Background Pathogens have been transmitted via flexible endoscopes that were reportedly reprocessed in accordance with guidelines. Methods Researchers observed reprocessing activities to ensure ...guideline compliance in a large gastrointestinal endoscopy unit. Contamination was assessed immediately after bedside cleaning, manual cleaning, high-level disinfection, and overnight storage via visual inspection, aerobic cultures, and tests for adenosine triphosphate (ATP), protein, carbohydrate, and hemoglobin. Results All colonoscopes and gastroscopes were reprocessed in accordance with guidelines during the study. Researchers collected and tested samples during 60 encounters with 15 endoscopes. Viable microbes were recovered from bedside-cleaned (92%), manually cleaned (46%), high-level disinfected (64%), and stored (9%) endoscopes. Rapid indicator tests detected contamination (protein, carbohydrate, hemoglobin, or ATP) above benchmarks on bedside-cleaned (100%), manually cleaned (92%), high-level disinfected (73%), and stored (82%) endoscopes. Visible residue was never observed on endoscopes, but it was often seen on materials used to sample endoscopes. Seven endoscopes underwent additional reprocessing in response to positive rapid indicators. Control endoscope channels were free of biologic residue and viable microbes. Conclusion Despite reprocessing in accordance with US guidelines, viable microbes and biologic debris persisted on clinically used gastrointestinal endoscopes, suggesting current reprocessing guidelines are not sufficient to ensure successful decontamination.
Background Direct endoscopic necrosectomy (DEN) for treatment of walled-off pancreatic necrosis (WOPN) has been performed as an alternative to operative or percutaneous therapy. Objective To report ...the largest combined experience of DEN performed for WOPN. Design Retrospective chart review. Setting Six U.S. tertiary medical centers. Patients A total of 104 patients with a history of acute pancreatitis and symptomatic WOPN since 2003. Interventions DEN for WOPN. Main Outcome Measurements Resolution or near-resolution of WOPN without the need for surgical or percutaneous intervention and procedural complications. Results Successful resolution was achieved in 95 of 104 patients (91%). Of the patients in whom it failed, 5 died during follow-up before resolution, 2 underwent operative drainage for persistent WOPN, 1 required surgery for massive bleeding on fistula tract dilation, and 1 died periprocedurally. The mean time to resolution from the initial DEN was 4.1 months. The first débridement was performed a mean of 63 days after the initial onset of acute pancreatitis. In 73%, the entry was transgastric with median tract dilation diameter of 18 mm. The median number of procedures was 3 with 2 débridements. Complications occurred in approximately 14% and included 5 retrogastric perforations/pneumoperitoneum, which were managed nonoperatively. Univariate analysis identified a body mass index >32 as a risk factor for failed DEN. Limitations Retrospective, highly specialized centers. Conclusions This large, multicenter series demonstrates that transmural, minimally invasive endoscopic débridement of WOPN performed in the United States is an efficacious and reproducible technique with an acceptable safety profile.
Background Minimum training for capsule endoscopy (CE) is based on societal guidelines and expert opinion. Objective measures of competence are lacking. Objectives Our objectives were to (1) ...establish structured CE training curriculum during a gastroenterology fellowship, (2) develop a formalized assessment tool to evaluate CE competency, (3) prospectively analyze trainee CE competency, (4) define metrics for trainee CE competence by using comparative data from CE staff, and (5) determine the correlation between CE competence and previous endoscopy experience. Design Single-center, prospective analysis over 6 years. Setting Tertiary academic center. Subjects Gastroenterology fellows and CE staff. Interventions Structured CE training was implemented with supervised CE interpretation. Capsule Competency Test (CapCT) was developed and data were collected on the number of CEs, upper endoscopies, colonoscopies, and push enteroscopies performed. Main Outcome Measurements Trainee competence defined as CapCT score 90% or higher of the mean staff score. Results A total of 39 fellows completed CE training and CapCT. Fellows were grouped according to number of completed CE interpretations: 10 or fewer (n = 13), 11 to 20 (n = 19), and 21 to 35 (n = 7). Eight CE staff completed CapCT with a mean score of 91%. Mean scores for trainees with fewer than 10, 11 to 20, and 21 to 35 CE interpretations were 79%, 79%, and 85%, respectively. A significant difference was seen between staff and fellow scores with 10 or fewer and 11 to 20 interpretations ( P < .001). No correlation was found between trainee scores and previous endoscopy experience. Limitations Single center. Conclusion Using a structured CE training curriculum, we defined competency in CE interpretation by using the CapCT. Based on these findings, trainees should complete more than 20 CE studies before assessing competence, regardless of previous endoscopy experience.
Background Endoscopic retrograde cholangiography (ERC) is technically challenging in liver transplant patients with Roux-en-Y biliary anastomosis. The optimal endoscope for such cases remains ...unknown. Objective Compare efficacy and safety of performing ERC in liver transplant patients with Roux-en-Y biliary anastomosis by using an adult colonoscope (AC), a pediatric colonoscope (PC), and a single-balloon enteroscope (SBE). Design Retrospective chart review. Setting Tertiary-care referral center. Patients Liver transplant patients with Roux-en-Y biliary anastomoses. Intervention ERC with AC, PC, and SBE. Main Outcome Measurements Rates of reaching the afferent limb and biliary anastomosis; rates of cannulation; rates of diagnostic, therapeutic, and procedural success; and number of adverse events. Results Ninety patients underwent 199 ERCs from 2002 to 2012; 86 with an AC, 55 with a PC, and 58 with an SBE. Biliary cannulation and diagnostic, therapeutic, and procedural success rates were all significantly higher with an SBE than with a PC. Among patients undergoing the initial ERC, no statistical difference was found among SBE, the PC, and an AC. However, the rate of procedural success with SBE during initial ERC over the last 4 years has increased. Of 25 total failures with ACs, exchange for SBEs resulted in procedural success in 4 of 4 attempts. Of 22 failures with a PC, exchange for an SBE resulted in success in 3 of 4 cases. Of 4 failures with SBE exchange in 6 cases (4 to AC, 2 to PC), SBE resulted in success in only 1. No adverse events occurred directly related to type of endoscope. Limitations Retrospective study, single center, lack of standardized approach to selection of endoscopes, uncontrolled variables (general anesthesia, learning curve). Conclusion In liver transplant patients with Roux-en-Y anatomy, rates of biliary cannulation, therapeutic success, and procedural success are higher with use of an SBE than with a PC and tend to be higher compared with use of an AC among the overall cohort. Use of an SBE and procedural success rates with SBEs have increased over the last 4 years. Failed cases with either an AC or PC can be completed if exchanged for an SBE.
Background and Aims Flexible endoscopic septum division (FESD) is a rapidly evolving technique for the treatment of Zenker's diverticulum (ZD). The aim was to perform a systematic review and ...meta-analysis of the literature focusing on FESD for ZD, including an in-depth evaluation of its efficacy, safety, and limitations. Methods A comprehensive literature search was completed to identify papers that examined the efficacy and safety of FESD for ZD. Demographic, clinical, and technical information was retrieved. Main outcomes were extracted, pooled, and analyzed. Heterogeneity among studies was assessed using the I2 statistic. A random effect model was used as the pooling method in cases of high heterogeneity; otherwise the fixed effect model was applied. Meta-regression was also performed. Main outcomes such as rates of success, adverse events, and recurrences were evaluated. Results Twenty studies with a total of 813 patients were selected. The pooled success, adverse events, and recurrence rates were 91% (95% confidence interval CI, 86%–95%; I2 = 69.5%), 11.3% (95% CI, 8%–16%; I2 = 64%), and 11% (95% CI, 8%–15%; I2 = 38.4%), respectively. Substantial heterogeneity across studies was found. However, for success rates, excluding 3 studies reduced heterogeneity to non-significant rates I2 = 25.6%; P = .154. Adverse event rates decreased with larger samples (coefficient, −0.0123; 95% CI, −0.03 to −0.003; P = .017), whereas recurrence rates increased (coefficient, 0.006; 95% CI, −0.0010 to 0.0125; P = .093). Year of publication was negatively associated with success rate, whereas the opposite pattern was found for recurrence rates. Conclusions FESD is a feasible, safe, and effective treatment for symptomatic ZD, with low adverse event and recurrence rates.
Background and Aims There are limitations to enteral self-expandable metal stents and surgical gastrojejunostomy in the treatment of patients with gastric outlet obstruction (GOO). EUS-guided ...gastroenterostomy (EUS-GE) is a novel procedure that potentially offers long-lasting luminal patency without the risk of tumor ingrowth and/or overgrowth, while avoiding the morbidity of a surgical procedure. The aims of this study were to report the first U.S. clinical experience with EUS-GE in terms of technical success, clinical success, and adverse events and to detail the technical aspects of performing EUS-GE. Methods This was a retrospective study from two tertiary-care centers. EUS-GE was performed by using either the direct EUS-GE or balloon-assisted EUS-GE technique. Technical success was defined as adequate positioning and deployment of the stent as determined endoscopically and radiologically. Clinical success was defined as the patient’s ability to tolerate oral intake without vomiting. Results A total of 10 patients underwent attempted EUS-GE. Malignant GOO was present in 3 patients, whereas benign obstruction was found in the remaining 7. One patient had complete GOO and underwent successful direct EUS-GE. In the remaining 9 patients, balloon-assisted EUS-GE was attempted and was successful in 8. Thus, technical success occurred in 9 patients (90%). There were no procedure-related adverse events. Mean procedure time was 96 minutes (range 45-152 minutes), and mean length of hospital stay was 2.2 days. Clinical success with resumption of solid oral intake was achieved in all 9 patients (100%) who underwent successful EUS-GE. A total of 8 patients were able to tolerate almost a normal diet and/or full diet, and 1 patient tolerated a soft diet. There was no symptom recurrence during a mean follow-up period of 150 days. Conclusions EUS-GE is a promising new technique for the treatment of symptoms of benign and malignant GOO. Prospective, multicenter trials are needed to confirm these results.
Background and Aims Extension of ampullary adenomas into the common bile duct (CBD) or pancreatic duct (PD) may be difficult to treat endoscopically. We evaluated the feasibility, safety, and ...efficacy of endoscopic radiofrequency ablation (RFA) in the management of ampullary neoplasms with intraductal extension. Methods This was a multicenter, retrospective analysis of all patients with intraductal extension of ampullary neoplasms treated with endoscopic RFA between February 2012 and June 2015. Treatment success was defined as the absence of detectable intraductal polyps by ductography, visual inspection, and biopsy sampling. Results Fourteen patients with adenoma extension into the CBD (13 ± 7 mm, n = 14) and PD (7 ± 2 mm, n = 3) underwent a median of 1 RFA sessions (range, 1-5). Additional modalities (thermal probes, argon plasma coagulation, and/or photodynamic therapy) were also used in 7 patients, and prophylactic stents were routinely placed. Thirteen assessable patients underwent a median of 2 surveillance ERCPs after completion of treatment over a median follow-up of 16 months (range, 5-46), with intraductal biopsy specimens showing no neoplasm in 12 patients at the conclusion of endoscopic treatment. Treatment success was achieved in 92%, including 100% of those treated with RFA alone. Adverse events occurred in 43% and included ductal strictures (5 patients) and retroduodenal abscess (1 patient), all of which were successfully treated endoscopically. Conclusions Endoscopic RFA, alone or in combination with other modalities, may effectively treat intraductal extension of ampullary neoplasms. Ductal strictures were common after RFA but responded to endoscopic stent therapy. RFA may be appropriate in selected patients, particularly when the main treatment alternative is pancreaticoduodenectomy.
Background and Aims Balloon enteroscopy–assisted ERCP has provided a marked improvement in the success rate of reaching the papilla and consecutive ERCP procedures in patients with surgically altered ...anatomy in the Roux-en-Y reconstruction setting. However, limited data are available on the outcome of balloon enteroscopy–assisted ERCP in patients with Roux-en-Y anatomy who have naïve papillae. We retrospectively evaluated the feasibility of balloon enteroscopy–assisted ERCP in Roux-en-Y reconstruction after total or subtotal gastrectomy (RYG) with native papillae. Methods We performed 123 ERCP procedures in 109 patients with RYG. Among these patients, 90 consecutive ERCPs in 90 patients with native papillae were included. When selective biliary cannulation failed, the double-guidewire technique, the precut technique, or the rendezvous technique were performed as advanced cannulation methods. Results The overall success rate of reaching the papilla was 93.5% (115/123). The total procedure success rate was 88.1% (96/109). The adverse event rate was 7.3% (8/109). The success rate of the standard cannulation of the intact papilla was 67.8% (61/90). The final cannulation success rate was 95.6% (86/90) by using advanced cannulation methods. Conclusions Standard cannulation of the intact papilla in RYG cases remains challenging and uncertain. The use of various advanced cannulation methods improves the deep cannulation rate. Once selective cannulation succeeds, the treatment success rate is very high.
Background and Aims The efficacy and safety of endoscopic gallbladder drainage (EGBD) performed via endoscopic retrograde cholangiography (ERC)-based transpapillary stenting or EUS-based transmural ...stenting are unknown. We aimed to conduct a proportion meta-analysis to evaluate the cumulative efficacy and safety of these procedures and to compare them with percutaneous gallbladder drainage (PGBD). Methods We searched several databases from inception through December 10, 2015 to identify studies (with 10 or more patients) reporting technical success and postprocedure adverse events of EGBD. Weighted pooled rates (WPRs) for technical and clinical success, postprocedure adverse events, and recurrent cholecystitis were calculated for both methods of EGBD. Pooled odds ratios (ORs) were also calculated to compare the technical success and postprocedure adverse events in patients undergoing EGBD versus PGBD. Results The WPRs with 95% confidence intervals (CIs) of technical success, clinical success, postprocedure adverse events, and recurrent cholecystitis for ERC-based transpapillary drainage were 83% (95% CI, 78%-87%; I2 = 38%), 93% (95% CI, 89%-96%; I2 = 39%), 10% (95% CI, 7%-13%; I2 = 27%), and 3% (95% CI, 1%-5%; I2 = 0%), respectively. The WPRs for EUS-based drainage for technical success, clinical success, postprocedure adverse events, and recurrent cholecystitis were 93% (95% CI, 87%-96%; I2 = 0%), 97% (95% CI, 93%-99%; I2 = 0%), 13% (95% CI, 8%-19%; I2 = 0%), and 4% (95% CI, 2%-9%; I2 = 0%), respectively. On proportionate difference, EUS-based drainage had better technical (10%) and clinical success (4%) in comparison with ERC-based drainage. The pooled OR for technical success of EGBD versus PGBD was .51 (95% CI, .09-2.88; I2 = 23%) and for postprocedure adverse events was .33 (95% CI, .14-.80; I2 = 16%) in favor of EGBD. Conclusions EGBD is an efficacious and safe therapeutic modality for treatment of patients with acute cholecystitis who cannot undergo surgery. EGBD shows a similar technical success as PGBD but appears to be safer than PGBD.
