Liquid Nitrogen Spray Cryotherapy in Treatment of Barrett's Esophagus, where do we stand? A Systematic Review and Meta-Analysis.

Radiofrequency ablation (RFA) is the preferred treatment option for Barrett's esophagus (BE) to achieve complete eradication (CE) of dysplasia (D), and intestinal metaplasia (IM). Cryotherapy, using liquid nitrogen (LNC), is a cold-induced tissue-injury technique option for the ablation of BE. We conducted a systematic review and meta-analysis to assess the overall efficacy and safety of LNC in the treatment of BE. We conducted a search of multiple electronic databases and conference proceedings from inception through June 2018. The primary outcome was to estimate the pooled rates of CE-IM, CE-D, and CE-HGD. The secondary outcome was to estimate the risk of adverse events and recurrence of disease after LNC. Nine studies reported 386 patients who were treated with LNC. The pooled rate of CE-IM was 56.5% (95% CI 48.5-64.2, I2 = 47), pooled rate of CE-D was 83.5% (95% CI 78.3-87.7, I2 = 22.8), and pooled rate of CE-HGD was 86.5% (95% CI 64.4-95.8, I2 = 88.1). Rate of adverse events was 4.7%, and the risk of BE recurrence was 12.7%. On subgroup analysis, the pooled rate of CE-IM with LNC in patients who failed RFA was 58.4% (95% CI 47.2-68.8, I2 = 32.5), and the pooled rate of CE-D in the same population was 81.9% (95% CI 72.5-88.6, I2 = 5.9). CE-D rates with LNC are comparable to RFA while CE-IM rates appear to be lower than the rates achievable with RFA. CE-IM rate in RFA failed patients is 58.4% and thus LNC is a rescue option to consider in this population.

Trends in diagnoses after implementation of the Chicago classification for esophageal motility disorders (V3.0) for high-resolution manometry studies.

To determine trends in the diagnostic distribution of esophageal motility disorders after implementation of the Chicago Classification Version 3.0 (CC V3.0) for interpretation of high-resolution manometry (HRM) studies compared to non-Chicago Classification criteria. Retrospective trends analysis of patients with an HRM study conducted at a single center from January 1, 2013 to September 30, 2015. The implementation of the CC V3.0 for manometry interpretation occurred in September 2014. Patient charts were manually reviewed for data collection including demographics and HRM diagnoses. The prevalence and relative risks (RR) of CC V3.0 diagnostic categories (i.e. normal, indeterminate, achalasia, and EGJ outflow obstruction [EJGOO], and major and minor motility disorders) were calculated before and after CC V3.0 implementation. Four hundred sixty-five HRM studies were included in the study including 268 before and 179 after CC V3.0 implementation. The mean ± SD age was 54 ± 15.4 years and 59.8% were female (n = 278). The percentage with indeterminate diagnosis decreased from 35.3% before CC V3.0 implementation to 16.8% after implementation (adjusted RR 0.5, 95%CI 0.30-0.70, p < 0.001). The percentage with a major motility disorders decreased from 13.9% to 7.3% (adjusted RR 0.5, 95%CI 0.2-1.0, p < 0.001). The percentage with EJGOO and minor diagnoses increased from 1.4% to 14.5% and 11.9% to 22.9%, respectively. The percentage with achalasia and normal diagnosis did not change over the study period. Implementation of CCV3.0 was associated with changes in the distribution of esophageal motility diagnoses in clinical practice. The percentage of indeterminate and major diagnosis decreased and EGJOO and minor diagnoses increased. The decrease in the number of indeterminate studies suggests that the CC V3.0 may clarify the criteria for the interpreting physician. The increase in studies with a diagnosis of EGJ outflow obstruction may reflect the heterogeneity of disorders with clinically relevant outflow obstruction.

Peroral cholangioscopy facilitates targeted tissue acquisition in patients with suspected cholangiocarcinoma.

AIM: Biliary strictures that are suspicious for cholangiocarcinoma (CCA) are commonly encountered in clinical practice in patients with and without primary sclerosing cholangitis (PSC). A definitive histologic diagnosis of CCA via endoscopic retrograde cholangiography (ERCP) is often not obtainable with standard biliary brush cytology. Peroral cholangioscopy is an additional tool to help provide a diagnosis of CCA in patients with suspicious biliary strictures. Aim of the study was to assess the use of peroral cholangioscopy in patients with and without PSC and indeterminate biliary strictures. METHODS: Retrospective study. RESULTS: 25 patients were included in the study. All patients underwent ERCP with peroral cholangioscopy. Tissue samples obtained included routine cytology, fluorescent in-situ hybridization, and cholangioscopic-directed forceps biopsies. The operating characteristics of cholangioscopy to detect malignancy in 18 PSC patients with suspected cholangiocarcinoma were a sensitivity of 75%, specificity of 55%, and a positive predictive value (PPV) of 23%, and a negative predictive value of 92%. In 7 non-PSC patients with suspected cholangiocarcinoma these values sensitivity=100%, 25%, 50%, and NPV=100%, respectively. The overall operating characteristics of cholangioscopy to detect malignancy in all 25 patients with suspected cholangiocarcinoma were: sensitivity of 86%, specificity of 50%, PPV of 32%, and NPV of 93%. CONCLUSION: Cholangioscopy helps identify sites for tissue acquisition in PSC and non-PSC patients with biliary strictures suspicious for malignancy.

Double balloon enteroscopy: is it efficacious and safe in a community setting?

AIM: Double balloon enteroscopy (DBE) has been extensively used in tertiary referral centers but little literature exists on the efficacy, complications and outcomes of patients undergoing DBE in the community setting. We present our findings regarding the use of DBE in a community hospital. METHODS: From March 2007 to January 2011, 88 DBE procedures were performed on 66 patients. Indications included evaluation anemia/gastrointestinal bleed, small bowel IBD and dilation of strictures. Video-capsule endoscopy (VCE) was used prior to DBE in 43 of the 66 patients prior to DBE evaluation. RESULTS: The mean age was 62 years. Thirty-two patients were female, 15 were African-American; 44 antegrade and 44 retrograde DBEs were performed. The mean time per antegrade DBE was 107.4±30.0 minutes with a distance of 318.4±152.9 cm reached past the pylorus. The mean time per lower DBE was 100.7±27.3 minutes with 168.9±109.1 cm meters past the ileocecal valve reached. Endoscopic therapy in the form of electrocautery to ablate bleeding sources was performed in 20 patients (30.3%), biopsy in 17 patients (25.8%) and dilation of Crohn's-related small bowel strictures in 4 (6.1%). 43 VCEs with pathology noted were performed prior to DBE, with findings endoscopically confirmed in 32 cases (74.4%). In 3 cases the DBE showed findings not noted on VCE. CONCLUSION: DBE appears to be equally safe and effective when performed in the community setting as compared to a tertiary referral center with a comparable yield, efficacy, and complication rate.

A large multicenter study analysis of adverse events associated with single operator cholangiopancreatoscopy.

AIM: Cholangiopancreatoscopy (CP) is an endoscopic technique that allows for direct visualization of the biliary and pancreatic ducts using a narrow caliber endoscope that passes through the working channel of a duodenoscope directly into the bile and/or pancreatic ducts. Little data is available on the safety of CP. We performed a multicenter retrospective study to evaluate the frequency and severity of adverse events with single operator CP. METHODS: A multicenter retrospective study was conducted. RESULTS: A total of 282 single operator peroral CP procedures were performed in 224 patients (128 M, 96 F). Most procedures involved the performance of therapeutic maneuvers, with most cases including multiple therapeutic maneuvers. Cholangioscopic or pancreatoscopic-assisted tissue sampling was performed in 222 procedures. Thirty-seven patients underwent electrohydraulic lithotripsy (EHL) for the treatment of common bile duct stones. Adverse events in patients undergoing single cholangioscopy and pancreatoscopy included post-ERCP pancreatitis (N.=11, 3.9%, all mild), post-ERCP cholangitis (N.=4, 1.4%), bleeding (N.=3, 1%), and perforation (N.=2, 0.7%). CONCLUSION: Overall, our data shows that ERCP performed with single operator cholangioscopy or pancreatoscopy is safe with adverse events similar to that seen in large studies of ERCP performed without these additional techniques. Of note, vigorous irrigation of the bile ducts was not associated with increased rates of post-procedure cholangitis in our study.

Primary esophageal motility disorders.

Esophageal motility disorders often manifest with chest pain and dysphagia. Achalasia is a disorder of the lower esophageal sphincter and the smooth musculature of the esophageal body. In achalasia the lower esophageal sphincter typically fails to relax with swallowing, and the esophageal body fails to undergo peristalsis. In contrast to spastic disorders of the esophagus, achalasia can be progressive and cause pronounced morbidity. Pseudoachalasia mimics achalasia in terms of symptoms but can be caused by infectious disorders or malignancy. Treatment for achalasia is nonstandardized and includes medical, endoscopic, and surgical options. Spastic disorders of the esophagus, such as diffuse esophageal spasm and nutcracker esophagus, and nonspecific esophageal motility disorder are benign and nonprogressive, with similar findings on esophageal manometry. Although the exact cause remains unknown, these disorders may represent a manifestation of gastroesophageal reflux disease. Treatment of spastic disorders includes medical and surgical approaches and is aimed at symptomatic relief.

Endoscopic palliation of malignant dysphagia.

Esophageal cancer is the primary cause of malignant dysphagia, a major cause of morbidity and mortality. In patients with esophageal cancer that is unresectable at the time of diagnosis, palliation is the major goal. Surgical treatment as well as radiation and chemoradiation therapy are traditional approaches for such patients. Endoscopic therapy is useful for patients with poor performance status, those in whom other treatments have failed, and those with tracheoesophageal fistulas. In recent years, self-expanding metal stents have become an important new endoscopic treatment modality for palliation of malignant dysphagia in a wide range of patients. Appropriate patient selection is paramount when a mode of palliation for malignant dysphagia is being selected. Although various treatment options exist for palliation of malignant dysphagia, comparative studies among these modalities are needed.

Stents and lasers for colonoscopic lesions.

The use of self-expanding metal stents (SEMS) in the colon is now becoming more commonplace. These devices can be employed to decompress large bowel that has become obstructed from either benign or malignant disease. Many studies in the past year have validated the use of colonic SEMS to allow preoperative bowel preparation in resectable patients, or as an alternative to surgery in those requiring palliative therapy alone. Laser therapy has also gained new ground in recent months because it has been shown to help in recanulation of obstructed bowel to aid in SEMS placement. In addition, laser therapy alone can be used to treat some colonic lesions that had formerly been treated surgically.

Placement of PEG tubes through previously placed self-expanding esophageal metal stents.

BACKGROUND: Self-expanding metal stents are frequently used to palliate patients with malignant dysphagia and close tracheoesophageal fistulae. Despite proper stent positioning and deployment, in a subset of patients there is no improvement in dysphagia, closure of tracheoesophageal fistulae, or resolution of anorexia. Such patients may require a PEG tube. It has been suggested that PEG placement through a preexisting esophageal stent is problematic because of the risks of gastrostomy tube impaction within the stent and resultant stent migration. METHODS: Case records were retrospectively reviewed of 9 consecutive patients with indwelling esophageal self-expanding metal stents undergoing attempted PEG. OBSERVATIONS: PEG tube placement was successful in all patients. In 1 patient, the stent migrated distally into the stomach during PEG placement. This was managed endoscopically without further complication. CONCLUSIONS: PEG placement in patients with previously placed esophageal self-expanding metal stents is a relatively safe and feasible procedure, although stent migration may occur.