Alberto Herreros de Tejada

Complete Barrett's Eradication Endoscopic Mucosal Resection: An Effective Treatment Modality for High-Grade Dysplasia and Intramucosal Carcinoma—An American Single-Center Experience

OBJECTIVES:Complete Barretts eradication endoscopic mucosal resection (CBE-EMR) is the endoscopic removal of all Barretts epithelium with the curative intent of eliminating high-grade dysplasia (HGD)/intramucosal carcinoma (IMC) and reducing the risk of metachronous lesion development. We report our single tertiary referral centers long-term clinical experience using this modality in HGD/IMC management.METHODS:In this study, we retrospectively reviewed all patients who had CBE-EMR for Barretts esophagus (BE) with HGD/IMC who had been entered into our centers prospectively collected database. High-definition white-light and narrow-band imaging examinations were used according to the protocol. Staging endoscopic ultrasound was done before CBE-EMR to exclude invasive disease or suspicious lymphadenopathy. High-dose proton pump inhibition was instituted after initial treatment, and Seattle-type surveillance biopsies were performed on follow-up every 6 months once the CBE-EMR procedure was completed.RESULTS:A total of 49 patients (mean age 67 years, median 65, s.d. 11; 75% men) with histologically confirmed BE and HGD (33), IMC (16), underwent CBE-EMR from August 2003 to August 2008. The mean BE segment length was 3.2 cm (median 2, s.d. 2.2); 26 patients had short-segment BE, and 30 had visible lesions. A total of 106 EMR procedures were performed. On initial EMR, two patients had superficial submucosal carcinoma invasion (sm1) and two had IMC with lymphatic channel invasion. All four patients were referred for esophagectomy, but one opted for continued endoscopic management, without evidence of residual or recurrent carcinoma. A total of 14 patients await completion of EMR (9) or first follow-up endoscopy (5). CBE-EMR therapy was completed in 32 patients by an average of 2.1 sessions (median 2, s.d. 0.9). Surveillance biopsies showed normal squamous epithelium in 31 of 32 (96.9%) patients (mean remission time 22.9 months, median 17, s.d. 16.7, interquartile range 11–38). In all, 10 of 46 patients who continued in the endoscopic protocol had subsquamous Barretts epithelium on EMR specimens and/or treatment endoscopy biopsies. Overall, 1 of these 10 patients had Barretts underneath squamous mucosa on most recent surveillance biopsies. CBE-EMR upstaged pre-EMR pathology results in 7 of 49 (14%) of patients and downstaged pathology in 15 of 49 (31%) patients. In all, 18 of 49 (37%) patients developed symptomatic esophageal stenosis after a mean of 24.4 days (median 13.5, s.d. 27.8); all were successfully managed by endoscopic treatment. No perforations or uncontrollable bleeding occurred.CONCLUSIONS:To our knowledge, this is the largest American single-center experience demonstrating that CBE-EMR with close endoscopic surveillance is an effective treatment modality for BE with HGD/IMC. Although the rate of stenosis development is significant, it is easily treated by endoscopic dilation. Patients considering endoscopic ablation should be counseled appropriately. The role of CBE-EMR in patients with lymphatic invasion or superficial submucosal invasion remains to be defined.

Double-guidewire technique for difficult bile duct cannulation: a multicenter randomized, controlled trial

BACKGROUND ERCP can be associated with serious complications. Difficulty in common bile duct (CBD) cannulation is one of the main risk factors for post-ERCP pancreatitis. The double-guidewire technique (DGT) has been considered a promising alternative approach in difficult cannulation situations. OBJECTIVE To compare the performance of DGT with the standard cannulation technique (SCT) in patients in whom CBD cannulation is difficult to perform. DESIGN Multicenter randomized, controlled trial. SETTING Six tertiary referral centers. PATIENTS A total of 188 patients with difficult CBD cannulation defined by completion of 5 unsuccessful cannulation attempts were enrolled. INTERVENTIONS Ninety-seven patients were assigned to the DGT group and 91 to the SCT group. Both techniques were compared for an extra 10 cannulation attempts. MAIN OUTCOME MEASUREMENTS CBD cannulation rate, number of attempts required to cannulate, and ERCP-related complications. RESULTS Successful CBD cannulation was achieved in 46 of 97 (47%) patients in the DGT group compared with 51 of 91 (56%) in the SCT group (OR 0.85; 95% CI, 0.64-1.12). The median number of attempts required for each group was 9 and 7, respectively (P = .128). The incidence of post-ERCP pancreatitis was 17% in the DGT group and 8% in the SCT group (OR 2.13; 95% CI, 0.89-5.05). LIMITATIONS Reduced number of enrolled subjects and a lack of detailed information regarding the number and extent of pancreatic duct contrast injections. CONCLUSIONS In patients with difficult CBD cannulation, DGT was not superior to SCT in achieving CBD cannulation. DGT might be associated with a higher risk of post-ERCP pancreatitis.

Colorectal endoscopic submucosal dissection from a Western perspective: Today’s promises and future challenges

Over the last few years, endoscopic submucosal dissection (ESD) has shown to be effective in the management of early colorectal neoplasms, particularly in Asian countries where the technique was born. In the Western world, its implementation has been slow and laborious. In this paper, the indications for ESD, its learning model, the available methods to predict the presence of deep submucosal invasion before the procedure and the published outcomes from Asia and Europe will be reviewed. Since ESD has several limitations in terms of learning achievement in the West, and completion of the procedure for the first cases is difficult in our part of the world, a short review on colorectal assisted ESD has been included. Finally, other endoscopic and surgical treatment modalities that are in competition with colorectal ESD will be summarized.

Severe splenic rupture after colorectal endoscopic submucosal dissection

Splenic rupture (SR) after colonoscopy is a very rare but potentially serious complication. Delayed diagnosis is common, and may increase morbidity and mortality associated. There is no clear relation between SR and difficult diagnostic or therapeutic procedures, but it has been suggested that loop formation and excessive torquing might be risk factors. This is a case of a 65-year-old woman who underwent endoscopic submucosal dissection (ESD) for lateral spreading tumor in the descending colon, and 36 h afterwards presented symptoms and signs of severe hypotension due to SR. Standard splenectomy was completed and the patient recovered uneventfully. Colorectal ESD is usually a long and position-demanding technique, implying torquing and loop formation. To our knowledge this is the first case of SR after colorectal ESD reported in the literature. Endoscopists performing colorectal ESD in the left colon must be aware of this potential complication.

Line-assisted endoscopic complete closure of a large perforation during colonic endoscopic submucosal dissection

A 71-year-old woman was found to have a laterally spreading tumor (non-granular type) adjacent to a previous surgical anastomosis (▶Fig. 1 a). Endoscopic submucosal dissection (ESD) with carbon dioxide insufflation was attempted using an esophagogastroduodenoscope (GIFH180J; Olympus Co., Tokyo, Japan) and a FlushKnife BT (DK2618JB15; Fujifilm Medical, Tokyo, Japan) during the fourth edition of International ESD Live Madrid 2016, endorsed by the European Society of Gastrointestinal Endoscopy. Severe fibrosis was found during the procedure and it was very difficult to approach the appropriate submucosal plane. While a switch to snare removal was being considered, a large perforation occurred as a result of the colonoscope being pushed in a retroflexed position (▶Fig. 1b). As a result, the lesion was removed en bloc using an electrosurgical snare (so-called “hybrid ESD”), because it was essential to complete the procedure immediately. As the perforation was large, we used the line-assisted complete closure (LACC) technique [1–3]. The closure was successfully completed using 30 endoclips (HX-610-090 and HX-202UR; Olympus Co.) without decompressing the pneumoperitoneum (▶Fig. 1 c; ▶Video1). A contrast-enhanced computed tomography (CT) scan immediately after the procedure showed the presence of the pneumoperitoneum but the absence of leaking contrast agent (▶Fig. 2). The patient was kept fasted and treated with intravenous antibiotics for 24 hours, before being given oral antibiotics for an additional 8 days. She was hospitalized for 4 days without further complications. Histological examination showed low grade dysplasia, with clear lateral and vertical margins. The patient was followed up 5 months later, at which time she was Video 1 Endoscopic complete closure of a large perforation that occurred during colonic endoscopic submucosal dissection using the line-assisted technique. ▶ Fig. 1 Endoscopic views showing: a a large flat lesion adjacent to a previous colorectal anastomotic suture line; b a large perforation that developed immediately after pushing the colonoscope in a retroflexed position to approach the cephalic end of the lesion; c the large perforation following successful closure using the line-assisted complete closure technique. E-Videos

Su1950 Increased Colorectal Cancer Risk in First-Degree Relatives of Patients With Multiple Serrated Polyps Who Do Not Fulfill Criteria for Serrated Polyposis Syndrome

in 32 (15.4%) AJ and 22 (0.5%) NAJ (p=0.0001); among AJ this variant was significantly associated with a diagnosis of CRC (OR: 2.6 [95% CI: 1.1-5.8]). Conclusion: Overall, the frequency of pathogenic APC or MUTYH mutations increases with adenoma count and is lower in AJ compared to NAJ. The low yield of comprehensive MUTYH testing in AJ suggests this gene plays a small role in AJ with polyposis and that other genes may be responsible for the polyposis phenotype in Ashkenazim. The higher prevalence of the APC*R332X mutation in AJ compared to NAJ suggests R332X may be a founder mutation. This should be further explored through haplotype analysis. Finally, we propose that increased colorectal screening be considered in Ashkenazim who have the I1307K variant and report a personal history of colorectal adenomas.

Sa1776 Use of BRAF and KRAS Somatic Mutation as a Molecular Marker of Serrated Polyposis in Patients Not Fulfilling Who Criteria

at least one new peak compared to the product from the matching normal tissue. Statistical Analysis: The Kaplan-Meier method was used for estimating recurrence-free survival. Cox proportional hazard analysis was used to evaluate the association between MSI status and other clinicopathological factors for predicting recurrent distant metastasis. The P value less than 0.05 was considered to be statistically significant. Results: Stage II and III patients with MSI-L and/or EMAST had a shorter recurrence-free survival than patients with high levels of MSI (MSI-H) (P=0.0084) or with highly stable microsatellites (H-MSS) (P=0.0415) by Kaplan-Meier analysis. MSI-L and/or EMAST are independent predictors of recurrent distant metastasis in primary stage II and III CRCs by Cox proportional hazard analysis (Hazard Ratio: 1.83, 95%CI: 1.06-3.15, P=0.0301). Compatible with other studies, the present study also showed that MSI-H is associated with proximal location and exhibited lowest risk for recurrent distant metastasis. Conclusions: Our results showed that MSI-L/EMAST is a predictive factor of stage II/III primary CRC for recurrent distant metastasis. Because MSI-L/EMAST CRC is different from MSI-H and H-MSS CRC, we proposed to define MSI-L/EMAST as one group and named this group of CRC moderate MSI (MSI-M).