Deepak Agrawal

Spiral enteroscopy with the new DSB overtube: a novel technique for deep peroral small-bowel intubation

BACKGROUND AND STUDY AIMS Spiral enteroscopy is a new technique for deep small-bowel intubation that uses a special overtube (Discovery Small Bowel, DSB) to pleat small bowel. The aims of this prospective study were to evaluate the use of a new-design DSB over new, longer and smaller-diameter enteroscopes, the Fujinon EN-450T5 and the Olympus SIF-Q180. PATIENTS AND METHODS This is a prospective study of 75 patients at two referral centers. All enteroscopies were performed by two experienced endoscopists. Patients underwent spiral enteroscopy perorally with the DSB and either the Fujinon EN-450T5 or the Olympus SIF-Q180 enteroscope. Procedure time and depth of insertion past the ligament of Treitz were determined for all patients. RESULTS Peroral spiral enteroscopy with DSB was performed in 50 patients with the Fujinon enteroscope and in 25 patients with the Olympus. Average estimated depth of insertion was 243 cm (range 50 - 380 cm) vs. 256 cm (range 50 - 400 cm) and the average time to reach this depth was 18.7 minutes (range 7 - 52 minutes) vs. 16.2 minutes (range 7 - 33 minutes) in the Fujinon and the Olympus groups respectively. Overall findings were 10 angiodysplasias, 2 small-bowel tumors, 1 Peutz-Jeghers polyp, 1 case of celiac sprue, 2 of small-bowel strongyloidiasis, and 2 small-bowel ulcers. All angiodysplasias were treated with bipolar cauterization. Biopsies were taken from the small-bowel tumors. There were no major complications. CONCLUSIONS The new DSB is a means of rapid, safe, and effective deep small-bowel intubation. Depth of insertion into the small bowel and total procedure time compare favorably with other deep enteroscopy techniques. The DSB performed equally well with both enteroscopes.

Spiral enteroscopy: a novel method of enteroscopy by using the Endo-Ease Discovery SB overtube and a pediatric colonoscope

BACKGROUND Pathologic diagnosis and therapeutic interventions on the small bowel have been difficult and challenging for gastroenterologists. In the last few years, significant advances have been made in this direction. New diagnostic and therapeutic modalities for visualizing the small bowel have been introduced. Furthermore, increased indications for small-bowel imaging and therapeutics have been recognized. However, the currently available methods have limitations, and development of newer, rapid, minimally invasive, safe, and readily available techniques is needed. OBJECTIVE Our purpose was to evaluate the safety and efficacy of a novel method of spiral enteroscopy using a specialized overtube (Endo-Ease Discovery SB) with a pediatric colonoscope (PCF-140L). DESIGN Case series. SETTING Two international tertiary referral centers. PATIENTS Twenty-seven adult patients with obscure GI bleeding were enrolled in this study. INTERVENTION Spiral enteroscopy with the Endo-Ease Discovery SB overtube and a pediatric colonoscope. MAIN OUTCOME MEASUREMENTS Depth of insertion, time of procedure, and complications. RESULTS Average depth of insertion was 176 cm (range 80-340 cm) from ligament of Treitz, and average time of procedure was 36.5 minutes (range 90-65 minutes). Eleven patients had minor complications, which included minimal mucosal trauma and sore throat. LIMITATIONS Small number of patients with a case series study design. CONCLUSIONS Preliminary data suggest that use of Endo-Ease Discovery SB overtube for enteroscopy is a safe and effective technique for visualization of the small bowel.

Immunogenicity of a Recombinant Human Immunodeficiency Virus (HIV)–Canarypox Vaccine in HIV-Seronegative Ugandan Volunteers: Results of the HIV Network for Prevention Trials 007 Vaccine Study

In the first preventative human immunodeficiency virus (HIV) vaccine study to be carried out in Africa, 40 HIV-seronegative Ugandan volunteers were randomly assigned to receive a canarypox vector containing HIV-1 clade B (env and gag-pro) antigens (ALVAC-HIV; n = 20), control vector containing the rabies virus glycoprotein G gene (n = 10), or saline placebo (n = 10). Cytotoxic T lymphocyte activity against target cells expressing clade A, B, and D antigens was assessed using standard chromium-release and confirmatory interferon-gamma enzyme-linked immunospot (ELISPOT) assays. Neutralizing antibody responses to cell line-adapted strains and primary isolates in all 3 clades were also tested. Twenty percent of vaccine recipients generated detectable cytolytic responses to either Gag or Env, and 45% had vaccine-induced HIV-specific CD8(+) T cell responses, as measured by the ELISPOT assay. In contrast, only 5% of the control group had vaccine-specific responses. Neutralizing antibodies against primary and laboratory-adapted HIV-1 clade B strains were seen in 10% and 15% of vaccine recipients, respectively, but responses against clades A and D were not detected. Although the immunogenicity of this clade B-based vaccine was low, ALVAC-HIV elicited CD8(+) T cell responses with detectable cross-activity against clade A and D antigens in a significant proportion of vaccine recipients.

Guidelines for privileging, credentialing, and proctoring to perform GI endoscopy

Ashley L. Faulx, MD, FASGE, Jenifer R. Lightdale, MD, MPH, FASGE, NASPGHAN representative, Ruben D. Acosta, MD, Deepak Agrawal, MD, MPH, David H. Bruining, MD, Vinay Chandrasekhara, MD, Mohamad A. Eloubeidi, MD, MHS, FASGE, Suryakanth R. Gurudu, MD, FASGE, Loralee Kelsey, BSN, RN, CGRN, SGNA representative, Mouen A. Khashab, MD, Shivangi Kothari, MD, V. Raman Muthusamy, MD, FASGE, Bashar J. Qumseya, MD, MPH, Aasma Shaukat, MD, MPH, FASGE, Amy Wang, MD, FASGE, Sachin B. Wani, MD, Julie Yang, MD, John M. DeWitt, MD, FASGE, Chair

Evaluation of antigen-specific responses using in vitro enriched T cells

Antigen-specific lymphocytes are important in the immune response to viral infection. Peripheral blood mononuclear cells (PBMC) are traditionally used as a source of effector cells in most immunological studies. We described here the use of the bispecific monoclonal antibodies (BSMAB) anti CD3:CD8 (CD3,8) and anti CD3:CD4 (CD3,4B) to expand and selectively enrich CD4+ and CD8+ T cells populations, respectively. The expanded cells demonstrated >90% CD3+CD4+ or CD3+CD8+ by 14 days. We measured HIV- and CMV-specific responses of these subset-enriched T cell and found that sensitivity and specificity is similar or higher when compared to PBMC in various cellular immunology assays (CMI). Vbeta analysis of BSMAB-enriched cells demonstrated comparable repertoire to the parent PBMC. Although both CD45RA(hi) and CD45RO(hi) cell populations were expanded with the BSMAB, selective subset depletion demonstrated that the antigen-specific T cell responses were restricted to the initial CD45RO(hi) memory effector subgroup. In conclusion, BSMAB in vitro enrichment of T cells allows significant expansion of the cell population without loss of specificity. This technique of cell expansion permits studies of T cell subset function in situations where the initial cell source is scarce, and presents an alternative for viable and functional T cells in immunological assays.

Endoscopic mucosal resection with full-thickness closure for difficult polyps: a prospective clinical trial

BACKGROUND Large flat polyps may be more amenable to endoscopic resection if an endoluminal method for full-thickness closure were available. OBJECTIVE Assessment of feasibility of endoluminal full-thickness closure. DESIGN Prospective, open-label, interventional study. SETTING Tertiary referral center. PATIENTS Patients referred to surgery for endoscopically unresectable polyps. INTERVENTIONS Endoscopic resection of colon polyps with full-thickness closure of the resection site under laparoscopic observation by using a novel needle and T-tag tissue apposition system. MAIN OUTCOME MEASUREMENTS Feasibility and efficacy of tissue apposition with the TAS during procedure and safety at 3-month follow-up. RESULTS Nineteen patients referred with unresectable polyps at initial colonoscopy were enrolled. Five patients had successful endoscopic polypectomy and did not require closure of the resulting defect. In 6 patients, the polyp could not be resected endoscopically and surgical resection was performed. Use of the TAS was attempted in 8 and successfully deployed in 7 patients; there was 1 device malfunction. Deployment of the tags through the needle could be performed more safely under laparoscopic guidance when the resection site was visible from the peritoneal cavity. The location of the tags could not be safely determined when the needle was directed toward the retroperitoneal or mesenteric site. There were no long-term complications. Colonoscopy at a 3-month follow-up showed normal healed mucosa with the sutures and anchoring devices in place. LIMITATIONS Small number of patients, single-center feasibility study without control arm. CONCLUSIONS Full-thickness endoluminal closure of large polypectomy sites in humans is feasible for selected difficult polyps. Closure should be performed with concurrent laparoscopic guidance to maximize safety. ( CLINICAL TRIAL REGISTRATION NUMBER NCT00553436.).

Variability in measurements of pancreatic cyst size among EUS, CT, and magnetic resonance imaging modalities.

BACKGROUND Cyst size is an important factor in the management of pancreatic cysts, both in predicting the need for surgery and the frequency of follow-up. OBJECTIVE To determine agreement and precision of EUS, CT, and magnetic resonance imaging (MRI) modalities in the evaluation of pancreatic cyst diameter. DESIGN Retrospective chart review. SETTING Tertiary-care center, January 2000 to June 2009. PATIENTS This study involved 175 patients presenting for EUS evaluation of pancreatic cysts, with size measured by at least two of the aforementioned imaging studies within a 90-day period. MAIN OUTCOME MEASUREMENTS Largest cyst diameter from EUS, CT, MRI/MRCP, and surgical pathology. RESULTS A total of 175 patients underwent EUS. Seventy-three had CT plus EUS, 33 had MRI/MRCP plus EUS, 23 had MRI/MRCP plus CT, and 15 had all imaging studies, occurring within 90 days of each other. Median size differences between studies: EUS and CT (ie, absolute value of size determined by EUS minus size determined by CT) = 4 mm (range 0-25 mm), EUS and MRI = 4 mm (range 0-17 mm), CT and MRI = 3 mm (range 2-20 mm). Median size differences for surgical pathology specimens compared with results of 12 EUS, 13 CT, and 8 MRI/MRCP studies were as follows: EUS and pathology = 9.5 mm (range 0-20 mm), CT and pathology = 5 mm (range 0-21 mm), MRI and pathology = 5.5 mm (range 2-44 mm). LIMITATIONS Interobserver variability and small sample of surgical pathology cysts. CONCLUSION There is considerable variation in size estimates of pancreatic cysts by different imaging modalities, which practitioners should take into account when making management decisions. Use of a single imaging modality is recommended during follow-up. The precision of imaging studies for measuring pancreatic cysts must be prospectively defined if change in size is to be reliably used for clinical management.

Delivery of Exogenous Protein Antigens to Major Histocompatibility Complex Class I Pathway in Cytosol

A fragment of anthrax lethal factor possesses the interesting function of delivering recombinant protein antigens through the classical major histocompatibility complex (MHC) class I pathway. This region of the lethal factor lacks the domain associated with anthrax cytotoxicity and functions independently of its binary partner, protective antigen. Experiments that used inhibitors at different steps of the MHC class I pathway supported this hypothesis. Application of this discovery to current T cell assays allows for the measurement of cytotoxic T lymphocyte function without resorting to live vectors and provides a useful new tool to design and test T cell-dependent vaccines.

Management of idiopathic Budd-Chiari syndrome with primary stent placement: early results.

PURPOSE To evaluate the utility of primary stent placement in the management of Budd-Chiari syndrome (BCS) secondary to idiopathic inferior vena caval (IVC) obstruction. PATIENTS AND METHODS The case records of nine patients (four women, five men), ranging in age from 22 to 58 years (median, 26 years), with idiopathic IVC obstruction were reviewed. Hepatosplenomegaly, esophageal varices, and prominent collateral veins were found in all patients, while four also had ascites. Hepatic functional reserve was graded as Child class A in three patients and class B in the remaining six. All had at least one patent hepatic vein opening into the IVC below the site of occlusion. Percutaneous angioplasty of the IVC was performed, followed by the placement of double-skirt Gianturco-Rösch or hybrid Gianturco stents. Clinical follow-up was supplemented with duplex ultrasound (n = 8), endoscopy (n = 4), and cavography (n = 2). RESULTS Caval lesions were segmental. Revascularization was technically successful in all patients. The median pressure gradient across the lesion dropped from 38 mm Hg (range, 27-61 mm Hg) to 15 mm Hg (range, 10-20 mm Hg) (P = .008). Residual stenosis after stent placement ranged from 9% to 40% (median, 20%). One patient died of presumed pulmonary embolism; another patient experienced an episode of epistaxis. The procedure was followed by regression of signs and symptoms in the eight survivors. During the follow-up period (range, 3-31 months; median, 7 months) the IVC remained patent in all patients, and clinical features of BCS did not recur. CONCLUSION Primary stent placement could serve as the first line of treatment in patients with idiopathic BCS when the underlying lesion is not amenable to angioplasty.

Outreach invitations for FIT and colonoscopy improve colorectal cancer screening rates: A randomized controlled trial in a safety-net health system.

The effectiveness of colorectal cancer (CRC) screening is limited by underuse, particularly among underserved populations. Among a racially diverse and socioeconomically disadvantaged cohort of patients, the authors compared the effectiveness of fecal immunochemical test (FIT) outreach and colonoscopy outreach to increase screening participation rates, compared with usual visit‐based care.