Shajan Peter

Endoscopist-Directed Administration of Propofol: A Worldwide Safety Experience

BACKGROUND & AIMSnEndoscopist-directed propofol sedation (EDP) remains controversial. We sought to update the safety experience of EDP and estimate the cost of using anesthesia specialists for endoscopic sedation.nnnMETHODSnWe reviewed all published work using EDP. We contacted all endoscopists performing EDP for endoscopy that we were aware of to obtain their safety experience. These complications were available in all patients: endotracheal intubations, permanent neurologic injuries, and death.nnnRESULTSnA total of 646,080 (223,656 published and 422,424 unpublished) EDP cases were identified. Endotracheal intubations, permanent neurologic injuries, and deaths were 11, 0, and 4, respectively. Deaths occurred in 2 patients with pancreatic cancer, a severely handicapped patient with mental retardation, and a patient with severe cardiomyopathy. The overall number of cases requiring mask ventilation was 489 (0.1%) of 569,220 cases with data available. For sites specifying mask ventilation risk by procedure type, 185 (0.1%) of 185,245 patients and 20 (0.01%) of 142,863 patients required mask ventilation during their esophagogastroduodenoscopy or colonoscopy, respectively (P < .001). The estimated cost per life-year saved to substitute anesthesia specialists in these cases, assuming they would have prevented all deaths, was

Multipurpose use of the 'bear claw' (over-the-scope-clip system) to treat endoluminal gastrointestinal disorders.

5.3 million.nnnCONCLUSIONSnEDP thus far has a lower mortality rate than that in published data on endoscopist-delivered benzodiazepines and opioids and a comparable rate to that in published data on general anesthesia by anesthesiologists. In the cases described here, use of anesthesia specialists to deliver propofol would have had high costs relative to any potential benefit.

Helicobacter pylori and Gastric Cancer: The Causal Relationship

The ‘bear‐claw’ or over‐the‐scope‐clip system (OTSC; Ovesco Endoscopy, Tübingen, Germany) is a new clipping device developed for closure of large luminal gastrointestinal (GI) defects. The aim of the present study was to evaluate the clinical outcomes of patients treated with the OTSC.

CCK1 Antagonists: Are They Ready for Clinical Use?

Gastric cancer has been recognized as an important cause of morbidity and mortality all over the world. Helicobacter pylori has been shown to have a causal relationship to gastric cancer. The knowledge into the mechanisms related to this has advanced considerably over the last few years thereby unarguably defining the role of this host-pathogen interaction. Epidemiological studies, research in animal models, molecular pathways involving host and bacterial factors, environmental factors and recent work on stem cells have contributed to understanding the origin and progress of this neoplasia. These form part of the myriad of interplaying factors resulting in the causal relationship. Nevertheless, current evidence is insufficient to accurately identify a definitive population where prevention or treatment strategies have to be targeted. Future trials will have to define the people at risk and shed more light in these areas.

Monitoring colonoscopy withdrawal time significantly improves the adenoma detection rate and the performance of endoscopists.

Cholecystokinin (CCK) is a peptide hormone which is found both in the gastrointestinal tract throughout the human small intestine and nerves in the myenteric plexus of the enteric nervous system and in the central nervous system. This dual location constitutes the anatomical basis for this in functions as a hormone and a neurotransmitter implicated in the regulation of both systems. CCK regulates not only motor functions in the gastrointestinal tract like lower oesophageal sphincter relaxation, gastric secretion and emptying, gall bladder contractility and bile secretion into the duodenum, intestinal and colonic motility, but also sensory functions and plays a role in the regulation of food intake. These effects are mediated through selective receptors CCK1 and CCK2. Over the last few years, research has focused on understanding the role of CCK, its receptors with antagonists at the biological, pharmacological, clinical and therapeutic level. As far as the CCK1 antagonists is concerned, important inroads have been made in the potential role of these antagonists in the treatment of GERD, IBS and pancreatitis. They have also shown encouraging results in sphincter of Oddi dysfunction and some gastrointestinal cancers. This review focuses on the recent ad vances of the biological role of CCK and their CCK1 antagonists: their current basic and clinical status in gastroenterology, with particular emphasis on the potential therapeutic role of the CCK1 antagonists and future research directions.

Small Bowel Stent-in-Stent Placement for Malignant Small Bowel Obstruction Using a Balloon-Assisted Overtube Technique.

BACKGROUND AND STUDY AIMSnThe recommended minimum withdrawal time for screening colonoscopy is 6 minutes. Adenoma detection rates (ADRs) increase with longer withdrawal times. We aimed to compare withdrawal times and ADRs of endoscopists unaware of being monitored vs. aware.nnnPATIENTS AND METHODSnSeven experienced gastroenterologists prospectively performed 558 screening colonoscopies during a 9-month period in a Swiss University hospital. Colonoscopy withdrawal times were first measured without the gastroenterologists’ knowledge of being monitored (nu200a=u200a355 colonoscopies) and then with their knowledge (nu200a=u200a203 colonoscopies).nnnRESULTSnThe median withdrawal time when gastroenterologists were unaware of being monitored was 4.5 minutes (interquartile range [IQR] 4u200a–u200a5.5 minutes) without intervention and 6 minutes (IQR 4u200a–u200a9 minutes) with intervention, increasing significantly to 7.3 minutes (IQR 6.5u200a–u200a9 minutes) and 8 minutes (IQR 7u200a–u200a11 minutes), respectively, when they were aware of being monitored (Pu200a<u200a0.001 both for colonoscopies with and without intervention). The ADR increased from 21.4u200a% when the gastroenterologists were unaware of being monitored to 36.0u200a% when they were aware (Pu200a<u200a0.001). In the multivariate regression model, the endoscopists knowing they were being monitored was the strongest factor associated with ADR (odds ratio 4.417; 95u200a% confidence interval [CI] 2.241u200a–u200a8.705; Pu200a<u200a0.001).nnnCONCLUSIONSnColonoscopy withdrawal time in unmonitored gastroenterologists is shorter than recommended and increases with awareness of monitoring. ADR significantly increases when gastroenterologists are aware of being monitored. Implementation of systematic monitoring, and analysis of withdrawal time and ADR for each endoscopist may help to increase the ADR.

Capsule Endoscopy of the Upper Gastrointestinal Tract – The Need for a Second Endoscopy

Self-expanding metal stents are a useful therapy to palliate malignant and benign luminal gastrointestinal obstruction. Self-expanding metal stents has been widely reported for colonic, esophageal, and gastric obstruction. However, endoscopic delivery and placement to the small bowel is more challenging and difficult. This case illustrates the usefulness and technical advantages of the balloon-overtube and enteroscopy technique for the palliative treatment of neoplastic stenosis affecting the small intestine.

Impact of Disconnected Pancreatic Duct Syndrome on the Endoscopic Management of Pancreatic Fluid Collections

Background and Aims: Capsule endoscopy (CE) has been recognised as an important investigational tool in the diagnosis of gastrointestinal disease. Studies have shown that CE can identify lesions in the upper gastrointestinal tract as well as in the small intestine. However, contrary to conventional oesophagogastroscopy results, the role of CE findings in the diagnostic algorithm of disorders such as gastrointestinal bleeding has not been well understood. We evaluated the frequency of lesions identified in the oesophagus and the stomach as well as their significance. Methods: We retrospectively evaluated patients who had undergone video CE over the last 2 years at our institution. Indication and findings in the oesophagus and the stomach were analysed and compared to previous oesophagogastroscopy findings. Patients in whom lesions were identified were followed up retrospectively for the significance of these findings. Results: 95 patients were included in the analysis (47 males, 48 females, mean ± SD age of 54.62 ± 19.2 years). The commonest indication for CE was gastrointestinal bleeding (45%), the second commonest anaemia (28%). CE identified significant lesions in the stomach of 11/95 (11.57%) patients. These lesions had been overlooked in 9/95 (9%) of patients by conventional oesophagogastroscopy prior to CE examination (p value < 0.05). Eight of 95 (8%) patients had oesophageal abnormalities detected by CE. The diagnosis changed the treatment of 8/11 (82%) patients with significant lesions. Conclusions: CE has an undefined role in evaluating upper gastrointestinal lesions. Significant lesions missed at oesophagogastroscopy were identified during CE examination. This study underpins the importance of a second conventional endoscopy in the diagnostic algorithm.

Endoscopic closure of a gastrocolic fistula using the over-the-scope-clip-system

Objective: To study the effect of disconnected pancreatic duct syndrome (DPDS) on endoscopic management of pancreatic fluid collections (PFCs). Background: Data on the impact of DPDS in patients undergoing endoscopic treatment of PFCs are limited. Methods: Retrospective study of patients undergoing endoscopic drainage of PFCs from 2003 to 2015. If treatment response was suboptimal following initial endoscopic or endoscopic ultrasound–guided transmural drainage, hybrid interventions (endoscopic ultrasound–guided multigate/dual modality technique, endoscopic/percutaneous sinus tract necrosectomy) were performed. Transmural stents were left permanently in situ in DPDS patients from 2008 onwards. Main outcome measures were to evaluate the effect of DPDS on need for hybrid treatment, reinterventions, rescue surgery, length of stay, and overall treatment success. Results: Of 361 patients, 34 (9.4%) were acute collections, 178 (49.3%) pseudocysts, and 149 (41.3%) walled-off necrosis (WON). DPDS was present in 167 (46.3%) patients, absent in 124 (34.3%), unknown in 70 (19.4%), and occurred more frequently in WON compared to other PFCs (68.3% vs 31.7%; P < 0.001). Although there was no difference in treatment success, more patients with DPDS required hybrid treatment (31.1% vs 4.8%, P < 0.001), reinterventions (30% vs 18.5%, P = 0.03), rescue-surgery (13.2% vs 4.8%, P = 0.02), and longer length of stay [median (interquartile range) days, 3 (2–10) vs 2 (1–4), P = 0.003]. PFC recurrence was lower in patients with DPDS with permanent transmural stents (17.4% vs 1.7%, P < 0.001). On multivariate logistic regression, DPDS [odds ratio (OR) 2.99], WON (OR 3.37), PFC size of 100 mm or more (OR 2.66), and multiple PFCs (OR 10.6) were associated with need for hybrid treatment. Conclusions: DPDS has a significant effect on endoscopic management of PFCs as more patients required hybrid treatment, reinterventions, and rescue surgery for achieving optimal clinical outcomes.

CHAPTER 11 – EUS in the Evaluation of Gastric Tumors

Gastrointestinal (GI) defects such as fistulas and leaks can be potentially closed endoscopically using hemoclips and loops. However, hemoclips may not allow for closure of large defects and they do not exert enough tensile force to keep fibrotic defects larger than 5 mm approximated. Herein we present a case of successful endoscopic closure of a gastrocolic fistula in a severely malnourished patient with complex post-surgical upper GI anatomy. We strongly believe that this device is a major breakthrough for the management of various types of discontinuity defects or fistulas. In addition, we show the usefulness of placing a direct jejunostomy using the double balloon enteroscopy (DBE) technique during the same procedure. The concept of providing direct jejunal feedings while allowing for upper gastrointestinal bowel rest to promote the healing of the minimally invasive endoscopic operation is novel. Thus, our case is unique and exemplifies the utility of minimally invasive endoscopic endoluminal surgery.