Ioannis S. Papanikolaou

A prospective randomised study on narrow-band imaging versus conventional colonoscopy for adenoma detection: does narrow-band imaging induce a learning effect?

Background and aims: Colonoscopy is an established method of colorectal cancer screening, but has an adenoma miss rate of 10–20%. Detection rates are expected to improve with optimised visualisation methods. This prospective randomised study evaluated narrow-band imaging (NBI), a new technique that may enhance image contrast in colon adenoma detection. Methods: Eligible patients presenting for diagnostic colonoscopy were randomly assigned to undergo wide-angle colonoscopy using either conventional high-resolution imaging or NBI during instrument withdrawal. The primary outcome parameter was the difference in the adenoma detection rate between the two techniques. Results: A total of 401 patients were included (mean age 59.4 years, 52.6% men). Adenomas were detected more frequently in the NBI group (23%) than in the control group (17%) with a number of 17 colonoscopies needed to find one additional adenoma patient; however, the difference was not statistically significant (p = 0.129). When the two techniques were compared in consecutive subgroups of 100 study patients, adenoma rates in the NBI group remained fairly stable, whereas these rates steadily increased in the control group (8%, 15%, 17%, and 26.5%, respectively). Significant differences in the first 100 cases (26.5% versus 8%; p = 0.02) could not be maintained in the last 100 cases (25.5% versus 26.5%, p = 0.91). Conclusions: The increased adenoma detection rate means of NBI colonoscopy were statistically not significant. It remains speculative as to whether the increasing adenoma rate in the conventional group may have been caused by a training effect of better polyp recognition on NBI.

Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline.

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It provides practical advice on how to achieve successful cannulation and sphincterotomy at minimum risk to the patient. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. Main recommendations 1 ESGE suggests that difficult biliary cannulation is defined by the presence of one or more of the following: more than 5 contacts with the papilla whilst attempting to cannulate; more than 5 minutes spent attempting to cannulate following visualization of the papilla; more than one unintended pancreatic duct cannulation or opacification (low quality evidence, weak recommendation). 2 ESGE recommends the guidewire-assisted technique for primary biliary cannulation, since it reduces the risk of post-ERCP pancreatitis (moderate quality evidence, strong recommendation). 3 ESGE recommends using pancreatic guidewire (PGW)-assisted biliary cannulation in patients where biliary cannulation is difficult and repeated unintentional access to the main pancreatic duct occurs (moderate quality evidence, strong recommendation). ESGE recommends attempting prophylactic pancreatic stenting in all patients with PGW-assisted attempts at biliary cannulation (moderate quality evidence, strong recommendation). 4 ESGE recommends needle-knife fistulotomy as the preferred technique for precutting (moderate quality evidence, strong recommendation). ESGE suggests that precutting should be used only by endoscopists who achieve selective biliary cannulation in more than 80 % of cases using standard cannulation techniques (low quality evidence, weak recommendation). When access to the pancreatic duct is easy to obtain, ESGE suggests placement of a pancreatic stent prior to precutting (moderate quality evidence, weak recommendation). 5 ESGE recommends that in patients with a small papilla that is difficult to cannulate, transpancreatic biliary sphincterotomy should be considered if unintentional insertion of a guidewire into the pancreatic duct occurs (moderate quality evidence, strong recommendation).In patients who have had transpancreatic sphincterotomy, ESGE suggests prophylactic pancreatic stenting (moderate quality evidence, strong recommendation). 6 ESGE recommends that mixed current is used for sphincterotomy rather than pure cut current alone, as there is a decreased risk of mild bleeding with the former (moderate quality evidence, strong recommendation). 7 ESGE suggests endoscopic papillary balloon dilation (EPBD) as an alternative to endoscopic sphincterotomy (EST) for extracting CBD stones < 8 mm in patients without anatomical or clinical contraindications, especially in the presence of coagulopathy or altered anatomy (moderate quality evidence, strong recommendation). 8 ESGE does not recommend routine biliary sphincterotomy for patients undergoing pancreatic sphincterotomy, and suggests that it is reserved for patients in whom there is evidence of coexisting bile duct obstruction or biliary sphincter of Oddi dysfunction (moderate quality evidence, weak recommendation). 9 In patients with periampullary diverticulum (PAD) and difficult cannulation, ESGE suggests that pancreatic duct stent placement followed by precut sphincterotomy or needle-knife fistulotomy are suitable options to achieve cannulation (low quality evidence, weak recommendation).ESGE suggests that EST is safe in patients with PAD. In cases where EST is technically difficult to complete as a result of a PAD, large stone removal can be facilitated by a small EST combined with EPBD or use of EPBD alone (low quality evidence, weak recommendation). 10 For cannulation of the minor papilla, ESGE suggests using wire-guided cannulation, with or without contrast, and sphincterotomy with a pull-type sphincterotome or a needle-knife over a plastic stent (low quality evidence, weak recommendation).When cannulation of the minor papilla is difficult, ESGE suggests secretin injection, which can be preceded by methylene blue spray in the duodenum (low quality evidence, weak recommendation). 11 In patients with choledocholithiasis who are scheduled for elective cholecystectomy, ESGE suggests intraoperative ERCP with laparoendoscopic rendezvous (moderate quality evidence, weak recommendation). ESGE suggests that when biliary cannulation is unsuccessful with a standard retrograde approach, anterograde guidewire insertion either by a percutaneous or endoscopic ultrasound (EUS)-guided approach can be used to achieve biliary access (low quality evidence, weak recommendation). 12 ESGE suggests that in patients with Billroth II gastrectomy ERCP should be performed in referral centers, with the side-viewing endoscope as a first option; forward-viewing endoscopes are the second choice in cases of failure (low quality evidence, weak recommendation). A straight standard ERCP catheter or an inverted sphincterotome, with or without the guidewire, is recommended by ESGE for biliopancreatic cannulation in patients who have undergone Billroth II gastrectomy (low quality evidence, strong recommendation). Endoscopic papillary ballon dilation (EPBD) is suggested as an alternative to sphincterotomy for stone extraction in the setting of patients with Billroth II gastrectomy (low quality evidence, weak recommendation).In patients with complex post-surgical anatomy ESGE suggests referral to a center where device-assisted enteroscopy techniques are available (very low quality evidence, weak recommendation).

Biliary stenting alone versus biliary stenting plus sphincterotomy for the treatment of post-laparoscopic cholecystectomy biliary leaks: a prospective randomized study.

Objective Although various endoscopic techniques have been proved effective in treating post-cholecystectomy biliary leaks, the choice of the best method remains controversial. The aim of this prospective study was to compare the efficacy and safety of biliary stenting alone with biliary stenting plus sphincterotomy for the treatment of post-cholecystectomy biliary leaks. Methods Patients with post-laparoscopic cholecystectomy leaks were randomized into two groups. The first group included 24 patients who were treated with a 7 Fr biliary stent alone, and the second group included 28 patients who underwent an endoscopic sphincterotomy followed by insertion of a 10 Fr biliary stent. Results Endoscopic therapy was successful in all patients (100%). Clinical improvement was observed after 2–6 days. Patients remained hospitalized for 4–12 days. Stents were removed after 6.7 (6–8) weeks. The overall complication rate was 4.16% for the first group and 10.71% for the second (P=0.615). No complications were recorded during the follow-up period. Conclusions Endoscopic therapy of biliary leaks with a small-diameter biliary stent alone is as effective and safe as endoscopic sphincterotomy followed by insertion of a large-diameter stent.

Endoscopic variceal ligation vs. propranolol for prevention of first variceal bleeding : a randomized controlled trial

Objectives Data in the literature regarding the role of endoscopic variceal ligation for the prevention of first variceal bleeding in cirrhotic patients are controversial. To further explore this issue we have compared ligation and propranolol treatment in a prospective randomized study. Methods Sixty patients with cirrhosis and oesophageal varices with no history but at high risk of bleeding were randomized to ligation treatment (30 patients) or propranolol (30 patients). Patients were followed for approximately 27.5 months. Results Variceal obliteration was achieved in 28 patients (93.3%) after 3±1 sessions. The mean daily dose of propranolol was 60.3±13.3 mg. Two patients (6.7%) in the ligation group and nine patients (30%) in the propranolol group developed variceal bleeding (P=0.043). The actuarial risks of variceal bleeding at 2 years were 6.7% and 25%, respectively. On multivariate analysis, propranolol treatment and grade III varices turned out to be predictive factors for the risk of variceal bleeding. Mortality was not different between the two groups. There were no serious complications due to ligation. Propranolol treatment was discontinued in four patients because of side effects. Conclusions Variceal ligation is a safe and more effective method than propranolol treatment for the prevention of first variceal bleeding in cirrhotic patients with high-risk varices.

Endoscopic ultrasonography for gastric submucosal lesions

Gastric submucosal tumors (SMTs) are a rather frequent finding, occurring in about 0.36% of routine upper GI-endoscopies. EUS has emerged as a reliable investigative procedure for evaluation of these lesions. Diagnostic Endoscopic ultrasonography (EUS) has the ability to differentiate intramural tumors from extraluminal compressions and can also show the layer of origin of gastric SMTs. Tumors can be further characterized by their layer of origin, echo pattern and margin. EUS-risk criteria of their malignant potential are presented, although the emergence of EUS-guided fne needle aspiration (EUS-FNA) has opened new indications for transmural tissue diagnosis and expanded the possibilities of EUS in SMTs of the stomach. Tissue diagnosis should address whether the SMT is a Gastrointestinal stromal tumour (GIST) or another tumor type and evaluate the malignant potential of a given GIST. However, there seems to be a lack of data on the optimal strategy in SMTs suspected to be GISTs with a negative EUS-FNA tissue diagnosis. The current management strategies, as well as open questions regarding their treatment are also presented.

Acute hepatitis associated with herb (Teucrium capitatum L.) administration.

Drug-induced hepatotoxicity due to medicinal plant administration has been infrequently reported. This case describes a 62-year-old Caucasian man with hypercholesterolaemia and hyperglycaemia, who started daily consumption of a tea containing the medicinal plant Teucrium capitatum L. Four months after initiation of this therapy he developed an acute icteric hepatitis-like illness. Other causes of acute hepatocellular necrosis were excluded. Liver histology demonstrated changes consistent with acute hepatitis with bridging necrosis. The medicinal plant was withdrawn. The patient recovered clinically and serum bilirubin and aminotransferases returned to normal levels within a 9-week time period. To the best of our knowledge, this is the first description of acute hepatitis associated with T. capitatum administration. This case suggests that T. capitatum can induce acute icteric hepatocellular necrosis, which could be clinically confused with acute viral hepatitis, and that some medicinal plants are not as safe as they are widely considered.

Endoscopic Ultrasound in Pancreatic Disease — Its Influence on Surgical Decision-Making An Update 2008

Endoscopic ultrasonography (EUS) was introduced about 25 years ago with the primary aim of better visualization of the pancreas as compared to transabdominal ultrasonography. This review discusses the current evidence in 2008 concerning the role of EUS in the clinical management of patients, with a special emphasis on its impact on surgical therapy. According to the literature, good indications are detection of common bile duct stones (e.g. in acute pancreatitis), the detection of small exo- and endocrine pancreatic tumors, the performance of fine-needle aspiration in pancreatic masses depending on therapeutic consequences. In other areas such as diagnosis of chronic pancreatitis and cystic pancreatic lesions, the contribution of EUS seems limited. Pancreatic cancer staging is discussed controversially due to conflicting evidence and certainly has lost grounds due to improvements in CT technology. Therapeutic EUS is, however, more widely accepted and may replace other techniques, e.g. in pancreatic cyst drainage and celiac plexus neurolysis; further techniques of interest are being developed.

Oral candidiasis in head and neck cancer patients receiving radiotherapy with amifostine cytoprotection

This controlled study assessed the incidence of oral candidiasis, a xerostomia-related complication, in head and neck cancer patients receiving radiotherapy, with amifostine cytoprotection. Thirty-eight patients received 500 mg amifostine i.v., prior to each radiotherapy fraction, while 16 patients received radiotherapy alone. Oral candidiasis was diagnosed according to the criteria described before. Subjective xerostomia scales were completed by all patients. Mucositis was evaluated using the RTOG criteria. Oral candidiasis was diagnosed in 11/38 amifostine patients and in 9/16 controls (P = 0.07). Severe xerostomia was reported by 4/38 amifostine patients and by 7/16 controls. Oral candidiasis was reduced with amifostine cytoprotection. Oral candidiasis is suggested as an objective, early, though indirect, endpoint for amifostines radioprotective effect on salivary glands.

Safety of extension of a previous endoscopic sphincterotomy: a prospective study

OBJECTIVES:Data in the literature regarding complication risks after the extension of a previous endoscopic biliary sphincterotomy (repeat endoscopic biliary sphincterotomy) are limited and controversial. To explore this issue, we prospectively studied complications after repeat sphincterotomy and compared them with those of biliary endoscopic sphincterotomy in consecutive patients with choledocholithiasis.METHODS:A total of 250 patients underwent endoscopic biliary sphincterotomy and 81 underwent extension of a previous one. All patients had choledocholithiasis and were enrolled using specific criteria, excluding parameters predisposing to increased postsphincterotomy complications.RESULTS:The overall complication rate was 2.46% in the repeat sphincterotomy and 8.4% in the sphincterotomy group (p > 0.05). Complications for the repeat sphincterotomy and initial sphincterotomy groups, respectively, were as follows: bleeding, 2.46% and 2.8%; pancreatitis, 0% and 4.8% (p < 0.05); cholangitis, 0% and 0.4%; perforation, 0% and 0.4%; and hyperamylasemia, 3.7% and 12.8% (p < 0.05). There were no deaths. Bleeding episodes in the former group occurred when repeat sphincterotomy was performed early after the primary one.CONCLUSIONS:Repeat sphincterotomy is a safe technique for the treatment of patients with choledocholithiasis and seems to be as safe as initial sphincterotomy. It is not associated with increased hemorrhage risk. There is a trend toward a higher risk of hemorrhage when repeat sphincterotomy is performed early. Repeat sphincterotomy is safer than the initial sphincterotomy with respect to pancreatic complications.

Autoimmune hepatitis associated with the antiphospholipid syndrome.

The antiphospholipid syndrome has rarely been described in patients with autoimmune hepatitis. Two cases with type I autoimmune hepatitis and antiphospholipid syndrome are presented. The first case is that of a 53-year-old Caucasian female with a history of arterial thrombosis and fetal loss who was submitted to clinical and laboratory testing due to persistent transaminasaemia and was found to have autoimmune hepatitis. Antiphospholipid antibodies (anticardiolipin antibodies and lupus anticoagulant) were positive. The second case is that of a 31-year-old Caucasian woman with a history of autoimmune hepatitis who was submitted to laboratory testing due to a second-trimester fetal death, revealing an increased activated partial thromboplastin time and positive antiphospholipid antibodies. In conclusion, secondary antiphospholipid syndrome may accompany autoimmune hepatitis.