Ruonan Wu

Interview From Anywhere: Feasibility and Utility of Web-Based Videoconference Interviews in the Gastroenterology Fellowship Selection Process

OBJECTIVES:Traditional personal interviews are subject to limitations imposed by geographic, financial, and scheduling constraints. Web-based videoconferencing (WVC) has the potential to simplify the interview process. This study was intended to evaluate the feasibility and utility of WVC using standard tablets/computers with videoconferencing capability in gastroenterology (GI) fellowship interviews.METHODS:At a single institution, 16 GI fellowship applicants participated in WVC with one interviewer, who was present at a remote location 750 miles away. In addition, each of the candidates underwent traditional interviews with four faculty members at the program site. All study interviewees used an iPad2 (Apple, iOS 5.1; Apple) with a videoconferencing application (Facetime). The interviewer (SRD) used Facetime on a MacBook Pro (Apple, Mac OS X 10.7.3). Each candidate completed a voluntary paper survey after completion of all assigned faculty interviews.RESULTS:The average age of the candidates was 30 years (range, 27–37 years). Fourteen candidates were native English speakers. Candidates expressed a high level of satisfaction, with 13 candidates (81%) stating that their WVC experience met or exceeded their expectations, and 87% of candidates stating that WVC should be an option in fellowship interviews. In addition, 25% of candidates felt that their WVC experience was equivalent to or better than their traditional interview experience on the same day.CONCLUSIONS:WVC can be an effective and useful tool in the fellowship interview process. It affords candidates increased flexibility, cost saving, convenience, and provides an option for participating in the selection process at more programs. For the programs and faculty, WVC has a potential to be an effective screening tool, can help minimize loss of clinical revenue and can also be an acceptable alternative to in-person interviews.

Intestinal Metaplasia of the Stomach

Abstract Intestinal metaplasia (IM) of the stomach is associated with a very small increased risk of developing gastric cancer. Endoscopic surveillance has been proposed and advocated for populations at risk. Risk factors for IM include Helicobacter pylori infection, high salt intake, smoking, alcohol consumption, and chronic bile reflux. IM tends to appear initially at the antrum–corpus junction, especially at the gastric angularis. As atrophy and metaplastic changes advance, they extend to the antrum and corpus. Gastric IM is categorized histopathologically into incomplete and complete types. Patients with incomplete IM should undergo endoscopic gastric mapping to define the extent of IM and rule out dysplasia or adenocarcinoma. In this video presentation, endoscopic and pathological findings in gastric IM and gastric mapping techniques has been described. This article is part of an expert video encyclopedia.

Pathogenesis, diagnosis, and management of gastric ischemia.

BACKGROUND & AIMS Gastric ischemia is infrequently reported in the medical literature and under-recognized clinically and histopathologically. Various medical terms are used to describe gastric ischemia. We define and review the pathogenesis, diagnosis, and management of gastric ischemia. METHODS We describe 6 cases of gastric ischemia. We discuss features of the gastric vascular supply and review literature on this disorder. RESULTS Gastric ischemia results from diffuse or localized vascular insufficiency caused by etiologies such as systemic hypotension, vasculitis, or disseminated thromboembolism. The disorder is managed by fluid resuscitation, nasogastric tube placement (for intermittent air and fluid aspiration, to prevent or reduce gastric distention), aggressive acid reduction (via intravenous administration of proton pump inhibitors), and selective use of broad-spectrum antibiotics for patients with sepsis or gastric pneumatosis. CONCLUSIONS Gastric ischemia has a poor prognosis. Early diagnosis is required for appropriate patient management.

High-dose circumferential chemodenervation of the internal anal sphincter: A new treatment modality for uncomplicated chronic anal fissure: A retrospective cohort study (with video)

BACKGROUND Botulinum toxin injection into the internal anal sphincter is gaining popularity as a second line therapy for chronic anal fissures if medical therapy fails. The dosage of botulinum toxin reported ranged from 20 to 50 IU with no more than 3 injection sites and results in a healing rate of 41%-88% at 3 months. We propose a new injection method of high-dose circumferential chemodenervation of 100 IU in treating chronic anal fissure. METHODS This was a retrospective review at a single academic center. 75 patients (50 women and 25 men) with uncomplicated chronic anal fissures underwent high-dose circumferential chemodenervation-internal anal sphincter (100 IU). We measured fissure healing, complication, and recurrence rates at 3 and 6 months post injection. RESULTS Of the 75 patients, healing rate was 90.7% at 3 months follow up with the first injection and 81.3% with the second injection. The recurrence rates were 20.6% and 12.5% at 6 months after the 1st and 2nd injections respectively. Excluding 5 patients who lost follow up, the total healing rate of the study cohort was 100%. At 2 weeks and 3 months, there were no major complications including hematoma, infection, flatus, fecal, and urinary incontinence. CONCLUSIONS High-dose circumferential chemodenervation-internal anal sphincter (100 IU) is a safe and effective method for uncomplicated chronic anal fissure.

Management of complicated chronic anal fissures with high-dose circumferential chemodenervation (HDCC) of the internal anal sphincter

BACKGROUND Botulinum toxin injection into the internal anal sphincter (IAS) is gaining popularity as a second line therapy for chronic anal fissures after patients fail medical therapy. The dosage of Botulinum toxin reported in the literature ranged from 20 to 50 IU. Complicated chronic anal fissure is defined as persistent fissure concurrent with other perianal pathology. We report a new approach involving high-dose circumferential chemodenervation (HDCC) of 100 IU in treating these complicated chronic anal fissures. AIM The aim of this study was to evaluate the fissure healing, complication, and recurrence rates with HDCC. METHODS Complicated anal fissure was defined as fissure with other perianal pathologies including skin tag, hypertrophied papilla, fistula, symptomatic hemorrhoids, anal condylomata, and abscess. Between 2008 and 2012, 62 consecutive patients (28 Blacks, 33 Whites, 1 Hispanic) with complete follow-up data were included in this single arm study. These patients underwent HDCC-IAS with addition interventions by a single colorectal surgeon. Follow up data were obtained by chart review and office follow up. RESULTS Of the 62 patients, the overall success rate was greater than 70% at 3 months follow-up. A few patients developed transient flatus or fecal incontinence, but shortly resolved. There was no major complication following HDCC-IAS. CONCLUSIONS Combination therapy involving HDCC-IAS and local anorectal surgery for associated condition is both safe and effective for fissure healing.

Esophageal introitus (with videos)

For GI endoscopists and otolaryngologists, esophageal introitus (EI) is an arbitrary yet overlapping boundary. Many times, the term EI is used interchangeably with pharyngoesophageal sphincter or upper esophageal sphincter. In this review, the authors broadened the definition of EI to cover the lower part of the hypopharynx posterior to the larynx, the esophageal opening posterior to the cricoid prominence, and the area between the bilateral pyriform fossae and the cervical esophagus (Fig. 1). Although much pathology can be observed within this region, careful and systemic examination of the EI often is not stressed enough during GI endoscopic training and practice. The authors demonstrate its anatomy, endoscopic findings, and pathologies within EI and their management. Dysphagia is a common symptom in patients with oropharyngeal or esophageal pathologies and is generally categorized into 2 types of dysphagia: oropharyngeal and esophageal. We prefer the term pharyngoesophageal dysphagia to describe dysphagia occurring within the EI, whereas oropharyngeal dysphagia more specifically refers to symptoms related to oropharyngeal pathologies, such as myasthenia and thyrotoxicosis. Therefore, dysphagia may be categorized into 3 types: oropharyngeal, pharyngoesophageal, and esophageal. Esophageal dysphagia refers to symptoms related to esophageal pathologies distal to the EI. The complete 1-hour digital video content pertaining to this review was published recently by the American Society for Gastrointestinal Endoscopy and is available at http://portal.asge.org/

Feasibility Study of Utilizing Ultraportable Projectors for Endoscopic Video Display (With Videos)

Background. Modern endoscopy requires video display. Recent miniaturized, ultraportable projectors are affordable, durable, and offer quality image display. Objective. Explore feasibility of using ultraportable projectors in endoscopy. Methods. Prospective bench-top comparison; clinical feasibility study. Masked comparison study of images displayed via 2 Samsung ultraportable light-emitting diode projectors (pocket-sized SP-HO3; pico projector SP-P410M) and 1 Microvision Showwx-II Laser pico projector. Bench-top feasibility study: Prerecorded endoscopic video was streamed via computer. Clinical comparison study: Live high-definition endoscopy video was simultaneously displayed through each processor onto a standard liquid crystal display monitor and projected onto a portable, pull-down projection screen. Endoscopists, endoscopy nurses, and technicians rated video images; ratings were analyzed by linear mixed-effects regression models with random intercepts. Results. All projectors were easy to set up, adjust, focus, and operate, with no real-time lapse for any. Bench-top study outcomes: Samsung pico preferred to Laser pico, overall rating 1.5 units higher (95% confidence interval [CI] = 0.7-2.4), P < .001; Samsung pocket preferred to Laser pico, 3.3 units higher (95% CI = 2.4-4.1), P < .001; Samsung pocket preferred to Samsung pico, 1.7 units higher (95% CI = 0.9-2.5), P < .001. The clinical comparison study confirmed the Samsung pocket projector as best, with a higher overall rating of 2.3 units (95% CI = 1.6-3.0), P < .001, than Samsung pico. Conclusions. Low brightness currently limits pico projector use in clinical endoscopy. The pocket projector, with higher brightness levels (170 lumens), is clinically useful. Continued improvements to ultraportable projectors will supply a needed niche in endoscopy through portability, reduced cost, and equal or better image quality.

Su1609 High-Dose Circumferential Chemodenervation (HDCC) of the Internal Anal Sphincter: A New Treatment Modality for Uncomplicated Chronic Anal Fissure

S A T A b st ra ct s surgery, patients underwent a regular follow up (range 12-26 months) for assessing recurrence. Results: Two patients were lost during the follow up. RNA transcripts for MMP-7 were detected in 31/57 samples (54%). Recurrence was diagnosed in 6 out of 55 patients (11%); 4 patients eventually died because of metastases or peritoneal dissemination. All the 6 patients who had relapsed were positive for MMP-7. Sensitivity and specificity of the test were 100% and 49% respectively. Conclusions: Positivity of MMP-7 in peritoneal cavity samples could be a novel biomarker for predicting disease recurrence in patients with CRC.