Hot avulsion versus argon plasma coagulation for the management of the non-ensnarable polyp: A multicenter, randomized controlled trial.

Background and Aim: Snare resection of nonlifting colonic lesions often requires supplemental techniques. We compared the success rates of neoplasia eradication using hot avulsion and argon plasma coagulation in colonic polyps when complete snare polypectomy had failed. Methods: Polyps that were not completely resectable by snare polypectomy were randomized to argon plasma coagulation or hot avulsion for completion of resection. Argon plasma coagulation was delivered using a forward shooting catheter, using a nontouch technique (flow 1.2 L, 35 watts). Hot avulsion was performed by grasping the neoplastic tissue with hot biopsy forceps and applying traction away from the bowel wall while using EndoCut I or soft coagulation for avulsion. Surveillance colonoscopies were performed at 6, 12, and 18 months. Results: From November 2013 to July 2017, 59 patients were randomized to argon plasma coagulation (28) or hot avulsion (31). The median age was 69 (60-75), with 46% being female. The median residual tissue size was 10 mm (6-12). The residual adenoma rate at 6 months (hot avulsion 6% vs argon plasma coagulation 21% P = 0.09) and 18 months was not different between the groups (6.6% vs 3.6% P = 0.25). One patient in the argon plasma coagulation arm was diagnosed with metastatic cancer of likely colorectal origin despite benign histology in the original polypectomy specimen, supporting the importance of tissue acquisition. Conclusion: Both hot avulsion and argon plasma coagulation are effective and safe modalities to complete resection of non-ensnarable colonic polyps.

Australian clinical practice guidelines for the diagnosis and management of Barrett's esophagus and early esophageal adenocarcinoma.

Barrett's esophagus (BE), a common condition, is the only known precursor to esophageal adenocarcinoma (EAC). There is uncertainty about the best way to manage BE as most people with BE never develop EAC and most patients diagnosed with EAC have no preceding diagnosis of BE. Moreover, there have been recent advances in knowledge and practice about the management of BE and early EAC. To aid clinical decision making in this rapidly moving field, Cancer Council Australia convened an expert working party to identify pertinent clinical questions. The questions covered a wide range of topics including endoscopic and histological definitions of BE and early EAC; prevalence, incidence, natural history, and risk factors for BE; and methods for managing BE and early EAC. The latter considered modification of lifestyle factors; screening and surveillance strategies; and medical, endoscopic, and surgical interventions. To answer each question, the working party systematically reviewed the literature and developed a set of recommendations through consensus. Evidence underpinning each recommendation was rated according to quality and applicability.

Hot avulsion: a modification of an existing technique for management of nonlifting areas of a polyp (with video).

BACKGROUND: Endoscopic management of the nonlifting areas of a colonic polyp is a significant challenge. The traditional approach has been to use ablative techniques with mixed long-term results. OBJECTIVE: To evaluate the safety and efficacy of hot avulsion (HA), a modification in the use of hot biopsy forceps in the management of the nonlifting areas of a colonic polyp. DESIGN: Retrospective review of data from a prospectively maintained colonic Endoscopic Mucosal Resection database. SETTING: Tertiary referral hospital. PATIENTS AND INTERVENTION: Twenty patients in whom HA was used as part of the polypectomy technique. MAIN OUTCOME MEASUREMENTS: Location and size of polyp, reasons for nonlifting, immediate success, residual rates, and adverse events. RESULTS: In our 20 patients studied, the main reasons for nonlifting were scarring from previous EMR attempts in 55% and scarring from previous biopsy in 35%. Mean size of avulsion was 4.4 mm (range, 1-15 mm). At the index procedure, HA was successful in removing macroscopic adenomatous tissue in all patients. At follow-up examinations, 85% (17/20) had no macroscopic or microscopic neoplasia residual and 15% (3/20) had a small area of residual that was easily treated with repeat HA. There were no immediate or long-term adverse events. LIMITATIONS: Nonrandomized, single-center experience. CONCLUSIONS: HA appears to be a safe and effective adjunct treatment to snare polypectomy for nonlifting areas of a colonic polyp. Further randomized multicenter studies are required with direct comparison to established techniques.

Exercise as medicine in the management of pancreatic cancer: a case study.

INTRODUCTION: Given the poor prognosis for patients diagnosed with pancreatic cancer, therapies that enhance the ability to tolerate adjuvant treatments, reduce the loss of physical functioning and optimize quality of life are critically important. Exercise may represent such a therapy; however, no previous research has investigated the potential impact of exercise on outcomes in pancreatic cancer patients. PURPOSE: This study aimed to determine the safety and efficacy of a 6-month supervised exercise program in a pancreatic cancer patient undergoing adjuvant treatment. METHODS: A case study was performed on a 49-yr-old male diagnosed with stage IIb pancreatic cancer. The patient had surgery (Whipple resection) followed by adjuvant chemotherapy (gemcitabine and fluorouracil) and radiotherapy (45 Gy). The patient initiated a supervised exercise program involving twice weekly resistance and aerobic exercise sessions during adjuvant therapy. Outcomes were assessed at baseline and after 3 and 6 months of exercise. RESULTS: The exercise program was well tolerated with 73% attendance throughout the 6 months. No treatment toxicities prevented the patient from complying with adjuvant treatment plans. Considerable improvements were observed at both 3- and 6-month assessment points for all measures of physical capacity and functional ability, lean mass, physical activity levels, general health and disease-specific quality of life, cancer-related fatigue, sleep quality, and psychological distress. CONCLUSIONS: In this first reported clinical case, exercise led to improvements in a variety of patient outcomes during adjuvant therapy for pancreatic cancer. This initial evidence has important clinical implications, indicating that exercise may be an effective adjunct therapy for the management of pancreatic cancer. Future trials are needed to confirm and expand our initial findings.

Detection of hypoxia with 18F-fluoromisonidazole (18F-FMISO) PET/CT in suspected or proven pancreatic cancer.

PURPOSE OF THE REPORT: Pancreatic carcinoma is known to demonstrate molecular features of hypoxia. The aim of this prospective pilot study is to analyze the hypoxia agent fluoromisonidazole (FMISO) using PET/CT in pancreatic carcinoma and to compare FMISO activity with glucose metabolism reflected by FDG. PATIENTS AND METHODS: Ten patients with pancreatic carcinoma underwent FMISO and FDG PET scans. FMISO and FDG PET/CT scans were analyzed by 2 PET physicians. Regions of interest drawn on the FDG images were transposed to the FMISO images after study coregistration. The FDG SUVmax was used to quantify metabolic activity and FMISO SUVmax and tumor-to-background (muscle) ratio to quantify hypoxia. RESULTS: Seven patients were diagnosed with pancreatic adenocarcinoma. The remaining patients had a neuroendocrine tumor, poorly differentiated/sarcomatoid carcinoma, and mucinous neoplasm. Visual analysis demonstrated increased FMISO activity in 2 pancreatic adenocarcinomas. All patients, however, had increased FDG activity at the tumor site. Mean FDG SUVmax was 6 (range: 3.8 to 9.5) compared to 2.3 for FMISO (range: 1 to 3.4). The 2 positive studies on visual analysis of FMISO did not correspond to the largest tumors, the studies with the highest FMISO or FDG SUVmax. There was no significant correlation between FMISO and FDG SUVmax values. CONCLUSIONS: The hypoxia imaging agent, FMISO, demonstrates minimal activity in pancreatic tumors. If FMISO PET/CT is to be included in clinical trial protocols of hypoxia in pancreatic cancer, it would require correlation with other imaging modalities to localize the tumor and allow semiquantitative analysis.

Wire assisted transpancreatic septotomy, needle knife precut or both for difficult biliary access.

BACKGROUND AND AIMS: Pre-cut techniques, the most commonly described being needle knife papillotomy (NK), have been used to facilitate biliary access in failed standard biliary cannulation (BC). Transpancreatic septotomy (TS) is a pre-cut technique with limited outcome data. We aim to assess the outcomes of wire assisted transpancreatic septotomy (WTS) as the primary pre-cut technique after initial failed attempted BC and to compare these with outcomes of primary NK. METHODS: We retrospectively reviewed all endoscopic retrograde cholangiopancreatographies (ERCPs) performed by endoscopists who performed WTS over a 3-year period. We selected cases where WTS and/or NK were performed, and these cases were reviewed to assess for procedure related complications and BC success. RESULTS: During the study period 1336 ERCPs were performed. WTS was performed in 53 cases. In seven cases WTS and NK were performed sequentially (resulting in immediate cannulation in all these cases). Immediate BC was achieved on first attempt in 36 (68%) WTS cases and in a further 14 cases on a repeat attempt (cumulative BC rate 94%). During the same period 66 (5%) patients underwent primary NK. In these cases initial cannulation was achieved in 50 (76%) cases and cannulation on repeat attempt in six cases (cumulative success rate 85%). Complications occurred in three WTS patients (5.6%) and seven NK patients (10.6%). The differences were not statistically significant. CONCLUSIONS: Wire assisted transpancreatic septotomy is a safe and effective alternative technique to traditional NK in patients who have failed standard BC techniques. It also allows other pre-cut techniques such as NK to be used should initial WTS be unsuccessful.

Gastric intraepithelial neoplasia in a Western population.

BACKGROUND AND STUDY AIMS: Descriptions of the natural history and endoscopic appearances of gastric dysplasia/intraepithelial neoplasia (IEN) that originate mainly from Europe. Currently, there are no Australian data available. We aimed to document endoscopic appearances and progression rates of gastric IEN and to determine the significance of indefinite for IEN. PATIENTS AND METHODS: This is a retrospective study, in which cases diagnosed with gastric IEN were identified between 2000 and 2009. Endoscopic appearances, progression rates to more advanced IEN or cancer, and long-term outcomes were recorded. RESULTS: A total of 160 cases with IEN (26.9% high grade, 57.5% low grade, 15.6% indefinite) were identified. The mean age was 67.8 years and 53.8% were men. Endoscopic lesions were polypoid in 29.4% and nonpolypoid in 70.6%. The most common location was the antrum (58.7%). Forty patients had an intervention and 76 underwent endoscopic follow-up only. Twenty-two cancers were diagnosed; three who had an intervention were diagnosed within 12 months, one with low-grade intraepithelial neoplasia developing a cancer after 9.9 years, and 13 undergoing surveillance only, were diagnosed with cancer within 12 months of index endoscopy. Five cases had cancer after a mean of 2.6 years. Forty-seven cases initially labelled as indefinite; following rereview 25 remained unchanged, 11 reclassified as negative for IEN, 10 as low grade, and one as high grade. Three of these cases developed cancer over the study period. CONCLUSION: We concluded that (a) majority of gastric IEN are associated with endoscopic lesions, (b) high rate of early cancer diagnosis was observed (c) rates of progression to cancer were lower than reported rates, and (d) indefinite for IEN is not innocuous requiring an expert pathologist's review.

A cohort study of missed and new cancers after esophagogastroduodenoscopy.

OBJECTIVES: Little is known about missed rates of upper gastrointestinal cancer (UGC) in Western populations, with most data originating from Japanese centers quoting high missed rates of 23.5-25.8%. The objective of this study was to better define missed rates of esophagogastroduodenoscopy (EGD) and the natural history of UGC in a Western population that underwent an initial EGD without cancer, but were subsequently diagnosed with a UGC. Our hypothesis was that a normal EGD rarely misses the detection of UGC. METHODS: This is a retrospective cohort study. A prospectively maintained electronic database was used to identify all patients who underwent EGD between 1990 and 2004 at the study institution. Patients in this cohort who were diagnosed with UGC before 2006 were identified through the Western Australian Cancer Registry. We defined missed cancers as those diagnosed within 1 year of EGD, possible missed cancers as those diagnosed 1-3 years after EGD, and new cancers as those diagnosed more than 3 years after EGD. This study had no interventions and was conducted at a tertiary referral center. The main outcome measurement included UGC. RESULTS: Of the 28,064 EGDs performed, UGC was diagnosed subsequent to the procedure in 116 cases (0.41%). There were 29 missed cancers, 26 possible missed cancers, and 75 new cancers. Of the missed cancers, 11 were esophageal, 15 were gastric, and 3 were duodenal. In 69% (n=20) of the missed cancers, an abnormality was described at the site of malignancy. In 59% (n=17) of the missed cancers, the indication for EGD was an alarm symptom of dysphagia or suspected blood loss. In an univariate analysis, the presence of an alarm symptom was related to missed cancers, whereas operator experience, trainee participation, and usage of newer equipment were not. One of the main limitations of this study is that it was a retrospective review. CONCLUSIONS: UGC is rare after normal EGD, confirming the high accuracy of EGD. Institutional approval was granted for the conduct of this study.

Repeat colonoscopy has a low yield even in symptomatic patients.

BACKGROUND: In many regions, the demand for colonoscopy exceeds its availability. Patients undergoing repeat examinations comprise a significant proportion of those on waiting lists. OBJECTIVE: To assess the yield of repeat colonoscopy in varied clinical settings. DESIGN: Cohort study. SETTING: Endoscopic database of an Australian tertiary referral hospital. PATIENTS: Adults who had >/=2 colonoscopies between 1992 and 2004. Patients were excluded if the repeat procedure was for completion or for high-risk surveillance. MAIN OUTCOME MEASUREMENTS: Yield for neoplasia by indication, interval to repeat examination, and appropriateness for surveillance (determined by National Australian guidelines). RESULTS: A total of 4974 colonoscopies in 2075 patients were studied. The mean age was 63.1 years (range, 19.2-92.4 years). The mean number of examinations was 2.4 (range, 2-8), with a mean interval between examinations of 2.9 years. Colorectal cancer (CRC) was significantly more prevalent at initial colonoscopy compared with subsequent colonoscopies (7.9% vs 0.6%; prevalence ratio 14.2, 95% confidence interval [CI] 8.5-23.7, P < .001), as were advanced adenomas (15.3% vs 4.8%; prevalence ratio 3.2, 95% CI 2.6-3.9, P < .001). No CRCs were detected in symptomatic patients undergoing polyp surveillance examinations performed before the recommended interval. LIMITATIONS: Retrospective design. CONCLUSIONS: Yield of repeat colonoscopy is significantly lower than for initial colonoscopy, irrespective of indication. In symptomatic patients within a polyp surveillance program, the yield is negligible when a colonoscopy is performed before the recommended surveillance interval. The need for a repeat colonoscopy should be carefully considered, and patients who have never had a colonoscopy must take priority on waiting lists over those awaiting repeat examinations.

Survey of consent practices for inpatient colonoscopy and endoscopic retrograde cholangiopancreatography at a tertiary referral center.

BACKGROUND: The purpose of the present paper was to determine informed consent practices for inpatient, open-access colonoscopy and endoscopic retrograde cholangiopancreatography (ERCP) at a tertiary referral center. METHODS: A two-part prospective study incorporating (i) an audit of consent practices for colonoscopy and ERCP; and (ii) a questionnaire directed at gastroenterologists and interns regarding information imparted to patients in the process of acquiring informed consent, was undertaken at Sir Charles Gairdner Hospital, Western Australia. Study subjects consisted of inpatients undergoing open-access colonoscopy and/or ERCP at the study center commencing May 2003; and gastroenterologists and interns at the study center. RESULTS: Written consent was obtained by junior medical staff in 89% of cases. Response rates for the questionnaire was 100% from interns, and 91% from gastroenterologists. Of interns surveyed, 93% had witnessed a colonoscopy, and 59% had witnessed an ERCP. For 12% of interns, colonoscopic bleeding or perforation were not always mentioned. Colonoscopy failure rate and perforation were overestimated by 51% and 63% of interns, respectively. Only 56% of interns always mentioned pancreatitis as a complication of ERCP. The rate of post-ERCP pancreatitis was overestimated by 25% of interns. Only 40% of gastroenterologists always provided additional information to patients whose consent was obtained by someone else. Written material was not routinely provided for patients. Consent was usually obtained on the day of the procedure. CONCLUSIONS: Written consent for inpatients undergoing open-access colonoscopy and ERCP is rarely obtained by the proceduralist. There is substantial variability in the information provided to patients. Guidelines are required to ensure best practice in this area.

Transesophageal echocardiography-related gastrointestinal complications in cardiac surgical patients.

OBJECTIVE: The aim of this audit was to determine the incidence of major gastrointestinal (GI) complications associated with intraoperative transesophageal echocardiography (TEE) in adult cardiac surgical patients in this institution. DESIGN: Retrospective database audit. SETTING: University-affiliated teaching hospital. PARTICIPANTS: Eight hundred fifty-nine consecutive cardiac surgical patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The records of all patients who developed a major upper GI complication within 30 days of cardiac surgery between January 2001 and May 2003 were examined. The patients were identified by cross-referencing cardiac surgery and endoscopy databases. A major GI complication was defined as a perforation of the esophagus or stomach or upper GI bleeding requiring transfusion, endoscopic, or surgical intervention. Early presentation was defined as <24 hours; late presentation was defined as >24 hours. During the audit period, 859 patients underwent cardiac surgery. Five hundred sixteen patients had cardiac surgery with TEE (group 1), and 343 patients had cardiac surgery without TEE (group 2). Six patients were identified, 1.2% (95% confidence interval [CI], CI, 0.5%-2.5%) in group 1 who had a major upper GI complication consistent with TEE injury. Two patients, 0.38% (95% CI, 0.05%-1.40%), presented early, and 4 patients, 0.76% (95% CI, 0.21%-1.98%), presented late. One patient in group 2 developed a major upper GI complication, 0.29% (95% CI, 0.01%-1.6%). CONCLUSION: The incidence of major GI complications attributed to TEE in this group of cardiac surgical patients was higher than previously reported. Late presentation was more common than early presentation. Previous studies that have not included late presentations may have underestimated the true incidence of major GI complications related to TEE.

A prospective comparison of the yield of EUS in primary vs. recurrent idiopathic acute pancreatitis.

BACKGROUND: It is uncertain whether EUS should be performed after a single episode of idiopathic pancreatitis vs. recurrent episodes or if clinical factors can predict positive EUS findings. METHODS: Consecutive patients with a single episode of idiopathic pancreatitis or with recurrent episodes underwent EUS (with analysis of bile for bilirubinate and cholesterol crystals, when possible). The diagnostic yield was compared for patients with a single episode of idiopathic pancreatitis and recurrent episodes (stratified by cholecystectomy status). Predictors of positive EUS findings were sought. EUS was considered "positive" if it identified any possible cause of pancreatitis other than chronic pancreatitis. RESULTS: A total of 370 patients were studied (246 no-cholecystectomy group [134 single episode of idiopathic pancreatitis, 112 recurrent episodes] and 124 post-cholecystectomy group [67 single episode of idiopathic pancreatitis, 57 recurrent episodes]). Overall, EUS yielded a positive finding in 29.2%. For patients in the no-cholecystectomy group, positive EUS findings were not significantly more frequent in those with a single episode of idiopathic pancreatitis vs. those with recurrent episodes (31.3% vs. 32.1%; p = 0.89). In the post-cholecystectomy group, the yield was not significantly different for single episode of idiopathic pancreatitis (29.9%) vs. recurrent episodes (17.5%) ( p = 0.15). Chronic pancreatitis was the only abnormality identified in 30.9% of patients in the no-cholecystectomy group vs. 26.6% of those in the post-cholecystectomy group ( p = 0.24). It was the most common abnormality found in all 4 subgroups (range 16.4%-42.0%) and was approximately twice as frequent in patients with recurrent episodes vs. a single episode of idiopathic pancreatitis (no-cholecystectomy: 42.0% vs. 21.6%, p = 0.0008; post-cholecystectomy: 38.6% vs. 16.4%, p = 0.008). Analysis of bile revealed crystals in 38/80 (47.5%) patients in whom it could be performed. Patients with positive EUS findings tended to be older. CONCLUSIONS: In patients with idiopathic pancreatitis, the yield of EUS is not significantly different after an initial attack or after recurrent attacks. Therefore, it is reasonable to perform EUS after an initial attack of idiopathic acute pancreatitis, especially in older patients.

Endoscopist administered propofol for upper-GI EUS is safe and effective: a prospective study in 500 patients.

BACKGROUND: The administration of propofol for endoscopic sedation by a qualified person, other than the endoscopist, is safe and effective. The aim of this study was to determine if propofol can be administered safely and effectively by the endoscopist performing the procedure. METHODS: All patients referred for upper-GI EUS were eligible for inclusion in the study. Exclusion criteria included the following: age less than 18 years, American Society of Anesthesiology physical status class greater than 2, a potential for difficulty in airway maintenance, and allergy to propofol constituents. The endoscopist administered propofol as an intravenous bolus followed by a constant infusion. Adverse events, drug dosage, complications, and patient/endoscopist satisfaction were recorded. RESULTS: A total of 500 patients (285 women, 215 men; mean age 53.4 [14.8 years]) were enrolled. Mean propofol dose was 301 mg (range 100-1000 mg). Mean procedure time was 19 minutes (range 3-70 minutes). The required examination was completed in all cases. There was no major adverse event. Oxygen desaturation (oxygen saturation < 95%) occurred in 16 (3%) patients. There were 4 (1%) cases of mild hypoxemia (saturation < 90%) but no case of severe hypoxemia (saturation <85%). The endoscopist rated the 92% of the procedures as "very smooth" or "smooth" and regarded administration of propofol as "easy" for 92%. All patients said they would prefer the same method of sedation if the procedure were repeated. CONCLUSIONS: Endoscopist-administered propofol is safe and effective in selected patients.

A prospective, quantitative assessment of the effect of ethanol and other variables on the endosonographic appearance of the pancreas.

BACKGROUND & AIMS: Studies comparing endosonography with endoscopic pancreatography, histological examination, and functional assays show that the number of endosonographic abnormalities (or "criteria") increases with the severity of chronic pancreatitis. However, it is unclear to what extent such variables as demographics, body habitus, and routine exposure to such pancreatic toxins as ethanol and cigarette smoke can affect pancreatic endosonography. The aim of the study is to quantify the effects of these variables precisely. METHODS: Pancreatic endosonography was performed by a single operator in consecutive patients referred for any indication. The relationship between 8 possible endosonographic criteria and these variables was studied. RESULTS: One thousand one hundred fifty-seven patients were studied (93% of eligible patients). Number of criteria correlated most strongly with ethanol ingestion (r = 0.273; P = 0.0001) and smoking history (r = 0.201; P = 0.0001). It did not correlate with age or body mass index. The strongest independent predictors of severe pancreatic abnormalities (>/=5 criteria) were heavy ethanol ingestion (odds ratio [OR], 5.1; 95% confidence interval [CI], 3.1-8.5), male sex (OR, 1.8; 95% CI, 1.3-2.55), clinical suspicion of pancreatic disease (OR, 1.7; 95% CI, 1.2-2.3), and heavy smoking (OR, 1.7; 95% CI, 1.2-2.4). Severe endosonographic abnormalities were found in only 2 of 51 patients (3.9%) with no risk factors or symptoms of pancreatic disease. CONCLUSIONS: Several variables can affect the endosonographic appearance of the pancreas independently. Severe abnormalities may be asymptomatic. The clinical, functional, and histological significance of endosonographic abnormalities requires clarification.

Diagnosis and management of cholecystitis and cholangitis.

Cholelithiasis is a prevalent condition in Western populations. Most cases are asymptomatic but complications can occur. Acute cholangitis, cholecystitis, and gallstone pancreatitis are the most common biliary tract emergencies and are usually caused by biliary calculi. Whenever possible, acute cholecystitis should be treated with early LC. AAC is an uncommon condition usually affecting patients with significant comorbidities. Treatment is usually with percutaneous cholecystostomy, which often is also the only required therapy. Endoscopic drainage is the preferred form of biliary decompression in acute cholangitis and these patients should subsequently undergo elective LC unless unfit for surgery. Effective and optimal management of biliary tract emergencies relies on close cooperation between gastroenterologist, surgeon, and radiologist.