Objective To assess the dose-response, safety, and efficacy of circumferential endoscopic ablation of Barrett's esophagus (BE) by using an endoscopic balloon–based ablation device (HALO360 System). ...Design This study was conducted in 2 serial phases (dosimetry phase and effectiveness phase) to evaluate a balloon-based ablation device that delivers a pre-set amount of energy density (J/cm2 ) to BE tissue. The dosimetry phase evaluated the dose-response and the safety of delivering 6 to 12 J/cm2 . The effectiveness phase used 10 J/cm2 (delivered twice ×2) for all patients, followed by EGD with biopsies at 1, 3, 6, and 12 months. A second ablation procedure was performed if BE was present at 1 or 3 months. Patients received esomeprazole 40 mg twice a day for 1 month after ablation, and 40 mg every day thereafter. Postablation symptoms were quantified by using a 14-day symptom diary (scale, 0-100). A complete response (CR) was defined as all biopsy specimens negative for BE at 12 months. Setting Eight U.S. centers, between September 2003 and September 2005. Patients Patients were 18 to 75 years of age, with a diagnosis of BE (without dysplasia), with histopathology reconfirmation of the diagnosis within 6 months of enrollment. Results In the dosimetry phase, 32 patients (29 men; mean age, 56.8 years) were enrolled. Median symptom scores returned to a score of 0 of 100 by day 3. There were no dose-related serious adverse events, and the outcomes at 1 and 3 months permitted the selection of 10 J/cm2 (×2) for the subsequent effectiveness phase of the study. In the effectiveness phase, 70 patients (52 men, 18 women; mean age, 55.7 years) were enrolled. Median symptom scores returned to a score of 0 of 100 by day 4. At 12 months (n = 69; mean, 1.5 sessions), a CR for BE was achieved in 70% of patients. There were no strictures and no buried glandular mucosa in either study phase (4306 biopsy fragments evaluated). Conclusions Circumferential ablation of nondysplastic BE by using this balloon-based ablation device can be performed with no subsequent strictures or buried glands and with complete elimination of BE in 70% of patients at 1-year follow-up.
Background Water infusion versus air insufflation during colonoscope insertion has been suggested to reduce patient discomfort and decrease sedation medication requirements. Warm water is thought to ...further facilitate colonoscopy perhaps by decreasing colon spasm. Objective To compare the utility of warm (35°-38°C) versus cool (20°-23°C) water infused during colonoscopic insertion by measuring patient sedation medication use and discomfort scores between the warm and cool water groups. Design Randomized, controlled, double-blinded study. Setting Outpatient endoscopy unit at an academic medical center. Patients A total of 175 adults. Intervention Elective outpatient sedated screening colonoscopies. Main Outcome Measurements Sedation medication used, pain scores, cecal intubation rate, endoscopy times, satisfaction scores, and patient willingness to repeat procedures. Results There was no significant difference in sedation medication requirement during colonoscopy with the use of warm or cool water (fentanyl 83.6 ± 29.0 μg vs 87.6 ± 39.6 μg; P = .45; midazolam 3.3 ± 1.2 mg vs 3.3 ± 1.3 mg; P = .91). There was no significant difference in patient pain scores or satisfaction scores. Cecal intubation rates (100%) were similar. There was no significant difference in cecal intubation times (6 minutes 40 seconds ± 4 minutes 9 seconds vs 7 minutes 49 seconds ± 4 minutes 0 seconds; P = .06) between the warm and cool water groups. All patients were willing to repeat the colonoscopy by using the same method in both groups. Limitations Limited generalizability to patients undergoing screening sedated colonoscopies with good to excellent bowel preparation. Conclusion Water does not need to be warmed before infusion in patients undergoing sedated colonoscopies. ( Clinical Trial registration number NCT01322724 .)
Endoscopy in the obese patient Schreiner, Mitchal A; Fennerty, M Brian
Gastroenterology clinics of North America,
03/2010, Letnik:
39, Številka:
1
Journal Article
Recenzirano
Obese patients present many unique challenges to the endoscopist. Special consideration should be given to these patients, and endoscopists need to be aware of the additional challenges that may be ...present while performing endoscopic procedures on obese patients. This article reviews the special risks that obese patients face while undergoing endoscopy, endoscopic management of patients postbariatric surgery, and future role of endoscopy in the management of obese patients.
Background We sought to investigate the efficacy of endoscopically created, full-thickness plications on the competency of the anti-reflux barrier when placed at different positions on the stomach ...adjacent to the gastroesophageal junction. Methods Explanted human cadaver stomachs and esophagi were used. An endoscopic plication system (Plicator, NDO Surgical, Mansfield, Massachusetts) was then fitted over a pediatric gastroscope and passed through the esophagus into the stomach. A full-thickness plication implant was then deployed at 1 of 3 positions (fundus, anterior, and between the anterior and the lesser curvature) on the explanted stomach within 1 cm of the gastroesophageal junction. Intragastric pressure was measured before and after plication at the time of visible reflux from the esophagus (reflux threshold) using a water-perfused manometer. Results Five explanted stomachs were used. The mean reflux threshold before plication (baseline) was 1.7 mm Hg. A single plication at each position resulted universally in a significantly increased reflux threshold over the baseline value (p < 0.006). The greatest reflux threshold was observed when plication was performed on the anterior wall of the stomach, although this reflux pressure did not achieve statistical significance over the other 2 positions. A second plication performed adjacent to the initial plication at the fundus (n = 2) and anterior (n = 2) positions did increase reflux threshold; however, this increase also failed to achieve statistical significance. Conclusions These results suggest that an endoscopic, full-thickness plication system can inhibit gastroesophageal reflux effectively in an explanted stomach model. Although anterior plication resulted in the greatest intragastric pressure at reflux, it was not significantly different from intragastric pressure recorded at the other plication positions. A second plication adjacent to the first showed incremental effect, but larger studies are warranted to understand its clinical significance.
In the United States, an estimated 15 million to 20 million people use nonsteroidal anti-inflammatory drugs (NSAIDs) on a long-term basis. With such statistics, it is not surprising that the most ...common side effect, gastrointestinal mucosal injury, remains a clinically important issue. Fortunately, this complication is largely preventable. In this review, Dr Fennerty focuses on the epidemiology, pathogenesis, risk factors, prevention, and treatment of NSAID-induced gastrointestinal injury and provides the reader with the data necessary to select care that prevents it.
