Sauid Ishaq

Flexible endoscopic treatment for Zenker's diverticulum with the SB Knife. Preliminary results from a single-center experience

Flexible endoscopic septum division is becoming a prominent treatment option for Zenkers diverticulum (ZD). Over the years, various techniques have been developed and many cutting tools have been tested with varying results. We report our experience with a recently designed, monopolar, rotating, scissor‐shaped device (SB Knife).

Adherence to a Gluten Free Diet Is Associated with Receiving Gluten Free Foods on Prescription and Understanding Food Labelling

Treatment of coeliac disease requires a strict gluten-free (GF) diet, however, a high proportion of patients do not adhere to a GF diet. The study explores the practical challenges of a GF diet and dietary adherence in Caucasian and South Asian adults with coeliac disease. Patients with biopsy- and serology-proven coeliac disease were recruited from a hospital database. Participants completed a postal survey (n = 375), including a validated questionnaire designed to measure GF dietary adherence. Half of Caucasians (53%) and South Asians (53%) were adhering to a GF diet. The quarter of patients (n = 97) not receiving GF foods on prescription had a lower GF dietary adherence score compared with those receiving GF foods on prescription (12.5 versus 16.0; p < 0.001). Not understanding food labelling and non-membership of Coeliac UK were also associated with lower GF dietary adherence scores. A higher proportion of South Asian patients, compared with Caucasians, reported difficulties understanding what they can eat (76% versus 5%; p < 0.001) and understanding of food labels (53% versus 4%; p < 0.001). We recommend retaining GF foods on prescription, membership of a coeliac society, and regular consultations with a dietitian to enable better understanding of food labels. Robust studies are urgently needed to evaluate the impact of reducing the amount of GF foods prescribed on adherence to a GF diet in all population groups.

Endoscopic submucosal dissection of early colorectal neoplasms with a monopolar scissor-type knife: short- to long-term outcomes

Background and study aims Endoscopic submucosal dissection (ESD) for colorectal neoplasms remains challenging because of technical issues imposed by the complex anatomical features of the large intestine. We evaluated the feasibility, and the short- and long-term clinical outcomes of ESD for early colorectal neoplasms performed using the Stag-beetle Knife Jr. (SB Knife Jr.) Patients and methods We retrospectively assessed 228 patients who underwent ESD for 247 colorectal lesions with the SB Knife Jr. Clinicopathological characteristics of the neoplasms, complications, and various short- and long-term outcomes were evaluated. Results Mean tumor size was 34.3 mm and median procedure time was 76 minutes. The SB Knife Jr. achieved 98.4 % en bloc resection, 93.9 % complete resection, and 85.4 % curative resection. No perforations occurred during the procedure, and a delayed bleeding rate of 2.4 % was observed. Long-term outcomes were favorable with no distant recurrence, 1.1 % local recurrence, a 5-year overall survival rate of 94.1 % and 5-year tumor-specific survival rate of 98.6 % in patients with cancer. Conclusions ESD using the SB Knife Jr. is technically efficient and safe in treating early colorectal neoplasms and is associated with favorable short- and long-term outcomes.

Advances in endoscopic imaging in ulcerative colitis.

Modern strategies for the treatment of ulcerative colitis require more accurate tools for gastrointestinal imaging to better assess mucosal disease activity and long-term prognostic clinical outcomes. Recent advances in gastrointestinal luminal endoscopy are radically changing the role of endoscopy in every-day clinical practice and research trials. Advanced endoscopic imaging techniques including high-definition endoscopes, optical magnification endoscopy, and various chromoendoscopy techniques have remarkably improved endoscopic assessment of ulcerative colitis. More recently, optical biopsy techniques with either endocytoscopy or confocal laser endomicroscopy have shown great potential in predicting several histological changes in real time during ongoing endoscopy. Here, we review current applications of advanced endoscopic imaging techniques in ulcerative colitis and present the most promising upcoming headways in this field.

Analysis of learning curves in gastroscopy training: the need for composite measures for defining competence

We read with interest and commend the study by Ward and colleagues which explores the learning curve in gastroscopy.1 The authors apply a D2 intubation rate of >95% as a proxy marker of trainee competency, and conclude that 187–200 procedures are sufficient to achieve this, in line with Joint Advisory Group (JAG) certification criteria.2 We would like to debate the following points with the authors. While we agree that D2 intubation and J-maneouvre reflect procedural completion and rely on motor skill, we argue that this stand-alone measure is insufficient to define competence. Competence is defined by the American Society for Gastrointestinal Endoscopy as the ’minimal level of skill, knowledge and/or expertise derived through training and experience that is required to safely and proficiently perform …

Endoscopic submucosal dissection with a scissors-type knife for post-EMR recurrence tumor involving the colon diverticulum

The advantages of endoscopic submucosal dissection (ESD) include the ability to control resection size and shape and permit en bloc resection of large and ulcerated lesions. However, even with ESD, endoscopic treatment is challenging for post-EMR recurrence of colorectal tumors because of severe fibrosis. Moreover, lesions involving the colon diverticulum are considered contraindicated for endoscopic treatment because of the risk of perforation in the absence of a muscle layer.

Diagnosis and Surveillance of Barrett’s Esophagus: Addressing the Transatlantic Divide

BackgroundBarrett’s esophagus is a premalignant condition of the esophagus leading to esophageal adenocarcinoma. No consensus exists between the UK and USA concerning the diagnosis of Barrett’s esophagus. Although the diagnostic procedure is common, the required findings and diagnostic criteria vary. Both guidelines require endoscopy showing columnar epithelia lining the esophagus, but the US guidelines require the additional finding of intestinal metaplasia on biopsy to confirm diagnosis. Achievement of a consensus is of particular importance due to the established progression from Barrett’s esophagus to esophageal adenocarcinoma. Of further importance is the increasing incidence of esophageal adenocarcinoma, a condition with poor overall survival, leading to various opinions on the utility of surveillance in patients.DiscussionA review of the vast array of literature revealed that substantial evidence exists in favor of both diagnostic criteria; hence, there is no easy way to identify the “correct” method of diagnosing Barrett’s esophagus. USA recommends surveillance of Barrett’s esophagus, whereas UK does not advocate it unless dysplasia is present. Surveillance was found to be effective, but this varied as did cost-effectiveness.SummaryFurther research into diagnostic methods for Barrett’s esophagus is needed to address areas of limited understanding, such that agreement can be reached and practice standardized. Surveillance was generally advocated, but with different criteria and time intervals, and new methods are being evaluated.

Unveiling Cancer in IBD: Screening Colonoscopy or Chromoendoscopy

The risk of developing colorectal cancer (CRC) is increased in patients with inflammatory bowel disease (IBD), particularly if the disease is extensive and its duration long-standing. Endoscopic guidelines have been developed with the goal of detecting early neoplastic changes prior to development of advanced malignancy. The current surveillance strategy of surveillance colonoscopy, with multiple random biopsies, most likely reduces morbidity and mortality associated with IBD-related CRC. Unfortunately, standard surveillance colonoscopy also has limitations, including high cost and sampling error at time of biopsy. The main issue is that colitis associated neoplasms often occur in flat mucosa of normal appearance, and are detected on taking random biopsies rather than by direct identification of these lesions via endoscopic imaging. Advances in endoscopic imaging techniques, such as vital or optical chromoendoscopy, that can enhance mucosal characteristics, may potentially aid in increasing dysplasia detection rate, and may reduce the workload of standard random biopsies. The aim of this review was to describe and summarize outcomes of more advanced endoscopic imaging techniques, including chromoendoscopy and magnification endoscopy.

Changes in Swallowing-Related Quality of Life After Endoscopic Treatment for Zenker’s Diverticulum Using the SWAL-QOL Questionnaire

Dysphagia affects the most cardinal of human functions: the ability to eat and drink. The aim of this prospective study was to evaluate swallowing dysfunction in patients diagnosed with Zenker’s diverticulum using the Swallowing Quality of Life (SWAL-QOL) questionnaire preoperatively. In addition, SWAL-QOL was used to assess changes in the outcome of swallowing function after endoscopic treatment of Zenker’s diverticulum compared to baseline. Pre- and postoperative SWAL-QOL data were analyzed in 25 patients who underwent endoscopic treatment of Zenker’s diverticulum between January 2011 and December 2013. Patients were treated by different endoscopic techniques, depending on the size of the diverticulum: CO2 laser technique or stapler technique, or the combination of both techniques used in larger diverticula. Their mean age was 69 years, and 28% of patients were female. The mean interval between endoscopic surgery and completion of the postoperative SWAL-QOL was 85 days. The median (min–max) preoperative total SWAL-QOL score was 621 (226–925) out of 1100, indicating the perception of oropharyngeal dysphagia and diminished quality of life. Following endoscopic treatment of Zenker’s diverticulum, significant improvement was demonstrated in the postoperative total SWAL-QOL score of 865 (406–1072) out of 1100 (p < 0.001). On the majority of subscales of SWAL-QOL there was significant improvement between pre- and postoperative scores. To the authors’ knowledge, this is the first report in the literature on the changes in pre- and postoperative SWAL-QOL scores for patients with Zenker’s diverticulum before and after treatment. The results of this study indicate that endoscopic treatment of Zenker’s diverticulum leads to significant symptom relief as documented by significant changes in the majority of the SWAL-QOL domains.

Usefulness and safety of a scissors-type knife in endoscopic submucosal dissection for nonampullary duodenal epithelial tumors

4,5 Duodenal endoscopic submucosal dissection (ESD) is considered challenging because of poor endoscopic operability. Furthermore, the muscle layer of the duodenum is thinner than that of any other site in the GI tract, resulting in higher reported perforation rates of up to 30%. To prevent the risk of adverse events (especially perforations) associated with the use of a conventional knife in ESD for nonampullary duodenal epithelial tumors (NADETs), we used a scissors-type knife, a stag beetle (SB) Knife Jr (Sumitomo Bakelite Co, Tokyo, Japan), which maintains an adequate dissection layer and a controlled