Pancreatoscopy-Guided Endotherapies for Pancreatic Diseases.

Per-oral pancreatoscopy (POP) is a pancreas-preserving modality that allows for targeted pancreatic duct interventions, particularly in cases where standard techniques fail. POP specifically has an emerging role in the diagnosis, risk stratification, and disease extent determination of main duct intraductal papillary mucinous neoplasms (IPMNs). It has also been successfully used for laser ablation of IPMNs in poor surgical candidates, lithotripsy for complex stone disease, and laser stricturoplasty. As experience with POP increases beyond select referral center practices, further studies validating POP efficacy with long-term follow-up will help clarify when POP-guided intervention is most beneficial in relation to surgical intervention.

Endoscopic submucosal dissection for colorectal dysplasia in inflammatory bowel disease: a US multicenter study.

Background and study aims In patients with inflammatory bowel disease (IBD), endoscopically visible lesions with distinct borders can be considered for endoscopic resection. The role of endoscopic submucosal dissection (ESD) for these lesions is not well defined because of a paucity of data. We aimed to evaluate the outcomes of colorectal ESD of dysplastic lesions in patients with IBD across centers in the United States. Patients and methods This was a retrospective analysis of consecutive patients with IBD who were referred for ESD of dysplastic colorectal lesions at nine centers. The primary endpoints were the rates of en bloc resection and complete (R0) resection. The secondary endpoints were the rates of adverse events and lesion recurrence. Results A total of 45 dysplastic lesions (median size 30mm, interquartile range [IQR] 23 to 42 mm) in 41 patients were included. Submucosal fibrosis was observed in 73 %. En bloc resection was achieved in 43 of 45 lesions (96 %) and R0 resection in 34 of 45 lesions (76 %). Intraprocedural perforation occurred in one patient (2.4 %) and was treated successfully with clip placement. Delayed bleeding occurred in four patients (9.8 %). No severe intraprocedural bleeding or delayed perforation occurred. During a median follow-up of 18 months (IQR 13 to 37 months), local recurrence occurred in one case (2.6 %). Metachronous lesions were identified in 11 patients (31 %). Conclusions ESD, when performed by experts, is safe and effective for large, dysplastic colorectal lesions in patients with IBD. Despite the high prevalence of submucosal fibrosis, en bloc resection was achieved in nearly all patients with IBD undergoing ESD. Careful endoscopic surveillance is necessary to monitor for local recurrence and metachronous lesions after ESD.

Spray cryotherapy prevents need for palliative stenting in patients with esophageal cancer-associated dysphagia.

BACKGROUND: Dysphagia is the most common symptom in advanced esophageal cancer patients. Esophageal stent placement (SP) is a common palliation method but can be associated with significant morbidity. Limited data exist regarding the ability of spray cryotherapy (SC) prolong time to SP. METHODS: A Mayo Clinic (Rochester, MN) patient database was reviewed for cases with a SC indication of esophageal cancer palliation from 2007-2019. Procedures were performed using a liquid nitrogen SC system to apply 2-5 separate 20 second freeze and 60 second thaw cycles based on tumor characteristics. Primary outcome was time to subsequent palliative SP. RESULTS: Of 56 patients (71.4% male, mean age 77.8 ± 10.2 years) who underwent a total of 199 SC sessions (mean 3.6 ± 2.7, range 1-12 per patient), 41 had adenocarcinoma and 15 squamous cell carcinoma (SCC). Overall, 13 patients underwent subsequent SP within a mean duration of 15.7 ± 11.0 months over a mean follow-up duration of 25.6 ± 29.4 months. Treatment did produce stenosis in 16 patients, who required dilation within a mean period of 193.1 ± 294.1 days; notably, 10 patients had a history of preceding malignant strictures requiring dilation. Two patients experienced bleeding requiring transfusion, whereas 1 experienced perforation at the start of SC. Prior chemotherapy and/or radiation was not associated with developing an SC-related complication (risk ratio (RR) 1.5; 95% CI 0.6-3.7, P > 0.4). CONCLUSIONS: SC appears to be an effective and safe modality to palliate esophageal cancer in appropriate candidates. Majority of patients who undergo SC avoid the need for future SP. If patients eventually require SP, they are able to, on average, defer stenting for >1 year from SC initiation.

Impact of bariatric surgery on surveillance and treatment outcomes of Barrett's esophagus: A stage-matched cohort study.

BACKGROUND: Obesity could increase the risk of Barrett's esophagus (BE). Roux-en-Y gastric bypass (RYGB) could alter the natural course of BE. Data on BE progression after RYGB are scarce. OBJECTIVES: To study endoscopic surveillance and endoscopic eradication therapy (EET) outcomes of BE in post-RYGB patients versus controls with obesity. SETTING: Academic referral centers, a retrospective cohort study. METHODS: Patients who underwent RYGB with biopsy-proven BE or intramucosal esophageal adenocarcinoma (IM-EAC) with an endoscopic follow-up of at least 12 months were identified from a prospectively maintained database between January 1992 and February 2019 at 3 tertiary care centers. RYGB patients were matched 1-to-2 to patients with obesity (body mass index > 30 kg/m2) by the initial BE stage at diagnosis. Surveillance and EET outcomes were compared. RESULTS: A total of 147 patients were included (49 RYGB and 98 BE stage-matched controls with obesity). For endoscopic surveillance, the rate of disease progression to high-grade dysplasia /IM-EAC was significantly lower in the RYGB patients than controls (2.6% versus 40.2%, respectively; P < .0001), with a comparable median follow-up time (85 months versus 80 months, respectively). This effect persisted in a multivariate analysis, with a hazard ratio of .09 (95% confidence interval, .01-.69). For EET, no difference in the rate of achieving complete remission of intestinal metaplasia was observed between the RYGB and control groups (71.2% versus 81.3%, respectively; P = .44). CONCLUSION: RYGB appears to be a protective factor for disease progression to neoplastic BE during endoscopic surveillance. However, disease progression was still observed after RYGB, warranting continuing endoscopic surveillance. EET appeared to be equally effective between RYGB patients and controls with obesity.

EUS-guided verteporfin photodynamic therapy for pancreatic cancer.

BACKGROUND AND AIMS: Locally advanced pancreatic cancer (LAPC) often causes obstruction. Verteporfin photodynamic therapy (PDT) can feasibly "debulk" the tumor more safely than noncurative surgery and has multiple advantages over older PDT agents. We aimed to assess the feasibility of EUS-guided verteporfin PDT in ablating nonresectable LAPC. METHODS: Adults with LAPC with adequate biliary drainage were prospectively enrolled. Exclusion criteria were significant metastatic disease burden, disease involving >50% duodenal or major artery circumference, and recent treatment with curative intent. CT was obtained between days -28 to 0. On day 0, verteporfin .4 mg/kg was infused 60 to 90 minutes before EUS, during which a diffuser was positioned in the tumor and delivered light at 50 J/cm for 333 seconds. CT was obtained on day 2, with adverse event monitoring occurring on days 1, 2, and 14. The primary outcome was presence of necrosis. RESULTS: Of 8 patients (62.5% men, mean age 65 ± 7.9 years) included in the study, 5 were staged at T3, 2 at T2, and 1 at T1. Most (n = 4) had primary lesions in the pancreatic head. Mean pretrial tumor diameter was 33.3 ± 13.4 mm. On day 2 CT, 5 lesions demonstrated a zone of necrosis measuring a mean diameter of 15.7 ± 5.5 mm; 3 cases did not develop necrosis. No adverse events were noted during the procedure or postprocedure observation period (days 1-3), and no changes in patient-reported outcomes were noted. CONCLUSIONS: In this pilot study, EUS-guided verteporfin PDT is feasible and shows promise as a minimally invasive ablative therapy for LAPC in select patients. Tumor necrosis is visible within 48 hours after treatment. Patient enrollment and data collection are ongoing. (Clinical trial registration number: NCT03033225.).

Efficacy of Endoscopic Submucosal Dissection for Superficial Gastric Neoplasia in a Large Cohort in North America.

BACKGROUND & AIMS: Endoscopic submucosal dissection (ESD) is a widely accepted treatment option for superficial gastric neoplasia in Asia, but there are few data on outcomes of gastric ESD from North America. We aimed to evaluate the safety and efficacy of gastric ESD in North America. METHODS: We analyzed data from 347 patients who underwent gastric ESD at 25 centers, from 2010 through 2019. We collected data on patient demographics, lesion characteristics, procedure details and related adverse events, treatment outcomes, local recurrence, and vital status at the last follow up. For the 277 patients with available follow-up data, the median interval between initial ESD and last clinical or endoscopic evaluation was 364 days. The primary endpoint was the rate of en bloc and R0 resection. Secondary outcomes included curative resection, rates of adverse events and recurrence, and gastric cancer-related death. RESULTS: Ninety patients (26%) had low-grade adenomas or dysplasia, 82 patients (24%) had high-grade dysplasia, 139 patients (40%) had early gastric cancer, and 36 patients (10%) had neuroendocrine tumors. Proportions of en bloc and R0 resection for all lesions were 92%/82%, for early gastric cancers were 94%/75%, for adenomas and low-grade dysplasia were 93%/ 92%, for high-grade dysplasia were 89%/ 87%, and for neuroendocrine tumors were 92%/75%. Intraprocedural perforation occurred in 6.6% of patients; 82% of these were treated successfully with endoscopic therapy. Delayed bleeding occurred in 2.6% of patients. No delayed perforation or procedure-related deaths were observed. There were local recurrences in 3.9% of cases; all occurred after non-curative ESD resection. Metachronous lesions were identified in 14 patients (6.9%). One of 277 patients with clinical follow up died of metachronous gastric cancer that occurred 2.5 years after the initial ESD. CONCLUSIONS: ESD is a highly effective treatment for superficial gastric neoplasia and should be considered as a viable option for patients in North America. The risk of local recurrence is low and occurs exclusively after non-curative resection. Careful endoscopic surveillance is necessary to identify and treat metachronous lesions.

Safety and feasibility of same-day discharge after esophageal endoscopic submucosal dissection.

BACKGROUND AND AIMS: Endoscopic submucosal dissection (ESD) is used for treating early luminal GI cancers. ESD is the standard of care in Asia, where it results in multiday admissions for observation. The goal of our study was to evaluate the safety and feasibility of same-day discharge (SDD) after ESD. METHODS: This is a retrospective cohort study of adults who underwent similar esophageal ESD with a Clutch Cutter device (DP2618DT; Fujifilm) at the Mayo Clinic (Rochester, Minn, USA) from 2017 to 2019 with a single endoscopist. The primary end point was postprocedural adverse events within 7 days of ESD. RESULTS: Of 96 patients (75% male, mean age, 70 ± 10.3 years) undergoing a total of 140 ESDs, 85 were SDD versus 55 admissions. Of the 55 admits, 53 were discharged within 24 hours, whereas 2 were admitted for 2 to 3 days for reasons unrelated to the ESD procedure. Admissions were more likely to have a history of antiplatelet/anticoagulant use (56.4% vs 34.1%; P = .01) and higher mean American Society of Anesthesiologists (ASA) score (3.2 vs 2.9; P = .007). Admissions had larger resections (28.6 vs 20.1 mm; P < .0001) with longer procedural durations (103.4 vs 62 minutes; P < .0001). Among SDDs, no intraprocedural or postprocedural adverse events were seen. Among admissions, 1 (1.8% vs 0%; P = .39) experienced intraprocedural bleeding requiring endoscopic intervention, 1 required transfusion before discharge within 24 hours of ESD (1.8% vs 0%; P = .39), and 1 required rehospitalization and endoscopic intervention within 7 days to address an active bleed along the resection margin (1.8% vs 0%; P = .39). CONCLUSIONS: SDD after esophageal ESD is safe and feasible. An experienced endoscopist can determine if SDD can be considered in patients with ASA physical classification status ≤2 who undergo resections off antiplatelet/anticoagulant therapy and do not experience intraprocedural adverse events.

Comparable Cancer-Specific Mortality of Patients With Early Gastric Cancer Treated With Endoscopic Therapy vs Surgical Resection.

BACKGROUND & AIMS: Endoscopic therapy is used commonly for superficial gastric cancer with very low risk of metastasis to the lymph nodes. However, limited population-based studies from the West have evaluated long-term outcomes of patients who received endoscopic therapy vs surgery. METHODS: We used the Surveillance Epidemiology and End Results database to identify and compare features and outcomes of patients who underwent endoscopic therapy (n = 786) or surgery (n = 2577) for Tis or T1aN0M0 superficial gastric cancer, diagnosed from 1998 to 2014. Multivariate logistic regression was performed to identify factors associated with endoscopic therapy. Overall survival and gastric cancer-specific survival times were compared after we controlled for covariates. RESULTS: Use of endoscopic therapy increased from 15.1% of cases in 1998 to 2000 to 39.0% of cases in 2013 to 2014. Endoscopic therapy was used more frequently in patients who were older, female, or Caucasian, or with lesions that were located in the proximal stomach or were limited in depth (Tis vs T1a) and size, compared with surgery. The median follow-up time was 59 months (interquartile range, 31-102 mo). Percentages of 5-year overall and cancer-specific survival were 57% and 99% in the endoscopic therapy group and 76% and 95% in the surgery group. After we adjusted for clinical factors using a multivariate Cox proportional hazards model, we found no significant difference in gastric cancer-specific mortality between patients who received endoscopic therapy vs surgery (hazard ratio, 1.42; 95% CI, 0.91-2.23; P = .12). CONCLUSIONS: In an analysis of a large population database, we found an increased trend in endoscopic therapy for superficial gastric cancer compared with surgery from 1998 through 2014. Patients who received endoscopic therapy vs surgery had comparable long-term cancer-specific mortality.

Endoscopic full-thickness resection using a clip non-exposed method for gastrointestinal tract lesions: a meta-analysis.

Background and study aims Endoscopic full-thickness resection (EFTR) allows for treatment of epithelial and sub-epithelial lesions (SELs) unsuitable to conventional resection techniques. This meta-analysis aimed to assess the efficacy and safety of clip-assisted method for non-exposed EFTR using FTRD or over-the-scope clip of gastrointestinal tumors. Methods A comprehensive literature search was performed. The primary outcome of interest was the rate of histologic complete resection (R0). Secondary outcomes of interest were the rate of enbloc resection, FTR, adverse events, and post-EFTR surgery. Random-effects model was used to calculate pooled estimates and generate forest plots. Results Eighteen studies with 730 patients and 733 lesions were included in the analyses. Indications for EFTR were difficult/residual colorectal adenoma, adenoma at a diverticulum or appendiceal orifice and early cancer (n = 634), colorectal SELs (n = 42), and upper gastrointestinal lesions (n = 51), other colonic lesions (n = 6). Median size of lesions was 13.5 mm. There were 22 failed EFTR attempts. Pooled overall R0 resection rate was 82 % (95 % CI: 75, 89). The pooled overall FTR rate was 83 % (95 % CI: 77, 89). The pooled overall enbloc resection rate was 95 (95 % CI: 92, 96). The pooled estimates for perforation and bleeding were < 0.1 % and 2 %, respectively. Following EFTR, a total of 110 patients underwent surgery for any reason [pooled rate 7 % (95 % 2, 14). The pooled rates for post-EFTR surgery due to invasive cancer, for non-curative endoscopic resection and for adverse events were 4 %, < 0.1 % and < 0.1 %, respectively. No mortality related to EFTR was noted. Conclusions EFTR appears to be safe and effective for gastrointestinal lesions that are not amenable to conventional endoscopic resection. This technique should be considered as an alternative to surgery in selected cases.

Safety and histologic outcomes of endoscopic submucosal dissection with a novel articulating knife for esophageal neoplasia.

BACKGROUND AND AIMS: Treatment of large esophageal neoplasia is gradually evolving from piecemeal to en bloc resections. Endoscopic submucosal dissection (ESD) is known to achieve more complete resections than piecemeal EMR for large lesions, yet it remains underused in the West because of technical and safety concerns with traditional electrosurgical knives. We aimed to evaluate a novel endoscopic articulating knife used with ESD (ESD-AR) to determine its safety and efficacy for large esophageal neoplasms in comparison with EMR. METHODS: We retrospectively studied clinically indicated cases of ESD-AR and EMR for esophageal lesions that were 15 mm or greater. All EMR cases had at least 3 simultaneous EMRs to adequately compare resection area. Rates of perforation, GI bleeding, technical performance, and pre- and postendoscopic resection diagnoses were evaluated. RESULTS: Seventy-two ESD-AR and 72 widespread EMR cases were evaluated for Barrett's esophagus (56%), adenocarcinoma (36%), squamous nodularity (2%), and squamous cell carcinoma (6%). There were no statistical differences in age, sex, Barrett's esophagus length, and lesion or resection size between the 2 groups. No perforations occurred. Two adverse events were recorded with ESD-AR and none with EMR (3% vs 0%, P = .50); these were associated with anticoagulation use (P = .04) and greater resection area (P = .02). There were more upgraded diagnoses post-ESD versus EMR (27% vs 12%, P = .05). CONCLUSIONS: ESD-AR by an experienced endoscopist has a comparable safety profile with widespread EMR for large esophageal neoplasia and may have advantages for diagnostic staging.

Low Frequency of Lymph Node Metastases in Patients in the United States With Early-stage Gastric Cancers That Fulfill Japanese Endoscopic Resection Criteria.

BACKGROUND & AIMS: In the West, early gastric cancer is increasingly managed with endoscopic resection (ER). This is, however, based on the assumption that the low prevalence and risk of lymph node metastases observed in Asian patients is applicable to patients in the United States. We sought to evaluate the frequency of and factors associated with metastasis of early gastric cancers to lymph nodes, and whether the Japanese ER criteria are applicable to patients in the US. METHODS: We performed a retrospective study of 176 patients (mean age 68.5 years; 59.1% male; 58.5% white) who underwent surgical resection with lymph node dissection of T1 and Tis gastric adenocarcinomas, staged by pathologists, at 7 tertiary care centers in the US from January 1, 1999, through December 31, 2016. The frequency of lymph node metastases and associated risk factors were determined. RESULTS: The mean size of gastric adenocarcinomas was 23.0 ± 16.6 mm-most were located in the lower-third of the stomach (67.0%), invading the submucosa (55.1%), and moderately differentiated (31.3%). Lymphovascular invasion was observed in 18.2% of lesions. Overall, 20.5% of patients had lymph node metastases. Submucosal invasion (odds ratio, 3.9; 95% CI, 1.4-10.7) and lymphovascular invasion (odds ratio, 4.6; 95% CI, 1.8-12.0) were independently associated with increased risk of metastasis to lymph nodes. The frequency of lymph node metastases among patients fulfilling standard and expanded Japanese criteria for ER were 0 and 7.5%, respectively. CONCLUSIONS: The frequency of lymph node metastases among patients with early gastric cancer in a US population is higher than that of published Asian series. However, early gastric cancer lesions that meet the Japanese standard criteria for ER are associated with negligible risk of metastasis to lymph nodes, so ER can be recommended for definitive therapy. Expanded criteria cancers appear to have a higher risk of metastasis to lymph nodes, so ER may be considered for select cases.

Prevalence of metastasis and survival of 788 patients with T1 rectal carcinoid tumors.

BACKGROUND AND AIMS: Prevalence of rectal carcinoids is increasing, partly because of increased colorectal cancer screening. Local excision (endoscopic or transanal excision) is usually performed for small (<1-2 cm) rectal carcinoids, but data on clinical outcomes from large population-based U.S. studies are lacking. The aims of this study were to determine the prevalence of metastasis of resected small rectal carcinoid tumors using a large national cancer database and to evaluate the long-term survival of patients after local resection as compared with radical surgery. METHODS: The Surveillance Epidemiology and End Results database was used to identify 788 patients with rectal T1 carcinoids <2 cm in size. Prevalence of metastases at initial diagnosis and risk factors for metastases were analyzed. Cancer-specific survival (CSS) was calculated. RESULTS: A total of 727 patients (92.3%) had tumors ≤10 mm in diameter and 61 (7.7%) had tumors 11 to 19 mm. Overall, 12 patients (1.5%) had metastasis at the time of diagnosis with prevalence of 1.1% in lesions ≤10 mm and 6.6% in lesions 11 to 19 mm (P = .01). Survival of patients with T1 rectal carcinoids without metastasis was significantly better than those with metastasis (5-year CSS of 100% vs 78%, P < .001). Of 559 patients with T1N0M0 rectal carcinoids ≤10 mm, 5-year CSS was 100% in both groups who underwent local excision and those who underwent radical surgery. CONCLUSIONS: Larger T1 rectal carcinoid tumors (11-19 mm) have significantly higher risk of lymph node metastases compared with those ≤10 mm. Survival is worse with metastatic disease. Local therapy is adequate for T1N0M0 rectal carcinoids ≤10 mm in size with excellent long-term outcomes.

Endoscopic suturing for management of peptic ulcer-related upper gastrointestinal bleeding: a preliminary experience.

Background and study aims Acute non-variceal upper gastrointestinal bleeding (UGIB) due to peptic ulcer disease (PUD) remains a common and challenging emergency managed by gastroenterologists. The proper role of endoscopic suturing on the management of PUD-related UGIB is unknown. Patients and methods This is an international case series of patients who underwent endoscopic suturing for bleeding PUD. Primary outcome was rate of immediate hemostasis and rate of early rebleeding (within 72 hours). Secondary outcomes included technical success, delayed rebleeding (> 72 hours), and rate of adverse events (AEs). Results Ten patients (mean age 66.7 years, 30 % female) were included in this study. Nine (90 %) had prior failed endoscopy hemostasis with an average of 1.4 ±â€Š0.7 (range 1 - 3) prior endoscopic sessions. Forrest classification was Ib in 5 (50 %), IIa in 3 (30 %), IIb in 1(10 %), and IIc in 1 (10 %). Mean suturing time was 13.4 ±â€Š5.6 (range 3.5 to 20) minutes. Technical success was 100 %. Rate of immediate hemostasis was 100 % and rate of early rebleeding was 0 %. Mean number of sutures was 1.5 (range, 1 - 4). No AEs were observed. Delayed recurrent bleeding was not observed in any cases after a median of 11 months (range 2 - 56), after endoscopic suturing. Conclusions Oversewing of a bleeding or high-risk ulcer using endoscopic suturing appears to be a safe and effective method for achieving endoscopic hemostasis. It may be considered as rescue endoscopic therapy when primary endoscopic hemostasis fails to control the bleeding or when hemorrhage recurs after successful control of bleeding.

Fully-covered metal stents with endoscopic suturing vs. partially-covered metal stents for benign upper gastrointestinal diseases: a comparative study.

BACKGROUND AND STUDY AIMS: Self-expandable metallic stents (SEMS) have been increasingly used in benign conditions (e. g. strictures, fistulas, leaks, and perforations). Fully covered SEMS (FSEMS) were introduced to avoid undesirable consequences of partially covered SEMS (PSEMS), but come with higher risk of stent migration. Endoscopic suturing (ES) for stent fixation has been shown to reduce migration of FSEMS. Our aim was to compare the outcomes of FSEMS with ES (FS/ES) versus PSEMS in patients with benign upper gastrointestinal conditions. PATIENTS AND METHODS: We retrospectively identified all patients who underwent stent placement for benign gastrointestinal conditions at seven US tertiary-care centers. Patients were divided into two groups: FSEMS with ES (FS/ES group) and PSEMS (PSEMS group). Clinical outcomes between the two groups were compared. RESULTS: A total of 74 (FS/ES 46, PSEMS 28) patients were included. On multivariable analysis, there was no significant difference in rate of stent migration between FS/ES (43 %) and PSEMS (15 %) (adjusted odds ratio 0.56; 95 % CI 0.15 - 2.00). Clinical success was similar [68 % vs. 64 %; P  = 0.81]. Rate of adverse events (AEs) was higher in PSEMS group [13 (46 %) vs. 10 (21 %); P  = 0.03). Difficult stent removal was higher in the PSEMS group (n = 5;17 %) vs. 0 % in the FS/ES group; P  = 0.005. CONCLUSIONS: The proportion of stent migration of FS/ES and PSEMS are similar. Rates of other stent-related AEs were higher in the PSEMS group. PSEMS was associated with tissue ingrowth or overgrowth leading to difficult stent removal, and secondary stricture formation. Thus, FSEMS with ES for stent fixation may be the preferred modality over PSEMS for the treatment of benign upper gastrointestinal conditions.

Non-Clostridium difficile Bacterial Infections Are Rare in Patients With Flares of Inflammatory Bowel Disease.

BACKGROUND & AIMS: Clostridium difficile infection (CDI) causes flares in patients with inflammatory bowel disease (IBD). We investigated the frequency and outcomes of non-CDI bacterial enteric infections in symptomatic patients with IBD. METHODS: We performed a retrospective study of patients with ulcerative colitis (UC) or Crohn's disease (CD) from whom stool samples were collected and analyzed by PCR or culture for bacterial pathogens (Campylobacter jejuni or C coli, Salmonella species, Shigella species, enteroinvasive Escherichia coli, shiga toxin-producing E coli, or Yersinia species) from November 19, 2011, through June 30, 2014. Patients were excluded if they had nonbacterial infections or no symptoms. Data were collected from medical records on IBD duration, treatment, age at diagnosis, and presence of concurrent CDI. Patients were followed for 1 year after the date of infection resolution or until date of last follow-up in the health record. Each patient with an enteric infection was matched with 2 patients with IBD flares and negative results from stool tests (non-infected control) and 2 patients with IBD and CDI (CDI control), adjusted for age (within 5 years at the time of stool test), sex, and IBD subtype. Outcome measures included IBD therapy escalation and hospitalization. RESULTS: Of 9247 patients with IBD seen during the study period, stool samples were tested from 1345 patients (50% with UC and 50% with CD). There were 3 positive results (detection of bacterial pathogens) from 339 PCR analyses of stool samples from 296 patients with UC (0.88%) and 12 positive results from 486 cultures of stool samples from 418 patients with UC (2.5%). There was 1 positive result from 355 PCR analyses of stool samples from 311 patients with CD (0.28%) and 9 positive results from 496 cultures of stool samples from 413 patients with CD (1.8%). Of the 19 patients followed beyond infection, 9 patients required escalation of their IBD therapy (47%)-most commonly addition of an immunomodulator (5 patients) or a biological agent (3 patients)-compared with 34% of CDI controls and 66% of non-infected controls (P < .001). Higher proportions of patients with non-CDI bacterial infections were in remission 1 year after their infection (89%) than patients with CDI (55%) or negative results of stool tests (63%; P = .04). We did not observe differences in hospitalization, emergency department visits, or surgical interventions among groups. CONCLUSIONS: In a retrospective study of patients with an IBD flare, we detected non-CDI bacterial infections in fewer than 3% of those who were tested. Higher proportions of patients with non-CDI bacterial infections were in remission in the year after their infection than patients with CDI.

Reprocessing of single-use endoscopic variceal band ligation devices: a pilot study.

Background and study aims The preferred management of bleeding esophageal varices includes endoscopic band ligation. Endoscopic ligation devices (ELDs) are expensive and designed for single use, limiting their uptake in developing countries. We aimed to assess the efficacy of reprocessing ELDs using terminal microbial cultures and adenosine triphosphate (ATP) testing. Materials and methods ELDs were recovered after clinical use and their components (cap, handle, and cord) were subjected to reprocessing. This included manual cleaning, automated high-level disinfection (HLD), and drying with forced air. Using sterile technique, ELD components were sampled for ATP at three stages: before manual cleaning, after manual cleaning, and after HLD. Components were sent to an external laboratory for culturing. Cultures were interpreted as positive upon identification of Gram-negative bacilli. Results A total of 14 clinically used ELDs were studied, and 189 ATP tests and 41 cultures were evaluated. Overall, 95 % (39/41) of components and 86 % (12/14) of ELDs were culture-negative or did not yield Gram-negative bacilli. Two components (5 %; one handle and one cord) harbored Gram-negative bacilli in quantities of 1 CFU per component. There was no apparent correlation between ATP at any juncture of reprocessing and terminal cultures. Conclusions Reprocessing of ELDs is effective, resulting in infrequent and minimal microbial contamination. Microbial culturing can be used to ensure adequacy of ELD reprocessing if pursued. Until reusable ELDs are commercially available, continued efforts to better define the adequacy and long-term effects of reprocessing ELDs are needed.

Duodenoscope reprocessing surveillance with adenosine triphosphate testing and terminal cultures: a clinical pilot study.

BACKGROUND AND AIMS: Recent reports of infectious outbreaks linked to duodenoscopes have led to proposals for duodenoscope surveillance culturing, which has inherent limitations. We aimed to assess the feasibility of real-time adenosine triphosphate (ATP) testing after manual cleaning and its ability to predict reprocessing adequacy, as determined by terminal duodenoscope cultures. METHODS: Clinically used duodenoscopes underwent reprocessing per current guidelines. After manual cleaning, ATP samples were obtained from the elevator, within the proximal biopsy port, and by flushing of the biopsy channel. After high-level disinfection (HLD), aerobic cultures of the elevator and biopsy channel were obtained using sterile technique. Duodenoscopes with any ATP sample ≥200 relative light units underwent repeated cycles of cleaning, ATP testing, HLD, and terminal culturing. RESULTS: Twenty clinically used duodenoscopes were included; 18 underwent a second reprocessing cycle, and 6 underwent a third reprocessing cycle because of detection of high ATP. After the initial reprocessing cycle, 12 of 20 (60%) duodenoscopes had positive culture results, most commonly yielding gram-negative bacilli (GNB, n = 11 from 9 duodenoscopes), and catalase-positive gram-positive cocci (CP-GPC, n = 7 from 7 duodenoscopes), suggesting staphylococcal organisms. Ambient environmental controls also showed GNB and CP-GPC growth. The overall sensitivity and specificity of ATP testing compared with terminal cultures were 30% and 53%, respectively. CONCLUSIONS: ATP sampling appears to correlate poorly with terminal culture results and cannot be recommended as a surrogate for terminal cultures. The performance and interpretation of cultures remains complicated by the potential recovery of environmental contaminants.