Evolution of endoscopic mucosal resection (EMR) technique and the reduced recurrence of large colonic polyps from 2012 to 2020.

BACKGROUND: Endoscopic mucosal resection (EMR) is an effective method for removing non-pedunculated polyps ≥ 20 mm. We aimed to examine changes in EMR techniques over a 9-year period and evaluate frequency of histologic-confirmed recurrence. METHODS: We identified patients who underwent EMR of non-pedunculated polyps ≥ 20 mm at a safety net and the Veteran's Affairs (VA) hospital in Houston, Texas between 2012 and 2020. Odds ratios (ORs) and 95% confidence intervals (CI) for associations with recurrence risk were estimated using multivariable logistic regression. RESULTS: 461 unique patients were included. The histologic-confirmed recurrence was 29.0% at 15.6 months median follow up (IQR 12.3 - 17.4). Polyps removed between 2018 and 2020 had a 0.43 decreased odds of recurrence vs. polyps removed between 2012 and 2014. The use of viscous lifting agents increased over time (from 0 to 54%), and the use of saline was associated with increased risk of recurrence (OR 2.28 [CI 1.33 - 3.31]). CONCLUSIONS: Histologic-confirmed recurrence after EMR for non-pedunculated polyps ≥ 20 mm decreased over the seven year-period. Saline was associated with a higher risk of recurrence and the use of more viscous agents increased over time.

Race/Ethnicity and Birthplace as Risk Factors for Gastric Intestinal Metaplasia in a Multiethnic United States Population.

INTRODUCTION: Several US subgroups have increased risk of gastric cancer and gastric intestinal metaplasia (GIM) and may benefit from targeted screening. We evaluated demographic and clinical risk factors for GIM and examined the interaction between race/ethnicity and birthplace on GIM risk. METHODS: We identified patients who had undergone esophagogastroduodenoscopy with gastric biopsy from 3/2006-11/2016 using the pathology database at a safety net hospital in Houston, Texas. Cases had GIM on ≥1 gastric biopsy histopathology, whereas controls lacked GIM on any biopsy. We estimated odds ratios and 95% confidence intervals (CI) for associations with GIM risk using logistic regression and developed a risk prediction model of GIM risk. We additionally examined for associations using a composite variable combining race/ethnicity and birthplace. RESULTS: Among 267 cases with GIM and 1,842 controls, older age (vs <40 years: 40-60 years adjusted odds ratios (adjORs) 2.02; 95% CI 1.17-3.29; >60 years adjOR 4.58; 95% CI 2.61-8.03), Black race (vs non-Hispanic White: adjOR 2.17; 95% CI 1.31-3.62), Asian race (adjOR 2.83; 95% CI 1.27-6.29), and current smoking status (adjOR 2.04; 95% CI 1.39-3.00) were independently associated with increased GIM risk. Although non-US-born Hispanics had higher risk of GIM (vs non-Hispanic White: adjOR 2.10; 95% CI 1.28-3.45), we found no elevated risk for US-born Hispanics (adjOR 1.13; 95% CI 0.57-2.23). The risk prediction model had area under the receiver operating characteristic of 0.673 (95% CI 0.636-0.710) for discriminating GIM. DISCUSSION: We found that Hispanics born outside the United States were at increased risk of GIM, whereas Hispanics born in the United States were not, independent of Helicobacter pylori infection. Birthplace may be more informative than race/ethnicity when determining GIM risk among US populations.

Endoscopic Diagnosis and Management of Gastrointestinal Trauma.

Trauma affects all sociodemographic profiles and is a major cause of morbidity and mortality particularly in patients less than forty years of age. A variety of endoscopic tools and techniques initially used for iatrogenic etiologies (post-operative bile or pancreatic duct leaks, intra-procedural perforation) have been adopted for use in the gastrointestinal trauma victim. The purpose of this review is to highlight a variety of gastrointestinal traumatic complications where endoscopy can serve a complement and/or definitive management strategy.

Cholangioscopy Is Safe and Feasible in Elderly Patients.

BACKGROUND & AIMS: Although cholangioscopy is widely used during endoscopic retrograde cholangiopancreatiography (ERCP), its safety and feasibility for elderly patients are not well established. We aimed to evaluate the safety and feasibility of cholangioscopy in elderly patients. METHODS: We performed a retrospective study of all ERCPs with single-operator cholangioscopy (SOC) performed at 3 tertiary referral hospitals from March 2012 through October 2015. We collected data on patient demographics, procedure indications, findings, complications, and success rates (complete success was achieved if all intended diagnostic and therapeutic procedures were performed, such as tissue sample collection or complete removal of stones). The cohort was divided into 3 groups: patients younger than 65 years (group 1, n = 178), patients 65-75 years old (group 2, n = 86), and patients older than 75 years (group 3, n = 77). We used 1-way ANOVA, the χ2 test, and the Wilcoxon sum rank test to compare study variables. The primary aim was to assess rates of complications from ERCP with SOC in elderly patients compared with younger patients. RESULTS: Baseline clinical features were similar among groups, except for a higher prevalence of co-morbidities in group 3. The indication for and findings from ERCP with SOC differed among the groups; stricture or tumor was the most common indication in groups 1 and 3-the most common findings were strictures and masses, respectively. In group 2, choledocholithiasis was the most common indication and finding. The success rate, analyzed in a subset of 209 patients, was 88.5% overall and did not differ significantly among groups. The overall rate of complication was 7.33% with no significant difference among groups (7.30% for group 1, 6.98% for group 2, and 7.79% for group 3) (P < .17). CONCLUSIONS: In a retrospective analysis of ERCPs with SOCs, we found this procedure to be safe for elderly patients (older than 75 years), who had rates of complications and hospital admission similar to those of younger patients.

Endoscopic vacuum therapy for treatment of spontaneous and iatrogenic upper gastrointestinal defects.

BACKGROUND/AIMS: Endoscopic vacuum therapy (EVT) can heal a variety of defects within the gastrointestinal (GI) tract via applying negative pressure, which reduces the defect size, aspirates the infected fluid, and promotes granulation tissue. Here we present our experience with EVT as it relates to both spontaneous and iatrogenic upper GI tract perforations, leaks, and fistulas. METHODS: This retrospective study was conducted at four large hospital centers. All patients who underwent EVT between June 2018 and March 2021 were included. Data on multiple variables were collected, including demographics, defect size and location, number and intervals of EVT exchanges, technical success, and hospital length of stay. Student t-test and the chi-squared test were used to analyze the data. RESULTS: Twenty patients underwent EVT. The most common defect cause was spontaneous esophageal perforation (50%). The most common defect location was the distal esophagus (55%). The success rate was 80%. Seven patients were treated with EVT as the primary closure method. The mean number of exchanges was five with a mean interval of 4.3 days between exchanges. The mean length of hospital stay was 55.8 days. CONCLUSION: EVT is a safe and effective initial management option for esophageal leaks and perforations.

Esophageal Perforation Successfully Treated With EVT.

Esophageal perforation is rare and carries high morbidity and mortality. A high degree of suspicion is needed for timely diagnosis and treatment. A 54-year-old man presented with fever and confusion. Imaging revealed air in the hepatic inferior vena cava and concern for a fistula between the distal esophagus and the inferior vena cava. An upper endoscopic evaluation revealed a dental floss pick penetrating the distal esophagus. The foreign body was removed, and endoluminal vacuum therapy was used to close the perforation. Endoluminal vacuum therapy is an emerging therapy to treat full-thickness gastrointestinal injuries.

Evaluating the Revised American Society for Gastrointestinal Endoscopy Guidelines for Common Bile Duct Stone Diagnosis.

BACKGROUND/AIMS: The American Society for Gastrointestinal Endoscopy (ASGE) revised its guidelines for risk stratification of patients with suspected choledocholithiasis. This study aimed to assess the diagnostic performance of the revision and to compare it to the previous guidelines. METHODS: We conducted a retrospective cohort study of 267 patients with suspected choledocholithiasis. We identified high-risk patients according to the original and revised guidelines and examined the diagnostic accuracy of both guidelines. We measured the association between individual criteria and choledocholithiasis. RESULTS: Under the original guidelines, 165 (62%) patients met the criteria for high risk, of whom 79% had confirmed choledocholithiasis. The categorization had a sensitivity and specificity of 68% and 55%, respectively, for the detection of choledocholithiasis. Under the revised guidelines, 86 (32%) patients met the criteria for high risk, of whom 83% had choledocholithiasis. The revised categorization had a lower sensitivity and higher specificity of 37% and 80%, respectively. The positive predictive value of the high-risk categorization increased with the revision, reflecting a potential decrease in diagnostic endoscopic retrograde cholangiopancreatograpies (ERCPs). Stone visualized on imaging had the greatest specificity for choledocholithiasis. Gallstone pancreatitis was not associated with the risk for choledocholithiasis. CONCLUSION: The 2019 revision of the ASGE guidelines decreases the utilization of ERCP as a diagnostic modality and offers an improved risk stratification tool.

Education, training, and knowledge of infection control among endoscopy technicians and nurses.

Our survey of 88 endoscopy technicians and nurses to determine their experience, training, and knowledge of infection control found that few personnel (<15%) received formal training in endoscope reprocessing or infection prevention before or after joining an endoscopy unit. While self-reported confidence in endoscope reprocessing was high (9 out of 10), knowledge of best practices in this regard lagged (average assessment score of 62%).

An international study of interobserver variability of "string sign" of pancreatic cysts among experienced endosonographers.

BACKGROUND AND OBJECTIVES: No single optimal test reliably determines the pancreatic cyst subtype. Following EUS-FNA, the "string sign" test can differentiate mucinous from nonmucinous cysts. However, the interobserver variability of string sign results has not been studied. METHODS: An experienced endosonographer performed EUS-FNA of pancreatic cysts on different patients and was recorded on video performing the string sign test for each. The videos were shared internationally with 14 experienced endosonographers, with a survey for each video: "Is the string sign positive?" and "If the string sign is positive, what is the length of the formed string?" Also asked "What is the cutoff length for string sign to be considered positive?" Interobserver variability was assessed using the kappa statistic (κ). RESULTS: A total of 112 observations were collected from 14 endosonographers. Regarding string sign test positivity, κ was 0.6 among 14 observers indicating good interrater agreement (P < 0.001) while κ was 0.38 when observers were compared to the index endosonographer demonstrating marginal agreement (P < 0.001). Among observations of the length of the string in positive samples, 89.8% showed >5 mm of variability (P < 0.001), indicating marked variability. There was poor agreement on the cutoff length for a string to be considered positive. CONCLUSION: String sign of pancreatic cysts has a good interobserver agreement regarding its positivity that can help in differentiating mucinous from nonmucinous pancreatic cysts. However, the agreement is poor on the measured length of the string and the cutoff length of the formed string to be considered a positive string sign.

Rare Collision Tumor of the Biliary Tract.

Malignancies of the gallbladder are uncommon in the developed world. Collision tumors are also extremely rare neoplastic phenomena. Given their scarcity, there are no guidelines for treatment, and prognosis is based on the more aggressive tumor type. We present a patient with a collision tumor consisting of signet-ring cholangiocarcinoma and large-cell neuroendocrine gallbladder carcinoma of the biliary tract, and we review the literature pertaining to biliary tract collision tumors and their management.

Long-term follow up of patients with obscure gastrointestinal bleeding examined with video capsule endoscopy.

BACKGROUND: Video capsule endoscopy (VCE) is a commonly used test for the evaluation of obscure gastrointestinal bleeding. However, long-term outcomes of patients undergoing VCE are unclear. AIMS: To evaluate the long-term outcomes in patients undergoing VCE for suspected obscure bleeding including iron deficiency anemia (IDA), and determine the need for additional intervention for persistence or recurrence of symptoms in patients with a diagnostic as well as non-diagnostic VCE. DESIGN: Retrospective cohort study within a large county hospital system. METHODS: We collected information on indications and findings of VCE and outcomes including further testing, bleeding, and hemoglobin (Hgb) at last follow-up through structured review of the electronic health records. VCE findings were classified as active bleeding or high potential for bleeding (P2), intermediate potential (P1) or without any disruption of the mucosa, and no potential for bleeding (P0). We compared demographic and clinical characteristics between patients with and without normal Hgb at the time of last follow up. RESULTS: We examined 116 patients who underwent VCEs performed for obscure gastrointestinal (GI) bleeding during 2010 to 2012 with mean duration of follow up after VCE completion of 571 days (standard deviation [SD] = 248). Abnormal VCE findings (37.9% for P1 lesions, 44.8% for P2 lesions) were seen in 106 (87.9%) patients. Additional diagnostic testing was performed in 55/116 (47.4%) (67.7% GI procedures). Hgb was restored to normal range in 59/116 (50.9%) by end of follow up which were attributed to iron supplementation and/or discontinuation of non-steroidal anti-inflammatory drugs (NSAIDs) in a majority. Twenty six of 116 patients experienced rebleeding (22.4%). CONCLUSIONS: The diagnostic yield of VCE is high among patients with obscure GI bleeding. More than 50% of patients achieve normal Hgb in the long term with conservative measures such as iron supplementation and the discontinuation of NSAIDs.

Toothpick perforation of the intestines presenting as recurrent abdominal pain: possible roles of abdominal ultrasound and MRI.

We report the case of a middle-aged man admitted for five months of unexplained left lower quadrant pain. He had been hospitalized on two prior occasions and treated with broad spectrum antibiotics. His clinical presentation was suggestive peritoneal irritation with severe, focal pain on abdominal palpation. Computed tomography scans showed non-specific inflammation in the left lower abdomen with adjacent small bowel wall thickening. Upper endoscopy and colonoscopy were unremarkable on prior admission. Given the severity and focality of the patient's recurrent abdominal pain he underwent laparoscopy and was found to have a wooden toothpick perforation of the small bowel thirty centimeters from the ileocecal valve requiring partial small bowel resection. The patient did well post-operatively. On retrospective questioning he may have eaten a cabbage roll or bacon wrapped shrimp pierced with a toothpick weeks before the onset of symptoms. Toothpick perforation should be a consideration in edentulous persons with focal, severe abdominal pain and trans-abdominal ultrasound or MRI may be a better choice for detecting wooden foreign objects.