Stefan Groth

A standardized injection technique and regimen ensures success and safety of N-butyl-2-cyanoacrylate injection for the treatment of gastric fundal varices (with videos)

BACKGROUNDnN-butyl-2-cyanoacrylate has been successfully used for the treatment of bleeding from gastric fundal varices (FV). However, significant rebleeding rates and serious complications including embolism have been reported.nnnOBJECTIVEnOur purpose was to analyze the safety and efficacy of N-butyl-2-cyanoacrylate for FV bleeding by using a standardized injection technique and regimen.nnnDESIGNnRetrospective.nnnSETTINGnTwo tertiary referral centers.nnnPATIENTSnA total of 131 patients (91 men/40 women) with FV underwent obliteration with N-butyl-2-cyanoacrylate by a standardized technique and regimen.nnnINTERVENTIONSn(1) Dilution of 0.5 mL of N-butyl-2-cyanoacrylate with 0.8 mL of Lipiodol, (2) limiting the volume of mixture to 1.0 mL per injection to minimize the risk of embolism, (3) repeating intravariceal injections of 1.0 mL each until hemostasis was achieved, (4) obliteration of all tributaries of the FV, (5) repeat endoscopy 4 days after the initial treatment to confirm complete obliteration of all visible varices and repeat N-butyl-2-cyanoacrylate injection if necessary to accomplish complete obliteration.nnnMAIN OUTCOME MEASUREMENTSnImmediate hemostasis rate, early rebleeding rate, bleeding-related mortality rate, procedure-related complications, long-term cumulative rebleeding-free rate, and cumulative survival rate.nnnRESULTSnInitial hemostasis and variceal obliteration were achieved in all patients. The mean number of sessions was 1 (range 1-3). The mean total volume of glue mixture used was 4.0 mL (range 1-13 mL). There was no occurrence of early FV rebleeding, procedure-related complications, or bleeding-related death. The cumulative rebleeding-free rate at 1, 3, and 5 years was 94.5%, 89.3%, and 82.9%, respectively.nnnCONCLUSIONnObliteration of bleeding FV with N-butyl-2-cyanoacrylate is safe and effective with use of a standardized injection technique and regimen.

LONG‐TERM RESULTS AFTER ENDOSCOPIC DRAINAGE AND NECROSECTOMY OF SYMPTOMATIC PANCREATIC FLUID COLLECTIONS

Aims:u2002 To determine the immediate and long‐term results of endoscopic drainage and necrosectomy for symptomatic pancreatic fluid collections.

Endoscopic ultrasound-guided drainage of abdominal abscesses and infected necrosis.

Traditionally abdominal abscesses have been treated with either surgical or radiologically guided percutaneous drainage. Surgical drainage procedures may be associated with considerable morbidity and mortality, and serious complications may also arise from percutaneous drainage. Endoscopic ultrasound (EUS)-guided drainage of well-demarcated abdominal abscesses, with adjunctive endoscopic debridement in the presence of solid necrotic debris, has been shown to be feasible and safe. This multicenter review summarizes the current status of the EUS-guided approach, describes the available and emerging techniques, and highlights the indications, limitations, and safety issues.

Endoscopic ultrasound staging in gastric cancer: Does it help management decisions in the era of neoadjuvant treatment?

BACKGROUND AND STUDY AIMSnEndoscopic ultrasonography (EUS) has been shown to be the most accurate test for locoregional staging of upper gastrointestinal tumors; however, recent studies have questioned its accuracy level in daily clinical application. The present retrospective study analyzes the accuracy of EUS in guiding interdisciplinary treatment decisions.nnnPATIENTS AND METHODSn123 primarily operated patients (63 % men, mean age 61.4 years) were included; only cases with tumor-free resection margins and without evidence of distant metastases were selected. EUS and histopathological findings were compared. Main outcome parameter was the distinction between tumors to be primarily operated (T1 /2N0) and those to be treated by neoadjuvant or perioperative chemotherapy (T3/4, or any N + ), based on an assumed algorithm for treatment stratification.nnnRESULTSnOverall staging accuracy of EUS was 44.7 % for T and 71.5 % for N status irrespective of tumor location. Overstaging was the main problem (44.9 % for T, 42.9 % for N staging). The overall EUS classification was correct in 79.7 % (accuracy), with a sensitivity 91.9 % and specificity 51.4 %; only 19 out of 37 cases with histopathological T1/2N0 were correctly classified by EUS. Positive and negative predictive values of EUS in diagnosing advanced tumor stage for assignment to neoadjuvant therapy were 81.4 % and 73.1 %, respectively.nnnCONCLUSIONSnWhereas EUS has a high sensitivity in the diagnosis of locally advanced gastric cancer, endosonographic overstaging of T2 cancers appears to be a frequent problem. EUS stratification between local (T1 /2N0) and advanced (T3/4 or any N + ) tumors would thus result in incorrect assignment to neoadjuvant treatment in half of cases.

High Cecal Intubation Rates With a New Computer-Assisted Colonoscope: A Feasibility Study

OBJECTIVES:The acceptability of colonoscopy as a screening test is limited by several factors including patient discomfort. A new self-propelled colonoscope, the Invendo SC20 (Invendo Medical GmbH), may be helpful in reducing sedation. It consists of a sheathed endoscope contained within an “inverted sleeve,” and having an instrument channel and an electrohydraulic bendable tip; it is steered using a handheld device and propelled by a motorized drive unit. This study assessed the safety and efficacy of this new endoscope in volunteers undergoing colorectal cancer (CRC) screening.METHODS:Paid healthy volunteers aged 50–70 years and eligible for screening colonoscopy were included. Total colonoscopy using carbon dioxide insufflation or water instillation on demand was attempted, with all procedures being started without sedation. The main outcome parameters were safety and the cecal intubation rate.RESULTS:A total of 61 volunteers participated (34 men and 27 women; mean age 57.5 years). The cecum was reached in 60 volunteers (cecal intubation rate of 98.4%). The median time to reach the cecum was 15u2009min (range 7–53.5). Sedation was given in three individuals (4.9%). On withdrawal (median time 15u2009min), the material for histological evaluation was obtained from 33 polyps (mean size 4.8u2009mm) in 23 people by biopsy forceps or snare. No device-related complications were encountered.CONCLUSIONS:A new computer-assisted colonoscope, controlled using a handheld device, showed excellent cecal intubation rates during screening examinations, with sedation required in only ∼5% of screenees. Further clinical and comparative studies are warranted.

Upper Gastrointestinal Endoscopy prior to Bariatric Surgery-Mandatory or Expendable? An Analysis of 801 Cases

BackgroundUpper gastrointestinal pathologies are common in bariatric patients. Preoperative esophagogastroduodenal endoscopy (EGD) should detect and treat pathologies that might alter the type of bariatric surgery. However, clinical consequences of these findings are often insignificant. The aim of this study was to assess the influence of preoperative endoscopy in our cohort and its clinical consequences.MethodsWe conducted a retrospective analysis of endoscopic findings in patients under evaluation for bariatric surgery. Endoscopic findings were compared to preoperative risk factors as well as postoperative complications, and its clinical consequences were analyzed.ResultsData was available for 801 patients. Abnormal endoscopic findings were found in 65.7% of all patients. The most common conditions were gastritis (32.1%) and gastroesophageal reflux (24.8%). Malignancies were observed in 0.5% of all patients. We observed early-stage adenocarcinoma of the esophagus in two patients through our routine preoperative evaluation. Helicobacter pylori infections were detected in preoperative biopsies in only 3.7% of all patients. Patients who reported reflux symptoms had a higher rate of pathological EGDs (74.2 vs. 64.9%, p .019). We did not find any other risk factors for a pathological endoscopy. The postoperative complication rate was 11.2%. Leakage rate was 1.1%. Mortality rate was 0.4%. We did not find any correlation between the incidence of postoperative complications and preoperative endoscopic findings.ConclusionsRelevant findings in routine preoperative endoscopy are rare but have significant influence on decision-making in bariatric patients and should be assessed as a necessary diagnostic tool.

Feasibility, safety, and diagnostic yield of the Extra Wide Angle View (EWAVE) colonoscope for the detection of colorectal lesions

BACKGROUND AND STUDY AIMSnThe adenoma detection rate (ADR) of conventional colonoscopy can still be improved. We conducted a prospective multicenter cohort study to assess the feasibility, safety, and diagnostic yield of the Extra Wide Angle View (EWAVE) colonoscope, which offers a 235° view obtained from a forward-viewing and two lateral backward-viewing lenses incorporated into one image.nnnPATIENTS AND METHODSnThe study was performed between November 2015 and June 2016.u200aEWAVE colonoscopy was performed in patients with an increased risk of colorectal cancer by experienced and EWAVE-trained endoscopists (≥u200a500 colonoscopies, ≥u200a10 with the EWAVE system).nnnRESULTSnA total of 193 patients underwent EWAVE colonoscopy. The cecal intubation rate was 97.4u200a%. EWAVE colonoscopy had a polyp detection rate (PDR) of 61.1u200a% (118u200a/193), ADR of 39.9u200a% (77u200a/193), and advanced ADR of 13.5u200a% (26u200a/193). No adverse events occurred.nnnCONCLUSIONSnEWAVE colonoscopy is feasible and safe. The ADR appears comparable to those achieved with conventional colonoscopes in similar patient populations. To further elucidate the additional benefits of wide-angle-view colonoscopes, randomized trials would be required.

Treatment of Zenker Diverticulum

The Zenker diverticulum (pharyngoesophageal diverticulum) arises from the triangle of mucosa located between the inferior pharyngeal constrictors and the cricopharyngeal muscle (Killian triangle). This type of diverticula is a false diverticulum and more common than true esophageal diverticula. The treatment options range from various endoscopic techniques to open surgical resection.

Indication and Procedure of Pancreatic and Bile Duct Stenting

Stenting is one of the most commonly practiced endoscopic procedures in the management of biliary and pancreatic disorders. Endoscopic stenting is the treatment of choice for biliary and pancreatic duct strictures. It serves as a palliation in patients with inoperable malignant bile duct obstruction to relieve jaundice and pruritus, thus improving quality of life. The self-expandable metallic stent (SEMS) with a 10-mm lumen diameter is preferable to plastic stents because it provides better and longer-lasting drainage. Plastic stents occlude after an average of 3 to 4 months because of bacterial growth and sludge formation. Patients with cholangitis and predicted survival longer than 6 months therefore benefit most from SEMS. A covered SEMS avoiding tumor ingrowth seems to improve drainage results. However, currently available covered SEMS may carry increased risks of cholecystitis and pancreatitis. For benign strictures of both biliary and pancreatic duct, a plastic stent is used because the SEMS is not readily removable. Placement of multiple stents for 6 to 12 months achieves a long-term dilatation of the strictures. In unresectable pancreatic cancer associated with intractable pain, decompression of the distended pancreatic duct may relieve pain. Temporary stent placement in the pancreatic duct following sphincterotomy or other procedures at the papilla is recommended to avoid acute pancreatitis.