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  • Adherence to colorectal cancer screening measured as the proportion of time covered
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-02-23
    Caitlin C. Murphy, Bianca M. Sigel, Edward Yang, Celette Sugg Skinner, Ethan A. Halm, Samir Gupta, Joanne M. Sanders, Katharine McCallister, Amit G. Singal

    Background and Aims Colorectal cancer (CRC) screening can reduce CRC incidence and mortality, but measuring screening adherence over time is challenging. We examined adherence using a novel measure characterizing the proportion of time covered (PTC) by screening tests. Methods Eligible patients were age 50 to 60 years and followed at a large, safety-net healthcare system between January 2010 and September 2014. We estimated PTC as the number of days up-to-date with screening divided by number of days from cohort entry until study end, CRC diagnosis, or death. We estimated mean and median PTC and used least significant difference tests to assess differences in adherence by patient characteristics. Results Of 18,257 patients, most were non-Hispanic black (40.5%) or Hispanic (34.9%) and female (62.4%). Approximately 40% (n=7,559) were never screened during the study period; the remaining 10,698 patients completed 19,105 screening examinations (14,481 FITs, 4,393 colonoscopies, 94 sigmoidoscopies, and 137 barium enemas). Overall, mean PTC was 29.1% (95% CI, 28.6% - 29.5%). Among those who completed at least one screening test (n=10,698), mean PTC was 49.0% (95% CI, 48.5% - 49.5%). Most common reasons for non-adherence were lack of repeat FIT and no diagnostic colonoscopy after abnormal FIT. Mean PTC increased with number of primary care visits (0 visits: 21%, 1 visit: 29%, 2-3 visits: 35%, ≥4 visits: 37%, all p<0.05). Conclusions PTC provides a reliable estimate of screening adherence, capturing breakdowns in the CRC screening process amenable to intervention. Repeat FIT and diagnostic colonoscopy are important intervention targets that may increase adherence in underserved populations.

    更新日期:2018-02-23
  • Identification of volumetric laser endomicroscopy features of colon polyps with histologic correlation
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-02-23
    Arvind J. Trindade, Arvind Rishi, Robert Hirten, Sumant Inamdar, Divyesh V. Sejpal, Jean-Frederic Colombel

    Background and Aims There is limited data on the use of volumetric laser endomicroscopy (VLE) in imaging for colon polyps. Our aim was to identify VLE features of colon polyps. Methods A total of 45 patients were included. 43 underwent endoscopic mucosal resection of colorectal polyps 2 cm or greater. These polyps were then scanned with VLE immediately after resection. Two patients that underwent partial colonic resection served as controls. Results Forty-three polyps were included with review of matching histology: 3 intramucosal adenocarcinoma (IMCA), 5 tubular adenoma (TA)/tubulovillous adenoma (TVA) with high-grade dysplasia (HGD), 9 TVA with only low-grade dysplasia (LGD), 5 serrated adenoma (SA), and 21 TA with LGD. All TA and TVA were hyper-reflective compared with normal tissue. Effacement occurred in 82.4% (14/17) of the colonic polyps with advanced pathology (TVA with HGD/IMCA) compared with 11.6% (3/26) of non-advanced pathology (TA with LGD and SA) (P<0.0001). Forty-seven percent (8/17) of advanced pathology had greater than 5 glands on VLE as compared with none in the non-advanced pathology group (P=0.0001). An irregular surface mainly occurred in polyps with high-grade pathology (HGD/IMCA) versus tubular adenomas. Eight-eight percent of polyps with HGD/IMC had an irregular surface (7/8) versus 6% (2/35) of TA (P<0.0001). Conclusions In this ex-vivo clinicopathological study, we show that there are distinct VLE features of colon polyps that may help identify polyps or features of a higher-grade lesion. This may have implications for possible in-vivo application to aid in dysplasia or polyp detection.

    更新日期:2018-02-23
  • Secondary tumors of the gastrointestinal tract: origin, histology, and endoscopic findings
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-02-22
    Magdalena M. Gilg, Hans-Peter Gröchenig, Andrea Schlemmer, Andreas Eherer, Christoph Högenauer, Cord Langner

    Background and Aims The gastrointestinal tract (GIT) is rarely affected by secondary tumors. Patients often present at advanced stage, and prognosis is dismal. This study aimed to analyze clinical, endoscopic and pathological features of secondary tumors that had been diagnosed endoscopically. Methods We conducted a retrospective database analysis of 217 patients with secondary tumors of the GIT. Endoscopic findings and histological diagnoses were systematically re-evaluated. Results Malignant melanoma (n= 33, 15%), breast (n= 32, 15%) and pancreatic cancer (n=27, 12%) were the most common corresponding primaries. About one-third of secondary tumors was detected in the stomach (n=76, 35%), followed by small intestine (n=54, 25%) and rectum (n=53, 24%). Median time between diagnosis of primary and secondary tumors was 19 months (mean, 31, range 0-251) and this was particularly long for renal cell carcinoma and breast cancer (median 38 and 45 months, respectively). Direct invasion from extragastrointestinal malignancies was more common (56%) than vascular cancer spread (44%) and depended on both site of tumor involvement and corresponding primary. Lesions presented with various endoscopic patterns. In patients for whom a definitive diagnosis of cancer was known before the examination (n=168), a secondary tumor was included in differential diagnosis in only 48% of lesions. It is of note that the remaining cases were diagnosed endoscopically as primary tumor and rarely also as non-neoplastic change. Conclusions Secondary tumors may affect all parts of the GIT. Malignant melanoma and breast and pancreatic cancer represent the most common primaries. Biopsy diagnosis is crucial to avoid misclassification.

    更新日期:2018-02-22
  • Gastric mucosal devitalization is safe and effective in reducing body weight and visceral adiposity in a porcine model
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-02-22
    Vivek Kumbhari, Stefanie Lehmann, Nadine Schlichting, Marco Heinrich, Yvonne Kullnick, Ulf Retschlag, Markus Enderle, Arne Dietrich, Mouen A. Khashab, Anthony N. Kalloo, Andreas Oberbach

    Background and Aims The early improvement in metabolic profile after sleeve gastrectomy (SG) indicates that the significant benefits of metabolic surgery are gastric in origin. We have previously demonstrated that devitalization of the gastric mucosa (without a reduction in gastric volume) in metabolically disturbed obese rats results in an improvement of obesity and its associated comorbidities. The aims of this study were to assess the technical feasibility, efficacy and safety of gastric mucosal devitalization (GMD) in a large animal (porcine) model. Methods A 3-arm (GMD versus SG versus sham (SH)) prospective randomized controlled trial with an 8-week follow-up period. Primary endpoint was relative weight loss. Secondary endpoints were included absolute body weight, abdominal visceral adiposity, abdominal subcutaneous adiposity, organ lipid content and serum ghrelin. Results GMD resulted in a significant relative weight loss of 36% over SH at 8 weeks (p<0.05). There was no significant difference in relative weight loss between GMD versus SG at 4 weeks; however, SG resulted in a 29% superior relative weight loss at 8 weeks (p<0.05). With regard to visceral adiposity, there was a significant benefit of GMD over SH at 8 weeks. Despite differences in relative weight loss, there was no significant difference in visceral adiposity between SG versus GMD at 8 weeks. Significant improvements in GMD over SH were noted with regards to skeletal and heart muscle lipid content. GMD pigs at 8 weeks demonstrated regeneration of the gastric mucosa without ulceration or significant scarring. Despite mucosal regeneration, the abundance of serum ghrelin was significantly lower in the GMD cohort compared with the SG and SH cohorts. Conclusions GMD was technically feasible and resulted in relative weight loss and an improvement in visceral adiposity. The benefits noted were out of proportion to what would be expected with weight loss alone.

    更新日期:2018-02-22
  • Cryotherapy for persistent Barrett’s esophagus after radiofrequency ablation: a systematic review and meta-analysis
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-02-22
    Kavel Visrodia, Liam Zakko, Siddharth Singh, Cadman L. Leggett, Prasad G. Iyer, Kenneth K. Wang

    Background and Aims A small but significant proportion of patients with Barrett’s esophagus (BE) have persistent dysplasia or intestinal metaplasia (IM) after treatment with radiofrequency ablation (RFA). Cryotherapy is a cold-based ablative modality that is increasingly being used in this setting. We aimed to better understand the efficacy of second-line cryotherapy in BE patients with persistent dysplasia or IM after RFA by conducting a systematic review and meta-analysis. Methods We performed a systematic literature search of PUBMED, EMBASE, and Web of Sciences through September 1, 2017. Articles were included for meta-analysis based on the following inclusion criteria: ≥5 BE patients treated with RFA had persistent dysplasia or IM; they subsequently underwent ≥1 session of cryotherapy with follow-up endoscopy; the proportions of patients achieving complete eradication of dysplasia (CE-D) and/or IM (CE-IM) were reported. The main outcomes were pooled proportions of CE-D and CE-IM using a random effects model. Results Eleven studies comprising 148 BE patients treated with cryotherapy for persistent dysplasia or IM after RFA were included. The pooled proportion of CE-D was 76.0% (95% CI, 57.7-88.0) with substantial heterogeneity (I2=62%). The pooled proportion of CE-IM was 45.9% (95% CI, 32.0-60.5) with moderate heterogeneity (I2=57%). Multiple pre-planned subgroup analyses did not sufficiently explain the heterogeneity. Adverse effects were reported in 6.7% of patients. Conclusions Cryotherapy successfully achieves CE-D in three-quarters and CE-IM in half of BE patients who do not respond to initial RFA. Considering its favorable safety profile, cryotherapy may be a viable second-line option for this therapeutically challenging cohort of BE patients, but higher-quality studies validating this remain warranted.

    更新日期:2018-02-22
  • A randomized trial of single versus double high-level disinfection of duodenoscopes and linear echoendoscopes using standard automated reprocessing
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-02-21
    Rebecca L. Bartles, James E. Leggett, Shannan Hove, Catherine D. Kashork, Lian Wang, Margret Oethinger, Lynda Baxter, Jack J. Brandabur

    Background and Aims In a pilot study (8) we demonstrated that current guidelines for duodenoscope and linear echoendoscope (DLE) reprocessing using a single cycle of high-level disinfection (HLD) in an automated reprocessor may be inadequate. In August 2015, the FDA offered double-HLD as a possible response to address this concern. As a result, Providence Health & Services adopted double-HLD as standard procedure for DLE, but no rigorous clinical studies supported this practice. We undertook a quality improvement (QI) study to compare single-HLD versus double-HLD at 4 of our 34 hospitals. Methods HLD of DLE was randomized, separately in each facility, to either single-HLD or double-HLD on weekdays, with standard double-HLD on weekends or holidays. There was 99.7% compliance with the randomization scheme. Daily qualitative surveillance cultures of dried, post-HLD DLE were collected for 6 months (1 swab sample from elevator mechanism and 1 combined brush sample from suction and working channels for each encounter), and each sample was incubated for 48 hours. Positivity rates of any microbial growth and growth of high-concern pathogens (potentially pathogenic enteric flora) were compared between the two study arms. Results Altogether, 5850 surveillance culture specimens were obtained during 2925 encounters from the 45 DLEs in clinical use in the participating hospitals. Of these, 3052 (52.2%) were from endoscopes cleaned by double HLD. Double-HLD demonstrated no benefit over single-HLD as similar positivity rates were observed (all p-values > 0.05). The elevator mechanism was more frequently colonized than the biopsy channel (5.2% vs 2.9%, p<0.001). Among the 224 encounters with positive growth, 140 (62.5%) recovered microbes from only the elevator mechanism specimens, 73 (32.6%) recovered microbes from only the channel specimens, and 11 (4.9%) recovered microbes from both types of specimens. Double-HLD failed to improve contamination rates for either sample site at any of the 4 endoscopy facilities, although there were significant overall differences in contamination rates among the facilities (p<0.001), as observed in our previous study. Only 8 high-concern pathogens were recovered from 5 DLE scopes, all from the elevator mechanism. Persistent growth was observed on two duodenoscopes. One grew Enterococcus spp (not vancomycin-resistant enterococci) on 3 occasions, Eschericia coli was present on 2 of these occasions, one of which was a multi-drug resistant organism (MDRO). The other grew different enteric flora on 2 specimens. Conclusions Our prospectively randomized study, involving 4 separate endoscopy facilities and standard automated endoscope reprocessing, showed that double-HLD did not reduce culture positivity rates compared with single-HLD in facilities with an already low positive culture rate. Alternative risk mitigation strategies will be assessed in an ongoing effort to reduce endoscope contamination.

    更新日期:2018-02-22
  • Optimizing duodenoscope reprocessing: rigorous assessment of a culture and quarantine protocol
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-02-21
    Jennifer T. Higa, Jaehoon Choe, Deborah Tombs, Michael Gluck, Andrew S. Ross

    Background/Aims Iatrogenic infections related to duodenoscopes remain a top concern for medical centers where ERCP is performed. We assess the long-term results and the impact of key interventions in the optimization of a rigorous “culture and quarantine” program for duodenoscope reprocessing. Methods Review of a prospectively collected, quality assurance database of all duodenoscope cultures (N = 4307) obtained for the initial 3-year duration of culture and quarantine from 2014 to 2017 in a single U.S.-based, high volume endoscopy center. All duodenoscopes were subject to manual cleaning and automated reprocessing and drying, followed by sampling using a modified protocol developed by the Centers for Disease Control and Prevention. Duodenoscopes were cultured per-use. Results A total of 4,307 duodenoscope cultures were obtained during the study period. High-concern organisms were isolated from 33 of these cultures, resulting in a 0.697 % HLD defect rate. Statistically significant interventions included withdrawal of a high-frequency culture-positive duodenoscope (scope A) from clinical service in addition to implementation of new manufacturer-recommended cleaning protocols. Withdrawal of a second high-frequency culture-positive duodenoscope (scope B) and a mandatory device retrofit had no effect on the observed rate of positive duodenoscope cultures. Conclusions Withdrawal of duodenoscopes with high rate of culture positivity, and optimizing manual cleaning practices have contributed to an overall decline in the high level disinfection defect rate. A stringent culture and quarantine protocol allowed identification of the culprit endoscopes. There remains a much-needed role for an inexpensive and highly reliable method to check on the adequacy of reprocessing given the inherent complexity of these tasks.

    更新日期:2018-02-22
  • Impact of cleaning monitoring combined with channel purge storage on elimination of Escherichia coli and environmental bacteria from duodenoscopes
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-02-21
    Harminder Singh, Donald R. Duerksen, Gale Schultz, Carol Reidy, Pat DeGagne, Nancy Olson, Zoann Nugent, Kathryn A. Bernard, Michelle J. Alfa

    Background and Aims We aimed to at determine whether monitoring of duodenoscope cleaning by rapid adenosine-tri-phosphate (ATP) combined with channel-purge storage could eliminate high-concern microorganisms. Methods In a simulated-use study, suction channels from two duodenoscopes models and the unsealed elevator guidewire (EGW) channel from one of these two duodenoscopes (the other model has a sealed EGW) were perfused with ATS2015 containing approximately 8 Log10 CFU/mL of both Enterococcus faecalis and Escherichia coli. Pump-assisted cleaning was monitored using rapid ATP testing. Duodenoscopes exceeding 200 relative light units (RLUs) were re-cleaned. Clean duodenoscopes were processed through an Automated Endoscope Reprocessor and then stored in a channel-purge storage cabinet for 1 to 3 days. Cultures of EGW channel and instrument channel combined with the lever recess (IC-LR) were taken after storage. The impact of extended cleaning and alcohol flush were evaluated. Results E coli was reliably eliminated in IC-LR and EGW channels of 119 duodenoscope tests (59 with sealed EGW and 60 with non-sealed EGW). However, actionable levels of E faecalis and environmental bacteria persisted. Neither alcohol flush nor extended cleaning resulted in a reduction of actionable levels for these organisms. Identification of isolates indicated that residual organisms in duodenoscope channels were hardy Gram positive bacteria (often spore formers) that likely originated from environmental sources. Conclusions These data indicate that high-concern gram negatives but not E faecalis or environmental bacteria can be reliably eliminated following manufacturer’s instructions for reprocessing with ATP monitoring of cleaning and channel-purge storage conditions.

    更新日期:2018-02-21
  • The phenotypic heterogeneity of hereditary diffuse gastric cancer: the report of one family with early-onset disease
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-02-15
    Irene Gullo, Vitor Devezas, Manuela Baptista, Luzia Garrido, Sérgio Castedo, Rui Morais, Xiaogang Wen, Elisabete Rios, Jorge Pinheiro, Inȇs Pinto-Ribeiro, Rui M. Ferreira, John Preto, João Santos-Antunes, Margarida Marques, Miquel Campos, Filipe Almeida, Maria do Céu Espinheira, Jorge Amil Dias, Céu Figueiredo, Carla Oliveira, Eunice Trindade, Fátima Carneiro

    Background and Aims The time-course for the development of clinically significant hereditary diffuse gastric cancer (HDGC) is unpredictable. Little is known about the progression from pre-clinical, indolent lesions to widely invasive, aggressive phenotypes. Gastro-endoscopy often fails to detect early lesions and risk-reducing/prophylactic total gastrectomy (PTG) is the only curative approach. We present a HDGC family with early-onset disease, in which clinical and histological findings provided insight into the understanding of different HDGC phenotypes. Methods and Results The proband was diagnosed at the age of 18 years with widely invasive, metastatic DGC. CDH1 genetic testing identified a pathogenic, germline CDH1-mutation (c.1901C>T, p.Ala634Val). Thirty family members were tested and 15 CDH1 carriers were identified. Six of them had PTG, with negative preoperative work-up. The proband’s 14-year-old sister is the youngest patient, reported to date, to have PTG after negative preoperative biopsies. Intramucosal HDGC foci were detected in all PTG specimens (n=1-33). In contrast to the “indolent” phenotype of these foci, the aggressive DGC from the proband showed pleomorphic cells, absent E-cadherin expression, increased proliferation (Ki-67 index) and activation of oncogenic events (p53, pSrc and pStat3 overexpression). All family members had Helicobacter pylori gastritis. Cag-A-positive strains were detected in all specimens, except in the proband’s sister. Conclusions HDGC is a heterogeneous disease regarding clinical behavior, endoscopic findings, histopathologic features, and immunophenotypic/molecular profile. The presence of bizarre, pleomorphic cells in endoscopic biopsy specimens is suggestive of advanced disease and should prompt clinical intervention. The involvement of a full multidisciplinary team is essential for the management of these patients.

    更新日期:2018-02-15
  • Clinical outcomes and factors related with colonic perforations in patients receiving self-expandable metal stent insertion for malignant colorectal obstruction
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-02-13
    Yoo Jin Lee, Jin Young Yoon, Jae Jun Park, Soo Jung Park, Jie-Hyun Kim, Young Hoon Youn, Tae Il Kim, Hyojin Park, Won Ho Kim, Jae Hee Cheon

    Background and aims Although colonic perforation is a dreadful adverse event associated with stent placement, data on this topic are sparse. We aimed to investigate the clinical outcomes of colonic perforation and factors related with its occurrence in patients who receiving self-expanding metal stents (SEMSs) for malignant colorectal obstruction. Methods We retrospectively reviewed the data of 474 patients with malignant colorectal obstruction who received endoscopic SEMS insertion from April 2004 to May 2011 in the Severance and Gangnam Severance Hospital. Early perforation, defined as perforation occurring within 2 weeks, was assessed in bridge-to-surgery (n=164) and palliative stent placement patient groups (n=310). Delayed perforation was analyzed using data from the palliative stent placement group alone. Results The technical and clinical success rates were 90.5% and 81.0%, respectively. Early and delayed perforations occurred in 2.7% (13/474) and 2.7% (8/301) of the patients, respectively. Among 21 patients with perforation, 14 (66.7%) received emergency surgery and 5 (23.8%) died within 30 days after perforation. Regarding the perforation-related factors, age of ≥70 years (odd ratio [OR], 3.276; 95% confidence interval [CI], 1.041–10.309) and sigmoid colonic location (OR, 7.706; 95% CI, 1.681–35.317) were independently associated with occurrence of early perforation. Stent location in the flexure (hazard ratio [HR], 17.573; 95% CI, 2.004–154.093) and absence of peritoneal carcinomatosis (HR, 6.139; 95% CI, 1.150–32.776) were significantly associated with delayed perforation. Conclusions The perforation-related 30-day mortality rate was 23.8%. Older age and sigmoid colonic location were significantly associated with occurrence of early perforation, whereas flexure location and absence of peritoneal carcinomatosis were related with delayed perforation.

    更新日期:2018-02-14
  • Feasibility of EUS-guided Nd:YAG laser ablation of unresectable pancreatic adenocarcinoma
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-02-13
    Francesco Maria Di Matteo, Paola. Saccomandi, Margareth Martino, Monica Pandolfi, Margherita Pizzicannella, Valerio Balassone, Emiliano Schena, Claudio Marcello Pacella, Sergio Silvestri, Guido Costamagna

    Background and aims Endoscopic ultrasound (EUS) has become an interventional technique in which a needle may be used as a vehicle to deliver therapeutic agents. Laser ablation (LA) has been used to treat many primary and secondary neoplasms. This study aimed to assess the feasibility of EUS-guided LA for unresectable (UR) pancreatic cancer. Methods Patients with a stage IIb-III pancreatic cancer underwent EUS-guided LA. All patients were unresponsive to previous chemo-radiotherapy. The laser ablation was performed by using a 300-μm flexible fiber preloaded on a 22-gauge fine needle. A 1064-nm wavelength Nd:YAG laser light with different power settings of 2 W for 800 J, 1000 J and 1200 J, 3 W for 800 J, 1000 J and 1200 J and 4 W for 800 J, 1000 J and 1200 J was used. Each patient was treated with a single application of one of these settings. The application time of the power settings ranged from 200s to600s. Results Nine patients (median age 74.7, range 55-85 years) underwent Nd:Yag LA. The mean size of the focal lesion was 35.4 mm (range 21-45 mm). The ablation area demonstrated by 24 hours computed tomography (CT)-scan, ranged from 0.4 cm3 (for the lower power setting of 2 W/800 J) to a maximum of 6.4 cm3 (for 4 W/1000 J). The procedure was completed in all 9 patients without adverse events. Conclusion In our human experience EUS-guided LA was feasible and well tolerated in patients with UR pancreatic cancer.

    更新日期:2018-02-14
  • Scoping the scope: endoscopic evaluation of endoscope working channels with a new high-resolution inspection endoscope (with video)
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-02-06
    Monique T. Barakat, Mohit Girotra, Robert J. Huang, Subhas Banerjee

    Background Outbreaks of transmission of infection related to endoscopy despite reported adherence to reprocessing guidelines, warrant scrutiny of all potential contributing factors. Recent reports from ambulatory surgery centers indicated widespread significant occult damage within endoscope working channels, raising concerns regarding the potential detrimental impact of this damage on the adequacy of endoscope reprocessing. Methods We inspected working channels of all 68 endoscopes at our academic institution using a novel flexible inspection endoscope. Inspections were recorded and videos reviewed by three investigators to evaluate and rate channel damage/debris. Working channel rinsates were obtained from all endoscopes and ATP bioluminescence measured. Results Overall endoscope working channel damage was rated as minimal/mild and consistent with expected “wear and tear” (median 1.59 on our 5-point scale), with predominant findings including superficial scratches (98.5%), and scratches with adherent peel (76.5%). No channel perforations, stains or burns were detected. Extent of damage was not predicted by endoscope age. Minor punctate debris was common and a few small drops of fluid were noted in 42.6% endoscopes after reprocessing and drying. The presence of residual fluid predicted higher ATP bioluminescence values. Presence of visualized working channel damage or debris was not associated with elevated ATP bioluminescence values. Conclusions The flexible inspection endoscope enables high-resolution imaging of endoscope working channels and offers endoscopy units an additional modality for endoscope surveillance, potentially complementing bacterial cultures and ATP. Our study, conducted in a busy academic endoscopy unit, indicated predominately mild damage to endoscope working channels, which did not correlate with elevated ATP values.

    更新日期:2018-02-07
  • ERCP performed through previously placed duodenal stents: a multicenter retrospective study of outcomes and adverse events
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-02-06
    Judith Staub, Ali Siddiqui, Linda Jo Taylor, David Loren, Tom Kowalski, Douglas G. Adler

    Background and Aims ERCP (endoscopic retrograde cholangiopancreatography) performed through previously placed enteral stents is an uncommon procedure without a significant amount of supporting literature, and with a wide reported range of technical success. The purpose of this study was to evaluate and better define the technical feasibility and safety of performing ERCP through enteral stents in patients with combined malignant biliary and gastric outlet obstruction (GOO). Methods We conducted a multicenter, retrospective study on 71 patients with combined gastric outlet and biliary obstruction who underwent ERCP through a previously placed enteral stent at 2 tertiary care centers. Outcomes included, but were not limited to, technical success, clinical success, need for repeat ERCP, adverse events, and survival time. Results Overall technical success was achieved in 60 of 71 patients (85%), with technical success of 40 of 46 (87%) in Type I obstructions (GOO above the ampulla), 16/21 (76%) in Type II obstructions (GOO at the level of the ampulla) and 4 of 4 (100%) in Type III obstructions (GOO distal to the ampulla). In general, patients who achieved technical success also achieved clinical success. Adverse events occurred in 3 patients (3/71), because 2 patients had acute cholangitis and 1 patient a perforation. Average survival time after the procedure was 4.6 months overall. Conclusions ERCP performed through enteral stents is safe with a high technical and clinical success rate, but may be more technically challenging in the setting of type II obstructions. This procedure could be considered first line in the unique setting that a patient requires ERCP through a previously placed enteral stent for malignant gastric outlet and biliary obstruction.

    更新日期:2018-02-07
  • Impact of 2 generational improvements of colonoscopes on adenoma miss rates: results of a prospective randomized multicenter tandem study
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-01-31
    Mathieu Pioche, Angelique Denis, Hans-Dieter Allescher, Gianluca Andrisani, Guido Costamagna, Evelien Dekker, Paul Fockens, Christian Gerges, Stefan Groth, Jennis Kandler, Isabelle Lienhart, Horst Neuhaus, Lucio Petruzziello, Guido Schachschal, Kristien Tytgat, Jürgen Wallner, Vincens Weingart, Sandrine Touzet, Thierry Ponchon, Thomas Rösch

    Background and Aims Numerous randomized studies have shown that changing certain features of colonoscopes, usually incorporated when switching from one endoscope generation to the next, mostly do not increase adenoma yield. There is, however, indirect evidence that it may be necessary to skip one instrument generation (ie, changing from one generation to the next but one) to achieve this effect. Methods We compared the latest-generation colonoscopes from one company (Olympus Exera III, 190-C) with the next to last one (Olympus 160/5-C) in a prospective multicenter study randomized for the order of colonoscopes in a tandem fashion, involving 2 different examiners. Patients with increased risk for colorectal neoplasia undergoing colonoscopy (FOBT positive, personal/familial history of CRC/adenoma, rectal bleeding, recent change in bowel movements) were included. Primary outcome was the adenoma miss rate with 190 (190-C) in comparison to 160/5 colonoscopes (160/5-C). Results 856 patients (48.8%male, mean age 58.3 years) with personal (41%) or family (38%) history of colorectal neoplasia, rectal bleeding (19%) and other indications were included. Of the 429 patients in the 190-C first group, 16.6% (95% CI, 13.0 % - 20.1%) had at least one adenoma missed during the first procedure, as compared with 30.2% (95% CI, 25.9% - 34.6%) in the group with 160/5-C first (p<0.001). Similarly, adenoma detection rate during the first colonoscopy was 43.8% versus 36.5% (p=0.030) for 190-C versus 160/5160/5-C, respectively. Conclusions This randomized tandem trial showed lower adenoma miss rates and higher adenomas detection rates for the newer 190-colonoscopes compared with the 160/5-series. These results suggest that it takes multiple improvements such as those implemented over 2 instrument generations before an effect on adenoma (miss) rate can be observed.

    更新日期:2018-02-04
  • Life after Per-oral Endoscopic Myotomy (POEM): Long-term Outcomes of Quality of Life and Their Association with Eckardt Score
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-02-02
    Yaseen B. Perbtani, Lazarus K. Mramba, Dennis Yang, Jorge Suarez, Peter V. Draganov

    Background and Aims The clinical efficacy of POEM has been commonly established by the reduction in the Eckardt score (<3) after the procedure. However, achalasia can lead to significant impairment in the patient’s quality of life that may go beyond the 4 classical achalasia symptoms as measured by the Eckardt score. The aims of our study were (1) to evaluate the effect of POEM on short and long-term health-related quality of life (HRQOL) and to (2) assess the association between HRQOL and Eckardt scores. Methods Single-center prospective cohort study of consecutive POEMs during a 3-year period. Eckardt and HRQOL scores as measured by the short-form survey questionnaire (SF-36) were obtained at baseline, and at various intervals post-POEM. Comparison of the mean scores were described using univariate linear regression. The association between Eckardt scores and HRQOL were performed by using a linear mixed model analysis. Results POEM was performed in 143 consecutive patients (54% male; mean age 56.9 ± 17.9 years). At long-term follow-up (mean 16.4 months, range: 12-40), both the HRQOL baseline mental and physical component scores improved significantly from 61.5 ± 2.2 to 71.2 ± 3.6 (p < 0.021), and from 55.8 ± 2.2 to 63.6 ± 3.3 (p = < 0.034), respectively. Mixed model analysis showed a significant association between Eckardt and all HRQOL scores (p<0.001). Conclusions POEM improved all dimensions of HRQOL as measured by the SF-36 survey at both short- and long-term follow-up. A strong association was seen between Eckardt score and all HRQOL domains. Further studies using disease specific HRQOL instruments are warranted.

    更新日期:2018-02-02
  • Outcomes of endoscopic biliary drainage in pancreatic cancer patients with an indwelling gastroduodenal stent: a multicenter cohort study in west Japan
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-01-31
    Kentaro Yamao, Masayuki Kitano, Mamoru Takenaka, Kosuke Minaga, Toshiharu Sakurai, Tomohiro Watanabe, Takahisa Kayahara, Tomoe Yoshikawa, Yukitaka Yamashita, Masanori Asada, Yoshihiro Okabe, Keiji Hanada, Yasutaka Chiba, Masatoshi Kudo

    Background and Aims Gastroduodenal and biliary obstruction may occur synchronously or asynchronously in advanced pancreatic cancer, and endoscopic double stent placement may be required. EUS-guided biliary drainage (EUS-BD) is often performed after unsuccessful endoscopic transpapillary stent placement (ETS), and EUS-BD may be beneficial in double stent placement. This retrospective multicenter cohort study compared the outcomes of ETS and EUS-BD in patients with an indwelling gastroduodenal stent (GDS). Methods We recorded the clinical outcomes of patients at 5 tertiary medical centers who required biliary drainage after GDS placement between March 2009 and March 2014. Results Thirty-nine patients were included in this study. Patients’ mean age was 68.5 years; 23 (59.0%) were men. The GDS overlaid the papilla in 23 patients (59.0%). The overall technical success rate was significantly higher with EUS-BD (95.2%) than ETS (56.0%, P <0.01). Furthermore, the technical success rate was significantly higher with EUS-BD (93.3%) than ETS (22.2%, P <0.01) when the GDS overlaid the papilla. The overall clinical success rate of EUS-BD was also significantly higher than for ETS (90.5% versus 52.0%, respectively; P = 0.01) and there was no significant difference in the incidence of adverse events (ETS, 32.0% versus EUS-BD, 42.9%; P = 0.65). Conclusions Endoscopic double stent placement with EUS-BD is technically and clinically superior to ETS in patients with an indwelling GDS. EUS-BD should be considered the first-line treatment option in patients with an indwelling GDS that overlies the papilla. ETS remains a reasonable alternative when the papilla is not covered by the GDS.

    更新日期:2018-02-02
  • rIncremental yield of dysplasia detection in Barrett’s esophagus using volumetric laser endomicroscopy with and without laser marking compared with a standardized random biopsy protocol
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-02-02
    Mohammad Alshelleh, Sumant Inamdar, Matthew McKinley, Molly Stewart, Jeffrey S. Novak, Ronald E. Greenberg, Keith Sultan, Bethany Devito, Mary Cheung, Maurice A. Cerulli, Larry S. Miller, Divyesh V. Sejpal, Anil K. Vegesna, Arvind J. Trindade

    Background and Aims Volumetric laser endomicroscopy (VLE) is a new wide field advanced imaging technology for Barrett’s esophagus (BE). No data exist on incremental yield of dysplasia detection. Our aim is to report the incremental yield of dysplasia detection in BE using VLE. Methods This is a retrospective study from a prospectively maintained database from 2011-2017 comparing the dysplasia yield of 4 different surveillance strategies in an academic BE tertiary care referral center. The groups were (1) random biopsies (RB), (2) Seattle protocol random biopsies (SP), (3) VLE without laser marking (VLE) and (4) VLE with laser marking (VLEL). Results A total of 448 consecutive patients (79 RB, 95 SP, 168 VLE, and 106 VLEL) met inclusion criteria. After adjusting for visible lesions, the total dysplasia yield was 5.7%, 19.6%, 24.8%, and 33.7%, respectively. When compared with just the SP group, VLEL group had statistically higher rates of overall dysplasia yield (19.6 % vs 33.7%, p=0.03; OR 2.1, p=0.03). The RB and VLE groups did not have statistically significant differences in dysplasia detection compared with the SP group. Both VLEL and VLE groups have statistically significant differences in neoplasia (high-grade dysplasia and intramucosal cancer) detection compared with the SP group (14% vs 1%, p=0.001 and 11% vs 1%, p=0.003). Conclusion A surveillance strategy involving VLEL lead to statistically significant higher yield of dysplasia and neoplasia detection compared with a standard random biopsy protocol. These results support the use of VLEL for surveillance in BE in academic centers.

    更新日期:2018-02-02
  • Hot snare polypectomy with or without saline solution/epinephrine lift for the complete resection of small colorectal polyps
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-02-02
    Hyun-Soo Kim, Ho Yeon Jung, Hong Jun Park, Hee Man Kim, Jae Ho Seong, Yong Seok Kang, Mee Yon Cho, Min Heui Yu, Dae Ryong Kang

    Background /Aim: The criterion standard polypectomy technique for the complete removal of small colorectal polyps has not yet been established. This study aimed to compare the complete resection rate of hot snare polypectomy (HSP) with that of endoscopic mucosal resection (EMR) for small, sessile, or flat polyps. Methods Patients with 5–9-mm non-pedunculated colorectal polyps were prospectively randomized to the HSP or EMR group. The presence of residual polyps was assessed by performing histological assessment of 4-quadrant forceps biopsies taken from the edges of the polypectomy site. The primary outcome was the complete resection rate after HSP or EMR, whereas the secondary outcomes were the proportion of procedure-related adverse events and specimen-loss rate. Sample size was estimated using a superiority trial design. We assumed that the complete resection rate of the EMR group would be at least 8% higher than the HSP group. Results A total of 382 polyps in 269 patients were assessed and randomly assigned to each method using 4 × 4 block randomization. Among them, 353 polyps were finally analyzed based on pathological results. The mean polyp size was 6.3 ± 1.3 mm. The complete resection rate did not differ between the HSP and EMR groups (88.4% [152/172] vs 92.8% [168/181], respectively; P = 0.2). The intraprocedural bleeding, immediately after polypectomy, was significantly higher in the HSP group than in the EMR group (5.2% vs 0.6%, respectively; P = 0.009). However, clinically significant bleeding and tissue retrieval failure rates did not differ between the groups. In the multivariate logistic regression analysis, the sessile serrated adenoma/polyp (SSA/P) or hyperplastic polyp (HP) was almost three times (odds ratio [OR], 2.824; 95% confidence interval [CI], 1.03–7.75; P = 0.044) more likely to be incompletely resected compared to other conventional adenomatous polyps. Except for pathology, we found no significant independent predictors for incomplete resection. Conclusion EMR for small non-pedunculated colorectal polyps is not superior to HSP in terms of complete resection or safety. Both methods can be performed according to the endoscopist’s preference.

    更新日期:2018-02-02
  • Outcomes of Endoscopic Intervention for Overt Gastrointestinal Bleeding in Severe Thrombocytopenia
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-02-02
    Guilherme Piovezani Ramos, Moritz Binder, Paul Hampel, Manuel Bonfim Braga Neto, Dharma Sunjaya, Badr Al Bawardy, Barham K. Abu Dayyeh, Navtej S. Buttar, David H. Bruining, Nayantara Coelho-Prabhu, Mark V. Larson, Louis M. Wong Kee Song, Elizabeth Rajan

    Background and Aims Gastrointestinal bleeding (GIB) in the setting of thrombocytopenia raises concerns about endoscopic procedure risk. We aimed to assess the safety and outcomes of endoscopy for overt GIB in the setting of severe thrombocytopenia in liver cirrhosis (LC) and non-liver cirrhosis (NLC). Methods Retrospective study on inpatients who underwent endoscopy within 24-hours of presentation for overt GIB with a platelet count (PC) of 20 to <50 x 103/mL. Outcomes included diagnostic and therapeutic yields, procedural adverse events, packed red blood cell (pRBC) and platelet transfusions, recurrent bleeding rate, all-cause and GIB-related mortality. Results 144 patients were identified. Median PC was 41 x 103/mL and 61% had LC. The diagnostic yield was 68% (LC=61%, NLC=79%, p=0.04). Therapeutic yield was 60% (59% vs 60%, p=1.00). Initial hemostasis rate was 94% with one adverse event. The median number of pRBC and platelet transfusions decreased after intervention in the entire cohort. Recurrent bleeding rates were 22% at 1 month and 30% at 1 year, with no difference between groups. An elevated INR >2 was a predictor of recurrent bleeding. All-cause mortality was 19% at 1 month and 37% at 1 year, whereas GIB-associated mortality in our cohort was only 3% at 1 month and 4% at 1 year, with no significant difference between LC and NLC. Predictors of mortality were INR >2, aPTT >38s, hypotension, ICU admission, and pulmonary comorbidities. Conclusion In this study cohort, we observed that endoscopy for overt GIB in the setting of severe thrombocytopenia in both LC and NLC patients appears safe, has moderate diagnostic and therapeutic yields with high initial hemostasis rate, and is associated with a significant decrease in pRBC and platelet transfusions. Recurrent bleeding and all-cause mortality rates remain high.

    更新日期:2018-02-02
  • Magnetic anchor-guided endoscopic submucosal dissection for gastric lesions (with video)
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-01-17
    Ippei Matsuzaki, Masashi Hattori, Ken Hirose, Masaya Esaki, Masakatsu Yoshikawa, Takio Yokoi, Makoto Kobayashi, Ryoji Miyahara, Yoshiki Hirooka, Hidemi Goto

    Background and Aim The feasibility of magnetic anchor-guided endoscopic submucosal dissection (MAG-ESD) using a neodymium magnet for gastric lesions has not been clarified. The aim of study was to evaluate the feasibility of MAG-ESD using neodymium magnets while treating gastric lesions. Methods This prospective trial was conducted at the Yamashita Hospital. The MAG-ESD was performed for 50 gastric lesions using an insulated-tip knife. The magnetic anchor consisted of an internal neodymium magnet attached to a hemoclip with 3-0 silk. The external and internal magnets were made from the neodymium magnet. The feasibility of traction using MAG-ESD, en bloc resection rate, complete en bloc resection rate, time required for preparation and attaching the magnetic anchor, procedure time, rate of retrieval of the magnetic anchors and adverse events were evaluated. Results Fifty patients (median lesion size 20 mm; range 5-100 mm) were enrolled. MAG-ESDs were successfully performed for all 50 gastric lesions. Adequate counter traction was obtained using the external magnet. En bloc resections were achieved and complete en bloc resections confirmed in all cases without adverse events. Attaching the magnetic anchor required a median of 6 minutes (range 2-14 minutes). The median procedure time was 49 minutes (range 15-301 minutes), and the magnetic anchors could be retrieved in all cases. Conclusion This study clearly demonstrated the feasibility of this MAG-ESD in the stomach. We hope that this procedure will facilitate the resection of difficult lesions.

    更新日期:2018-01-17
  • The presence of small and diminutive proximal hyperplastic polyps is associated with higher rates of synchronous advanced neoplasia compared with patients without serrated lesions
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-01-11
    Hamoudah Thayer, Ma Karen, Esteban Marcus, Hayat Waqas, Mahon Brett, Jakate Shriram, Melson Joshua

    Background The association of proximal small and diminutive hyperplastic polyps (HPs) with synchronous neoplasia (AN) is not well defined. However, sessile serrated polyps, even when small, are known to portend synchronous neoplastic risk. Currently, when proximal small hyperplastic polyps are detected, the USMTF does not recommend a change in surveillance interval. We aimed to compare the rates of synchronous AN in a screening colonoscopy cohort of patients with small and then diminutive proximal HPs in comparison, first to a cohort absent any serrated or proximal hyperplastic polyps, and then in comparison with a cohort with small proximal sessile serrated polyps (SSPs). Methods Consecutive screening colonoscopies were recorded between 2005 and 2010 at an academic medical center. Patients were divided into three mutually exclusive groups. Group 1 consisted of patients with at least one HP that is proximal to the sigmoid colon, <1 cm in endoscopic size, and up to 3 total HPs in number. Group 2 included patients without any proximal HPs or SSPs. Group 3 consisted of patients with 1 to 2 SSPs, with at least one being proximal to the sigmoid colon, that were <1 cm in endoscopic size, and without dysplasia. Rates of synchronous AN in patients with small (<1 cm) and diminutive (<5mm) proximal HPs were compared with the other two groups. Results There were 482/2569 (18.8%) patients with a small proximal HP who met criteria for Group 1. The rate of synchronous AN in patients with a small proximal HP (61/482, 12.7%) was significantly greater compared with the average risk non-serrated cohort (Group 2; 133/1878, 7.1%, p<0.001). There was no significant difference in rate of synchronous AN when the small proximal HP group was subdivided by size (<5 mm, 51/404, 12.6% vs 6-9 mm, 10/78, 12.8%; p=1.00). The rate of synchronous AN in patients with diminutive (<5mm) proximal HPs (51/404, 12.6%) was not significantly different than the rate observed with proximal SSPs of similar size (17/113, 15.0%; p= 0.529). Conclusions Patients with small and diminutive proximal HPs tend to harbor higher rates of synchronous AN compared with those without any serrated lesions detected on screening colonoscopy. Surveillance outcomes for metachronous advanced neoplasia for patients with small proximal HPs deserves further study. The synchronous AN rate in patients with proximal diminutive HP is similar to that of proximal diminutive SSP, and could have implications in a resect and discard strategy.

    更新日期:2018-01-12
  • Dynamic contrast-enhanced EUS for quantification of tumor perfusion in colonic cancer: a prospective cohort study
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-01-09
    Marie Louise Malmstrøm, Adrian Săftoiu, Lene B. Riis, Hazem Hassan, Tobias W. Klausen, Mikkel S. Rahbek, Ismail Gögenur, Peter Vilmann

    Background and Aims Dynamic contrast enhanced endoscopic ultrasound (CE-EUS) for quantification of perfusion in colonic tumors has not previously been reported in the literature. The aim of the study was to investigate correlations between perfusion parameters and vessel density assessed by immunohistochemical staining with antibodies toward CD31 and CD105. Methods We conducted a prospective clinical study. In total, 28 patients with left-sided colonic adenocarcinoma, underwent CE-EUS and left-sided hemicolectomy within 2 weeks. CE-EUS recordings were analyzed in 2 regions of interest: the entire tumor and the most enhanced area. Immunohistochemical staining with CD31 and CD105 was performed on tumor tissue sections. The slides were manually scanned for highly vascularized areas and counting of vessels was performed in hotspots within the tumor and the invasive front. New vasculature was assessed by CD105. Associations between CE-EUS and CD31 and CD105 were investigated using Spearman correlation. Results We found significant p-values for the correlation between CD31 and rise time (rho = 0.603 [0.238;0.816]; p = 0.001) in tumor tissue and for the correlation between CD31 and rise time (rho = 0.50 [0.201;0.695]; p = 0.008) and fall time (rho = 0.52 [0.204;0.723]; p = 0.006) corresponding to the invasive front. We found no correlations between perfusion values evaluated by CE-EUS and CD105. Conclusions Our results show that there is a significant correlation for vessel density evaluated by CD31 and perfusion parameters evaluated by CE-EUS. This may be the first step toward using real-time CE-EUS for monitoring antiangiogenic therapies in colonic cancer.

    更新日期:2018-01-10
  • EUS elastography (strain ratio) and fractal-based quantitative analysis for the diagnosis of solid pancreatic lesions
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-01-09
    Silvia Carrara, Milena Di Leo, Fabio Grizzi, Loredana Correale, Rahal Daoud, Andrea Anderloni, Francesco Auriemma, Alessandro Fugazza, Paoletta Preatoni, Roberta Maselli, Cesare Hassan, Elena Finati, Benedetto Mangiavillano, Alessandro Repici

    Background and Aims EUS elastography is useful in characterizing solid pancreatic lesions (SPLs), and fractal analysis-based technology has been used to evaluate geometric complexity in oncology. The aim of this study was to evaluate EUS elastography (strain ratio) and fractal analysis for the characterization of SPLs. Methods Consecutive patients with SPLs were prospectively enrolled between December 2015 and February 2017. Elastographic evaluation included parenchymal strain ratio (pSR) and wall strain ratio (wSR) and was performed with the EU-ME2 processor (Olympus). Elastographic images were analyzed using a computer program to determine the three-dimensional histogram fractal dimension. A composite cytology/histology/clinical reference standard was used to assess sensitivity, specificity, positive (PPV) and negative predictive (NPV) values, and area under receiver-operating curve (AUC). Results Overall, 102 SPLs from 100 patients were enrolled. At final diagnosis, 69/102 (68%) were malignant and 33/102 benign. At elastography, both pSR and wSR appeared to be significantly higher in malignant as compared with benign SPLs (pSR: 24.5 vs 6.4; P<0.001; wSR: 56.6vs 15.3; P<0.001). When the best cut-off levels of pSR and wSR at 9.10 and 16.2, respectively, were used, sensitivity/specificity/PPV/NPV/AUC were 88.4%/78.8%/89.7%/76.9%/86.7%, and 91.3%/69.7%/86.5%/80%/85.7%, respectively. Fractal analysis showed a significant statistical difference (P=0.0087) between the mean surface fractal dimension of malignant (D = 2.66 ± 0.01) vs. NET (D = 2.73 ± 0.03) lesions, and a statistical difference for all 3 channels red, green and blue (P<0.0001). Conclusions EUS elastography with pSR and fractal-based analysis are useful in characterizing SPLs.

    更新日期:2018-01-10
  • Successful creation of pancreatic cancer organoids by means of EUS-guided fine-needle biopsy for personalized cancer treatment
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-01-09
    Herve Tiriac, Juan Carlos Bucobo, Demetrios Tzimas, Suman Grewel, Joseph F. Lacomb, Leahana M. Rowehl, Satish Nagula, Maoxin Wu, Joseph Kim, Aaron Sasson, Shivakumar Vignesh, Laura Martello, Maria Munoz-Sagastibelza, Jonathan Somma, David A. Tuveson, Ellen Li, Jonathan M. Buscaglia

    Background and Aims Pancreatic cancer organoids are tumor models of individualized human pancreatic ductal adenocarcinoma (PDA), created from surgical specimens and used for personalized treatment strategies. Unfortunately the vast majority of patients with PDA are not operative candidates. Creation of human PDA organoids at the time of initial tumor diagnosis is therefore critical. Our aim was to assess the feasibility of creating human PDA organoids by EUS fine-needle biopsy (EUS-FNB) in patients with PDA. Methods Prospective clinical trial in patients referred to evaluate a pancreatic mass (ClincalTrials.gov: NCT01698190). EUS-FNA was performed for initial on-site diagnosis. Two additional needle passes were performed with a 22-gauge FNB needle for organoid creation. Primary outcome was successful isolation of organoids within 2 weeks of EUS-FNB (P0), confirmed by organoid morphology and positive genotyping. Results Thirty-seven patients with 38 PDA tumors were enrolled. Successful isolation of organoids (P0) was achieved in 33 of 38 tumors, or 87%. Establishment of PDA organoid lines for ≥5 passages of growth (P5) was reached in 25 of 38 tumors, or 66%. In the single patient with successful P5 FNB-derived and P5 surgically derived organoids, there was identical matching of specimens. There were no serious adverse events. Two patients developed bleeding at the EUS-FNB puncture site requiring hemostasis clips. Conclusions Pancreatic cancer organoids can be successfully and rapidly created by means of EUS-FNB using a 22-gauge needle at the time of initial diagnosis. Successful organoid generation is essential for precision medicine in patients with pancreatic cancer, in whom the majority are not surgically resectable.

    更新日期:2018-01-09
  • Contrast harmonic EUS for the prediction of pancreatic neuroendocrine tumor aggressiveness (with videos)
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-01-08
    Maxime Palazzo, Bertrand Napoléon, Rodica Gincul, Mathieu Pioche, Bertrand Pujol, Christine Lefort, Fabien Fumex, Vincent Hautefeuille, Monique Fabre, Jérome Cros, Michèle Felce, Anne Couvelard, Alain Sauvanet, Philippe Lévy, Philippe Ruszniewski, Laurent Palazzo

    Background and aim Contrast-harmonic EUS (CH-EUS) has the ability to depict a tumor microvasculature. Decreased microvascular density has been identified as a factor associated with tumor aggressiveness. We aimed to study the accuracy of CH-EUS for the prediction of pancreatic neuroendocrine tumor (PNET) aggressiveness. Methods Between June 2009 and March 2015, all consecutive patients with histology-proven PNETs and CH-EUS examination were included. Nine endosonographers analyzed blindly all the videos. CH-EUS tumor aggressiveness was defined as a heterogeneous enhancement at early arterial phase. The final diagnosis of tumor aggressiveness was defined as follows: G3 tumors; morphological and/or histological findings of metastatic disease in G1/G2 tumors. Diagnostic values were calculated. Intratumoral microvascular density and fibrosis were assessed on pathological specimens. Results Eighty-one tumors were included of which 26 were aggressive (32.1%). In CH-EUS, 35 tumors (43.2%) had a heterogeneous enhancement. The overall accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of CH-EUS for the diagnosis of tumor aggressiveness were 86%, 96%, 82%, 71%, and 98%, respectively. The interobserver agreement between the 9 endosonographers was good (k=0.66). The intraobserver agreement was excellent for the junior (k=0.83) and the senior (k=0.82). Heterogeneous tumors at CH-EUS corresponded to fewer vascular and more fibrotic tumors (p<0,01). Conclusion CH-EUS is accurate in the prediction of PNET aggressiveness, and could be a decision-making element in their management.

    更新日期:2018-01-09
  • The impact of wire caliber on ERCP outcomes: a multicenter randomized controlled trial of 0.025-inch and 0.035-inch guidewires
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-01-06
    Milan S. Bassan, Praka Sundaralingam, Scott B. Fanning, James Lau, Jayaram Menon, Evan Ong, Rungsun Rerknimitr, Dong-Wan Seo, Eng Kiong Teo, Hsiu-Po Wang, D Nageshwar Reddy, Khean Lee Goh, Michael J. Bourke

    Background and aims Wire-guided biliary cannulation has been demonstrated to improve cannulation rates and reduce post-ERCP pancreatitis (PEP), but the impact of wire caliber has not been studied. This study compares successful cannulation rates and ERCP adverse events using a 0.025-inch and 0.035-inch guidewire. Methods A randomized, single blinded, prospective multi-center trial at 9 high volume tertiary referral centers in the Asia Pacific region was performed. Patients with an intact papilla and conventional anatomy who did not have head of pancreas or ampullary malignancy undergoing ERCP were recruited. ERCP was performed using a standardized cannulation algorithm and patients were randomized to either a 0.025-inch or 0.035-inch guidewire. The primary outcomes of the study were successful wire guided cannulation and incidence of PEP. Overall successful cannulation and ERCP adverse events were also studied. Results Seven hundred ten patients were enrolled in the study. Primary wire-guided biliary cannulation rate was similar in 0.025-inch and 0.035-inch wire groups (80.7% vs 80.3% P = 0.9). The rate of post ERCP pancreatitis between the 0.025-inch and the 0.035-inch wire groups did not differ significantly (7.8 % vs 9.3%, P=0.5). No differences were noted in secondary outcomes. Conclusions Similar rates of successful cannulation and PEP using 0.025-inch or 0.035-inch guidewires were demonstrated.

    更新日期:2018-01-07
  • Combination of Albumin-Bilrubin Grade and Platelet to Predict Compensated Patient with Hepatocellular Carcinoma Who Do Not Require Endoscopic Screening for Esophageal Varices
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-01-06
    Ping-Hsien Chen, Wei-Yao Hsieh, Chien-Wei Su, Ming-Chih Hou, Yen-Po Wang, I-Fang Hsin, Tsung-Chieh Yang, Wei-Chih Liao, Han-Chieh Lin, Fa-Yauh Lee, Jaw-Ching Wu

    Background s & Aims: There is no consensus for screening high-risk esophageal varices (HRV) in patients with hepatocellular carcinoma (HCC). Here, we aimed to investigate the prevalence and risk factors of HRV in HCC patients and to assess the combination of albumin-bilirubin grade and platelet count (ALBI-PLT score) for predicting compensated patients who do not need unnecessary endoscopic screening for HRV. Methods The ALBI-PLT score was calculated by adding ALBI grade and point of platelet count (1 point if platelet count >150,000 /mm3 and 2 points if ≦150,000 /mm3). The predicting value of ALBI-PLT score for HRV was analyzed in 887 compensated patients enrolled from October 2007 to April 2014 (study cohort). This was validated in 215 compensated patients from May 2014 to December 2015 (validation cohort). Results In the study cohort, the rates of HRV were 2.9% and 21.1% in compensated HCC patients with an ALBI-PLT score of 2 and >2, respectively. The negative predictive values of the ALBI-PLT score for predicting HRV were 97.1% and 98.1% in the study and validation cohorts, respectively. For compensated patients who did not receive endoscopic screening at the time of HCC diagnosis, the 5-year cumulative variceal hemorrhage rate was lower in patients with an ALBI-PLT score of 2 than those >2 (1.7% vs 9.1%, p=0.007). Conclusion In HCC patients with compensated liver function, an ALBI-PLT score of 2 predicted a very low risk of HRV and variceal hemorrhage; therefore, endoscopic screening for esophageal varices was not recommended for these patients.

    更新日期:2018-01-06
  • Technical feasibility, diagnostic yield, and safety of micro forceps biopsies during EUS evaluation of pancreatic cystic lesions (with video)
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-01-06
    Chetan Mittal, Joshua C. Obuch, Hazem Hammad, Steven A. Edmundowicz, Sachin Wani, Raj J. Shah, Brian C. Brauer, Augustin R. Attwell, Jeffrey B. Kaplan, Mihir S. Wagh

    Background and Aims Through-the-needle micro forceps are a recent addition to the EUS armamentarium for evaluation of pancreatic cystic lesions (PCLs). The main aim of this study was to assess the technical feasibility, diagnostic yield and safety of EUS-guided micro forceps biopsy for PCLs. Methods Our electronic endoscopy database was queried to identify patients who underwent EUS-FNA of PCLs and micro forceps biopsies, during the same procedure. The wall of the cyst was biopsied with the micro forceps through the 19-gauge needle and cyst fluid was collected for cytology, and CEA levels. Adverse events were recorded per published ASGE criteria. Results Twenty-seven patients underwent EUS-FNA and micro forceps biopsy of PCLs from February 2016 to July 2017. Fourteen cysts were located in the pancreatic head/uncinate and 13 in the body/tail region. Micro forceps biopsies (MFB) were technically successful in all cases and provided a pathologic diagnosis in 24 of 27 cases (yield 88.9%). MFB diagnosed mucinous cyst (MC) in 9 (33.3%), serous cystadenoma (SCA) in 4 (14.8%), neuroendocrine tumor (NET) in 1 patient (3.7%), and benign/inflammatory cysts in 10 patients (37.1%). In 7 patients (26%), MFB results drastically changed the diagnosis, providing diagnoses otherwise not suggested by cytology or cyst fluid CEA. However, cytology provided a diagnosis of mucinous cyst in 4 cases (14.8%) not detected by MFB. No adverse events were noted. Conclusion Micro forceps biopsies were associated with high technical success and excellent safety profile, and may be a useful adjunctive tool, complement existing EUS-FNA sampling protocols for PCLs.

    更新日期:2018-01-06
  • Temporal trends in postcolonoscopy colorectal cancer rates in screen-eligible persons: a population-based study
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-01-06
    Sanjay K. Murthy, Eric I. Benchimol, Jill Tinmouth, Paul D. James, Robin Ducharme, Alaa Rostom, Catherine Dubé

    Background and Aims Colorectal cancers (CRCs) diagnosed between 6 and 36 months after colonoscopy, termed postcolonoscopy CRCs (PCCRCs), arise primarily due to missed or inadequately treated neoplasms during colonoscopy. Quality indicators and technological advances have been introduced to colonoscopy practice that should have reduced the PCCRC rate over time. We assessed temporal trends in the population rate of PCCRC as a measure of changing colonoscopy quality. Methods We conducted a population-based retrospective cohort study of 50- to 74-year-old people without major risk factors for CRC who underwent complete colonoscopy in Ontario, Canada between 1996 and 2010. We defined the PCCRC rate as the proportion of people diagnosed with CRC within 36 months of colonoscopy that had PCCRC. We compared age- and sex-adjusted rates of PCCRC over time based on three periods (1996–2001, 2001–2006 and 2006–2010) and assessed the independent association between time period and PCCRC risk through multivariable regression, with respect to all PCCRC, proximal PCCRC and distal PCCRC. Results There was a marked increase in colonoscopy volumes over the study period, particularly in younger age groups and non-hospital settings. Among 1,093,658 eligible people, the PCCRC rate remained stable at approximately 8% over the 15-year study period. The adjusted odds of PCCRC, distal PCCRC and proximal PCCRC, comparing the 2006 to 2010 to the 1996 to 2001 periods, were 1.14 (95% CI, 1.0 – 1.31), 1.11 (95% CI, 0.91 – 1.34) and 1.14 (95% CI, 0.94 - 1.38), respectively. Temporal trends in PCCRC risk did not differ by endoscopist specialty or institutional setting after covariate adjustment. Conclusions The PCCRC rate in Ontario has remained consistently high over time. Widespread initiatives are needed to improve colonoscopy quality.

    更新日期:2018-01-06
  • Clinical outcome of endoscopic mucosal resection of sporadic, nonampullary duodenal adenoma: a 10-year retrospective
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-01-06
    Yutaka Tomizawa, Gregory G. Ginsberg

    Background and Aims Sporadic non-ampullary duodenal adenomas (SNADAs), although uncommon, pose clinical challenges. Because SNADAs have malignant potential, endoscopic or surgical resection is generally recommended. Endoscopic mucosal resection (EMR) is increasingly used for resection of SNADAs, but large-scale data on natural history after EMR are scarce. In this study, we aimed to evaluate the clinical outcome of EMR for SNADAs and the natural history after EMR from a large single-operator experience with dedicated follow-up. Methods We performed a retrospective review of patients with SNADAs who were referred for endoscopic therapy from May 2007 to May 2016. Patient demographics, lesion characteristics, and procedural technical data were collected. The outcomes studied were complete endoscopic resection, major adverse events and recurrence. Results One hundred sixty-two patients were referred for endotherapy and 142 (88%) (median age 67 years [IQR 57-73]; 42% male) underwent a total of 166 EMRs using submucosal injection and thermal snare resection technique. Per-patient analysis, the median size of SNADAs was 20 mm (IQR 15-30) in diameter. Complete mucosal resection was achieved in 130 of 142 patients (92%). Local or residual recurrences were observed in 23% of patients (median time until recurrence 277 days [IQR 196-591]) and were treated endoscopically. No metachronous recurrences were found within median follow-up of 363 days. Per-procedure analysis, en bloc resection was achieved in 88 (53%). EMR related bleeding occurred in 18 (11%) of EMRs, and all the cases were successfully managed with supportive and/or endoscopic measures. No perforation occurred. Increasing size of adenoma was associated with recurrence (p<0.001). No association of recurrence was noted with endoscopic or histological features. Increasing size of resected specimen (p<0.001) was associated with increased risk of bleeding. Conclusions EMR of most SNADAs can be performed safely and effectively. Increasing size of adenoma was associated with recurrence and post-EMR bleeding. No association of recurrence was noted with endoscopic or histological features. Focal recurrence can be managed with additional endoscopic therapy. Metachronous lesions do not occur. The findings inform directed management and surveillance.

    更新日期:2018-01-06
  • Spiral enteroscopy-assisted ERCP in bariatric length Roux-en-Y anatomy: a large single-center series and review of the literature (with video)
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-01-06
    Mohammad F. Ali, Rani Modayil, Krishna C. Gurram, Collin Brathwaite, David Friedel, Stavros Stavropoulos

    Background Deep enteroscopy-assisted ERCP (DEA-ERCP) in post-bariatric Roux-en-Y (RY) anatomy is challenging. Laparoscopy-assisted ERCP (LA-ERCP) or EUS-directed transgastric ERCP (EDGE) are technically easier and faster, but are more invasive and morbid procedures. Therefore, we have used DEA-ERCP as our first-line approach, reserving EDGE and LA-ERCP for cases in which adjunctive techniques that cannot be performed through an enteroscope are required (eg, EUS-FNA, SO manometry), or DEA-ERCP failures. The two main methods for DEA-ERCP are balloon- and spirus-assisted. Current literature on spiral enteroscopy ERCP (SE-ERCP) in bariatric RY anatomy is scant with low reported success rates. Our center has nearly exclusively used SE-ERCP for bariatric patients. We report herein one of the largest such series to date. Methods This is a retrospective cohort study of consecutive patients with bariatric length RY anatomy who had SE-ERCP from December 2009 to October 2016 at a tertiary care center, by one operator (S.N.S.). Primary outcomes included success at reaching the papilla, cannulation success, success of desired therapeutic intervention, and overall SE-ERCP success. Results 35 SE-ERCPs were performed (28 in bariatric RYGB and 7 other “long-limb- RY” surgical reconstructions). The papilla was reached in 86% (30/35) of the cases. Cannulation success in patients in whom deep cannulation was indicated (28/30) was 100% (28/28 cases, including the 24 cases with native papilla). Therapeutic ERCP success was 100% (28/28). Overall SE-ERCP success was 86% (30/35). Median LOS was 3 days. Median procedure time was 189 minutes. Reasons for SE-ERCP failures included RY anastomosis stricture, adhesions (2), long Roux limb, and redundant small bowel. Two of these patients underwent interventional radiology guided percutaneous biliary drainage, two patients had laparoscopy assisted ERCP, and one patient had EUS guided antegrade cholangioscopy with sphincteroplasty and stone clearance. There were no adverse events (AEs). Conclusion With sufficient allotted time (median procedure time ∼3 hours) and high operator experience (a single-operator volume that exceeds that of other published series), SE-ERCP is safe and effective in bariatric, long-limb RY patients with overall success rate of 86%, which is higher than previously reported.

    更新日期:2018-01-06
  • Pancreatic cancer screening in high-risk individuals with germline genetic mutations
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-01-05
    Tomas DaVee, Emmanuel Coronel, Charilaos Papafragkakis, Sayam Thaiudom, Gandhi Lanke, Raja C. Chakinala, Graciela M. Nogueras González, Manoop S. Bhutani, William A. Ross, Brian R. Weston, Jeffrey H. Lee

    Background and Aims Pancreas cancer (PC) is a deadly disease, which is most commonly diagnosed at an incurable stage. Different high-risk genetic variants and cancer syndromes increase the lifetime risk of developing PC. This study aims to assess the yield of initial PC screening in patients with high-risk germline mutations. Methods Asymptomatic adults underwent PC screening by EUS, MRI or CT during a 10-year period, and were retrospectively identified. High-risk individuals were defined as carrying germline mutations in BRCA1, BRCA2, p53 (Li–Fraumeni), STK11 (Peutz–Jeghers), MSH2 (Lynch), ATM (ataxia-telangiectasia), or APC (familial adenomatous polyposis). Patients without germline mutations were excluded. Results In total, 86 patients met criteria. The median age was 48.5 years (interquartile range 40-58), 79.1% (68) were female, 43.0% (37) had a family history of PC. The genetic mutations were: BRCA2 (50, 58.1%), BRCA1 (14, 16.3%), p53 (12, 14.0%), STK11 (5, 5.8%), MSH2 (3, 3.5%), ATM (1, 1.2%), and APC (1, 1.2%). Screening detected a pancreatic abnormality (PA) in 26.7% (23/86), including: cysts (11, 47.8%), hyperechoic strands and foci (10, 43.5%), and mild pancreatic duct dilation (2, 8.7%). Patients older than 60 years were more likely to have a PA detected (p=0.043). EUS detected more PAs than MRI or CT. No cases of PC were diagnosed by screening, or during follow-up (median 29.8 months; IQR, 21.7-43.5). Conclusions Unless indicated otherwise by family or personal history, PC screening under the age of 50 is low-yield. Linear EUS may be the preferred modality for initial pancreatic cancer screening.

    更新日期:2018-01-06
  • Effectiveness of cap-assisted device in the endoscopic removal of food bolus obstruction from the esophagus
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-01-05
    Marie Ooi, Edward John Young, Nam Q. Nguyen

    Background and Aim The use of a transparent cap has been found to be effective in retrieval of esophageal foreign body. However, data on the use of a cap in food bolus obstruction (FBO) are limited. This study aims to assess the effectiveness of a cap-assisted technique compared with conventional techniques in removal of FBO. Methods All patients who underwent an endoscopy for boneless FBO between 2011-2016 were prospectively recruited. The measured outcomes were procedure time, success rate of food bolus (FB) extraction, rate of en bloc removal, procedure-related adverse events and length of hospital stay (LOS) between the 2 groups. Results Of the 315 patients who had an endoscopy for FBO, 48 (15.2%) had spontaneous passage of FB and 267 (84.8%) had impacted FB. 68 (25%) patients had the “push” maneuver and 199 (75%) patients had the “pull” maneuver to remove FB. Of those who had the “pull” maneuver, 93 used a cap and 106 used conventional device(s). The use of a cap was associated with a shorter procedural time (34.3 ± 8.0 minutes versus 43.3 ± 22.6 minutes, P=0.003), a higher rate of en bloc removal (87.3% versus 22.8%, P<0.001), a lower rate of adverse events (0/93 versus 7/106, P=0.01) and a shorter LOS (1.0 ± 0.6 days versus 1.6 ± 1.4 days (P=0.0017). Conclusion Cap-assisted technique has been found to be effective and safe in removal of esophageal FBO. This technique was associated with a shorter procedural time and a reduced LOS compared with conventional techniques. However, these findings require further validation in a randomized control study.

    更新日期:2018-01-06
  • Endoscopic mucosal resection of laterally spreading lesions around or involving the appendiceal orifice: technique, risk factors for failure, and outcomes of a tertiary referral cohort (with video)
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-01-05
    David J. Tate, Lobke Desomer, Halim Awadie, Kathleen Goodrick, Luke Hourigan, Rajvinder Singh, Stephen J. Williams, Michael J. Bourke

    Background and Aims Endoscopic mucosal resection (EMR) of peri-appendiceal sessile laterally spreading lesions (PA-LSLs) is technically demanding due to poor endoscopic access to the appendiceal lumen and the thin colonic wall at the base of the cecum. We aimed to assess the feasibility and safety of EMR for PA-LSLs. Methods Consecutive LSLs ≥20 mm and PA-LSLs ≥10 mm detected at 3 academic endoscopy centers from September 2008 until January 2017 were eligible. Prospective patient, procedural, and lesion data were collected. PA-LSLs were compared with LSLs in other colonic locations. Results Thirty-eight PA-LSLs were compared with 1721 LSLs. Referral for surgery without an attempt at EMR was more likely with PA-LSLs (28.9% vs 5.1%, P < .001) and those that involved a greater percentage of the appendiceal orifice (AO) were less likely to be attempted (P = .038). The majority (10/11) of PA-LSLs were not attempted due to deep extension into the appendiceal lumen; 2 of 11 of these surgical specimens contained invasive cancer. Once attempted, complete clearance of visible adenoma (92.6%[PA-LSL] versus 97.6%[LSL], p=.14), adverse events, and rates of adenoma recurrence did not vary significantly between PA-LSLs and LSLs. Seven of 7 patients with prior appendicectomy achieved complete adenoma clearance. There were no cases of post-EMR appendicitis. Twenty of 22 (91%) PA-LSLs eligible for surveillance avoided surgery to longest follow-up. Conclusions EMR is a safe, effective and durable treatment for PA-LSLs when specific criteria are fulfilled. If the distal margin of the PA-LSL within the appendiceal orifice cannot be visualized or more than 50% of the circumference of the orifice is involved, surgery should be considered. Clinicaltrials.gov (NTC01368289).

    更新日期:2018-01-06
  • Comparison of the diagnostic performance between magnifying chromoendoscopy and magnifying narrow-band imaging for superficial colorectal neoplasm: an online survey
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-01-05
    Taku Sakamoto, Takeshi Nakajima, Takahisa Matsuda, Yoshitaka Murakami, Hideki Ishikawa, Kenshi Yao, Yutaka Saito

    Background and Aims Magnifying narrow-band imaging (mag-NBI) and magnifying chromoendoscopy using crystal violet staining for pit pattern analysis (pit pattern) is highly accurate for invasion depth diagnosis for superficial colorectal neoplasm. However, NBI and pit pattern have not been compared. Methods We conducted an online survey of endoscopists interested in image-enhanced endoscopy. Still images using white light, mag-NBI, and pit pattern were collected from lesions diagnosed at the National Cancer Center Hospital, Tokyo, Japan (NCCH). Sixty endoscopists from outside NCCH who typically use magnifying endoscopy were recruited for this survey. We assessed the diagnostic accuracy, using receiver operating characteristic (ROC) analysis based on a calculation of the area under the ROC curve. Results One hundred early colorectal neoplasms were selected for this survey. Histopathology revealed that, although 67 of the lesions had a high-grade dysplasia or carcinoma with superficial submucosal (SM-s) invasion, the 33 other lesions had a carcinoma with deep submucosal invasion (SM-d). Comparing the area under the ROC curve from mag-NBI with that of pit pattern, the latter showed significantly higher diagnostic accuracy for depth invasion (0.83 [95% CI, 0.81-0.85] for mag-NBI, 0.88 [95% CI, 0.85-0.89] for pit pattern, p=0.013). Conclusions Pit pattern should be the first choice for invasion depth diagnosis as the most reliable modality, instead of mag-NBI.

    更新日期:2018-01-06
  • Obtaining Adequate Lamina Propria for Subepithelial Fibrosis Evaluation in Pediatric Eosinophilic Esophagitis
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-01-05
    Jason Wang, Jason Y. Park, Rong Huang, Rhonda F. Souza, Stuart J. Spechler, Edaire Cheng

    Background & Aims Subepithelial fibrosis in eosinophilic esophagitis (EoE) can be detected only in esophageal biopsies with adequate amounts of lamina propria (LP). We investigated how often pediatric esophageal biopsies contain adequate LP, and whether esophageal eosinophilia influences the acquisition rates. Methods We evaluated 284 esophageal biopsy specimens from 39 EoE patients, and 87 biopsy specimens from 32 patients without esophageal eosinophilia or other esophageal abnormalities for the presence of adequate LP and fibrosis. Results On a per-biopsy basis, there was no significant difference in the rate of procuring adequate amounts of LP between EoE patients and patients without esophageal eosinophilia (43% vs 31%, p=0.14). The majority of EoE patients (85%) had fibrosis. Fibrosis in EoE patients was patchy, and more likely to be detected in the middle or distal esophagus (OR 19.93; 95% CI, 4.12-91.52). Among patients with fibrosis, the probability of its detection reached >95% with 7 middle-distal esophageal biopsies. Most children with newly diagnosed EoE already had subepithelial fibrosis despite exhibiting only inflammatory endoscopic features. Conclusions Most individual esophageal biopsies in children are inadequate for assessing subepithelial fibrosis, and the rates of procuring adequate LP per biopsy are similar in patients with and without EoE. To reliably detect fibrosis in EoE patients, at least 7 biopsy specimens should be taken from middle-distal esophagus. The finding of fibrosis in children with newly diagnosed EoE and only inflammatory endoscopic features suggests that fibrosis can occur early in this disease.

    更新日期:2018-01-06
  • Assessment of Peri-Polyp Biopsies of Flat Mucosa in Patients with Inflammatory Bowel Disease
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-01-04
    Noa Krugliak Cleveland, Dezheng Huo, Farah Sadiq, M. Anthony Sofia, Julia Marks, Russell D. Cohen, Stephen B. Hanauer, Jerrold Turner, John Hart, David T. Rubin

    Background When colon polyps are removed in the setting of inflammatory bowel disease (IBD) involving the large intestine, biopsies of the flat mucosa surrounding such polyps have been recommended, but there are no data to support this practice. Methods We reviewed endoscopic and pathologic findings in IBD patients who had dysplastic polyps removed as well as biopsies of the adjacent flat mucosa. We assessed risk for subsequent neoplasia based on the presence or absence of dysplasia in the peri-polyp flat mucosa, and based on number and grade of index polypoid lesions. Kaplan-Meier survival analysis was performed. Results Fifty-six IBD patients (68% UC) underwent 102 colonoscopies, in which 129 dysplastic polyps were resected. 503 biopsies of the surrounding flat mucosa were performed (mean 3.9 biopsies/polyp), of which 16 (3.2%) were dysplastic. Thirty-four patients (21 UC) had follow-up in median 1.7 years (range 0.02-15 years), and 147 colonoscopies. The presence of dysplasia in peri-polyp biopsies during index colonoscopy was not associated with risk of developing HGD or cancer (Pr Chi2=0.19). The size and number of dysplastic polyps were not predictive of neoplastic outcomes, but the probability of developing subsequent advanced neoplasia for polypoid LGD was 18%, 29%, and 40% by 1, 3, and 5 years, respectively, and for polypoid HGD was 50%, 60%, and 70% by 1, 3, and 5 years, respectively (HR=7.0, standard error 4.8). Conclusions In patients with IBD-associated colitis, biopsies of the mucosa adjacent to discrete dysplastic polypoid lesions are low yield and do not predict findings in follow-up examinations. However, the grade of dysplasia of the polyp itself is predictive of subsequent advanced neoplasia.

    更新日期:2018-01-05
  • Predictors of clinical outcome of colonic stents in patients with malignant large-bowel obstruction due to extracolonic malignancy
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-01-04
    Shahdabul Faraz, Suhail B. Salem, Mark Schattner, Robin Mendelsohn, Arnold Markowitz, Emmy Ludwig, Junting Zheng, Hans Gerdes, Pari Shah

    Background and Aims Colonic stent placement in patients with large-bowel obstruction (LBO) secondary to extra colonic malignancy (ECM) has been evaluated in small series with heterogeneous results. Our aim is to better characterize the technical and clinical success of colonic stent placement and to identify factors that affect this success in ECM patients. Methods All patients at a single high-volume center who presented for colonic stent placement for LBO due to ECM between 2001 and 2012 were retrospectively identified. The outcomes of interest were technical success, clinical success, stent occlusion rate and overall survival. Results A total of 187 patients were identified. Mean age was 61.9 years (range 23-89) and 150 (80.2%) were female. The most common malignancy type and location was urogynecologic (n=104) and sigmoid colon (n=128), respectively. Overall, 142 patients (75.9%) achieved technical success and 102 patients (54.5%) achieved clinical success. Radiographic presence of peritoneal carcinomatosis (p<0.001) and multifocal disease (p<0.001) were associated with both decreased technical and clinical success. Procedure-related adverse events were seen in 12 patients (6.4%). In patients with clinical success, the incidence of stent occlusion at 3 months was 14.7% (95% CI, 7.8%-21.6%) and was higher in patients with prior radiation therapy (p=0.011). The median overall survival for all patients from time of attempted stent placement was 3.3 months (95% CI, 3.0-4.1 months). Conclusion This study represents the largest retrospective series of colonic stent placement for LBO in ECM patients in the literature. Our technical success rate of 75.9%, clinical success rate of 54.5% and 3-month stent occlusion rate of 14.7% suggest that stent placement is a viable palliative option for patients with advanced disease due to ECM. Patients with peritoneal carcinomatosis and multifocal disease have reduced technical and clinical success. However, these factors should not dissuade an attempt at stent placement, if risk-benefit analysis is favorable.

    更新日期:2018-01-05
  • Randomized Trial Comparing the Franseen and Fork-tip needles for EUS-guided fine-needle biopsy of solid pancreatic mass lesions
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2018-01-03
    Ji Young Bang, Shantel Hebert-Magee, Udayakumar Navaneethan, Muhammad K. Hasan, Robert Hawes, Shyam Varadarajulu

    Background and Aims Recently, 3-plane symmetric needle with Franseen geometry and Fork-tip biopsy needle have been developed for histological tissue procurement. We compared 22-gauge Franseen and 22-gauge Fork-tip needles in patients undergoing EUS-guided sampling of pancreatic masses. Methods Fifty patients underwent sampling using both 22-gauge Franseen and 22-gauge Fork-tip needles, with randomization of needle order. Two dedicated passes were performed using both needles for cell block. Subsequent passes were performed for rapid onsite evaluation (ROSE) using both needles alternately until diagnosis was established. Main outcome was to evaluate for histological core tissue by comparing area of total tissue, tumor, desmoplastic fibrosis and rate of retained tissue architecture between cohorts. Other outcomes were rates of diagnostic cell block and diagnostic adequacy at ROSE. Results Final diagnosis was pancreatic cancer in 44, neuroendocrine tumor in 2, lymphoma in 1 and chronic pancreatitis in 3 patients. There was no significant difference in area of total tissue (median 6.1 [IQR 3.5-10.5] vs 8.2 mm2 [IQR 4.0-13.0], p=0.50), tumor (median 0.9 [IQR 0.3-2.8] vs 1.0 mm2 [IQR 0.4-2.7], p=0.33), desmoplastic fibrosis (median 4.3 [IQR 2.0-6.7] vs 5.2 mm2 [IQR 1.7-6.1], p=0.71), retained architecture (100 vs 83%, p=0.25), diagnostic cell block (96.0 vs 92.0%, p=0.32) and diagnostic adequacy at ROSE (94.0 vs 98.0%, p=0.32) between Franseen and Fork-tip needles, respectively. Conclusions There was no significant difference between Franseen and Fork-tip needles in yielding histological tissue. Given their ability to yield diagnostic cell block in greater than 90% of patients, the new-generation FNB needles may obviate need for ROSE. (Clinicaltrials.gov identifier: NCT02910960.)

    更新日期:2018-01-03
  • 更新日期:2017-12-14
  • Safety and efficacy of lumen-apposing metal stents with and without simultaneous double-pigtail plastic stents for draining pancreatic pseudocysts
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2017-12-09
    Murad Aburajab, Zachary Smith, Abdul Khan, Kulwinder Dua

    Background and Aims Lumen-apposing metal stents (LAMSs) are used to perform necrosectomy in walled-off necrosis (WON). Although necrosectomy is not required for pancreatic pseudocyst (PP), an increasing number of PPs are also being drained with LAMSs in view of their ease of deployment. The aim of the present study was to evaluate the safety and efficacy of using LAMSs to drain PPs. Methods At one tertiary center, from January 2014 to May 2016, all consecutive patients with PPs were drained by LAMSs, and the data were retrospectively reviewed. After observing cyst-cavity infection in patients enrolled initially (Group I), a 10F double-pigtail stents (DPSs) were placed across LAMSs in the subsequent patients (Group II). Data on technical success, PP resolution, adverse events (AEs), and reintervention rates were collected. Results: Forty-seven patients with PPs (mean size 9.5 ± 4.0 cm) were enrolled (Group I: 24, Group II: 23). There was one perforation at deployment (technical success 98%). In the remaining 46 patients, resolution of the PP was observed in 44 patients (96%). Four patients (17%) in Group I presented with PP infection requiring reinterventions. Food material was observed in the cyst cavity. None of the patients in Group II had PP infection (RR, 0.84; 95% CI, 0.71 - 1.0; p = 0.054). Conclusion Similar to WON, LAMSs are also effective in endoscopic drainage of PPs. However, there was a trend toward higher PP infection with LAMSs, and placing a double-pigtail stent across the LAMS minimized this risk.

    更新日期:2017-12-14
  • Endoscopic detection rate of sessile serrated lesions in Lynch syndrome patients is comparable to an age- and gender-matched control population: case-control study with expert pathology review
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2017-12-09
    Jasper L.A. Vleugels, Husna Sahin, Yark Hazewinkel, Lianne Koens, Jose G. van den Berg, Monique E. van Leerdam, Evelien Dekker

    Background Carcinogenesis in Lynch syndrome involves fast progression of adenomas to colorectal cancer (CRC) due to microsatellite instability. The role of sessile serrated lesions (SSLs) and the serrated neoplasia pathway in these patients is unknown. The aim of this matched case-control study was to compare endoscopic detection rates and distribution of SSLs in Lynch syndrome patients to a matched control population. Methods We collected data of Lynch syndrome patients with a proven germline mutation who underwent colonoscopy between January 2011 and April 2016 in 2 tertiary referral hospitals. Controls undergoing elective colonoscopy from 2011 and onward for symptoms or surveillance were selected from a prospectively collected database. Patients were matched 1:1 for age, gender, and index versus surveillance colonoscopy. An expert pathology review of serrated polyps was performed. The primary outcomes included the detection rates and distribution of SSLs. Results We identified 321 patients with Lynch syndrome who underwent at least one colonoscopy. Of these, 223 Lynch patients (mean age 49.3, female 59%, index colonoscopy 56%) were matched to 223 controls. SSLs were detected in 7.6% (CI, 4.8–11.9) of colonoscopies performed in Lynch patients and in 6.7% (CI, 4.1–10.8) of controls (p = 0.86). None of the detected SSLs in Lynch patients contained dysplasia. Conclusion The detection rate of SSLs in Lynch patients undergoing colonoscopy is comparable to a matched population. These findings suggest that the role of the serrated neoplasia pathway in CRC development in Lynch syndrome seems to be comparable to that in the general population.

    更新日期:2017-12-14
  • Time latencies of Helicobacter pylori eradication after peptic ulcer and risk of recurrent ulcer, ulcer adverse events, and gastric cancer: a population-based cohort study
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2017-12-09
    Emma Sverdén, Nele Brusselaers, Karl Wahlin, Jesper Lagergren

    Background Helicobacter pylori (H pylori) is associated with peptic ulcer disease and gastric cancer. Aim To test how various lengths of delays in H pylori eradication therapy influence the risk of recurrent peptic ulcer, ulcer adverse events and gastric cancer. Methods This population-based nationwide Swedish cohort study included 29,032 patients receiving H pylori eradication therapy after peptic ulcer disease in 2005-2013. Pre-defined time intervals between date of peptic ulcer diagnosis and date of eradication therapy were analysed in relation to study outcomes. Cox regression provided hazard ratios (HRs) and 95% confidence intervals (95% CIs), adjusted for age, sex, comorbidity, history of ulcer disease, use of ulcerogenic drugs, and use of proton pump inhibitors (PPIs). Results Compared to eradication therapy within 7 days of peptic ulcer diagnosis, eradication therapy within 8 to 30, 31 to 60, 61 to 365, and >365 days corresponded with HRs of recurrent ulcer of 1·17 (95% CI, 1·08-1·25), 2·37 (95%,CI, 2·16-2·59), 2·96 (95%,CI, 2·76-3·16), and 3·55 (95% CI, 3·33-3·79), respectively. The corresponding HRs for complicated ulcer were 1·55 (95% CI, 1·35-1·78), 3·19 (95% CI, 2·69-3·78), 4·00 (95% CI, 3·51-4·55), and 6·14, 95% CI, 5·47-6·89), respectively. For gastric cancer, the corresponding HRs were 0·85 (95% CI, 0·32-2·23), 1·31 (95% CI, 0·31-5·54), 3·64 (95% CI, 1·55-8·56), and 4·71 (95% CI, 2·36-9·38), respectively. Conclusions Delays in H pylori eradication therapy after peptic ulcer diagnosis time-dependently increase the risk of recurrent ulcer, and even more so for complicated ulcer, starting from delays of 8 to 30 days.

    更新日期:2017-12-14
  • Conventional versus traction-assisted endoscopic submucosal dissection for gastric neoplasms: a multicenter, randomized controlled trial (with video)
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2017-12-09
    Masao Yoshida, Kohei Takizawa, Sho Suzuki, Yoshiki Koike, Satoru Nonaka, Yasushi Yamasaki, Takeyoshi Minagawa, Chiko Sato, Chihiro Takeuchi, Ko Watanabe, Hiromitsu Kanzaki, Hiroyuki Morimoto, Takafumi Yano, Kosuke Sudo, Keita Mori, Takuji Gotoda, Hiroyuki Ono

    Background and Aims To clarify whether dental floss clip traction improves the technical outcomes of endoscopic submucosal dissection (ESD). Methods A superiority, randomized control trial was conducted at 14 institutions across Japan. Patients with single gastric neoplasm meeting the indications of the Japanese guidelines for gastric treatment were enrolled and assigned to receive conventional ESD or dental floss clip traction ESD (DFC-ESD). Randomization was performed according to a computer-generated random sequence with stratification by institution, tumor location, tumor size, and operator experience. The primary endpoint was ESD procedure time, defined as the time from the start of the submucosal injection to the end of the tumor removal procedure. Results Between July 2015 and September 2016, 640 patients underwent randomization. Of these, 316 patients who underwent conventional ESD and 319 patients who underwent DFC-ESD were included in our analysis. The mean ESD procedure time was 60.7 and 58.1 minutes for conventional ESD and DFC-ESD, respectively (P=0.45). Perforation was less frequent in the DFC-ESD group (2.2% vs 0.3%, P=0.04). For lesions located in the greater curvature of the upper or middle stomach, the mean procedure time was significantly shorter in the DFC-ESD group (104.1 vs 57.2 minutes, P=0.01). Conclusion Our findings suggest that DFC-ESD does not result in shorter procedure time in the overall patient population, but it can reduce the risk of perforation. When selectively applied to lesions located in the greater curvature of the upper or middle stomach, DFC-ESD provides a remarkable reduction in procedure time.

    更新日期:2017-12-14
  • Enteral nutrition and quality of life in patients undergoing chemoradiotherapy for esophageal carcinoma: a comparison of nasogastric tube, esophageal stent, and ostomy tube feeding
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2017-12-07
    Fang-Jung Yu, Hsiang-Yao Shih, Chien-Yi Wu, Yun-Shiuan Chuan, Jui-Ying Lee, Hsien-Pin Li, Pen-Tzu Fang, Dong-Lin Tsai, Shah-Hwa Chou, I-Chen Wu

    Background and Aims This study prospectively recruited esophageal squamous-cell carcinoma patients who received esophageal stent, nasogastric tube (NG) or jejunostomy/gastrostomy feeding to compare the changes in nutritional status and quality of life during chemoradiation therapy (CRT). Methods In total, 81 patients were analyzed (stent 7, surgical ostomy 26, NG 19, oral intake 29). NG was inserted when despite medication dysphagia or pain worsened with oral feeding during CRT. Serial body weight and daily narcotic demand were recorded. Changes in serum albumin level and quality of life were also assessed. In subgroup analysis comparing the NG and prophylactic surgical ostomy feeding, 5 patients with total occlusion in the ostomy group were excluded. Results Patients in all groups had similar decrease in mean body weight with an overall change of -6.41±5.21% at the end of CRT. The stent group had significantly worse pain, more decrease in albumin (-1.03±0.9mg/dL) and quality of life across CRT compared with the other groups. In subgroup analysis, the stent group had significantly higher weight loss whereas the NG group had higher narcotic demand and slightly worse quality of life. Two patients (7.7%) had ileus days after jejunostomy creation. Five (19.2%) patients scarcely used ostomy feeding. Conclusions These preliminary results raise concerns that esophageal stent may be less suitable in patients undergoing CRT. Tube feeding by means of transnasal or percutaneous routes appear to be comparably effective during CRT, but both had advantages and disadvantages. We suggest a careful endoscopic evaluation to select the population more appropriate for NG feeding on an as-needed basis during CRT.

    更新日期:2017-12-14
  • Comparison of EUS with magnetic resonance cholangiopancreatography in idiopathic acute pancreatitis: a systematic review and meta-analysis
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2017-12-07
    Jianhua Wan, Yaobin Ouyang, Chen Yu, Xiaoyu Yang, Liang Xia, Nonghua lu

    Background /Aims: Idiopathic acute pancreatitis (IAP) poses a diagnostic challenge for gastroenterologists, as confirmation of the disease etiology has important implications for the selection of the best possible treatment and the prevention of possible recurrence or the development of chronic pancreatitis. ERCP, EUS, and magnetic resonance cholangiopancreatography (MRCP) are typically used to diagnose IAP when conventional radiological methods fail. However, their exact role in the diagnosis of IAP has not yet been determined. Methods We searched the PubMed, EMBASE, OVID, Cochrane Library (including CENTRAL), CNKI and Wanfang databases from inception to April 2017. Studies involving the use of EUS and/or MRCP for the etiological diagnosis of IAP were included. A meta-analysis was performed using Review Manager Version 5.2 for comparative studies and R software 3.3.3 to determine diagnostic yield of the studies. Results Among the 34 studies that met the inclusion criteria (n = 2338, seven studies used a combination of EUS and MRCP and included 249 patients. The results comparing EUS with MRCP showed a diagnostic yield of 153 of the 239 patients (64%) in the EUS group, which was higher than the yield of 82 of 238 patients (34%) in the MRCP group (P < 0.001) in the seven studies, and the diagnostic yield was 60% in the EUS group, 24% in the MRCP group, and 43% in the MRCP after secretin stimulation (S-MRCP) group. In our subgroup analysis of chronic pancreatitis and biliary disease, EUS was superior to MRCP (P < 0.001), but when comparing the efficacy of the modalities in the diagnosis of pancreatic divisum, S-MRCP was obviously superior to MRCP and EUS (12% vs 2% vs 2%). Conclusions EUS and MRCP should both be used in the diagnostic work-up of Idiopathic acute pancreatitis (IAP) as complementary techniques. EUS had a higher diagnostic accuracy than MRCP (64% vs 34%) in the etiological diagnosis of IAP, and should be preferred for establishing a possible biliary disease and chronic pancreatitis diagnosis, whereas S-MRCP was superior to EUS and MRCP in diagnosing a possible anatomical alteration in the biliopancreatic ductal system, such as pancreatic divisum.

    更新日期:2017-12-14
  • Computer-aided diagnosis for identifying and delineating early gastric cancers in magnifying narrow-band images
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2017-12-07
    Takashi Kanesaka, Tsung-Chun Lee, Noriya Uedo, Kun-Pei Lin, Huai-Zhe Chen, Ji-Yuh Lee, Hsiu-Po Wang, Hsuan-Ting Chang

    Background and Aims Magnifying narrow-band imaging (M-NBI) is important in the diagnosis of early gastric cancers (EGCs), but requires expertise to master. We developed a computer-aided diagnosis (CADx) system to assist endoscopists in identifying and delineating EGCs. Methods We retrospectively collected and randomly selected 66 EGC M-NBI images and 60 non-cancer M-NBI images into a training set, and 61 EGC M-NBI images and 20 non-cancer M-NBI images into a test set. After preprocessing and partition, we determined eight gray-level co-occurrence matrix (GLCM) features for each partitioned 40×40 pixel block, and calculated coefficient of variation of eight GLCM feature vectors. We then trained a support vector machine (SVMLv1) based on variation vectors from the training set, and examined in the test set. Furthermore, we collected two determined P and Q GLCM feature vectors from cancerous image blocks containing irregular microvessels from the training set, and trained another SVM (SVMLv2) to delineate cancerous blocks, which were compared with expert-delineated areas for area concordance. Results The diagnostic performance revealed accuracy of 96.3%, precision (PPV) of 98.3%, recall (sensitivity) of 96.7%, and specificity of 95%, at a rate of 0.41 ± 0.01 second per image. The performance of area concordance, on a block basis, demonstrated accuracy of 73.8 ± 10.9%, precision (PPV) of 75.3 ± 20.9%, recall (sensitivity) of 65.5 ± 19.9%, and specificity of 80.8 ± 17.1%, at a rate of 0.49 ± 0.04 sec per image. Conclusions This pilot study demonstrates that our CADx system has great potential in real time diagnosis and delineation of EGCs in M-NBI images.

    更新日期:2017-12-14
  • Risk factors for postpolypectomy bleeding in patients receiving anticoagulation or antiplatelet medications
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2017-12-06
    David Lin, Roy M. Soetikno, Kenneth McQuaid, Chi Pham, Gilbert Doan, Shanshan Mou, Amandeep K. Shergill, Ma Somsouk, Robert V. Rouse, Tonya Kaltenbach

    Background and Aims Balancing the risks for thromboembolism and postpolypectomy bleeding in patients requiring anticoagulation and antiplatelet agents is challenging. We investigated the incidence and risk factors for postpolypectomy bleeding on anticoagulation, including heparin bridge, and other antithrombotic therapy. Methods We performed a retrospective cohort and case control study at 2 tertiary care medical centers from 2004 to 2012. Cases included male patients on antithrombotics with hematochezia after polypectomy. Nonbleeding controls were matched to cases 3 to 1 by antithrombotic type, study site, polypectomy technique, and year of procedure. Our outcomes were the incidence and risk factors for postpolypectomy bleeding Results There were 59 cases and 174 matched controls. Postpolypectomy bleeding occurred in 14·9% on bridge anticoagulation. This was significantly higher than the overall incidence of bleeding on antithrombotics at 1·19% (95% CI, 0·91 – 1·54%) (59/4923). We identified similarly low rates of bleeding on warfarin (0·66%), clopidogrel (0·84%), and aspirin (0·92%). Patients who bled tended to have larger polyps (13·9 vs. 7·3mm, p<0·001) and more polyps ≥2cm (41 vs. 10%, p<0·001). Bleeding risk was increased with restarting antithrombotics within one week postpolypectomy (OR 4·50, p<0·001), having polyps ≥2cm (OR 5·94, p<0·001), performing right-sided cautery (OR 2·61, p=0·004), and having multiple large polyps (OR 2·92, p=0·001). Among patients on warfarin, the presence of bridge anticoagulation was an independent risk factor for postpolypectomy bleeding (OR 12·27, p=0·0001). Conclusions We conclude that bridge anticoagulation is associated with a high incidence of postpolypectomy bleeding and is an independent risk factor for hemorrhage compared with those on warfarin alone. A higher threshold to use bridge anticoagulation should be considered in patients with an elevated bleeding risk.

    更新日期:2017-12-14
  • Dissection-enabled scaffold-assisted resection (DeSCAR): a novel technique for resection of residual or non-lifting GI neoplasia of the colon (with video)
    Gastrointest. Endosc. (IF 6.501) Pub Date : 2017-11-21
    Matthew W. Stier, Christopher G. Chapman, Allie Kreitman, John A. Hart, Shu-Yuan Xiao, Uzma D. Siddiqui, Irving Waxman

    Background and Aims Due to previous manipulation or submucosal invasion, GI lesions referred for endoscopic mucosal resection (EMR) frequently have flat areas of visible tissue that cannot be snared. Current methods for treating residual tissue may lead to incomplete eradication or not allow complete tissue sampling for histologic evaluation. Our aim is to describe dissection-enabled scaffold-assisted resection (DeSCAR), a new technique combining circumferential ESD with EMR for removal of superficial non-lifting or residual “islands” with suspected submucosal involvement/fibrosis. Methods From 2015 to 2017, lesions referred for EMR were retrospectively reviewed. Cases were identified where lifting and/or snaring of the lesion was incomplete and the DeSCAR technique was undertaken. Cases were reviewed for location, prior manipulation, rates of successful hybrid resection, and adverse events. Results Twenty-nine lesions underwent DeSCAR due to non-lifting or residual “islands” of tissue. Patients were 52% male, 48% female, and average age 66 (SD +/- 9.9 years). Lesions were located in the cecum (n=10), right side of the colon (n=12), left side of the colon (n=4) and rectum (n=3). Average size was 31 mm (SD +/- 20.6 mm). Previous manipulation occurred in 28/29 cases (83% biopsy, 34% resection attempt, 52% tattoo). The technical success rate for resection of non-lifting lesions was 100%. There was one delayed bleeding episode but no other adverse events. Conclusions DeSCAR is a feasible and safe alternative to argon plasma coagulation and avulsion for the endoscopic management of non-lifting or residual GI lesions, providing en-bloc resection of tissue for histologic review. Further studies are needed to demonstrate long-term eradication and for comparison with other methods.

    更新日期:2017-12-14
Some contents have been Reproduced with permission of the American Chemical Society.
Some contents have been Reproduced by permission of The Royal Society of Chemistry.
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