BACKGROUND & AIMS: Clinically significant postendoscopic mucosal resection bleeding (CSPEB) is the most frequent significant complication of wide-field endoscopic mucosal resection (WF-EMR) of advanced mucosal neoplasia (sessile or laterally spreading colorectal lesions > 20 mm). CSPEB requires resource-intensive management and there is no strategy for preventing it. We investigated whether prophylactic endoscopic coagulation (PEC) reduces the incidence of CSPEB.METHODS: We performed a prospective randomized controlled trial of 347 patients (mean age, 67.1 y; 55.3% with proximal colonic lesions) undergoing WF-EMR for advanced mucosal neoplasia at 3 Australian tertiary referral centers. Patients were assigned randomly (1:1) to groups receiving PEC (n = 172) or no additional therapy (n = 175, controls). PEC was performed with coagulating forceps, applying low-power coagulation to nonbleeding vessels in the resection defect. CSPEB was defined as bleeding requiring admission to the hospital. The primary end point was the proportion of CSPEB.RESULTS: Patients in each group were similar at baseline. CSPEB occurred in 9 patients receiving PEC (5.2%) and 14 controls (8.0%; P = .30). CSPEB was associated significantly with proximal colonic location on multivariate analysis (odds ratio, 3.08; P = .03). Compared with the proximal colon, there was a significantly greater number (3.8 vs 2.1; P = .002) and mean size (0.5-1 vs 0.3-0.5 mm; P = .04) of visible vessels in the distal colon.CONCLUSIONS: PEC does not significantly decrease the incidence of CSPEB after WF-EMR. There were significantly more and larger vessels in the WF-EMR mucosal defect of distal colonic lesions, yet CSPEB was more frequent with proximal colonic lesions.

BACKGROUND/AIM:We describe a simulation and scenario-based model of training in gastrointestinal endoscopic hemostasis, which combines acquisition of procedural and problem-solving skills in a close to reality simulated clinical setting.METHODS:Two day courses in endoscopic hemostasis were conducted at the Clinical Training and Education Centre, the University of Western Australia, Perth, Australia. In total, 23 trainees were enrolled. The Erlangen Endo-Trainer simulator, porcine specimens of esophagus, stomach, and duodenum with a range of simulated bleeding sources, a separate catheter and a pump to simulate massive bleeding, and a full arm model with injectable veins were used. The SimMan monitor and software package were used to simulate hemodynamic parameters and electrocardiogram. Faculty members adjusted the rate of bleeding and vital parameters. The exercise was video recorded. On the first day, the group underwent simulator training in techniques of endoscopic hemostasis. On the second day, participants were scenario-based trained in full management of a "bleeding patient," which included resuscitation, sedation, endoscopy, and hemostasis, acting as leaders in teams of three. The course was evaluated by participants using a standardized questionnaire.RESULTS:A complex clinical setting of acute gastrointestinal bleeding was recreated with a high degree of realism. All participants reported that the simulated clinical scenario was a positive learning experience, helpful in managing complications and performing complex problem-solving tasks in a dynamic environment.CONCLUSIONS:Scenario and simulation-based training in endoscopic hemostasis may provide an opportunity to improve procedural skills and acquire practical experience in managing this medical emergency, which requires the ability to process, integrate, and adequately and quickly respond to complex information in unexpected conditions working as a team leader.

Background and Aims: Pre-cut techniques, the most commonly described being needle knife papillotomy (NK), have been used to facilitate biliary access in failed standard biliary cannulation (BC). Transpancreatic septotomy (TS) is a pre-cut technique with limited outcome data. We aim to assess the outcomes of wire assisted transpancreatic septotomy (WTS) as the primary pre-cut technique after initial failed attempted BC and to compare these with outcomes of primary NK. Methods: We retrospectively reviewed all endoscopic retrograde cholangiopancreatographies (ERCPs) performed by endoscopists who performed WTS over a 3-year period. We selected cases where WTS and/or NK were performed, and these cases were reviewed to assess for procedure related complications and BC success. Results: During the study period 1336 ERCPs were performed. WTS was performed in 53 cases. In seven cases WTS and NK were performed sequentially (resulting in immediate cannulation in all these cases). Immediate BC was achieved on first attempt in 36 (68%) WTS cases and in a further 14 cases on a repeat attempt (cumulative BC rate 94%). During the same period 66 (5%) patients underwent primary NK. In these cases initial cannulation was achieved in 50 (76%) cases and cannulation on repeat attempt in six cases (cumulative success rate 85%). Complications occurred in three WTS patients (5.6%) and seven NK patients (10.6%). The differences were not statistically significant. Conclusions: Wire assisted transpancreatic septotomy is a safe and effective alternative technique to traditional NK in patients who have failed standard BC techniques. It also allows other pre-cut techniques such as NK to be used should initial WTS be unsuccessful.

Background and Aims: In patients undergoing colonoscopy for diarrhea, when the examination is normal, the role of routine mucosal biopsy remains controversial, particularly in the open-access setting. It is uncertain whether routine ileoscopy adds anything to colonoscopy alone. We aimed to assess the yield of mucosal biopsy and ileoscopy in patients with diarrhea.Methods: We retrospectively reviewed all colonoscopies performed for diarrhea over a 9-year period in a tertiary referral center with an open-access service. We then selected cases where the examination was normal and biopsies were performed. The histopathology reports of these selected cases were then reviewed.Results: There were 1131 cases identified. The mucosal examination was normal in 465 cases (41%); 362 of these had colonic biopsies performed. Histology was normal in 316 cases (87%) and was non-specific in 28 cases (8%). Significant histopathology was present in 18 cases (5%) with a significantly higher prevalence of microscopic colitis in patients above 60 years old. Ileoscopy was performed in 508 cases and was abnormal in 26 cases (5%). The abnormality on ileoscopy was the sole abnormality in 13 cases (3%).Conclusions: Routine colonic mucosal biopsy and ileoscopy each identify significant additional pathology in 5% of cases when investigating patients with diarrhea, and are recommended as routine practice in this setting. We found ileal biopsy unhelpful when ileoscopy was normal. (C) 2002 Blackwell Science Asia Pty Ltd.

PEG has become widely accepted for providing long-term enteral nutrition safely. First introduced by Gauderer et al. 1 Gauderer MW Ponsky JL Izant Jr., RJ Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg. 1980; 15: 872-875 Abstract Full Text PDF PubMed Scopus (1758) Google Scholar in 1980, reported complication rates are low 2 Bourdel-Marchasson I Dumas F Pinganaud G Emeriau JP Decamps A. Audit of percutaneous endoscopic gastrostomy in long-term enteral feeding in a nursing home. Int J Qual Health Care. 1997; 9: 297-302 Crossref PubMed Scopus (70) Google Scholar , 3 Chowdhury MA Batey R. Complications and outcome of percutaneous endoscopic gastrostomy in different patient groups. J Gastroenterol Hepatol. 1996; 11: 835-839 Crossref PubMed Scopus (65) Google Scholar , 4 Calton WC Martindale RG Gooden SM. Complications of percutaneous endoscopic gastrostomy. Mil Med. 1992; 157: 358-360 PubMed Google Scholar , 5 Finocchiaro C Galletti R Rovera G et al. Percutaneous endoscopic gastrostomy: a long-term follow-up. Nutrition. 1997; 13: 520-523 Abstract Full Text PDF PubMed Scopus (123) Google Scholar , 6 Gutt CN Held S Paolucci V Encke A. Experiences with percutaneous endoscopic gastrostomy. World J Surg. 1996; 20 (discussion 1108-9): 1006-1008 Crossref PubMed Scopus (50) Google Scholar and the procedure is well tolerated.

BACKGROUND: Routine mucosal biopsy in patients undergoing colonoscopy for diarrhoea, in whom macroscopic examination is normal, remains controversial and practice varies widely without clear guidelines. Reported rates of clinically significant microscopic abnormalities vary from 2-27%.It is unclear if ileal biopsy adds anything to colonic biopsy alone. OBJECTIVES: We sought to evaluate the diagnostic yield of colonic and ileal mucosal biopsy in patients undergoing colonoscopy for diarrhoea in whom the macroscopic examination was normal. METHODS: We retrospectively reviewed all colonoscopies performed over a nine year period in a tertiary referral centre with an open access endoscopy service. Cases were selected where the sole indication for colonoscopy was diarrhoea, the musosa was macroscopically normal (other than diverticulosis) and biopsies were performed. Cases were excluded if the examination was inadequate. The histopathology reports of the selected cases were then reviewed. RESULTS: 362 cases were identified. Colonoscopy and biopsy was normal in 260 patients.Ileal biopsies were performed (in addition to colonic biopsies) in 158 cases, none of which revealed clinically significant abnormalities. Clinically significant histological findings were present in 18 cases (5%). Findings included collagenous colitis (5 cases), lymphocytic colitis (1 case), possible lymphocytic colitis (1 case), possible collagenous colitis (1 case), inflammatory bowel disease (2 cases), melanosis coli (2 cases) and significant eosinophil mucosal infiltration (6 cases). 28 patients (8%) had minor histological abnormalities with no specific diagnostic features. The diagnostic yield was highest in patients above 60 years old, where 10% had clinically significant histological abnormalities. All patients with collagenous colitis were female and only 1 was less than 60 years old. CONCLUSIONS: When colonoscopy is normal in patients with diarrhoea, routine colonic biopsy identifies significant pathology in 5% of cases. The diagnostic yield is highest in patients over 60 years old. Routine ileal biopsy is unhelpful.

Background: Intravariceal injection of the tissue adhesive Histoacryl (nbutyl-2-cyanoacrylate) will induce sclerosis of gastric varices, however its role in the treatment of variceal bleeding is not clear. The aim of this study was to document the outcome of patients treated with Histoacryl injection therapy (HIT) at The Wellesley Central Hospital. Methods: The patient records of all patients treated with HIT at the Wellesley Central Hospital were retrospectively reviewed and pertinent data recorded. Results: Between 1986 and 1999, 112 patients were treated with HIT on 149 occasions. The average age was 61 (range 27-80) with 64 men and 50 women. The variceal etiology was alcohol in 51 (46%), hepatitis B in 7 (6%), venous thrombosis in 6 (5%), hepatitis C in 5 (4%), other in 4 (4%) and unknown or unrecorded in 39 (35%). The varices were esophageal in 30 (27%), gastric in 31 (28%), gastric and esophageal in 44 (39%), duodenal in 2 (2%), gastric and duodenal in 3 (2%) and esophageal and duodenal in 2 (2%). Gastric varices were the site of HIT in 76 patients. The indication for endoscopy at index HIT was active bleeding in 72 (64%), recent bleeding in 21 (19%), routine follow up in 18 (16%) and occult bleeding in 1 (1%). Active bleeding was seen at endoscopy on 31 occasions in 25 patients of which 13 were gastric and 12 esophageal. Bleeding was controlled at endoscopy in 28/31 and was not recorded in 3. Bleeding was induced at endoscopy on 8 occasions (banding 3, HIT 3, overtube 1, spontaneous 1), all of which were controlled with initiation of or continued HIT. Stigmata of recent bleeding were present at endoscopy 16 times in 16 patients. Histoacryl was injected as 50% Histoacryl in Lipiodol (Ethiodized oil) (mean 3ml per treatment, range 1-10ml). Adjunct endoscopic treatment was performed on 27 occasions including banding on 25/27 occasions (24 esophageal) and epinephrine and metal clips on one occasion each. One patient had splenic artery embolisation and another had splenectomy and gastrectomy. Upper gastrointestinal tract bleeding within 30 days of the index HIT for gastric varices occurred on 6 occasions in 5 patients (7%). Complications occurred in 2 patients with an esophageal ulcer in 1 and cerebral embolism in 1. Inhospital mortality occurred in 14 patients (12%), due to bleeding in 6/14. Conclusions: HIT is a safe and effective method for the control of bleeding in gastric varices. It may also be an effective method for rescue from variceal bleeding induced by other endoscopic techniques.

Background: Benign ampullary neoplasms have traditionally been managed by surgical local excision or Whipple resection. Endoscopic techniques now provide a means of non-operative local resection. Patients and Methods: 25 pts (17 males) underwent endoscopic resection from 1989 to 1999. Mean age was 62.2 yrs (34-83). 7 pts has Familial Adenomatous Polyposis (FAP). 21 of 25 pts has sphincterotomy prior to or at ampullectomy. Resections were performed using a therapeutic duodenoscope. A monopolar polypectomy snare was employed for piecemeal (n=20) or enblock(n=5)resection. 18 pts had submucosal saline injections. Argon Plasma Coagulation (APC) was used in 6 and YAG Laser in 3 to ablate residual tissue. 20 pts had pancreatic stents to prevent pancreatitis and 6 had common bile duct stents. Results: Follow up range from 1-97 mos (average 22.5). Ampullectomy was successful in all patients with a mean of 1.3 procedures. Histology: 11 had tubulovillous adenoma, 11 tubular adenoma, 2 hamartomas, 1 adenomyoma. 9 pts had high grade and 5 had low grade dysplasia. 3 out of 9 had foci of intramucosal carcinoma. 1 died from perioperative complications, 2 refused surgery. Total recurrance rate for adenomas was 32% (8/25). The recurrance in the non FAP pts was 16.7% (3/18). In the FAP group, initial pathology showed severe dysplasia in 4 and mild dysplasia in 2. All FAP pts had reoccurance of adenoma (2 with low grade dysplasia) at follow up biopsy. Complications: 30 day: Pancreatitis - 3 mild, 1 severe (died-no pancreatic stent placement). Bleeding - 3 (2 endoscopic hemoclips, 1 surgery). Overall morbidity was 27%, mortality 4%. Conclusions: Endoscopic resection is indicated for benign ampullary tumors. Tissue acquisition is important in ruling out underlying malignancy and no patients in this series developed carcinoma in follow up. Current practice should include placement of a pancreatic stent to prevent severe pancreatitis. Background: Benign ampullary neoplasms have traditionally been managed by surgical local excision or Whipple resection. Endoscopic techniques now provide a means of non-operative local resection. Patients and Methods: 25 pts (17 males) underwent endoscopic resection from 1989 to 1999. Mean age was 62.2 yrs (34-83). 7 pts has Familial Adenomatous Polyposis (FAP). 21 of 25 pts has sphincterotomy prior to or at ampullectomy. Resections were performed using a therapeutic duodenoscope. A monopolar polypectomy snare was employed for piecemeal (n=20) or enblock(n=5)resection. 18 pts had submucosal saline injections. Argon Plasma Coagulation (APC) was used in 6 and YAG Laser in 3 to ablate residual tissue. 20 pts had pancreatic stents to prevent pancreatitis and 6 had common bile duct stents. Results: Follow up range from 1-97 mos (average 22.5). Ampullectomy was successful in all patients with a mean of 1.3 procedures. Histology: 11 had tubulovillous adenoma, 11 tubular adenoma, 2 hamartomas, 1 adenomyoma. 9 pts had high grade and 5 had low grade dysplasia. 3 out of 9 had foci of intramucosal carcinoma. 1 died from perioperative complications, 2 refused surgery. Total recurrance rate for adenomas was 32% (8/25). The recurrance in the non FAP pts was 16.7% (3/18). In the FAP group, initial pathology showed severe dysplasia in 4 and mild dysplasia in 2. All FAP pts had reoccurance of adenoma (2 with low grade dysplasia) at follow up biopsy. Complications: 30 day: Pancreatitis - 3 mild, 1 severe (died-no pancreatic stent placement). Bleeding - 3 (2 endoscopic hemoclips, 1 surgery). Overall morbidity was 27%, mortality 4%. Conclusions: Endoscopic resection is indicated for benign ampullary tumors. Tissue acquisition is important in ruling out underlying malignancy and no patients in this series developed carcinoma in follow up. Current practice should include placement of a pancreatic stent to prevent severe pancreatitis.

Background: Bile leak is the most common post-cholecystectomy complication with a variety of highly successful endoscopic therapies. In 1994, one author (MB) proposed a grading system to distinguish the severity of leak into low-grade (LG, leak identified only after intra-hepatic filling of contrast) or high-grade (HG, leak seen prior to intrahepatic filling). Subsequent therapy was based on this classification with sphincterotomy (BS) alone in LG and a stent (St) to bridge the leak in HG. Results: During a 10 yr period, 207 pts (mean age 54 yrs, 127 F) with bile leaks were referred to our unit for endoscopic management. Of these, 134 underwent laparoscopic cholecystectomy, 72 open cholecystectomy and 1 had spontaneous rupture of the bile duct. Pts presented 11.8 d (mean, range 1-50 d) after surgery. Modes of presentation were leakage of bile (drains 37%, T tube 11%, incisions 12%), pain (56%), jaundice (16%), fever (11%) and abdominal distension (7%). ERCP identified the site of leak in 204 pts: cystic duct stump in 159 (78%), duct of Luschka in 26 (13%) and other in 19 (9%). A review of the initial 85 pts classified leaks into LG and HG (see above). BS alone for LG leaks and St for HG leaks proved effective in 82/85 pts (96%). This strategy was then prospectively validated in the subsequent 122 pts. Results of the combined group (104 LG, 100 HG) are presented here. In the LG group, 75/104 pts had BS alone with improvement in 68 pts (91%). Further treatment was required in 7 pts (6 had St, 1 underwent surgery). St was the initial treatment in the remaining 29/104 pts. The reasons for this were: CBD stricture (11/29), coagulopathy preventing BS (8/29), severe sepsis (3/29), prior BS with inadequate drainage (2/29) and unclear indications (5/29). In the HG group, 97/100 pts had St. Persistent leakage necessitated re-stenting in 4/97 pts. Healing of the leak was documented on follow-up ERCP in all 97 pts. Three pts were not amenable to endoscopic therapy (2 with clips across CBD and 1 with incomplete cholecystectomy) and were referred for surgery. CBD stones were identified in 41 pts (28/104 LG, 13/100 HG) and extracted in all. The distribution of stone cases indicates no impact on severity of leak. Only 3 complications occured: 2 pts developed post-ERCP pancreatitis and 1 had duodenal perforation. There was no mortality. Conclusion: The use of this simple grading system for bile leaks and the relevent therapy has proven to be a useful tool for choice of endotherapy. The role of a stent without sphincterotomy or naso-biliary tube alone has not been evaluated in this series.

An accurate and functional system for grading acute liver allograft rejection is important for patient management, research, and communication. The Banff schema is a consensus document designed to provide an internationally accepted standard for this purpose. The aim of this study is to determine if application of the Banff schema would significantly alter the grading of acute liver allograft rejection compared with the Birmingham system. One hundred twenty-four post-liver transplantation biopsies performed by the Western Australian Liver Transplantation Service between 1992 and 1997 were retrospectively analyzed by a pathologist and a hepatologist. Each was supplied with a brief clinical history before applying the Banff and Birmingham criteria. Results were compared with each other and to the diagnosis made at the time of the biopsy, which was based on the European grading system. Rejection was diagnosed by the reviewers in 61 of 124 biopsy specimens according to the criteria of Snover. The Banff schema and Birmingham system agreed on the grade of rejection in 22 of the 61 biopsy specimens. The Banff schema elevated the grade of rejection in 39 specimens by an increment of one. In no instance did the Banff schema reduce the grade. Comparison between the Banff schema and diagnosis made at the time of biopsy showed agreement in 39 specimens, whereas the Banff schema elevated the grade in 15 specimens and reduced the grade in 23 specimens. In comparison to the Birmingham system, the Banff schema elevated the grade of liver allograft rejection in the majority of biopsy specimens, and this has the potential to alter clinical management with the adoption of the Banff schema or if the systems are used interchangeably.

BACKGROUND:A review of biliary tract complications was performed in 32 patients who underwent liver transplantation by the Western Australian Liver Transplantation Service during a 2-year period.METHODS:A review was made of patient data collected prospectively, and confirmed by retrospective casenote review.RESULTS:A total of 30 patients (31 grafts) survived more than 2 days after transplantation, and of these 28 had an end-to-end biliary anastomosis. Analysis of these 28 patients found that eight of 17 patients with T-tubes had complications: three leaks at T-tube removal; two strictures and leaks; and three strictures. Six of 11 patients without a T-tube had complications: one leak; three strictures and leaks; and two strictures. Predisposing factors were present in eight of the 14 patients with biliary tract complications: hepatic artery stenosis in three; and one each with hepatic artery thrombosis; biliary calculi; donor-recipient bile duct mismatch; severe cellular rejection: and prolonged postoperative hypotension. Acute rejection, steroid-resistant rejection and cytomegalovirus infection were all significantly more common in those patients with biliary tract complications compared with those without. There was no difference in cold ischaemic time or donor age. Twelve of the 14 patients with biliary complications required endoscopic stenting with or without balloon dilation, and eight patients required radiological percutaneous drainage of bile collections. Only one patient required biliary reconstruction and two patients required re-transplantation. One patient died of uncontrolled infection. Of three patients who underwent choledochojejunostomy, biliary leak developed in two patients, both of whom required operative biliary and hepatic repair. One of the three patients died from disseminated Aspergillus infection. The median total hospital stay of patients with biliary complications was 61 days (range: 30-180 days) compared with 33.5 days (range: 22-70 days) for patients without. Of patients with end-to-end biliary anastomosis, 50% had biliary tract complications and more than half of these had predisposing factors. The majority of biliary complications were managed without the need for surgery.CONCLUSION:A total of 50% of patients with end-to-end biliary anastomosis had biliary tract complications. Biliary strictures presented later than leaks, and the majority of these complications were managed without the need for surgery.

OBJECTIVE:To assess performance of the Western Australian Liver Transplantation Service in the light of debate about whether small transplant centres can produce optimal outcomes.DESIGN:Review of patient data collected prospectively and confirmed by retrospective casenote review.SUBJECTS:All patients referred to the Western Australian Liver Transplantation Assessment Panel. Those who underwent transplantation at the Western Australian Liver Transplantation Service (to June 1996) were compared with those referred to other transplant centres before the elective service was established in July 1994.OUTCOME MEASURES:Numbers of referrals and transplants; characteristics of the transplantation procedure; and patient outcomes.RESULTS:Annual referrals for liver transplant in Western Australia (WA) increased from 12 (1985-1993) to 41 (July 1994-June 1996), with five deaths on the "activated" list before July 1994, but none after. To June 1996, 30 patients had received 31 transplants by the Western Australian Liver Transplantation Service (two emergency transplants in 1992 and 1993, respectively, and 28 elective transplants and one retransplant after June 1994), with median operation time of 5.5 hours (range, 3-10.5), median red cell transfusion of 4 units (range, 0-55) and median hospital stay of 24 days (range, 12-128). There was no severe primary graft dysfunction. Major complications included hepatic artery thrombosis or stenosis (5 patients, one requiring retransplant), biliary stricture not associated with hepatic artery pathology, bile leak and perihepatic abscess (4 each), and cytomegalovirus infection (3). Patient survival was 83% and graft survival 81% at a mean follow-up of 13 months, compared with 86% and 83%, respectively, at one year for WA patients who received transplants elsewhere before July 1994.CONCLUSIONS:Performance of the Western Australian Liver Transplantation Service compares favourably with national and international standards, and WA patients receiving liver transplants have increased dramatically since the service was established. This supports the viability of committed liver transplantation centres with only 10-15 patients a year and argues the need for nationally decentralised services.