Ischemic Polypectomy Through Detachable Snare and Rubber Band Ligation in Peutz-Jeghers Syndrome.

Endoscopic polypectomy is essential for the prevention of Peutz-Jeghers syndrome-associated complications, including intussusception, intestinal obstruction, and malignant transformation. Conventional polypectomy is the preferred approach, but it can be challenging to achieve in patients with Peutz-Jeghers syndrome because of the high polyp burden and polyps located in areas with difficult endoscopic access. This case report highlights 2 different techniques of ischemic polypectomy and its advantage compared with conventional polypectomy in this subset of patients.

Efficacy of international web-based educational intervention in the detection of high-risk flat and depressed colorectal lesions higher (CATCH project) with a video: Randomized trial.

OBJECTIVES: Three subcategories of high-risk flat and depressed lesions (FDLs), laterally spreading tumors non-granular type (LST-NG), depressed lesions, and large sessile serrated lesions (SSLs), are highly attributable to post-colonoscopy colorectal cancer (CRC). Efficient and organized educational programs on detecting high-risk FDLs are lacking. We aimed to explore whether a web-based educational intervention with training on FIND clues (fold deformation, intensive stool/mucus attachment, no vessel visibility, and demarcated reddish area) may improve the ability to detect high-risk FDLs. METHODS: This was an international web-based randomized control trial that enrolled non-expert endoscopists in 13 Asian countries. The participants were randomized into either education or non-education group. All participants took the pre-test and post-test to read 60 endoscopic images (40 high-risk FDLs, five polypoid, 15 no lesions) and answered whether there was a lesion. Only the education group received a self-education program (video and training questions and answers) between the tests. The primary outcome was a detection rate of high-risk FDLs. RESULTS: In total, 284 participants were randomized. After excluding non-responders, the final data analyses were based on 139 participants in the education group and 130 in the non-education group. The detection rate of high-risk FDLs in the education group significantly improved by 14.7% (66.6-81.3%) compared with -0.8% (70.8-70.0%) in the non-education group. Similarly, the detection rate of LST-NG, depressed lesions, and large SSLs significantly increased only in the education group by 12.7%, 12.0%, and 21.6%, respectively. CONCLUSION: Short self-education focusing on detecting high-risk FDLs was effective for Asian non-expert endoscopists. (UMIN000042348).

Pancreatic cancer masquerading as ischemic enteritis on endoscopy.

Pancreatic tumors usually produce painless jaundice. Other associated symptoms may be secondary, from a direct extension of the tumor, resulting in bowel obstruction. It is extremely rare that pancreatic malignancy presents with ischemic enteritis by invasion of the major arteries, and no report has documented it endoscopically. We present a rare case of pancreatic adenocarcinoma masquerading as ischemic enteritis diagnosed on enteroscopy and endoscopic ultrasound. An initial computed tomography (CT) scan performed in another hospital showed long segmental wall thickening involving the third part of the duodenum to the proximal segment of the jejunum. The patient was referred to our institution for enteroscopy, which showed a poorly distensible third part of the duodenum with purplish mucosa starting at the fourth part of the duodenum until the proximal jejunum. With suspicion of ischemic enteritis, a mesenteric CT angiography was performed, which showed a long segment circumferential wall thickening of the duodenum to jejunum with fullness of the pancreatic head and uncinate process that encases the superior mesenteric artery. Endoscopic ultrasound (EUS) showed a hypoechoic lesion at the head of the pancreas. EUS-guided fine-needle biopsy was performed, which revealed pancreatic adenocarcinoma on histopathology.

Moving Forward: Gradual Return of Gastroenterology Practice during the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic has caused disruption of routine gastroenterology practice, which has resulted in the suspension of elective endoscopic procedures and outpatient consults. For the past months, the strategy was to mitigate infection risk for the healthcare team while still providing essential service to patients. Prolonged suspension of the outpatient clinics and endoscopy practice, however, is deemed unsustainable and could even be detrimental. It can compromise patient care and result in poor outcomes; hence, a well-crafted plan is needed for the gradual resumption of clinic operations and endoscopic procedures. SUMMARY: As the world begins to transition to the "new normal," there are new health and safety issues to consider. Adaptive measures like telemedicine and electronic health records should be utilized to facilitate patient care while minimizing exposure. Careful patient screening, adequate supply of personal protective equipment, effective infection-control policies, as well as appropriate administrative modifications are needed for a safe return of gastroenterology practice. Key Messages: Ensuring the safety of patients, caregivers, and healthcare workers should remain as top priority. To help ease the transition as we move forward from this pandemic, we present a review of recommendations to guide gastroenterologists and endoscopy unit administrators in the gradual return to gastroenterology practice.

Standards of diagnostic colonoscopy for early-stage neoplasia: Recommendations by an Asian private group.

BACKGROUND AND AIM: In recent years, the incidence of colorectal cancer has been increasing, and it is now becoming the major cause of cancer death in Asian countries. The aim of the present study was to develop Asian expert-based consensus to standardize the preparation, detection and characterization for the diagnosis of early-stage colorectal neoplasia. METHODS: A professional group was formed by 36 experts of the Asian Novel Bio-Imaging and Intervention Group (ANBI2 G) members. Representatives from 12 Asia-Pacific countries participated in the meeting. The group organized three consensus meetings focusing on diagnostic endoscopy for gastrointestinal neoplasia. The Delphi method was used to develop the consensus statements. RESULTS: Through the three consensus meetings with debating, reviewing the literature and regional data, a consensus was reached at third meeting in 2016. The consensus was reached on a total of 10 statements. Summary of statements is as follows: (i) Adequate bowel preparation for high-quality colonoscopy; (ii) Antispasmodic agents for lesion detection; (iii) Image-enhanced endoscopy (IEE) for polyp detection; (iv) Adenoma detection rate for quality indicators; (v) Good documentation of colonoscopy findings; (vi) Complication rates; (vii) Cecal intubation rate; (viii) Cap-assisted colonoscopy (CAC) for polyp detection; (ix) Macroscopic classification using indigocarmine spray for characterization of colorectal lesions; and (x) IEE and/or magnifying endoscopy for prediction of histology. CONCLUSION: This consensus provides guidance for carrying out endoscopic diagnosis and characterization for early-stage colorectal neoplasia based on the evidence. This will enhance the quality of endoscopic diagnosis and improve detection of early-stage colorectal neoplasia.

EMR of large, sessile, sporadic nonampullary duodenal adenomas: technical aspects and long-term outcome (with videos).

BACKGROUND: EMR is a viable alternative to surgery for removal of large mucosal neoplastic lesions of the entire GI tract. Few studies have, however, been published on the safety, efficacy, and technical aspects of EMR in the duodenum. OBJECTIVE: Our purpose was to evaluate the efficacy and safety of EMR of large (>15 mm) duodenal adenomas. DESIGN: Retrospective evaluation of a defined patient cohort. SETTING: Tertiary academic referral center. PATIENTS: Patients with large (>15 mm) sporadic nonampullary duodenal adenomas managed by a standardized technique who were referred by other specialist endoscopists for endoscopic treatment. METHODS: Five-year data from patients undergoing EMR for large duodenal adenomas were reviewed retrospectively. Immediate and delayed complications were recorded. RESULTS: Twenty-one lesions were removed by EMR in 23 patients (mean age 62.2 years, 13 female, 10 male). The mean size of lesions resected was 27.6 mm (median 20 mm, range 15-60 mm). Post-EMR histologic examination revealed mucosal adenocarcinoma in 1, low-grade tubulovillous adenoma (TVA) in 16, high- or focal high-grade TVA in 3 patients, and 1 with both high-grade TVA and carcinoid. EMR was performed successfully in 18 patients during a single session. Two patients required 2 sessions and 1 required 3 sessions for complete resection. The median follow-up was 13 months (range 4-44 months). During follow-up, 5 patients had minor residual adenomas that were treated successfully with snare resection and/or argon plasma coagulation. One patient had EMR site bleeding. There were no perforations. LIMITATION: Retrospective study. CONCLUSION: EMR for large sporadic nonampullary duodenal adenomas is a safe and effective technique.

Novel subtypes (subgenotypes) of hepatitis B virus genotypes B and C among chronic liver disease patients in the Philippines.

Several hepatitis B virus (HBV) subtypes (subgenotypes), HBV/Aa (A1 : Asia/Africa), Ae (A2 : Europe), Bj (B1 : Japan) and Ba (B2 : Asia), have been reported with respect to clinical differences between patients infected with these subtypes (subgenotypes). HBV genotype distribution among patients with chronic liver diseases was investigated in the Philippines, where such studies have not been carried out previously. One hundred sera were obtained from such patients, consisting of 32 chronic hepatitis (CH), 37 cirrhosis and 31 hepatocellular carcinoma (HCC) patients. Nine complete genomes and 100 core promoter/precore genes of HBV were sequenced directly. Phylogenetic analyses revealed 51 HBV/A (Aa/A1), 22 HBV/B and 27 HBV/C strains. Interestingly, most HBV/C strains in the Philippines formed a specific cluster distinct from previous HBV/C strains (C1-4), indicating a novel subtype (subgenotype), HBV/C5. Moreover, most HBV/B strains fell within the specific cluster of the HBV/B subtype (subgenotype) B5, with viral characteristics of HBV/Ba (B2) carrying a recombination with HBV/C over the precore and core genes. Of the three genotypes, HBV/B and HBV/C were significantly more prevalent than HBV/A in cirrhosis and HCC patients (P<0.02). The prevalence of the core promoter mutations T1762/A1764 was higher in HCC patients with HBV/B and HBV/C. Multivariate analysis indicated that age [odds ratio (OR) 3.43; 95 % confidence interval (CI) 1.04-11.36; P=0.044] and the core promoter mutation (OR 14.08; 95% CI 3.62-4.74; P<0.001) were significant factors for HCC development. In conclusion, novel HBV subtypes (subgenotypes) C5 and B5 are prevalent in the Philippines, as well as HBV/Aa (A1).