Background and Aims Capsule endoscopy for visualization of the upper GI tract has thus far been experimental and potentially expensive. Our aim was to demonstrate the maneuverability and evaluate the ...ability to completely visualize and maintain views in the upper GI tract by using a simple magnetic-assisted capsule endoscopy (MACE) system. Methods Twenty-six volunteers were recruited. The hand-held magnet was placed at strategic points on the body surface and rotated to hold and maneuver the capsule. The ability to view the upper GI tract landmarks was noted: esophagogastric junction (EGJ), cardia, fundus, body, incisura, antrum, and pylorus. Control was assessed by the ability to hold the capsule for 1 minute at 5 positions: the lower esophagus and 4 designated positions in the proximal and distal stomach and also traversing the stomach and through the pylorus. Volunteers subsequently underwent a standard gastroscopy. Results The median data are as follows: age, 38 years (range 26-45 years); BMI, 24 (range 19–38); and procedure time, 24 minutes (range 12-39 minutes). Successful visualization of each landmark was EGJ, 92%; cardia, 88%; fundus, 96%; body, 100%; incisura, 96%; antrum, 96%; and pylorus, 100%; with fewer clear views of the EGJ and fundus. The capsule could be held in 88% of designated positions for 1 minute, moved from the fundus to the antrum in all cases, and traversed the pylorus in 50% (n = 13). An age of 40 years and older was associated with successful pyloric traversing ( P = .04). There was positive concordance for 8 of 9 minor pathological findings on standard gastroscopy. Conclusion MACE in the upper GI tract is feasible. There is a high degree of visualization and control, with some improvement required for optimizing proximal gastric views and traversing the pylorus.
Background and Aims Endoscopic submucosal dissection (ESD) is currently commonly performed, but colorectal ESD has a substantial risk of adverse events, including post-ESD electrocoagulation syndrome ...(PEECS). We investigated whether the use of prophylactic antibiotics can reduce the occurrence of PEECS. Methods Patients who underwent colorectal ESD were randomly assigned to 1 of 2 treatment regimens. Ampicillin and/or sulbactam mixed with normal saline solution was administered 1 hour before ESD in group 1 then additionally injected every 8 hours twice more. In group 2, normal saline solution without antibiotics was administered following the same schedule. We investigated the characteristics of the patients and tumors, the incidence of PEECS, laboratory findings, and the visual analog scale (VAS) score for abdominal pain measured on the morning after ESD. Results A total of 100 cases (50 per group) were finally analyzed, and 97 tumors were successfully resected en bloc. The number of patients having C-reactive protein (CRP) levels ≥1 mg/dL and the number of patients having VAS scores for abdominal pain ≥1 were greater in group 2 than in group 1 ( P = .008 and .023, respectively). The incidence of PEECS in group 2 also was higher than that in group 1 (1 and 8 in groups 1 and 2, respectively; P = .031). Conclusions The prophylactic use of ampicillin and/or sulbactam in colorectal ESD is associated with reduced risk of PEECS, decreased CRP levels, and decreased abdominal pain. The use of prophylactic antibiotics in colorectal ESD may be an effective tool for reducing the risk of PEECS. (Clinical trial registration number: KCT0001102.)
Background Peroral cholangioscopy (POC) provides direct visualization of the bile duct and facilitates diagnostic procedures and therapeutic intervention. The currently available mother−baby ...endoscope system is not widely used because of several limitations. Although direct cholangioscopy with an ultraslim upper endoscope with a guidewire has been reported, success is not always guaranteed. Objective To evaluate the feasibility and success rate of direct POC using an ultraslim endoscope with an intraductal balloon to maintain access compared with the guidewire method. Design Prospective, observational clinical feasibility study. Setting Tertiary referral center. Main Outcome Measurements We compared overall procedure success rates and complications. A successful procedure was defined as one in which the endoscope was advanced into the bifurcation or stenotic segment of the biliary system. Patients and Methods Twenty-nine patients with biliary disease underwent direct POC. All patients had previously undergone an endoscopic sphincterotomy or papillary balloon dilation with a large balloon. Eleven patients underwent wire-guided direct POC. Intraductal balloon-guided direct POC was performed in 21 patients. The balloon catheter was used to maintain access while an ultraslim upper endoscope was advanced over the balloon catheter, through the ampulla of Vater, and directly into the bile duct. Results Wire-guided direct POC was successful in 5 of 11 (45.5%) patients. In contrast, the success rate of intraductal balloon-guided direct POC was 95.2% (20/21 patients, P < .05). Forceps biopsies under direct visualization of the intraductal lesion and therapeutic intervention, including laser lithotripsy or electrohydraulic lithotripsy, were performed successfully. Procedure-related complications were not observed. Limitations A small number of patients and no comparison with conventional cholangioscopy. Conclusions Intraductal balloon-guided direct POC with an ultraslim upper endoscope allows the direct visual examination and therapeutic intervention of bile ducts in patients with biliary disease. Further development of the endoscopic apparatus and specialized accessories are expected to facilitate this procedure.
Background The newly developed i-SCAN application can theoretically maximize the effectiveness of colonoscopy. However, the practical usefulness of the i-SCAN application during screening colonoscopy ...has not been assessed. Objective To assess the efficacy of the i-SCAN application during screening colonoscopy. Design A prospective, randomized trial that used a modified, back-to-back colonoscopy. Setting Academic hospital. Patients This study involved 389 asymptomatic, consecutive, average-risk patients who underwent screening colonoscopy. Intervention The patients were randomized to the first withdrawal with either conventional high-definition white light (HDWL group; n = 119), i-SCAN contrast/surface enhancement (CE/SE) mode (i-SCAN1 group; n = 115), or i-SCAN CE/SE/tone enhancement-colorectal mode (i-SCAN2 group; n = 118). All patients underwent a second examination with HDWL as the criterion standard. Main Outcome Measurements The primary outcome measurement was the adenoma detection rate and adenoma miss rate. The secondary outcome measurement was the accuracy of the histologic prediction of neoplastic and nonneoplastic polyps. Results The adenoma detection rates during the first withdrawal of HDWL, i-SCAN1, and i-SCAN2 were 31.9%, 36.5%, and 33.1%, respectively ( P = .742), and the adenoma miss rates of each group were 22.9%, 19.3%, and 15.9%, respectively ( P = .513). Based on the multivariate analysis, the application of i-SCAN was not associated with an improvement in adenoma detection and the prevention of missed polyps. However, the prediction of neoplastic and nonneoplastic colorectal lesions was more precise in the i-SCAN2 group compared with the HDWL group (accuracy 79.3% vs 75.5%, P = .029; sensitivity 86.5% vs 72.6%, P = .020; and specificity 91.4% vs 80.6%, P = .040). Limitations Single-center trial. Conclusion i-SCAN during the screening colonoscopy may fail to improve adenoma detection and the prevention of missed polyps, but i-SCAN appears to be effective for real-time histologic prediction of polyps compared with conventional HDWL colonoscopy. (Clinical trial registration number: NCT01417611 .)
Background Hepatolithiasis is a common disease in East Asia. Operative and nonoperative procedures for the management of hepatolithiasis have been discussed, but long-term follow-up results of such ...treatments are only reported rarely. We evaluated the long-term results of operative and nonoperative treatments and examined risk factors for the recurrence of stones or cholangitis. Methods We conducted a retrospective study of case records of patients with hepatolithiasis who underwent treatment by operative therapy or nonoperative percutaneous transhepatic cholangioscopy (PTCS), or peroral cholangioscopy. Of 311 patients with hepatolithiasis, 236 underwent follow-up after operative ( n = 90 ) , PTCS ( n = 97 ) , or peroral cholangioscopy ( n = 49 ) treatment. Results Complete stone clearance was achieved in 83.3% of hepatectomy, 63.9% of PTCSL, and 57.1% of peroral cholangioscopy patients. After a median follow-up period of 8.0 years (up to 37 years), we observed stone recurrence in 30.9% (73/236) of patients, secondary biliary cirrhosis in 8.5% (19/224), late development of cholangiocarcinoma in 4.8% (11/227), and a mortality rate of 8.1% (19/236). Stricture, stones in both lobes, and nonoperative treatments were significant risk factors for incomplete stone clearance on multivariate analysis. In addition, recurrent stones and/or cholangitis were associated with nonoperative therapy (hazard ratio HR, 2.01; 95% confidence interval CI, 1.10–3.65), biliary cirrhosis (HR, 2.22; 95% CI, 1.24–3.98), residual stones (HR, 1.98; 95% CI, 1.24–3.17), and stricture (HR, 1.86; 95% CI, 1.01–3.43). Conclusion In this long-term follow-up study, nonoperative therapy, biliary cirrhosis, residual stones, and biliary stricture were associated with recurrent stones and/or cholangitis after treatment.
Background The “mother–baby” endoscope system currently used for peroral cholangioscopy (POC) has several limitations. Endoscopic direct cholangioscopy when using an ultra-slim upper endoscope with a ...guidewire to maintain access has been reported, but appropriate accessories are required to increase the success rate. Herein, we describe a novel method, overtube-balloon–assisted endoscopy, for direct POC. Objective To evaluate the feasibility and usefulness of direct POC when using an ultra-slim upper endoscope with an overtube balloon to maintain access. Setting A single center. Design Case series. Patients Twelve patients with biliary disease. Interventions Direct POC by using an ultra-slim upper endoscope and diagnostic and/or therapeutic procedures. Main Outcome Measurements Success rate of this technique, diagnostic or therapeutic feasibility, and complications. Results Overtube-balloon–assisted direct POC was performed successfully in 10 of 12 patients (83.3%). The procedure revealed 4 common bile duct (CBD) stones, 4 benign biliary strictures, 1 polypoid tumor, and 1 cholangiocarcinoma. Five patients underwent forceps biopsy under direct visualization of the intraductal lesion. Laser lithotripsy was successfully performed in 1 patient. No procedure-related complication occurred. Limitations A small number of patients and no comparison with conventional cholangioscopy. Conclusions The overtube balloon appears to be a useful accessory in direct POC when using an ultra-slim upper endoscope. However, further development of a slim overtube or other accessories is necessary to improve the success rate of direct POC.
Objective To examine whether the MMP-8 PTD Check (SK Pharma Co, Ltd, Kyunggi-do, Korea), a rapid bedside test that can be performed in 15 minutes, is of value in the identification of intraamniotic ...infection and/or inflammation and in the assessment of the likelihood of adverse pregnancy outcome in patients with preterm premature rupture of membranes (PPROM). Study Design Amniotic fluid was retrieved by transabdominal amniocentesis in 141 women with PPROM (<35 weeks’ gestation). Fluid was cultured for aerobic and anaerobic bacteria and genital mycoplasmas; the remaining amniotic fluid was stored. The stored amniotic fluid was analyzed for interleukin-6 and MMP-8 PTD Check test. Intraamniotic infection/inflammation was defined as a positive amniotic fluid culture and/or elevated amniotic fluid interleukin-6 concentration (>2.6 ng/mL). Nonparametric and survival analysis were used. Results The prevalence of intraamniotic infection/inflammation was 43% (60/141 women) and that of proven amniotic fluid infection was 18% (25/141 women). Patients with a positive MMP-8 PTD Check test result had a significantly higher rate of intraamniotic infection/inflammation (77% 54/70 women vs 9% 6/71 women; P < .001); proven amniotic fluid infection (33% 23/70 women vs 3% 2/71 women; P < .001), and adverse outcome than those with a negative MMP-8 PTD Check test result. Adverse outcome included shorter interval to delivery and higher rate of preterm delivery, histologic chorioamnionitis, funisitis, low Apgar scores, and significant neonatal morbidity. A positive MMP-8 PTD Check test result had a sensitivity of 90%, a specificity of 80%, a positive predictive value of 77%, and a negative predictive value of 92% in the identification of intraamniotic infection/inflammation, and was an independent predictor of interval to delivery (hazards ratio, 3.7; 95% CI, 2.4-5.9) and significant neonatal morbidity (odds ratio, 3.1; 95% CI, 1.2-7.9). Conclusion The MMP-8 PTD Check test is a rapid, simple, and sensitive bedside test to detect intraamniotic infection/inflammation and to predict adverse outcome that includes short latency, chorioamnionitis, and significant neonatal morbidity in patients with PPROM. The results of this study bring the rapid detection of intraamniotic infection/inflammation to the bedside in clinical obstetrics.
Background A paucity of information exists regarding colorectal neoplasm in asymptomatic, average-risk individuals 40 to 49 years of age. Objective To evaluate the prevalence and risk factors of ...colorectal neoplasms in those in their 40s. Design Cross-sectional study. Setting Results offered to subjects of a health care provider that offers screening services as part of an employer-provided wellness program. Patients A consecutive series of 1761 asymptomatic, average-risk screenees 40 to 59 years of age. Intervention First screening colonoscopy. Results The prevalence of overall colorectal neoplasm in subjects of ages 40 to 44 years, 45 to 49 years, 50 to 54 years, and 55 to 59 years increased significantly with increasing age (13.7%, 20.2%, 21.0%, and 23.8%, respectively; P < .001). The prevalence of advanced adenomas in subjects of ages 40 to 44 years, 45 to 49 years, 50 to 54 years, and 55 to 59 years increased significantly with age (1.9%, 3.0%, 3.2%, and 5.9%, respectively; P = .004). Multivariate analysis of data from the 40- to 49-year age group identified an increased risk of colorectal neoplasm associated with ages 45 years and older (odds ratio OR, 1.68; 95% CI, 1.20-2.35), male sex (OR, 1.76; 95% CI, 1.15-2.69), presence of abdominal obesity (OR, 1.57; 95% CI, 1.12-2.21), and metabolic syndrome (OR, 1.56; 95% CI, 1.03-2.35), whereas for advanced adenomas, abdominal obesity (OR, 2.37; 95% CI, 1.06-5.27) and metabolic syndrome (OR, 2.83; 95% CI, 1.23-6.53) were the independent risk factors. Limitations Single-center study and the cohort composed of ethnic Korean subjects who lived in the same geographic region. Conclusion In average-risk individuals 40 to 49 years of age, men with abdominal obesity or metabolic syndrome might benefit from screening colonoscopy starting at 45 years of age to detect colorectal neoplasm.
Background Self-expandable metal stents (SEMSs) are an effective palliative treatment for malignant biliary or duodenal strictures, but endoscopic stenting for combined malignant biliary and duodenal ...obstruction remains technically difficult. Objective To evaluate the feasibility and clinical success rate of endoscopic double stent-in-stent placement by using a new duodenal metallic stent for the management of malignant biliary and duodenal obstructions. Design Prospective, observational clinical feasibility study. Setting Tertiary referral center. Main Outcome Measurement Technical and clinical success, complications, midterm outcome. Patients and methods Eight patients with inoperable malignant biliary and duodenal strictures were enrolled. Endoscopic placement of a biliary SEMS was performed through the mesh of the duodenal stent. Results The duodenal strictures were in the first part of the duodenum in 3 patients (type 1) and in the second part in 5 patients (type 2). Duodenal stents were successfully deployed in all patients. Endoscopic placement of a biliary SEMS through the mesh of the duodenal stent was successful in 7 (87.5%) of 8 patients. In 2 of 3 patients with type 2 duodenal strictures with failed bile duct cannulation, biliary stenting was successful by using the rendezvous procedure. Early complications occurred in 1 patient. The overall median survival after combined stenting was 91 days (range 36–314 days). Limitations Small number of patients and no comparison with other enteral stents. Conclusions Biliary stenting through the new duodenal metallic stent is technically feasible and has a high success rate. Combined endoscopic biliary and duodenal stent-in-stent placement is a promising solution for the palliation of malignant biliary and duodenal obstruction.
Background Migration of biliary stents is a well-documented problem that can result in a variety of complications. The newly designed polyurethane (PU) stent, which is made of a soft and pliable ...material, may prevent distal and proximal stent migration. Objective To compare the migration rate of the PU stent with that of the conventional polyethylene stent (PE). Design Prospective, comparative, randomized trial. Setting Tertiary academic medical centers. Patients Fifty patients with a hilar stricture who had not undergone a previous drainage procedure. Intervention In patients with hilar stricture, random assignment of either a PU stent or PE stent. Main Outcome Measurement The rate of early proximal or distal migration before stent occlusion. Results Overall and distal migration rates were significantly lower in the PU group than in the PE group (4.5% vs 29%, P = .032 and 4.5% vs 26.1%, P = .049, respectively). There was no significant difference between the migration rate in benign and malignant biliary strictures (5.9% vs 21.4%, P = .167). Sex, stent length, preprocedure bilirubin level, and Bismuth type were not associated with migration rate in either the PU or PE group. Median stent patency was 148 days (range 36–224 days) in the PU group and 151 days (range 40–241 days) in the PE group ( P = .891). Limitations Small sample size. Conclusions Use of the new PU stent, which is soft and pliable, decreased distal migration. The PU stent patency rates appear similar, but this study is not powered to demonstrate equivalency of patency.
