Underwater endoscopic mucosal resection is associated with fewer recurrences and earlier curative resections compared to conventional endoscopic mucosal resection for large colorectal polyps.

BACKGROUND: Studies comparing the efficacy and safety of conventional saline-assisted piecemeal endoscopic mucosal resection (EMR) to underwater EMR (UEMR) without submucosal lifting of colorectal polyps are lacking. The objective of this study was to compare the efficacy and safety of EMR to UEMR of large colorectal polyps. METHODS: Two hundred eighty-nine colorectal polyps were removed by a single endoscopist from 7/2007 to 2/2015 using EMR or UEMR. 135 polyps (EMR: 62, UEMR: 73) that measured ≥15 mm and had not undergone prior attempted polypectomy were evaluated for rates of complete macroscopic resection and adverse events. 101 of these polyps (EMR: 46, UEMR: 55) had at least 1 follow-up colonoscopy and were studied for rates of recurrence and the number of procedures required to achieve curative resection. RESULTS: The rate of complete macroscopic resection was higher following UEMR compared to EMR (98.6 vs. 87.1%, p = 0.012). UEMR had a lower recurrence rate at the first follow-up colonoscopy compared to EMR (7.3 vs. 28.3%, OR 5.0 for post-EMR recurrence, 95% CI: [1.5, 16.5], p = 0.008). UEMR required fewer procedures to reach curative resection than EMR (mean of 1.0 vs. 1.3, p = 0.002). There was no significant difference in rates of adverse events. CONCLUSIONS: UEMR appears superior to EMR for the removal of large colorectal polyps in terms of rates of complete macroscopic resection and recurrent (or residual) abnormal tissue. Compared to conventional EMR, UEMR may offer increased procedural effectiveness without compromising safety in the removal of large colorectal polyps without prior attempted resection.

ERCP-directed radiofrequency ablation and photodynamic therapy are associated with comparable survival in the treatment of unresectable cholangiocarcinoma.

BACKGROUND: Cholangiocarcinoma (CCA) is a malignancy with a poor 5-year survival rate (5%-10%). ERCP-directed radiofrequency ablation (RFA) or photodynamic therapy (PDT) can be performed as palliative therapy for unresectable CCA. ERCP with PDT is associated with improved survival compared with stent placement alone. However, ERCP-directed RFA has not been directly compared with PDT in patients with CCA. OBJECTIVE: To compare overall survival in patients with unresectable CCA who underwent palliative ERCP-directed RFA versus PDT. DESIGN: Retrospective cohort study. SETTING: Tertiary-care academic medical center. PATIENTS: Forty-eight patients with unresectable CCA who underwent ERCP-directed ablative therapy for palliation of unresectable CCA. INTERVENTIONS: ERCP-directed RFA or PDT. MAIN OUTCOME MEASUREMENTS: Overall survival by Kaplan-Meier analysis after initial treatment with either RFA or PDT. RESULTS: Patients who underwent RFA (n = 16) demonstrated an overall survival similar to that of those who underwent PDT (n = 32), with a median survival of 9.6 versus 7.5 months, respectively (P = .799). Patient age (P = .45), sex (P = .52), and lead time (P = .59) from presentation to initial RFA or PDT had no significant association with survival. The presence of distant metastasis was inversely associated with survival (hazard ratio 3.55; 95% confidence interval, 1.29-9.77; P = .014). Patients who underwent RFA (compared with PDT) had a lower mean number of plastic stents placed per month (0.45 vs 1.10, P = .001) but also had more episodes of stent occlusion (0.06 vs 0.02, P = .008) and cholangitis (0.13 vs 0.05, P = .008) per month. LIMITATIONS: Retrospective, single-center design. CONCLUSIONS: Survival after ERCP-directed RFA and PDT was not statistically different in patients with unresectable CCA. A randomized, controlled trial is warranted to validate these preliminary results.

Underwater endoscopic mucosal resection of colorectal neoplasia is easily learned, efficacious, and safe.

BACKGROUND: Underwater endoscopic mucosal resection (UEMR) without submucosal injection is a novel endoscopic procedure. It is not known if UEMR can be easily taught and learned, and the efficacy and safety of UEMR has not been demonstrated at multiple medical centers. Our aims were to demonstrate that (1) UEMR is a technique that can be easily learned by an endoscopist trained in traditional EMR, (2) endoscopic ultrasound (EUS) may not be required before UEMR, and (3) UEMR is an efficacious and safe method for resection of large or flat neoplastic colorectal lesions. METHODS: An experienced interventional endoscopist began performing UEMR after observing UEMR procedures. Colorectal UEMR was performed using a pediatric colonoscope with a cap, a waterjet, and a 'duck-bill' snare using blended current. Submucosal injection was not used. Patient data were collected prospectively. RESULTS: A total of 21 patients (17 men, mean age 64.9 years, range 51-83) referred for polypectomy of large colorectal lesions underwent UEMR. A total of 43 colorectal lesions with a mean size of 20 mm (range 8-50) were resected by UEMR. Lesions were found in the right colon (N = 16), transverse colon (N = 5), left colon (N = 19), and rectum (N = 3). Pathology demonstrated tubular adenoma (N = 29), tubulovillous adenoma (N = 5), high-grade dysplasia (N = 3), serrated sessile adenoma without dysplasia (N = 3), and non-neoplastic tissue (N = 3). EUS was used in only two cases of rectal neoplasia (4.7 %). Of the UEMRs, 97.7 % were successful with complete resection of colorectal polyps. The only adverse event was one case (2.3 %) of delayed post-UEMR bleeding. CONCLUSIONS: UEMR was easily learned by an endoscopist already skilled in conventional EMR. EUS may not be required prior to most UEMR procedures. UEMR appears to be an efficacious and safe alternative to traditional EMR or ESD for large or flat colorectal neoplasms.

Endoscopic submucosal dissection with electrosurgical knives in a patient on aspirin therapy (with video).

BACKGROUND: The electrosurgical knives required to perform endoscopic submucosal dissection (ESD) have recently passed the 510(k) premarketing evaluation by the U.S. Food and Drug Administration and are now available for purchase in the United States. Challenges to ESD being more widely performed in the United States include the lack of intensive hands-on training programs and a low incidence of appropriate, highly dysplastic gastric lesions on which an ESD-trained endoscopist can begin performing this procedure in patients. Furthermore, there are no guidelines regarding the safety of continuing antiplatelet therapy in patients undergoing ESD. OBJECTIVE: To report on the first gastric ESD performed in the United States by using recently approved electrosurgical knives on a patient who was maintained on aspirin therapy. DESIGN: Case report. SETTING: Large academic medical center. PATIENT: One patient with a 2-cm high-grade dysplasia (HGD) lesion in the posterior antrum who had indwelling coronary stents and was maintained on aspirin therapy throughout the periprocedural period. INTERVENTIONS: High-definition white-light and narrow-band imaging endoscopy, endosonography, and ESD by using recently approved electrosurgical knives. MAIN OUTCOME MEASUREMENTS: Complete resection of the HGD gastric lesion. RESULTS: En bloc complete resection of the HGD gastric lesion was achieved without any immediate or delayed bleeding or perforation. No residual or recurrent dysplasia was found on 1- or 3-month follow-up endoscopies. LIMITATIONS: Generalizations cannot be made from this single case. CONCLUSIONS: After receiving intensive hands-on training in both ex vivo and in vivo animal models, gastric ESD was successfully performed by 2 U.S. endoscopists by using recently approved electrosurgical knives in a patient maintained on aspirin therapy without any complications.

Meshed capillary vessels found on narrow-band imaging without optical magnification effectively identifies colorectal neoplasia: a North American validation of the Japanese experience.

BACKGROUND: The presence of meshed capillary (MC) vessels is highly sensitive (96%) and specific (92%) for diagnosing colorectal neoplasia on colonoscopy by using narrow-band imaging (NBI) with optical magnification, which is not available in North America. However, the efficacy of NBI to identify an MC pattern without optical magnification has not been determined. OBJECTIVE: To determine the diagnostic capabilities of NBI colonoscopy without optical magnification in differentiating neoplastic from non-neoplastic colorectal polyps by using the MC pattern. DESIGN: Retrospective comparison of prospectively collected colorectal polyp data. SETTING: Large, academic medical center. PATIENTS: This study involved 126 consecutive colorectal polyps (median size 3 mm) that were found in 52 patients (33 men) with a median age of 59.5 years. INTERVENTION: All lesions identified by white-light colonoscopy were prospectively diagnosed in real-time by using the MC pattern as determined on high-definition NBI, with 1.5x zoom but without true optical magnification, and then endoscopically excised. Surgical pathology was used as the criterion standard. MAIN OUTCOME MEASUREMENTS: Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of identifying neoplastic polyps were calculated. RESULTS: NBI without optical magnification was found to have a sensitivity of 93%, specificity of 88%, positive predictive value of 90%, negative predictive value of 91%, and diagnostic accuracy of 91% when all polyp sizes were considered. For lesions < or =5 mm, sensitivity was 87%, specificity was 93%, positive predictive value was 89%, negative predictive value was 91%, and diagnostic accuracy was 90%. LIMITATIONS: Single-center, single-endoscopist experience. CONCLUSION: Use of the MC pattern on NBI colonoscopy without optical magnification effectively distinguishes neoplastic from non-neoplastic colorectal polyps. NBI colonoscopy without optical magnification for neoplastic polyp diagnosis appears to be comparable with NBI with optical magnification when the MC pattern is used. A large, prospective trial is needed for further validation.

A lucky break. Interview by Alison Moore.

Patients in Leicester with minor fractures are now seen by a specialist nursing team, reducing the time patients have to wait for treatment.

Single-balloon enteroscopy effectively enables diagnostic and therapeutic retrograde cholangiography in patients with surgically altered anatomy.

BACKGROUND: In patients with surgically altered anatomy, ERCP is often unsuccessful. Single-balloon enteroscopy (SBE) enables deep intubation of the small bowel, permitting diagnostic and therapeutic ERCP in this subset of patients. OBJECTIVE: To determine the effectiveness of SBE in performing endoscopic retrograde cholangiography (ERC) in patients with surgically altered anatomy. DESIGN: Case series. SETTING: Large quaternary-care center. PATIENTS: Thirteen patients (11 women) underwent 16 SBE procedures with ERCP. Patient anatomy consisted of Whipple (n = 3), hepaticojejunostomy (n = 3), Billroth II (n = 1), and Roux-en-Y (n = 9). INTERVENTIONS: Patients with surgically altered anatomy in whom standard ERCP techniques had failed or were not possible underwent ERC by using SBE with initial therapeutic intent. MAIN OUTCOME MEASUREMENTS: Success rates of diagnostic ERC and therapeutic ERC in those patients who required biliary intervention. Procedure-related complications were also assessed. RESULTS: Diagnostic ERC was successful 12 (92.3%) of 13 patients and in 13 (81.3%) of 16 cases. Therapeutic ERC was required in 10 patients in whom diagnostic ERC was first accomplished, and therapeutic ERC was successful in 9 (90%) of 10 patients. Biliary interventions included balloon dilation (n = 4), stone extraction (n = 2), sphincterotomy (n = 4), removal of a surgically placed stent (n = 3), and stenting (n = 2). Two patients developed pancreatitis after therapeutic ERC. Median follow-up was 53 days (range 22-522 days). Overall procedural success in an intent-to-treat analysis by case was 75%. LIMITATION: Single-center experience. CONCLUSION: SBE enables diagnostic and therapeutic ERC in most patients with altered anatomy. SBE-assisted therapeutic ERC may be associated with an increased risk of pancreatitis. Improvement of the available equipment is necessary to perform more efficient and effective biliary interventions.

A fatality from sevoflurane abuse.

A case is presented of a 47-year-old man who died as a result of sevoflurane abuse. Sevoflurane was identified and confirmed by headspace gas chromatography-mass spectrometry. The heart blood sevoflurane concentration was 16 mg/L, and the peripheral blood sevoflurane concentration was 8.0 mg/L. No drugs or other volatile substances were found in the heart blood. The medical examiner ruled that the cause of death was cardiac arrhythmia due to sevoflurane toxicity. Cardiomegaly was listed on Part II of the death certificate. The manner of death was undetermined.

Distribution of phencyclidine into vitreous humor.

Vitreous humor is a fluid contained in the eye that is largely composed of water. The advantages of vitreous humor as a specimen for postmortem drug analysis include its relatively low susceptibility to contamination and the ability to analyze vitreous humor with little or no pretreatment. The postmortem analysis of ethanol in vitreous humor has been well established. However, studies of drug disposition into vitreous humor are limited. Heart blood, subclavian blood, and vitreous humor specimens from 26 phencyclidine-positive postmortem cases were analyzed to evaluate the distribution of phencyclidine into vitreous humor. Phencyclidine intoxication was not the cause of death in any of the cases analyzed. Specimens were analyzed by solid-phase extraction followed by gas chromatography-mass spectrometry. All positive blood specimens were associated with a positive vitreous humor specimen. On average, the blood phencyclidine concentrations were greater than the vitreous humor phencyclidine concentrations, with average blood/vitreous ratios of 2.85 for heart blood and 2.51 for subclavian blood. However, there was considerable variability between cases, which indicates that although vitreous humor is an appropriate specimen for the detection of phencyclidine in postmortem cases, its interpretative value is limited.

Distribution of ether in two postmortem cases.

Diethyl ether (ether) is a volatile liquid that was used in the 1800s as an anesthetic agent; however, it is no longer used for this purpose, partly because of its odor and flammability. Two postmortem cases in which ether was detected are presented. The first case was an 18-year-old male found hanging from a basement ceiling brace in a semi-sitting position with a gas mask covering his face. A container of Prestone starting fluid and a bong were found on the floor close to the body. The second case was a 20-year-old male found unresponsive in his dormitory room with two black plastic trash bags secured over his head. Two saturated rags and a resealable bag containing a clear liquid were contained within these trash bags. An almost empty can of Tradco starting fluid was also found at the scene. Ether concentrations were determined by headspace gas chromatography-mass spectrometry in the selective ion monitoring mode. In case #1, the medical examiner ruled that the cause of death was asphyxia due to hanging; the manner of death was undetermined. In case #2, the medical examiner ruled that the cause of death was asphyxia and the manner of death was suicide.

Tizanidine distribution in a postmortem case.

The case of a 57-year-old white female who was found deceased at home by her husband is presented. A suicide note was found at the scene. No remarkable findings were observed at autopsy. Comprehensive toxicological analysis of the heart blood identified ethanol (0.16 g/dL), diazepam (1.1 mg/L), and tizanidine (2.3 mg/L). Blood concentrations of tizanidine following therapeutic use do not exceed 0.025 mg/L. The medical examiner ruled that the cause of death was combined ethanol and multiple drug intoxication, and the manner of death was suicide.