Advances in gastrointestinal endoscopy.

Gastrointestinal endoscopy has undergone a remarkable expansion in its capabilities as a result of sophisticated technological advances in recent years. New imaging technologies, novel ablation and resection techniques, cutting-edge endoscope development and creative extraluminal applications have taken gastrointestinal endoscopy to an exciting new level. An update on some of these advances is presented for the physician audience.

Autoimmune pancreatitis: an important diagnostic consideration in obstructive jaundice due to a pancreatic mass lesion.

Autoimmune or immunoglobulin G subtype (IgG4) pancreatitis is a newly recognised clinical entity and is an important differential diagnosis for patients presenting with obstructive jaundice. Knowledge of autoimmune pancreatitis (AIP) continues to evolve both for pathogenesis and management; however diagnosis is often not straightforward or even considered, therefore a high index of suspicion remains an important tool for the treating physician. The six cases presented illustrate both the difficulties in diagnosis as well as management of this condition.

Endoscopic treatment of postoperative enterocutaneous fistulas after bariatric surgery with the use of a fistula plug: report of five cases.

Anastomotic leaks frequently occur after bariatric surgery and their management includes different options. The present study describes the management of enterocutaneous fistulas in patients in whom surgical or endoscopic treatments have failed, by insertion of a biomaterial (Surgisis fistula plug) to facilitate healing of the gastrocutaneous fistula. Five patients with leaks after bariatric surgery were treated. All patients had undergone previous failed surgical or endoscopic attempt(s) at closure. Our technique entailed insertion of the Surgisis fistula plug into the fistula tract by a "rendezvous" procedure, via both percutaneous and endoscopic routes. The data were collected retrospectively. Initially, two patients were treated by fistula plug alone and three received fistula plug plus a self-expanding stent. In two patients, cutaneous fistula outflow ceased within a few days. The other three patients required one additional endoscopic procedure. At the end we observed healed leaks in four of the five patients (80 %). The median follow-up duration was 18 months. In conclusion, the combined therapy consisting of fistula plug implantation with optional stenting helps closure in these difficult refractory cases of gastrocutaneous fistula.

A prospective randomized trial of cannulation technique in ERCP: effects on technical success and post-ERCP pancreatitis.

BACKGROUND AND STUDY AIMS: Inadvertent injection of contrast agent into the pancreatic duct is believed to be an important contributor to pancreatitis occurring after endoscopic retrograde cholangiopancreatography (post-ERCP pancreatitis, PEP). Our aim was to examine whether primary deep biliary cannulation with a guide wire is associated with a lower rate of PEP than conventional contrast-assisted cannulation. PATIENTS AND METHODS: From August 2003 to April 2006 all patients with an intact papilla who were referred for ERCP were eligible. Patients with pancreatic or ampullary cancer were excluded. Patients were randomized to undergo sphincterotomy biliary cannulation using either contrast injection or a guide wire. The ERCP fellow attempted initially for 5 minutes. If unsuccessful, the consultant attempted for 5 minutes using the same technique, followed by crossover to the other technique in the same sequence and then needle-knife sphincterotomy where appropriate. Patients were assessed clinically after the procedure, then followed up with telephone interviews after 24 hours and 30 days, and serum amylase and lipase tests after 24 hours. RESULTS: Out of 1654 patients undergoing ERCP, 413 were included in the study. PEP occurred in 29/413 (7.0 %): 16 in the guide-wire arm, 13 in the contrast arm ( P = 0.48). The overall cannulation success rate was 97.3 %. Cannulation was successful without crossover in 323/413 patients (78.2 %): 167/202 (81.4 %) in the guide-wire arm and 156/211 (73.9 %) in the contrast arm ( P = 0.03). Multivariate analysis demonstrated female sex (OR = 2.7, P = 0.04), suspected sphincter of Oddi dysfunction (OR = 5.5, P = 0.01), and complete filling of the pancreatic duct with contrast agent (OR = 3.5, P = 0.02) to be independently associated with PEP. The risk of PEP increased incrementally with each attempt at the papilla (OR 1.4 per attempt, P = 0.04) to greater than 10 % after four or more attempts. CONCLUSIONS: The guide-wire technique improves the primary success rate for biliary cannulation during ERCP but does not reduce the incidence of PEP compared to the conventional contrast technique. The incidence of PEP increases incrementally with each attempt at the papilla.

Argon plasma coagulation in the management of symptomatic gastrointestinal vascular lesions: experience in 100 consecutive patients with long-term follow-up.

BACKGROUND: The long-term efficacy of argon plasma coagulation (APC) in the management of gastrointestinal vascular lesions has not been evaluated in a large and well-defined series. The impact of APC on transfusion requirements and hemoglobin, and technical parameters including complications and number of treatment sessions, is assessed in this series. METHODS: Patients who underwent APC for bleeding gastrointestinal vascular lesions were identified via interrogation of an established endoscopic database, excluding patients with radiation proctitis, tumors, residual polypectomy tissue and acute ulcer bleeding. Follow-up data were collected via interview with patients and referring doctors, review of medical records, and follow-up blood tests. RESULTS: One hundred patients were enrolled, males = 46, median age = 74 yr (range: 19-99 yr). Median follow-up time was 16 months (range: 4-47 months). Lesions treated were arteriovenous malformations (n = 74) and gastric antral vascular ectasia (n = 26). Fifty-three patients required transfusion. In this group, median hemoglobin improved from 66 g/L (range: 35-114) to 111 g/L (range: 55-155, p < 0.001). Median transfusion velocity fell from 2 units/month (range: 0.1-6) to 0 units/month (range: 0-4, p < 0.001). Transfusion requirement was abolished in 77%. In non-transfusion-requiring patients, median hemoglobin improved from 105 g/L (range: 58-143) to 123 g/L (range: 79-158, p < 0.001). No complications occurred. CONCLUSIONS: APC is effective and safe in the management of gastrointestinal vascular lesions.

Liver disease due to parenteral and enteral nutrition.

Liver disease due to parenteral and enteral nutrition is a well-recognized iatrogenic phenomenon, but its cause and pathogenesis have not been clearly elucidated. Various mechanisms have been postulated, but it is likely that the cause is multifactorial with significant interplay among several factors. A preventive approach to management is ideal but awaits a more complete understanding of the pathophysiology. A variety of management strategies has been proposed in small case series, but level 1 evidence-based guidelines have yet to be established. Although an abundance of both clinical and animal studies exist regarding liver disease associated with parenteral nutrition (PN), there is a paucity of data regarding enteral nutrition (EN)-associated hepatic disease. The latter probably reflects differences in the frequency and severity of PN- versus EN-associated liver disease. This article addresses the two routes of nutritional support individually, with the major focus on PN-associated liver disease.

Pancultural explanations for life satisfaction: adding relationship harmony to self-esteem.

The first part of the study confirmed an additive effect of the newly proposed construct of relationship harmony to self-esteem in predicting life satisfaction across student samples from the United States and Hong Kong. As predicted from the dynamics of cultural collectivism, the relative importance of relationship harmony to self-esteem was greater in Hong Kong than in the United States. In the second part of the study, the independent and interdependent self-construals (H. R. Markus & S. Kitayama, 1991) and the 5 factors of personality (P. T. Costa & R. R. McCrae, 1992) were advanced to be the culture-general determinants of life satisfaction, acting through the mediating variables of self-esteem and relationship harmony. Both self-construals and the 5 factors of personality were shown to influence life satisfaction through the mediating agency of self-esteem and relationship harmony in equivalent ways across these 2 cultural groups.