Objective: The purpose of this review is to familiarize the reader with endoscopic resection (ER) options for early -stage esophageal cancers. Background: Esophageal cancer consists of squamous cell carcinoma (SCC) and adenocarcinoma (EAC) and is associated with significant worldwide morbidity and mortality. People who are diagnosed after the development of symptoms, such as dysphagia, typically have more advanced tumor stages and poorer longterm outcomes. surgical esophagectomy is a historic gold standard curative treatment for patients with esophageal cancer. Endoscopic screening and surveillance in at -risk patients, such as those with Barrett's esophagus, allows detection of esophageal cancer at an earlier stage. Recent developments in endoscopic techniques allow endoscopic removal of very early stage esophageal cancers, sparing some patients the need for esophagectomy, which harbors significant morbidity and mortality. Methods: An electronic search and data extraction of literature from inception was performed to present a narrative review on the endoscopic management of early esophageal cancer. Conclusions: The goal for curative surgical management of esophageal tumors is to achieve an R0 en bloc resection. The earliest stages of esophageal cancer (carcinoma -in -situ, moderately -to -well differentiated pT1a carcinomas without lymphatic or vascular invasion) of are now increasingly treated with ER techniques, such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). These effective resection techniques offer an additional curative treatment option for carefully selected patients. However, ER is only curative in patients without locoregional or distant metastatic disease. In this review we discuss the different approaches to endoscopic management of early esophageal cancer.

Acute Gastrointestinal Bleeding Acute gastrointestinal bleeding (GIB) is a common clinical entity. Expert management of acute GIB requires collaborative care between internists and other specialists. This article reviews the presentation, treatment, and prevention of acute GIB using recommendations from recent guidelines and expert panel reviews. The article acknowledges the pivotal role played by primary care providers in the inpatient and outpatient management of acute GIB.

Albert Civitarese: NO financial relationship with a commercial interest | Neda Khanjari: NO financial relationship with a commercial interest | Scott Levin: NO financial relationship with a commercial interest | Reza Milano: NO financial relationship with a commercial interest | Gaurav Parmar: NO financial relationship with a commercial interest | Neil Sood: NO financial relationship with a commercial interest | Mark McFarland: NO financial relationship with a commercial interest | Krupa Patel: NO financial relationship with a commercial interest | Ussama Ghumman: NO financial relationship with a commercial interest | Jeffrey Tokar: YES financial relationship with a commercial interest;Fujifilm Endoscopy:Consulting | Minhhuyen Nguyen: NO financial relationship with a commercial interest | Jennifer Higa: NO financial relationship with a commercial interest | David Weinberg: NO financial relationship with a commercial interest | Michael Bartel: NO financial relationship with a commercial interest

Acute gastrointestinal bleeding (GIB) is a common clinical entity. Expert management of acute GIB requires collaborative care between internists and other specialists. This article reviews the presentation, treatment, and prevention of acute GIB using recommendations from recent guidelines and expert panel reviews. The article acknowledges the pivotal role played by primary care providers in the inpatient and outpatient management of acute GIB.

Michael Bartel: NO financial relationship with a commercial interest | Thiruvengadam Muniraj: NO financial relationship with a commercial interest | Jordan Anaokar: NO financial relationship with a commercial interest | Neda Khanjari: NO financial relationship with a commercial interest | Gaurav Parmar: NO financial relationship with a commercial interest | Praneet Wander: NO financial relationship with a commercial interest | Ussama Ghumman: NO financial relationship with a commercial interest | Jay Parekh: NO financial relationship with a commercial interest | Reza Milano: NO financial relationship with a commercial interest | Sameer Dawoodi: NO financial relationship with a commercial interest | Jeffrey Tokar: YES financial relationship with a commercial interest;Fujifilm Endoscopy:Consulting | Saraswathi Cappelle: NO financial relationship with a commercial interest | Harry Aslanian: YES financial relationship with a commercial interest;olympus:Consulting;boston scientific:Consulting | Sanjay Reddy: NO financial relationship with a commercial interest

Incidental discovery of nonampullary and ampullary duodenal adenomas (DAs) during a routine EGD often evokes a ripple effect of clinical considerations. “Should this finding prompt additional imaging to exclude jejunoileal adenomas (JIAs)?” and “Is this a sporadic DA, or does the patient have an underlying hereditary cancer syndrome?” The study by Awadie et al1Awadie H. Klein A. Tate D. et al.The prevalence of small-bowel polyps on video capsule endoscopy in patients with sporadic duodenal or ampullary adenomas.Gastrointest Endosc. 2021; 93: 630-636Abstract Full Text Full Text PDF Scopus (1) Google Scholar in the current issue of Gastrointestinal Endoscopy used video capsule endoscopy (VCE) to determine the prevalence of downstream small-bowel adenomas in a cohort of patients with incidentally detected DAs. The authors speculated that the prevalence of VCE-detected small-bowel adenomas would fall between the low published rate observed in obscure GI bleeding (∼10%) and the comparatively higher rate observed in hereditary polyposis syndromes. Herein, we provide a brief review of selected hereditary syndromes associated with small-bowel adenomas. Familial adenomatous polyposis (FAP) is an autosomal dominant condition resulting from mutations in the APC tumor suppressor gene. Nearly all persons (>90%) will experience duodenal adenomas in their lifetime. Duodenal cancer (nonampullary and ampullary) is the second most common cause of cancer death (4%-10% by age 60). A person’s modified Spigelman stage (range 0-IV) helps predict their risk of duodenal cancer. This scoring system incorporates duodenal adenoma size, number, and histologic features (ampullary adenomas are excluded from the calculation but remain a separate risk factor for duodenal cancer). Persons with modified Spigelman stage IV have a duodenal cancer risk of approximately 36%. Jejunal and ileal adenomas occur less frequently than DAs in patients with FAP (45%-75% and 10%-20%, respectively). Interestingly, JIAs are uncommon without coexistent DAs; conversely, they are more likely to occur in persons with higher Spigelman stage. The long-term risk of JIAs progressing to cancer in FAP is unknown. The effectiveness of endoscopic therapy (polypectomy, ablation) directed at lowering the Spigelman score remains controversial; the absolute magnitude of lifetime risk reduction is not clearly defined. The American Society for Gastrointestinal Endoscopy (ASGE) and the European Society of Gastrointestinal Endoscopy (ESGE) guidelines endorse endoscopic resection of duodenal adenomas ≥10 mm (weak/conditional recommendations based on low quality of evidence).2Yang J. Gurudu S.R. Koptiuch C. et al.American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in familial adenomatous polyposis syndromes.Gastrointest Endosc. 2020; 91: 963-982 e962Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar,3van Leerdam M.E. Roos V.H. van Hooft J.E. et al.Endoscopic management of polyposis syndromes: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.Endoscopy. 2019; 51: 877-895Crossref PubMed Scopus (38) Google Scholar We use targeted endoscopic therapy for duodenal adenomas in FAP patients, particularly those with advanced Spigelman stage.4Moussata D. Napoleon B. Lepilliez V. et al.Endoscopic treatment of severe duodenal polyposis as an alternative to surgery for patients with familial adenomatous polyposis.Gastrointest Endosc. 2014; 80: 817-825Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar In addition, as per the ASGE guideline, we also pursue small-bowel evaluation in asymptomatic FAP individuals with advanced Spigelman stage every 2 to 4 years (or before duodenectomy), using VCE or magnetic resonance enterography (MRE), reserving direct enteroscopy (eg, double-balloon or single-balloon enteroscopy) for those in whom a JIA ≥10 mm is suspected.2Yang J. Gurudu S.R. Koptiuch C. et al.American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in familial adenomatous polyposis syndromes.Gastrointest Endosc. 2020; 91: 963-982 e962Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar MUTYH-associated polyposis (MAP) is an autosomal recessive syndrome resulting from mutations in a DNA base excision repair gene (MUTYH). The estimated cumulative colorectal cancer (CRC) risk is 63% by age 60.5Nieuwenhuis M.H. Vogt S. Jones N. et al.Evidence for accelerated colorectal adenoma--carcinoma progression in MUTYH-associated polyposis?.Gut. 2012; 61: 734-738Crossref PubMed Scopus (37) Google Scholar MAP should be considered for persons with ≥20 colon adenomas (cumulative), ≥10 adenomas on a single examination, or features of serrated polyposis syndrome with concomitant conventional adenomas. The lifetime duodenal cancer risk in MAP is ≤4%.6Pavlovic-Markovic A. Dragasevic S. Krstic M. Stojkovic Lalosevic M. Milosavljevic T. Assessment of duodenal adenomas and strategies for curative therapy.Dig Dis. 2019; 37: 374-380Crossref PubMed Scopus (3) Google Scholar DAs are less common (17%-25%) than FAP and have a later age at onset. There is limited information about JIAs in MAP, and therefore there are inadequate data upon which to base screening recommendations. Some advocate following a paradigm similar to that used for FAP patients. Hereditary nonpolyposis colon cancer (Lynch syndrome [LS]) is an autosomal dominant condition resulting from mutations in DNA mismatch repair genes. Small-bowel cancer occurs in 0.4% to 12%7Giardiello F.M. Allen J.I. Axilbund J.E. et al.Guidelines on genetic evaluation and management of Lynch syndrome: a consensus statement by the U.S. Multi-Society Task Force on Colorectal Cancer.Gastrointest Endosc. 2014; 80: 197-220Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar of people with LS and may be more common in persons with MLH1/MSH2 variants. The role of routine small-bowel evaluation in LS is controversial. Screening VCE does not appear to be cost effective,8Watson P. Vasen H.F.A. Mecklin J.P. et al.The risk of extra-colonic, extra-endometrial cancer in the Lynch syndrome.Int J Cancer. 2008; 123: 444-449Crossref PubMed Scopus (422) Google Scholar and many VCE-detected “polyps” prove to be clinically insignificant and/or nonneoplastic on further evaluation. The U.S. Multi-Society Task Force on CRC and the ESGE advise against routine small-bowel inspection; the former encourages examination of the entire duodenum and distal ileum during EGD and colonoscopy.3van Leerdam M.E. Roos V.H. van Hooft J.E. et al.Endoscopic management of polyposis syndromes: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.Endoscopy. 2019; 51: 877-895Crossref PubMed Scopus (38) Google Scholar,7Giardiello F.M. Allen J.I. Axilbund J.E. et al.Guidelines on genetic evaluation and management of Lynch syndrome: a consensus statement by the U.S. Multi-Society Task Force on Colorectal Cancer.Gastrointest Endosc. 2014; 80: 197-220Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar,9Schulmann K. Brasch F.E. Kunstmann E. et al.HNPCC-associated small bowel cancer: clinical and molecular characteristics.Gastroenterology. 2005; 128: 590-599Abstract Full Text Full Text PDF PubMed Scopus (144) Google Scholar We have thus far discussed the risk of small-bowel neoplasia in patients with FAP, MAP, and LS. In light of the ASGE recommendations to reserve routine jejunoileal screening with VCE primarily for FAP patients with high Spigelman stage, it begs the question: is there any justifiable role for it in cases of sporadic ampullary or nonampullary duodenal adenomas (detected in 0.04%-0.12% and <0.5%, respectively)?6Pavlovic-Markovic A. Dragasevic S. Krstic M. Stojkovic Lalosevic M. Milosavljevic T. Assessment of duodenal adenomas and strategies for curative therapy.Dig Dis. 2019; 37: 374-380Crossref PubMed Scopus (3) Google Scholar The study by Awadie et al1Awadie H. Klein A. Tate D. et al.The prevalence of small-bowel polyps on video capsule endoscopy in patients with sporadic duodenal or ampullary adenomas.Gastrointest Endosc. 2021; 93: 630-636Abstract Full Text Full Text PDF Scopus (1) Google Scholar is the largest prospective study designed to define the prevalence of downstream adenomas in patients with sporadic DAs.1Awadie H. Klein A. Tate D. et al.The prevalence of small-bowel polyps on video capsule endoscopy in patients with sporadic duodenal or ampullary adenomas.Gastrointest Endosc. 2021; 93: 630-636Abstract Full Text Full Text PDF Scopus (1) Google Scholar In this single-center study, data were collected from 2 cohorts of patients who underwent VCE prompted by different indications: 100 with DAs found on EGD (25% ampullary, 75% nonampullary) and 101 with obscure GI bleeding or iron-deficiency anemia. No polyps were found by the use of VCE in either group. This finding potentially disproves the authors’ hypothesis that patients with DAs carry an intermediate risk of downstream adenomas. If valid, this would obviate the role for VCE in these patients. However, the clinical impact and real-world applicability of these striking results are diminished by their overestimation that synchronous downstream small-bowel polyps would be present in 25% of DA patients, which resulted in an underpowered study. As acknowledged by the authors, a sufficiently powered study (to confirm these results) might be prohibitively large, requiring a study cohort of >1100 patients. In spite of the underpowered nature of the study, the absence of any findings in their 100 patients with DAs makes a reasonably compelling argument against the routine use of VCE for every sporadic patient with DA. Critics might assert that overtube-assisted (double-balloon or single-balloon) enteroscopy is a superior modality for detecting small-bowel masses, citing reports that VCE misses small-bowel tumors in 10% to 66% of cases.10Bartel M.J. Stark M.E. Lukens F.J. Clinical review of small-bowel endoscopic imaging.Gastroenterol Hepatol (NY). 2014; 10: 718-726PubMed Google Scholar However, a recent meta-analysis reported a high concordance rate for overtube-assisted enteroscopy and VCE for detection of small-bowel polyps and tumors.11Sulbaran M. de Moura E. Bernardo W. et al.Overtube-assisted enteroscopy and capsule endoscopy for the diagnosis of small-bowel polyps and tumors: a systematic review and meta-analysis.Endosc Int Open. 2016; 4: E151-E163Crossref PubMed Google Scholar Compared with other forms of noninvasive imaging, VCE and MRE may be superior for detection of polyps. Although MRE and VCE appear comparable at detecting polyps >15 mm, VCE may excel at detecting smaller polyps, whereas MRE may more accurately localize the polyps.12Caspari R. von Falkenhausen M. Krautmacher C. et al.Comparison of capsule endoscopy and magnetic resonance imaging for the detection of polyps of the small intestine in patients with familial adenomatous polyposis or with Peutz-Jeghers' syndrome.Endoscopy. 2004; 36: 1054-1059Crossref PubMed Scopus (186) Google Scholar We favor VCE and MRE as the initial tests for asymptomatic persons in whom small-bowel screening is being considered, because they are noninvasive and have an acceptable diagnostic yield. Therefore, in our opinion, the choice of VCE in the current study is justifiable. The investigators also retrieved colonoscopy data (from the preceding 5 years) in >80% of both cohorts and found that DA patients had significantly more colorectal polyps than did the non-DA patients (polyps of any histologic characteristics in 61% vs 37%; adenomatous polyps in 46% vs 24%). Advanced adenomas (HGD, >10 mm, or villous histologic appearance) were also more common in the DA group (18% vs 5%), suggesting at least a 2-fold greater risk compared with the general population. We believe there are 3 salient take-home messages from the current study. First, the low detection rate for JIAs in patients with DAs suggests that routine VCE screening may not be merited. However, future practice would be best informed by additional studies to corroborate the authors’ findings. Second, by excluding subjects with broader clinical evidence of a hereditary GI cancer syndrome, the investigators highlight the importance of an accurate and comprehensive family history, indirectly reminding readers that the absence of jejunoileal polyps in a patient with DAs does not exclude the possibility of an underlying hereditary syndrome. Last, sporadic patients with DAs appear to be at increased risk of colorectal neoplasia, a highly germane finding supported by other studies. In conclusion, for sporadic patients with DAs, it appears appropriate to defer capsule endoscopy and focus on the colon instead. Dr Tokar is a consultant for Fujifilm Corporation. The other author disclosed no financial relationships. The prevalence of small-bowel polyps on video capsule endoscopy in patients with sporadic duodenal or ampullary adenomasGastrointestinal EndoscopyVol. 93Issue 3PreviewAlthough sporadic duodenal and/or ampullary adenomas (DAs) are uncommon, they are increasingly diagnosed during upper endoscopy. These patients have a 3- to 7-fold increased risk of colonic neoplasia compared with the normal population. It is unknown, however, whether they also have an increased risk of additional small-bowel (SB) polyps. Our aim was to establish the prevalence of SB polyps in patients with DA. Full-Text PDF

Introduction of the full-thickness resection device (FTRD) has allowed endoscopic resection of difficult lesions such as those with deep wall origin/infiltration or those located in difficult anatomic locations. The aim of this study is to assess the outcomes of the FTRD among its early users in the USA. Patients who underwent endoscopic full-thickness resection (EFTR) for lower gastrointestinal tract lesions using the FTRD at 26 US tertiary care centers between 10/2017 and 12/2018 were included. Primary outcome was R0 resection rate. Secondary outcomes included rate of technical success (en bloc resection), achievement of histologic full-thickness resection (FTR), and adverse events (AE). A total of 95 patients (mean age 65.5 ± 12.6 year, 38.9% F) were included. The most common indication, for use of FTRD, was resection of difficult adenomas (non-lifting, recurrent, residual, or involving appendiceal orifice/diverticular opening) (66.3%), followed by adenocarcinomas (22.1%), and subepithelial tumors (SET) (11.6%). Lesions were located in the proximal colon (61.1%), distal colon (18.9%), or rectum (20%). Mean lesion diameter was 15.5 ± 6.4 mm and 61.1% had a prior resection attempt. The mean total procedure time was 59.7 ± 31.8 min. R0 resection was achieved in 82.7% while technical success was achieved in 84.2%. Histologically FTR was demonstrated in 88.1% of patients. There were five clinical AE (5.3%) with 2 (2.1%) requiring surgical intervention. Results from this first US multicenter study suggest that EFTR with the FTRD is a technically feasible, safe, and effective technique for resecting difficult colonic lesions.

Many endoscopy centers utilize anesthesia providers for sedation. Incentives between academic and private practice anesthesia models can vary. Our endoscopy center utilized 3 different anesthesia groups over 10-year period; one academic group (group 2: 2013-2016), and two private practice groups with different provider incentives (group 1: 2010-2013, group 3: 2016 until today). One example of incentive variability: certified registered nurse anesthetists (CRNA) in group 3 are permitted to leave work early when all scheduled procedures are finished.

646 Background: Multiple studies have shown the superiority of biliary metal compared with plastic stents for pre-operative (preop) biliary drainage in pancreatic cancer (PDAC). Despite the importance of preop cross-sectional imaging, particularly in the era of neoadjuvant treatment, there is no data on the impact of such stents on the quality of preop cross-sectional imaging. We hypothesis, that biliary metal stents negatively impact the accuracy of preop cross-sectional imaging in pancreatic cancer, with unknown impact for the adequacy of surgical candidacy. Methods: Data of all patients undergoing pancreatic resection for PDAC between 1/1/2012 and 1/1/2018 was retrospectively abstracted. Clinical staging based on preop cross-sectional imaging following biliary stent placement (within 2 months prior surgical resection) was compared with the surgical pathology (staging gold standard). Accuracy of clinical and surgical pathology staging was compared. Logistic regression was performed to control for biliary stent type, neoadjuvant treatment and patient baseline characteristics including BMI and type of imaging. Results: 312 patients underwent pancreatic resections. 118 patients required preop biliary drainage in setting of PDAC, including 92 ERCPs of which 83 were successful (46 plastic and 37 metal stents). 76 patients underwent neoadjuvant chemoradiation therapy. Surgical pathology revealed following stages: 0 n = 4, 1A n = 5, 1B n = 8, 2A n = 20, 2B n = 24, 3 n = 1, 4 n = 14. 96% underwent preop CT and 4% MRI pancreas protocol imaging. Exact correlation between clinical and surgical pathology was present in only 48% of cases (57% plastic, 46% metal stent), with 28% of clinical T overstaging, 4% clinical T understaging, 16% clinical N understaging and 4% unable to stage due to artefacts. More importantly, 8% patients were incorrectly staged to be surgical candidates (14% plastic, 6% metal). Controlling for stent type, neoadjuvant treatment and BMI did not impact preop cross-sectional imaging accuracy. Conclusions: Despite their impact on preop cross-imaging biliary metal stents did not negatively impact the accuracy and patient selection for surgical candidacy compared with biliary plastic stents in PDAC.

BACKGROUND AND AIMS:Simulation refers to educational tools that allow for repetitive instruction in a nonpatient care environment that is risk-free. In GI endoscopy, simulators include ex vivo animal tissue models, live animal models, mechanical models, and virtual reality (VR) computer simulators. METHODS:After a structured search of the peer-reviewed medical literature, this document reviews commercially available GI endoscopy simulation systems and clinical outcomes of simulation in endoscopy. RESULTS:Mechanical simulators and VR simulators are frequently used early in training, whereas ex vivo and in vivo animal models are more commonly used for advanced endoscopy training. Multiple studies and systematic reviews show that simulation-based training appears to provide novice endoscopists with some advantage over untrained peers with regard to endpoints such as independent procedure completion and performance time, among others. Data also suggest that simulation training may accelerate the acquisition of specific technical skills in colonoscopy and upper endoscopy early in training. However, the available literature suggests that the benefits of simulator training appear to attenuate and cease after a finite period. Further studies are needed to determine if meeting competency metrics using simulation will predict actual clinical competency. CONCLUSIONS:Simulation training is a promising modality that may aid in endoscopic education. However, for widespread incorporation of simulators into gastroenterology training programs to occur, simulators must show a sustained advantage over traditional mentored teaching in a cost-effective manner. Because most studies evaluating simulation have focused on novice learners, the role of simulation training in helping practicing endoscopists gain proficiency using new techniques and devices should be further explored.

Data on the efficacy of intralesional steroid injection as treatment modality for benign esophageal anastomotic strictures is conflicting. Most prior studies and meta-analysis combined the outcomes of different esophageal strictures etiologies. In this analysis, we focus solely on benign esophageal anastomotic stricture.

Editorials20 August 2019Colonoscopic Polypectomy in Patients Receiving Anticoagulation Therapy: Some Like It ColdJeffrey L. Tokar, MD and Michael J. Bartel, MDJeffrey L. Tokar, MDFox Chase Cancer Center, Philadelphia, Pennsylvania (J.L.T., M.J.B.)Search for more papers by this author and Michael J. Bartel, MDFox Chase Cancer Center, Philadelphia, Pennsylvania (J.L.T., M.J.B.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M19-1708 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Despite best efforts, medical and surgical interventions have inherent risks, and colonoscopy is no exception. Although colonoscopic complications (such as bleeding) are uncommon among persons with average risk, the chances of them occurring increase when polypectomy is performed, particularly in patients receiving antithrombotic medications. Polypectomy risk may be influenced further by tool selection, removal technique (by fluid injected submucosally beneath the polyp, electrical current, or both), technical proficiency, and periprocedural antithrombotic management decisions.Many professional societies advocate temporary withdrawal of oral anticoagulants and case-by-case decision making regarding heparin bridging (HB) on the basis of a patient's estimated risk for thromboembolic ...References1. Douketis JD, Spyropoulos AC, Kaatz S, et al; BRIDGE Investigators. Perioperative bridging anticoagulation in patients with atrial fibrillation. N Engl J Med. 2015;373:823-33. [PMID: 26095867] doi:10.1056/NEJMoa1501035 CrossrefMedlineGoogle Scholar2. Lin D, Soetikno RM, McQuaid K, et al. Risk factors for postpolypectomy bleeding in patients receiving anticoagulation or antiplatelet medications. Gastrointest Endosc. 2018;87:1106-1113. [PMID: 29208464] doi:10.1016/j.gie.2017.11.024 CrossrefMedlineGoogle Scholar3. Pohl H, Srivastava A, Bensen SP, et al. Incomplete polyp resection during colonoscopy—results of the complete adenoma resection (CARE) study. Gastroenterology. 2013;144:74-80.e1. [PMID: 23022496] doi:10.1053/j.gastro.2012.09.043 CrossrefMedlineGoogle Scholar4. Horiuchi A, Nakayama Y, Kajiyama M, et al. Removal of small colorectal polyps in anticoagulated patients: a prospective randomized comparison of cold snare and conventional polypectomy. Gastrointest Endosc. 2014;79:417-23. [PMID: 24125514] doi:10.1016/j.gie.2013.08.040 CrossrefMedlineGoogle Scholar5. Kawamura T, Takeuchi Y, Asai S, et al. A comparison of the resection rate for cold and hot snare polypectomy for 4-9 mm colorectal polyps: a multicentre randomised controlled trial (CRESCENT study). Gut. 2018;67:1950-1957. [PMID: 28970290] doi:10.1136/gutjnl-2017-314215 CrossrefMedlineGoogle Scholar6. Piraka C, Saeed A, Waljee AK, et al. Cold snare polypectomy for non-pedunculated colon polyps greater than 1 cm. Endosc Int Open. 2017;5:E184-E189. [PMID: 28331902] doi:10.1055/s-0043-101696 CrossrefMedlineGoogle Scholar7. Takeuchi Y, Mabe K, Shimodate Y, et al. Continuous anticoagulation and cold snare polypectomy versus heparin bridging and hot snare polypectomy in patients on anticoagulants with subcentimeter polyps. A randomized controlled trial. Ann Intern Med. 2019;171:229-37. doi:10.7326/M19-0026 LinkGoogle Scholar8. Arimoto J, Chiba H, Ashikari K, et al. Safety of cold snare polypectomy in patients receiving treatment with antithrombotic agents. Dig Dis Sci. 2019. [PMID: 30684074] doi:10.1007/s10620-019-5469-1 Google Scholar9. Shioji K, Suzuki Y, Kobayashi M, et al. Prophylactic clip application does not decrease delayed bleeding after colonoscopic polypectomy. Gastrointest Endosc. 2003;57:691-4. [PMID: 12709699] CrossrefMedlineGoogle Scholar10. Pohl H, Grimm IS, Moyer MT, et al. Clip closure prevents bleeding after endoscopic resection of large colon polyps in a randomized trial. Gastroenterology. 2019. doi:10.1053/j.gastro.2019.03.019 CrossrefGoogle Scholar Author, Article, and Disclosure InformationAffiliations: Fox Chase Cancer Center, Philadelphia, Pennsylvania (J.L.T., M.J.B.)Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-1708.Corresponding Author: Jeffrey L. Tokar, MD, Fox Chase Cancer Center, Department of Medicine, 333 Cottman Avenue, Philadelphia, PA 19111; e-mail, jeffrey.[email protected]edu.Current Author Addresses: Dr. Tokar: Fox Chase Cancer Center, Department of Medicine, 333 Cottman Avenue, Philadelphia, PA 19111.Dr. Bartel: 738 Market Street, Apartment 704, Philadelphia, PA 19106.This article was published at Annals.org on 16 July 2019. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoContinuous Anticoagulation and Cold Snare Polypectomy Versus Heparin Bridging and Hot Snare Polypectomy in Patients on Anticoagulants With Subcentimeter Polyps Yoji Takeuchi , Katsuhiro Mabe , Yuichi Shimodate , Shinji Yoshii , Shinya Yamada , Mineo Iwatate , Takuji Kawamura , Kinichi Hotta , Koji Nagaike , Nobuaki Ikezawa , Tomoaki Yamasaki , Yoriaki Komeda , Satoshi Asai , Yasuhiro Abe , Takuji Akamatsu , Yuko Sakakibara , Hisatomo Ikehara , Yuzuru Kinjo , Takashi Ohta , Yoko Kitamura , Takashi Shono , Takuya Inoue , Yoshio Ohda , Nozomu Kobayashi , Tokuma Tanuma , Ryu Sato , Taku Sakamoto , Naohiko Harada , Akiko Chino , Hideki Ishikawa , Masanori Nojima , Toshio Uraoka , and Metrics 20 August 2019Volume 171, Issue 4Page: 285-286KeywordsAnticoagulantsColonoscopyHemorrhageHemostaticsHeparinOdds ratioPolypectomiesSafetySafety studiesThromboembolism ePublished: 16 July 2019 Issue Published: 20 August 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. 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The full-thickness resection device (FTRD) was recently introduced in the US and has made endoscopic resection of difficult lesions and those with deep wall origin/infiltration possible using non-exposure resection technique. Although initial studies were promising, outcome results of FTRD in the literature are scarce.

Benign biliary strictures can be treated with plastic stents and self-expandable metal stents (SEMS). This review article delineates the latest scientific evidence for their usage. Despite evolving literature on both type of stents as treatment modalities of benign biliary strictures, which encompass mainly anastomotic strictures and strictures related to chronic pancreatitis, no final conclusions can be drawn regarding the superiority of a particular stent. SEMS tend to have higher stricture resolution rates and fewer procedural requirements which are partly offset by higher stent migration and stricture recurrence rates compared with plastic stents. Additional studies focusing on new SEMS types with anti-migration features as well as cost-effectiveness calculations are necessary for clinical decision-making when treating patients with benign biliary strictures.

Deciding to perform antegrade or retrograde double-balloon enteroscopy (DBE) accordingly to identify findings on video capsule endoscopy (VCE) can be challenging. We ought to develop a model to facilitate the decision making process on the DBE approach according to VCE findings and other possible pertinent factors, like intake of opioid and prior bowel surgery.

The new EN-580T double balloon enteroscope (DBE) system from Fujifilm has improved image quality compared with its predecessor, the EN-450 DBE system which was introduced in 2004. Historically, the diagnostic yield of DBE approaches only 66%, depending on the procedure indication. Our goal was to compare the outcome of the new EN-580T enteroscope system to the EN-450T5 enteroscope system in terms of the diagnostic yield. 50 consecutive patients who underwent DBE with the new EN-580T system between September 2016 and June 2017 at our tertiary center were matched according to the procedure indication in a 1:2 ratio with 100 consecutive patents that underwent DBE with the EN-450T5 system between February 2015 and September 2016. The included procedure indications were overt and occult obscure gastrointestinal bleeding (OGIB), abnormal cross-sectional imaging and abnormal video capsule endoscopy. The primary outcome of interest was to compare the diagnostic yield of DBE. 50 patients underwent 62 DBE (46 anterograde, 16 retrograde) with the new EN-580T DBE system for overt OGIB (46%) and occult OGIB (30%). These patients were compared with 100 patients who underwent 119 DBE (90 upper, 29 lower) with the EN-450T5 DBE system for overt (46%) and occult (30%). There was no significant difference in the baseline characteristics age, gender, antiplatelet, anticoagulation, NSAID use and blood product transfusion requirement (Table 1). Both DBE scope systems achieved comparable intubation depth on anterograde and retrograde intubation (Table 1). Although there was no statistically significant difference between the proportion of the diagnostic findings and the diagnostic yield between both DBE systems, there was a trend of a higher diagnostic yield with the new EN-580T enteroscope system, particularly for detecting patients with angioectasia (NS). In our experience, the new EN-580T enteroscope is a valuable instrument given its improved image and color resolution, in addition to other advantages such as a larger working channel. Our initial evaluation did not show any improvement of DBE outcome with the EN-580T enteroscope. However, we cannot exclude a type II statistical error, as there was a trend towards an improved diagnostic yield.Tabled 1Table 1ENT-580T (n=50)EN-450T5 (n=100)p-valueAge, mean years (SD)70.3 (10.7)68.6 (14)0.4521Gender, % male31 (62%)50 (50%)0.2242Indication, n (%)Overt GI bleed23 (46%)46 (46%)Occult GI bleed15 (30%)30 (30%)Abnormal CT/MRI2 (4%)4 (4%)Abnormal video capsule10 (20%)20 (20%)DBE, n (%)0.5743Anterograde34 (68%)71 (71%)Retrograde4 (8%)10 (10%)Anterograde + Retrograde12 (24%)19 (19%)DBE anterograde, mean (SD)Intubation depth244.8 cm (77.4)223.4 cm (69.4)0.1381Scope time86.2 min (45)69.4 min (23)0.0071DBE retrograde, mean (SD)Intubation depth154.7 cm (63.4)141.3 cm (70.3)0.5311Scope time87.5 min (23.6)80 min (25)0.2511Total enteroscopy attempted, n1820Total enteroscopy achieved, n (%)8 (55.6%)18 (90%)0.0272Diagnostic findings on DBE, n (%)0.2643None / Normal17 (34%)45 (45%)Angioectasia22 (44%)29 (29%)Ulcer, Stricture3 (6%)1 (1%)Polyp, Tumor4 (8%)11 (11%)Other (e.g. Meckel)4 (8%)14 (14%)Diagnostic yield, n (%)All33 (66%)52 (52%)0.1181High confidence only30 (60%)44 (44%)0.18111. t-Test; 2. Chi-square; 3. ANOVA Open table in a new tab

Background The optimal approach to the drainage of malignant obstruction at the liver hilum remains uncertain. We aim to compare percutaneous transhepatic biliary drainage (PTBD) to endoscopic retrograde cholangiography (ERC) as the first intervention in patients with cholestasis due to suspected malignant hilar obstruction (MHO). Methods The INTERCPT trial is a multi-center, comparative effectiveness, randomized, superiority trial of PTBD vs. ERC for decompression of suspected MHO. One hundred and eighty-four eligible patients across medical centers in the United States, who provide informed consent, will be randomly assigned in 1:1 fashion via a web-based electronic randomization system to either ERC or PTBD as the initial drainage and, if indicated, diagnostic procedure. All subsequent clinical interventions, including crossover to the alternative procedure, will be dictated by treating physicians per usual clinical care. Enrolled subjects will be assessed for successful biliary drainage (primary outcome measure), adequate tissue diagnosis, adverse events, the need for additional procedures, hospitalizations, and oncological outcomes over a 6-month follow-up period. Subjects, treating clinicians and outcome assessors will not be blinded. Discussion The INTERCPT trial is designed to determine whether PTBD or ERC is the better initial approach when managing a patient with suspected MHO, a common clinical dilemma that has never been investigated in a randomized trial. Trial registration ClinicalTrials.gov, Identifier: NCT03172832 . Registered on 1 June 2017.