Purpose: Small bowel enteroscopy (SBE) insertion depth is limited by loss of vector forces and looping within the stomach. These limitations are partially overcome by use of capsule endoscopy (CE), development of double-balloon enteroscopy (DBE), and variable use of conventional overtubes. CE is unable to perform biopsy or therapy, and DBE requires a significant capital expenditure. Conventional overtubes have been associated with inadvertent strip mucosectomy and procedural pancreatitis has been noted from damage to the papilla. A shape-locking guide, marketed for difficult colonoscopy, was adapted (USGI Medical, San Clemente, CA) for use in a multicenter trial in patients with small bowel disorders in whom no diagnosis/treatment was noted with CE and/or conventional SBE. Methods: A 48 or 54 Fr. (14 and 11 patients respectively), 80 or 100 cm (3 and 22 patients respectively) ShapeLock® device (SL) was used investigationally in conjunction with an Olympus pediatric colonoscope (3 patients) or SB enteroscope (22 patients). Conscious sedation was achieved with Demerol/Fentanyl and Versed. After initial scope passage into the ligament of Trietz, the SL was passed under fluoroscopic control through the EG junction and pylorus, and locked in place within the C-loop to prevent looping. Thereafter, scope and SL were passed to the limits of the scope length or definable pathology using push and pull maneuvers with and without unlocking and advancement of the SL. Results: The ShapeLock® was placed beyond the pylorus in 22/25 patients (28–85 years). Three patients had surgically altered anatomy that eliminated the pylorus. The endoscope was advanced into the terminal ileum in 3 patients, and to mid to distal jejunum in the remaining 22 patients. Bleeding sites were treated in 6/15 patients; a lymphoma in 1, an anastomotic stenosis in 1, and inactive IBD in 1. Minor proximal esophageal abrasions were seen in 5 patients, a non-significant cricopharyngeal tear in 3, and minor pyloric abrasions in 8. An asymptomatic Mallory-Weiss tear was seen in one patient and significant uvula edema in another. Conclusions: 1) ShapeLock® endoscopy precludes looping in the stomach and potentially improves efficacy when compared to CE and/or conventional SBE in this series of patients. 2) Additional studies are needed to define its role relative to CE and DBE.

Background: Tumors arising from the duodenal papilla account for approximately 5% of GI neoplasms, but are increasingly identified.Objective: To describe the clinical characteristics and Outcomes in a large single-center experience with patients referred for ampullary lesions.Design: A retrospective review of the Virginia Mason Medical Center endoscopy and hospital service database.Setting: Tertiary referral center.Patients: One hundred ninety-three patients referred for ampullary lesions from 1997 to 2007.Interventions: Endoscopic management of ampullary lesions.Main Outcome Measurements: The relationship of demographic and clinical data with endoscopic treatment and clinical outcomes in these patients.Results: One hundred ninety-three patients underwent endoscopy for ampullary lesions. Fifteen juxta-ampullary lesions and 10 normal variants were excluded. Among 168 patients, there were 112 (67%) adenomas, 38 (23%) adenocarcinomas, and 18 (10%) nonadenomatous lesions. There were 88 men and 80 women, with a mean age of 64 years. Clinical presentation included cholestasis/cholangitis (72 patients), abdominal pain (54 patients), incidental/asymptomatic (51 patients), pancreatitis (9 patients), and bleeding (7 patients). Of the 57 patients referred to surgery, 42 were sent directly without papillectomy, and 16 were sent after papillectomy Papillectomies were performed in 102 patients with adenomatous lesions. The mean tumor size was 2.4 cm (range 0.5-6 cm). The papillectomy complication rate was 21%: mild pancreatitis in 10 (10%) patients, cholangitis in 1, retroperitoneal perforation in I (adenocarcinoma), intraperitoneal perforation in 1 (lateral extension), bleeding in 5 (lateral extension in 2 of these 5), and delayed papillary stenosis in 3. Recurrences were seen in 8%. The endoscopic success rate was 84%. Factors affecting Success were a smaller adenoma size and the absence of dilated ducts.Conclusions: Most ampullary adenomas are amenable to endoscopy. Underlying malignancy and lateral extension may be risk factors for bleeding and perforation. Smaller lesion size and the absence of dilated ducts are factors favorably affecting Success. (Gastrointest Endosc 2009;70:923-32.)

Background: Currently small bowel enteroscopy (SBE) is limited by loss of vector forces and curling of scope within the stomach. Attempts to overcome these limitations have led to widespread application of capsule endoscopy (CE), development of double-balloon enteroscopy (DBE), and use of conventional overtubes. CE is limited by inability to undertake endotherapy. DBE requires a significant capital expenditure. Conventional overtubes prove difficult to get through the pylorus and have been associated with inadvertent strip mucosectomy and even procedural pancreatitis from damage to the papilla.

Background: GERD arises from the abnormal backflow of gastric contents into the esophagus. Data suggest that 20% of the US population experience GERD symptoms weekly. Complications may include esophagitis, stricture, and Barrett's esophagus (BE). BE is a premalignant condition that affects nearly 2% of the US population and may lead to esophageal adenocarcinoma. The PillCam™ ESO video capsule, manufactured by GivenR Imaging Ltd., utilizes dual cameras to visualize the esophagus without need for sedation or risk associated with conventional endoscopy. Objective: To compare test characteristics [specificity, sensitivity, positive predictive value (PPV) and negative predictive value (NPV)], safety and tolerability of ECE to conventional upper endoscopy (EG) for the visualization of esophageal pathology in subjects with chronic GERD symptoms. To date 3 women and 5 men, mean age 56.5 years, range 38-76, with diagnosed GERD are enrolled in a prospective, controlled study (100 subjects expected to be enrolled). Results: ECE visualization was possible in 7 of the 8 subjects enrolled. One subject did not complete the ECE procedure due to a previously undiagnosed motility disorder. The capsule was prophylacticly retrieved. Results are provided for the 7 subjects who underwent both procedures. ECE and EGD findings were reported by independent gastroenterologists blinded to the results of the alternate procedure. The capsule was easily swallowed by 7 (87.5%) of the subjects. For ECE, mean transit time was 43 seconds (range 3-158). Transit time for 4 of the 7 subjects was less than 10 seconds. While overall concordance for the visualization of possible BE and esophagitis was 57%, upon review, ECE was 100% sensitive and specific for histologically proven BE. The Z-Line was successfully visualized in all ECE and traditional endoscopy cases completed. This initial series made evident the importance of standardizing capsule administration, given the rapid and highly variable capsule transit times. Efforts will be undertaken to establish a transit time in alignment with previous studies (∼245 seconds). Conclusions: With appropriate attention to capsule administration, this technology appears to have potential for visualizing esophageal mucosal pathology. Sensitivity and specificity data, in conjunction with histological data, will be reported on a series of 100 subjects.