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Capsule Endoscopy (CE) Increases the Diagnostic Yield of Double Balloon Enteroscopy (DBE) in Patients Being Investigated for Obscure Gastrointestinal Bleeding (OGIB)
Abstracts
S1510 Capsule Endoscopy (CE) Increases the Diagnostic Yield of Double Balloon Enteroscopy (DBE) in Patients Being Investigated for Obscure Gastrointestinal Bleeding (OGIB) Lucia C. Fry, Klaus Mo ¨ nkemu ¨ ller, Helmut Neumann, Ulrike Von Arnim, Michael Bellutti, Peter Malfertheiner Background: Both capsule endoscopy (CE) and double balloon enteroscopy (DBE) are valuable methods for the evaluation of obscure gastrointestinal bleeding (OGIB). Many experts recommend the use of CE to guide DBE. However, the true impact of CE on the yield of DBE in the daily clinical practice has not been evaluated. We had the unique opportunity to observe the impact of CE on DBE in patients with OGIB, as the introduction of CE in our clinical setting occurred reversed, i.e. after DBE. Aim: To evaluate the impact of DBE on the yield of DBE in patients with OGIB. Patients and Methods: 60 consecutive patients (50 male, 34 female, mean age 65.6 yrs., range 12.4-88.4 yrs.) were evaluated for OGIB at the University of Magdeburg Medical Center, Germany. OGIB was defined according to AGA guidelines (Gastroenterology, 2008). All procedures were performed using a therapeutic or diagnostic enteroscopes (Fujinon Corp., Japan). The patients were categorized into two periods: before CE (2006) and after CE (2007). Patients referred for DBE because of abnormal CE findings from outside institutions were excluded. Results: During the first period (before CE) a total of 27 patients (69 yrs, range 12-88) underwent 33 DBEs for OGIB (over OGIB, nZ20, occult, nZ7). During the second period (after CE) a total of 24 patients (71 yrs, range 25-85) underwent 27 DBEs for OGIB (over OGIB, nZ17, occult, nZ7). The diagnostic yield of DBE was 39.9% during the first period (DBE alone), compared to 62.9% during the second period (DBE after CE) (p! 0,002). The following diagnoses were made: Dieulafoy lesions, nZ4, AVMs, nZ10, tumors, nZ4, ulcers and erosions, nZ6. The following lesions were more common in patients undergoing both CE and DBE: tumors (3 versus 1) and Dieulafoy lesions (3 versus 1) (p! 0.05). Conclusions: In this study we found that in patients with OGIB performance of CE prior to DBE increases the diagnostic yield of DBE. Thus, our data support the concept that CE should serve as guiding method for the performance of invasive small bowel enteroscopy.
S1511 Confocal Laser Endomicroscopy for In Vivo Diagnosis of PreMalignant and Malignant Lesions of the Stomach: An Ongoing Prospective Study Cristina Trovato, Angelica Sonzogni, Davide Ravizza, Darina Tamayo, Giuseppe De Roberto, Giancarla Fiori, Cristiano Crosta Background and Aim: Confocal laser endomicroscopy is a new technology for the observation of cellular morphology during ongoing endoscopy (in-vivo virtual histology). In 2006 the confocal analysis of gastric cancer in-vivo was evaluated in a few patients, but technical difficulties were shown. Recently, endomicroscopy has been reported as useful for the diagnosis and classification of gastric intestinal metaplasia in-vivo. The aim of the present study was to assess the potential of endomicroscopy for predicting histology in-vivo during endoscopy in patient with suspected gastric dysplasia/early gastric cancer. Methods: Consecutive patients with suspected gastric dysplasia/early gastric cancer who had been referred for endoscopic surveillance or therapy were enrolled. Fluorescein-aided endomicroscopy (EC-3870CIFK; Pentax, Tokyo, Japan) was carried out in standardized gastric locations. In addition, macroscopic lesions, when present, were also analyzed. Confocal images were classified into 3 types: normal, intestinal metaplasia, and neoplasia. The neoplasia pattern was scored by three sub-types: atypical regenerative hyperplasia/low-grade dysplasia, high-grade dysplasia/ differentiated adenocarcinoma, undifferentiated adenocarcinoma. In accordance with STARD guidelines, targeted biopsy specimens were compared with histopathological results. Results: Forty-seven patients were enrolled. Retroflexion maneuver was performed in all patients. In one patient the gastric mucosa was not totally explored for technical difficulties. The mean duration of confocal examination was 29 minutes (range, 16-43). At endomicroscopy neoplasias were diagnosed in 31/46 patients (67.4%). The overall accuracy for the diagnosis of neoplasia was 85%. Intra- and interobserver agreements were 0.89 and 0.86, respectively. Conclusions: Confocal laser endomicroscopy is able to provide in-vivo diagnosis of pre-malignant and malignant lesions of the stomach. The small size of our population sample requires further studies for the results to be confirmed. Further improvements in the device are anticipated. Agreement between confocal neoplasia pattern sub-types and histology in the 31/46 patients with neoplasia confocal features.
AB190 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
Histology
Endomicroscopy
Atypical regenerative hyperplasia/ LGIN HGIN/ welldifferentiated adenocarcinoma Poorly differentiated adenocarcinoma Total
No neoplasia
Atypical regenerative hyperplasia/ LGIN
4
16
1
0
21
0
0
4
0
4
0
0
1
5
6
4
16
6
5
31
Poorly HGIN/ welldifferentiated differentiated adenocarcinoma Total adenocarcinoma
S1512 Development of a New Inflatable Spiral Is a Potentially Important Advancement in Spiral Enteroscopy Paul A. Akerman, Daniel Cantero, Jesus Pangtay Spiral enteroscopy currently employs a fixed raised spiral at the end of the overtube. Although the fixed spiral has been demonstrated to be safe, an inflatable spiral may offer some advantages including (1)simplifying introduction of the spiral through the upper gi tract, (2)decreasing risks of complications, (3)improving rapid removal during an emergency, (4)decreasing the time of the procedure, (5)allowing simpler passage of the spiral past the Ligament of Treitz and (6)variable heights of the spiral may improve performance. Patients, Methods, and Materials: 4 consecutive patients were included in this prospective pilot study. All patients had informed consent under IRB protocol. The Olympus SIF-180 enteroscope is 200 cm long, 9.2 mm in diameter and has a 2.8 mm working channel. The Discovery SB with the inflatable spiral is 118cm long with a deflated spiral at the distal end that inflates with water to 6 mm. The spiral is 22 cm long. A locking device on the Discovery SB allows fixation to the enteroscope. The Discovery SB with the inflatable spiral was fixed on the Olympus SIF-180 enteroscope and the enterosocope was introduced into the stomach. The Discovery SB, with the spiral deflated, was lubricated and advanced over the enteroscope to the stomach. The enteroscope was then pushed past the Ligament of Treitz. The Discovery SB was then advanced over the enteroscope past the Ligament of Treitz. The spiral was then inflated with water. Spiral enteroscopy was then begun with rotation of the Discovery SB while fixed to the enteroscope. Spiral enteroscopy was defined as advancement of the enteroscope through the small bowel by rotating the overtube with the spiral inflated. Findings: 4 patients, 1 male and 3 female, underwent enteroscopy. In all patients, the spiral was inflated past the Ligament of Treitz and spiral enteroscopy was initiated. Estimated average maximum depth of insertion past the LOTwas 150 cm. The average time of procedure was 25 minutes. On withdrawal, the spiral was deflated in the stomach, total deflation occured in less than 20 seconds. There were no complications. There was no esophageal trauma. All the examinations were normal. Conclusions: In this small series, the inflatable spiral was safe and effective. Spiral enteroscopy can be achieved with an inflatable spiral and may offer a significant advance in spiral enteroscopy technique. Use of the inflatable spiral simplified the technique to install the spiral past the LOT and initiate spiral enteroscopy. Further studies will be needed to determine whether the inflatable spiral offers a significant improvement in the spiral enteroscopy technique.
S1513 Endoscopic Predictors of Successful Endoluminal Eradication of Sporadic Duodenal Adenomas and Its Acute Complications Prashant Kedia, Colleen M. Brensinger, Gregory G. Ginsberg Introduction: Sporadic non-ampullary duodenal adenomas have a rate of malignant transformation ranging from 35% to 85%. Endoscopic resection is indicated when feasible. However, optimal treatment technique and predictors of success have not been defined. This research analyzes predictors of successful endoscopic eradication of sporadic non-ampullary duodenal adenomas. Methods: Retrospective cohort analysis of consecutive patients referred for endoscopic resection of sporadic duodenal adenoma at a tertiary center was performed. Endoluminal snare resection was individualized and performed with or without submucosal injection in en bloc or piecemeal fashion. Adjunctive argon plasma coagulation [APC] was used to eradicate residual adenoma. The data set was established prospectively and lesion size, location, morphology, luminal circumference and resection techniques were recorded. Multiple regression analysis employing Pooled T-Test, Fischer-Exact Test,
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S1510 Capsule Endoscopy (CE) Increases the Diagnostic Yield of Double Balloon Enteroscopy (DBE) in Patients Being Investigated for Obscure Gastrointestinal Bleeding (OGIB) Lucia C. Fry, Klaus Mo ¨ nkemu ¨ ller, Helmut Neumann, Ulrike Von Arnim, Michael Bellutti, Peter Malfertheiner Background: Both capsule endoscopy (CE) and double balloon enteroscopy (DBE) are valuable methods for the evaluation of obscure gastrointestinal bleeding (OGIB). Many experts recommend the use of CE to guide DBE. However, the true impact of CE on the yield of DBE in the daily clinical practice has not been evaluated. We had the unique opportunity to observe the impact of CE on DBE in patients with OGIB, as the introduction of CE in our clinical setting occurred reversed, i.e. after DBE. Aim: To evaluate the impact of DBE on the yield of DBE in patients with OGIB. Patients and Methods: 60 consecutive patients (50 male, 34 female, mean age 65.6 yrs., range 12.4-88.4 yrs.) were evaluated for OGIB at the University of Magdeburg Medical Center, Germany. OGIB was defined according to AGA guidelines (Gastroenterology, 2008). All procedures were performed using a therapeutic or diagnostic enteroscopes (Fujinon Corp., Japan). The patients were categorized into two periods: before CE (2006) and after CE (2007). Patients referred for DBE because of abnormal CE findings from outside institutions were excluded. Results: During the first period (before CE) a total of 27 patients (69 yrs, range 12-88) underwent 33 DBEs for OGIB (over OGIB, nZ20, occult, nZ7). During the second period (after CE) a total of 24 patients (71 yrs, range 25-85) underwent 27 DBEs for OGIB (over OGIB, nZ17, occult, nZ7). The diagnostic yield of DBE was 39.9% during the first period (DBE alone), compared to 62.9% during the second period (DBE after CE) (p! 0,002). The following diagnoses were made: Dieulafoy lesions, nZ4, AVMs, nZ10, tumors, nZ4, ulcers and erosions, nZ6. The following lesions were more common in patients undergoing both CE and DBE: tumors (3 versus 1) and Dieulafoy lesions (3 versus 1) (p! 0.05). Conclusions: In this study we found that in patients with OGIB performance of CE prior to DBE increases the diagnostic yield of DBE. Thus, our data support the concept that CE should serve as guiding method for the performance of invasive small bowel enteroscopy.
S1511 Confocal Laser Endomicroscopy for In Vivo Diagnosis of PreMalignant and Malignant Lesions of the Stomach: An Ongoing Prospective Study Cristina Trovato, Angelica Sonzogni, Davide Ravizza, Darina Tamayo, Giuseppe De Roberto, Giancarla Fiori, Cristiano Crosta Background and Aim: Confocal laser endomicroscopy is a new technology for the observation of cellular morphology during ongoing endoscopy (in-vivo virtual histology). In 2006 the confocal analysis of gastric cancer in-vivo was evaluated in a few patients, but technical difficulties were shown. Recently, endomicroscopy has been reported as useful for the diagnosis and classification of gastric intestinal metaplasia in-vivo. The aim of the present study was to assess the potential of endomicroscopy for predicting histology in-vivo during endoscopy in patient with suspected gastric dysplasia/early gastric cancer. Methods: Consecutive patients with suspected gastric dysplasia/early gastric cancer who had been referred for endoscopic surveillance or therapy were enrolled. Fluorescein-aided endomicroscopy (EC-3870CIFK; Pentax, Tokyo, Japan) was carried out in standardized gastric locations. In addition, macroscopic lesions, when present, were also analyzed. Confocal images were classified into 3 types: normal, intestinal metaplasia, and neoplasia. The neoplasia pattern was scored by three sub-types: atypical regenerative hyperplasia/low-grade dysplasia, high-grade dysplasia/ differentiated adenocarcinoma, undifferentiated adenocarcinoma. In accordance with STARD guidelines, targeted biopsy specimens were compared with histopathological results. Results: Forty-seven patients were enrolled. Retroflexion maneuver was performed in all patients. In one patient the gastric mucosa was not totally explored for technical difficulties. The mean duration of confocal examination was 29 minutes (range, 16-43). At endomicroscopy neoplasias were diagnosed in 31/46 patients (67.4%). The overall accuracy for the diagnosis of neoplasia was 85%. Intra- and interobserver agreements were 0.89 and 0.86, respectively. Conclusions: Confocal laser endomicroscopy is able to provide in-vivo diagnosis of pre-malignant and malignant lesions of the stomach. The small size of our population sample requires further studies for the results to be confirmed. Further improvements in the device are anticipated. Agreement between confocal neoplasia pattern sub-types and histology in the 31/46 patients with neoplasia confocal features.
AB190 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
Histology
Endomicroscopy
Atypical regenerative hyperplasia/ LGIN HGIN/ welldifferentiated adenocarcinoma Poorly differentiated adenocarcinoma Total
No neoplasia
Atypical regenerative hyperplasia/ LGIN
4
16
1
0
21
0
0
4
0
4
0
0
1
5
6
4
16
6
5
31
Poorly HGIN/ welldifferentiated differentiated adenocarcinoma Total adenocarcinoma
S1512 Development of a New Inflatable Spiral Is a Potentially Important Advancement in Spiral Enteroscopy Paul A. Akerman, Daniel Cantero, Jesus Pangtay Spiral enteroscopy currently employs a fixed raised spiral at the end of the overtube. Although the fixed spiral has been demonstrated to be safe, an inflatable spiral may offer some advantages including (1)simplifying introduction of the spiral through the upper gi tract, (2)decreasing risks of complications, (3)improving rapid removal during an emergency, (4)decreasing the time of the procedure, (5)allowing simpler passage of the spiral past the Ligament of Treitz and (6)variable heights of the spiral may improve performance. Patients, Methods, and Materials: 4 consecutive patients were included in this prospective pilot study. All patients had informed consent under IRB protocol. The Olympus SIF-180 enteroscope is 200 cm long, 9.2 mm in diameter and has a 2.8 mm working channel. The Discovery SB with the inflatable spiral is 118cm long with a deflated spiral at the distal end that inflates with water to 6 mm. The spiral is 22 cm long. A locking device on the Discovery SB allows fixation to the enteroscope. The Discovery SB with the inflatable spiral was fixed on the Olympus SIF-180 enteroscope and the enterosocope was introduced into the stomach. The Discovery SB, with the spiral deflated, was lubricated and advanced over the enteroscope to the stomach. The enteroscope was then pushed past the Ligament of Treitz. The Discovery SB was then advanced over the enteroscope past the Ligament of Treitz. The spiral was then inflated with water. Spiral enteroscopy was then begun with rotation of the Discovery SB while fixed to the enteroscope. Spiral enteroscopy was defined as advancement of the enteroscope through the small bowel by rotating the overtube with the spiral inflated. Findings: 4 patients, 1 male and 3 female, underwent enteroscopy. In all patients, the spiral was inflated past the Ligament of Treitz and spiral enteroscopy was initiated. Estimated average maximum depth of insertion past the LOTwas 150 cm. The average time of procedure was 25 minutes. On withdrawal, the spiral was deflated in the stomach, total deflation occured in less than 20 seconds. There were no complications. There was no esophageal trauma. All the examinations were normal. Conclusions: In this small series, the inflatable spiral was safe and effective. Spiral enteroscopy can be achieved with an inflatable spiral and may offer a significant advance in spiral enteroscopy technique. Use of the inflatable spiral simplified the technique to install the spiral past the LOT and initiate spiral enteroscopy. Further studies will be needed to determine whether the inflatable spiral offers a significant improvement in the spiral enteroscopy technique.
S1513 Endoscopic Predictors of Successful Endoluminal Eradication of Sporadic Duodenal Adenomas and Its Acute Complications Prashant Kedia, Colleen M. Brensinger, Gregory G. Ginsberg Introduction: Sporadic non-ampullary duodenal adenomas have a rate of malignant transformation ranging from 35% to 85%. Endoscopic resection is indicated when feasible. However, optimal treatment technique and predictors of success have not been defined. This research analyzes predictors of successful endoscopic eradication of sporadic non-ampullary duodenal adenomas. Methods: Retrospective cohort analysis of consecutive patients referred for endoscopic resection of sporadic duodenal adenoma at a tertiary center was performed. Endoluminal snare resection was individualized and performed with or without submucosal injection in en bloc or piecemeal fashion. Adjunctive argon plasma coagulation [APC] was used to eradicate residual adenoma. The data set was established prospectively and lesion size, location, morphology, luminal circumference and resection techniques were recorded. Multiple regression analysis employing Pooled T-Test, Fischer-Exact Test,
www.giejournal.org