Recurrence of subsquamous dysplasia and carcinoma after successful endoscopic and radiofrequency ablation therapy for dysplastic Barrett's esophagus.

Barrett's esophagus with dysplasia is commonly treated with radiofrequency ablation (RFA). Despite its effectiveness, a concern of any ablative technique is the development of subsquamous intestinal metaplasia, which could have potential for future neoplastic progression. To date, 34 cases of subsquamous neoplasia have been described in the literature after various ablation therapies. However, only three cases of subsquamous neoplasia have been reported after successful RFA treatment of dysplastic Barrett's esophagus. In this case series, we report on four additional cases of subsquamous neoplasia detected after successful endoscopic resection and RFA for neoplastic and dysplastic Barrett's esophagus. All four patients were treated successfully with endoscopic resection of their recurrent subsquamous neoplastic and dysplastic lesions. This case series highlights the need for continued surveillance following successful treatment of dysplastic Barrett's esophagus with RFA.

Endoscopic ultrasound-guided drainage of pancreatic fluid collections with indeterminate adherence using temporary covered metal stents.

Transenteric drainage of a pancreatic fluid collection (PFC) with poor adherence to the bowel wall risks leakage and perforation. Elimination of tract dilation and the use of a fully covered self-expanding metal stent (FCSEMS) may improve safety. We evaluated endoscopic ultrasound (EUS)-guided drainage of PFCs using a one-step access device followed by placement of a FCSEMS. Eighteen patients (12 males; median age 50) with PFCs (median size 135 mm) meeting the criteria for indeterminate adherence were enrolled. After 7 - 10 days, the FCSEMSs were removed and exchanged for double-pigtail stents. When indicated, tract dilation and endoscopy-guided cyst debridement was performed. FCSEMS placement was technically successful in all patients without complications. Median procedure time was 37.5 minutes. Cystgastrostomy dilation resulted in dehiscence in one patient and was treated with repeat FCSEMS placement. Cyst resolution was achieved in 78 % of patients. FCSEMS placement without tract dilation enables safe initial drainage of PFCs with indeterminate adherence.

Endoscopic ultrasound-guided gastroenterostomy using novel tools designed for transluminal therapy: a porcine study.

BACKGROUND AND STUDY AIMS: Surgical gastroenterostomy is associated with appreciable morbidity and mortality. We evaluated the technical feasibility and outcomes of a new method of endoscopic ultrasound (EUS)-guided gastroenterostomy using novel tools designed for transluminal therapy. METHODS: In one acute and four survival female pigs, a gastroenterostomy was created under EUS guidance. Novel tools used included: (i) an anchor wire; (ii) an access device; (iii) a fully covered metal stent with bilateral lumen-apposing anchors. The anchor guide wire was inserted through a standard 19-G fine needle aspiration (FNA) needle to appose the small-bowel and stomach walls. The access device created a 3.5-mm fistula opening for insertion of the stent delivery catheter. The stent lumen was dilated to 10 mm to pass a gastroscope into the small bowel. RESULTS: The procedure was technically successful in all animals. No bleeding occurred. In one acute animal, necropsy showed good stent position and no tissue injury. In four survival animals, the stents remained fully patent and all animals showed normal eating behavior without signs of infection. Stents were easily removed without tissue trauma at 4.5 weeks (n = 3) or 5.5 weeks (n = 1). After stent removal, the tracts appeared mature and were easily intubated with the gastroscope. Necropsy and histopathology showed complete fusion of the stomach and small-bowel wall layers at the site of gastroenterostomy. CONCLUSIONS: EUS-guided gastroenterostomy is feasible using novel tools with no adverse outcomes in a survival porcine model. Further study of this is indicated as an alternative to surgical bypass for the palliation of malignant gastric outlet obstruction in appropriately selected patients.

Endoscopic ultrasound-guided anterograde treatment of biliary stones following gastric bypass.

Endoscopic treatment of bile duct stones in gastric bypass patients is challenging. We describe a novel method involving endoscopic ultrasound (EUS)-guided anterograde interventions. After prior experience with EUS-guided rendezvous endoscopic retrograde cholangiopancreatography (ERCP) and direct EUS-guided anterograde stenting for malignant biliary obstruction, we have attempted EUS-guided treatment of biliary stones as first-line therapy following gastric bypass. Our approach involves: (i) EUS-fine needle aspiration (FNA) puncture into an intrahepatic bile duct; (ii) EUS-guided cholangiography; (iii) guide wire advancement across the ampulla; (iv) catheter dilation of the transhepatic-transgastric access tract; (v) anterograde balloon sphincteroplasty; and (vi) anterograde advancement of stones across the ampulla using a balloon catheter. We reviewed outcomes and complications of this technique. Six patients with previous Roux-en-Y gastric bypass were referred for treatment of symptomatic choledocholithiasis. EUS-guided transhepatic puncture and cholangiography was successful in 100 %, and revealed choledocholithiasis in all patients. Tract dilation, anterograde balloon sphincteroplasty, and stone extraction were successful in four (67 %). Anterograde sphincteroplasty failed in two patients due to inability to advance the transhepatic dilation catheters. In both cases, wires were advanced down the afferent limb, and rendezvous ERCP using double-balloon enteroscopy was successful. Five patients experienced no complications. One patient in whom EUS anterograde therapy failed due to difficulty in advancing the transhepatic dilation catheter, developed a subcapsular hepatic hematoma. This was managed conservatively. Direct EUS-guided treatment of biliary stones after gastric bypass appears safe and feasible. Further studies are needed to confirm the safety and efficacy of this technique.

A novel lumen-apposing stent for transluminal drainage of nonadherent extraintestinal fluid collections.

BACKGROUND AND STUDY AIMS: Tubular stents have been used to accomplish endoscopic transluminal drainage, but do not impart lumen-to-lumen anchorage. We evaluated a novel lumen-apposing stent designed for enteric drainage of nonadherent lumens. MATERIAL AND METHODS: Ex vivo benchtop testing was performed to quantify various physical and performance metrics of the stent (Axios). A simulator was developed to test the stent deployment through an echoendoscope. Survival experiments were performed on four pigs. Under endosonographic guidance, a cholecystogastrostomy tract was created and the stent was deployed across the lumens. Direct cholecystoscopy was performed. Surveillance gastroscopy was performed at weekly intervals for up to 8 weeks. Measured outcomes were procedural success, safety, and device durability and patency. RESULTS: In benchtop testing, the Axios stent withstood various vector forces of movement, yet allowed easy removability from the simulated tissue. The stent was successfully deployed across the stomach and gallbladder lumens in all four animals without complication. Direct cholecystoscopy and contrast injection documented the absence of tissue trauma and leakage. Gastroscopy at weekly intervals showed the stent in stable position without dislodgment. The stent remained patent in all animals. The covering remained intact and there was no hyperplastic tissue ingrowth or overgrowth, or tissue injury. One stent was removed at 4 weeks. On necropsy, the gallbladders showed focal adherence to the stomach at the site of cystogastrostomy with a negative leak test. CONCLUSIONS: The Axios stent enables the creation of a robust and reliable conduit between nonadherent lumens around the gastrointestinal tract.

Outcomes of endoscopic papillectomy in elderly patients with ampullary adenoma or early carcinoma.

Outcomes for 14 elderly (age ≥ 70 years) patients (79.4 ± 1.0 years) who underwent endoscopic papillectomy for ampullary tumors were compared with those of 22 younger (age < 70 years) patients (52.5 ± 1.9 years). There were no differences in procedural success (100%), bleeding (5/14 vs. 6/22), adenoma recurrence (0/14 vs. 2/22) and median survival (24.0 vs. 25.5 months) between the elderly and younger patients. In younger patients, although adenoma recurrences (n=2) were managed endoscopically, invasive adenocarcinomas (n=3) were treated by pancreatoduodenectomy. All elderly patients with invasive (T2) tumors (n=5) were not surgically fit and underwent successful palliation with further endoscopic resection and stenting. Whilst all younger patients survived, five elderly patients died but three of these deaths were not cancer-related. Advanced age, therefore, did not adversely influence the outcomes of endoscopic papillectomy, suggesting it may be a treatment of choice for elderly patients with ampullary tumors or early cancer who are deemed unfit for surgery.

Endoscopic ultrasound (EUS)-guided transhepatic anterograde self-expandable metal stent (SEMS) placement across malignant biliary obstruction.

Endoscopic retrograde cholangiopancreatography (ERCP) with placement of self-expandable metal stents (SEMS) for palliation of malignant obstruction may not be possible in patients with an inaccessible biliary orifice. Endoscopic ultrasound (EUS)-guided drainage methods may be useful in this setting. This study aimed to determine the outcomes of EUS-guided anterograde SEMS placement across malignant strictures in patients with an inaccessible biliary orifice. Over a 2-year period, procedural and outcomes data on all patients undergoing EUS-guided anterograde SEMS drainage after failed ERCP were prospectively entered into a database and reviewed. Five patients underwent EUS-guided anterograde SEMS. Indications included: advanced pancreatic cancer (n = 3), metastatic cancer (n = 1), and anastomotic stricture (n = 1). The biliary orifice could not be reached endoscopically due to duodenal stricture (n = 4) or inaccessible hepaticojejunostomy (n = 1). EUS-guided punctures were performed transgastrically into left intrahepatic ducts (n = 4) or transbulbar into the common bile duct (n = 1). Guide wires were passed and SEMS were successfully deployed across strictures in an anterograde fashion in all patients. Jaundice resolved and serum bilirubin levels decreased in all cases. No procedure-related complications were noted during a mean follow-up of 9.2 months. EUS-guided anterograde SEMS placement appears to be a safe and efficient technique for palliation of biliary obstruction in patients with an endoscopically inaccessible biliary orifice. The procedure can be performed at the time of failed standard ERCP, and provides an alternative drainage option to percutaneous or surgical decompression and to EUS-guided creation of bilioenteric fistulae.

[Interventional endoscopic ultrasound: an evolving technique]. / Echoendoscopie interventionnelle: une technique en pleine évolution.

The availability of smaller instruments with larger working channels and higher imaging resolution has led to important development of endoscopic ultrasound (EUS) techniques these past years. From a purely diagnostic instrument, EUS guided fine needle aspiration has become a well recognized technique to acquire tissue in the mediastinum and the upper abdomen, more and more complex therapeutic procedures are now performed. It is now possible to precisely inject therapeutic agents under EUS guidance, drain intraabdominal collections and drain previously inaccessible obstructed pancreatic and bile ducts. The currently accepted indications of interventional endosonography and the technique currently under evaluation will be discussed.

Double-balloon endoscopy.

Double balloon endoscopy (DBE) was developed for the examination of the small intestine. DBE together with capsule endoscopy have improved the endoscopic approach to the small intestine, and revolutionized the management of small-intestinal diseases. DBE features not only deep intubation of the small bowel, but also the improved control of the endoscope tip, even in the distal small intestine. This improved control is provided by stabilization from the overtube balloon. In this article, we explain how to use DBE effectively and safely. The basic principles of DBE are discussed as well as proper techniques, tips for effective insertion of the double balloon endoscope, proper indications of DBE, and endoscopic therapies in the small intestine.

Primary precutting versus conventional over-the-wire sphincterotomy for bile duct access: a prospective randomized study.

BACKGROUND AND STUDY AIMS: Precut is a well-known technique that is used if repeated attempts at common bile duct (CBD) cannulation fail. Opinions on the complication rate of precut are conflicting, however. The aim of the present study was to compare the efficacy and complication rate of precut used as a primary method of CBD access with the efficacy and safety of the conventional technique. PATIENTS AND METHODS: During the 19-month study period, consecutive patients who were scheduled for first-time endoscopic sphincterotomy (ES) for a variety of biliary disorders were randomized into two groups: patients in group A underwent conventional wire-guided biliary cannulation followed by ES (with precut being performed only when this failed); in patients in group B precut was used as a primary technique to gain biliary access, followed by wire-guided ES. We used a specially designed, modified Erlangen type of sphincterotome for precutting. RESULTS: A total of 291 patients (100 men, 191 women; mean +/- SD age 65 +/- 17.5 years) were recruited: 146 patients were assigned to group A (conventional approach) and 145 to group B (primary precut approach). The indications for ES were comparable in the two groups. In group A, wire-guided cannulation of the CBD failed in 42 patients. Secondary precut was successful in 41 of these patients, leading to an overall success rate of 99.3 %. In group B, the ES success rate using primary precut was 100 % at the first attempt. The mean time to successful deep CBD cannulation was 8.3 +/- 2.1 minutes in group A and 6.9 +/- 1.8 minutes in group B ( P < 0.001). The incidence of mild to moderate pancreatitis was similar in the two groups (2.9 % in group A vs. 2.1 % in group B, P > 0.05). Mild bleeding occurred in only one patient (from group A) and this was controlled by epinephrine injection. None of the study patients developed severe pancreatitis or perforation. CONCLUSIONS: In experienced hands, an approach using primary precut appears to be at least as successful and safe as a conventional approach using guide-wire-based CBD cannulation followed by ES, and might also be a quicker method.

Argon plasma coagulation for the treatment of colonic varices.

Various individually tailored endoscopic treatment modalities have been described for bleeding colorectal varices. We describe a case of a 65-year-old man, in whom argon plasma coagulation successfully eradicated ectopic varices at the ileocolonic anastomosis; bleeding could be stopped.

Impact of endoscopic ultrasound for evaluation of submucosal lesions in gastrointestinal tract.

BACKGROUND: Endoscopic ultrasound is widely used following endoscopy for evaluation of suspected submucosal lesions and may guide further management of patients. PATIENTS AND METHOD: A total of 181 consecutive patients with suspected submucosal lesion in the upper gastrointestinal tract were diagnosed by endoscopic ultrasound between 1990-97. We evaluated: 1) the potential of endoscopic ultrasound criteria to predict histological type of submucosal lesions in 69 patients with available histology, 2) the ability of endoscopic ultrasound alone or with clinical presentation, to predict malignancy in 86 patients with available histology or follow-up of >12 months. RESULTS: Sensitivity and specificity for diagnosing 44 gastrointestinal stromal tumours were 95 and 72%, respectively, while 25 miscellaneous lesions were diagnosed correctly in only 56% by endoscopic ultrasound. Diagnosis of malignancy, using any two of three endoscopic ultrasound criteria (heterogeneous echotexture, size >3 cm, irregular margins) showed a sensitivity of 80% and specificity of 77%, giving accurate endoscopic ultrasound diagnosis in 16/20 malignant and 51/66 benign submucosal lesion. Heterogeneous echotexture, size >3 cm, and irregular margins showed a relative risk of 7.2, 5.4 and 4.6, respectively, for presence of malignancy. The presence of symptoms, potentially suggesting malignancy (dysphagia, gastrointestinal bleeding, pain and weight loss), had a relative risk of 4.2, however this did not increase the accuracy of diagnosing malignancy based on endoscopic ultrasound criteria alone. CONCLUSION: The accuracy of endoultrasound is high in diagnosing gastrointestinal stromal tumours, which show a significant potential of malignancy. Endoscopic ultrasound morphology appears to be helpful in selection of patients for surgical or conservative treatment. The accuracy of endoscopic ultrasound in differential diagnosis of non-gastrointestinal stromal tumour lesions is limited.

Endoscopic management of bile duct stones.

The advantages of endoscopic retrograde cholangiopancreatography (ERCP) over open surgery make it the predominant method of treating choledocholithiasis. Today, technologic advances such as magnetic resonance cholangiopancreatography and laparoscopic surgery are challenging ERCP's primacy in the management of common bile duct (CBD) stones. This article reviews the current status of endoscopic treatment of biliary stones and examines this in relation to laparoscopic management. The techniques and safety of endoscopic sphincterotomy and balloon sphincteroplasty are reviewed. Balloon sphincteroplasty should be limited to study protocols because of safety questions and inherent limitations. After sphincterotomy, 85% to 90% of CBD stones can be removed with a Dormia basket or balloon catheter. These techniques are described as having both advantages and disadvantages. Methods for managing "difficult stones" include mechanical lithotripsy, intraductal shock wave lithotripsy, extracorporeal shock wave lithotripsy, chemical dissolution, and biliary stenting. These approaches are presented along with data supporting their use in specific situations. Laparoscopic cholecystectomy has emerged as the preferred alternative to open cholecystectomy. Parallel advances in the endoscopic and laparoscopic management of CBD stones have made the issue regarding the optimal treatment strategy complex. Three approaches to the management of choledocholithiasis in the laparoscopic era are presented as follows: strict therapeutic splitting, flexible therapeutic splitting, and strict laparoscopic management. The optimal approach needs to be defined in prospective comparative trials. For now, preoperative endoscopic stone extraction should still be recommended as the approach of choice in patients suspected to have CBD stones based on clinical, biochemical, and imaging parameters. Primary laparoscopic evaluation and management is reasonable in patients who have a low-to-moderate probability of having CBD stones.

Variceal bleeding and portal hypertension.

Within the short span of half a century, the treatment of variceal bleeding has become highly differentiated, with multiple treatment options. Pharmacological therapy with beta-blockers is well established for preventing the first variceal bleeding. The utility of adding a vasodilator to beta-blockers needs to be studied further. Octreotide is widely used as an adjuvant to standard endoscopic treatment to prevent variceal rebleeding, and the utility of this approach has been validated in several randomized controlled trials. Band ligation is well established, and its popularity has increased with the introduction of multiple ligation devices. The technical simplicity and safety of band ligation has sparked interest in using this technique for primary prophylaxis of variceal bleeding. However, randomized trials have not shown any advantage for band ligation over beta-blocker therapy, and the high variceal recurrence rate after band ligation may eliminate any theoretical advantage. A synchronous combination of band ligation and sclerotherapy has not been shown to improve the results of band ligation alone, but a metachronous approach using sclerotherapy to treat recurrent varices after band ligation has shown beneficial results. Histoacryl remains the best treatment option for gastric varices, but band ligation and loop ligation have shown promising results, and should be considered when Histoacryl is not available. Balloon-occluded retrograde transvenous obliteration is a new radiological modality for gastric varices, and one that sounds promising. TIPS is well established as an alternative to elective endoscopic treatment. Compared with endoscopic treatment, TIPS has been shown to improve the survival rate in one randomized trial. However, the cost and complications of TIPS have restricted its use. The use of endoscopic ultrasound for Doppler studies of blood flow in portal hypertension is currently investigational, but it may gain a role in selecting the optimal treatment approach for the individual patient.

Endoscopic retrograde cholangiopancreatography in the next millennium.

Rapid technologic advances in radiologic imaging and laparoscopic surgery are redefining the indications for endoscopic retrograde cholangiopancreatography (ERCP). The diagnostic role of ERCP continues to diminish in favor of newer imaging modalities such as magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasonography. Laparoscopic surgery recaptures some of the indications for therapeutic intervention. The spectrum of diagnostic and therapeutic applications of ERCP, however, continues to expand, enabling a more differentiated diagnosis and treatment of biliopancreatic disease. These applications include ongoing developments of cholangioscopy, pancreatoscopy, and molecular analysis of biliary and pancreatic secretions, photodynamic therapy, and gene therapy.

Endoscopic ultrasound for differential diagnosis of focal pancreatic lesions, confirmed by surgery.

BACKGROUND: Endoscopic ultrasound is increasingly used for evaluation of pancreatic cancer. The potential of sonographic morphology to differentiate histology type and biological behaviour of pancreatic lesions is doubtful. METHODS: We prospectively studied 115 patients with focal pancreatic lesions on endoscopic ultrasound. Morphology was assessed using Olympus UM3/20/200 echoendoscopes. Histologic confirmation of diagnosis was obtained in all patients. RESULTS: Endoscopic ultrasound correctly diagnosed 18/34 benign and 77/81 malignant lesions. Sensitivity, specificity, accuracy, PPV and NPV for diagnosing malignancy were 95%, 53%, 83%, 83% and 82%, respectively. Endosonographic diagnosis of the lesions (% correct) were: pancreatic cancer, 84 (63.3%); chronic pancreatitis, 14 (71.4%); ampullary cancer, 9 (77.8%); cystadenoma, 5 (80%); ampullary adenoma, 2 (50%); acute pancreatitis, 1 (0). In 13 patients of chronic pancreatitis, diagnosed as cancer, diagnosis was based on absence of sonographic features of chronic pancreatitis (7) or suspected involvement of adjacent structures (6). In 3 patients malignancy was missed owing to features of chronic pancreatitis. Non-suspected neuroendocrine tumours were misjudged in all 10 cases using morphologic criteria as pancreatic cancer (8), cystadenoma and chronic pancreatitis. Accuracy for prediction of metastatic lymph nodes and an advanced pancreatic cancer stage (TxN1 or T3Nx) was 61% and 75%, respectively. On retrospective analysis, a lesion >2 cm, vessel ingrowth, absence of cystic spaces and absence of diffuse pancreatitis were associated with pancreatic cancer. CONCLUSIONS: While overall sensitivity was high, specificity of endoscopic ultrasound for diagnosis of malignancy was low, especially in presence of chronic pancreatitis. In addition, endosonography had only a limited potential to predict the histological type of lesions.