The role of a novel self-expanding metal stent in variceal bleeding: a multicenter Australian and New Zealand experience.

Background and study aims Refractory variceal bleeding is associated with high mortality in patients with chronic liver disease. A fully-covered self-expanding metal stent (SEMS) has been reported to have excellent rates of technical success and initial bleeding control; however, studies to date are small and limited to Europe and Asia. Our aim was to evaluate the efficacy and safety of this SEMS for control of refractory variceal bleeding (VB). Patients and methods A retrospective analysis was undertaken of all patients who received the SX-ELLA Danis SEMS for management of VB at 9 tertiary centers across Australia and New Zealand. A total of 32 SEMS had been deployed in 30 patients (median age 53.3). Results Technical success of SEMS placement was achieved in 100 % of cases, resulting in immediate control of bleeding across 31 of 32 cases (96.9 %). Re-bleeding with SEMS in situ occurred in three of 32 cases (9.4 %). Mean SEMS in-dwelling time was 6.4 days. Delayed SEMS migration occurred in 6.3 % of cases. Interventional radiological therapy for management of varices within 6 weeks was performed in 12 of 30 patients (40 %). Death with SEMS in situ occurred in seven of 30 patients (23.3 %). Seven-day bleeding-related mortality was 16.7 %, 14-day mortality 23.3 %, and 6-week mortality 33.3 %. Three of 30 patients (10 %) received orthotopic liver transplantation following SEMS insertion, including two patients within 6 weeks. Conclusions SX-Danis Ella SEMS is highly effective for immediate control of refractory VB and bridging to definitive therapy because it has excellent technical success rates, appears to be relatively easy to use, and has low rates of serious adverse events.

Tamoxifen Therapy for Recurrent Mucosal Bleeding in Hereditary Hemorrhagic Telangiectasia.

A 60-year-old Caucasian man had a 55-year history of recurrent severe epistaxis and later presented with multiple gastrointestinal (GI) bleeding from hereditary hemorrhagic telangiectasia (HHT). Bleeding was exacerbated due to coexistent mild hemophilia A. Despite repeated conventional surgical interventions, tranexamic acid and recombinant factor VIII (FVIII) prophylaxis, bleeding episodes worsened in frequency and severity, resulting in the patient becoming transfusion dependent. The introduction of tamoxifen therapy resulted in reduced transfusion requirement.

A pilot study of intrastricture steroid versus placebo injection after balloon dilatation of Crohn's strictures.

BACKGROUND & AIMS: Restricturing after ileocolonic resection for Crohn's disease is common. Colonoscopic balloon dilatation is effective but repeated dilatations often are required. Intrastricture steroid injection after balloon dilatation has been reported to reduce the need for repeat dilatation in retrospective series, but no randomized data are available. METHODS: We performed a pilot study comparing local quadrantic injection of triamcinolone (40 mg total dose) after endoscopic balloon dilatation of Crohn's ileocolonic anastomotic strictures vs saline placebo. The primary end point was time to redilatation or surgery. Patients were followed up for 52 weeks. RESULTS: Thirteen patients were randomized, 7 to steroid and 6 to placebo. Groups were well matched for baseline and dilatation characteristics. In the intention-to-treat analysis, 1 of 6 patients in the placebo group and 5 of 7 patients in the steroid group needed redilatation (log rank test P = .06; Cox regression P = .10; hazard ratio, 6.1; 95% confidence interval, 0.7-53.0). In the per-protocol analysis the differences were more significant (log rank test P = .03; Cox regression P = .07; hazard ratio, 7.7; 95% confidence interval, 0.9-67.9). CONCLUSIONS: A single treatment of intrastricture triamcinolone injection did not reduce the time to redilatation after balloon dilatation of Crohn's ileocolonic anastomotic strictures and there was a trend toward a worse outcome. The use of this technique in clinical practice should be considered carefully until more data are available.

Colonoscopic balloon dilation of Crohn's strictures: a review of long-term outcomes.

OBJECTIVE: To study the long-term outcomes of patients who have had endoscopic balloon dilation of Crohn's strictures. DESIGN: Retrospective case-note review over a 16-year period. PATIENTS: Patients with a Crohn's stricture causing obstructive symptoms and who had at least 6 months' follow-up data or a surgical outcome following dilation were sought; 59 patients (124 dilations) were identified. INTERVENTION: Patients all underwent endoscopic balloon dilation. RESULTS: Strictures were anastomotic in 53 patients (111 dilations) and de novo in six patients (13 dilations). The median stricture length was 3.0 cm. Median follow-up time was 29.4 months. Out of the total group, 41% of patients achieved long-term clinical benefit following dilation and in 17% after only a single dilation. The median number of dilations per patient was one. A total of 35 (59%) patients required surgery for their stricture during follow-up. There were two (1.6%) perforations as a result of dilation, one in an anastomotic stricture (managed conservatively) and one in a de-novo stricture (requiring surgery). There were no deaths. CONCLUSIONS: Colonoscopic balloon dilation of Crohn's strictures can achieve long-term clinical benefit in many patients. Repeat dilations are justified in initial non-responders. In this series, the procedure appears safe with low morbidity.

A case of oesophageal varices and portal hypertension in an HIV-positive patient with no evidence of cirrhosis.

We present a case of portal hypertension and variceal bleeding in the absence of cirrhosis, in an HIV-positive patient on long-term antiretroviral treatment with didanosine. We believe this to be the first such case identified in New Zealand (NZ).

Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps: a randomized trial and recommendations.

BACKGROUND: Recurrence is frequent after piecemeal snare resection of large sessile colorectal polyps. The aim of this study was to evaluate the safety and efficacy of argon plasma coagulation (APC) in preventing recurrence when applied to the edge and base of the polypectomy site after apparently complete piecemeal resection. METHODS: Patients with large (>1.5 cm) sessile polyps removed by piecemeal snare cautery were placed into 2 groups. The first consisted of patients with polyps believed by the endoscopist to be completely excised. These patients were randomized to either no further therapy (control) or to APC of the rim and any residual mucosal or submucosal tissue in the base of the polypectomy site. The second group comprised patients in whom polyps, as judged by the endoscopist, were incompletely excised by snare polypectomy; APC was routinely applied without randomization to all visible remaining adenomatous tissue. Follow-up colonoscopy was performed within 3 months and 1 year; biopsy specimens were taken routinely from the resection site and further polypectomy was performed as indicated. RESULTS: There were fewer recurrences after APC in the randomized group (1/10 APC, 7/11 no APC; p = 0.02). In the group with initial incomplete snare polypectomy, recurrence was detected at 3 months in 6 of 13 despite APC. One patient was hospitalized with abdominal pain and minor rectal bleeding but required no intervention. There were no other episodes of significant late bleeding caused by piecemeal polypectomy. One patient was referred for surgery after unsuccessful endoscopic management. CONCLUSIONS: In patients with apparent complete endoscopic snare resection of large adenomas, postpolypectomy application of APC reduces adenomatous recurrence.

Effect of magnetic endoscope imaging on patient tolerance and sedation requirements during colonoscopy: a randomized controlled trial.

BACKGROUND: Pain during colonoscopy is primarily related to mesenteric stretching from looping of the colonoscope insertion tube. Prompt recognition and removal of loops reduces patient discomfort and may lessen sedation requirements. Magnetic endoscope imaging allows real-time visualization of the colonoscope during insertion. The effect of magnetic endoscope imaging on patient pain and sedation requirements was assessed in a prospective randomized controlled trial. METHODS: A total of 122 consecutive patients undergoing routine colonoscopy by a single experienced endoscopist were randomized to have the procedure performed either with the endoscopist viewing the imager display (n = 62), or without the imager view (n = 60). Procedures began with administration of hyoscine-N-butylbromide alone, and sedative medications (midazolam and meperidine) were self-administered by the patient with a patient-controlled analgesia pump. Cardiorespiratory parameters were recorded and patient pain was assessed with a 100-mm visual analogue scale. RESULTS: The number of attempts at straightening the colonoscope was fewer (median 8 [0-66] vs. 15 [0-87], p = 0.0076) and the duration of looping less (median 4.5 min [0-27.3 min] vs. 6.4 min [0-29.4 min]), when the endoscopist was able to see the imager view. The total number of patient demands (by patient-controlled analgesia) for medication (median 1 vs. 2.5) and total doses of midazolam (median 0.44 mg vs. 0.88 mg) and meperidine (median 16.75 mg vs. 32.5 mg) administered did not significantly differ between patients examined with or without the imager. Patient pain scores were also similar. CONCLUSIONS: Magnetic endoscope imaging allows accurate assessment and straightening of loops during colonoscopy, but without a significant reduction in patient requirements for sedative medication or improvement in patient tolerance. However, the dosages of sedation drugs used were small.

The variable stiffness colonoscope: assessment of efficacy by magnetic endoscope imaging.

BACKGROUND: Variable-stiffness colonoscopes combine the flexibility of pediatric instruments for negotiation of the sigmoid colon with the ability to stiffen the insertion tube to prevent or control looping after straightening. Previous studies have found wide variation in the efficacy of the stiffening mechanism. Thus, two studies were conducted to assess the potential benefit of the stiffening device and its optimal use. METHODS: In study 1, the effect of routinely stiffening the straightened variable-stiffness colonoscopes in the mid-descending colon was determined in 82 patients. Two insertions were performed (mid-descending colon to cecum) in each patient with and without application of the stiffening device (randomized). The time to negotiate the proximal colon (mid-descending to cecum), time to pass the variable-stiffness colonoscopes across the splenic flexure into the transverse colon, time to pass the right colon, and ancillary maneuvers used were recorded for each insertion. In study 2, consecutive patients, excluding any with previous colonic resection, were examined by using standard adult variable-stiffness colonoscopes. Real-time views of the procedure with magnetic endoscope imaging were recorded for all examinations, but procedures were randomized to be done either with (n = 88), or without (n = 87) the endoscopist viewing the magnetic endoscope imaging display. Whenever stiffening was applied, the anatomic location of the colonoscope tip and stiffness efficacy were recorded. RESULTS: In study 1, time taken to negotiate the proximal colon (p = 0.0041) and time to negotiate the splenic flexure (p = 0.006) were significantly shorter and ancillary maneuvers performed were fewer (p = 0.0014) with the stiffening device activated. In study 2, stiffening was used with similar frequency in patients examined with and without the magnetic endoscope imaging view, most commonly for passing the splenic flexure (71%), but also in the transverse colon (12%), right colon (9%), and sigmoid/descending colon (8%). Stiffening was significantly more effective when used in combination with magnetic endoscope imaging (69% with imager vs. 45% without imager; p = 0.0102). CONCLUSIONS: Overall, the variable-stiffness device used was effective in controlling looping 57% of the time. Activating maximum stiffness appears to be effective once the sigmoid colon has been negotiated and the colonoscope straightened with the tip in the proximal colon, reducing the number of ancillary maneuvers and shortening the insertion time through the proximal colon. Routine magnetic endoscope imaging further enhances the efficacy of the variable-stiffness colonoscopes by helping to identify the optimal time for stiffening.

Haemorrhagic radiation proctitis: endoscopic severity may be useful to guide therapy.

BACKGROUND AND AIMS: Management of haemorrhagic radiation proctitis remains controversial. Both endoscopically delivered argon plasma coagulation and rectal administration of formalin have been recommended. We evaluated the efficacy of argon plasma coagulation according to endoscopic severity of radiation proctitis. PATIENTS AND METHODS: Fourteen patients treated with argon plasma coagulation for rectal bleeding due to radiation proctitis were reviewed. Patients were classified with a new endoscopic score for haemorrhagic radiation proctitis, comprising three factors: telangiectasia distribution, surface area involved, and presence of fresh blood. Seven patients were categorised as having grade A (mild), four grade B (moderate), and three grade C (severe) radiation proctitis. Rectal bleeding was assessed pre- and post-treatment using a five-point bleeding scale. RESULTS: All patients with grade A and B radiation proctitis were treated successfully by argon plasma coagulation (mean 1.5 sessions). In one patient with grade C radiation proctitis argon plasma coagulation was successful after four sessions, but in the other two patients bleeding could not be controlled; a subsequent single formalin administration was successful in both. Overall in 12 patients (85.7%) bleeding ceased or improved significantly. The mean rectal bleeding scale reduced significantly from 2.6 to 0.9. One patient treated with argon plasma coagulation developed an asymptomatic rectosigmoid stenosis. CONCLUSION: Argon plasma coagulation is a simple, safe and efficacious therapy for mild/moderate radiation proctitis. In patients with severe radiation proctitis several sessions are usually necessary, and success is not certain; in these cases, topical formalin administration may be more effective. Endoscopic severity of haemorrhagic radiation proctitis may be useful to guide appropriate therapy.

Total colonic dye-spray increases the detection of diminutive adenomas during routine colonoscopy: a randomized controlled trial.

BACKGROUND: Small adenomas may be missed during colonoscopy, but chromoscopy has been reported to enhance detection. The aim of this randomized-controlled trial was to determine the effect of total colonic dye spray on adenoma detection during routine colonoscopy. METHODS: Consecutive outpatients undergoing routine colonoscopy were randomized to a dye-spray group (0.1% indigo carmine used to coat the entire colon during withdrawal from the cecum) or control group (no dye). RESULTS: Two hundred fifty-nine patients were randomized, 124 to the dye-spray and 135 to the control group; demographics, indication for colonoscopy, and quality of the preparation were similar between the groups. Extubation from the cecum took a median of 9:05 minutes (range: 2:48-24:44 min) in the dye-spray group versus 4:52 minutes (range: 1:42-15:21 min) in the control group (p < 0.0001). The proportion of patients with at least 1 adenoma and the total number of adenomas were not different between groups. However, in the dye-spray group significantly more diminutive adenomas (<5 mm) were detected proximal to the sigmoid colon (p = 0.026) and more patients were identified with 3 or more adenomas (p = 0.002). More non-neoplastic polyps were detected throughout the colon in the dye-spray group (p = 0.003). There were no complications. CONCLUSIONS: Dye-spray increases the detection of small adenomas in the proximal colon and patients with multiple adenomas, but long-term outcomes should be studied to determine the clinical value of these findings.

Use of video and magnetic endoscope imaging for rating competence at colonoscopy: validation of a measurement tool.

BACKGROUND: Counting the number of procedures performed provides at best a crude measure of technical competence in colonoscopy. The aim of this study was to develop and validate a qualitative and a quantitative score for measuring technical competency in colonoscopy using videotape evaluation. METHODS: Eighteen endoscopists with varying levels of experience were prospectively videotaped during colonoscope insertion. The following were recorded simultaneously: a closed circuit television view showing instrument handling, the endoscopic luminal view, and a continuous display of the colonoscope configuration (magnetic endoscope imaging). Videotapes were reviewed blindly and in random order by 3 experts. Performance in 3 categories was evaluated: (1) manipulation of instrument controls (0-10), (2) manipulation of the insertion tube (0-6) and (3) depth of insertion (0-4). A global assessment of competence was given for each endoscopist. RESULTS: Comparing the total scores as assessed by the 3 blinded experts, for each individual endoscopist, there were significant differences. However, there was good interobserver agreement and correlation between the individual scores and global assessment ratings of competence (p < 0.0001). CONCLUSIONS: The video assessment tool described appears to measure technical competence at colonoscopy, although in its present form it lacks reliability. Refinement of the score may improve reliability and deserves further evaluation.