Effect of prophylactic clip placement following endoscopic mucosal resection of large colorectal lesions on delayed polypectomy bleeding: A meta-analysis

BACKGROUND The role of prophylactic clipping for the prevention of delayed polypectomy bleeding(DPB) remains unclear and conclusions from prior meta-analyses are limited due to the inclusion of variety of resection techniques and polyp sizes.AIM To conduct a meta-analysis on the effect of clipping on DPB following endoscopic mucosal resection(EMR) of colorectal lesions ≥ 20 mm.METHODS We performed a search of PubMed and the Cochrane library for studies comparing the effect of clipping vs no clipping on DPB following endoscopic resection. The Cochran Q test and I^2 were used to test for heterogeneity. Pooling was conducted using a random-effects model.RESULTS Thirteen studies with a total of 7794 polyps were identified, of which data was available on 1701 cases of EMR of lesions ≥ 20 mm. Prophylactic clipping was associated with a lower rate of DPB(1.4%) when compared to no clipping(5.2%)(pooled OR: 0.24, 95%CI: 0.12-0.50, P < 0.001) following EMR of lesions ≥ 20 mm.There was no significant heterogeneity among the studies(I^2 = 0%, P = 0.67).CONLUSION Prophylactic clipping may reduce DPB following EMR of large colorectal lesions.Future trials are needed to further identify risk factors and stratify high risk cases in order to implement a cost-effective preventive strategy.

Indomethacin for post-endoscopic retrograde cholangiopancreatography pancreatitis prophylaxis:Is it the magic bullet?

Acute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography(ERCP).Pancreatic duct stent insertion after ERCP has been widely accepted as the standard of care for the prevention of this complication in high-risk patients.Unfortunately,the placement of pancreatic stents requires higher level of endoscopic expertise and is not always feasible due to anatomic considerations.Therefore,effective non-invasive pharmacologic prophylaxis remains appealing,particularly if it is inexpensive,easily administered,has a low risk side effect profile and is widely available.There have been multiple studies evaluating potential pharmacologic candidates for post-ERCP pancreatitis(PEP) prophylaxis,most of them yielding disappointing results.A recently published large,multicenter,randomized controlled trial reported that in high risk patients a single dose of rectal indomethacin administered immediately after the ERCP significantly decreased the incidence of PEP compare to placebo.

Advances in the management of cholangiocarcinoma

Cholangiocarcinoma(CCA)is a primary malignancy of the bile ducts with three anatomically and molecularly distinct entities:Intrahepatic CCA(iCCA),perihilar CCA(pCCA),and distal CCA.As a result of phenotypic and anatomic differences they differ significantly with respect to management.For each type of CCA there have been significant changes in management over the last several years which will be discussed in this review.Although resection remains the standard of care for all types of CCA,liver transplantation has been established as curative treatment for selected patients with pCCA and is being evaluated for iCCA with early success.With respect to systemic therapy capecitabine is now first line adjuvant therapy for all biliary tract malignancies after curative intent resection.Progress in exploiting the pathologic mutations and molecular abnormalities has also yielded regulatory approval of targeted therapy for CCA in patients with acquired alterations in the fibroblast growth factor receptor.There is also increased consensus in managing malignant biliary obstruction associated with CCA where pre-operative biliary stenting is not beneficial while self-expanding metal stents have been shown to be superior to plastic stents in patients who are not surgical candidates.

Endoscopic management of colorectal polyps: From benign to malignant polyps

Colorectal cancer(CRC)is the third most common cancer worldwide and the second leading cause of cancer related death in the world.The early detection and removal of CRC precursor lesions has been shown to reduce the incidence of CRC and cancer-related mortality.Endoscopic resection has become the first-line treatment for the removal of most precursor benign colorectal lesions and selected malignant polyps.Detailed lesion assessment is the first critical step in the evaluation and management of colorectal polyps.Polyp size,location and both macro-and micro-features provide important information regarding histological grade and endoscopic resectability.Benign polyps and even malignant polyps with superficial submucosal invasion and favorable histological features can be adequately removed endoscopically.When compared to surgery,endoscopic resection is associated with lower morbidity,mortality,and higher patient quality of life.Conversely,malignant polyps with deep submucosal invasion and/or high risk for lymph node metastasis will require surgery.From a practical standpoint,the most appropriate strategy for each patient will need to be individualized,based not only on polyp-and patient-related characteristics,but also on local resources and expertise availability.In this review,we provide a broad overview and present a potential decision tree algorithm for the evaluation and management of colorectal polyps that can be widely adopted into clinical practice.

Patient perceptions of stool DNA testing for pan-digestive cancer screening:A survey questionnaire

AIM:To explore patient interest in a potential multiorgan stool-DNA test(MUST)for pan-digestive cancer screening.METHODS:A questionnaire was designed and mailed to 1200 randomly-selected patients from the Mayo Clinic registry.The 29-item survey questionnaire included items related to demographics,knowledge of digestive cancers,personal and family history of cancer,personal concern of cancer,colorectal cancer(CRC)screening behavior,interest in MUST,importance of test features in a cancer screening tool,and comparison of MUST with available CRC screening tests.All responses were summarized descriptively.χ2 and Rank Sum Test were used for categorical and continuous variables,respectively.RESULTS:Completed surveys were returned by 434(29%aged 50-59,37%60-69,34%70-79,52%women).Most participants(98%)responded they would use MUST.In order of importance,respondents rated multicancer detection,absence of bowel preparation,safety and noninvasiveness as most attractive characteristics.For CRC screening,MUST was preferred over colorectal-only stool-DNA testing(53%),occult blood testing(75%),colonoscopy(84%),sigmoidoscopy(91%),and barium enema(95%),P<0.0001 for each.Among those not previously screened,most(96%)indicated they would use MUST if available.Respondents were confident in their ability to follow instructions to perform MUST(98%).Only 9%of respondents indicated that fear of finding cancer was a concern with MUST,and only 3%indicated unpleasantness of stool sampling as a potential barrier.CONCLUSION:Patients are receptive to the concept of MUST,preferred MUST over conventional CRC screening modalities and valued its potential feature of multi-cancer detection.

Endoscopic ultrasound guided gastrojejunostomy for gastric outlet obstruction

Gastric outlet obstruction(GOO)is a clinical syndrome secondary to luminal obstruction at the level of the stomach and/or duodenum.GOO can be caused by either benign or malignant etiologies,often resulting in early satiety,nausea,vomiting and poor oral intake.GOO is associated with decreased quality of life and has been shown to significantly impact survival in patients with advanced malignancies.Traditional treatment options for GOO can be broadly divided into surgical[surgical gastrojejunostomy(GJ)]and endoscopic interventions(dilation and/or placement of luminal self-expanding metal stents).While surgical GJ has been shown to provide a more lasting relief of symptoms when compared to luminal stenting,it has also been associated with a higher rate of adverse events.Furthermore,many patients with advanced metastatic disease are not good surgical candidates.More recently,endoscopic ultrasound(EUS)-guided GJ has emerged as a potential alternative to traditional surgical and endoscopic approaches.This review focuses on the new advances and technical aspects of EUS-GJ and clinical outcomes in the management of both benign and malignant disease.

Feasibility and safety of endoscopic cryoablation at the duodenal papilla: Porcine model

AIM: To assess the feasibility and safety of liquid nitrogen spray cryoablation at the duodenal papilla in a porcine model. METHODS: This prospective study protocol was approved by the University of Florida Institutional Animal Care and Use Committee. Six pigs underwent liquid nitrogen spray cryotherapy at the duodenal papilla. Freeze time of 20-s was applied per cycle(4 cycles/session). Survival animals(n = 4) were monitored for adverse events. Hemoglobin, white blood count, liver tests, and lipase were obtained at baseline and post-treatment. EGD was performed on day#7 to evaluate the papilla and for histology. All animals were euthanized and necropsy was performed at the end of the one-week survival period. Feasibility was defined as successful placement of the decompression tube in the duodenum, followed by delivery of spray cryotherapy to the duodenal papilla. Safety was determined by monitoring post-treatment blood tests and clinical course. Treatment effect was defined as endoscopic and histologic changes after cryotherapy. This was established by comparing endoscopic and histologic findings from mucosal biopsies prior to cryotherapy and on post-operative day(POD)#7. Full-thickness specimen was obtained post-mortem to assess depth of injury. RESULTS: Spray cryotherapy was feasible and successfully performed in all 6/6(100%) animals. Cryospray with liquid nitrogen(four 20-s freeze-thaw cycles) at the duodenal papilla resulted in white frost formation at and around the target region. The mean proceduraltime was 54.5 min(range 50-58 min). All six animals studied had stable blood pressure, heart rate, and pulse oximetry measurements during the procedure. There were no significant intra-procedural adverse events. There were no significant differences in hemoglobin, white cell count, liver tests or lipase from baseline to post-cryotherapy. Survival animals were monitored daily post-operatively without any clinical ill effects from the cryotherapy. There was no bleeding, infection, or perforation on necropsy. Endoscopic on POD#7 showed edema and ulceration at the duodenal papilla. On histology, there was loss of crypt architecture with moderate to severe necrosis and acute mixed inflammatory infiltration in each specimen following cryotherapy. The extent of cryogen-induced tissue necrosis(depth of injury) was limited to the mucosa on full-thickness specimen evaluation. CONCLUSION: Endoscopic liquid nitrogen spray cryotherapy is feasible and safe for ablation at the duodenal papilla in a porcine model.

Third-space endoscopy:the final frontier

Over the years,our growing experience with endoscopic submucosal dissection along with technological advances has so-lidified our comfort and knowledge on working in the submucosa,also referred to as the“third space.”Per-oral endoscopic myotomy(POEM)was thefirst prototype third-space endoscopy(TSE)procedure,demonstrating the feasibility and clinical utility of endoscopic esophagogastric myotomy via submucosal tunneling.The launch of POEM accelerated the evolution of TSE from a vanguard concept to an expandingfield with a wide range of clinical applications.In this review,we discuss the status and future directions of multiple TSE interventions.