Alain Suissa

A novel diagnostic tool for detecting oesophageal pathology: the PillCam oesophageal video capsule

Background : Gastro‐oesophageal reflux disease is a common entity. Erosive oesophagitis, ulcers and Barretts oesophagus, which is found in up to 10% of gastro‐oesophageal reflux disease patients, characterize severe gastro‐oesophageal reflux disease. Patients with Barretts oesophagus have 0.5% per patient‐year risk of developing oesophageal adenocarcinoma. Currently, it appears that a minority of those at risk for Barretts oesophagus undergo screening in part because of the costs associated with endoscopy as well as risks of sedation. A new ingestible PillCam oesophageal capsule developed may offer an alternative office‐based approach to visualize the oesophagus without sedation.

NOD2/CARD15 genotype and phenotype differences between Ashkenazi and Sephardic Jews with Crohn's disease

OBJECTIVE:NOD2/CARD15 has been identified as a major susceptibility gene for Crohns disease (CD). Three mutations, Arg702Trp, Gly908Arg, and Leu1007fsinsC, are associated with CD. The incidence and prevalence rate of inflammatory bowel diseases is two- to four-fold higher in Ashkenazi Jews as compared to non-Jewish Caucasians. The aim of this study was to determine the significance of the NOD2/CARD15 mutations in Jewish CD patients in Israel, and more specifically, to compare the significance of the mutations to the expression of CD in the Ashkenazi and Sephardic Jewish populations.METHODS:Allele frequencies of the mutations were determined in 180 Jewish CD patients, 73 ulcerative colitis patients, and 159 ethnically matched controls. Variants were detected using allele-specific PCR and restriction enzyme digestion assay. Demographic and phenotypic characterizations of the CD patients were determined.RESULTS:The carrier rate of the three mutations in the entire Jewish Israeli CD cohort is 41.1%versus 10.7% in controls (p < 0.0001). The Ashkenazi Jewish CD patients have an increased carrier rate compared to Sephardic Jews (47.4%vs 27.45%, p= 0.034). Association analyses in Ashkenazi Jews reveal odds ratios of 10.5, 9, and 4.8 for carriage of Gly908Arg, Arg702Trp, and Leu1007fsinsC mutations, respectively. Significantly higher rates of smoking, family history of inflammatory bowel diseases, and extraintestinal manifestations were found among the Sephardic CD patients.CONCLUSIONS:NOD2/CARD15 CD-associated mutations confer increased risk mainly to the Ashkenazi Jewish CD patients in Israel. This suggests that NOD2/CARD15 mutations could contribute to the higher incidence and prevalence rates of CD among Ashkenazi Jews.

Linear EUS for bile duct stones

BACKGROUND Radial scanning endoscopic ultrasonography (EUS) has been shown, in experienced hands, to be a safe and accurate means of detecting bile duct stones. We compared linear array EUS with endoscopic retrograde cholangiopancreatography (ERCP), in our first 50 cases, to evaluate efficacy of this examination as well as the learning curve for this indication. METHODS A retrospective study was conducted on 50 patients with suspected choledocholithiasis. We compared results of EUS with those of ERCP as a reference. First a linear EUS examination was performed followed by ERCP, at a median interval of 31 days (range 3 to 162 days). RESULTS The average age of patients was 56 years (range 26 to 76); 48% were women. Fifteen (30%) had undergone cholecystectomy, a mean of 8.5 years (range 1 to 22) before the EUS. EUS compared with ERCP had a 97% sensitivity, 77% specificity, and 90% accuracy. In 14% of patients EUS provided an additional or alternative diagnosis: chronic pancreatitis (n = 3), duodenitis (2), bile duct stricture (1), chronic gastritis (1). No complications were encountered due to EUS. CONCLUSIONS We found in this early experience that linear array EUS is a reasonably safe and accurate means of detecting choledocholithiasis. Linear array EUS, despite the learning curve, seems to be about equivalent to radial EUS in accuracy. Appropriate use of this less invasive technique may possibly replace the use of diagnostic ERCP.

Natural beta-carotene for the prevention of post-ERCP pancreatitis.

OBJECTIVE Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly used procedure. Pancreatitis is its most common complication. As the injury may be mediated by oxidative stress, it could be ameliorated by antioxidants. METHODS We conducted a double-blind trial, giving the patients a single dose of natural beta-carotene or placebo, 12 hours prior to procedure, and monitoring them for 24 hours post-procedure for procedure complications, antioxidant levels, and plasma oxidation. RESULTS The overall incidence of acute pancreatitis according to our definition was 9.6%. The incidence of pancreatitis was not significantly different between the beta-carotene group (10%) and the placebo group (9.4%). Four patients in the placebo group had severe pancreatitis (2.22%), but none in the beta-carotene group. This difference is statistically significant. CONCLUSION We did not see a reduction in the incidence of post-ERCP pancreatitis, but there may be some protective effect of treatment with beta-carotene regarding the severity of disease.

Oral Corticosteroids and the Risk of Serious Infections in Patients With Elderly-Onset Inflammatory Bowel Diseases

OBJECTIVES:Systemic corticosteroids are among the most common anti-inflammatory treatments in elderly-onset inflammatory bowel disease (IBD) patients. Steroid use and older age each independently predisposes to infections, and infections increase mortality in hospitalized older IBD patients. Therefore, our objective was to examine the risk of serious infections in elderly-onset IBD patients treated with oral corticosteroids, and explore how the timing of exposure affects the risk estimates.METHODS:Using the health-care databases of the province of Quebec, Canada, we conducted a population-based cohort study with a nested case–control analysis. Incident IBD patients aged ≥66 years were identified. Conditional logistic regression was performed to estimate crude and adjusted rate ratios (aRRs) with 95% confidence intervals (CIs).RESULTS:We identified 3,522 elderly-onset patients, of which 564 cases with serious infections were identified during a mean 4.4 years of follow-up (incidence rate 3.7 per 100 per year) and matched to 2,646 controls. The rate of serious infections was significantly higher in those exposed to oral corticosteroids any time during the previous 6-month period compared with those nonexposed (aRR 2.3; 95% CI 1.8–2.9). Those currently exposed (within 45 days) had a higher risk (aRR 2.8; 95% CI 2.1–3.7). The residual effect of oral corticosteroids remained marginally statistically significant up to the 90-day period before the index date (aRR 1.7; 95% CI 1.0–2.7).CONCLUSIONS:We found an excess relative risk for serious infections in elderly-onset IBD patients on oral corticosteroid therapy. Those with current exposure demonstrated a higher vulnerability to infections.

The Impact of Endoscopic Ultrasonography on the Management of Suspected Pancreatic Cancer-a Comprehensive Longitudinal Continuous Evaluation

Objectives: Between 1997 and 2001, a single-center chart review demonstrated significant impact of endoscopic ultrasonography (EUS) in evaluating suspected pancreatic cancer (PCA). Repeating and comparing this review with that from 2001 to 2004 was performed to determine whether increased use of EUS results in more patients being accurately chosen for curative versus palliative procedures, and for surgical versus nonsurgical oncotherapy. Methods: The complete systematic review was made up of electronic files from the gastroenterology, oncology, and pathology departments of patients presenting with suspected PCA. Results were compared with those obtained in 1997-2001. Results: From 2001 to 2004, 72 patients had PCA. Seven tumor types were identified. Forty-seven percent (34/72) of patients with suspected PCA were preoperatively staged by EUS; 24% (17/72) of all patients underwent surgery. Comparatively, from 1997 to 2001, only 32% (20/62) of patients were evaluated by EUS (P = 0.056) and 45% (28/62) of all patients underwent surgery (P < 0.01). The EUS detected a tumor in 32 of 34 cases. The EUS-guided fine-needle aspiration cytology identified PCA in 14 of 18 cases. F-18-deoxyglucose-positron emission tomography and magnetic resonance imaging were not used. Endoscopic retrograde cholangiopancreatography was performed in 29% (21/72) of patients, with 15 stents inserted. Conclusions: Increased EUS use for diagnosing and staging PCA resulted in fewer patients undergoing futile surgery. The EUS plays a pivotal role in the management of patients with PCA.

Outcome and Complications of Colonoscopy: A Prospective Multicenter Study in Northern Israel

Background. Colonoscopy for screening the population at an average risk of colorectal cancer (CRC) is recommended by many leading gastrointestinal associations. Objectives. The objective was to assess the quality, complications and acceptance rate of colonoscopy by patients. Methods. We prospectively gathered data from colonoscopies which were performed between October 2003 and September 2006. Patients were asked to return a follow-up form seven days after the procedure. Those who failed to do so were contacted by phone. Results. 6584 patients were included (50.4% males). The average age of subjects was 57.73 (SD 15.22). CRC screening was the main indication in 12.8%. Cecal intubation was achieved in 92% of patients and bowel preparation was good to excellent in 76.2%. The immediate outcome after colonoscopy was good in 99.4%. Perforations occurred in 3 cases—1 in every 2200 colonoscopies. Significant bleeding occurred in 3 cases (treated conservatively). 94.2% of patients agreed to undergo repeat colonoscopy in the future if indicated. Conclusions. The good quality of examinations, coupled with the low risk for complications and the good acceptance by the patients, encourages us to recommend colonoscopy as a primary screening test for CRC in Israel.

Proton-pump inhibitors and increased gastric cancer risk: time-related biases

We read with interest the cohort study by Cheung et al 1 reporting that use of proton-pump inhibitors (PPIs) after Helicobacter pylori eradication is associated with an increased risk of gastric cancer (GC). We believe that the significantly elevated HR of GC with PPI use (HR 2.44; 95% CI 1.42 to 4.20) is a consequence of two time-related biases. Immortal time bias was introduced by misclassifying exposure,2–4 while latency bias was introduced by not incorporating latency in the exposure definition, a major issue for potential carcinogenic drug effects.5 6 Immortal time in a cohort study refers to a period of follow-up time when the outcome could not occur.3 It arises in this study from the definition of frequency of PPI use, ‘calculated by dividing the total treatment duration by the duration of follow-up’, namely the average use over the entire follow-up. Exposure to PPIs was then categorised ‘into non-regular use (<weekly use; reference group) and regular use (at least weekly use)’.1 Thus, the PPI ‘non-users’ included authentic non-users of PPIs and the non-regular PPI users (less than weekly use), together making up the reference group against which the risk …

Endoscopic Removal of Partially Migrated Intragastric Bands Following Surgical Gastroplasty: a Prospective Case Series

BackgroundThe intragastric migration of a surgically placed adjustable gastric band is believed to occur slowly, over months to years. Band removal procedures necessitate surgical laparotomy, thus increasing the risk of complications.MethodsThe endoscopic technique for band removal described in this case-series provides a minimally invasive approach.ResultsFifteen patients referred for endoscopic removal of a partially migrated intragastric band. The partially migrated intragastric bands were all successfully removed in a mean of 1.1 endoscopic sessions. No patient required subsequent surgical intervention, and there were no immediate or delayed adverse events including no infections, bleeding, or perforations.ConclusionsEndoscopic removal of partially migrated intragastric bands appears feasible, effective, safe, and is a minimally invasive alternative to repeat surgery.

Management of gastric fistula complicating laparoscopic sleeve gastrectomy with biological glue in a combined percutaneous and endoscopic approach

BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is considered as a first line treatment for morbid obesity around the globe. Leakage and subsequent gastric fistula is the most dreadful complication, which may lead to serious morbidity and even mortality. OBJECTIVES To assess the safety and efficacy of fibrin glue application in the setting of gastric fistula after LSG. SETTING University hospital, Israel. METHODS Twenty-four morbidly obese patients (mean age = 42.2 yr, mean body mass index = 42 kg/m2) developed gastric fistula after LSG. The fistula was acute in 10 patients, subacute in 9, and chronic in 5. Sixteen patients (67%) have had previous failed endoscopic interventions. Fibrin glue was applied percutaneously with fluoroscopic guidance, under endoscopic visualization. A pigtail drain was left in the distal tract to monitor and manage possible continuous leakage. RESULTS There were no complications except abdominal pain in 2 patients associated with fever in 1. Both resolved within 1 to 2 days. Fistula closure was achieved in all patients but 1 (95.8%). Closure was accomplished after a single application in 9 patients (39%), 2 applications in 8, 3 applications in 3, 5 applications in 2, and 6 applications in 1. All patients were followed with a mean time of 42.3 months (range, 20-46). CONCLUSIONS Although in most patients there was a need for multiple applications, our experience indicates that percutaneous fluoroscopic application of Fibrin glue under endoscopic visualization proved to be a simple, tolerable, and highly effective method for the treatment of selected patients with gastric fistula after LSG.