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BACKGROUND: Esophageal capsule endoscopy (ECE) is an alternative to EGD for Barrett's esophagus screening. A multicenter study found ECE to be safe, well tolerated, and accurate; however, a post hoc adjudication process was used that may have biased results. OBJECTIVE: To assess the accuracy of ECE for the diagnosis of Barrett's esophagus. DESIGN: Prospective and blinded, with no adjudication. PATIENTS: Screening patients with chronic gastroesophageal reflux and surveillance patients with known Barrett's esophagus. INTERVENTIONS: ECE followed by EGD in each subject. MAIN OUTCOME MEASUREMENTS: Sensitivity, specificity, and positive and negative predictive values of ECE for Barrett's esophagus by using EGD results, with histologic confirmation as the criterion standard. RESULTS: Ninety-six subjects were enrolled, of whom 90 (94%) completed the study, including 66 screening and 24 surveillance patients. ECE was 67% sensitive and 84% specific for identifying Barrett's esophagus, diagnosing 14 of 21 cases of biopsy-confirmed Barrett's esophagus. Positive and negative predictive values were 22% and 98%, respectively (calculated for screening patients only). Sensitivity for short- and long-segment Barrett's esophagus was similar. CONCLUSIONS: Our blinded, unadjudicated study shows that ECE had only moderate sensitivity and specificity for identifying Barrett's esophagus. ECE in its present form is not suitable as a primary screening tool for Barrett's esophagus but may be used in patients unwilling to undergo EGD. Inadequate visualization of the gastroesophageal junction may be the cause of suboptimal ECE accuracy; this may be improved by advances in ingestion protocol and capsule calibration. [ABSTRACT FROM AUTHOR]

During endoscopy, simethicone defoaming agents are commonly used to improve visualization, but they leave residues and impact drying. This clinical trial involved patients undergoing colonoscopy procedures with substantial bubbles that impeded mucosal wall visibility. As an alternative to simethicone, investigators evaluated a water-soluble, ginger-based gastrointestinal supplement (GI-Ease) that did not contain sugars, thickeners, or binding agents. In 112/114 cases (98%), the bubbles were reduced sufficiently to allow visualization of the gastrointestinal tract, with no adverse events., (Copyright © 2023 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

Cholestatic liver diseases (CLDs) occur as a result of bile duct injury, emanating into duct obstruction and bile stasis. Advances in radiological imaging in the last decade has replaced endoscopic retrograde cholangiopancreatography (ERCP) as the first diagnostic tool, except in certain groups of patients, such as those with ischemic cholangiopathy (IsC) or early stages of primary sclerosing cholangitis (PSC). ERCP provides an opportunity for targeted tissue acquisition for histopathological evaluation and carries a diverse therapeutic profile to restore bile flow. The aim of this review article is to appraise the diagnostic and therapeutic roles of ERCP in CLDs., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: The Glasgow-Blatchford Bleeding Score (GBS) was designed to identify patients with upper gastrointestinal bleeding (UGIB) who do not require hospitalisation. It may also help stratify patients unlikely to benefit from intensive care., Design: We reviewed patients assigned a GBS in the emergency room (ER) via a semiautomated calculator. Patients with a score ≤7 (low risk) were directed to an unmonitored bed (UMB), while those with a score of ≥8 (high risk) were considered for MB placement. Conformity with guidelines and subsequent transfers to MB were reviewed, along with transfusion requirement, rebleeding, length of stay, need for intervention and death., Results: Over 34 months, 1037 patients received a GBS in the ER. 745 had an UGIB. 235 (32%) of these patients had a GBS ≤7. 29 (12%) low-risk patients were admitted to MBs. Four low-risk patients admitted to UMB required transfer to MB within the first 48 hours. Low-risk patients admitted to UMBs were no more likely to die, rebleed, need transfusion or require more endoscopic, radiographic or surgical procedures than those admitted to MBs. No low-risk patient died from GIB. Patients with GBS ≥8 were more likely to rebleed, require transfusion and interventions to control bleeding but not to die., Conclusion: A semiautomated GBS calculator can be incorporated into an ER workflow. Patients with a GBS ≤7 are unlikely to need MB care for UGIB. Further studies are warranted to determine an ideal scoring system for MB admission., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Aims: In a pilot study, we demonstrated that current guidelines for duodenoscope and linear echoendoscope (DLE) reprocessing using a single cycle of high-level disinfection (HLD) in an automated reprocessor may be inadequate. In August 2015, the U.S. Food and Drug Administration offered double HLD as a possible response to address this concern. As a result, Providence Health and Services adopted double HLD as standard procedure for DLEs, but no rigorous clinical studies supported this practice. We undertook a quality improvement study to compare single HLD versus double HLD at 4 of our 34 hospitals., Methods: HLD of DLE was randomized, separately in each facility, to either single HLD or double HLD on weekdays, with standard double HLD on weekends or holidays. There was 99.7% compliance with the randomization scheme. Daily qualitative surveillance cultures of dried, post-HLD DLEs were collected for 6 months (1 swab sample from the elevator mechanism and 1 combined brush sample from the suction and working channels for each encounter), and each sample was incubated for 48 hours. Positivity rates of any microbial growth and growth of high-concern pathogens (potentially pathogenic enteric flora) were compared between the 2 study arms., Results: Altogether, 5850 surveillance culture specimens were obtained during 2925 encounters from the 45 DLEs in clinical use in the participating hospitals. Of these, 3052 (52.2%) were from endoscopes cleaned by double HLD. Double HLD demonstrated no benefit over single HLD because similar positivity rates were observed (all P > .05). The elevator mechanism was more frequently colonized than the biopsy channel (5.2% vs 2.9%, P < .001). Among the 224 encounters with positive growth, 140 (62.5%) recovered microbes from only the elevator mechanism specimens, 73 (32.6%) recovered microbes from only the channel specimens, and 11 (4.9%) recovered microbes from both types of specimens. Double HLD failed to improve contamination rates for either sample site at any of the 4 endoscopy facilities, although there were significant overall differences in contamination rates among the facilities (P < .001), as observed in our previous study. Only 8 high-concern pathogens were recovered from 5 DLEs, all from the elevator mechanism. Persistent growth was observed on 2 duodenoscopes. One grew Enterococcus spp (not vancomycin-resistant enterococci) on 3 occasions, and Escherichia coli was present on 2 of these occasions, 1 of which was a multidrug-resistant organism. The other grew different enteric flora on 2 specimens., Conclusions: Our prospectively randomized study, involving 4 separate endoscopy facilities and standard automated endoscope reprocessing, showed that double HLD did not reduce culture positivity rates compared with single HLD in facilities with an already low positive culture rate. Alternative risk mitigation strategies will be assessed in an ongoing effort to reduce endoscope contamination., (Copyright © 2018 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background and Aims: To assess the adequacy of currently recommended duodenoscope and linear echoendoscope (DLE) automatic endoscope reprocessing (AER) and high-level disinfection (HLD), we collected daily post-reprocessing surveillance cultures of 106 DLEs in 21 Providence and Affiliate Hospitals., Methods: Daily qualitative surveillance of dried, post-HLD DLEs was conducted for a minimum of 30 days at each facility. Positivity rates for any microbial growth and growth of high-concern pathogens were reported. Potential effects of DLE manufacturer, age, and AER processor on culture-positivity rate were assessed., Results: Microbial growth was recovered from 201 of 4032 specimens (5%) or 189 of 2238 encounters (8.4%), including 23 specimens (.6%) or 21 encounters (.9%) for a high-concern pathogen. Wide variations in culture-positivity rate were observed across facilities. No striking difference in culture-positivity rate was seen among 8 DLE models, 3 DLE manufacturers, DLE age, manual or bedside cleanser, or automatic flushing system use. However, there was suggestive evidence that Custom Ultrasonics AER (Warminster, Pa, USA) had a lower culture-positivity rate than Medivators AER (Cantel Medical Corp., Little Falls, NJ, USA) for high-concern pathogen growth (0/1079 vs 21/2735 specimens or 0/547 vs 20/1582 encounters). Two endoscopes grew intestinal flora on several occasions despite multiple HLD. No multidrug-resistant organism was detected., Conclusions: In this multicenter DLE surveillance study, microbial growth was recovered in 5.0% of specimens (8.4% of encounters), with most being environmental microbes. Enteric bacterial flora was recovered in .6% of specimens (.9% of encounters), despite compliance with 2014 U.S. guidelines and manufacturers' recommendations for cleaning and HLD process. The observed better performance of Custom Ultrasonics AER deserves further investigation., (Copyright © 2016 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background: An external pancreatic fistula (EPF) generally results from an iatrogenic manipulation of a pancreatic fluid collection (PFC), such as walled-off pancreatic necrosis (WOPN). Severe necrotizing pancreatitis can lead to complete duct disruption, causing disconnected pancreatic duct syndrome (DPDS) with viable upstream pancreas draining out of a low-pressure fistula created surgically or by a percutaneous catheter. The EPF can persist for months to years, and distal pancreatectomy, often the only permanent solution, carries a high morbidity and defined mortality., Objective: To describe 3 endoscopic and percutaneous rendezvous techniques to completely resolve EPFs in the setting of DPDS., Design: A retrospective review of a prospective database of 15 patients who underwent rendezvous internalization of EPFs., Setting: Tertiary-care pancreatic referral center., Patients: Fifteen patients between October 2002 and October 2011 with EPFs in the setting of DPDS and resolved WOPN., Intervention: Three rendezvous techniques that combined endoscopic and percutaneous procedures to internalize EPFs by transgastric, transduodenal, or transpapillary methods., Main Outcome Measurements: EPF resolution and morbidity., Results: Fifteen patients (12 men) with a median age of 51 years (range 24-65 years) with EPFs and DPDS (cutoff/blowout of pancreatic duct, with inability to demonstrate upstream body/tail of pancreas on pancreatogram) resulting from severe necrotizing pancreatitis underwent 1 of 3 rendezvous procedures to eliminate the EPFs. All patients were either poor surgical candidates or refused surgery. At the time of the rendezvous procedure, WOPN had fully resolved, DPDS was confirmed on pancreatography, and the EPF had persisted for a median of 5 months (range 1-48 months), producing a median output of 200 mL/day (range 50-700 mL/day). The rendezvous technique in 10 patients used the existing percutaneous drainage fistula to puncture into the stomach/duodenum to deliver wires that were captured endoscopically. The transenteric fistula was dilated and two endoprostheses placed into the lesser sac. A second technique was used in 3 patients where EUS was used to avoid large varices and create a fistula to the percutaneous drainage catheter. Wires were delivered transenterally then grasped by an interventional radiologist. The new fistula was dilated, and, again, two endoprostheses were placed. Two patients underwent a rendezvous technique that resulted in transpapillary stents and removal of percutaneous catheters. The median duration to EPF closure was 7 days (range 1-73 days) during a median follow-up of 25 months (range 6-113 months). No EPF has recurred in any patient, although 3 symptomatic fluid collections have occurred. These collections have been successfully treated with combined percutaneous and endoscopic treatment or endoscopic treatment alone. One patient had postprocedural fever. There were no associated deaths., Limitations: Small, selected group of patients without a comparative group., Conclusion: The management of EPFs in the setting of DPDS is challenging but can be treated effectively by combined endoscopic and percutaneous rendezvous techniques. The rendezvous procedures were associated with minimal morbidity, no mortality, avoidance of surgery, and complete elimination of the EPFs., (Copyright © 2012. Published by Mosby, Inc.)

Background: Most outcomes data on pancreatic extracorporeal shock wave lithotripsy (P-ESWL) for chronic calcific pancreatitis (CCP) are based on studies with <4 years' follow-up, and U.S. long-term studies are lacking., Objective: To report long-term P-ESWL outcomes for CCP and to assess whether smoking or alcohol use influences P-ESWL outcomes., Design: Cross-sectional study, retrospective chart review., Setting: Virginia Mason Medical Center, Seattle, Washington., Patients: This study involved 120 patients who underwent P-ESWL and ERCP for CCP and completed an outcomes questionnaire., Intervention: P-ESWL and ERCP, outcomes survey., Main Outcome Measurements: Pain, quality of life, narcotics use, diabetes status, pancreatic enzyme requirement, repeat P-ESWL, repeat ERCP, surgery., Results: A total of 120 patients underwent P-ESWL followed by ERCP (mean ± standard deviation [SD] follow-up 4.3 [± 3.7] years) and completed a survey. The mean (± SD) before-P-ESWL pain score was 7.9 (± 2.6) compared with 2.9 (± 2.6) after P-ESWL (P < .001). Improved pain was reported by 102 patients (85%); 60 (50%) reported complete pain relief and no narcotic use. The mean (± SD) before-P-ESWL quality-of-life score was 3.7 (± 2.4) compared with 7.3 (± 2.7) after P-ESWL (P < .001). In patients with ≥ 4 years' follow-up, repeat procedures included P-ESWL (29%), ERCP (84%), and surgery (16%). Smokers who quit smoking after P-ESWL had improved narcotic requirements compared with those who continued smoking (95% vs 67%; P = .014), and a trend suggested a decreased need for repeat ERCPs (68% vs 84%; P = .071)., Limitations: Single center, retrospective, recall bias, nonvalidated pain and quality-of-life scales., Conclusion: P-ESWL as the initial therapy for CCP may lead to more lifetime procedures; however, partial pain relief in 85%, complete pain relief with no narcotic use in 50%, and avoidance of surgery in 84% of patients may be achieved. Quitting smoking after P-ESWL may improve outcomes., (Copyright © 2012 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Data on balloon enteroscopy-assisted ERCP (BEA-ERCP) versus laparoscopy-assisted ERCP (LA-ERCP) in post-Roux-en-Y gastric bypass (RYGB) patients are lacking., Objectives: To compare BEA-ERCP with LA-ERCP in post-RYGB patients and to identify factors that predict therapeutic success with BEA-ERCP., Design: Retrospective chart review., Setting: A single North American tertiary referral center., Patients: The review included 56 bariatric post-RYGB patients who underwent ERCP., Interventions: BEA-ERCP or LA-ERCP., Main Outcome Measurements: Cannulation rate, therapeutic success, hospital stay, complications, procedure duration, endoscopist time, and cost., Results: A total of 32 patients underwent BEA-ERCP, and 24 underwent LA-ERCP. LA-ERCP was superior to BEA-ERCP in papilla identification (100% vs 72%, P = .005), cannulation rate (100% vs 59%, P < .001), and therapeutic success (100% vs 59%, P < .001). The total procedure time was shorter (P < .001) and endoscopist time was longer (P = .006) for BEA-ERCP. There was no difference in postprocedure hospital stay (P = .127) or complication rate (P = .392) between the 2 groups. In the BEA-ERCP group, in patients having a Roux limb + biliopancreatic (from ligament of Treitz to jejunojejunal anastomosis), a limb length less than 150 cm was associated with therapeutic success. Starting with BEA-ERCP and continuing with LA-ERCP after a failed BEA-ERCP saved $1015 compared with starting with LA-ERCP., Limitations: Single center, retrospective study., Conclusions: In centers with expertise in deep enteroscopy and ERCP, post-RYGB patients with a Roux + ligament of Treitz to jejunojejunal anastomosis limb length less than 150 cm should first be offered deep enteroscopy-assisted ERCP. In patients with Roux + ligament of Treitz to jejunojejunal anastomosis (LTJJ) limb length 150 cm or longer, LA-ERCP should be the preferred approach because of the lack of need for a second procedure, equivalent morbidity and hospital stay, decreased endoscopist time, and decreased cost., (Copyright © 2012 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: There are limited data on the incidence of afferent limb syndrome and other delayed GI problems in pancreatic cancer (PaC) patients, especially among long-term survivors (>2 years)., Objective: To evaluate the incidence of afferent limb syndrome (chronic afferent limb obstruction resulting in pancreatobiliary obstruction) and delayed GI problems in PaC patients after pancreaticoduodenectomy (PD)., Design: Retrospective case series., Setting: Tertiary referral center., Patients: PaC patients treated with PD (N = 186) over a 14-year period (January 1995-October 2009)., Interventions: Endoscopic balloon dilation and stent placement, percutaneous biliary drainage., Main Outcome Measurements: Incidence of afferent limb syndrome and delayed GI complications (marginal ulcers, radiation enteropathy, anastomotic strictures)., Results: Mean age was 63 ± 10 years; 55% of patients were male. Afferent limb syndrome was noted in 24 patients (13%). Median time to diagnosis was 1.2 years (range 0.03-12.3 years); obstruction was primarily caused by recurrent PaC (8 patients, 33%) and radiation enteropathy (9 patients, 38%). Afferent limb syndrome was more likely to develop in patients with 2 years or longer of follow-up (n = 71, [38%]) compared with patients with 2 years or less of follow-up, after controlling for age, sex, surgery type, and adjuvant treatment (adjusted odds ratio, 4.5; 95% CI, 1.8-11.7). Other delayed GI problems included radiation enteropathy (6%), marginal ulcers (5%), anastomotic strictures (4%), cholangitis/liver abscesses (5%), and GI bleeding (6%)., Limitations: Retrospective, single-center study., Conclusions: GI problems, including afferent limb syndrome, are relatively common in PaC patients after surgery and adjuvant therapy. Clinicians should recognize and effectively treat these delayed GI problems, especially in long-term survivors., (Copyright © 2011 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: A redundant colon can lead to incomplete colonoscopy. A variety of tools and techniques are available to complete colonoscopy but have limitations., Objective: To determine the feasibility and safety of using a spiral overtube to complete a difficult colonoscopy., Design: Retrospective review of a prospectively collected database., Setting: Single tertiary institution., Patients: Twenty-four patients with incomplete colonoscopy because of redundant colons underwent 26 procedures. The median age was 68 years, and 58% were men., Interventions: All patients underwent colonoscopy performed with a 90-cm flexible threaded overtube and a variable-stiffness pediatric colonoscope. Four individuals (18%) required exchanging the colonoscope for an enteroscope., Main Outcome Measurements: Successful cecal intubation, polyp identification and removal, time to reach the cecum, sedation needed, and complications., Results: Cecal intubation was achieved in 22 patients (92%). Failures occurred in 2 patients with large hernias. The median time from insertion of the colonoscope to reaching the cecum was 14.5 minutes. All procedures were performed by using conscious sedation with midazolam (median dose 7 mg) and fentanyl (median dose 150 μg). Significant findings were encountered in 17 of 22 patients (77%) including 1 cancer and 2 advanced polyps. A median of 3 polyps was removed from each patient who had polyps. All noncancerous polyps were removed during the procedure. There were no complications., Limitations: Retrospective design, no control group, single center., Conclusion: Spiral overtube-assisted colonoscopy can enable cecal intubation in the majority of patients in whom standard colonoscopy fails because of a redundant colon., (Copyright © 2011. Published by Mosby, Inc.)

Background: Tumors arising from the duodenal papilla account for approximately 5% of GI neoplasms, but are increasingly identified., Objective: To describe the clinical characteristics and outcomes in a large single-center experience with patients referred for ampullary lesions., Design: A retrospective review of the Virginia Mason Medical Center endoscopy and hospital service database., Setting: Tertiary referral center., Patients: One hundred ninety-three patients referred for ampullary lesions from 1997 to 2007., Interventions: Endoscopic management of ampullary lesions., Main Outcome Measurements: The relationship of demographic and clinical data with endoscopic treatment and clinical outcomes in these patients., Results: One hundred ninety-three patients underwent endoscopy for ampullary lesions. Fifteen juxta-ampullary lesions and 10 normal variants were excluded. Among 168 patients, there were 112 (67%) adenomas, 38 (23%) adenocarcinomas, and 18 (10%) nonadenomatous lesions. There were 88 men and 80 women, with a mean age of 64 years. Clinical presentation included cholestasis/cholangitis (72 patients), abdominal pain (54 patients), incidental/asymptomatic (51 patients), pancreatitis (9 patients), and bleeding (7 patients). Of the 57 patients referred to surgery, 42 were sent directly without papillectomy, and 16 were sent after papillectomy. Papillectomies were performed in 102 patients with adenomatous lesions. The mean tumor size was 2.4 cm (range 0.5-6 cm). The papillectomy complication rate was 21%: mild pancreatitis in 10 (10%) patients, cholangitis in 1, retroperitoneal perforation in 1 (adenocarcinoma), intraperitoneal perforation in 1 (lateral extension), bleeding in 5 (lateral extension in 2 of these 5), and delayed papillary stenosis in 3. Recurrences were seen in 8%. The endoscopic success rate was 84%. Factors affecting success were a smaller adenoma size and the absence of dilated ducts., Conclusions: Most ampullary adenomas are amenable to endoscopy. Underlying malignancy and lateral extension may be risk factors for bleeding and perforation. Smaller lesion size and the absence of dilated ducts are factors favorably affecting success.

Objectives: We sought to test the hypothesis that placement of a new nitinol duodenal self-expandable metallic stent (SEMS) for palliation of malignant gastroduodenal obstruction is effective and safe in allowing patients to tolerate an oral diet., Methods: In a prospective multicenter study, SEMSs (Duodenal WallFlex, Boston Scientific) were placed to alleviate gastroduodenal obstruction in inoperable patients without the ability to tolerate solid food. The primary study end point was improvement in oral intake monitored according to the 4-point Gastric Outlet Obstruction Scoring System (GOOSS) up to 24 weeks after stent placement., Results: Forty-three patients received SEMSs, which were successfully deployed on the first attempt in 41 cases (95%) and the second attempt in two (5%). Within 1 day and 7 days after SEMS placement, 52% and 75% of patients, respectively, benefited from a GOOSS increase > or =1. Resumption of solid food intake (GOOSS 2-3) was attained by 56% of patients within 7 days and 80% by 28 days. Of the patients attaining GOOSS 2-3, 48% remained on solid food until death or last follow-up. Device-related adverse events included stent occlusion/malfunction in 9% of patients and perforation in 5% of patients., Conclusions: Duodenal WallFlex stent placement promptly improves oral intake in a majority of inoperable patients with malignant gastroduodenal obstruction. In approximately half the patients achieving GOOSS 2-3, the capacity for solid food intake endures until death or last follow-up.

Background: Pancreatic duct stents are used for a variety of endoscopic pancreatic manipulations, and small surgical stents are used prophylactically to bridge pancreatic-enteric anastomoses. With increasing use of pancreatic stents, many complications have been recognized., Objective: To determine the complications and outcomes of pancreatic stent migration., Design: Case series from a retrospective review of all cases of upstream or proximally migrated pancreatic duct stents, placed either endoscopically or surgically, identified between 2000 and 2007., Setting: Tertiary referral center., Patients: This study involved 33 patients; 23 postendoscopic and 10 postsurgical stents., Main Outcome Measurements: Retrieval rates, minor/major complications., Results: Endoscopic stents had a successful retrieval rate of 78%. Most patients were asymptomatic. The most common procedure was balloon extraction (8 of 18; 44%). Nine patients required multiple procedures (3 patients, 2 attempts; 5 patients, 3 attempts; 1 patient, 4 attempts). Five stents could not be retrieved. Of these, 4 were associated with downstream stenosis. Four patients underwent surgery, and 1 patient was treated with observation. Complications included pancreatic duct disruption (1 of 23), stent fragmentation (1 of 23), and postprocedure pancreatitis (1 of 23). Surgically placed stents had a successful retrieval rate of 80%. Most surgical stents had migrated into the biliary tree (8 of 10). All of these patients were symptomatic with pain or fever. Two stents could not be retrieved; 1 of those patients underwent surgery., Limitation: Retrospective study., Conclusion: The majority of upstream-migrated stents can be endoscopically removed. Despite manipulation of the pancreatic duct, pancreatitis was infrequent. Surgically placed pancreatic stents migrate downstream and into the open biliary anastomosis and are associated with pain, cholangitis, or liver abscesses.

Background: Capsule impaction is a well-recognized complication of capsule endoscopy, with an incidence rate of 0.75% to 21%, depending on indication. There have been only 2 reported cases of capsule impaction causing symptomatic obstruction., Objective: We present 3 cases of capsule impaction causing acute symptomatic obstruction and/or perforation., Design: Case series., Setting: Teaching hospital., Patients: A 71-year-old woman had iron deficiency anemia in the setting of negative upper endoscopy, colonoscopy, enteroclysis, and enteroscopy. She developed severe abdominal pain, vomiting, and leukocytosis 20 hours after capsule ingestion. Emergent surgery was performed to remove the capsule, which was impacted at a previously undiagnosed ileal Crohn's stricture leading to perforation. A 64-year-old woman with Gardner's syndrome and a history of colectomy and subsequent episodes of small bowel obstruction underwent capsule endoscopy to define the site of obstruction. She experienced severe abdominal pain 24 hours after capsule ingestion, and emergent enteroscopy was done to retrieve the capsule, which was impacted at a previously undiagnosed annular mass in the distal duodenum. An 85-year-old man with episodic small bowel obstruction due to radiation enteritis underwent capsule endoscopy to localize the site of obstruction in anticipation of surgery. He returned with severe abdominal pain and vomiting 3 days later. At surgery, the capsule was found to be impacted at an ileal radiation stricture., Main Outcome Measurements: Acute symptomatic bowel obstruction., Results: These cases show that bowel obstruction and even possibly perforation can occur as a result of capsule impaction., Conclusions: The possibility of acute symptomatic small bowel obstruction should be included in the informed consent for capsule endoscopy.

Background: Self-expandable metal stents (SEMS) are being increasingly used to palliate malignant stenoses of the gastric outlet and proximal small bowel. Accordingly, we reviewed our experience in this setting., Methods: Patients with gastric outlet or proximal small bowel stents were identified by reviewing hospital charts. Outcome criteria included survival data, need for reintervention, and clinical improvement., Results: A total of 52 SEMS were placed in 36 patients with nonesophageal upper GI stenosis. Initial stent placement was successful in 92% and clinical improvement documented in 75%. Mean survival of patients who eventually died was 3.5 months. Seven patients are alive (mean follow-up, 5.0 months). Stent dysfunction occurred in 36% and required subsequent interventions. Biliary obstruction was documented in 50% of patients, 12 of whom had previously undergone biliary stenting and 5 who needed subsequent biliary decompression., Conclusions: Enteral stent placement has been reported to be an effective alternative for palliation of high-risk surgical patients with malignant gastric outlet and small bowel obstruction. Considering the short life expectancy of these patients and significant complications including stent migration, perforation, biliary obstruction, and need for subsequent endoscopic, radiologic and surgical interventions, the authors suggest that this procedure be performed in experienced centers on selected patients only and that biliary decompression be ensured early.

Background: The self-expandable metallic stent is of proven benefit in patients with malignant disease; however, its use in patients with benign disease is not well established. There are few data available regarding long-term complications and outcomes with use of self-expandable metallic stents in benign disease and virtually none regarding attempted removal once the acute problem is resolved., Methods: Thirteen patients who had a self-expandable metallic stent placed for benign GI disorders were included in a retrospective analysis. Data collected included patient demographics, indication for procedure, type of stent used, complications, and patient outcomes., Results: Thirteen patients (7 women, 6 men; mean age 67 years, range 34-84 years) had one or more self-expandable metallic stents placed for benign disease and were followed for a mean of 3.4 years (3 weeks to 10 years). Of the 13 patients, 8 had esophageal stents, 4 biliary stents, and 1 had dual stents placed in the pancreaticobiliary tree. Complications developed in 8 (62%) patients; 4 (31%) ultimately died, either from the primary disease process (3) or from stent-related complications (1)., Conclusions: Self-expandable metallic stent placement is effective treatment for benign esophageal leaks, providing the stent can be removed. It also may be used in either the esophagus or biliary tree in patients who are poor candidates for surgery and short expected survival. However, a self-expandable metallic stent should not be placed in a patient with a benign GI disorder who has a significant life expectancy and is a good candidate for surgery.

Background: There is controversy as to whether extracorporeal shock wave lithotripsy fragmentation and ERCP retrieval of pancreatic stones are associated with relief of chronic pain or relapsing attacks of pancreatitis. Our most recent experience with this technology is reviewed., Methods: Forty patients with chronic calcific pancreatitis who required extracorporeal shock wave lithotripsy between 1995 and 2000 to facilitate pancreatic duct stone removal were retrospectively reviewed. Data collected included patient presentation, number of lithotripsy and ERCP sessions required, complications, and outcomes measures to include pre- and post-ESWL pain scale, monthly oxycodone (5 mg)-equivalent pills ingested, yearly hospitalizations, and need for subsequent surgery., Results: A single extracorporeal shock wave lithotripsy session was required for 35 patients who underwent a total of 86 ERCPs to achieve complete stone extraction from the main pancreatic duct. Minor complications occurred in 20%. There was one episode of pancreatic sepsis that was treated with antibiotics and removal of an occluded pancreatic prosthesis. At a mean [SD] follow-up of 2.4 (0.6) years, 80% of patients had avoided surgery and there was a statistically significant decrease in pain scores (6.9 [1.3] vs. 2.9 [1.1]; p = 0.001), yearly hospitalizations for pancreatitis (3.9 [1.9] vs. 0.9 [0.9]; p = 0.001), and oxycodone-equivalent narcotic medication ingested monthly (125 [83] vs. 81 [80]; p = 0.03)., Conclusions: Extracorporeal shock wave lithotripsy fragmentation of pancreatic duct calculi in conjunction with endoscopic clearance of the main pancreatic duct is associated with significant improvement in clinical outcomes in most patients with chronic pancreatitis.

Background: Recent studies have indicated that reusable biopsy forceps remain contaminated after reprocessing and can only be used a mean of 12 to 25 times without malfunction. Because this contradicts traditional endoscopic practice, our study investigated the ability to sterilize a type of commercially available biopsy forceps and prospectively evaluated their function in vivo until malfunction and/or breakage., Methods: Thirty reusable biopsy forceps were studied, 15 of which were contaminated for 5 trials each with 10(6) Bacillus stearothermophilus, and 15 of which were prospectively evaluated clinically over an 18-month period (9/98-3/00). Contaminated forceps were reprocessed by using a standard protocol and placed in a sterile bag containing soy broth. The latter was passed through a 0.2 micron filter and was subsequently cultured. In vivo data included biopsy site, size, adequacy, problems obtaining a biopsy specimen, and reasons for ultimate forceps failure., Results: After contamination, all biopsy forceps yielded a heavy growth of B stearothermophilus. No forceps, including 5 that were piecemeal dismantled with a wire cutter, had residual bacteria after reprocessing. In the in vivo study, 1507 biopsy sessions were undertaken in 1339 procedures. Forceps were categorized as new or like-new in 1259 of 1339 (94%) procedures, some loss of function but usable in 72 of 1339 (5.4%), and inadequate function or broken at use in 8 of 1339 (0.6%). Histologically, 1501 specimen sets were adequate (99.6%) and mean specimen size was 2.7 +/- 0.1 mm. Mechanical problems were noted in only 38 of 1507 (3%) sessions to include such things as sticky forceps, and the mean number of uses to malfunction or breakage was 91 +/- 15 (SEM) (range 19-132)., Conclusions: This reusable biopsy forceps can be sterilized and used a mean of 91 times with adequate tissue sampling. Mechanical problems were minor to time of breakage. Contingent on acquisition and reprocessing costs as well as the number of procedures performed, this reusable forceps has the potential for significant cost savings.

Background and Study Aims: Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) has been deemed to be a "cost-prohibitive" procedure, based upon the cumulative costs of one-time-use accessories and current reimbursement plans. One-time-use sphincterotomes comprise a significant component of that cost and, accordingly, we evaluated the disability and clinical usefulness of a recently introduced reusable double-channel sphincterotome., Materials and Methods: We studied a reusable 6-Fr sphincterotome at baseline and following contamination with 10(6) Bacillus stearothermophilus. Reprocessing included a unique 30-minute ultrasonic cleaning step in lieu of manual cleaning, followed by steam sterilization. Parameters evaluated included sphincterotome function, electrical integrity, and our ability to sterilize the devices for three in vitro trials. In vivo studies included patient demographics and outcomes, procedural findings, and success rates, and the mean number of times the sphincterotome was used, functional grading at time of use, and reasons for sphincterotome malfunction., Results: Ten out of ten sphincterotomes maintained form, function, and electrical integrity in vitro, and all cultures were negative after sterilization. In the initial in vivo study, ten sphincterotomes were used in 50 patients (mean, 5 uses) with a 94% success rate. Reasons for sphincterotome failure included leak or breakage of the accessory port in 70%, wire fracture in 10%, incorrect wire bow in 10%, and clogged injection port in 10%. Following reconfiguration of the insertion-port polymer, an additional ten sphincterotomes were used in 110 patients (mean, 11 uses). Mechanical failure occurred primarily at the wire-insertion port, resulting in progressive friction with reuse. There were neither electrical nor infectious complications associated with reuse., Conclusions: A reusable double-channel sphincterotome is available which can theoretically be reprocessed and sterilized without the manual cleaning step of the reprocessing process. Contingent upon both provider and patient, multiple reuse can be anticipated, and contingent upon purchase price and reprocessing costs, the potential for procedural cost savings is significant.

Background: To date, one reusable, double-channel sphincterotome has been approved by the Food and Drug Administration in the United States. Whether this device can be reprocessed easily and whether it is more durable than currently manufactured disposable sphincterotomes are uncertain., Methods: Thirty double-channel, 20 mm, braided-wire sphincterotomes approved for multiple uses were studied in vitro/in vivo with regard to durability and sterilization. A cost analysis of reusable, disposable, and reprocessed disposable sphincterotomes was also carried out., Results: Three of 10 sphincterotomes evaluated in vitro broke after 3, 4, and 8 uses. Electrical integrity was preserved after 10 uses in the remaining sphincterotomes. Nine sphincterotomes remained functional for at least 3 uses, five for 6 uses, and one for 10 uses. Culture results after inoculation demonstrated contamination with surviving organisms after manual cleaning and no growth after ethylene oxide sterilization. Sixty-one procedures were performed in vivo using 20 sphincterotomes (mean number of uses 3.1). No evidence of procedurally related infection occurred with reuse. Cost per use of this reusable sphincterotome was calculated to be $62.98; it became cost effective after 2.2 and 7.9 uses when compared with disposable and reprocessed, disposable sphincterotomes, respectively., Conclusions: This reusable sphincterotome proved to be safe, easily sterilized, and electrically intact after repeated use. In vivo, however, a progressive loss of function limited the mean number of uses to 3.1. In settings that preclude reuse of reprocessed disposable accessories, this reusable sphincterotome may provide a means to decrease costs associated with endoscopic retrograde cholangiopancreatography.

Background: Although previous studies have documented that single-channel sphincterotomes can be sterilized and used up to 10 times, no studies have prospectively evaluated the reuse of disposable sphincterotomes., Methods: Five- and six-French double-channel sphincterotomes marketed as one-time-use only were manually cleaned, sterilized with ethylene oxide, and used up to 10 times. Over a 1-year period, total number of uses as a cannulation or cutting device, reason for sphincterotome dysfunction, possible infectious complications were evaluated, and cost-savings associated with reuse were evaluated., Results: The mean number of times sphincterotomes could be used in our institution was 3.4; a broken or stiff cutting wire was the main reason for discard. There were two infectious complications during the study period. Both were experienced by patients with unrelieved obstruction treated with new sphincterotomes. Contingent on the method used, total savings related to sphincterotome reuse was approximately $66,000., Conclusions: Double-channel sphincterotomes marketed as one-time-use items can be reused safely when properly cleaned. Reuse was associated with significant cost savings in our institution.

Objectives: Expandable metallic prostheses have been used widely for malignant biliary stenoses and are being used increasingly for malignant dysphagia and esophago-airway fistulas. Potentially, such prostheses can be placed for gut neoplasms obstructing beyond the esophagus or gastric cardia. This series reports our experience with expandable metallic stents in the stomach, jejunum, and colon., Methods: All patients with expandable gastrointestinal stents (other than biliary tree or esophagus) were reviewed. Indications for stent placement, type and location of prosthesis, patient demographics, procedural problems, and data with regard to outcome were defined., Results: Over a 6-yr period, expandable prostheses (Z stent, Esophacoil, and Ultraflex) were placed in nine patients with widespread malignancy (afferent loop obstruction, three; colon obstruction, three; gastric outlet obstruction, two; and esophagojejunal interposition stricture, one). There was one colon perforation as a consequence of dilation prior to placement of the prosthesis. Subsequent problems included migration (one), occlusion by food bolus (one), and tumor overgrowths/ingrowths (three) which were treated with laser. Median survival approximated 9 months., Conclusions: Expandable metallic prostheses have the potential to palliate malignant gastrointestinal stenoses that have traditionally been treated with surgical bypass or comfort care measures only.

Background: Although expandable esophageal endoprostheses may be easier to insert and are associated with fewer procedure-related perforations, data comparing clinical results with these stents to those obtained with conventional prostheses are sparse., Methods: We reviewed the records of all patients undergoing esophageal stent placement at our institution between October 1983 and July 1995 to define relative risks, clinical results, and need for reintervention prior to death, contrasting conventional to a variety of expandable esophageal endoprostheses., Results: Over the period of review, 47 patients had conventional prostheses (CP) and 38 had expandable prostheses (EP) placed. Fifteen of 44 patients with CP and 14 of 38 with EP for malignancy also had esophago-airway fistulas. Insertion complications, prestent and poststent dysphagia scores, and complete fistula occlusion rates were comparable. Subacute complications were higher in the patients receiving EP (80%) than in those receiving CP (60%), possibly related to the prospective accumulation of data in patients receiving EP. Survival data were virtually identical and approximated 3 months for either group., Conclusions: Although both CP and EP improve dysphagia and occlude tracheoesophageal fistulae, patients ill enough to require a prosthesis do poorly regardless of prosthesis design. Moreover, although EP may be easier to insert than CP, stent- and patient-related problems persist and may require additional intervention.

Pancreas divisum has been claimed to be a harmless congenital variant or to occasionally cause acute relapsing pancreatitis (ARP), chronic pancreatitis (CP), or a chronic abdominal pain (CAP) syndrome. Both surgical and endoscopic approaches to accessory papilla decompression have been promulgated and widely disparate results reported in the literature. We retrospectively reviewed a five-year experience with dorsal pancreatic duct decompression at our institution utilizing a variety of endotherapeutic techniques. Data collected included procedural complications; patient interpretation of pre- and posttherapy pain, frequency, and intensity graded on an analog pain scale; frequency of hospitalization; and patient perception of "global" improvement to endotherapy. At a mean follow-up of 20 months, there was a statistically significant decrease in pancreatitis incidence in 15 patients with ARP (P = 0.016) and 19 patients with CP (P = 0.025). The frequency and intensity of chronic pain was also significantly improved (P < 0.001) in the latter group. In contrast, only one of five patients with CAP and normal dorsal pancreatography and secretin tests experienced global improvement, and there was no improvement utilizing an analog pain scale (P = 0.262) in the group as a whole. There was a 20% incidence of mild procedure or subsequent stent-related pancreatitis and an 11.5% accessory papilla restenosis rate. It is concluded that a subset of carefully selected patients with pancreas divisum may respond to endotherapy but that long-term follow-up will be required to define its ultimate place in the management of symptomatic patients with this anomaly.

Maxims for safe esophageal dilation have included recommendations to use fluoroscopy in all instances and to limit dilation sessions to 2-mm increments. We reviewed a 34-month experience of all esophageal dilations undertaken at a large multispecialty clinic to define adherence to these recommendations and to delineate whether deviation was associated with significant complications. Four hundred thirty-two patients underwent 716 courses of esophageal dilation during this time, 92% of whom had benign disease. Eighty-nine percent of patients were dilated with polyvinyl dilators (Savary/American) and only 8% of these patients required fluoroscopic monitoring for the bougienage. Seventy-eight percent of the dilating sessions for patients without achalasia were undertaken using either a single large dilator (> or = 45 Fr) or employed incremental dilator sizes > 2 mm (6 Fr) in a single session. There was a single perforation in 662 nonachalasia dilations and this was a consequence of attempted placement of an esophageal endoprosthesis. We conclude that use of guide wire technology and newer dilating techniques do away with the need for routine fluoroscopic control. Moreover, single large dilators or dilator increments > 2 mm may be safely used, contingent on endoscopic stricture assessment.

Background: Cystic duct leak (CDL) appears to complicate laparoscopic cholecystectomy (LC) more often than open cholecystectomy (OC). No mention of CDL was found in a literature review that covered 48,822 OCs and their complications., Patients and Methods: Fifty-four patients who developed biliary tract injuries following LC were reviewed for: the time from LC to presentation, presenting symptoms, method of diagnosis, treatment, outcome, and follow-up., Results: Seventeen of 54 biliary tract complications (31%) were CDLs. The CDLs presented at a median of 4 days after LC with pain (76%) and nausea and/or vomiting (35%). Endoscopic retrograde cholangiopancreatography (ERCP) defined the diagnosis and the anatomy of the leak in 11 patients (65%). Biliary endoprosthesis placement was employed in 8 patients, with concomitant sphincterotomy in 5 (63%), and resolved CDL in every case. Seven (88%) of these patients were asymptomatic at a median interval of 10 months after stent retrieval. Six patients (35%) underwent reoperation. Five had laparotomy with ligation of the cystic duct stump and 1 underwent laparoscopic examination with reclipping of the cystic duct stump. Five (83%) were asymptomatic at a median follow-up of 26 months. CDLs may result from inaccurate clip placement, perforations proximal to the clips, and stump necrosis, as documented at reoperation., Conclusions: CDLs occur more frequently in LC than in the OCs reported in the literature. Most leaks require intervention. ERCP with stent placement is the diagnostic and therapeutic procedure of choice and has a high success rate of resolving leaks. To forestall CDLs, it is important to place clips accurately and avoid electrocautery in the vicinity of the cystic duct.

Fifty-six patients, 54 of whom had chronic pancreatitis, underwent endoscopic pancreatic duct sphincterotomy during a 4-year period from 1988 to 1992. Acute complications noted in 10% of patients included exacerbation of pancreatitis (4) and cholangitis (2). Chronic complications included induction of asymptomatic ductal changes in 16%, thought to be related to endoprosthesis placement, and stenosis of the sphincterotomy site in 14%, requiring repeated endoscopic or surgical sphincter section. When combined with a number of ancillary procedures, including removal of obstructing ductal calculi and stent placement for ductal disruption or stenosis, pancreatic duct sphincterotomy was associated with amelioration of chronic pain or decreased number of clinical attacks of pancreatitis in a subset of patients. The authors conclude that endoscopic pancreatic duct sphincterotomy enlarges our endotherapeutic armamentarium and deserves additional evaluation.

During a 2-year period in which the application of laparoscopic cholecystectomy became widespread in the Pacific Northwest, 33 patients with surgically related bile duct injury were seen by the gastroenterology section of a large multi-specialty clinic. Twenty-nine of these patients had anatomy amenable to endoscopic approach, and 25 of the 29 are symptom-free, with normal ultrasonography and serum liver function tests, at a minimum of 1 year of follow-up after undergoing a variety of endotherapeutic procedures. The authors conclude that endoscopic therapy, in conjunction with percutaneous drainage of large bilomas, is effective treatment for cystic duct leak and minor damage to the common bile duct. Further data and prolonged follow-up are required in patients with more significant biliary injury who undergo endoscopic endoprosthesis and/or dilation therapy.

Procedural (room fee) reimbursement from insurance payers is usually fixed for individual endoscopic procedures and may not include the costs of disposable equipment. This study estimated costs of disposable items used in ERCP procedures and calculated the percentage of total reimbursement spent on such equipment. A total of 248 ERCPs were performed in a 5-month study period, 192 (77%) of which were therapeutic. Total reimbursement was estimated to be $112,262 ($452 per procedure) and total disposable equipment costs were $47,195 ($190 per procedure), or 42% of total reimbursement. Disposable instrument costs in diagnostic ERCP approximated 13% of those associated with therapeutic ERCP, and the latter costs in turn utilized more than 60% of Medicare/Medicaid room fee reimbursement. This reimbursement may be inadequate to cover both disposable instrument costs and other procedural expenses, such as admit-recovery costs, nursing assistance, expenses related to endoscope purchase and capitalization, and equipment cleaning or sterilization. Our data suggest the need for either re-usable endoscopic accessories or adequate compensation to cover disposable instrument costs.

Laparoscopic cholecystectomy has quickly eclipsed open cholecystectomy as the standard approach to symptomatic gallstones and acalculous biliary disease. Procedure-related morbidity and mortality continue to be defined, but a higher incidence of bile duct injuries has been reported to date using present technology and procedure. Key principles in the management of these problems include definition of the anatomy, relief of any impedance to biliary-enteric flow, and drainage of significant extrahepatic fluid collections. A cooperative, multispecialty approach involving surgeons, radiologists, and gastroenterologists is critical to successful outcomes. Future studies will help streamline the management of bile duct injuries and aid physicians in their selection of the best approach for each individual patient.

We assessed the use of endoscopic retrograde cholangiopancreatography (ERCP) after laparoscopic cholecystectomy (LC) at our hepatobiliary referral center. This assessment included patients from outside institutions with post-LC problems. Between May 1990 and September 1992, we performed 522 LCs and 1,723 ERCP examinations. There were 78 patients who underwent 143 ERCP examinations after LC, 65% of whom were referred. ERCP findings were categorized as follows: normal results (8%), problems inherent to stone disease (65%), and iatrogenic injury (27%). The types of inherent problems were common bile duct (CBD) stones, pancreatitis, and papillary stenosis/microlithiasis. Within the CBD stone group, 5 of 26 patients also had papillary stenosis, and, within the pancreatitis group, 9 of 11 patients also had papillary stenosis, making papillary stenosis the most frequent observation (55%). Almost all of these patients (96%) required endoscopic papillotomy for successful treatment. The iatrogenic injury group was comprised of 21 patients, 16% of whom had cystic duct leak and 84% of whom had CBD injury. These patients required a variety of endoscopic procedures including endoscopic papillotomy (67%), CBD endoscopic stenting (76%), percutaneous drainage of biloma (29%), and percutaneous transhepatic biliary drainage (24%). Open surgical procedures after endoscopic assessment or treatment were required in only three patients in the iatrogenic group and in none in the inherent group. At this time, long-term follow-up is not possible with regard to biliary stricture. We conclude that the majority of problems after LC are either due to papillary stenosis/microlithiasis with or without CBD stones or to biliary injury. Both can be successfully diagnosed and treated with endoscopic techniques.

Pancreatic carcinoma is complicated by malignant obstructive jaundice in 40-70% of cases. Patients frequently are old, debilitated, unresectable, and faced with a dismal prognosis. Invasive endoscopic and radiologic procedures in the inoperable patient can provide palliation without the need for surgery, in most cases. Few studies have compared nonoperative palliation with conventional surgical biliary enteric bypass procedures. In a retrospective study of patients with pancreatic carcinoma, we found no difference between operative and nonoperative treatment in survival, total hospitalization, or morbidity and mortality. Cost analysis revealed significant savings with nonoperative treatment.