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Background Obesity is a significant health problem and additional therapies are needed to improve obesity treatment. Objective Determine the efficacy and safety of a 6-month swallowable gas-filled intragastric balloon system for weight loss. Setting Fifteen academic and private practice centers in the United States. Methods This was a double-blind, randomized sham-controlled trial of the swallowable gas-filled intragastric balloon system plus lifestyle therapy compared with lifestyle therapy alone for weight loss at 6 months in participants aged 22 to 60 years with body mass index 30 to 40 kg/m2, across 15 sites in the United States. The following endpoints were included: difference in percent total weight loss in treatment group versus control group was >2.1%, and a responder rate of >35% in the treatment group. Results Three hundred eighty-seven patients swallowed at least 1 capsule. Of participants, 93.3% completed all 24 weeks of blinded study testing. Nonserious adverse events occurred in 91.1% of patients, but only .4% were severe. One bleeding ulcer and 1 balloon deflation occurred. In analysis of patients who completed treatment, the treatment and control groups achieved 7.1 ± 5.0% and 3.6 ± 5.1% total weight loss, respectively, and a mean difference of 3.5% (P = .0085). Total weight loss in treatment and control groups were 7.1 ± 5.3 and 3.6 ± 5.1 kg (P Conclusions Treatment with lifestyle therapy and the 6-month swallowable gas-filled intragastric balloon system was safe and resulted in twice as much weight loss compared with a sham control, with high weight loss maintenance at 48 weeks.

Contains fulltext : 215317.pdf (Publisher’s version ) (Closed access) OBJECTIVES: In patients with acute recurrent pancreatitis (ARP), pancreas divisum, and no other etiologic factors, endoscopic retrograde cholangiopancreatography (ERCP) with minor papilla endoscopic sphincterotomy (miES) is often performed to enlarge the minor papillary orifice, based on limited data. The aims of this study are to describe the rationale and methodology of a sham-controlled clinical trial designed to test the hypothesis that miES reduces the risk of acute pancreatitis. METHODS: The SpHincterotomy for Acute Recurrent Pancreatitis (SHARP) trial is a multicenter, international, sham-controlled, randomized trial comparing endoscopic ultrasound + ERCP with miES versus endoscopic ultrasound + sham for the management of ARP. A total of 234 consented patients having 2 or more discrete episodes of acute pancreatitis, pancreas divisum confirmed by magnetic resonance cholangiopancreatography, and no other clear etiology for acute pancreatitis will be randomized. Both cohorts will be followed for a minimum of 6 months and a maximum of 48 months. RESULTS: The trial is powered to detect a 33% risk reduction of acute pancreatitis frequency. CONCLUSIONS: The SHARP trial will determine whether ERCP with miES benefits patients with idiopathic ARP and pancreas divisum. Trial planning has informed the importance of blinded outcome assessors and long-term follow-up.

The American Society for Gastrointestinal Endoscopy (ASGE), as well as a number of federal agencies and medical societies, recognizes obesity as a disease requiring primary therapy. In 2011, the ASGE and the American Society for Metabolic and Bariatric Surgery (ASMBS) jointly published a white paper with the intent of providing a pathway for bringing endoscopic bariatric therapy (EBT) to clinical practice and Preservation and Incorporation of Valuable Endoscopic Innovations thresholds for safety and efficacy. As multiple EBTs are on the verge of being approved for clinical use, this position statement addresses the ASGE position on the role of the endoscopist in the primary treatment and bridge treatment of obesity with EBT. The prevalence of obesity (body mass index [BMI] of 30 kg/m) in adults in the United States remains high at 35%. Although the total number of U.S. adults with a BMI of 30 kg/m has remained stable since 2003, the prevalence of adults with a BMI >40 kg/m increased 70% between 2000 and 2010. This is of particular concern due to the positive correlation between increasing BMI above >30 kg/m with rates of obesityrelated comorbidities and mortality. The estimated cost associated with treating obesity and directly attributable

BACKGROUND Endoscopic mucosal resection (EMR) for small (

There are limited data comparing imaging modalities in the diagnosis of pancreas divisum. We aimed to: (1) evaluate the sensitivity of endoscopic ultrasound (EUS), magnetic resonance cholangiopancreatography (MRCP), and multidetector computed tomography (MDCT) for pancreas divisum; and (2) assess interobserver agreement (IOA) among expert radiologists for detecting pancreas divisum on MDCT and MRCP.For this retrospective cohort study, we identified 45 consecutive patients with pancreaticobiliary symptoms and pancreas divisum established by endoscopic retrograde pancreatography who underwent EUS and cross-sectional imaging. The control group was composed of patients without pancreas divisum who underwent endoscopic retrograde pancreatography and cross-sectional imaging.The sensitivity of EUS for pancreas divisum was 86.7%, significantly higher than the sensitivity reported in the medical records for MDCT (15.5%) or MRCP (60%) (P0.001 for each). On review by expert radiologists, the sensitivity of MDCT increased to 83.3% in cases where the pancreatic duct was visualized, with fair IOA (κ = 0.34). Expert review of MRCPs did not identify any additional cases of pancreas divisum; IOA was moderate (κ = 0.43).Endoscopic ultrasound is a sensitive test for diagnosing pancreas divisum and is superior to MDCT and MRCP. Review of MDCT studies by expert radiologists substantially raises its sensitivity for pancreas divisum.

Investigators have proposed "predict, resect, and discard" strategies for diminutive (≤ 5 mm) or small (6-9 mm) polyps to reduce screening colonoscopy costs. Advanced histological features such as villous histology, high-grade dysplasia, and/or cancer in these polyps could deter adoption of these strategies.Determine the prevalence of advanced histological features in diminutive and small colon polyps.Retrospective analysis of data from 3 prospective clinical trials.Two tertiary-care referral centers.This study involved patients undergoing screening or surveillance colonoscopy.The location, size, and morphology of each polyp detected was documented. Each polyp was then resected, placed in a unique specimen jar, and sent for histopathological evaluation.Rates of advanced histological features (villous histology, high-grade dysplasia, and cancer).A total of 2361 polyps were detected, removed, and retrieved. Both diminutive and small polyps had a lower frequency of any advanced histological features compared with large polyps (0.5% and 1.5%, respectively vs 15.0%; P.001 for both comparisons). Polyps10 mm in size had a lower frequency of advanced histology compared with polyps ≥ 10 mm (0.8% vs 15.0%; P.001). During sensitivity analysis, the frequency of advanced histological features varied from 0.2% to 0.7% within diminutive polyps, 1.5% to 3.6% within small polyps, and 0.8% to 1.2% within polyps10 mm.Retrospective analysis from tertiary-care referral centers; predominantly white, male, veteran patient population resulting in limited generalizability of results.The prevalence of advanced histological features in colon polyps ≤ 5 mm is very low (0.5%). This has important implications for the potential practice of "predicting, resecting, and discarding" diminutive colon polyps.

Primary endoscopic obesity treatments include a variety of restrictive and malabsorptive procedures that are emerging as alternatives to bariatric surgery. Although bariatric surgery is extremely effective and generally considered safe, there is a small, albeit significant, morbidity and mortality. This makes less invasive treatments attractive. In addition to being less invasive and perhaps safer, endoscopic treatments may be more cost-effective and reversible. Additionally, endoscopic treatments may prove to be a viable alternative in poor surgical candidates, or as a method to induce weight loss in super obese patients before definitive surgical bariatric procedures, and may be an option for the nonmorbidly obese who have failed diet and exercise. Experience with these emerging endoscopic technologies, however, is limited to feasibility and safety studies and small prospective trials with minimal long-term follow-up. There have been no large, prospective, randomized, or sham-controlled trials evaluating the long-term durability of endoscopic obesity treatments, and there have been no such trials comparing endoscopic treatments with traditional bariatric surgery. In this article, we will review these emerging primary endoscopic obesity treatments with a focus on procedural techniques.

Propofol is an effective sedative in advanced endoscopy. However, the incidence of sedation-related complications is unclear. We sought to define the frequency of sedation-related adverse events, particularly the rate of airway modifications (AMs), with propofol use during advanced endoscopy. We also evaluated independent predictors of AMs.Patients undergoing sedation with propofol for advanced endoscopic procedures, including endoscopic retrograde cholangiopancreatography, endoscopic ultrasound, and small-bowel enteroscopy, were studied prospectively. Sedative dosing was determined by a certified registered nurse anesthetist with the goal of achieving deep sedation. Sedation-related complications included AMs, hypoxemia (pulse oximetry [SpO(2)]90%), hypotension requiring vasopressors, and early procedure termination. AMs were defined as chin lift, modified face mask ventilation, and nasal airway. We performed a regression analysis to compare characteristics of patients requiring AMs (AM+) with those who did not (AM-).A total of 799 patients were enrolled over 7 months. Procedures included endoscopic ultrasound (423), endoscopic retrograde cholangiopancreatography (336), and small-bowel enteroscopy (40). A total of 87.2% of patients showed no response to endoscopic intubation. Hypoxemia occurred in 12.8%, hypotension in 0.5%, and premature termination in 0.6% of the patients. No patients required bag-mask ventilation or endotracheal intubation. There were 154 AMs performed in 115 (14.4%) patients, including chin lift (12.1%), modified face mask ventilation (3.6%), and nasal airway (3.5%). Body mass index, male sex, and American Society of Anesthesiologists class of 3 or higher were independent predictors of AMs.Propofol can be used safely for advanced endoscopic procedures when administered by a trained professional. Independent predictors of AMs included male sex, American Society of Anesthesiologists class of 3 or higher, and increased body mass index.

Background Abdominal pain after ERCP is common, and although it is frequently nonspecific and self-limited, it may provoke concern for complications and thus distress both patients and physicians. Carbon dioxide (CO 2 ) insufflation during ERCP may reduce abdominal distension in comparison to insufflation of air, resulting in less pain. Objective To compare the incidence and severity of post-ERCP pain in patients receiving CO 2 versus air insufflation during ERCP. Design Randomized, double-blind, controlled trial. Setting University medical center. Patients This study involved consecutive patients presenting for ERCP, excluding those with significant preprocedure pain or obstructive lung disease. Intervention Randomization to insufflation with air or CO 2 ; all other care was identical. Main Outcome Measurements Pre-ERCP and post-ERCP pain and nausea were assessed by using a 0 to 10 visual analogue scale. Patient waist circumferences were measured before and after procedures. Results One hundred patients (82 outpatients, 51 women, mean age 54.4 years, 50 randomized to CO 2 ) completed the study. The CO 2 and air groups were similar in regard to demographics, indication for ERCP, and procedure duration. The mean pain score 1 hour post-ERCP was higher with air than with CO 2 insufflation (1.9 vs 0.7, P = .01). Similarly, the incidence of any pain at 1 hour post-ERCP was higher with air than with CO 2 (48% vs 28%, P = .04). The mean increase in waist circumference was greater with air than with CO 2 (2.1 cm vs 0.3 cm, P = .003). Adverse events were infrequent and did not differ by group. No serious cardiopulmonary complications occurred. Limitations Single-center, selected patient population. Conclusion Insufflation of CO 2 during ERCP reduces postprocedure pain and abdominal distension in comparison to insufflation of air. The use of CO 2 in deeply sedated, prone patients appears to be safe.

Self-expandable metal stent placement for palliation of malignant colonic obstruction for colorectal cancer (CRC) is safe and efficacious. In contrast, outcomes of stent placement for extracolonic malignancy (ECM) are unclear.To compare the success and complication rates of colorectal stenting in patients with CRC versus those with ECM.Retrospective chart review.Tertiary-care academic medical center.Between September 2000 and December 2007, all patients with malignant colon obstruction in whom endoscopy was performed with the intention of placing a colonic metal stent.Technical and clinical success rates, surgical interventions, and procedure-related complications.Colonic stenting was performed for CRC in 34 patients and for ECM in 15 patients. Patients with CRC were more likely to have clinical success after all endoscopic therapy (94.1%) than those with ECM (20.0%) (P.0001). Surgical diversion to relieve persistent obstructive symptoms was required in significantly more patients with ECM. Five patients with ECM (33.3%) had at least one complication, including 2 deaths, compared with 3 patients with CRC (8.8%) (P = .046). Only underlying ECM was predictive of failed colon stent placement by multivariate analysis (hazard ratio 21.0, P = .0013). A history of radiation therapy was the sole predictor of complications (hazard ratio 7.8, P = .048).Single institution, retrospective analysis, relatively small sample size.Colon stenting for large-bowel obstruction from ECM is infrequently successful and is associated with a significantly higher risk of complications in comparison with patients with CRC.

SUMMARY. Accurate staging of esophageal cancer is critical to achieving optimal treatment outcomes. End-oscopic ultrasound with fine needle aspiration (EUS-FNA) has emerged as a valuable tool for locoregional staging. However, it is unclear how different physician specialties perceive the benefit of EUS-FNA for esophageal cancer staging, and thus utilize this modality in clinical practice. A survey regarding utilization of EUS-FNA in esophageal cancer was distributed to 211 thoracic surgeons and 251 EUS-capable gastroenterologists. Seventy-six thoracic surgeons (36%) and 78 gastroenterologists (31%) responded to the survey. Most surgeons (75%) use EUS to stage potentially resectable esophageal cancer 75% of the time. Surgeons using EUS less often are less likely to have access to high-quality EUS services than their peers. Fewer surgeons believe EUS is the most accurate test for T and N-staging (84% and 71%, respectively) as compared with gastroenterologists (97% and 96%, P < 0.01 for both). Most endosonographers (68%) decide whether to dilate a malignant esophageal stricture to complete the staging exam on a case-by-case basis. Surgeons disagree as to whether involvement of celiac lymph nodes should preclude esophagectomy in distal esophageal cancer. While most thoracic surgeons have embraced EUS-FNA as the most accurate locoregional staging modality in esophageal cancer, this attitude is not fully reflected in utilization patterns due to a lack of quality EUS services in some centers. Controversial areas that warrant further study include dilation of malignant strictures to facilitate EUS staging, and the implication of involved celiac lymph nodes on management.

Roux-en-Y gastric bypass is the most frequently performed bariatric surgery for morbid obesity. Gastrojejunal anastomotic strictures are a relatively frequent postoperative complication.To evaluate the clinical outcomes and therapeutic response to through-the-scope balloon dilation performed to treat anastomotic strictures after Roux-en-Y gastric bypass surgery.Single-center, retrospective study.Academic medical center.Between 1997 and 2005, 801 patients with morbid obesity underwent Roux-en-Y gastric bypass surgery at our institution.The development of an anastomotic stricture after Roux-en-Y gastric bypass surgery. The response to through-the-scope balloon dilation after diagnosis.Forty-three of 801 patients (5.4%) developed an anastomotic stricture (26 of 294 open surgeries [8.8%]; 17 of 507 laparoscopic surgeries [3.4%]; P.001). Strictures were dilated to 15.5 +/- 0.4 mm. There were no perforations or clinically significant bleeding after dilation; 93% of the strictures were successfully managed with 1 or 2 endoscopic sessions. Dilation to at least 15 mm did not affect weight loss at 1 year when compared with the group without a stricture (percentage excess weight loss: stricture group, 76%; no stricture group, 74%).Single-center, retrospective study.Endoscopic balloon dilation is a safe and effective method for the management of gastrojejunostomy strictures after Roux-en-Y gastric bypass. Dilation to at least 15 mm is safe and decreases the need for further endoscopic dilation.

Context: Atypical antipsychotic agents (clozapine, olanzapine) have been linked to metabolic effects and acute pancreatitis. Case Report: We reviewed the inpatient and outpatient records of three patients who developed acute pancreatitis while being treated with olanzapine. The mean age of the patients was 37.7 years (range 18–54 years, 2 female, 1 male). No alternative cause of acute pancreatitis was found in two of the three patients. In the remaining patient, olanzapine may have contributed to acute pancreatitis in the setting of hypertriglyceridemia. Olanzapine was discontinued in all instances. Over a mean follow-up of 14 months, one patient has had a relapsing course, but the remaining two patients have been symptom free without recurrence of acute pancreatitis. Conclusions: Our case series adds further support to the potential link between olanzapine use and acute pancreatitis. Close monitoring of metabolic parameters is suggested in patients treated with olanzapine. Alternative antipsychotic agents should be considered in patients at high risk for pancreatitis.

Endoscopic complications were thought to be on the decline with more flexible endoscopes, new devices, and increased endoscopist experience. However, endoscopy has concurrently changed from mainly a diagnostic to a therapeutic modality. With these trends, complications such as bleeding and perforation continue to occur, especially during therapeutic procedures. Understanding and minimizing the risk factors that predispose to certain complications may prevent their occurrence. In addition, there are effective preventative endoscopic strategies that decrease the risk of complications. The past management of these serious complications has primarily been surgical. However, there has been a significant trend toward the use of endoscopic modalities to manage some of these serious complications. The incidences, risk factors, and management approaches to bleeding, perforation, and stricturing related to esophagogastroduodenoscopy, colonoscopy, and endoscopic retrograde will be reviewed. The discussion will focus primarily on endoluminal approaches to complication prevention and management.

Few patients have significant symptoms during wireless esophageal pH monitoring, and the capsule typically sloughs spontaneously. Severe discomfort during monitoring can occur that requires endoscopic dislodgement of the capsule.To determine the frequency with which endoscopic capsule dislodgement is required and the outcomes of the intervention.Chart review.University-based outpatient endoscopy facility.A total of 452 consecutive patients undergoing wireless pH monitoring over a 3.5-year period.Endoscopic dislodgement of the capsule by using nudging with the endoscope tip and cold snare techniques.Eight subjects (1.8%) required endoscopic capsule dislodgement because of severe chest pain or odynophagia (n = 7) or severe foreign-body sensation (n = 1). Chest pain was the initial indication for pH monitoring in 5 (62.5%) of the subjects. Initial nudging with the endoscope tip successfully dislodged 2 capsules; continued nudging produced mucosal stripping in 3 subjects, which required hemostasis in 1. A cold snare was used successfully, without complication, to separate the capsule from stripped mucosa and as a primary removal method in the remainder of subjects. Capsule removal uniformly resulted in marked improvement of discomfort.Endoscopic removal of the capsule was required in2% of subjects who underwent wireless pH monitoring. Separation of the capsule from the mucosa with a cold snare may be the preferred method of accomplishing uncomplicated removal.

Background Various methods to drain pancreatic pseudocysts by using EUS guidance have been reported in the literature. Objective A new drainage technique is described that uses a modified needle knife advanced over a guidewire positioned in the pseudocyst by EUS guidance. Design Retrospective chart review. Setting Academic medical center. Patients Consecutive subjects from December 1, 2002, to January 10, 2005, with symptomatic pseudocysts in whom EUS-guided drainage was attempted. Interventions By using a therapeutic linear echoendoscope, a 19-gauge aspiration needle was inserted into the pseudocyst. A guidewire was placed through the needle, and a needle knife with the cutting wire protruding and bent was advanced over the guidewire to contact the stomach mucosa. The needle knife was then advanced by using electrocautery into the pseudocyst. The cystenterostomy was dilated by using a balloon over the guidewire. One to 4 stents were placed through the tract. Main Outcome Measurements Successful pseudocyst drainage. Results A total of 21 of 23 patients underwent technically successful pseudocyst drainage. One patient had self-limited hypotension during the procedure. Another patient had free intraperitoneal air after the procedure but correct stent placement. Limitations Retrospective analysis, small sample size. Conclusions In this preliminary experience, wire-guided pseudocyst drainage with a modified needle knife appears effective and safe while allowing for a more controlled pseudocyst puncture.

Pancreatic fluid collections (PFCs) arise as a consequence of pancreatic injury. Pancreatic pseudocysts, pancreatic abscess, and walled-off pancreatic necrosis are types of PFCs. The terminology of PFCs was developed to allow proper classification and define the severity of disease. PFCs that are misclassified can have clinical consequences.

Obscure GI bleeding is uncommon, accounting for approximately 5 % of all GI bleeding episodes [1]. With the advent of capsule endoscopy and introduction of balloon enteroscopy to the United States in 2004, endoscopic visualization of the small bowel has become feasible and successful. Double-balloon enteroscopy (DBE) is associated with diagnostic yields of approximately 50–60 %, which exceed 70 % in patients with obscure gastrointestinal bleeding (OGIB) [2]. Performance of video capsule endoscopy (VCE) prior to deep enteroscopy is associated with increased diagnostic yields. In an updated metaanalysis, the yield for DBE was 75 % when a prior VCE study was abnormal, but only 27 % after a negative VCE examination [3]. Single-balloon enteroscopy (SBE) was subsequently introduced into US clinical practice in 2008 in an effort to reduce time and complexity of the double-balloon procedure. Instead of using a second balloon on the distal end of the enteroscope as an anchor when the overtube is advanced, the tip of the enteroscope is deflected during the SBE procedure, creating a ‘‘hook’’ which functions similarly to the second balloon on the DBE enteroscope. Although less data have been published regarding SBE outcomes compared with DBE, initial studies reported somewhat lower diagnostic yields, potentially due to decreased rates of total enteroscopy [4, 5]. Higher total enteroscopy rates and therapeutic interventions with DBE compared to SBE were reported when the enteroscope balloon was removed from the Fujinon system [6]. Nevertheless, a subsequent randomized controlled trial did not confirm these results [7]. In this issue of Digestive Diseases and Sciences, Kushnir et al. [8] from Washington University School of Medicine performed a retrospective cohort study in order to determine long-term outcomes after SBE. While longterm outcomes studies have been performed for DBE and are discussed below [9, 10], this literature contribution is the first long-term outcomes assessment for SBE. Given the conflicting data regarding efficacy of SBE compared to DBE, the major question is whether recurrent bleeding rates differ post-SBE compared to published rates postDBE. In this study, the authors reviewed 147 SBE examinations performed for the evaluation of OGIB between 2008 and 2010, following 110 (75 %) patients for a mean of 24 months post-procedure. Patients who participated in the follow-up phone calls or visits were more likely to have undergone SBE with positive findings in the small bowel leading to endoscopic therapy compared with patients who were lost to follow-up post-enteroscopy (69 vs. 35 %, p \ 0.001). Seventy percent of the patients had undergone VCE studies before the enteroscopy examination. Significant lesions in the small bowel including vascular, ulcerative, and/or suspected neoplasms were detected in 91 % of the patients undergoing capsule endoscopy. A source of bleeding was identified in 95/147 (65 %) SBE examinations including vascular lesions in 54 %, ulcers or erosions in 5 %, and small bowel masses in 3 %. Endoscopic therapy was performed in 76 (52 %) patients, and an additional eight were referred to surgery. Recurrent OGIB occurred in 50/110 (45 %) patients available for follow-up. The authors were unable to find any risk factors associated with recurrent OGIB including Charlson co-morbidity index score, although the number of patients with valvular heart disease (22 %) was small. Recurrent bleeding occurred overall in 31/76 (41 %) of patients with a source found on SBE, and in 19/34 (56 %) of patients with normal L. B. Gerson (&) Stanford University School of Medicine, Stanford, CA, USA e-mail: lgersonmd@yahoo.com

Among cases of difficult biliary cannulation, alternatives include use of a pancreatic duct stent (PDS) or guidewire (PDW) to facilitate access. We compared the effectiveness of a PDS versus a PDW to facilitate common bile duct (CBD) cannulation.We conducted a randomized, crossover trial at two endoscopy referral centers, limited to patients undergoing ERCP without a history of biliary sphincterotomy. After meeting predefined criteria for difficult cannulation, patients were randomized to using a PDS or PDW to facilitate CBD cannulation. Outcomes included cannulation rate within 6 min, overall cannulation rate, frequency of precut, and complication rates.Among 442 eligible patients, 87 (19.7 %) met criteria for difficult cannulation. Forty two were randomized to PDW, 54 to PDS (including 9 PDW patients crossed over to PDS). The rate of CBD cannulation within 6 min was similar in the PDW (38.1 %) and PDS (51.9 %) groups (p = 0.18). In a secondary analysis limited to patients who successfully underwent PDW or PDS deployment, the rate was also comparable (PDW 59.3 %, PDS 65.1 %; p = 0.62). The overall frequency of CBD cannulation was 66.7 % in PDW and 90.7 % in PDS patients. Precut was required in 9.5 % of PDW and 25.9 % of PDS patients. Complication rates were similar, with 4 (4.6 %) patients having post-ERCP pancreatitis and 1 (1.1 %) having post-ERCP pain without confirmation of pancreatitis.Use of a PDS or PDW facilitates CBD cannulation while maintaining a low complication rate and reducing the need for precut sphincterotomy in the majority of cases.

Background There are limited data on the safety of anesthesia-assisted endoscopy by using propofol-mediated sedation in obese individuals undergoing advanced endoscopic procedures (AEPs). Objective To study the association between obesity (as measured by body mass index [BMI]) and the frequency of sedation-related complications (SRCs) in patients undergoing AEPs. Design Prospective cohort study. Setting Tertiary referral center. Patients A total of 1016 consecutive patients undergoing AEPs (BMI 35, 127 [12%]). Intervention Monitored anesthesia sedation with propofol alone or in combination with benzodiazepines and/or opioids. Main Outcome Measurements SRCs, airway maneuvers (AMs), hypoxemia, hypotension requiring vasopressors, and early procedure termination were compared across 3 groups. Results There were 203 AMs in 13.9% of patients, hypoxemia in 7.3%, need for vasopressors in 0.8%, and premature termination in 0.6% of patients. Increasing BMI was associated with an increased frequency of AMs (BMI 35–26.8%; P 35, 13.4%; P = .001); there was no difference in the frequency of need for vasopressors ( P = .254) and premature termination of procedures ( P = .401). On multivariable analysis, BMI (odds ratio [OR] 2.0; 95% CI, 1.3-3.1), age (OR 1.1; 95% CI, 1.0-1.1), and American Society of Anesthesiologists class 3 or higher (OR 2.4; 95% CI, 1.1-5.0) were independent predictors of SRCs. In obese individuals (n = 286), there was no difference in the frequency of SRCs in patients receiving propofol alone or in combination ( P = .48). Limitations Single tertiary center study. Conclusions Although obesity was associated with an increased frequency of SRCs, propofol sedation can be used safely in obese patients undergoing AEPs when administered by trained professionals.

Objectives: Extracorporeal shock wave lithotripsy (ESWL) and endoscopic retrograde cholangiopancreatography (ERCP) are used to clear main pancreatic duct (MPD) stones and alleviate pain in patients with chronic pancreatitis. The goal of this study was to determine if delayed ERCP after disintegration of MPD stones with ESWL improves the successful clearance of the MPD. Methods: Adult patients with chronic pancreatitis who underwent ESWL for stone disintegration were identified from an ESWL database at a single tertiary referral center. The complete clearance of stones from the MPD with ERCP performed less than 2 days after ESWL was compared to complete clearance from ERCP more than 2 days after ESWL. Results: Nineteen patients underwent ERCP less than 2 days after ESWL, and 3 (16%) of the 19 achieved MPD clearance. Eleven patients underwent ERCP more than 2 days after ESWL, and 9 (82%) of 11 patients achieved MPD clearance (P = 0.001). In total, 19 of 30 ERCPs were performed less than 2 days after ESWL, and 84% failed to clear the MPD (P = 0.001). Conclusions: The timing of ERCP after ESWL may be important to successfully clear stones from the MPD. This study shows that ERCP performed less than 2 days after ESWL may be more likely to fail, possibly owing to ESWL-induced edema. Delaying ERCP after ESWL may allow tissue recovery after ESWL.

Background The American Society for Gastrointestinal Endoscopy (ASGE) recently developed thresholds for the performance characteristics of technologies for real-time assessment of histology of diminutive (≤5 mm) colon polyps. Narrow-band imaging (NBI) has been shown to predict polyp histology with moderate to high accuracy in several studies. Objective To determine whether in vivo optical diagnosis of polyp histology by using NBI can reach the 2 benchmarks set forth by the ASGE. Design Retrospective analysis of data from 3 prospective clinical trials. Setting Two tertiary referral centers. Patients Subjects undergoing screening or surveillance colonoscopy. Interventions In vivo optical diagnosis of polyp histology by using NBI. Main Outcome Measurement Accuracy in predicting colonoscopy surveillance intervals, negative predictive value (NPV) for diagnosing adenomatous histology in the rectosigmoid. Results A total of 410 patients met the inclusion/exclusion criteria and had at least 1 polyp seen and resected during colonoscopy. Using in vivo optical diagnosis instead of histopathology for all diminutive polyps predicted the correct colonoscopy surveillance interval in 86% to 94% patients. When optical diagnosis was limited to diminutive polyps in the rectosigmoid only, the NPV for diagnosing adenomatous histology with NBI was 95%. Limitations Retrospective analysis from tertiary referral centers. Conclusions The threshold NPV for diagnosing adenomatous histology in diminutive rectosigmoid polyps recently set forth by the ASGE can be achieved by using NBI. The threshold accuracy rate for predicting surveillance interval recommendations can be reached by using NBI, but only if patients with 1 to 2 small adenomas without advanced features have a repeat colonoscopy in 10 years.

Colonoscopy may fail to detect neoplasia located on the proximal sides of haustral folds and flexures. The Third Eye Retroscope (TER) provides a simultaneous retrograde view that complements the forward view of a standard colonoscope.To evaluate the added benefit for polyp detection during colonoscopy of a retrograde-viewing device.Open-label, prospective, multicenter study evaluating colonoscopy by using a TER in combination with a standard colonoscope.Eight U.S. sites, including university medical centers, ambulatory surgery centers, a community hospital, and a physician's office.A total of 249 patients (age range 55-80 years) presenting for screening or surveillance colonoscopy.After cecal intubation, the disposable TER was inserted through the instrument channel of the colonoscope. During withdrawal, the forward and retrograde video images were observed simultaneously on a wide-screen monitor.The number and sizes of lesions (adenomas and all polyps) detected with the standard colonoscope and the number and sizes of lesions found only because they were first detected with the TER.In the 249 subjects, 257 polyps (including 136 adenomas) were identified with the colonoscope alone. The TER allowed detection of 34 additional polyps (a 13.2% increase; P.0001) including 15 additional adenomas (an 11.0% increase; P.0001). For lesions 6 mm or larger, the additional detection rates with the TER for all polyps and for adenomas were 18.2% and 25.0%, respectively. For lesions 10 mm or larger, the additional detection rates with the TER for all polyps and for adenomas were 30.8% and 33.3%, respectively. In 28 (11.2%) individuals, at least 1 additional polyp was found with the TER. In 8 (3.2%) patients, the polyp detected with the TER was the only one found. Every polyp that was detected with the TER was subsequently located with the colonoscope and removed. For all polyps and for adenomas, the additional detection rates for the TER were 9.7%/4.1% in the left colon (the splenic flexure to the rectum) and 16.5%/14.9% in the right colon (the cecum to the transverse colon), respectively.There was no randomization or comparison with a separate control group.A retrograde-viewing device revealed areas that were hidden from the forward-viewing colonoscope and allowed detection of 13.2% additional polyps, including 11.0% additional adenomas. Additional detection rates with the TER for adenomas 6 mm or larger and 10 mm or larger were 25.0% and 33.3%, respectively. (NCT00657371.).

Background Successful cannulation of the common bile duct (CBD) remains the benchmark for ERCP. Use of a pancreatic duct (PD) stent to facilitate biliary cannulation has been described, although the majority of patients require precut sphincterotomy to achieve CBD cannulation. Objective To report the performance characteristics of using a PD stent in conjunction with physician-controlled wire-guided cannulation (WGC) to facilitate bile duct cannulation. Design Retrospective cohort. Setting Two tertiary care, academic medical centers. Patients All undergoing ERCP with native papillae. Intervention In cases of difficult biliary access in which the PD is cannulated, a pancreatic stent is placed. After this, physician-controlled WGC is attempted by using the PD stent to direct the sphincterotome into the biliary orifice. If cannulation is unsuccessful after several minutes, a precut sphincterotomy is performed over the PD stent or the procedure is terminated. Main Outcome Measurements Frequency of successful bile duct cannulation and precut sphincterotomy. Results A total of 2345 ERCPs were identified, 1544 with native papillae. Among these, CBD and PD cannulation failed in 16 (1.0%) patients, whereas 76 (4.9%) patients received a PD stent to facilitate biliary cannulation. Successful cannulation was achieved in 71 (93.4%) of 76 patients, 60 (78.9%) of whom did not require precut sphincterotomy. Complications included mild post-ERCP pancreatitis in 4 (5.3%) and aspiration in 1 (1.3%). Precut sphincterotomy was complicated by hemorrhage, controlled during the procedure in 2 (13.3%) of 15. Conclusions Physician-controlled WGC over a PD stent facilitates biliary cannulation while maintaining a low rate of precut sphincterotomy.

Background and study aims Narrow band imaging (NBI) with optical magnification is useful in predicting colon polyp histology. As magnifying endoscopes are not routinely available, we investigated the use of NBI and high definition white light imaging in determining polyp histology, using images obtained with colonoscopes without optical magnification. Patients and methods Images (white light and NBI) of colon polyps less than 10 mm in diameter were collected prospectively from patients undergoing screening colonoscopy and digitally stored. Two endoscopists later reviewed all images and predicted polyp histology as neoplastic or non-neoplastic using a modified Kudo classification. Comparison was made with histopathology. Results Separate white light and NBI images of 80 polyps (49 neoplastic, 31 non-neoplastic) from 63 patients were recorded. Mean polyp size was 5.1 +/- 2.1 mm (5.4 +/- 2.2 neoplastic; 4.4 +/- 1.8 non-neoplastic; P = 0.02). In a pooled analysis, NBI correctly predicted neoplastic histology in 93 of 98 images (sensitivity 95 %, positive predictive value [PPV] 94 %) whereas white light did so in 58 of 98 images (sensitivity 59 %, PPV 79 %). NBI correctly predicted non-neoplastic histology in 56 of 62 images (specificity 90 %, negative predictive value [NPV] 92 %) whereas white light did so in 47 of 62 images (specificity 76 %, NPV 54 %). Conclusions NBI without optical magnification was more accurate in predicting colon polyp histology compared with white light imaging. Image quality and confidence in histology were significantly higher in the NBI group. NBI without optical magnification may be useful in predicting colon polyp histology.

Background Because of greater recognition and improved imaging capabilities, intraductal papillary mucinous neoplasms (IPMNs) are being diagnosed with increasing frequency. IPMNs of the main pancreatic duct cause symptoms and lead to pancreatitis. Side-branch (SB) IPMNs are thought to cause symptoms less frequently, and their association with pancreatitis is not well defined. Objective Our purpose was to ascertain whether an association exists between SB-IPMN and pancreatitis. Design Single-center, retrospective study. Setting Academic medical center. Patients A total of 305 patients underwent EUS examinations between October 2002 and October 2006 for pancreatic cystic lesions. Main Outcome Measurement The main outcome measure was the frequency of acute or chronic pancreatitis that was not procedurally related. Results Thirty-two patients had SB-IPMNs, and 11 (34%) had pancreatitis. Three patients reported a single episode, and 8 patients reported having recurrent episodes of pancreatitis. Overall, 17 (53%) patients had symptoms possibly attributable to SB-IPMN. Female sex (73% vs 38%) and multiple pancreatic lesions (54% vs 24%) were more commonly seen in those with pancreatitis, but were not statistically significant factors. Larger cyst size or cyst fluid marker levels did not appear associated with pancreatitis occurrence. EUS-FNA demonstrated communication with the pancreatic duct in 94% and thick, mucinous fluid in 84%. Limitations Single-center, retrospective study. Conclusions Pancreatitis was frequently associated with the presence of SB-IPMNs in our referral practice. SB-IPMNs should be considered in the differential diagnosis of patients with recurrent pancreatitis with cystic lesions seen on imaging studies. EUS-FNA was the most useful modality in helping to differentiate SB-IPMNs from other lesions.

Internal drainage of pancreatic pseudocysts can be accomplished by traditional open or minimally invasive laparoscopic or endoscopic approaches. This study aimed to evaluate the primary and overall success rates and clinical outcomes after laparoscopic, endoscopic, and open pancreatic cystgastrostomy for pancreatic pseudocysts. Records of 83 patients undergoing laparoscopic (n = 16), endoscopic (n = 45), and open (n = 22) pancreatic cystgastrostomy were analyzed on an intention-to-treat basis. There were no significant differences (p

Background In many centers, on-site cytopathologists are not available during EUS-guided FNA (EUS-FNA) examinations. Often, endosonographers request that technologists assess the adequacy of FNA by gross inspection of the slides. To date, there has not been a study that assessed the accuracy of experienced technologists in predicting tissue sampling adequacy by gross inspection before cytologic staining. Objectives To assess a grading system used by cytotechnologists and EUS technologists during gross inspection of FNA slides in reliably predicting specimen adequacy compared with the final cytologic diagnoses. Design Prospective, double-blind, controlled study. Setting Academic tertiary-referral center with a high-volume EUS practice. Patients Fifty-one patients with a suspected solid pancreatic mass who were undergoing planned EUS-FNA. Main Outcome Measurements The degree of correlation in the assessment of specimen adequacy as exhibited by a weighted kappa statistic between 2 groups of technologists and a board-certified cytopathologist. Results FNA was performed in 37 cases with 234 individual slide specimens available for analysis. Only fair agreement was observed between cytotechnologists and EUS technologists versus final cytopathologic assessment of adequacy (kappa 0.20 and 0.19, respectively). The routine practice of 6 to 7 FNA passes yielded adequate tissue for assessment in 36 of 37 patients (97%). Limitations Interobserver variability, single center, and findings applicable only to solid pancreatic lesions. Conclusions Neither trained EUS technologists nor cytotechnologists were able to provide a reliable assessment of pancreatic-mass FNA adequacy by using gross visual inspection of the specimen on a slide. Rapid on-site cytopathology reduced the number of passes, ensured specimen adequacy, provided definitive diagnosis, and should be used in centers where available.

Background Recommended techniques for minor papilla sphincterotomy include performing a standard pull-type sphincterotomy (PTS) or using a needle-knife over a stent. A wire-assisted access sphincterotomy (WAAS) technique may hold some technical advantages over these accepted methods, but has not been robustly described. Objective To describe the safety and efficacy of WAAS compared with PTS in a series of patients from our institution. Design Retrospective audit of initial minor papilla sphincterotomies over a 6-year period. Demographic and procedural data were abstracted, and the medical record was reviewed for clinical follow-up. Setting A large tertiary referral center. Patients One hundred twenty-eight consecutive patients with pancreas divisum who underwent ERCPs between April 2001 and April 2007, 64 of whom underwent an initial minor papilla sphincterotomy. Interventions WAAS was performed by deeply cannulating the dorsal duct with a guidewire and then passing a needle-knife sphincterotome alongside the wire and cutting the minor papilla by inserting the needle-knife beside the wire and cutting away from the wire. Main Outcome Measurements Clinical procedural success and reported adverse events. Results Thirty-two patients had recurrent acute pancreatitis, 15 had pain only, and 13 had chronic pancreatitis. Thirty-two underwent WAAS, 24 had PTS, and 8 had other types of sphincterotomies. Patients undergoing WAAS (32) versus PTS (24) were similar in age, sex, and procedural indication. Mild post-ERCP pancreatitis and mild intraprocedural bleeding occurred more commonly in the WAAS group, although the differences were not statistically significant. Limitations Retrospective, nonrandomized study. Conclusions WAAS is an effective technique that may be used either to begin a minor papilla sphincterotomy or to perform the entire sphincterotomy. Complications appear similar to those seen with conventional methods but require a larger patient sample to fully evaluate.

The purpose of this study is to determine the incidence of residual common bile duct (CBD) stones after preoperative ERCP for choledocholithiasis and to evaluate the utility of routine intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) in this patient population.All patients who underwent preoperative ERCP and interval LC with IOC from 5/96 to 12/05 were reviewed under an Institutional Review Board (IRB)-approved protocol. Data collected included all radiologic imaging, laboratory values, clinical and pathologic diagnoses, and results of preoperative ERCP and LC with IOC. Standard statistical analyses were used with significance set at p0.05.A total of 227 patients (male:female 72:155, mean age 51.9 years) underwent preoperative ERCP for suspicion of choledocholithiasis. One hundred and eighteen patients were found to have CBD stones on preoperative ERCP, and of these, 22 had choledocholithiasis diagnosed on IOC during LC. However, two patients had residual stones on completion cholangiogram after ERCP and were considered to have retained stones. Therefore, 20 patients overall were diagnosed with either interval passage of stones into the CBD or a false-negative preoperative ERCP. In the 109 patients without CBD stones on preoperative ERCP, nine patients had CBD stones on IOC during LC, an 8.3% incidence of interval passage of stones or false-negative preoperative ERCP. In both groups, there was no correlation (p0.05) between an increased incidence of CBD stones on IOC and a longer time interval between ERCP and LC, performance of sphincterotomy, incidence of cystic duct stones, or pathologic diagnosis of cholelithiasis.The overall incidence of retained or newly passed CBD stones on IOC during LC after a preoperative ERCP is 12.9%. Although the natural history of residual CBD stones after preoperative ERCP is not known, the routine use of IOC should be considered in patients with CBD stones on preoperative ERCP undergoing an interval LC.