Mukund Venu

Physician Assessment and Management of Complex Colon Polyps: A Multicenter Video-Based Survey Study

Objectives:The management of complex colorectal polyps varies in practice. Accurate descriptions of the endoscopic appearance by using a standardized classification system (Paris classification) and size for complex colon polyps may guide subsequent providers regarding curative endoscopic resection vs. need for surgery. The accuracy of this assessment is not well defined. Furthermore, the factors associated with decisions for endoscopic vs. surgical management are unclear. To characterize the accuracy of physician assessment of polyp morphology, size, and suspicion for malignancy among physician subspecialists performing colonoscopy and colon surgery. In addition, we aimed to assess the influence of these polyp characteristics as well as physician type and patient demographics on recommendations for endoscopic vs. surgical resection of complex colorectal polyps.Methods:An online video-based survey was sent to gastroenterologists (GIs) and gastrointestinal surgeons affiliated with six tertiary academic centers. The survey consisted of high-definition video clips (30–60 s) of six complex colorectal polyps (one malignant) and clinical histories. Respondents were blinded to histology. Respondents were queried regarding polyp characteristics, suspicion for malignancy, and recommendations for resection.Results:The survey response rate was 154/317 (49%). Seventy-eight percent of respondents were attending physicians (91 GIs and 29 surgeons) and 22% were GI trainees. Sixteen percent of respondents self-identified as specialists in complex polypectomy. Accurate estimation of polyp size was poor (28.4%) with moderate interobserver agreement (k=0.52). Accuracy for Paris classification was 47.5%, also with moderate interobserver agreement (k=0.48). Specialists in complex polypectomy were most accurate, whereas surgeons were the least accurate in assigning Paris classification (66.0 vs. 28.7%, P<0.0001). Specialists in complex polypectomy were most likely to correctly identify the malignant lesion compared with other physicians (87.5 vs. 56.2%, P=0.008). Surgical removal of colon adenomas was recommended least frequently by specialists in complex polypectomy (3.1%) compared with nonspecialists in complex polypectomy (13.3%); surgeons were most likely to recommend surgical resection (17.2%, P=0.009). There were no differences in recommendations for endoscopic vs. surgical resection observed on the basis of years in practice, polyp morphology (polypoid vs. nonpolypoid), polyp location (right vs. left colon), or patient ASA class.Conclusions:In this large survey of GIs and surgeons, physician specialty was strongly associated with accurate polyp characterization and a recommendation for endoscopic resection of complex polyps. Surgeons were most likely to recommend surgical resection of complex nonmalignant colorectal polyps compared with specialists in complex polypectomy who were the least likely. Therefore, collaboration with specialists in complex polypectomy may be helpful in determining the appropriate management of complex colon polyps. Further teaching is needed among all specialists to improve accurate communication and ensure optimal management of these lesions.

High prevalence of vitamin A deficiency and vitamin D deficiency in patients evaluated for liver transplantation.

Deficiencies in vitamins A, D, and E have been linked to night blindness, bone health, and post–liver transplant reperfusion injury. The aim of this study was to determine the prevalence and predictive factors of fat‐soluble vitamin deficiencies in liver transplant candidates. We reviewed the medical records of liver transplant candidates at our center from January 2008 to September 2011. The etiology of cirrhosis, Model for End‐Stage Liver Disease score, Child‐Pugh class, body mass index (BMI), and vitamin A, vitamin E, and vitamin 25‐OH‐D levels were recorded. Patients were excluded for incomplete laboratory data, short gut syndrome, celiac disease, pancreatic insufficiency, or prior liver transplantation. Sixty‐three patients were included. The most common etiologies of liver disease were alcohol (n = 23), hepatitis C virus (n = 19), and nonalcoholic steatohepatitis (n = 5). Vitamin A and D deficiencies were noted in 69.8% and 81.0%, respectively. Only 3.2% of the patients were vitamin E–deficient. There were no documented cases of night blindness. Twenty‐five of the 55 patients with bone density measurements had osteopenia, and 10 had osteoporosis. Four patients had vertebral fractures. There was 1 case of posttransplant reperfusion injury in a patient with vitamin E deficiency. In a multivariate analysis, there were no statistically significant predictors for vitamin D deficiency. The Child‐Pugh class [odds ratio (OR) = 6.84, 95% confidence interval (CI) = 1.52‐30.86, P = 0.01], elevated total bilirubin level (OR = 44.23, 95% CI = 5.02‐389.41, P < 0.001), and elevated BMI (OR = 1.17, 95% CI = 1.00‐1.36, P = 0.045) were found to be predictors of vitamin A deficiency. In conclusion, the majority of liver disease patients evaluated for liver transplantation at our center had vitamin A and D deficiencies. The presence or absence of cholestatic liver disease did not predict deficiencies, whereas Child‐Pugh class, bilirubin level, and elevated BMI predicted vitamin A deficiency. Liver Transpl 19:627–633, 2013.

Laboratory diagnosis and nonoperative management of biliary complications in living donor liver transplant patients.

Background Biliary complications associated with living donor liver transplantation (LDLT) remain a major problem. Information regarding biochemical abnormalities helpful for the diagnosis and the nonoperative management of such complications are limited. Methods Adult patients who underwent LDLT were retrospectively studied for biliary complications. Clinical findings and laboratory studies, that is, serum bilirubin, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase were evaluated. Diagnostic percutaneous transhepatic cholangiogram or endoscopic retrograde cholangiogram followed by therapeutic interventions such as endoscopic sphincterotomy, stone extraction, balloon dilation, or stent placement were done as indicated. Follow-up data on clinical and biochemical outcomes were assessed. Results Among the first 29 patients who underwent LDLT, 7 patients (24%) developed biliary complications. Nonoperative treatment was undertaken through endoscopic retrograde cholangiogram in 4 cases, percutaneous transhepatic cholangiogram in 3 cases with a successful clinical outcome in 6 cases (84%). All patients with biliary stricture had a bilirubin level >1.5 mg/dL with 100% sensitivity. Conclusions A number of patients developed biliary complications after LDLT. Nonoperative treatments were successful in most patients. Elevated serum bilirubin level may be helpful in the diagnosis of biliary stricture complicating LDLT.

Impaired Upper Esophageal Sphincter Reflexes in Patients With Supraesophageal Reflux Disease

BACKGROUND & AIMS Normal responses of the upper esophageal sphincter (UES) and esophageal body to liquid reflux events prevent esophagopharyngeal reflux and its complications, however, abnormal responses have not been characterized. We investigated whether patients with supraesophageal reflux disease (SERD) have impaired UES and esophageal body responses to simulated reflux events. METHODS We performed a prospective study of 25 patients with SERD (age, 19-82 y; 13 women) and complaints of regurgitation and supraesophageal manifestations of reflux. We also included 10 patients with gastroesophageal reflux disease (GERD; age, 32-60 y; 7 women) without troublesome regurgitation and supraesophageal symptoms and 24 healthy asymptomatic individuals (controls: age, 19-49 y; 13 women). UES and esophageal body pressure responses, along with luminal distribution of infusate during esophageal rapid and slow infusion of air or liquid, were monitored by concurrent high-resolution manometry and intraluminal impedance. RESULTS A significantly smaller proportion of patients with SERD had UES contractile reflexes in response to slow esophageal infusion of acid than controls or patients with GERD. Only patients with SERD had abnormal UES relaxation responses to rapid distension with saline. Diminished esophageal peristaltic contractions resulted in esophageal stasis in patients with GERD or SERD. CONCLUSIONS Patients with SERD and complaints of regurgitation have impaired UES and esophageal responses to simulated liquid reflux events. These patterns could predispose them to esophagopharyngeal reflux.

High Prevalence of Vitamin A and D Deficiency in Patients Evaluated for Liver Transplantation

Deficiencies in vitamins A, D, and E have been linked to night blindness, bone health, and post–liver transplant reperfusion injury. The aim of this study was to determine the prevalence and predictive factors of fat‐soluble vitamin deficiencies in liver transplant candidates. We reviewed the medical records of liver transplant candidates at our center from January 2008 to September 2011. The etiology of cirrhosis, Model for End‐Stage Liver Disease score, Child‐Pugh class, body mass index (BMI), and vitamin A, vitamin E, and vitamin 25‐OH‐D levels were recorded. Patients were excluded for incomplete laboratory data, short gut syndrome, celiac disease, pancreatic insufficiency, or prior liver transplantation. Sixty‐three patients were included. The most common etiologies of liver disease were alcohol (n = 23), hepatitis C virus (n = 19), and nonalcoholic steatohepatitis (n = 5). Vitamin A and D deficiencies were noted in 69.8% and 81.0%, respectively. Only 3.2% of the patients were vitamin E–deficient. There were no documented cases of night blindness. Twenty‐five of the 55 patients with bone density measurements had osteopenia, and 10 had osteoporosis. Four patients had vertebral fractures. There was 1 case of posttransplant reperfusion injury in a patient with vitamin E deficiency. In a multivariate analysis, there were no statistically significant predictors for vitamin D deficiency. The Child‐Pugh class [odds ratio (OR) = 6.84, 95% confidence interval (CI) = 1.52‐30.86, P = 0.01], elevated total bilirubin level (OR = 44.23, 95% CI = 5.02‐389.41, P < 0.001), and elevated BMI (OR = 1.17, 95% CI = 1.00‐1.36, P = 0.045) were found to be predictors of vitamin A deficiency. In conclusion, the majority of liver disease patients evaluated for liver transplantation at our center had vitamin A and D deficiencies. The presence or absence of cholestatic liver disease did not predict deficiencies, whereas Child‐Pugh class, bilirubin level, and elevated BMI predicted vitamin A deficiency. Liver Transpl 19:627–633, 2013.

480 Efficacy of a Novel “UES Assist Device” in Management of Supraesophageal Complications of Reflux Disease: the Results of a Limited Clinical Trial

Background:Management of supraesophageal reflux disease complications of poses a significant clinical challenge. Acid suppressive therapy does not prevent volume refluxate into the pharynx and as such in a substantial percentage of these patients outcome of medical management has been disappointing. The efficacy of a novel “UES Assist Device” in preventing of simulated pharyngeal reflux in experimental setting have been recently reported. (Shaker et al. DDW 2010) The aim of the present study was to test the efficacy of the “UES Assist Device” in management of supraesophageal symptoms of reflux disease in a clinical trial. Method: We studied 14 patients with a variety of supraesophageal symptoms most notably chronic cough, excess phlegm and throat clearing referred from GI clinic in our institution. Participants filled out a detailed symptom questionnaire at baseline and following application of the device with randomly applied therapeutic and sub-therapeutic pressure assist. Symptoms were quantified using a 5-pont Likert scale. Each therapeutic modality was tested randomly for 7 days. Result: All patients tolerated the device well and completed the study. There were no complications or complaints for the use of the device. The global symptoms severity and impact score for therapeutic and sub-therapeutic pressure assist was significantly lower than that of the baseline. In addition, therapeutic pressure assist resulted in a significantly lower symptom severity compared to sub-therapeutic pressure assist (p=0.003 ANOVA) . (Figure) Furthermore, therapeutic pressure assist significantly decreased the most bothersome symptom compared to sub-therapeutic pressure assist (p<0.05). Conclusion: “UES Assist Device” is safe and effective in management of supraesophageal complications of reflux disease.

Occlusion of choledochoduodenostomy stent with food

re 1. A, Identification of the common bile duct through the use of a linear echoendoscope. B, Advancement of the VisiGlide wire through the y tree. C, Dilation of the tract by use of a 6-mm balloon. D, Fully covered metal stent placed in the tract. E, Previously placed stent observed dvancement of endoscope to the bile duct. F, Previously placed stent observed and advancement of endoscope to the bile duct.

Endoscopic suturing of esophageal stent into skin flap after laryngectomy

A 75-year-old woman had received a diagnosis of oropharyngeal cancer in 2009. It was treated with concurrent chemoradiation in 2009. In 2010 there was a recurrence of the cancer, which was treated with total laryngectomy and reconstruction with skin flap. In 2016, a large tracheoesophageal fistula, over 25 mm in diameter, developed. As a result, the patient had recurrent aspiration pneumonia despite receiving no food or intake by mouth. The patient was not a candidate for surgical correction after being evaluated by 2 different surgeons. They both thought that the patient was not healthy enough for a surgical repair of the fistula and requested a novel attempt at endoscopic therapy. An 18-mm by 8-cm fully covered metal stent was placed across the fistula. After stent placement, there was no further leakage through the fistula, no recurrent aspiration pneumonia, and no foreign-body sensation problems. A decision was made to endoscopically suture the stent in place through the skin flap to

Use of adenosine triphosphate to audit reprocessing of flexible endoscopes with an elevator mechanism

HighlightsUse of ATP testing improves quality of manual cleaning of ERCP endoscopes over time.Reprocessing effectiveness varies considerably based on individual reprocessing technician.Ongoing auditing and feedback should assess each individual reprocessing technician.Working channel lumen had more failed ATP tests compared to elevator mechanism. Background: There have been reported outbreaks of carbapenem‐resistant Enterobacteriaceae infections linked to endoscopes with elevator mechanisms. Adenosine triphosphate (ATP) testing has been used as a marker for bioburden and monitoring manual cleaning for flexible endoscopes with and without an elevator mechanism. The objective of this study was to determine whether routine ATP testing could identify areas of improvement in cleaning of endoscopes with an elevator mechanism. Methods: ATP testing after manual cleaning of TJF‐Q180V duodenoscopes and GF‐UCT180 linear echoendoscopes (Olympus America Inc, Center Valley, PA) was implemented. Samples were tested from the distal end, the elevator mechanism, and water flushed through the lumen of the biopsy channel. Data were recorded and compared by time point, test point, and reprocessing technician. Results: Overall failure rate was 6.99% (295 out of 4,219). The highest percentage of failed ATP tests (17.05%) was reported in the first quarter of routine testing, with an overall decrease in rates over time. The elevator mechanism and working channel lumen had higher failure rates than the distal end. Quality of manual cleaning between reprocessing technicians showed variation. Conclusion: ATP testing is effective in identifying residual organic material and improving quality of manual cleaning of endoscopes with an elevator mechanism. Cleaning efficacy is influenced by reprocessing technicians and location tested on the endoscope. Close attention to the working channel and elevator mechanism during manual cleaning is warranted.

Proof of Concept: Design and Initial Evaluation of a Device to Measure Gastrointestinal Transit Time

Chronic constipation and gastrointestinal motility disorders constitute a large part of a gastroenterology practice and have a significant impact on a patients quality of life and lifestyle. In most cases, medications are prescribed to alleviate symptoms without there being an objective measurement of response. Commonly used investigations of gastrointestinal transit times are currently limited to radiopaque markers or electronic capsules. Repeated use of these techniques is limited because of the radiation exposure and the significant cost of the devices. We present the proof of concept for a new device to measure gastrointestinal transit time using commonly available and inexpensive materials with only a small amount of radiotracer. Methods: We assembled gelatin capsules containing a 67Ga-citrate–radiolabeled grain of rice embedded in paraffin for use as a point-source transit device. It was tested for stability in vitro and subsequently was given orally to 4 healthy volunteers and 10 patients with constipation or diarrhea. Imaging was performed at regular intervals until the device was excreted. Results: The device remained intact and visible as a point source in all subjects until excretion. When used along with a diary of bowel movement times and dates, the device could determine the total transit time. The device could be visualized either alone or in combination with a barium small-bowel follow-through study or a gastric emptying study. Conclusion: The use of a point-source transit device for the determination of gastrointestinal transit time is a feasible alternative to other methods. The device is inexpensive and easy to assemble, requires only a small amount of radiotracer, and remains inert throughout the gastrointestinal tract, allowing for accurate determination of gastrointestinal transit time. Further investigation of the device is required to establish optimum imaging parameters and reference values. Measurements of gastrointestinal transit time may be useful in managing patients with dysmotility and in selecting the appropriate pharmaceutical treatment.