Luis F. Lara

The safety of same-day CT colonography following incomplete colonoscopy with polypectomy

Background Concerns about the risk of bowel perforation for same-day computed tomography colonography (CTC) following an incomplete colonoscopy with polypectomy may lead to unnecessarily postponing the CTC. Objective The objective of this article is to describe the complications including colon perforations associated with same-day CTC in a cohort who had polypectomies but an incomplete colonoscopy. Design We conducted a retrospective study. Setting Our study took place in a single, tertiary referral center. Patients We studied consecutive patients who had CTC the same day as an incomplete colonoscopy with polypectomy. Interventions Interventions included optical colonoscopy (OC), endoscopic polypectomies, and same-day CTC. Main outcome measurements: Our main outcome measurements included perforation rate with long-term follow-up. Results A total of 3% of patients undergoing colonoscopy from January 2008 to December 2012 had same-day CTC following incomplete OC, and 72 polypectomies were performed in 34 (or 17%) of these patients. Incomplete colonoscopies were due to colon tortuosity and looping (25), severe angulations (five), colon mass (two), colon stenosis (one), bradycardia (one). Fifty-three percent of the OCs were screening for colon neoplasia, 29% diagnostic and 18% were surveillance of colon polyps. Most polyps were ≤ 5 mm, and found in the left colon. There were no reported complications or perforations associated with same-day CTCs during short- and long-term follow-up. Limitations Limitations of our analysis included retrospective single-center design, small number of patients for the occurrence, referral to same-day CTC was not standardized, inability to establish safety of CTC for specific scenarios such as after complex polypectomies, strictures, or advanced IBD. Conclusions Radiologists’ apprehension to perform a CTC the same day as an incomplete colonoscopy following polypectomies because of perceived risk of perforation may be unfounded. More data are needed to determine the safety of same-day CTC in patients with high-risk findings during colonoscopy such as a stricture, severe IBD, and after complex polypectomies.

Effect of a quality program with adverse events identification on airway management during overtube-assisted enteroscopy.

BACKGROUND AND STUDY AIMS Adverse events associated with overtube-assisted enteroscopy are similar to those with routine endoscopy. Our endoscopy quality program identified a number of respiratory adverse events resulting in emergency resuscitation efforts. The aim is to report all adverse events identified by quality monitoring and outcomes of adverse events associated with overtube-assisted enteroscopy. METHODS A retrospective study used data prospectively obtained from consecutive patients undergoing overtube-assisted enteroscopy between December 2008 and July 2012. Patient characteristics, medical history, procedure indication, and procedure outcomes, including diagnosis, endoscopic therapy, and complications, were obtained. RESULTS In 432 overtube-assisted enteroscopies, 15 adverse events (most frequently hypoxemia, 9 /15, 60 %) occurred in 14 patients (3.2 % of total cohort; 12 were outpatients) mostly during antegrade enteroscopy. Four patients required endotracheal intubation and 4 /12 outpatients required intensive care. The procedure was aborted in 13 /14 patients, and only 1 of 10 patients scheduled for repeat antegrade enteroscopy returned. There was no mortality. Based on the frequency of adverse events, and in consultation with anesthesia providers, from August 2012 all antegrade overtube-assisted enteroscopies at our institution were done with general anesthesia. From then till September 2013, 145 antegrade and 52 retrograde overtube-assisted enteroscopies have been done, with no adverse events. CONCLUSIONS Monitoring of endoscopy practice identified adverse events associated with overtube-assisted enteroscopy. The peer-review prompted a change in practice: all patients undergoing antegrade overtube-assisted enteroscopy at our institution now have endotracheal intubation which has dramatically decreased the rate of respiratory adverse events. The impact of endoscopic quality measurements on practices, procedures, and outcomes will be of further interest.

Double-balloon overtube—assisted endoscopic pancreas function test as a tool to rule out chronic pancreatitis in a patient with a previous Frey procedure

existing duodenal stents. Hamada et al suggest that EUSguided transpapillary stenting may not be the optimal approach in these patients because both duodenal obstruction and enteral stents predispose to increased duodenobiliary reflux and biliary stent dysfunction. In our series, 7 patients underwent EGBD with antegrade (n 3) or retrograde (n 4) transpapillary stenting. In ddition, 2 patients underwent EGBD by the direct transluinal approach (ie, choledochoduodenostomy). None of he patients who underwent transpapillary stenting expeienced recurrent biliary obstruction during follow-up. ost patients, however, died within a few weeks after GBD.1 One patient survived 367 days after transpapillary tenting without recurrent obstruction. Another patient emains without recurrent obstruction 408 days after transapillary stenting. Nonetheless, our study was not powred to perform a sound comparison between the transluinal and transpapillary approaches in terms of risk of ecurrent biliary obstruction during long-term follow-up. n our experience, however, most patients who undergo GBD have advanced malignancies, and the risk of recurent biliary obstruction is small as a result of short survival. here are not enough data to suggest better safety or fficacy of 1 EGBD technique over another. Our approach s to initially attempt a rendezvous technique because this voids the need for tract dilation and risk of bile duct leak n most cases. However, this technique is successful in nly 75% of cases in experienced hands.2 We introduce an ver-the-wire catheter after initial bile duct puncture durng the rendezvous approach for wire manipulation. This echnique allows wire manipulation in the direction of the tricture/papilla and permits traction and wire passage hrough tight biliary strictures. We reserve the transluminal pproach if antegrade transpapillary stenting or a rendezous technique (ie, retrograde transpapillary stenting) is ot possible, because of our concern that the transluminal pproach may be a riskier technique. In our experience, owever, this technique is safe, and bile leak and pneuoperitoneum can be avoided with the use of selfxpandable metal stents (SEMS) and carbon dioxide insufation, respectively. The use of SEMS usually provides a omplete seal of the iatrogenic choledochoenteric tracts nd prevents bile leak.

Long-Term Therapy With Teduglutide in Parenteral Support-Dependent Patients With Short Bowel Syndrome: A Case Series

OBJECTIVE To review all cases of parenteral support (PS)-dependent patients with short bowel syndrome (SBS) treated with teduglutide (Gattex, Shire) and to evaluate its efficacy and adverse effects. METHODS This is a retrospective descriptive cohort of SBS patients treated with teduglutide. Demographics, bowel length, primary diagnosis, PS volume/duration, teduglutide dose, and side effects were collected prospectively. RESULTS Six SBS patients (4 females, 2 males) received teduglutide. Mean age was 46.3 years (range 26-71). SBS etiology was vascular (n = 3), multiple resections (n = 2), and strangulation (n = 1). Length of residual small bowel was between 30-120 cm. The bowel anatomy was colon present (n = 3) and stoma n = 3 (ileostomy, 2; colostomy, 1). PS duration was 1.5-14 years. Weekly PS volume was mean 7.7 liters/week (1-14). Number of PS days per week ranged 1-7 days. Mean duration of teduglutide therapy was 31 months (24-36). All patients achieved ≥20% reduction in PS weekly volume within 6 months. PS was weaned in all patients. Adverse effects included abdominal bloat/discomfort (n = 3), stoma enlargement (n = 3), bowel obstruction (n = 1), and congestive heart failure (n = 1). CONCLUSIONS All PS-dependent SBS patients treated with teduglutide were weaned off PS. Patients with colon in continuity and lower PS weekly volume requirements were weaned off PS sooner than those with end-stomas and higher PS volume requirements. Teduglutide was well tolerated. Additional clinical studies of teduglutide in SBS patients with marginal PS requirements are needed.

Initial experience with a variable width and extreme tip angulation colonoscope

Screening and surveillance colonoscopies can be affected by colon looping, angulations, diverticulosis, previous surgeries, body mass index, ability to sedate or type of sedation, bowel preparation, and female sex. Incomplete colonoscopies can be economically and emotionally costly and may result in decreased compliance with screening for colon neoplasia [1]. Instruments that improve the cecal intubation and adenoma detection rate, reduce the number of incomplete colonoscopies and improve patient satisfaction are desirable. Studies have shown that pediatric as well as variable stiffness colonoscopes achieve cecal intubation rates similar to standard colonoscopes, but possibly with less pain and with faster cecal intubation times [2, 3]. More recently, ultrathin colonoscopes have been reported to be better at negotiating acute luminal angulations, and patients may require less sedation than when standard colonoscopes are used. However, looping, difficulty removing larger polyps, and a higher ileal intubation failure rate have been reported [1, 4, 5]. We are, to the best of our knowledge, the first to report the ease of use and initial impressions with a newly available variable width colonoscope with extreme tip angulation capability.