Syed M. Abbas Fehmi

Endoscopic ultrasound in the diagnosis of pancreatic cancer

INTRODUCTION Cross sectional imaging is important for initial evaluation of pancreatic cancer, whereas endoscopic ultrasound (EUS) will often help better visualize, differentiate and make final tissue diagnosis. It plays an important role in the multi-disciplinary evaluation and staging of pancreatic cancer as accurate staging has significant impact on treatment decisions. AREAS COVERED This review will cover the yield and utility of EUS and EUS FNA for diagnosis of pancreas cancer. In addition, this article reviews the utility and diagnostic yield of the non-invasive imaging modalities, including surface ultrasound, CT scan, PET CT scan and MRI. Tumor size, histology and disease processes that mimic pancreatic cancers will also be reviewed. EXPERT OPINION The accurate diagnosis and staging of pancreatic neoplasms is essential for optimal patient management. Abdominal imaging with multidetector CT or MRI is the most important initial step in the evaluation of pancreatic cancer because they are widely available and can detect most masses and/or demonstrate dilated bile or pancreatic ducts indicative of obstruction. Endoscopic ultrasound will remain important for detecting small tumors, ruling out diseases that mimic adenocarcinoma and for obtaining tissue diagnosis with fine needle aspiration.

Preventing Rescue Surgeries by Endoscopic Clipping: A Valuable Resource in the Surgeon Toolbox

AIM Over-the-scope-clip (OTSC) System is a relatively new endoluminal intervention for gastrointestinal (GI) leaks, fistulas, and bleeding. Here, we present a single center experience with the device over the course of 4 years. METHODS Retrospective chart review was conducted for patients who received endoscopic OTSC treatment. Primary outcome is the resolution of the original indication for clip placement. Secondary outcomes are complications and time to resolution. RESULTS Forty-one patients underwent treatment with the OTSC system from 2011 to 2015 with average follow-up of 152 days. The average age is 53.7. The most common site of clip placement was in the stomach (44%). Clips were placed after surgical complication for 28 patients (68%), endoscopic complications for 8 patients (19%), and spontaneous presentation in 5 patients (12%). Technical success was achieved in all patients. Overall, 34 patients (83%) were successfully treated. Nine patients required multiple clips and three patients required additional treatment modalities after OTSC. Four patients used the OTSC as a bridging therapy to surgery. Using OTSC for palliation versus nonpalliative indications was associated with lower rates of treatment success (50% versus 86%, P = .028). Using OTSC for symptoms <6 months had higher rates of treatment success than those experiencing longer symptoms (88% versus 65%, P = .045). There were no major morbidities or mortalities directly associated with the OTSC system. Complications from clip use were pain in two patients (5%) and hematemesis in one patient (3%). CONCLUSIONS The OTSC System can be a very successful treatment for iatrogenic or spontaneous GI leaks and bleeds. Treatment success is more likely in patients treated within 6 months of diagnosis and less likely to when used for palliation. It was also successfully used as bridging therapy in several patients.

Optimizing ergonomics before endoscopy

Ergonomics plays an important role in injury prevention for endoscopists. Raising awareness and enhancing the knowledge of ergonomics in endoscopy may prevent endoscopic-related injury. In this video (Video 1, available online at www.VideoGIE.org), we review proper attire and equipment before endoscopy, and room setup before endoscopy, including bed position, monitor position, and processor and endoscope position (Fig. 1A-D). On the basis of survey data, 37% to 89% of endoscopists experience work-related injuries. Suspected risk factors include repetitive hand motion, high hand forces, and awkward wrist, shoulder, and neck postures. As the number of endoscopic procedures increases, the risk for injury will also rise. The goal of this video is to enhance

Optimizing ergonomics during endoscopy

Ergonomics plays an important role in injury prevention for endoscopists. Raising awareness and enhancing ergonomics in endoscopy may prevent endoscopicrelated injury. Most endoscopists learn their skills through individual teaching during fellowship training. The level of skill among trainees and teachers varies widely, and most endoscopic teaching neglects ergonomics. Certain techniques offer advantages to prevent repetitive stress injury during endoscopy. In this video (Video 1, available online at www.VideoGIE.org) we review techniques for optimizing ergonomics during endoscopy including body position, endoscope positioning, and gripping the endoscope to prevent injury (Fig. 1A-D). The goal of this video is to enhance awareness of ergonomic principles and prevent endoscopic-related injuries.

Optimizing ergonomics after endoscopy

Ergonomics plays an important role in injury prevention for endoscopists. Raising awareness and enhancing ergonomics in endoscopy may prevent endoscopic-related injury. In this video (Video 1, available online at www.VideoGIE.org), we review techniques for optimizing ergonomics after and between endoscopic procedures. This includes stretches and exercises of the hand, wrist, elbow, shoulders, back, and neck (Fig. 1A-D). The goal of this video is to enhance awareness of ergonomic principles and prevent endoscopic-related injuries.