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Novel SEMS for malignant hilar biliary obstruction

Inoue_headshotTadahisa Inoue, MD, from the Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, in Gifu, Japan, describes this New Methods article “Feasibility of the placement of a novel 6-mm diameter threaded fully covered self-expandable metal stent for malignant hilar biliary obstructions (with videos).”

The focus of this study was to evaluate the safety and efficacy of the placement of a novel 6-mm threaded fully covered self-expandable metal stent (T-FCSEMS) for unresectable malignant hilar biliary obstruction (MHBO).

Biliary stents placed in patients with unresectable tumors will ideally remain patent without adverse events until death. However, progress in chemotherapy, including the treatment of cholangiocarcinomas and gallbladder carcinomas, is expected to prolong the prognoses of patients with MHBO. For this reason, the frequency of recurrent biliary obstruction (RBO) increases even when placing an uncovered self-expandable metal stent (USEMS), and reintervention is required. However, preventing tumor ingrowth can be difficult for the USEMS, and it can never be removed; thus, reintervention for RBO is often troublesome.

Inoue_fig
Figure 1. The novel 6-mm threaded fully covered self-expandable metal stent (TaeWoong Medical Co, Ltd, Seoul, Korea). A, The thread is tied to the duodenal side of the stent. B, The threads are drawn from the duodenal papilla into the duodenum.

The availability of T-FCSEMS may solve these issues. This novel stent prevents tumor ingrowth, and stent replacement can be performed at the time of reintervention after the stent has been removed using the thread. Thus, performing the reintervention.

The result of this study determined that T-FCSEMS placement for MHBO was associated with a high technical success rate, and the time to RBO was favorable. In addition, T-FCSEMS removal was successful in all patients in whom it was attempted during reinterventions for RBO, and the success rate was 100% for endoscopic reintervention. However, liver abscesses developed because of posterior bile duct occlusions in the posterior segments 8 and 22 days after T-FCSEMS placement in 2 cases whose stents were placed across the posterior bifurcation.

T-FCSEMS placement is a promising option for MHBO, particularly in patients with a high probability for reintervention, and the stents do not reach the intrahepatic bile duct bifurcation. However, the indications for the use of this stent should be carefully considered in patients who require placement across the intrahepatic bile duct bifurcation, such as those categorized as Bismuth types III and IV, because intrahepatic bile duct occlusion can occur.

Find the article abstract here.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

Confocal laser endomicroscopy in ulcerative colitis

Karstensen_headshot John Gásdal Karstensen, MD, from the Gastro Unit, Division of Endoscopy, Copenhagen University Hospital Herlev, in Copenhagen, Denmark, describes his article “Confocal laser endomicroscopy in ulcerative colitis: a longitudinal study of endomicroscopic changes and response to medical therapy (with videos).”

The focus of this study was to correlate endomicroscopic mucosal features with disease activity and histopathology in ulcerative colitis (UC). Further, we examined how endomicroscopic findings change after intensified medical treatment and correlated these with changes in endoscopic and histopathological scores.

The majority of studies with confocal laser endomicroscopy (CLE) has been conducted with endoscope-based CLE. We wanted to test whether the promising results in patients with UC could be reproduced with probe-based CLE and how the findings correlated with endoscopic and histopathological scores. The study was longitudinal, which in addition enabled us to correlate endomicroscopic changes over time with corresponding endoscopic and histopathological changes.

Karstensen_fig

In UC patients with clinical relapse, an augmented crypt architecture and colonic fluorescein leakage were significantly correlated to the severity of the disease (Table 3). After intensified medical treatment, a significant correlation was found between histopathological progress and improvement of abnormal colonic crypt architecture, but we did not observe a resolution of the intestinal barrier dysfunction without fluorescein leakage. The latter may reflect that few patients reached complete endoscopic remission, and we hypothesize that a restored barrier function represents the deepest state of mucosal remission.

Find the article abstract here.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

OTSC-assisted endoscopic resection of gastric submucosal nodule

Singhal_headshotShashideep Singhal, MD, from the University of Texas Health Science Center in Houston, Texas describes this video case “Over-the-scope clip-assisted endoscopic resection of gastric submucosal nodule.”

A 61-year-old woman with refractory dyspepsia underwent upper endoscopy, which showed an incidental gastric submucosal nodule. EUS showed a 1.4-cm nodule arising from the muscularis propria. FNA results were inconclusive. We performed an over-the-scope clip (OTSC)-assisted endoscopic resection of a gastric submucosal nodule. The nodule was suctioned into the cap, and a 12/6 gc OTSC was placed over the nodule. The nodule was removed by use of a hot snare over the OTSC, which was left in place.

Gastric submucosal nodules are common incidental findings during an upper endoscopy. The management options are: EUS with FNA for diagnosis which is often limited by ability to determine malignant potential. Continued surveillance is practiced in lesions with low malignant potential and surgical resection for high-risk nodules. Both approaches involve significant anxiety and morbidity due to repeat procedures and risks associated with surgical procedures.

Endoscopic resection is a safe single step procedure for management of small gastric submucosal nodules with accurate tissue diagnosis, determination of malignant potential and potentially curative.

OTSC selection is important and is based on the size of nodule.

Biopsy of the base can be done after resection and send in a separate specimen container to confirm complete resection as cautery artifact can sometimes limit pathological assessment of margins in resected specimen.

Find more VideoGIE cases online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

Surgery for benign colon polyps

Keswani_headshotRajesh N. Keswani, MD, MS, Associate Professor of Medicine at Northwestern University Feinberg School of Medicine, in Chicago, Illinois, USA describes his article “Adverse events after surgery for nonmalignant colon polyps are common and associated with increased length of stay and costs.”

Most colon polyps are endoscopically resected with ease. Some polyps require additional expertise for removal due to their morphology, size or location—we refer to these as “complex polyps.” Our primary aim was to report the outcomes, specifically adverse events (AE) rates, length of stay, and costs, in a large cohort of patients undergoing surgical resection (SR) for nonmalignant colon polyps. The secondary aim was to compare actual surgical outcomes data with a cohort of patients undergoing primary endoscopic muscosal resection (ER) of complex polyps at our institution.

The origin of this article lies within our group’s interest in pursuing value-based care and shared decision making. There is robust data demonstrating the safety and efficacy of ER in expert hands. We know comparatively little about the morbidity and costs associated with SR of benign colon polyps with most data extrapolated from resection of malignant and inflammatory disease. Furthermore, cost-effectiveness studies that have compared endoscopy and surgery have often used imputed surgical costs, limiting generalizability. We felt “real-world” data comparing the cost-effectiveness of surgery and endoscopy for complex polyps would more effectively influence practice.

Keswani table 5

The first major finding from our study was that surgery for benign polyps is not, itself, benign. Approximately one-sixth of patients will experience an AE resulting in an increased length of stay. As expected, when an AE occurs, this markedly increases treatment costs. Furthermore, while surgical risks significantly increase with patient factors (ASA class and BMI), they do not correlate with surgical approach (open vs. laparoscopic) or location (right vs left colon). For the patients experiencing an AE, the median hospital length of stay over the year following surgery increases to 11 days. Thus, surgery for a nonmalignant polyp is life disrupting.

The second major finding is that, in a cohort of overlapping patients who undergo attempted primary ER, there is a trend towards a lower AE rate and a markedly shorter “length of stay” with most ERs not requiring admission. Primary ER costs—accounting for AEs, unexpected malignancy, and resection failures requiring surgery as well as necessary surveillance colonoscopies—were significantly lower for complex polyps compared to SR. On average at our institution, attempting primary ER would save about $13,000 in direct costs per patient. If the nearly 200 patients who were treated with primary ER over a 3-year period had, instead, gone straight to surgery the increase in costs to the hospital would have been $2,600,000. Considering charges (amount billed to the payer), primary ER represents a saving of is approximately $40,000 per patient compared to SR.

Our data should be shared with surgical colleagues and that formal or informal teams be developed to manage patients with complex polyps. In fee-for-service systems such as the United States, endoscopists should be incentivized to perform ER of benign polyps. As we move toward bundled care, payers should work toward identifying value-based solutions to managing disease. Management of large colon polyps endoscopically is one such area where care can be optimized.

Find the article abstract here.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

Editor’s Choice: Presence of small SSPs increases rate of advanced neoplasia

Strate_headshotAssociate Editor, Dr. Lisa Strate, highlights this article from the August issue “Presence of small sessile serrated polyps increases rate of advanced neoplasia upon surveillance compared with isolated low-risk tubular adenomas” by Joshua Melson, MD, Karen Ma, MD, Saba Arshad, MBBS, et al.

Large sessile serrated adenomas are associated with an increased risk of synchronous and metachronous advanced neoplasia. The association between small sessile serrated adenomas and risk of subsequent colorectal neoplasia is less clear. Understanding this association could impact recommendations for colon surveillance. In this study of nearly 800 patients with a colon adenoma and/or sessile serrated lesion on index colonoscopy, the risk of advanced neoplasia on surveillance colonoscopy was higher in patients with sessile serrated polyps than those without such lesions.

StrateFigure 1. Flow diagram of patient exclusions (some patients met more than 1 exclusion criterion), resulting in 788 patients included in the study.

I recommend this article because it raises awareness of the unique significance of sessile serrated lesions in the colon.

Small sessile polyps may increase the risk of subsequent colorectal neoplasia. Although further study is needed, this study indicates that surveillance recommendations for small sessile serrated colon polyps may need to be reconsidered.

Read the article abstract here.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

pCLE for differential diagnosis of gastric tubular adenoma and IM

Baba_headshotElisa Ryoka Baba, MD, from the Institute of Cancer of the Department of Gastroenterology, University of São Paulo Medical School, in São Paulo, Brazil writes about this video case “Probe-based confocal laser endomicroscopy for the differential diagnosis of gastric tubular adenoma and intestinal metaplasia in a patient with severe atrophic pangastritis.”

We reported a 65-year-old female Japanese descendant who presented dyspeptic complaints. The upper endoscopy revealed severe atrophic pangastritis with numerous slightly elevated whitish lesions, measuring 5 to 15 mm, mostly located at the antrum. We performed pCLE of the lesions. The images of the antrum lesions were suggestive of intestinal metaplasia, which was characterized by goblet cells filled with oval appearance dark mucin, within small and round glands. The surrounding columnar cells were small and the mucosal surface was flat. Forceps biopsies were taken and histology confirmed intestinal metaplasia. At the distal portion of gastric body, pCLE demonstrated a lesion with homogeneous elongated cells in palisade arrangement, and diminishing number of goblet cells. The tubules were also elongated, and the mucosal surface was composed of regular and homogeneous villiform structures, compatible with adenoma. It was resected by endoscopic submucosal dissection and histology confirmed low-grade adenoma.

Baba_fig Figure 1. A, Confocal endomicroscopic image of intestinal metaplasia of gastric antrum with goblet cells. B, Microscopic view of histologic findings (H&E, orig. mag. 40).

In the circumstances that upper GI endoscopy reveals lesions suspicious for neoplasia, chromoendoscopy, virtual chromoendoscopy, and magnification are some of the available tools to suggest a definitive diagnosis. In addition, probe-based confocal endomicroscopy (pCLE) has the particularity to offer virtual real time histology. In this particular video, pCLE was useful for the differential diagnosis of intestinal metaplasia and gastric adenoma, both present in this patient. The pCLE findings oriented the adequate endoscopic treatment.

The pCLE images showed an agreement with the histology during endoscopy in real time. It could be useful for the histological diagnosis of suspicious lesions, as well as for the surveillance of gastric mucosa in patients with increased risk for gastric cancer.

The correct interpretation of pCLE images is probably facilitated by the presence of an operator with some pathology expertise. In this sense, the interaction between the endoscopist and the pathologist might be useful for the pCLE learning curve.

Find more VideoGIE cases online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

Pilot study: EUS forceps biopsy

Nakai_headshotYousuke Nakai, MD, PhD, from the Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, in Tokyo, Japan discusses this New Methods article, “A pilot study of EUS-guided through-the-needle forceps biopsy (with video).”

In this pilot study, we evaluated EUS-guided through-the-needle forceps biopsy (EUS-TTNFB), using a 0.75-mm biopsy forceps through a 19-gauge FNA needle.

Advances in next-generation sequencing for personalized medicine have increased the demand for core tissue, and EUS-TTNFB enables the acquisition of additional “core” during EUS-FNA procedures. In addition, recent development of miniature devices enables various through-the-needle procedures such as cystoscopy, confocal laser endomicroscopy, portal vein pressure measurement and photodynamic therapy. This study adds to this growing variety of through-the-needle procedures.

Nakai_fig Figure 1. Miniature biopsy forceps going through a 19-gauge needle.

A total of 49 passes of EUS-TTNFB were performed in 17 cases and were technically successful in 100%. Macroscopic histologic core was obtained in 71% per pass by EUS-TTNFB and with a single pass of a 19-gaguge FNA needle the tissue acquisition rate was 89%. Of note, EUS-TTNFB provided a histologic specimen in 5 of 14 passes when subsequent EUS-FNA failed to obtain a histologic specimen.

Find the article abstract here.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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