Erwin Santo

A prospective cohort study evaluating a novel colonoscopy platform featuring full-spectrum endoscopy

BACKGROUND AND STUDY AIMSnAlthough colonoscopy is the criterion standard for detecting colorectal adenomas and cancers, a significant percentage of adenomas are missed with this technique. We aimed to establish the feasibility, usability, and safety of a novel colonoscopy platform featuring full-spectrum endoscopy (FUSE).nnnPATIENTS AND METHODSnThis was a prospective, single-center pilot and feasibility study. In total, 50 individuals, ages 18 - 70 years, underwent colonoscopy featuring FUSE (up to 330° field of view) for colorectal cancer screening, polyp surveillance, or diagnostic evaluation. Study end points included success of cecal intubation, time to cecal intubation, withdrawal time, total procedure time, success of therapeutic interventions, adverse events, and endoscopists subjective evaluation of FUSE.nnnRESULTSnCecal intubation was achieved in 50/50 individuals (100 %). Time to cecum (minutes, mean ± SD) was 3.1 ± 1.5 minutes, withdrawal time 12.7 ± 4.4 minutes, and total procedure time 15.3 ± 4.6 minutes. In 22/50 cases (44 %), 26 therapeutic interventions were performed: 19 (73.1 %) biopsies and 7 (26.9 %) polypectomies. No acute or delayed adverse events were observed. Patient satisfaction and endoscopist subjective evaluation were high.nnnCONCLUSIONSnA colonoscopy platform featuring full-spectrum endoscopy appears feasible, usable, and safe. These results represent an important advance in colonoscopy imaging technology and should be further pursued in comparative human studies.

Comparison of standard forward-viewing mode versus ultrawide-viewing mode of a novel colonoscopy platform: a prospective, multicenter study in the detection of simulated polyps in an in vitro colon model (with video)

BACKGROUNDnAlthough colonoscopy is the criterion standard for detecting colorectal adenomas and cancers, a significant percentage of adenomas are missed.nnnOBJECTIVEnTo compare forward-viewing with ultrawide-viewing colonoscopy in the detection of simulated colon polyps in an in vitro colon model.nnnDESIGNnProspective, multicenter.nnnSETTINGnSix endoscopy units (3 in the United States and 3 in Israel).nnnPATIENTSnIn vitro colon model with simulated colon polyps (n = 21 metallic beads).nnnINTERVENTIONSnDetection of simulated colon polyps on colonoscope withdrawal.nnnMAIN OUTCOME MEASUREMENTSnIncremental detection of simulated colon polyps and endoscopist evaluation of the usability, visibility, and maneuverability of ultrawide-viewing colonoscopy.nnnRESULTSnOn forward-viewing colonoscopy, the number of simulated polyps (mean ± standard deviation) detected per endoscopist was 11.1 ± 2.3 polyps, a 52.9% detection rate. Simulated polyp detection rates per colon segment were 3.0 ± 0.93 (60.0%) right colon, 2.4 ± 0.87 (48.0%) transverse colon, and 5.7 ± 1.5 (51.8%) left colon. On ultrawide-viewing colonoscopy, the simulated polyp detection rate per endoscopist significantly increased to 18.0 ± 1.98 polyps, an overall 85.7% polyp detection rate (P < .001). Simulated polyp detection rates were also significantly higher by using the ultrawide-viewing mode in each colon segment, 4.5 ± 0.65 polyps (90.0%) right colon, 4.0 ± 0.87 (80.0%) polyps transverse colon, and 9.6 ± 1.28 polyps (87.3%) left colon (all comparisons, P < .001). Importantly, the ultrawide-viewing mode detected significantly more hidden simulated polyps (81.9% vs 31.9%, P < .0001).nnnLIMITATIONSnNonrandomized design, use of a colon model, and simulated colon polyps.nnnCONCLUSIONSnUltrawide-view colonoscopy significantly improved simulated polyp detection in a colon model. Clinical studies in human subjects should be pursued to further evaluate this new endoscopic technology.

Comparison of adenoma detection and miss rates between a novel balloon colonoscope and standard colonoscopy: a randomized tandem study

BACKGROUND AND STUDY AIMSnAlthough colonoscopy is the gold standard for colorectal cancer screening, a significant number of adenomas are still missed during standard colonoscopy, often because they are hidden behind colonic folds and flexures. The aim of this study was to assess the ability of a novel balloon colonoscope (G-EYE endoscope; Smart Medical Systems, Raanana, Israel) to increase adenoma detection and reduce the miss rate compared with standard colonoscopy.nnnPATIENTS AND METHODSnThis was a multicenter, randomized, prospective, controlled study in patients (ageu200a≥u200a40 years) undergoing colonoscopy for screening or diagnostic work-up (including surveillance). Patients underwent same-day, back-to-back tandem colonoscopy. Patients in Group A underwent standard colonoscopy followed by balloon colonoscopy, and patients in Group B underwent balloon colonoscopy followed by the standard technique. The adenoma detection and miss rates were compared between the two colonoscopy procedures.nnnRESULTSnA total of 126 patients were enrolled and randomized into Group A (nu200a=u200a60) or Group B (nu200a=u200a66). The adenoma miss rate of balloon colonoscopy was significantly lower than that of standard colonoscopy (7.5u200a% vs. 44.7u200a%; Pu200a=u200a0.0002). The detection of additional adenomas by balloon colonoscopy was significant (81.0u200a%; Pu200a=u200a0.0002), in particular, the relative amount of adenomas detected in the ascending colon by balloon colonoscopy was 41u200a% versus 14u200a% for standard colonoscopy.nnnCONCLUSIONSnA novel balloon colonoscopy technique detected significantly more adenomas than standard colonoscopy, and missed fewer adenomas. Balloon colonoscopy has the potential to increase the effectiveness of colorectal cancer screening and surveillance colonoscopy.

Balloon dilatation for symptomatic gastric sleeve stricture

During recent years, laparoscopic sleeve gastrectomy (LSG) for morbidly obese patients has been gaining popularity. Several studies have reported that it yields a percentage of weight loss similar to that of Roux-en-Y gastric bypass (RYGB). Moreover, LSG has demonstrated a good safety profile and is not as technically demanding as RYGB. In addition, LSG has fewer late adverse events, such as nutrient and vitamin deficiencies, marginal ulceration, and internal hernia. Last, it leaves the gut in continuity and allows future ERCP without difficulty. Nevertheless, because of a long staple line and altered intragastric pressures, sleeve gastrectomy is prone to some serious adverse events, such as staple line leakage in 1% to 20% of patients, bleeding, and sleeve stricture. The reported prevalence of sleeve stricture is between 0.7% and 4% in different studies. Early strictures are symptomatic in the first 6 weeks after surgery. Strictures may be caused by imbrications of the staple line, overretraction of the greater curvature during stapling, progressive rotation of the staple line, and scarring of the sleeve in a kinked rotation. Whether the size of the bougie is related to the incidence of strictures remains controversial. The incisura angularis is the site most prone to stricture development. Typical symptoms of sleeve stenosis include dysphagia, vomiting, and rapid weight loss. Different therapeutic approaches have been suggested including conservative

MedJet – a new CO2-based disposable cleaning device allows safe and effective bowel cleansing during colonoscopy: a pilot study

BACKGROUND AND STUDY AIMSnComplete bowel cleansing is mandatory for effective colon cancer screening and surveillance. The aim of the current pilot study, which was conducted in humans, was to test the safety and efficiency of a newly developed disposable cleaning device, the MedJet, for intraprocedural bowel cleansing.nnnPATIENTS AND METHODSnPatients with screening or surveillance colonoscopy after previous polypectomy were included. The colonoscope was first inserted to the cecum and the overall cleansing was assessed according to the Ottawa scale. The MedJet device was used if colon cleansing had been incomplete. The MedJet catheter was passed over the working channel of the colonoscope and the colon was cleaned during withdrawal. The MedJet device delivered controlled jets comprising compressed CO2 and minimal amounts of sterile water, which allowed disintegration and removal of residual stool. The efficiency of cleaning was assessed according to the Boston scale.nnnRESULTSnA total of 32 patients (16 female; mean age 61 years) were treated with the device. No device-related adverse or serious adverse events were noted. MedJet application during withdrawal provided effective and significant improvement in bowel cleansing (P = 0.005). Furthermore, 18 adenomas and 1 colon cancer, which were hidden behind stool remnants, could be identified in 11 patients following use of the MedJet device. However, the withdrawal times were prolonged (11.4±6.0 minutes) due to the additional cleaning procedure. All patients tolerated the procedure well.nnnCONCLUSIONSnThe new MedJet device enabled highly effective and safe bowel cleansing during colonoscopy. The catheter-based system was easy to use and CO2 was applied for cleansing. The procedure was well tolerated by patients.

Clinical presentation can predict disease course in patients with intraductal papillary mucinous neoplasm of the pancreas.

BackgroundPreoperative diagnosis of malignancy within intraductal papillary mucinous neoplasm of the pancreas (IPMN) solely by clinical or radiological findings is not always possible. We sought a correlation between preoperative clinico-radiological findings and outcome.MethodsA prospective database of pancreatic resections for IPMN (2002–2008) and a retrospective pathological revision of all pancreatic cancer specimens (1995–2001) were analyzed. The patients were grouped into asymptomatic with preoperative diagnosis of IPMN (group 1), symptomatic with a preoperative diagnosis of IPMN (group 2), and those with a preoperative diagnosis of pancreatic cancer whose specimen revealed a background of IPMN (group 3). The groups were compared for demographics, clinical presentation, pathological findings, and outcome.ResultsOf the 62 patients with IPMN, 19 were in group 1, 23 in group 2, and 20 in group 3. Their median age (range) was 65.6 (46–80), 67 (50–84), and 73.4 (57–86) years, respectively. The clinical presentation for groups 2 and 3 included abdominal pain (56% vs. 32 %), weight loss (8% vs. 52%), obstructive jaundice (4% vs. 57%), pancreatitis (22% and 5%), and new onset of diabetes (14% and 44%). Invasive cancer was found in one patient in group 1 (5.2%), two patients in group 2 (8.7%), and all patients in group 3. IPMN was present in 23 of 217 (10.6%) of all resected pancreatic cancer specimens. Five year survival for patients with invasive disease was 47% and 92% for patients with noninvasive disease (mean follow-up 37.6 months).ConclusionsBenign IPMN can usually be differentiated from adenocarcinoma preoperatively. The clinical presentation is highly indicative of disease course.

Use of sleeve-customized self-expandable metal stents for the treatment of staple-line leakage after laparoscopic sleeve gastrectomy

Bariatric procedures have emerged as a leading therapeutic approach in morbidly obese patients. Laparoscopic sleeve gastrectomy (LSG) was originally introduced as a bridge procedure before Roux-en-Y gastric bypass (RYGB) but has subsequently become a definitive procedure after demonstrating similar efficacy to that of RYGB for inducing weight loss. Moreover, LSG has demonstrated a good safety profile and is less technically demanding than RYGB. However, LSG is prone to some adverse events because of the long staple line and elevated intragastric pressure. These include staple-line leakage, bleeding, and sleeve stricture. The prevalence of staple-line leaks has been as high as 20% in some reports, but a more traditional estimate is 1% to 9%. The onset of leaks is defined as acute, early, late, or chronic depending on the time interval since surgery: up to 1 week, 1 to 6 weeks, 6 to 12 weeks, and more than 12 weeks, respectively. Immediate treatment usually includes surgical or percutaneous drainage, antibiotics, and nutritional support. After primary control of the leakage, further specific therapeutic approaches have been described: surgical

Role of glucose‐dependent insulinotropic polypeptide in adipose tissue inflammation of dipeptidylpeptidase 4‐deficient rats

Dipeptidyl peptidase 4 (DPP4) inhibitors, used in obese diabetic patients, reduce inflammation in several models. The role of chronic DPP4‐deficiency (DPP4‐) in diet‐induced obesity with respect to insulin sensitivity and adipose tissue inflammation was investigated.

Practice guidelines for endoscopic ultrasound-guided celiac plexus neurolysis

Objectives: The objective of guideline was to provide clear and relevant consensus statements to form a practical guideline for clinicians on the indications, optimal technique, safety and efficacy of endoscopic ultrasound guided celiac plexus neurolysis (EUS-CPN). Methods: Six important clinical questions were determined regarding EUS-CPN. Following a detailed literature review, 6 statements were proposed attempting to answer those questions. A group of expert endosonographers convened in Chicago, United States (May 2016), where the statements were presented and feedback provided. Subsequently a consensus group of 35 expert endosonographers voted based on their individual level of agreement. A strong recommendation required 80% voter agreement. The modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria were used to rate the strength of recommendations and the quality of evidence. Results: Eighty percent agreement was reached on 5 of 6 consensus statements, 79.4% agreement was reached on the remaining one. Conclusions: EUS-CPN is efficacious, should be integrated into the management of pancreas cancer pain, and can be considered early at the time of diagnosis of inoperable disease. Techniques may still vary based on operator experience. Serious complications exist, but are rare.

A multicenter randomized trial comparing a 25-gauge EUS fine-needle aspiration device with a 20-gauge EUS fine-needle biopsy device

BACKGROUND AND AIMSnSeveral studies have compared EUS-guided FNA with fine-needle biopsy (FNB), but none have proven superiority. We performed a multicenter randomized controlled trial to compare the performance of a commonly used 25-gauge FNA needle with a newly designed 20-gauge FNB needle.nnnMETHODSnConsecutive patients with a solid lesion were randomized in this international multicenter study between a 25-gauge FNA (EchoTip Ultra) or a 20-gauge FNB needle (ProCore). The primary endpoint was diagnostic accuracy for malignancy and the Bethesda classification (non-diagnostic, benign, atypical, malignant). Technical success, safety, and sample quality were also assessed. Multivariable and supplementary analyses were performed to adjust for confounders.nnnRESULTSnA total of 608 patients were allocated to FNA (nxa0= 306) or FNB (nxa0= 302); 312 pancreatic lesions (51%), 147 lymph nodes (24%), and 149 other lesions (25%). Technical success rate was 100% for the 25-gauge FNA and 99% for the 20-gauge FNB needle (Pxa0= .043), with no differences in adverse events. The 20-gauge FNB needle outperformed 25-gauge FNA in terms of histologic yield (77% vs 44%, Pxa0< .001), accuracy for malignancy (87% vs 78%, Pxa0= .002) and Bethesda classification (82% vs 72%, Pxa0= .002). This was robust when corrected for indication, lesion size, number of passes, and presence of an on-site pathologist (odds ratio, 3.53; 95% confidence interval, 1.55-8.56; Pxa0= .004), and did not differ among centers (Pxa0= .836).nnnCONCLUSIONnThe 20-gauge FNB needle outperformed the 25-gauge FNA needle in terms of histologic yield and diagnostic accuracy. This benefit was irrespective of the indication and was consistent among participating centers, supporting the general applicability of our findings. (Clinical trial registration number: NCT02167074.).