Marios Efthymiou

Biopsy forceps is inadequate for the resection of diminutive polyps.

BACKGROUND AND STUDY AIMS Cold biopsy forceps polypectomy (CBP) is often used for the removal of diminutive polyps. The efficacy of the technique has not been thoroughly assessed. The aim of this study was to prospectively assess the efficacy of CBP for removing diminutive polyps. PATIENTS AND METHODS This was a prospective study from St Vincents Hospital, a tertiary referral hospital in Melbourne, Australia. A total of 143 patients were screened and 52 patients with ≥ 1 diminutive polyps were enrolled. CBP was used to resect diminutive polyps until no polyp tissue was visible. The polyp base was then resected using endoscopic mucosal resection (EMR) with a 1 - 2-mm margin. The CBP and EMR samples were compared to assess completeness of the resection. RESULTS Overall 39 % (21 / 54) of diminutive polyps were completely resected using CBP. After binary logistic regression analysis, polyp histology was found to be predictive of resection, with complete resection of 62 % (13 / 21) for adenomas and 24 % (8 / 33) for hyperplastic polyps (odds ratio 5.1; P = 0.008). The size and number of bites taken with the forceps were not predictive of complete response. CONCLUSIONS Within the limitations of a modest sample size, CBP appears to be inadequate treatment for the removal of diminutive polyps.

Chromoendoscopy versus narrow band imaging for colonic surveillance in inflammatory bowel disease.

Background: Mucosal dye spraying (chromoendoscopy [CE]) has been shown in controlled studies to enhance lesion detection in colitis surveillance. Narrow band imaging (NBI) potentially offers a more convenient mode of highlighting mucosal lesions. The primary objectives of this study were to compare CE and NBI in colitis surveillance with respect to lesion detection. A secondary objective was to assess the accuracy of the mucosal pit pattern (Kudo classification) with NBI in predicting mucosal histology. Methods: Patients with colitis of 8 years or greater disease duration underwent screening colonoscopy with NBI, followed immediately by CE by 2 endoscopists blinded to each other’s results. All lesions were biopsied to confirm histology. Diagnostic yield of each modality for dysplastic lesions. Accuracy of Kudo classification by NBI for neoplasia. Results: Forty-four participants were enrolled. One hundred forty-four colonic lesions were identified in total. Overall, CE identified more lesions than NBI (131 versus 102, P < 0.001); however, most were nondysplastic. CE detected 23 neoplastic (dysplastic or indefinite for dysplasia) lesions in 11 patients and NBI 20 lesions in 10 patients, P = 0.180. Kudo assessment by NBI had low sensitivity for dysplasia (42%) and modest accuracy (74%) for dysplasia. Conclusions: NBI detected fewer lesions than CE in chronic colitis; however, most were not dysplastic. There was a nonsignificant trend in favor of CE for detection of dysplasia. At present, NBI cannot be recommended as an alternative to CE for dysplasia surveillance in colitis.

SINGLE-01: a randomized, controlled trial comparing the efficacy and depth of insertion of single- and double-balloon enteroscopy by using a novel method to determine insertion depth.

BACKGROUND Single-balloon enteroscopy (SBE) was introduced as an alternative to double-balloon enteroscopy (DBE) for the investigation and management of small-bowel conditions. To date, there is only 1 randomized, controlled trial comparing SBE and DBE in a Western population. OBJECTIVE To compare the 2 instruments in a Western population to assess for differences in clinical outcomes and insertion depth (ID). A novel method to determine ID by counting folds on withdrawal was used. DESIGN Multicenter, randomized, controlled trial. SETTING University hospitals in Melbourne and Sydney, Australia. PATIENTS Patients with suspected or proven small-bowel disease. INTERVENTIONS SBE and DBE. MAIN OUTCOME MEASUREMENT The primary endpoint was diagnostic yield (DY). Secondary endpoints were therapeutic yield (TY), procedure times, and ID. An intention-to-treat analysis was performed. RESULTS A total of 116 patients were screened, and 107 patients were enrolled between July 2008 and June 2010, in whom 119 procedures were undertaken (53 SBEs and 66 DBEs). DY was 57% for SBE and 53% for DBE (P = .697). TY was 32% for SBE and 26% for DBE (P = .490). The median enteroscopy times were identical for SBE and DBE at 60 minutes. The mean ID by the fold-counting method for antegrade procedures was 201.1 folds for SBE and 258.6 folds for DBE (P = .046). After multiple comparisons adjustment, this difference did not reach statistical significance. Mean IDs by using the visual estimation method for SBE and DBE were, respectively, 72.1 cm and 75.2 cm (P = .835) for retrograde procedures and 203.8 cm and 234.1 cm (P = .176) for antegrade procedures. LIMITATIONS Unable to reach target sample size, mostly single-center recruitment, novel method to determine ID, which requires further validation. CONCLUSIONS SBE has DY, TY, and procedure times similar to those of DBE. There were no statistically significant differences in ID between SBE and DBE. By using the fold-counting method for antegrade procedures, the estimated IDs for SBE and DBE were 201.1 folds versus 258.6 folds (P = .046; P = not significant after adjustment for multiple comparisons). ( CLINICAL TRIAL REGISTRATION NUMBER ACTRN12609000917235.).

Right-sided adenoma detection with retroflexion versus forward-view colonoscopy.

BACKGROUND Colonoscopy and polypectomy can prevent up to 80% of colon cancer; however, a significant adenoma miss rate still exists, particularly in the right side of the colon. OBJECTIVE To assess whether retroflexion in the right side of the colon significantly improves the adenoma detection rate (ADR) over forward-view assessment. DESIGN Multicenter prospective cohort study. SETTING Three tertiary care public and 2 private hospitals. PATIENTS A total of 1351 consecutive adult patients undergoing elective colonoscopy. INTERVENTION Withdrawal from the cecum was performed in the forward view initially and identified polyps removed. Once the hepatic flexure was reached, the cecum was reintubated and the right side of the colon was assessed in the retroflexed view to the hepatic flexure. MAIN OUTCOME MEASUREMENTS ADR in the retroflexed view when compared with forward-view examination of the right side of the colon. RESULTS Retroflexion was successful in 95.9% of patients, with looping the predominant (69.6%) reason for failure. Forward-view assessment of the right side of the colon identified 642 polyps, of which 531 were adenomas yielding a polyp and ADR of 28.57% and 24.64%, respectively. Retroflexion identified a further 84 polyps of which 75 were adenomas, improving the polyp and ADR to 30.57% and 26.4%, respectively. LIMITATIONS Observational study. CONCLUSION Right-sided retroflexion was successful in most of our cohort with a statistically significant but small increase in ADR. Right-sided retroflexion is safe when performed by experienced endoscopists with no adverse events observed in this cohort. ( CLINICAL TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry, ACTRN12613000424707.).

Cancer surveillance strategies in ulcerative colitis: the need for modernization.

&NA; The risk of colorectal cancer is increased in patients with longstanding ulcerative colitis. Traditional surveillance has centered around regular standard white‐light colonoscopy, with multiple biopsies aimed at detecting dysplasia or the identification of early cancer. This has resulted in only a modest reduction in cancer incidence and mortality. A better understanding of disease risk factors may allow endoscopic resources to be more focused on patients at higher risk. In addition, advanced endoscopic techniques have the potential to improve dysplasia detection, minimize the need for routine biopsies, and allow for the removal of dysplastic lesions, avoiding the need for surgery. Techniques such as magnification colonoscopy, chromoendoscopy, narrow band imaging, autofluorescence, and confocal endomicroscopy may all have a role to play in improving the benefits of endoscopic surveillance. Revised endoscopic surveillance strategies are proposed, incorporating aspects of risk stratification, a well‐established practice in noncolitis‐related colorectal cancer screening, and some of these new technologies. (Inflamm Bowel Dis 2010;)

Value of fecal occult blood test as a screening test before capsule endoscopy.

Background The primary aim was to assess the value of immunochemical and guaiac fecal occult blood test (FOBT) as a screening test before capsule endoscopy (CE) in the setting of obscure gastrointestinal bleeding (OGIB). Methods A prospective study from the St Vincents Hospital, a tertiary referral hospital in Melbourne, Australia. Sixty-eight patients referred for CE to investigate OGIB underwent two immunochemical/guaiac FOBTs within 2 weeks preceding CE. The correlation between a positive FOBT before CE and clinically significant findings (CSFs) on CE was assessed. Results Thirty of 68 (44%) patients with OGIB had significant findings on CE. The accuracy of a combined immunochemical and guaiac FOBT for predicting clinically significant findings on CE was 62% [95% confidence interval (CI): 0.50–0.72]. The sensitivity and specificity were low at 63% (95% CI: 0.50–0.75) and 61% (95% CI: 0.50–0.70), respectively. Conclusion FOBT has low accuracy as a screening test before CE and thus cannot be recommended for this purpose.

Risk factors for band-induced ulcer bleeding after prophylactic and therapeutic endoscopic variceal band ligation.

Background and aims Endoscopic variceal band ligation (EVBL) aims to eradicate high-risk oesophageal varices. There is a small risk of precipitating bleeding from EVBL-induced oesophageal ulceration, which is associated with significant mortality. We explore the risk factors and outcome of EVBL-induced ulcer bleeding. Methods Retrospective review of our endoscopy database between 2007 and 2012 identified upper endoscopies during which EVBL was performed. Patient demographics, biochemistry and endoscopic findings were recorded as were the complications of EVBL-induced ulcer bleeding and death. Results A total of 749 episodes of EVBL were performed in 347 patients with a mean Model for End-stage Liver Disease (MELD) score of 15.8. In all, 609 procedures were performed for prophylaxis and 140 for acute haemorrhage. There were 21 episodes (2.8% of procedures) of EVBL-induced ulcer bleeding in 18 patients, five of whom subsequently died (28%). On multivariable analysis, acute variceal haemorrhage was the only significant predictor of EVBL-induced ulcer bleeding [odds ratio (OR) 6.25 (2.57–15.14), P<0.0001]. In 609 procedures performed for prophylaxis, the EVBL-induced ulcer bleeding rate was 1.5%, with 22% mortality. In this group, higher MELD score and reflux oesophagitis were associated significantly with EVBL-induced ulcer bleeding [OR 25.53 (2.14–303.26), P=0.010 and OR 1.07 (1.01–1.13), P=0.019, respectively]. Conclusion Our EVBL-induced ulcer bleeding rate was low, but associated with significant mortality. Highest rates were observed following EVBL for acute variceal haemorrhage, for which EVBL is unavoidable. The incidence was lower following prophylactic EVBL, with the MELD score being the predominant risk factor. Reflux oesophagitis requires further investigation as a potentially modifiable risk factor for EVBL-induced ulcer bleeding.

A pilot study of EUS-guided fiducial insertion for the multidisciplinary management of gastric cancer.

Background and study aims: The 5-year survival rates for gastric cancer remain poor despite evolving therapies, and fiducial insertion via endoscopic ultrasound (EUS) is novel within this setting. We aimed to assess the feasibility of fiducial insertion for response assessment and anatomic localization in patients with gastric cancer. Patients and methods: A prospective phase II feasibility study was undertaken at Austin Health (Victoria, Australia) from February 2011 to November 2012. Consecutive adult patients were enrolled who had primary adenocarcinoma of the stomach with American Joint Committee on Cancer stage T1 – 3,N0 – 1,M0 – 1a and Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1. In addition, the patients were medically suitable for gastrectomy and chemotherapy/chemoradiotherapy. Gold fiducial markers were inserted under EUS guidance into the margins of the gastric cancer primary. The main outcome was successful insertion of the fiducial without complications for response assessment and anatomic localization. Results: A total of 15 fiducials were successfully inserted into 7 (88 %) of 8 patients. No immediate or delayed complications were noted. One patient proceeded to image-guided radiotherapy through the use of fiducials and is disease free at 12 months. Fiducials were used to assess treatment response in all patients who underwent computed tomographic imaging after insertion. Follow-up computed tomography with fiducial placement improved anatomic localization and estimation of the gastric cancer primary size in 3 (60 %) of 5 patients. Conclusions: Within the limitations of our small study cohort, fiducials were placed in gastric cancers under EUS guidance without complications, and placement was successful in the majority of our patients. Although potential benefits exist, there remain substantial limitations to the generalization of this technique across our patient population.

Somatostatinoma of the Minor Papilla Treated by Local Excision in a Patient with Neurofibromatosis Type 1

CONTEXT Somatostatinoma arising from the minor papilla in a patient with neurofibromatosis type 1 (NF1) is a known but very rare condition, which may cause non-specific symptoms and can present because of its mass effect. CASE REPORT A fifty-year-old female presenting with ongoing non-specific abdominal pain for a few months duration was found to have a mass involving the minor papilla. She had a history of NF1 but was otherwise well. Magnetic resonance imaging showed a dilated pancreatic duct and the finding of pancreatic divisum. The lesion was (18)fluorine-fluoro-2-deoxyglucose positron emission tomography/computed tomography and (68)gallium (Ga) DOTATATE negative. Endoscopic ultrasound revealed a 1.7 cm lesion confined to the minor ampulla. Endoscopic retrograde pancreatography attempts with biopsy and endoscopic ultrasound fine needle aspiration biopsy were inconclusive and resulted in mild pancreatitis on two occasions. Open local excision of the minor papilla was undertaken without complications. Histology confirmed a completely excised grade 1 neuroendocrine tumor with intense diffuse somatostatin staining. CONCLUSION Somatostatinoma of the minor papilla is a rare tumor that most commonly occurs in the setting of NF1 and may be amenable to local excision.

Angiodysplasia resistant to endoscopic therapy: Letters to the editor

A 75-year-old man was referred in February 2007 for push enteroscopy, for the management of angiodysplasia. Between 2005 and 2007, he required transfusion of 43 units of packed cells. There was history of moderate chronic obstructive airway disease, but no history of valvular heart disease, antiplatelet therapy or warfarin. Previous gastroscopy confirmed duodenal angiodysplasia, colonoscopy was normal and capsule endoscopy showed tiny red spots in the proximal duodenum. Push enteroscopy was undertaken and angiodysplasia was treated in the second part of the duodenum using argon plasma coagulation (APC) at 50 W. The patient was readmitted every 1–2 months with melaena. Each time endoscopy confirmed bleeding from the duodenum. Each time, the bleeding area was treated with APC, adrenaline, electrocautery or clipping, with control of bleeding by the end of the procedure. In September 2008, tranexamic acid was commenced for persistent bleeding. By May 2009, he required 100 units of packed cells despite treatment and was readmitted with further bleeding. At gastroscopy, the duodenal bleeding site was marked using endoscopic clips and the patient underwent angiography. Angiography confirmed increased vascularity between the two clips (Fig. 1); the vessel of interest was catheterized and coiled. The patient was discharged 2 days later and has maintained normal haemoglobin for the last 4 months. Angiodysplasias are dilated capillaries and may occur anywhere in the gastrointestinal tract. They are more common with increasing age, in patients with aortic stenosis, end-stage renal failure and Von Willebrand’s disease. Angiodysplasia is a common cause of obscure gastrointestinal bleeding. First-line therapy is endoscopy with APC or electrocautery. Medical therapies including oestrogen/ progesterone, tranexamic acid, and thalidomide have been used with variable efficacy. Surgical resection is sometimes helpful especially for colonic angiodysplasia. In this case, clip-guided angiography with coiling was beneficial. Clip-guided angiography should be considered as part of the treatment algorithm for treatment-resistant angiodysplasia.