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Evaluation of Small Bowel Images According to the Preparation Method for Capsule Endoscopy: NPO vs. PEG 2L vs. PEG 4L
Abstracts
S1502 Dilatation of Small Bowel Strictures By Double Balloon Enteroscopy: Further Results from the UK Edward J. Despott, Eric Tripoli, Krysia Konieczko, Adel Polecina, Chris H. Fraser Introduction: Double balloon enteroscopy (DBE) facilitates endotherapy of deep SB pathology. Our preliminary prospective proof of concept analysis on DBE dilatation of Crohn’s Disease (CD) SB strictures was presented to the ASGE at DDW 2008. We now report further on our prospective data of DBE stricture dilatation in an expanding cohort of patients with CD and NSAID induced SB strictures from the UK. Aims and Methods: Since introduction of DBE to our unit in 2005, data on cases of DBE SB stricture dilatation were prospectively collected for outcome, need for repeat dilatation and surgery. The DBEs were performed using the EN-450T5 scope (Fujinon, Saitama, Japan). Balloon ilatation was performed using controlled radial expansion (CRE)balloon dilators. A standardised 10cm visual analogue scale (VAS) characterised symptoms and dietary restriction before DBE stricture dilatation and at follow-up. Results: A total of 14 DBEs were done in 12 consecutive cases (mean age 46.4 7.8 years). In all but 2 cases, the strictures were characterised radiologically before DBE. In 11 of the cases, the SB strictures were CD related, in 1 case they were NSAID induced. Twenty six SB stricture dilatations were performed in 10 of 12 patients. The patient with NSAID related strictures had successful dilatation of 8 strictures in one session. In another case of CD SB strictures, a retained video capsule was retrieved after dilatation of the culprit strictures. Mean stricture dilatation diameter was 14.5mm (range 12-20mm). In the 2 cases where stricture dilatation was not performed, DBE hindrance by adhesions made reaching the strictures impossible. These two cases were then managed surgically. One case of complex CD stricture dilatation was complicated by a delayed perforation. This case required a temporary jejunostomy which has since been reversed. In the other 9 cases SB stricture dilatation by DBE was an unhindered success; the symptom and dietary restriction scores improved dramatically and to date (mean follow up 19.4; range 1-40 months) none of these cases has required surgery for SB strictures. At follow-up, 2 patients required a repeat straightforward DBE dilatation (at 6.5 and 13 months respectively) due to recurrence of some of their symptoms. Although the numbers in this series are small, the clinical improvements in pre and post DBE VAS scores were large enough (means of 9.2 vs 1.7 respectively; p!0.001). Conclusion: This series adds to the growing body of published evidence that DBE SB stricture dilatation can be very effective, with the potential to help avoid the risks of surgery, small bowel resection and the associated risks of short bowel syndrome.
S1503 The Clinical Utility of Single Balloon Enteroscopy: A Single Center Experience of 172 Procedures Bennie R. Upchurch, John J. Vargo, Madhusudhan R. Sanaka, Mohammad Alhaji Objectives: Single balloon enteroscopy (SBE) is a novel endoscopic technique designed to evaluate and treat small bowel disease. It represents the second method of deep enteroscopy available after the advent of double balloon enteroscopy. While there is substantial literature addressing double balloon enteroscopy and its impact in the diagnosis and management of small bowel disease, there are limited data available on the clinical utility of SBE. The aim of this study was to evaluate the clinical utility and diagnostic impact of SBE in a large cohort of patients at a single tertiary center. Methods: This study is a retrospective review of patient charts of those referred for deep enteroscopy from January 11, 2006 to August 5, 2008. Demographic, clinical, procedural and outcome data were collected and analyzed. Results: 172 patients (85 women, 87 men) were studied. Average age was 64 years with a range of 23-88 years of age. The most common indication was anemia, with 102 patients referred. 51 patients had occult bleeding, 46 were referred for overt bleeding, 11 for suspected IBD, 8 for abd pain, 8 for suspected mass, and 5 for diarrhea. We used conscious sedation in 146 patients, MAC or general anesthesia in 26 patients. Antegrade and retrograde approaches were performed in 143 and 29 respectively. Average depth of insertion from the antegrade approach was 132 cm beyond the ligament of Trietz (range 20-400 cm). Average depth of insertion from the retrograde approach was 73 cm above the ileocecal valve (range 10-160 cm). Average procedure time was 40 mins overall, 38 mins antegrade (range 12-90), 48 mins retrograde (range 28-89). Flouroscopy was used in 20 cases (12%) and the average time used per case was 4 minutes (range 12 seconds to 14 minutes). The abnormalities detected were angioectasia in 63 patients (36%), telangiectasias in 12 patients, 10 patients with polyps, 8 with ulcers, 6 with small bowel diverticula, 4 with blood in the lumen, 3 with acid hematin seen, 2 strictures, and 2 erosions. There were normal findings (no pathology detected) in 65 patients (37%). Diagnostic yield was 62% (107/172). 41% (72/172) were therapeutic cases. AVMs or telangectasias were treated in 66 cases, 5 polyps were removed, and 1 stricture was dilated. There were no significant complications.135 patients (78%) had capsules studies done prior to the enteroscopy. In 70 cases (40%) the capsule findings were confirmed by the enteroscopy. Conclusions: SBE demonstrated a high diagnostic yield, and frequently provided useful therapeutic intervention. It appears to be a safe and effective method of performing deep enteroscopy.
AB188 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
S1504 Clinical Outcomes of Endoscopic Submucosal Dissection for Duodenal Epithelial Tumors Yoshifumi Miyata, Shu Hoteya, Naohisa Yahagi Background and Aims: Endoscopic submucosal dissection (ESD) is a promising endoscopic resection technique for gastrointestinal superficial tumors since en bloc resection is requisite on pathological diagnosis. Therefore, we applied ESD for the treatment of duodenal epithelial tumors in order to achieve reliable en bloc resection. The therapeutic efficacy and safety were assessed in this study. Materials and Methods: ESD was performed on 24 consecutive patients (17 men, 7 women; mean age 62.8 years) with 24 duodenal lesions diagnosed as non invasive neoplastic lesions. Results: Among 24 treated cases ESD was completed in 22 cases. One case required surgical rescue due to uncontrollable perforation. And one case with very large lesion switched to surgery due to poor maneuverability of the endoscope. The en bloc resection rate was 91.7% (22/24), and curative resection with tumorfree margin was achieved in 83.3% (20/24). The mean lesion size was 22.0 mm (range 5 - 70 mm). Pathological examination showed adenocarcinoma in 5 cases (non invasive); tubular adenoma in 15 cases; tubulovillous adenoma in 1 case; Brunner gland adenoma in 1 case. Five cases of perforation (20.8% 5/24) and four cases of delayed bleeding (18.2% 4/24) were experienced. All perforations, except for one uncontrollable case, and all delayed bleedings were successfully managed endoscopically. After discharge from the hospital, no further complication was occurred. Conclusions: Outcomes of ESD for duodenal epithelial tumors is comparable to the treatment results of esophageal, gastric and colorectal tumors, although the complication rate in the duodenum is considerably higher. However, most of those complications were manageable by endoscopic means. ESD seemed far better than the surgical treatment which might cause major complication.
S1505 Management of Duodenal Lesions in Familial Adenomatous Polyposis (FAP) Sathya Jaganmohan, Apurv K. Varia, Jeffrey H. Lee Objective: To review the natural course of duodenal adenomas and results of endoscopic and surgical management in patients with FAP. Methods: Retrospective chart review of patients with FAP who underwent upper endoscopy for screening or surveillance of duodenal adenomas. Results: 70 patients with FAP and duodenal flat adenomas were identified from the endoscopy database undergoing screening and/ or surveillance for duodenal neoplasm between 2001 and 2008. 26 male patients and 44 female patients were identified. Mean age of the patients was 44, ranging from 13-83. Mean follow up was 4 years ranging from 1-14 years. The number of upper endoscopies performed on these patients ranged from 1-20 with a mean of 4.2. 59/70 patients had colectomy either as a prophylactic measure or diagnosis of malignancy. 69/70 patients had multiple flat adenomas in the duodenum. 13/70 lesions were larger than 1 cm. Mucosal abnormalities of the ampulla was observed in 42 of the 70 patients and biopsies showed 34/42 patients had adenomatous changes including villous changes in 20 patients and dysplastic changes in 2 patients(1 high grade and 1 low grade dysplasia). APC was performed in 16 patients including APC alone for ablation of lesions in 10 patients and in conjunction with EMR in 6 patients to ablate the edges of the EMR site. The indication for APC was debulking of lesions in 9 patients and in 1 patient for tubulovillous adenoma with low grade dysplasia. EMR was done on 8 patients including ampullectomy in 3 patients (one patient had ampullectomy prior to referral). The indications for ampullectomy were large ampullary adenoma not amenable to APC in one patient and enlarged ampulla(1.5 cm) with no dysplasia in one patient. Prophylactic PD stent was placed with ampullectomy in the latter and not in the former. One patient developed duodenal perforation requiring surgery after EMR and one patient developed bleeding after ampullectomy that was controlled with APC and clips. Two patients were referred for duodenectomy due to circumferential lesion not amenable to EMR in one patient and high grade dysplasia in the other patient. Two patients died with metastatic colon cancer and one patient died of leukemia during follow up. None of the patients were diagnosed duodenal adenocarcinoma during the follow up period. Conclusions: This study establishes that endoscopic management of duodenal lesions is a feasible strategy in long term management of patients with FAP. The significant morbidity associated with Whipple’s procedure and duodenectomy should be considered in management of these patient.
S1506 Evaluation of Small Bowel Images According to the Preparation Method for Capsule Endoscopy: NPO vs. PEG 2L vs. PEG 4L Sung Chul Park, Eun Sun Kim, Eun Suk Jung, Sehe Dong Lee, Jin Su Jang, Yong Dae Kwon, Sanghoon Park, Bora Keum, Yeon Seok Seo, Yoon Tae Jeen, Hoon Jai Chun, Soon Ho Um, Chang Duck Kim, Ho Sang Ryu Background and Aims: Wireless capsule endoscopy (WCE) is popular method for diagnosing small bowel lesions. However, there is the problem of impaired lumen
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Abstracts
visualization by air bubbles, bile pigments, and debris. According to the methods, the benefits of bowel preparation are still controversial and the best method of preparation remains to be determined. The aim of this study was to evaluate the effect of bowel preparation on the quality of visualization and the transit time according to the methods. Methods: The study sample consisted of 68 patients for capsule endoscopy. Patients were randomly allocated to three groups. In group A (nZ23), patients were fasting for 12 hours before WCE. In group B (nZ20) and C (nZ25), patients were prepared by 2L and 4L of polyethylene glycol (PEG), respectively. Small bowel images were assessed by using grading system, 5-minute interval method. The protocol utilized two visual parameters: proportion of luminal visibility and degree of obscuration. One frame of every 5-minute interval (1 frame/5 min) of entire small bowel images was serially chosen and scores were calculated from 0 to 3 points with the two parameters. The cut off score of adequacy was 2.25. Gastric transit time (GTT), small bowel transit time (SBTT), cecal completion rates, and the detection rates of the lesion were assessed. Results: The median scores of image quality in group A, B and C were 2.26, 2.43, and 2.55, respectively (pZ0.034). There was no difference in cecal completion rates: 73.9, 75.0, and 80.0% in group A, B and C, respectively. There was no statistical difference in GTT and SBTT among the three groups. The detection rates of the lesion in group A, B and C were 56.5, 65.0, and 68.0%, respectively. Conclusions: Bowel preparation with PEG offered better image quality than fasting alone and no difference was observed between 2L and 4L. In consideration of patients’ inconvenience, 2L of PEG may be a proper method of preparation for WCE.
S1507 Gastric Mucosal Pattern Using Magnifying NBI Endoscopy Clearly Distinguishes Histological, and Serological Severity of Chronic Gastritis and Predicts Gastric Cancer Occurrence Tomomitsu Tahara, Tomoyuki Shibata, Masakatsu Nakamura, Daisuke Yoshioka, Masaaki Okubo, Naoko Maruyama, Toshiaki Kamano, Yoshio Kamiya, Hiroshi Fujita, Yoshihito Nakagawa, Mitsuo Nagasaka, Masami Iwata, Kazuya Takahama, Makoto Watanabe, Tomiyasu Arisawa, Ichiro Hirata Background: Combining the Narrow band imaging (NBI) system and magnifying endoscope clearly visualize micro structures of the superficial mucosal patterns and its capillary patterns. Aim: To investigate gastric mucosal patterns by using magnifying NBI endoscopy, and its relation to H. pylori induced gastritis and gastric cancer (GC) occurrence. Method: Capillary and mucosal structures by magnifying NBI in the uninvolved gastric corpus were divided into following categories: normal pattern; small round pits surrounded by regular sub epithelial capillary network (SCEN) with collecting venuls (CV), type1; slightly enlarged round pit with unclear or irregular SCEN, type2; obviously enlarged oval or prolonged pit with increased density of irregular vessels, type 3; well demarcated oval or tubulo-villous pit with clearly visible coiled or wavy vessels. In study A, correlations between NBI gastric mucosal patterns and H. pylori infection, histological severity of gastritis, serum pepsinogen, and endscopic gastric atrophy were assessed in 106 subjects. In study B, the association between NBI gastric mucosal patterns and occurrence of gastric cancer (GC) was investigated among all subjects undergoing magnifying NBI upper endoscopy from April 2007 to October 2008. Results: In Study A, the sensitivity and specificity of type 1 þ 2 þ3 for detection of H. pylori infection positive was, 95.2% and 82.2%. Advance of the mucosal patterns from normal to type 1, 2, and 3 was correlated with all histological parameters (acute inflammation; RZ0.38, p!0.0001, chronic inflammation; RZ0.69, p!0.0001, atrophy; RZ0.58, p!0.0001, and intestinal metaplasia; RZ0.52, p!0.0001). The sensitivity and specificity of type 3 for detection of intestinal metaplasia was, 73.3% and 95.6%. Advance of the mucosal patterns was inversely correlated with serum pepsinogen I/II ratios (RZ-0.78, p!0.0001), and positively correlated with extension of endoscopic atrophy (RZ0.72, p!0.0001). The sensitivity and specificity of type 3 pattern for predict severe histological atrophy was 50.0%, and 96.3%, and was favorable when compared to serum pepsinogen and standard endoscopy. In study B, advance of the mucosal patterns from normal to type 1, 2, and 3 was significantly associated with GC occurrence (RZ0.49, p!0.0001). Conclusions: Gastric mucosal pattern by using magnifying NBI endoscopy closely correlates with H. pylori infection, and histological severity of gastritis. Furthermore, these patterns is also useful to predict the conditions of atrophic gastritis in the entire stomach, and GC occurrence. (Tahara T. Gastrointestinal Endoscopy, in press)
S1508 Diagnostic Yield and Success Rate of Single Balloon Enteroscopy for Conventional and Novel Clinical Applications Patrick Okolo, Vinay Chandrasekhara, Jonathan M. Buscaglia, Kerry B. Dunbar, Naudia N. Lauder, Anne Marie Lennon, Sanjay B. Jagannath Single Balloon Enteroscopy (SBE) is a novel endoscopic technique using a flexible single-balloon overtube via a per-oral approach to achieve greater depth of
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insertion. There is limited data reporting the use of SBE to manage patients with (1) small bowel disease and (2) surgically altered anatomy who require ERCP. Aim: To evaluate the diagnostic yield and success rate of the OlympusÒ SIF-Q160 single balloon enteroscope. Methods: Prospective evaluation of SBE from September 2006 to March 2008 in consecutive patients referred for: (1) small bowel disease or (2) ERCP in patients with surgically altered anatomy. Novel clinical applications of SBE were defined as active GI bleeding (nondiagnostic EGD/colonoscopy with clinical features of continued GI bleeding) and SBE based ERCP. Patient characteristics, procedural indications and technical factors, endoscopic manuevers, outcome and complications were recorded. Success rate is the percentage of SBE cases where the indication was accomplished without complication. Results: 125 patients (91 females, 34 males, mean age 63.4 years) underwent SBE. 111 patients were evaluated for small bowel disease and 14 patients underwent SBE based ERCP. Indications included: obscure GI bleeding (NZ52), abnormal capsule endoscopy (NZ27), iron deficiency anemia (NZ16), biliary obstruction/cholangitis (NZ13), active GI bleeding (NZ4), pancreatic duct leak (NZ1), and misc. (NZ12). The average procedure time was 4715 minutes. Mean depth of insertion was 224 65 cm beyond the presumed ligament of Treitz. The overall success rate for SBE for accepted small bowel indications was 98.1% (105/107). The diagnostic yield of SBE for accepted small bowel indications were: obscure GI bleeding (74.0%), abnormal capsule endoscopy (74.1%), and iron deficiency anemia (62.5%). Successful polypectomy in jejunum or ileum was performed in all indicated cases (NZ4). Novel clinical applications. include SBE of active GI bleeding and SBE based ERCPs. 75% (3/4) patients with active GI bleeding were successfully treated using standard hemostatic methods. SBE based ERCP was successful in 64% (9/14) of patients. Therapeutic manuevers were balloon dilation of the ampulla (NZ7) and sphincterotomy (NZ2). The overall complication rate was 1.6% (1 perforation, 1 mild pancreatitis). Conclusions: SBE is a feasible endoscopic procedure with a wide range of clinical applications in patients with small bowel disease or those with surgically altered anatomy that require ERCP. In this study, the success rate for small bowel disease was 98.1%, and 64% for SBE based ERCP. Further direct comparison with other existing technologies is required
S1509 Can We Shorten the Small-Bowel Capsule Reading Time? Validation of the ‘‘Quick-View’’ Image Detection System Jean-Christophe Saurin, Emmanuel Ben Soussan, Marianne Gaudric, Marie-George Lapalus, Franck Cholet, Pierre Nicolas D’Halluin, Bernard Filoche, Patrick Adenis Lamarre, Claire Savalle, Murielle Frederique Aim: The mean small-bowel (SB) capsule reading time is about 30 minutes. Shortening this reading time is a major aim for gastroenterologists in clinical practice. The « Quick-view » system (QV) developed by Given Imaging has two potentials including this reading time shortening and the improvement of the detection of significant images detected by the SB2 capsule, but lacks validation. We aimed at evaluating the sensitivity and specificity of this detection algorithm. Patients and Methods: We selected 106 SB capsule films from the last 10 cases of 12 centres having an experience of at least 200 cases. Ten experimented readers, one from each centre, participated to a common reading in QV mode of these selected cases, using a predefined protocol. Each image detected in QV mode was classified according to it’s relevance (high relevance P2, uncertain P1, low P0). These results were compared, image per image, to the results of the normal, initial, reading (IR) of the case. Each discordant result between the initial and the QV readings was reviewed and discussed by 3 experts. Results: The mean reading time in QV mode was of 11.6 mn (2-27). The mean SB transit time evaluated in QV or IR was of 258 and 260 mn respectively, significantly correlated (p! 0.01). In 41 cases, no P2 or P1 image was detected (38.6%) either in the QV reading or IR. At least one P2 or P1 image was detected, in a concordant way, by the QV reading and IR, in 35 cases (33.0%). A discordant result was obtained in 30 (28.3%) cases. After expert review, theses cases corresponded to 21 false positive cases (IR 12 cases, QV reading 9 cases), to 7 lesions missed at initial reading, 7 lesions missed at QV reading, 5 cases belonging to 2 categories. Table 1 shows the corresponding sensitivity and specificity according to this expert review. From the 7 lesions missed at QV reading, 4 (in 3 patients) were not present on the QV film, corresponding to a ‘‘theoretical sensitivity’’ of the QV algorithm of 93.5%. Conclusion: In our study, the QV informatic algorithm was able to detect nearly 94% of significant lesions, and the QV mode reading was as sensible as the initial reading, but with a very short reading time. Further studies are required to confirm our results, but this suggests that SB capsule films could be red with an excellent sensitivity using only the QV mode.
Sensitivity Specificity
Initial Reading
Quick View reading
Theoretical quick view
85.6% 82.0%
85.7% 86.6%
93.5% -
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB189
S1502 Dilatation of Small Bowel Strictures By Double Balloon Enteroscopy: Further Results from the UK Edward J. Despott, Eric Tripoli, Krysia Konieczko, Adel Polecina, Chris H. Fraser Introduction: Double balloon enteroscopy (DBE) facilitates endotherapy of deep SB pathology. Our preliminary prospective proof of concept analysis on DBE dilatation of Crohn’s Disease (CD) SB strictures was presented to the ASGE at DDW 2008. We now report further on our prospective data of DBE stricture dilatation in an expanding cohort of patients with CD and NSAID induced SB strictures from the UK. Aims and Methods: Since introduction of DBE to our unit in 2005, data on cases of DBE SB stricture dilatation were prospectively collected for outcome, need for repeat dilatation and surgery. The DBEs were performed using the EN-450T5 scope (Fujinon, Saitama, Japan). Balloon ilatation was performed using controlled radial expansion (CRE)balloon dilators. A standardised 10cm visual analogue scale (VAS) characterised symptoms and dietary restriction before DBE stricture dilatation and at follow-up. Results: A total of 14 DBEs were done in 12 consecutive cases (mean age 46.4 7.8 years). In all but 2 cases, the strictures were characterised radiologically before DBE. In 11 of the cases, the SB strictures were CD related, in 1 case they were NSAID induced. Twenty six SB stricture dilatations were performed in 10 of 12 patients. The patient with NSAID related strictures had successful dilatation of 8 strictures in one session. In another case of CD SB strictures, a retained video capsule was retrieved after dilatation of the culprit strictures. Mean stricture dilatation diameter was 14.5mm (range 12-20mm). In the 2 cases where stricture dilatation was not performed, DBE hindrance by adhesions made reaching the strictures impossible. These two cases were then managed surgically. One case of complex CD stricture dilatation was complicated by a delayed perforation. This case required a temporary jejunostomy which has since been reversed. In the other 9 cases SB stricture dilatation by DBE was an unhindered success; the symptom and dietary restriction scores improved dramatically and to date (mean follow up 19.4; range 1-40 months) none of these cases has required surgery for SB strictures. At follow-up, 2 patients required a repeat straightforward DBE dilatation (at 6.5 and 13 months respectively) due to recurrence of some of their symptoms. Although the numbers in this series are small, the clinical improvements in pre and post DBE VAS scores were large enough (means of 9.2 vs 1.7 respectively; p!0.001). Conclusion: This series adds to the growing body of published evidence that DBE SB stricture dilatation can be very effective, with the potential to help avoid the risks of surgery, small bowel resection and the associated risks of short bowel syndrome.
S1503 The Clinical Utility of Single Balloon Enteroscopy: A Single Center Experience of 172 Procedures Bennie R. Upchurch, John J. Vargo, Madhusudhan R. Sanaka, Mohammad Alhaji Objectives: Single balloon enteroscopy (SBE) is a novel endoscopic technique designed to evaluate and treat small bowel disease. It represents the second method of deep enteroscopy available after the advent of double balloon enteroscopy. While there is substantial literature addressing double balloon enteroscopy and its impact in the diagnosis and management of small bowel disease, there are limited data available on the clinical utility of SBE. The aim of this study was to evaluate the clinical utility and diagnostic impact of SBE in a large cohort of patients at a single tertiary center. Methods: This study is a retrospective review of patient charts of those referred for deep enteroscopy from January 11, 2006 to August 5, 2008. Demographic, clinical, procedural and outcome data were collected and analyzed. Results: 172 patients (85 women, 87 men) were studied. Average age was 64 years with a range of 23-88 years of age. The most common indication was anemia, with 102 patients referred. 51 patients had occult bleeding, 46 were referred for overt bleeding, 11 for suspected IBD, 8 for abd pain, 8 for suspected mass, and 5 for diarrhea. We used conscious sedation in 146 patients, MAC or general anesthesia in 26 patients. Antegrade and retrograde approaches were performed in 143 and 29 respectively. Average depth of insertion from the antegrade approach was 132 cm beyond the ligament of Trietz (range 20-400 cm). Average depth of insertion from the retrograde approach was 73 cm above the ileocecal valve (range 10-160 cm). Average procedure time was 40 mins overall, 38 mins antegrade (range 12-90), 48 mins retrograde (range 28-89). Flouroscopy was used in 20 cases (12%) and the average time used per case was 4 minutes (range 12 seconds to 14 minutes). The abnormalities detected were angioectasia in 63 patients (36%), telangiectasias in 12 patients, 10 patients with polyps, 8 with ulcers, 6 with small bowel diverticula, 4 with blood in the lumen, 3 with acid hematin seen, 2 strictures, and 2 erosions. There were normal findings (no pathology detected) in 65 patients (37%). Diagnostic yield was 62% (107/172). 41% (72/172) were therapeutic cases. AVMs or telangectasias were treated in 66 cases, 5 polyps were removed, and 1 stricture was dilated. There were no significant complications.135 patients (78%) had capsules studies done prior to the enteroscopy. In 70 cases (40%) the capsule findings were confirmed by the enteroscopy. Conclusions: SBE demonstrated a high diagnostic yield, and frequently provided useful therapeutic intervention. It appears to be a safe and effective method of performing deep enteroscopy.
AB188 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
S1504 Clinical Outcomes of Endoscopic Submucosal Dissection for Duodenal Epithelial Tumors Yoshifumi Miyata, Shu Hoteya, Naohisa Yahagi Background and Aims: Endoscopic submucosal dissection (ESD) is a promising endoscopic resection technique for gastrointestinal superficial tumors since en bloc resection is requisite on pathological diagnosis. Therefore, we applied ESD for the treatment of duodenal epithelial tumors in order to achieve reliable en bloc resection. The therapeutic efficacy and safety were assessed in this study. Materials and Methods: ESD was performed on 24 consecutive patients (17 men, 7 women; mean age 62.8 years) with 24 duodenal lesions diagnosed as non invasive neoplastic lesions. Results: Among 24 treated cases ESD was completed in 22 cases. One case required surgical rescue due to uncontrollable perforation. And one case with very large lesion switched to surgery due to poor maneuverability of the endoscope. The en bloc resection rate was 91.7% (22/24), and curative resection with tumorfree margin was achieved in 83.3% (20/24). The mean lesion size was 22.0 mm (range 5 - 70 mm). Pathological examination showed adenocarcinoma in 5 cases (non invasive); tubular adenoma in 15 cases; tubulovillous adenoma in 1 case; Brunner gland adenoma in 1 case. Five cases of perforation (20.8% 5/24) and four cases of delayed bleeding (18.2% 4/24) were experienced. All perforations, except for one uncontrollable case, and all delayed bleedings were successfully managed endoscopically. After discharge from the hospital, no further complication was occurred. Conclusions: Outcomes of ESD for duodenal epithelial tumors is comparable to the treatment results of esophageal, gastric and colorectal tumors, although the complication rate in the duodenum is considerably higher. However, most of those complications were manageable by endoscopic means. ESD seemed far better than the surgical treatment which might cause major complication.
S1505 Management of Duodenal Lesions in Familial Adenomatous Polyposis (FAP) Sathya Jaganmohan, Apurv K. Varia, Jeffrey H. Lee Objective: To review the natural course of duodenal adenomas and results of endoscopic and surgical management in patients with FAP. Methods: Retrospective chart review of patients with FAP who underwent upper endoscopy for screening or surveillance of duodenal adenomas. Results: 70 patients with FAP and duodenal flat adenomas were identified from the endoscopy database undergoing screening and/ or surveillance for duodenal neoplasm between 2001 and 2008. 26 male patients and 44 female patients were identified. Mean age of the patients was 44, ranging from 13-83. Mean follow up was 4 years ranging from 1-14 years. The number of upper endoscopies performed on these patients ranged from 1-20 with a mean of 4.2. 59/70 patients had colectomy either as a prophylactic measure or diagnosis of malignancy. 69/70 patients had multiple flat adenomas in the duodenum. 13/70 lesions were larger than 1 cm. Mucosal abnormalities of the ampulla was observed in 42 of the 70 patients and biopsies showed 34/42 patients had adenomatous changes including villous changes in 20 patients and dysplastic changes in 2 patients(1 high grade and 1 low grade dysplasia). APC was performed in 16 patients including APC alone for ablation of lesions in 10 patients and in conjunction with EMR in 6 patients to ablate the edges of the EMR site. The indication for APC was debulking of lesions in 9 patients and in 1 patient for tubulovillous adenoma with low grade dysplasia. EMR was done on 8 patients including ampullectomy in 3 patients (one patient had ampullectomy prior to referral). The indications for ampullectomy were large ampullary adenoma not amenable to APC in one patient and enlarged ampulla(1.5 cm) with no dysplasia in one patient. Prophylactic PD stent was placed with ampullectomy in the latter and not in the former. One patient developed duodenal perforation requiring surgery after EMR and one patient developed bleeding after ampullectomy that was controlled with APC and clips. Two patients were referred for duodenectomy due to circumferential lesion not amenable to EMR in one patient and high grade dysplasia in the other patient. Two patients died with metastatic colon cancer and one patient died of leukemia during follow up. None of the patients were diagnosed duodenal adenocarcinoma during the follow up period. Conclusions: This study establishes that endoscopic management of duodenal lesions is a feasible strategy in long term management of patients with FAP. The significant morbidity associated with Whipple’s procedure and duodenectomy should be considered in management of these patient.
S1506 Evaluation of Small Bowel Images According to the Preparation Method for Capsule Endoscopy: NPO vs. PEG 2L vs. PEG 4L Sung Chul Park, Eun Sun Kim, Eun Suk Jung, Sehe Dong Lee, Jin Su Jang, Yong Dae Kwon, Sanghoon Park, Bora Keum, Yeon Seok Seo, Yoon Tae Jeen, Hoon Jai Chun, Soon Ho Um, Chang Duck Kim, Ho Sang Ryu Background and Aims: Wireless capsule endoscopy (WCE) is popular method for diagnosing small bowel lesions. However, there is the problem of impaired lumen
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Abstracts
visualization by air bubbles, bile pigments, and debris. According to the methods, the benefits of bowel preparation are still controversial and the best method of preparation remains to be determined. The aim of this study was to evaluate the effect of bowel preparation on the quality of visualization and the transit time according to the methods. Methods: The study sample consisted of 68 patients for capsule endoscopy. Patients were randomly allocated to three groups. In group A (nZ23), patients were fasting for 12 hours before WCE. In group B (nZ20) and C (nZ25), patients were prepared by 2L and 4L of polyethylene glycol (PEG), respectively. Small bowel images were assessed by using grading system, 5-minute interval method. The protocol utilized two visual parameters: proportion of luminal visibility and degree of obscuration. One frame of every 5-minute interval (1 frame/5 min) of entire small bowel images was serially chosen and scores were calculated from 0 to 3 points with the two parameters. The cut off score of adequacy was 2.25. Gastric transit time (GTT), small bowel transit time (SBTT), cecal completion rates, and the detection rates of the lesion were assessed. Results: The median scores of image quality in group A, B and C were 2.26, 2.43, and 2.55, respectively (pZ0.034). There was no difference in cecal completion rates: 73.9, 75.0, and 80.0% in group A, B and C, respectively. There was no statistical difference in GTT and SBTT among the three groups. The detection rates of the lesion in group A, B and C were 56.5, 65.0, and 68.0%, respectively. Conclusions: Bowel preparation with PEG offered better image quality than fasting alone and no difference was observed between 2L and 4L. In consideration of patients’ inconvenience, 2L of PEG may be a proper method of preparation for WCE.
S1507 Gastric Mucosal Pattern Using Magnifying NBI Endoscopy Clearly Distinguishes Histological, and Serological Severity of Chronic Gastritis and Predicts Gastric Cancer Occurrence Tomomitsu Tahara, Tomoyuki Shibata, Masakatsu Nakamura, Daisuke Yoshioka, Masaaki Okubo, Naoko Maruyama, Toshiaki Kamano, Yoshio Kamiya, Hiroshi Fujita, Yoshihito Nakagawa, Mitsuo Nagasaka, Masami Iwata, Kazuya Takahama, Makoto Watanabe, Tomiyasu Arisawa, Ichiro Hirata Background: Combining the Narrow band imaging (NBI) system and magnifying endoscope clearly visualize micro structures of the superficial mucosal patterns and its capillary patterns. Aim: To investigate gastric mucosal patterns by using magnifying NBI endoscopy, and its relation to H. pylori induced gastritis and gastric cancer (GC) occurrence. Method: Capillary and mucosal structures by magnifying NBI in the uninvolved gastric corpus were divided into following categories: normal pattern; small round pits surrounded by regular sub epithelial capillary network (SCEN) with collecting venuls (CV), type1; slightly enlarged round pit with unclear or irregular SCEN, type2; obviously enlarged oval or prolonged pit with increased density of irregular vessels, type 3; well demarcated oval or tubulo-villous pit with clearly visible coiled or wavy vessels. In study A, correlations between NBI gastric mucosal patterns and H. pylori infection, histological severity of gastritis, serum pepsinogen, and endscopic gastric atrophy were assessed in 106 subjects. In study B, the association between NBI gastric mucosal patterns and occurrence of gastric cancer (GC) was investigated among all subjects undergoing magnifying NBI upper endoscopy from April 2007 to October 2008. Results: In Study A, the sensitivity and specificity of type 1 þ 2 þ3 for detection of H. pylori infection positive was, 95.2% and 82.2%. Advance of the mucosal patterns from normal to type 1, 2, and 3 was correlated with all histological parameters (acute inflammation; RZ0.38, p!0.0001, chronic inflammation; RZ0.69, p!0.0001, atrophy; RZ0.58, p!0.0001, and intestinal metaplasia; RZ0.52, p!0.0001). The sensitivity and specificity of type 3 for detection of intestinal metaplasia was, 73.3% and 95.6%. Advance of the mucosal patterns was inversely correlated with serum pepsinogen I/II ratios (RZ-0.78, p!0.0001), and positively correlated with extension of endoscopic atrophy (RZ0.72, p!0.0001). The sensitivity and specificity of type 3 pattern for predict severe histological atrophy was 50.0%, and 96.3%, and was favorable when compared to serum pepsinogen and standard endoscopy. In study B, advance of the mucosal patterns from normal to type 1, 2, and 3 was significantly associated with GC occurrence (RZ0.49, p!0.0001). Conclusions: Gastric mucosal pattern by using magnifying NBI endoscopy closely correlates with H. pylori infection, and histological severity of gastritis. Furthermore, these patterns is also useful to predict the conditions of atrophic gastritis in the entire stomach, and GC occurrence. (Tahara T. Gastrointestinal Endoscopy, in press)
S1508 Diagnostic Yield and Success Rate of Single Balloon Enteroscopy for Conventional and Novel Clinical Applications Patrick Okolo, Vinay Chandrasekhara, Jonathan M. Buscaglia, Kerry B. Dunbar, Naudia N. Lauder, Anne Marie Lennon, Sanjay B. Jagannath Single Balloon Enteroscopy (SBE) is a novel endoscopic technique using a flexible single-balloon overtube via a per-oral approach to achieve greater depth of
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insertion. There is limited data reporting the use of SBE to manage patients with (1) small bowel disease and (2) surgically altered anatomy who require ERCP. Aim: To evaluate the diagnostic yield and success rate of the OlympusÒ SIF-Q160 single balloon enteroscope. Methods: Prospective evaluation of SBE from September 2006 to March 2008 in consecutive patients referred for: (1) small bowel disease or (2) ERCP in patients with surgically altered anatomy. Novel clinical applications of SBE were defined as active GI bleeding (nondiagnostic EGD/colonoscopy with clinical features of continued GI bleeding) and SBE based ERCP. Patient characteristics, procedural indications and technical factors, endoscopic manuevers, outcome and complications were recorded. Success rate is the percentage of SBE cases where the indication was accomplished without complication. Results: 125 patients (91 females, 34 males, mean age 63.4 years) underwent SBE. 111 patients were evaluated for small bowel disease and 14 patients underwent SBE based ERCP. Indications included: obscure GI bleeding (NZ52), abnormal capsule endoscopy (NZ27), iron deficiency anemia (NZ16), biliary obstruction/cholangitis (NZ13), active GI bleeding (NZ4), pancreatic duct leak (NZ1), and misc. (NZ12). The average procedure time was 4715 minutes. Mean depth of insertion was 224 65 cm beyond the presumed ligament of Treitz. The overall success rate for SBE for accepted small bowel indications was 98.1% (105/107). The diagnostic yield of SBE for accepted small bowel indications were: obscure GI bleeding (74.0%), abnormal capsule endoscopy (74.1%), and iron deficiency anemia (62.5%). Successful polypectomy in jejunum or ileum was performed in all indicated cases (NZ4). Novel clinical applications. include SBE of active GI bleeding and SBE based ERCPs. 75% (3/4) patients with active GI bleeding were successfully treated using standard hemostatic methods. SBE based ERCP was successful in 64% (9/14) of patients. Therapeutic manuevers were balloon dilation of the ampulla (NZ7) and sphincterotomy (NZ2). The overall complication rate was 1.6% (1 perforation, 1 mild pancreatitis). Conclusions: SBE is a feasible endoscopic procedure with a wide range of clinical applications in patients with small bowel disease or those with surgically altered anatomy that require ERCP. In this study, the success rate for small bowel disease was 98.1%, and 64% for SBE based ERCP. Further direct comparison with other existing technologies is required
S1509 Can We Shorten the Small-Bowel Capsule Reading Time? Validation of the ‘‘Quick-View’’ Image Detection System Jean-Christophe Saurin, Emmanuel Ben Soussan, Marianne Gaudric, Marie-George Lapalus, Franck Cholet, Pierre Nicolas D’Halluin, Bernard Filoche, Patrick Adenis Lamarre, Claire Savalle, Murielle Frederique Aim: The mean small-bowel (SB) capsule reading time is about 30 minutes. Shortening this reading time is a major aim for gastroenterologists in clinical practice. The « Quick-view » system (QV) developed by Given Imaging has two potentials including this reading time shortening and the improvement of the detection of significant images detected by the SB2 capsule, but lacks validation. We aimed at evaluating the sensitivity and specificity of this detection algorithm. Patients and Methods: We selected 106 SB capsule films from the last 10 cases of 12 centres having an experience of at least 200 cases. Ten experimented readers, one from each centre, participated to a common reading in QV mode of these selected cases, using a predefined protocol. Each image detected in QV mode was classified according to it’s relevance (high relevance P2, uncertain P1, low P0). These results were compared, image per image, to the results of the normal, initial, reading (IR) of the case. Each discordant result between the initial and the QV readings was reviewed and discussed by 3 experts. Results: The mean reading time in QV mode was of 11.6 mn (2-27). The mean SB transit time evaluated in QV or IR was of 258 and 260 mn respectively, significantly correlated (p! 0.01). In 41 cases, no P2 or P1 image was detected (38.6%) either in the QV reading or IR. At least one P2 or P1 image was detected, in a concordant way, by the QV reading and IR, in 35 cases (33.0%). A discordant result was obtained in 30 (28.3%) cases. After expert review, theses cases corresponded to 21 false positive cases (IR 12 cases, QV reading 9 cases), to 7 lesions missed at initial reading, 7 lesions missed at QV reading, 5 cases belonging to 2 categories. Table 1 shows the corresponding sensitivity and specificity according to this expert review. From the 7 lesions missed at QV reading, 4 (in 3 patients) were not present on the QV film, corresponding to a ‘‘theoretical sensitivity’’ of the QV algorithm of 93.5%. Conclusion: In our study, the QV informatic algorithm was able to detect nearly 94% of significant lesions, and the QV mode reading was as sensible as the initial reading, but with a very short reading time. Further studies are required to confirm our results, but this suggests that SB capsule films could be red with an excellent sensitivity using only the QV mode.
Sensitivity Specificity
Initial Reading
Quick View reading
Theoretical quick view
85.6% 82.0%
85.7% 86.6%
93.5% -
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB189