Michael P. Swan

Endoscopic Resection for Barrett's High-Grade Dysplasia and Early Esophageal Adenocarcinoma: An Essential Staging Procedure With Long-Term Therapeutic Benefit

OBJECTIVES: Patients with Barretts high‐grade dysplasia (HGD) or early esophageal adenocarcinoma (EAC) that is shown on biopsy alone continue to undergo esophagectomy without more definitive histological staging. Endoscopic resection (ER) may provide more accurate histological grading and local tumor (T) staging, definitive therapy, and complete Barretts excision (CBE); however, long‐term outcome data are limited. Our objective was to demonstrate the effect on histological grade or local T stage, efficacy, safety and long‐term outcome of ER for Barretts HGD/EAC and of CBE in suitable patients. METHODS: This prospective study at two Australian academic hospitals involved 75 consecutive patients over 7 years undergoing ER for biopsy‐proven HGD or EAC, using multiband mucosectomy or cap technique. In addition, CBE by 2–3‐stage radical mucosectomy was attempted for all Barretts segments ≤3 cm in length in patients aged <75 years with minimal comorbidities. RESULTS: Biopsy histology showed HGD in 89% of patients and EAC in 11%. However, ER histology resulted in altered grading or staging in 48% of patients (down 28%, up 20%), with HGD in 53%, low‐grade dysplasia (LGD) in 19%, mucosal adenocarcinoma in 13%, submucosal adenocarcinoma in 9%, and no dysplasia in 4% of patients. The CBE success rate was 94%. Complications were one aspiration (hospitalization with full recovery) and six strictures successfully dilated endoscopically. During the mean follow‐up of 31 months (range 3–89), there was no recurrence at ER sites, 11% developed metachronous lesions and five patients underwent esophagectomy for ER‐demonstrated submucosal invasion. Esophagectomy specimens were T0N0M0 in three and T1N0M0 in two patients. There were no deaths due to adenocarcinoma. CONCLUSIONS: ER alters histological grade or local T stage in 48% of patients and dramatically reduces esophagectomy rates by providing safe and effective therapy. ER has a high success rate (94%) for CBE in short segment Barretts esophagus.

Large refractory colonic polyps: is it time to change our practice? A prospective study of the clinical and economic impact of a tertiary referral colonic mucosal resection and polypectomy service (with videos)

BACKGROUND Patients who have large, difficult, colorectal lesions not readily amenable to endoscopic resection are often referred directly to surgery. The application of advanced polypectomy and endoscopic mucosal resection (EMR) techniques undertaken by a tertiary referral colonic mucosal resection and polypectomy service (TRCPS) is not often considered but may be superior to surgery. OBJECTIVE To evaluate the safety, efficacy, and cost savings of a TRCPS for colorectal lesions. DESIGN Prospective intention-to-treat analysis. SETTING Tertiary academic referral center. PATIENTS In a 21-month period ending in April 2008, consecutive patients with large or complex colorectal polyps referred by other specialist endoscopists were prospectively enrolled on an intention-to-treat basis. INTERVENTION For sessile lesions, a standardized EMR approach was used. Pedunculated lesions were removed with or without pretreatment with an Endoloop procedure. MAIN OUTCOME MEASUREMENTS Complete resection, complications, recurrence, and potential cost savings comparing actual outcome of the cohort with a hypothetical analysis of surgical management. RESULTS This study included 174 patients (mean age 68 years) who were referred with 193 difficult polyps (186 laterally spreading, mean size 30 mm [range 10-80 mm]). We totally excised 173 laterally spreading lesions by EMR (115 piecemeal, 58 en bloc). Invasive adenocarcinoma was found in 6 lesions-5 treated successfully with EMR. Eleven patients were referred directly to surgery without an endoscopic attempt due to suspected invasive carcinoma. Seven >30-mm, pedunculated polyps were removed. There were no perforations. A total of 20 bed days was used because of endoscopic complications. Among all patients referred, 90% avoided the need for surgery. Excluding patients who were treated surgically for invasive cancer, the procedural success was 95% (157 of 168). By using Australian cost estimates applied to the entire group and compared with cost estimates assuming all patients had undergone surgery, we calculated the total medical cost savings was

Factors that predict bleeding following endoscopic mucosal resection of large colonic lesions.

6990 (U.S.) per patient, or a total savings of

The target sign: an endoscopic marker for the resection of the muscularis propria and potential perforation during colonic endoscopic mucosal resection

1,216,231 (U.S.). LIMITATION Not a randomized trial. CONCLUSIONS Colonoscopic polypectomy performed by a TRCPS on large or difficult polyps is technically effective and safe. This approach results in major cost savings and avoids the potential complications of colonic surgery. This type of clinical pathway should be developed to enhance patient outcomes and reduce health care costs.

Needle Knife Sphincterotomy Does Not Increase the Risk of Pancreatitis in Patients With Difficult Biliary Cannulation

BACKGROUND AND STUDY AIMS Endoscopic mucosal resection (EMR) for large colonic laterally spreading tumors (LSTs) is a safe, efficacious, and cost-effective treatment. The most common serious complication is delayed bleeding, which reduces these advantages, but consensus guidelines for large-polyp EMR do not exist. PATIENTS AND METHODS Data from two large prospective intention-to-treat studies of EMR for colonic LSTs 20 mm or greater in size were analyzed. Data collection was comprehensive, and included patient and lesion characteristics. EMR technique and cessation of anticoagulant and antiplatelet therapy was standardized. Clinically significant delayed bleeding was defined as that requiring hospital admission. RESULTS EMR was performed on 302 lesions in 288 patients. There was clinically significant delayed bleeding in 21 cases (7 %). Ten underwent colonoscopy. One required angiography. One required surgery after perforation following hemostatic clip placement. There were no deaths. Risk factors for bleeding on multivariate analysis were right colon location [adjusted odds ratio (OR) 4.4, P = 0.01], use of aspirin (OR 6.3, P = 0.005), and age (OR per decade of age 1.70). All bleeds occurred before aspirin was restarted. Patient characteristics, including ASA grade and co-morbidity type, were not predictive. Despite requiring more complex EMR, larger lesion size ( P = 0.2), multiple excisions rather than en bloc resection ( P = 0.1), polyp morphology ( P = 0.2), and previous attempts ( P = 0.5), were not associated with increased risk. CONCLUSIONS Proximal lesion location is a highly significant risk for clinically significant delayed bleeding following colonic EMR, and this knowledge could form the basis of a targeted therapeutic trial. Recent aspirin use also increases bleeding risk--specific consensus guidelines in this area are required for colonic EMR.

Giant laterally spreading tumors of the papilla: endoscopic features, resection technique, and outcome (with videos).

BACKGROUND EMR of large sessile polyps and laterally spreading tumors (LSTs) of the colon is safe and cost-effective. Perforation remains a feared and well-recognized complication; however, endoscopic detection is often absent, and most commonly, diagnosis is delayed and depends on clinical signs and/or radiology findings. To date, an endoscopic sign to identify muscularis propria (MP) resection and potential perforation has not been described. OBJECTIVE To describe an endoscopic sign for prompt recognition of EMR-related MP resection. DESIGN Prospective analysis. SETTINGS Tertiary referral academic gastroenterology unit. PATIENTS Patients with the target sign were identified prospectively in 2 large prospective studies of EMR for colonic LSTs 20 mm or larger. INTERVENTION A standardized EMR approach was used. MP defects were closed endoscopically with clips. MAIN OUTCOME MEASUREMENTS The presence or absence of the target sign in the polypectomy specimen and its influence on subsequent endoscopic management of polypectomy complications. RESULTS A total of 445 patients with LSTs or sessile polyps 20 mm or larger (mean size 33 mm, range 20-85 mm) were prospectively enrolled in 2 studies. Ten patients (mean age 70.3 years, range 48-83 years, 50% male) with target lesions and histologically confirmed MP resection were identified prospectively at the time of EMR, with 3 having full-thickness resection. All cases were identified intraprocedurally by a target sign on the underside of the specimen and a mirror target evident in the mucosal defect. All patients were treated endoscopically with 1 to 5 endoscopic clips. None required operative management. Thirteen inpatient days were required to treat the 10 patients (mean 1.3 days). LIMITATIONS Nonrandomized study. CONCLUSIONS Careful analysis of the post-EMR specimen and resection defect may reveal a target sign, an easily recognized and reliable marker of either partial- or full-thickness MP resection and potential perforation. Prompt recognition of this sign facilitates endoscopic management.

En-bloc resection of multiple type 1 gastric carcinoid tumors by endoscopic multi-band mucosectomy.

BACKGROUND & AIMS Biliary cannulation is unsuccessful during 5%-10% of endoscopic retrograde cholangiopancreatography (ERCP) procedures. Needle knife sphincterotomy (NKS) can improve success of cannulation but is often used as a last resort and is associated with post-ERCP pancreatitis (PEP). We evaluated the safety and efficacy of performing NKS during early stages of difficult cannulation and the relationship between difficult cannulation and the risk of PEP. METHODS We performed a prospective trial of consecutive patients with an intact papilla who were undergoing ERCP at tertiary referral center; 73 patients were defined as having difficult biliary cannulation according to predefined cannulation parameters. These patients were randomly assigned to groups that received either NKS or continued standard cannulation. Main outcome measures were PEP and successful biliary cannulation. RESULTS Of 464 patients with an intact papilla undergoing ERCP, 73 met the criteria for difficult cannulation. Cannulation success in difficult cannulation cases was 86%, with a PEP rate of 19%. There was no difference in eventual cannulation success between the groups. However, 65% of the patients assigned to the standard cannulation group required crossover to NKS. There was no significant difference in development of PEP among patients in the early NKS group (20.5%) vs standard cannulation (17.6%). Pancreatic duct stents were inserted in 23 of the patients in the early NKS arm and in 15 in the standard cannulation arm. The number of cannulation attempts (more than 7) increased the risk of PEP (P < .01). On the basis of multivariate analysis, independent risk factors for PEP were failure of early cannulation and failure of biliary cannulation. CONCLUSIONS Early application of NKS during difficult cannulation does not increase the risk of PEP. The risk of PEP increases greatly after 7-8 attempts at or failure of cannulation. Further studies are required to assess whether early implementation of NKS during difficult cannulation reduces the development of PEP. Australia and New Zealand Clinical Trials registry: ANZTRN 12,612,000,060,842.

Failed biliary cannulation: clinical and technical outcomes after tertiary referral endoscopic retrograde cholangiopancreatography.

BACKGROUND Successful endoscopic treatment of conventional papillary adenomas is well described. However, many authors recommend surgical resection for larger lesions with extrapapillary extension. OBJECTIVE To describe the classification, technique, and outcome for the endoscopic resection of giant laterally spreading tumors of the papilla (LST-P). DESIGN Single-center case series. SETTINGS Tertiary referral academic gastroenterology unit. PATIENTS Patients referred for endoscopic treatment of LST-P. INTERVENTION Pre-resection staging and single-session endoscopic removal of papillary adenomas. For those classified as LST-P (>30 mm, extending beyond the papilla onto the duodenal wall and involving as much as two thirds of the duodenal circumference), a standardized single-session EMR technique was used. MAIN OUTCOME MEASUREMENTS Technical success, complications, and adenoma recurrence for single-session removal of LST-P. Outcomes were compared with those of conventional ampullary adenoma resection during the same period. RESULTS Twenty-five patients with ampullary adenomas were referred. In 10 patients identified with LST-P (mean age 70.2 years; adenoma size 30-80 mm), combination EMR and papillectomy was performed in a single session. The median admission duration was 1 night (range 0-35). Complications included bleeding (30%) and cholecystitis (10%), with no cases of pancreatitis or perforation. Adenoma recurrence at 3 months was found in 1 patient (10%). Complication and recurrence rates in smaller (<30 mm) ampullary adenoma resections were not significantly different. LIMITATIONS A relatively uncommon entity and thus small sample size. CONCLUSIONS Endoscopic resection of carefully staged LST-P is a viable therapeutic alternative to surgery. In experienced hands, the outcomes are comparable to those for conventional ampullary adenomas.

Autoimmune pancreatitis: an important diagnostic consideration in obstructive jaundice due to a pancreatic mass lesion

Background and Aim:  Gastric carcinoid tumors are rare but increasing in incidence. Current recommendations suggest endoscopic resection for type I carcinoids found in the stomach, however reports of incomplete resection have led to difficulty planning future management. Our purpose was to describe the application of the endoscopic multi‐band mucosectomy (MBM) device to achieve en‐bloc resection of multiple gastric carcinoid tumors.

Gastroduodenal Outlet Obstruction and Palliative Self-Expandable Metal Stenting: A Dual-Centre Experience

AIM Prospective evaluation of repeat endoscopic retrograde cholangiopancreatography (ERCP) for failed Schutz grade 1 biliary cannulation in a high-volume center. METHODS Prospective intention-to-treat analysis of patients referred for biliary cannulation following recent unsuccessful ERCP. RESULTS Fifty-one patients (35 female; mean age: 62.5 years; age range: 40-87 years) with previous failed biliary cannulation were referred for repeat ERCP. The indication for ERCP was primarily choledocholithiasis (45%) or pancreatic malignancy (18%). Successful biliary cannulation was 100%. The precut needle knife sphincterotomy (NKS) rate was 27.4%. Complications occurred in 3.9% (post-ERCP pancreatitis). An identifiable reason for initial unsuccessful biliary cannulation was present in 55% of cases. Compared to a cohort of 940 naïve papilla patients (female 61%; mean age: 59.9 years; age range: 18-94 years) who required sphincterotomy over the same time period, there was no statistical difference in the cannulation success rate (100% vs 98%) or post-ERCP pancreatitis (3.1% vs 3.9%). Precut NKS use was more frequent (27.4% vs 12.7%) (P = 0.017). CONCLUSION Referral to a high-volume center following unsuccessful ERCP is associated with high technical success, with a favorable complication rate, compared to routine ERCP procedures.