Endoscopic Ultrasound-Guided Radiofrequency Ablation of the Pancreatic Tumors: A Promising Tool in Management of Pancreatic Tumors

Objective. Radiofrequency ablation is a well-established antitumor treatment and is recognized as one of the least invasive therapeutic modalities for pancreatic neoplasm. Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) delivery can be used to treat both pancreatic cancer and asymptomatic premalignant pancreatic neoplasms and may serve as a less invasive alternative to surgical resection. This is an appealing option that may result in less morbidity and mortality. The aim of this review was to summarize and evaluate the clinical and technical effectiveness of EUS-guided RFA of pancreatic neoplasms. Methods. A through literature review was performed to identify the studies describing this novel technique. In this review article, we have summarized human case series. The indications, techniques, limitations, and complications reported are discussed. Results. A total of six studies were included. Overall, a 100% technical success rate was reported in human studies. Complications related to endoscopic ultrasound-guided radiofrequency ablation delivery have been described; however, few cases have presented life-threatening outcomes. Conclusion. We believe that this novel technique can be a safe and effective alternative approach in the management of selected patients.

Endoscopic ultrasound-guided fine-needle aspiration in the diagnosis of adrenal lesions

The use of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) appears to be a safe and feasible means of confirming or excluding malignancy in the adrenal glands. EUS-FNA with biopsy of suspicious masses in either adrenal gland allows for assessment of these lesions while keeping complications relatively rare. The main advantages of EUS-FNA are that it can be done as an outpatient procedure, with good results, minimal morbidity, and a short hospital stay. Nevertheless, EUS-FNA of adrenal masses should be indicated only in selected cases, in which there is potential to either decrease unnecessary treatment or guide therapy in cancer patients by aiding in either staging of malignancy or treatment of recurrence.v.

Endoscopic ultrasound-guided placement of AXIOS stent for drainage of pancreatic fluid collections

Pancreatic fluid collections (PFCs) have conventionally been treated with surgery, percutaneous drainage, or with the more recently established endoscopic ultrasound (EUS)-guided drainage modality. Currently, endoscopic plastic or metallic stents are used for PFC drainage. Plastic stents present issues with stent migration and premature occlusion requiring frequent stent exchanges or placement of additional stents. Metallic stents are tubular and may migrate, resulting in inefficient drainage, content leakage, retrieval and replacement, and possible mucosal injury. The aim of this review was to summarize and evaluate the clinical and technical effectiveness of EUS-guided placement of the recently developed AXIOS stent, a lumen-apposing self-expandable metallic stent (LASEMS)for PFC drainage. A literature review was performed to identify the studies describing this technique. In this review article we have summarized case series or reports describing EUS-guided LASEMS placement. The indications, techniques, limitations and complications reported are discussed. A total of 298 patients were included across all studies described thus far in the literature. Overall, a 97% technical success rate and a 96% clinical success rate have been reported. Early and late complications related to the placement or removal of LASEMS have been reported, however few cases have presented life-threatening results. EUS-guided PFC drainage and LASEMS placement can be a safe and effective alternative approach in the management of selected patients.

Endoscopic ultrasound-guided placement of the lumen-apposing self-expandable metallic stent for gallbladder drainage: a promising technique

Acute cholecystitis and other clinical problems requiring gallbladder removal or drainage have conventionally been treated with surgery, endoscopic retrograde cholangiopancreatography or percutaneous transhepatic drainage of the gallbladder and/or extrahepatic bile duct. Patients unable to undergo these procedures due to functional status or anatomical anomalies are candidates for endoscopic ultrasound (EUS)-guided gallbladder drainage with stent placement. The aim of this review was to evaluate the technical feasibility and efficacy of EUS-guided placement of the recently developed lumen-apposing self-expandable metallic stent (LASEMS). A literature review was performed to identify the studies describing this technique. In this review article we have summarized case series or reports describing EUS-guided LASEMS placement. The indications, techniques, limitations and complications reported are discussed. A total of 78 patients were included across all studies described thus far in the literature. Studies have reported near 100% technical and clinical success rates in selected cases. No major complications were reported. EUS-guided gallbladder drainage and LASEMS placement can be a safe and effective alternative approach in the management of selected patients.

Peroral endoscopic reduction of dilated gastrojejunal anastomosis after bariatric surgery: Techniques and efficacy

AIM: To investigate the techniques and efficacy of peroral endoscopic reduction of dilated gastrojejunal anastomosis after bariatric surgery.

METHODS: An extensive English language literature search was conducted using PubMed, MEDLINE, Medscape and Google to identify peer-reviewed original and review articles using the keywords “bariatric endoscopic suturing”, “overstitch bariatric surgery”, “endoscopic anastomotic reduction”, “bariatric surgery”, “gastric bypass”, “obesity”, “weight loss”. We identified articles describing technical feasibility, safety, efficacy, and adverse outcomes of overstitch endoscopic suturing system for transoral outlet reduction in patients with weight regain following Roux-en-Y gastric bypass (RYGB). All studies that contained material applicable to the topic were considered. Retrieved peer-reviewed original and review articles were reviewed by the authors and the data extracted using a standardized collection tool. Data were analyzed using statistical analysis as percentages of the event.

RESULTS: Four original published articles which met our search criteria were pooled. The total number cases were fifty-nine with a mean age of 46.75 years (34-63 years). Eight of the patients included in those studies were males (13.6%) and fifty-one were females (86.4%). The mean time elapsed since the primary bypass surgery was 5.75 years. The average pre-endoscopic procedure body mass index (BMI) was 38.68 (27.5-48.5). Mean body weight regained post-RYGB surgery was 13.4 kg from their post-RYGB nadir. The average pouch length at the initial upper endoscopy was 5.75 cm (2-14 cm). The pre-intervention anastomotic diameter was averaged at 24.85 mm (8-40 mm). Average procedure time was 74 min (50-164 min). Mean post endoscopic intervention anastomotic diameter was 8 mm (3-15 mm). Weight reduction at 3 to 4 mo post revision noted to be an average of 10.1 kg. Average overall post revision BMI was recorded at 37.7. The combined technical and clinical success rate was 94.9% (56/59) among studied participants.

CONCLUSION: Endoscopic suturing can be technically feasible, effective and safe for transoral outlet reduction in patients with weight regain following RYGB.

Wire assisted sigmoid intubation: An alternative approach to overcome technically difficult colonic angulations

Complete colonoscopy can sometimes prove technically challenging. Sharp colonic angulation can be one of the contributing factors. With the advancement in technology, various modalities have been employed to overcome technical difficulties. Here we describe a guidewire assisted sigmoid intubation to overcome this hurdle with limited resources.

Endoscopic closure of persistent gastrocutaneous fistulae, after percutaneous endoscopic gastrostomy (PEG) tube placement, using the over-the-scope-clip system

OBJECTIVES

The Over-The-Scope-Clip (OTSC) has had an evolving role in endoscopic closure of gastrointestinal wall defects, in hemostasis of primary or postinterventional bleeding, and approximation of postbariatric surgery defects. Rapid and effective closure of gastrocutaneous (GC) fistulae using this device has been recently described in the literature. The aim of this study was to evaluate the technical feasibility, efficacy and safety of OTSC as an effective tool in the management of persistent GC fistulae secondary to a complication of percutaneous endoscopic gastrostomy (PEG) tube placement.

METHOD

In this multicenter prospective observational study, we describe our experience with OTSC in the closure of persistent GC fistulas secondary to PEG tube placement. Patients with GC fistulas were sequentially enrolled with a mean age of 84 years. Primary treatment outcome was the immediate successful closure of GC fistula and resolution of leak. Secondary outcome was no recurrence of the fistula and leaks on follow up.

RESULTS

A total of 10 patients were enrolled over the study period. Mean age was 84.4 ± 8.75 years. The primary treatment outcome was achieved in all the patients undergoing this intervention. Secondary outcome was observed in 9/10 (90%) subjects. No procedural complications were reported. Larger fistulae (>2.5 cm) and those with significant fibrosis were more difficult to close with the OTSC system. The mean follow-up time after OTSC application was 43.7 ± 20.57 days. A limitation of this study was that there was no control group.

CONCLUSIONS

OTSC application is a safe and effective endoscopic approach for the closure of persistent GC fistulae secondary to a complication of PEG tube placement.

Hemostatic powder spray: a new method for managing gastrointestinal bleeding

Gastrointestinal bleeding is a leading cause of morbidity and mortality in the United States. The management of gastrointestinal bleeding is often challenging, depending on its location and severity. To date, widely accepted hemostatic treatment options include injection of epinephrine and tissue adhesives such as cyanoacrylate, ablative therapy with contact modalities such as thermal coagulation with heater probe and bipolar hemostatic forceps, noncontact modalities such as photodynamic therapy and argon plasma coagulation, and mechanical hemostasis with band ligation, endoscopic hemoclips, and over-the-scope clips. These approaches, albeit effective in achieving hemostasis, are associated with a 5-10% rebleeding risk. New simple, effective, universal, and safe methods are needed to address some of the challenges posed by the current endoscopic hemostatic techniques. The use of a novel hemostatic powder spray appears to be effective and safe in controlling upper and lower gastrointestinal bleeding. Although initial reports of hemostatic powder spray as an innovative approach to manage gastrointestinal bleeding are promising, further studies are needed to support and confirm its efficacy and safety. The aim of this study was to evaluate the technical feasibility, clinical efficacy, and safety of hemostatic powder spray (Hemospray, Cook Medical, Winston-Salem, North Carolina, USA) as a new method for managing gastrointestinal bleeding. In this review article, we performed an extensive literature search summarizing case reports and case series of Hemospray for the management of gastrointestinal bleeding. Indications, features, technique, deployment, success rate, complications, and limitations are discussed. The combined technical and clinical success rate of Hemospray was 88.5% (207/234) among the human subjects and 81.8% (9/11) among the porcine models studied. Rebleeding occurred within 72 hours post-treatment in 38 patients (38/234; 16.2%) and in three porcine models (3/11; 27.3%). No procedure-related adverse events were associated with the use of Hemospray. Hemospray appears to be a safe and effective approach in the management of gastrointestinal bleeding.

Hemostatic powder spray: a new method for managing gastrointestinal bleeding

Gastrointestinal bleeding is a leading cause of morbidity and mortality in the United States. The management of gastrointestinal bleeding is often challenging, depending on its location and severity. To date, widely accepted hemostatic treatment options include injection of epinephrine and tissue adhesives such as cyanoacrylate, ablative therapy with contact modalities such as thermal coagulation with heater probe and bipolar hemostatic forceps, noncontact modalities such as photodynamic therapy and argon plasma coagulation, and mechanical hemostasis with band ligation, endoscopic hemoclips, and over-the-scope clips. These approaches, albeit effective in achieving hemostasis, are associated with a 5-10% rebleeding risk. New simple, effective, universal, and safe methods are needed to address some of the challenges posed by the current endoscopic hemostatic techniques. The use of a novel hemostatic powder spray appears to be effective and safe in controlling upper and lower gastrointestinal bleeding. Although initial reports of hemostatic powder spray as an innovative approach to manage gastrointestinal bleeding are promising, further studies are needed to support and confirm its efficacy and safety. The aim of this study was to evaluate the technical feasibility, clinical efficacy, and safety of hemostatic powder spray (Hemospray, Cook Medical, Winston-Salem, North Carolina, USA) as a new method for managing gastrointestinal bleeding. In this review article, we performed an extensive literature search summarizing case reports and case series of Hemospray for the management of gastrointestinal bleeding. Indications, features, technique, deployment, success rate, complications, and limitations are discussed. The combined technical and clinical success rate of Hemospray was 88.5% (207/234) among the human subjects and 81.8% (9/11) among the porcine models studied. Rebleeding occurred within 72 hours post-treatment in 38 patients (38/234; 16.2%) and in three porcine models (3/11; 27.3%). No procedure-related adverse events were associated with the use of Hemospray. Hemospray appears to be a safe and effective approach in the management of gastrointestinal bleeding.

Self-Expanding Metal Stent (SEMS): an innovative rescue therapy for refractory acute variceal bleeding

BACKGROUND

Acute variceal bleeding (AVB) is a life-threatening complication of liver cirrhosis or less commonly splenic vein thrombosis. Pharmacological and endoscopic interventions are cornerstones in the management of variceal bleeding but may fail in 10 - 15 % of patients. Rescue therapy with balloon tamponade (BT) or transjugular intrahepatic portosystemic shunt (TIPS) may be required to control refractory acute variceal bleeding effectively but with some limitations. The self-expanding metal stent (SEMS) is a covered, removable tool that can be deployed in the lower esophagus under endoscopic guidance as a rescue therapy to achieve hemostasis for refractory AVB.

AIMS

To evaluate the technical feasibility, efficacy, and safety of SEMS as a rescue therapy for AVB.

METHODS

In this review article, we have performed an extensive literature search summarizing case reports and case series describing SEMS as a rescue therapy for AVB. Indications, features, technique, deployment, success rate, limitations, and complications are discussed.

RESULTS

At present, 103 cases have been described in the literature. Studies have reported 97.08 % technical success rates in deployment of SEMS. Most of the stents were intact for 4 - 14 days with no major complications reported. Stent extraction had a success rate of 100 %. Successful hemostasis was achieved in 96 % of cases with only 3.12 % found to have rebleeding after placement of SEMS. Stent migration, which was the most common complication, was observed in 21 % of patients.

CONCLUSION

SEMS is a safe and effective alternative approach as a rescue therapy for refractory AVB.

Acute liver function decompensation in a patient with sickle cell disease managed with exchange transfusion and endoscopic retrograde cholangiography

Sickle cell intrahepatic cholestasis is a relatively uncommon complication of homozygous sickle cell anemia, which may lead to acute hepatic failure and death. Treatment is mainly supportive, but exchange transfusion is used as salvage therapy in life threatening situations. We describe a case of a 16-year-old female with homozygous sickle cell anemia who presented to the emergency room with fatigue, malaise, dark urine, lower back pain, scleral icterus and jaundice. She was found to have marked hyperbilirubinemia, which persisted after exchange transfusion. Because of the concomitant presence of gallstones and choledocholithiasis, the patient underwent endoscopic ultrasound and laparoscopic cholecystectomy followed by endoscopic retrograde cholangiography and sphincterotomy.

Role of over the scope clips in the management of iatrogenic gastrointestinal perforations

Advances in endoscopic and surgical techniques have increased the frequency and complexity of these procedures and associated complications such as gastrointestinal perforation. With the advancements in the field of gastroenterology, the promising use of an over the scope clips (OTSC) has fulfilled the unmet need for a reliable endoscopic devise in approximation of gastrointestinal perforation. This novel approach has raised the level of confidence in endoscopist in dealing with this serious complication during endoscopy. Here we have shared our experience with OTSC to evaluate its efficacy and safety in managing iatrogenic gastrointestinal perforations during endoscopy.

Bowel preparation regimens for colon capsule endoscopy: a review

Colon capsule endoscopy (CCE) is being actively evaluated as an emerging complementary or alternative procedure for evaluation of the colon. The yield of CCE is significantly dependent on the quality of bowel preparation. In addition to achieving a stool-free colon the bowel preparation protocols need to decrease bubble effect and aid propulsion of the capsule. An extensive English literature search was done using PubMed with search terms of colon capsule endoscopy, PillCam and bowel preparation. Full-length articles which met the criteria were included for review. A total of 12 studies including 1149 patients were reviewed. There was significant variability in the type of bowel preparation regimens. Large-volume (3-4 liters) polyethylene glycol (PEG) was the most widely used laxative. Lower volumes of PEG showed comparable results but larger studies are needed to determine efficacy. Sodium phosphate was used as an effective booster in most studies. Magnesium citrate and ascorbic acid are emerging as promising boosters to replace sodium phosphate when it is contraindicated. The potential benefit of prokinetics needs further evaluation. Over the past decade there has been significant improvement in the bowel preparation regimens for CCE. Further experience and studies are likely to standardize the bowel preparation regimens before CCE is adopted into routine clinical practice.

Endoscopic ultrasound-guided hepatic and perihepatic abscess drainage: an evolving technique

Interventional radiology-guided percutaneous drainage of liver abscesses with concomitant use of antibiotics has been the conventional approach for the treatment of liver abscesses. Hepatic abscesses refractory or not amenable to percutaneous drainage have been treated with surgical drainage, either via laparoscopic or open laparotomy techniques. The aim of this review was to evaluate the technical feasibility and efficacy of endoscopic ultrasound (EUS)-guided drainage of liver abscesses. A literature review was performed to identify the studies describing the technique. In this review article we have summarized case series or reports describing EUS-guided liver abscess drainage. The indications, techniques, endoprostheses, limitations and complications reported are discussed. A total of seven cases have been described so far in the literature which included patients with failed conventional treatment modalities. The EUS-guided drainage technique involves puncturing the abscess using endosonography to gain access, passing a guidewire followed by tract dilation and placement of an endoprosthesis for drainage. Studies have reported 100% technical and clinical success rates in selected cases. No complications were reported. EUS-guided drainage of liver abscesses can be a safe and effective alternative approach in the management of liver abscesses in selected patients.

Barriers to screening colonoscopy in an urban population: a study to help focus further efforts to attain full compliance

BACKGROUND

Awareness of colorectal cancer and decision for colorectal cancer screening is influenced by multiple factors including ethnicity, level of education, and adherence to regular medical follow up.

OBJECTIVE

Our survey aimed at assessing barriers to colorectal cancer screening among urban population.

DESIGN

This study is a survey of the general population.

SETTING

This study was made at a local community in the downtown area of a metropolitan city.

PATIENTS/SUBJECTS

The study population for this survey included 2000 non-institutionalized residents from local community of Brooklyn downtown area of City of Brooklyn, NY, USA. All participants were 50 years or older.

INTERVENTION

No intervention was done.

MAIN OUTCOME MEASUREMENT

The survey questionnaire collected information about demographic, socioeconomic level, awareness of various cancers and their screening methods, and awareness of screening colonoscopy.

RESULTS

Colonoscopy was identified as the best screening test by 31 % of the subjects. Pain and discomfort was the major reason for not having a colonoscopy. The fear of a complication declined significantly after the first colonoscopy but fear of pain and discomfort increased. Difficulty with bowel preparation before a colonoscopy was a significant problem; it discouraged significant number of participants from having another colonoscopy.

LIMITATION

This study is limited by its small sample size.

CONCLUSION

Physician/family and peer influence seems important but influencing only a minority of subjects. Fear of complications should be allayed using accurate statistical information. Pain should be significantly diminished and/or eliminated during colonoscopy. Future research should focus to minimize complexity and discomfort associated with bowel preparation.

Multi-disciplinary approach for management of refractory benign occlusive esophageal strictures

BACKGROUND

Benign occlusive esophageal strictures create substantial morbidity and have poor surgical outcomes. Various endoscopic techniques have been described to manage these strictures. The challenge remains to maintain adequate long-term esophageal patency and to limit the need for serial endoscopic dilations. Little has been reported regarding the management of these benign occlusive strictures.

METHODS

We report a case series describing the management of technically challenging benign occlusive esophageal strictures. Three patients with occlusive esophageal strictures of differing etiologies were treated using a variety of endoscopic methodologies.

RESULTS

The first patient sustained a caustic oropharyngeal injury resulting in a proximal esophageal stricture which was treated by using a combined antegrade retrograde dilation (CARD) with argon plasma coagulation (APC) and needle knife dissection resulting in the successful recanalization and patency of his stricture. A second patient developed an esophageal stricture following radiotherapy, and was treated with a CARD procedure and serial balloon dilations in combination with APC to successfully achieve esophageal luminal patency. The final patient acquired an occlusive esophageal stricture after treatment for thyroid cancer which was treated with endoscopic needle knife dissection followed by serial balloon dilations to successfully manage this stricture.

CONCLUSIONS

Occlusive esophageal strictures pose a difficult challenge to gastroenterologists and little has been reported with regards to their endoscopic management. Using the CARD technique, needle knife dissection and APC, individually or in combination, luminal patency of occlusive esophageal strictures can be accomplished safely with good results.

The role of endoscopy in bariatrics: past, present, and future

The exponential increase in the rate of obesity and its associated co-morbidities has increased the demand for bariatric surgery. Over the past few decades, surgical weight reduction by gastric restriction, malabsorption, or a combination of both has been the preferred approach to achieve sustained weight loss in the morbidly obese. Although extremely effective, surgical procedures carry significant complications and risk with mortality rates of 1%. Because of the cost, surgical risk, and complications, there is a demand for less invasive procedures. Endoscopic approaches include placement of endoluminal space-occupying devices, stapling devices to reduce gastric volume, barrier devices to reduce small bowel absorptive area, and methods to regulate gastric emptying. Current and ongoing studies have delivered promising results across many aspects of endoscopic approaches. However, many technical obstacles still exist that have to be resolved with further research before endoscopic bariatrics can be widely deployed. At present the role of endoscopy is well established in preoperative evaluation as well as in recognition and management of many postoperative complications in bariatrics. In this article, we review the current and future endoscopic methods for weight reduction that are either in practice or in testing.

A colorimetric method for detection of K-ras codon 12 point mutations in DNA extracted from tissue and peripheral blood in pancreatic disorders

Molecular-based methods to monitor point mutations require special and expensive equipment unavailable in most hospitals. Colorimetric-based analysis is an ideal platform for K-ras codon 12 gene point mutations because it uses commonly found hospital equipment. The colorimetric assay is sensitive and specific, detecting mutated DNA levels as low as 1% in a wild-type background. Paired genomic DNA extracts of fixed tissue and cellular fractions of peripheral blood are more sensitive and accurate than unpaired samplings. This approach has the potential to improve K-ras point mutation scans as well as to detect micrometastases in circulating tumor cells.

Determination of differential activities of soluble and membrane-bound catechol-O-methyltransferase in tissues and erythrocytes

Catechol-O-methyltransferase (COMT) exists as two isoenzymes, a membrane-bound form (MB-COMT) and a soluble form (S-COMT), with different roles in the metabolism of catecholamines and other catechol compounds. This report documents an HPLC assay for separate estimation of S-COMT and MB-COMT activity and examines activities of the two isoenzymes among different rat tissues and in human and rat erythrocytes. Activities of MB-COMT and S-COMT varied widely among tissues. There were higher activities of S-COMT than MB-COMT in all tissues except the adrenal medulla where MB-COMT was the predominant isoenzyme, consistent with the importance of this tissue and MB-COMT for the O-methylation of catecholamines. MB-COMT and S-COMT in rat and human erythrocytes showed divergent levels and patterns of activity. The assay represents a rapid and accurate method for quantifying MB-COMT and S-COMT in various tissues and examining the relative roles of COMT isoenzymes in the metabolism of catechol compounds in health and disease.

Plasma metanephrines are markers of pheochromocytoma produced by catechol-O-methyltransferase within tumors

This study examined whether the high sensitivity of plasma free metanephrines for diagnosis of pheochromocytoma may result from production of free metanephrines within tumors. Presence in pheochromocytomas of catechol-O-methyltransferase (COMT), the enzyme responsible for conversion of catecholamines to metanephrines, was confirmed by Western blot analysis, enzyme assay, and immunohistochemistry. Western blot analysis and enzyme assay indicated that membrane-bound and not soluble COMT was the predominant form of the enzyme in pheochromocytoma. Immunohistochemistry revealed colocalization of COMT in the same chromaffin cells where catecholamines are translocated into storage vesicles by the vesicular monoamine transporter. Levels of free metanephrines in pheochromocytoma over 10,000 times higher than plasma concentrations in the same patients before removal of tumors indicated production of metanephrines within tumors. Comparisons of the production of metanephrines in patients with pheochromocytoma with production from catecholamines released or infused into the circulation indicated that more than 93% of the consistently elevated levels of circulating free metanephrines in patients with pheochromocytoma are derived from metabolism before and not after release of catecholamines into the circulation. The data indicate that the elevated plasma levels of free metanephrines in patients with pheochromocytoma are derived from catecholamines produced and metabolized within tumors. Some tumors do not secrete catecholamines, but all appear to metabolize catecholamines to free metanephrines, thus explaining the better sensitivity of plasma free metanephrines over other tests for diagnosis of pheochromocytoma.