Torsten Beyna

Colonoscopic full-thickness resection using an over-the-scope device: a prospective multicentre study in various indications

Objective Endoscopic full-thickness resection (EFTR) is a novel treatment of colorectal lesions not amenable to conventional endoscopic resection. The aim of this prospective multicentre study was to assess the efficacy and safety of the full-thickness resection device. Design 181 patients were recruited in 9 centres with the indication of difficult adenomas (non-lifting and/or at difficult locations), early cancers and subepithelial tumours (SET). Primary endpoint was complete en bloc and R0 resection. Results EFTR was technically successful in 89.5%, R0 resection rate was 76.9%. In 127 patients with difficult adenomas and benign histology, R0 resection rate was 77.7%. In 14 cases, lesions harboured unsuspected cancer, another 15 lesions were primarily known as cancers. Of these 29 cases, R0 resection was achieved in 72.4%; 8 further cases had deep submucosal infiltration >1000 µm. Therefore, curative resection could only be achieved in 13/29 (44.8%). In the subgroup with SET (n=23), R0 resection rate was 87.0%. In general, R0 resection rate was higher with lesions ≤2 cm vs >2 cm (81.2% vs 58.1%, p=0.0038). Adverse event rate was 9.9% with a 2.2% rate of emergency surgery. Three-month follow-up was available from 154 cases and recurrent/residual tumour was evident in 15.3%. Conclusion EFTR has a reasonable technical efficacy especially in lesions ≤2 cm with acceptable complication rates. Curative resection rate for early cancers was too low to recommend its primary use in this indication. Further comparative studies have to show the clinical value and long-term outcome of EFTR in benign colorectal lesions. Trial registration number NCT02362126; Results.

CO2 insufflation during single-balloon enteroscopy: a multicenter randomized controlled trial.

BACKGROUND AND STUDY AIMS Carbon dioxide (CO2) insufflation has previously been shown to have advantages over air insufflation in terms of procedure-related pain and oral insertion depth during double-balloon enteroscopy. The aim of this prospective study was to evaluate the performance of CO2 vs. air insufflation during single-balloon enteroscopy. PATIENTS AND METHODS This study was a randomized European multicenter trial (ClinicalTrials.gov: NCT01524055). Patients and endoscopists were blinded to the type of insufflation gas used. Patient discomfort during and after the procedure was scored using a visual analog scale. RESULTS A total of 107 patients were enrolled in the study (52 in the CO2 group and 55 in the air group). Patient characteristics were comparable in both groups. The mean (±SD) oral intubation depth was not significantly deeper in the CO2 group vs. the air group (254±80 vs. 238±55 cm; P=0.726). However, in patients with previous abdominal surgery, oral intubation depth was significantly higher in the CO2 group compared with the air group (258±84 vs. 192±42 cm; P<0.05). In patients undergoing SBE via the anal approach, CO2 showed no significant difference in intubation depth compared with air insufflation (86±67 vs. 110±68 cm; P=0.155). The diagnostic yield was comparable (CO2 67%; air 73%). Procedure times, dosage of sedation, and therapeutic interventions did not differ between the two groups. Patients in the CO2 group reported less pain than those in the air group. CONCLUSIONS This study demonstrated an advantage of using CO2 insufflation during single-balloon enteroscopy in patients with a history of previous abdominal surgery. Overall, single-balloon enteroscopy was a well-tolerated procedure that may benefit from the use of CO2 insufflation to reduce post-procedural pain.

Direct retrograde cholangioscopy with a new prototype double-bending cholangioscope

BACKGROUND AND STUDY AIMS Direct retrograde cholangioscopy (DRC) enables high quality video imaging of the bile ducts and allows intraductal treatment with optical control. We evaluated the feasibility, success, and complications of a new third-generation prototype cholangioscope. PATIENTS AND METHODS All consecutive patients from two tertiary endoscopy centers who had undergone DRC with the prototype were included. Indications for DRC were: evaluation of indeterminate strictures, filling defects, and complex bile duct stones. Technical success was investigated in terms of indication and treatment performed. All adverse events were recorded. RESULTS DRC with the prototype was performed in 74 patients. Therapeutic interventions included laser or electrohydraulic lithotripsy and stone removal, among others. The papilla was entered in 72/74 patients (97 %). The targeted bile duct segment was reached in 62 /74 patients (84 %), with an anchoring balloon catheter needed in 21/74 (28 %). Mean investigation time was 21 minutes (15 - 27 minutes) CONCLUSIONS DRC using the prototype is feasible, safe, and attains access to the bile ducts in almost all patients, with less need of an anchoring balloon catheter compared with the standard technique and short investigation and fluoroscopy times.

Novel Motorized Spiral Enteroscopy: First Clinical Case

re 1. A, Integrated electric motor of the novel enteroscope. B, Disposable short spiral overtube and rotation coupler of the insertion tube. C, The l overtube is connected to the rotation coupler. D, Prototype spiral enteroscope ready for use. E, Spiral rotation force indicator. F, Insertion of spiral on of the endoscope. G, Detection of arteriovenous malformation of the jejunum during spiral enteroscopy. H, Treatment of arteriovenous malforn by argon plasma coagulation.

Direct peroral cholangioscopy with a new anchoring technique using the guide probe of Kautz – first clinical experiences

Background and study aims We present the first clinical results of a new tandem technique for direct peroral cholangioscopy using a standard ultraslim upper gastrointestinal endoscope and a guide probe that was originally developed for the non-transendoscopic placement of biliary endoprostheses (guide probe of Kautz; MTW, Wesel, Germany). Patients and methods Twenty direct peroral cholangioscopy procedures were performed with the new anchor-assisted method using the guide probe of Kautz in a single center and were retrospectively analyzed. Results  Indications for anchor-assisted cholangioscopy procedures included indeterminate bile duct strictures (n = 14), filling defects that remained after stone extraction (n = 4), and complex stone extractions (n = 2). Biliary access and visualization of the target region were achieved in 18/20 procedures (90 %). The interventional success rate was 85 % (11 /13 interventions). One case of postinterventional cholangitis occurred (5 %), along with one case of minor peri-interventional papillary bleeding (5 %). Conclusions The anchor-assisted cholangioscopy technique is feasible and safe for direct cholangioscopy and provides reliable success rates in clinical practice. This technique represents an alternative approach for direct cholangioscopy on a single-operator basis using standard endoscopes.

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

BACKGROUND AND STUDY AIMS The 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. PATIENTS AND METHODS The study was performed between November 2015 and June 2016. EWAVE colonoscopy was performed in patients with an increased risk of colorectal cancer by experienced and EWAVE-trained endoscopists (≥ 500 colonoscopies, ≥ 10 with the EWAVE system). RESULTS A total of 193 patients underwent EWAVE colonoscopy. The cecal intubation rate was 97.4 %. EWAVE colonoscopy had a polyp detection rate (PDR) of 61.1 % (118 /193), ADR of 39.9 % (77 /193), and advanced ADR of 13.5 % (26 /193). No adverse events occurred. CONCLUSIONS EWAVE 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.

Motorized spiral colonoscopy: a first single-center feasibility trial

BACKGROUND Cecal intubation rate represents a key procedural quality parameter in diagnostic colonoscopy. However, even experienced investigators report 10 % of all colonoscopies to be difficult and intubation of the cecum is sometimes impossible. A recently developed novel motorized spiral endoscope might potentially overcome some limitations of standard colonoscopy by actively pleating the bowel onto the endoscope. The study aim was to evaluate the feasibility and safety of motorized spiral colonoscopy (MSC) for diagnostic colonoscopy. METHODS 30 consecutive patients with an indication for diagnostic colonoscopy were enrolled in a proof-of-concept single-center trial. RESULTS 13 men and 17 women (mean age 68.9 years, range 30 - 90) were enrolled; 43.3 % had diverticula. Mean procedure time was 20.8 min (range 11.4 - 55.3). Cecal intubation rate was 96.7 %. One incomplete colonoscopy occurred because of an unexpected postinflammatory stricture. Adenoma detection rate was 46.6 %. No severe adverse events occurred. CONCLUSIONS Results indicate that MSC is safe and effective for diagnostic colonoscopy. It potentially offers advantages in terms of ease and it may facilitate therapeutic interventions.

Endoscopic treatment of pancreatic duct stones under direct vision: Revolution or resignation? Systematic review

The main treatment aim in chronic pancreatitis (CP) is symptom control and especially pain relief. Management of stone‐predominant CP is challenging and requires a multidisciplinary approach. Extracorporeal shock wave lithotripsy (ESWL) has emerged as the cornerstone of non‐surgical treatment as a result of disappointing results of available endoscopic treatment options during the last decades. With new developments in the field of direct peroral pancreatoscopy (POP) and intracorporeal lithotripsy, direct intraluminal treatment of main pancreatic duct (MPD) stones returns to the spotlight.

Endobiliary polypectomy of biliary tumor using a prototype dedicated cholangioscope with double-bending technology

A67-year-oldwomanwas admittedwith recurrent episodes of upper-abdominal pain, obstructive jaundice, and cholangitis. One year earlier, a complicated open cholecystectomy had been performed because of symptomatic gallbladder stones. Several previous conventional ERCPs showed recurrent obstructing bile duct stones and filling defects of the proximal common bile duct (CBD), necessitating a continuous indwell of biliary plastic stents. EUS and magnetic resonance imaging again confirmed a filling defect of the proximal CBD, suggesting a bile duct stone. During ERCP with single-operator cholangioscopy (Fig. 1), a large stone in the proximal CBD could be visualized. After electrohydraulic lithotripsy under direct vision, cholangioscopy revealed a lumen-obstructing large pedunculated polypoid mass of the CBD that was hidden under the stone surface as the underlying cause of obstruction and recurrent stone formation. Repeated cholangioscopically guided microforceps biopsy was performed, but the results of examination were negative for the histologic diagnosis of the lesion, suggesting a subepithelial localization. EUS andmagnetic resonance imaging showedno evidence of deep infiltration. Direct per-oral cholangioscopywith a prototype dedicated cholangioscope with double-bending tech-

A prospective multicenter study using a new multiband mucosectomy device for endoscopic resection of early neoplasia in Barrett’s esophagus

BACKGROUND AND AIMS Early neoplasia in Barretts esophagus (BE) can be effectively and safely removed by endoscopic resection (ER) using multiband mucosectomy (MBM). This study aimed to document performance of a novel MBM device designed for improved visualization, easier passage of accessories, and better suction power compared with other marketed MBM devices. METHODS This international, single-arm, prospective registry in 14 referral centers (Europe, 10; United States, 3; Canada, 1) included patients with early BE neoplasia scheduled for ER. The primary endpoint was successful ER defined as complete resection of the delineated area in 1 procedure. Secondary outcomes were adverse events and procedure time. RESULTS A total of 332 lesions was included in 291 patients (248 men; mean age, 67 years [standard deviation, 9.6]). ER indication was high-grade dysplasia in 64%, early adenocarcinoma in 19%, lesion with low-grade dysplasia in 11%, and a lesion without definite histology in 6%. Successful ER was reached in 322 of 332 lesions (97%; 95% confidence interval [CI], 94.6%-98.4%). A perforation occurred in 3 of 332 procedures (.9%; 95% CI, .31%-2.62%), all were managed endoscopically, and patients were admitted with intravenous antibiotics during days 2, 3, and 9. Postprocedural bleeding requiring an intervention occurred in 5 of 332 resections (1.5%; 95% CI, .65%-3.48%). Dysphagia requiring dilatation occurred in 11 patients (3.8%; 95% CI, 2.1%-6.6%). Median procedure time was 16 minutes (interquartile range, 12.0-26.0). CONCLUSIONS In expert hands, the novel MBM device proved to be effective for resection of early neoplastic lesions in BE, with successful ER in 97% of procedures. Severe adverse events were rare and were effectively managed endoscopically or conservatively. (Clinical trial registration number: NCT02482701.).