Constantinos P. Anastassiades

The Impact of Bowel Cleansing on Follow-Up Recommendations in Average-Risk Patients With a Normal Colonoscopy

OBJECTIVES:Repeat colonoscopy in 10 years after a normal screening colonoscopy is recommended in an average-risk patient, and it has been proposed by American Gastroenterological Association (AGA), American College of Gastroenterology (ACG), and American Society for Gastrointestinal Endoscopy (ASGE) as a quality measure. However, there are little quantitative data about adherence to this recommendation or factors that may improve adherence. Our study quantifies adherence to this recommendation and the impact of suboptimal bowel preparation on adherence.METHODS:In this retrospective database study, endoscopy reports of average-risk individuals ≥50 years old with a normal screening colonoscopy were reviewed. Quality of colon cleansing was recorded using the Aronchick scale as excellent, good, fair, or poor. Main outcome measurements were quality of bowel preparation and recommendation for timing of repeat colonoscopy. Recommendations were considered consistent with guidelines if 10-year follow-up was documented after excellent, good, or fair prep or if ≤1-year follow-up was recommended after poor prep.RESULTS:Among 1,387 eligible patients, recommendations for follow-up colonoscopy inconsistent with guidelines were seen in 332 (23.9%) subjects. By bowel preparation quality, 15.3% of excellent/good, 75% of fair, and 31.6% of poor bowel preparations were assigned recommendations inconsistent with guidelines (P<0.001). Patients with fair (odds ratio=18.0; 95% confidence interval 12.0–28.0) were more likely to have recommendations inconsistent with guidelines compared with patients with excellent/good preps.CONCLUSIONS:Recommendations inconsistent with guidelines for 10-year intervals after a normal colonoscopy occurred in >20% of patients. Minimizing “fair” bowel preparations may be a helpful intervention to improve adherence to these recommendations.

Cap-assisted ERCP with a forward-viewing gastroscope as a rescue endoscopic intervention in patients with Billroth II anatomy.

BackgroundERCP, especially therapeutic, is difficult in patients with Billroth II surgical reconstruction and is associated with a higher rate of complications. This has led to controversy on the choice between a forward-viewing and side-viewing endoscope for performing the procedure. A previous case series from Asia reported a high rate of success with a cap-fitted ERCP technique. To our knowledge, the utility of cap-assisted ERCP with a forward-viewing gastroscope when other techniques fail has not been reported. We describe and demonstrate a novel rescue approach using a cap-fitted, forward-viewing gastroscope in patients with Billroth II anatomy, when attempts with duodenoscopes, pediatric colonoscopes, and gastroscopes previously failed.MethodsRetrospective case series. Inclusion criteria were: (a) documented Billroth II anatomy; and (b) use of cap-assisted ERCP as a rescue intervention on the first endoscopic encounter after failed attempts to perform ERCP with a duodenoscope. Patients were excluded if they successfully underwent ERCP with a duodenoscope. One advanced endoscopist and one advanced endoscopy fellow performed all but one of the procedures.ResultsFive cap-assisted ERCP procedures were performed in three patients with Billroth II anatomy. A wide variety of diagnostic and therapeutic endoscopic maneuvers were technically feasible and successful, including the endoscopic treatment of an afferent limb perforation caused by a duodenoscope.ConclusionsCap-assisted ERCP is a novel and underutilized technique that adds to the armamentarium of experienced therapeutic endoscopists. This approach may help ensure a successful endoscopic outcome and spare patients with Billroth II anatomy a percutaneous or surgical approach when ERCP with a duodenoscope, pediatric colonoscope or non-cap-fitted gastroscope fails.

Precut needle-knife sphincterotomy in advanced endoscopy fellowship

a c Many advanced endoscopists finish their fellowship with very little training on how to perform needle-knife sphincterotomies. It has been described as a procedure not for the faint of heart and a technique that should not be substituted for lack of experience. I recently spoke to John Goff, creator of the transpancreatic septotomy technique, and asked for his thoughts on the subject. His reply was “know your anatomy, know when to stop, know when to regroup and when to try again the next day.” In this month’s Fellows’ Corner, Drs Anastassiades and Saxna share with us the tips and tricks of successful mastery f the needle-knife technique during advanced fellowship. he purpose of this article is to share their recent personal xperiences and thoughts on the current training during dvanced fellowship to help current and prospective felows make the most of their training experience.

Predictors of suboptimal bowel preparation in asymptomatic patients undergoing average-risk screening colonoscopy

AIM To identify risk factors for a suboptimal preparation among a population undergoing screening or surveillance colonoscopy. METHODS Retrospective review of the University of Michigan and Veterans Administration (VA) Hospital records from 2009 to identify patients age 50 and older who underwent screening or surveillance procedure and had resection of polyps less than 1 cm in size and no more than 2 polyps. Patients with inflammatory bowel disease or a family history of colorectal cancer were excluded. Suboptimal procedures were defined as procedure preparations categorized as fair, poor or inadequate by the endoscopist. Multivariable logistic regression was used to identify predictors of suboptimal preparation. RESULTS Of 4427 colonoscopies reviewed, 2401 met our inclusion criteria and were analyzed. Of our population, 16% had a suboptimal preparation. African Americans were 70% more likely to have a suboptimal preparation (95%CI: 1.2-2.4). Univariable analysis revealed that narcotic and tricyclic antidepressants (TCA) use, diabetes, prep type, site (VA vs non-VA), and presence of a gastroenterology (GI) fellow were associated with suboptimal prep quality. In a multivariable model controlling for gender, age, ethnicity, procedure site and presence of a GI fellow, diabetes [odds ratio (OR) = 2.3; 95%CI: 1.6-3.2], TCA use (OR = 2.5; 95%CI: 1.3-4.9), narcotic use (OR = 1.7; 95%CI: 1.2-2.5) and Miralax-Gatorade prep vs 4L polyethylene glycol 3350 (OR = 0.6; 95%CI: 0.4-0.9) were associated with a suboptimal prep quality. CONCLUSION Diabetes, narcotics use and TCA use were identified as predictors of poor preparation in screening colonoscopies while Miralax-Gatorade preps were associated with better bowel preparation.

Acute pancreatitis complicated by an abdominal mass

Commentary In “The Red-Headed League” case, Sherlock Holmes told his dear Watson that the two “shared (Holmes’) love of all that is bizarre and outside the conventions and humdrum routine of everyday life.” Well, Holmes and Watson would have loved this case of gastric ischemia, portal venous gas, and gastric emphysema in a woman who survived it all, apparently none the less for wear. Ischemic gastric necrosis is a rare occurrence, in large measure because of the stomach’s abundant blood supply, which includes 5 major arteries (right and left gastric arteries, right and left gastroepiploic arteries, and the short gastric vessels) as well as numerous minor and collateral vessels. Studies in cadavers have shown that complete gastric wall vascular filling is possible with only one patent major artery, and in animal models it is only after ligation of all the major arteries and most of the collateral circulation that gastric necrosis can be produced. Despite this great wealth of arterial circulation and the stomach’s resistance to ischemia, gastric necrosis has been seen with occlusive splanchnic arterial disease, excessive distention of the stomach, intrathoracic herniation, volvulus, and ingestion of corrosives and certain medications such as nonsteroidal anti-inflammatory drugs, or as a result of the best of iatric intention from therapeutic embolization and laparoscopic gastric banding. In healthy volunteers with normal splanchnic vasculature, transient gastric ischemia has been shown during maximal exercise as judged by intragastric PCO2 tonometry. In modern facilities, diagnosis is usually made upon CT scanning (gastric pneumatosis, pneumoperitoneum, and portal venous gas), at endoscopy, or in the surgical theater. Gastric emphysema or its much more malignant cousin, emphysematous gastritis, may be seen as air either dissects into the gastric wall with the former or is locally produced by various bacteriadmost commonly streptococci, Escherichia coli, Staphylococcus aureus, or Enterobacter and Pseudomonasdin the latter. Hepatic portal venous gas is merely the last leg of the intramural gas’ journey via draining splanchnic veins, but its presence portends a bad prognosis. Hepatic portal venous gas has a high carbon dioxide content and therefore is absorbed and resolves quickly if gas production is not continued. The mid-19th century popular agnostic orator Robert G. Ingersoll once said, “Truth scorns the assistance of miracle.” Well, the truth is that this patient lived, and I find that wonderfully miraculous. Lawrence J. Brandt, MD Associate Editor for Focal Points