard-dose or low-dose settings limited to 3 seconds each time the foot-operated switch was depressed. Results Seventy-eight patients undergoing ERCP were enrolled and randomized. No difference in age, gender, or body mass index was found between the two groups. No significant difference in image quality was found between standard-dose and low-dose fluoroscopy P = 0.925). The low-dose group was exposed to significantly less radiation when compared with standard-dose P < 0.05). Fluoroscopy time (minutes) was similar in both groups (2.0 vs 1.9), further suggesting that group assignment had no impact on image quality or procedure time. Conclusions Low-dose pulsed fluoroscopy is a reliable method that substantially reduces radiation without compromising image quality or affecting procedure or fluoroscopy times. This underscores the need for standardization in ERCP fluoroscopy settings to limit radiation exposure.

Recognizing intrapancreatic accessory spleen via EUS: Interobserver variability.

BACKGROUND AND OBJECTIVE: Accessory spleen (AS) may be encountered as an intrapancreatic lesion on EUS. This can look similar to other pancreatic pathologies and may lead to unnecessary interventions. The goal of this study was to evaluate the accuracy of EUS in distinguishing intrapancreatic AS (IPAS) from other pancreatic lesions. MATERIALS AND METHODS: Twelve sets of endoscopic images of the spleen and various pancreatic lesions confirmed on histology or cytology were gathered. Ten endosonographers were asked to characterize and identify the lesions. The responses were analyzed via Excel and the interobserver agreement was analyzed using Gwet's agreement coefficient statistic via Stata I/C v15. RESULTS: In our sample, the interobserver agreement was 0.37 (-+1-1; 0-0.2 poor, 0.2-0.4 fair, 0.4-0.6 moderate, 0.6-0.8 substantial, and 0.8-1.0 almost perfect) for determining whether or not the pancreatic lesion is IPAS. The reviewers were able to correctly determine IPAS endosonographically with a sensitivity of 77%, specificity of 74%, and positive and negative predictive values of 50% and 92%, respectively. CONCLUSION: There is a moderate-to-substantial interobserver agreement in describing the sonographic characteristics of the pancreatic lesions, such as the shape, echogenicity compared to spleen, echotexture, and border of the lesions. However, the interobserver agreement is only fair when deciding if the pancreatic lesion is an IPAS. The similar profile of IPAS and pancreatic neuroendocrine tumor could confound the diagnosis of IPAS, thus contributing to the decreased interobserver agreement. This study demonstrates that EUS criteria alone are not accurate for IPAS diagnosis. Fine-needle aspiration (FNA) may be required for a confirmatory diagnosis.

Carcinoid tumor causing ileoceccal intussusception in an adult patient.

Introduction: Little is known about adult intussusception, but current evidence suggests that malignancy, polyps, and diverticula are usual etiologies. We present a case of adult ileoceccal intussusception secondary to carcinoid tumor. Case Presentation: A 53-year-old African American male presented with hematochezia and non-radiating constant left upper quadrant pain accompanied by nausea and vomiting. CT of the pelvis demonstrated a pathognomic 'target' sign, consistent with ileoceccal intussusception and early small bowel obstruction. Two years prior to this current presentation, the patient had experienced an episode of hematochezia for which he underwent colonoscopy and polypectomy, with subsequent pathology results negative for colon cancer. He denies diarrhea, constipation, weight loss, decreased appetite or skin flushing. Due to persistent symptoms of bowel obstruction, he underwent exploratory laparotomy. During the surgery a white-colored, chalky mass indicative of penetrating tumor was noted 13 cm proximal to the ileocecal valve. An extended right hemi-colectomy followed the discovery of the mass. Pathology showed a well-differentiated neuroendocrine tumor consistent with carcinoid tumor. Evaluation for metastatic disease using 5-HIAA and chromogranin A was unremarkable, and the resection of the right colon carcinoid tumor was felt to be curative. Conclusion: It is uncommon for adults to present with intussusception; in such cases, malignancy should be ruled out as an underlying cause. Carcinoid should be listed among the other secondary causes, which include inflammatory bowel disease, diverticulitis, polyps, scar tissue, adhesions, and lipomas. Abbreviation: CT (Computer tomography), 5-HIAA (5-hydroxyindole acetic acid), NCCN (National Comprehensive Cancer Network).

Comparison of the Diagnostic Yield of EUS Needles for Liver Biopsy: Ex Vivo Study.

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.

Liquid nitrogen spray cryotherapy in Barrett's esophagus with high-grade dysplasia: long-term results.

BACKGROUND: Liquid nitrogen endoscopic spray cryotherapy can safely and effectively eradicate high-grade dysplasia in Barrett's esophagus (BE-HGD). Long-term data on treatment success and safety are lacking. OBJECTIVE: To assess the long-term safety and efficacy of spray cryotherapy in patients with BE-HGD. DESIGN: Single-center, retrospective study. SETTING: Tertiary-care referral center. PATIENTS: A total of 32 patients with BE-HGD of any length. INTERVENTION: Patients were treated with liquid nitrogen spray cryotherapy every 8 weeks until complete eradication of HGD (CE-HGD) and intestinal metaplasia (CE-IM) was found by endoscopic biopsy. Surveillance endoscopy with biopsies was performed for at least 2 years. MAIN OUTCOME MEASUREMENTS: CE-HGD, CE-IM, durability of response, disease progression, and adverse events. RESULTS: CE-HGD was 100% (32/32), and CE-IM was 84% (27/32) at 2-year follow-up. At last follow-up (range 24-57 months), CE-HGD was 31/32 (97%), and CE-IM was 26/32 (81%). Recurrent HGD was found in 6 (18%), with CE-HGD in 5 after repeat treatment. One patient progressed to adenocarcinoma, downgraded to HGD after repeat cryotherapy. BE segment length ≥3 cm was associated with a higher recurrence of IM (P = .004; odds ratio 22.6) but not HGD. No serious adverse events occurred. Stricture was seen in 3 patients (9%), all successfully dilated. LIMITATIONS: Retrospective study design, small sample size. CONCLUSION: In patients with BE-HGD, liquid nitrogen spray cryotherapy has an acceptable safety profile and success rate for eliminating HGD and IM and is associated with a low rate of recurrence or progression to cancer with long-term follow-up.

Minimally invasive repair of a late stricture in a reversed gastric tube.

Ingestion of caustic agents may result in severe scarring and stricture formation of the esophagus. Reversed gastric tube esophagoplasty is an option for definitive surgical management of severe esophageal stricture refractory to medical treatment. Delayed complications from this procedure have rarely been reported. We present a case involving a patient who developed a delayed gastric stricture three decades after receiving a reversed gastric tube esophagoplasty. A historical review of the reversed gastroplasty is presented as well.

Jackson Pratt drain fluid-to-serum bilirubin concentration ratio for the diagnosis of bile leaks.

BACKGROUND: Jackson Pratt (JP) drain fluid bilirubin levels may be assayed in the evaluation of possible bile leaks. Although fluid color and bilirubin level may prompt additional evaluation, there are no reference data available. OBJECTIVE: To assess the JP drain fluid-to-serum bilirubin ratio in patients with documented bile leaks. DESIGN: Prospective case series. SETTING: Tertiary referral center. METHODS: Patients referred for ERCP for the management of documented bile leaks with a JP drain in place were included. Demographic data, bile leak etiology, and serum bilirubin levels were recorded. JP drain fluid was sent for color evaluation and bilirubin concentration. Control subjects included both patients after nonbiliary surgery with a JP drain in place and medical patients with ascites undergoing paracentesis. RESULTS: JP drain fluid-to-serum bilirubin concentration and fluid color evaluation was performed on 23 patients with documented bile leaks by ERCP and compared with 26 controls (16 surgical and 10 medical). The JP drain fluid/ascites-to-serum bilirubin ratio was significantly higher in those with bile leaks (mean ratio 45.6) compared with combined controls (mean ratio 0.9). Use of a cutoff JP drain fluid-to-serum bilirubin ratio of 5 would be 100% sensitive and specific for the prediction of a bile leak in the selected control group. There was overlap in fluid color evaluation between the groups. LIMITATIONS: Controls did not include those with suspected bile leaks and negative technetium 99m-HIDA scintigraphy or ERCP findings. CONCLUSIONS: JP drain fluid-to-serum bilirubin concentration ratio greater than 5 seems to be highly sensitive and specific for the detection of a bile leak. Used along with clinical criteria, this ratio could be used to select patients to proceed directly to ERCP.

Evaluation of subepithelial abnormalities of the appendix by endoscopic ultrasound.

Background. The use of through-the-scope (TTS) miniprobe catheter endoscopic ultrasound is a valuable technique for evaluating subepithelial lesions in the proximal colon. Few reports include the evaluation of the appendix by EUS. Objective. To describe endoscopic and endosonographic characteristics of subepithelial lesions of the appendix. Methods. Retrospective case series in a single academic medical center. Adult patients referred for evaluation of subepithelial lesions of the appendix identified by colonoscopy between April 1, 2003 to February 29, 2008. Data were abstracted from an electronic endoscopic database for all patients undergoing miniprobe endoscopic ultrasound examination of the appendix. Medical records were reviewed for patient followup and outcomes. Results. Nine cases were identified. Seven (78%) patients were female. Seven (78%) utilized the 12 MHz miniprobe device and two (22%) used the 20 MHz device. Three mucoceles were described and confirmed by surgical resection. Cases also included one inverted appendix, one gastrointestinal stromal tumor, and one lipoma. In three cases, no abnormality was found. Conclusions. EUS evaluation of the appendix is feasible with standard miniprobe devices and may assist in the selection of patients who may benefit from surgical management.

Time-limited fluoroscopy to reduce radiation exposure during ERCP: a prospective randomized trial.

BACKGROUND: Measures should be used to limit radiation exposure of the staff and patients during ERCP. OBJECTIVE: To determine whether "time-limited fluoroscopy" reduces radiation exposure and fluoroscopy time (FT) compared with continuous fluoroscopy. DESIGN: Prospective randomized trial. SETTING: Tertiary academic medical center. PATIENTS: Consecutive adult patients presenting for ERCP. INTERVENTIONS: Subjects were randomized into 2 fluoroscopy setting groups: (1) time-limited, where x-ray exposure is limited to 3 seconds each time the foot-operated switch is depressed; (2) continuous, where x-ray exposure continues for as long as the switch is depressed. MAIN OUTCOMES MEASUREMENTS: FT, patient, and procedure-related data were recorded. Radiation dosimetry badges were used to estimate cumulative exposure. RESULTS: Ninety-nine procedures were performed in the time-limited group and 100 by using continuous fluoroscopy. The mean FT for time-limited fluoroscopy was 284.4 seconds (95% confidence interval [CI] 247.1-321.6) and for continuous fluoroscopy was 314 seconds (95% CI 265.6-362.4; P=.34). Longer FT was associated with moderate or difficult cannulation (P=.008), lithotripsy (P<.001), stent placement (P=.007), sphincterotomy (P<.001), and longer overall procedure length (P<0.001). After controlling for confounding factors and interactions with a multiple linear regression model, time-limited fluoroscopy was associated with a 16.4% lower FT (P=.029). The average radiation dose was not amenable to multivariate analysis, and, therefore, no significant difference between groups was found. LIMITATIONS: Endoscopists were not blinded to the study group assignments. CONCLUSIONS: FT and radiation exposure are dependent upon numerous patient-, operator-, and procedure-related factors. This study found that, after controlling for the impact of confounding factors, time-limited fluoroscopy significantly decreases FTs.

Effect of physician training on fluoroscopy time during ERCP.

Our purpose was to compare fluoroscopy time during endoscopic retrograde cholangiopancreatography (ERCP) between endoscopists with different levels of experience. We performed a cross-sectional analysis of 269 consecutive ERCPs at an academic hospital during 1 year. Median fluoroscopy time was significantly longer in more complex cases, such as in therapeutic (406.5 s [IQR, 235.5-685]) compared to diagnostic (202 s [IQR, 141-481]; P = 0.002) procedures. The experience (number of prior ERCPs) of gastroenterology fellows involved in procedures was an independent predictor of shorter fluoroscopy time when controlling for patient and procedure characteristics (P < 0.0001). Median fluoroscopy time was 2.73 min shorter after at least 50 procedures had been performed (P = 0.039). Time for ERCPs involving fellows was not significantly longer than cases by attending physicians alone (P = 0.23). Increased experience is associated with lower radiation exposure during ERCP training. Radiation reduction methods should be prospectively investigated and integrated into training programs.

Quality assessment of colonoscopic cecal intubation: an analysis of 6 years of continuous practice at a university hospital.

BACKGROUND: Despite increased emphasis on endoscopic performance indicators, e.g., cecal intubation rates, limited data from actual clinical practice have been published. OBJECTIVES: Retrospective database review to determine the rate and documentation of cecal intubation during colonoscopy at the University of Maryland Medical Center. METHODS: We reviewed 5,477 consecutive colonoscopies performed by 10 faculty gastroenterologists at a University hospital over a 6-yr period (March 1, 1999 to February 28, 2005). Unadjusted cecal intubation rates were analyzed as were rates that were adjusted based on the U.S. Multi-Society Task Force on Colorectal Cancer recommendations. We analyzed trends in overall and individual cecal intubation rates, circumstances that impact these rates, and the quality of documentation of cecal intubation. RESULTS: The overall adjusted cecal intubation rate for the entire 6 yr was 90.3%, and increased over the study period with the highest adjusted rate (93.7%) in the most recent year studied. There was no correlation between cecal intubation rate and patient age, gastroenterology fellow involvement, or endoscopist experience and number of procedures/year. In contrast, colon cancer screening, male gender, outpatient colonoscopy, and adequate bowel preparation predicted a higher cecal intubation rate. Written and photographic documentation of cecal intubation improved significantly after 2002. CONCLUSIONS: Our analysis revealed cecal intubation and documentation rates that meet current guidelines, and identified factors that may cause substantial variance in these rates depending on the nature of the practice. The present analysis confirms that computerized databases can be used to assess individual and group cecal intubation and documentation rates on an annual basis, and to make these data available to the public.