Masud Shaukat

Outcomes of endoscopic treatment of gastroduodenal Dieulafoy's lesion with rubber band ligation and thermal/injection therapy

Background Dieulafoys lesion is a rare but important cause of upper gastrointestinal bleeding. Current endoscopic methods used to treat Dieulafoys lesion include injection, with or without thermal methods, and mechanical methods. The latter include variceal ligation and hemoclips. There are no studies comparing the outcomes of rubber band ligation and injection with or without thermal therapy. Aim To report the outcomes of Dieulafoys lesion treated endoscopically with rubber band ligation and injection with or without thermal therapy at a single institution. Methods Patients with the diagnosis of Dieulafoys lesion treated endoscopically at the Carl T. Hayden VA Medical Center in Phoenix, between August 1994 and August 2002 were analyzed. Demographic data, mode of presentation, risk factors for gastrointestinal bleeding, hemodynamic parameters, blood transfusion requirements, endoscopic findings, details of endoscopic therapy, length of stay in ICU/hospital, complications, recurrence of bleeding, and mortality rates were collected and compared between those receiving endoscopic band ligation (EBL group) and those receiving injection with or without thermal therapy (non-EBL group). Results Twenty-three patients with Dieulafoys lesion (14 in the EBL group and nine in the non-EBL group) were studied. All patients were men. The mean age, hemoglobin levels on admission, and the transfusion requirements before therapy were similar in both groups. Fourteen patients (eight in the EBL- and six in the non-EBL groups) presented with hematemesis and the remaining with melena. The majority of Dieulafoys lesions (91.3%) were located in the stomach and two in the duodenum. Active bleeding at the time of endoscopy was seen in 61% of cases, and immediate hemostasis was achieved with either method in 100% of patients. Early rebleeding (within 72 hours of endoscopic therapy) occurred in only one patient treated with epinephrine plus heater probe therapy. The length of stay in ICU was longer in the non-EBL group (6.7 days) compared with the EBL group (1.8 days) (P = 0.2). There were six deaths (three in the non-EBL group and three in the EBL group) within 30 days of the index hospitalization. The causes of death included infection/sepsis (n = 3), complications of acute myocardial infarction (n = 2), and end-stage liver disease (n = 1). Conclusions Endoscopic rubber band ligation is as effective as injection with or without thermal therapy in the treatment of Dieulafoys lesion.

Screening of Barrett's esophagus with string-capsule endoscopy: a prospective blinded study of 100 consecutive patients using histology as the criterion standard.

BACKGROUND The yield of wireless capsule endoscopy for Barretts esophagus (BE) has not been compared with its true criterion standard, histology. OBJECTIVE To determine the sensitivity, specificity, positive predictive value, and negative predictive value of string capsule endoscopy (SCE) for the screening of BE by using specialized intestinal metaplasia as the criterion standard. DESIGN Prospective, blinded, comparative study. SETTING Endoscopy unit, Veterans Affairs medical center. PATIENTS Patients with chronic reflux symptoms who were undergoing EGD for screening for BE. INTERVENTIONS SCE performed immediately before EGD. MAIN OUTCOMES MEASURES The yield of SCE was compared with EGD for the visual and histologic diagnosis. RESULTS One hundred patients, 86 men and 14 women, with a mean age of 56.5 years. The sensitivity and the specificity of SCE for the visual diagnosis of BE were 78.3% and 82.8%, respectively, when compared with EGD; the kappa index was 0.676. The sensitivity and the specificity of SCE for the histologic diagnosis of BE were 93.5% and 78.7%, respectively, with a kappa index of 0.66. No complications occurred; the procedure was well tolerated, and 80% of the patients indicated that they would prefer SCE to EGD. A total of 4 capsules were used for the study. CONCLUSIONS When compared with EGD, SCE had an acceptable sensitivity and specificity for the visual diagnosis of BE and compared favorably when histology was used as the criterion standard. SCE was safe and well tolerated, with a high patients preference rate, and it may prove to be cost effective for the screening of this condition.

Feasibility and safety of string, wireless capsule endoscopy in the diagnosis of Barrett's esophagus

BACKGROUND Capsule endoscopy is a major technological advancement in the visualization of the small bowell. Its utility in the evaluation of the esophagus is mainly limited by its rapid and unpredictable transmission, thus limiting the number of pictures of the esophagus, in particular, the distal esophagus. METHODS Strings were attached to the wireless capsule endoscopy device to allow its controlled movement up and down the esophagus. Microbiologic cultures of the capsules surface after high-level disinfection were carried out after the procedure. At the time of recording, discomfort associated with the procedure was documented. Patient preference compared with conventional EGD was recorded. An independent endoscopist blinded to the EGD diagnoses assessed the diagnostic accuracy of pictures obtained. OBSERVATIONS Fifty patients with Barretts esophagus were enrolled: 28 with short-segment Barretts and 22 with long-segment Barretts. The procedure was safe (no strings were disrupted, and no capsule was lost), and it rendered negative microbiologic cultures after high-level disinfection. The mean recording time was 7.9 minutes; all patients with both short- and long-segment Barretts esophagus were successfully identified. The difficulty/discomfort associated with swallowing the device, throat discomfort, gagging, moving the capsule (up and down and upon retrieval of the capsule) was none or minimal in 74%, 98%, 96%, 94%, and 76%, respectively. A single capsule was used in 24 studies, and the majority of patients (92%) preferred string-capsule endoscopy to EGD. CONCLUSIONS String-capsule endoscopy was feasible, safe, and highly acceptable, and was preferred by patients and may prove to be more cost effective than screening EGD.

Feasibility and Safety of String Wireless Capsule Endoscopy in the Diagnosis of Esophageal Varices

OBJECTIVE:To assess the feasibility, safety, accuracy, and acceptability of “string-capsule endoscopy” in the evaluation of esophageal varices.MATERIAL AND METHODS:Strings were attached to the wireless capsule endoscopy device to allow its controlled movement up and down the esophagus. Time of recording and discomfort associated with the procedure was documented. Patients preference compared to conventional esophago-gastro-duodenoscopy (EGD) was recorded. An independent endoscopist blinded to EGD diagnoses assessed the diagnostic accuracy of pictures obtained.RESULTS:Thirty patients with clinical liver cirrhosis (mean age: 54.4 yr; mean MELD score: 12.5, and mean Child-Pugh score: 6.3) were enrolled; 19 for surveillance and 11 for screening purposes. The procedure was safe (no strings were disrupted and no capsule was lost). The mean recording time was 5.8 min (2.9–8.7), the accuracy 96.7%, and discomfort was minimal. The majority (83.3%) of patients preferred string-capsule endoscopy to EGD.CONCLUSIONS:String-capsule endoscopy was feasible, safe, accurate, highly acceptable, and preferred by cirrhotic patients undergoing screening/surveillance of esophageal varices. The technique may prove to be more cost effective than conventional EGD.

Feasibility of string-capsule endoscopy in the diagnosis of esophageal mucosal disorders

Purpose: The diagnostic utility of capsule endoscopy in the esophagus is precluded by its rapid transit time. An attached string to the capsule would allow its controlled and on-purpose movement up and down the esophagus. Aims: 1) To determine if the esophageal mucosal pictures allow accurate diagnoses of mucosal conditions. 2) To assess patients discomfort and acceptability when compared to EGD. 3) To determine whether the capsule can be re-used after conventional disinfection/sterilization.

Diagnostic and therapeutic endoscopy through the gastrostomy site

We report a successful diagnostic and therapeutic endoscopy through the gastrostomy site in two patients in whom conventional antegrade upper endoscopy was not possible. In one, the endoscopic and histologic diagnosis of a completely obstructing malignant lesion in the upper esophagus was possible by retrograde intubation using a bronchoscope. In the other, the gastrostomy site was used to gain access and assist in the placement of a jejunostomy tube. We describe a technique to help circumvent the lack of air insufflation with the bronchoscope. Both endoscopies were carried out without the need for drugs for conscious sedation. This percutaneous route, through a gastrostomy site, in the technique described by us uses a readily available endoscope in any hospital setting, does not need conscious sedation, and does not need dilation of the stoma site, allowing access to the gastrointestinal tract for diagnostic and therapeutic purposes.

String capsule endoscopy: A novel application for the preoperative identification of a small-bowel obscure GI bleeding source (with video)

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⁎4508 Screening flexible sigmoidoscopy beyond the age of seventy: when to stop?

Currently there are no national guidelines addressing at what age screening for colon cancer should be stopped. As the population grows older the theory of competing risks takes place and screening procedures may become unnecessary. AIM: To assess the impact of flexible sigmoidoscopy in patients who are older than 70 years of age. MATERIAL AND METHODS: All flexible sigmoidoscopies performed at a single institution between February 1993 and February 1995 were reviewed. Those patients whose age was 70 or older were studied and further divided into 3 groups: 70-74 years (Group A), 75-79 years (Group B) and older than 80 years (Group C). The prevalence of adenomas or carcinoma found as a result of the flexible sigmoidoscopy and overall 5-year mortality were determined. RESULTS: A total of 1271 flexible sigmoidoscopies were performed during the study period. Of these, 369 (29%) corresponded to patients 70 years of age or older. Of this group, there were 245 patients in Group A (66.4%), 101 in Group B (27.4%) and 23 in Group C (6.2%). The rate of adenomas found in the entire group of elderly patients was 16.3% (60/369). The probability of finding adenomas progressively decreased from Group A to Group C (p=0.09). The probability of finding carcinoma was not statistically different amongst the 3 groups. Of the 3 cancers in Group B, only one was detected as a result of screening flexible sigmoidoscopy, the other 2 had symptoms that prompted the study. The 5-year mortality from any cause was significantly higher in Groups B and C when compared to Group A (Table). CONCLUSIONS: 1) Screening flexible sigmoidoscopy remains an invaluable tool for colon cancer screening purposes but may not be indicated at age 80 or older given the low yield and the high 5-year mortality. 2) Based on our findings, age 75 may be a reasonable cutoff for screening flexible sigmoidoscopy.