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Endotherapy for distally migrated metallic biliary endoprostheses
LETTERS TO THE EDITOR Acute upper-GI bleeding does not decrease the diagnostic yield of gastric biopsies for Helicobacter pylori infection
TABLE 1. Positivity for H pylori in biopsy specimens taken during endoscopy in bleeding versus nonbleeding ulcers
To the Editor: We have read with interest the paper by Laine et al1 in the December issue of Gastrointestinal Endoscopy on the appropriate timing of Helicobacter pylori diagnosis during GI bleeding. Several studies have suggested a lower sensitivity of diagnostic methods for H pylori when performed during GI bleeding.2-4 Laine et al1 suggest, on the contrary, that bleeding does not decrease the yield of a rapid urease test. We would like to share our own findings on this topic. Between January 2002 and December 2003, we studied 206 patients, age average 51.4 G 18 years; 64% were men. Eighty-eight patients who had gastric biopsy specimens (2 antral and 2 corporal) taken during the first 24 hours of the bleeding episode were compared with 118 patients with a nonbleeding ulcer whose biopsy specimens were obtained during diagnostic endoscopy. Our results are shown in Table 1. The diagnostic yield of the gastric biopsy specimens was no different in both groups and close to the prevalence reported in Peru for the last decade.5 We concluded that biopsy specimens can be obtained during the initial diagnostic endoscopy and thus establish the H pylori status and treatment strategy, without repeating the procedure or without performing additional noninvasive tests. We believe that this strategy is particularly important in countries like Peru with a scarcity of resources and at institutions like ours where biopsies are the only available diagnostic method. In accordance with Laine et al,1 we strongly support that the H pylori status should be assessed during the initial endoscopy. Francisco Aquino, MD Pedro Montes, MD Eduardo Monge, MD, MSc Gastroenterology Division Hospital Nacional Daniel Carrion Callao, Peru REFERENCES 1. Laine L, Nathwani R, Naritoku W. The effect of GI bleeding on Helicobacter pylori diagnostic testing: a prospective study at the time of bleeding and 1 month later. Gastrointest Endosc 2005;62:853-9. 2. Grin˜o P, Pascual S, Such J, et al. Comparison of diagnostic methods for Helicobacter pylori infection in patients with upper gastrointestinal bleeding. Scand J Gastroenterol 2001;36:1254-8. 3. Schilling D, Demel A, Adamek H, et al. A negative rapid urease test is unreliable for exclusion of Helicobacter pylori infection during acute
www.giejournal.org
Endoscopy in bleeding ulcers
Endoscopy in nonbleeding ulcers
N
88 (100)
118 (100)
H pylori C (%)
58 (65.9)
73 (61.9)
H pylori – (%)
30 (34.1)
45 (38.1)
P Z .551.
phase of ulcer bleeding. A prospective case control study. Dig Liver Dis 2003;35:217-21. 4. Tu TC, Lee CL, Wu CH, et al. Comparison of invasive and noninvasive tests for detecting Helicobacter pylori infection in bleeding peptic ulcers. Gastrointest Endosc 1999;49:302-6. 5. Ramirez-Ramos A, Chinga-Alayo E, Mendoza-Requena D, et al. Changes in the prevalence of H. pylori in Peru; during the 1985-2002 period in medium and upper socio-economic strata. Rev Gastroenterol Peru 2003;23:92-8. doi:10.1016/j.gie.2005.12.028
Endotherapy for distally migrated metallic biliary endoprostheses To the Editor: Petersen1 has recently written a most thoughtful editorial relating to biliary SEMS removal. In the editorial, Petersen reviews many problems that may occur after endoscopic biliary SEMS placement, and he puts into perspective the options for rectifying such occurrences. When discussing the problem of distally migrated SEMSs, Petersen notes the use of argon plasma coagulation (APC) to cut stents off nearer the papilla, on the basis of an abstract published last year.2 It should be noted that endotherapy for ‘‘resizing’’ SEMS is not a recent development, because it was initially reported more than a decade ago3 and has also been published in full article form in 1997.4 These earlier publications describe the use of endoscopic yttrium aluminum garnet (YAG) laser therapy to vaporize the end of metal mesh stents, to allow more appropriate sizing in the duodenum, when necessary. Although endoscopists may now choose to use APC for this purpose, it should be noted that other options for SEMS ‘‘resizing’’ are available and have been safely used for quite some time. Joseph C. Yarze, MD, FACP, FACG Gastroenterology Associates of Northern New York Glens Falls, New York, USA Volume 63, No. 6 : 2006 GASTROINTESTINAL ENDOSCOPY 889
Letters to the Editor
REFERENCES 1. Petersen BT. SEMS removal: salvage technique or new paradigms. Gastrointest Endosc 2005;62:911-3. 2. Springer E, Nash SR, Shah RJ, et al. Argon plasma coagulation for distal migration or improper placement of self-expanding metal stents (SEMS) [abstract]. Gastrointest Endosc 2004;59:AB200. 3. Schwartz R, Zera R, Cass O. Laser endosurgery on biliary wire mesh stents [letter]. Gastrointest Endosc 1993;39:735-6. 4. Yarze JC, Poulos AM, Fritz HP, et al. Treatment of metallic biliary stentinduced duodenal ulceration using endoscopic laser therapy. Dig Dis Sci 1997;42:6-9.
2. Fazel A, Moezardalan K, Varadarajulu S, Dragnov P, Eloubeidi MA. The utility and the safety of EUS-guided FNA in the evaluation of duplication cysts. Gastrointest Endosc 2005;62:575-80. doi:10.1016/j.gie.2005.12.029
Colonoscopic resection of an asymptomatic colon lipoma To the Editor:
doi:10.1016/j.gie.2005.12.017
1. Pai KR, Page RD. Mediastinitis after EUS-guided FNA biopsy of a posterior mediastinal metastatic teratoma. Gastrointest Endosc 2005;62: 980-1.
I recently had the opportunity to read the interesting case report of Drs. Raju and Gomez.1 The case involves the utilization of a novel endoscopic technique, which was employed to resect an asymptomatic colon lipoma. After reading the authors’ report, I was impressed from two perspectives. First, the authors are to be commended for reporting a novel approach to endoscopic lipoma resection. As the authors suggest, this technique would appear to be safer than utilizing a snare with electrocautery. The second issue I would raise is more complex, but in my mind, equally if not more important. I am bothered by the use of an invasive GI endoscopic procedure to remove a benign, non-neoplastic lesion in an asymptomatic 72-yearold patient who was ‘‘uncomfortable leaving the lesion in situ.’’ Although relatively safe when performed by an expert endoscopist with Dr. Raju’s level of skill, colonoscopy is nonetheless associated with a small, but finite complication rate. I wonder how ‘‘uncomfortable’’ this patient would have been had they sustained a colonoscopic perforation, requiring surgical intervention and associated with a prolonged and complicated hospital course and recuperative period. I wholeheartedly advocate that my patients be involved in decisions relating to their medical care, but I would clearly draw the line at a different point than was done in this case. Under no circumstances would I allow a patient who was ‘‘uncomfortable’’ with leaving a completely asymptomatic, benign, and non-neoplastic lesion in situ to force me to perform a procedure that carries even a minute potential risk. In the case under discussion, I would not have allowed resection (endoscopic or otherwise) of the lipoma to be an ‘‘option on the table.’’ Further, this patient ultimately underwent a total of 4 colonoscopic procedures (3 after the initial screening examination). Given the clinical scenario, in my opinion, it would be a hard, if not impossible, ‘‘sell’’ to suggest that this was an appropriate use of GI endoscopic talent and resources. Now that the government and most private insurance carriers have agreed to reimburse for screening colonoscopy, I would suggest that gastroenterologists must be aware of the latitude and privilege we finally and appropriately have been given. Control of the volume of GI endoscopic
890 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 6 : 2006
www.giejournal.org
Antibiotics are mandatory before EUS-guided FNA in cystic or semisolid lesions of the mediastinum and the pancreas To the Editor: I read with interest the case of mediastinitis resulting from EUS-guided FNA of a metastatic teratoma to the posterior mediastinum.1 I noticed that the investigators did not describe the lesion as initially seen by EUS before EUSguided FNA. As endosonographers, we gain a great deal of information about the lesion by characterizing its nature: solid, semisolid, cystic, etc. As more endoscopists around the world embrace EUS and EUS-guided FNA, this fact cannot be overemphasized. It appears that this case could have benefited from preoperative administration of antibiotics because of the semisolid nature of the lesion, as the investigators later describe in the discussion. Because of our policy of universal administration of antibiotics in cystic or semisolid lesions, we encountered, to date, no infections of any cystic lesion of the pancreas or the mediastinum. We also recently reported our multicenter study in collaboration with the University of Florida.2 In that study, no infectious complications were encountered after aspiration of mediastinal cystic lesions, because universal applications of antibiotics were used in these cases. When in doubt of the nature of the lesion or when there is a cystic component associated with the lesion, intravenous antibiotics should be strongly considered, followed by 5 to 7 days of oral antibiotics before EUS-guided FNA. Mohamad A. Eloubeidi, MD, MHS, FACP, FACG Division of Gastroenterology and Hepatology University of Alabama at Birmingham Birmingham, Alabama, USA REFERENCES
TABLE 1. Positivity for H pylori in biopsy specimens taken during endoscopy in bleeding versus nonbleeding ulcers
To the Editor: We have read with interest the paper by Laine et al1 in the December issue of Gastrointestinal Endoscopy on the appropriate timing of Helicobacter pylori diagnosis during GI bleeding. Several studies have suggested a lower sensitivity of diagnostic methods for H pylori when performed during GI bleeding.2-4 Laine et al1 suggest, on the contrary, that bleeding does not decrease the yield of a rapid urease test. We would like to share our own findings on this topic. Between January 2002 and December 2003, we studied 206 patients, age average 51.4 G 18 years; 64% were men. Eighty-eight patients who had gastric biopsy specimens (2 antral and 2 corporal) taken during the first 24 hours of the bleeding episode were compared with 118 patients with a nonbleeding ulcer whose biopsy specimens were obtained during diagnostic endoscopy. Our results are shown in Table 1. The diagnostic yield of the gastric biopsy specimens was no different in both groups and close to the prevalence reported in Peru for the last decade.5 We concluded that biopsy specimens can be obtained during the initial diagnostic endoscopy and thus establish the H pylori status and treatment strategy, without repeating the procedure or without performing additional noninvasive tests. We believe that this strategy is particularly important in countries like Peru with a scarcity of resources and at institutions like ours where biopsies are the only available diagnostic method. In accordance with Laine et al,1 we strongly support that the H pylori status should be assessed during the initial endoscopy. Francisco Aquino, MD Pedro Montes, MD Eduardo Monge, MD, MSc Gastroenterology Division Hospital Nacional Daniel Carrion Callao, Peru REFERENCES 1. Laine L, Nathwani R, Naritoku W. The effect of GI bleeding on Helicobacter pylori diagnostic testing: a prospective study at the time of bleeding and 1 month later. Gastrointest Endosc 2005;62:853-9. 2. Grin˜o P, Pascual S, Such J, et al. Comparison of diagnostic methods for Helicobacter pylori infection in patients with upper gastrointestinal bleeding. Scand J Gastroenterol 2001;36:1254-8. 3. Schilling D, Demel A, Adamek H, et al. A negative rapid urease test is unreliable for exclusion of Helicobacter pylori infection during acute
www.giejournal.org
Endoscopy in bleeding ulcers
Endoscopy in nonbleeding ulcers
N
88 (100)
118 (100)
H pylori C (%)
58 (65.9)
73 (61.9)
H pylori – (%)
30 (34.1)
45 (38.1)
P Z .551.
phase of ulcer bleeding. A prospective case control study. Dig Liver Dis 2003;35:217-21. 4. Tu TC, Lee CL, Wu CH, et al. Comparison of invasive and noninvasive tests for detecting Helicobacter pylori infection in bleeding peptic ulcers. Gastrointest Endosc 1999;49:302-6. 5. Ramirez-Ramos A, Chinga-Alayo E, Mendoza-Requena D, et al. Changes in the prevalence of H. pylori in Peru; during the 1985-2002 period in medium and upper socio-economic strata. Rev Gastroenterol Peru 2003;23:92-8. doi:10.1016/j.gie.2005.12.028
Endotherapy for distally migrated metallic biliary endoprostheses To the Editor: Petersen1 has recently written a most thoughtful editorial relating to biliary SEMS removal. In the editorial, Petersen reviews many problems that may occur after endoscopic biliary SEMS placement, and he puts into perspective the options for rectifying such occurrences. When discussing the problem of distally migrated SEMSs, Petersen notes the use of argon plasma coagulation (APC) to cut stents off nearer the papilla, on the basis of an abstract published last year.2 It should be noted that endotherapy for ‘‘resizing’’ SEMS is not a recent development, because it was initially reported more than a decade ago3 and has also been published in full article form in 1997.4 These earlier publications describe the use of endoscopic yttrium aluminum garnet (YAG) laser therapy to vaporize the end of metal mesh stents, to allow more appropriate sizing in the duodenum, when necessary. Although endoscopists may now choose to use APC for this purpose, it should be noted that other options for SEMS ‘‘resizing’’ are available and have been safely used for quite some time. Joseph C. Yarze, MD, FACP, FACG Gastroenterology Associates of Northern New York Glens Falls, New York, USA Volume 63, No. 6 : 2006 GASTROINTESTINAL ENDOSCOPY 889
Letters to the Editor
REFERENCES 1. Petersen BT. SEMS removal: salvage technique or new paradigms. Gastrointest Endosc 2005;62:911-3. 2. Springer E, Nash SR, Shah RJ, et al. Argon plasma coagulation for distal migration or improper placement of self-expanding metal stents (SEMS) [abstract]. Gastrointest Endosc 2004;59:AB200. 3. Schwartz R, Zera R, Cass O. Laser endosurgery on biliary wire mesh stents [letter]. Gastrointest Endosc 1993;39:735-6. 4. Yarze JC, Poulos AM, Fritz HP, et al. Treatment of metallic biliary stentinduced duodenal ulceration using endoscopic laser therapy. Dig Dis Sci 1997;42:6-9.
2. Fazel A, Moezardalan K, Varadarajulu S, Dragnov P, Eloubeidi MA. The utility and the safety of EUS-guided FNA in the evaluation of duplication cysts. Gastrointest Endosc 2005;62:575-80. doi:10.1016/j.gie.2005.12.029
Colonoscopic resection of an asymptomatic colon lipoma To the Editor:
doi:10.1016/j.gie.2005.12.017
1. Pai KR, Page RD. Mediastinitis after EUS-guided FNA biopsy of a posterior mediastinal metastatic teratoma. Gastrointest Endosc 2005;62: 980-1.
I recently had the opportunity to read the interesting case report of Drs. Raju and Gomez.1 The case involves the utilization of a novel endoscopic technique, which was employed to resect an asymptomatic colon lipoma. After reading the authors’ report, I was impressed from two perspectives. First, the authors are to be commended for reporting a novel approach to endoscopic lipoma resection. As the authors suggest, this technique would appear to be safer than utilizing a snare with electrocautery. The second issue I would raise is more complex, but in my mind, equally if not more important. I am bothered by the use of an invasive GI endoscopic procedure to remove a benign, non-neoplastic lesion in an asymptomatic 72-yearold patient who was ‘‘uncomfortable leaving the lesion in situ.’’ Although relatively safe when performed by an expert endoscopist with Dr. Raju’s level of skill, colonoscopy is nonetheless associated with a small, but finite complication rate. I wonder how ‘‘uncomfortable’’ this patient would have been had they sustained a colonoscopic perforation, requiring surgical intervention and associated with a prolonged and complicated hospital course and recuperative period. I wholeheartedly advocate that my patients be involved in decisions relating to their medical care, but I would clearly draw the line at a different point than was done in this case. Under no circumstances would I allow a patient who was ‘‘uncomfortable’’ with leaving a completely asymptomatic, benign, and non-neoplastic lesion in situ to force me to perform a procedure that carries even a minute potential risk. In the case under discussion, I would not have allowed resection (endoscopic or otherwise) of the lipoma to be an ‘‘option on the table.’’ Further, this patient ultimately underwent a total of 4 colonoscopic procedures (3 after the initial screening examination). Given the clinical scenario, in my opinion, it would be a hard, if not impossible, ‘‘sell’’ to suggest that this was an appropriate use of GI endoscopic talent and resources. Now that the government and most private insurance carriers have agreed to reimburse for screening colonoscopy, I would suggest that gastroenterologists must be aware of the latitude and privilege we finally and appropriately have been given. Control of the volume of GI endoscopic
890 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 6 : 2006
www.giejournal.org
Antibiotics are mandatory before EUS-guided FNA in cystic or semisolid lesions of the mediastinum and the pancreas To the Editor: I read with interest the case of mediastinitis resulting from EUS-guided FNA of a metastatic teratoma to the posterior mediastinum.1 I noticed that the investigators did not describe the lesion as initially seen by EUS before EUSguided FNA. As endosonographers, we gain a great deal of information about the lesion by characterizing its nature: solid, semisolid, cystic, etc. As more endoscopists around the world embrace EUS and EUS-guided FNA, this fact cannot be overemphasized. It appears that this case could have benefited from preoperative administration of antibiotics because of the semisolid nature of the lesion, as the investigators later describe in the discussion. Because of our policy of universal administration of antibiotics in cystic or semisolid lesions, we encountered, to date, no infections of any cystic lesion of the pancreas or the mediastinum. We also recently reported our multicenter study in collaboration with the University of Florida.2 In that study, no infectious complications were encountered after aspiration of mediastinal cystic lesions, because universal applications of antibiotics were used in these cases. When in doubt of the nature of the lesion or when there is a cystic component associated with the lesion, intravenous antibiotics should be strongly considered, followed by 5 to 7 days of oral antibiotics before EUS-guided FNA. Mohamad A. Eloubeidi, MD, MHS, FACP, FACG Division of Gastroenterology and Hepatology University of Alabama at Birmingham Birmingham, Alabama, USA REFERENCES