Sri Komanduri

Increases in free radicals and cytoskeletal protein oxidation and nitration in the colon of patients with inflammatory bowel disease

Background: Overproduction of colonic oxidants contributes to mucosal injury in inflammatory bowel disease (IBD) but the mechanisms are unclear. Our recent findings using monolayers of intestinal cells suggest that the mechanism could be oxidant induced damage to cytoskeletal proteins. However, oxidants and oxidative damage have not been well characterised in IBD mucosa. Aims: To determine whether there are increases in oxidants and in tissue and cytoskeletal protein oxidation in IBD mucosa. Methods: We measured nitric oxide (NO) and markers of oxidative injury (carbonylation and nitrotyrosination) to tissue and cytoskeletal proteins in colonic mucosa from IBD patients (ulcerative colitis, Crohn’s disease, specific colitis) and controls. Outcomes were correlated with IBD severity score. Results: Inflamed mucosa showed the greatest increases in oxidants and oxidative damage. Smaller but still significant increases were seen in normal appearing mucosa of patients with active and inactive IBD. Tissue NO levels correlated with oxidative damage. Actin was markedly (>50%) carbonylated and nitrated in inflamed tissues of active IBD, less so in normal appearing tissues. Tubulin carbonylation occurred in parallel; tubulin nitration was not observed. NO and all measures of oxidative damage in tissue and cytoskeletal proteins in the mucosa correlated with IBD severity. Disruption of the actin cytoarchitecture was primarily within the epithelial cells and paracellular area. Conclusions: Oxidant levels increase in IBD along with oxidation of tissue and cytoskeletal proteins. Oxidative injury correlated with disease severity but is also present in substantial amounts in normal appearing mucosa of IBD patients, suggesting that oxidative injury does not necessarily lead to tissue injury and is not entirely a consequence of tissue injury. Marked actin oxidation (>50%)—which appears to result from cumulative oxidative damage—was only seen in inflamed mucosa, suggesting that oxidant induced cytoskeletal disruption is required for tissue injury, mucosal disruption, and IBD flare up.

Endoscopic submucosal dissection

ESD is an established effective treatment modality for premalignant and early-stage malignant lesions of the stomach, esophagus, and colorectum. Compared with EMR, ESD is generally associated with higher rates of en bloc, R0, and curative resections and a lower rate of local recurrence. Oncologic outcomes with ESD compare favorably with competing surgical interventions, and ESD also serves as an excellent T-staging tool to identify noncurative resections that will require further treatment. ESD is technically demanding and has a higher rate of adverse events than most endoscopic procedures including EMR. As such,sufficient training is critical to ensure safe conduct and high-quality resections. A standardized training model for Western endoscopists has not been clearly established,but will be self-directed and include courses, animal model training, and optimally an observership at an expert center.Numerous dedicated ESD devices are now available in the United States from different manufacturers. Although the use of ESD in the United States is increasing, issues related to technical difficulty, limited training opportunities and mentors, risk of adverse events, long procedure duration,and suboptimal reimbursement may limit ESD adoption in the United States to a modest number of academic referral centers for the foreseeable future.

ASGE Technology Committee systematic review and meta-analysis assessing the ASGE Preservation and Incorporation of Valuable Endoscopic Innovations thresholds for adopting real-time imaging–assisted endoscopic targeted biopsy during endoscopic surveillance of Barrett’s esophagus

BACKGROUND AND AIMS Endoscopic real-time imaging of Barretts esophagus (BE) with advanced imaging technologies enables targeted biopsies and may eliminate the need for random biopsies to detect dysplasia during endoscopic surveillance of BE. This systematic review and meta-analysis was performed by the American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee to specifically assess whether acceptable performance thresholds outlined by the ASGE Preservation and Incorporation of Valuable Endoscopic Innovations (PIVI) document for clinical adoption of these technologies have been met. METHODS We conducted meta-analyses calculating the pooled sensitivity, negative predictive value (NPV), and specificity for chromoendoscopy by using acetic acid and methylene blue, electronic chromoendoscopy by using narrow-band imaging, and confocal laser endomicroscopy (CLE) for the detection of dysplasia. Random effects meta-analysis models were used. Statistical heterogeneity was evaluated by means of I(2) statistics. RESULTS The pooled sensitivity, NPV, and specificity for acetic acid chromoendoscopy were 96.6% (95% confidence interval [CI], 95-98), 98.3% (95% CI, 94.8-99.4), and 84.6% (95% CI, 68.5-93.2), respectively. The pooled sensitivity, NPV, and specificity for electronic chromoendoscopy by using narrow-band imaging were 94.2% (95% CI, 82.6-98.2), 97.5% (95% CI, 95.1-98.7), and 94.4% (95% CI, 80.5-98.6), respectively. The pooled sensitivity, NPV, and specificity for endoscope-based CLE were 90.4% (95% CI, 71.9-97.2), 98.3% (95% CI, 94.2-99.5), and 92.7% (95% CI, 87-96), respectively. CONCLUSIONS Our meta-analysis indicates that targeted biopsies with acetic acid chromoendoscopy, electronic chromoendoscopy by using narrow-band imaging, and endoscope-based CLE meet the thresholds set by the ASGE PIVI, at least when performed by endoscopists with expertise in advanced imaging techniques. The ASGE Technology Committee therefore endorses using these advanced imaging modalities to guide targeted biopsies for the detection of dysplasia during surveillance of patients with previously nondysplastic BE, thereby replacing the currently used random biopsy protocols.

Use of a new jumbo forceps improves tissue acquisition of Barrett's esophagus surveillance biopsies.

BACKGROUND The major risk factors for the development of esophageal adenocarcinoma remain long-standing GERD and resultant Barretts esophagus (BE). Finding the exact method of adequate tissue sampling for surveillance of dysplasia in BE remains a dilemma. OBJECTIVE We prospectively compared standard large-capacity biopsy forceps with a new jumbo biopsy forceps for dysplasia detection in BE. SETTING/DESIGN Prospective, single-center investigation. PATIENTS/INTERVENTIONS We prospectively enrolled 32 patients undergoing surveillance endoscopy for BE. Biopsy samples were obtained in paired fashion alternating between the experimental (jumbo) and control (large-capacity) forceps. MAIN OUTCOME MEASUREMENTS Each sample was assessed for histopathology, specimen size, and adequacy. RESULTS A total of 712 specimens were available for analysis for this investigation. Six patients were found to have dysplasia, and in 5 of those patients, the dysplasia was only detected with the jumbo forceps. The mean width was significantly greater in the Radial Jaw 4 jumbo group (3.3 mm vs 1.9 mm [P < .005]) as was the mean depth (2.0 mm vs 1.1 mm [P < .005]). Sixteen percent of samples obtained with the standard forceps provided an adequate sample, whereas the jumbo forceps provided an adequate sample 79% of the time (P < .05). LIMITATIONS A lack of a validated index for assessment of tissue adequacy in BE. CONCLUSION The Radial Jaw 4 jumbo biopsy forceps significantly improves dysplasia detection and adequate tissue sampling in patients undergoing endoscopy for BE.

Technologies for monitoring the quality of endoscope reprocessing

1 The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, with a MEDLINE literature search to identify pertinent preclinical and clinical studies on the topic, and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported adverse events of a given technology. Both are supplemented by accessing the “related articles” feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but, in many cases, data from randomized, controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. For this review, the MEDLINE database was searched through September 2013 by using the keywords “endoscope reprocessing,” “endoscope disinfection,” “endoscope cleaning,” “high-level disinfection,” “surveillance cultures,” and “ATP bioluminescence.” Reports on Emerging Technologies are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the governing board of the ASGE. These reports are scientific reviews provided solely for educational and informational purposes. Reports on Emerging Technologies are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.

An audit of the utility of in-patient fecal occult blood testing

Abstract OBJECTIVES: Recent surveys of physician practice have suggested the existence of excessive, inappropriate use of the fecal occult blood test (FOBT). We studied the implementation of this test in hospitalized patients. METHODS: We performed a retrospective chart review of 1000 randomly selected patients who had been discharged from the Medicine service at four teaching hospitals. Patient demographics, clinical presentation, presence or absence of overt GI bleeding, and use of medications that might affect the FOBT were recorded. Reviewers assessed whether patients who had FOBT would have been candidates for colon resection if asymptomatic colon cancer had been found. RESULTS: Digital rectal examination was documented in 44.8% of patients; the findings were recorded in only 9%. A total of 421 patients had FOBT on admission, usually on stool obtained at digital rectal examination. Of the patients with a positive FOBT, 17% had active GI bleeding. Only 41.1% of patients with a positive FOBT were referred to the gastroenterology service. In 70.5% of patients, FOBT could be considered inappropriate because of factors such as age, active GI bleeding, or use of aspirin or other nonsteroidal anti-inflammatory drugs. CONCLUSIONS: The FOBT, which is validated only for colorectal cancer screening, is often performed inappropriately in patients admitted to the hospital. This test should be restricted in hospital practice. It would be preferable to identify patients who are appropriate candidates for colorectal cancer screening at the time of hospital discharge and to advise them about the appropriate performance of the FOBT at home.

Diagnostic yield of a novel jumbo biopsy “unroofing” technique for tissue acquisition of gastric submucosal masses

BACKGROUND AND STUDY AIMS Adequate tissue acquisition for the diagnosis of gastric submucosal masses (GSMs) has been challen ging for gastroenterologists. The use of standard biopsy forceps generally recovers non-diagnostic overlying mucosa. Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) provides a significant improvement, but is often still inadequate for diagnosis. The aim of the current study was to assess the efficacy of a novel jumbo biopsy unroofing technique (JUT) for tissue acquisition in GSM. PATIENTS AND METHODS This prospective study recruited patients who were referred for EUS for the evaluation of GSM between 2006 and 2009. All patients underwent EUS with FNA when feasible followed by JUT. The primary outcome was diagnostic yield of JUT. RESULTS A total of 93 patients were enrolled, 72 of whom were included in the investigation; 16 patients were excluded with no evidence of a submucosal mass or extrinsic compression, and five patients were further excluded by pathology confirming mucosal lesions. Of the 72 jumbo biopsies 66 (92%) provided diagnostic tissue without significant complications and 42 (58%) had lesions amenable to FNA. Although 34 of the 42 lesions were deemed adequate at the time of on-site cytological evaluation, only 28 (67%) provided sufficient tissue for final diagnosis. More importantly, only 37/72 (52%) of all patients had lesions that required any further intervention. CONCLUSIONS Utilization of JUT is safe and effective for diagnosis of GSM. The data suggest that the jumbo biopsy unroofing technique should be considered as an initial diagnostic strategy for GSMs found during upper endoscopy.

Endoscopes and devices to improve colon polyp detection

The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, with a MEDLINE literature search to identify pertinent clinical studies on the topic, and a MAUDE (Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported adverse events of a given technology. Both are supplemented by accessing the “related articles” feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but, in many cases, data from randomized, controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the governing board of the ASGE. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review the MEDLINE database was searched through March 2014 for articles related to endoscopy in patients with colon polyps by using the keywords “colon polyp,” “colon adenoma,” and “colon neoplasm” paired with “colonoscopy,” “third eye retroscope,” “cap-fitted,” “cap-assisted,” “transparent cap,” “retroflexion,” “cuff,” “endoscope,” “colonoscope,” “detection,” “wide-angle,” and “full spectrum endoscope.” Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.

Per-oral endoscopic myotomy (with video)

The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used by performing a MEDLINE literature search to identify pertinent clinical studies on the topic as well as a U.S. Food and Drug Administration Center for Devices and Radiological Health (MAUDE) database search to identify the reported complications of a given technology. Both are supplemented by accessing the related articles feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but in many cases, data from randomized, controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the Committee as a whole, and approved by the Governing Board of the ASGE. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review, the MEDLINE database was searched through July 2015 for relevant articles by using the key words “per-oral endoscopic myotomy,” “endoscopic myotomy,” “POEM,” “achalasia,” “nutcracker esophagus,” “jackhammer esophagus,” “diffuse esophageal spasm,” and “laparasocopic Heller myotomy.” Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring,

Interventional EUS (with videos)

John T. Maple, DO, FASGE, Chair and primary author, Rahul Pannala, MD, MPH, Barham K. Abu Dayyeh, MD, MPH, Harry R. Aslanian, MD, FASGE, Brintha K. Enestvedt, MD, MBA, Adam Goodman, MD, Sri Komanduri, MD, Michael Manfredi, MD, Udayakumar Navaneethan, MD, Mansour A. Parsi, MD, FASGE, Zachary L. Smith, DO, Nirav Thosani, MD, Shelby A. Sullivan, MD, Subhas Banerjee, MD, FASGE, previous Committee Chair