Arthur J. Kaffes

Argon plasma coagulation in the management of symptomatic gastrointestinal vascular lesions: experience in 100 consecutive patients with long-term follow-up.

BACKGROUND:The long-term efficacy of argon plasma coagulation (APC) in the management of gastrointestinal vascular lesions has not been evaluated in a large and well-defined series. The impact of APC on transfusion requirements and hemoglobin, and technical parameters including complications and number of treatment sessions, is assessed in this series.METHODS:Patients who underwent APC for bleeding gastrointestinal vascular lesions were identified via interrogation of an established endoscopic database, excluding patients with radiation proctitis, tumors, residual polypectomy tissue and acute ulcer bleeding. Follow-up data were collected via interview with patients and referring doctors, review of medical records, and follow-up blood tests.RESULTS:One hundred patients were enrolled, males = 46, median age = 74 yr (range: 19–99 yr). Median follow-up time was 16 months (range: 4–47 months). Lesions treated were arteriovenous malformations (n = 74) and gastric antral vascular ectasia (n = 26). Fifty-three patients required transfusion. In this group, median hemoglobin improved from 66 g/L (range: 35–114) to 111 g/L (range: 55–155, p < 0.001). Median transfusion velocity fell from 2 units/month (range: 0.1–6) to 0 units/month (range: 0–4, p < 0.001). Transfusion requirement was abolished in 77%. In non-transfusion-requiring patients, median hemoglobin improved from 105 g/L (range: 58–143) to 123 g/L (range: 79–158, p < 0.001). No complications occurred.CONCLUSIONS:APC is effective and safe in the management of gastrointestinal vascular lesions.

Impact of endoscopic intervention in 100 patients with suspected postcholecystectomy bile leak.

BACKGROUND Bile leak is a recognized complication of cholecystectomy. Endoscopic intervention is widely accepted as a treatment for this complication, but the optimal form is not well defined. METHODS An ERCP database was reviewed retrospectively to identify all cases of bile leak related to cholecystectomy. Patient records and endoscopy reports were reviewed, and structured telephone interviews were conducted to collect data. RESULTS A total of 100 patients (61 women, 39 men; mean age, 53 [17] years) with suspected postcholecystectomy bile leak were referred for ERCP. Cholecystectomy was commenced laparoscopically in 83 patients (with an open conversion rate of 30%). The most common symptoms were pain (n = 62) and fever (n = 37). Cholangiography was obtained in 96 patients. A leak was identified in 80/96 patients, the most common site being the cystic-duct stump (48), followed by ducts of Luschka (15), the T-tube site (7), and other sites (10). Treatment included stent insertion alone (40), sphincterotomy alone (18), combination stent/sphincterotomy (31), none (6), and other (1). Three patients with major bile-duct injuries were excluded from the analysis. Endoscopic therapy was unsuccessful in 7 patients (6 in the sphincterotomy alone group; p = 0.001). Four patients underwent surgery subsequent to ERCP to control the leak. All 4 were in the sphincterotomy alone group ( p = 0.001). Post-ERCP pancreatitis developed in 4 patients (3 mild, 1 moderate). CONCLUSIONS The optimal endoscopic intervention for postcholecystectomy bile leak should include temporary insertion of a biliary stent.

Needle-knife sphincterotomy: factors predicting its use and the relationship with post-ERCP pancreatitis (with video)

BACKGROUND In the absence of precut needle-knife sphincterotomy (NKS), failure of biliary cannulation may occur in up to 10% of cases. There are few prospective evaluations of the safety and efficacy of NKS, and studies of its early use in difficult cannulation have been inconclusive. Whether precut NKS after failure of primary biliary cannulation is independently associated with post-ERCP pancreatitis (PEP) remains controversial. OBJECTIVE To examine the relationship between NKS and PEP. DESIGN Analysis of prospectively collected data from two randomized trials of ERCP techniques, with PEP as the primary endpoint measure. SETTING Tertiary-care academic medical center. PATIENTS This study involved 732 patients from two successive, prospective, randomized trials of naïve papilla cannulation between November 2001 and April 2006. Patients with pancreatic or ampullary cancer were excluded. INTERVENTION Naïve papilla cannulation, NKS, primary guidewire versus contrast-assisted cannulation, and glyceryl trinitrate patch versus placebo. MAIN OUTCOME MEASUREMENTS PEP and procedure-related complications. RESULTS NKS was performed in 94 of 732 patients (12.8%) and was successful in achieving bile duct access in 80 of 94 patients (85%). Cannulation success in the entire group was 717 of 732 patients (97.7%). The overall frequency of PEP following NKS was 14.9% (14 of 94 patients) compared with 6.1% (39 of 638 patients) without NKS (P < .001). The incidence of PEP increased with an increasing number of attempts at cannulating the papilla. Pancreatic stents were inserted in 22 patients, 5 of whom developed pancreatitis. In multivariate analysis, independent predictors of PEP were as follow: female sex (odds ratio [OR] = 3.5, P = .028), suspected sphincter of Oddi dysfunction (SOD) (OR = 9.7, P < .001), partial pancreatic drainage (OR = 4.8, P = .011), 10 to 14 attempts at papilla cannulation (OR = 4.4, P = .031), and >/=15 attempts at papilla cannulation (OR = 9.4, P = .013). NKS was not an independent predictor of PEP. There were no perforations, no major bleeding, and no cases of severe pancreatitis in the NKS group. LIMITATIONS Nonrandomized for NKS intervention. CONCLUSIONS The number of attempts at cannulating the papilla is independently associated with PEP, and the risk increases with an increasing number of attempts. NKS is not an independent predictor of PEP.

Synchronous primary adenocarcinoma, mucosa-associated lymphoid tissue lymphoma and a stromal tumor in a Helicobacter pylori-infected stomach.

Abstract We report the case of a 78‐year‐old man with Helicobacter pylori infection and three primary neoplasms of the stomach: adenocarcinoma, mucosa‐associated lymphoid tissue (MALT) lymphoma and a gastrointestinal stromal cell tumor. Helicobacter pylori infection is associated with gastric carcinoma and MALT lymphoma, although their simultaneous occurrence is rare. Gastrointestinal stromal cell tumors have not been associated with infection to date. This appears to be the first report of the synchronous occurrence of these three gastric tumors.

Iron deficiency anaemia: a review of diagnosis, investigation and management.

Iron deficiency anaemia (IDA) is the most common form of anaemia worldwide. In men and postmenopausal women the commonest cause of IDA is blood loss from lesions in the gastrointestinal tract, making it a common cause of referral to gastroenterologists. Causes of IDA relate either to blood loss or iron malabsorption. After confirmation with laboratory tests, gastrointestinal evaluation is almost always indicated to exclude gastrointestinal malignancy. Specific patient groups such as premenopausal women, patients with low-normal ferritin and iron-deficient patients without anaemia may need an individualized approach. A small proportion of patients have recurrent or persistent IDA despite negative standard endoscopies. These patients with obscure gastrointestinal bleeding usually require evaluation of the small bowel with capsule endoscopy or double balloon enteroscopy. Treatment should involve prompt iron replacement plus diagnostic steps directed towards correcting the underlying cause of IDA. Oral iron replacement is cheap and effective, but parenteral (intravenous) therapy may be required due to intolerance, noncompliance or treatment failure with oral therapy.

Review article: the diagnosis and investigation of obscure gastrointestinal bleeding

Aliment Pharmacol Ther 2011; 34: 416–423

An intragastric balloon in the treatment of obese individuals with metabolic syndrome: a randomized controlled study.

There are limited controlled data for intragastric balloons (IGB) in obesity treatment. This randomized, controlled study evaluated the efficacy and safety of an IGB in obese individuals with metabolic syndrome (MS).

SINGLE-01: a randomized, controlled trial comparing the efficacy and depth of insertion of single- and double-balloon enteroscopy by using a novel method to determine insertion depth.

BACKGROUND Single-balloon enteroscopy (SBE) was introduced as an alternative to double-balloon enteroscopy (DBE) for the investigation and management of small-bowel conditions. To date, there is only 1 randomized, controlled trial comparing SBE and DBE in a Western population. OBJECTIVE To compare the 2 instruments in a Western population to assess for differences in clinical outcomes and insertion depth (ID). A novel method to determine ID by counting folds on withdrawal was used. DESIGN Multicenter, randomized, controlled trial. SETTING University hospitals in Melbourne and Sydney, Australia. PATIENTS Patients with suspected or proven small-bowel disease. INTERVENTIONS SBE and DBE. MAIN OUTCOME MEASUREMENT The primary endpoint was diagnostic yield (DY). Secondary endpoints were therapeutic yield (TY), procedure times, and ID. An intention-to-treat analysis was performed. RESULTS A total of 116 patients were screened, and 107 patients were enrolled between July 2008 and June 2010, in whom 119 procedures were undertaken (53 SBEs and 66 DBEs). DY was 57% for SBE and 53% for DBE (P = .697). TY was 32% for SBE and 26% for DBE (P = .490). The median enteroscopy times were identical for SBE and DBE at 60 minutes. The mean ID by the fold-counting method for antegrade procedures was 201.1 folds for SBE and 258.6 folds for DBE (P = .046). After multiple comparisons adjustment, this difference did not reach statistical significance. Mean IDs by using the visual estimation method for SBE and DBE were, respectively, 72.1 cm and 75.2 cm (P = .835) for retrograde procedures and 203.8 cm and 234.1 cm (P = .176) for antegrade procedures. LIMITATIONS Unable to reach target sample size, mostly single-center recruitment, novel method to determine ID, which requires further validation. CONCLUSIONS SBE has DY, TY, and procedure times similar to those of DBE. There were no statistically significant differences in ID between SBE and DBE. By using the fold-counting method for antegrade procedures, the estimated IDs for SBE and DBE were 201.1 folds versus 258.6 folds (P = .046; P = not significant after adjustment for multiple comparisons). ( CLINICAL TRIAL REGISTRATION NUMBER ACTRN12609000917235.).

Hyoscine butylbromide administered at the cecum increases polyp detection: a randomized double-blind placebo-controlled trial.

BACKGROUND AND STUDY AIMS Removal of colonic polyps prevents progression of colonic neoplasia. Miss rates of polyps range from 5 % to 32 %. The effect of colonic contractility on polyp detection has not been studied adequately. Hyoscine butylbromide results in colonic spasmolysis and may improve polyp detection. PATIENTS AND METHODS Patients undergoing colonoscopy for standard indications were included and randomized to receive either 20  mg hyoscine butylbromide or placebo at cecal intubation. Operators were blind to the intervention. Data on indication, preparation, sedation, colonoscope type, times of insertion/withdrawal, polyps, and failure were recorded. The primary end point was the number of polyps detected per patient. Secondary endpoints were adenoma detection rate and polyp detection rate. RESULTS A total of 303 patients received hyoscine butylbromide and 298 received placebo. More polyps per patient were identified in the hyoscine group than in the placebo group (0.91 vs. 0.70; P = 0.044). Adenoma detection rate and polyp detection rate were higher in the hyoscine arm but not significantly different (27.1 % vs. 21.8 % [P = 0.13] and 43.6 % vs. 36.6 % [P = 0.08], respectively). After adjusting for confounding variables, the odds of detecting any polyp were 1.56 higher in the hyoscine than the placebo group (95 % confidence interval [CI] 1.09 - 2.21, P = 0.014). The adjusted odds of detecting any adenoma were 1.62 higher in the hyoscine group compared with the placebo group (95 %CI 1.09 - 2.42, P = 0.017). There were no differences in baseline characteristics between the groups. No adverse colonoscopy-related events were recorded. One patient experienced transient tachycardia without sequelae. CONCLUSIONS Hyoscine butylbromide administered at the cecum aids polyp detection. Further studies are required to determine the contribution of colonic spasm to polyp miss rates.

A prospective trial of variable stiffness pediatric vs. standard instrument colonoscopy

BACKGROUND The pediatric variable stiffness colonoscope is believed to have theoretical advantages over the standard colonoscope, however a systematic evaluation of this instrument in routine clinical practice involving adult patients is lacking. METHODS Consecutive patients (blinded) undergoing colonoscopy in an outpatient endoscopy center by one of 4 experienced colonoscopists had the procedure performed with a standard colonoscope (n=384) or pediatric variable stiffness colonoscope (n=413). Failure to negotiate the sigmoid colon within 10 minutes was regarded as a failure and, if suitable, the patient was crossed over to colonoscopy with the alternative instrument. RESULTS Median (95% CI) time to the cecum was significantly faster in the pediatric variable stiffness colonoscope group (odds ratio 5.0: 95% CI[4.7,5.3] minutes) compared with the standard colonoscope group (odds ratio 5.5: 95% CI[5.2,5.8] minutes, p=0.01). There were 22 failures overall (2.8%), 14 in the standard colonoscope group (3.6%) and 8 in the pediatric variable stiffness colonoscope group (1.9%; p=0.1). With regard to the 14 failures in the standard colonoscope group, colonoscopy was attempted with the pediatric variable stiffness colonoscope in 13 and completed successfully in 12 (92%). The pediatric variable stiffness colonoscope was superior in cases of severe stenosing diverticular disease; two of 27 examinations with the pediatric variable stiffness colonoscope were rated as failed vs. 12 of 18 with the standard colonoscope (p<0.001). CONCLUSIONS Intubation time was faster with the pediatric variable stiffness colonoscope, but use of this instrument was not associated with a superior cecal intubation rate compared with the standard colonoscope. However, in patients with severe stenosing diverticular disease, the intubation rate with the pediatric variable stiffness colonoscope was superior.