Sujievvan Chandran

Right-sided adenoma detection with retroflexion versus forward-view colonoscopy.

BACKGROUND Colonoscopy and polypectomy can prevent up to 80% of colon cancer; however, a significant adenoma miss rate still exists, particularly in the right side of the colon. OBJECTIVE To assess whether retroflexion in the right side of the colon significantly improves the adenoma detection rate (ADR) over forward-view assessment. DESIGN Multicenter prospective cohort study. SETTING Three tertiary care public and 2 private hospitals. PATIENTS A total of 1351 consecutive adult patients undergoing elective colonoscopy. INTERVENTION Withdrawal from the cecum was performed in the forward view initially and identified polyps removed. Once the hepatic flexure was reached, the cecum was reintubated and the right side of the colon was assessed in the retroflexed view to the hepatic flexure. MAIN OUTCOME MEASUREMENTS ADR in the retroflexed view when compared with forward-view examination of the right side of the colon. RESULTS Retroflexion was successful in 95.9% of patients, with looping the predominant (69.6%) reason for failure. Forward-view assessment of the right side of the colon identified 642 polyps, of which 531 were adenomas yielding a polyp and ADR of 28.57% and 24.64%, respectively. Retroflexion identified a further 84 polyps of which 75 were adenomas, improving the polyp and ADR to 30.57% and 26.4%, respectively. LIMITATIONS Observational study. CONCLUSION Right-sided retroflexion was successful in most of our cohort with a statistically significant but small increase in ADR. Right-sided retroflexion is safe when performed by experienced endoscopists with no adverse events observed in this cohort. ( CLINICAL TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry, ACTRN12613000424707.).

Risk stratification of upper GI bleeding with an esophageal capsule

BACKGROUND Analysis of upper GI bleeding (UGIB) presentations to our institutions suggests that many patients admitted for endoscopic investigation could be managed safely as outpatients. OBJECTIVE To learn whether an esophageal capsule could identify a low-risk group of patients with UGIB who could safely wait for elective EGD. DESIGN Diagnostic, nonrandomized, single-blind (investigator) study. SETTING Three tertiary-care referral centers. PATIENTS Eighty-three consecutive adult patients referred for management of UGIB. INTERVENTION A capsule endoscopy (CE) was performed before EGD for the investigation and management of UGIB. MAIN OUTCOME MEASUREMENTS Detection rates of UGIB source and identification of a low-risk group of patients who would have been suitable for outpatient EGD based on CE findings. RESULTS In total, 62 of 83 patients (75%) had a cause for bleeding identified. Findings were concordant across both modalities in 34 patients (55%). Twenty-one patients (38%) with positive EGD results had negative CE results, 7 of whom were due to lack of duodenal visualization alone. However, 7 of 28 patients (25%) with normal EGD results had positive CE results. The subgroup of patients with duodenal visualization on CE, 23 of 25 (92%), were concordant with EGD for low-risk lesions that would have been suitable for outpatient management. LIMITATIONS Low duodenal visualization rates with CE and low concordance between EGD and CE. CONCLUSION Although CE is not currently ready to be used as a triage tool, when duodenal visualization was achieved CE correlated well with EGD findings and identified 92% of patients who may have been managed as outpatients.

Common Symptoms from an Uncommon Infection: Gastrointestinal Anisakiasis

Clinicians can be forgiven for thinking of anisakiasis as a rare condition low in the differential diagnosis of abdominal pain. Gastrointestinal anisakiasis is a zoonotic parasitic disease caused by consumption of raw or undercooked seafood infected with nematodes of the genus Anisakis. Even though the reported cases indicate that this is a rare disease, the true incidence of the disease could be potentially higher than what is reported in the literature as cases can go undiagnosed. Diagnosis and treatment of gastric anisakiasis are made by a compatible dietary history, direct visualization, and removal of the larvae via gastroscopy. Serologic testing and imaging studies are useful in the diagnosis of intestinal anisakiasis and conservative management should be considered. This disease may mimic other diseases and lead to unnecessary surgery. This emphasizes the importance of suspecting gastrointestinal anisakiasis by history taking and by other diagnostic modalities.

A pilot study of EUS-guided fiducial insertion for the multidisciplinary management of gastric cancer.

Background and study aims: The 5-year survival rates for gastric cancer remain poor despite evolving therapies, and fiducial insertion via endoscopic ultrasound (EUS) is novel within this setting. We aimed to assess the feasibility of fiducial insertion for response assessment and anatomic localization in patients with gastric cancer. Patients and methods: A prospective phase II feasibility study was undertaken at Austin Health (Victoria, Australia) from February 2011 to November 2012. Consecutive adult patients were enrolled who had primary adenocarcinoma of the stomach with American Joint Committee on Cancer stage T1 – 3,N0 – 1,M0 – 1a and Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1. In addition, the patients were medically suitable for gastrectomy and chemotherapy/chemoradiotherapy. Gold fiducial markers were inserted under EUS guidance into the margins of the gastric cancer primary. The main outcome was successful insertion of the fiducial without complications for response assessment and anatomic localization. Results: A total of 15 fiducials were successfully inserted into 7 (88 %) of 8 patients. No immediate or delayed complications were noted. One patient proceeded to image-guided radiotherapy through the use of fiducials and is disease free at 12 months. Fiducials were used to assess treatment response in all patients who underwent computed tomographic imaging after insertion. Follow-up computed tomography with fiducial placement improved anatomic localization and estimation of the gastric cancer primary size in 3 (60 %) of 5 patients. Conclusions: Within the limitations of our small study cohort, fiducials were placed in gastric cancers under EUS guidance without complications, and placement was successful in the majority of our patients. Although potential benefits exist, there remain substantial limitations to the generalization of this technique across our patient population.

The use of fiducial markers in image-guided radiotherapy for gastric cancer.

The use of fiducial markers (FM) in image‐guided radiotherapy (IGRT) to increase treatment precision is emerging for upper gastrointestinal malignancies. To our knowledge there is no data beyond technical reports for the use of FMs in IGRT for gastric cancers in the current literature. We report a case of an 89‐year old gentleman with localised gastric cancer who was deemed unfit for surgery and chemotherapy. He had FMs inserted endoscopically around the tumour via ultrasound guidance and received radiotherapy with a high‐dose palliative intent via a two‐phase technique to 54 Gy in 30 fractions with IGRT. The use of FMs allowed confidence in tumour delineation and together with IGRT enabled precise and safe delivery of a higher dose. The patient tolerated the treatment without significant toxicity and had no evidence of residual or recurrent tumour 12 months following radiotherapy. The use of FMs with IGRT in upper gastrointestinal malignancies warrants further collaborative studies.

The utility of upfront double wire guided biliary cannulation following early unintentional pancreatic cannulation in patients undergoing ERCP

This study aims to assess the impact of upfront double-guidewire technique (DGT) following inadvertent early pancreatic duct (PD) cannulation or biliary cannulation and post-endoscopic retrograde cholangiopancreatography (ERCP) complications. A pilot non-randomized cohort study was performed in patients undergoing ERCP. DGT was utilized in the first 25 patients followed by standard cannulation technique (SCT) in the subsequent 25. A significantly lower PD cannulation rate [median (range)] was noted in the DGT group [1 (0–5) vs. 3 (0–6); p=0.013]; however, the pancreatitis rate was similar [2 (9 %) DGT, 1 (4 %) SCT; p=0.601]. In the SCT group, 15/25 (60 %) required DGT to achieve biliary cannulation. The majority of our cohort proceeding to an SCT following early PD cannulation required a DGT to achieve biliary cannulation. Early DGT resulted in a significant reduction in unintentional pancreatic cannulation but did not translate into a reduction in pancreatitis in our cohort.

Reply: To PMID 23453185.

Philip S. Schoenfeld, Section Editor John Y. Kao, Section Editor 64 65 STAFF OF CONTRIBUTORS 66 67 68 69 70 71 72 73 74 Joseph Anderson, White River Junction, VT Darren M. Brenner, Chicago, IL Andrew T. Chan, Boston, MA Francis K. L. Chan, Hong Kong, China Massimo Colombo, Milan, Italy Gregory A. Cote, Indianapolis, IN B. Joseph Elmunzer, Ann Arbor, MI Alex Ford, Leeds, United Kingdom Timothy B. Gardner, Lebanon, NH Lauren B. Gerson, San Francisco, CA