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BACKGROUND AND AIMS: Water exchange (WE) and cap-assisted colonoscopy (CAC) separately reduced pain during insertion in unsedated patients. We hypothesized that compared with WE, WECAC could significantly lower real-time maximum insertion pain (RTMIP). METHODS: Veterans without escort were recruited, randomized, blinded, and examined at three United States Veterans Affairs sites. The primary outcome was RTMIP, highest segmental pain (0 = no pain, 10 = most severe pain) during insertion. RESULTS: Randomization [WECAC (n = 143) and WE (n = 137)] produced even distribution of a racially diverse group of males and females of low socioeconomic status. Intention-to-treat analysis reported results of WECAC (listed first) and WE (listed second): cecal intubation [93%, 94.2%]; mean (SD) of RTMIP [2.9 (2.5), 2.6 (2.4)]; the proportion with no pain (28.7%, 27.7%); the insertion time [18.6 (15.6), 18.8 (15.9) min]; overall ADR (55.2%, 62.8%), all P values were > 0.05. When RTMIP was binarized as "no pain" (0) vs. "some pain" (1-10), or "low pain" (0-7) vs. "high pain" (8-10), different significant predictors (see text) of RTMIP were identified. CONCLUSIONS: Unsedated colonoscopy was appropriate for unescorted Veterans. WE alone was sufficient. Adding a cap did not reduce RTMIP. Patient specific factors and application of WE with insertion suction of infused water contributed to high and low RTMIP, respectively. For unesorted patients, selecting those with low anxiety, avoiding low body mass index, history of depression or self-reported poor health and adhering to the steps of WE can minimize RTMIP to ensure success of unsedated colonoscopy.
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BACKGROUND AND AIMS: Complete closure after endoscopic resection of large nonpedunculated colorectal lesions (LNPCLs) can reduce delayed bleeding but is challenging with conventional through-the-scope (TTS) clips alone. The novel dual-action tissue (DAT) clip has clip arms that open and close independently of each other, facilitating tissue approximation. We aimed to evaluate the rate of complete closure and delayed bleeding with the DAT clip after endoscopic resection of LNPCLs. METHODS: This was a multicenter prospective cohort study of all patients who underwent defect closure with the DAT clip after EMR or endoscopic submucosal dissection (ESD) of LNPCLs ≥20 mm from July 2022 to May 2023. Delayed bleeding was defined as a bleeding event requiring hospitalization, blood transfusion, or any intervention within 30 days after the procedure. Complete closure was defined as apposition of mucosal defect margins without visible submucosal areas <3 mm along the closure line. RESULTS: One hundred seven patients (median age, 64 years; 42.5% women) underwent EMR (n = 63) or ESD (n = 44) of LNPCLs (median size, 40 mm; 74.8% right-sided colon) followed by defect closure. Complete closure was achieved in 96.3% (n = 103) with a mean of 1.4 ± .6 DAT clips and 2.9 ± 1.8 TTS clips. Delayed bleeding occurred in 1 patient (.9%) without requiring additional interventions. CONCLUSIONS: The use of the DAT clip in conjunction with TTS clips achieved high complete defect closure after endoscopic resection of large LNPCLs and was associated with a .9% delayed bleeding rate. Future comparative trials and formal cost-analyses are needed to validate these findings. (Clinical trial registration number: NCT05852457.).
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Neoplasias Colorretais , Ressecção Endoscópica de Mucosa , Humanos , Feminino , Pessoa de Meia-Idade , Masculino , Estudos Prospectivos , Hemorragia , Ressecção Endoscópica de Mucosa/efeitos adversos , Ressecção Endoscópica de Mucosa/métodos , Instrumentos Cirúrgicos , Mucosa Intestinal/cirurgia , Mucosa Intestinal/patologia , Neoplasias Colorretais/cirurgia , Neoplasias Colorretais/patologia , Resultado do Tratamento , Estudos RetrospectivosRESUMO
INTRODUCTION: There has been increasing interest in artificial intelligence in gastroenterology. To reduce miss rates during colonoscopy, there has been significant exploration in computer-aided detection (CADe) devices. In this study, we evaluate the use of CADe in colonoscopy in community-based, nonacademic practices. METHODS: Between September 28, 2020, and September 24, 2021, a randomized controlled trial (AI-SEE) was performed evaluating the impact of CADe on polyp detection in 4 community-based endoscopy centers in the United States Patients were block-randomized to undergoing colonoscopy with or without CADe (EndoVigilant). Primary outcomes measured were adenomas per colonoscopy and adenomas per extraction (the percentage of polyps removed that are adenomas). Secondary end points included serrated polyps per colonoscopy; nonadenomatous, nonserrated polyps per colonoscopy; adenoma and serrated polyp detection rates; and procedural time. RESULTS: A total of 769 patients were enrolled (387 with CADe), with similar patient demographics between the 2 groups. There was no significant difference in adenomas per colonoscopy in the CADe and non-CADe groups (0.73 vs 0.67, P = 0.496). Although the use of CADe did not improve identification of serrated polyps per colonoscopy (0.08 vs 0.08, P = 0.965), the use of CADe increased identification of nonadenomatous, nonserrated polyps per colonoscopy (0.90 vs 0.51, P < 0.0001), resulting in detection of fewer adenomas per extraction in the CADe group. The adenoma detection rate (35.9 vs 37.2%, P = 0.774) and serrated polyp detection rate (6.5 vs 6.3%, P = 1.000) were similar in the CADe and non-CADe groups. Mean withdrawal time was longer in the CADe group compared with the non-CADe group (11.7 vs 10.7 minutes, P = 0.003). However, when no polyps were identified, there was similar mean withdrawal time (9.1 vs 8.8 minutes, P = 0.288). There were no adverse events. DISCUSSION: The use of CADe did not result in a statistically significant difference in the number of adenomas detected. Additional studies are needed to better understand why some endoscopists derive substantial benefits from CADe and others do not. ClinicalTrials.gov number: NCT04555135.
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Adenoma , Pólipos do Colo , Neoplasias Colorretais , Humanos , Pólipos do Colo/diagnóstico por imagem , Pólipos do Colo/cirurgia , Inteligência Artificial , Colonoscopia/métodos , Adenoma/diagnóstico , Computadores , Neoplasias Colorretais/diagnósticoRESUMO
BACKGROUND: Complete closure of large mucosal defects following colorectal endoscopic submucosal dissection (ESD) with through-the-scope (TTS) clips is oftentimes not possible. We aimed to report our early experience of using a novel TTS suturing system for the closure of large mucosal defects after colorectal ESD. METHODS: We performed a retrospective multicenter cohort study of consecutive patients who underwent attempted prophylactic defect closure using the TTS suturing system after colorectal ESD. The primary outcome was technical success in achieving complete defect closure, defined as a <â5âmm residual mucosal defect in the closure line using TTS suturing, with or without adjuvant TTS clips. RESULTS: 82 patients with a median defect size of 30 (interquartile range 25-40) mm were included. Technical success was achieved in 92.7â% (nâ=â76): TTS suturing only in 44 patients (53.7â%) and a combination of TTS suturing to approximate the widest segment followed by complete closure with TTS clips in 32 (39.0â%). Incomplete/partial closure, failure of appropriate TTS suture deployment, and the need for over-the-scope salvage closure methods were observed in 7.3â% (nâ=â6). One intraprocedural bleed, one delayed bleed, and three intraprocedural perforations were observed. There were no adverse events related to placement of the TTS suture. CONCLUSION: The TTS suture system is an effective and safe tool for the closure of large mucosal defects after colorectal ESD and is an alternative when complete closure with TTS clips alone is not possible.
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Neoplasias Colorretais , Ressecção Endoscópica de Mucosa , Humanos , Ressecção Endoscópica de Mucosa/métodos , Estudos de Coortes , Mucosa Intestinal/cirurgia , Neoplasias Colorretais/cirurgia , Suturas , Estudos RetrospectivosRESUMO
INTRODUCTION: Optimizing complete resection during colonoscopy is important because residual neoplastic tissue may play a role in interval cancers. The US Multi-Society Task Force recommends diminutive (≤5 mm) and small (6-9 mm) polyps be removed by cold snare polypectomy (CSP). However, evidence is less clear whether CSP retains significant advantage over cold forceps polypectomy (CFP) for polyps ≤3 mm. METHODS: This study is a single-center prospective noninferiority randomized clinical trial evaluating CFP and CSP for nonpedunculated polyps ≤3 mm. Patients 18 years and older undergoing colonoscopy for any indication were recruited. During each colonoscopy, polyps underwent block randomization to removal with CFP or CSP. After polypectomy, 2 biopsies were taken from the polypectomy margin. The primary noninferiority outcome was the complete resection rate, defined by absence of residual polyp in the margin biopsies. RESULTS: A total of 179 patients were included. Patients had similar distribution in age, sex, race/ethnicity, as well as indication of procedure. A total of 279 polyps ≤3 mm were identified, with 138 in the CSP group and 141 in the CFP group. Mean polypectomy time was longer for CSP compared with CFP (42.3 vs 23.2 seconds, P < 0.001), although a higher proportion of polyps removed by CFP were removed in more than 1 piece compared with CSP (15.6 vs 3.6%, P < 0.001). There were positive margin biopsies in 2 cases per cohort, with a complete resection rate of 98.3% in both groups. There was no significant difference in cohorts in complete resection rates (difference in complete resection rates was 0.057%, 95% confidence interval: -4.30% to 4.53%), demonstrating noninferiority of CFP compared with CSP. DISCUSSION: Use of CFP was noninferior to CSP in the complete resection of nonpedunculated polyps ≤3 mm. CSP required significantly more time to perform compared with CFP. CFP should be considered an acceptable alternative to CSP for removal of polyps ≤3 mm.
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Pólipos do Colo , Neoplasias Colorretais , Pólipos do Colo/patologia , Pólipos do Colo/cirurgia , Colonoscopia/métodos , Neoplasias Colorretais/patologia , Neoplasias Colorretais/cirurgia , Humanos , Estudos Prospectivos , Instrumentos Cirúrgicos , Resultado do TratamentoRESUMO
BACKGROUND: Endoscopic resection of lesions involving the appendiceal orifice remains a challenge. We aimed to report outcomes with the full-thickness resection device (FTRD) for the resection of appendiceal lesions and identify factors associated with the occurrence of appendicitis. METHODS: This was a retrospective study at 18 tertiary-care centers (USA 12, Canada 1, Europe 5) between November 2016 and August 2020. Consecutive patients who underwent resection of an appendiceal orifice lesion using the FTRD were included. The primary outcome was the rate of R0 resection in neoplastic lesions, defined as negative lateral and deep margins on post-resection histologic evaluation. Secondary outcomes included the rates of: technical success (en bloc resection), clinical success (technical success without need for further surgical intervention), post-resection appendicitis, and polyp recurrence. RESULTS: 66 patients (32 women; mean age 64) underwent resection of colonic lesions involving the appendiceal orifice (mean [standard deviation] size, 14.5 (6.2) mm), with 40 (61â%) being deep, extending into the appendiceal lumen. Technical success was achieved in 59/66 patients (89â%), of which, 56 were found to be neoplastic lesions on post-resection pathology. Clinical success was achieved in 53/66 (80â%). R0 resection was achieved in 52/56 (93â%). Of the 58 patients in whom EFTR was completed who had no prior history of appendectomy, appendicitis was reported in 10 (17â%), with six (60â%) requiring surgical appendectomy. Follow-up colonoscopy was completed in 41 patients, with evidence of recurrence in five (12â%). CONCLUSIONS: The FTRD is a promising non-surgical alternative for resecting appendiceal lesions, but appendicitis occurs in 1/6 cases.
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Apêndice , Ressecção Endoscópica de Mucosa , Colonoscopia , Feminino , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
INTRODUCTION: Currently, cold snare polypectomy (CSP) without submucosal injection is recommended for removing polyps < 10 mm. Use of viscous submucosal agents has not been previously evaluated in CSP. We investigate the potential role of EverLift™ (GI Supply, Pennsylvania) in CSP. METHODS: The study is a single-center prospective randomized non-inferiority clinical trial evaluating CSP of non-pedunculated 4-9 mm polyps, with or without submucosal injection of EverLift™. Patients 18-80 years of age presenting for colonoscopy were recruited. Eligible polyps underwent block randomization to CSP with or without EverLift™. Following CSP, two biopsies were performed at the CSP site margin. The primary non-inferiority outcome was complete resection rate, defined by absence of residual polyp in the margin biopsies (non-inferiority margin -10%). RESULTS: A total of 291 eligible polyps underwent CSP, with 142 removed using EverLift™. There was similar polyp size and distribution of pathology between the two groups. Overall, there was a low rate of positive margins with (1.4%) or without submucosal injection (2.8%), with no significant difference in complete resection (difference 1.28%, 95% CI: -2.66 to 5.42%), demonstrating non-inferiority of EverLift™ injection. Use of EverLift™ significantly increased CSP time (109.8 vs 38.8 s, p < 0.0001) and frequency of use of hemostatic clips (13.4 vs 3.6%, p = 0.002). CONCLUSION: Submucosal injection of EverLift™ was non-inferior to CSP of 4-9 mm polyps without injection and increased time for resection as well as use of hemostatic clips to control acute bleeding. Our results suggest that polypectomy of 4-9 mm polyps can be safely performed without submucosal injection of EverLift™.
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Pólipos do Colo , Neoplasias Colorretais , Hemostáticos , Pólipos do Colo/patologia , Pólipos do Colo/cirurgia , Colonoscopia/métodos , Neoplasias Colorretais/cirurgia , Humanos , Margens de Excisão , Estudos Prospectivos , Resultado do TratamentoRESUMO
BACKGROUND AND AIMS: Loop formation can impede endoscope advancement, destabilize the tip, and cause pain. Strategies to mitigate looping include torque-based reduction maneuvers, variable stiffness shafts, and abdominal splinting. In some cases, these strategies are insufficient, and there is need for novel instruments. Loop formation is of particular concern in colonoscopy, but it can also impact performance of other endoscopic procedures such as enteroscopy and altered-anatomy ERCP. In this case series we demonstrate the utility of a novel rigidizing overtube (Pathfinder; Neptune Medical, Burlingame, Calif, USA) in colonoscopy and other endoscopic procedures where loop management is critical. METHODS: We describe our initial experience with the Pathfinder overtube in 29 patients. The overtube is 85 cm long and can accommodate a pediatric colonoscope. In its native state, the overtube is extremely flexible. Once the overtube is advanced to the desired location, application of a vacuum to the device causes the device to become 15 times stiffer. The endoscope can then be advanced through the overtube without loop formation in the region that the overtube traverses. RESULTS: The overtube was used in 29 patients to assist with difficult procedures. Patients were predominantly men (n = 18; 62.1%), with a median age of 66 years (interquartile range, 57-72). One patient received an upper endoscopy (3.4%), 24 received colonoscopy (82.8%), and 4 received enteroscopy (13.8%). The overtube was used in 12 procedures for incomplete colonoscopy (41.4%), 6 for depth (20.7%), and 11 for stability (37.9%). Colonoscopy was performed in the setting of screening (n = 3), surveillance given polyp history (n = 7), referrals for polyp removal (n = 10), workup of iron deficiency anemia (n = 2), and incomplete colonoscopy (n = 1). The lower endoscopy cases had a median cecal intubation time of 5 minutes (interquartile range, 4.25-7). Enteroscopy was performed in 4 patients: In one patient the distal 60 cm of the ileum was examined with a pediatric colonoscope to exclude ileitis, in another the overtube was used to stabilize a 6-mm endoscope to traverse a tight Crohn's ileocolonic stricture, in a third patient altered-anatomy ERCP was performed using an enteroscope through the overtube to reach a hepaticojejunostomy, and in the final patient upper enteroscopy was performed and the mid-jejunum was reached. We present 4 cases that demonstrate the use of the overtube. There were no adverse events. CONCLUSIONS: Initial experience with a novel rigidizing overtube suggests that this tool can be useful in colonoscopy and other endoscopic procedures affected by looping.
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Ceco , Colonoscopia , Idoso , Criança , Colonoscópios , Endoscopia Gastrointestinal , Desenho de Equipamento , Humanos , Masculino , Programas de RastreamentoRESUMO
BACKGROUND AND AIMS: Since 2008, a plethora of research studies has compared the efficacy of water-assisted (aided) colonoscopy (WAC) and underwater resection (UWR) of colorectal lesions with standard colonoscopy. We reviewed and graded the research evidence with potential clinical application. We conducted a modified Delphi consensus among experienced colonoscopists on definitions and practice of water immersion (WI), water exchange (WE), and UWR. METHODS: Major databases were searched to obtain research reports that could potentially shape clinical practice related to WAC and UWR. Pertinent references were graded (Grading of Recommendations, Assessment, Development and Evaluation). Extracted data supporting evidence-based statements were tabulated and provided to respondents. We received responses from 55 (85% surveyed) experienced colonoscopists (37 experts and 18 nonexperts in WAC) from 16 countries in 3 rounds. Voting was conducted anonymously in the second and third round, with ≥80% agreement defined as consensus. We aimed to obtain consensus in all statements. RESULTS: In the first and the second modified Delphi rounds, 20 proposed statements were decreased to 14 and then 11 statements. After the third round, the combined responses from all respondents depicted the consensus in 11 statements (S): definitions of WI (S1) and WE (S2), procedural features (S3-S5), impact on bowel cleanliness (S6), adenoma detection (S7), pain score (S8), and UWR (S9-S11). CONCLUSIONS: The most important consensus statements are that WI and WE are not the same in implementation and outcomes. Because studies that could potentially shape clinical practice of WAC and UWR were chosen for review, this modified Delphi consensus supports recommendations for the use of WAC in clinical practice.
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Adenoma , Água , Adenoma/diagnóstico , Adenoma/cirurgia , Colonoscopia , Consenso , Técnica Delphi , HumanosRESUMO
INTRODUCTION: Many centers have reported excellent short-term efficacy of per-oral endoscopic myotomy (POEM) for the treatment of achalasia. However, long-term data are limited and there are few studies comparing the efficacy of POEM versus Heller Myotomy (HM). AIMS: To compare the long-term clinical efficacy of POEM versus HM. METHODS: Using a retrospective, parallel cohort design, all cases of POEM or HM for achalasia between 2010 and 2015 were assessed. Clinical failure was defined as (a) Eckardt Score > 3 for at least 4 weeks, (b) achalasia-related hospitalization, or (c) repeat intervention. All index manometries were classified via Chicago Classification v3. Pre-procedural clinical, manometric, radiographic data, and procedural data were reviewed. RESULTS: 98 patients were identified (55 POEM, 43 Heller) with mean follow-up of 3.94 years, and 5.44 years, respectively. 83.7% of HM patients underwent associated anti-reflux wrap (Toupet or Dor). Baseline clinical, demographic, radiographic, and manometric data were similar between the groups. There was no statistical difference in overall long-term success (POEM 72.7%, HM 65.1% p = 0.417, although higher rates of success were seen in Type III Achalasia in POEM vs Heller (53.3% vs 44.4%, p < 0.05). Type III Achalasia was the only variable associated with failure on a univariate COX analysis and no covariants were identified on a multivariate Cox regression. There was no statistical difference in GERD symptoms, esophagitis, or major procedural complications. CONCLUSION: POEM and HM have similar long-term (4-year) efficacy with similar adverse event and reflux rates. POEM was associated with greater efficacy in Type III Achalasia.
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Endoscopia/métodos , Acalasia Esofágica/cirurgia , Miotomia de Heller/métodos , Laparoscopia/métodos , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Rates of incomplete colonoscopy in non-expert settings range up to 13%. Expert colonoscopists can complete ~ 95% colonoscopies when other endoscopists fail; however, a small number remain incomplete even in expert hands, typically due to bowel fixity. AIMS: Pentax Retroview™ (EC-3490TLi) is a new slim colonoscope with a short turning radius (STR) and greater tip deflection (210°), which allows easy maneuverability across sharply angulated/fixed colonic bends. We evaluated the utility of this colonoscope for completing colonoscopies that fail even in the hands of expert colonoscopists. METHODS: Retrospective chart review was performed, and main outcomes measured included cecal intubation rate, lesions detected, dosage of sedation used, and complications. RESULTS: Using the STR colonoscope, complete colonoscopy to the cecum was possible in 34/37 patients (91.9%). No loss of lumen/blind advancement was necessary in any of the procedures. No adverse events occurred. Among the completed colonoscopies, 6/34 (17.6%) patients had adenomas, all proximal to the site of prior failure, including one advanced adenoma. All failures (n = 3, 8.1%) had a history of cancer surgeries, with peritoneal carcinomatosis/extensively fixed/frozen bowel (two patients) and an additional diverticular stricture with colo-vesical fistula (one patient). CONCLUSION: STR colonoscope facilitates completion of a high proportion (91.9%) of colonoscopies that previously failed in expert hands. Its STR allows easy maneuverability across segments of sharp angulation with bowel fixity without need for blind advancement. The use of this colonoscope led to the detection of adenomas in 17.6% of patients, all proximal to the site of prior failed colonoscopy.
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Colonoscópios , Colonoscopia/instrumentação , Desenho de Equipamento , Enteropatias/cirurgia , Idoso , Colo/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Rotação , Resultado do TratamentoRESUMO
BACKGROUND & AIMS: Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have demonstrated similar efficacy in removal of neoplastic esophageal lesions. However, significant controversy exists over the preferred resection technique. Our primary aim was to compare the pathologic specimens produced via EMR and ESD and secondarily gauge their effect on clinical decision making and patient outcomes. METHODS: Using a retrospective cohort study design, all esophageal Barrett's-associated neoplastic lesions resected by a single provider from 2012 to 2017 were reviewed. The pathology was re-reviewed by two blinded authors for diagnosis, margins, and adverse outcomes and recurrence rates were also collected. RESULTS: Thirty-one EMR and 20 ESD cases were identified. Baseline demographics and lesion characteristics were similar. ESD produced more R0 resections and more en bloc resections compared to EMR. EMR produced more equivocal lateral (13/31, 41.9% vs 1/20, 5.0%) and vertical margins (13/31, 41.9% vs. 0/20, 0%, both P < 0.05). This led to an inability to reach a definitive diagnosis in 13/31 EMR vs 0/20 ESD pathology specimens (P = 0.003). Of the 13 EMR specimens with equivocal pathology, 11 were noted to have 'at least intramucosal adenocarcinoma'. Four of the 11 patients chose to undergo elective esophagectomy with final surgical pathology demonstrating ≤T1a disease in 2, and ≥T1b disease in two. CONCLUSION: Compared to ESD, EMR was associated with greater pathologic uncertainty in Barrett's-associated neoplasia.
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Adenocarcinoma/patologia , Esôfago de Barrett/patologia , Esôfago de Barrett/cirurgia , Dissecação , Ressecção Endoscópica de Mucosa , Neoplasias Esofágicas/patologia , Adenocarcinoma/cirurgia , Idoso , Tomada de Decisão Clínica , Neoplasias Esofágicas/cirurgia , Esofagectomia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Estudos RetrospectivosRESUMO
BACKGROUND: Larger caliber lumen-apposing stents (LAMSs) have been increasingly used in the management of pancreatic fluid collections, specifically when solid debris is present; however, their advantages over smaller caliber plastic stents in the management of pancreatic pseudocysts are unclear. The aim of this study was to investigate the safety and efficacy of LAMS specifically in the management of pancreatic pseudocysts compared with double-pigtail plastic stents (DPPSs). METHODS: We performed a multicenter, international, retrospective study between January 2012 and August 2016.âA total of 205 patients with a diagnosis of pancreatic pseudocysts were included, 80 patients received LAMSs and 125 received DPPSs. Measured outcomes included clinical success, technical success, adverse events, stent dysfunction, pancreatic pseudocyst recurrence, and need for surgery. RESULTS: Technical success was similar between the LAMS and the DPPS groups (97.5â% vs. 99.2â%; Pâ=â0.32). Clinical success was higher for LAMSs than for DPPSs (96.3â% vs. 87.2â%; Pâ=â0.03). While the need for surgery was similar between the two groups (1.3â% vs. 4.9â%, respectively; Pâ=â0.17), the use of percutaneous drainage was significantly lower in the LAMS group (1.3â% vs. 8.8â%; Pâ=â0.03). At 6-month follow-up, the recurrence rate was similar between the groups (6.7â% vs 18.8â%, respectively; Pâ=â0.12). The rate of adverse events was significantly higher in the DPPS group (7.5â% vs. 17.6â%; Pâ=â0.04). There was no difference in post-procedure mean length of hospital stay (6.3 days [standard deviation 27.9] vs. 3.7 days [5.7]; Pâ=â0.31). CONCLUSION: When compared to DPPSs, LAMSs are a safe, feasible, and effective modality for the treatment of pancreatic pseudocysts and are associated with a higher rate of clinical success, shorter procedure time, less need for percutaneous interventions, and a lower overall rate of adverse events.
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Colangiopancreatografia Retrógrada Endoscópica/métodos , Drenagem/métodos , Pseudocisto Pancreático/cirurgia , Plásticos , Implantação de Prótese/métodos , Stents , Endossonografia , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Pseudocisto Pancreático/diagnóstico , Desenho de Prótese , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
BACKGROUND: Fluoroscopy use during ERCP exposes patients and providers to deleterious effects of radiation. Formal training in fluoroscopy/radiation protection is not widely emphasized during therapeutic endoscopy training, and radiation use during GI endoscopy has not previously been characterized in the USA. In this study, we evaluated radiation training, fluoroscopy use patterns, and radiation protection practices among US therapeutic endoscopists. METHODS: An anonymous electronic survey was distributed to US therapeutic endoscopists, and responses were analyzed using descriptive statistics. State-specific requirements for fluoroscopy utilization were determined from state radiologic health branches. RESULTS: A total of 159 endoscopists (response rate 67.8%) predominantly those working in university hospitals (69.2%) with > 5 years of experience performing ERCP (74.9%) completed the questionnaire. Although the majority of endoscopists (61.6%) reported that they personally controlled fluoroscopy during ERCP, most (56.6%) had not received training on operating their fluoroscopy system. Only a minority (18-31%) of all respondents reported consistently utilizing modifiable fluoroscopy system parameters that minimize patient radiation exposure (pulsed fluoroscopy, frame rate modification or collimation). Endoscopists appear to undertake adequate personal radiation protective measures although use of a dosimeter was not consistent in half of respondents. The majority of states (56.8%) do not have any stated requirement for certification of non-radiologist physicians who intend to operate fluoroscopy. CONCLUSIONS: Most US gastroenterologists performing ERCP have not received formal training in operating their fluoroscopy system or in minimizing radiation exposure to themselves and to their patients. Such formal training should be included in all therapeutic endoscopy training programs, and fluoroscopy system-specific training should be offered at all hospitals.
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Colangiopancreatografia Retrógrada Endoscópica/estatística & dados numéricos , Fluoroscopia/estatística & dados numéricos , Exposição Ocupacional/prevenção & controle , Padrões de Prática Médica/estatística & dados numéricos , Exposição à Radiação/prevenção & controle , Proteção Radiológica/estatística & dados numéricos , Endoscopia do Sistema Digestório/educação , Fluoroscopia/métodos , Humanos , Legislação como Assunto , Doses de Radiação , Dosímetros de Radiação , Inquéritos e Questionários , Estados UnidosRESUMO
BACKGROUND: Severe necrotizing pancreatitis may result in midbody necrosis and ductal disruption leaving an isolated pancreatic tail. The purpose of this study was to characterize outcomes among patients with an isolated tail remnant who underwent transgastric drainage or necrosectomy (endoscopic or surgical) and determine the need for subsequent operative management. MATERIALS AND METHODS: Patients with necrotizing pancreatitis and retrogastric walled-off collections treated by surgical transgastric necrosectomy or endoscopic cystgastrostomy ± necrosectomy between 2009 and 2017 were identified by a retrospective chart review. All available preprocedure and postprocedure imaging was reviewed for evidence of isolated distal pancreatic tail remnants. RESULTS: Seventy-four patients were included (40 surgical and 34 endoscopic). All the patients in the surgical group underwent laparoscopic transgastric necrosectomy; the endoscopic group consisted of 26 patients for pseudocyst drainage and eight patients for necrosectomy. A disconnected pancreatic tail was identified in 22 (29%) patients (13 laparoscopic and nine endoscopic). After the creation of the "cystgastrostomy," there were no external fistulas despite the viable tail. Of the 22 patients, four patients developed symptoms at a median of 23 months (two, recurrent episodic pancreatitis; two, intractable pain). Two patients (both initially in endoscopic group) ultimately required distal pancreatectomy and splenectomy at 24 and 6 months after index procedure. CONCLUSIONS: Patients with a walled-off retrogastric collection and an isolated viable tail are effectively managed by a transgastric approach. Despite this seemingly "unstable anatomy," the creation of an internal fistula via surgical or endoscopic "cystgastrostomy" avoids external fistulas/drains and the short-term necessity of surgical distal pancreatectomy. A very small subset requires intervention for late symptoms.
Assuntos
Pancreatite Necrosante Aguda/cirurgia , Complicações Pós-Operatórias/epidemiologia , Adulto , California/epidemiologia , Procedimentos Cirúrgicos do Sistema Digestório , Feminino , Humanos , Laparoscopia , Masculino , Pessoa de Meia-Idade , Cirurgia Endoscópica por Orifício Natural , Pâncreas/diagnóstico por imagem , Complicações Pós-Operatórias/diagnóstico por imagem , Estudos RetrospectivosRESUMO
BACKGROUND AND AIMS: Recent outbreaks of duodenoscope-transmitted infections underscore the importance of adequate endoscope reprocessing. Adenosine triphosphate (ATP) bioluminescence testing allows rapid evaluation of endoscopes for bacteriologic/biologic residue. In this prospective study we evaluate the utility of ATP in bacteriologic surveillance and the effects of endoscopy staff education and dual cycles of cleaning and high-level disinfection (HLD) on endoscope reprocessing. METHODS: ATP bioluminescence was measured after precleaning, manual cleaning, and HLD on rinsates from suction-biopsy channels of all endoscopes and elevator channels of duodenoscopes/linear echoendoscopes after use. ATP bioluminescence was remeasured in duodenoscopes (1) after re-education and competency testing of endoscopy staff and subsequently (2) after 2 cycles of precleaning and manual cleaning and single cycle of HLD or (3) after 2 cycles of precleaning, manual cleaning, and HLD. RESULTS: The ideal ATP bioluminescence benchmark of <200 relative light units (RLUs) after manual cleaning was achieved from suction-biopsy channel rinsates of all endoscopes, but 9 of 10 duodenoscope elevator channel rinsates failed to meet this benchmark. Re-education reduced RLUs in duodenoscope elevator channel rinsates after precleaning (23,218.0 vs 1340.5 RLUs, P < .01) and HLD (177.0 vs 12.0 RLUs, P < .01). After 2 cycles of manual cleaning/HLD, duodenoscope elevator channel RLUs achieved levels similar to sterile water, with corresponding negative cultures. CONCLUSIONS: ATP testing offers a rapid, inexpensive alternative for detection of endoscope microbial residue. Re-education of endoscopy staff and 2 cycles of cleaning and HLD decreased elevator channel RLUs to levels similar to sterile water and may therefore minimize the risk of transmission of infections by duodenoscopes.
Assuntos
Trifosfato de Adenosina/análise , Infecção Hospitalar/prevenção & controle , Transmissão de Doença Infecciosa/prevenção & controle , Desinfecção/métodos , Duodenoscópios/microbiologia , Contaminação de Equipamentos/prevenção & controle , Reutilização de Equipamento , Medições Luminescentes , Endoscopia Gastrointestinal , Humanos , Competência ProfissionalRESUMO
BACKGROUND AND AIMS: The 6-minute withdrawal time for colonoscopy, widely considered the standard of care, is controversial. The skill and technique of endoscopists may be as important as, or more important than, withdrawal time for adenoma detection. It is unclear whether a shorter withdrawal time with good technique yields an acceptable lesion detection rate. Our objective was to evaluate a 3-minute versus a 6-minute withdrawal time by using segmental tandem colonoscopy. METHODS: We performed a prospective, randomized trial by using 4 expert endoscopists. Patients were randomized to a 3-minute or a 6-minute initial withdrawal, each followed by a tandem second 6-minute withdrawal. All polyps were removed. The primary outcomes were adenoma miss rates (AMRs), adenomas per colonoscopy (APC) rates, and adenoma detection rates (ADRs). RESULTS: A total of 99 and 101 patients were enrolled in the 3-minute and 6-minute withdrawal groups, respectively. The AMR was significantly higher in the 3-minute withdrawal group (48.0% vs 22.9%; P = .0001). After controlling for endoscopist, patient age and/or sex, Boston Bowel Preparation Scale score, and size and/or location and/or morphology of adenoma, the AMR remained significantly higher in the 3-minute withdrawal group (odds ratio, 2.78; 95% confidence interval, 1.35-5.15; P = .0001). The ADR was similar between both groups (39.2% vs 40.6%; P = .84). However, the mean APC rate was significantly lower in the 3-minute withdrawal group (0.55 vs 0.80; P = .0001). CONCLUSIONS: The AMR was significantly higher, and the APC rate was significantly lower in the 3-minute withdrawal group versus the 6-minute withdrawal group. Despite expert technique, a shorter withdrawal time is associated with an unacceptably high AMR and low APC rate. (Clinical trial registration number: NCT01802008.).
Assuntos
Adenoma/diagnóstico , Colonoscopia/métodos , Neoplasias Colorretais/diagnóstico , Erros de Diagnóstico , Duração da Cirurgia , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Estudos ProspectivosRESUMO
BACKGROUND & AIMS: Endoscopic ultrasound-guided transmural drainage and necrosectomy have become the standard treatment for patients with pancreatic walled-off necrosis (WON). Lumen-apposing metal stents (LAMS) have shown success in the management of pancreatic fluid collections. However, there are few data on their specific roles in management of WON. We investigated the efficacy and safety of LAMS in treatment of WON. METHODS: We performed a retrospective multicenter case series of 124 patients with WON who underwent endoscopic transmural drainage by using LAMS at 17 tertiary care centers from January 2014 through May 2015. Patients underwent endoscopic ultrasound-guided cystogastrostomy or cystoenterostomy with placement of an LAMS into the WON collection. At the discretion of the endoscopist, we performed direct endoscopic necrosectomy, irrigation with hydrogen peroxide, and/or nasocystic drain placement. We performed endoscopic retrograde cholangiopancreatography with pancreatic duct stent placement when indicated. Concomitant therapies included direct endoscopic debridement (n = 78), pancreatic duct stent placement for leak (n = 19), hydrogen peroxide-assisted necrosectomy (n = 38), and nasocystic irrigation (n = 22). We collected data for a median time of 4 months (range, 1-34 months) after the LAMS placement. The primary outcomes were rates of technical success (successful placement of the LAMS), clinical success (resolution of WON, on the basis of image analysis, without need for further intervention via surgery or interventional radiology), and adverse events. RESULTS: The median size of the WON was 9.5 cm (range, 4-30 cm). Eight patients had 2 LAMS placed for multiport access, all with technical success (100%). Clinical success was achieved in 107 patients (86.3%) after 3 months of follow-up. Thirteen patients required a percutaneous drain, and 3 required a surgical intervention to manage their WON. The stents remained patent in 94% of patients (117 of 124) and migrated in 5.6% of patients (7 of 124). The median number of endoscopic interventions was 2 (range, 1-9 interventions). CONCLUSIONS: On the basis of a retrospective analysis of 124 patients, endoscopic therapy of WON by using LAMS is safe and effective. Creation of a large and sustained cystogastrostomy or cystoenterostomy tract is effective in the drainage and treatment of WON.
Assuntos
Endoscopia/métodos , Pancreatite Necrosante Aguda/cirurgia , Stents/efeitos adversos , Idoso , Feminino , Humanos , Masculino , Metais , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND AND AIMS: EMR is used widely for treatment of nonpedunculated colorectal adenomas ≥ 2 cm. Recurrence at the resection site occurs in 10% to 30% of cases. METHODS: Records of consecutive patients referred for endoscopic resection over a 4-year period were reviewed retrospectively. In the first part of the study period, our routine practice was to use argon plasma coagulation (APC) to treat all visible residual neoplasia after exhaustive attempts at snare resection during EMR. In the second part of the study period, we changed our practice to use avulsion to treat all visible residual neoplasia after exhaustive attempts at snare resection during EMR. We analyzed the effect of this change in practice on recurrence rates after EMR. RESULTS: Two hundred twenty-three resected lesions were analyzed. Fifty-nine (26%) were treated with en-bloc EMR, 55 (25%) by piecemeal EMR with complete snare removal of all visible neoplasia, 63 (28%) by piecemeal EMR with APC of visible residual neoplasia, and 46 (21%) by piecemeal EMR with avulsion of visible residual neoplasia. There was no significant difference in adverse event rates among the 4 groups. The recurrence rates on follow-up colonoscopy were 4.2%, 3.0%, 59.3%, and 10.3%, respectively. The recurrence rate for patients treated with avulsion was significantly lower than for those treated with APC (odds ratio, .079; P < .001). Multivariate analysis demonstrated that use of avulsion instead of APC was a significant predictor of no recurrence. CONCLUSIONS: After exhaustive attempts at snare resection during EMR, avulsion is superior to APC for treatment of residual visible neoplasia. Compared with APC, avulsion significantly decreases the recurrence rate without significantly increasing the risk of the procedure.