Endoscopic resection in the duodenum: current limitations and future directions.

Duodenal lesions that should be considered for endoscopic resection comprise a heterogeneous group of disorders. Most are adenomas, primarily located in the descending duodenum. In comparison to lesions of a similar size elsewhere in the gastrointestinal tract, the risk of major complications from endoscopic resection of duodenal lesions is magnified. The unique anatomical features of the duodenum are largely responsible for this, but despite this we continue to apply conventional endoscopic therapies when a more sophisticated approach is required. Many other important clinical questions in relation to duodenal adenomas remain unanswered. This review aims to identify the gaps in the knowledge base and therapeutic approach and propose some solutions and directions for future research.

Factors that predict bleeding following endoscopic mucosal resection of large colonic lesions.

BACKGROUND AND STUDY AIMS: Endoscopic mucosal resection (EMR) for large colonic laterally spreading tumors (LSTs) is a safe, efficacious, and cost-effective treatment. The most common serious complication is delayed bleeding, which reduces these advantages, but consensus guidelines for large-polyp EMR do not exist. PATIENTS AND METHODS: Data from two large prospective intention-to-treat studies of EMR for colonic LSTs 20 mm or greater in size were analyzed. Data collection was comprehensive, and included patient and lesion characteristics. EMR technique and cessation of anticoagulant and antiplatelet therapy was standardized. Clinically significant delayed bleeding was defined as that requiring hospital admission. RESULTS: EMR was performed on 302 lesions in 288 patients. There was clinically significant delayed bleeding in 21 cases (7 %). Ten underwent colonoscopy. One required angiography. One required surgery after perforation following hemostatic clip placement. There were no deaths. Risk factors for bleeding on multivariate analysis were right colon location [adjusted odds ratio (OR) 4.4, P = 0.01], use of aspirin (OR 6.3, P = 0.005), and age (OR per decade of age 1.70). All bleeds occurred before aspirin was restarted. Patient characteristics, including ASA grade and co-morbidity type, were not predictive. Despite requiring more complex EMR, larger lesion size ( P = 0.2), multiple excisions rather than en bloc resection ( P = 0.1), polyp morphology ( P = 0.2), and previous attempts ( P = 0.5), were not associated with increased risk. CONCLUSIONS: Proximal lesion location is a highly significant risk for clinically significant delayed bleeding following colonic EMR, and this knowledge could form the basis of a targeted therapeutic trial. Recent aspirin use also increases bleeding risk--specific consensus guidelines in this area are required for colonic EMR.

Complete Barrett's excision by stepwise endoscopic resection in short-segment disease: long term outcomes and predictors of stricture.

BACKGROUND AND STUDY AIMS: Complete Barrett's excision (CBE) of short-segment Barrett's high grade dysplasia (HGD) and early esophageal adenocarcinoma by stepwise endoscopic resection is a precise staging tool, detects covert synchronous disease, and may produce a sustained treatment response. Esophageal stricture is the most commonly reported complication of CBE although risk factors have not yet been clearly defined. PATIENTS AND METHODS: Data were recorded prospectively on patients with limited co-morbidity and age ≤ 80 years undergoing CBE for histologically proven HGD or esophageal adenocarcinoma within ≤ C3M5 segments. Endoscopic resection was performed by standardized protocol every 6 - 8 weeks until CBE was achieved. Esophageal dilation was performed when patients reported dysphagia. Dysphagia scores were recorded at scheduled endoscopic surveillance or by telephone interview. RESULTS: By intention-to-treat analysis, complete eradication of neoplasia and intestinal metaplasia was achieved in 95 % and 82 %, respectively, in 77 patients undergoing a median of 2 resection sessions (interquartile range [IQR] 1 - 3). Esophageal dilation was required in 33 % (median 3 dilations, IQR 1 - 3.5) at median follow-up of 20 months (IQR 6 - 40). Independent risk factors for dilation requirement were the number of mucosal resections at the index procedure (odds ratio [OR] 1.3 per resection, 95 % confidence interval [CI] 1.0 - 1.9; P = 0.043) and maximal extent of the Barrett's segment (OR 2.2 per cm, 95 %CI 1.2 - 3.9; P = 0.009). CONCLUSIONS: Although CBE is highly effective in the treatment of Barrett's HGD and esophageal adenocarcinoma, the risk of post-CBE dysphagia increases with the maximal extent of the Barrett's segment and the number of mucosal resections at the index procedure. These data could be used to inform treatment decisions and identify those patients who may benefit from prophylactic therapies such as dilation.

Lesion isolation by circumferential submucosal incision prior to endoscopic mucosal resection (CSI-EMR) substantially improves en bloc resection rates for 40-mm colonic lesions.

BACKGROUND AND AIMS: En bloc resection is preferred for colonic laterally spreading tumors, but is limited to 20 mm with endoscopic mucosal resection (EMR) using normal saline submucosal injection. Our aims were to compare the efficacy and safety of circumferential submucosal incision prior to EMR (CSI-EMR) versus conventional EMR for en bloc resection of artificial lesions 40 x 40 mm in size using submucosal injection of succinylated gelatin in a porcine colon model. SUBJECTS AND METHODS: Two areas of normal rectosigmoid mucosa measuring 40 x 40 mm were marked with soft coagulation for en bloc resection in each of 10 pigs. By alternate allocation, one was removed with conventional snare-based EMR following submucosal injection of succinylated gelatin. The other was circumferentially incised using an insulated-tip knife, followed by submucosal succinylated gelatin injection followed by EMR of the isolated area. All procedures were performed by a single endoscopist with significant experience of EMR but none of endoscopic submucosal dissection (ESD). Euthanasia and colectomy were performed on day 10. Specimens and ex vivo colon resection sites were examined by a specialist gastrointestinal histopathologist blinded to the technique used. RESULTS: En bloc excision rates were 70 % for CSI-EMR vs. 0 % for conventional EMR ( P = 0.016). The median number of resections was 1 (interquartile range, IQR: 1-2) for CSI-EMR vs. 4 (3 - 6) for EMR ( P < 0.001). Mean specimen dimensions were 50 x 43 mm for CSI-EMR vs. 37 x 32 mm for EMR ( P = 0.001). Overall procedure duration (mean +/- SD) was 30.3 +/- 19.8 minutes for CSI-EMR vs. 12.4 +/- 6.8 minutes ( P = 0.003) for EMR. The mean duration of the final 5 CSI-EMRs was 17 minutes, with a statistically significant learning effect R = -0.7, P = 0.025. No perforations or bleeding occurred. All animals were euthanased on day 10. Histologically, CSI-EMR resulted in larger specimens and deeper submucosal resections. CONCLUSIONS: CSI-EMR with submucosal injection of succinylated gelatin is safe and superior to conventional EMR, consistently resulting in en bloc resections larger than 50 x 40 mm. With experience, total procedure duration is comparable.

Autoimmune pancreatitis: an important diagnostic consideration in obstructive jaundice due to a pancreatic mass lesion.

Autoimmune or immunoglobulin G subtype (IgG4) pancreatitis is a newly recognised clinical entity and is an important differential diagnosis for patients presenting with obstructive jaundice. Knowledge of autoimmune pancreatitis (AIP) continues to evolve both for pathogenesis and management; however diagnosis is often not straightforward or even considered, therefore a high index of suspicion remains an important tool for the treating physician. The six cases presented illustrate both the difficulties in diagnosis as well as management of this condition.

Biliary cannulation during endoscopic retrograde cholangiopancreatography: core technique and recent innovations.

Despite advances in imaging and device technology over the past decade, endoscopic retrograde cholangiopancreatography (ERCP) continues to be one of the most technically challenging interventions in endoscopy. The procedure remains compounded by two persistent problems: failure of successful biliary cannulation and post-ERCP pancreatitis (PEP). When performed outside expert high-volume centers, failed biliary cannulation may occur in up to 20 % of cases; repeated and prolonged attempts at cannulation increase the risk of pancreatitis, delay definitive therapy, and necessitate alternative therapeutic techniques with inferior safety profiles . Cannulation technique is believed to be a pivotal factor in the genesis of PEP and is obviously important for successful cannulation. This review will discuss some recent innovations in cannulation technique.

The suction pseudopolyp technique: a novel method for the removal of small flat nonpolypoid lesions of the colon and rectum.

BACKGROUND AND STUDY AIMS: Small flat nonpolypoid lesions of the colorectum can be technically difficult to target and completely remove; techniques such as hot biopsy forceps electrocauterization are associated with serositis, delayed bleeding, and perforation. This study aimed to describe a novel technique for the removal of such lesions and demonstrate its safety and efficacy. PATIENTS AND METHODS: Patients aged 18 - 80 years with flat nonpolypoid lesions (Paris-Japanese classification 0-IIa and 0-IIb, measuring less than 10 mm) identified at colonoscopy were included in this prospective study. The lesions were removed by the suction pseudopolyp technique (SPT): the lesion is aspirated into the suction channel of the colonoscope and continuous suction applied for 5 seconds whilst the colonoscope is gently retracted. On release of the suction, the resulting pseudopolyp containing the lesion and a margin of normal tissue is easily ensnared and resected. The primary outcomes were endoscopic completeness of polyp resection and complication rate. RESULTS: Over a 12-month period, 1231 polyps were removed during 2656 colonoscopies; 126 polyps (in 101 patients) met inclusion criteria. Complete endoscopic resection was achieved in 100 % of the polyps, without immediate or delayed complication. Of the resected lesions, 57 % had malignant potential (adenomas 47 % and sessile serrated lesions 10 %); a higher proportion of lesions removed from the right colon had malignant potential compared with those from the left colon (75 % vs. 41 %, P = 0.0066). CONCLUSIONS: Diminutive flat lesions of the colorectum are predominantly adenomas and sessile serrated lesions. SPT is a safe, effective, and reproducible therapy for removal of these lesions.

A prospective randomized trial of cannulation technique in ERCP: effects on technical success and post-ERCP pancreatitis.

BACKGROUND AND STUDY AIMS: Inadvertent injection of contrast agent into the pancreatic duct is believed to be an important contributor to pancreatitis occurring after endoscopic retrograde cholangiopancreatography (post-ERCP pancreatitis, PEP). Our aim was to examine whether primary deep biliary cannulation with a guide wire is associated with a lower rate of PEP than conventional contrast-assisted cannulation. PATIENTS AND METHODS: From August 2003 to April 2006 all patients with an intact papilla who were referred for ERCP were eligible. Patients with pancreatic or ampullary cancer were excluded. Patients were randomized to undergo sphincterotomy biliary cannulation using either contrast injection or a guide wire. The ERCP fellow attempted initially for 5 minutes. If unsuccessful, the consultant attempted for 5 minutes using the same technique, followed by crossover to the other technique in the same sequence and then needle-knife sphincterotomy where appropriate. Patients were assessed clinically after the procedure, then followed up with telephone interviews after 24 hours and 30 days, and serum amylase and lipase tests after 24 hours. RESULTS: Out of 1654 patients undergoing ERCP, 413 were included in the study. PEP occurred in 29/413 (7.0 %): 16 in the guide-wire arm, 13 in the contrast arm ( P = 0.48). The overall cannulation success rate was 97.3 %. Cannulation was successful without crossover in 323/413 patients (78.2 %): 167/202 (81.4 %) in the guide-wire arm and 156/211 (73.9 %) in the contrast arm ( P = 0.03). Multivariate analysis demonstrated female sex (OR = 2.7, P = 0.04), suspected sphincter of Oddi dysfunction (OR = 5.5, P = 0.01), and complete filling of the pancreatic duct with contrast agent (OR = 3.5, P = 0.02) to be independently associated with PEP. The risk of PEP increased incrementally with each attempt at the papilla (OR 1.4 per attempt, P = 0.04) to greater than 10 % after four or more attempts. CONCLUSIONS: The guide-wire technique improves the primary success rate for biliary cannulation during ERCP but does not reduce the incidence of PEP compared to the conventional contrast technique. The incidence of PEP increases incrementally with each attempt at the papilla.

Transpapillary choledochoscopy.

This article reviews the current and future applications of peroral endoscopic choledochoscopy. As endoscopic technology has evolved with smaller, more durable miniscopes, the range of diagnostic and therapeutic uses has increased proportionately. The success of intraductal lithotripsy coupled with the advent of miniscopes that can be used through standard duodenoscopes will enable most endoscopists to remove almost all bile duct stones. Similarly, the accuracy of tissue sampling and tumor staging will be enhanced. The clinical impact of these developments are reviewed.

Standardised reporting protocol for endoscopic resection for Barrett oesophagus associated neoplasia: expert consensus recommendations.

Endoscopic resection (ER) is considered the therapy of choice for intraepithelial neoplasia associated with visible lesions and T1a adenocarcinoma. Pathologists are bound to encounter specimens collected via these techniques more frequently in their practice. A standardised protocol for handling, grossing, and assessing ER specimens should be adopted to ensure that all prognostic information and characteristics influencing treatment are included in reports (see Supplementary Video Abstract, http://links.lww.com/PAT/A22). The entire specimen should be appropriately oriented, processed and assessed. An ER specimen will commonly show intraepithelial neoplasia or invasive carcinoma. There are essential features that should be recorded if invasive carcinoma is found as they dictate further management and follow-up. These features are the margin status, depth of invasion, degree of differentiation and presence or absence of lymphovascular invasion. Important features such as duplication of muscularis mucosae should be recognised to avoid misinterpretation of depth of invasion. Key diagnostic and prognostic elements that are essential for optimal clinical decisions have been included in the reporting format proposed by the Structured Pathology Reporting committee of the Royal College of Pathologists of Australasia (RCPA).

Argon plasma coagulation in the management of symptomatic gastrointestinal vascular lesions: experience in 100 consecutive patients with long-term follow-up.

BACKGROUND: The long-term efficacy of argon plasma coagulation (APC) in the management of gastrointestinal vascular lesions has not been evaluated in a large and well-defined series. The impact of APC on transfusion requirements and hemoglobin, and technical parameters including complications and number of treatment sessions, is assessed in this series. METHODS: Patients who underwent APC for bleeding gastrointestinal vascular lesions were identified via interrogation of an established endoscopic database, excluding patients with radiation proctitis, tumors, residual polypectomy tissue and acute ulcer bleeding. Follow-up data were collected via interview with patients and referring doctors, review of medical records, and follow-up blood tests. RESULTS: One hundred patients were enrolled, males = 46, median age = 74 yr (range: 19-99 yr). Median follow-up time was 16 months (range: 4-47 months). Lesions treated were arteriovenous malformations (n = 74) and gastric antral vascular ectasia (n = 26). Fifty-three patients required transfusion. In this group, median hemoglobin improved from 66 g/L (range: 35-114) to 111 g/L (range: 55-155, p < 0.001). Median transfusion velocity fell from 2 units/month (range: 0.1-6) to 0 units/month (range: 0-4, p < 0.001). Transfusion requirement was abolished in 77%. In non-transfusion-requiring patients, median hemoglobin improved from 105 g/L (range: 58-143) to 123 g/L (range: 79-158, p < 0.001). No complications occurred. CONCLUSIONS: APC is effective and safe in the management of gastrointestinal vascular lesions.

Endoscopic band ligation for non-variceal non-ulcer gastrointestinal hemorrhage.

BACKGROUND: There is no consensus as to the best treatment for non-variceal, non-ulcer gastrointestinal hemorrhage. Endoscopic band ligation is an inexpensive, readily available, and easily learned technique in contrast to conventional thermal methods of endoscopic hemostasis. We present the preliminary results of an open trial using endoscopic band ligation for non-variceal, non-ulcer bleeding in the gastrointestinal tract. METHODS: Eighteen patients were treated by band ligation between June 1996 and November 1997. The lesions treated were: arteriovenous malformations in 10, Dieulafoy's lesions in 4, Mallory-Weiss tear in 2, and post-colonic polypectomy bleeding in 2. RESULTS: Endoscopic band ligation was successful in 17 of 18 cases, with a follow-up period ranging from 2 to 18 months. The remaining case, a duodenal Dieulafoy's lesion, bled again at 24 hours but was successfully treated by adrenalin injection. CONCLUSIONS: Endoscopic band ligation is effective for non-variceal, non-ulcer bleeding. It has the advantage of ease of use and is relatively inexpensive.

A prospective study of the safety of endoscopic therapy for choledocholithiasis in an outpatient population.

OBJECTIVE: Many centers routinely admit patients for observation after endoscopic therapy of choledocholithiasis although this is contrary to the current mandate for cost containment. The purpose of this study was to determine the safety, success, and complication rates of outpatient therapeutic ERCP in the management of choledocholithiasis. METHODS: Over a 4-month period, 97 consecutive outpatients undergoing endoscopic treatment for choledocholithiasis were enrolled in a prospective manner. Each subject was observed 1-3 h postprocedure before discharge with follow-up at 10 days. RESULTS: Successful endoscopic management of choledocholithiasis was achieved in 100% of patients. Complication rates were as follows: pancreatitis (2.1%), postsphincterotomy bleeding (3.2%), perforation (0%), and sepsis (0%). One patient required admission during the observation period, and two others with pancreatitis were readmitted within 24 h of discharge. There was no apparent adverse clinical outcome related to this policy. CONCLUSION: Endoscopic therapy of choledocholithiasis may be performed safely on an outpatient basis, realizing significant cost savings.

Concordance of iron storage in siblings with genetic hemochromatosis: evidence for a predominantly genetic effect on iron storage.

Phenotypic concordance between siblings has been demonstrated in some inherited conditions, and such data provide strong evidence that the severity of disease is affected by genetic factors. We assessed the concordance of liver iron stores between siblings in 22 sibling pairs (15 same-sex pairs and 7 opposite-sex pairs) with genetic hemochromatosis. In this study population a wide range was found in the hepatic iron concentration and the hepatic iron index (32 to 833 mumol/gm dry wt and 1.65 to 14.4, respectively), which could not be accounted for by differing exposure to the environmental factors that influence iron stores. Despite the large variation of hepatic iron concentration within the group, siblings of identical sex had accumulated similar amounts of liver iron. A highly significant correlation for hepatic iron concentration (r = 0.81) and hepatic iron index (r = 0.70) was found between siblings of the same sex. The hepatic iron concentration and the hepatic iron index of one sibling was less than 50% of the other in only three same-sex sibling pairs. In each instance, reasons existed (blood donation, age at diagnosis and human leukocyte antigen nonidentity) for this discordance. In six of the seven opposite-sex pairs, the woman had lower hepatic iron stores than her male sibling, consistent with previous studies on the extent of iron overload in women and its modification by physiological blood loss.(ABSTRACT TRUNCATED AT 250 WORDS)

Sphincterotomy-associated biliary strictures: features and endoscopic management.

BACKGROUND: "Sphincterotomy stenosis" is a recognized late complication of endoscopic biliary sphincterotomy. The narrowing is limited to the biliary orifice and can be managed simply by repeat sphincterotomy. A similar but poorly characterized post-sphincterotomy complication involves narrowing that extends from the biliary orifice for a variable distance along the bile duct, beyond the duodenal wall. This lesion cannot be managed by repeating the sphincterotomy. METHODS: Six patients (3 men) are described with sphincterotomy associated biliary strictures, all smooth and high grade, presenting at a median of 19 months (range 8 to 60 months) after sphincterotomy. Further sphincterotomy was not possible as an intra-duodenal segment of bile duct was no longer visible. Endoscopic management consisted of serial incremental stent exchange at 2- to 4-month intervals. The goal of therapy was to place two 11.5F stents side-by-side. RESULTS: Stricture resolution was documented by cholangiography in all patients. One patient with a stricture resistant to treatment required three 10F stents side-by-side, and another underwent treatment to a maximum of adjacent 11.5F and 7F stents. Two 11.5F stents were eventually placed in the other four patients. Overall median duration of stent placement was 12.5 months. At a median of 26.5 months of stent-free follow-up, all patients remain asymptomatic. CONCLUSION: Sphincterotomy-associated biliary strictures are a distinct late complication of biliary sphincterotomy. These recalcitrant lesions are not amenable to repeat sphincterotomy; however, the results of this study suggest that they may be managed successfully by serial placement of stents of incrementally increasing diameter.