Jonathan M. Buscaglia

A comparative evaluation of single-balloon enteroscopy and spiral enteroscopy for patients with mid-gut disorders.

BACKGROUND Single-balloon enteroscopy (SBE) and spiral enteroscopy (SE) are recently described device-assisted techniques in endoluminal evaluation of the small bowel. No studies comparing SBE and SE in patients with suspected small-bowel disorders have previously been reported. OBJECTIVE The aims of this study were to compare SBE and SE in terms of diagnostic yield, procedure time, depth of maximal insertion, and complications. DESIGN Retrospective cohort study. SETTING Tertiary-care referral center. PATIENTS A retrospective analysis was performed on all patients at our institution undergoing anterograde SBE or SE between 2007 and 2009. Patients with altered anatomy or prior small-bowel surgery were excluded. INTERVENTION Deep enteroscopy. MAIN OUTCOME MEASUREMENT Diagnostic yield. RESULTS During the study period, 92 patients underwent 105 procedures (52 SBE, 53 SE). The most common indication for small-bowel endoscopy was obscure GI bleeding (n = 42). The diagnostic yield was not statistically different between SBE and SE (59.6% and 43.4%, respectively, P = .12). The overall diagnostic yield in patients with obscure GI bleeding was 67%. There was no significant difference between mean SBE and SE procedure times (53 minutes [range 15-99 minutes] vs 47 minutes [range 20-125 minutes], respectively; P = .2). The mean depth of maximal insertion beyond the ligament of Treitz for SE was significantly higher than that for SBE (301 cm [range 175-400 cm] vs 222 cm [range 110-400 cm], respectively; P < .001). Perforation occurred in one SBE procedure. LIMITATIONS Retrospective design and nonstandardized gas insufflation. CONCLUSION This is the first report comparing SE and SBE. Although SE yielded greater depth of maximal insertion than SBE, both techniques had similar diagnostic yields and procedure times. In addition, both techniques were safe and were particularly useful in patients with obscure GI bleeding.

EUS-guided portal vein catheterization: a promising novel approach for portal angiography and portal vein pressure measurements

BACKGROUND Portal vein (PV) pressure measurements can provide valuable information for the management of patients with liver disease and portal hypertension. OBJECTIVE To evaluate the feasibility and the safety of EUS-guided PV catheterization and pressure measurements in a porcine model. SETTING Acute and survival experiments on five 50-kg pigs. DESIGN AND INTERVENTIONS Intrahepatic PV was punctured under EUS guidance by using a 19-gauge FNA needle. A 0.035-inch guidewire was advanced through the needle into the PV. The needle was withdrawn. A 5.5F ERCP catheter was advanced over the guidewire into the PV and then connected to a pressure monitor. Continuous PV measurements were obtained for an hour. Afterward, the catheter was removed, and the animals were observed for 30 minutes. Three animals were then immediately euthanized for a necropsy. The other two animals were observed for two weeks and then were euthanized. MAIN OUTCOME MEASUREMENTS The ability to perform EUS-guided PV catheterization and pressure measurement without complications. RESULTS PV catheterization, angiography, and pressure measurements were performed without any problems or complications. There were no changes in vital signs and hemodynamic parameters during PV catheterizations, angiography, pressure measurements, and catheter removal. Survival experiments did not demonstrate any change in animal condition, behavior, or eating habits after the procedure. A necropsy in all animals revealed no active bleeding, and no damage to the liver, other intra-abdominal organs, or blood vessels. LIMITATIONS No validation of measured PV pressure was made. CONCLUSIONS EUS-guided PV catheterization is feasible, safe, and can be used for portal angiography and pressure measurements.

How good is capsule endoscopy for detection of periampullary lesions? Results of a tertiary-referral center

BACKGROUND Ampullary adenomas are increasingly being recognized, particularly in patients with familial adenomatous polyposis. A capsule endoscopy (CE) is routinely recommended for surveillance of small-intestinal polyposis. Performance characteristics of CE for the detection of periampullary lesions are unclear. OBJECTIVE To evaluate the ability of CE to detect the major duodenal papilla. DESIGN AND PATIENTS A total of 146 consecutive CE studies were reviewed by 2 CE gastroenterologists at 5 frames per second. Primary outcome was visualization of the major duodenal papilla. Discrepancies were reviewed by 5 CE gastroenterologists. SETTING A tertiary-referral center. MAIN OUTCOME MEASUREMENTS The ability of CE to detect the duodenal papilla. RESULTS Among 146 consecutive CE studies, 21 were excluded: capsule retention (3), patient age <18 years (6), duplicate study (8), and prior surgery disrupting duodenal anatomy (4). Of the remaining 125 studies, indications were the following: obscure GI bleeding (45.6%), iron deficiency anemia (19.2%), abdominal pain (17.6%), diarrhea (10.4%), and Crohns disease (4.8%). In total, 13 major duodenal papillae were visualized. The median time of detection was 31 seconds after the first duodenal image. This translates to a CE sensitivity of 10.4% for detection of the major papilla. LIMITATION Papilla position was not verified by an EGD. CONCLUSIONS CE has limited sensitivity to visualize the major papilla and lesions in the periampullary small intestine. Nondiagnostic CE studies must not be relied upon as proof that small-bowel lesions do not exist. Consideration should be given for an enteroscopy or side-viewing duodenoscopy in cases where significant clinical concern exists for unrecognized periampullary lesions. The current recommendations about surveillance for small-bowel polyposis should be revised.

Air and fluid leak tests after NOTES procedures: a pilot study in a live porcine model (with videos)

BACKGROUND Transluminal access site closure remains a major challenge in natural orifice transluminal endoscopic surgery (NOTES). OBJECTIVE Our purpose was to develop in vivo leak tests for evaluation of the integrity of transgastric access closure. SETTINGS Survival experiments on 12 50-kg pigs. DESIGN AND INTERVENTIONS After a standardized transgastric approach to the peritoneal cavity and peritoneoscopy, the gastric wall incision was closed with T-bars (Wilson-Cook Medical, Winston-Salem, NC) deployed on both sides of the incision and then cinched together. Gastrotomy closure was assessed with air and fluid leak tests. The animals were observed for 1 week and then underwent endoscopic evaluation and necropsy. MAIN OUTCOME MEASUREMENTS (1) Leak-proof closure of the gastric wall incision. (2) Gastric incision healing 1 week after the procedure. RESULTS The mean intraperitoneal pressure increased 10.7 +/- 3.7 mm Hg during gastric insufflation when the air leak test was performed before closure compared with 0.9 +/- 0.8 mm Hg after transmural closure of the transgastric access site with T-bars (P < .001). Fluid leak tests demonstrated no leakage of liquid contrast from the stomach into the peritoneal cavity after closure. Necropsy in 1 week confirmed completeness of the gastric closure in all animals with full-thickness healing and no spillage of the gastric contents into the peritoneal cavity. LIMITATIONS Leak tests were only evaluated on an animal model. CONCLUSIONS Fluid and air leak tests are simple techniques to evaluate in vivo the adequacy of the transluminal access site closure after NOTES procedures. Leak-proof gastric closure resulted in adequate tissue approximation and full-thickness healing of the gastric wall incision.

Spiral Enteroscopy Is Safe and Effective for an Elderly United States Population of Patients With Numerous Comorbidities

BACKGROUND & AIMS Preliminary studies performed outside of the United States demonstrated that spiral enteroscopy is safe and effective when performed in young, healthy patients. However, spiral enteroscopy has not been evaluated in a US population of patients with numerous comorbidities. We evaluated the feasibility, efficacy, and safety of spiral enteroscopy in a US population of older patients with multiple comorbidities and a high prevalence of pathologic findings. METHODS We performed a prospective case series of 61 patients with clinical indications for deep enteroscopy conducted at 2 US academic tertiary referral centers. Patients underwent deep enteroscopy with the spiral Endo-Ease Discovery SB overtube. Insertion depth, procedure time, diagnostic findings, therapeutic maneuvers, sedation type, and complications were recorded. RESULTS Spiral enteroscopy was attempted in 61 patients (mean age, 65.4 +/- 12.4 years); 52% were rated by American Society of Anesthesiologists guidelines as class 3 (n = 30) or 4 (n = 2). The procedure was successfully completed in 56 of 61 patients (92%). Average insertion depth was 217.4 +/- 79 cm beyond the ligament of Treitz. The total mean procedure time was 41 +/- 15 minutes (diagnostic time, 36 +/- 12 minutes; therapy time, 5 +/- 9 minutes). Positive findings were noted in 36 cases (59%), with therapeutic maneuvers performed in 30 cases (49%). A total of 41 cases (67%) were performed under conscious sedation; fluoroscopy was not used in any case. Four mild complications occurred, and there were no perforations. CONCLUSIONS Spiral enteroscopy is technically feasible and safe in an elderly US population of patients with numerous comorbidities.

Diagnostic yield and safety of jumbo biopsy forceps in patients with subepithelial lesions of the upper and lower GI tract

BACKGROUND EUS-FNA often fails to make a definitive diagnosis in the evaluation of subepithelial lesions. The addition of jumbo biopsy forceps has the potential to improve diagnostic yield, but published series are limited. OBJECTIVE To assess the likelihood of definitive diagnosis for subepithelial lesions by using jumbo biopsy forceps during EUS examination. DESIGN Pooled retrospective analysis. SETTING 6 tertiary referral centers. PATIENTS All patients having undergone EUS examination for a subepithelial lesion in which jumbo biopsy forceps were used for tissue acquisition. MAIN OUTCOME MEASUREMENTS Diagnostic yield of jumbo biopsy forceps use, complication rates, and comparison of diagnostic yield with that of EUS-FNA. RESULTS A total of 129 patients underwent EUS with jumbo biopsy forceps; 31 patients (24%) had simultaneous EUS-FNA. The lesion locations were stomach (n = 98), esophagus (n = 14), duodenum (n = 11), colon (n = 5), and jejunum (n = 1). The average lesion size was 14.9 mm ± 9.3 mm. Overall, definitive diagnosis was obtained in 87 of 129 patients (67.4%) by using either method. A definitive diagnosis was provided by jumbo biopsy forceps use in 76 of 129 patients (58.9%) and by FNA in 14 of 31 patients (45.1%) (P = .175). The results in third-layer lesions were definitive with jumbo biopsy forceps in 56 of 86 lesions (65.1%) and with FNA in 6 of 16 lesions (37.5%) (P = .047). For fourth-layer lesions, the results with jumbo biopsy forceps were definitive in 10 of 25 (40.0%) and with FNA in 8 of 14 (57.1%) (P = .330). Forty-five of 129 patients (34.9%) experienced significant bleeding after biopsy with jumbo forceps and required some form of endoscopic hemostasis. LIMITATIONS Retrospective study. CONCLUSIONS Jumbo forceps are a useful tool for the definitive diagnosis of subepithelial lesions. The greatest benefit appears to be with third-layer (submucosal) lesions. The risk of bleeding is significant.

Diagnostic Yield of Spiral Enteroscopy When Performed for the Evaluation of Abnormal Capsule Endoscopy Findings

Background Spiral enteroscopy (SE) has emerged as a new alternative for deep intubation of the small intestine. SE is most often used to evaluate abnormal findings on capsule endoscopy (CE). Objective Investigate the ability of SE to reproduce abnormal findings detected on preceding CE. Design Prospective study. Setting Two academic tertiary care centers. Patients Consecutive patients undergoing SE to investigate a clinically significant finding on CE. Main Outcome Measurement Ability of SE to identify findings on CE. Results Total of 56 anterograde SE procedures were performed. CE findings included arteriovenous malformations (AVMs) (n=26), masses (n=8), ulcers (n=4), polyps (n=4), abnormal mucosa (n=6), fresh blood (n=6), and stricture (n=1). Majority of the patients had CE findings located in the jejunum (41 of 56 or 73.2%). Mean depth of enteroscope insertion was 224.6±68.7 cm. SE detected relevant small bowel pathology in 32 of 56 (57.1%) patients. Findings on CE were reproduced in 30 of 56 (53.6%) cases. Reproducibility was independent of patient body mass index (P=0.38), CE indication (P=0.24), CE lesion location (P=0.29), days between CE and SE (P=0.30), and depth of insertion (P=0.81). Type of CE findings (particularly AVMs) significantly affected SE reproducibility (P=0.015). SE procedure time was inversely related to SE reproducibility (odds ratio=0.94, 95% confidence interval=0.88-0.99, P=0.02). Limitations Small sample size and potential for false-positive CE study. Conclusions SE seems to be moderately effective (57.1%) in terms of its ability to locate pathology within the small intestine. The type of small bowel pathology targeted by SE may affect its clinical utility. AVMs observed on CE can be seen at the time of SE in the majority of cases (60%).

Patient- and Cyst-Related Factors for Improved Prediction of Malignancy within Cystic Lesions of the Pancreas

Background and Aims: Early diagnosis of cancer in pancreatic cysts is important for timely referral to surgery. The aim of this study was to develop a predictive model for pancreatic cyst malignancy to improve patient selection for surgical resection. Methods: We performed retrospective analyses of endoscopic ultrasound (EUS) and pathology databases identifying pancreatic cysts with available final pathological diagnoses. Main-duct intraductal papillary mucinous neoplasms (IPMNs) were excluded due to the clear indication for surgery. Patient demographics and symptoms, cyst morphology, and cyst fluid characteristics were studied as candidate risk factors for malignancy. Results: 270 patients with pancreatic cysts were identified and analyzed (41% men, mean age 61.8 years). Final pathological diagnoses were branch-duct IPMN (n = 118, 50% malignant), serous cystadenoma (n = 71), pseudocyst (n = 37), mucinous cyst adenoma/adenocarcinoma (n = 36), islet cell tumor (n = 4), simple cyst (n = 3), and ductal adenocarcinoma with cystic degeneration (n = 1). Optimal cut-off points for surgical resection were cyst fluid carcinoembryonic antigen (CEA) ≥3,594 ng/ml, age >50, and cyst size >1.5 cm. Cyst malignancy was independently associated with white race (OR = 4.1, p = 0.002), weight loss (OR = 3.9, p = 0.001), cyst size >1.5 cm (OR = 2.4, p = 0.012), and high CEA ≥3,594 (OR = 5.3, p = 0.04). In white patients >50 years old presenting with weight loss and cyst size >1.5 cm, the likelihood of malignancy was nearly sixfold greater than in those patients who had none of these factors (OR = 5.8, 95% CI = 2.1–16.1, p = 0.004). Conclusions: Risk factors other than cyst size are important for determination of malignancy in pancreatic cysts. Exceptionally high cyst fluid CEA levels and certain patient-related factors may help to better predict cyst malignancy and the need for surgical treatment.

Multisociety guideline on reprocessing flexible GI endoscopes: 2016 update.

1,2 The beneficial role of GI endoscopy for the prevention, diagnosis, and treatment of many digestive diseases and cancer iswell established. Likemany sophisticatedmedical devices, the endoscope is a complex, reusable instrument that requires meticulous cleaning and reprocessing in strict accordance with manufacturer and professional organization guidance before being used on subsequent patients. To date, published episodes of pathogen transmission related to GI endoscopy using standard end-viewing instruments have been associated with failure to follow established cleaning and disinfection/sterilization guidelines or use of defective equipment. Recent reports pertaining to transmission among patients undergoing specialized procedures using side-viewing duodenoscopes with distal tip elevators have raised questions about the best methods for the cleaning and disinfection or sterilization of these devices between patient uses. In 2003 the American Society for Gastrointestinal Endoscopy (ASGE) and the Society for Healthcare Epidemiology of America collaborated with multiple physician and nursing organizations, infection prevention and control organizations, federal and state agencies, and industry leaders to develop evidence-based guidelines1,2 The beneficial role of GI endoscopy for the prevention, diagnosis, and treatment of many digestive diseases and cancer iswell established. Likemany sophisticatedmedical devices, the endoscope is a complex, reusable instrument that requires meticulous cleaning and reprocessing in strict accordance with manufacturer and professional organization guidance before being used on subsequent patients. To date, published episodes of pathogen transmission related to GI endoscopy using standard end-viewing instruments have been associated with failure to follow established cleaning and disinfection/sterilization guidelines or use of defective equipment. Recent reports pertaining to transmission among patients undergoing specialized procedures using side-viewing duodenoscopes with distal tip elevators have raised questions about the best methods for the cleaning and disinfection or sterilization of these devices between patient uses. In 2003 the American Society for Gastrointestinal Endoscopy (ASGE) and the Society for Healthcare Epidemiology of America collaborated with multiple physician and nursing organizations, infection prevention and control organizations, federal and state agencies, and industry leaders to develop evidence-based guidelines

Transpapillary drainage has no added benefit on treatment outcomes in patients undergoing EUS-guided transmural drainage of pancreatic pseudocysts: a large multicenter study.

BACKGROUND AND AIMS The need for transpapillary drainage (TPD) in patients undergoing transmural drainage (TMD) of pancreatic fluid collections (PFCs) remains unclear. The aims of this study were to compare treatment outcomes between patients with pancreatic pseudocysts undergoing TMD versus combined (TMD and TPD) drainage (CD) and to identify predictors of symptomatic and radiologic resolution. METHODS This is a retrospective review of 375 consecutive patients with PFCs who underwent EUS-guided TMD from 2008 to 2014 at 15 academic centers in the United States. Main outcome measures included TMD and CD technical success, treatment outcomes (symptomatic and radiologic resolution) at follow-up, and predictors of treatment outcomes on logistic regression. RESULTS A total of 375 patients underwent EUS-guided TMD of PFCs, of which 174 were pseudocysts. TMD alone was performed in 95 (55%) and CD in 79 (45%) pseudocysts. Technical success was as follows: TMD, 92 (97%) versus CD, 35 (44%) (P = .0001). There was no difference in adverse events between the TMD (15%) and CD (14%) cohorts (P = .23). Median long-term (LT) follow-up after transmural stent removal was 324 days (interquartile range, 72-493 days) for TMD and 201 days (interquartile range, 150-493 days) (P = .37). There was no difference in LT symptomatic resolution (TMD, 69% vs CD, 62%; P = .61) or LT radiologic resolution (TMD, 71% vs CD, 67%; P = .79). TPD attempt was negatively associated with LT radiologic resolution of pseudocyst (odds ratio, 0.11; 95% confidence interval, 0.02-0.8; P = .03). CONCLUSIONS TPD has no benefit on treatment outcomes in patients undergoing EUS-guided TMD of pancreatic pseudocysts and negatively affects LT resolution of PFCs.