Predictors of Malignancy in Patients With Indeterminate Biliary Strictures and Atypical Biliary Cytology: Results From Retrospective Cohort Study

Background

Atypical cellular features are commonly encountered in patients with indeterminate biliary strictures, which are nondiagnostic of malignancy yet cannot rule it out. This study aims to identify clinical features that could discriminate patients with indeterminate biliary strictures and atypical biliary cytology who may harbor underlying malignancy.

Methods

All patients with an indeterminate biliary stricture and an atypical brush cytology obtained during endoscopic brushings were identified in a large tertiary-care center. Demographical information, clinical data and the final pathological diagnosis were collected. The study cohort was divided based on the final diagnosis into benign and malignant groups. Descriptive and multivariable analyses were performed.

Results

A total of 151 patients were included in the analysis. Of these, 62.9% were males with mean age of 61.7 ± 16.4 years. Overall, there was an almost equal distribution of patients in the benign and malignant groups. Older age (≥65 years), jaundice, weight loss, intrahepatic biliary and pancreatic duct dilation, double-duct sign and presence of a mass were associated with malignancy in the univariate analysis. However, only older age (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.00 to 1.03), jaundice (OR 3.33, 95% CI 1.11 to 9.98) and presence of a mass (OR 12.10, 95% CI 4.94 to 29.67) were significantly associated with malignancy in the multivariate analysis. High CA19-9 was associated with malignancy only in patients with primary sclerosing cholangitis.

Conclusion

In patients with indeterminate biliary stricture and atypical brush cytology, older age, jaundice and presence of a mass are significant predictors of malignancy. Patients with such characteristics need prompt evaluation to rule out underlying malignancy.

Combined EsophaCap cytology and MUC2 immunohistochemistry for screening of intestinal metaplasia, dysplasia and carcinoma

Purpose: The incidence of esophageal adenocarcinoma (EAC) has increased by 700% in Western countries over the last 30 years. Although clinical guidelines call for endoscopic surveillance for EAC among high-risk populations, fewer than 5% of new EAC patients are under surveillance at the time of diagnosis. We studied the accuracy of combined cytopathology and MUC2 immunohistochemistry (IHC) for screening of Intestinal Metaplasia (IM), dysplasia and EAC, using specimens collected from the EsophaCap swallowable encapsulated cytology sponge from Canada and United States. Patients and methods: By comparing the EsophaCap cytological diagnosis with concurrent endoscopic biopsies performed on the same patients in 28 cases, we first built up the cytology diagnostic categories and criteria. Based on these criteria, 136 cases were evaluated by both cytology and MUC2 IHC with blinded to patient biopsy diagnosis. Results: We first set up categories and criteria for cytological diagnosis of EscophaCap samples. Based on these, we divided our evaluated cytological samples into two groups: non-IM group and IM or dysplasia or adenocarcinoma group. Using the biopsy as our gold standard to screen IM, dysplasia and EAC by combined cytology and MUC2 IHC, the sensitivity and specificity were 68% and 91%, respectively, which is in the range of clinically useful cytological screening tests such as the cervical Pap smear. Conclusions: Combined EsophaCap cytology and MUC2 IHC could be a good screening test for IM and Beyond.

Endoscopic Resection of Ampullary Tumours: Long-term Outcomes and Adverse Events

Background

The management of ampullary lesions has shifted from surgical approach to endoscopic resection. Previous reports were limited by small numbers of patients and short follow-up. The aim of this study is to describe short- and long-term outcomes in a large cohort of patients undergoing endoscopic ampullectomy.

Methods

Retrospective study of endoscopic ampullectomies performed at a tertiary center from January 1999 to October 2016. Information recorded includes patient demographics, clinical outcomes, lesion pathology, procedural events, adverse events and follow-up data.

Results

Overall, 103 patients underwent endoscopic resection of ampullary tumours (mean age 62.3 ± 14.3 years, 50.5% female, mean lesion size 20.9 mm; 94.9% adenomas, with a majority of lesions exhibiting low-grade dysplasia (72.7%). Complete endoscopic resection was achieved in 82.5% at initial procedure. Final complete endoscopic resection was achieved in all patients with benign pathology on follow-up procedures. Final pathology showed that 11% had previously undiagnosed invasive carcinoma. Delayed postprocedure bleeding occurred in 21.4%, all of which were managed successfully at endoscopy. Acute pancreatitis complicated 15.5% of procedures (mild in 93.8%). Perforation occurred in 5.8%, all treated conservatively except for one patient requiring surgery. Piecemeal resection was associated with significantly higher recurrence compared to en-bloc resection (54.3% versus 26.2%, respectively, P = 0.012). All recurrences were treated endoscopically.

Conclusion

Endoscopic ampullectomy appears both safe and effective in managing patients with ampullary tumours in experienced hands. Most adverse events can be managed conservatively. Many patients develop recurrence during long-term follow-up but can be managed endoscopically. Recurrence rates may be reduced by performing initial en-bloc resection.

Hot avulsion may be effective as salvage treatment for focal Barrett's esophagus remaining after endoscopic therapy for dysplasia or early cancer: a preliminary study

BACKGROUND AND STUDY AIM

Both endoscopic mucosal resection (EMR) and radiofrequency ablation (RFA) are used to treat Barrett's esophagus (BE) complicated by dysplasia and intramucosal cancer. However, focal areas of BE can remain after otherwise successful application of these techniques. We report the results of hot avulsion using a hot biopsy forceps to resect these residual focal areas.

PATIENTS AND METHODS

This was a retrospective study from a prospective database in a tertiary reference center from August 2013 to May 2015. All included patients had undergone hot avulsion for eradication of residual focal areas of BE that were ≤ 1 cm and not suspicious for dysplasia, following at least one previous endoscopic treatment for dysplasia or intramucosal cancer.

RESULTS

35 patients harboring 124 residual areas of 1 - 7 mm were treated with hot avulsion. After a mean follow-up of 17.4 months, all patients achieved complete eradication of residual focal BE. One of the patients required a second hot avulsion treatment. Hot avulsion provided samples in all cases but limited the assessment of dysplasia (cautery artifact) in 20.2 % of them. The only complication was bleeding in two patients, which was easily stopped by soft coagulation.

CONCLUSIONS

Hot avulsion appears to be effective and safe in removing focal BE ≤ 1 cm at its greatest length remaining after endoscopic treatment for dysplasia or early cancer. Further studies are required before this technique can be considered the standard of care.

A feasibility study of photoacoustic imaging of ex vivo endoscopic mucosal resection tissues from Barrett's esophagus patients

BACKGROUND AND STUDY AIMS

Accurate endoscopic detection of dysplasia in patients with Barrett's esophagus (BE) remains a major clinical challenge. The current standard is to take multiple biopsies under endoscopic image guidance, but this leaves the majority of the tissue unsampled, leading to significant risk of missing dysplasia. Furthermore, determining whether there is submucosal invasion is essential for proper staging. Hence, there is a clinical need for a rapid in vivo wide-field imaging method to identify dysplasia in BE, with the capability of imaging beyond the mucosal layer. We conducted an ex vivo feasibility study using photoacoustic imaging (PAI) in patients undergoing endoscopic mucosal resection (EMR) for known dysplasia. The objective was to characterize the esophageal microvascular pattern, with the long-term goal of performing in vivo endoscopic PAI for dysplasia detection and therapeutic guidance.

MATERIALS AND METHODS

 EMR tissues were mounted luminal side up. The tissues were scanned over a field of view of 14 mm (width) by 15 mm (depth) at 680, 750, and 850 nm (40 MHz acoustic central frequency). Ultrasound and photoacoustic images were simultaneously acquired. Tissues were then sliced and fixed in formalin for histopathology with hematoxylin and eosin staining. A total of 13 EMR specimens from eight patients were included in the analysis, which consisted of co-registration of the photoacoustic images with corresponding pathologist-classified histological images. We conducted mean difference test of the total hemoglobin distribution between tissue classes.

RESULTS

 Dysplastic and nondysplastic BE can be distinguished from squamous tissue in 84 % of region-of-interest comparisons (42/50). However, the ability of intrinsic PAI to distinguish dysplasia from NDBE, which is the clinically important challenge, was only about 33 % (10/30).

CONCLUSION

 We demonstrated the technical feasibility of this approach. Based on our ex vivo data, changes in total hemoglobin content from intrinsic PAI (i. e. without exogenous contrast) can differentiate BE from squamous esophageal mucosa. However, most likely intrinsic PAI is unable to differentiate dysplastic from nondysplastic BE with adequate sensitivity for clinical translation.

Efficacy of single-incision needle-knife biopsy for sampling subepithelial lesions

Background and study aims Single-incision needle-knife (SINK) biopsy is a diagnostic method for acquiring tissue samples for subepithelial lesions (SELs). A single linear incision is made in the overlying mucosa and tissue samples are obtained by passing conventional biopsy forceps through the opening and deep into the lesion. The aim of this study was to describe the efficacy and safety of this technique. Patients and methods Consecutive patients who underwent SINK biopsy for an upper gastrointestinal SEL between October 2013 and September 2015 were retrospectively reviewed. Results Forty-nine patients underwent 50 SINK biopsies. Sufficient sampling for a definite pathologic diagnosis was obtained in 42 (86 %) cases, with 91 % (40/44) having sufficient sample to perform immunohistochemistry when deemed clinically relevant. Of the 26 patients with prior non-diagnostic biopsies or FNA, a specific diagnosis was obtained in 85 % (22/26). There were no significant adverse events. Conclusions SINK biopsy is a safe and feasible strategy for obtaining a definitive tissue diagnosis with immunohistochemistry for SELs.

Diffuse reflectance spectroscopy in Barrett's esophagus: developing a large field-of-view screening method discriminating dysplasia from metaplasia

We evaluated diffuse reflectance spectroscopy implemented as a small field-of-view technique for discrimination of dysplasia from metaplasia in Barrett's esophagus as an adjuvant to autofluorescence endoscopy. Using linear discriminant analysis on 2579 spectra measured in 54 patients identified an optimum a 4-wavelength classifier (at 485, 513, 598 and 629 nm). Sensitivity and specificity for a test data set were 0.67 and 0.85, respectively. Spectroscopic results show that this technique could be implemented in wide-field imaging mode to improve the accuracy of existing endoscopy techniques for finding early pre-malignant lesions in Barrett's esophagus. Results show that the discrimination occurs likely due to redistribution of blood content in the tissue sensed by the optical probing with the wavelength-dependent sampling depth.

Treatment of dysplasia in barrett esophagus

Barrett esophagus is recognized as a risk factor for the development of dysplasia and adenocarcinoma of the esophagus. Cancer is usually diagnosed at an advanced stage with a 5-year survival rate of 15%. Most of these patients present de novo and are not part of a surveillance program. Endoscopic screening with improvement in recognition of early lesions may change this pattern. In the past, patients diagnosed with dysplasia and mucosal cancer were best managed by esophagectomy. Endoscopic techniques such as endoscopic mucosal resection and radiofrequency ablation have resulted in high curative rates and a shift away from esophagectomy. This pathway is supported by the literature review of esophagectomies performed for mucosal disease, as well as pathologists' interpretation of endoscopic mucosal specimens, which document the low risk of lymph node metastasis. The role of endoscopic therapy for superficial submucosal disease continues to be a challenge.

Advanced imaging technologies for the detection of dysplasia and early cancer in barrett esophagus

Advanced esophageal adenocarcinomas arising from Barrett esophagus (BE) are tumors with an increasing incidence and poor prognosis. The aim of endoscopic surveillance of BE is to detect dysplasia, particularly high-grade dysplasia and intramucosal cancers that can subsequently be treated endoscopically before progression to invasive cancer with lymph node metastases. Current surveillance practice standards require the collection of random 4-quadrant biopsy specimens over every 1 to 2 cm of BE (Seattle protocol) to detect dysplasia with the assistance of white light endoscopy, in addition to performing targeted biopsies of recognizable lesions. This approach is labor-intensive but should currently be considered state of the art. Chromoendoscopy, virtual chromoendoscopy (e.g., narrow band imaging), and confocal laser endomicroscopy, in addition to high-definition standard endoscopy, might increase the diagnostic yield for the detection of dysplastic lesions. Until these modalities have been demonstrated to enhance efficiency or cost effectiveness, the standard protocol will remain careful examination using conventional off the shelf high-resolution endoscopes, combined with as longer inspection time which is associated with increased detection of dysplasia.

Length of Barrett's segment predicts success of extensive endomucosal resection for eradication of Barrett's esophagus with early neoplasia

BACKGROUND

Although the efficacy and safety of extensive endomucosal resection (EMR) in eradicating Barrett's esophagus (BE) harbouring early neoplasia have been established, factors predicting efficacy remains unclear.

AIM

To determine the complete eradication rate of Barrett's esophagus with high-grade intraepithelial neoplasia (HGIN) or intramucosal carcinoma (IMC), safety, and factors predicting complete eradication by EMR.

METHODS

Patients with histological confirmation of Barrett's HGIN/IMC were prospectively identified. EMR was performed using Duette multiband ligator or cap technique by a single operator (NEM).

RESULTS

99 patients (81 males) with median age 67 years [interquartile range (IQR) 60-77 years] and median Barrett's length 4 cm (IQR 2-6 cm) were included. Of 628 index EMRs [mean 6.3, median 5 (IQR 3-8)], 23% showed IMC, 58.5% showed HGIN, and 16% showed low-grade dysplasia only. A median of 8 EMR resections per patient (IQR 6-16, 1,064 resections in 89 patients) resulted in complete eradication of BE harboring neoplasia in 49.4% and eradication of HGIN/IMC in 81% (BE <5 cm subgroup: 65% complete eradication and 91% HGIN eradication) at median follow-up of 18 months (range 6-27 months). On univariate analysis, focal dysplasia (P = 0.003) and Barrett's length <5 cm (P = 0.001) were predictors of complete BE eradication. Barrett's length <5 cm was the only significant predictor [odds ratio (OR) 3.4, standard error (SE) 0.11, P = 0.0006] on multiple logistic regression analysis. Strictures developed in 27% and major bleeding in 2% with no procedure-related perforations or mortality.

CONCLUSIONS

Extensive EMR for removal of BE with early neoplasia is safe. Outcomes for complete BE eradication are modest at 49.4% and eradication of high-grade dysplasia at 81%. Barrett's length <5 cm is the only significant predictor of complete response.

Abstract B34: Association of endogenous oxidative and aldehyde stress: Implications for studies of colon carcinogenesis

The results of a small pilot study provided new insights into the process of colon carcinogenesis.

Background: The known risk factors for colorectal cancer (CRC) suggested that CRC resulted from the interaction of exposure to energy excess and to oxidative stress [McKeown-Eyssen G et al. pp 673-693 in “Endogenous Toxins” Wiley, 2010]. The suggestion was supported by: cellular studies that demonstrated the cytotoxicity and genotoxicity of excess energy substrate (fructose) with oxidative stress (H2O2); animal studies that showed a wide range of pathology associated with fructose-based diets when combined with oxidative stress; and clinical studies that described the association of advanced glycation end-products (AGEs) with chronic diseases associated with the Western lifestyle.

Methods: A pilot case-control study at a hospital-based gastroenterology clinic was conducted to assess methods for future tests of the hypothesis. It was based on an analysis of plasma samples collected from patients with (n = 20) or without (n = 21) colonoscopy-demonstrated polyps.

Results: Although as anticipated none of the differences between polyp and non-polyp plasma samples achieved statistical significance, there were unexpectedly strong associations of the concentrations of the endogenous plasma aldehydes, glyoxal and methylglyoxal (r = 0.92), and glyoxal and 4-hydroxynonenal (r = 0.52) across the collected samples.

Conclusions: The associations were likely a consequence of the known interaction of endogenous aldehydes with oxidative stress: endogenous aldehydes increased oxidative stress; oxidative stress increased the formation of endogenous aldehydes [e.g. Vander Jagt DL. Drug Metab Drug Interact 2008;23:93-124]. The products of such interactions, AGEs and advanced lipid oxidation endproducts (ALEs), could explain the known accumulation of fluorescent lipofuscin observed with dysplastic adenomas.

Impact: Exposure to endogenous aldehydes and oxidation products is complex. Endogenous aldehyde derived — AGEs could provide robust biomarkers of this exposure including information relating to the tissues, cells and cellular organelles affected.

Citation Information: Cancer Prev Res 2010;3(12 Suppl):B34.

Assessment of photobleaching during endoscopic autofluorescence imaging of the lower GI tract

BACKGROUND AND OBJECTIVES

In autofluorescence endoscopy, the difference in the fluorescence of intrinsic fluorophores is imaged to help visualize pre-malignant lesions, as in the system evaluated here. In this, blue light is used for excitation and the green autofluorescence is normalized by the red diffuse reflectance and presented using a false color scale. The present study was designed to quantify the degree of fluorescence photobleaching induced by the excitation light during use in the colon, since significant photobleaching could lead to false interpretation of the images, particularly false-positive lesions.

STUDY DESIGN

Measurements were made ex vivo and in vivo, both using the endoscopic imaging system and a separate fiberoptic spectroscopy probe in externalized rat jejunum and in patients undergoing routine colonoscopy, using exposures typical of autofluorescence endoscopic examination.

RESULTS

Photobleaching could be potentially caused at blue light exposure. However, at light intensities and exposure times that are typically used in clinical practice, the average photobleaching (% loss of peak fluorescence intensity) was <1% and <6% in the rat and human tissues, respectively. Nevertheless, the range was large: from -17% to +18% in rats and -33% to +43% in patients, where negative values denote an apparent increase in fluorescence. Both the large positive and negative deviations are believed in part to be due to a measurement artifact caused by uncontrollable tissue motility.

SUMMARY AND CONCLUSIONS

It is concluded that, using exposures typically encountered in clinical practice, there is minimal photobleaching during fluorescence endoscopy at exposure such as are used in the Onco-LIFE and comparable systems. The small changes in fluorescence intensity and spectral shift that do occur are not likely to be detectable by eye, and so should not impact significantly on the diagnostic accuracy of the technique.

Endoscopic cryotherapy for the management of gastric antral vascular ectasia

BACKGROUND

Gastric antral vascular ectasia (GAVE) is an uncommon but clinically significant cause of chronic GI bleeding.

OBJECTIVE

To assess the efficacy and safety of cryotherapy for endoscopic treatment of GAVE.

DESIGN

Patients received 3 sessions of endoscopic cryotherapy at 3-week to 6-week intervals and had a follow-up endoscopy 4 weeks thereafter. They were followed prospectively in terms of clinical and endoscopic response.

SETTING

Tertiary-care center, between October 2004 and April 2006.

PATIENTS

The patients were 43 to 89 years of age, with a diagnosis of GAVE and documented iron deficiency anemia. Eight patients had a history of overt GI bleeding. Eight patients (67%) had previously been treated with argon plasma coagulation (APC) (median 6 sessions, range 1-10 sessions) and failed to respond or had a recurrence.

RESULTS

Twelve patients were enrolled. Six patients (50%) had a complete response, and 6 patients had a partial response. The mean number of units of blood transfused in the period of 3 months before cryotherapy and during the period of follow-up of 3 months was 4.6 and 1.7 units, respectively. An increased mean Hb level, from 9.9 to 11.3 g/dL, was noted. The average duration of the cryotherapy was 5 minutes (range 1-15 minutes). In 32 of 36 cryotherapy treatment sessions performed (89%), it was technically possible to treat more than 90% of GAVE lesions. There were no immediate cryotherapy-related complications, and none of the patients required admission after the procedure.

LIMITATIONS

A pilot study from a single center.

CONCLUSIONS

Endoscopic cryotherapy is a safe and effective treatment for GAVE. It appears to be effective, even for GAVE refractory to APC therapy. Optimal cryogen, delivery device, and treatment protocols are yet to be determined.

A pilot randomised controlled trial to reduce colorectal cancer risk markers associated with B-vitamin deficiency, insulin resistance and colonic inflammation

Colorectal cancer risk is associated with biochemical markers for B-vitamin deficiency, insulin resistance and colonic inflammation, suggesting that these three conditions are each involved in colon carcinogenesis. We expected that dietary supplements of folic acid, n-3 fatty acids and calcium would reduce the markers and thus possibly cancer risk. We therefore randomised 98 participants, with previous colonic polyps or intramucosal carcinomas, to a combined treatment of supplementary folic acid, fish oil and calcium carbonate, or placebos for 28 days. Blood and faecal samples were obtained prior to and at the conclusion of the intervention and analysed for plasma folate, homocysteine, insulin, free fatty acids, triglycerides and faecal calprotectin. In addition, plasma vitamin B12, thiamin, glucose and C-reactive protein were assessed. Our supplemental strategy modestly affected some of the biomarkers associated with folate metabolism and insulin resistance, but had no effect on those associated with colonic inflammation. This pilot study demonstrates the feasibility and practicality of clinical trials aimed at reducing diet-related biochemical risk markers for colon cancer. We suggest that long-term intervention studies with tumour-related end points should be undertaken when the intervention agents used are found effective in short-term biochemical risk marker trials.

Autofluorescence characterisation of isolated whole crypts and primary cultured human epithelial cells from normal, hyperplastic, and adenomatous colonic mucosa

BACKGROUND/AIMS

In vivo autofluorescence endoscopic imaging and spectroscopy have been used to detect and differentiate benign (hyperplastic) and preneoplastic (adenomatous) colonic lesions. This fluorescence is composed of contributions from the epithelium, lamina propria, and submucosa. Because epithelial autofluorescence in normal and diseased tissues is poorly understood, this was the focus of the present study.

METHODS

Whole colonic crypts were isolated, and short term primary cultures of epithelial cells were established from biopsies of normal, hyperplastic, and adenomatous colon. Autofluorescence (488 nm excitation) was examined by confocal fluorescence microscopy. Fluorescently labelled organelle probes and transmission electron microscopy were used to identify subcellular sources of fluorescence.

RESULTS

Mitochondria and lysosomes were identified as the main intracellular fluorescent components in all cell types. Normal and hyperplastic epithelial cells were weakly autofluorescent and had similar numbers of mitochondria and lysosomes, whereas adenomatous (dysplastic) epithelial cells showed much higher autofluorescence, and numerous highly autofluorescent lysosomal (lipofuscin) granules.

CONCLUSIONS

Short term primary cell cultures from endoscopic biopsies provide a novel model to understand differences in colonic tissue autofluorescence at the glandular (crypt) and cellular levels. The differences between normal, hyperplastic, and adenomatous epithelial cells are attributed in part to differences in the intrinsic numbers of mitochondria and lysosomes. This suggests that the detection of colonic epithelial fluorescence alone, if possible, may be sufficient to differentiate benign (hyperplastic) from preneoplastic and neoplastic (adenomatous) colonic intramucosal lesions during in vivo fluorescence endoscopy. Furthermore, highly orange/red autofluorescent intracellular granules found only in dysplastic epithelial cells may serve as a potential biomarker.

Endoscopic Doppler optical coherence tomography in the human GI tract: initial experience

BACKGROUND

Expanding the current endoscopic optical coherence tomography (OCT) system with Doppler capability may augment this novel high-resolution cross-sectional imaging technique with functional blood flow information. The aim of this feasibility study was to assess the clinical feasibility of an endoscopic Doppler OCT (EDOCT) system in the human GI tract.

METHODS

During routine endoscopy, 22 patients were imaged by using a prototype EDOCT system, which provided color-Doppler and velocity-variance images of mucosal and submucosal blood flow at one frame per second, simultaneously with high-spatial-resolution (10-25 mum) images of tissue microstructure. The images were acquired from normal GI tract and pathologic tissues.

OBSERVATIONS

Subsurface microstructure and microcirculation images of normal and pathologic GI tissues, including Barrett's esophagus, esophageal varices, portal hypertensive gastropathy, gastric antral vascular ectasia, gastric lymphoma, and duodenal adenocarcinoma, were obtained from 72 individual sites in vivo. Differences in vessel diameter, distribution, density, and blood-flow velocity were observed among the GI tissue pathologies imaged.

CONCLUSIONS

To our knowledge, this is the first study to demonstrate the feasibility of EDOCT imaging in the human GI tract during routine endoscopy procedures. EDOCT may detect the different microcirculation patterns exhibited by normal and diseased tissues, which may be useful for diagnostic imaging and treatment monitoring.

Precut papillotomy versus persistence in difficult biliary cannulation: a prospective randomized trial

BACKGROUND AND STUDY AIMS

Failed biliary cannulation occurs in up to 10% of patients undergoing ERCP. There is some controversy as to the safety and efficacy of using precut techniques to achieve biliary cannulation in difficult cases. To date, no randomized trial has compared the success and complication rates of precut with the rates for persistence when biliary cannulation is difficult. The aim of this study was to compare the success rates and complication rates of precut with the success rates and complication rates of persistence in cases of difficult biliary cannulation.

PATIENTS AND METHODS

Patients without prior sphincterotomy who required biliary cannulation were screened. A "difficult biliary cannulation" was arbitrarily defined as failed cannulation after 12 minutes. These patients were then randomized to continue treatment by needle-knife cut over the roof of the papilla or by persistence with a non-wire-guided, single-lumen papillotome. "Primary" success was defined as deep cannulation within 15 minutes of randomization. Primary and final success rates and complication rates within 30 days after ERCP were compared.

RESULTS

Over a 38-month period a total of 642 patients were screened. Patients in whom biliary cannulation was successful within a time period of 12 minutes or less formed the reference group (n = 580). The remainder of the patients were randomly assigned to the "precut" arm (n = 32) or to the "persistence" arm (n = 30). Primary success rates and complication rates were similar in the precut and persistence arms (75% and 4% respectively for the precut arm vs. 73% and 9% for the persistence arm). The final successful cannulation rate in the entire group of 642 patients was 99.5%.

CONCLUSIONS

In experienced hands, precut papillotomy and persistence in cannulation are equally effective in cases of difficult cannulation, with a similar complication rate.

Wireless capsule endoscopy for obscure gastrointestinal bleeding: a single-centre, one-year experience

BACKGROUND

Wireless capsule endoscopy (CE) is increasingly being used in the investigation of obscure gastrointestinal (GI) bleeding, but some studies have found that many of the bleeding lesions recognized by this technique are within the reach of conventional endoscopy.

METHODS

The results of CE performed in the authors' centre in a 12 month period for obscure GI bleeding were retrospectively reviewed.

RESULTS

Of the 46 patients with obscure GI bleeding, CE found a definite or probable cause in 19 (41%) and a possible cause in another 10 (22%), with an overall diagnostic yield of 63%. One of these lesions was found to be within reach of conventional gastroscopy, two were within reach of push enteroscopy, four were within reach of colonoscopy and one was within reach of retrograde enteroscopy through a stoma. The percentage of patients with a bleeding source within reach of routine endoscopy but missed during pre-CE endoscopy was significantly higher for those patients having endoscopy only in the community (30% [eight of 27]) versus in the authors' centre (0% [zero of 19]).

CONCLUSIONS

CE was valuable for diagnosing bleeding lesions not only within the small bowel, but also in the stomach and colon. However, "second-look" endoscopy may be considered before ordering CE for obscure GI bleeding when local expertise is available.

Diagnosis of small-bowel varices by capsule endoscopy

BACKGROUND

Capsule endoscopy is being used increasingly to investigate GI bleeding of obscure origin and disorders of the small bowel.

METHODS

Four cases of small-bowel varices of various etiologies diagnosed by capsule endoscopy are described: a bleeding small-bowel varix because of hepatic portal hypertension, oozing small-bowel anastomotic or adhesion-related varices, small-bowel varices secondary to mesenteric vein thrombosis, and "idiopathic intestinal varices."

OBSERVATIONS

Over a 12-month period, small-bowel varices were found in 4 of 46 patients (8.7%) who underwent capsule endoscopy for GI bleeding. Fresh blood adjacent to the varices was documented in 3 patients. The small-bowel varices had serpiginous or nodular shapes, with or without a bluish coloration. The variceal mucosa appeared mosaic-like, shining, or normal compared with surrounding mucosa.

CONCLUSIONS

Capsule endoscopy is invaluable for the diagnosis of small-bowel varices. It is highly sensitive for detection of fresh blood in the small bowel. Clinical suspicion, capsule endoscopy image recognition, and alertness during capsule endoscopy interpretation are keys to diagnosis.

Capsule endoscopy regional transit abnormality: a sign of underlying small bowel pathology

BACKGROUND

Wireless capsule endoscopy is being used increasingly to investigate GI bleeding of obscure etiology and other small bowel abnormalities. Currently, there is no standard for capsule endoscopy image interpretation and classification

METHODS

This report describes an abnormality, termed "regional transit abnormality," noted during a review of capsule endoscopic images. Capsule regional transit abnormality simply refers to delayed capsule transit within a segment of small bowel, with or without visualization of a mucosal abnormality. The slowed transit usually is accompanied by mucosal collapse, sometimes with the appearance of the capsule pressing or impacting upon the mucosa. Regional transit abnormality usually persists more than 15 minutes

CONCLUSIONS

Capsule regional transit abnormality is considered to be a "red flag" sign that indicates a likelihood of some underlying small bowel pathology.

In vivo Doppler optical coherence tomography of mucocutaneous telangiectases in hereditary hemorrhagic telangiectasia

BACKGROUND

Hereditary hemorrhagic telangiectasia is characterized by mucocutaneous telangiectases and visceral arteriovenous malformations. Knowledge is limited concerning the development hemodynamics of mucocutaneous telangiectases. Doppler optical coherence tomography can demonstrate microvascular blood flow at flow rates as low as 20 microm/second, which is up to approximately 100 times more sensitive than Doppler US. The aims of this study were to collect in vivo Doppler optical coherence tomography images of mucocutaneous telangiectases and normal surrounding mucosa and skin, and to gain experience for an in vivo GI endoscopic study. It was hypothesized that visibly normal areas may have occult telangiectases and that mucocutaneous telangiectases that have bled may have a higher rate of blood flow than mucocutaneous telangiectases with no history of bleeding.

METHODS

Twelve patients with hereditary hemorrhagic telangiectasia and mucocutaneous telangiectases were studied. Two to 3 visible mucocutaneous telangiectases on the digits, lips, and tongue were imaged with Doppler optical coherence tomography, along with visually normal surrounding areas at each site. The Doppler optical coherence tomography images were obtained in 0.5 second by using 1310 nm light.

RESULTS

A total of 67 mucocutaneous telangiectases from the 12 patients were imaged (38 digit, 16 lip, 13 tongue). Blood flow was demonstrated within every mucocutaneous telangiectasis imaged. Doppler optical coherence tomography did not identify any abnormal vasculature within visually normal areas. Mucocutaneous telangiectases with a history of bleeding (n = 18) were situated closer to the surface, compared with mucocutaneous telangiectases with no bleeding history (n = 49), but there was no difference in the Doppler flow appearance.

CONCLUSIONS

Visually normal areas in patients with hereditary hemorrhagic telangiectasia did not appear to have abnormal vasculature. Mucocutaneous telangiectases with a history of bleeding were more superficial but were otherwise similar to mucocutaneous telangiectases with no bleeding history.

Photodynamic therapy for the treatment of tumor ingrowth in expandable esophageal stents

BACKGROUND AND STUDY AIMS

Tumor ingrowth through self-expanding metal stents presents a difficult problem for management. The techniques for treating tumor ingrowth have not yet been well described, and the optimal endoscopic approach is not clear. We have recently used photodynamic therapy (PDT) to treat tumor ingrowth through uncovered nitinol mesh stents.

PATIENTS AND METHODS

Four patients (mean age 73) with obstructive adenocarcinomas of the distal esophagus had received self-expanding stents for palliation of their dysphagia. After stent placement, tumor ingrowth had caused progressive dysphagia in all of the patients; the dysphagia was graded on a scale from 0 (normal) to 4 (inability to swallow liquids). All of the patients received PDT treatment.

RESULTS

After PDT, excellent palliation of the dysphagia was seen in all of the patients, with a mean improvement in the dysphagia score of 2.25 and a mean dysphagia-free interval of 92 days. There were no major complications.

CONCLUSION

The use of PDT to treat tumor ingrowth through self-expanding metal esophageal stents is effective and safe.

A prospective study of the repeated use of sterilized papillotomes and retrieval baskets for ERCP: quality and cost analysis

BACKGROUND

The impact on instrument quality and cost of the practice of reusing ERCP accessories has not been fully addressed.

METHODS

Twenty-five new papillotomes and 15 new retrieval baskets were labeled and evaluated over time by staff blinded to the number of prior uses. Instruments were scored as to their function for the designated task. The cost of this practice was calculated from the purchase price of accessories and the costs of cleaning, sterilization, and disposal, and then compared with the estimated cost of a practice of one-time use of similar instruments.

RESULTS

Twenty-five papillotomes were used 246 times (median 8; mean 9.8). Fifteen retrieval baskets were used 193 times (median 13; mean 12.9). The median survival of both papillotomes and baskets before being considered inadequate (score < 6 out of 10) was 9 uses. There were no complications attributable to using reused equipment. The projected yearly cost savings of using reusable versus disposable instruments was $94,095 for papillotomes and $61,809 for baskets, a 475% and 322% cost reduction, respectively.

CONCLUSION

The papillotomes and baskets in this study could be reused reliably and safely multiple times, with considerable cost savings compared with the practice of using disposable instruments.