Mihir S. Wagh

Endoscopic transgastric abdominal exploration and organ resection: initial experience in a porcine model.

BACKGROUND & AIMS The evolution of flexible endoscopes and endoscopic devices has recently enabled per-oral transgastric abdominal exploration in animal models. This study was undertaken to assess the ability to systematically identify abdominopelvic organs and to determine the feasibility of organ resection via the transgastric route. METHODS Female Yorkshire pigs were used for the study. Under general anesthesia, a gastroscope was used to place a sterile overtube into the esophagus. After antibacterial lavage, the gastric wall was incised, and a sterile dual-channel endoscope was advanced into the peritoneal cavity. Endoscopic abdominal exploration was then methodically performed in 9 animals with oophorectomy and partial hysterectomy in 6 animals. The gastric incision was closed with endoclips. Of the animals that underwent organ resection, 3 were sacrificed immediately after surgery, and the subsequent 3 survived. RESULTS The peritoneal cavity was accessed uneventfully, and the stomach, liver, small bowel, colon, urinary bladder, uterus, fallopian tubes, and ovaries were able to be evaluated in all cases. The gallbladder could be visualized in only 5 of the 9 animals, and retroperitoneal structures could not be consistently identified. Oophorectomy with partial hysterectomy was performed in 6 animals. The 3 animals in the survival group did well for 24 hours without sequelae. CONCLUSIONS This study shows the ability of endoscopic transgastric peritoneal exploration to successfully identify most abdominopelvic organs and demonstrates the technical feasibility of transgastric organ resection.

Diagnostic accuracy of conventional and cholangioscopy-guided sampling of indeterminate biliary lesions at the time of ERCP: a prospective, long-term follow-up study

BACKGROUND The diagnostic accuracy of cholangioscopy-guided sampling has not been rigorously evaluated. OBJECTIVE To prospectively evaluate the accuracy of cholangioscopy-guided mini-forceps sampling and compare it with standard cytology brushings and forceps biopsies for the tissue diagnosis of indeterminate biliary lesions. DESIGN Prospective, long-term follow-up, paired design cohort study. SETTING Tertiary center. PATIENTS Patients undergoing cholangioscopy for the evaluation of indeterminate biliary lesions. INTERVENTIONS Each patient underwent triple sampling with cholangioscopy-guided mini-forceps, cytology brushing, and standard forceps. MAIN OUTCOME MEASUREMENTS Diagnostic accuracy of each sampling method compared with the patient final status (cancer vs no cancer). RESULTS A total of 26 patients (17 cancer positive/9 cancer negative) were enrolled. The mean follow-up in the patients with no cancer was 21.78 (SD ±6.78) months. The procedure was technically successful in all cases (100%). Sample quality was adequate in 25 of 26 (96.2%) of the cytology brushings, in 26 of 26 (100%) of the standard forceps biopsies, and in 25 of 26 (96.2%) of the mini-forceps biopsies. The sensitivity, accuracy, and negative predictive values were 5.9%, 38.5%, and 36% for standard cytology brushings; 29.4%, 53.8%, and 42.8% for standard forceps biopsies; and 76.5%, 84.6%, and 69.2% for mini-forceps biopsies, respectively. When comparing the 3 methods of sampling, mini-forceps biopsy provided significantly better sensitivity and overall accuracy compared with standard cytology brushing (P < .0001) and standard forceps biopsy (P = .0215). LIMITATIONS Potential for selection bias. CONCLUSIONS Cholangioscopy-guided biopsies of indeterminate biliary lesions have significantly higher accuracy compared with ERCP-guided cytology brushings and standard forceps biopsies, but negative findings on mini-forceps biopsy cannot rule out malignancy with a high degree of certainty. ( CLINICAL TRIAL REGISTRATION NUMBER NCT01227382.).

Prospective evaluation of the use of fully covered self-expanding metal stents for EUS-guided transmural drainage of pancreatic pseudocysts

2. Rumalla A, Baron TH. Results of direct percutaneous endoscopic jejunostomy, an alternative method for providing jejunal feeding. Mayo Clin Proc 2000;75:807-10. 3. Panagiotakis PH, DiSario JA, Hilden K, et al. DPEJ tube placement prevents aspiration pneumonia in high-risk patients. Nutr Clin Pract 2008;23:172-5. 4. Kwon RS, Banerjee S, Desilets D, et al. Enteral nutrition access devices. Gastrointest Endosc 2010;72:236-48. 5. Maple JT, Petersen BT, Baron TH, et al. Direct percutaneous endoscopic jejunostomy: outcomes in 307 consecutive attempts. Am J Gastroenterol 2005;100:2681-8. 6. Foutch PG, Talbert GA, Waring JP, et al. Percutaneous endoscopic gastrostomy in patients with prior abdominal surgery: virtues of the safe tract. Am J Gastroenterol 1988;83:147-50. 7. Varadarajulu S, Delegge MH. Use of a 19-gauge injection needle as a guide for direct percutaneous endoscopic jejunostomy tube placement. Gastrointest Endosc 2003;57:942-5. 8. Cotton PB, Eisen GM, Aabakken L, et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010;71:446-54.

Prospective evaluation of the clinical utility of ERCP-guided cholangiopancreatoscopy with a new direct visualization system

BACKGROUND Older systems for cholangiopancreatoscopy have demonstrated improved diagnostic and therapeutic abilities over standard ERCP but have shown limited feasibility. The SpyGlass Direct Visualization System addresses many of the shortcomings of the older platforms, but its potential advantages have not been rigorously evaluated. OBJECTIVE To prospectively evaluate the feasibility, clinical efficacy, and safety of the SpyGlass system. DESIGN Prospective cohort study. SETTING Tertiary care center. PATIENTS All patients undergoing cholangiopancreatoscopy at our institution. INTERVENTIONS Cholangiopancreatoscopy with the SpyGlass system. MAIN OUTCOME MEASUREMENTS Procedure success, defined as complete stone clearance for stone cases. For nonstone-related lesions, success was defined when all 3 of the following were met: (1) advancement of the SpyScope to the desired target, (2) adequate visualization, and (3) successful applications of all necessary diagnostic and/or therapeutic maneuvers. RESULTS Overall, SpyGlass was successful in 70 of 75 patients (93.3%). In patients with biliary stones, complete stone clearance was achieved in 24 of 26 patients (92.3%). Cholangioscopy for nonstone-related indications was successful in 43 of 44 patients (97.7%). Pancreatoscopy was attempted in 5 patients and was successful in 3 (60%). The mean total procedure time (standard ERCP plus SpyGlass) was 64.3 minutes, the total SpyGlass time was 27.5 minutes, the mean SpyGlass visualization time was 14.2 minutes, the mean SpyBite sampling time was 12.1 minutes, the mean Spy therapy time was 8.4 minutes, and the mean set-up time was 5 minutes. There were 4 adverse events (4.8%). LIMITATIONS Single-center experience, no comparison group, potential for selection bias. CONCLUSIONS ERCP-guided cholangiopancreatoscopy with the SpyGlass system is technically feasible and can be successfully and safely performed in the vast majority of patients. ( CLINICAL TRIAL REGISTRATION NUMBER NCT00861198.).

Randomized, controlled trial of standard, large-capacity versus jumbo biopsy forceps for polypectomy of small, sessile, colorectal polyps

BACKGROUND Polypectomy with cold biopsy forceps is a frequently used technique for removal of small, sessile, colorectal polyps. Jumbo forceps may lead to more effective polypectomy because of the larger size of the forceps cup. OBJECTIVE To evaluate the efficiency of cold jumbo biopsy forceps compared with standard forceps for polypectomy of small, sessile, colorectal polyps. DESIGN Randomized, controlled trial. SETTING Outpatient endoscopy center. PATIENTS This study involved 140 patients found to have at least one eligible polyp defined as a sessile polyp measuring ≤6 mm. INTERVENTION Polypectomy with cold biopsy forceps. MAIN OUTCOME MEASUREMENTS Complete visual polyp eradication with one forceps bite. RESULTS In 140 patients, a total of 305 eligible polyps were detected (151 removed with jumbo forceps and 154 with standard forceps). Complete visual eradication of the polyp with one forceps bite was achieved in 78.8% of the jumbo forceps group and 50.7% of the standard forceps group (P < .0001). Biopsies from the polypectomy sites of adenomatous polyps thought to be visually completely eradicated with one bite showed a trend toward a higher complete histologic eradication rate with the jumbo forceps (82.4%) compared with the standard forceps (77.4%), but the difference did not reach statistical significance (P = .62). The withdrawal time for visual inspection of the colon and time to perform polypectomies were significantly shorter in the jumbo forceps group (mean 21.43 vs 18.23 minutes; P = .02). LIMITATIONS Lack of blinding to the type of forceps used. CONCLUSION The jumbo biopsy forceps is superior to the standard forceps in removing small, sessile polyps. ( CLINICAL TRIAL REGISTRATION NUMBER NCT00855790.).

Fully Covered Alimaxx Esophageal Metal Stents in the Endoscopic Treatment of Benign Esophageal Diseases

BackgroundExpandable esophageal stents are widely used for the palliation of dysphagia in patients with esophageal cancer and are also beginning to be used in patients with benign esophageal diseases such as refractory strictures and fistulas. There is concern regarding the increased risk of migration of the fully covered Alimaxx metal esophageal stent and experience with this stent in benign esophageal pathology has been reported in only a small series of patients.AimsTo evaluate the technical success in placement and removal, efficacy and complications of the Alimaxx esophageal stent for benign esophageal diseases.MethodsOur endoscopy database was retrospectively reviewed from 1/2003 to 2/2009 to identify patients with Alimaxx esophageal stent placement for benign diseases. Chart review was performed for age, gender, indication, site of the lesion, success of placement, outcome, and incidence of complications.ResultsTwenty-eight stents were successfully placed in 14 patients with benign esophageal diseases (mean: two stents/patient; range 1–7). Indications included esophageal fistula in seven (50%) and benign strictures in 7/14 (50%). Dysphagia improved in all patients while the fistula resolved in 6/7 (85.8%) patients. Complications related to stents included pain (2/28, 7%), stent related gastric ulcer (1/28, 4%), nausea and vomiting (3/21, 11%) and stent migration (11/28, 39%). All migrated stents were successfully endoscopically retrieved.ConclusionsThe fully covered and removable Alimaxx stent is effective in the endoscopic management of benign esophageal strictures or fistulas, despite its relatively high rate of migration. Stent migration was successfully managed endoscopically without complications.

Variation in Aptitude of Trainees in Endoscopic Ultrasonography, Based on Cumulative Sum Analysis

BACKGROUND & AIMS Studies have reported substantial variation in the competency of advanced endoscopy trainees, indicating a need for more supervised training in endoscopic ultrasound (EUS). We used a standardized, validated, data collection tool to evaluate learning curves and measure competency in EUS among trainees at multiple centers. METHODS In a prospective study performed at 15 centers, 17 trainees with no prior EUS experience were evaluated by experienced attending endosonographers at the 25th and then every 10th upper EUS examination, over a 12-month training period. A standardized data collection form was used (using a 5-point scoring system) to grade the EUS examination. Cumulative sum analysis was applied to produce a learning curve for each trainee; it tracked the overall performance based on median scores at different stations and also at each station. Competency was defined by a median score of 1, with acceptable and unacceptable failure rates of 10% and 20%, respectively. RESULTS Twelve trainees were included in the final analysis. Each of the trainees performed 265 to 540 EUS examinations (total, 4257 examinations). There was a large amount of variation in their learning curves: 2 trainees crossed the threshold for acceptable performance (at cases 225 and 245), 2 trainees had a trend toward acceptable performance (after 289 and 355 cases) but required continued observation, and 8 trainees needed additional training and observation. Similar results were observed at individual stations. CONCLUSIONS A specific case load does not ensure competency in EUS; 225 cases should be considered the minimum caseload for training because we found that no trainee achieved competency before this point. Ongoing training should be provided for trainees until competency is confirmed using objective measures.

Endoscopic Optical Coherence Tomography (OCT): Advances in Gastrointestinal Imaging.

In the rapidly evolving field of endoscopic gastrointestinal imaging, Optical Coherence Tomography (OCT) has found many diverse applications. We present the current status of OCT and its practical applications in imaging normal and abnormal mucosa in the esophagus, stomach, small and large intestines, and biliary and pancreatic ducts. We highlight technical aspects and principles of imaging, assess published data, and suggest future directions for OCT-guided evaluation and therapy.

The Utility of Repeat Endoscopic Ultrasound-Guided Fine Needle Aspiration for Suspected Pancreatic Cancer

Background. The utility of repeat EUS in patients with suspicion for pancreatic cancer after non-diagnostic EUS-FNA study is not well established. Aim. Determine the accuracy of repeat EUS-FNA in patients with suspected pancreatic cancer and prior non-diagnostic EUS-FNA. Methods. Retrospective cohort study. Results. From 2002 to 2008 in our institution 28 patients underwent repeat EUS-FNA for suspected pancreatic cancer. Initial EUS showed a pancreatic mass in 24 (85.71%), no mass in 3 (10.71%) and possible mass in 1 (3.58%). FNA was performed and was negative for malignancy in all patients. Repeat EUS showed pancreatic mass in 27 patients (96.42%) and no mass in 1 (3.58%). FNA was performed in all patients and cytology was positive for malignancy in 6 (21.43%). Out of the 28 patients, 17 (60.71%) were eventually confirmed to have cancer. Overall repeat EUS-FNA correctly determined the true final status in 17 out of 28 patients providing sensitivity for the diagnosis of cancer of 35% (95% CI 14%–62%), specificity 100% (95% CI 72%–100%), and overall accuracy of 61%, (95% CI 28%–72%). Conclusion. Repeat EUS-FNA provides reasonable accuracy and may be worthwhile in patients with suspected pancreatic cancer who had had prior negative EUS-FNA.

Transpapillary drainage has no added benefit on treatment outcomes in patients undergoing EUS-guided transmural drainage of pancreatic pseudocysts: a large multicenter study.

BACKGROUND AND AIMS The need for transpapillary drainage (TPD) in patients undergoing transmural drainage (TMD) of pancreatic fluid collections (PFCs) remains unclear. The aims of this study were to compare treatment outcomes between patients with pancreatic pseudocysts undergoing TMD versus combined (TMD and TPD) drainage (CD) and to identify predictors of symptomatic and radiologic resolution. METHODS This is a retrospective review of 375 consecutive patients with PFCs who underwent EUS-guided TMD from 2008 to 2014 at 15 academic centers in the United States. Main outcome measures included TMD and CD technical success, treatment outcomes (symptomatic and radiologic resolution) at follow-up, and predictors of treatment outcomes on logistic regression. RESULTS A total of 375 patients underwent EUS-guided TMD of PFCs, of which 174 were pseudocysts. TMD alone was performed in 95 (55%) and CD in 79 (45%) pseudocysts. Technical success was as follows: TMD, 92 (97%) versus CD, 35 (44%) (P = .0001). There was no difference in adverse events between the TMD (15%) and CD (14%) cohorts (P = .23). Median long-term (LT) follow-up after transmural stent removal was 324 days (interquartile range, 72-493 days) for TMD and 201 days (interquartile range, 150-493 days) (P = .37). There was no difference in LT symptomatic resolution (TMD, 69% vs CD, 62%; P = .61) or LT radiologic resolution (TMD, 71% vs CD, 67%; P = .79). TPD attempt was negatively associated with LT radiologic resolution of pseudocyst (odds ratio, 0.11; 95% confidence interval, 0.02-0.8; P = .03). CONCLUSIONS TPD has no benefit on treatment outcomes in patients undergoing EUS-guided TMD of pancreatic pseudocysts and negatively affects LT resolution of PFCs.