Sun-Joo Kim

Prophylactic argon plasma coagulation ablation does not decrease delayed postpolypectomy bleeding

BACKGROUNDnThe most common complication of colonoscopic polypectomy is postpolypectomy bleeding (PPB). However, there are no established guidelines for the prevention of delayed PPB. It is possible that submucosal vessels of an artificial ulcer are a potential source of delayed bleeding that occurs several days after polypectomy.nnnOBJECTIVEnThe aim of this randomized, controlled study was to evaluate the efficacy of prophylactic argon plasma coagulation (APC) of nonbleeding visible vessels in preventing delayed PPB.nnnDESIGNnA prospective, randomized, controlled study.nnnSETTINGnA tertiary referral center.nnnPATIENTSnA total of 987 polyps in 600 consecutive patients were resected by colonoscopic polypectomy.nnnINTERVENTIONnIn patients who underwent APC (APC group), all nonbleeding visible vessels on the ulcer crater were targeted and were then coagulated by APC ablation until they disappeared, but not in patients who did not undergo APC (control group).nnnMAIN OUTCOME MEASUREMENTnThe incidence of delayed PPB in the APC group was compared with that in the control group.nnnRESULTSnDelayed PPB occurred in 3.3% (16/475) of all the patients, including 2.5% (6/240) in the APC group and 4.3% (10/235) in the control group. No significant differences were observed between the 2 groups in the rates of delayed PPB, irrespective of the type of delayed bleeding (significant bleeding: 0.8% [2/240] vs 1.3% [3/235], P = .638; minor bleeding: 1.7% [4/240] vs 3% [7/235], P = .378). There were no significant APC-related complications.nnnLIMITATIONnSingle-center study.nnnCONCLUSIONnProphylactic APC ablation does not appear to have an additional advantage in the prevention of delayed PPB.

Primary incisional therapy with a modified method for patients with benign anastomotic esophageal stricture

BACKGROUNDnBenign anastomotic esophageal stricture after surgical resection is not uncommon and requires repeated dilation sessions to maintain patency because of the significant recurrence rate with bougie or balloon dilation.nnnOBJECTIVEnOur study was designed to evaluate whether a modified method of incisional therapy is effective and maintains a good patency in a benign anastomotic esophageal stricture.nnnDESIGNnA prospective outcome study.nnnSETTINGnTertiary-care academic medical centers.nnnPATIENTSnA total of 24 patients with benign anastomotic esophageal strictures after esophagojejunostomy.nnnINTERVENTIONSnUnder direct vision through a transparent hood, radial incisions parallel to the longitude of the esophagus were performed by pulling up the Iso-Tome or insulated-tip-knife.nnnMAIN OUTCOME MEASUREMENTSnEfficacy, safety, and long-term patency after procedures were evaluated.nnnRESULTSnDuring 24 months of follow-up observations, 21 of 24 patients (87.5%) who received only 1 dilation session resumed eating solid meals and had no dysphagia. Only 3 patients (12.5%) developed restricture at a mean of 1.6 months. Of the patients with a recurrence, 2 experienced no recurrence after one additional dilation session, and another patient was refractory and underwent 5 dilation sessions. The occurrence of restricture after incisional therapy was statistically more prevalent in long-segment stricture (>1 cm) (2/3 [66.7%]) than short-segment stricture (<1 cm) (1/21 [4.8%]) (P = .032). There were no significant procedure-related complications.nnnLIMITATIONnOur study included a small number of patients. Therefore, further prospective randomized controlled trials are needed.nnnCONCLUSIONSnA modified method of incisional therapy as a primary treatment is safe and feasible, and appears to maintain a longer duration of patency in benign anastomotic esophageal stricture.

Balanced Propofol Sedation Versus Propofol Monosedation in Therapeutic Pancreaticobiliary Endoscopic Procedures

BackgroundProlonged or complex endoscopic procedures are frequently performed under deep sedation. However, no studies of therapeutic ERCP have yet compared the use of balanced propofol sedation (BPS) to propofol alone, titrated to moderate levels of sedation.AimThis prospective, randomized, double-blind study was planned to compare the sedation efficacy and safety of BPS (propofol in combination with midazolam and fentanyl) and propofol monosedation in therapeutic ERCP and EUS.MethodsBPS, or propofol monosedation titrated to a moderate level of sedation, was performed by trained registered nurses under endoscopist supervision. The main outcome measurements included sedation efficacy focusing on recovery time, sedation safety, endoscopic procedure outcomes, and complications.ResultsThere were no significant differences in sedation efficacy, safety, procedure outcomes, and complications, with the exception of recovery time. Mean recovery time (standard deviation) was 18.37 (7.86)xa0min in BPS and 13.4 (6.24)xa0min in propofol monosedation (Pxa0<xa00.001). In a safety analysis, cardiopulmonary complication rates related to BPS and propofol monosedation were 7.8xa0% (8/102) and 9.6xa0% (10/104), respectively (Pxa0=xa00.652). No patient required assisted ventilation or permanent termination of a procedure in either group. Technical success of the endoscopic procedures was 96.3 and 97.2xa0%, respectively (Pxa0=xa00.701). Endoscopic procedure-related complications and outcomes did not differ depending on sedation procedure.ConclusionsPropofol monosedation by trained, registered sedation nurses under supervision resulted in a more rapid recovery time than BPS. There were no differences in the sedation safety, endoscopic procedure outcomes, and complications between BPS and propofol monosedation.

Endoscopic full-thickness resection of a gastric subepithelial tumor by using the submucosal tunnel technique with the patient under conscious sedation (with video)

A 47-year-old woman was referred to our hospital for evaluation of a gastric subepithelial tumor. EUS revealed a 16.0 11.2–mm, intraluminal growing, hetergeneous, hypoechoic mass originating from the musularis propria. We planned an EFTR of the lesion for he dual purpose of obtaining a histopathological diagosis and performing definite treatment. The instituional review board approved the human trial, and inormed consent was obtained from the patient. All procedures were performed with the patient uner sedation with midazolam and propofol in the enoscopy unit. Aseptic preparation and prophylaxis with road-spectrum antibiotics were carried out. The proedure was done by using a cap-fitted therapeutic gasroscope (GIF-Q260J, D-201-11804; Olympus, Tokyo, apan), with room-air insufflation after gastric lavage Fig. 1; Video 1, available online at www.giejournal. rg).1 After submucosal injection of a hyaluronic acid ixture, a 20-mm transverse incision was made by using flex knife (KD-630L; Olympus).2 A 40-mm submucosal unnel was created by using the endoscopic submucosal issection (ESD) technique.3 After the endoscope roximal seromuscular layer of the tumor.4 A fullhickness incision around three-fourths of the circumerence of the tumor was made by using an IT-2 knife KD-611L; Olympus).5 Then, the tumor was resected ith a snare, and it was suctioned into the cap.6 The ucosal defect in the tunnel was closed successfully by sing the endoloop-clips technique, by using a twohannel gastroscope (GIF-2TQ260M; Olympus).4 The retrieved specimen was identified as a gastric chwannoma. On the second hospital day, the luminal atency of the stomach was confirmed in an EGD and ater-soluble contrast study, and the patient was disharged the following day.

Optimal duration of proton pump inhibitor in the treatment of endoscopic submucosal dissection-induced ulcers: a retrospective analysis and prospective validation study.

BackgroundThe optimal duration of proton pump inhibitor (PPI) use in the treatment of endoscopic submucosal dissection (ESD)-induced ulcers has not been well defined.AimsThe aim of study was to determine the optimal duration of PPI treatment for ESD-induced gastric ulcers.MethodsA total of 333 patients who underwent ESD were included in this retrospective analysis and prospective randomized validation. Medical records and endoscopic images for the 221 patients in our ESD-database were reviewed retrospectively. Based on the results of the retrospective analysis, 112 patients with ESD-induced ulcers over 40xa0mm were randomly assigned to two groups (4- or 8-week course of Lansoprazole 30xa0mg). Main outcome measurements were to assess the healing-related factors of post-ESD ulcers (retrospective analysis) and to compare complete mucosal healing rate in large (≥40xa0mm) ESD-induced ulcers according to the duration of PPI treatment (prospective validation).ResultsMultivariate logistic regression from a retrospective analysis showed that a duration of PPI treatment <8xa0weeks and a post-ESD ulcer ≥40xa0mm in size were associated with incomplete healing. In a prospective validation, the rate of complete healing in the 8-week PPI group was significantly higher than that of the 4-week PPI group for a large (≥40 mm) ESD-induced ulcer at 8xa0weeks follow-up (83.3 vs. 42.6%, Pxa0<xa00.01).ConclusionsThe optimal duration of PPI treatment varies based on the initial ulcer size. Patients with an ESD-induced ulcer over 40xa0mm should be treated with an 8-week course of PPIs.

Human applications of submucosal endoscopy under conscious sedation for pure natural orifice transluminal endoscopic surgery

BackgroundThe submucosal endoscopy provide not only a reliable methods of access and closure for peritoneoscopy, but also an endoscopic working space for full-thickness resection. The aim of this study was to report the clinical outcome of submucosal endoscopy for pure natural orifice transluminal endoscopic surgery.MethodsWe prospectively evaluated 10 patients who received submucosal endoscopies. The indications of submucosal endoscopy were transgastric peritoneoscopy (TGP) and endoscopic full-thickness resection (EFTR) of a gastric subepithelial tumor. All procedures were performed with a standard gastroscope under conscious sedation with the balanced propofol method in the endoscopic unit. After a 40xa0mm submucosal tunnel was created using an endoscopic submucosal dissection technique, (1) in TGP, balloon dilation of a serosal puncture and intraperitoneal exploration was performed; (2) in EFTR, a full-thickness incision and snaring resection was performed. Closure of the mucosal incision was performed by endoclips.ResultsAll cases were technically feasible. The mean times for creating the submucosal tunnel, main procedure (peritoneal exploration or resection), and closure were acceptable (10.44xa0±xa02.42 minutes, 18.80xa0±xa09.41 minutes, and 5.63xa0±xa02.17 minutes, respectively). The mean hospital stay was 3.8xa0±xa01.48xa0days. All TGPs were diagnostic (4 peritoneal carcinomatosis and 1 tuberculosis). En bloc and complete resections were possible in all EFTRs (3 gastrointestinal stromal tumors and 2 schwannomas; mean tumor size, 20.8xa0±xa03.27xa0mm). There were no procedure-related complications, such as significant bleeding or peritonitis.ConclusionsHuman applications of submucosal endoscopy under conscious sedation for pure NOTES were feasible and safe.

Sequential algorithm analysis to facilitate selective biliary access for difficult biliary cannulation in ERCP: a prospective clinical study

BackgroundNumerous clinical trials to improve the success rate of biliary access in difficult biliary cannulation (DBC) during ERCP have been reported. However, standard guidelines or sequential protocol analysis according to different methods are limited in place. We planned to investigate a sequential protocol to facilitate selective biliary access for DBC during ERCP.MethodsThis prospective clinical study enrolled 711 patients with naïve papillae at a tertiary referral center. If wire-guided cannulation was deemed to have failed due to the DBC criteria, then according to the cannulation algorithm early precut fistulotomy (EPF; cannulation timeu2009>u20095xa0min, papillary contactsu2009>u20095 times, or hook-nose-shaped papilla), double-guidewire cannulation (DGC; unintentional pancreatic duct cannulationu2009≥u20093 times), and precut after placement of a pancreatic stent (PPS; if DGC was difficult or failed) were performed sequentially. The main outcome measurements were the technical success, procedure outcomes, and complications.ResultsInitially, a total of 140 (19.7%) patients with DBC underwent EPF (nu2009=u200971) and DGC (nu2009=u200969). Then, in DGC group 36 patients switched to PPS due to difficulty criteria. The successful biliary cannulation rate was 97.1% (136/140; 94.4% [67/71] with EPF, 47.8% [33/69] with DGC, and 100% [36/36] with PPS; Pu2009<u20090.001). The mean successful cannulation time (standard deviation) was 559.4 (412.8) seconds in EPF, 314.8 (65.2) seconds in DGC, and 706.0 (469.4) seconds in PPS (Pu2009<u20090.05). The DGC group had a relatively low successful cannulation rate (47.8%) but had a shorter cannulation time compared to the other groups due to early switching to the PPS method in difficult or failed DGC. Post-ERCP pancreatitis developed in 14 (10%) patients (9 mild, 1 moderate), which did not differ significantly among the groups (Pu2009=u20090.870) or compared with the conventional group (Pu2009=u20090.125).ConclusionsBased on the sequential protocol analysis, EPF, DGC, and PPS may be safe and feasible for DBC. The use of EPF in selected DBC criteria, DGC in unintentional pancreatic duct cannulations, and PPS in failed or difficult DGC may facilitate successful biliary cannulation.

Comparison of Endoscopic Papillary Balloon Dilation and Sphincterotomy in Young Patients with CBD Stones and Gallstones

Background and AimsEndoscopic biliary sphincterotomy (EBS) results in permanent loss of sphincter function and its long-term complications are unknown. Endoscopic papillary balloon dilation (EPBD) is an alternative procedure that preserves sphincter function, although it is associated with a higher risk of pancreatitis than is EBS. The aim of this study was to evaluate the safety and outcomes of EPBD with limited indications for removal of common bile duct (CBD) stones combined with gallstones in patients younger than 40xa0years.MethodsYoung (agexa0<xa040xa0years) patients who had CBD stones combined with gallstones on imaging studies were enrolled in this study. A total of 132 patients were randomly divided into the EPBD group (nxa0=xa062) or the EBS group (nxa0=xa070) for extraction of CBD stones. The ballooning size of EPBD ranged from 6 to 10xa0mm.ResultsComplete bile duct clearance was achieved in 98.4xa0% (61/62) of the EPBD group and 100xa0% (70/70) of the EBS group. Mechanical lithotripsy was required in 8.1xa0% (5/62) of the EPBD group and 8.6xa0% (6/70) of the EBS group. The early complication rates were 8.1xa0% (5/62) (five pancreatitis) in the EPBD group and 11.4xa0% (8/70) (five [7.1xa0%] pancreatitis, two bleeding and one perforation) in the EBS group. The recurrence rates of CBD stones were 1.6xa0% (1/62) in the EPBD group and 5.7xa0% (4/70) in the EBS group.ConclusionsEPBD with limited indications was safe and effective as EBS for removal of CBD stones combined with gallstones in young patients who had a longer life expectancy.

Trainees’ adenoma detection rate is higher if ≥10 minutes is spent on withdrawal during colonoscopy

BackgroundIt has been demonstrated that prolonged colonoscopic withdrawal times (WT; >6xa0min) are beneficial for the adenoma detection rate (ADR) for experienced endoscopists. There are little data, however, to guide the appropriate colonoscopic withdrawal times for trainees. The purpose of this study was to determine whether there is a relationship between WTs and ADR for first-year fellows training in colonoscopy.MethodsThis is a prospective study of first-year gastroenterology fellows at a single academic teaching hospital who documented each colonoscopy with a self-report form over the course of an academic year (March 2010 to February 2011). The internal policy for the trainees was to have at least a 6-min withdrawal time for each colonoscopy.ResultsFour first-year fellows in gastroenterology at an academic medical center completed self-reports for 1,210 colonoscopies. Mean WT was 10.2xa0±xa03.4 min. The aggregate polyp detection rate was 33.2% and the aggregate ADR was 22.3%. For colonoscopies with WTxa0<xa010 min, ADR was 9.5%, and for colonoscopies with WTxa0≥xa010 min, ADR was 32.3% (pxa0<xa00.001). When the quality indicator of 25% goal ADR for males and 15% goal ADR for females is applied, this aggregate rate is achieved for both sexes for screening colonoscopies (nxa0=xa0676) with WTxa0≥xa010 min.ConclusionsFirst-year trainees had a significantly higher ADR if their colonoscopic WT isxa0≥xa010 min.

Endoscopic management of multiple colonic fistulae secondary to acute pancreatitis (with video)

confluent exudative white plaques in the distal esophagus (C). Biopsies confirmed the diagnosis of eosinophilic esophagitis and revealed different degrees of eosinophilic infiltration along the segments of the esophagus (upper esophagus 12 Eo/HPF, mid esophagus 56 Eo/HPF, and distal esophagus 89 Eo/HPF). Whitish plaques were pathologically associated with the densest areas of eosinophilic infiltration (D) and flat disrupted fragments from the surface strata contained eosinophils, which interestingly resembled histopathologic findings of esophageal candidiasis and macroscopic plaques at endoscopy (E).