Diagnosis of Barrett's esophagus and esophageal varices using a magnetically assisted capsule endoscopy system.

BACKGROUND AND AIMS: Magnetically assisted capsule endoscopy (MACE) potentially offers a comfortable, patient friendly, and community-based alternative to gastroscopy (EGD). This pilot study aims to explore whether this approach can be used to accurately diagnose Barrett's esophagus (BE) and esophageal varices. METHOD: The MiroCam Navi capsule system was used to examine the upper GI tract in patients due to undergo a clinically indicated EGD. A total of 50 participants were enrolled: 34 had known pathology (17 BE, 17 esophageal varices [EV]) and 16 controls. Patients underwent the MACE procedure with the operator blinded to the indication and any previous endoscopic diagnoses. The subsequent EGD was performed by an endoscopist blinded to the MACE findings. Diagnostic yield, comfort, and patient preference between the 2 modalities were compared. RESULTS: The mean age of the participants was 61 years, the male/female ratio was 2.1:1, the mean body mass index was 29.5 kg/m2, and the average chest measurement was 105.3 cm. Forty-seven patients underwent both procedures; 3 patients were unable to swallow the capsule. With the use of the magnet, it was possible to hold the capsule within the esophagus for a mean duration of 190 seconds and up to a maximum of 634 seconds. A correct real-time MACE diagnosis was made in 11 of 15 patients with EV (sensitivity 73.3% [95% confidence interval (CI), 44.9%-92.2%] and specificity 100% [95% CI, 89.1%-100%]) and 15 of 16 patients with BE (sensitivity 93.8% [95% CI, 69.8%-99.8%] and specificity of 100% [95% CI, 88.8%-100%]). MACE was considered more comfortable than conventional endoscopy (P < .0001); the mean score was 9.2 for MACE compared with 6.7 for EGD when assessed on a 10-point scale. No MACE- or EGD-related adverse events occurred. CONCLUSION: This pilot study demonstrates that MACE is both safe and well tolerated by patients. Accuracy for the diagnosis of BE was high, and therefore MACE may have a role in screening for this condition. (Clinical trial registration number: NCT02852161.).

The BougieCap - a new method for endoscopic treatment of complex benign esophageal stenosis: results from a multicenter study.

BACKGROUND: A major limitation of current treatment strategies for nonmalignant upper gastrointestinal stenoses is the lack of either optical or haptic feedback during dilation. Wire guidance and fluoroscopy is often necessary to control the position. METHODS: A novel device for endoscopic dilation, the BougieCap (Ovesco Endoscopy AG, Tübingen, Germany) was evaluated in a prospective multicenter trial. Primary outcome was successful dilation of stenosis and secondary outcome was alteration in dysphagia symptoms in short-term follow-up.  RESULTS: 50 patients with benign esophageal strictures were included. Endoscopic bougienage was successful in 96 %. Bougienage failed in two cases because of high resistance. Symptoms of dysphagia decreased significantly after bougienage (59.0 points at Day 0 vs. 28.6 points at Day 14; P < 0.001). Adverse events were loss of BougieCap into the stomach in two cases; no severe adverse events were reported. CONCLUSIONS: Endoscopic treatment of benign stenoses using the BougieCap enabled direct visual control of the bougienage procedure. This might help to adapt treatment more precisely to the stricture. Symptoms of dysphagia were improved in short-term follow-up. Additional wire guidance may be used for selected cases (e. g. narrow lumen, pediatric scope).

Magnetic-assisted capsule endoscopy in the upper GI tract by using a novel navigation system (with video).

BACKGROUND AND AIMS: Capsule endoscopy for visualization of the upper GI tract has thus far been experimental and potentially expensive. Our aim was to demonstrate the maneuverability and evaluate the ability to completely visualize and maintain views in the upper GI tract by using a simple magnetic-assisted capsule endoscopy (MACE) system. METHODS: Twenty-six volunteers were recruited. The hand-held magnet was placed at strategic points on the body surface and rotated to hold and maneuver the capsule. The ability to view the upper GI tract landmarks was noted: esophagogastric junction (EGJ), cardia, fundus, body, incisura, antrum, and pylorus. Control was assessed by the ability to hold the capsule for 1 minute at 5 positions: the lower esophagus and 4 designated positions in the proximal and distal stomach and also traversing the stomach and through the pylorus. Volunteers subsequently underwent a standard gastroscopy. RESULTS: The median data are as follows: age, 38 years (range 26-45 years); BMI, 24 (range 19-38); and procedure time, 24 minutes (range 12-39 minutes). Successful visualization of each landmark was EGJ, 92%; cardia, 88%; fundus, 96%; body, 100%; incisura, 96%; antrum, 96%; and pylorus, 100%; with fewer clear views of the EGJ and fundus. The capsule could be held in 88% of designated positions for 1 minute, moved from the fundus to the antrum in all cases, and traversed the pylorus in 50% (n = 13). An age of 40 years and older was associated with successful pyloric traversing (P = .04). There was positive concordance for 8 of 9 minor pathological findings on standard gastroscopy. CONCLUSION: MACE in the upper GI tract is feasible. There is a high degree of visualization and control, with some improvement required for optimizing proximal gastric views and traversing the pylorus.

BOB CAT: A Large-Scale Review and Delphi Consensus for Management of Barrett's Esophagus With No Dysplasia, Indefinite for, or Low-Grade Dysplasia.

OBJECTIVES: Barrett's esophagus (BE) is a common premalignant lesion for which surveillance is recommended. This strategy is limited by considerable variations in clinical practice. We conducted an international, multidisciplinary, systematic search and evidence-based review of BE and provided consensus recommendations for clinical use in patients with nondysplastic, indefinite, and low-grade dysplasia (LGD). METHODS: We defined the scope, proposed statements, and searched electronic databases, yielding 20,558 publications that were screened, selected online, and formed the evidence base. We used a Delphi consensus process, with an 80% agreement threshold, using GRADE (Grading of Recommendations Assessment, Development and Evaluation) to categorize the quality of evidence and strength of recommendations. RESULTS: In total, 80% of respondents agreed with 55 of 127 statements in the final voting rounds. Population endoscopic screening is not recommended and screening should target only very high-risk cases of males aged over 60 years with chronic uncontrolled reflux. A new international definition of BE was agreed upon. For any degree of dysplasia, at least two specialist gastrointestinal (GI) pathologists are required. Risk factors for cancer include male gender, length of BE, and central obesity. Endoscopic resection should be used for visible, nodular areas. Surveillance is not recommended for <5 years of life expectancy. Management strategies for indefinite dysplasia (IND) and LGD were identified, including a de-escalation strategy for lower-risk patients and escalation to intervention with follow-up for higher-risk patients. CONCLUSIONS: In this uniquely large consensus process in gastroenterology, we made key clinical recommendations for the escalation/de-escalation of BE in clinical practice. We made strong recommendations for the prioritization of future research.

Magnetically steerable gastric capsule endoscopy is equivalent to flexible endoscopy in the detection of markers in an excised porcine stomach model: results of a randomized trial.

BACKGROUND AND STUDY AIMS: Capsule endoscopy is well tolerated but control of its movement is needed in order to visualize the whole gastric surface. Technological developments have produced an external magnet to allow manipulation of the capsule within the gastric cavity. The aim of this study was to compare magnetically steerable gastric capsule endoscopy (MSGCE) with flexible endoscopy for the detection of beads in a porcine stomach. MATERIALS AND METHODS: Beads were sewn onto the mucosal surface of 12 ex vivo porcine stomachs. Each model was examined by flexible endoscopy and MSGCE by two blinded investigators. MSGCE was performed according to a protocol using positional changes and magnetic steering. Outcome measures were number and location of beads identified, and duration of procedure. RESULTS: Flexible endoscopy identified 79 /90 beads (88 %), and MSGCE identified 80 /90 (89 %). The difference in sensitivities was 1.11 (95 % confidence interval 0.06 - 28.26). Thus, MSGCE was noninferior to flexible endoscopy. Mean examination times for flexible endoscopy and MSGCE were 3.34 minutes and 9.90 minutes, respectively. CONCLUSION: MSGCE was equivalent to conventional flexible endoscopy in the detection of beads in a porcine stomach model.

Over-the-scope-grasper: A new tool for pancreatic necrosectomy and beyond - first multicenter experience.

BACKGROUND: Endoscopic treatment of pancreatic necrosis can be challenging and time-consuming because sticky necrotic debris is sometimes difficult to remove. The over-the-scope-grasper, a new tool that has recently become available for this purpose, might also be useful for other indications. However, clinical data on the efficacy and safety of this new device are lacking. AIM: To evaluate the technical success and safety of the device in a multicenter setting. METHODS: The over-the-scope-grasper was used in nine selected endoscopic centers between November 2020 and October 2021 for appropriate indications. Overall, 56 procedures were included in the study. We retrospectively evaluated procedural parameters of all endoscopic interventions using a predefined questionnaire, with special respect to technical success, indications, duration of intervention, type of sedation, and complications. In the case of pancreatic necrosectomy, the access route, stent type, number of necrosis pieces removed, and clinical handling were also recorded. RESULTS: A total of 56 procedures were performed, with an overall technical success rate of 98%. Most of the procedures were endoscopic pancreatic necrosectomies (33 transgastric, 4 transduodenal). In 70% of the procedures, access to the necrotic cavity was established with a lumen apposing metal stent. The technical success of pancreatic necrosectomy was 97%, with a mean of 8 pieces (range, 2-25 pieces) of necrosis removed in a mean procedure time of 59 min (range, 15-120 min). In addition, the device has been used to remove blood clots (n = 6), to clear insufficiency cavities before endoluminal vacuum therapy (n = 5), and to remove foreign bodies from the upper gastrointestinal tract (n = 8). In these cases, the technical success rate was 100%. No moderate or severe/fatal complications were reported in any of the 56 procedures. CONCLUSION: These first multicenter data demonstrate that the over-the-scope-grasper is a promising device for endoscopic pancreatic necrosectomy, which is also appropriate for removing foreign bodies and blood clots, or cleaning insufficiency cavities prior to endoluminal vacuum therapy.

Endoscopic full thickness resection in the colo-rectum: outcomes from the UK Registry.

BACKGROUND: Endoscopic full-thickness resection (eFTR) of the colon using the full-thickness resection device (FTRD) is a novel method for removing lesions involving, or tethered to, deeper layers of the colonic wall. The UK FTRD Registry collected data from multiple centres performing this procedure. We describe the technical feasibility, safety and early outcomes of this technique in the UK. METHODS: Data were collected and analysed on 68 patients who underwent eFTR at 11 UK centres from April 2015 to June 2019. Outcome measures were technical success, procedural time, specimen size, R0 resection, endoscopic clearance, and adverse events. Reported technical difficulties were collated. RESULTS: Indications for eFTR included non-lifting polyps (29 cases), T1 tumour resection (13), subepithelial tumour (9), and polyps at the appendix base or diverticulum (17). Target lesion resection was achieved in 60/68 (88.2%). Median specimen size was 21.7 mm (10-35 mm). Histologically confirmed R0 resection was achieved in 43/56 (76.8%) with full-thickness resection in 52/56 (92.9%). Technical difficulties occurred in 17/68 (25%) and complications in 3/68 (5.9%) patients. CONCLUSION: eFTR is a useful technique with a high success rate in treating lesions not previously amenable to endoscopic therapy. Whilst technical difficulties may arise, complication rates are low and outcomes are acceptable, making eFTR a viable alternative to surgery for some specific lesions.

The Role of National Specialist Societies in Influencing Transformational Change in Low-Middle Income Countries - Reflections on the Model of Implementation for a National Endoscopy Training Programme in Bangladesh.

The British Society of Gastroenterology (BSG) and the Bangladesh Gastroenterology Society (BGS) have collaborated on an endoscopy training programme, which has grown up over the past decade from a small scheme borne out of the ideas of consultant gastroenterologists in Swansea, South Wales (United Kingdom) to improve gastroenterology services in Bangladesh to become a formalised training programme with broad reach. In this article, we document the socioeconomic and historical problems that beset Bangladesh, the current training needs of doctors and how the BSG-BGS collaboration has made inroads into changing outcomes both for gastroenterologists in Bangladesh, but also for the populations they serve.

The role of magnetic assisted capsule endoscopy (MACE) to aid visualisation in the upper GI tract.

Examination of the upper gastrointestinal tract by a standard endoscope is often thought as a daunting experience to many who have undertaken or are about to undergo the procedure. The overall perceived size of the gastroscope, unpleasantness of stimulation of the gag reflex and the need often for sedation is discouraging to many. A method to visualise the upper gastrointestinal mucosa which negates the need for sedation, the associated expensive decontamination costs and the possibility of having a community based examination would be particularly welcoming to this endoscopy field. Since the first swallow of a capsule endoscope by a human volunteer in 1999, their usage for examining the small bowel has exponentially grown to that of over a million patients worldwide. More recently, innovation in this field have shown plausibility for its use to visualise the upper gastrointestinal tract, with the integration of magnets within the capsule the most promising method.

Utilisation of magnets to enhance gastrointestinal endoscopy.

Methods to assess, access and treat pathology within the gastrointestinal tract continue to evolve with video endoscopy replacing radiology as the gold standard. Whilst endoscope technology develops further with the advent of newer higher resolution chips, an array of adjuncts has been developed to enhance endoscopy in other ways; most notable is the use of magnets. Magnets are utilised in many areas, ranging from endoscopic training, lesion resection, aiding manoeuvrability of capsule endoscopes, to assisting in easy placement of tubes for nutritional feeding. Some of these are still at an experimental stage, whilst others are being increasingly incorporated in our everyday practice.

Optimizing the performance of magnetic-assisted capsule endoscopy of the upper GI tract using multiplanar CT modelling.

BACKGROUND AND AIMS: This study used computed tomography modelling of the abdomen to determine the optimal placements of a magnetic capsule endoscope in the stomach that allows complete mucosal visualization and determined the optimal placement of the handheld magnet to aid pyloric traversing. MATERIALS AND METHODS: Using multiplanar reformatting, 100 abdominal computed tomography scans were analysed to assess gastric luminal visualization by a capsule endoscope from five fixed stations throughout the stomach. From each station, we assessed the ability of a capsule endoscope to visualize six gastric landmarks. The pyloric canal angles were calculated to create a vector. We mapped the position of this vector on the patient to determine the optimal placement of the magnet that would aid pyloric traversing. RESULTS: Complete visualization of the stomach (viewing all landmarks) was only achievable in up to 29% of cases when viewed from a sole station. Maximal visualization required combining stations. Fundal dependent (station 1) and opposite antral dependent (station 4) was the best, achieving visualization in 85% (P<0.01). The optimal positioning of the magnet to aid pyloric traversing was posteriorly between vertebrae T5 and L2 in an area 10 cm to the left and 18 cm to the right (83% cases). Age older than 55 years (P=0.03) and the ability to view the pylorus from station 3 (P=0.04) were associated with an extreme pyloric vector. CONCLUSION: Although there is some extreme variation in the upper gastrointestinal anatomy, the majority of cases will allow the use of a single standard method in performing MACE, which may be very useful for screening purposes.

Therapeutic upper gastrointestinal tract endoscopy in Paediatric Gastroenterology.

Since the first report of use of endoscopy in children in the 1970s, there has seen an exponential growth in published experience and innovation in the field. In this review article we focus on modern age therapeutic endoscopy practice, explaining use of traditional as well as new and innovative techniques, for diagnosis and treatment of diseases in the paediatric upper gastrointestinal tract.

Recurrent Kikuchi-Fujimoto disease.

We report the case of a 27-year-old, UK-born, Asian woman who suffered a rare recurrence of Kikuchi-Fujimoto disease. She presented with tender lymphadenopathy of the neck, fever and a prodrome of flu-like symptoms. She had a past medical history of biopsy-proven Kikuchi-Fujimoto disease of her right axilla 2 years earlier, which required no treatment. Following her repeat admission, a cervical lymph node biopsy confirmed a diagnosis of recurrent Kikuchi-Fujimoto disease. She did not improve despite treatment with paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs). She was started on high-dose prednisolone and her symptoms, pyrexia, and inflammatory markers settled within 24 h. She continually improved and the prednisolone was slowly reduced over 9 months. Kikuchi-Fujimoto is a rare, benign, self-limiting disease that presents with lymphadenopathy and fever. It rarely reoccurs. The severity, recurrence and the different body site make this an unusual case.