Lucia C. Fry

Endoscopic Retrograde Cholangiopancreatography Using the Single Balloon Enteroscope Technique in Patients with Roux-en-Y Anastomosis

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging or impossible in patients with complex postsurgical anatomy. The aim of this cohort study was to assess the technical success of ERCP with the single balloon enteroscope (SBE) in patients with Roux-en-Y anastomosis. Patients: Patients with Roux-en-Y anastomosis presenting with cholestasis undergoing ERCP with the SBE technique in a tertiary university hospital. Diagnostic success was defined as successful duct cannulation or securing the diagnosis and therapeutic success was defined as the ability to successfully accomplish endoscopic therapy. Results: ERCP using the SBE was performed on 17 occasions in 13 patients (5 F, 8 M, mean age 66.5 years, range 25–77) with Roux-en-Y anastomosis. Indications for ERCP were biliary obstruction with common bile duct stones and/or cholangitis in all patients. The diagnostic success was 61.5% and the therapeutic success was 53.8%. Therapeutic interventions included dilation of common bile duct stenosis with a balloon (n = 4), biliary stent insertion (n = 2), removal of bile duct stones (n = 2), stent retrieval (n = 2), papillectomy (n = 1), and sphincterotomy (n = 1). No major complications occurred. Conclusions: ERCP using the SBE is feasible in patients with altered postsurgical anatomy presenting with biliary problems permitting diagnostic and therapeutic interventions.

Usefulness of the double-balloon enteroscope in colonoscopies performed in patients with previously failed colonoscopy

TO THE EDITOR: Incomplete colonoscopy can be caused by difficulty in passing through stenosis and/ or the looping of the endoscope within the colon, specifically in the sigmoid. Even with colonoscopes of variable stiffness (VS) or the use of sigmoid stabilizers, cecal intubation may not be possible [1,2]. The double-balloon enteroscope (DBE) is a relatively new device designed for examination of the small intestine. Properties of the DBE are its thin external diameter, length, flexibility, and stabilizing external overtube [3]. Thus, we used the DBE to examine the colon in patients with previously failed colonoscopies in a single center feasibility study. Patients who were evaluated for suspected colonic pathology at the University of Magdeburg, Germany during a one-year period (from April 2004 to March 2006) were included in the study. All patients had undergone at least two previous attempts at colonoscopy (range 2 4), including the use of a pediatric VS colonoscope by experienced endoscopists. The characteristics of the study group are presented in Table I.

Review Article on Current Applications and Future Concepts of Capsule Endoscopy

Since the advent of capsule endoscopy (CE) more than one decade has passed. During this time, extensive efforts have been made to proof the relevance of CE for diagnosis of various disease entities within the esophagus, small bowel, and colon. To date, the most common indications for CE are obscure gastrointestinal bleeding, Crohn’s disease, polyposis syndromes and evaluation of patients with complicated celiac disease. In this review we will focus on the current clinical applications of CE for imaging of the esophagus, small bowel and colon and will additionally give an outlook on future concepts and developments of CE.

Interleukin-1beta and interleukin-8 expression correlate with the histomorphological changes in esophageal mucosa of patients with erosive and non-erosive reflux disease.

Background: Gastroesophageal reflux disease (GERD) leads to endoscopic and histomorphological changes in the gastroesophageal (GE) mucosa. Aims: To evaluate the expression of the cytokines interleukin-1β (IL-1β) and interleukin-8 (IL-8) in the GE mucosa in GERD patients and controls and to correlate the cytokine expression with the histomorphological parameters. Methods: One hundred and fifteen patients, 48 with erosive reflux disease (ERD) and 41 with non-erosive reflux disease (NERD) with typical GERD-related symptoms, and 26 controls were included. Endoscopic and histological characterization of esophagitis was performed according to the Los Angeles and Ismeil-Beigi/Vieth criteria, respectively. Mucosal gene expression levels of IL-1β and IL-8 were analyzed by real-time RT-PCR. Results: ERD and NERD patients revealed significant higher levels of IL-1β and IL-8 transcript levels in the cardia and esophageal mucosa than controls. The esophageal mucosa revealed elevated IL-8 (2.5- and 8.7-fold) and IL-1β (4.1- and 7.8-fold) transcript levels in NERD and ERD, respectively. Histological analysis demonstrated a stepwise increase of dilatation of intercellular spaces and the degree of basal cell hyperplasia from controls, NERD towards ERD. Gene expression levels of both cytokines correlated with histology. Conclusions: ERD and NERD are associated with an induction of the proinflammatory cytokines IL-1β and IL-8 that correlates with histomorphological changes in esophageal mucosa.

Learning curve of virtual chromoendoscopy for the prediction of hyperplastic and adenomatous colorectal lesions: a prospective 2-center study

BACKGROUND Computed virtual chromoendoscopy (CVC) enables high-definition imaging of mucosal lesions with improved tissue contrast. Previous studies have shown that CVC yields an improved detection rate of colorectal lesions. However, the learning curve for interpretation of CVC images is unknown. OBJECTIVE To examine the learning curve of correctly identifying hyperplastic and adenomatous colorectal lesions by using CVC. DESIGN Prospective, 2-center study. PATIENTS Consecutive patients undergoing screening colonoscopy were included. CVC images were analyzed by using corresponding polypectomies as the reference standard followed by a prospective, double-blind review of i-scan images. METHODS A training set containing 20 images with known histology was reviewed to standardize image interpretation, followed by a blind review of 110 unknown images. Overall, 4 endoscopists from 2 different endoscopy centers evaluated the images, which were obtained by 1 endoscopist using high-definition endoscopy with CVC. RESULTS Patients were included in a prospective fashion. Seventy-seven of 110 colorectal lesions were adenomas and 33 were hyperplastic lesions. Mean diameter of colonic polyps was 4 mm (range, 2-20 mm). Overall accuracy for the group was 73.9% for lesions 1 to 22, 79.6% for lesions 23 to 44, 84.1% for lesions 45 to 66, 87.5% for lesions 67 to 88, and 94.3% for lesions 89 to 110. Accuracy of i-scan for prediction of polyp histology was not dependent on polyp size (≤5 mm, 6-10 mm, or > 10 mm). The ability to obtain high-quality images was stable over time, and high-quality images were constantly produced. LIMITATION Post-hoc assessment. CONCLUSION Accurate interpretation of CVC images for prediction of hyperplastic and adenomatous colorectal lesions follows a learning curve but can be learned rapidly.

Advanced Endoscopic Imaging Methods for Colon Neoplasia

The main goal of lumenal endoscopic visualization of the colon is to detect mucosal pathologies, which when removed will result in cure or palliation of a disease process. Whereas traditionally endoscopic imaging was performed with fiber-optic technology, currently there are many new methods that improve our visual acuity when evaluating the colon mucosa. Most of these methods are collectively called ‘advanced colonic imaging’. The 2 main aims of standard (white light) and advanced colonic imaging are to enhance the superficial mucosal detail (i.e. ‘pit pattern’) and allow a detailed view of the submucosal capillary pattern, thus potentially improving the detection characterization of pathological lesions. However, the current literature dealing with most methods used for advanced endoscopic imaging of the colon is fraught with many controversial findings which have resulted in opposing views regarding its utility. Whereas some investigators vehemently support the use of most of these methods in routine clinical practice, most experts and practicing endoscopists still refuse to accept that these methods aid in the clinical routine. For now, white light video-colonoscopy and high-definition white light video-colonoscopy will remain the standard endoscopic methods for investigating the colon mucosa until new methods convincingly and clearly prove their superiority over white light endoscopy.

Therapeutic Double-Balloon Enteroscopy: A Binational, Three-Center Experience

Background/Aims: There are few reports focusing on therapeutic small bowel endoscopy. The aim of this study was to analyze the results of therapeutic small bowel endoscopy in a large cohort of patients. Methods: A retrospective study of a prospectively collected database comprising all patients undergoing diagnostic and therapeutic small bowel endoscopy in three centers. Results: A total of 614 double-balloon enteroscopies were performed in 534 patients. The most common pathological findings were angiodysplasias and vascular lesions (n = 98, 18%), mucosal ulcers and erosions (n = 95, 17.8%), polyps and tumors (including patients with familiar polyposis syndrome such as Peutz-Jeghers syndrome, familiar adenomatous polyps syndrome, neurofibromatosis, adenocarcinoma, neuroendocrine tumors and gastrointestinal stromal tumors) (n = 52, 9.7%), and strictures (Crohn’s disease, ischemia, tumors) (n = 12, 2.2%). The mean duration of therapeutic small bowel enteroscopy was 67 min (range 30–115) compared to 50 min (range 25–105) for diagnostic procedures (p < 0.05). A therapeutic small bowel endoscopy was performed in 121 patients (22%). Therapeutic procedures included argon plasma coagulation of vascular lesions (n = 73), polypectomy (n = 49), mucosectomy (n = 5), stricture dilation (n = 7), foreign body extraction (n = 7), injection of fibrin glue (n = 10), and clip placement (n = 5). There were a total of 5 complications (0.9%; paralytic ileus, n = 2, pancreatitis, n = 1, bleeding n = 2). No perforations or deaths occurred. Conclusion: Endoscopists performing double-balloon enteroscopy should be trained and prepared to provide therapeutic interventions for small bowel disorders including argon plasma coagulation, injection, hemoclipping, polypectomy, mucosectomy and foreign body extraction. Therapeutic small bowel endoscopy, albeit associated with complications in about 1% of cases, can be considered a relatively safe procedure.

Wireless capsule endoscopy of the small intestine: a review with future directions.

Purpose of review Here, we review the clinical applications of small bowel capsule endoscopy. Moreover, we provide an outlook on the exceptional future developments of small bowel capsule endoscopy. We discuss clinical algorithms for diagnosis of small bowel diseases. Multiple studies have shown the potential of capsule endoscopy for identification of the bleeding source located in the small bowel and the increased diagnostic yield over radiographic studies. Capsule endoscopy could detect villous atrophy and severe complications in patients with nonresponsive celiac disease. In addition, small bowel capsule endoscopy was proven as a valid tool to diagnose polyps and tumors and Crohns disease. Summary Major current clinical indications of capsule endoscopy in the small bowel include evaluation of obscure gastrointestinal bleeding, diagnosis and surveillance of small bowel polyps and tumors, celiac disease and Crohns disease. Recent developments have also passed the way for small bowel capsule endoscopy to become a therapeutic instrument.

Lectin UEA-I-binding proteins are specifically increased in the squamous epithelium of patients with Barrett's esophagus.

Background: Chronic gastritis and esophagitis are associated with changes in mucosal glycosylation patterns. Lectins represent a group of specific carbohydrate binding proteins that can be used as sensitive tools for the analysis of glycosylation patterns. Aim: To investigate the binding patterns of lectins Ulex europaeus agglutinin-I (UEA-I), Dolichos biflorus agglutinin (DBA), Helix pomatia agglutinin (HPA) and peanut agglutinin (PNA) at the gastroesophageal junction in nonerosive (NERD), erosive reflux disease (ERD) and Barrett’s esophagus (BE). Methods: One hundred and twenty-two patients (female n = 53; male n = 69; controls n = 28; NERD n = 36; ERD n = 24 and BE n = 34) were included in this study. The binding patterns of lectins were examined immunohistochemically at the squamocolumnar junction, in squamous epithelium and columnar-lined epithelium. Staining patterns of lectins were semiquantitatively evaluated using an immunohistochemical score and the data were analyzed using non-parametric tests. Results: BE, as compared to the controls, was associated with specific lectin-binding patterns: lectin binding of UEA-I and DBA were significantly decreased at the superficial (p = 0.012; p = 0.00036, respectively) and at the deep glandular body (p = 0.045; p = 0.055, respectively). Comparisons of lectin-staining scores between GERD and BE revealed significant increases of UEA-I in both the stratum superficiale (p = 0.0155) and stratum spinosum (p = 0.0048) of SE in patients with BE. Notable, this change was specific for patients with BE, while no difference was observed between patients with GERD and controls. Conclusion: We found two major types of lectin-binding patterns. First, lectin-binding characteristics associated with GERD in general, and second, lectin-binding patterns which were specific for BE. Lectin UEA-I-binding proteins were specifically increased in the squamous epithelium of patients with BE. Thus, UEA-I may serve as a potential marker for BE, especially in patients with short segment BE.

Pancreatic Cancer Is 'Always Non-Resectable'

Pancreatic cancer is characterized by its very aggressive biological behavior which makes it a rapidly disseminating and deadly tumor. Due to their initial ‘silent’ behavior, pancreatic cancers are generally diagnosed too late and at that point surgical or medical interventions are futile. The outcome of pancreatic cancer has not improved over the last decades. It is evident that only very few pancreatic cancers are potentially resectable and curable, but many times even these small cancers have poor prognostic factors. Furthermore, upon surgery many of the patients considered preoperatively to have resectable tumors are found to have non-resectable disease. The problem of pancreatic cancer is further compounded by the fact that most tumors are diagnosed in elderly, frail or chronically ill patients, which makes them poor surgical candidates, and only half or fewer of these patients can undergo surgery. The stress of surgery is poorly tolerated by many patients who either die, develop complications or are then unable to receive adjuvant chemotherapy. The bottom line is that pancreatic cancer is a very aggressive tumor. Currently, most cancers are treated by non-surgical methods, and the very few patients with tumors which are potentially resectable should be operated on in specialized, high-volume pancreatic centers.