Successful use of biliary accessories in antegrade dilation of complex upper esophageal stricture due to chemoradiation and surgery

Endoscopic management of complete or near complete upper esophageal strictures is challenging. Current methods such as retrograde esophageal access are high risk and may require additional abdominal surgery. A biliary cannulation technique with a 0.035 inch guidewire was utilized to obtain antegrade esophageal access in a patient with near complete high esophageal stricture due to chemo radiation and surgery for head and neck cancer. Biliary accessories including bougie and balloon dilators were used for the initial dilation of the esophageal stricture, followed by the traditional approach of stricture dilation using over-the-wire dilators. The procedure was successfully performed in a patient with near complete upper esophageal stricture due to chemo radiation and surgery for recurrent laryngeal cancer. The dysphagia of this patient was resolved following serial esophageal dilations and his esophageal stricture was wide open on the last upper endoscopy. Biliary accessories can be safely used for obtaining antegrade esophageal access and dilation of near complete upper esophageal strictures. This approach should be considered in patients with complex esophageal strictures, especially after chemo radiation or surgery for head and neck cancer and prior to seeking other more complex alternatives involving retrograde esophageal access.

Needle-knife papillotomy: a helpful and safe adjunct to endoscopic retrograde cholangiopancreatography in a selected population

BACKGROUND AND STUDY AIMS

Needle-knife papillotomy (NKP) has been shown to be a useful alternative when standard techniques fail to provide access during ERCP. A retrospective review was conducted to reevaluate the indications, efficacy, and complications of NKP at a tertiary referral center.

PATIENTS AND METHODS

A total of 1205 therapeutic endoscopic retrograde cholangiography procedures (ERCPs) were reviewed. Sixty-eight patients (5.6%) had undergone NKP after an established algorithm of techniques had failed to provide access. The NKP results were analyzed in two periods, including initial experience with 470 ERCPs (group 1, NKP n = 22) and later experience with 735 patients (group 2, NKP n = 46).

RESULTS

Immediate free cannulation in group 1 was achieved in 14 of 22 patients (64%), vs. 34 of 46 (74%) in group 2. The delayed cannulation rate was five of eight patients in group 1 (62.5%) vs. 11 of 12 in group 2 (92%). The success rate was 19 of 22 patients in group 1 (86%) vs. 45 of 46 in group 2 (98%). The overall success rate was 64 of 68 (94%). Successful cannulation led to a therapeutic intervention in 94% of these patients. A complication rate of 6%, without mortality, was noted.

CONCLUSIONS

NKP is a valuable tool that allows a high success rate for cannulation, with a low complication rate. The success rate increases with operator experience. NKP should be carried out by experienced endoscopists after standard maneuvers fail to provide access, and when cannulation is likely to be followed by a therapeutic intervention.

Gastric polyps: relationship of size and histology to cancer risk

OBJECTIVES

Management of gastric polyps based on polyp size (< or > 2 cm), and histology obtained from forceps biopsy sampling is controversial. To illuminate this subject, the 4-yr experience with endoscopic management of gastric epithelial polyps at a university hospital and a Veterans Administration medical center was reviewed with histopathologic correlation.

METHODS

A computer data-base was used to recall the endoscopic diagnosis of "gastric polyp." Endoscopy reports, video, and still photography were reviewed for data on polyp appearance, size, location, and management. These data had been entered prospectively as required by the Computer-Based Management System. Histopathology was reviewed by a second, blinded, pathologist. Gastric polyps of epithelial origin, at least 0.5 cm in diameter, and not associated with polyposis syndromes, were included.

RESULTS

Thirty-five gastric polyps in 23 patients met inclusion criteria. Snare polypectomy was ultimately performed on 26, and complete resection with forceps biopsy alone on 9. On histopathology 31 polyps were hyperplastic and 4 were adenomas. Six hyperplastic polyps contained focal dysplasia. Among these, carcinoma in situ was identified in three, all <2.0 cm. Furthermore, forceps biopsy in two of these did not reveal the dysplastic components. One adenomatous polyp also contained carcinoma, also <2.0 cm.

CONCLUSIONS

These data emphasize that management based on polyp size or histology obtained from forceps biopsy sampling may be faulty. We recommend that gastric polyps >0.5 cm be removed in toto.

High-resolution chromoendoscopy for the diagnosis of diminutive colon polyps: implications for colon cancer screening

BACKGROUND & AIMS

A visual, nonbiopsy technique that could reliably determine the histology of diminutive colorectal polyps could greatly reduce the cost of colon cancer screening. This study was designed to report our experience using a high-resolution colonoscope combined with indigo carmine dye to diagnosis diminutive colorectal polyps.

METHODS

Colonoscopy using a Fujinon EC-400 HM/HL was performed in 36 patients with polyps <10mm in diameter. Polyps from the first 12 patients (phase 1) were sprayed with 10 mL of 0.2% indigo carmine dye, and a biopsy was performed or a specimen removed and submitted for histological analysis. The morphological data were used to predict polyp histology in the subsequent 24 patients (phase 2).

RESULTS

Hyperplastic polyps had a characteristic surface "pit pattern" of orderly arranged "dots" that resembled the surrounding, nonpolypoid mucosa. Adenomatous polyps had surface "grooves" or "sulci." Sensitivity and specificity of our techniques in distinguishing adenomatous from nonadenomatous colorectal polyps were 93% and 95% respectively.

CONCLUSIONS

High-resolution chromoendoscopy provides morphological detail of diminutive colorectal polyps that correlates well with polyp histology. If incorporated into colon cancer screening, these techniques may limit the need for biopsy and/or subsequent colonoscopy and ultimately decrease costs.

Technology assessment status evaluation: balloon dilation of gastrointestinal tract strictures. American Society for Gastrointestinal Endoscopy

Balloon dilation is an acceptable modality for the dilation of stenoses at various sites in the gastrointestinal tract. In the esophagus its reported efficacy and safety is similar to bougienage; in other sites it offers an alternative to surgical treatment, in most cases as the definitive therapy.

Technology assessment status evaluation: monitoring equipment for endoscopy. American Society for Gastrointestinal Endoscopy

An understanding of the principles and limitations of monitoring devices is valuable for their appropriate use and interpretation. Reliable monitoring de available as an adjunct to skilled personnel to detect changes in patient condition during endoscopy. Combination units that provide pulse oximetry, automated sphygmomanometry and ECG monitoring appear to be the most convenient and cost effective products.

Technology assessment status evaluation: disposable endoscopic accessories. American Society for Gastrointestinal Endoscopy

Data supporting the preferential use of disposable endoscopic accessories is limited. These devices have been widely disseminated without careful evaluation of their impact on the environment and medical costs. In addition, current facility reimbursement for endoscopic procedures does not adequately cover the costs of these accessories. Re-use of accessories labelled "for single use only" as a potential means to reduce costs has not been carefully evaluated. More prospective data comparing the efficacy, safety, and cost effectiveness of disposable versus reusable accessories is needed.

Lymphadenopathy in celiac disease: not always a sign of lymphoma

A patient with celiac disease and mesenteric adenopathy discovered on computerized scanning of the abdomen is described. Lymphadenopathy resolved more than 6 months after the institution of a gluten-free diet. Adenopathy without evidence of lymphoma may be part of the clinical manifestations of patients with celiac disease. Follow-up with computerized tomography may be an option in patients with low clinical suspicion for lymphoma.

Myositis associated with Crohn's colitis

A patient with myositis associated with Crohn's colitis is reported. Myositis preceded the clinical manifestations of colitis. Both symptoms responded promptly and rapidly to sulfasalazine. Serum creatine phosphokinase was markedly elevated and returned to normal after treatment. Muscle biopsy and electromyography were nondiagnostic. Myositis may be more common than reported in patients with inflammatory bowel disease. Careful attention to muscle pain and serum level of creatine phosphokinase in patients with inflammatory bowel disease is suggested.

Allopurinol hepatotoxicity. Report of two cases and review of the literature

Allopurinol hepatotoxicity occurred in two patients. Data from the literature suggest that allopurinol can occasionally cause liver injury, particularly in persons receiving diuretic drugs or with compromised renal function. Clinical and laboratory findings are consistent with hepatocellular injury mediated by a hypersensitivity reaction. Most patients recover when the drug is withdrawn; the possible benefits of corticosteroid treatment remain to be established.